This material was prepared byTelligen, the QualityInnovation Network National
Coordinating Center, under contract with the Centers for Medicare & Medicaid Services
(CMS), an agencyof the U.S. Department of Health and Human Services. The content
presented does not necessarilyreflect CMS policy 11SOW-QINNCC-00379-08/20/15
Peer Coaching
Resources
National Nursing Home Quality Care Collaborative
August 2015

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The National Nursing Home Quality Care Collaborative (NNHQCC) is led by the Centers for Medicare &
Medicaid Services (CMS) and the Medicare Quality Innovation Network-Quality Improvement
Organizations (QIN-QIOs).
Greetings! I will be your helpful
guide throughout your peer
coaching journey. The following
pages will provide you with the tools
and information to support you and
your efforts. Thank you for agreeing
to be a peer coach! Your efforts are
greatly appreciated.

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INTRODUCTION
The Peer Coaching Resource Packet is intended to be an aid to you in your role as a peer
coach. You will find friendly tips and tools that can be easily read and implemented to support
you in your efforts.
Peer coaches are selected based on personal areas of expertise and passion for the work.
Peer coaches represent diverse levels of nursing home staff, both administrative and direct care, and
represent different locations and types of nursing homes.
Peer coaches may be asked to:
o Provide best practice support for other nursing homes participating in the NNHQCC.
o Assist the QIN-QIO to instill quality improvement methodologies in nursing homes
participating in the NNHQCC.
o Along with the QIN-QIO, foster the creation of quality-centric nursing homes among
your peer nursing homes.
You are an important part of the NNHQCC which strives to:
 Instill quality and performance improvement practices,
 Eliminate Healthcare-Acquired Conditions, and
 Dramatically improve resident satisfaction by focusing on the systems that impact quality such
as:
o Staffing
o Operations
o Communication
o Leadership
o Compliance
o Clinical models
o Quality of life
o Specific, clinical outcomes (such as inappropriate antipsychotic use in persons living
with dementia, falls, pressure ulcers, physical restraints, urinary tract infections, and
healthcare-acquired infections).
You are a very important part of achieving the goal to improve resident care by increasing the
perspective and capability of the people with whom you will engage.
Thank you for agreeing to be a Peer Coach!

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CONTENTS
Introduction ....................................................................................................................................................2
What is Peer Coaching?..................................................................................................................................4
Peer Coaching................................................................................................................................................5
Expectations...................................................................................................................................................6
Session Planning Worksheet ...........................................................................................................................7
Active Listening ..............................................................................................................................................8
Powerful Questions.......................................................................................................................................10
Constructive Feedback..................................................................................................................................12
Establishing Goals ........................................................................................................................................14
Adult Learning Principles...............................................................................................................................16
Learning Styles.............................................................................................................................................17
Practiver Your Skills......................................................................................................................................18
Coaching Evaluation .....................................................................................................................................19
Quality Improvement & QAPI.........................................................................................................................20
QAPI............................................................................................................................................................21
Quality Improvement Process ........................................................................................................................23
Plan-Do-Study-Act (PDSA): Structured QI Process/Approach ..........................................................................24
Quality Improvement – Tips for Success.........................................................................................................25
Quality Improvement Team Problems & Mitigation Strategies ..........................................................................26
References...................................................................................................................................................28
Additional Resources ....................................................................................................................................30
Coaching relationships help people
in organizations take flight--

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WHAT IS PEER COACHING?
Coaching is described as a mentoring function – a relationship that focuses on task and performance-
related skills and the enhancement of specific work competencies.1
Peer coaching is a process where
colleagues work together to build skills, share ideas, reflect on practices, and explore together avenues
to solve issues/problems and improve performance. The peer coach engages the person being
coached in professional dialogue in a safe and respectful environment, actively listening and providing
feedback to improve knowledge, skills, confidence, and competence.
How is coaching different from advising, consulting, mentoring or training?
Advising/Consulting Mentoring/Training Coaching
Expertise in process change or
clinical guidelines
Expertise in a skill, concept, or
area of knowledge
Expertise in developing growth
and leadership in others
Tools: data & reports Tools: knowledge & teaching Tools: provocative questions
Shares with individuals
information on performance,
practice, clinical guidelines and
measurement
Individuals look to the
mentor/trainer for answers and
expertise
Enables individuals to identify
their own strengths, to learn from
their own outcomes, and to take
action
Uses information to initiate
improvement
Develops others’ skills and
knowledge
Develops others’ skills, capacity,
and knowledge
Shows or tells to intervene “Tests the student” Encourages and facilitates
interdependent leadership
Heavily reliant on the
consultant role
Often one-directional limited
growth
Nurtures shared ownership to
decrease dependence on the
coach

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PEER COACHING
The International Coach Federation (ICF)2
defines coaching as partnering in a thought-
provoking and creative process that inspires individuals to maximize their potential.
The ICF has established core coaching competencies to support the skills and
approaches used to coach individuals. These competencies can be used to guide and
support you as peer coach in your relationship with the person you are coaching.
A. Setting the Foundation: establishing expectations for the coaching relationship in terms of time
commitment, setting goals, monitoring actions, discussing how feedback is provided, and how
progress will be tracked or evaluated.
B. Co-Creating the Relationship: establishing trust and creating a supportive environment that
produces ongoing mutual respect and trust.
C. Communicating Effectively: active listening, powerful questioning and direct communication in
sharing and providing feedback.
D. Facilitating Learning and Results: providing best-practice support, instilling quality
improvement methodologies, assisting with planning and goal setting to facilitate learning and
build on successes achieved by the team.
Establishing
Expectations
Establishing
Trust
Communicating
Effectively
Planning &
Goal Setting
Team
Successes

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Coaching relationships can create a climate where knowledge and best practices
can be shared to foster the creation of quality centric nursing homes.
EXPECTATIONS
Coaching is a partnership between committed peers to provide support, foster growth, and instill quality
improvement methodologies. This checklist is intended to be a list of memory-joggers and reminders as
you establish your peer coaching relationship.
 How will we meet/communicate? (In-person, conference call, skype, etc.)
 How often will we meet?
 How long will our meetings last?
 How long are we committing to work together?
 How will we set goals?
 How will we monitor actions between meetings?
 If an email or voice mail is received, what amount of time is needed to respond? (24
hours, 1-2 days, etc.)
 If we are unable to make a scheduled meeting/phone conversation – how shall we
contact each other?
 How will feedback be provided?
 What kind of resources might be provided?
 When and how will we monitor, track or evaluate progress?
 How will we determine success?
 ___________________________________________________________
 ___________________________________________________________
 ___________________________________________________________

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SESSION PLANNING WORKSHEET
This worksheet may help you prepare for, and evaluate, your coaching session.
1. What is the focus of the coaching session? What are the needs of the organization and person
being coached?
2. What are the objectives of your coaching session? What do you want the person you are
coaching to be able to identify, recognize, and do or achieve?
3. Why are these objectives important?
4. What are the opportunities and/or challenges related to the topic of focus?
5. What strategies will best facilitate learning and action?
6. What tools or resources will be needed to support learning and action?
7. What are the next steps, or action plan?
8. How will progress be measured?
Evaluation of coaching session
 What worked?
 What didn’t work? Where are there opportunities for growth or change? What can be done to
help shift the situation?
 What additional tools or resources, if any, will be needed?

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ACTIVE LISTENING
'Active listening' means, as its name suggests, actively listening. That is fully concentrating
on what is being said rather than just ‘hearing’ the message of the speaker. Active
listening involves listening with all senses, as well as giving full attention to the speaker.
Tips for being a good listener3
 Give the speaker your undivided attention
o Look at the person directly.
o Put aside distracting thoughts.
o Avoid being distracted by environmental factors.
 Show that you are listening
o Be a “whole body listener” – hearing the speaker, as well as including eye
contact and intellect.
o Give both nonverbal and verbal signs of listening: nod occasionally, smile and
use other facial expressions.
o Encourage the speaker to continue with small verbal comments like “yes” and
“ah.”
 Provide feedback
o Reflect what has been said by paraphrasing or asking questions to clarify
points.
 Defer judgment
o Allow the speaker to finish each point before asking questions.
o Avoid interrupting with counter arguments.
 Respond appropriately
o Active listening is a model for respect and understanding. You are gaining
information and perspective.
o Be candid, open, and honest in your response.

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Active Listening Skills
Technique What is it? Purpose Example
PARAPHRASING Restating a message,
usually with fewer words.
To test understanding
of what is heard
indicating your
understanding of the
basic message.
“What I’m hearing is…”
or “Sounds like you are
saying…”
CLARIFYING
Process of bringing vague
information into sharper
focus.
To get more
information, identify
what was said, untangle
unclear interpretation.
“You have given me a lot
of information, let me see
if I’ve got it all…”
PERCEPTION
CHECKING
Requesting verification of
perceptions.
To give and receive
feedback or check out
assumptions.
“I would like to
understand you correctly,
when you say ____, is
this what you mean…..?”
SUMMARIZING
Pulling together,
organizing and integrating
major aspects of the
dialogue, putting key ideas
and feelings into broad
statements.
To establish a basis for
further discussion,
pulling together key
facts and feelings.
“The three major points
of our discussion are…”
EMPATHY
Reflection of content and
feeling at a deeper level.
Seeking an
understanding of what
may be deeper feelings.
“I get the sense that you
are frustrated about what
was said, but I am
wondering if you are also
feeling a little hurt by it.”

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POWERFUL QUESTIONS
The usefulness of the knowledge we acquire and the effectiveness of the actions we take depend on the quality of
the questions we ask. Questions open the door to dialogue and discovery. They are an invitation to creativity and
breakthrough thinking. Questions can lead to movement and action on key issues; by generating creative insights
they can ignite change.5
–Vogt, Brown and Isaacs, 2003
A fundamental skill in the coach’s toolbox is the ability to ask powerful questions.
Powerful questions lead to clarity and introspection, bringing about enhanced creativity,
action, and discovery to help reveal additional solutions. They encourage people to
stretch their thinking and increase their insight (vs. making suggestions, giving advice,
or telling the person you are coaching what to do).
A Powerful Question
 Is truly an open-ended question, not
asking for a “yes” or “no” response
 Generates curiosity and thought in the
person being coached, bringing out
underlying assumptions
 Invites introspection
 Inspires greater creativity, insight and
reveals additional solutions
 Does not “lead” to a certain answer
 Generates energy and forward movement
 Evokes more questions
 Helps the person to go forward by shifting
how he/she looks at the situation,
identifying next steps to take, learning
from what works and doesn’t work
 Fosters learning through reflection on
both successes and failures – adults learn
by closely examining their own thinking
Generative Questions
Questions for Evaluating Questions for Integrating Questions for Taking Action
 What is important to you in
this situation?
 What are challenges?
 What are opportunities?
 What additional information
do we need?
 Are there assumptions we
need to explore?
 How else could we look at
this?
 Are there new ideas and
connections that are
emerging for you?
 Have there been “a-ha”
moments or insights that
have surfaced for you?
 Is there anything missing
or needs more clarity?
 What actions could be
taken? (Rather than
“What’s wrong and who’s
responsible?”)
 What are next steps?
 What challenges do you
anticipate and how might
they be addressed?
 What support and/or
resources will be helpful as
you take the next steps?

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As you move from simple yes/no questions to “why” and “what if,” the question stimulates
more reflective thinking and more creative responses.
 Are you talking to…..?
 Which interventions are you using?
 Who is a member of your team? What kind of support do you have from your
leadership?
 What have you tried so far? What has been successful in the past?
 What is it about the process that has enabled success?
 How is that working? How can you tell? How will you…..?
 Can you tell me more about how or why you chose that approach?
 What if you had additional allies – what if the physical therapist served as a champion?
* NOTE: Unless a “Why?”question is carefully constructed, it can evoke a defensive
response and undermine growth. For example, “Why did you do that?” could cause
defensiveness. However, “Why do you think we achieved our goal?” might illicit a
more reflective response.

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CONSTRUCTIVE FEEDBACK
Constructive feedback is information and data driven, focuses on
issues, and inspires action to improve outcomes. Constructive
feedback is not judgmental nor does it place blame on the person,
it is specific and directed toward the action or event.
Feedback Principles
 Ask questions and listen to the response.
 Focus on the issues – not on blaming the person.
 Meet in a quiet place without interruptions.
 Provide feedback in a ‘sandwich’ – start with a positive comment
or observation, focus on what can be improved, then follow with a
positive comment or observation.
 Check for understanding. For example, ask the person to
summarize the discussion.
Constructive Feedback is: Constructive Feedback is not:
 Timely  Critical
 Specific  Personal
 Useful  Ambiguous
 Easy to Understand
 Choose specific
examples
 Gather
information
through
questions
 Share
information
rather than give
advice
 Include positive
messages
 Be descriptive,
not evaluative
 Determine the
key messages
 Focus on the
action or event,
not the person
 Ensure feedback
is objective
FEEDBACK TIPS

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Reframing & Facilitative Questioning
Useful Techniques7
Reframing
 Enables the person you are coaching to view an issue or situation in a new way
 Raises awareness of different perspectives
 Facilitates ‘insight’ and changing perceptions
 Enables the person you are coaching to seek and implement solutions
 Seeks to gain commitment to a change in process
Reframing entails:
 Reflecting back/empathizing
(to show you have heard
what the person you are
coaching said)
 Asking open ended
questions based on How?
or What?
Facilitative Questioning
 Invites interaction
 Encourages exploring
together
 Helps the person you are
coaching reflect on what they
have learned
Examples of Facilitative Questioning
 Tell me more about…
 Can you please describe for me…
 How do you think this might look for you?
 How about we brainstorm together pros and cons
of…
Examples of Reframing Responses
 “We’ve tried that already and it didn’t work.”
Reframing Response: I’m glad to hear you’ve had
previous experience of __________. What would we
need to do to make it work this time?
 “I seem to be having a tough time getting started on
this goal.”
Reframing Response: “Has there been a time in the
past when you achieved a goal? What did you do in
the past to be successful? How could that
experience help you with your goal now?”

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ESTABLISHING GOALS
Goal setting is important to assess and measure your progress and impact.
 For individual measures
 For improvement projects
Goals should be clearly stated and describe what the organization or team intends to accomplish.
Follow the SMART formula:
S Specific What do we want to accomplish, who will be involved/affected, and where
will it take place?
M Measurable What is the measure you will use, what is the current data for that measure
and what do you want to decrease or increase the number to?
A Attainable Based on best practice, average or benchmark? Too low (not
challenging)? Too high (unreasonable)?
R Relevant Addresses an important business problem, what is the objective of the
goal? Will the objective meet your desired outcome?
T Time-bound Includes a target date for achieving the goal.
SMART Goal Example
Increase the number of long-term nursing home residents with a vaccination against both influenza and
pneumococcal disease documented in their medical record from 61 percent to 90 percent by December
31, 2015.

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Goal Setting Worksheet
Complete the following worksheet including as much detail as possible under each heading. Use the
information in the table to write SMART goals.
Intention Specific Measurable Attainable Relevant Time Based
What is it
that you
want to
achieve?
Who?
What?
Why?
Where?
When?
What is being measured?
What data is needed?
How will changes be
measured?
Is this goal
achievable?
Will this
objective meet
your desired
outcome?
By when do you
want to achieve
your objective?

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ADULT LEARNING PRINCIPLES
No single theory of learning can be applied to all adults. Three major theories of learning are
andragogy, self-directed learning, and transformational learning. Andragogy is an adult learning theory
that documents differences between the ways adults and children learn. Self-directed learning
describes a process in which an individual takes the initiative and responsibility in planning, managing,
and assessing his/her own learning experiences. Transformational learning is learning that changes the
way an individual thinks about him/herself and the world, and involves a paradigm shift that affects
subsequent experiences.
These theories help us to understand that adult learners:8
 Have a need to know why they should learn something.
 Have a deep need to be self-directing.
 Draw upon their own experience for learning.
 Are motivated to learn when they assume new roles.
 Want to solve problems and apply new knowledge immediately.
Traditional Teaching10
Adult Learner-Centered Training
 Teacher/trainer is the “expert.”
 Shares knowledge through lectures.
 Role of the student is to listen, ask questions,
and absorb information.
 Trainer acts as a facilitator for the learning
process.
 The trainer ensures the learning process is
interactive and engaging by asking questions
that guide participants to reflection.
 Builds on what learners already know.
 Learning is active, not passive.
 Relies on role plays, case scenarios, small
group discussion, and other forms of
interactive learning.
 Adults teach back new skills amongst their
peers.
Adults learn best when:
 They feel respected and the learning
environment feels safe and supportive.
 The content is relevant to their needs.
 Learning has a self-directed element.
 Their personal knowledge and experiences
are called upon for increased learning and
development.
 Opportunities are provided for practicing skill
and applying knowledge in realistic situations.
Adult learning is best achieved in dialogue…adults have enough life experience to be in dialogue
with any teacher about any subject and will learn new knowledge, attitudes, and skills best in
relation to that life experience.9 Jane Vella
Whos is
Keep in mind the principles of adult
learning when you are coaching.

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LEARNING STYLES
Matching knowledge of learning styles with teaching strategies and techniques is
important. Individuals respond to learning based on their personal learning style and
type of learning activities that most appeal to them. The table below lists seven types of
learning styles. For each style there is a list of characteristics for that type of learner,
and techniques that will enhance the learning for a person with that sensory style.11
Sensory-Intake Learning Styles
Sensory Style Characteristics Teaching Technique
Print: seeing printed or
written words
Often takes notes, learns better
after seeing or writing something,
grasps important concepts on first
reading of material
Reading, writing about, book-based
discussion, written outlines, maps
Aural: refers to listening
Is an excellent listener, learns well
through lectures, tends to
remember and repeat ideas that are
verbally presented, can learn
concepts by listening to tapes
Lecture/verbal presentations, group
discussion, exchange of ideas, story-
telling, music at the beginning or during
transitions, oral presentations of working
groups, listening to webinars
Haptic: sense of touch or
grasp
Likes a “hand-on” approach to
learning, involves the sense of
touch in learning, likes to piece
things together, may be fond of
doodling, is successful with tasks
requiring manipulation
Demonstration, “making and
constructing” activities, laboratory work,
nonverbal exercise
Interactive: verbalization
Learns best through verbalization,
likes to use other people as a
sounding board, enjoys
question/answer sessions, finds
small group discussions stimulating
and informative, prefers to discuss
things with others
Panel discussions, dialogue, interview,
debate, role play, games
Kinesthetic: whole body
movement
Learns by doing, direct involvement,
tries things out and likes to
manipulate objects, gestures when
speaking, learns better when able to
move during learning, uses
movement to help concentrate
Role play, ‘hands on’ experience to learn
a task, frequent breaks, regular
opportunities to change seating or room
arrangement, just doing it rather than
talking about it, games, action mazes,
learning centers
Olfactory: sense of smell
and taste
Finds that smells add to learning,
learns best through the sense of
smell and taste, smells have a
special significance
Trips, exhibits, addition of taste and smell
experiences to daily activity
Visual: seeing visual
depictions such as pictures
and graphs
Learns by seeing and by watching
demonstrations, likes visual stimuli
such as pictures, slides, graphs,
demonstrations, can visualize by
seeing it in the “mind’s eye,” needs
something to watch, may drift away
when extensive listening is required
PowerPoint presentations, graphic
illustrations such as bar graphs, color
codes to highlight salient information,
maps, wall charts to display points to
remember, exhibits, visual arts/media,
drawings or designs

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PRACTIVER YOUR SKILLS
You have been introduced to new skills – skills of active listening, asking powerful
questions, and providing constructive feedback. A good way for new skills to become
part of your memory and ‘flow from you’ is to practice them. Practicing new (or recently
reviewed) skills allows you to refresh your memory, work out the ‘bugs,’ and use the
new skill until it becomes internalized and feels comfortable – not ‘stilted.’
The following scenarios may be typical examples when you as a peer coach may be asked to provide
support. Try out your new skills – possibly with a fellow staff member or friend. How would you respond
in the following scenarios?
Practice Scenarios
 A nursing home has not been able to maintain their lowered rate of antipsychotic
medication use. While they initially lowered the rate, it has crept back up…although it
is still lower (better) than the national average.
 A nursing home has fairly frequent staff turnover (i.e., administrator, DON, nurses, or
aides)
 A nursing home took the AHRQ Survey on Patient Safety Culture and found that staff
believe they have a punitive culture – that is, staff fear reporting mistakes.
 A nursing home’s fall rate is higher than average; they have “tried everything” and are
not able to lower their rate.
 A nursing home describes quality improvement teams that have “floundered” in the
past and have been unsuccessful in making changes. They state that they just don’t
have enough time or resources for improvement projects.

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COACHING EVALUATION
Over time, the nature of your coaching relationship may alter and support needs could
change. Therefore it is valuable for a coach and the person being coached, together, to
review their relationship at appropriate points and make any adjustments as necessary
to the way they work together, and the type of support provided.
As you sit down together, here is a list of some questions that might be useful in this process:
 Were our goals clear?
 Were we on task while we worked toward our goal(s)?
 Was the communication in our meeting(s) open and honest?
 Were there verbal or nonverbal distractions that made the meeting(s) less efficient and
effective?
 What is working well in our coaching partnership?
 What do you value most in our coaching partnership?
 What could we do more of?
 Are there any changes that could be made to enhance our coaching partnership?

Page | 20
QUALITY IMPROVEMENT & QAPI
Continuous Quality Improvement
Continuous Quality Improvement (CQI) is a quality management process that
encourages all health care team members to continuously ask the questions, “How are
we doing?” and “Can we do it better?” It focuses on the process, rather than the
individual. CQI involves staff in planning and executing a continuous flow of
improvements to provide quality health care that meets or exceeds expectations.
What is QAPI?
QAPI is the merger of two complementary approaches to quality management, Quality Assurance (QA)
and Performance Improvement (PI). Both involve using information, but differ in key ways:
 Quality Assurance is a process of meeting quality standards and assuring that care reaches an
acceptable level. Nursing homes typically set QA thresholds to comply with regulations. They may
also create standards that go beyond regulations. QA is a reactive, retrospective effort to examine
why a facility failed to meet certain standards. QA is on-going, both preventive as well as looking
back, in its efforts to identify how the organization is performing – including where and why facility
performance is at risk or has failed to meet standards.
 Performance Improvement (also called Quality Improvement – QI) is a proactive and continuous
study of processes with the intent to better services or outcomes, and prevent or decrease the
likelihood of problems by identifying areas of opportunity and testing new approaches to fix
underlying causes of persistent/systemic problems or barriers to improvement. PI in nursing homes
aims to improve processes involved in health care delivery and resident quality of life. PI can make
good quality even better.
Quality Assurance + Performance Improvement = QAPI
QA and PI combine to form QAPI, a comprehensive approach to ensuring high quality care. QAPI is a
data-driven, proactive approach to improving the quality of life, care and services in nursing homes.
The activities of QAPI involve members at all levels of the organization to:
 Identify opportunities for improvement
 Address gaps in systems or processes
 Develop and implement an improvement or corrective plan
 Continuously monitor effectiveness of interventions

Page | 21
QAPI
Element 1: Design and Scope
Support from leadership is
essential, fostering participation from all levels of
staff being involved in planning and improving
systems and processes to get effective results.
Element 2: Governance and Leadership
Executive leadership develops a culture that seeks
input from residents and staff. Opinions and
priorities of individual residents and family
members should guide QAPI.
Element 3: Feedback, Data Systems and Monitoring
QAPI is a proactive and data-driven process. A facility puts in place systems to monitor care and
services, drawing data form multiple sources which includes staff, residents and family, as well as
performance indicators to monitor a wide range of processes and outcomes.
Element 4: Performance Improvement Projects (PIPs)
Conducting a Performance Improvement Project allows nursing homes to examine performance and
make improvements. It is a concentrated effort on a particular problem that involves gathering
information systematically to clarify issues or problems, intervening for improvements.
Element 5: Systematic Analysis and Systemic Action
Uses an in-depth process that looks at events and incidents from a systems perspective. It avoids
focusing on individual performance, and instead focuses on the underlying breakdowns or gaps in the
systems or processes.
QAPI Builds on Quality Assessment and Assurance (QA&A)
QAPI is not entirely new. It uses the existing QA&A regulation and guidance as a foundation. Maybe
you recognize some of the statements below as things you are already doing:
 You create systems to provide care and achieve compliance with nursing home regulations.
 You track, investigate, and try to prevent recurrence of adverse events.
 You compare the quality of your home to that of other homes in your state or company.
 You seek feedback from residents and direct caregivers.
 You set targets for quality.
 You strive to achieve improvement in specific goals related to pressure ulcers, falls, restraints,
or permanent caregiver assignment; or other areas.

Page | 22
Quality Assurance and Performance Improvement: Compare and Contrast
Quality Assurance Performance Improvement
Focus Assure standards are consistently met
Improve processes and systems,
continually “raise the bar” on
performance
Outlook Retrospective review and correction
Proactive: identify processes or
systems for improvement, then test,
make and measure changes
Goal To meet minimum standards, reduce
variation, and reduce errors
To exceed expectations and produce
excellent outcomes
Responsibility All, wherever there is a need to meet
internal or external standards
All, interdisciplinary teams
Motivation To get it “right,” often required by state
and federal law
To become “great”
Frequency
Regularly, in conjunction with goods or
service delivery, or process
implementation
Continuous activity
Begins with
Understanding standards and examining
goods, services, or processes
Proactively selecting a process or
system to measure and improve after
collecting data
Both approaches are good and both are useful. PI is not intended to replace QA. Instead, PI builds on
QA. The key is understanding the two separate purposes. QA focuses on assuring standards are
consistently met. PIs focus is to improve processes and systems to continuously raise the bar on
performance. The real difference with QAPI is the importance placed on all five elements of QAPI, as
opposed to only the improvement work that is triggered through QA monitoring.

Page | 23
QUALITY IMPROVEMENT PROCESS
Ideal Quality Improvement Process:
 Measure performance against goals
 Prioritize areas to improve
 Set aim and measure(s)
 Analyze the problem, understand the current process
and the root causes of problems
 Consider options of what to change that would address
the root causes
 Choose option to implement
 Plan the change
 Test changes (for example, using PDSA cycles)
 Evaluate results – did we implement what we intended
and did it work?
Here is a more typical process –
what often happens:
 Pick anything to work on
 Think of one option to implement
 Implement change
 Hit system barriers
 Fail

Page | 24
PLAN-DO-STUDY-ACT (PDSA): STRUCTURED QI PROCESS/APPROACH
PDSA is a structured approach for testing changes in organizations. PDSA is one of the sequence
steps in the Model for Improvement,12
a common quality management or improvement model. The
Model for Improvement, developed by the Associates in Process Improvement (API) involves three
sequenced steps:
1. Setting aims
2. Establishing measures
3. Testing changes (PDSA cycles)
Here is an illustration of the three
sequenced steps:
1. “What are we trying to accomplish (the
aim)?” The aim is articulated. Often this is
a bold aim to improve an aspect of health
or health care.
2. “How will we know that change is an
improvement?” Here, the measurable
outcome(s) you want to see are described.
These are the measures you will use to
understand if the changes you make are
resulting in an improvement.
3. “What change can we make that will result in an improvement?” Before answering this
question, the group needs to define the processes currently in place, and then identify opportunities
for improvement that exist. To determine what changes to make, the team can use process
mapping to understand the processes currently in place. That will enable the team to identify
opportunities for improvement that exist. Once the team identifies and analyzes opportunities for
improvements, they then decide what to change in the process. The key is to make changes that
clearly link to the opportunity or process breakdown. Key changes are then tested using PDSA
cycles.
Individuals and organizations often want to skip the testing phase and move right to full implementation
of a change.
Why test changes with PDSA cycles?
You can learn from failures without a large impact, you can start to document the improvement resulting
from the change, you can learn how to adapt the change to conditions in your local environment, you
can evaluate costs and side-effects or unintended consequences, and you can start to build buy-in and
minimize resistance.

Page | 25
QUALITY IMPROVEMENT – TIPS FOR SUCCESS
Characteristics of successful improvement projects
• Goals and objectives are clear and concise
• The measurement plan is clear – as to how success will be measured
• A realistic plan is built and agreed upon
• Resources and tasks are successfully identified
• The right resources are available at the right time (including involvement of the right people –
those who are involved in and care about the topic)
• There is careful reporting and monitoring
• Conflict is resolved quickly
• A skilled project manager is used and connects with the team and stakeholders
Traits of successful project managers
QI projects need project management. Make sure you have someone as project manager who has:
• Enthusiasm for the project
• Ability to oversee a process & manage change
• Team building and negotiating skills
• Problem solving skills
• Customer orientation
• Business priority orientation
• Management and leadership skills
• Flexibility

Page | 26
QUALITY IMPROVEMENT TEAM PROBLEMS & MITIGATION STRATEGIES
John Moran notes the following major problems that QI teams have encountered13
1. GOAL STATEMENT. This important goal statement was often too large; the scope of the initial
project was so large – “solve world hunger” – that the team floundered for many meetings trying
to figure out what they were going to work on. Goal statements should be discrete,
measureable, and time-bound.
2. TEAM CHARTER. Many teams were simply started by management with no formal direction
and were left to find their own way – “We think this is what management wanted” was a familiar
statement. A detailed team charter provides the start-up direction a team needs to be successful
in tackling the task it has been assigned. Too often teams spend a considerable amount of their
Recommendations/tips from nursing homes that have
successfully implemented QAPI projects
• Gather information systematically to clarify issues and identify opportunities
• Topics should be meaningful and address the unique needs of residents, staff and
others who care about the performance of the nursing home
• Have relevant performance improvement projects so people want them to succeed
• Test and implement changes
• Involve people who care about improvements to the process
• Move beyond the quick fix – focus on systems and processes rather than individual
behavior
• Practice root cause analysis
• Take more time to understand why something happened – that will avoid rework
down the line
• When staff come with a problem, ask them why they think that happened. Don’t
respond with a solution – try to understand the “why?”

Page | 27
valuable resources trying to figure out what it is they are supposed to do. A well-developed team
charter helps increase a team’s maturity since it answers a number of issues that usually arise
in the start-up phase of a team.
3. TEAM MEMBERS. Team members were selected on the basis of who was available rather than
who was needed. Starting off with the wrong team is a key ingredient in the recipe for disaster.
Get the right people at the start, not those who are available.
4. PROBLEM-SOLVING PROCESS. Teams began their journey by not following a defined
problem-solving process like Plan. Do. Study. Act. (PDSA), or they skipped steps since the
solution seemed obvious. If there is no defined process, the team wanders aimlessly.
5. RAPID CYCLE. Teams took too long to go through the PDSA cycle. Meeting for one hour every
other week or once a month with many meetings cancelled soon left those remaining with the
feeling that this was an endless cycle. Instead, have a limited goal statement, go through the
PDSA cycle quickly, and get a quick win. Then move on to something more complex and keep
repeating the PDSA cycle.
6. TEAM MATURITY. Teams go through a growth cycle; too often the fact is missed that every
team meeting needs to focus on behavior, as well as the problem solving process. If the
behaviors are not maturing, it can derail the problem solving process.
7. BASE-LINE DATA. Teams never collected any data on where they were starting from and
never knew if they made an improvement.
8. TRAINING. Lack of training is a problem. People think, “This quality improvement stuff seemed
so obvious we just jumped right in and started solving problems.” Team members were never
sure what was going on or what the next steps were.
9. ROOT CAUSE ANALYSIS (RCA). Treating the symptom instead of doing an RCA is a common
problem. RCA is a structured investigation that aims to identify the true cause of a problem and
the actions necessary to eliminate it with a permanent fix rather than continuing to deal with the
symptoms on an ongoing basis. In RCA we need to determine what happened, why it
happened, and how to eliminate it so it will not happen again. Treating the symptom may
provide a temporary fix, but it just masks the real cause until it reappears.
10. PILOT TESTING. Many teams like to jump to solutions and not identify potential improvements
that could address the root cause, agreeing on which one to test. Pilot testing a potential
solution is needed to determine how the solution will impact the problem. This step provides an
opportunity to collect data, to alter the improvement if it is not achieving the goal, and/or develop
countermeasures as needed to address any potential unintended consequences.

Page | 28
REFERENCES
1. Murrell, Audrey. “Five Key Steps for Effective Mentoring Relationships.” Kaitz Quarterly.
Q1,Vol 1, Issue 1, 2007. http://nl.walterkaitz.org/FiveStepsInMentoring_Murrell.pdf.
Web. 30 June 2015.
2. Adapted from International Coach Foundation. “Core Competencies.”
http://coachfederation.org//credential/landing.cfm?ItemNumber=2206&navItemNumber=576.
Web. 30 June 2015.
3. Adapted from MindTools.com. (2015). “Active Listening, Hear What People are Really Saying.”
http://www.mindtools.com/CommSkll/ActiveListening.htm. Web. 5 May 2015.
4. Adapted from Taft College. “Active Listening Skills,” n.d.
http://www.taftcollege.edu/lrc/class/assignments/actlisten.html. Web. 5 May 2015.
5. Vogt, E., Brown, J. Isaacs, D. “The Art of Powerful Questions: Catalyzing Insight, Innovations, and
Action,” 2003.
http://www.principals.ca/documents/powerful_questions_article_(World_Cafe_Website).pdf.
Web. 30 June 2015.
6. Appreciation for the graphic idea to: Kansas Coalition against Sexual and Domestic Violence, 2015.
7. University of South Australia. “Providing Quality Feedback, a Good Practice Guide,” March, 2012.
http://w3.unisa.edu.au/staffdev/guides/good_practice_guide_to_providing_quality_feedback.pdf
Web. 30 June 2015.
8. Knowles, M. (1984). As cited in Paraprofessional Healthcare Institute. “Adult Learner-Centered
Training: An Introduction for Educators in Home and Residential Care,” 2008.
http://phinational.org/workforce/resources/phi-curricula/adult-learner-centered-training.
Web. 2 July 2015.
9. Vella, Jane. “Learning to Listen, Learning to Teach: Twelve Principles for Effective Adult Learning,”
Jossey Bass, 2002.
http://www.globallearningpartners.com/downloads/resources/LTL_Sample_Chapter.pdf.
Web. 2 July 2015.
10. Institute of Learning Styles Research. “Overview of the Seven Perceptual Styles,” n.d.
http://www.learningstyles.org/index.html. Web. 18 May 2015.
11. Adapted from Paraprofessional Healthcare Institute. “Adult Learner-Centered Training: An
Introduction for Educators in Home and Residential Care,” 2008.
http://phinational.org/workforce/resources/phi-curricula/adult-learner-centered-training.
Web. 2 July 2015.

Page | 29
12. Langley, G., Moen, R., Nolan, K., Nolan, R., Norman, C., Provost, L. The Improvement Guide, 2nd
Edition. San Francisco: Jossey-Bass, 2009.
13. Moran, John. “Top 10 Problems Encountered by Quality Improvement Teams,” Public
Foundation Blog.
http://www.phf.org/phfpulse/pages/top_problems_encountered_by_qi_teams.aspx. Web 2 July
2015.

Page | 30
ADDITIONAL RESOURCES
Coaching
 Peer Coaching, University of Wyoming
o http://www.wyomingextension.org/wiki/index.php5?title=Informal_Learning:Peer_coaching
 AIESC Peer Coaching Guide
o http://www.slideshare.net/fkaris/peer-coaching-guide
 Honing your skills as a Peer Coach, Harvard Business Review
o https://hbr.org/2010/02/honing-your-skills-as-a-peer-c/
Adult Learning Techniques
 Adult Learner-Centered Training: An Introduction for Educators in Home and Residential Care
o http://phinational.org/workforce/resources/phi-curricula/adult-learner-centered-training
 Adult Learning Theory and Principles
o http://www.qotfc.edu.au/resource/?page=65375
 Application of Adult Learning Theory
o http://www.nrcs.usda.gov/Internet/FSE_DOCUMENTS/nrcs143_024001.pdf
 Bloom’s Taxonomy
o http://cft.vanderbilt.edu/guides-sub-pages/blooms-taxonomy/
Quality Improvement
 QAPI Tools and Resources
o http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/nhqapi.html
 Guide to Implementing Quality Improvement Principles (64-page guide)
o http://www.gmcf.org/AlliantWeb/Files/QIOFiles/Nursing%20Homes/Implementing%20QI%20Princ
iples%2010SOW-GA-IIPC-12-237.pdf
 The Model for Improvement
o http://www.ihi.org/resources/Pages/HowtoImprove/default.aspx
 QAPI at a Glance
o http://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/QAPI/Downloads/QAPIAtaGlance.pdf
 Root Cause Analysis Toolkit for Long Term Care (website, short webinars, tools)
o http://www.stratishealth.org/providers/rca-toolkit/index.html
 Effective QI Meeting Management and Facilitation for Nursing Homes (47-minute webinar and slides)
o http://www.stratishealth.org/events/recorded.html
o http://www.stratishealth.org/documents/Effective-QI-Mtg-Mgmt-Facilitation-Slides-2014-07-09.pdf
CASPER Data
 MDS 3.0 RAI Manual and QM User’s Manual (manual)
o https://www.qtso.com/mds30.html
 CASPER Reporting User’s Guide (manual)
o https://www.qtso.com/mds30.html
 Understanding the Nursing Home Quality Measures (59-minute webinar)
o https://www.youtube.com/watch?v=g0H7SDRJ9NI

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