ATX17- “Creating a Patient Safety Chain”
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This document discusses factors that contribute to high and low performance in long term care organizations. High performers have a culture of person-centered care, committed workforces, and effective leadership. Low performers have task-centered cultures, unstable workforces, and poor leadership. Absenteeism is identified as a key factor influencing outcomes. Consistent staff assignment, reliable communication systems, visible leadership, and addressing the root causes of absenteeism can help tip an organization from low to high performance.
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ATX17- “Creating a Patient Safety Chain”
- 1. Creating a Patient Safety Chain www.thegreenhouseproject.org David Farrell, MSW, LNHA Director
- 2. High Performing Organizations Three Common Elements • Culture – person-centered care • Workforce commitment • Leadership practices All three are interdependent Grant, L. 2008
- 3. Results are Interrelated • • • • • • • Implement person-centered Employee satisfaction Workforce stability Consumer satisfaction Good clinical outcomes Regulatory compliance High occupancy rate and mix Grant, L. 2008
- 4. Low Performing Organizations Three Common Elements • Culture – task-centered care • Unstable workforce • Leadership practices All three are interdependent
- 5. Results are Interrelated • Sustain institutional model • Employee dissatisfaction • Workforce instability – High turnover of new hires, high retention of low performers, high absenteeism • Consumer dissatisfaction • Poor clinical outcomes • Lack of regulatory compliance • Low occupancy rate and mix
- 6. Vicious Cycle of Low Performer Staff Instability • Leadership turnover • Crises • Correcting and in-servicing • Trim staffing • Low morale • Cut costs • Poor attendance Poor Outcomes Limited Resources • Clinical, Survey, HR, Q of Life • Fewer higher paying patients • Fewer physicians willing to recommend
- 7. All Nursing Homes Have Tipping Points Assume decline happens steadily… but… it can happen all at once.
- 8. The Tipping Point How Little Things Can Make a Big Difference By Malcom Gladwell
- 9. Organizational Change and Epidemics Characteristics of Epidemics • Contagiousness • Little changes have a big impact • Tipping point
- 10. Epidemics are a Function of • People who spread infections • Infectious agent • Environment surrounding infectious agent Epidemics tip when changes occur in one, two or three of these areas
- 11. Three Agents of Change in Social Epidemics 1.) The Law of the Few Leaders that infect people 2.) The Power of Context Environment 3.) The Stickiness Factor Messages that trigger action
- 12. The Law of the Few • Special skills • Connectors • Some people matter more than others – In epidemics – it’s a tiny # of people – Quality Improvement works the same way
- 13. “The Tipping Point” - The Power of Context New York City 1980’s • 2,000 murders a year • 600,000 felonies • NYC Subway System – 6,000 trains covered in graffiti – Fare-beating common practice – Ridership at an all-time low Gladwell, M., 2000
- 14. New York City Early 1990’s • • • • Murders dropped to 667 Felonies plunged to 3,000 Not a gradual decline Crime plummeted – it TIPPED!
- 15. NYC Transit Authority • Hired George Kelling • Advisors said – “focus on the big issues” • Instead – Painted the graffiti and stopped fare-beating – “Small infractions symbolic of collapse” • Utilized the “broken windows” theory Gladwell, M., 2000
- 16. Broken Windows Theory • Crime results from disorder • Broken windows and graffiti = no one cares – Leads to more broken windows and graffiti – Results in crime on the street • Social “broken windows” – – Aggressive panhandling – Public disorder Wilson, J., Kelling, G., 1984
- 17. “Broken Windows” in Healthcare Settings • • • • • • • • • Vacant shifts Dirty depressing break room Illegible forms Overflowing charts Frayed binders Patients screaming out Physical restraints Old Geri-chairs Disorder at the nursing station
- 18. Applied to Low-Performers • Can be tipped by evidence-based changes – Leadership, Environment, Communication • Employees influenced by little things – Acutely aware and sensitive – Graffiti on the building and chaos at nursing station = call-outs, skipped treatments, neglect
- 19. Oakland – I Volunteered Baseline measures - January 2011 • Red ink for years • Restraints 15% • Pressure ulcers 9% • Average of 40 call-outs per month – 1st weekend 10 call-outs and 7 falls • Long history of non-compliance
- 20. Which Nursing Homes Close? • “Critical Access” nursing homes • Variables associated with closure – Urban zip codes – Serving minorities – Pockets of concentrated poverty – High Medicaid population Mor, V., 2011
- 21. The Impact of Leaders Healthcare organizations • Leader’s actions influence: – Culture Relationships – Staff engagement – Clinical outcomes – Quality of life
- 23. “What a Difference Management Makes” • Paired 4 high vs. 4 low turnover facilities – 159 on-site interviews • Areas that distinguished low vs. high – Leadership visibility – Cared for caregivers – Orientation, career ladders, scheduling – Primary assignments – Rarely worked short Eaton, Phase II Final Report, 2001
- 24. A Vicious Cycle Vacant Shifts • Financial burden • Instability • Working short staffed • Resentment • Poor outcomes • Waiting • Lack of trust • Anxiety • Vacant Shifts Turnover Stress • Errors • Poor judgment • Injuries • Fractured relationships Eaton, Phase II Final Report, 2001
- 25. The Impact of High Absenteeism Vacant shifts = more or different patients What do C.N.A.’s skip – – Range of motion – Hydration – Feeding – Bathing Hawes, 2002
- 26. Absenteeism is Inevitable? Sick Days and Demographics of US Workers • 5 = average sick days • 6 sick days for women and 4 for men • 3 = sick days college graduates • 8 = sick days H.S. diploma or less • 9 = sick days of divorced or separated • 4 sick days for married or never married • 13 = sick days of those on Medicaid • 3 sick days for those covered by insurance CDC, National Health Interview 2011
- 27. Who are the CNAs? • • • • • • • Total 1.47 million Deliver 80% of hands-on care 90% are women 51% are non-white Average age is 38 50% are near or below the poverty line 41% rely on public benefits GAO, 2001 National Clearinghouse on the Direct care Workforce, 2006 BLS 2006, FHCEF 2010
- 28. Instability = Poor Outcomes Effects communication and continuity: • • • • Incontinence Facility acquired pressures sores Urinary tract infections Falls and fractures Dresser et. al. 1999; Harrington et. al. 1999
- 29. Absenteeism Complex organizational problem • Morale • Quality • Service • Safety • Relationships • Communication • Labor costs • Re-hospitalization rates
- 30. WFR Collaborative Findings What does it feel like when understaffed? • “Stressful; no lunch break, your back hurts.” • “Unsafe for patients and self.” • “Hectic – finger nails do not get clipped, men don’t get shaved, people are left with empty cups.” • “Hell.”
- 31. WFR Findings Continued What happens that leads your co-workers to call-off? • “Just tired mentally. Overwhelmed and can’t overcome it.” • “Burnout if you worked 7 am to 11 pm the day before.” • “Stress – someone is always asking you to stay late.” Top reasons for call-offs: • Sickness of self • Sick family member • Baby sitter problem
- 32. WFR Findings Continued What does it feel like when you have enough staff? • “Relief – feel you accomplished something.” • “I can do little things for the residents like give them a hug.” • “I can give them a back rub, talk to them, I can take the time to be more human.”
- 33. Addressing Absenteeism Why do staff call-off? Why does absenteeism vary from SNF to SNF? What motivates staff to come to work more consistently? What are the SNFs that have low rates of absenteeism doing?
- 34. Cause and Effect Diagram Systems People High absenteeism Environment Equipment/Supplies 34
- 35. Collect Data • • • • • Single point person Review individual records daily, monthly % of shifts worked understaffed Focus - Total number of call-offs per month Individual’s and facility trends – By day of the week, month – By unit, shift
- 36. No-Fault Attendance Policy If call-off – it counts No more qualifying absences Removes inequity No need for physician notes – Just be honest • Absences are simply measured • • • •
- 37. Goal – A Perfectly Staffed Day No all-outs and no sick pay hours No registry hours No light duty assignments No orientation hours Fully staffed to budget – every shift, every neighborhood • Total hours = 378 • Overtime = less than 1% (or 4 OT hours) • • • • •
- 38. Consistent Feedback • Leadership accountability – Set the example • Discuss attendance and its’ impact – Rewards and recognition Individuals and groups – Show data • Individual feedback – Letters with attendance record quarterly
- 39. You Are Important “We missed you yesterday…and the residents did too. I hope your son is feeling better. We are a better place when you are here.” Performance Compassion
- 40. To Be Expected “Thanks for being here today. I’ll see you tomorrow?”
- 41. Eaton’s Findings on Scheduling Most Common Reason for Termination • Flexible in low turnover facilities – Allow for different start times – Consider personal lives • Rigid in high turnover facilities – In response to problems – “Personal life is not my problem.” Eaton, Phase II Final Report, 2001
- 42. A Root-Cause of Absenteeism on the PM Shift? www.thegreenhouseproject.org Nurse Ratchet
- 43. Staffing Coordinators • • • • • Complex task Requires education Support – meet weekly Recognition and rewards Character traits: – integrity, fairness
- 44. Scheduling Success • • • • • • Allow staff to trade days Honor requests for time off Increase FT and decrease PT Avoid every other weekend off 4 on 2 off Consistent assignments – Indicate assignment on the master schedule
- 45. 4 on 2 off schedule Even # of CNA assignments 3 CNAs serve 2 resident assignments M T W Th F S S M T W Th F S S 1 1 1 1 O O 1 1 1 1 O O 1 1 2 2 O O 2 2 2 2 O O 2 2 2 2 O O 2 2 1 1 O O 2 2 1 1 O O Maria Jen Ellie
- 46. Proactive Replacement Plan • Call employee who called off – Show concern – Replace for next shift? • Replacement priority list daily – On-Call confirmed to come in – Name, phone number – Best time to call
- 47. If Working Short Staffed • Have a plan • All hands on deck • Managers and non-nursing staff assist
- 48. Empowerment = Engagement • Empower employees by giving them: – Knowledge of what is expected – Skills, resources and supplies – Feedback on how they are doing – Feedback on how the facility is performing – Opportunity to improve work processes – Opportunity to provide feedback (surveys) – Consistent assignments
- 49. Staffing Models Consistent Assignment = Consistently assigning the same caregivers to the same nursing home residents every day Rotating Assignment = Rotating caregivers from one group of residents to the next after a period of time
- 50. Support for Consistent Assignment • Results from 13 research studies: – – – – – Enhanced relationships Improved staff attendance Improved staff, resident, family satisfaction Lower staff turnover Improved accuracy, timeliness: screening and assessments – Improved clinical outcomes – Improved quality of life Allow for individualized care
- 51. Same SNF – Different Units Consistent Assignment: Rotating Assignment: Top Five Stressors Top Five Stressors • Preventing Falls • Low Wage • Stubborn Residents • Abusive Residents • Terminal Residents • Heavy Workload • Depressed Residents • Disagreements w/ Coworkers • Death as Emotional Stress • Lack of Staff Gruss, V. et al., 2004
- 52. Who Preaches the Benefits? Those who support consistent assignment: • • • • • • • • • Eden LEAP ActionPact Pioneer Network CMS National Commission on Nursing Workforce for LTC Quality Improvement Organizations (QIOs) Culture change coalitions Advancing Excellence Campaign
- 53. Theory of Relational Coordination • The effectiveness of care and service is determined by the quality of communication among staff • Which depends on the quality of the underlying relationships • The quality of the relationships reinforce the quality of the communication Gittell, et al, 2008
- 54. Relational Coordination in Healthcare • Task interdependence • Uncertainty • Time constraints Gittell
- 55. Healthcare Organizations CNAs CNAs Nurses Therapists Nurses Therapists Physicians Food Service Within functions Food service Physicians Across functions Gittell
- 56. Trigger Relational Coordination Leadership actions • Increase Communication – Frequent, timely – Accurate – Model problem solving • Enhance Staff Relationships – Shared goals – Enhance knowledge – Model mutual respect
- 57. Relational Coordination Works • Significantly associated with – – Enhanced resident quality of life – Higher nursing assistant job satisfaction • Evident in SNFs implementing person-centered care Gittell, et al, 2008
- 58. Red Auerbach
- 59. Relational Coordination Tipping Points • • • • • Ample higher quality supplies Resident transfer equipment Staff composition Consistent assignment Systems of regular communication – Report between shifts – Safety huddles
- 60. Systems of Communication Key changes – Change of shift huddles Start of shift huddles Mid-shift safety huddles Standing root-cause analysis End of shift check in and follow up
- 61. Patient Safety Huddle • • • • • • Bring the white board Write down all the ideas Prompt people Set Rules - “No blame” Enhance problem solving competence Stay with it © B & F Consulting, Inc. 2012 www.BandFConsultingInc.com & www.BandFConsultingInc.com/WhatYouDoMatters
- 62. Infectious Agent - The Stickiness Factor • The message has to “stick” – Trigger people to change • Increase volume • Consistent and optimistic
- 63. Effective Rounds • • • • Mood, posture and paradigm Content – what you say and do Timing Following up
- 64. Mood / Posture / Paradigm • • • • • • Flip the switch You are in the spotlight Make eye contact Praise, build self-esteem Smile Linger
- 65. Content – What You Say and Do Trigger higher performance • Say - “I’m worried about…I’m proud about… thanks for helping her with that…that was nice of you…the residents really love you…I notice that you really care…thanks for being here today…I really like working with you” • Do – Answer call lights…hold doors open…sit in the break room…sit at the end of a residents bed and talk to them…shake hands…carry a leftover food tray back to the kitchen…move a linen barrel to the right spot…slow down…go look everywhere…
- 66. Invisibility “The problem is not motivation. It is the ways in which we unintentionally de-motivate employees.” Quint Studer
- 67. Timing of Rounds Priority is Visibility • Before morning stand-up meeting • Lunch • Shift change • Last rounds • Weekends • Nights
- 68. Following Up • • • • Keep notes Do not carry a cell phone Listen intently Get back to people who made requests
- 69. Drivers of Staff Engagement • Management cares • Management listens • Help with job stress MyInnerView, Inc. 2011
- 70. Employee Engagement • The amount of discretionary effort and care that employees put into their jobs above and beyond the minimum required • Want the organization to succeed • Feel connected – – Emotionally – Socially – Spiritually
- 71. Employees are Engaged When • Leaders’ are engaged • Understand the business and their role in its’ success • Trust leadership is making good decisions • Feel valued and appreciated • Are well informed
- 72. Notes to Staff – Make the Message stick Monday 2/21/11 • Congratulations to Cynthia Poppens – February Employee of the Month! Also – Congratulations to Laurianne Niko – February Rookie of the Month! Both of these C.N.A.’s exemplify our core values. It’s an honor to work with both of you! On behalf of everyone here – thank you! • Thanks you for accepting and wearing your new name badges. By displaying our place of birth on our name badges we can all be transparent and celebrate the tremendous diversity that we have here. Our staff speak 21 different first languages! I’m proud of that fact and of all of you. I see great people here. • Our next community meeting will be held on 2/25/11. Please join us for updates, education, recognition, good food and rewards. • We are starting to get some new admissions and this is very good news for us. Every new admission needs a warm welcome from our staff. Be sure to reach out to strangers and say “Hello.” If you want to reflect in a friendly home – be friendly…act friendly…smile at people! I continue to proudly serve as your interim Administrator. If you need anything, please come and see me, call my cell phone or send me an email. Thank you for all that you are doing to enhance our residents’ lives here! Sincerely, David Farrell 510-725-7409 dfarrell@snfmgt.com
- 73. Community Meetings • Simple metrics – Human resource – Clinical outcomes – Business results • Benchmark and compare • Strategic plan • What – How - Why
- 74. Decline in Pressure Ulcers – What, How, Why Huddles started New admissions Plan implemented PUSH tool adopted Root-cause Analysis done New mattresses in place All staff in-service 74
- 75. Transparency Steps forward Visible results People Energized
- 76. Community Meetings The messages stick with emotion backed by data • Tell a story • Predictability • Optimism • “I care about you.” • Celebrate positives – Employee and Rookie of the month – Raffles – Visibly Strengthen Patient Safety Chain
- 77. Rewarding Quality Performance Who do we recognize? Who gets rewarded? What do they get? Is the recognition fair and based on clear goals? 77
- 78. Recognition • Gratitude • Thank you cards are powerful – Send them to staff members’ homes – “I appreciate you” – “I am glad you work for us. On behalf of the residents, their families and your co-workers – Thank you.”
- 79. What Matters the Most? • Systems • Environment • People
- 80. Drivers of Consumer Satisfaction • • • • • • Caring staff Competent staff Choices and preferences Nursing care Responsive management Respectfulness of staff MyInnerView, Inc. 2011
- 81. Comprehensive People Assessment • Meet with key leaders with a list of all staff • Rate every employee * = Triple crown winners – reliable/skills/attitude > = Lowest rated staff ? = Unreliable but excellent skills and attitude ! = Reliable but poor skills and attitude
- 82. People Assessment • • • • • Focus on the triple crown winners Shift from tolerance to quality improvement Publicly share the performance standards Have conversations – give feedback Make changes
- 83. Wally Pipp
- 84. Lou Gehrig
- 85. Exercise Who are your triple crown winners? Who are your lowest performers?
- 86. Bad is Stronger Than Good Some turnover can have a positive effect • Eliminate the negative • Negative feelings = greater effects – Interdependent work = larger negative effect • Grumpiness and laziness are contagious Felps, W. 2001
- 87. First Who…Then What Three simple truths • Key to adapting to change • Motivation and management • Wrong people Collins, 2001
- 88. Careful Selection Ask the right questions to screen for key character traits: • Observe their interactions • Maturity – self reflection • Compassionate • Sensitivity to others needs • Self esteem • Ability to communicate, learn • Friendliness, 5 smiles
- 89. Environment Impacts People Signals disorder: Not one living indoor plant Neglected courtyards Dead space Broken furniture Mismatched chairs
- 90. Tipping Point – July 2011 • Profitable • Culture changed • Kept up with initial changes – Community meetings, awards, staff stability, thank you cards, healthy snacks, painting, art work, heritage days, notes to staff
- 91. Care, Listen, Prevent Stress Oakland - 70 Changes • Some were small and simple • Some were big and complex
- 92. Oakland – 9 Months Later • • • • • • • Employee satisfaction top 5% Deficiencies dropped 35% Medicare census doubled Restraints eliminated Attendance improved 50% Overtime declined by 50% Pressure ulcers declined to 1%
- 93. Transparency Steps forward Visible results People Energized
- 94. Paint the Graffiti Everyday
- 95. Contact Information David J. Farrell, MSW, LNHA Director The Green House Project (510) 725-7409
Hinweis der Redaktion
- Why I took on this job Story of Mr. Watts
- A you recall from the first LS, Eaton identified the following vicious cycles that occurs in facilities. This can happen fast.
- Interview only on Tuesdays at 11 Graffitti, trash, overgrown trees and shrubs
- What to do with the data? Follow the path in G to G
- Here we are twenty six years later, and the largest data base of resident and family satisfaction in the nation essentially says the same thing – it’s all about the people who work there. Do they care? Do they know what they are doing? Do they offer choice? Do they listen? Do they love?
- What to do with the data? Follow the path in G to G
- What to do with the data? Follow the path in G to G
- What to do with the data? Follow the path in G to G
- In researching the links between quality leadership and quality of care I have found some clear patterns emerge. It is important to note that, the modern nursing home , as we know it today, has been around for less than 40 years. Now, there is a growing body of research-based evidence that supports the fact that leaders of successful nursing homes engage in certain activities on a consistent basis that the leaders of unsuccessful nursing homes do not. It’s more about practices than personality. There is some thing about the organizational makeup of these fragile ecosystems we call SNFs that make them very susceptible to poor leadership practices. However, because of their fragility, they are also very responsive to excellent leadership actions. Administrators and DONs have an extremely strong influence on the performance of Skilled Nursing Facilities As the research evidence grows, we will come to know these certain leadership activities of successful facilities to be universal truths – unarguable natural laws related to creating a culture of excellence and improving quality of care.
- Similar to the approach by Jim Collins in G to G, Professor Susan Eaton from Harvard, conducted a very interesting research study. The burning question for her was – why do we have such extreme variation in turnover rates among SNFs located within the same geographic regions (who re essentially just down the street from one another), offering the same starting salaries, employing the same types of people, offering the same staffing ratios and what difference does management practices make. She looked for and found a total of eight facilities, 4 with high rates of turnover and 4 with low rates of turnover, each of the contrasting pairs were located within the same labor market. She then went on-site and conducted 159 interviews and made observations seeking to explain the variation. She identified 5 distinct areas – High quality leadership and management, offering recognition, meaning, and feedback as well as the opportunity to see one’s work as valued and valuable; managers who built on the intrinsic motivation of workers in this field An organizational culture, communicated by managers, families, supervisors, and nurses themselves, of valuing and respecting the nursing caregivers themselves as well as residents Basic positive or ‘high performance’ Human Resource policies, including wages and benefits but also in the areas of ‘soft’ skills and flexibility, training and career ladders, scheduling, realistic job previews, etc. Thoughtful and effective, motivational work organization and care practices Adequate staffing ratios and support for giving high quality care The best part about her research study is the specifics, the how-to, regarding the actions that leaders must take on a consistent basis.
- A you recall from the first LS, Eaton identified the following vicious cycles that occurs in facilities. This can happen fast.
- Example – Braintree Manor Relationship to clinical care – most fac. Tie their skin check system to the shower schedule. Therefore, even if a fac. Is only short staffed two days in a week, if those days happen to fall on Mabel’s shower day, she may go ten days without a full body check. This is where a stage one is not identified and turns into a stage two. Low morale Poor clinical outcomes Rushed, hurried depersonalized care
- Facilities with chronic absenteeism usually have high turnover. Therefore, we must address the issue of absenteeism. A Complex Organizational problem– There is no perfect plan. The root causes in each of your facilities is different. Therefore, they require careful analysis before deciding on interventions. However, there are best practices out there. Some organizations actually have systems that encourage absenteeism. Company-wide attendance problems are the sign of a sick system, not a sick employee. Oftentimes, we react to the problem as if getting tougher on the violators will solve the problem. In this sense we are blaming the problem on the personal short comings of the staff rather than looking at our own organizational or leadership practices as the cause. Morale – facilities with absenteeism problems have morale problems. Quality – absenteeism leads to tired staff or vacant shifts – both of which have a negative effect on q of care and life. Service – absenteeism leads to delayed, or worse, denied service. Safety – tired staff and vacant shifts leads to workplace injuries. Retention – often, the vicious cycle of turnover starts with flawed organizational systems related to scheduling and absenteeism.
- 16% live in poverty 25% have no health insurance Why do they enter this field – based on the research, they intentionally choose LTC, not because they do not have other options, but because they have a desire to help others. Single moms at or near the poverty line have limited resources to fall back on when their kid is sick or their car won’t start. In addition, we know that most are uninsured. In fact, most for-profit chains encourage it by offering as much a $1 more per hour to entice staff to waive their right to coverage. 25% have no health insurance Avg. age is 37, 10% are over 55, 50% have at least one child under 18 20% are below the poverty line 75% have a high school diploma Avg. rate is $9.85 = $ 20,500 per year. Cashiers make $7.60 All occup. Avg. is $13.50 30-35% receive food stamps. Four major causes of stress – Pillemer - lack of time, lack of good supervision, lack of staff, lack of training in psych/social aspects of care giving. NOT unskilled labor. Example - Philome These are the people I worked with at Braintree Manor on PMs and NOCs. I was not welcome into the group. In fact, I ate all of my meals alone. Looking back, I realize now how poorly I was trained and how alienated I felt. It was only the residents that kept me coming back. Ironically, I was fired for visiting the residents when I was not on the clock – I policy I ignored.
- The link between turnover and quality has been empirically established. Instability in the schedule
- Facilities with chronic absenteeism usually have high turnover. Therefore, we must address the issue of absenteeism. A Complex Organizational problem– There is no perfect plan. The root causes in each of your facilities is different. Therefore, they require careful analysis before deciding on interventions. However, there are best practices out there. Some organizations actually have systems that encourage absenteeism. Company-wide attendance problems are the sign of a sick system, not a sick employee. Oftentimes, we react to the problem as if getting tougher on the violators will solve the problem. In this sense we are blaming the problem on the personal short comings of the staff rather than looking at our own organizational or leadership practices as the cause. Morale – facilities with absenteeism problems have morale problems. Quality – absenteeism leads to tired staff or vacant shifts – both of which have a negative effect on q of care and life. Service – absenteeism leads to delayed, or worse, denied service. Safety – tired staff and vacant shifts leads to workplace injuries. Retention – often, the vicious cycle of turnover starts with flawed organizational systems related to scheduling and absenteeism.
- What happens that leads to call-offs? It sounds like they are answering for themsleves
- More human – Does this imply that when they are understaffed you can not be human. That you shut down your human emotions in order to get through the shift. In no case did the answers indicate that money was a factor.
- Single point person – usually staffing coordinator Review individual records monthly Individual’s and facility trends By day of the week By unit, shift Alert supervisors to alert individuals- before violation of policy Average number of call-offs per employee per quarter Report on the total number of call-offs per month First and foremost, an effective program starts with collecting accurate data. Collect data for each individual employee, department, facility both for absenteeism and the number of shifts worked short staffed. Usually, having one person (and one back-up) coding and tracking absenteeism works best. In terms of effective systems – this single point person would then review all of the attendance records monthly and alert supervisors of trends (both positive and negative) by making a copy of employees attendance records and sending them to their supervisors. *Also, make a copy of the each employee’s attendance record on a quarterly basis and include it in the employee’s paycheck in order to provide them with regular and consistent feedback. Letters example. *In addition, as part of the process of employee evaluations, they would make a copy of the employees attendance record and attach it to the appraisal forms to be completed. These simple processes related to data collection and alerting supervisors are important and tell the staff you take the problem very serious.
- *Bear in mind that the process of qualifying whether or not an absence is excused or not is important and those decisions can make or break the foundation of trust in an organization. Some facilities have adopted a “no-fault” attendance policy – this takes the guess work out of trying to qualify absences. You are either here or you are not. No need for M.D. notes to justify an absence. Absences for any reason are all treated the same. Takes leaders out of the position of
- Single point person – usually staffing coordinator Review individual records monthly Individual’s and facility trends By day of the week By unit, shift Alert supervisors to alert individuals- before violation of policy Average number of call-offs per employee per quarter Report on the total number of call-offs per month First and foremost, an effective program starts with collecting accurate data. Collect data for each individual employee, department, facility both for absenteeism and the number of shifts worked short staffed. Usually, having one person (and one back-up) coding and tracking absenteeism works best. In terms of effective systems – this single point person would then review all of the attendance records monthly and alert supervisors of trends (both positive and negative) by making a copy of employees attendance records and sending them to their supervisors. *Also, make a copy of the each employee’s attendance record on a quarterly basis and include it in the employee’s paycheck in order to provide them with regular and consistent feedback. Letters example. *In addition, as part of the process of employee evaluations, they would make a copy of the employees attendance record and attach it to the appraisal forms to be completed. These simple processes related to data collection and alerting supervisors are important and tell the staff you take the problem very serious.
- Beyond that – leaders are charged with keeping the issue at the forefront of everyone. It should be a standard agenda item during dept. meetings. *Recognition – there needs to be both public and private recognition for excellent attendance. On a quarterly basis, leaders should send thank you cards for good attendance. *Reward reliable staff – allow staff to cash out one sick day per quarter for no call-offs. There are many other incentives facilities have designed. The key is, are you rewarding the right behavior. Consider raffles and include only those staff in the raffle who had perfect attendance for a specified period of time. *Reward improvement – for those who had poor attendance and received counseling, oftentimes, when they improve, it’s ignored. Therefore, leaders must seek out those who have had improvement and let the employee know that they noticed it and appreciate it. *Reward new staff and allow them to cash out a sick day if no call offs in the first six months. Leaders are the key and they must set the example by having excellent attendance records themselves. Care Using the system I just described, leaders must meet with their staff as problems arise. Being concerned for the welfare of the employee and showing it and expressing it. Exploring how they may assist the staff member to solve the issues getting in the way. Leaders should be fair yet firm. There will be individuals who have no legitimate excuse and they must be dealt with. But collecting good data allows you to identify these individuals. However, this must be balanced with a genuine care and concern for the well being of the staff and their families.
- “Know me, care about me, focus me” WE de-motivate our staff when we don’t notice when people return from a call off- “ I missed you yesterday- Is everything ok- the residents missed you- we worked understaffed but everyone chipped in.” What your conveying to the employ is- you are an important person.
- In Eaton’s study, she found that one of the most common reasons for termination were conflicts related to showing up at work not work performance. She found some significant differences in practices and systems in the low vs. high turnover facilities in her study. In low turnover homes, schedules were posted well in advance, sufficient notice was provided to the staff regarding open shifts or any changes to the schedule. The staff could rely on the consistency of it. In the high turnover facilities, the scheduling was very haphazard as if it was as simple as placing peoples names on a sheet of paper. The schedule was seen by the staff as very chaotic. Changes were made to the schedule without sufficient notice to the staff and, in the staff’s view, without justification. The first issue to identify is are the schedules rigid or flexible. The flexibly scheduled facilities in Eaton’s study had the least absenteeism and lowest turnover. Consider personal lives – of the front-line staff. Handle call-offs with compassion and concern for the well being of the person calling in. Then, they assisted the employee with the problem at a later date. In Eaton’s low turnover facilities, the managers had an understanding of what their employees lives were like outside of work. Rigid In response to problems – most facility leaders respond to attendance problems with more rigidity and disciplinary action. “Personal life is not my problem.” – was a pervasive attitude among the leaders of high turnover facilities in Eaton’s study. Yet, in the low turnover homes, they had the opposite attitude and it showed in the way they treated the employee’s who called off. Used as punishment – Changes in the schedule used as disciplinary action was a hated practice among the CNAs. In one example in her study, a C.N.A. was hired and requested day shift but accepted pm shift until a day shift position opened up. His attendance was fair but not perfect due working on pm shift did not fit his personal responsibilities outside of work. After working for a year, he found out that two new CNAs were hired to day shift. When he inquired as to why he was not moved to day shift as he had requested he was told he was not moved because of his attendance on .
- It is interesting to note that both the high and low turnover facilities had full time scheduling coordinators. However, how this key, powerful individual handles this responsibility can make or break the organization. Scheduling is complex and requires education. In addition, this individual should be carefully selected. If this individual appears to act with favoritism, the morale of the facility will sink to new depths. If they are rigid, turnover and absenteeism become more common. Favoritism damages morale – Thus, the scheduler needs to be someone who is fair, flexible, friendly and focused on the elders. They are the most harassed person in the facility and they hold tremendous power.
- Allow staff to trade days – the schedule may look like a mess and you may get some OT. But, the shifts are filled, you allowed the staff to do a favor for one another (trust). Primary assignments and primary days – if you can set days and set assignments, you are well on your ways to improved attendance. Rotating days leads employees to guess when they may be off. In the last facility I managed, it worked great and our top performers worked almost every weekend. Indicate assignment on the master schedule – by indicating which assignment a C.N.A. is working on the master schedule, you have eliminated that chaotic moment at the beginning of each shift when the C.N.A.’s are standing around the nursing station waiting for the charge nurse to give them their assignment. Have a contingency plan for call offs.
- Care about the staff by having a proactive replacement plan Short term: - one shift Clear policy regarding who to call and when to call off (prevent tomorrows staffing issue today) Call employee who called off – must have high levels of trust Show concern – “Hope you are feeling better soon.” Replace for next shift? – “In order to prevent short staffing, we want to be proactive and replace you now if you think that you will not be in for your next shift.” Replacement priority list – in order No overtime- for the replacement Voluntary overtime no double time – 4 hours during peak time Voluntary OT/DT – eat the expense to prevent working short (employees who called off early in week) Agency staff – if needed, but only if good and reliable (next slide) Staff member who previously called off in pay period – ask this person last. Do not reward them for calling off for a regular shift by providing them with OT/DT. If you do, they earned more that week by calling off. (set up-”who to cal if someone calls off list” lists Staffing coordinator preps list daily for pms and Nocs Detailed list for nurses and WE mgr
- Leaders should be visible and help to diffuse stress when a shift will be understaffed. Relieve licensed staff or C.N.A.’s of certain duties Housekeepers pass trays and make beds Dietary staff pass trays, pick up trays, pass water pitchers D.O.N. complete some treatments Managers assist on the floor –Answer call lights Feed the staff – Assist in dining room Pats on the back - Assist
- This is one of the most difficult and time consuming aspects of the CC journey if you are focused on deep organizational change. To go from a paradigm of control requires high levels of trust within the organization. You simply can not rush the process of laying a foundation of trust. When you build knowledge and skills you build self esteem in the frontline caregivers and confidence in the leaders that they can release control. It takes longer to ask the staff for their feedback and input. An empowered staff feels valuable and important. They come to work because they know they make a difference. It is difficult to pull CNAS off the floor for care planning meetings. However, research shows that low turnover facilities find a way to get their input and demonstrate that their opinion matters. the best decisions about how care should be carried out should be made by the front-line staff who know the resident. empower staff through extensive education, shared decision making and enhancing the critical thinking skills of the front-line staff.
- Low turnover facilities utilize primary assignments of their staff. speaks to the power of primary assignments. Why is that empowering – Primary assignments allow staff to really get to know the residents. They become the experts on a group of residents and everyone knows that they can go to them for answers. This is empowering and boosts peoples self-esteem. In addition, primary assignments allow for staff to notice the clinical changes early before it’s too late. This is essential to reducing exposure and risk. Also, primary assignments reduce turnover because it allows staff to form close relationships with the residents. It also allows staff to provide more resident-centered care and enables them to follow the individual routines of their residents thus enhancing residents quality of life.
- Used quality improvement strategies to operationalize, measure, and spread effective change
- The theory of relational coordination suggests that the effectiveness of care and service coordination is determined by the quality of communication among staff - Which depends on the quality of their underlying relationships and…the quality of the relationships reinforce the quality of the communication. This theory is highly applicable where I work. Where the tasks we perform are closely interrelated with the tasks others are performing…where we have uncertainty and unpredictability require staff to be aware of others and flexible to make changes on the go…and where we have time pressures hanging over all of us. The bottom line is, if my people are getting along, they give better individualized care. And I need to do the right things so that they get along.
- Interview only on Tuesdays at 11 Graffitti, trash, overgrown trees and shrubs
- The single most noticeable and important behavior is to establish eye contact, smile, and say “hello” to employees, residents, physicians, visitors as you walk along instead of being absorbed in your own thoughts with a concerned look on your face. It is important to be a positive force. The key is to do rounds religiously because visibility must stay a priority. It is not the first priority to eliminate when other demands arise. Rounds are not a race – slow down. The quality of the walkthrough is more important than the number of walkthroughs. Invisibility Most healthcare leaders are not mean, callous individuals. However, many, unknowingly ignore their staff. Their staff are invisible to them. Boost their self-esteem, notice, have high standards and expectations.
- Leadership presence and visibility on the units and in resident rooms modeling excellent customer relations is key. Communication during rounds allows you to catch your staff doing something right and let them know they have been caught. Every hour, employees are committing acts of compassion. Let them know you saw them and appreciate it. Nothing is more important to creating a culture of excellence than rounds. Talking to your people and taking action based on what you hear. Rounding for outcomes – How is the family What's working well today Are there any individuals doing great work today – who? Is there anything we can do better Do you have the tools and equipment to do your job Notice – how far are people walking to fax something Who answers the phone after 5 PM and on weekends How far do staff walk for linen What kind of chairs are they sitting on
- Know me, care about me, focus me
- Leadership presence and visibility on the units and in resident rooms modeling excellent customer relations is key. Communication during rounds allows you to catch your staff doing something right and let them know they have been caught. Every hour, employees are committing acts of compassion. Let them know you saw them and appreciate it. Nothing is more important to creating a culture of excellence than rounds. Talking to your people and taking action based on what you hear. Rounding for outcomes – How is the family What's working well today Are there any individuals doing great work today – who? Is there anything we can do better Do you have the tools and equipment to do your job Notice – how far are people walking to fax something Who answers the phone after 5 PM and on weekends How far do staff walk for linen What kind of chairs are they sitting on
- Leadership presence and visibility on the units and in resident rooms modeling excellent customer relations is key. Communication during rounds allows you to catch your staff doing something right and let them know they have been caught. Every hour, employees are committing acts of compassion. Let them know you saw them and appreciate it. Nothing is more important to creating a culture of excellence than rounds. Talking to your people and taking action based on what you hear. Rounding for outcomes – How is the family What's working well today Are there any individuals doing great work today – who? Is there anything we can do better Do you have the tools and equipment to do your job Notice – how far are people walking to fax something Who answers the phone after 5 PM and on weekends How far do staff walk for linen What kind of chairs are they sitting on
- What do I need to focus on, to do, in order to engage the hearts and minds of the staff in Oakland to deliver safe, individualized care. To engage the staff… I have to say and demonstrate how much I care about them as people, I have to ask the right questions…listen to their concerns and act accordingly, and I have to proactively minimize their stress at work.
- The single most noticeable and important behavior is to establish eye contact, smile, and say “hello” to employees, residents, physicians, visitors as you walk along instead of being absorbed in your own thoughts with a concerned look on your face. It is important to be a positive force. The key is to do rounds religiously because visibility must stay a priority. It is not the first priority to eliminate when other demands arise. Rounds are not a race – slow down. The quality of the walkthrough is more important than the number of walkthroughs. Invisibility Most healthcare leaders are not mean, callous individuals. However, many, unknowingly ignore their staff. Their staff are invisible to them. Boost their self-esteem, notice, have high standards and expectations.
- The single most noticeable and important behavior is to establish eye contact, smile, and say “hello” to employees, residents, physicians, visitors as you walk along instead of being absorbed in your own thoughts with a concerned look on your face. It is important to be a positive force. The key is to do rounds religiously because visibility must stay a priority. It is not the first priority to eliminate when other demands arise. Rounds are not a race – slow down. The quality of the walkthrough is more important than the number of walkthroughs. Invisibility Most healthcare leaders are not mean, callous individuals. However, many, unknowingly ignore their staff. Their staff are invisible to them. Boost their self-esteem, notice, have high standards and expectations.
- Here is a graph with outcomes data – as you see, this facility achieved huge improvement with pressure ulcer incidence. You can see how looking at trended data, presented graphically like this, can be very effective in telling the story of your success.
- Picture a huge heavy flywheel – a massive metal disk mounted horizontally on an axle, about 30 feet in diameter, 2 feet thick and weighing about 5,00 pounds. Now imagine your task is to get the flywheel rotating on the axle as fast and long as you can. Pushing with great effort, you get the flywheel to inch forward. You keep pushing and, after 2 to 3 hours of consistent effort, you get the flywheel to complete one single turn. You keep pushing, and the flywheel begins to move a bit faster. You complete a second turn. You keep pushing in a consistent direction, 3 turns…4…5…6..it builds momentum…7…8 turns…it builds momentum…20…25…30. The, at some point, breakthrough! The momentum kicks in your favor, hurling the flywheel forward, turn after turn…whoosh! Each turn of the flywheel builds upon the work done earlier, compounding your investment of effort. Now, if someone came along and asked, “what was the one big push that caused this thing to go so fast?” You wouldn't be able to answer. It was all of the pushes added together in an over accumulation of effort applied in a consistent direction. G to G transformations never happened in one fell swoop. G to G comes about as a cumulative process – step by step, action by action, decision by decision, turn by turn of the flywheel. All of which added together leads to sustained great results. In the case of stabilizing a workforce, we need to recognize that to do so requires hundreds of small, coordinated/calculated steps.
- Cards are a powerful way to reinforce positive behavior Send the cards to their homes. This sends a powerful message to their families that their place of work is proud of them. Their families knowledge reinforces the positive feeling that comes from praise. Send b day cards, anniversary cards, congratulations and condolences. Get to know your staff as people and you will learn what's going on in their lives which is significant. Cards say, “I care about you.” At Department head meetings, pass out blank cards and have them write them during the meeting. Then mail them and 10 –12 will go out that day. Pass out blank cards at family council meetings. Action – write a card now. And, we’ll get you started by giving you a box. At this point during our workshops we stopped, handed out thank you cards, and had the participants take the time to write a thank you card to a C.N.A. We encouraged them to send the card to the staff members home as this is more powerful than handing them the card at work. Also, internal contests, employee of the month, rookie of the month.
- Here we are twenty six years later, and the largest data base of resident and family satisfaction in the nation essentially says the same thing – it’s all about the people who work there. Do they care? Do they know what they are doing? Do they offer choice? Do they listen? Do they love?
- Getting the right people on the bus, the wrong people off the bus and the right people in the right seats – these are all crucial steps in the early stages of buildup leading to breakthrough. G to G leaders understood three simple truths – If you begin with who rather than what you can more easily adapt to a changing world. If people are on the bus because of who else is on the bus then it is much easier to change direction if you need to. If you have the right people on the bus, the problems of how to motivate and manage people largely goes away. The right people do not need to be fired up or tightly managed; they will be self motivated by the inner drive to produce the best results and to be part of creating something great. Third – if you have the wrong people on the bus, it does not matter whether you discover the right direction, you still will not have a great organization. Great organizations do not become great without great people. First who – is a very simple idea to grasp, and a very difficult idea to do – and most do not do it very well in LTC. It is easy to talk about paying attention to people decisions, but how many LTC executives have the knowledge or discipline. They key point of this principle is not simply about assembling the right team, that is nothing new. It is the the sheer rigor needed in people decisions in order to take a LTC facility and move it from good to great.
- Personal characteristics are more important than experience or skills. SNFs routinely violate the very basics of HR practices and then wonder why they are in staffing dilemmas. Some of my best hiring decisions came from individuals with no experience in LTC. SNFs must do a much better job of hiring right. After selection and hiring occurs, fac. Leaders must understand that they are still recruiting the new hire. New staff are still deciding.
- What to do with the data? Follow the path in G to G
- Interview only on Tuesdays at 11 Graffitti, trash, overgrown trees and shrubs
- Picture a huge heavy flywheel – a massive metal disk mounted horizontally on an axle, about 30 feet in diameter, 2 feet thick and weighing about 5,00 pounds. Now imagine your task is to get the flywheel rotating on the axle as fast and long as you can. Pushing with great effort, you get the flywheel to inch forward. You keep pushing and, after 2 to 3 hours of consistent effort, you get the flywheel to complete one single turn. You keep pushing, and the flywheel begins to move a bit faster. You complete a second turn. You keep pushing in a consistent direction, 3 turns…4…5…6..it builds momentum…7…8 turns…it builds momentum…20…25…30. The, at some point, breakthrough! The momentum kicks in your favor, hurling the flywheel forward, turn after turn…whoosh! Each turn of the flywheel builds upon the work done earlier, compounding your investment of effort. Now, if someone came along and asked, “what was the one big push that caused this thing to go so fast?” You wouldn't be able to answer. It was all of the pushes added together in an over accumulation of effort applied in a consistent direction. G to G transformations never happened in one fell swoop. G to G comes about as a cumulative process – step by step, action by action, decision by decision, turn by turn of the flywheel. All of which added together leads to sustained great results. In the case of stabilizing a workforce, we need to recognize that to do so requires hundreds of small, coordinated/calculated steps.
- What to do with the data? Follow the path in G to G