Reducing Healthcare-Acquired Conditions in Nursing Homes

A commitment to making care safer

Improving Quality of Care in Nursing Homes

There are 1.4 million Americans living in the nation’s 15,600 nursing homes. We must be able to depend on nursing homes to provide reliable, compassionate, high-quality care. The Centers for Medicare & Medicaid Services (CMS) has created a strategy for guiding local, state and national efforts to improve nursing home quality of care. As part of that strategy,

Great Plains QIN is uniting nursing homes in a collaborative structure to share tools, knowledge and experiences for improving resident safety and clinical processes and reducing preventable healthcare conditions. Participants are learning from the best practices of nursing homes that have consistently earned a “5-star” rating in Nursing Home Compare, receive free education, resources and participate in rapid-cycle improvement projects. Our efforts align with the CMS National Nursing Home Quality Care Collaborative to:

  • Assist nursing homes to attain a score of six or better on the National Nursing Home Composite Quality Measure
  • Improve the rate of mobility among long-stay nursing home residents
  • Improve the targeted rate of reduction in the use of unnecessary antipsychotic medication in dementia residents
  • Decrease HAIs, other Healthcare–Acquired Conditions (HACs) and potentially avoidable hospitalizations
Through the five-year Nursing Home Collaborative, we are offering:
  • Customized onsite consultation
  • Quality improvement skills training
  • Evidence-based tools and resources
  • Ongoing educational opportunities
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Initiative Documents
More than Meds ToolkitAntipsychotic Medication ReductionMore than Meds: A Toolkit for Creating Change in Nursing HomesMore than Meds Project
Resource links with descriptions, to support incontinence.ContinenceResources to Support Incontinence Management for Residents Living in Nursing HomesNCC
Resources to Support Mobility in Residents Living in Nursing HomesFalls/MobilityMobility Resources for Residents Living in Nursing Homes
Promote Mobility and Prevent Falls in
Persons with Dementia Living in Nursing Homes
Falls/MobilityPreventing Falls in Older Adults with Dementia
Prevention of Falls in Older Persons - Summary of RecommendationsFalls/Mobility2010 AGS/BGS Clinical Practice Guideline
American Geriatrics
Fall Risk Assessment for Older Adults: The Hendrich II Fall Risk Model ™ By: Ann Hendrich, PhD, RN, FAAN Patient Safety Organization (PSO); Ascension HealthFalls/MobilityThe Hendrick II Fall Risk Model TMHartford Institute for Geriatric Nursing, New York University, College of Nursing
Use this Plan-Do-Study-Act (PDSA) tool to plan and document your progress with tests of change conducted as part of chartered performance improvement projects (PIPs).QAPI ToolQAPI PDSA Cycle TemplateCMS
Use this template to tell the story of a change your nursing home made that lead to a
demonstrable improvement.
QAPI ToolQAPI Improvement Success Story TemplateCMS
Guidance for Performing Root Cause Analysis (RCA) with Performance Improvement Projects (PIPs)QAPI ToolQAPI Guidance for Performing RCA with PIPsCMS
Five Whys Tool for Root Cause Analysis - This technique can help you to quickly determine the root cause of a problem.QAPI ToolQAPI Five WHYs Tool for Root Cause AnalysisCMS
Goal setting is important for any measurement related to performance improvement. This worksheet is intended to help QAPI teams establish appropriate goals for individual measures and also for
performance improvement projects.
QAPI ToolQAPI Goal Setting WorksheetCMS
A Step by Step Guide to Implementing Quality Assurance and Performance Improvement (QAPI) in Your Nursing HomeQAPI ToolCMS QAPI At a Glance ToolkitCMS
The QAPI plan will guide your organization’s performance improvement efforts. Prior to developing your plan, complete the Guide to Develop Purpose, Guiding Principles, and Scope for QAPI.QAPI ToolQAPI Guide for Developing a QAPI PlanCMS
Use this tool as you begin work on QAPI and then for annual or semiannual evaluation of your organization’s progress with QAPI.QAPI ToolQAPI Self Assessment ToolCMS
QAPI Written Plan How To GuideQAPI ToolsQAPI Written Plan How To Guide (Dec. 2016)GPQIN
Composite Sore Calculator for Nursing Homes using Microsoft Office 2007 and NewerToolNursing Home Composite Score Calculator - 2007 and NewerGPQIN
Composite Score Calculator for Nursing Homes with Microsoft Office 2003 and OlderToolNursing Home Composite Score Calculator - 2003 and OlderGPQIN
Tool in table form showing quality measures and their respective reporting systems.ToolCrosswalk of Quality Measures and Reporting Systems
This is a short video that will help you understand the composite score calculator tool for nursing homes.ToolNursing Home Composite Score Calculator VideoGPQIN
Antipsychotic reduction; resident prioritization tool Part 1 and 2ToolAntipsychotic Reduction; Resident Prioritization Tool Part 1 and 2Telligen
This change package is intended for nursing homes participating in the National Nursing Home Quality Care Collaborative led by the Centers for Medicare & Medicaid Services (CMS) and the Medicare Quality Improvement Organizations (QIOs), to improve care for the millions of nursing home residents across the country.ToolCMS National NH Collaborative Change PackageCMS
A step by step evidenced based approach to caring for people with DementiaToolDementia Pocket CardsIowa Geriatric Education Center
Design for Nursing Home Compare
Five-Star Quality Rating System: Technical Users’ Guide - February 2015
User's GuideCMS Nursing Home Compare Five Star Rating System User GuideCMS
Dec 6 @ 12:30 pm – 2:00 pm
  Description: During this call, learn about the reform of requirements for long-term care facilities, highlighting the Behavioral Health Services & Pharmacy Services sections. A Tennessee nursing home will also discuss innovative approaches that they[...]
Nov 17 @ 10:00 am – 11:00 am
Start WebEx Playback Download Presentation Handouts The Great Plains Quality Innovation Network invites you to attend this webinar. Join guest presenter, Johnathan Reeves, as he guides us through practical application of using data to meet[...]
Sep 22 @ 3:00 pm – 4:00 pm WebEx
MDS Part III: Understanding Quality Measures and Avoiding Common Pitfalls Start WebEx Playback Handouts MDS Series Part 3 Quality Measures Quality Measures Scoring Chart Presenters: Lisa Hohlbein, RN, RAC-MT, CDP,CADDCT AANAC Curriculum Development Judi Kulus,[...]
Sep 15 @ 12:30 pm – 2:00 pm
  Presentation Handout and Recording   Overview and Purpose: This call focused on effective care transitions between long-term and acute care settings, highlighting transitions that involve residents with dementia. This is critical for residents with[...]
Sep 8 @ 3:00 pm – 4:00 pm
Start WebEx Playback WebEx Objectives: As a result of this training, participants will be able to: •    Describe the population distribution according to age •    Explain why the older person’s pain is difficult to diagnose[...]
Aug 25 @ 3:00 pm – 4:00 pm WebEx
  Start WebEx Playback MDS Part II: Sections C, D, F and J: Capturing Resident Voice through Resident Interviews Presenter: Judi Kulus, MSN, MAT, RN, NHA, RAC-MT, DNS-CT, QCP Vice President of AANAC Curriculum Development[...]
Aug 18 @ 10:00 am – 11:00 am
Start WebEx Playback Vaccinations in North Dakota Nursing Homes Handout The North Dakota Immunization Information System (NDIIS) is a confidential, population-based, computerized information system that attempts to collect vaccination data for all North Dakotans. Registered[...]
Aug 9 @ 11:00 am – 12:00 pm WebEx
Start WebEx Playback Presentation Handout Great Plains Quality Innovation Network (QIN) C. difficile Reporting and Reduction Initiative Members will be required to enroll their facility into the National Healthcare Safety Network (NHSN) as well as[...]
Jul 21 @ 3:00 pm – 4:00 pm WebEx
Start WebEx Playback Slide handouts PDF Great 8 MDS Webinar Series 1 Handout MDS Sections AA and GG Handout Section GG Key Coding Tool MDS Part I: Section GG: What You Need to Know about[...]
Jul 15 @ 10:00 am – 11:00 am
Start WebEx Playback Please Note: The audio for this recording cuts out at 16:29 and resumes at 18:29. C. difficile Reporting and Reduction Presentation Handout Clostridium difficile (C. difficile) is a germ that causes major[...]
Jun 15 @ 3:00 pm – 4:00 pm
Start WebEx Playback   Objectives: Upon conclusion of this webex, participants will be able to: Discuss how specific leadership practices generate positive staff, resident and organizational outcomes Identify concrete strategies and systems for recruiting and[...]
Apr 13 @ 1:00 pm – 2:00 pm WebEx
Presentation Download: Prevention of Resident-to-Resident Negative Interactions Overview: The presenter discussed identification, triggers and strategies to manage this type of negative interaction.  Target Audience: This presentation is directed to the long-term care setting. Physicians, nurses,[...]
Feb 24 @ 10:00 am – 11:00 am WebEx
  Start WebEx Playback   Vaccination Quality Measures Handouts Recommended Adult Immunization Schedule -2016 LTCF Annual Influenza Checklist Vaccination Quality Measure Checklist Vaccination Log Vaccination Quality Measure Checklist – Fillable Form Overview Some quality measures[...]
Jan 15 @ 10:00 am – 11:00 am
The Great Plains Quality Innovation Network/Quality Health Associates of North Dakota invites you to attend the webinar “North Dakota Nursing Home Quality Care Collaborative: Where Are We Now?” Start WebEx Playback   Webinar Description Join[...]
Jan 14 @ 2:00 pm – 3:00 pm
Start WebEx Playback Download Presentation Purpose: CMS and long-term care providers have never considered sleep as an integral part of the plan of care and services provided for the resident. This Restorative Sleep Vitality Program[...]
Dec 1 @ 2:00 pm – 3:00 pm
All too often patients do not receive the care they wish for as they approach their last days or in medical emergencies. Having conversations about these situations is difficult, but it is critical that these[...]
Nov 19 @ 2:00 pm – 3:00 pm
  Start WebEx Playback   Webinar Objectives This webinar will be a discussion on strategies to engage community-based programs to support advance care planning. Learn about the Institute for Healthcare Improvement’s (IHI) The Conversation Project[...]
Oct 8 @ 1:30 pm – 2:30 pm
Start WebEx Playback Objectives Describe how the use of coaching techniques can enhance communication and strengthen relationships in the workplace Discuss strategies for using coaching tools Target Audience This presentation is directed to all healthcare settings[...]
Sep 10 @ 2:00 pm – 3:15 pm
Start WebEx Playback Presentation Handouts Dr. Lisa O’Hara’s PowerPoint Presentation Comprehensive Therapy Specialists Behavioral Health Evaluation Overview CMS has issued a new challenge to reduce antipsychotic utilization in nursing homes by 25 percent by the[...]
Aug 13 @ 2:30 pm – 3:30 pm
Start WebEx Playback   Presentation Handout Purpose: Treating dementia does not warrant a “one size fits all” method. There are many types of dementia resulting in a myriad of behaviors. Dr. Fisher will explore non-pharmacological[...]
Jul 16 @ 12:30 pm – 1:30 pm
Start WebEx Playback Presentation Handout AD8 Dementia Screening Interview Behavior Log This program explores key elements in addressing the needs of individuals with dementia who are experiencing behavioral and affective challenges across the care continuum.[...]
Jul 9 @ 2:00 pm – 3:00 pm
  Start WebEx Playback Promoting Mobility Access Ms. Lundgren’s Promoting Mobility Presentation We invite you to attend this webinar to learn more about the impact immobility/mobility has on the overall health of the elderly. This[...]
Jun 30 @ 3:00 pm – 4:00 pm
To access the presentation slides/handouts, click here. Start WebEx Playback Overview: This presentation is directed to healthcare professionals in the long-term care setting. You are invited to attend to learn more about Nursing Home Quality[...]
Jun 24 @ 2:00 pm – 3:00 pm
South Dakota Nursing Home Quality Care Collaborative – What’s Your Composite Score Number? Start WebEx Playback Quality Milestones Program Introduction and Step Checklists South Dakota Milestones Success Story Template Milestones PDSA Cycle Template SD NHQCC[...]
Apr 29 @ 2:00 pm – 3:15 pm
Start WebEx Playback   PIP Guide 11SOW Presentation Slides CMS QAPI Goal Setting Overview This webinar will serve as the kickoff event and Learning Session 1 of the South Dakota Nursing Home Quality Care Collaborative.  This[...]
Mar 19 @ 1:30 pm – 2:30 pm
Start WebEx Playback Overview and Purpose: QAPI is the merger of two approaches to quality—Quality Assurance and Performance Improvement.  When these efforts are blended together, the result can be significant improvements to important outcomes: residents can experience[...]
HAC NH Care Contacts
Brenda GrovesLPNNursing Home Project Quality ManagerKansasBrenda.Groves@area-a.hcqis.org
Krystal HaysRN, MSN, RAC-CTQuality Improvement AdvisorNebraskaKrystal.Hays@area-a.hcqis.org
Michelle LaucknerRN, BA,RAC-CTQuality Improvement SpecialistNorth DakotaMichelle.Lauckner@area-a.hcqis.org
Lori HintzRNProgram ManagerSouth DakotaLori.Hintz@area-a.hcqis.org

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Learning and Action Network

We invite you to join the Great Plains Learning and Action Network (LAN). All LAN partners will be invited to attend educational sessions on a variety of topics, have opportunities to learn from peers throughout the state and region and have access to an abundance of resources and tools. The LAN is a great opportunity to get connected and demonstrate your commitment to quality improvement.

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