Tools & Resources

All Cause Harm Prevention in Nursing Homes: Change Package to Prevent Harm

QIO Program Admin
QIO Program Admin • October 20, 2022
Image of nursing home staff kneeling next to man in wheelchair looking out the window.

This Change Package, released in 2018, aims to serve as a key resource for anyone interested in improving the quality of life and quality of care for those living in nursing homes. The package is focused on the successful practices of high-performing nursing homes. It was developed from a series of site visits to nursing homes across the country and the themes that emerged regarding how they approached prevention of harm while honoring each resident’s rights and preferences and how they carried out their work. The practices in the Change Package reflect how the nursing home leaders and direct care staff at these sites shared and described their efforts to prevent, detect, and mitigate harm. This Change Package includes two additional resources:

Six Steps Toward Implementing Strategies in the Change Package includes strategies to prevent adverse events and abuse and neglect identified by two reports published in 2014 by the Office of Inspector General. It focuses on practices of high-performing nursing homes, and reflects how the staff described their efforts to prevent, detect, and mitigate harm. A nursing home can choose from these strategies to begin improving residents’ quality of life through safer care. Because there is no single, magic bullet to prevent all causes of harm, the Change Package covers a wide range of strategies to promote resident safety. This resource includes suggestions that may be helpful when implementing the Change Package.

National Nursing Home Quality Care Collaborative Change Package v2.2 updated in 2017, is intended to support overall nursing home quality and performance improvement and focuses on the systems that impact quality such as: staffing, operations, communication, leadership, compliance, clinical models, promoting resident quality of life, and specific, clinical outcomes It was developed from a series of site visits to nursing homes across the country in 2012 and the themes that emerged regarding how they approached quality and carried out their work. The practices in the change package reflect how the nursing homes leaders and direct care staff at these sites shared and described their efforts. The change package is a menu of strategies, change concepts, and specific actionable items that any nursing home can choose from to begin testing for purposes of improving residents’ quality of life and care.

Files