Improving Patient Safety in Long-Term Care Facilities

Module 1. Detecting Change in a Resident's Condition

Instructor Guide

This module focuses on detecting changes in a nursing home resident's condition. This Instructor's Guide describes how to use the materials in the companion Student Workbook as a teaching session and how to apply a quality improvement project for the topic of detecting change. Suggested slides are provided in Appendix 1-A.

Principal Message

The single most important message your audience should come away with is that it is essential to notice and report change in a resident's condition, and it is everyone's responsibility to do so. Staff should know the signs of illness in older adults and other nursing center residents, and they should know how to watch for and report changes in a resident's condition.

Staff also should understand what it means to work in a safe environment. This means that nursing staff can work together as a team and share information openly. It also means they understand that keeping residents safe—and not worrying about who might be to blame when things go wrong—is the most important consideration. Participants should experience the setting of your teaching as an example of a safe environment, where information is freely shared and concerns are openly reported and supportively addressed.

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Principal Audiences

This training is geared towards licensed nurses (RNs/LPNs/LVNs), occupational and physical therapists, and nursing assistants. However, portions of the training are relevant for custodial and activities staff, who also are important for identifying change. The training is designed to be accessible and relevant to all these care providerwws. So you can teach your participants all together, mixing the professional roles.

The importance of teaching the different professions together is that it will, in and of itself, likely improve teamwork by allowing members of each profession to better understand the staff from other professions. For instance, anecdotal research suggests that nursing assistants feel that licensed nurses rarely read their notes. Learning together presents an opportunity for nursing assistants to understand more about what licensed nurses need to see in a nursing assistant's note, and it allows licensed nurses to understand that it is important to read the notes and to let nursing assistants know that they do so.

If the learning culture of your audience suggests they will have problems learning together, you can separate your participants into different sessions according to their professional roles. However, you should aim to get them comfortable learning together for the next module in this series, "Communicating Change in a Resident's Condition."

More abbreviated training might be appropriate for custodial and activities staff. This includes slides numbered 6, 8, 11-16, 18, 19, and 21 (go to Appendix 1-A for suggested slides).

There is only one portion of this module that is targeted particularly to RNs, and that is the nursing assessment that is triggered by a change in the resident's condition. Note, however, that the specifics of how to conduct a nursing assessment are not within the scope of the module. Also, occupational and physical therapists and nursing assistants who might report a change all need to know that nursing assessments are an appropriate response to a potentially meaningful change in a resident. So, that section of the module can be included for all participants, even though its significance will differ depending on their professional roles.

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Workbook Content Overview

Clinical Content

A change in a resident's condition may mean that he or she is at risk. Action can be taken only if changes are noticed and reported, the earlier the better. Changes that are not reported can lead to serious outcomes, including medical complications, transfer to a hospital, or even death.

In order to identify a change in condition and know when to report it, staff need to understand what is normal (baseline) for a particular resident's condition when he or she first comes into the nursing center, and over time after that. Armed with this information, staff will be able to identify changes and decide which ones need to be reported to others on the care team.

This module reviews ways to notice changes from the resident's normal condition. The more common of these changes are listed by their physical and non-physical categories.

The module also identifies ways the care team may best communicate with each other about such changes and use reporting tools. It notes the importance of logging shift-to-shift changes, and provides the Early Warning tool and the SBAR (Situation, Background, Assessment, and Recommendation) tool for the participants to get to know and use.

Content by Session

This module is designed for presentation in two sessions. The first session introduces the importance of detecting change and describes how to detect change. The second session discusses the top 12 changes to watch for and describes how to use tools to document and get ready to communicate about the changes.

Your teaching goals for both sessions of the module are to:

Have participants understand what it means to be in a safe work environment with open reporting and to buy into that as something they want to be part of at their nursing center.

Develop participants' knowledge and skills in detecting changes in a resident's condition.

The module materials also can be used flexibly to fit a range of session lengths. Selecting materials to suit a 30-minute single session, for instance, is quite possible. However, this module is designed to be a 2-hour session.

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Objectives of the Session

Objectives are separated into knowledge and performance objectives. Suggested slides are provided in Appendix 1-A of this Instructor Guide, but they are not in the Student Workbook. You can use these at the start of the session and even have them up on a flip chart or screen that stays on the side of the room during the session. Alternatively, you can return to them at the end of the session to give participants a sense that they are following your road map. It is often best to select one, two, or three objectives and leave the others aside. In teaching material that you want participants to really take in and use in practice, "less is often more," so that participants can take in and integrate the new material in a usable way. You can remove unwanted items on the slides or highlight the information on which you will focus.

Knowledge Objectives for Participants

For all:

  • Understand why detecting change is important.
  • Understand how to know a resident's normal (baseline) condition.
  • Understand how to watch for change.
  • Understand how the Early Warning tool and SBAR tool work.
  • Understand how to follow up at the first sign of change.

Performance Objectives for Participants

For all:

  • Summarize a resident's normal (baseline) condition for other team members.
  • Identify whether changes in a resident's condition are important or not important.
  • Promote behaviors that improve change detection.
  • Use the Early Warning tool and SBAR tool.
  • Decide when to report or when to ask for help when observing changes in a resident's condition.

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Preparing for a Session

1. Assess the Needs of Your Audience

These training materials are meant to be used as a complete package. However, you may tailor them to the needs of participants and current practice at their nursing center. To determine needs, you may use a survey or talk to individuals familiar with the nursing center. Whether you choose to use all or some of the material in the Student Workbook, decide on a focused goal for teaching. It is better for participants to learn and remember a few important pieces of new information than to feel overwhelmed by many new ideas.

Consider the language level that will best suit your audience. If you use technical medical terms, be sure to insert the meaning of the term. If your audience uses English as a second language, speak clearly and not too quickly.

2. Consider Your Teaching Method(s)

Most instructors find that a combination of methods—lecture and interactive—works best. Consider using a selection of these teaching methods:

  • Lecture with slides.
  • Whole group discussion.
  • Break-out group discussion.
  • Case discussion.
  • Role play.

Suggestions for ways to use these methods are in the "Recommended Teaching Methods" section of this module.

3. Presentation Timing

The suggested timing for each part of this 2-hour module is:

Activity Time
Introduction of Instructor, Topic, and Objectives 5 minutes
Pre-test 5 minutes
Case Discussion 10 minutes
Presentation 1, Interactive Lecture 20 minutes
Case and "Critical Reflection" Discussion 15 minutes
Break 5 minutes
Presentation 2, Interactive Lecture 18 minutes
Case Discussion and Role Play (2 scenarios) 20 minutes
Debrief on Teaching Methods 5 minutes
Key Take-Home points 5 minutes
Post-test. 5 minutes
  Total: 115 minutes

Although this is a 2-hour module, you can teach it in two 1-hour blocks. You can also select material within the module to make a 30-minute or a 45-minute session or two 30-minute sessions within a 1-hour time slot. This flexibility is important, as some nursing centers might not have adequate nursing coverage for a 2-hour session.

4. Using the Slides

The Student Workbook is not meant to be used as a prepared speech. It assumes that you know the subject and offers material you may want to use. The suggested slides (Appendix 1-A) are meant to trigger your presentation. You will find it useful to practice speaking with them.

5. Preparing Your Presentation: Overview of Effective Instruction for Adult Learners

Adult learning involves changes in knowledge, behavior, and skills.

This module aims to help participants improve the way they notice, report, and keep track of changes in a resident's condition.

Adults are usually most motivated to learn when:

  • They see the subject as directly related to their own needs and goals.
  • They see ways for their learning to be applied to their own work settings.
  • They are responsible for their own learning.
  • Their own knowledge and skills are appreciated.
  • "Mistakes" are seen as chances to learn.
  • Practical, hands-on experience is part of the instruction.

Adults take in new information more quickly and remember it better when it relates to their own experience. Structure your session to draw on what participants already know and what they want to learn. Make sure everyone feels that they have something to contribute.

Teaching methods such as interactive lecture, case discussion, and role play help lead adults to make changes on the job. A good way to get your group moving in this direction is by starting with a case for discussion. If the case reflects a situation that's familiar to participants, with a problem they want to solve, you will have a "teachable moment."

Interactive Lecture

With this method you present the material, using questions-and-answers (Appendix 1-B) and slides (Appendix 1-A) or other visual aids.

Case Discussion

The case tells a story. It involves situations similar to those faced by participants at work. You lead a discussion that brings in what they know and how they might handle the situation. You will want to be sure that different ideas are heard, and see if anyone changes his or her mind. You'll find a sample case in the "Making the Presentation" section, below.

Role Play

"Learning through acting" gives participants a chance to use what they know and practice something new in a real-world setting. It can help them see a situation from different points of view. It also helps them develop communications skills.

Writing It Down

With all these techniques, it's useful to note participants' ideas and questions—a flip chart works well. This helps keep participants thinking and engaged. You can keep a "parking lot" list of thoughts that may not be on point at the moment, but should be kept in mind when you're summing up the session.

More information on how to teach this material is, in the "Giving Your Presentation" section.

6. Preparing a Handout for Participants

These training materials are meant to be used as a complete package. However, you should feel free to choose the parts you think are most relevant for your particular audience and their nursing center. The slides in Appendix 1-A may be reproduced and provided to participants. For this module, you will want to include the Early Warning and SBAR tools.2 The case is presented in the Student Workbook.

7. Learning Settings that Work for this Module

Think ahead about the kind of setting that will be available and best allows your targeted group to participate in the training. You'll also want to consider work shifts, and how your session can fit with in-service training requirements or other options. It helps if your session meets some of the nursing center's requirements for staff training. It's also good to provide refreshments if you can—that tends to increase attendance. Post announcements ahead of time so that people know when and where your session is going to happen. You might have a leader introduce the session to show that it's important.

8. Using Pre- and Post-Tests

A series of pre/post-test questions and answers can be found in Appendix 1-B. These provide real-time feedback on how well the training session worked. The pre-test sets a baseline of what participants knew about the topic before the session; this can be compared to the results of the post-test to answer the questions, "What changed from the beginning of the session to the end? Did participants learn what we wanted them to learn?"

9. Equipment

You will need equipment that allows you to display slides and also record discussion points and questions from participants. You may use:

  • PowerPoint®.
  • Slide projector and screen.
  • Flip chart.
  • Overhead projector with transparencies.

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Giving Your Presentation

  • Introduce yourself and your purpose in being there.
  • Hand out the pre-tests. Explain that pre- and post-tests help participants evaluate themselves and help you evaluate the course. Have participants complete the pre-test.
  • Introduce the topic and review session objectives (using slides).
  • Present the material.

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Recommended Teaching Methods

For this module, a mix of teaching methods may be the best—some interactive lecture, some case discussion, and some role play.

Interactive Lecture

The "stand-up" lecture works well when it's about something participants care about, and when the speaker is engaging. It's best used when a large amount of information needs to be delivered to a silent audience. In an "interactive lecture" you still speak most of the time and control the subject being addressed, but the audience participates in different ways—asking or answering questions, giving examples from their experience, and expressing opinions.

Like a story, any lecture—regardless of length—has a beginning (the introduction), a middle (the body), and an end (the summary). Each of these serves a different purpose.

Introduction: establishes the purpose of the lecture, including overall goals and specific objectives. It should include an overview of the whole lecture. You are aiming to get participants interested and make them aware of expectations for the session.

Body: includes the material needed to meet the objectives stated in the introduction. Your session will be most effective if you:

  • Grab participants' attention in the first few minutes.
  • Involve them in fine-tuning the focus of learning.
  • Plan a change of pace every 8-10 minutes during a lecture.
  • Give participants a chance to reflect.
  • Use visual aids.

Give participants a chance to share experiences.

Summary: includes a recap of the material presented in the body of the lecture. It may also include an opportunity for participants' questions and feedback.

Case Discussion

Most instructors prefer to use the case provided in this module. A clinically experienced instructor who is also a seasoned teacher may also invite participants to contribute relevant cases in which they have been involved. But a new instructor may prefer to keep the focus on a familiar case.

Case Study

Ms. A is a mentally intact 79-year-old frail (in a weakened condition) woman who arrived at the Manor Nursing Center following a hip fracture suffered at home. After a stay at an acute rehabilitation center, she is still not able to manage by herself. Ms. A walks with difficulty with a walker, and needs help with daily living activities. Ms. A also has several other medical problems, including high blood pressure, diabetes, and arthritis. She is also being treated for depression. Her family visits her regularly on weekends. She rarely participates in activities of the Manor Nursing Center; at mealtimes she tends to avoid conversation. Recently, she had diarrhea, was incontinent of liquid stool, was placed in adult briefs, and nursing assistants had to change her adult briefs once or twice per shift. She began taking meals in her room. Stool tests showed that she had a bowel infection with Clostridium difficile. An antibiotic was started. Even with the antibiotic, her bowel movements continued to be liquid and frequent over the next week, and she was eating less. Her blood pressure had been normal for her at 130/80, but her pulse rate was higher than her usual 70-75 at 90-100. Yesterday she had a fever of 102.5 and was transferred to the acute hospital, where she was admitted to the intensive care unit.

How did Ms. A get so sick with only diarrhea? What changes might you have noticed about Ms. A? When might you have decided to do something about it? What could you have done?

The case in the Student Workbook is the same. You may not need to use much or any of the clinical detail in your teaching; it is provided here in case it is relevant. Once the case has been presented, pause and invite participants to comment. Questions to get discussion going and draw on prior knowledge might be of the "survey" type:

  • Have any of you worked with a resident who had to be transferred to the intensive care unit?
  • How often would you say this happens in your nursing center?
  • Does your nursing center have procedures to follow when you see a change in a resident, such as Ms. A's need for adult briefs?
  • Could you give an example of what you're supposed to do when you see a change like this?

Questions you could ask to reinforce the knowledge you are sharing might be:

  • Could you give an example of a warning sign that Ms. A was becoming more ill?
  • Ordinarily, what is the result of treatment with an antibiotic for people with diarrhea?

You can then encourage critical thinking and communication with questions such as:

  • At what point would you think that the diarrhea might be a symptom of something more serious?
  • Who could you share these concerns with?
  • What do you think Ms. A's nursing team might have done differently that could have prevented her condition from getting worse?

You might ask participants to brainstorm ideas about ways to communicate that would prevent this situation.

Keep in mind that you are trying to get participants to think in terms of teamwork rather than blame.

Try to get them to talk with each other, not just to you. Have them discuss a topic in pairs or in groups of three. This method makes it easier for a shy person to be heard as the less shy member of the pair or team can speak up for both or all of them.

If the number of participants is small, you could lead the case discussion with the whole group. Larger groups may be broken up into smaller ones, with each taking one or two questions and then reporting out to the whole group. Or, you could divide the participants into groups according to what they do (i.e. licensed nurses, nursing assistants, occupational and physical therapists, etc.).

Role Play

This technique has participants take on roles in a clinical interaction. There is no written script, and the "actors" don't have to memorize anything.

There are five parts to this technique.

Set-up: Ask participants about their previous experiences with role play. Explain the goals of this exercise and relate them to the key learning objectives. Make sure everyone is familiar with the overview of the case. Only the "actors," however, will know the details of their roles. It may be helpful to provide the description of the role play to those who are not participating as actors in the role play.

Then go over some guidelines:

  • Anything that comes up is confidential.
  • This is a safe place. Actors should not be afraid to take risks.
  • Feel free to be spontaneous.

Assign the roles: You may have actors play a role similar to the one they have in their real jobs, or you might encourage them to try out a new one. A licensed nurse, for example, could take the part of a resident, or a nursing assistant could act as a licensed nurse. Involve as many people as possible in the role play. Because role play requires participants to be somewhat emotionally open, they may feel anxious or resist being an actor. Your own positive attitude and a light touch will help. Any participants who are not assigned to a role should be asked to be observers.

Conduct the role play: Participants act out their roles in the "scenario" you provide (example below), based on the case. Try not to interrupt the role play while it is running; just let the interactions flow naturally.

Before the scenario, explain how much time it will take, and that it will be followed by discussion. It should take only 2-3 minutes, followed by perhaps 5 minutes of discussion.

Don't let the role play go on for too long—most of the learning happens in the first few minutes. If actors seem too carried away by their roles, remind them to keep it simple.

Scenario 1. Two roles: Mary and Marli. Mary is worried about how depressed Ms. A seems. She has tried unsuccessfully to get Ms. A to talk. Marli is concerned about there not being enough people on the floor to get all the work done, and thinks Mary is spending too much time with Ms. A. Marli has had the experience of bringing concerns to the RN and nothing being done. They talk about whether they should mention anything about Ms. A to anyone else.

Tell the role players to simulate the interaction between the nursing assistant and the licensed nurse, making it clear when the interaction is happening and in what setting (e.g. on the phone as soon as possible, at change of shift, etc.). Tell them their goals are to: (1) get all the information across, (2) communicate about the situation in a timely fashion, and (3) be able to push if the message does not seem to be getting across. You can also tell the role players that the purpose of this role play is to discuss barriers to communication and how to effectively overcome the barriers.

Discuss the role play: Discuss the issues that came up in the role play. Everyone's input should be included. After each scenario is played out, ask the actors: What went well? What did not go well? What would they do differently next time? How did it feel to say____? How did it feel to hear____? Ask observers for their opinions about what the desired outcome was in each situation and how they might have handled the situation differently.

Conclude the role play: Encourage a round of applause as the participants transition "out of role." Summarize the major themes and issues. Consider with the group how to apply the role play to real life clinical situations. Emphasize what was learned during the role play.

Debrief About the Teaching Method

  • Ask participants what methods they think you used. Get their thoughts on what worked and what could be done better.
  • Listen and thank them for their thoughts.

Review Key Take-Home Points

  • Promote a safe environment based on teamwork and thinking about how the system of care works and how it can be improved, rather than thinking about blame.
  • Educate the entire staff about the importance of falls, risk factors for residents, and methods of prevention.
  • Use appropriate risk-assessment and reporting tools.


Thank your participants for attending. Let them know that you enjoyed being with them. Hand out the post-tests. Emphasize how important it is to complete the post-tests because they can get feedback on what they've learned (based on their answers to the pre- and post-tests). Tell participants that you will provide the correct answers and rationales for the tests after they are done.

Also, you should stress that the post-test is anonymous.

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Translating the Teaching into Practice

It is often hard to get what is taught in a classroom or in-service learning session translated into action as part of resident care. Even if the teaching has gone well and the learning was taken in and appreciated, it can be hard to put the new learning into practice. There are many possible barriers. For instance, the system of care may not accommodate the new practice, or the culture of care may not accept the change, or the leadership may not be aware of the new learning and so may not make room for it.

Following up after a teaching session with a quality improvement project in which the new learning is put into practice by the whole team can help a lot. Quality improvement projects use a step-by-step approach to improving care by taking a long, hard look at what needs to be done; starting out with a small change, watching it, adding to it, and continuing in this fashion until the job is done. There is a method at work here, and the method is described in the next section, "Quality Improvement."

Quality improvement methods often include a teaching step. This module can be the teaching material for that step. If the quality improvement project is to improve the way nursing assistants and licensed nurses detect and communicate changes in a resident's condition, then this module is perfect for the teaching portion of the project.

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Quality Improvement

"Quality Improvement" (QI) is an approach that may be used by nursing staff and managers to improve quality and safety in patient care. The three main components are to:

  • Gain knowledge and skills to understand systems of care and minimize adverse outcomes.
  • Apply methods to identify, measure, and analyze problems with care delivery.
  • Act on the results of data collection and analysis to improve both individual care delivery and systems of care delivery.

QI is a team approach that involves everyone in thinking about innovation and recognizing that the key to improvement is the people who care for patients. It is not about individual rewards and punishments, but rather QI relies on measurement to improve the center's performance as a whole.

At the core of QI is the "Plan-Do-Study-Act (PDSA) Cycle," based on trial and error over time.

  • Plan: Identify a problem and design a change to address it.
  • Do: Implement a small change.
  • Study: Measure and analyze the effects of the change.
  • Act: Take action based on the results of analysis, such as trying another change, formally implementing a change, or extending implementation more broadly.

When you engage in a QI project you will be using information/data that you have on current practices at your site to develop goals based on both best practices and realistic expectations.

The five phases of the QI process are outlined here.

For more detailed information on QI and measurement tools, please see "The Patient Safety Education Project (PSEP), Module 9: Methods for Improving Safety," which can be found at

1. Project Initiation Phase

Decide on the Area of Work that Needs Improvement

In this example we focus on detection of changes in a resident's condition. Most likely, a process to get to this point is already in place at the center. Still, it is helpful when starting the project to make sure everyone believes in its importance. Collect data to support your assumption that there is a problem and establish a baseline for measuring improvement.

Form Teams

Leadership teams must include one or a few people with enough institutional authority to help get the resources that the project team needs

For this project, the Director of Nursing, the Quality Improvement Officer, the center's overall Director, or the Chief Operating Officer are potentially good choices.

Project teams must:

  • Have basic knowledge of the problem.
  • Represent all parts of the process and different levels of the organization.
  • Have at least one member trained in QI.
  • Recognize that good ideas can come from anyone.

The ideal team size is five to nine members. Additional temporary members with special areas of expertise can be invited to particular meetings as needed.

For a "detection of changes" improvement project, the following project team members are one example of a good team.

  • Registered nurse.
  • Two nursing assistants.
  • Director of nursing.
  • Education director.
  • Geriatrician.

Write an Aim or Mission Statement that is “SMART”

  • Specific.
  • Measurable.
  • Appropriate.
  • Result-oriented.
  • Time-scheduled.

The aim should include a "stretch" goal that may be hard to reach but is achievable—for example: Decrease the rate of resident falls by 50 percent in 12 months.

Consider Appropriate Measures

Examples of measurement (data) include a "process measure" like compliance rates for use of the Early Warning Tool or SBAR, or documented nursing notes in a resident's chart on reports of change.

To show improvement, you should be able to plot the variable being measured on a run chart (a graph that displays observed data in a time sequence).

2. Identifying the Problem

Identify the Problem

At the outset, you need to identify:

  • The problem and the extent of the problem—that is, what are the barriers to detecting changes and how poor is detection of change now?
  • Changes that can be made that are expected to result in improvement—that is, what might improve the detection of changes in a resident's condition by overcoming those barriers and how?
  • How the effects of the changes will be measured—that is, select the measures that you will use to assess change over time in detection of changes in a resident's condition.
Plan for Data Collection and Analysis

Tools that you can use to collect and analyze data include process flow charts, brainstorming, cause and effect diagrams, and consumer focus groups. These are readily accessible at: (Easy Guide to Clinical Practice Improvement: A Guide for Healthcare Professionals. New South Wales Department of Health).

3. Intervention Phase

Get Consensus

Get team consensus on priorities and changes most likely to result in improvement and then decide on an intervention.

Remember Culture and Teaching, as well as Protocols

Many interventions focus on what is done—for instance, changing or adding a protocol. These are good, but they often don't work as well as they could unless they go along with changing the culture to appreciate the importance of the new protocol. The best interventions tend to address culture with team meetings and other educational or inspirational materials at the same time that the new protocol is added. Usually, culture change includes implementing and disseminating some core teaching.

Conduct PDSA (Plan, Do, Study, Act) Cycles

The cycle begins with a plan and ends with an action based on learning gained. It should specify who, what, when, and where. The end of one cycle leads directly to the start of the next one.

  • Try a change; for example, conduct a 1-hour, online educational session for nurses on a specific ward.
  • Observe consequences by using the selected measures.
  • Learn from consequences—for example, some people used SBAR and the Early Warning Tool, but others did not, and you discover that those who used the tools had taken the online learning and the others had not.
  • Try a change—for example, in-service time is given for all staff to complete the online education. Then run another PDSA cycle.

The way you document observations may be simple, such as counting and recording on a tally sheet, or it may be more complex, such as using sophisticated tools for data analysis.

If the data do not support the intervention, they may not be appropriate. Look at the data for clues about what to change, and run another PDSA cycle. When you have finally arrived at a sustained change of the kind you intended, that final version of the intervention may be implemented on a larger scale.

4. Implementation and Impact

Implement the Change

This means making it a permanent part of normal business throughout the unit or setting. It may mean applying the intervention throughout the nursing center, for instance. In this case, it would probably mean ensuring that all nurses and nursing assistants take the online teaching and demonstrate their familiarity with SBAR and Early Warning Tool.

Relevant support processes have to be implemented at the same time. For instance, the rollout of education will need to be supported with suitable in-service learning time.

Measure the Impact of the Change

To provide evidence that the intervention resulted in improvement in all places where it was implemented, you will need to collect, analyze, and display the data. For example, you might create an annotated run chart showing changes in reported use rates for SBAR, unit by unit in the whole nursing center, after nursing assistants started using a new form to document changes in a resident's condition. You will be able to choose your measure from the experience you gained in the Intervention Phase (as described previously).

5. Sustaining Improvement

The QI step that fails most often is sustaining the improvement. When the project is done, even if it has been successful, if it is not monitored and no one is assigned to make sure the new standards are kept up, it will probably fade away.

Mechanisms for sustaining change include:

  • Standardization—that is, ensuring that new methods are implemented consistently over time.
  • Documentation of the project from planning through testing, implementation, and followup.
  • Indefinite periodic measurement—for example, of reported use rates of SBAR and the Early Warning Tool—and review to ensure that the change becomes routine practice. The measure chosen for this is called a quality indicator, and usually, it is easy to establish (for instance, something that is part of the Minimum Data Set or some other set of data that is always collected) and part of what a senior person reviews regularly.
  • Staff training and education, geared to the type of change proposed, the people who will be asked to implement it, and the skill level and work experience of the target group.

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Applying QI to Improving Detection of Change in a Resident's Condition

Starting the Improvement Effort

First, you will generate and look at relevant data on detecting resident change in your area, probably with some of your lead team members. For instance, you might survey staff about how long they think it usually takes between the onset of a behavior change and getting a nurse or physician evaluation. Then you will ask questions and discuss how this state of affairs stacks up against other institutional priorities. When you have decided that this is the area you want to work on, you will form your teams; you will have a leadership team of one or a few people and a project team of five to nine. The project team will write a mission statement and select measures that the leadership team will review, adjust as needed, and approve.

Next, the project team will decide which problem to address in order to help detect change. Whatever the intervention, it will likely be essential to enhance the culture of awareness and the importance placed on the topic. That is usually where the teaching module comes into play. The project team will decide what area to work in first and will identify what process to change. Then the people in that unit will be educated about the topic area.

The Intervention

In the case of detecting change, the primary intervention may be teaching this module, but it is likely that there will be a corresponding change in standard operations. For instance, daily rounds may add a specific question for every resident: Did you notice anything new about Mr. Jones? Or it may add this question to the format used by nursing assistants in their change-of-shift verbal and written reports. Each QI effort may have its own intervention to enhance detection of change.

Including Teaching for Culture Change in the Effort

Finding the right person to teach the module is important. It is essential to find someone that the participants will look up to and respect for their knowledge of the area. A person who teaches well is also very important and not always easy to find. The person can be a lead nurse or other clinician, a QI officer, or a special guest teacher.

Plan-Do-Study-Act (PDSA) Cycles

When the teaching is done and the new protocol is starting, the project team will assign someone to collect and review the data. That person will look at it, decide what seems to be working and what seems to not be working, adjust the protocol, let the staff know, and try again. He or she will continue until things seem to be where they should be for a sustained period of time.

Implementation and Impact

Next, the protocol and education will be rolled out throughout the relevant area—say, the whole nursing center. A small number of key measures will be collected that the center can monitor to know how well the implementation worked.

Concluding the Improvement Effort

Finally, a routine measure—such as the rates of documented nursing assistant reports of change, documented communications from nursing assistants to licensed nurses about change, or reported SBAR or CUS use rates—should be chosen as a quality indicator. The leadership team then needs to ensure that the quality indicator is routinely collected and reviewed by a responsible member of the center in order to ensure that the improvement is sustained over time and, if it falls off over time, that attention to the problem is renewed.

2. Note: The Early Warning tool is available online at
The SBAR is available online at

Page last reviewed March 2018
Page originally created June 2012
Internet Citation: Module 1. Detecting Change in a Resident's Condition. Content last reviewed March 2018. Agency for Healthcare Research and Quality, Rockville, MD.
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