The East Midlands Patient Safety Collaborative (EMPSC) piloted an audit tool to measure the prevalence of common care problems found in nursing and residential homes. The audit tool was first rolled out to 26 care homes across Nottinghamshire and Derbyshire in 2015, extending to 30 care homes across the East Midlands in 2016, 31 in 2017 and 39 in 2018.
The tool is called the International Prevalence Measurement of Care Problems in Care Homes (Landelijke Prevalentiemeting Zorgkwaliteit, or LPZ for short, in Dutch). LPZ was developed in the Netherlands to provide a reliable mechanism for measuring the prevalence of common care problems within care homes and provide consistent recording of data to drive, or measure, the impact of quality improvement initiatives in the sector. It is currently used to deliver an annual audit of data for care settings in the Netherlands, Germany, Austria, Switzerland, New Zealand, Indonesia and Brazil.
The tool supplies participating care homes with insight into the quality of care provided in their setting through measuring the extent of common care issues. This can support decision-making by care homes, regulatory bodies and policymakers regarding implementing measures such as preventative screening and specific interventions to improve the quality and safety of care provided. Moreover, the large scale and scope of the audit tool enables the participating care homes and regions to compare themselves with similar settings and populations, using the data to facilitate benchmarking.
LPZ has provided valuable learning from local, national and international comparisons and demonstrated quantifiable improvements in standards of care problems (which we refer to as safety). More details of the tool can be found at www.lpz-um.eu.
Care home providers in the UK use different indicators and metrics for care quality. With no nationally agreed benchmarking tools it is impossible to know the true incidence or prevalence of common problems such as pressure ulcers. In particular, large chains / providers with multiple care settings collect data in different ways, making cross-sector comparisons difficult. Evidencing system-wide improvements in quality and safety of care is also challenging due to a lack of consistent recording of comparable indicators and data.
In the absence of a reliable mechanism for measuring instances of common care problems across UK care homes, the LPZ tool was adopted to establish a mechanism for measuring, recording, analysing and sharing prevalence of common care problems in care homes across the East Midlands, and to use such benchmarks to drive quality improvement and improve patient safety.
The EMAHSN Patient Safety Collaborative (PSC) worked with a selection of care homes to trial LPZ in order to ascertain whether this proven system could be successfully implemented in the UK in order to improve the care and safety of care home residents. The initial 2015 pilot and two associated research projects established that the tool was feasible in the UK setting and so the programme was repeated in 2016 and 2017, and expanded to cover the following six domains:
- Pressure ulcers
- Pain management
- Hydration and nutrition.
Working with Dr Adam Gordon, Clinical Associate Professor in Medicine of Older People, colleagues from The University of Nottingham, regional community services and Clinical Commissioning Groups (CCGs), the PSC assisted with care home staff training and supported the audit from start to completion over each 12 month data collection period. The aim was to increase care home capacity and capability to recognise, prevent and manage care problems through the introduction of measurement tools and techniques supported by quality improvement interventions.
The EMPSC approached care homes through Clinical Commissioning Groups’ Quality Teams and community nurses through local community providers and Trusts. Developing these relationships gave direct access to the care homes we invited to take part. This was facilitated through information and networking events which brought care home leaders, CCG quality teams, community nurses, commissioners from health and social care and care home staff together to share challenges and understand the benefits of joining LPZ. A team of people, including a care home owner, NHS Improvement Chief Nurse, a social care commissioner, CCG commissioner, PSC project manager, clinical champion, and project nurse went to visit the Netherlands to see LPZ in action and bring back learning for implementation. This involved visiting care homes and the University of Maastricht where the data is analysed.
Prior to launch in 2015, the PSC wrote to all East Midlands Safeguarding Boards to inform them of the project and to provide assurance that as a pilot we would be asking for individual consent from care home residents in allowing their care home to record patient-level data. As data collection through LPZ became standard practice within many of the homes we omitted individual consent in year three. This has resulted in a greater number of residents being entered into the audit. It is important to enter all eligible residents to improve data volume and quality and achieve a more accurate picture of true prevalence.
The PSC coordinates and hosts two events each year, one in September to prepare staff for the audit and provide training in pressure ulcer recognition and grading and the other in January to share results, learning and support continued quality improvement.
As a result the ‘React to Moisture’ educational resource has been developed (building on the React to Red model) as care home audit results indicated a high prevalence of moisture lesions and in some cases a misunderstanding between the presentation of moisture lesions and grade one pressure ulcers.
The following actions were key to successful implementation:
- Training in pressure ulcer recognition took place using the locally developed ‘React to Red’ training package in all years
- Training in continence management was added during year two and a further resource developed: ‘React to Moisture’
- Annual training events were held to prepare homes for the audit
- Individual support was provided to care homes to support understanding of audit results
- NHS staff supporting the ‘Head to Toe’ skin inspections (known as verifiers) were supported to understand their role and verifier training was developed
- The PSC wrote to Safeguarding Boards and prepared information for care homes, residents, staff and relatives, including consent
- Active promotion of dignity and respect for residents as a priority. The audit involved a head to toe skin inspection and therefore examinations were scheduled for the time the resident usually woke and dressed to minimise inconvenience and any avoidable distress
- PSC project team support to those care homes with limited IT infrastructure. This resulted in a combination of paper and electronic data recording to complete audit requirements During year two, masterclasses covering all audit areas were made available to care homes at follow up learning events, utilising specialist expertise from within the region
- Action planning around the findings were incorporated as part of the year two audit and care homes were introduced to basic quality improvement tools at a dedicated training event facilitated via the PSC
- Promotion of the LPZ model was undertaken across the East Midlands at a number of different events and forums to increase participation across the region in readiness for the 2017 audit
- Agreement was achieved with programme partners to fund additional care home training resources to address audit findings
- Infographics were developed which proved to be a more successful way of using and displaying data
- The first LPZ Awards were held following the 2017 audit to recognise excellence in care homes as a result of LPZ implementation and learning.
The initial measure was to test whether LPZ could be translated to the UK and implemented successfully. Researchers were employed to develop field notes about the process.
- Process measures: The number of care homes taking part in LPZ, number of residents entered into the audit, number of case studies generated by care homes showing evidence of improvement.
- Outcome measures: Prevalence of pressure ulcers, incontinence, falls, pain, restraint and malnutrition.
- Balancing measures: N/A.
The PSC commissioned economic and academic evaluations of the project and development of a business case for longer-term sustainability.
- The 2015 pilot demonstrated that the LPZ tool can be used effectively in the UK setting and was therefore repeated in 2016, 2017 and 2018
- Implementing LPZ would lead to an overall three year cost savings of £915,830.
- The projected cost of running LPZ is £150,207 per year, or £450,621 over three years*
- This results in a net saving of £465,209 based on reduced costs of treating pressure ulcers. This is before effects on falls and admissions related to dehydration are taken into account
*includes analysis fees, admin support and back fill expenses
LPZ in action
- The LPZ tool provides a validated and consistent measurement of common care problems
- Year 1 – 26 care homes took part and 489 residents’ data uploaded (2015)
- Year 2 – 30 care homes and 511 residents’ data uploaded (2016)
- Year 3 – 31 care homes, from all 5 counties in the East Midlands with 634 residents’ data uploaded (2017)
- Year 4 – 39 homes, from all 5 counties in the East Midlands with 1045 residents’ data uploaded (2018)
- The tool can be used to improve care through identification of trends in common issues / health and wellbeing indicators and opportunities for early interventions / treatment
- Audit results have been shown to be a reliable measure of how many residents are affected by the common problems so that care homes can be assisted to make improvements and, through the PSC funding, resources have been developed to support improved training and education within the homes
- Care homes have actively engaged in quality improvement capability events in order to support the development of improvement approaches. Hundreds of care home staff have attended the events across the East Midlands to prepare care homes for audit and to share results afterwards
- Thousands of React to Red resources shared across the UK, this has now been evaluated and is the only training resource of its kind been shown to improve care http://www.reactto.co.uk
- Staff that took part were engaged and reported back positively on the process
- Care homes report greater awareness and early recognition of skin damage and other common problems, and less reliance on community nursing staff
- Barriers broken down and improved relationships between care homes and community nursing teams through collaborative working as part of the ‘top to toe’ skin inspections conducted on audit day
- An introduction to quality improvement methodologies was introduced to support care homes in 2017
- Care homes starting to implement changes to practice to improve care using recognised tools to support them in 2017, which will be built on as the LPZ programme progresses
- Increased confidence and leadership skills of participating care home managers and staff
- A care home in Lincolnshire has used the LPZ findings for focused work on implementing changes and improvements in the nutrition of residents using Wessex AHSN’s toolkit and resources
- Five case studies from homes demonstrating improvements and outcomes in the quality of care for residents
- The LPZ Awards have been established, recognising quality improvements in care homes as a result of LPZ
- Six new quality standards developed to support ongoing improvements in care homes
- The Care Quality Commission (CQC) has highlighted the implementation of LPZ as a proactive approach that care homes are taking to improve quality and safety in two of its recent inspection reports of homes in the region
- The EM PSC has created various infographics about this work and more information can be found on their website.
- The care home sector is a dynamic sector, with high staff turnover and this affects engagement and relationship building
- Quality Improvement training needs to be tailored to this sector
- Care home staff receive little training in common care areas, such as pressure ulcers, continence, falls etc.
- Verifiers are required for the head to toe skin inspection
- Measurement leads to improvement through the identification of issues and trends
- Care homes do not wait for the annual results to improve, they are motivated to act immediately during the audit
- Using infographics is an effective and engaging way of displaying data and is well received
- Whilst LPZ improves transparency, true prevalence is difficult to achieve and therefore benchmarking data more difficult to establish.
- The EMPSC is working with Prof. Dr. Jos M.G.A. Schols, Professor of Old Age Medicine, Maastricht University to progress the development of international benchmarking
- The PSC have have worked with stakeholders to scale up this work across all five counties within the region and are working with other AHSNs/PSCs for potential wider roll out
- Ongoing awareness raising with regulators (CQC) to recognise the impact on quality within participating homes and correlate improvements with LPZ implementation
- Continued support to staff to develop the quality improvement skills and educational awareness of participating care homes.
March 2015 to January 2019
Dr Cheryl Crocker, Regional Lead: Patient Safety Programme, East Midlands AHSN
Read about how the Safer Provision and Caring Excellence (SPACE) programme has been recognised by the CQC for improving quality in West Midlands’ care homes.