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Leading and Sustaining Systemic Change Collaborative
Thank you for your commitment to improving the quality of life for your residents by participating in the Leading and Sustaining Systemic Change Collaborative (LSSCC). You are the leaders of a more resident-centered culture dedicated to achieving national quality improvement goals.
National Goals:
- Improve QAPI practices
- Eliminate preventable healthcare-acquired conditions
- Dramatically improve resident satisfaction
How We Will Achieve These Goals:
We will also use evidence-based tools and methods:
- Team STEPPS
- Kotter’s 8 Step Process for Leading Change
- NEW! National Nursing Home Change Package
- Advancing Excellence
- CMS QAPI
New Resources
Preview: Facility Assessment
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483.97 KB | Last Updated: September 12, 2017
Preview: Dementia Care in Nursing Homes - Call Presentation
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342.47 KB | Last Updated: September 12, 2017
Disclaimer: This optional template is intended to help facilities comply with the new requirement that “Nursing facilities will conduct, document, and annually review a facility-wide assessment, which includes both their resident population and the resources the facility needs to care for their residents (§483.70(e))”. Use of this specific tool is not mandated by CMS, nor does its completion ensure regulatory compliance.
QIN NCC Train the Trainer Series *CEUs available
Click the GO button to view.
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Hand in Hand: A Training Series for Nursing Homes
This training focuses on caring for residents with dementia and on preventing abuse. CMS, supported by a team of training developers and subject matter experts, created this training to address the need for nurse aides’ in-service training on these important topics.
Self-Paced Online Training: Hand in Hand: A Training Series for Nursing Homes Online
Downloadable Materials for Instructor-Led Training: Hand in Hand: A Training Series for Nursing Homes Download
Outcomes Congress Nov. 8, 2018
Preview: Best Practices Booklet Collab II
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2.12 MB | Last Updated: November 6, 2018
CHECKLIST Reform of Requirements for Long-Term Care Facilities: 483.80 Infection Control
Preview: Antibiotics Aware Word Search
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320.94 KB | Last Updated: July 26, 2018
Learning Session 2 April 12, 2018
Watch the Recorded Presentation
Learning Session 2 Presentation
CMS Change Bundle: Prevent HAIs
Infection Prevention and Control Assessment Tool for Long-term Care Facilities
SHEA/APIC Guideline: Infection Prevention and Control in LTC
Action Period 2 (Sept. 2017 – March 2018)
Focus: Composite Score Improvement
Download the audio from the call
Preview: Nursing Home Composite Score Calculator
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1.13 MB | Last Updated: August 30, 2018
Preview: Nursing Home Composite Score Calculator Instructions
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647.61 KB | Last Updated: July 20, 2015
Focus: Infection Prevention and Antibiotic Stewardship Email
Preview: AP2 Focus Sharing Call
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3.08 MB | Last Updated: March 8, 2018
Preview: Antibiotic Stewardship Toolkit for Nursing Homes
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558.21 KB | Last Updated: December 12, 2017
Podcasts:
Beverly Carnal, Director of Education for Tennessee Health Management, shares with us how she is prepared for an auditor to review her infection prevention plan. Listen Here
Hope Forderhase with the Tennessee State Survey Agency shares what she is looking for in a home’s infection prevention plan. Listen Here
Lisa Pezent with the Alabama State Survey Agency discusses the top three things she looks for in infection prevention programs. Listen Here
Focus: QAPI Written Plan Email
Mia Sadler from the Alabama State Survey Agency shares the top three things she will be looking for in a QAPI Written Plan. Listen Here
Diane Carter from the Tennessee State Survey Agency shares the top three things she will be looking for in a QAPI Written Plan. Listen Here
Beverly Carnal, Director of Education for Tennessee Health Management, shares with us how she is prepared for an auditor to review her QAPI Written Plan. Listen Here
Learning Session 1 August 10, 2017
Watch the Presentation Recording
Learning Session 1 Presentation
NEW! National Nursing Home Change Package
Podcasts:
Teresa Smucker, Administrator at Healthwin in South Bend, Indiana shares how her team communicates well and emphasizes teamwork in their daily tasks. Listen Here
Josephina Batton, the director of nursing at Waters of Union City in Union City, Tennessee shares how she used the atom Alliance QAPI Written Plan How To Guide to draft her required performance improvement plan. Listen Here
atom Alliance QAPI Written Plan How To Guide
Kickoff Webinar April 13, 2017
Kickoff Webinar Video Recording
Collaborative II Kickoff Webinar Presentation
A Step in the Right Direction – Ave Maria Home Success Story Video
Preview: QAPI Written Plan How-To Guide
Download
1.02 MB | Last Updated: March 14, 2017
Beverly Carnal, Director of Education for Tennessee Health Management, shares with us how she is prepared for an auditor to review her infection prevention plan. Listen Here
Hope Forderhase with the Tennessee State Survey Agency shares what she is looking for in a home’s infection prevention plan. Listen Here
Lisa Pezent with the Alabama State Survey Agency discusses the top three things she looks for in infection prevention programs. Listen Here
Mia Sadler from the Alabama State Survey Agency shares the top three things she will be looking for in a QAPI Written Plan. Listen Here
Diane Carter from the Tennessee State Survey Agency shares the top three things she will be looking for in a QAPI Written Plan. Listen Here
Beverly Carnal, Director of Education for Tennessee Health Management, shares with us how she is prepared for an auditor to review her QAPI Written Plan. Listen Here
Teresa Smucker, Administrator at Healthwin in South Bend, Indiana shares how her team communicates well and emphasizes teamwork in their daily tasks. Listen Here
Josephina Batton, the director of nursing at Waters of Union City in Union City, Tennessee shares how she used the atom Alliance QAPI Written Plan How To Guide to draft her required performance improvement plan. Listen Here
Here are some recorded consultations that you may find useful: http://mpqhf.com/QIO/quality-improvement-tools-resources/nursing-home-quality-improvement-tools-resources/
Consult I: https://youtu.be/kb24LwjUvnE
Consult II: https://youtu.be/ESnkrY6cEXA
Preview: Incontinence Management for Nursing Home Residents
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199.38 KB | Last Updated: August 3, 2017
Preview: Change Bundle: Avoidance of Unnecessary Antipsychotic Medications in Nursing Home Residents Living with Dementia
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43.03 KB | Last Updated: July 15, 2015
Preview: Change Bundle: To Encourage Nursing Home Residents' Mobility
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34.80 KB | Last Updated: July 15, 2015
Preview: Change Bundle: To Prevent Healthcare Acquired Infections.
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41.81 KB | Last Updated: July 15, 2015
Preview: Change Package Strategy 1: Lead with a Sense of Purpose
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733.37 KB | Last Updated: July 15, 2015
Preview: Change Package Strategy 2: Recruiting and Retaining Quality Staff
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934.02 KB | Last Updated: July 15, 2015
Preview: Change Package Strategy 3: Connect with Residents
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1.02 MB | Last Updated: July 15, 2015
Preview: Change Package Strategy 4: Nourish Teamwork and Communication
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225.46 KB | Last Updated: July 15, 2015
Preview: Change Package Strategy 5: Be a Continuous Learning Organization
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432.53 KB | Last Updated: July 15, 2015
Preview: Change Package Strategy 6: Provide Exceptional Compassionate Care That Treats the Whole Person
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335.15 KB | Last Updated: July 15, 2015
Preview: Change Package Strategy 7: Construct Solid Business Practices
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230.32 KB | Last Updated: July 15, 2015
Person-Centered Care
Missouri LANE Webinar Series
Monday, September 21, 2015
Opening Our Eyes to a Person-Directed Culture
Webinar: Advancing Excellence MOLANE Webinar Series Getting Into Action Person-Centered Culture #1
Handout: MOLANE and MC5 Webinar Person Centered Culture #1 9-21-15.pdf
Website: MOLANE Resources
Thursday, October 1, 2015
Communicating in a Person-Directed Culture
Webinar: Person-Centered Culture Webinar Oct 1 2015
Handout: MOLANE & MC5 Webinar Series Person Centered Culture #2
Website: MOLANE Resources
Tuesday, October 27, 2015
Rolling Out the Person-Centered Care Tool with Advancing Excellence
Webinar: Webinar #3 Oct 27 2015
Handout: Handout of AE MOLANE Presentation PCC goal
Website: MOLANE Resources
Thursday, November 5, 2015
Learning from the Experts: Using Data to Improve Care with Abramson Center, Pennsylvania
Webinar: Learning from the Experts Person Centered Care Nov 5 2015
Handout: Advancing Excellence/Missouri LANE Webinar Updated #4
Website: MOLANE Resources
QAPI
Preview: QAPI Written Plan How-To Guide
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1.02 MB | Last Updated: March 14, 2017
12 Steps to QAPI
Four recorded webinars provide on-demand insight and instruction on how to implement the 12 Steps to QAPI in your facility. These webinars outline the principles of QAPI and review the following resources to help you with implementation:
- QAPI at a Glance
- QAPI Companion Guide
- Nursing Home Change Package
Learn about the action steps to QAPI, proven change concepts, quality improvement tools and practical implementation tips. Watch them at your convenience on your own time.
MDS 3.0 QM User’s Manual Version 10
The MDS 3.0 QM User’s Manual V10.0 contains detailed specifications for the MDS 3.0 quality measures, including the six new measures.
An 11 minute recorded webinar entitled Quality Assurance and Performance Improvement (QAPI) Self-Assessment, intended for nursing home QAPI leaders, is available for you to use and share. This webinar discusses the value of the QAPI Self-Assessment and provides an overview of how to complete a QAPI Self-Assessment and use the results to implement and monitor QAPI broadly in an organization. This is presented by Jane Pederson MD, MS, Geriatrician & Nursing Home Subject Matter Expert, Quality Innovation Network-National Coordinating Center Team, Chief Medical Quality Officer, Stratis Health.
The recording, slides, and transcript are available here: http://www.healthcarecommunities.org/Communities/MyCommunities/QIO11thSOW/QIN-QIO/Documents.aspx?CategoryID=832265&EntryID=93112
QAPI Companion Guide
Antipsychotics
AE/ National Partnership to Improve Dementia Care Resources
Hand in Hand: A Training Series for Nursing Homes
Available as a self-paced training as well as an instructor-led course and may be accessed using the links below. The self-paced training may take approximately 24 hours to complete.
This training focuses on caring for residents with dementia and on preventing abuse. CMS, supported by a team of training developers and subject matter experts, created this training to address the need for nurse aides’ in-service training on these important topics.
Hand in Hand: A Training Series for Nursing Homes Online
Hand in Hand: A Training Series for Nursing Homes Download
Role of Geriatric Psychiatry in Caring for Persons with Dementia, MP3 audio file
Geriatric Psychiatry Dementia Care Transcript
Geriatric Psychiatry Role Dementia Care Brochure
Preview: Change Bundle: Avoidance of Unnecessary Antipsychotic Medications in Nursing Home Residents Living with Dementia
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43.03 KB | Last Updated: July 15, 2015
Increasing Mobility
Preview: Joint Commission: Preventing Falls and Fall-Related Injuries in Health Care Facilities
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130.24 KB | Last Updated: October 8, 2015
Preview: Elements of Pressure Ulcer Prevention - a Discussion and Evaluation
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1.11 MB | Last Updated: August 25, 2015
Preview: Change Bundle: To Encourage Nursing Home Residents' Mobility
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34.80 KB | Last Updated: July 15, 2015
Person-Centered Care
Managing Personality and Behavior Changes (PDF)
Preview: Person-Centered Care Webinars and Resources from the Missouri LANE
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5.06 MB | Last Updated: January 14, 2016
Resident/Family/Beneficiary Engagement
Preview: A Process for Care Planning & Resident Choice
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2.21 MB | Last Updated: November 2, 2015
Preview: Antibiotic Stewardship Toolkit for Nursing Homes
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558.21 KB | Last Updated: December 12, 2017
The Core Elements of Antibiotic Stewardship for Nursing Homes (CDC Webpage)
Practical ways to initiate or expand antibiotic stewardship activities in nursing homes
Preview: Antibiotic Stewardship Assessment
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195.29 KB | Last Updated: September 5, 2017
Preview: Hand Hygiene Assessment
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158.73 KB | Last Updated: September 5, 2017
Preview: Environmental Cleaning Assessment
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352.43 KB | Last Updated: September 5, 2017
Nursing Home CDC Core Elements of Antibiotic Stewardship
Nursing Home CDC Core Elements Antibiotic Stewardship Appendix A
Nursing Home CDC Core Elements Antibiotic Stewardship Appendix B
Nursing Home CDC Core Elements Antibiotic Stewardship Checklist
Long-Term Care NHSN Enrollment Checklist
Nursing Home Antimicrobial Stewardship Guide
NHSN Tip Sheet (Add new facility administrator)
Tip Sheet: Entering CDI even in NHSN
Tracking and Reporting CDI in Nursing Homes (Webinar)
After you’re registered with NHSN, you need to get started tracking and reporting your CDI data. This webinar will show you some websites and resources that will help you maintain complete and thorough infection records for your long-term care facility.
You will learn:
- How to use the Advancing Excellence tracking tool
- How to input CDI data for your residents
- How to report CDI data to NHSN
National Healthcare Safety Network Enrollment for LTC Facilities (Webinar)
This presentation provides instruction for enrolling your Long-Term Care facility in the National Healthcare Safety Network (NHSN), the CDC’s Healthcare Associated Infection Tracking System. Entering infection data into NHSN will allow facilities to help establish a national baseline for nursing home C. Difficile rates and subsequently identify goals to improve the quality of care and resident outcomes.
What you will learn
- How to successfully enroll your long-term care facility into NHSN and the Secure Access Management System (SAMS)
- Identify CDC resources to assist in NSHN and SAMS enrollment
Preparing your Long Term Care Facility to Report C. difficile in NHSN (Webinar)
This presentation provides instruction for preparing your long-term care facility to report to the National Healthcare Safety Network (NHSN), the CDC’s Healthcare Associated Infection Tracking System. Entering infection data into NHSN will allow facilities to help establish a national baseline for nursing home C. Difficile rates and subsequently identify goals to improve the quality of care and resident outcomes.
You will learn:
- How to successfully set up for reporting C. diff statistics
- How to create a monthly reporting plan
- How to join groups in NHSN system
Beyond CDI Basics Prevention Strategies: Reaching Across the Continuum of Care to Decrease CDI Events (Webinar Series)
atom Alliance and the Tennessee Department of Health have partnered to develop a five-part Webinar training series for healthcare providers to decrease C. difficile infections (CDI). Topics covered in the series include:
- Testing and Early Detection
- Contact Precautions and hand Hygiene
- Antibiotic Stewardship
- Environmental Cleaning
- Resources Available for Healthcare Providers
Each session includes downloadable presentation slides and a transcript, along with other relevant resources.
Five part series on Antimicrobial Stewardship in Long-term Care Facilities
- Antimicrobial Stewardship and Long-term Care Facilities: Introduction – Video 1 (11 min.)
- What is Antimicrobial Stewardship – Video 2 (10 min.)
- Antimicrobial Stewardship in Long-term Care Facilities – Video 3 (10 min.)
- Stewardship Interventions in Long-term Care Facilities – Video 4 (16 min.)
- Interpreting Clinical Microbiology Reports – Video 5 (15 min.)
QuILTSS Consistent Assignment Webinar Series Session 1
May 18, 2016
Session 1 Webinar Powerpoint Presentation
Q&A Summary from the Kick-Off Webinar
QuILTSS Consistent Assignment Webinar Series Kick-Off
April 20, 2016
Our Iceberg Is Melting: Cartoon
John Kotter: The Heart of Change
Explaining Kotter’s 8-Step Change Model
John Kotter: The Perils of Confusing Management with Leadership
John Kotter: Change Management vs. Change Leadership — What’s the Difference?
John Kotter: Organizational Hierarchy
John Kotter: Leadership
John Kotter: Why Do Change Efforts Lose Momentum?
Do You Know Your Number?
Lake Superior QIN-QIO explains the composite score measure
What Is Palliative Care?
Video: Domestic Lean Goddess PDSA
QAPI Overview Video Presentation
LSSCC Blog
Creative Ways to Teach Infection Prevention in Nursing Homes
Creative Ways to Teach Infection Prevention in Nursing Homes All staff members in a nursing home play an important role in keeping residents safe from infections. They should know some basics about the germs (like bacteria and viruses) which cause infections. They should also know steps they can take to prevent the spread of germs… Read More »
New Resource for Preventing Harm in Nursing Homes
New Resource for Preventing Harm in Nursing Homes One-third of nursing home residents experience an adverse or temporary harm event, and the majority of those are preventable. To raise awareness of nursing home safety and support safer care, the Centers for Medicare & Medicaid Services (CMS) and the Quality Innovation Network National Coordinating Center (QIN-NCC)… Read More »
Vaccinations Protect Residents and Staff, also Affect Nursing Home Composite Scores
Vaccinations Protect Residents and Staff, also Affect Nursing Home Composite Scores Influenza Vaccinations Around 3,500 people die of the flu each year across the nation. An institutional Influenza A outbreak can result in up to 60 percent of the population becoming ill, with 25 percent of those affected developing complications severe enough to result… Read More »
Pain Management for Nursing Home Residents
Pain Management for Nursing Home Residents A high percentage of nursing home residents experience pain that impairs mobility, diminishes quality of life and often goes unrecognized and untreated by healthcare providers. Pain is not a part of normal aging and unrelieved pain can have enormous physiological and psychological effects on residents. Pain management is a… Read More »
Improving Quality Measures in atom Alliance Nursing Homes
When it comes to Composite Scores, the lower the better. Scores are comprised of 13 long-stay quality measures. The Centers for Medicare & Medicaid Services (CMS) has set a national goal for nursing homes to achieve a 6.00 or less. Read More »