Frontline staff in personal care homes will receive quality improvement training from an experienced quality advisor and support staff in making changes aimed to improve the quality of care for residents in the home.

Quality improvement training for frontline PCH staff

Frontline teams will implement their change ideas using iterative plan-do-study-act (PDSA) cycles. Each team's progress will be captured by the SHIFT quality advisor during regular meetings. After each meeting the quality advisor will complete a structured diary that captures each team's PDSA process using a published scoring system (DOI: org/10.1186/s40814-022-00975-8). This tool measures the appropriateness of each team's aim statement (e.g., being specific, having timeframes), assesses their ability to properly measure and interpret data (e.g., documents pain reduction using run charts) to guide next PDSA steps, and reports the number of PDSA cycles they completed. As described in the aforementioned manuscript, multiple researchers will judge each team's progress independently and then meet to reach consensus opinion.

Each participant will complete a baseline survey to assess their R4C. This survey uses questions from existing tools modified for our target group. It will assess people's perceived R4C at the macro (e.g. "SHIFT aligns with our health system priorities"), meso (e.g. "SHIFT is viewed strongly by leaders at my site"), and micro level (e.g. "I have the skills to conduct SHIFT").

Team R4C scores will be correlated with results of Outcome Measure 1 (team fidelity to the implementation process) to descriptively assess if teams with higher baseline R4C scores make better PDSA progress.

While readiness for change (R4C) is a well-established concept, it is unclear if and how these processes help teams be more successful. At study start participants will engage in R4C discussions to understand their role in SHIFT, responsibilities and time required, and supports available.

During focus groups at study end, we will ask participants to (1) reflect on preparatory R4C activities, and (2) compare these to their SHIFT experiences including successes and challenges they encountered. During these focus groups people will suggest additional R4C activities that would have helped them to better prepare for SHIFT.

Each team will participate in an end-of-study focus group where members will be asked to reflect on their change ideas and discuss how these ideas improved resident care. Teams will be asked to provide examples illustrating how residents benefited from their change ideas. Following the principles employed by others (doi.org/10.1016/j.jcjq.2018.04.009) focus group data will be analyzed using a qualitative constant comparative analysis technique to understand the properties, processes, and causes of each team's perceived success.