Table 1 SSaSSy aims, measures and analyses

Semi-structured in-person interviews with the QI Team lead, senior sponsor, and QI advisor

A hybrid approach of qualitative methods will be used, thematic analysis [28], which incorporates both an inductive approach that allows themes to emerge from the data [29] and a deductive a priori template-of-codes approach [30] based on research we review above. Audiotapes of the interviews will be transcribed verbatim and data analysis will be completed using line-by-line coding and constant comparative methods [31]

Aim 2: Explore the relative effects of the high- and low-intensity boosters

2a: Sustainability: Sustained or renewed improvements to quality of resident care

Unit-level quality indicators generated using RAI-MDS 2.0 data on resident outcomes (mobility, pain, behavior)

Run charts will be generated for the RAI-MDS data⁽ⁱ⁾ collected SSaSSy start for each of the three quality indicators for each unit (RAI data elements MOB01/MOB1A; PAI0X/PAN01; BEHD4/BEHI4). For the clinical area on which QI Teams focus, we will analyze the relevant RAI-MDS quality indicator using statistical process control methods [32] and a procedure that members of our research team developed for the SCOPE proof of principle study [21] which categorizes control charts in terms of demonstrated changes to performance.

Notes:

(i) RAI-MDS 2.0 is a valid, reliable standardized assessment of resident outcomes that includes a comprehensive set of clinical outcomes and captures characteristics of nursing home residents and their care [33]. Each resident has a full assessment (~450 items) performed on admission, and a shorter (300 item) assessment is performed quarterly. These data are routinely collected from all 94 participating TREC sites, from which SCOPE study sites were drawn, and are the source of SSaSSy’s resident outcome data

2b & 2d: Sustainment: Sustained or renewed changes in staff behavior and senior leadership support behaviors

SCOPE templates completed by QI Team leads. diaries and feedback reports completed by QI Advisors

SCOPE Templates⁽ⁱⁱ⁾ will be analyzed, using document analysis [34, 35], at two junctures: analysis of the SCOPE Templates accrued over SCOPE implementation, and over the SSaSSy booster interval to determine peri-intervention fidelity and post-intervention fidelity, respectively. First, gross-grained assessments of the use/non-use of the templates (sustainment) by each QI Team will be made (i.e., were templates complete and posted on intranet site available to Teams). Thematic analysis (see above) will then be used to analyze the contents of the QI Team templates, as well as the QI advisor diaries and feedback reports⁽ⁱⁱⁱ⁾

2c: Sustainability: Sustained or renewed changes to staff work attitudes and outcomes related to work performance

TREC HCA Survey [36]

While quantitative data will be collected and analyzed over the course of the project, SSaSSy likely will not be adequately powered for statistical inference. Descriptive statistics including statistics of central tendency, dispersion, and standard deviation will be computed for each unit-level variable, for each booster arm collected through the TREC Survey waves. However, if changes in the primary outcome of the SCOPE intervention, Care Aide-reported conceptual use of best practices, are sufficient over the booster interval (e.g., an effect size of 0.29), we will use one-way ANOVA (repeated measures, within-between interaction) to test for “pre–post” differences in the means of each variable within and between groups/booster arms, followed by Tukey–Kramer test for significant differences between all pairs of groups if appropriate (where distributions are not normal the Kruskal–Wallis test will be used, and where data are heteroscedastic Welch's ANOVA will be used). In the more likely event that changes of this magnitude do not occur, we will compute p-values by time point before and after the SSaSSy booster interval. We are constrained in our sample size because we are studying the post-implementation of a trial with a fixed number of experimental sites.

(ii) SCOPE Templates refer to documents introduced during SCOPE implementation, in the all-team Learning Congresses, that are designed to assist care aide-led QI Teams in planning and managing their QI projects, and measuring and reporting their progress against their project aims

(iii) The quality advisors keep diaries in which they prepared structured summaries of each interaction with the QI Teams, whether face-to-face or telephone, outside of the all-team Learning Congresses. Quality advisors also prepare written, structured, quarterly feedback reports for each QI Team

2e: Spread: Indications of spread to other units within the SCOPE intervention sites

Semi-structured in-person interview with the QI Team lead, senior sponsor, and QI advisor

As above

Documentation of resources and associated costs for low- and high-booster conditions

This cost analysis is exploratory in nature. We plan a simple, disaggregated reporting of costs. We will report the intervention costs (costs to deliver the boosters) separately from the costs incurred by the participating units. Each unit will report their incurred costs for staff, training and materials and supplies. Disaggregated presentation will allow units to understand what is driving the costs and identify possible areas where costs could be modified within the overall intervention