Co-Design for Improvement in Long-Term Care

Background: Existing challenges in providing high quality care within Long-Term Care (LTC) are often compounded by mistrust and poor relationships. Ameliorating this through intentionally building trust and relationships requires focused effort and necessitates the inclusion of staff, residents, and families as valued partners who effectively contribute to improved quality of care. Approach: The People-Centred Care Strategy (PCS) Team in the Saskatchewan Health Authority (SHA) co-created and facilitated an 8-month co-designed quality improvement (QI) pilot project in a rural LTC Home in southern Saskatchewan. The primary aim was to strengthen trust and relationships between residents, families, staff, and managers through working together on a specific improvement project.The PCS team introduced the co-design concept to the Managers and broadly within the Home and asked for volunteers for a Working Group (WG) made up of residents, families, staff, and Managers. The team became external facilitators of the WG and helped the group work through initial formation issues and to build relationships through getting to know each other and learning to work together. However, all improvement decisions and actions were driven by the WG. The WG decided on two areas for improvement and split into two sub-groups that created and implemented tools to improve quality of life for residents. Although Managers were members of the WG, other staff members took the lead role within the group. Additionally, the Managers and Director of the Home received tailored leadership coaching, particularly around teamwork and communication. A pre- and post-intervention evaluation and a Realist Evaluation was conducted to develop and refine a program theory (PT) identifying key mechanisms of building trust. Results: The WG got off to a slow start and was slow to develop cohesion. Members were dissatisfied with the early pace as the PCS team intentionally spent time on building relationships and ensuring co-identification of the project. The WG wanted less talk and more action. However, the PCS team repeatedly emphasized that building trust and relationships was the focus of this project rather than simply QI. In addition, the time spent getting to know each other would speed up the later stages of project implementation. This prediction was fulfilled as differences in group dynamics became evident in later stages. The WG not only achieved results through pilot testing the improvement tools, but had fun along the way.All participants gained new insights about the work and experiences of the others. Although psychological safety is often a concern within the hierarchy of health care, we saw staff increasingly willing to push back against the opinions of others and to speak out as the central point-of-care providers. We saw a shared leadership model emerge as group members shared their ideas and questioned Managers about decisions and next steps.Preliminary data analyses confirm that top-down hierarchical approaches contribute to mistrust and frustration with staff, residents, and families and reducing this approach through co-design has a positive effect on relationships. Eight mechanisms that contribute to trust have been identified: autonomy/sense of control, transparency, shared goals/values, an expressed commitment to building relationships, optimism for change, and feeling acknowledged, valued, and respected. Implications: The practical learnings will be synthesized and used together with the PT to help other SHA LTC Homes work on building trust and relationships as the foundation for improved quality of care and quality of life for residents. Future co-design efforts will include prioritizing relationship building over initial quick actions, sharing power with key partners, ensuring shared values and goals, ensuring the organizational culture is supportive of co-design and sufficient time and resources are allocated, and having clear communication within and beyond the co-design team.

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