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5 Whys Tool - a Root Cause Analysis Tool
This Root Cause Analysis (RCA) template will allow facilities to use as a tool to identify and work through the process of doing a RCA.
Adobe PDF    Date Added: 07/24/2012    Date Last Modified: Nov 18 2021 10:19AM  
Adverse Events in Nursing Homes
CMS has added the February 2014 OIG report on Adverse Events in SNFs as well as a listing of Potentially Preventable Adverse Events, the Adverse Drug Event Trigger Tool, Acronyms Related to Adverse Events & a comment they will add more tools and resources.
Web link    Date Added: 02/06/2017    Date Last Modified: Feb 6 2017 12:00AM  
Adverse Events in Skilled Nursing Facilities: National Incidence Among Medicare Beneficiaries
This study from the Department of Health and Human Services found an estimated 22 percent of Medicare beneficiaries experienced temporary harm events during their skilled nursing facility stays, with 59 percent of these events being preventable.
Adobe PDF    Date Added: 04/25/2014    Date Last Modified: Jun 11 2020 1:27PM  
Appendix PP – CMS State Operations Manual, Guidance to Surveyors for Long-Term Care Facilities
Appendix PP of the CMS State Operations Manual offers day-to-day operating instructions, policies and procedures as a guide to surveyors of long-term care facilities.
Adobe PDF    Date Added: 05/21/2014    Date Last Modified: May 21 2014 12:00AM  
Care Compare
Care Compare has detailed information about Medicare and Medicaid-certified nursing homes. This is a government site.
Web link    Date Added: 01/05/2015    Date Last Modified: Apr 21 2022 7:37AM  
Change Package: National Nursing Home Quality Care Collaborative - Individual Sections
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 Innovation Network Quality Improvement Organizations (QIN-QIOs), to improve care for the millions of nursing home residents across the country.
Adobe PDF    Date Added: 12/15/2014    Date Last Modified: Dec 15 2014 12:00AM  
Domestic Lean Goddess - Clothing Processing Center – Eliminating Waste
This video shows how to eliminate the seven wastes: Waiting, Overproduction, Rework, Motion, Processing, Inventory and Transportation. Nursing home staff can view this video to better understand how to make process improvements within their organization.
Web link    Date Added: 12/29/2013    Date Last Modified: Dec 29 2013 12:00AM  
Domestic Lean Goddess Video - PDSA
This video shows how applying the four steps of the Plan-Do-Study-Act (PDSA) cycle pinpoints the root cause of a problem and provides a method for achieving improvement, even in a domestic situation. Nursing home staff can view this video to better understand how to use the PDSA cycle to help improve processes within their organization.
Web link    Date Added: 07/23/2013    Date Last Modified: Jul 23 2013 12:00AM  
Facility Assessment Tool
The Centers for Medicare & Medicaid Services - through the Quality Improvement Organization program - has posted a facility assessment tool template to its website for nursing facilities to download and use. According to the U.S. Code of Federal Regulation (§483.70(e)), nursing facilities will conduct, document and annually review a facility-wide assessment, which includes both the facility's resident population and the resources the facility needs to care for its residents. It is optional for nursing facilities to use this template, and if used, it may be modified. Each facility has the flexibility to decide the best way to comply with this requirement.
Web link    Date Added: 11/15/2020    Date Last Modified: Nov 13 2020 2:02PM  
Fishbone Diagram 2
Use this Fishbone Diagram to help your organization conduct a Root Cause Analysis (RCA). Note that there are three different versions of this tool, please pick the version that works best for your facility.
Adobe PDF    Date Added: 06/01/2014    Date Last Modified: Jun 1 2014 12:00AM  
Fishbone Diagram 3
Use this Fishbone Diagram to help your organization conduct a Root Cause Analysis (RCA). Note that there are three different versions of this tool, please pick the version that works best for your facility.
Adobe PDF    Date Added: 06/01/2014    Date Last Modified: Jun 3 2020 5:00PM  
Fishbone Diagrams 1
Use this Fishbone Diagram to help your organization conduct a Root Cause Analysis (RCA). Note that there are three different versions of this tool, please pick the version that works best for your facility.
Adobe PDF    Date Added: 06/01/2014    Date Last Modified: Jun 1 2014 12:00AM  
Five Elements of QAPI
This tool provides information on the five elements of a Quality Assessment and Performance Improvement (QAPI) program that nursing facilities can use to adhere to QAPI practices.
Adobe PDF    Date Added: 07/30/2012    Date Last Modified: Jul 30 2012 12:00AM  
Five-Star Quality Rating System
Learn more about the Five-Star Quality Rating System that the Centers for Medicare & Medicaid Services (CMS) created to help consumers compare nursing homes more easily.
Web link    Date Added: 07/22/2013    Date Last Modified: Jul 22 2013 12:00AM  
Five-Star Quality Rating System Technical Users’ Guide
Learn more about the Five-Star Quality Rating System that the Centers for Medicare & Medicaid Services (CMS) created to help consumers compare nursing homes more easily.
Web link    Date Added: 07/22/2013    Date Last Modified: Nov 7 2019 5:21PM  
Goal Setting Worksheet (Word)
This worksheet is intended to help Quality Assurance and Performance Improvement (QAPI) teams establish appropriate goals for individual measures and performance improvement projects.
Microsoft Word    Date Added: 11/04/2013    Date Last Modified: Nov 4 2013 12:00AM  
Guide for Developing a QAPI Plan
This Quality Assurance and Performance Improvement tool provides step-by-step directions for developing a QAPI plan for your organization.
Adobe PDF    Date Added: 06/18/2013    Date Last Modified: Jun 18 2013 12:00AM  
Guide for Developing Purpose, Guiding Principles, and Scope for QAPI
This Quality Assurance and Performance Improvement (QAPI) tool can be used to establish the purpose, guiding principles and scope for QAPI in your organization.
Adobe PDF    Date Added: 06/17/2013    Date Last Modified: Jun 17 2013 12:00AM  
Instructions to Develop a QAPI Dashboard
These instructions will assist you in developing a dashboard, which can be helpful way to monitor the progress of Quality Assurance and Performance Improvement (QAPI) in your organization by tracking key performance indicators.
Adobe PDF    Date Added: 09/18/2017    Date Last Modified: Sep 18 2017 12:00AM  
MDS 3.0 Quality Measures User's Manual
The user's manual covers the Centers for Medicare & Medicaid Services MDS 3.0 quality measures. Scroll to the bottom of the page to access the full user's manual.
Web link    Date Added: 03/23/2012    Date Last Modified: Mar 23 2012 12:00AM  
MDS Resources for Texas HHS Service Providers
This Texas Health and Human Services website provides links and resources for MDS completion. It also includes links to other state’s MDS websites.
Web link    Date Added: 06/01/2014    Date Last Modified: Jun 1 2014 12:00AM  
Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual
Find the current version of the RAI Manual in the Download section of the CMS webpage.
Web link    Date Added: 05/23/2013    Date Last Modified: Nov 7 2019 5:15PM  
QAPI at a Glance: A Step by Step Guide to Implementing Quality Assurance and Performance Improvement (QAPI) in Your Nursing Home
This step-by-step guide, developed by the Centers for Medicare & Medicaid Services (CMS), is a resource for nursing homes striving to embed QAPI principles into their daily work of providing quality care and services.
Adobe PDF    Date Added: 06/26/2013    Date Last Modified: Jun 26 2013 12:00AM  
QAPI Land
Download and display this brightly-colored Quality Assurance and Performance Improvement (QAPI) road map where all of your team members can see and access it. This document was designed to help your facility develop and implement a QAPI program.
Adobe PDF    Date Added: 12/16/2013    Date Last Modified: Dec 16 2013 12:00AM  
QAPI Land Caution Checklist
Use this two-page document as a guide for you and your team as you move through the steps outlined in the QAPI Land document, which is also available in the Resource Library as a PDF.
Adobe PDF    Date Added: 12/16/2013    Date Last Modified: Jan 6 2020 4:56PM  
QAPI Leadership Rounding Guide
Use this guide to implement leadership rounding in your facility, a process in which leaders speak directly with staff and residents about their organization’s services and care. This resource will help you monitor your progress in Quality Assurance Performance Improvement (QAPI) initiatives.
Adobe PDF    Date Added: 09/15/2017    Date Last Modified: Sep 15 2017 12:00AM  
QAPI News Brief
In this first issue of the QAPI News Brief, read a definition of Quality Assurance and Performance Improvement (QAPI), and learn about the 5 Elements of QAPI.
Adobe PDF    Date Added: 11/11/2013    Date Last Modified: Nov 11 2013 12:00AM  
QAPI Self-Assessment Tool
This Quality Assurance and Performance Improvement self-assessment tool can be used for evaluation of your organization's progress.
Adobe PDF    Date Added: 06/17/2013    Date Last Modified: Jun 17 2013 12:00AM  
QAPI Written Plan How-To-Guide
This how-to-guide, developed by the Lake Superior Quality Innovation Network, can help nursing homes write their Quality Assurance Performance Improvement (QAPI) plan.
Microsoft Word    Date Added: 09/07/2017    Date Last Modified: Jun 16 2020 10:23AM  
Quality Assurance & Performance Improvement (QAPI) Self-assessment
Nursing homes can use this document to help them work through building their Quality Assurance & Performance Improvement (QAPI) process and plan.
Microsoft Word    Date Added: 09/03/2013    Date Last Modified: Sep 3 2013 12:00AM  
Quality Improvement Example Adverse Drug Event Plan
This quality improvement plan provides an example of how to identify a concern, determine the root cause(s) and develop a plan with outcome measures. This is to be used only as a reference.
Adobe PDF    Date Added: 01/20/2022    Date Last Modified: Jan 24 2022 9:15AM  
Quality Improvement Example Infection Prevention Plan
This quality improvement plan provides an example of how to identify a concern, determine the root cause(s) and develop a plan with outcome measures. This is to be used only as a reference.
Adobe PDF    Date Added: 01/20/2022    Date Last Modified: Jan 20 2022 5:22PM  
Quality Improvement Outcomes Tracking Table
Use this quality improvement tracking Table as a standalone tool or use it to include additional measures to your quality improvement plan.
Adobe PDF    Date Added: 07/22/2021    Date Last Modified: Jul 19 2021 1:12PM  
Quality Improvement Plan
Use this quality improvement plan template as a guide for you and your team to conduct a root cause analysis, develop a plan for interventions and determine outcome measures.
Adobe PDF    Date Added: 07/22/2021    Date Last Modified: Nov 18 2021 10:03AM  
Quality Improvement Plan Table
Use this quality improvement plan table as a stand alone tool or use to include additional areas needing improvement to your Quality Improvement Plan.
Adobe PDF    Date Added: 07/22/2021    Date Last Modified: Nov 18 2021 10:03AM  
Sharing Successes: Successful Nursing Home Strategies for QAPI and Improvements in Antipsychotic and Bowel/Bladder Rates
This webinar features leadership from Grace Living Center - Tahlequah University Northwest, The Renaissance at Kessler and Wedgewood Nursing Home sharing their experiences in implementing successful strategies and interventions for improving bowel and bladder rates, implementing Quality Assurance Performance Improvement (QAPI) and reducing the use of psychotropic medications.
Video    Date Added: 10/16/2018    Date Last Modified: Oct 6 2021 4:15PM  
TeamSTEPPS Long-Term Care

This article provides information on implementing the TeamSTEPPS® program in nursing homes and other long-term care settings.

Web link    Date Added: 04/21/2014    Date Last Modified: Apr 21 2014 12:00AM  
Texas HHS MDS Links and Resources
This Texas Health and Human Services (HHS) website provides links and resources for MDS completion. It also includes links to other state’s MDS websites.
Web link    Date Added: 02/19/2018    Date Last Modified: Feb 19 2018 12:00AM  
Video: Domestic Lean Goddess - The 5 S's of Quality Improvement
Watch this video from the Learning and Action Network National Coordinating Center and discover how applying the 5 S's (Sort, Straighten, Shine, Standardize, Sustain), a quality improvement technique, can improve any work space.
Web link    Date Added: 03/03/2014    Date Last Modified: Mar 3 2014 12:00AM  
Worksheet for Testing Change
This is a tool to help implement the Plan Do Study Act (PDSA) process improvement method. “Plan”: The organization digs deep to determine the root causes that triggered the need for improvement. “Do”: The plan is put into action. “Study”: How well did the plan work? If it worked well, proceed to “act.” If not, go back to “plan” and start over. “Act”: Integrate successful plans into organizational processes.
Adobe PDF    Date Added: 11/22/2011    Date Last Modified: Dec 7 2021 6:30PM  
Worksheet for Testing Change - Spanish
This is a tool to help implement the Plan Do Study Act (PDSA) process improvement method. “Plan”: The organization digs deep to determine the root causes that triggered the need for improvement. “Do”: The plan is put into action. “Study”: How well did the plan work? If it worked well, proceed to “act.” If not, go back to “plan” and start over. “Act”: Integrate successful plans into organizational processes.
Adobe PDF    Date Added: 09/18/2013    Date Last Modified: Dec 7 2021 6:30PM