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Deciding what you want to change and communicating that intention is the first step of the quality improvement cycle. This page provides a general description of the goal and its benefits to share with your team.

Most residents are more comfortable with caregivers they know. When long-term care communities achieve stable staffing, direct care staff, certified nursing assistants (CNAs), nurses, and administrators work in the community long enough to learn each resident’s needs and preferences. A stable staff allows the community to benefit from experience and knowledge that staff gain over time, increasing the overall competence and confidence of staff, while building strong bonds between residents and caregivers.

  • How Does Staff Stability Benefit Residents?

    Residents do not have to explain to new caregivers how to care for them day after day.

    Staff can anticipate resident needs and respond more quickly, confidently and naturally when they know the residents.

    Residents are more comfortable with the intimate aspects of care when they know their caregivers.

    Residents with dementia are much more comfortable with familiar caregivers.

    Residents can have stronger relationships with staff.

    Residents in communities with stable leadership and care staff have better clinical outcomes.

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  • How Does Staff Stability Benefit Long-term Care Staff?

    Staff know what residents want and need.

    Staff can give better care and be more organized in their work with team members they know.

    Staff are less likely to be working with “temporary” nurses or CNAs who are not as familiar with resident routines.

    Staff turnover is reduced.

    Staff have greater work satisfaction and are less likely to leave.

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  • How Does Staff Stability Benefit Long-term Care Communities?

    Providers reduce the costs involved in repeatedly advertising, interviewing, and training new staff.

    Communities with satisfied staff members are able to recruit other good workers.

    Providers have better survey outcomes and quality measures.

    Family satisfaction rates improve.

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Step 2 – Tracking Tool  >

Tracking Tool

The Campaign Tracking Tools allow you to document your work, monitor outcomes and the processes related to your outcomes. To achieve a data-driven quality improvement project, collect data for several months to establish a solid baseline and set a target for your improvement; then continue collecting data -- charts within the workbooks and trend graphs on the website provide you and your team with the feedback you need to determine if the changes you are making are being fully implemented and if they are having the expected impact on your outcomes. Keep your workbook up-to-date on a daily or weekly basis and look at data often to support a rapid cycle quality improvement project. Download the data tracking tool and collect data for a month or so to determine your starting point.

Questions? Contact the NNHQI Campaign Help Desk:

Before you start, read our Tip Sheet on Testing Change & Starting Small (PDF).

Step 3 – Examine Process  >

Examine Process

This set of probing questions will help you evaluate your current processes and provide guidance for ways to make improvements.

  • Improve Staff Stability Probing Questions

  • Why are our staff turnover rates high?

    • Are we documenting turnover rates accurately and consistently?
    • Are we reviewing turnover information on a regular basis?
    • Is the information collected systematically and consistently?
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  • Which groups are most affected?

    • Which employees are most affected: nurses, CNAs, dietary staff, maintenance, unit supervisors, or those with specific credentials (e.g., RN, LPN, and BSN)?
    • Are turnover rates different for new and long term employees?
    • Do we collect information separately on supervisor turnover?
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  • Absenteeism

  • Why is our absenteeism rate high?

    • Has our absenteeism rate been increasing?
    • Has our usage of agency staff increased?
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  • Which groups are most affected?

    • Do our records identify which staff, shifts and units are most affected?
    • Are there particular employee groups that are experiencing higher rates of absenteeism, including nurses, CNAs, dietary staff, maintenance staff, supervisors, housekeeping staff, or staff from other countries?
    • Is absenteeism a problem more with long stay or newer staff?
    • What are the trends over time in absenteeism in each of the groups?
    • Are the same staff repeatedly calling in or are there many staff calling in?
    • Is staff with higher absenteeism rates leaving at a higher rate than other staff?
    • Is absenteeism higher at a particular time of the year – e.g., religious holidays, vacations?
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  • Use of Agency Staff

  • Why is our agency staff usage high?

    • Are we maintaining careful records of agency staff use?
    • Are we regularly reviewing use of agency staff?
    • Are we collecting and reviewing data on turnover?
    • Are we collecting and reviewing data on absenteeism?
    • Are we reviewing trends and patterns in use of agency staff?
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  • Which groups are most affected?

    • What categories of staff are we replacing with agency staff? (staff type, staff tenure, staff position, unit, shift)
    • Has any of our staff switched from regular employee to agency staff?
    • Are agency staff consistent?
    • What units, shifts, positions are most affected?
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  • Processes and Resources to Consider

    • What is causing the gap that we are filling with agency staff? Turnover? Absenteeism?
    • How do we decide whether to use agency staff to cover a gap in staffing?
    • What have we done to prevent the loss of staff due to turnover and absenteeism?
    • Do we know whether staff prefer to work here as agency staff? Do we know the reasons? What specifically have we done to address the reasons?
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Step 4 – Create Improvement  >

Create Improvement

The Science of Change

  • The Circle of Success is a quality improvement framework and a guide to finding the resources you need on the website.
  • Quality Improvement Methods are evidence-based approaches for creating systemic change. This collection includes quick-start instructions, templates, and mini-videos.
Key Resources
Website Staffing Toolkits from the Civil Money Penalty Reinvestment Program
These free toolkit resources are meant to assist teams with improving staff competency and employee satisfaction.
  • The competency toolkit includes instruction, competency assessments, supporting materials, numerous resources and worksheets to compile and analyze core care strengths and weaknesses. The results can help identify future training and in-servicing needs.
  • The employee satisfaction toolkit is a free, anonymous survey that offers long-term care staff an opportunity to share their perceptions about their workplace. Resources are available to support managers in implementing the survey, as well as aggregating and interpreting survey results. The results can help your community to recruit, motivate and retain staff.
Adobe PDF Recruit and Retain Quality Staff is a key improvement strategy identified by the National Nursing Home Quality Care Collaborative as they interviewed some of the best performing homes in the country. Download the Change Package and scroll to Strategy 2 for a list of change concepts and action items.
Adobe PDF Strategy: Nourish Teamwork & Communication
These strategy sheets include specific action items and successful practices of high performing communities. From the National Nursing Home Quality Care Collaborative.
Adobe PDF Implementing Change for Long Term Care Manual - Leadership
This manual is designed as a general guide to administrators and staff in long term care settings who are contemplating or engaged in significant organizational change. It can be used to assist in planning, implementation and evaluation of organizational change.
Adobe PDF Huddles Tip Sheet
Staff Competency
Use competency assessments from CMPRP to identify areas of staff strength and identify opportunities for improvement. The assessments cover behavioral, technical and resident-based competencies and should be completed as needed.
Instruction Manual (PDF) includes videos, talking points, email memo, poster, assessment completion tracker, manager's guide to meeting one-on-one with staff, and assessment results worksheet to compile and analyze results.
CNA/CMT Assessment Electronic (PDF) | Paper (PDF)
Management Assessment Electronic (PDF) | Paper (PDF)
Nurse Assessment Electronic (PDF) | Paper (PDF)
All Answer Sheets
Website CMPRP Staff Satisfaction Survey Toolkit
Staff Satisfaction Survey Toolkit resources
Adobe PDF Benjamin Rose Nurse Assistant Job Satisfaction Scale
18-item scale for measuring CNA job satisfaction.
Adobe PDF Staff Satisfaction with Supervisors Survey Scale:
Supervisory Support Scale Instructions | Supervisory Support Scale
15-item survey scale for assessing relationships between direct care staff and supervisors/charge nurses.
Adobe PDF Measuring Long-Term Care Work: A Guide to Selected Instruments to Examine Direct Care Worker Experiences and Outcomes
Guide designed to help organizations develop surveys for measuring direct care worker satisfaction and opinions.
Staff Empowerment
Adobe PDF Perception of Empowerment Instrument (PEI)
Measuring Empowerment: The Perception of Empowerment Instrument (PEI)
The Perceptions of Empowerment Instrument measures the empowerment dimensions of autonomy, responsibility, and participation.
Adobe PDF Predictable Scheduling: Nursing homes can boost quality, bottom line with "consistent assignment"
By Mary Jane Koren. Published in Modern Healthcare.
Adobe PDF Pioneer Network Tip Sheet - Consistent Assignment
This resource provides information on why to implement consistent assignment as well as practical steps for successful implementation.
Website Find more information on our Consistent Assignment Goal Pages
Website The 8-Step Process for Leading Change
Highlights eight steps to follow in order to make change successful.
Adobe PDF Implementing Change for Long Term Care Manual - Leadership
This manual is designed as a general guide to administrators and staff in long term care settings who are contemplating or engaged in significant organizational change. It can be used to assist in planning, implementation and evaluation of organizational change.
Adobe PDF Orientation Guide
A sound orientation program is an investment in retaining employees. This is when new employees form impressions about the nursing home's culture, grow relationships, and become part of the community. Orientation also provides an opportunity to assess the new employee's competencies and provide instruction and mentoring to strengthen any deficits identified.
Adobe PDF Manitoba Manual
This manual was developed for orienting new staff to long term care and for ongoing staff development. It contains a rich source of information on many of the conditions commonly experienced by long term care residents. This is appropriate for nurses new to long term care as well as experienced nurses.
Staff Recruitment and Retention
Adobe PDF 12 Steps for Creating a Culture of Retention
This resource guides providers in developing excellent recruitment, orientation and retention practices – three key elements necessary to manage long term care organizations successfully. Although created for home and community based long term care, the key concepts, concrete steps and best practices outlined are applicable across the continuum. The framework for the 12 Steps workbook is based on the principle of "quality care through quality jobs," recognizing that quality direct care jobs are essential to delivering high quality eldercare.
Adobe PDF Direct Care Worker Retention: Strategies for Success
Report contains research and programs shown to increase the retention of direct care workers in long term care.
Adobe PDF BJBC: Solutions You Can Use: Transforming the Long Term Care Workforce
This report presents the major findings from the eight Better Jobs Better Care research projects and what they mean for aging services providers as they strive to build a quality workforce.
Staff Communication
Website TeamSTEPPS for Long Term Care
The Agency for Healthcare Research and Quality’s (AHRQ) TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety) 2.0 for Long-Term Care curriculum is an evidence-based framework to optimize team performance across the healthcare delivery system. The core of the TeamSTEPPS framework is comprised of four skills: Leadership, Situation Monitoring, Mutual Support, and Communication. Ver 2.0 curriculum updates have improved the usability and flow of materials, added training scenarios to reflect health care issues in long-term care settings, and added a new measurement module to help teams track progress. Users may download and/or print all the free TeamSTEPPS 2.0 for Long-Term Care materials for training.
Adobe PDF Pioneer Network Shift Huddles Tip Sheet
Tip sheet provides a description of the purpose of shift huddles and suggested ways to conduct them effectively to improve staff communication.

Step 5 – Engage  >


Engaging stakeholders creates a robust and successful quality improvement project. Use these fact sheets to start the conversation and encourage everyone to be involved. A story board is a wonderful, visual way to engage your community in the project, keep everyone in the know about new changes that are being tested, and share your challenges and successes along the way.

Story Board Guide
Adobe PDF Storyboard guide from QAPI
Use this guide to create a compelling poster to keep your community engaged in your project, monitor your progress, and celebrate your success. Print outcome trend graphs from your Campaign account to document your change!
Staff Stability Fact Sheets
Adobe PDF Leadership Fact Sheet
Adobe PDF Staff Fact Sheet
Adobe PDF Consumer Fact Sheet

Step 6 – Monitor & Sustain  >

Monitor & Sustain

Once you make a change or an improvement, it’s important that you continue to collect and submit your data to ensure your improvements are working.

Step 7 – Celebrate Success  >

Celebrate Success

Too often we let accomplishments pass by without notice because we are already moving on to the next step. But, it's important to take a moment to celebrate accomplishments, big and small.

A celebration program can create a spirit of community in your nursing home. Use visible awards such as certificates, plaques and other tangible rewards that can be proudly displayed. Try giving a spontaneous award from time to time to acknowledge people who are going the extra mile.

More resources on their way. Please check back soon.

Back to Goals  >

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