How to Support Effective Quality Improvement in Nursing Homes

How to Support Effective Quality Improvement in Nursing Homes

Why It Matters

The IHI innovation team made some surprising discoveries while researching ways to increase adoption of QI practices in nursing homes.


Health care regulations are meant to enforce the standards necessary to provide safe care to all patients. Sometimes, however, regulations can be a burden and lead to an overemphasis on compliance at the expense of improvement.

This was the concern the Institute for Healthcare Improvement (IHI) innovation team had when we were developing a theory of change on activities needed to increase adoption of effective quality improvement (QI) practices in US nursing homes. We wondered if the heavy regulations imposed on the industry could be counterproductive to QI.

Interestingly, many of our interviewees told us that Quality Assurance and Performance Improvement (QAPI) regulations are not contributing to the quality problem in nursing homes. In fact, prior to its being so highly regulated, the nursing home industry was more susceptible to care deficiencies. The QAPI regulations might be complicated and in need of simplification, but the regulations themselves are not problematic.

However, a consequence of a system that penalizes infractions — rather than investigates them as potential learning opportunities — can be seen in what one of our interviewees provocatively called a “surplus of safety.” To be clear: Errors, negligence, and risk-taking that has the potential to cause harm are serious and require diligent management. But we heard in our expert interviews that the focus on avoiding citations or potential penalties can be pushed to the point of making compromises when it comes to residents’ quality of life and staff well-being.

Why Focus on Nursing Homes?

The request to conduct this innovation cycle came directly from IHI President and CEO Kedar Mate because the COVID-19 pandemic put the issue of nursing home quality into sharp relief. IHI wanted to expand upon what we had learned from the COVID-19 Rapid Response Network for Nursing Homes we launched in 2020 with support from The John A. Hartford Foundation.

In addition, the National Academies of Sciences, Engineering, and Medicine (NASEM) published a consensus study in 2020 on US nursing home quality and safety called The National Imperative to Improve Nursing Home Quality. The study makes wide-ranging recommendations for improving the quality of care in nursing homes, noting, “The COVID-19 pandemic…[revealed] and [amplified] long-existing shortcomings in nursing home care such as inadequate staffing levels, poor infection control, failures in oversight and regulation, and deficiencies that result in actual patient harm.”

Two of the seven goals outlined in the NASEM report are focused specifically on quality improvement and the quality assurance and performance improvement regulations specific to nursing homes. The pandemic has also brought more attention to equity issues, staffing and funding challenges, and other factors that contribute to quality. As it has for the rest of health care, COVID has sounded the alarm for nursing homes.

Key Findings

To quote W. Edwards Deming, every system is perfectly designed to get the results it gets. What systems can we put into place to better support the health and well-being of nursing home residents and empower staff to speak up about risks or deficiencies without fear of reprisal? Instead of focusing solely on adherence to requirements, what would help staff create new and person-centered ways of working and partnering with residents and families? Our research highlighted the following key points about supporting adoption of effective QI practices in US nursing homes:

  • Capitalize on the strengths of nursing home staff. Because nursing homes often serve as long-term homes for residents, staff have more time than they do in hospitals to build relationships and provide person-centered care. Encouraging staff to address opportunities for improvement in partnership with residents, families, and care partners could build on that foundation while improving residents’ quality of life and staff well-being.
  • Relentlessly focus on practicality. Any effort to promote QI in nursing homes must demonstrate respect for the dedicated staff who work in these highly constrained circumstances. It should be clear how improvement methods can immediately be applied to nursing home-specific challenges, including pressure sores or infection control. Given how difficult it is to take time away from day-to-day responsibilities, how can we provide compensated time specifically dedicated to training? Certain kinds of training and professional development opportunities could reduce turnover and, therefore, be cost effective.
  • Recognize and respect the concerns and motivations of nursing home staff. There is a lot of stress and pressure related to meeting regulatory requirements. Nursing home staff, understandably, want to know what they have to do to avoid being penalized. Being mindful of what is driving actions helps us understand what can drive change.
  • Develop and support a robust and resilient culture of safety and inquiry. A commitment to developing and sustaining a transparent and quality improvement-oriented culture must be maintained. This is crucial even in times of crisis and constraint when it might naturally be assumed that leadership, culture, and staff development should take a backseat to pressing day-to-day demands. We heard in interviews that times of strain are, in fact, critical moments in which to invest in organizational culture and staff development.
  • Build trusting and supportive relationships with engaged leaders. A recent article in the Journal of Nursing Care Quality summarizing “positive deviant” leadership and staffing strategies in Missouri long-term care facilities described how some organizations stood out among their peers: “Leaders were persistent and consistent in their communication, making sure every staff member’s every question was answered. They were flexible with staff about time off for family needs and generous in supporting staff when they or their family had COVID-19. Caring for staff, going the extra mile to support them, and being flexible with staff’s situations generated reciprocity. Staff, in turn, took the extra shifts to cover for workmates and pitched in to make each day work. Leaders’ commitment generated staff’s commitment.”
  • Do not assume you know best without specialized knowledge of nursing homes. Nursing homes are already inundated with materials designed to help explain quality concepts and QAPI regulations, so toolkits and general guidance documents are insufficient. Nursing home staff members also tend to be wary of academics or consultants who arrive to “fix” an organization without taking the time to acknowledge its specific strengths and challenges.

One of the most important things we noted during our research was how motivated nursing home staff are to make residents’ experience as positive as possible. They work hard to create home-like environments with often limited resources. We hope future improvement work capitalizes on this dedication to make nursing homes high-quality places to live and receive care.

Marina Renton, MPhil, is an IHI Innovation and Design Research Associate.

You may also be interested in:

IHI report - Enhancing Quality Improvement Adoption in US Nursing Homes

Driving the Urgent Need to Improve Nursing Home Care