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It’s easy to think that the problems we face in providing high-quality care to frail elders is a challenge that is unique to health care in the United States. We are not alone. You only have to look across our border to the province of Ontario, Canada, to see evidence that ensuring quality is a universal challenge.

While the Canadian health care system is very different from that in the U.S., we share many challenges when it comes to eldercare. In fact, on July 1, 2010, the Ontario Ministry of Health (MOH) implemented the Long-Term Care Homes Act, 2007. The act reads much like a modern-day version of the Omnibus Budget Reconciliation Act of 1987.

MOH (like the Centers for Medicare & Medicaid Services) was charged with developing a regulatory approach to transform long-term care along the lines of what residents and families and other stakeholders recommended. They identified the Quality Indicator Survey (QIS) as a possible evolution to a more structured and resident-centered “inspection” (their term for survey) of their skilled nursing care centers.

A contract for developing content, Web-based technology to conduct inspections throughout the 630 nursing centers in the province, training for inspectors, and continued refinement was put out for bid.

Through that contract, I was fortunate enough to be able to participate in the development of the methodology and the Web application, and I have greatly enjoyed an ongoing working relationship with the ministry staff and long term care providers in Ontario.

The universality of quality constructs was apparent from early development of the questions that would provide the basis for Stage 1. The wording in the Act is certainly different, but the question sets for resident, family, and staff interview, as well as observation and chart review, overlapped more than 90 percent with QIS. The new inspection process was dubbed the Resident Quality Inspection (RQI).

The Ontario Auditor General (akin to the General Accountability Office) reviewed the RQI recently. The agency observed, “In early 2011, the ministry implemented comprehensive inspections, which aim to assess residents’ satisfaction and homes’ compliance with legislative requirements. On average, a comprehensive inspection involves three or four inspectors examining the home over an eight-day period. This inspection process has two stages and 31 inspection protocols, five of which are mandatory protocols.”

Sound familiar? Of course, eight days is even longer than the U.S. annual survey. So what did AG suggest?
“To put the safety of residents first by focusing on high-risk areas, the Ministry of Health and Long-Term Care should…prioritize comprehensive inspections based on long term care homes’ complaints and critical incidents, compliance history, and other risk factors.”

And what was the MOH response?

“The ministry is evaluating options to consider a focused, comprehensive inspection which would be shorter and less resource-intensive for homes that are substantially compliant and [at] lower risk.”

MOH already has a risk stratification methodology for its nursing centers. A proposed annual “focused inspection” methodology for all low-risk centers that maintain the integrity of the original process is now being developed.

Andy Kramer, MD, is a long term care researcher and professor of medicine who was instrumental in the design and development of the Quality Indicator Survey.