Table 1.

The original intervention and how it evolved

Intervention component	Original/added later	Ways in which the component were implemented	Extent to which component was used
NHS Safety Thermometer (NHS designed and owned online tool for collecting process and outcomes data)	Original	Implemented with first cohort and offered to all of second cohort, then replaced by Safety Cross and Monthly Mapping tools (see below)	66% of first cohort homes tried the Safety Thermometer. About one-third input data
Active involvement of staff, residents and relatives in sharing data and co-creating improvement solutions	Original	Staff initially slow to share data but became enthusiastic as project progressed. Residents and relatives hardly actively involved at all but project details and data displayed on public notice boards in most homes	Fewer than 10% of first cohort homes shared Safety Thermometer data. Eighty per cent of homes used the Safety Cross and displayed this for staff, residents and families to see. Sixty per cent displayed graphs from the Monthly Mapping tool
Training for care home staff in improvement methodologies	Original	Quality improvement training was provided initially by the NHS staff, then adapted and provided by the improvement team	All homes took part in training. In first cohort, this was chiefly home managers but in subsequent cohorts some senior carers also attended
Participants able to deliver the training to peers (train-the-trainer)	Original	Formal train-the-trainer model was not implemented though local advocates (‘champions’) were encouraged to roll out learning to others	Champions were found to work well to spread learning informally
Intervention toolkit containing a compendium of evidenced-based interventions for each of the domains of the Safety Thermometer	Original	Toolkit with worksheets and information sheets developed	All homes received a hard copy and an online version. Unclear how much they were used by first cohort and then dropped as Safety Thermometer replaced by Safety Cross
Safety culture assessed using the MaPSaF tool at three time points (before, during and after PROSPER), using the tool to understand and address barriers to change	Original	MaPSaF revised and tested in different ways with various cohorts	Use not prioritised by the improvement team or by the homes. Small number of homes actively used it. Progressively more significant changes made to the tool for each cohort to make it more relevant
Communities of practice	Original	Three community of practice events held throughout project	Between a half and two-thirds of homes attended the events
Improvement tools and case studies uploaded to resource tool for peer learning	Original	Knowledge hub set up and documents uploaded periodically, mainly copies of things sent by email	10% of homes signed up and none of them posted information
Ongoing support from improvement team including meetings, visits and telephone conferences	Original	Facilitators visited homes with varied frequency. During the intensive phase, some homes were visited monthly and others every 3–4 months. Group telephone conferences were not used	Some homes received regular support and others did not. Some homes reported that they had no contact with their allocated improvement adviser for 6 months
‘Safety Cross' for displaying information about monthly incidents replaced Safety Thermometer (see above)	Addition	Used from cohort two homes onwards then also rolled out to cohort one	About 80% of homes reported using it
‘Monthly Mapping tool’ using graphs with monthly data to track changes over time and compare averages	Addition	All homes were invited to provide data about the monthly incidence of harms. From cohort three onwards, homes were given access to an online tool	About 60% of homes provided some data. One-quarter used the tool regularly without prompting
Provision of resources such as information posters, certificates of training, mirrors to view pressure ulcers and other tangible resources	Addition	Resources developed ad hoc	Homes offered tools during community of practice and visits. Variable uptake depending on focus. Resources appeared to be highly appreciated
Provision of additional training beyond improvement methods courses, such as training in infection control and pressure ulcers	Addition	Twenty-six training sessions run	About 50% of homes participated
Coordination with partner organisations in the NHS	Addition	Varied by geographical area	Varied by geographical area
Monthly newsletter	Addition	Sent monthly to participating homes	Sixty per cent of home managers reported reading it

Green=implemented as planned; Amber=partly implemented as planned; Red=not implemented as planned.

MaPSaF, Manchester Patient Safety Framework.