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QI Huddles Closest to the Resident

Tip Sheet

A QI huddle is a problem solving exchange done by and with the people directly caring for residents. It can be a quick "on-the-spot" exchange focused on a particular resident or a more in depth analysis on a topic identified for performance improvement affecting a number of residents. Whether for one resident or many, the group comes together to analyze what is happening, why it is happening, and to figure out together what can be done about it.

QI huddles can be done as a planned huddle at a set time or an ad hoc meeting in a quick moment when a quick solution is needed. A QI huddle is the time to think out loud, share ideas, and figure out a solution. It is a high engagement, short meeting. It brings together the people closest to the situation to shape the solution.

QI huddles are a tool for Quality Assurance & Performance Improvement (QAPI). Quality Improvement is a process predicated on the notion that the end user (in nursing homes, the resident), and those closest to the end user (in nursing homes, the resident's consistent caregivers) are in key positions to understand all of the ramifications of the problem and the solution, and are therefore key in making decisions to remedy a problem. For example, if a resident falls frequently or uses or exhibits distressed behaviors or has a persistent pressure ulcer, the staff closest to the resident can come together with other clinical and operations staff to share perspectives on how to improve the situation. Homes often use QI huddles when removing alarms, reducing anti-psychotic medications, or trouble-shooting other areas of concern.

QI huddles are in effect mini-assessment and care plan meetings, held on the spot, to look at a concerning situation or trend for one or more residents. Using root cause analysis, staff then make decisions that are immediately incorporated into the care plan. Subsequent care plan meeting discussion builds on the QI huddle.

QI huddles provide staff with frequent, timely, accurate, problem-solving mechanisms for working together. These mechanisms ensure that everyone has the information they need, common goals, and appreciation for each other's contributions.

QI huddles maximize effective problem-solving to get the best care for residents. A QI huddle focused on one resident can occur for a new resident as staff learn more about the person and collaborate to meet the person's needs. It can occur for a resident who is at risk for decline or shows indication of an issue, such as someone who has developed a reddened area or a shift in mood, appetite or function. Staff can use a QI huddle to look one by one at residents during a process of addressing a clinical area such as reducing alarms or antipsychotic medications.

While these concerns are typically reviewed in a 24 hour report meeting among clinicians, the staff closest to the resident who know the person best have the most pertinent details about what is happening, and will be the ones to implement any intervention. QI huddles closest to the resident combine the intimate knowledge of the CNAs and nurses who care for the residents with clinicians' expertise, to ensure that interventions are most effective. For example, in reviewing why a resident fell and how to intervene to prevent future falls and promote safer mobility, clinical leaders can only know so much from looking at a fall investigation report. Going to the place where the fall occurred and meeting with the resident and the staff who work daily with the person allows everyone to come up with an effective plan of action.

QI huddles are a tool for prevention. They provide a mechanism to catch and address a problem at an earlier stage, before it ends up on a 24 hour report. Consistently assigned CNAs recognize the slightest changes when they are dedicated to their residents, and can use a quick QI huddle to be pro-active and preventive. Working together, clinicians, other departments, and staff closest to the resident can make a game plan and then immediately update the MDS, care plan, and CNA assignment sheet.

QI huddles closest to the resident bring QAPI to life. For work in an area affecting a number of residents, QI huddles are a great mechanism for implementing Performance Improvement Projects (PIP) under Quality Assurance & Performance Improvement (QAPI). According to CMS, PIPs gather information systematically to clarify issues or problems, and intervene for improvements. QAPI expands current Quality Assessment and Assurance (QA) requirements by adding Performance Improvement (PI), also called Quality Improvement (QI). This is a pro-active and continuous process of root cause analysis of problems and pilot tests of new approaches to fix underlying causes of persistent, systemic problems.

QAPI drives a high involvement approach that combines regular conference room review of a homes trends by clinical leadership with engagement of staff closest to the resident in the problem solving needed to improve these trends. Clinical issues are addressed most effectively through application of residents' customary routines. QI huddles are a mechanism for all departments to work together to support staff closest to the resident to implement interventions that honor those routines.

As one of the four foundational practices, QI huddles work best when the other three practices are also in place. Consistently assigned CNAs know their residents best which increases the value of their contribution in a huddle. When staff have daily shift huddles and participate in care planning meetings, they hone their skills for the quick or in-depth problem solving needed in an ad hoc or PIP-type QI huddle.
  • Facilitate well. To capture ideas, bring a white board or paper on an easel and write all ideas down. Prompt people who are less likely to jump into the discussion by asking them what they think, what are they seeing. Set rules of "no blame" to keep the discussion positive and constructive. Use this time to enhance critical thinking by going through each decision and connecting the root cause to the intervention. This time is truly a teachable moment for all involved.
  • Locate well. Hold this meeting in a place is easy for those attending to get to. This is not usually a conference room meeting, but rather a space closest to the action. Find an accessible, private place to meet, such as the shower room or behind the nurses' station or in a nearby empty resident room. Use the resident's room if the resident or their family will be involved and their roommate is not in the room.
  • Be action oriented. End with a clear understanding by all involved of who will do what and when it should happen. Have a follow-up process, such as a "stand-down" meeting to check that all action has been taken and find out what else is needed.
  • Provide the support staff need to be on time. Be sure that everyone knows that there is an expectation of this meeting starting promptly, staying on topic, and getting things done. If there is a set time, everyone is there on time. To help everyone who is attending be on time, give staff notice so they can finish what they are doing or offer to take over so they can be freed up to participate in the huddle.
  • Have the people who need to be there. Make sure that any department involved in the issue or its resolution is in on the huddle. Communicate and problem solve across shifts. Include families and residents, and schedule at a time when families can come. Having people there only works if they know what they have to say will truly be used to benefit the resident. Ask people closest to the resident to share first.
  • The more you do it the better you'll get. Critical thinking and collaborative problem solving are skills that get better with practice. As staff see the impact of their collective efforts, and the follow-through and cooperation it engenders, you'll see their eagerness and effectiveness, and their participation will increase.

Pioneer Network
  • Pioneer Network's website provides links to many affiliate resource organizations.
  • Pioneer Network National Learning Collaborative Webinar series includes, for every topic, nursing home staff sharing examples of problem solving through QI huddles. All 12 webinars are also available for purchase as a set of discs, at a discounted rate. To purchase viewings of one or more of the webinars, or the entire package of 12 webinars, go to Pioneer Network store.
  • This tip sheet is from the Pioneer Network Starter Toolkit: Engaging Staff in Individualizing Care. The entire toolkit, with additional tip sheets, starter exercise and resources, is available at

Advancing Excellence in America's Nursing Homes
Data collection can help determine whether the changes being made are working, and continue to work. The Advancing Excellence in America's Nursing Homes campaign has the tools and excel sheets for collecting data on consistent assignment (are we REALLY doing this?) and on Person Centered Care (are the wishes and preferences of the residents actually being delivered, and are the direct care workers attending and participating in the care plan meetings?), as well as other organizational and clinical goals.

B&F Consulting
Short videos available under free resources at

Getting Better All the Time, working together for continuous improvement, a guide for nursing home staff at and

For more information about Quality Assurance & Performance Improvement, see QAPI at a Glance and other resources available on the CMS website at this address:

MDS Care Area Assessments (CAAs) can serve as an excellent tool to use in guiding an assessment or root cause analysis of a number of resident conditions such as falls, antipsychotic use, decline in ADLs, Dining, etc.

Download QI  Huddles Closest to the Resident Tip Sheet (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.
All webinars in this series are available as archived recordings at
In addition, the full series is available as packaged DVD set in the Pioneer Network store.