Reaching for the Stars: Nursing Home Uses CMS Change Package to Significantly Improve Quality

Roger Mynatt settled into a local Starbucks to drink coffee, get some work done and do a little soul searching. He got his latte, found a good spot to sit and fired up his laptop. The first place he went online was to Nursing Home Compare to check his facility’s star rating.

As Administrator for Jefferson County Nursing Home in Dandridge, Tenn., he was deeply considering the quality of care his facility provides to its residents, prompted by his decision to sign up for the atom Alliance nursing home collaborative—a five-state collaborative designed to improve healthcare quality in nursing homes.

Created by the Centers for Medicare & Medicaid Services (CMS), Nursing Home Compare is a public site that lists detailed information about every Medicare and Medicaid-certified nursing home in the country. The quality of care provided by each facility is indicated by a star rating—one is the lowest and five is the highest (best). He was shocked that out of five stars, his facility only had two.

“My shock went to anger thinking that I was the administrator of a below-average facility, by CMS standards,” Mynatt said.

“If you want to move anywhere with quality you have to commit to continual training to get better.”
~ Roger Mynatt

That’s when he realized he needed help.

That moment of realization is now what he calls his “Starbucks Moment.”

He began looking through the resources on the atom Alliance website where he found the CMS National Nursing Home Change Package. The change package shares successful practices of high-performing nursing homes. It’s a menu of strategies, change concepts and actionable items that any nursing home can use to begin improving quality of care for residents

“The more I read the package, the more excited I became. It was the blueprint I was looking for to make improvements,” said Mynatt.

He spent a week studying the resources and then began implementing some of its best practices at his facility.

“One of the things you hear about top-performing companies throughout the country is that they are learning organizations,” Mynatt said. “If you want to move anywhere with quality you have to commit to continual training to get better.”

Mynatt increased his focus on training. He chose the Hand-in-Hand Toolkit from his stockpile of resources. CMS Hand in Hand is a training series for nursing homes that offers person-centered care training designed to help staff work with dementia residents and to prevent abuse. Mynatt used it to re-train staff and implemented it broadly throughout the facility.

The Nursing Home Change Package also includes sample practices and policies that facilities can use. He took one idea from the package and tweaked it to create a solutions team that he calls the “Red Team.” This team is comprised of 12 positive and motivated staff members from different departments dedicated to finding solutions to any problems that arise.

Mynatt’s Red Team

Now the Red Team meets regularly and has been able to solve some sizable problems in the facility. For example, one shower room never had heaters added during a recent renovation. The Red Team identified the problem and brought it to the administration’s attention. As promised when the Red Team was created, problems and their suggested solutions are taken seriously and acted upon. The shower was promptly repaired.

Mynatt has come to rely on the Red Team for honest feedback, frank discussions and viable solutions leading to measurable quality improvement.

“We’re working hard to become a learning organization and we are seeing results,” Mynatt said.

In May 2015, Jefferson County Nursing Home’s composite score was 9.0. Composite scores are generated from 12 quality measures reported by the nursing home to CMS. The national goal established by CMS for nursing homes is 6.0. The national average is 8.4. In less than a year, Jefferson County had lowered their score from 9.0 to 6.4.

In addition to significant composite score improvement, he saw an increase in their national five-star rating from the game-changing “Starbucks Moment.” Mynatt had expected the facility to gain only one star, but it gained two, increasing from two to four stars in just under a year.

And they’re not done yet. The team is striving to continuously improve for their residents so they can reach that fifth and final star.

Listen to Roger Mynatt’s story, which details more ideas he used at Jefferson County Nursing home to foster improvement.

Contracted by CMS, atom Alliance works in Alabama, Indiana, Kentucky, Mississippi and Tennessee to improve the quality of care. Learn more at

Leave A Comment