Approximately 1.2 million people resided in over 15,000 nursing homes in the U.S., where nearly 30% of older adults spend their final days. The high volume of deaths has made improving end-of-life care in nursing homes a national priority. However, the lack of a universally recognized standard for advance care planning implementation contributed to inconsistent practices and suboptimal outcomes. This study aimed to develop and evaluate an ACP implementation quality assessment tool (ACP-QAT) in nursing homes.

Paper 1 conducted a systematic review of influential factors of ACP implementation in nursing homes and identified 19 studies. A thematic analysis of the selected studies following Donabedian’s model of quality of care was conducted and 11 subthemes under two major themes emerged: (1) nursing home structural support in ACP, including regulations incorporating ACP into admission, role clarity, and resource availability, and (2) standardized implementation processes. As a result, a drafted ACP-QAT, consisting of 13 binary items, was created.

Paper 2 revised the drafted ACP-QAT using a Delphi consensus approach. Eighteen clinical experts from different professional backgrounds participated in the study. The first round involved 5 focus groups on the Delphi panelists’ opinions, then the tool was iteratively revised and presented back to panelists in surveys with response options (1=endorse, 2=would endorse with modification, and 3=not endorse). The revised tool reached the consensus after two rounds of rating (interquartile range=0, median =1). The final ACP-QAT included 19 binary items under the Structural Support Subscale (8 items) and the Implementation Procedures Subscale (11 items).

Paper 3 examined psychometric properties of the ACP-QAT. It demonstrated excellent internal consistency reliability with Kuder-Richardson Formula 20 coefficients for both subscales and full scale (Structural Support Subscale: 0.92, Implementation Procedures Subscale: 0.96, Full Scale: 0.91). Inter-rater reliability at the total score level was almost perfect (ICC=.80). The tool also demonstrated acceptable convergent validity (r=0.81, p<.001), and known-group validity, χ2(2)=62.7, p<.001. This tool is among the first rigorously developed measures designed to evaluate the quality of ACP implementation in nursing homes. By offering a structured framework, it has strong potential to advance both research and practice in ACP and end-of-life care.