Specialized Information for:

Nursing HomesAssisted Living/Board & Care Home and Community Based Services

Quality Initiatives

This page contains information on ongoing quality initiatives happening in nursing homes across the country, as well as resources and examples of how long-term care ombudsmen can get involved.

Advancing Excellence in America's Nursing Homes

The Advancing Excellence Campaign started as a two-year national campaign to address quality in nursing homes. A kickoff summit meeting was held September 29, 2006. The campaign stakeholders represent consumers, providers, caregivers, health care practitioners and professionals, medical and quality improvement experts and government agencies.

Vist NORC's Advancing Excellence issue page for more information and resources.

Resources for Long-Term Care Ombudsmen
LTC Ombudsman Programs across the country are involved in The Advancing Excellence Campaign in their states. Materials developed by the ombudsman program as part of their campaign efforts include:

Ombudsman Best Practices
The State of Oregon Long-Term Care Ombudsman Office, led by State Ombudsman, Mary Jaeger, developed a set of four “Ask the Ombudsman” webinars for Oregon long-term care facility providers. Technical support and CEU management is coordinated by Oregon Health Care Association (OHCA). (2011)

Quality Assurance Performance Improvement (QAPI)

Quality Assurance Performance Improvement (QAPI) is an initiative undertaken by the Center for Medicare and Medicaid studies to expand improvement activities in nursing homes. The provision is included in the Affordable Care Act and states that QAPI programs shall develop regulations that help facilities meet new established standards. The QAPI program also gives CMS  the opportunity to find the best practices in nursing home quality , identiy areas of need and advancement, and expand the level of activites currently required by the existigng Quality Assesment and Assurance provision. Below are resources to help better understand the Quality Assurance Performance Improvement initative.

Visit NORC's QAPI issue page for more information and resources, including factsheets, training materials and resources developed by CMS.

Resources for Long-Term Care Ombudsmen

Quality Assurance and Performance Improvement (QAPI) Dialogue between State Ombudsmen and CMS (November 2012)
During this dialogue, Alice Bonner provided an update on the timeline for implementing QAPI, an overview of what they learned from the pilot projects in 17 nursing homes, CMS’s expectations for facilities, and the role of QIOs.



Quality Assurance & Performance Improvement, Root Cause Analysis and the Model for Improvement
The Texas LTCOP conducted a training on QAPI with an emphasis on root cause analysis. Melody Malone from the Texas Quality Improvement Organization presented.  The materials from the training are below:



MDS 3.0

The MDS (Minimum Data Set) is a tool for implementing standardized assessment and for facilitating care management in nursing homes (NHs) and non-critical access hospital swing beds (SBs). Its content has implications for residents, families, providers, researchers and policymakers. MDS 3.0 has been designed to improve the reliability, accuracy and usefulness of the MDS, to include the resident in the assessment process and to use standard protocols used in other settings.

Visit NORC's MDS 3.0 issue page for more information and resources, including factsheets, training materials and resources developed by CMS.

Resource for Long-Term Care Ombudsmen

Fact Sheet for Long-Term Care Ombudsmen: MDS 3.0 Section Q (November 2010)

The Impact of MDS 3.0/Section Q Implementation
Since the implementation of MDS 3.0 in October 2010, the Ombudsman Resource Center and the Administration on Aging (AOA) has been seeking information regarding the impact of MDS 3.0, specifically Section Q, on residents and the Ombudsman program. The Center solicited information through quarterly questionnaires and shared information with the Ombudsman network, AOA, and the Centers for Medicare and Medicaid Services (CMS). The information gathered from these questionnaires will be used by NORC, AOA, and CMS to provide support and training to ombudsman programs and entities designated as local contact agencies as they assist residents in transitioning out of nursing homes.

Questionaire Results: 

Information Brief: Changes in the MDS 3.0 for Long-Term Care Ombudsman (September 2010)
This document, by Sara Hunt, MSSW, NORC Consultant, provides long-term care ombudsmen with information about the primary changes in the updated version (3.0) of the Minimum Data Set (MDS). The MDS 3.0 will be used by certified nursing facilities beginning in October 2010. This document focuses on the changes that are most applicable to ombudsman advocacy, educational and empowerment activities with residents and families. For a more thorough understanding of the resident assessment and care planning process and how ombudsmen can use these as advocacy tools, refer to Using Resident Assessment and Care Planning As Advocacy Tools: A Guide for Ombudsmen and Other Advocates. Additional resources are included under Resources in this document.

CMS Presentation on MDS 3.0 and Section Q from the 2010 Annual State Ombudsman Training Conference
CMS presented on the implementation of nursing home (NH) minimum data set (MDS), version 3.0 and Section Q, which asks a resident’s expectations about transitioning out of a facility. The session provided information on the impact of the MDS 3.0 Section Q and the ombudsman program’s unique role in this process. Ombudsmen will have the opportunity to work with partners across many LTC settings as they advocate for NH consumers who want to talk with a community agency to learn about community care and supports. Ombudsman will provide information to State NH surveyors if referral and/or discharge planning issues are identified.

Presenter: Mary Beth Ribar, MS, RN, Centers for Medicare and Medicaid Services, Center for Medicaid & State Operations, Division of Advocacy & Special Initiatives


National Partnership to Improve Dementia Care in Nursing Homes

CMS is partnering with federal and state agencies, nursing homes, other providers, advocacy groups, and caregivers to improve comprehensive dementia care.  CMS and its partners are committed to finding new ways to implement practices that enhance the quality of life for people with dementia, protect them from substandard care and promote goal-directed, person-centered care for every nursing home resident.  The Partnership promotes a multidimensional approach that includes public reporting, state-based coalitions, research, training and revised surveyor guidance.

Click here to visit the CMS website and learn more about the partnership.

Visit NORC's Dementia Care issue page for more information and resources.

Culture Change

ulture change is a movement that seeks to create an environment for residents, which follows the residents' routines rather than those imposed by the facility; encourages appropriate assignments of staff with a team focus to make deep culture change possible; allows residents to make their own decisions; allows spontaneous activity opportunities; and encourages and allows residents to be treated as individuals. Deep culture change is an important component of the right of residents to “care and services to attain or maintain the highest practicable physical, mental and psychosocial well being;” as promised in the 1987 Nursing Home Reform Law. It is the role of the Ombudsman to advocate for residents and their right to make choices to direct their care and life in long-term care facilities.

Visit NORC's Culture Change issue page for more information and Resources

Resources for Long-Term Care Ombudsmen

Culture Change Resources (NORC 2012)

LTCOP Innovative Practices: Incorporating Person-Centered Care in Ombudsman Training, Complaint Investigation and Advocacy  (October 2012)
This webinar is designed to help ombudsmen think about applying person centered care principles to the role of the ombudsman in advocacy and program management. The presentations delve into the gray areas around avoiding the perception of being more of a provider advocate than a consumer advocate, resource allocation, and teaching ombudsmen how to apply the principles to their ongoing work.

The Role of the LTC Ombudsman in Culture Change: Promoting Resident Directed Care in Nursing Homes and Assisted Living (NORC 2007)
This resource brief is designed to generate ideas about how long-term care ombudsmen can promote systemic, resident-directed care practices in facilities. Included are examples of state and local ombudsman program involvement in promoting culture change practices, offers tips for ombudsman advocacy, discusses the role of the ombudsman and lists salient resources.

Ombudsman Best Practices: Supporting Culture Change to Promote Individualized Care in Nursing Homes (NORC 2000)
This paper presents long-term care ombudsman practices in supporting culture change in nursing homes, drawing on lessons learned by State Ombudsman Programs that have engaged in such initiatives. It includes an overview of the issues, relevant practice precedents and examples of best practice. The section “Lessons Learned” examines important considerations for state and local ombudsmen who want to begin or continue culture change efforts.

LTCOP Innovative Practices: Incorporating Person-Centered Care in Ombudsman Training, Complaint Investigation and Advocacy Intensive

Culture Change Inservice Training (NORC)

Texas Long-Term Care Ombudsman Initial Certification Training Manual: Module 10- Resident-Directed Care and Module 11- Systems Advocacy

Ombudsman Best Practices

The SLTCOP has created, conducts, and leads a regional culture change coalition of PSA. (2011)

During the last year, the Ombudsman Program has worked to introduce culture change in a variety of arenas so that the term becomes a part of policy discussions and so the concept would be utilized more frequently in long term care facilities – nursing homes and assisted living facilities. The Department of Aging also worked to develop Maryland’s first GreenHouse and promoted other culture change activities.

Ombudsman steps included: participating in the development of Maryland’s Alzheimer’s Statewide Plan that was legislatively mandated to guide the Governor and other decision makers; encouraging the Alzheimer’s Commission to include in the plan the development of a Culture Change Coalition, language about the importance of person centered/directed care, and training for all facilities in successful practices that are resident focused; identifying an expert in Culture Change to present at the legislatively mandated Nursing Home and Assisted Living Oversight Committee; encouraging statewide conferences to include sessions on Culture Change (GSA, etc.); holding meetings at facilities that incorporate comprehensive culture change so that participants can see firsthand this kind of model; and identifying retired persons who are interested in Culture Change to participate in the development of a Coalition.

The initial meeting to form a Culture Change Coalition will be held April 2013. The Ombudsman Program took the lead on the administrative work including sending out invitations, keeping a list of interested persons, etc. Two local ombudsmen were identified to participate in the forming of a coalition. There is increased excitement and interest in Culture Change including possible inclusion in the Medicaid incentive program. (2013)

The Ohio program is using Civil Money Penalty funds to improve person-centered care in nursing homes. Each of twelve regional ombudsman programs applied to the state ombudsman for funds to work with individual homes on person-centered strategies. The program is also using funds to enhance training for ombudsmen to use root cause analysis so that resolution of complaints is person-centered. (2011)

After hearing about TimeSlips, a creative storytelling process for people with dementia, developed at the University of Wisconsin Milwaukee, a staff ombudsman educated facility staff about the benefits of person-centered activities and encouraged staff to implement these principles on an ongoing basis. (2011)

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