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The Florida Nursing Home Quality Care Connection
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Do You Know Your Nursing Home's Current Quality Measure (QM) Composite Score?
Upon joining the National Nursing Home Quality Care Collaborative (NNHQCC) many nursing homes were aware of their Quality Measure (QM) composite score. Have you tracked your home's progress over time to measure your hard work? The Centers for Medicare & Medicaid Services (CMS) developed the QM composite score to help you gauge your nursing home's success in the NNHQCC. This composite score is composed of 13 different long-stay measures that represent larger systems within the long-term care setting, and is an excellent barometer of your home's performance; that is why it is so important to keep current on your QM composite score.
To obtain information regarding the QM composite score visit https://goo.gl/GbwMHA.
Need assistance in obtaining your current QM composite score? Contact us at fl-nnhqcc@hsag.com.
QAPI Corner
STEP 11: Getting to the "Root" of the Problem

A major challenge in process improvement is getting to the root of the problem or opportunity.


Root cause analysis (RCA) is a term used to describe a systematic process for identifying contributing causal factors that underlie variations in performance. This structured method of analysis is designed to get to the underlying cause of a problem - which then leads to identification of effective interventions that can be implemented in order to make improvements.


RCA helps teams understand that the most immediate or seemingly obvious reason for the problem or an event may not be the real reason that an event occurred. The RCA process leads to digging deeper and deeper - looking for the reasons behind the reasons. This process will generally lead to the identification of more than one root cause.  The root cause(s) and any contributing factors can then be sorted into categories to facilitate the identification of various actions that can be taken to make improvements.


RCA focuses primarily on systems and processes, not individual performance.


The RCA process takes practice, but can be a valuable tool for performance improvement. In order to get familiar with RCA you and your team may consider:

  • Studying case examples of RCAs.
  • Applying RCA to an adverse event and discussing this technique with the team.
  • Building RCA examples into training opportunities.

For more information on this topic,

read page 18 of QAPI at a Glance.

Next issue: Take Systemic Action
Long-Stay Influenza Vaccine Quality Measure Overview
Importance of Section O (Influenza Vaccine)



Health-related quality of life and planning for care are two important rationale for coding Section O (Influenza Vaccine). When infected with influenza, older adults and persons with underlying health problems are at increased risk for complications and are more likely than the general population to require hospitalization. Influenza vaccines have been proven to be effective in preventing hospitalizations.
Steps for Assessment
  1. Review the resident's medical record to determine whether an influenza vaccine was received in the facility for this year's influenza vaccination season. If vaccination status is known, proceed to the next step.
  2. Ask the resident if he or she received the influenza vaccine outside of the facility for this year's influenza vaccination season. If vaccination status is still unknown, proceed to the next step.
  3. If the resident is unable to answer, then ask the same question of the responsible party/legal guardian and/or primary physician. If influenza vaccination status is still unknown, proceed to the next step.
  4. If influenza vaccination status cannot be determined, administer the influenza vaccine to the resident according to standards of clinical practice.

Coding Tips and Special Populations

  • Once the influenza vaccination has been administered to a resident for the current influenza season, this value is carried forward until the new influenza season begins.
  • Influenza can occur at any time, but most influenza occurs from October through May. However, residents should be immunized as soon as the vaccine becomes available and continue until influenza is no longer circulating in your geographic area.

More information

Access all of the CMS tools for QAPI from one easy-to-use electronic resource library. Learn more.
This QAPI Plan Template can help guide nursing home staff members as they develop specific quality improvement plans for their organizations. Learn more.
This guide helps walk your team through the action steps of developing your organization's QAPI plan. Learn more.
Register Now!
You still have a chance to attend
one of the remaining Florida
NNHQCC learning sessions.
A Fort Myers session has been added! Secure your spot now.
Tuesday, May 3
HSAG Office
Thursday, May 12
Azalea Trace - WillowBrooke Court
Tuesday, May 17
Good Samaritan Society - Florida Lutheran

Thursday, June 30
HealthPark Care and Rehabilitation Center

All sessions run from
9 a.m. to 11:30 a.m. (ET)
Upcoming Webinar

Medications and Fall Risk
in the Elderly

Tuesday, May 24
2:00 p.m. ET
Have you completed your QAPI Self-Assessment? 
Interested in Learning About How Quality Improvement Organizations (QIOs) Can Help You?
Read the 2015 QIO Program Progress Report which highlights how Quality Innovation Network-QIOs (QIN-QIOs) nationwide are bringing together local providers, partners, and other stakeholders to achieve bold goals in healthcare quality improvement. You'll see highlights of success, data-driven recruitment results from QIN-QIOs, examples of how QIN-QIOs help providers address quality improvement challenges, video clips of quality improvement in action, and more.
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