Improving Approaches to Everyday Care in Nursing Homes: A Study Protocol to Evaluate a Provider-led Quality Improvement Initiative (Preprint)

BACKGROUND Older people are the fastest-growing segment of the population in all developed countries, and in part due to this trend, nursing homes (NHs) are now reserved for people with extensive comorbid physical, cognitive, and social needs. While the challenges related to NH care are well known, strategies are needed to more effectively bridge the transactional gap between what we know from research and what we do in practice. OBJECTIVE This protocol paper describes how we designed, implemented, and evaluated an innovation called SHIFT (Supporting Healthcare Improvement through Facilitated Training) that helps front-line NH providers incorporate formal quality improvement techniques (e.g., Plan-Do-Study-Act, PDSA cycles) into their everyday care routines. Our goal was to understand how providers received this facilitated support and implemented their quality improvement ideas, assess their ability to use more structured care improvement processes, examine the facilitators and barriers to their success, and describe how SHIFT impacted resident quality of care and staff-related outcomes. METHODS SHIFT is a sequential mixed-methods clinical trial guided by key implementation science frameworks and lessons learned from the Translating Research in Elder Care (TREC) research program. It consists of a core module based on the Institute for Healthcare Improvement (IHI) Breakthrough Series framework (e.g., learning congresses interspersed with action periods, various forms of facilitation). From TREC learnings, we added to this core module (i) readiness-for-change activities to help identify suitable intervention environments and team members with requisite skills, and (ii) a leadership program that provides person-level coaching to boost internal facilitation. SHIFT and its components were examined using a suite of quantitative (e.g., team member surveys) and qualitative (e.g., focus groups, quality advisor field notes, research observations) data. Our primary goal was to assess implementation strategies and secondarily measure intervention effectiveness. RESULTS Ten NH sites involving 65 team members have participated in SHIFT. Recruitment occurred in February 2024, and the study concluded in July 2024. As of January 2026, all data have been analyzed, and four manuscripts are in preparation that discuss participant perspectives on (i) SHIFT team implementation and intervention effectiveness, (ii) the value of R4C and leadership activities and how they impacted innovation success, (iii) challenges teams encountered specific to SHIFT fidelity, and (iv) future innovation directions based on participant input (e.g., creating more targeted quality advisor training sessions, increasing the number of these sessions with fewer cross-team learning congress workshops). CONCLUSIONS SHIFT investigates strategies that help NH front-line care teams embed, with support, quality improvement methodology into their daily care routines. This innovation is positioned as the first in a series of iterative collaborations that aim to achieve this goal while balancing best evidence with the everyday complexities of NH care. CLINICALTRIAL ClinicalTrials.gov NCT06106087; https://clinicaltrials.gov/study/NCT06106087