Institutional Life Evaluation Scale (ILES-27)

Description

The Institutional Life Evaluation Scale (ILES-27) is a specialized observational assessment instrument developed to systematically evaluate the quality of institutional living conditions and the therapeutic environment within psychiatric hospitals and long-term mental health care facilities. The scale was originally designed during the evaluation of the Leros Psychiatric Hospital in Greece as part of the psychiatric reform process, providing an objective method for assessing institutional conditions and monitoring improvements in patient care.

Unlike conventional self-report questionnaires, the ILES-27 is completed by a trained external observer during an on-site visit to a psychiatric ward. Assessment is based on direct observation of the physical environment, living conditions, and interactions between healthcare professionals and patients. The instrument evaluates nine core domains that collectively reflect the quality of institutional life:

  • General appearance of the ward and common areas
  • Adequacy and condition of patients’ clothing
  • Quality of sleeping conditions and bedding
  • Quality of food provided
  • Opportunities for occupational and recreational activities
  • Condition of sanitary facilities
  • Quality and accessibility of outdoor areas
  • Quality of staff–patient relationships
  • Cleanliness and hygiene of the facilities

The scale provides a comprehensive overview of the therapeutic environment, enabling objective evaluation of institutional care and the quality of services delivered to individuals with severe mental illness.

The ILES-27 is widely applicable in:

  • Psychiatric Hospitals
  • Mental Health Facilities
  • Psychosocial Rehabilitation Units
  • Long-Term Residential Care Facilities
  • Clinical Psychiatry
  • Mental Health Nursing
  • Public Health
  • Healthcare Quality Assessment
  • Mental Health Services Research

Assessment using the ILES-27 contributes to evidence-based evaluation of institutional environments, supports quality improvement initiatives, and facilitates monitoring of psychiatric reform and service development.

Objective

The primary objective of the Institutional Life Evaluation Scale (ILES-27) is to provide a reliable and systematic assessment of the quality of life experienced by individuals residing in psychiatric institutions through the objective evaluation of key characteristics of the institutional environment.

More specifically, the instrument aims to:

  • Assess patients’ living conditions within psychiatric facilities.
  • Evaluate the quality of the physical and therapeutic environment.
  • Examine the adequacy of essential services and resources.
  • Assess the quality of relationships between staff and patients.
  • Monitor the effectiveness of psychiatric reform initiatives and quality improvement programs.
  • Compare different psychiatric units or residential care facilities.
  • Support quality assurance and continuous service improvement.
  • Facilitate research on institutional care and mental health service delivery.

Although originally developed for the Leros Psychiatric Hospital, the ILES-27 can also be applied to other psychiatric hospitals, residential mental health facilities, and long-term care institutions, providing a standardized framework for evaluating institutional quality.

Scoring

The ILES-27 evaluates nine domains, each scored on a three-point rating scale ranging from 1 to 3.

The total score ranges from 9 to 27, with the following interpretation:

  • 9–18 points: Low quality of institutional life or low level of satisfaction with institutional conditions.
  • 19–27 points: Moderate to high quality of institutional life and more satisfactory living conditions.

Assessment is performed exclusively by a trained observer based on direct observation of the environment and staff–patient interactions at the time of the visit.

The instrument demonstrated excellent inter-rater reliability, with Cohen’s Kappa coefficients ranging from 0.90 to 0.95 in evaluations conducted by two independent observers across 25 wards of the Leros Psychiatric Hospital, indicating outstanding agreement between raters.

Data Analysis and Applications

Statistical analysis of ILES-27 data includes descriptive, psychometric, and comparative statistical procedures that evaluate both institutional quality and changes associated with organizational or therapeutic interventions.

Descriptive Statistics

Initial analyses typically include:

  • Mean
  • Median
  • Standard Deviation
  • Minimum and Maximum values
  • Range
  • Frequencies and Percentages

These statistics provide an overall profile of institutional living conditions across psychiatric facilities.

Reliability Analysis

The reliability of the instrument may be evaluated using:

  • Inter-rater Reliability
  • Cohen’s Kappa
  • Cronbach’s Alpha (where appropriate)
  • McDonald’s Omega
  • Test–Retest Reliability

Because the ILES-27 is based on observer ratings, inter-rater agreement represents one of its most important psychometric properties.

Validity Assessment

Psychometric validity may be examined through:

  • Content Validity
  • Construct Validity
  • Exploratory Factor Analysis (EFA)
  • Confirmatory Factor Analysis (CFA)
  • Convergent Validity
  • Discriminant Validity

These analyses help determine whether the instrument accurately evaluates institutional quality and the therapeutic environment.

Group Comparisons

The ILES-27 may be used to compare:

  • Different psychiatric hospitals
  • Different residential care facilities
  • Different treatment units
  • Pre- and post-intervention assessments
  • Different phases of psychiatric reform

using statistical procedures such as:

  • Independent Samples t-test
  • Paired Samples t-test
  • Analysis of Variance (ANOVA)
  • Mann–Whitney U Test
  • Kruskal–Wallis Test
  • Analysis of Covariance (ANCOVA)

Correlation Analysis

ILES-27 scores may be examined in relation to variables such as:

  • Quality of life
  • Patient functioning
  • Patient satisfaction
  • Treatment adherence
  • Psychosocial rehabilitation outcomes
  • Healthcare quality indicators
  • Staff job satisfaction
  • Organizational climate

Associations are typically evaluated using Pearson or Spearman correlation coefficients, depending on the characteristics of the data.

Predictive Modeling

Advanced statistical procedures commonly include:

  • Simple Linear Regression
  • Multiple Linear Regression
  • Multilevel (Hierarchical) Modeling
  • Structural Equation Modeling (SEM)

These analyses facilitate investigation of factors influencing institutional quality and evaluation of the effectiveness of psychiatric reform initiatives, organizational changes, and quality improvement programs.

References

  • Donabedian, A. (1988). The Quality of Care: How Can It Be Assessed? JAMA, 260(12), 1743–1748.
  • Madianos, M., & Economou, M. (1990). Institutional Care and Rehabilitation in Greece: A General View and the Case of Leros. In C. Stefanis, A. Soldatos, & A. Rabavilas (Eds.), Psychiatry: A World Perspective (Vol. 4, pp. 629–634). Amsterdam: Elsevier.
  • Thornicroft, G., & Tansella, M. (2004). Components of a Modern Mental Health Service: A Pragmatic Balance of Community and Hospital Care. British Journal of Psychiatry, 185, 283–290.
  • World Health Organization. (2021). Guidance on Community Mental Health Services: Promoting Person-Centred and Rights-Based Approaches. World Health Organization.