White Boards for Communication

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White Boards for Communication

From the Conference Room to Staff Closest to the Residents

Hear an administrator and Director of Nursing describe how they use white boards for their morning meeting in the conference room, and for their huddles with staff on the unit to share timely information. With the white board and the huddle, all staff know what they need to about at-risk residents, and together they can prevent avoidable declines.

Leadership You Can Count On

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Leadership You Can Count On

Hear from administrators and Directors of Nursing at three Indiana nursing homes about how they’ve taken their daily management stand-up meetings and expanded them to include the staff that work closest with the residents. They are able to ensure that staff have what they need to care for residents, address any clinical issues with the people who have the most intimate knowledge of the residents, and resolve problems on the spot.

Instead of leaving a management stand-up with a huge to-do list, most everything is taken care of. Staff can count on their leaders’ regular availability, and can see that their needs and ideas matter.

Thanks to Holy Cross Village, South Bend, IN; Harrison Terrace, Indianapolis, IN; and Heritage House, Shelbyville, IN. These homes participated in Nursing Home Leadership Collaboratives sponsored by the Community Foundation of St. Joseph’s County, and the Community Foundation of Marion County, in coordination with Health Care Excel, and the Indiana stakeholder organizations.

QAPI Success: From Plan to Action

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QAPI Success: From Plan to Action

Huddles & Consistent Assignment: Working Together to Build Trust and Reduce Residents’ Distressed Behaviors

Huddles and consistent assignments help staff work together to reduce anti-psychotic medications. Staff at Beth Abraham Centerlight in Bronx, NY huddle throughout the day to share vital information and problem solve. By caring for the same people everyday, staff build trust with residents, and learn how to put them at ease.

They improve outcomes for individual residents, and succeed in organization-wide quality initiatives. These practices allow staff to care from the heart, and the organization to support them in doing so. Beth Abraham Centerlight is a participating in the IPRO New York State Learning & Action Network.

Kaizen: Getting Better by Working Together

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Kaizen: Getting Better by Working Together

A Team Approach to Quality Improvement

Hear administrator Bill Pierce from Heritage House in Shelbyville, IN describe how he threw his old QA quarterly (boring) meetings out the window, and in their place, redesigned three key elements:

  • Management Team daily rounding became ways to be accessible and supportive to the staff

  • Management Stand-Up expanded to include staff closest to the residents

  • QA became short, frequent, and focused QI meetings with staff teams, including on-the-spot QI for individual incidents

All Hands On Deck

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All Hands On Deck

Hear the administrator and admissions coordinator at Bayberry Commons in Pascoag, RI describe why and how they used a leadership intervention–All Hands on Deck–to reduce stress and instability, and transform from a special focus “nursing home in need” to an AHCA Silver Award winning “nursing home in the lead”.

Their story is captured in the May 2013 issue of Provider Magazine.

All Hands On Deck

What Is It:
“All Hands on Deck” is a leadership practice in which managers help out hands-on care-giving staff members during the busiest times of day

Why Do It:
Management can help alleviate stress for staff and for residents during extremely labor intensive and stressful peak times; Doing so models teamwork, meets residents’ needs, and gives the management team a “finger on the pulse” to see how people and systems are working; Helping out during high stress times has a number of benefits including, but not limited to:

  • Residents’ care needs better met

  • Staff stress is relieved

  • Managers get first-hand knowledge of the work load and workplace dynamics

  • Managers role-model teamwork

  • Builds different and better relationships with staff

  • Breaks the cycle of staff instability

When managers pitch in during stress times, their actions demonstrate that they care about staff and residents, because they are providing tangible help that ensures the day runs smoother for staff and residents.

Staff stress is a primary cause of staff instability. For organizations experiencing staff instability, these benefits can help break a negative cycle of staff turnover and absenteeism. However, this is an extreme intervention, and not a long-term substitute for having enough staff; It is a bridge from instability to stability.

It is important not to mask the problem of understaffing, but instead to use this approach as a bridge to better staffing. It serves as a bridge by reducing unscheduled absences that come from staff stress, building teamwork so that staff work better together, and by providing the management with a first-hand feel for how the work flows, and where more staff is needed.

In organizations with stable staffing, All Hands On Deck builds a culture in which everyone helps each other out. Everyday teamwork helps people and organizations perform at their best.

How To Do It:

  1. This is a management intervention: Managers go first. As staff see management roll up their sleeves and help out during these stressful times, others will follow their lead. However, if managers merely direct non-nursing staff to help rather than commuting to provide personal assistance, the directive will generate resentment rather than goodwill. This is a way of building better relationships, having your finger on the pulse of workflow, and role modeling teamwork.

  2. Find out from staff when and what help is needed: Meet with staff on each unit and shift to ask when they need assistance, and what they need assistance with. Usually, meal times are high stress times. Other labor intensive times may be the time around shift changes, when extra help is needed so that the out-going staff can give proper report to the incoming staff. Additionally, help may be needed for transportation to an event in the home, or an appointment.

  3. Schedule from the top: Have someone on the management team develop the schedule and communicate it to all units and all management team members.

  4. Be reliable and consistent: Set a schedule and keep to it. Once a promise is made to help, it is essential to keep the promise. Treat time scheduled for helping on the unit as protected time that cannot be interfered with. Make sure to get a substitute from the management team if you are unable to meet your obligation.

  5. Report to the charge nurse to be assigned duties during your assigned time to help: While you may have agreed upon tasks, when you come onto the unit, you need to find out exactly what is needed then and there. Checking in with the charge nurse ensures that you can be immediately helpful. It also respects the dynamics on the unit, and shores up the chain of leadership.

  6. Help seven days a week: Weekend staff need the help as well. While it’s harder to arrange to help on the weekends, doing so will have an enormously positive impact.

  7. Monitor at management team meetings: At daily stand-up, check in on what managers are doing and finding. All hands on deck gives managers a “finger on the pulse” of care-giving, and workplace dynamics. Identify strong performers, solid leaders, and people who need more guidance and development. Talk through ways to use the time on the unit to bring out the best in staff. Note areas of stress, and brainstorm interventions that can improve workflow, or areas to target for hiring more staff as you are able.

What Types of Assistance to Provide:

  • Help at meals: Many residents need a lot of assistance, and eat at a slow pace. Others need to be cued, and talked to so that their meal is enjoyable and digestible. There are many meal related tastes that managers can do that can free up time for CNAs to provide intensive assistance. Additionally, you can pass trays, open milk cartons, poured rinks, transport people to the dining room, get substitute meals from the kitchen, be a companion to a resident who is eating, or answer call bells while staff is assisting with meals.

  • Answer call bells: The majority of call-bells involve requests for non-nursing assistance. However, should you need to ask for a CNA’s help, offer to pick up something that she was doing, or ask how you can be of assistance to her.

  • Make fall prevention, comfort rounds, and other check-ins: Go room to room and ask residents if there is anything they need assistance with. Make sure watch pitchers, TV remotes, call-bells, and other items are within a residents’ reach. Do they need a straw, or a snack? Does a resident want their face washed at the end of a meal? Non-trained staff need to be very careful about ensuring these things. Residents can be diabetic, or unable to have water and a straw due to swallowing problems. Managers need to take guidance from nursing staff when providing a helping hand.

  • Be a “runner”: Ask unit staff, “How can I save you some steps?” Offer to make the trip to the kitchen for any food substitutes, or refills. Does the linen need to be restocked?

  • Help wherever and whenever is needed: Perhaps a surge of help is needed to transport residents when a lot of people are attending a group activity or special event. Help out when a new resident arrives, when staff are attending an in-service, or when staff is short a co-worker. Discuss these situations in the morning management stand-up and plan together how to provide the support hands-on staff will need. Create a culture where anyone on staff can issue a call for “all hands on deck” and can trust that others will make themselves available to help out.

Who Does It:
Include all department heads and anyone else who regularly attends your management meetings, such as nursing management, head of the business office, admissions, food services, housekeeping, maintenance, activities, and rehabilitation services.

How Long:
Carve out increments of 15-30 minutes, and make a schedule so that every manager knows where they are needed, and when. You may need some people to help out twice a day in order to have enough people spread out over the busy times on all shifts for all units.

Providing help for a special event or responding in the moment to a call for “all hands on deck” won’t take very long. When everyone pitches in, the need is quickly addressed.

What A Facility Policy Should Include:
All activity should be within the scope of each person’s training, and under the supervision of the nurse or other department head in charge.

  • Check with the nurse or CNA before giving any food or drink to make sure the resident can have it

  • Only lift or transfer someone if you are trained in how to do so

  • Follow infection control protocol

  • Understand any triggers for someone’s behavior

  • Respect residents’ privacy and customary routines

Make It Part of Your Culture. While “all hands on deck” can be a stop-gap measure when times are tough, it can also become a way of life, so that staff know they can count on help whenever it is needed.

Management Stand-Up

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Management Stand-Up

Why & How To Conduct an Effective Morning Meeting for Your Management Team

Morning Stand-Up for Leadership Team

What It Is:
Morning Stand-up is a short daily meeting of department heads/others on the leadership team to share current essential information that everyone present needs to know.

Why To Do It:
Communication of essential information cannot be left to chance. It is most efficient to share the information in a group, rather than walk it around. When it is shared in a group, the group also has the opportunity to problem solve any issues on the spot, and ask questions. Additionally, everyone hears EXACTLY the same information.

Who Attends:
Participants include all department heads, and staff responsible for HR, QI, Staff Development, MDS, and Admissions. Often, Nursing Leaders such as Unit Managers or Shift Supervisors also attend.

When To Do It:
The meeting should occur early enough in the morning to give everyone present the information they need for the day, and late enough in the morning to allow all attending to have gathered the information they need to bring to the meeting. It should be done at a time that does not interfere with essential services that would keep a department head from attending. Many homes have found 9:00 to be a good time.

How Long:
Most stand-ups can be completed in approximately 15 minutes, unless there is a need for an in-depth conversation requiring involvement of the entire team. The meetings should not exceed 30 minutes.

Where To Do It:
The meeting needs to be in a room that is easy to get to, big enough for all to comfortably attend, and in a place that allows for a private discussion.

How To Do It:

  1. Be On Time: This is a short meeting. IT needs to start and end on time. Everyone expected to come needs to be there on time and be prepared to share

  2. Participation: Each attendee shares anything from their department or sphere of responsibility that will be helpful for others to know, or that needs input or involvement of others

  3. Process: In a go-round, each person shares information; Be brief–any areas that need discussion are discussed briefly as they come up; If more discussion is needed, a time is arranged for further discussion

  4. Standing Agenda Items May Include:

    • Census provided in a written document, and with highlights reviewed; Potential information for such a document includes:

      • Residents by Room & By Payment Source

      • Recent & Expected Discharges

      • Recent & Pending Hospitalizations

      • Possible Admissions

    • Information About New Residents

      • Social history, family information, medical needs, room assignment, payment source, and any special needs

    • Information About New Employees

      • Names, assignments, backgrounds, and a “check-in” of how they’re adapting to their new environment

    • Reportable Events, Incidents, & Accidents

    • Complaints & Compliments

    • Follow-Up from Complaints of Previous Day

    • Employees Who Have Excelled & Are To Be Recognized

    • Business Metrics Updates & New Business Developments

    • Clinical, Operational, or Human Resource Area

      • Attendance, Open Positions, Pressure Ulcers, New Lines of Business, etc.

    • Any Key Meetings Scheduled for the Day

    • Any News from Departments

      • Activities events, maintenance, physical plant, build-wide environmental issues rebuilding interdepartmental knowledge or coordination

    • Follow-Up on Any Unresolved Issues Raised

    • Note anyone in their ARD for MDS

Consistency is crucial. To be successful, morning stand-up has to be valuable to the participants. Starting on time, and with an expectation of full attendance is key to making this communication tool really work for you.