A 145-bed nursing home located near the coast of western Michigan was referred by the Centers for Medicare & Medicaid Services (CMS) to Superior Health Quality Alliance (Superior Health), a CMS Quality Innovation Network-Quality Improvement Organization (QIN-QIO), for assistance with improving its resident COVID-19 booster rate. With the help of Superior Health’s intensive one-on-one virtual coaching, the facility saw a 49.9 percent net increase in its resident COVID-19 booster rate from the time the nursing home was referred to the QIN-QIO in January 2023 and the last report to the National Healthcare Safety Network (NHSN) in March 2023.
Performing a Root-Cause Analysis to Identify Opportunities for Improvement
Following an initial reach out, Superior Health performed a root-cause analysis to determine why the nursing home’s resident COVID-19 vaccination rate in NHSN was not reflective of the facility’s actual vaccination/up-to-date rate despite hosting weekly vaccination clinics. The analysis revealed two issues: 1) The nursing home had poor tracking and reporting processes due to turnover; and 2) Multiple staff and steps were involved in the facility’s NHSN reporting. The staff who were most aware of the correct numbers did not know who was submitting the data to NHSN.
Coaching to Help Streamline Internal Processes and Vaccine Tracking
To help the facility improve its tracking and reporting processes, Superior Health offered intensive one-on-one virtual coaching to the facility’s new infection prevention nurse whose father is also a resident. The nurse had an Excel-based tracking system, but she was not the person entering vaccine information into NHSN and did not know which staff member was completing this task. Superior Health worked with the nurse to help her get NHSN access and choose an option for reporting.
Changing How Data is Reported to Improve Accuracy
The facility was using the weekly COVID-19 vaccination summary reporting option which allows for tracking and adding aggregate numbers each week. After learning from Superior Health about other reporting options, the nurse chose to start using person-level tracking. This style of reporting lists residents individually and allows the person entering the data to make updates in one place before clicking “submit.” This option also allows the nurse to identify residents who are due for a booster vaccine or correct a resident’s vaccine status if listed incorrectly. Superior Health helped the facility access the state immunization registry to verify this information.
Reducing Burden for Nursing Home Staff
The QIN-QIO also helped reduce burden for the nurse who was coming into the facility on her day off to submit data. Superior Health assured the nurse that while the weekly reporting period is Monday through Sunday, the facility did not have to report on Sunday and could designate a different day to enter data. The QIN-QIO encouraged the nurse to switch to Wednesday so 1) She didn’t have to come in on her day off and 2) If she were to get locked out of the system or it was down, she could enter data the next day. While the facility was nervous to make the change, they ultimately accepted Superior Health’s recommendation.
Ongoing Support and Resources
In addition to providing one-on-one virtual coaching, Superior Health shared NHSN New User information and resources related to NHSN person-level tracking including:
- Person-Level COVID-19 Vaccination Forms: A How-To Guide
- Person-Level Vaccination Forms – Instructions and Guidance Documents
- NHSN Person-Level (Event-Level) Vaccination Forms: General Training
- NHSN Question & Answer Session Roundtable hosted by Superior Health
The nursing home also receives the QIN-QIO’s monthly vaccination newsletter and bi-weekly nursing home newsletter. Both publications offer live and on-demand learning opportunities and incorporate a variety of immunization, vaccination and infection prevention resources.
Keys to Success 
Superior Health’s success can be replicated by taking the following steps:
- Offer one-on-one coaching to help facilities improve and streamline internal processes.
- Be responsive to facilities requests for assistance, Monday through Friday within 24 hours, if possible.
- Offer multiple ways for nursing homes to stay engaged with your QIN-QIO.
All nursing homes in the region served by Superior Health that were referred to the QIN-QIO for assistance between October 16, 2022, and May 7, 2023, saw a 9.7 percent net increase in resident COVID-19 bivalent booster rates as compared to nursing homes in the region that were not referred to the QIN-QIO for assistance. In addition, the percentage of residents who are up to date in nursing homes in the region that were referred to the QIN-QIO for assistance increased by 14 percent, compared to residents who are up to date in nursing homes not referred to the QIN-QIO, which increased by only four percent.
Superior Health’s Regional Nursing Home Resident COVID-19 Bivalent Booster Rates Including Referrals from October 16, 2022 – May 7, 2023
The graph compares bivalent vaccination rates of CMS-referred facilities (orange) with never-referred facilities (blue) and only includes referrals made between October 16, 2022, and May 7, 2023. Never-referred facilities did not meet initial criteria for booster referral because CMS focused on facilities with significantly lower rates.
This material was prepared by The Bizzell Group (Bizzell), the Data Validation and Administrative (DVA) contractor, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services (HHS). Views expressed in this material do not necessarily reflect the official views or policy of CMS or HHS, and any reference to a specific product or entity herein does not constitute endorsement of that product or entity by CMS or HHS. 12SOW/Bizzell/DVA-1111-07/18/2023