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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.

Long-term care residents are at increased risk of infections for many reasons. As more people enter long-term care communities following hospital stays, communities are providing more hands-on, complex medical care to residents, such as wound care and maintenance of indwelling devices, which can lead to increased exposure to bacteria and infection. The shared living environment of a long-term care community can allow the spread of easily transmissible viral infections which cause respiratory or gastrointestinal infections among both staff and residents.

Gastrointestinal infections from Clostridium difficile (C. diff) are a major problem across U.S. healthcare settings. Although at one time most of these infections occurred in hospitals, now over 75% of C. diff infections are first identified outside of the hospital setting. Long-term care communities are among the most common places where C. diff infections can happen.

Reducing C. diff infections occurring among residents in a long-term care community has been selected as the first focus area for performance improvement within the infection prevention goal. Working on this goal will allow a community to implement strategies which also reduce spread of other infections.

  • How Does Preventing and Reducing C. diff Benefit Residents?

    Residents have lower risk of illness and serious complications related to infections from C. diff.

    Residents live in an environment with decreased transmission of C. diff.

    Residents have fewer hospitalizations resulting from C. diff.

    Residents are able to freely participate in activities within the long-term care setting or in the larger community.

    Residents and families gain knowledge about prevention of C. diff and other infections.

    Residents may have reduced exposure to unnecessary antibiotics as part of C. diff prevention efforts.

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  • How Does Preventing and Reducing C. diff Benefit Long-term Care Staff?

    Staff members are more skilled and confident in care delivery related to early identification and management of infections.

    Staff are knowledgeable about evidence-based care practices for reducing spread of C. diff and other infections.

    Staff are able to provide continuous support to the resident and family member affected by C. diff and other infections.

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  • How Does Preventing and Reducing C. diff Benefit Long-term Care Communities?

    Long-term care communities promote a culture of safety and infection prevention for residents, family members, and staff.

    Providers decrease spending on isolation supplies (gowns/gloves), and environmental services that are utilized during management of C. diff cases.

    Communities save time and money by reducing the hospitalizations and readmissions related to C. diff and other infections.

    Providers will meet the national Partnership for Patients efforts and Quality Assurance Performance Improvement (QAPI) requirements by performing surveillance, analyzing data and implementing interventions to reduce C. diff events.

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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.

  • Why is our C. difficile infection (CDI) rate high?

    • Is our CDI rate higher than in previous years?
    • What is driving our high CDI rate?
    • Are CDI rates high at the hospitals that frequently transfer residents to our nursing home?
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  • Which groups are most affected?

    • Are the CDI cases mainly happening with residents that have had a recent history of CDI? Or, are they brand new cases (incident cases)?
    • Are CDI rates higher among residents that have been hospitalized within the last 30 days?
    • Are CDI rates higher among residents who were admitted on antibiotics or who have recently (within past 2 weeks) received an antibiotic course?
    • Are CDI cases happening throughout the nursing home or limited to one hallway or unit?
    • Are new CDI cases happening among residents with roommates that have had a current or previous history of CDI?
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  • Processes and Resources to Consider

  • Is there a process for early diagnosis and isolation of CDI?

    • Do staff know the signs/symptoms of CDI?
    • Do staff know why it is important to report signs/symptoms as early as possible, and to whom they should report?
    • Is new onset or worsening diarrhea well documented in the resident’s chart and reported to nursing and medical staff?
    • How soon are stool specimens collected and sent for C. diff laboratory testing after a resident develops new or worsening diarrhea?
    • How soon after we send a sample do laboratory results for C. difficile get reported back to us?
    • When CDI is diagnosed, what is the process for assessment of the resident and beginning treatment?
    • At what point do we implement contact precautions for CDI? At the time diarrhea starts? At the time a stool test is sent for C. difficile? After a stool test is positive for C. difficile?
    • Are residents and families aware of, and understand the need to comply with, isolation requirements?
    • How are toileting needs accommodated for residents with new or suspected CDI and their non-affected roommates?
    • Are staff members wearing gowns/gloves appropriately before providing care for residents with suspected or confirmed CDI?
    • Does our nursing home have a process to monitor and report staff adherence to gown/glove use practices on a monthly basis?
    • What is our policy for a resident’s participation in activities and group therapy when he/she has active diarrhea from CDI?
    • Do we have a process to monitor residents with a known history of CDI for signs/symptoms of CDI after antibiotics are started?
    • Are residents with a history of CDI immediately placed on contact precautions when they develop new or worsening diarrhea?
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  • Do we have preventative hand hygiene processes in place?

    • Where in our nursing home are sinks for hand washing located?
    • Are alcohol-based hand sanitizers available in our nursing home, specifically in resident care areas?
    • Are staff members performing appropriate hand hygiene with soap and water after caring for residents with new diarrhea?
    • Do staff members know when a resident has new or worsening diarrhea?
    • Does our nursing home have a process to monitor and report staff adherence to hand hygiene practices on a monthly basis?
    • Does our nursing home have a program for resident hand hygiene?
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  • Are there environmental factors connected with our CDI rates?

    • Does our room cleaning procedure change for residents with known or suspected CDI?
    • How does environmental service staff know which residents are known or suspected of having CDI?
    • What products are being used to clean/disinfect rooms for residents with CDI?
    • What is our policy about frequency of cleaning for residents known to have active CDI?
    • Does our nursing home have dedicated equipment for use with residents with CDI (e.g., blood pressure cuff, Hoyer lift pad, etc.)?
    • What are the high-risk surfaces that might be contaminated in the room of a resident with known or suspected CDI?
    • Do we have a process to audit the adequacy of our environmental cleaning?
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  • How do we use antibiotics?

    • Does our nursing home have a process to measure antibiotic use?
    • Does our nursing home have a process to assess and track appropriateness of antibiotic use?
    • What drives the majority of antibiotic use in our nursing home?
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  • How effective are our systems for assessment of infections, communication and tracking?

    • How do frontline staff communicate with clinical providers about residents suspected of having an infection?
    • Do our clinical providers have a standard way to assess and document residents suspected of having an infection?
    • What factors impact CDI recurrences?
    • Does our nursing home have a mechanism to communicate "history of CDI" to hospitals at the time of transfer?
    • Do we have a system to track and alert providers to "history of CDI" among current residents and new admissions?
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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.

Free Training

National Nursing Home Quality Care Collaborative online training sessions:

Packages & Toolkits

Adobe PDF Change Bundle: Prevent Healthcare-Acquired Infections
Change Bundle: Prevention of C. difficile Infections
Change bundles from the National Nursing Home Quality Care Collaborative share successful practices of high performing communities. Each bundle includes a 6-point approach to prevention.

Self-Assessment Tools

CMS has made available the Critical Elements Pathways used by state survey. Use these Pathways to identify your strengths and your opportunities for improvement, and to plan your next steps. Routine review of these Pathways supports your continuous readiness.

National Nursing Home Quality Improvement Checklists
Use these checklists to assess your current policies, procedures, knowledge and practices as a first step to identify opportunities to improve.
Adobe PDF Early Identification/Containment Assessment Checklist
This checklist examines nursing home processes and staff practices for identification and diagnosis of CDI and implementation of appropriate precautions to limit spread of C. difficile.
Adobe PDF Hand Hygiene Assessment Checklist
This checklist examines nursing home processes and staff practices for performing appropriate hand hygiene during resident care to reduce spread of C. difficile and other germs. View additional hand hygiene resources.
Adobe PDF Cleaning/Disinfection Assessment Checklist
This checklist examines nursing home processes and staff practices for performing appropriate cleaning/disinfection of equipment and rooms to reduce spread of C. difficile and other germs. View additional environmental cleaning resources.
Adobe PDF Antibiotic Stewardship Assessment Checklist
This checklist examines nursing home processes and staff practices for improving antibiotic use to decrease residents’ risk of C. difficile infection. View additional antibiotic stewardship resources.
More C. difficile Resources
Website Toolkit for CDI Prevention and Management in Long Term Care
The Minnesota Department of Health's toolkit for C. difficile (CDI) prevention and management in long-term care includes resources in six topic areas: prepare, detect, contain, clean, prevent, and educate.
Website CDC C. difficile Website
CDC website with information and resources about Clostridium difficile in healthcare facilities.
Adobe PDF Clinical Practice Guidelines for C. difficile
Guideline for providers about C. difficile management and prevention.
Adobe PDF APIC: Guide to the Elimination of Clostridium difficile in Healthcare Settings
Comprehensive guidance on C. difficile prevention (2013).
Environmental Cleaning
Video Infection Prevention Video: Not Just a Maid Service
Two hospitals share stories about engaging environmental services staff in infection prevention.
Website Guidelines for Environmental Infection Control
PDF of the 2003 CDC guideline which is a compilation of recommendations for the prevention and control of infectious diseases that are associated with healthcare environments.
Website EPA's Registered Antimicrobial Products Effective Against Clostridium difficile Spores
List of products that carry an EPA label as being effective at removing C. difficile spores.
Website Centers for Disease Control and Prevention
CDC website on processes for assessing adequacy of cleaning practices.
Adobe PDF CDC Environmental Checklist
Example of an environmental cleaning auditing form for high-touch surfaces.
Hand Hygiene
Website Wi-Five Hand Hygiene Game
Very simple, fun, online game used to raise awareness of the World Health Organization's (WHO) Five Moments for hand hygiene approach.
Adobe PDF WHO: Hand hygiene: Why, How and When
An info-graphic rich guide to the 'Why, How and When' of hand hygiene, including the WHO '5 Moments.' Perfect for sharing!
Website CDC Hand Hygiene Website
CDC website with information and resources about hand hygiene in healthcare facilities.
Adobe PDF Guidelines for Hand Hygiene in Healthcare Settings
PDF of the 2002 CDC Hand Hygiene Guideline.
Website WHO: "Clean Care is Safer Care"
WHO Patient Safety team has provided a suite of tools to support health-care facilities in implementing a multi-modal strategy in order to improve hand hygiene practices among health-care workers.
Adobe PDF WHO: Comprehensive Hand Hygiene Program Self-Assessment
Validated survey which can be used to identify gaps in a healthcare facility's hand hygiene program.
Website Hand Hygiene Posters
These printable posters can be used to help raise awareness about handwashing. They are designed for all audiences, and some are available in multiple sizes and languages.
Antibiotic Stewardship
Website AHRQ Antimicrobial Stewardship Toolkits
AHRQ's toolkits can help you optimize your use of antibiotics. As reported by AHRQ, between 25 percent and 75 percent of antibiotics prescribed in nursing homes are unnecessary. Antimicrobial stewardship protects the effectiveness of antibiotics and reduces the risk of complications associated with antibiotic use, such as C. difficile. Antibiotic stewardship saves money too – up to $1,098 per resident.
Website AHRQ Improving Patient Safety in Long-term Care Facilities
Training modules to help nursing home staff detect and communicate changes in resident conditions.
Website Clinical Practice Guideline for the Evaluation of Fever and Infection in Older Adult Residents of Long-Term Care Facilities
Guideline for providers about standard assessments for fever or suspected infection in residents of long-term care facilities.
Website Development of Minimum Criteria for the Initiation of Antibiotics in Residents of Long-Term Care Facilities
Consensus criteria which can be used to determine whether an antibiotic might be indicated for residents suspected of having an infection in a long-term care facility.
Website Get Smart for Healthcare Website
CDC website with information and resources about the importance of antibiotic stewardship.
Website Get Smart for Healthcare: Nursing Home Fact Sheet
Fact sheet about the concerns of antibiotic overuse in the nursing home setting (PDF available).
Website INTERACT Communication Tools and Care Paths
Examples of assessment tools, communication tools, and algorithms for specific clinical conditions like fever, symptoms of UTI, and symptoms of respiratory infection.
Website Evaluation and Research on Antimicrobial Stewardship's Effect on Clostridium difficile (ERASE C. difficile) Project
An AHRQ toolkit to help hospitals explore the implementation and impact of an antimicrobial stewardship program on C. difficile infections.
Brochures and other materials
Adobe PDF Working Together to Prevent Infections Brochure
This family brochure can be modified to include your nursing home's contact information. Show that you promote Community Immunity™ (CI): it takes everyone to prevent infections and promote good health for all.
Community Immunity is a trademark of Kimberly-Clark

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!
Infections 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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