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QI Huddles Closest to the Resident

Facilitator Instructions for Starter Exercise

WHAT: This is a mock QI huddle to start conversation about how to share information and problem solve together, so staff can think through how it can work in your home.

WHY: Change is hard. Successful change requires discussion about why and how. Use this discussion to find out how the staff closest to the resident, who will implement a new approach, think it will work best. Have on-going discussions as the change evolves.

HOW: This guide includes discussion prompters to use after the personalized experience first to draw out staff's experience and reflections, and then to hear their ideas on how to do it. Allow time for each discussion. Hear from everyone. Ask for responses from quieter people. It may be tempting to brush off staff members who are openly skeptical, but putting into play major changes requires that concerns be welcomed as a contribution to the effort's success; get to the root of the concern, and note it as an area to keep an eye on.

RESOURCES: Toolkit Tip Sheet and Video Clip on QI Huddles Closest to the Resident
Entire Toolkit and Webinar Series available at Pioneer Network store.

Preparation: Review tip sheet and video clip on QI Huddles Closest to the Resident

Time: 30 – 45 min
Card Small Group Exercise: 10 – 15 min.
Discussion of Exercise: 10 – 20 min.
How to make QI huddles happen: 10 min.

Case Study Cards for Mr. McNally (download Case Study Cards pdf)

To learn the benefits of a QI huddle for problem solving together and how to use a QI huddle effectively.


Form groups of 4 – 6 people.

Explain: This is as a practice QI huddle, using a case study of a real situation. The home where it happened used a QI huddle to figure out what went wrong and how to set things right.

Share background: Mr. McNally had a stroke, went to the hospital, and then went to a nursing home for a short stay to ready for home. Instead, he went downhill fast.

Explain: The medical term for why he went downhill is a Greek word, iatrogenesis. It means "inadvertent harm caused by the treatment;" a decline that didn't have to happen.

In each group, have someone deal out the entire deck of cards to all the people in the group. As a team share your cards and figure out the answer to these two questions:
  1. What was Mr. McNally like when he first came in?
  2. What is the sequence of events that caused his decline?

Encourage groups to lay their cards out so everyone can see the cards.

Circulate among the tables to help any group that needs assistance. When people seem to have the general idea, bring the small group work to an end.

Make two points:
  1. Huddle: Point out that the process they have just gone through is a QI huddle – a quick 10 - 15 minute stand-up to review what they know about a resident they are concerned about, to determine the root cause of problems and possible solutions. Just as occurs in the exercise, many people on the care team have valuable information, including CNAs and nurses, housekeeping and maintenance staff, activities and social services, and others.
  2. Baseline: It's important in such a discussion to start with a review of what a resident was like when he first came in. Sometimes when a resident has started to have incidents and declines, staff forget the person's baseline.

Ask the group to share what Mr. McNally was like when he first came in. In addition to his personality and interests, the group will note aspects of his customary routines.

The group will share information about Mr. McNally. When they have pieced together what he was like when he first came in, recap by noting that he was sweet in his temperament, independent in his life, engaged in many activities, and used to helping others. He was also independent of bowel and bladder, had lived on his own for many years and had developed his own ways. Hold off on any discussion of his medical decline – keep the focus at first on Mr. McNally as a person.

Ask if these attributes are still true – is he still sweet, independent and engaged? The group will give you a mixed response – some will say no, he's no longer that way, and others will say yes he is still who he is, even if he can't live accordingly.

Remind the group of the term "iatrogenic" and ask if his changes are a natural progression of his illness. The group will know that the changes are a result of his experience in the nursing home, not his illness.

Ask the participants to piece together what caused his decline, what started it?
Here's the chronology of what happened along with a sequence of questions you can use to facilitate the group discussion:

  1. Night owl. Ask: When did his decline start? It started with a sleeping pill the first night, which he accepted because he saw that others were going to bed and then felt the need to go along. The sleeping pill made him groggy in the middle of the night when he got up to go to the bathroom. He was in an unfamiliar environment where the bed width and height were different than what he was used to. When he started to fall he grabbed for the first piece of furniture nearby to steady himself – the bedside table, with wheels. At this point he fell.
  2. Critical thinking and root cause analysis. Ask: What was the staff's response to the fall? Staff put on a bed alarm. What was the root cause of his fall? It was the sleeping pills and an unfamiliar environment. Does the alarm address either root cause? Clearly it doesn't. What would be better interventions? Answer – not giving him the sleeping pill, and helping prepare him and his environment so he can navigate safely when he needs to go to the bathroom at night.
  3. One thing leads to the next. Keep asking and filling in: What happened next? Once Mr. McNally has the bed alarm, he starts to decline further. The alarm bothers him and bothers his roommate. He can't sleep and is upset when the alarm goes off. (And, he's a fireman, so it makes him feel like he needs to get up when he hears it go off.) He is given medication because he is upset. So that he will not set off the alarm at night, he decides to curb his need to go to the bathroom at night. He stops drinking. This leads to a UTI. He is given medication for his behavior that contributes, with not drinking, to sluggish bowels and eventually constipation. He also misses therapy appointments and is behind in rehabilitation for his return home. As he declines, he develops the beginnings of a pressure ulcer, affected by his lack of movement and his poor nutrition.

Tell them how the story ended:
The Administrator and Director of Nursing saw on the 24 hour report that Mr. McNally had hit the nurse while she was giving him a suppository for his constipation. They agreed that if they had been Mr. McNally, awakened early in the morning to receive a suppository, they might also have had a negative reaction. They were surprised that Mr. McNally needed a suppository because he had been independent of bowel and bladder when he first came in. They are also surprised to see how his mood has changed, because they knew he was a very sweet, independent, personable man. They had a QI huddle with the staff and pieced together what's in these cards.

Ask the groups to figure out what to do to make things better for Mr. McNally.

Have them use the information in the cards to come up with a game plan.

As a whole group, discuss what help will be needed from other departments

Tell the group they just did what is called a QI Huddle and that what made it work best was that they all contributed the information they had so that everyone had the whole picture and could think it through together.

Begin the discussion on how to make it happen.

Where would we start?
What would we need to make this work?

Download Facilitator Instructions for Starter Exercise: QI Huddles Closest to the Resident (PDF)

Starter Toolkit Home          Step One          Step Two          Step Three          Self-Assessment
Prepared by B&F Consulting for Pioneer Network's National Learning Collaborative on Using the MDS as the Engine for High Quality Individualized Care. Funded by The Retirement Research Foundation.