June 2, 2026
Strengthening Nursing Home Leadership and Quality Assurance Performance Improvement Readiness: Lessons from the Moving Forward Michigan Model
By Nancy Swierz, MSN, RN, CMC; Joan Michelle Moccia, DNP, ANP-BC, GS-C; Alice Bonner, PhD, RN; and Molly Wylie, MS
This article summarizes key program elements and lessons from the Moving Forward Michigan initiative, a project generously supported by the Michigan Health Endowment Fund designed to strengthen leadership capacity and improve Quality Assurance and Performance Improvement (QAPI) in nursing homes. Moving Forward Michigan is a project within the Moving Forward Nursing Home Quality Coalition.
Why This Work Matters
Nursing homes operate in a constant state of pressure, balancing staffing challenges, regulatory requirements, and the day-to-day realities of caring for residents with complex needs. While QAPI programs are required, many organizations struggle to move beyond compliance and fully integrate improvement work into daily practice (https://www.nationalacademies.org/publications/26526).
At the same time, staff across roles consistently express a desire to improve care and be more involved in problem-solving. What is often missing is not motivation, but practical support, time-efficient training, and the structure needed to translate ideas into action. The Centers for Medicare & Medicaid Services (CMS) acknowledges that motivation alone is insufficient – structure and support are required to translate ideas into action (CMS QAPI Website | CMS).
The Moving Forward Michigan initiative was designed to address this gap by focusing on leadership development and hands-on QAPI implementation in a way that fits the realities of nursing home operations.
Program Approach
Four Michigan nursing homes participated in this 18-month initiative. Selection criteria included: a CMS Five-Star Quality Rating of 1-3 stars, at least 25% racial/ethnic minoritized residents or a 62% or greater proportion of residents with Medicaid as the payer source, and leadership support.
Each organization formed an interdisciplinary team that included leadership, nurses, certified nursing assistants, and other key staff. The model combined three integrated elements: coaching, leadership education, and applied QAPI training.
Coaching created the foundation of the initiative, with each nursing home partnering with experienced long-term care professionals for regular team meetings. Sessions focused on applying concepts to real challenges, addressing barriers, and building confidence. In total, teams and coaches completed 94 sessions, providing consistent opportunities to translate learning into practice.
Leadership education was delivered through a nine-module series adapted from the Nurse LEAD program. Topics included communication, conflict management, teamwork, and coaching. Sessions were intentionally brief, with 30-minute virtual presentations followed by 30-minute coach-facilitated team discussions. This structure supported active learning while reinforcing real-time application of key principles.
For organizations interested in accessing this leadership content, the full Nurse LEAD program is available here.
QAPI training built on this foundation by guiding teams through identifying priorities, developing Performance Improvement Projects (PIPs), and using Plan-Do-Study-Act cycles to test changes. The emphasis was on practical tools followed by immediate application. Using their own data, teams identified meaningful priorities and implemented structural improvement efforts within their organizations.
Free access to all templates, tools, and the comprehensive QAPI workbook developed through this initiative is available here.
Key Findings from the Program Evaluation
An independent evaluation conducted by the LTSS Center @UMass Boston, including surveys and one-on-one interviews, suggests that this model is both feasible and effective in real-world nursing home settings.
Engagement and Knowledge Acquisition
Participation was consistent and interdisciplinary across all four nursing homes, with completion of 10 leadership and QAPI training sessions, completion of 94 coaching sessions, and successful implementation of at least one PIP per site. These findings demonstrate that, even in the context of staffing challenges and competing priorities, teams can implement leadership and quality initiatives when appropriately supported.
Ongoing support from coaches played a central role in helping teams apply learning, navigate challenges, and sustain momentum. These results suggest that leadership development and QAPI are most effective when implemented together, with leadership driving engagement and QAPI providing the structure for measurable improvement.
Much of the nursing home staff had generally high baseline knowledge about leadership principles; therefore, quantifiable knowledge gains were modest. However, qualitative data indicated that the education was relevant, practical, and helpful in fostering behavior change among staff.
Behavior Change and Care Process Outcomes
Following the training sessions, participants noted increased confidence, stronger communication and advocacy, and greater engagement in problem-solving, particularly among frontline staff. Alongside these outcomes, teams described a cultural shift toward more collaborative, data-informed decision-making. Staff at all levels and across disciplines became more involved in identifying problems and testing solutions, moving away from blame-based thinking toward shared accountability.
Teams also achieved measurable improvements in care processes. Performance Improvement Projects addressed issues such as reducing infection and hospital readmissions, strengthening care planning, and promoting resident engagement, with several teams seeing positive results within a relatively short timeframe.
Despite the perceived benefits of the training, participants noted persistent challenges such as limited staff time, turnover, and variable leadership engagement. These findings underscore the need for flexible, practical approaches aligning with the realities of nursing home operations.
Practical Lessons for Implementation
To address challenges related to staff attrition, short, focused learning sessions were more effective than longer formats because they aligned with staff schedules. Teams were most successful when improvement work was tied to issues that were actively chosen by direct care staff and had meaningful implications for the nursing home.
Ongoing support, including coaching and reinforcement of training principles, was essential to sustaining progress and building confidence.
Sustainability and Future Use
A key goal of the initiative was to ensure that resources remain accessible beyond the project period. Leadership education is available through the Nurse LEAD platform, and the QAPI workbook and tools are hosted by the Moving Forward Coalition. Together, these resources provide a practical starting point for organizations looking to strengthen leadership and QAPI capacity.
Conclusion
The Moving Forward Michigan initiative demonstrates that meaningful improvements in leadership capacity and QAPI readiness are achievable, even in challenging environments. By combining practical education, structured improvement methods, and consistent support, nursing home teams strengthened communication, engaged staff across roles, and implemented measurable improvements in care.
This work reinforces a simple but important principle: when leaders create the conditions for success and staff are supported with the right tools, structure, and encouragement, teams are fully capable of leading improvement within their own organizations.
Nancy Swierz, MSN, RN, CMC, served as program director for the Moving Forward Michigan initiative. (Joan) Michelle Moccia, DNP, ANP-BC, GS-C, is the Michigan State Long-term Care Team Lead and geriatric clinician for ApogeeCare telehealth services in emergency departments. Alice Bonner, PhD, RN, is senior advisor for aging at the Institute for Healthcare Improvement and chair of the Moving Forward Nursing Home Quality Coalition. Molly Wylie, MS, is research associate at the LeadingAge LTSS Center @UMass Boston and a gerontology PhD candidate.