McNally Cards

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McNally Cards

This is a case study exercise about a resent, Mr. McNally, who came into a nursing home for short-term rehab after a stroke. He declined rapidly, and in ways that were avoidable.

Using the deck of cards, the group determines what caused his decline, and learns how quality of life and customary routines affect quality of care. The exercise helps participants identify the importance of a critical thinking, individualized care, and a team approach to the MDS.

Components of a team approach include consistent assignment, daily huddles, alignment of caregiver documentation with MDS, and interdisciplinary care planning, and performance improvement by staff closest to the resent.

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.

Attendance Strategies

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Attendance Strategies

Do your current attendance policies and practices promote stability, or contribute to instability?

In this excerpt, two administrators talks about their uncommon approaches to common problems, and how these approaches promote attendance and contribute to stability.

  • Lauren Salvietti, Administrator at Quahog-on-the-Common, West Brookfield, MA, realized that under her attendance policy, she was looking too many good staff people facing stresses in their personal lives. She reoriented her policy to work with people as they faced stresses. She not only reduced terminations due to attendance, but she also reduced her unschedule absences.

  • David Farrell, NHA, talks about the benefits to employees and employers of staffing to steady hours, and the negative consequences of staffing to census. He makes the business case for staffing to regular consistent hours rather than dropping hours if the census fails.

Check out Attendance, Scheduling, & Assignments on Page 32 of the Staff Stability Tool-Kit, and refer to Worksheets 7 & 8.

Eliminating Alarms & Reducing Falls

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Eliminating Alarms & Reducing Falls

Alarms: Do They Do More Harm Than Good?

What role do alarms play in today’s nursing homes—do they really keep people safe or are they over-used

When alarms were first introduced in nursing homes they were part of the effort to remove restraints. They were intended as a means of getting to know a resident’s routine, so that their individual needs could be met.  However, today alarms are used in many homes on a major portion of the residents.  For many people alarms are the new restraints. They cause people to feel isolated, dependent and afraid to move. Homes that use them with great frequency have not reduced falls.

The current practice in most nursing homes is to put a chair or bed alarm on people who demonstrate a risk of falling. This is a one-size-fits-all approach that, in the name of preventing risks can actually contribute to other risks – the risk of isolation, depression, and malnutrition, loss of mobility, sleep depravation, and skin breakdown. Instead of alarms, we can actually promote good health by helping people with their mobility. This actually strengthens them, decreases the danger of injury from falls, and allows us to respond to their needs instead of to the alarms.

We need to recognize the value of a good night’s sleep, which is hard to have when you’ve got alarms on at night. 

Click the buttons below to download a case study prepared for MassPro, or to read an article by Joanne Rader, Cathie Brady, & Barbara Frank.

Our Advice?

Experience alarms yourself. Wear an alarm for half an hour. That’s what the management team did at Quaboag on the Common in North Brookfield, MA.

Individualizing the Morning Routine Through Gentle Awakening

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Individualizing the Morning Routine Through Gentle Awakening

Individualized Morning Routines

“Each facility must provide care and services to attain or maintain the highest practicable physical, mental and psycho-social well-being of each resident.”
— OBRA '87

When we go by the normal rhythms of a resident, individualizing their care, we support their experience of being at home. When we don’t, we induce agitation and despair, without ever intending to.

We wake people out of a sound sleep in the morning so that we can get them to breakfast at a set time. We shower people on the facility’s schedule, not according to their own routines.  We even have people go to the bathroom based on when we’ve determined it’s time for them to go. A woman on her second day living in a nursing home told Carter Williams, “You haven’t lived til you’ve gone to the bathroom on someone else’s schedule.”

While institutional care may seem efficient, it really isn’t. Homes that have individualized their care have found that they actually have more time, and better quality time, with residents. Instead of a rush hour getting everyone up, washed, dressed, and transported to the dining room where they fall back to sleep waiting for their food trays to come, staff at homes that have gone to having people awaken of their own accord, find that they actually have more time to help each resident start their day.

Hear Experiences from Two Different Homes:

MaineGeneral Rehab and Nursing Care at Glenridge, Augusta, ME

  • Their journey was chronicled in Culture Change in Long-Term Care: A Case Study, created by the American Health Quality Foundation to guide Quality Improvement Organizations and nursing homes interested in using a quality improvement approach to individualizing care and initiating culture change. Funding for this film was provided by The Commonwealth Foundation and Quality Partners of Rhode Island. B&F Consulting guided the production of this film as a model for an effective change process that starts with nursing, and relies on inclusive and empowering leadership.

St. Camillus Health Center, Whitinsville, MA

  • St. Camillus Health Center has been on its culture change journey for about 5 years. In From Institutional to Individualized Care, Sandy Godfrey, Director of Nursing, describes their process of working through issues with staff and residents. Staff initiated the decision to begin consistent assignments as a way to know residents’ individual routines. Nurses monitored issues such as weight loss to ensure no negative outcomes. Administration talked through changes with families. The process was successful, and a building block to further efforts to individualize care.

Both nursing homes used very systematic, interdisciplinary, and inclusive processes to make their changes.

Making It Home Through Low-Cost Changes to the Physical Environment

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Making it Home Through Low Cost Changes to the Physical Environment

Your nursing home is just ‘home’ to the residents who live there.

This excerpt offers guidance on low cost changes to the physical environment that can help residents be more at home, whether their stay is short or long term. It draws from the research of Judith Carboni, a nurse gerontologist, who saw alarming parallels between the experience of homeless people on the streets of Boston and the experience of people living in nursing homes in 1987.

She documented the “psychic despair” among nursing home residents who felt a sense of displacement in their physical environment. This clip describes her research and uses pictures of residents’ bedrooms, dining methods, shower rooms, and common areas, to demonstrate the range of ways the physical environment can support residents in being at home.

What a difference management makes!

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What a difference management makes!

In Loving Memory of Susan C. Eaton

Susan C. Eaton

July 9, 1957 – December 30, 2003

In 2002, CMS commissioned research by Susan Eaton into the causes of turnover in nursing homes. She compared practices at high and low turnover homes. Her findings provide guidance on ways to stabilize staffing from day-to-day.

Below, is a chart of the five management practices she found to contribute to high retention:

High Retention Practices

Click the button below to download Susan’s work, ‘What A Difference Management Makes’.

RI Surveyors Talk About Individualized Care

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RI Surveyors Talk About Individualized Care

This video clip features surveys from Rhode Island’s Department of Health, speaking about their experience in the Individualized Care Pilot, funded by The Commonwealth Foundation. They heightened their attention to residents’ choices about waking and going to bed, eating, and bathing.

These ideas developed for Rhode Island’s nursing homes were a collaborative effort from Quality Partners of Rhode Island, along with B&F Consulting, and the RI Department of Health. These ideas provide guidance for:

  • Consistent Assignment

  • Dining

  • Individual Choice

  • Pleasant Bathing

  • Waking & Sleeping

Look At Me

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Look At Me

Produced by the Veterans Administration

Look At Me

What do you see, nurses, what do you see? 

What are you thinking when you're looking at me? 

A crabby old woman, not very wise, 

Uncertain of habit, with faraway eyes?

Who dribbles her food and makes no reply 

When you say in a loud voice, "I do wish you'd try!" 

Who seems not to notice the things that you do, 

And forever is missing a stocking or shoe...

Who, resisting or not, lets you do as you will, 

With bathing and feeding, the long day to fill...

Is that what you're thinking? Is that what you see? 

Then open your eyes, nurse; you're not looking at me. 

I'll tell you who I am as I sit here so still, 

As I do at your bidding, as I eat at your will. 

I'm a small child of ten ... with a father and mother, 

Brothers and sisters, who love one another. 

A young girl of sixteen, with wings on her feet, 

Dreaming that soon now a lover she'll meet. 

A bride soon at twenty -- my heart gives a leap, 

Remembering the vows that I promised to keep.

At twenty-five now, I have young of my own, 

Who need me to guide and a secure happy home. 

A woman of thirty, my young now grown fast, 

Bound to each other with ties that should last.

At forty, my young sons have grown and are gone, 

But my man's beside me to see I don't mourn. 

At fifty once more, babies play round my knee, 

Again we know children, my loved one and me. 

Dark days are upon me, my husband is dead; 

I look at the future, I shudder with dread. 

For my young are all rearing young of their own, 

And I think of the years and the love that I've known.

I'm now an old woman ... and nature is cruel; 

'Tis jest to make old age look like a fool. 

The body, it crumbles, grace and vigor depart, 

There is now a stone where I once had a heart.

But inside this old carcass a young girl still dwells, 

And now and again my battered heart swells. 

I remember the joys, I remember the pain, 

And I'm loving and living life over again. 

I think of the years...all too few, gone too fast, 

And accept the stark fact that nothing can last. 

So open your eyes, nurses, open and see, 

Not a crabby old woman; look closer...see ME!!