International Journal of Health Care Quality Assurance

Emerald Article: Developing criteria for elderly nursing homes: the case
of Lebanon
Ramzi Nasser, Jacqueline Doumit

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To cite this document: Ramzi Nasser, Jacqueline Doumit, (2011),"Developing criteria for elderly nursing homes: the case of
Lebanon", International Journal of Health Care Quality Assurance, Vol. 24 Iss: 3 pp. 211 - 222
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Developing criteria for elderly

nursing homes: the case of
Lebanon
Ramzi Nasser
Qatar University, Doha, Qatar, and

Jacqueline Doumit
Notre Dame University, Zouk Mikael, Lebanon

Elderly nursing
homes

211
Received 13 February 2009
Revised 17 August 2009
3 November 2009
Accepted 11 November 2009

Abstract
Purpose The purpose of this study is to establish a set of measurable criteria for elderly nursing
homes (ENHs) in Lebanon. Donabedians model known by structure/process/outcome was used as the
driving conceptual framework for the study.
Design/methodology/approach The study reports on a panel discussion where
administrators, caregivers and specialists, separately established and exchanged key information
on best practice approach. The work was carried out in the summer of 2008, using the consensus
panel method. A group of expert opinions (Dalkey) made up of elderly home administrators and
caregivers, policy makers, and academics discussed specific key issues related to elderly health and
quality of life.
Findings A total of 40 criteria were retained along seven main dimensions: types of elderly homes;
funding; health services; boarding services; activities; structures; and elderly rights.
Research limitations/implications A major limitation in this study is that elderly were not part
of the consensus making process. Thus, including elderly in the process would have substantiated and
added validity to the established criteria.
Practical implications The criteria developed in this study can be turned into key performance
standards for elderly homes in Lebanon, other Mediterranean and Arab countries. These criteria
would greatly benefit elderly homes if validated and used as guidelines for quality care.
Originality/value The study is original in the sense that it seeks to establish measures for criteria,
a blueprint, and benchmarks for ENH standards.
Keywords Performance levels, Quality awareness, Nursing homes, Elderly people, Elder care, Lebanon
Paper type Research paper

Introduction
In Lebanon, elderly reliance on private care has largely increased over the decade. The
expansion of health related services, management and oversee of Elderly Nursing
Homes (ENHs) has demanded greater accountable measures by these institutions.
Elderly persons and their guardians stipulate a greater quality service, transparency,
suitable structures, and a functional health care system. Hence, ENHs in Lebanon face
the challenges of providing quality care in a new era of administrative accountability
and accreditation systems.
The study was funded by the World Health Organization (Grant No. EM08058111).

International Journal of Health Care

Quality Assurance
Vol. 24 No. 3, 2011
pp. 211-222
q Emerald Group Publishing Limited
0952-6862
DOI 10.1108/09526861111116651

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Representatives from the World Health Organization (WHO); Lebanon office, the
Ministry of Public Health (MoPH), and the Ministry of Social Affairs (MoSA) have
suggested that ENH quality assurance and standards are much-called measures for
health services. The work of the MoPH with the Australian consultants on the
Overseas Project Cooperation of Victoria resulted in the development and
implementation of a national accreditation program for hospitals (El-Jardali, 2007).
This impetus, supported by WHO, the MoPH, and the MoSA brought interest to the
development of procedures and key performance standards to upraise quality for
ENHs. Despite the call for surveillance of ENHs, the development of standards and
guidelines has not materialized within Lebanon in a foreseen national strategy. If
translated into policy, it would envision a plan to develop standards as guidelines to
upraise ENHs in promoting elderly wellbeing. Thus, the establishment of criteria is a
first step in the development of quality assurance measures across ENHs (Cesarotti
and Di Silvio, 2006).
Elderly health systems in the US (Joint Commission for the Accreditation of
Healthcare Organizations (JCAHO), 2007), England (Department of Health, 2003),
Australia (Braithwaite et al., 1993), and other Western countries follow strict
administrative practice, and high standards (Sewell, 1997). The recognition of
performance measures as indicators to evaluate and assess institutional performance
within ENHs (Joint Commission for the Accreditation of Healthcare Organizations
( JCAHO), 1989, cited in Idvall et al., 1997; Proctor and Campbell, 1999), they underline
the outcome-based approach to quality service.
In Lebanon, survey studies by the National Commission of Elderly Affairs,
sponsored by both MoSA and United Nations Population Fund (UNFPA), and Doumit
and Nasser (n.d.) study; identified a number of measures used as indicators for the
betterment of elderly life in ENHs but made little pathway among policy makers to
develop a national elderly health strategy. The current synergy among the different
Ministries and WHO underlines the awareness and need of elderly homes base-line
information to better the structures, outcomes and processes of elderly lives.
According to Waltz and Sylvia (1991), previous literature has been criticized by a
lack of conceptual framework guiding the selection of outcome indicators. Hence, the
approach used in this work is to build on available evidence in the field and literature,
along a theoretical framework expressed in Donabedians (2005) model known by
structure/process/outcome for quality assessment. Donabedians dimensions
characterize a system in terms of resources, organization, and operational aspects of
the healthcare delivery system. Process measures referred care, including elderly
health assessment procedures, feeding, and daily care outcomes related to elderly
quality of life and wellbeing (Mularski, 2006). Unique to Donabedians model is that it
provides a framework to evaluate structure, skills, and activities within ENHs and
subsequently the establishment of criteria that result in objective measures and key
performance indicators (Fahey et al., 2003).
The importance of the structure, processes, and outcome framework for service
users in ENHs cannot be overly stressed. Evidence of facilities, resources, policies,
activities, are outcome measures used as indicators for performance. The authors
sought out criteria drawing from recent literature and existing consensus documents of
the University of Wisconsin-Madison Center for Health Service Research and Analysis

(Zimmerman et al., 1995), the Minimum Data Set in all US Medicare/Medicaid certified
nursing homes, and the standard handbooks that assess ENHs in England
(Department of Health, 2003). The criteria were selected and organized nominally to
include:
.
types of ENHs;
.
funding;
.
health services;
.
boarding services;
.
activities;
.
structures; and
.
elderly rights.
The seven issues that were conceptualized in this study were grounded from the field
and used to carry out the panel discussion and fit within Donebedians framework of
structures, processes, and outcomes.
The study surveyed a representative sample of administrators and practitioners of
ENHs (known as the panel). All administrators of the 46 registered ENHs in Lebanon
were invited to a one-day panel discussion. A second panel discussion invited the
caregivers and support team in ENHs.
The objectives of the study were to:
.
establish indicator measures for elderly living in ENHs;
.
provide face validity for the criteria measures judged by elderly home
administrators and caregivers; and
.
provide recommendations and future direction in the development of criteria for
ENHs.
Method
The method used in this study combined evidence from elderly wellbeing literature
and expert perspectives. A panel of experts was invited to attend a roundtable
discussion made up of elderly home administrators, caregivers, specialists, public
health practitioners, association members, researchers, and academics. They were
asked to provide a perspective on a set of criteria for ENHs and explore aspects related
to ENH structures, skills, activities, and knowledge. Specifically, the expert panel
provided face validity for each of the seven aspects mentioned earlier. The method in
this study follows the consensus panel method (Campbell and Cantrill, 2001) were
issues are quantified having limited evidence. This method is used to develop
appropriate criteria (Ashton et al., 1994) and quality indicators (Campbell et al., 1998). It
has experts or practitioners establish consensus on issues in a one-shot approach. The
authors (group facilitators) with participants debate a topic, advance a view, discuss
and share information. The debate is considered nominal to the extent that not one idea
or discourse emerges. The panel members review, suggest, and generate quality
improvement criteria for ENHs.
The study employed two panel discussions. The first panel had administrators, the
second panel had caregivers and support team of ENHs. A set of themes were

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214

presented separately to both panels. This approach prompted professional views,

perspectives, and discussions that were carried out in an academic setting. A closed
roundtable with administrators and specialists was held in one session while another
was held with caregivers. The panel was given nominal questions or propositions
about the seven main issues dealing with structure, skills, activities, and knowledge. In
the discussion each idea was mulled over to generate a wider perspective and
consensus over an issue.
The panel was presented with questions and suggestions substantiated by the
research literature, and Doumit and Nassers (2008) field results. Investigators
provided the panel with detailed background information and field data. One
investigator introduced the panel to the conceptual framework and objectives followed
with a set of factual information like the number of ENHs in Lebanon and the type of
available services. Seven dimensions were posted on the wall for all participants to see.
The panel was asked to brainstorm, develop recommendations, discuss, provide
relevancy, consider alternatives, and provide rationale for each of the criteria as a
consensus building activity. Each of these aspects and issues were discussed again
with the elderly caregivers.
The expert panel responses was used to collate opinions (Dalkey, 1969). Several
perspectives and views presented a variety of perspectives that were nominally
organized (Robert-Davis and Read, 2001).
Sample
Present in the first panel discussion were one representative from the MoPH, one
representative from the MoSA, one representative from the National Commission of
Elderly Affairs, one representative from the National Service Center, and 15
administrators including geriatricians: two physicians and one nurse. The second
panel discussion included the Syndicate of Hospitals president, one representative
from the MoSA, one representative from the UNFPA, one representative from the
National Commission of Elderly Affairs, six registered nurses, three practical nurses,
two physiotherapists and one social worker.
Data collection
The data collection method was performed through simultaneous field observation and
video recording. The content was obtained from the working sessions and reflections
made by the panel that focus on the quality of life criteria. The main instruments in this
study were the researchers. They questioned, probed, suggested, and recorded field
information. Investigators presented information regarding criteria and asked
administrators, caregivers, and policy makers to list which criteria exist, suggest
new ones, and provide measures as guidelines for ENHs.
Results
The results of the study were organized around seven main issues:
(1) types of ENHs;
(2) funding;
(3) health services;

(4)
(5)
(6)
(7)

boarding services;
activities (social, spiritual, physical and mental);
structures; and
elderly rights.

The comments on the seven main issues during the panel discussion made by
administrators, caregivers, and specialists, gave perceptible criteria and measures for
ENH. The seven sections below present the content analysis field notes and video
recordings of the two sessions.
Types and classification of ENHs
Many administrators considered classifying ENHs into three types:
(1) those ENHs that receive independent elderly (middle old elderly);
(2) those who received dependent or sick elderly (older old); and
(3) those who received all types of elderly (middle old and older old).
One administrator and physiotherapist suggested one type of ENH with different units
as Dementia Special Care or Terminal Care Unit. Each unit may have its own
standards and criteria. Administrators agreed that nursing homes generally should not
provide services for hospitals in terms of medical treatment and intensive care
procedures.
Financial aspects/funding
Elderly home administrators suggested the need to have subsidized financial support
from both ministries MoSA and MoPH. The current cost rate per elderly was between
600,000 and 900,000 Lebanese Liras equivalent to US$400 to $600 per month in todays
currency exchange prices. The National Health Insurance sponsored by MoPH covers
each elderly with $300 a month. MoSA welfare system reimburses a lower rate of $80
per month. Both MoSA and MoPH do not cover costs for medical care and treatment.
The cost for each elderly home is established as a criterion to assess whether ENHs
have the budget to cover those elderly unable to fund their stay. Furthermore, ENH
administrators suggested that financial statements, elderly home budgets, and elderly
financial files are administrative elements that ENH maintain for each elderly as
necessary documents for the assessment of administrative service costs.
Caregivers and administrators suggested equal treatment across conditions. Two of
the administrators informed the panel that fee paying elderly are provided with better
services, and single rooms it was evident among discussants that differences in
services are dependent whether elderly pay or not.
Health services
Administrators as well as caregivers suggested that specialists from the relevant
professions like social workers, physiotherapists, psychologists, dieticians, and others
as vital human resources for ENHs. Many administrators complained about the lack of
specialized nursing staff needed to support the elderly, and underlined the importance
of in-house professional development. In line with Bolton et al. (2001) findings,

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administrators underlined the development of a sound administrative public policy

related to nurse staffing grounded on empirical evidence. They also recommended
pre-measures such as ratios of specialized nurses and helpers to elderly residents
(Buerhaus and Needleman, 2000). They pointed to the high ratio of elderly caregivers to
residents in their institutions. Administrators added that a needs assessment tool to
measure cognitive impairment, nutritional status, physical functioning, and elderly
wellbeing. As suggested by Caramanica et al. (2003) elderly quality care management
has largely depended on actions of health care providers associated with safety and
structure of ENHs.
Boarding services
Administrators suggested that elderly in long-term stay are provided regular meals
and continuous feeding assistance with timely snacks and drinks combined with
specialized diets. They stressed on several important components of a well kept ENH,
these include:
.
accessible facilities, accessible grounds, accessible activity areas, rooms, and
toilets,
.
safety, tidiness, and hygiene;
.
maintain a home-like environment for elderly residents that engages them in
daily living activities;
.
provision of proper environmental conditions as in lighting, noise-free settings,
designated sleeping hours, acclimatized environment (heating-cooling/
winter-summer), grab rails, and space for movement;
.
availability/provision of proper equipment such as wheel chairs, walkers,
adjustable beds, and medical measurement tools; and
.
a maintained elderly resident files, an up to date record, diagnostics and health
screening results.
Records kept within a centrally located administrative unit, regularly updated by a
geriatric physician or registered nurse.
Activities
Administrators and caregivers complained about the lack of family involvement in
elderly activities and care. Both underlined the importance of family and friendship
visits. Elderly care administrators said that visits are restricted to the time frame
established by the ENH, and that certain responsibilities including frequency of
visitations should be attached to the contract between the guardians and ENHs. Many
guardians (families) rarely provide the necessary emotional support.
Both caregivers and administrators considered that homes should provide activities
rendering the elderly completely independent. They believed that elderly lives would
be greatly enhanced if the elderly were drawn to activities that stimulated their
interests. They also considered the importance of voluntary help in elderly activities
including the type of activities in and outside the ENH such as cooking, gardening and
other functions that take into consideration the physical and the mental state of the
elderly. Hence, all types of activities whether social, physical, mental, and spiritual are

conditions that improve the quality of life among elderly living in ENHs. WHOs study
on patient-family centered care recommended the need for social workers to offer
assistance and guidance for elderly residents and their guardians. WHOs study had
concluded that elderly interact the most with nurses, physicians, therapists, chaplains,
pharmacists, volunteers, and others (WHO, 2005). The interaction should reflect
quality time for elderly and such discussions and interaction should be encouraged.
Administrators suggested that elderly bring certain possessions with them in order to
feel at home and cope better with their new living conditions.
Structures and facilities
Distribution of elderly according to choice, gender, socioeconomic strata, mental status,
or those undergoing treatment are key issues that administrators have paid little
attention to in Lebanese ENHs.
Functional facilities as handrails, telephones, medical supplies, wheelchairs,
accessible toilets, walkers are criteria measured per resident are criteria that could be
used to provide some indication of quality service. Both administrators and caregivers
considered safety as a vital component for the ENH structure as suggested by Mueller
and Karon (2004) that safety issues are important quality indicators for ENHs. Many
administrators showed concern for cramming of elderly in single rooms, mixing of
sick, demented, or suffering from terminal diseases; they suggested that criteria should
indicate the standards and specifications of passage for movement, the number of
elderly per room, safety in mobility, and movement within the confined spaces.
Elderly rights
Administrators and caregivers were asked by one of the investigators whether elderly
wishes and views were respected. One administrator explained that although decisions
or attitudes are judgmental, they could not be easily turned into simple and measurable
criteria. However, administrators were concerned that elderly personalized services
were generally not available in a number of ENHs as in personal clothing, private room
phones or free movement in or outside the ENHs. One caregiver inquired whether
elderly should set their own criteria for free movement, when to eat, what to wear, who
to choose as roommates, and how to engage in activities. Administrators felt that little
has been done in ways to deal with death. It was suggested that elderly homes
maintain the spiritual and personal space for each elderly. A key aspect outlined by
caregivers was the lack of written policies that honor the rights of elderly, specifically
those bed-ridden or dying.
Discussion
This study sought to identify concerns and issues dealing with structures, processes,
and activities in ENHs. As a result 40 criteria were retained; many of those are now in
use by various health care organizations around the world as competency measures for
accreditation. Perspectives and ideas reported by health care administrators and
caregivers in the study can be transformed into criteria that produce quality services.
The study used a group consensus approach to generate ideas about measures to
improve the quality of life. There were seven main issues that identify the criteria

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required by administrative and nursing staff to meet the needs of elderly people being
cared for in ENHs.
It is evident that the criteria established were not exhaustive. Further involvement
of the ministries can be crucial in the development of a national policy on elderly public
health and enforce regulatory guidelines. Although, the attempt was to develop
measurable indicators, we were faced by a number of needs called for by both
administrators and caregivers. For example, administrators were complaining about
insufficient financial subsidies, but, as we learned later from MoPH, a large number of
ENHs were not willing to provide government financial documents even to receive
more assistance. These and other needs often drove the discussion away from the
intended scope but refocused through moderator interventions.
A number of criteria were identified by the panel but were difficult to include in the
list, such as the physicians assessments, patients perspectives, and attitudes.
Zingmond et al. (2007) explained that these measures are not easily observable and
generalized within ENHs. A number of indicators were not evident and did not
generate consensus, or missed altogether by administrators and caregivers. In one case
the panel members diverged somewhat to lay concerns specific to their institutions, as
to engage MoPH and MoSA; however, the moderators were cautious to set the
discussion back to the intended course. In summary, the key criteria and indicators
raised by the panel are summarized in Table I.
Building measures and criteria is not new to public health in Lebanon. More recent
attempt by the MoSA in partnership with the Population Development Strategic
Program of the United Nations and the National Committee of Elderly Affairs for the
collection of data through year 2005-2006 has not led to a published report. A pressing
need calls for a national and integrative data base on a set of validated criteria for
ENHs. These criteria if turned into competencies and standards can contribute to
quality improvement for ENHs. There is a need for a well informed team with a
multi-disciplinary strategy involving health professionals, decision-makers (within the
Ministries of Public Health and Social Affairs), academicians, specialists, social
workers, clinicians, ENH leaders, public and private sectors, not only to review, rate,
validate, and prioritize the quality and importance of criteria, in terms of their
applicability, appropriateness, and adequacy (Johnson et al., 2006) but also to provide
elderly with the quality service they expect and to translate these expectations into
performance standards with the appropriate level of practice for each criterion (Clare,
1996). Anecdotal evidence suggests that policy makers need elderly home standards in
order to increase government accountability. Thus, an inter-judge agreement measure
as to whether the criteria were applicable, appropriate, or adaptable would provide
further evidence to the construct validity of the criteria. In future studies, elderly
opinion is a vital component to the effectiveness and quality of care (Langemo et al.,
2002). Once indicators or criteria are conceptualized as we have done in this study,
operationally defining these criteria will help us measure, them in real life conditions
(Quality Indicator Study Group, Society for Health Care Epidemiology of America,
1995) as to establish a standard for ENH quality.
Hence, this project has several key operational outcomes that could help in the
implementation of a mechanism for establishing quality indicators. Future work would
suggest:

Themes

Consensualized aspects

Classification of ENHs

For independent elderly

For dependent elderly
One type of ENH which accommodate to all types of
elderly with specialized units within each home
Subsidized by Ministry of Social Affairs and
Ministry of Public Health
Elderly as a fee paying
Annual budget
Costs per elderly
Income from other sources
Availability of specialists
Geriatricians
Physiotherapists
Social Workers
Psychologists
Specialized training
Specialized/qualified nurses
Dietitian
On-going training for caregivers
Ratio of geriatricians to elderly
Ratio of caregivers to elderly
Ratio of specialized/qualified nurses to elderly
Availability of assessment tools for elderly
Availability of a varied diet
Availability of recreation/activity areas
Number of elderly per room
Number of rooms
Appropriate lighting
Appropriate/types of heating and cooling
Accessibility of all utilities
Elderly panel records
Number of visits by family members and friends
Number of social activities at the ENH
Outside/inside voluntary involvement in services
Availability of physical activities
Availability of mental activities
Availability of spiritual activities
Telephone
Bell
Accessibility
Wheelchairs
Walkers
Adjustable beds
Water beds
Availability of medical measurement tools as
sphygmomanometer, height scale, weight scale
Specialized units for different elderly conditions
Observable treatment of elderly
Ability of elderly to move from one place to another
Policies written to the rights

Financial aspects/funding

Health services

Boarding services

Activities

Structures and facilities

Elderly rights

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Table I.
Consensualized criteria
classified within each
elderly home aspects

IJHCQA
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.
.
.

220

normative standards, those defined by administrators and caregivers;

elderly assessment of quality indicators in ENHs; and
involvement of both ministries, MoSA and MoPH in the process of implementing
standards, surveillance and programmatic system appraisals.

Thus, in reporting outcomes and established a set of criteria as essential aspects for the
functioning of ENHs. The criteria (measures) proposed by this consensus process are
viewed as an early step to establish standards offer their services to dependent,
semi-independent, and independent elderly to improve their care by stimulating
further discussion, innovation, testing, and refinement. Additional works suggest
underwriting procedures and key performance standards that involve experts,
practitioners, and academics to integrate elderly heath care information across the
different health services as in hospitals, clinics and elderly homes. This work is
preliminary in the establishment of criteria as measures of ENH quality. Enforcing
these measures suggests a set of policies, laws, and regulations to ensure consistency
across health services (Fleishman et al., 1996). The results of this study are preliminary
and future work should promote resident elderly voices that engage family members in
the process of quality care through participation and development of the ENH criteria.
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Further reading
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indicators for the primary care management of pediatric epilepsy: expert consensus
recommendations based on the available evidence, Epilepsia, Vol. 47 No. 12, pp. 2011-9.
Corresponding author
Ramzi Nasser can be contacted at: ramzin@qu.edu.qa

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