**Improving the Quality of Care in Care Homes Using the Quality Improvement Collaborative Approach: Lessons Learnt from Six Projects Conducted in the UK and The Netherlands**

**Reena Devi 1,\*, Graham Martin <sup>2</sup> , Jay Banerjee 3,4, Louise Butler <sup>5</sup> , Tim Pattison <sup>5</sup> , Lesley Cruickshank <sup>6</sup> , Caroline Maries-Tillott <sup>7</sup> , Tracie Wilson <sup>8</sup> , Sarah Damery <sup>9</sup> , Julienne Meyer <sup>10</sup>, Antonius Poot <sup>11</sup>, Peter Chamberlain <sup>12</sup>, Debbie Harvey <sup>12</sup> , Clarissa Giebel 13,14, Kathryn Hinsli**ff**-Smith <sup>15</sup>, Neil Chadborn 16,17 and Adam Lee Gordon 16,17**


Received: 11 September 2020; Accepted: 13 October 2020; Published: 19 October 2020

**Abstract:** The Breakthrough Series Quality Improvement Collaborative (QIC) initiative is a welldeveloped and widely used approach, but most of what we know about it has come from healthcare settings. In this article, those leading QICs to improve care in care homes provide detailed accounts of six QICs and share their learning of applying the QIC approach in the care home sector. Overall, five care home-specific lessons were learnt: (i) plan for the resources needed to support collaborative teams with collecting, processing, and interpreting data; (ii) create encouraging and safe working environments to help collaborative team members feel valued; (iii) recruit collaborative teams, QIC leads, and facilitators who have established relationships with care homes; (iv) regularly check project ideas are aligned with team members' job roles, responsibilities, and priorities; and (v) work

flexibly and accept that planned activities may need adapting as the project progresses. These insights are targeted at teams delivering QICs in care homes. These insights demonstrate the need to consider the care home context when applying improvement tools and techniques in this setting.

**Keywords:** Quality Improvement Collaborative; Quality Improvement; Implementation Science; residential facilities; older people

#### **1. Introduction**

The rising number of older people is a global phenomenon [1]. One option for older people who are not able to live independently is to live in a long-term care facility, such as a nursing home. An internationally agreed definition of nursing homes is provided by Sanford et al., defining these as facilities that "(i) provide 24-h functional support for people who require assistance with activities of daily living and have identified health needs, (ii) may or may not be staffed with health care professionals, (iii) provide long-term care and/or rehabilitation as part of hospital avoidance or to facilitate early hospital discharges (iv) do not function as a hospital ward and are not hospital based, and (v) may play a role in providing palliative and/or hospice care at end of life" [2]. There are differences between countries in the way that facilities operate, the way that care is financed, how quality of care is regulated, and in the mix and type of professionals employed [3]. For instance, nursing homes in the Netherlands employ a mix of health care professionals and care workers, and in the UK, nursing homes employ Registered Nurses and care workers (with wider healthcare input received from community services). On the other hand, residential homes (referred to as care homes in the Netherlands) in both the UK and the Netherlands employ care workers to provide direct care and healthcare professional input is received from community services. The general characteristics of residents living in nursing and residential homes, however, are similar [4]. In this article, we use the general term "care homes" to refer to both nursing and residential homes.

In the UK, the quality of care across the sector varies [5] and several initiatives dedicated to improving the quality and safety of care have been introduced in recent years. Since 2013, 15 regional Academic Health Science Networks (AHSN) across England have supported projects focused on improving quality and safety in care homes [6]. In 2016, National Health Service (NHS) England commissioned the Enhanced Health in Care Home Vanguards, an initiative to implement a suite of evidence-based interventions in care homes located in six areas of England [7]. In the Netherlands, national initiatives focused on improving quality of care in care homes were supported by the Dutch National Care for Frail Elderly Persons Programme, which took place from 2007 to 2016, and comprised a series of Quality Improvement (QI) initiatives and studies clustered around eight academic medical centres [8].

An approach used in several of these initiatives is the Quality Improvement Collaborative (QIC) intervention [9]. Various versions of the QIC intervention exist. One of the most prominent is the Breakthrough Series Collaborative, as developed by the Institute for Healthcare Improvement (IHI) [10,11]. A QIC based on the Breakthrough Series model is a multifaceted intervention that typically lasts 6–15 months [12] and generally includes five essential features: (1) a team of clinical and QI experts bring clinical and QI knowledge and lead the QIC; (2) local multi-professional teams take part and form the collaborative; (3) the collaborative focuses on a specific topic; (4) participants engage in structured activities; and (5) they use the IHI's Model for Improvement to guide change [13]. The Model for Improvement is a framework used to guide improvement projects where goals are set and a process called the Plan–Do–Study–Act (PDSA) cycle is used to test the impact of changes [14]. A PDSA cycle is a cyclical process of planning change (plan), actioning plans (do), observing and reflecting on the result (study), and modifying plans to address what has been learnt (act) [14]. Previously, collaboratives have been studied mainly in hospital settings [9]. The recent use of QICs with care homes in the UK and the Netherlands provides an opportunity to examine and learn whether and how this approach works in this setting.

A recent scoping review conducted by Chadborn et al. highlighted that while there is a body of evidence around QI strategies used in the care home setting, without detailed descriptions of how strategies are applied, the extent to which others can replicate and learn from them is limited [15]. The aims of this paper are firstly to provide detailed descriptions of six QIC projects carried out in care home settings in two countries, and secondly, to share insights and learning from these projects.

#### **2. Method**

Representatives of teams delivering QIC interventions were identified through our networks and UK national organisations including the British Geriatrics Society, AHSNs, the Health Foundation Q Network, and Health Services Research UK. Representatives attended an initial face-to-face meeting where detailed descriptions of each QIC intervention were presented and structured using the Template for Intervention Description and Replication (TIDieR) standardised reporting template [16]. This was followed by a series of face-to-face, electronic, and telephone meetings where the TIDieR framework descriptions were used to elicit discussion about lessons learned during conduct of the QICs. The focus was to find lessons that applied across more than one QIC initiative and those specific to the care home setting, as opposed to generic lessons that might apply to QICs conducted in other contexts. A list of lessons learnt is provided and each is summarised, outlining the challenges faced and the ways that these were addressed. The learning is targeted at teams leading and facilitating QICs in care homes.

#### **3. Results**

#### *3.1. QICs in the Care Home Setting*

The insights in this article are based on six QIC projects. Five were conducted in the UK and one in the Netherlands:


Projects took place in five areas of England (Nottinghamshire, Salford, Essex, Walsall and Wolverhampton, and Bootle) and one area in the Netherlands (Leiden). The earliest project started in 2009 (MOVIT), the most recent started in 2017 (Safer Care Homes), and the length of completed programmes ranged from 13 months (Safer Care Homes) to 42 months (MOVIT), with one project still ongoing since 2014 (PROSPER). Projects' specific aims varied. The PROSPER, Safer Care Homes, and SPACE QICs focused on improving safety and reducing avoidable harms. The PEACH QIC aimed to improve healthcare and used Comprehensive Geriatric Assessment (CGA) as a template to guide discussions. The MOVIT project aimed to improve fragmentation of medical care and the CHIP QIC focused on reducing ambulance conveyances.

#### *3.2. Descriptions of the Quality Improvement Collaborative Initiatives*

Detailed descriptions of each QIC are provided in Tables 1–6, broadly following the TIDieR template, with the addition of information on evaluation activities undertaken for each project.






#### *Int. J. Environ. Res. Public Health* **2020**, *17*, 7601



Essex (Tendring,

 Colchester,

Chelmsford,

 Basildon,

 and Harlow).

 Care home support

 visits were held at care home locations.







Recognition/sharing of best practice:

• • • - Bi-monthly newsletters to highlight achievements, share learning, notify about forthcoming training events, and signpost to useful resources. Care home managers and sta ff also provided content (e.g., photos and articles describing events held at their home). Annual awards ceremony and "celebrating success" forum as part of the shared learning events, to recognise and reward

Programme sustainability: resource toolkit and best practice guidelines developed. Facilitator role in Wolverhampton integrated into the CCQ Quality Nurse Advisor (QNA) role, and quality assurance o fficers trained in QI. In Walsall, QI nurses undertake joint quality visits with the localauthority.








#### *3.3. Delivering a QIC in the Care Home Sector: Lessons Learnt*

Five "lessons learnt", specific to the care home sector and observed across more than one QIC initiative, were identified. These are listed in Box 1 and summarised below.

**Box 1.** Applying the QIC approach in the care home sector: what have we learnt?

	- a. Collecting the data needed to test the impact of change. Data collection burden could be reduced by identifying ways that data collection might be incorporated into care home routine practice in an intuitive way (e.g., the Falls Safety Cross approach).
	- b. Processing and interpreting data. Ensure data are presented in an accessible way, particularly for those who have not previously used data to evaluate change.

#### *3.4. Plan for the Resource Needed to Support Collaborative Teams with Collecting, Processing, and Interpreting Data*

Collaborative teams taking part in a QIC carry out projects where changes are made that aim to improve the quality of care, and PDSA cycles are used to test the impact of those changes. Data are an essential ingredient in assessing whether or not changes result in improvement. However, the data to inform PDSA cycles are not readily available in care homes in the same way as they are in health sector settings (Box 1, point 1a). Or, if data are available, the specific nature of the data might not match the specific aims of the QI projects. For example, collaborative teams in the Safer Care Homes collaborative faced challenges with establishing a baseline number of falls with harm and medication errors in care homes, and for this reason, the QIC facilitators worked closely with care homes to support data collection. Indeed, QIC facilitators were needed to provide support in all projects assessed in this paper. Collaborative team members provided data and the QIC facilitators then processed the data, constructing data dashboards and runtime charts. In some cases, QIC facilitators also helped with collecting data. In addition to this, the frontline staff taking part in the collaboratives may not have worked in this way before, where changes to care are made and data are used to evaluate the impact, and for this reason, QIC facilitators helped with interpreting data and reviewing PDSA cycles, arranging meetings where the data were interpreted and discussed.

A shared observation across projects was the importance of presenting data in an easy-to-digest way that enabled collaborative teams to review the impact of their changes (Box 1, point 1b). The level of support with data collection, processing, and interpretation required substantial resources from the QIC facilitators, which was not always anticipated during the planning phases of projects. To reduce data collection burden, the SPACE and PROSPER projects looked for ways that data could be collected within care home routine practice in an intuitive way. Both the SPACE and PROSPER projects used the Falls Safety Cross (for example, see https://www.livingwellessex.org/media/571058/falls-safety-cross.pdf), a data collection tool where care workers indicated the number of falls per resident on a prominent visual aide memoire display. This allowed falls-related data to be collated over time and allowed the data to be used to link to the improvement aim. Over time, care homes modified the Falls Safety Cross to also capture additional aspects of care quality such as incidents of challenging behaviour or resident hydration. An additional benefit for the care home was that the collection of data provided evidence of their safety culture, which was noted positively during inspections by the English regulator, the CQC.

#### *3.5. Create Encouraging and Safe Working Environments*

Care homes are heavily regulated, face negative public perceptions and stigma, and the majority of care homes are run by private companies (in the UK), and thus, there can be a sense of competitiveness between care home organisations. For these reasons, those working in care homes might be wary of and have reservations towards both those external to the care home sector (for example, academic researchers and those working in an NHS or commissioning role) and those from other care home organisations.

Across all QICs projects, conscious efforts were made to help create environments where participants felt safe and valued (Box 1, point 2). One technique was the use of appreciative language when asking collaborative teams for project progress updates. This could involve, for example, asking teams to focus on "*What worked well and why?*", "*How would you want things to be?*", "*How can we work together to make this happen?*", and "*What needs to be in place to make it happen more of the time?*". Phrasing questions carefully using appreciative language helped to focus on moving forward instead of focusing on barriers or problems. Another technique used by QIC facilitators was to create a celebratory atmosphere during shared learning events by congratulating collaborative teams, sharing positive stories. Ice-breaker activities helped to create an atmosphere of inclusivity and encourage connections amongst collaborative teams. Establishing agreed ways of working (e.g., listen to whoever is speaking, no question is a silly question, do not speak using acronyms) helped to create a safe environment and reduce perceived hierarchical imbalances, particularly where teams were mixed in seniority and/or professional status. In some projects, backfill payments were provided to care home staff to reimburse the cost of the time taken to attend meetings and help with arranging staff cover. Small gestures also helped to create an atmosphere where collaborative members' attendance and input was valued, such as providing high-quality catering at collaborative shared learning events. An observation across all projects was that over time, trust, relationships, and a sense of community developed where care homes started to work more collaboratively, openly sharing their ideas and learning and resources (e.g., training resources).

#### *3.6. Seek Out Collaborative Teams and Leads*/*Facilitators with Existing and Longstanding Relationships*

A shared observation across QIC projects was the time needed to establish teams, build trusting relationships, and develop and implement improvement projects should not be underestimated (Box 1, point 3). The MOVIT project's experience suggests that recruiting and forming collaborative teams takes at least one year, establishing team rapport and developing QI projects could take up to six months, and depending on the improvement projects, the time required to be able to notice effects could be a matter of years. The PEACH study recognised this and actively sought out collaborative teams where there were established relationships, enabling teams to "hit the ground running". Similarly, good working relationships between the collaborative members and the QIC leadership team also help with project progress. The Safer Care Homes project leads used their pre-existing relationships and recruited care homes known to the QIC leads and facilitators, and found faster progress where collaborative team members knew the facilitating staff. In projects where the QIC project facilitators were not known to the care homes taking part, it was found that progress became easier once trust was established and any previous disputes or misunderstandings resolved.

#### *3.7. Clarify Collaborative Member Priorities and Lines of Responsibilities*

The care home sector is distinctive in that there are multiple organisations and multiple and different health or social care professionals provide health- and care-related services to residents. When delivering a QIC project, those leading and facilitating need to ensure collaborative teams develop QI projects which are directly related to team member job roles and responsibilities, and in which team members believe their job role and responsibilities could have some influence (Box 1, point 4). For example, the Safer Care Homes project set out to reduce falls, pressure ulcers, and medication errors. In the initial stages, care home staff viewed the cause of these issues as external to the home, believing that pressure area damage was acquired during hospital admissions and not inside the care home. In this case, QIC leads sought to discuss the factors which affected resident safety both inside and outside the homes, and participants started to engage when they saw they had some influence. The variety and mix of health and social care professionals may also mean differences in perceived priorities. In a similar way, it is worth spending time checking collaborative teams are invested and view QI project topics as a priority. For example, in the MOVIT project, collaborative teams spent some time at the beginning of the project reflecting on and choosing project ideas that aligned with their priorities. This ensured collaborative teams worked on topics that mattered to them. Allowing teams to work on their local priorities helped to maintain the ownership and buy-in needed to implement change. Working in this way and allowing local priorities to take precedence might not be possible if projects are funded to achieve objectives focused on a predefined topic.

#### *3.8. Work Flexibly and Modify Planned Activities Where Needed*

The experience shared across projects is that whilst QIC facilitators may have had project activities planned, they often had to work flexibly and adapt activities in response to collaborative teams, adapting their activity plans as they went along (Box 1, point 5). This is true in all QICs, but particularly when working in care homes because processes and principles which work for community healthcare or hospital teams will need adaptation to work in this setting. For example, the CHIP project reduced original meeting durations to enable greater focus and maximum attendance, and the PEACH project changed the programme remit from one around Comprehensive Geriatric Assessment, which members found difficult to understand, to one around delivering holistic care to residents. More examples around how QICs projects were modified are provided in Tables 1–6. We suggest that project teams carry out initial pilot/set up phases. This would help to "test" planned activities, check feasibility, and examine potential modifications that might be needed. Initial pilot/set up phases would also help to build in the time needed to establish collaborative teams and build trusting relationships (Box 1, point 3).

#### **4. Discussion**

The extent of what we can learn from publicly available reports of QI in care homes is limited due to the lack of detailed reporting in this field [15]. This article helps to address this gap by providing detailed descriptions of how the QIC method has been applied and insight into the experiences of six projects using this methodology in care homes in the UK and the Netherlands. The insights described in this paper are also likely to be of value to those working in healthcare settings. While there is a wide-ranging QI evidence base, there is also a wide-ranging care home evidence base, with limited interaction between the two. Currently, insightful learning from each literature base has not yet been brought together, and thus, insights which may surprise experts in QI may not surprise those who are expert in care homes, and vice versa. Bringing insights and learning together in one paper is an important step forward.

One common observation across projects was that QIC leads and facilitators had not anticipated the extent of support collaborative teams would need with collecting, processing, and interpreting data. Use of baseline data and comparison groups to determine the effect of changes made to practice is rare in the care home sector, but of great importance to robust evaluation. It is important to take time establishing the data needed at the beginning of the project so its implementation and impacts can be properly monitored. The observation around data collection is perhaps unsurprising in countries where care home sector data are not routinely available and are held across different organisations. The collaborative nature of the QIC approach, though, could bring together key stakeholders from across organisations where data are held, and thus, help with accessing relevant data. This is an issue in countries as diverse as England, Austria, Portugal, and Brazil. In England, numerous ongoing research studies are focused on addressing this [25,26]. Countries such as the Netherlands and the United States have more consistent approaches to collecting care home quality benchmarking data [27,28].

Our other observations provide practical recommendations that are consistent with, and build upon, the wider care home literature. Previous findings show when dialogue with care homes is appreciative and focused on what is working well, this helps to develop practice in care homes [29]. Evidence also shows that working relationships in the care home sector are of particular importance, as successful innovations in care homes are established on a foundation of longstanding collaboration and trust [30]. In addition, previous evidence highlights how the lines of responsibility for those working in and with care homes are not always clear, as people living in care homes receive care from professionals working in different organisations. Thus, there can be uncertainty and dispute over roles and responsibilities for particular aspects of care [31].

#### *Strengths and Limitations*

A key limitation is that the learning described here reflects the experience and perspectives of those who led and facilitated QICs, and not the views of collaborative participants. The insights we present were developed through a relatively unstructured, discussion-based approach, though our use of the TIDieR framework enabled us to identify, present, and compare key points of similarity and difference across the cases. Some of our observations might be unsurprising to those working in care homes; however, we believe these care home-specific insights may not be fully appreciated by improvement practitioners who work outside the care home setting.

The main strength of our article is that it addresses a gap in the existing QI and care home evidence base. A recent review of QI strategies applied in care home settings included 65 studies, and reported that to date, the evidence in this field lacks comprehensive reporting, limiting the extent to which others can replicate and learn from existing work [15]. This paper makes a start in addressing this gap. To our knowledge, this article is the first to provide detailed descriptions of multiple QICs applied in the care home setting and describe learning from across these projects. Our detailed descriptions are structured using standardised reporting (the Template for Intervention Description and Replication—TIDieR). Reporting templates have not yet been used in the existing evidence base. Nevertheless, we have only begun to scratch the surface of learning from collaborative projects in care homes. We recommend that future research builds on this foundation by continuing to comprehensively describe how QICs are applied in this setting and conducting in-depth process evaluations to generate more learning about how to apply QIC methodologies in the care home sector.

#### **5. Conclusions**

As Marshall et al. put it, "frontline practice is messy, it is never possible to do things perfectly, and good improvers are always learning" [19]. The experiences described here illustrate that improvement tools and techniques cannot to be taken "off-the-shelf" and applied without adaptation to the local context [19]. Our detailed descriptions of how the QIC approach has been applied in care homes, and the practical lessons learnt, will enable future teams to progress more quickly. We recommend that teams leading QICs in this sector continue to share detailed descriptions, given the paucity of literature available on the topic to date.

**Author Contributions:** All authors contributed to the insights described in this paper (R.D., G.M., J.B., L.B., T.P., L.C., C.M.-T., T.W., S.D., J.M., A.P., P.C., D.H., C.G., K.H.-S., N.C., and A.L.G.). R.D. and A.L.G. wrote an initial draft and co-authors (G.M., J.B., T.P., L.C., C.M.-T., T.W., S.D., J.M., A.P., P.C., D.H., C.G., K.H.-S., N.C.) contributed to reviewing and editing the paper. All authors have read and agreed to the published version of the manuscript.

**Funding:** The PEACH programme was funded by The Dunhill Medical Trust (grant number FOP1/0115). The Safer Care Homes collaborative was delivered by a local organisation called Haelo; an innovation and improvement science centre based in Salford commissioned by Salford Clinical Commissioning Group. The PROSPER collaborative was originally funded by the Health Foundation and has been sustained with Essex County Council and Better Care Fund funding. The SPACE programme was funded by the West Midlands Academic Health Sciences Network (WMAHSN) Patient Safety Collaborative. The MOVIT project was funded by the Dutch Ministry of Health via the National Programme on Elderly care. The CHIP project was funded by the South Sefton Clinical Commissioning Group. C.G. is funded by the National Institute for Health Research (NIHR) Applied Research Collaboration (ARC) North West Coast, A.L.G. is funded by the NIHR ARC East Midlands, and S.D. is funded by the NIHR ARC West Midlands. The views expressed in this publication are those of the author(s) and not necessarily those of the NIHR, the NHS, or the Department of Health and Social Care.

**Acknowledgments:** The authors would like to thank and acknowledge the teams who participated in each of the QIC projects described in this paper.

**Conflicts of Interest:** The authors played a key role in leading and facilitating the PEACH (A.L.G., J.M., J.B., R.D., N.C., K.H.-S.), Safer Care Homes (L.B., T.P.), PROSPER (L.C.), SPACE (C.M.-T., T.W., S.D.), MOVIT (A.P.), and CHIP (P.C., D.H., C.G.) QICs.

#### **References**


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International Journal of *Environmental Research and Public Health*
