Explore Goal

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.

Person-centered care promotes choice, purpose and meaning in daily life. Person-centered care means that nursing home residents are supported in achieving the level of physical, mental and psychosocial well-being that is individually practicable. This goal honors the importance of keeping the person at the center of the care planning and decision-making process. Care plans are living documents that are revised to reflect a person’s changing needs. In person-centered care, staff places a premium on active listening and observing, so staff can adapt to each resident’s changing needs regardless of cognitive abilities.

  • How Does Person-Centered Care Benefit Residents?

    Residents have autonomy and are able to direct care and services.

    Resident choice fosters engagement and improves quality of life.

    Residents live in an environment of trust and respect.

    Residents are in a close relationship with staff that are attuned to their changes and can respond appropriately.

    Residents continue to live in a way that is meaningful to them.

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  • How Does Person-Centered Care Benefit Nursing Home Staff?

    Staff members are more comfortable caring for people they know.

    Staff form a strong partnership with residents and their families.

    Staff know a person’s preferences, can anticipate the person’s needs and adapt accordingly.

    Staff are highly valued in person-centered care organizations.

    Staff work more efficiently in person-centered care environments and can devote time where it is most needed.

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  • How Does Person-Centered Care Benefit Nursing Homes?

    Nursing homes have better quality outcomes due to the ability of staff to identify and respond appropriately to changes in a resident’s condition.

    Nursing homes gain referrals from people who have a good experience and recommend the nursing home to others as a place for care.

    Nursing homes have better staff retention due to a strong relationship between staff and residents.

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Step 2 – Identify Baseline  >

Identify Baseline

The AE 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 AE Helpdesk: help@nhqualitycampaign.org.

Person-Centered Care Tracking Tool
Zip file Use this Excel tool to log results from your residents' Preference Satisfaction Interviews and record how their subsequent care plans address those preferences. It will create graphic displays indicating opportunities to fulfill residents' preferences, evaluate community trends, and calculate an overall Preference Congruence Quality Indicator and the percent of care plan meetings with key participants.
AE_PCCTrackingTool_v1.15_7-02-15.zip
Adobe PDF Illustrated instructions for using the AE_PersonCenteredCareTrackingTool.
AE_PersonCenteredCareInstructions_4-30-13.pdf
Adobe PDF Illustrated instructions for entering data.
AE_SubmittingDataInstructions_9-16-15.pdf
Website Get the Preference Satisfaction Interview Form and related information for implementing your project.

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.

  • How do we know if there is a gap in meeting our residents’ needs?

    • In what areas are there gaps between resident preferences and reported experiences?
    • Why aren’t our residents’ preferences being met?
    • Is there a trend associated with the gap(s)?
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  • Which groups are most affected?

    • Is the issue affecting a certain group of residents with common characteristics?
      • Physical disabilities
      • Cognitive impairment
      • Length of stay
      • Mental health issues, such as depression
      • Recent losses, for example, death of spouse
      • Unit/area in nursing home, perhaps dementia care or rehab
      • LGBT
      • Cultural/ethnic/religious preferences
    • Do roommates report similar gaps in meeting person-centered care needs?
    • Do we support choice in roommates?
    • Is the preference/experience gap associated with a seasonal issue, such as holidays or weather, that would benefit from additional support?
    • Do residents prefer to work with certain staff members?
    • Do our organizational policies and practices support resident preferences?
    • Does our environment support resident preferences?
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  • Processes and Resources to Consider

  • How do we communicate with residents and families?

    • Are residents and family members able to effectively communicate preferences?
    • How do residents communicate choices to staff?
    • What is our process for recording resident preferences?
      • Where and when do we record changes (e.g., care plan, communication book)?
      • Which staff have access to the information?
      • Does the process adapt to changes in preferences?
    • Have we asked residents what additional activities or programming would support their cultural/ethnic/religious preferences?
    • How (and how often) do we encourage residents to share their preferences in care plan meetings?
    • Do residents that indicate a preference/experience gap have family members or close friends involved in their lives at our nursing home?
    • How (and how often) do we communicate with family and friends regarding resident choices?
    • How (and how often) do we encourage family and friends to share their loved ones’ known preferences in the care plan meeting?
    • Is there a protocol and process in place to resolve family and resident differences in preferences? Example: Resident wishes to sleep-in but family wants resident to be out of bed by a certain time.
    • Do we have an active resident council? Family council?
    • Do we provide information and/or educational opportunities for residents and families to learn about person-centered care?
    • Do we utilize the Long-Term Care Ombudsman Program as a resource?
    • What is our process to learn about the resident in the first hours/days that they come to our home?
      • Through what process?
      • At what times?
      • By what individuals?
      • How often?
    • Do we have adaptive mechanisms that support resident choice regardless of physical and cognitive differences (e.g., accessible devices, Skype, phone-in options, language support, bariatric beds, etc.)?
    • Do we have training/education to support staff working with subgroups of residents with special needs (e.g., dementia or rehab)?
    • How do we respect the sexual orientation of our residents? Have we considered preferences and activities for these residents? Have we discussed the implications of interactions with residents with dementia based on sexual orientation?
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  • What staff communications practices do we use to support a resident centered focus?

    • Are staff consistently assigned to residents in a way that they are able to learn and maintain resident preferences?
      • What are the mechanisms for measuring consistent assignment?
      • What are the barriers
      • What are the areas it works well?
    • How do staff communicate with each other regarding resident preferences?
      • Across work areas, departments, shifts?
      • About specific topics such as bathing preferences, food and dining preferences and activity preferences?
      • How is privacy of the resident considered?
    • Are there mechanisms in place (e.g., scheduling, training) to enable staff to accommodate current and changing resident preferences (e.g., Resident wants to go to an activity when it is “shower time” or therapy)? What are these mechanisms?
    • Do direct care staff attend care conferences and communicate known resident preferences?
    • How does leadership introduce and track roles and responsibilities related to PCC?
    • How does leadership discuss the importance, rationale and benefits of person-centered care to the organization with staff?
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  • What organizational policies and procedures are we using?

    • What person-centered care processes have we implemented that are successful (for example, dining, wake-up time, activities)? Can we replicate any of those systems in other areas?
    • Are there reasons that we wouldn’t honor a resident’s choice even if we knew it?
      • Adequate resources to fulfill requests
      • Permission (empowerment) to fulfill requests
      • Perceived liability issues (e.g., injury from fall, choking from unapproved food choices)
      • Interpretation of regulations and internal polices
      • Organizational systems do not support the choice (e.g., meal not available at the time requested, medication pass is rigid, time of therapy, staffing is not adequate at certain times in various departments, etc.)
    • What procedural/administrative tools and resources do we have in place to support resident choice? Examples include welcoming process, waivers, and forms.
    • Is there a certain time of day, such as change of shift, that we are not able to accommodate resident preferences?
    • Which strategies does leadership use to support caregivers in making decisions, and welcoming and honoring residents’ preferences and choices about care and activities?
      • Staff education
      • Problem-solving
      • Scheduling
      • Appropriate staffing levels
      • Time for communication
      • Time for training
    • Has leadership asked staff how the leaders can help caregivers honor resident choice?
    • What does staff say are the barriers to honoring resident choice? Give examples.
    • Is there a champion for person-centered care in our organization?
    • Where are PCC policies reflected?
      • Job descriptions and evaluations
      • Mission statement/Values
      • Training materials
    • How does our organization involve residents and staff in determining PCC policies? Do we use strategies such as education, high involvement techniques, and surveys?
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  • What types of environmental factors impact our ability to be person-centered?

    • Is there an element of the environment (inside or outside) that presents a barrier to honoring a resident’s preference, for example, inclement weather, access to a kitchen, or heavy doors?
    • Are there spaces in our environment to support privacy and private time?
    • Are there spaces in our environment to support engagement and group activities?
    • Does our environment support safety?
    • Is our environment comfortable?
    • Do we have what we need to deliver the care the residents prefer? (Examples: towels, dining environments that accommodate meals at flexible hours, etc.)
    • Does our environment support residents’ use of familiar personal furniture and belongings?
    • How do we determine what residents want (such as personal furniture or items of their choice) and ensure that we respond to those needs?
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Step 4 – Create Improvement  >

Create Improvement


In addition to using a PDSA cycle to create change, the AE Campaign has identified best practices to help you get started.

Working the Goal and Using the AE PCC Tracking Tool
Website Get the AE Person-Centered Care Tracking Tool
Link to the AE PCC Identify Baseline web page
Adobe PDF Preference Congruence Interview FORM
"What is important to your residents?" "Are their preferences being fulfilled?" Try this brief interview, developed by Polisher Research Institute. Enter results into the tracking tool for terrific graphic results for your neighborhoods and home.
Adobe PDF Preference Congruence Interview INSTRUCTIONS
Instructions for the Preference Congruence Interview from Polisher Research Institute
Adobe PDF Why Should I Use the PCC Tool?
The tool is fun and easy to use, but there is much to be gained from the interview process itself and sharing your data with the community.
Adobe PDF PCC Implementation Guide
This is your soup-to-nuts manual that covers questions from who should do the interviewing and when, to how to enter data in the Tracking Tool, and tips for interpreting and using the information your workbook will produce for you.
Adobe PDF PCC Top 10 Pilot Tips
These top 10 tips are also a terrific quick-start guide. Build on the experience of our pilot testers to jump-start your project!
Adobe PDF Guide to Exploring the Gaps
Great to know where your opportunities to close preference gaps exist, but now what? Use this one-page diagram to sort through the options. Note that the three resources below (Adapting Preferred Activities, Further Conversations, and Detailed Preference Congruence Interview) are referenced in this flowchart.
Adobe PDF Adapting Preferred Activities to Residents
Build on strengths and ensure success with cognitive, physical, social-emotional and environmental tailoring to create the opportunity for residents to enjoy their preferred activities. Use these ideas to start brainstorming your own solutions.
Adobe PDF Continuing the Conversation
The brief Preference Congruence Interview is just the start of a great conversation! Open up the dialogue and get to know your residents with these open-ended questions developed at the University of Pittsburg to further explore preferences.
Adobe PDF Detailed Preference Congruence Interview: The Preference for Everyday Living Inventory
Like the brief Preference Congruence Interview, but feel like there's more ground to cover? This is the mother of the AE version. Created by Polisher Research Institute, it covers a much broader range of preferences and includes structured follow-up to guide 'closing the gaps.'
Resident/ Family Communication and Care Planning
Website New Tool Assesses Older Adults' Everyday Living Preferences
Provider Magazine article describing the Preferences for Everyday Living Inventory (PELI) tool
Adobe PDF How Reliable are Resident Preferences?
PowerPoint from the Polisher Research Institute of the Madlyn and Leonard Abramson Center for Jewish Life on the Preferences for Everyday Living Study
Adobe PDF Exploring Preference Fulfillment in a Nursing Home Sample
Gerontological Society of America (GSA) Poster from the Polisher Research Institute of the Madlyn and Leonard Abramson Center for Jewish Life on the Preferences for Everyday Living Pilot
Adobe PDF Individual Level Charts on Preference Fulfillment
Data from the validation study of the Preference Fulfillment measure from the Preferences for Everyday Living Study conducted by the Polisher Research Institute of the Madlyn and Leonard Abramson Center for Jewish Life.
Adobe PDF Interdisciplinary Team Care Planning Manual
Example of a manual to support an interdisciplinary care planning team from the Polisher Research Institute of the Madlyn and Leonard Abramson Center for Jewish Life on the Preferences for Everyday Living Study
Website Quality of Life Structured Resident Interview and Care Plan System
The Quality of Life Structured Resident Interview and Care Plan is a system for creating individualized, person-centered care plans in the nursing home. This interview-based approach to care planning generates the information staff need to tailor a resident's care plan to their preferences, as well as quantitative measurement of individual and facility-level outcomes.
Video Interviewing Vulnerable Elders (VIVE)
The systematic inclusion of resident voice through specific direct interviews represents an enormous advance in the new Minimum Data Set 3.0 (MDS 3.0). The Video on Interviewing Vulnerable Elders (VIVE) demonstrates best practice approaches for implementing the new MDS interviews for cognition, mood, preferences and pain. (64 minutes)
Adobe PDF My Personal Directions for Quality Living
A resource developed by the National Consumer Voice for Quality Long-Term care. This tool assists residents in recording my personal preferences and information about self.
Adobe PDF Know Me Form
This provider developed tool provides a method for recording and understanding resident preferences .
Adobe PDF Assessment and Care Planning: The Key to Quality Care
A resource developed by the National Consumer Voice for Quality Long-Term care. This tool provides guidance for care planning.
Adobe PDF 10 No Cost Ideas to Advance Your Culture Change Journey
This information emphasizes the involvement of residents and families in the culture change journey. The ideas listed here are practical and can be implemented in any nursing home.
Adobe PDF Conversations that Light the Way
Developed by the State of Ohio, when caregivers spend time getting to know resident preferences, relationships begin to develop that lead to optimal quality of life for both staff and residents. "Conversations that Light the Way" is a useful guide to facilitate caring communications.
Adobe PDF Planetree Long Term Care Improvement Guide
Tools for supporting residents in preserving their personal routines, making decisions about how their day unfolds and maintaining control and autonomy in their lives.
Website Dining Practice Standards
Nationally agreed upon new food and dining standards of practice support individualized care and self-directed living versus traditional diagnosis-focused treatment for people living in nursing homes. The Food and Dining Clinical Standards Task Force made a significant effort to obtain evidence and thus the New Dining Practice Standards document reflects evidence-based research available to-date.
Adobe PDF The Deep Seated Issues of Choice
This background paper was developed for the Pioneer Network Creating Home Symposium on Dining. It contains practical discussion on integrating quality through resident choice.
Staff Communications Practices
Website Pioneer Network's Starter Toolkit for Engaging Staff in Individualizing Care
This free toolkit is a product of the Pioneer Network's National Learning Collaborative on Using the MDS as an Engine for High Quality Individualized Care, made possible with the support of The Retirement Research Foundation. The Collaborative incubated B&F Consulting's method for engaging staff in individualizing care to improve outcomes for residents.
Video MPRO Michigan QIN-QIO - Consistent Assignment in Nursing Home
Video discussing the impact of consistent staff assignment in nursing homes. Interviews with administrators, staff and residents from three Michigan nursing homes help to highlight the positive impact this model creates. (12 minutes)
Adobe PDF Staff Communication 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.
Adobe PDF Implementing Consistent Assignment Tip Sheet
Resource provides information on why to implement consistent assignment as well as practical steps for successful implementation.
Adobe PDF A Guide for Nursing Home Staff: Getting Better All the Time (Working Together for Continuous Improvement)
Developed by the Cobble Hill - Isabella Collaboration Project, this manual provides guidance and resources for homes engaging in a change process. Appendices include checklists, communication tools, and outcomes measurement.
Website Staff Stability
Link to AE Staff Stability Resources
Organizational Change
Adobe PDF Planetree Long Term Care Improvement Guide
Developed by Planetree in partnership with Picker Institute, the Long-Term Care Improvement Guide was created in 2010 to propel long-term care communities in their improvement efforts. Informed by focus groups with residents and staff, executive interviews, and a series of site visits to organizations with well-established resident-centered cultures, the Guide features more than 250 concrete strategies for actualizing a resident-directed, relationship-centered approach and demonstrates how culture change makes an impact on operational, clinical and financial outcomes.
Adobe PDF Implementing Change in Long-Term Care A Practical Guide to Transformation
Developed by University of Wisconsin-Madison, this manual is based largely on feedback from staff in many organizations that have implemented significant practice and/or organizational changes. It includes examples, worksheets and tools for sustainable change.
Website Artifacts of Culture Change
The Artifacts of Culture Change contains ideas, measures and benchmarks for PCC implementation.
Website PEAK-ED (Promoting Excellent Alternatives In Kansas Educational Modules)
Free to download these modules are available in a variety of areas including Culture Change, Staff, Leadership, and Creating Home.
Website Positive Outcomes of Culture Change
Empirical and anecdotal data outlining some of the operational advantages and outcomes of PCC
Environment
Adobe PDF Low Cost Practical Strategies to Transform Nursing Home Environments
Developed by Lois Cutler and Rosalie Kane, this change package highlights low-cost environmental ideas for creating a homelike environment. Funded by Retirement Research Foundation.
Website Design on a Dollar
Design on a Dollar is adapted from Practical Strategies to Transform Nursing Home Environments developed by Lois Cutler & Rosalie Kane. Both projects were made possible through the generous support of The Retirement Research Foundation. The free online module provides ideas, self-assessment tools, and practical resources.
Website Creating Home in the Nursing Home
Free to download papers and presentations from the CMS sponsored Creating Home in the Nursing Home Symposium
Care for Subgroups of Residents
Video GWEP Geriatric Nursing Assistant Education DVD
Free training DVD for educating nursing assistant staff about dementia, delirium, & depression; end of life care; nutrition in older adults; pain in older adults; and sensory changes and communication with older adults.
Contact: Beth Barba, PhD, RN, FAGHE, FAAN at beth_barba@uncg.edu
Website Ethnogeriatrics and Cultural Competence for Nursing Practice
Online resource from the Hartford Institute for Geriatric Nursing with information about culturally competent nursing care when working with older adults
Website Assessing Cognitive Function
Online resource from the Hartford Institute for Geriatric Nursing with information on assessing cognitive function in older adults
Website Nursing Standard of Practice Protocol: Depression in Older Adults
Online resource from the Hartford Institute for Geriatric Nursing with information about assessment and care of depression in older adults
Adobe PDF Best Practices in Nursing Care to Older Adults with Dementia
Quick Reference Guide for Communication Assessment of Older Adults with Dementia (Hospital resource; can this also be used in Nursing Homes?)

Step 5 – Leadership & Stakeholders  >

Engage

Any time that you make changes, it is important to keep all of your stakeholders involved. Use these AE fact sheets to share information about the Campaign and to encourage feedback from others.

Person-Centered Care Fact Sheets
Adobe PDF Staff Fact Sheet
Adobe PDF Leadership Fact Sheet
Adobe PDF Consumer Fact Sheet
Top 10 Ideas to Involve All Staff in Advancing Excellence
Adobe PDF We know that homes that involve staff in all aspects of performance improvement are more successful in reaching their goals. Check out these ten ideas for involving your staff.

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.

You can submit your data, set your goal targets and view your trend graphs, if you have selected this goal.

Step 7 – Celebrate Success  >

Celebrate Success

All too often, we let accomplishments pass by without notice because we are already moving on to the next step. When we’ve reached a goal, it is important to take a moment to celebrate that milestone, even if it is a small step. In this way, challenges become linked with something positive.

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.

These resources are still under development and will be posted here as soon as they are complete. Please check back here often.

Back to Goals  >

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