Triggering Staff Reliability David Farrell, MSW, LNHA This material - - PDF document

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Triggering Staff Reliability

David Farrell, MSW, LNHA

This material was prepared by Telligen, the Medicare Quality Innovation Network Quality Improvement Organization, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency

• f the U.S. Department of Health and Human Services. The contents

presented do not necessarily reflect CMS policy. This material is for informational purposes only and does not constitute medical advice; it is not intended to be a substitute for professional medical advice, diagnosis or treatment . 11SOW-QIN-C2-06/25/19-3472

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Serving Colorado, Illinois and Iowa

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• All lines have been muted
• All lines will remain muted during this presentation
• Type questions and comments in chat

Meeting Norms

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• We will chat with each other today
• David will ask you to do a short root cause analysis and

chat in your organizations reply…..

• Here is what you do:

1. Click on Chat icon at the bottom of the screen

• 2. You will be able to see the chat box come up and view the dialogue
• 3. To send a Message in chat, use reply to everyone and type your

response at the Message Prompt

Using The Chat Function

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David Farrell, LNHA, MSW

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Why do Staff Call Off From Work?

 Identify all possible root-causes

 Brainstorming reasons why  Avoid discussing solutions  Keep asking - what else? Why? What have we

missed? Are there other factors?

 Arrange the causes along “bones”

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Cause and Effect Diagram

Systems Environment People Equipment/Supplies

High absenteeism

Chat Time:

 Share you’re responses here  React/Discuss responses  Next Steps

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Social Determinants of Absenteeism

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 2016

Who are the Nursing Assistants?

 Total 1.55 million  90% are women  20% are born outside the U.S.  Average age is 37  Injured 3.4 times more frequently  Median hourly wage is $12.84  50% no formal education beyond high school  15% live below federal poverty line  37% rely on public benefits  13% uninsured and 25% on Medicaid

PHI, 2018

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“What a D Differe erence nce Manage gement ment Makes”

 4 high turnover vs. 4 low turnover SNFs  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

A Vicious Cycle of Staff Instability

Turnover Vacant Shifts

Eaton, Phase II Final Report, 2001

Stress

• Working short staffed
• Resentment
• Waiting
• Anxiety
• Errors
• Poor judgment
• Injuries
• Vacant

Shifts

• Lack of

trust

• Instability
• Poor
• utcomes
• Financial

burden

• Fractured relationships

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High Turnover = Low Quality

 Catheter use  Contractures  Pressure ulcers  Psychoactive drug use  Quality-of-Care deficiencies

Castle et al., 2005 Castle, 2007

Turnover + Absenteeism = Instability

Inte terr rrupts s contin tinuity: ity:

 Incontinence  Community acquired pressures sores  Urinary tract infections  Falls and fractures

Dresser et. al. 1999; Harrington et. al. 1999

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The Impact of High Absenteeism

Vacant shifts = more or different patients What get’s skipped –

Range of motion Hydration Dining assistance Bathing

Hawes, 2002

The Impact of Leaders

Healthcare organizations

 Leader’s actions influence:  Culture  Relationships  Staff engagement  Clinical outcomes  Quality of life

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Person-Centered Care Leadership

My Old and Ineffectiv ective e Met ethod

• d -

 Let department managers track attendance

 Discipline the very worst offenders when things got

really bad

 Maybe fire someone to demonstrate that we are

serious about this

 Forget about it until it get’s really bad again

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A Better Approach -

Treat it like an organizational problem -

 Single point person tracks everyone  Monitor the TOTAL number of unscheduled call-offs

per month

 Share the total number with staff  Demonstrate cause and effect on residents

A Better Approach -

 Goal – Reduce the total number

 Focus efforts on staff in the middle  Have critical conversations more frequently  Examine environmental factors including co-

workers influence

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Nurse Ratched

A Root-Cause of Absenteeism on the PM Shift?

Scheduling Success

Meet with staffing coordinator twice a week

 Support, guide, monitor  Care and be fair  Allow staff to trade days  Honor requests for time off

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Rule – Staff must provide a 30 day advance notice to request a day off

 A rule for a more predictable schedule

Or…

 A rule that leads to a less predictable schedule

Staff are just following the Rule…

 Does a staff member know before the hours of 11 PM – 1 AM that

they are going to call off for tomorrow’s 7 AM shift?

 Then why do they wait and call so late?  Did they know days ago that they were not coming in tomorrow?  Why don’t they tell us earlier to give us a better chance of

covering their shift?

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Goal – A More re Predict edictab able le Schedu hedule

 Please provide as much advance notice as possible (but at least 30

days notice) when requesting more than one day off

 Please let us know as soon as you can when you know that you can

not work a scheduled shift

Eaton’s Findings on Scheduling

Most Common Reason for Termination

 Flexible in low turnover SNFs Allow for different start times Consider personal lives  Rigid in high turnover SNFs  In response to problems “Personal life is not my problem.”

Eaton, Phase II Final Report, 2001

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No-Fault Attendance Policy

 If call-off – it counts as 1  No more qualifying absences  They are all “excused”  Removes inequity  No need for physician notes  Ask staff to tell the truth because you care about them

Goal – A Perfectl ctly Staffed Day

 No call-offs

 No registry hours  No modified duty assignments  No employee orientation hours  Fully staffed to budget – every shift/unit  Overtime = less than 2%

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Consistent Feedback

 Leadership accountability

Set the example  Discuss attendance and its’ impact Rewards and recognition Show data  Individual feedback Share their own attendance record

Provide Respectful Feedback

Analyze attendance records

 Two lists – over 6 callouts and 1 or less  Meet with each staff member -  “What happened to you?”

Or…

 “Thank you for your reliability!”

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You Are Important

“We missed you yesterday…and the clients did

• too. I hope your son is feeling better. We are a better

place when you are here.”

Invisibility

“The problem is not motivation. It is the ways in which we unintentionally de-motivate employees.”

Quint Studer

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Proactive Replacement Plan

 Call employee who called off Show concern Replace for next shift?  Replacement priority list daily Stand-by Pay confirmed to come in Name, phone number Best time to call

Triggering Reliability -

 Root-Cause Analysis

 Organizational issue  Collect accurate data  Closely monitor  Have timely critical conversations  Change rigid policies  Address other root causes  Recognize improvement  Public awareness campaign

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Mutually y Reinf nfor

• rci

cing g Bundle e – Leadersh ship

Community Meetings Rounds

Notes

• Mood
• Content
• Timing
• Data
• Stories
• Strategic Plan
• Timing
• Predictability
• Content

Leadership Rounds

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Effective Rounds

• 1. Mood, posture and paradigm
• 2. Content – what you say and do
• 3. Timing
• 4. Following up

Mood / Posture / Paradigm

 Flip the switch 

You are in the spotlight

 Make eye contact  Praise, build self-esteem  Smile  Linger  Hand out granola bars

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Five Key Questions To Ask Staff

 Relationship building  “How are your beautiful kids doing?”  Focus on the positive  “What is working well today?”  Positive feedback loop  “Is there anybody who has gone above and beyond the call of duty

today?”

 QI - systems focus  “Is there anything we can do better?”  Needs  “Do you have the tools and equipment to do your job?”

Studer, Q., “Hardwiring Excellence.” 2003

Rounds Content – What You Say and Do 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…

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Model the Way

“You pick up the trash in the parking lot!?!. ”

Penni, CNA

Timing of Rounds

Priority is Visibility

 Before morning stand-up meeting  Lunch  Shift change  Last rounds  Weekends  Nights

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Following Up

 Keep notes  Do not carry a cell phone  Listen intently  Get back to people who made requests  Safe

Leadership Notes to Staff

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Elements of a Good Note

 Informative  Complimentary  Standard setting  Update on PIPs  Point out positive trends  Staffing changes  Sincere

Note from the Administrator

March 12, 2018 Update from the Administrator Dear Staff- We had another good week last week and demonstrated that we are working better together. Thank you for all of your hard work to help contain the

• utbreak and minimize its’ impact. We did a great job and I am proud of the staff here.

I’m learning a lot here. Now…I can see that –

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It takes an extra effort to be in the moment, engaged and eavesdropping on conversations…making observations and gently intervening to prevent an altercation or a fall.



It takes a high degree of competence to take a power with approach with clients using respectful language and speaking the truth.



It takes a team to keep our clients not just safe…but also thriving with their own hopes and dreams.



It takes committed leaders at MBC to provide the support and guidance to create the right conditions for our staff to thrive and do their best work with our clients. Positive Trends -



We had our annual Special Treatment Program inspection by the Department of Healthcare Services. The outcome of the inspection was excellent! No major issues. Congratulations to Julia, Maria and their incredible teams!



We have sustained our positive clinical outcomes that we achieved last month – fewer falls while we are only using PRN antipsychotics when

• ur individualized behavioral interventions are not successful.



I appreciate that overall we are experiencing fewer staff call-outs. Please continue to be reliable and only call-out when it is unavoidable. Your reliability enables us to deliver better care and service to the clients. You matter… a lot!



Our new Dietary Services Supervisor, Andres, Starts on March 19th.



New carpet has been installed in the Living or Family Room (no more big TV room). Please stay on High Alert - We are due for our inspection anytime. This is a very important measure of quality at MBC and we need everyone’s help to have a successful inspection and achieve a 5 Star rating. Thanks for all that you are doing here at MBC. I appreciate all that you are doing! Sincerely, David Farrell Phone: (510) 725-7409 Email: dfarrell@telecarecorp.com

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Attention all Staff 4/2/18 QAPI – PIP Update – Enhancing the dining experience Our latest tests of change this week involved 1.) Having prepared and offering more and different alternatives to clients who want something else to eat, 2.) Assigned seating of clients which allows us to deliver hot food hot and cold foods cold. We are addressing the clients complaints about hot food served cold. Our root-cause analysis revealed that – 1.) Three carts is just too many trays to pass at once and not enough hands to pass them all, 2.) Dietary tray line starts too early in order to deliver three carts out to nursing all at once, 3.) Temps are out of compliance for the first trays placed on the first cart. Solutions to root causes – Assigned seating of clients would allow us to set up food delivery carts by client and table

• number. This will allow dietary to deliver a cart to nursing immediately after it is prepared rather than waiting for

the other carts. Our pilot test of the new process went well at lunch. We will continue to test the new process and refine changes. The key is for staff to help direct clients to their assigned tables. Many clients always sit at their assigned table without prompting. In some cases, clients will sit at the wrong table or the wrong time. That is a small problem compared to the bigger problem that we are addressing here – proper food temperatures. Regarding alternatives – yes – we have more than cheese sandwiches! Please refer to the alternatives board in the dining room and when you see that clients have not eaten much of the main entrée, go ahead and offer the alternatives. Thanks to Andres, Maria, Mark and our dietary department for all the adjustments that you folks are making behind the scenes to facilitate the new process. Thanks, David Farrell, Administrator 510-725-7409 dfarrell@telecarecorp.com

April 13, 2018

Dear sta taff, I wa want t to to tha hank to toy ag again ain fo for r a a gr great Ins nspecti tion! It me mean ans a lot

• t to

to me me, Ann nne Bak akar ar, and nd ma many y oth thers at at Tele

• lecare. I am

m ve very pr prou

• ud of

f the de depar artment he head ads and nd the he staff he here at at MBC. And I am m so so gl glad ad that t I ha have be been able ble to to se serve in n a lead adership ip role le he here. I ha have lear arned a gr great t de deal al and nd ha have de deep respect for

• r the

he work we do do and nd the he pe peop

• ple

le that t we se serve. We are ma maki king an n offer to to an n Admin inis istrator to to repla lace me.

• me. If

f all l goe goes as s pl plan anned, the he ne new Admin inis istrator wi will l star art in n mi mid-May. Pl Pleas ase mak make su sure to to pr prov

• vid

ide a warm welc lcome to to the he ne new Adm dmin inis istr trator. Now Now it is s the he time to to br brin ing our ur occupan ancy y ba back up up to to a pl plac ace wher where

• ur business is profitable again. Each clients’ care is reimbursed by

MediC iCal and nd countie

• ies. We ne

need to to be be carin ing for

• r at

at leas ast 94 94 clie ients

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Sincere and Transparent

“My intent is always centered on 2 goals -providing better care and service to our clients combined with creating a great place for you to work. I care about you, your families and the clients.” “I want to sincerely thank you all for your hard work and caring

• approach. I do not take your incredible commitment lightly!”

Community Meetings

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Community Meetings

 Simple metrics Human resource Clinical outcomes Business results  Benchmark and compare  Strategic plan  What – How - Why

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

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Employees are Engaged When -

 Leaders’are engaged  Understand the business and their role  Trust leadership is making good decisions  Feel valued and appreciated  Are well informed

 Rounds, Notes, Community Meetings Compassion Performance

Person-Centered Care Leadership

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David Farrell, LNHA, MSW (510) 725-7409 djfarrell1963@yahoo.com

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