We conducted focus groups with the care home and NHS staff across three East Midlands counties to understand what they regarded as safety priorities in care homes. Focussing on these, we identified an international benchmarking tool, the Landelijke Prevalentiemeting Zorgkwaliteit (LPZ) which considered the delivery of care related to pressure ulcers, nutrition, falls, continence, pain management and restraint. We visited Maastricht to see this tool in use, taking members of care home staff to understand whether it would be feasible in Britain.
We conducted an initial pilot of the LPZ benchmarking audit using only the pressure ulcer and continence modules in November 2015, collecting data from 489 residents of 26 care homes across two East Midlands counties. Data were uploaded using a web-interface and care homes received their individual results, benchmarked against the other 25 participating homes, via an online dashboard.
We worked with care homes to understand the training and preparation required, and how they made sense of the data. Based upon these findings we used all seven LPZ modules once yearly from 2016 onwards. We worked with care homes to develop a quality improvement workshop run once yearly to enable them to develop improvement plans based upon LPZ results.
Care delivery in care homes is often excellent but variable in quality. Partnerships between NHS and care home providers are stymied by: 1) lack of high-quality data about care delivery and the outcomes; and 2) lack of shared understanding about the processes underpinning effective quality improvement. These observations came from academic research undertaken in the East Midlands and from long-established patterns of working with care homes as part of NHS Vanguards initiatives.
We, at the East Midlands Patient Safety Collaborative, set out to establish a consistent way of benchmarking the quality of care in care homes and to work with care homes to develop a way of using this data to drive up the quality of care. Existing tools which had been used to benchmark care in the care homes were either specific to particular care home providers or, if supported by the NHS (for example, the patient safety thermometer), were not widely implemented due to perceived lack of relevance to care homes.
We adopted the following principles:
- We would do this WITH rather than TO the care homes - We would use measurement to drive improvements in care - We would celebrate good care whilst maximising opportunities for improvement
We repeated the benchmarking audit in November 2016, 2017 and 2018, with 511, 634 and 1045 residents from 29, 30 and 39 care homes respectively.
In response to care home requests, we ran a training event each September, prior to audit day, which used locally developed React to Red training materials to provide staff with the necessary skills to recognise and document pressure ulcers.
Each audit was cross-sectional and conducted during a single week. Data were uploaded electronically and returned using the LPZ online dashboard. In February 2016, 2017 and 2018 we ran quality improvement workshops. These were attended by staff from all participating homes, with presentations on how to interpret benchmarking data followed by a round-robin exercise where staff could develop improvement plans with support of NHS experts in tissue viability, continence, nutrition, dementia and pain management.
To further develop a community around the LPZ project we launched the LPZ awards in November 2017, with homes encouraged to share their innovations and nominate exceptional staff. The inaugural Home of the Year ward was won by Alexandra Lodge in February 2017, for innovative approaches taken to menu planning and dietary supplementation in response to LPZ nutritional benchmarking data.
We adopted and spread the LPZ audit tool from the Netherlands and used this in Homes across the East Midlands. Our unique approach of combining the audit tool with QI Collabortives and encouraging Staff to drive this from the ‘bottom-up’, has generated a lot of interest with our European colleagues. These lead to us seeing Dutch, Swiss and Austrian researchers (who are all using LPZ) to recently conduct a visit to learn from us.
Please see the BBC East Midlands Today news coverage on LPZ available here at 04:30 https://www.bbc.co.uk/iplayer/episode/b0c1w4gg/east-midlands-today-lunchtime-news-05022019
After having great success across 5 counties, we’re now ready to spread this across the UK. We’re exploring options for doing this via our existing AHSN and PSC networks.
Most data are available for pressure ulcers where we have seen a 30% fall in pressure ulceration rate across the homes which have been recurrent participants in the LPZ – this is a drop in point prevalence of pressure ulcers from 8%-5%, equating in absolute numbers (95% CI) to a fall from 2.12 (1.15–3.10) to 1.5 (0.57-2.43) ulcers per home. We are compiling similar data for the other LPZ modules at present. See attached economic summary showing conservative estimates of £465,209 over three years based on the reduced costs of treating pressure ulcers alone.
LPZ’s impact is perhaps best understood at an individual home level:
Wren Hall Nursing Home found in 2016 that they were in the 95 percentile for residents reporting pain in the last 7 days. They were in the 95th percentile for paracetamol prescription and 25th percentile for opioid prescription. They instituted a plan to institute Abbey pain scales as part of standard documentation alongside an escalation plan to discuss residents with GPs where the pain was poorly controlled. As a consequence, prevalence of pain dropped from 52%-22%, placing them below the benchmarked average prevalence.
Each home has responded to their own data in individually, supported by the quality improvement workshops.
Feedback from care home staff and PPI representatives has been universally positive, with particular emphasis on the way that LPZ has empowered staff to understand and improve the care they provide, and also the way it has helped build partnerships with NHS-based staff including tissue viability and continence nurses.
A video, including testimonies from care home staff, is available online at: http://atlas.ahsnnetwork.com/lpz-improving-quality-and-safety-in-care-homes/
We designed the quality improvement workshops in partnership with care home staff and PPI representatives who told us that it wasn’t enough to measure outcomes, we had to use this data to help care homes improve their care. When we piloted generic quality improvement workshops, care home staff told us that the learning seemed distant from practice and irrelevant. In response to this, working with care home and PPI representatives, we created a care home-specific approach, with individual topicspecific workshops which the staff could visit in a round-robin way to discuss their benchmarking data and identify opportunities for improvement.
Feedback from UK care homes has changed the international LPZ benchmarking questions asked in all countries via the LPZ international research group.