title: Implementing a quality improvement programme in palliative care in care homes: a qualitative study.
abstract: BACKGROUND
  An increasing number of older people reach the end of life in care homes. The aim of this study is to explore the perceived benefits of, and barriers to, implementation of the Gold Standards Framework for Care Homes (GSFCH), a quality improvement programme in palliative care.
  
  
  METHODS
  Nine care homes involved in the GSFCH took part. We conducted semi-structured interviews with nine care home managers, eight nurses, nine care assistants, eleven residents and seven of their family members. We used the Framework approach to qualitative analysis. The analysis was deductive based on the key tasks of the GSFCH, the 7Cs: communication, coordination, control of symptoms, continuity, continued learning, carer support, and care of the dying. This enabled us to consider benefits of, and barriers to, individual components of the programme, as well as of the programme as a whole.
  
  
  RESULTS
  Perceived benefits of the GSFCH included: improved symptom control and team communication; finding helpful external support and expertise; increasing staff confidence; fostering residents' choice; and boosting the reputation of the home. Perceived barriers included: increased paperwork; lack of knowledge and understanding of end of life care; costs; and gaining the cooperation of GPs. Many of the tools and tasks in the GSFCH focus on improving communication. Participants described effective communication within the homes, and with external providers such as general practitioners and specialists in palliative care. However, many had experienced problems with general practitioners. Although staff described the benefits of supportive care registers, coding predicted stage of illness and advance care planning, which included improved communication, some felt the need for more experience of using these, and there were concerns about discussing death.
  
  
  CONCLUSIONS
  Most of the barriers described by participants are relevant to other interventions to improve end of life care in care homes. There is a need to investigate the impact of quality improvement programmes in care homes, such as the GSFCH, on a wider range of outcomes for residents and their families, and to monitor the sustainability of any resulting improvements. It is also important to explore the impact of the different components of these complex interventions.
authors.affiliation: Department of Palliative Care, Policy & Rehabilitation, Cicely Saunders Institute, King's College London, Bessemer Road, Denmark Hill, London, UK. sue.hall@kcl.ac.uk
authors.forename: Sue
authors.initials: S
authors.lastname: Hall
authors.forename: Cassie
authors.initials: C
authors.lastname: Goddard
authors.forename: Frances
authors.initials: F
authors.lastname: Stewart
authors.forename: Irene J
authors.initials: IJ
authors.lastname: Higginson
mesh_terms: D001291:Attitude of Health Personnel; D006282:Health Personnel / Q000592:standards* / Q000639:trends; D006707:Homes for the Aged / Q000592:standards* / Q000639:trends; D006801:Humans; D009735:Nursing Homes / Q000592:standards; D010166:Palliative Care / Q000592:standards* / Q000639:trends; D058996:Quality Improvement / Q000592:standards* / Q000639:trends; D059039:Standard of Care / Q000592:standards / Q000639:trends; D011795:Surveys and Questionnaires / Q000592:standards