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Better Health Care for Communities

Care CoordinationNursing Home Resident Safety Collaborative

Nursing Home Quality ImprovementAs part of the National Nursing Home Quality Care Collaborative, HealthInsight convenes local communities of nursing homes, residents and families, and community stakeholders to improve nursing home care in our four-state region. Together, we identify and implement solutions to decrease healthcare-acquired conditions and healthcare-associated infections, increase resident satisfaction, improve quality of life and lower health care costs in the Medicare program.

Support for Clostridium difficile Infection (CDI) and New Infection Prevention QMs

CMS began a Quality Assurance Performance Improvement (QAPI) initiative in May 2016 to support nursing homes in addressing the burden of CDI. HealthInsight is assisting a group of nursing homes in each state in

  • Submitting CDI data into the CDC’s National Healthcare Safety Network (NHSN) databank, to develop a national baseline for CDIs in nursing homes and track CDI during the post-baseline measurement period
  • Using their data to identify opportunities and monitor progress in preventing infections through proactive, interdisciplinary approaches

CDI Initiative FAQs on data collection
NHSN training videos

Contact us


Donna S. Thorson, MS, CPHQ, CPPS
Project Manager
(702) 933-7327Call: (702) 933-7327

New Mexico:

Shannon Cupka, EdM
Project Manager
(505) 938-9124Call: Call: (505) 938-9124


Leah Brandis, RDN, CSG
Lead Project Coordinator
(503) 382-3909Call: (503) 382-3909


Michelle Carlson, SSW, CPHQ
Lead Project Manager
(801) 892-6646Call: (801) 892-6646

Learning Session 1: Applying Safety Principles - May 2017

Highlights and Resources
A brief summary of the main concepts from this session with action steps identified; includes links to key resources related to the session.

Discussion Guide
Questions related to each part of the session, on separate pages for printing and use in inservice learning at the nursing home.

Part 1: Creating a Safety Culture

It is essential for leadership to make safety culture a priority and establish a culture of trust. In a fully functioning safety culture, everyone in the organization is engaged in safety. Staff should feel comfortable speaking up.

Creating a Safety Culture (video, The Joint Commission, 4 min.)

Part 2: Systemic Safety for Residents and Staff (Mike Silver, HealthInsight)

Staff’s physical and emotional needs must be met before they can be actively engaged in resident safety. Investigators postulate that emotionally exhausted clinicians curtail performance to focus on only the most necessary and pressing tasks. Many of our resident safety issues may really be a symptom of a much deeper problem related to worker satisfaction. Focusing our effort on improving staff satisfaction will likely improve resident safety significantly faster than focusing solely on resident safety and result in more sustained gains.

Recorded program (20 min.)

Part 3: From Safety-I to Safety-II

“We really need to change our focus, we are spending most of our time learning from things that go wrong. Complement that with why is it that so often we deliver excellent care, safe care, to the patients that we serve, and what can we learn from what has gone right. Stop identifying the bad apples and tend to the whole orchard.” —Derek Feeley, President and CEO, Institute for Healthcare Improvement

Handout on Safety-I and Safety-II

Part 4: Applying Safety Principles: Incontinence, Sepsis and Antibiotic Stewardship (Carol Eastburg, Nevada Division of Public and Behavioral Health)

Part 1 focuses on regulatory requirements of Section 483.25(e) Incontinence and avoiding Tag F315. The different types of incontinence are reviewed and the speaker highlights what state surveyors look for at the facility during an inspection. Recorded program, part 1 (22 min.)

Part 2 focuses on why incontinence is a serious safety concern. The speaker addresses unnecessary treatment with antibiotics, antibiotic resistance, and Clostridium difficile infection. Recorded program, part 2 (22 min.)

Worksheet: Reviewing Patterns of Low Risk Residents with Loss of Bowel or Bladder in Your Home (Alliant Quality, 2015)

Part 5: Just Culture

A Just Culture is one that promotes a questioning attitude, is resistant to complacency, and creates an atmosphere of trust in which people are encouraged (even rewarded) for providing essential information, but in which they are also clear about where the line must be drawn between acceptable and unacceptable behavior.

Agency for Healthcare Research and Quality video: Understand Just Culture  (6 min., best in Internet Explorer)

Part 6: Decision Tree and Intervention Tool

The HealthInsight Decision Tree and Intervention Tool is intended to engage employees who did not intend to cause harm. The intention is to guide supervisors away from assumptions that there was an intentional violation and look at system interventions.

Recorded program (10 min.)
Decision Tree and Intervention Tool (PDF)

Resources for Collaborative Participants

Quality assurance and performance improvement (QAPI) tools

QAPI self-assessment: We recommend using this 5-page tool once or twice a year to evaluate progress of your QAPI program and identify areas for improvement.

Process tool framework: Links to QAPI tools provided by CMS.

Root Cause Analysis: A Building Block for Performance Improvement (webinar, 43 min.)
Root Cause Analysis (RCA) applies the principle that problems are less likely to recur after identifying and addressing root causes than by dealing only with immediate symptoms. Conducting RCA as team effort enables staff to understand why events occur and help identify solutions.

Root Cause Analysis (RCA): HealthInsight 5 steps guide

RCA Worksheet: blank

RCA Worksheet: example

Plan-Do-Study-Act Worksheet and instructions: PDSA is a tool to plan and document effectiveness of small tests of change, conducted as part of performance improvement projects.

Quality Measures (QMs)

MDS 3.0 QM User’s Manual and other CMS resources: Scroll to the bottom of the web page for download links. We suggest bookmarking this page in order to locate the most current version when updates are posted.

Five-Star Quality Rating System: Scroll to the bottom of the web page for download links.

Understanding the New MDS 3.0 Quality Measures: A Resource Manual: Compiled by the New England Quality Innovation Network, this guide is designed to assist you in identifying how a resident will "trigger" for a quality measure based on QM specifications and the coding of MDS 3.0 Resident Assessment Instrument (RAI). Updated May 2017.

New Nursing Home Quality Measures, April 2016: Information published by CMS on claims-based and MDS quality measures that went into effect April 2016 and will be factored into Nursing Home star ratings in July 2016.

FAQs about the Quality Measure Composite Score: Used by the Nursing Home Collaborative to measure progress of the collaborative.

MDS 3.0 Webinars, sponsored by Mountain-Pacific Quality Health:

MDS Part 1: Section GG: What You Need To Know About Coding the New Section GG (65 min.)
AANAC Master Teacher Amy Franklin.

MDS Part 2: Sections C, D, F and J (80 min.)
AANAC vice president and RAC-CT Master Teacher Judi Kulus.

MDS Part 3: Understanding Quality Measures and Avoiding Common Pitfalls (60 min.)
AANAC Master Teacher Amy Franklin and AANAC vice president and RAC-CT Master Teacher Judi Kulus.

MDS Part 4: MDS 3.0 RAI Manual Updates: What Changed for October 1 (“The Finalized MDS 3.0 RAI Manual,” 90 min.)
AANAC Master Teacher Amy Franklin and AANAC vice president and RAC-CT Master Teacher Judi Kulus.

Promising Practices to address quality measures

National Nursing Home Quality Care Collaborative Change Package: A curated collection of strategies, change concepts, and specific actionable items to provide inspiration and ideas for nursing homes wanting to improve residents’ quality of life and care. These concepts were collected from high-performing nursing homes across the country. (v 2.1, April 2017)

INTERACT tools: Website devoted to tools to reduce the frequency of transfers to the acute hospital.

Fall Prevention resources:

Promote Mobility and Prevent Falls in Persons with Dementia Living in Nursing Homes: Tip sheet from QIN National Coordinating Center (QIN-NCC) 

Nursing Home Fall Assessment: Fall assessment forms for nursing homes, adapted by TMF Health Quality Institute from content developed by the CAPTURE Falls Research Team at the University of Nebraska Medical Center.

New Look at Managing Falls (webinar, 59 min.): Mobility expert Sue Ann Guildermann shares insights on fall prevention.

Mobility resources:

Resources to Support Mobility in Residents Living in Nursing Homes (QIN-NCC) 

Incontinence resources:

Resources to Support Incontinence Management for Residents Living in Nursing Homes (QIN-NCC)

Pain resources:

Chronic Pain Management, a New Approach—Part 2: Treatment (webinar, 80 min.)
HealthInsight Oregon clinical director Nicole O'Kane, PharmD, discusses treatment options for chronic pain.

Chronic Pain Management, a New Approach—Part 3: Assessment (webinar, 75 min.)
Sharon Faulk, RN, and HealthInsight Oregon clinical director Nicole O'Kane, PharmD, discuss assessment of chronic pain.

Infection control resources

Severe Sepsis Across the Continuum of Care (webinar, 85 min.)
Dr. Steven Simpson discusses appropriate management of the sepsis patient.

Nursing Home Training Sessions on C. difficile and Antibiotic Stewardship
Self-paced modules on topics including communication strategies to promote quality and safety; antibiotics, antibiotic resistance and antibiotic stewardship; C. difficile clinical overview and strategies to prevent, track and monitor. Developed by the Quality Innovation Network National Coordinating Center (QIN NCC), under contract with CMS, with support from CDC. Presented in sections for 30-90 minute training sessions. Nursing contact hours or certificate of completion available for continuing education credits.


Pressure injuries

Pressure Injury Definition and Stages: Changes to the Staging System in 2016 (webinar, 81 min.)
Dr. Joyce Black summarizes the 2016 changes to the guidelines for staging pressure injuries (also known as pressure ulcers or bedsores).

Antipsychotic Reduction Toolkit

Materials on identification and management of behavioral expressions of distress among residents with dementia, developed by participants in the 2013–2014 Oregon Nursing Home Quality Care Collaborative.

Facilitator’s guide
Potty scenarios
Pain scenarios
Snack scenarios
Bored scenarios

Staffing and leadership for change

Coaching techniques and tools to enhance communication and strengthen relationships in the workplace.

We Got Softer Toilet Paper—and Other Low-Cost Ways to Engage, Retain and Recruit Staff (webinar, 60 min)
David Farrell, MSW, LNHA shares his experience on how to engage, retain and recruit nursing home staff.

NHSN Training Videos from HealthInsight

Step 1: SAMS Registration

Overview: Tracking Infections in Long-Term Care Facilities
Enrollment: Getting Access to NHSN for Your LTCF

Step 2: NHSN Facility Enrollment

Materials introduced in Step 1 (linked above): Checklist for SAMS Registration and NHSN Enrollment Facility Contact Information form

Step 3: NHSN Facility Setup—Mapping & Joining; Conferring Rights

Step 4: Modifying NHSN Users—Adding / Deactivating, Change in NHSN Facility Administrator

Step 5: NHSN Reporting