RAI-benchmarking: An instrument for leadership and development

Why was this example implemented?

Many kinds of assessment instruments are used in assessing residents' needs depending on the professional's background. Variations in assessments and the absence of a shared view of the residents' needs between different professionals cause difficulties in arranging and integrating services. Thus, the quality of care may decrease and the resources may not be used in an efficient way. Furthermore, variation in efficiency between care units and organisations suggest that efficiency could be improved through better management and resource allocation. Standardised assessment data is viewed as a source of management information to be used to track the case mix of residents, allocate resources such as staff, and evaluate care quality (structure, process, outcomes).

Folkhälsan started to provide care for older people in 1990. From the start, Folkhälsan's vision was to be two steps ahead in developing high-quality services for their residents. Therefore there was a need to have a tool to provide a clear picture of what is working well and what still needs to be developed and improved. A good management system enables cooperation and the control of interfaces between different professional groups and different management levels. The focus of this example is to show that RAI-benchmarking can improve residents and staff satisfaction, as well as quality management on many levels.

RAI-benchmarking is based on individual RAI (Resident Assessment Instrument) evaluations of residents in older people’s care units in Finland that have been amalgamated to a unit level to enable comparison with units of similar case mix. RAI is a tool for planning  individual care and integrating different services (health, social, rehabilitation) based on residents' needs. It is also a tool for measuring quality and efficiency of care units.

RAI indicates the weaknesses and strengths of a care unit and gives a clear picture of its case mix and staff requirements.  Although RAI is not a genuine management instrument, RAI enables the follow-up of large-scale quality targets and helps to improve management decisions. Therefore RAI is a concrete aid for management and leadership. RAI is a part of Folkhälsan's management system.

In Folhälsan sheltered houses, each resident is assessed using RAI at least twice yearly and when there is significant change is the resident’s status. Furthermore, all staff are involved in using the RAI -system, because the RAI assessment requires multi-professional co-operation. Folkhälsan has put a systematic strategy in place that includes senior management down to each individual employee. 

Description

In 2009 approximately one third of the residential and home care services in Finland were using RAI-systems for quality improvement. Folkhälsan participated in the 'Benchmarking and the Implementation of the RAI system in Older People’s Care' project in 2000 run by Stakes and the Chydenius Institute. The aims of this project were

1. to implement RAI by using software and to train the staff (health, social, rehabilitation) on long-term wards to assess residents in order to make comprehensive individual care and service plans with the RAI,
2. to improve the quality and productivity of care in wards and in institutions by comparing the results to other facilities and
3. to provide the participating units with ward-specific feedback reports and password-protected Internet-based benchmarking databases.

RAI is a tool for both planning of individual care (goal setting), and measuring quality and efficiency of care units. The quality of care is assessed by 27 clinical quality indicators that describe the prevalence and incidence of potential quality problems in care processes and outcomes. The RAI-system establishes a web-based benchmarking database for facilities to compare quality and cost of care (to learn from best practice). The benchmarking databases are updated twice a year.

RAI facilitates the follow-up of large-scale quality targets and therefore is a concrete aid for management and leadership. RAI helps in drawing up training plans, familiarizing new staff, enabling multidisciplinary cooperation, supporting staff development discussions, shaping strategic plans of action, and aiding in continuous follow-up of operations. RAI points at the weaknesses and strengths of a unit and gives a clear picture of its case mix and staff requirements. Benchmarking enables participating organisations and units to compare their own performance, client structure and quality of care at care unit levels, organisational and national levels.

Folkhälsan has used the RAI-system since the year 2000, and in 2006 the RAI long-term care facility assessment form was used in each of its older people’s care units.  RAI is a basic part of the quality assurance system. A named quality manager coordinates the whole RAI-system, in each organisation and ward there is a RAI contact person (a head nurse) and a named RAI person. Twice a year, the feedback of RAI data is discussed at management/organizational level. The RAI contact person at the organisational level cooperates with head nurses on the ward and supports management and leadership. Head nurses support (with RAI contact person at the organisational level) the staff to make RAI assessments, discuss feedback with the staff (monthly) and develop the work on the ward based on feedback.  Each resident is assessed, at least twice yearly and when there is significant change in the status, by a nurse assigned to him/her. The resident and his/her family member are involved in the assessment. The RAI-system, at the organisational level (about 500 residents), costs about €10-15,000 per year including staff training, license and feedback report.

Folkhälsan sends a copy of residents' RAI assessments to the National Institute of Health and Welfare (THL) who administer the RAI database and produce feedback reports and the benchmarking databases. The databases are public only for RAI-benchmarking participants Feedback reports are considered at meetings at different levels: twice a year at unit and management levels. Oy Raisoft Ltd is responsible for the development and maintenance of the software solutions. Nowadays RAI version LTC 3 is used.

What are/were the effects?

RAI is an internationally accepted assessment instrument for LTC and used in many countries. RAI-benchmarking enables participating organisations and care units to reliably compare their own performance, resident structure and quality of care at an organisational and care unit level with national figures. The main impact is not through cost containment, but through improving the quality and productivity of care in institutional care by comparing the results to other facilities that provide care for similar residents. 

In Folkhälsan the main goal of the implementation of the RAI-benchmarking was to improve the quality of care starting at first with four quality elements, namely the use of medication, and the amount and quality of rehabilitative care. Significant improvements were achieved in these areas. Folkhälsan's units have been honoured by THL for excellent results in RAI monitoring (Best care provider, Nutrition, Rehabilitative care, Nutrition, Use of psychiatric medicines). 

Further, Folkhälsan has received international recognition for its operations' development (the Palladium Balanced Scorecard Hall of Fame for Executing Strategy). Folkhälsan's older people’s care has taken a big step forward with a transparent management system which supports its care and encourages staff to work in the clients' best interest. 

What are the strengths and limitations?

Strengths

• The RAI-system supports residents' autonomy  and helps to make an individual care plan for a resident and to integrate different services (health, social and rehabilitation services) together
• The RAI-system indentifies strengths and weaknesses at  the care unit and organisational level
• RAI-benchmarking enables the comparison of interventions and actions between professionals, and it is possible to learn from best practices 

Weaknesses

• Developing services using RAI take up a lot of professional time and resources.
• Major orientation on medical and nursing care, less attention to social demands. Ongoing, questions about social demands are being developed, tested and added to RAI instruments, also questions concerning clients' autonomy.

Opportunities

• The RAI-system could become the shared tool through which various professional groups 'speak the same language'.
• The RAI-system facilitates the choice and follow up many kinds of quality indicators.  

Threats

• Without good training, support and enough resources the RAI system can create an excessive burden on staff. 

Credits

External Links and References

• Niemi M, Emet E-M, Exell-Paakki K. (2010) RAI-benchmarking - verktyg för ledarskap och utveckling, best practice på Folkhälsan. Helsinki: THL Yliopistopaino (Rapport 18/2010) [Swedish, abstract in Finnish].
• Alanen HM, Finne-Soveri H, Noro A, Leinonen E. (2006). 'Use of antipsychotics among nonagenarian residents in long-term institutional care in Finland' in: Age Ageing, Vol. 28.
• Björkgren, MA, Fries, BE, Häkkinen, U & M Brommels (2004). 'Case-mix adjustment and efficiency measurement' in: Scandinavian Journal of Public Health, Vol. 32: 464-471.
• Noro, A (2005) National Institute for Health and Welfare (THL), Helsinki, RAI: quality and productivity in elderly care, on Health Policy Monitor.
• Noro A, Finne-Soveri H, Björgren M & P Vähäkangas (eds.) (2005) ‘Ikääntyneiden laitoshoidon laatu ja tuottavuus -RAI -järjestelmä vertailukehittämisessä’ [Quality and Productivity in Institutional Care for Elderly Residents - Benchmarking with the RAI] in: Stakes, Sosiaali- ja terveysalan tutkimus- ja kehittämiskeskus, Gummerus Kirjapaino Oy, Saarijärvi. [abstract in English]
• http://www.stakes.fi/finrai
• http://www.finrai.org
• http://www.interrai.org