2017 Illinois Pioneer Coalition Summit March 27 2017

2017 Illinois Pioneer Coalition Summit March 27, 2017 Staff Stability Boot Camp Cathie Brady & Barbara Frank, B&F Consulting www. bandfconsultinginc. com

Introduce yourselves to your tablemates What are you seeing in terms of stability and your ability to hire? ©B&F Consulting 2017 www. bandfconsultinginc. com 2

Staff Stability – Why It’s Important • Succeed in Performance Based Payment - Prevent avoidable hospitalizations and adverse events • Provide consistent care so staff know residents, can individualize care and eliminate antipsychotics • Improve resident and staff satisfaction • Better teamwork ©B&F Consulting 2017 www. bandfconsultinginc. com

Two choices: Short term fixes that perpetuate long term problems vs. Long-term fixes that promote and perpetuate stability ©B&F Consulting 2017 www. bandfconsultinginc. com 4

Why is stability so hard? • If it feels like the deck is stacked against you, it’s because it is • But it’s not impossible, just hard • You have to understand some of today’s unique dynamics ©B&F Consulting 2017 www. bandfconsultinginc. com

Overall unemployment below 5% • 2008 housing bubble burst • Little or no new home or business construction for five years • Home Depot, Lowes • Your employees have options ©B&F Consulting 2017 www. bandfconsultinginc. com

In 2008 there were 6. 7 people for every job opening Today there are 1. 5 people for every job opening ©B&F Consulting 2017 www. bandfconsultinginc. com

Turnover • Not inevitable • Research shows that it’s not • Your colleagues have shown that it’s not • You have a unique workplace with something to offer that people with an intrinsic motivation to be caregivers can’t get from Mc. Donalds or Lowes ©B&F Consulting 2017 www. bandfconsultinginc. com

Employment • PAY CHECK • AFFILIATION ©B&F Consulting 2017 www. bandfconsultinginc. com

A Vicious Cycle of Vacant Shifts, Stress, and Turnover Vacant Shifts • Working short staffed • Financial burden • Resentment • Instability • Overtime • Poor outcomes • Agency use • Lack of trust Stress • Vacant Shifts • Errors • Poor judgment Turnover • Injuries • Fractured relationships Eaton, What a difference management makes!, 2002 ©B&F Consulting 2017 www. bandfconsultinginc. com

My Inner. View Priorities: Would you recommend your workplace to others? CNAs NURSES 1 Help with job stress and burnout 2 Management listens 3 Management cares 2 Management cares ©B&F Consulting 2017 www. bandfconsultinginc. com

ding xpan efits ben o stem h 65 y • E ipes. T rill, wit g pa r isin ees' g Fire G n ploy • Ra a to em s Bar & las. Today, l May g 2015 USA t fal be 29, tening okey Bone U. S. , ers to • Lis ver, Sm the Eastern " with manag. turno ants in y interviews ir work lives r restau ng "sta ve the o nducti how to impr co s ne eir job etermi quit th d people ick reason " says D iggest r boss, b single ust thei chain. he • "T n't tr for the hey do consultant is t gan, a Finne ©B&F Consulting 2017 www. bandfconsultinginc. com

It’s all about affiliation What a difference management makes! Five Management Practices Associated with Low-Turnover, High Attendance and High Performance: High quality leadership at all levels of the organization Valuing staff day-to-day in policy and practice, word and deed High performance, high commitment HR policies Work systems aligned with and serving organizational goals Sufficiency of staff and resources to care humanely Eaton, 2002 ©B&F Consulting 2017 www. bandfconsultinginc. com

Root Cause Analysis ©B&F Consulting 2017 www. bandfconsultinginc. com

Dig Deeper • When are people leaving and what does that tell you? • Use your analytical thinking – why, why ©B&F Consulting 2017 www. bandfconsultinginc. com

Possible “root causes” • Pay • Work not appreciated – “I’m just a CNA” • Work too hard – always asked to work doubles • Don’t have enough clean linen when we need it; don’t have the working equipment we need • Feeling like I don’t matter, or worse- I don’t make it better ©B&F Consulting 2017 www. bandfconsultinginc. com

Terminations by Length of Service WHY? Position 1 day – 1 – 3 3 - 6 1 mo mo mo 6 mo 1– 2 yr > 2 yr – 1 yr RN LPN CNA Other 27% 16% 12% 18% 7% 23% 8% 13% 30% 27% 18% 33% 23% 39% 18% 20% 3% 14% 0% 0% 5% 0% What impact does this have on staff stability and care continuity? ©B&F Consulting 2017 www. bandfconsultinginc. com

Incentives Bonus Amt Offered Sign-on bonus Paid after 6 mos. RN -- $2000 LPN -- $500 CNA -- $250 Referral bonus RN, LPN --$1000 Paid after 6 mos. CNA -- $500 Longevity $0 Raises Average 2% Quarter - Annual $12, 500 - $50, 000 $6, 000 $0 $90, 710 What impact does this have on staff stability and care continuity? ©B&F Consulting 2017 www. bandfconsultinginc. com

List all those who have left in the last four months and mark off those that were new and those that were established employees Month N=New E= Established October September August July ©B&F Consulting 2017 www. bandfconsultinginc. com

List Reasons for Leaving Month N=New E= Established April March February January ©B&F Consulting 2017 www. bandfconsultinginc. com Reason

Group Reasons: Reasons ©B&F Consulting 2017 www. bandfconsultinginc. com

Which ones can team as currently constructed address and which need someone not now on team to address Reasons Team Can Do ©B&F Consulting 2017 www. bandfconsultinginc. com Someone Not Now on the Team

When Pay Does Matter • When you’re not being paid as much as others doing the same job somewhere else • When you cannot pay your bills and yet you’re working full time ©B&F Consulting 2017 www. bandfconsultinginc. com

Wages -- What we heard: “You try making ends meet on $9/hr. ” • $600 for rent (single mom) • $400 for groceries (4 kids) • $400 for car payment, insurance • $640 for gas ($160/week) • $300 for utilities • $370 for child care ($18. 50/day) $2, 710 for monthly expenses How many hours would you have to work? ©B&F Consulting 2017 www. bandfconsultinginc. com

Walmart’s goal: To improve employee retention and customer service . ©B&F Consulting 2017 www. bandfconsultinginc. com

They hit the reset button Walmart, which employs 1. 4 million people in the U. S. , announced sweeping changes to employee wages and training initiatives last year after facing years of pressure to increase pay. That included raising its minimum wage up to $9 an hour in 2015, with plans to get to $10 in 2016. ©B&F Consulting 2017 www. bandfconsultinginc. com

To keep customers and employees ©B&F Consulting 2017 www. bandfconsultinginc. com

Walmart's mission to improve employee retention and customer service ©B&F Consulting 2017 www. bandfconsultinginc. com

It’s Working!! The moves have already made a difference in customer experience and employee engagement, said Walmart U. S. Chief Operating Officer Judith Mc. Kenna in a company statement, citing the company's five straight quarters of same-store sales growth. ©B&F Consulting 2017 www. bandfconsultinginc. com

Dig Deeper • Pay scale analysis of other nursing homes in your immediate area – by years of service • Pay scale of work outside of health care that is taking your good employees ©B&F Consulting 2017 www. bandfconsultinginc. com

Wage analysis Starting wages Years of service – caps Health care competitors Non health care competitors ©B&F Consulting 2017 www. bandfconsultinginc. com

Root Cause Analysis Table work: How will you find out why people are leaving? For the reasons you know about, what steps can you take? ©B&F Consulting 2017 www. bandfconsultinginc. com

Take a Break

Bundles

What is a Bundle? n Structured way of improving processes of care n A set of 3 -5 evidence-based best practices n When performed collectively and reliably, have been proven to improve patient outcomes ©B&F Consulting and David Farrell 2017 www. bandfconsultinginc. com and djfarrell 1963@yahoo. com IHI, 2016

What Makes a Bundle Special? so Three Common Elements – • The method of execution – with complete consistency • The reinforcing nature of the best practices contained within the bundle • The understanding that all of the best practices are necessary for the bundle to succeed IHI, 2016 ©B&F Consulting and David Farrell 2017 www. bandfconsultinginc. com and djfarrell 1963@yahoo. com

Is a Bundle Just a Checklist? Much more than a checklist – • • • Cohesive unit of steps taken together Performed uniformly not sequentially Measured by all or nothing – no partial credit Smaller than a checklist Higher level of accountability tied to a bundle IHI, 2016 ©B&F Consulting and David Farrell 2017 www. bandfconsultinginc. com and djfarrell 1963@yahoo. com

Mutually Reinforcing Bundle – Staff Stability Selection Welcome Attendance ©B&F Consulting and David Farrell 2017 www. bandfconsultinginc. com and djfarrell 1963@yahoo. com

Map your current processes Recruitment Hiring Process Welcoming Identify areas for improvement ©B&F Consulting 2017 www. bandfconsultinginc. com 39

Step 2. Improve your pool of candidates Don’t cast a wide net. . . Be Targeted to the people you want to hire ©B&F Consulting 2017 www. bandfconsultinginc. com

What’s the draw to working in long-term care? What’s good about working with you? ©B&F Consulting 2017 www. bandfconsultinginc. com

Red Auerbach “The key to winning is putting the five players on the court who play together best. ”

Recruitment • Seek Triple Crown Winners: – Reliable – Good interpersonal skills – Competency in job skills • Use Your Triple Crown Winners to recruit: – Micro-target advertising – Refer a friend – Nursing schools ©B&F Consulting 2017 www. bandfconsultinginc. com 43

Grow Your Skills - Grow Your Career We pride ourselves in our high quality care and our great work environment Join our family environment and staff longevity Join a group that loves to work together and loves our residents Our company has advancement opportunities to help you grow Excellent benefits – low cost health, Paid tuition for nursing school Work as a CNA and get paid to get your nursing license “I came here because I can use my skills and they’re invested in my future” – Brett, RN We have an opening for an LPN or RN for a charge nurse position – call us if you are a good match for our team. ©B&F Consulting 2017 www. bandfconsultinginc. com 44

Refer-a-friend Bonus • Word of mouth is best advertisement • Actively promote refer-a-friend bonus ~Personally approach your best employees • Pay as soon as you hire – it’s up to you then, to have them stay ©B&F Consulting 2017 www. bandfconsultinginc. com

Nursing School Students • Word of mouth from current students and recent graduates • Offer flexibility so people in school can fill in shifts • As nursing students work as CNAs, have them also shadow nurses to cover areas normally provided after hire as a nurse • Offer a good on-boarding process to help new nurses settle in to their new career ©B&F Consulting 2017 www. bandfconsultinginc. com

Discuss at your table Which of your recruitment efforts generate good staff who stay? What more and different do you need to do? ©B&F Consulting 2017 www. bandfconsultinginc. com

Step 3. Improve your Hiring Process ©B&F Consulting 2017 www. bandfconsultinginc. com

Screen before you hire, not after Take the time to hire someone who will be value added to your team Make hiring process a good screen – have a multi-layer process “Measure twice – Cut once” ©B&F Consulting 2017 www. bandfconsultinginc. com

Focus on Character Traits • • • Maturity – self reflection Compassionate Sensitivity to others needs Self esteem Ability to communicate, learn Friendliness - Five smile rule ___ ___ ___ ©David Farrell and B&F Consulting 2017 www. bandfconsultinginc. com

Welcoming Applicants • Make a good first impression • Receptionist/person at front door is key – Make sure she has postings, applications, info on benefits, and she’s tuned in to welcoming • Make it a priority to meet new applicants ©David Farrell and B&F Consulting 2017 www. bandfconsultinginc. com

Screen, tour, interview right when they come in • Facility tour observations – Walk quickly and see how they keep up – Go up and down stairs if you have them – Place them next to residents who will engage them – see how they respond (resident ambassador) – Monitor interactions with people – afterwards, ask staff what they know about person ©B&F Consulting 2017 and David Farrell www. bandfconsultinginc. com

Include others in interview • Teach interview and hiring skills • Include: co-workers, supervisor, resident and/or family • Once Talladega unit managers were involved, they wanted them to succeed • Give training on how to interview and legal prep on what’s acceptable • This starts the process of a warm welcome – builds confidence in the new employee and starts the relationship ©B&F Consulting 2017 www. bandfconsultinginc. com

Interview Tips • High standards • Ask to see their last performance evaluation • Where have they been trained? (Does it make a difference? ) • Do they have experience? • Do they have realistic expectations about the job? • Ask the right questions – Open ended – Behavior based; scenario based – Character based ©David Farrell and B&F Consulting 2017 www. bandfconsultinginc. com

Interview Questions • Who is the nicest person you know, and why? • What are you most proud of? • Tell me about your prior experiences in caregiving? • Tell me about a time that you’ve had a conflict with a co-worker. What did you do? • Tell me the names of three elders you had a close relationship with in your past job? ©David Farrell and B&F Consulting 2017 www. bandfconsultinginc. com

Loomis House Involves Residents • What do you do when you are stressed? • What made you decide to become a CNA? • If a 96 year old resident was going toward the door to leave and told you that she was waiting for her mother to pick her up, how would you respond? • If you were going in to care for a resident who was agitated, how would you handle it? ©B&F Consulting 2017 www. bandfconsultinginc. com

Discuss at your table Hiring practices: What’s working now? What more and different do you need to do? ©B&F Consulting 2017 www. bandfconsultinginc. com

Step 4. Provide a Good Welcome Increasing Percent of Newly Hired Staff Who Stay MEASURE!! ©B&F Consulting 201 www. bandfconsultinginc. com

A Warm Welcome from Management and Co-workers Helps New Staff Stay • Leadership – Administrator personally tune in to new person • Supervisor responsibility for welcome – Frequent check-ins • Co-workers – Invite to lunch and to go on breaks together Remember: It takes 3 months to be comfortable ~ 6 months to feel competent in a new job ©B&F Consulting 2017 www. bandfconsultinginc. com

Friendships at Work People stay in places where they have friends ©B&F Consulting 2017 www. bandfconsultinginc. com

Welcoming • Active learning instead of a check-off. Adults retain more as active, engaged learners than as passive learners. Add engagement to the required content. • Break up the sitting still with moving around • Scavenger Hunt • Pay attention to the classroom atmosphere. Decorate it - make it welcoming. • Act as warmly as you would if you are welcoming someone into your home. Serve food and drinks. ©B&F Consulting 2017 www. bandfconsultinginc. com 61

Establish relationships right away. – Lunch with administrator – Lunch with co-workers – Have a resident be a part of the welcome process. – Have nurses have individual time with Do. N as they learn so that they have a relationship and feel they can come back to the Do. N with questions. ©B&F Consulting 2017 www. bandfconsultinginc. com 62

From Classroom to Floor • Stable assignments – DON’T MOVE NEW STAFF AROUND • Hire into positions –create stable assignments ©B&F Consulting 2017 www. bandfconsultinginc. com 63

Mentor for Retention – Do it Right • Take it seriously • Make sure you have the right people as mentors – Application, interviews and recommendations • Training – How to teach to other people’s strengths – How to handle conflict and give feedback • Clear lines of responsibility – how to handle deficits in new staff developmentally – Who’s accountable for what ©B&F Consulting 2017 www. bandfconsultinginc. com

Team Rewards when new employees succeed ©B&F Consulting 2017 www. bandfconsultinginc. com

Younger Employees • You may be their first real employer • Young staff need structure and guidance – develop them – take them under your wing • Maximize sense of affiliation – they love connection and are very social ©B&F Consulting 2017 www. bandfconsultinginc. com

Discuss at your table Welcoming and orientation practices What’s working now? What more and different do you need to do? ©B&F Consulting 2017 www. bandfconsultinginc. com

LUNCH

Get a handle on attendance and let the staff know you’re paying attention • If you can’t come in, call the administrator or Do. N • A Do. N had a white board in her office listing everyone who’d called off STAFF KNOW YOU MEASURE WHAT MATTERS ©B&F Consulting 2017 www. bandfconsultinginc. com

From Absenteeism to Attendance • Track absences • Single point person to track • Discuss in stand-up • Intercede immediately • Review individual records and give feedback – one of three letters in paychecks – Thanks for good attendance – Come see us if you need help – We need to talk to you about your poor attendance B&F Consulting 2017 www. bandfconsultinginc. com

From Absenteeism to Attendance • Enforce attendance policies – Require staff to Call administrator or Do. N • Provide support and flexibility to staff whose personal lives create attendance challenges • Be Proactive in anticipating absences – If someone calls off, call them to find out if they expect to be in on their next scheduled day – If someone is asked to work a double or take a last minute assignment, find a replacement for their next scheduled shift so they can have a needed rest. • Have consistent back-ups for each unit/shift • Reward individuals and teams for good attendance B&F Consulting 2017 www. bandfconsultinginc. com

Create conditions for attendance success • Simplify your schedule. • Post it at least a month ahead, in an easy to read format. ©B&F Consulting 2017 www. bandfconsultinginc. com

An Option for Scheduling 4 on 2 off schedule With an Even # of CNA assignments, 3 CNAs serve 2 resident assignments M Maria Jen Ellie T W Th F S S M T W Th F S S 1 1 1 1 O O 1 1 2 2 O O 2 2 1 1 O O This can be modified to every third weekend off. B&F Consulting and David Farrell 2017 www. bandfconsultinginc. com David Farrell

Create conditions for attendance success • Honor people’s requests for time off • Move to more full-time positions and fewer part-time and per diem. ©B&F Consulting 2017 www. bandfconsultinginc. com

Composition of staff by work status: Position FT PT Per diem Baylor RN 27% 13% 47% 13% LPN 55. 5% 0% 18. 5% 26% CNA 48% 10% 9% 32% What impact does this have on staff stability and care continuity? ©B&F Consulting 2017 www. bandfconsultinginc. com

Incentives Bonus for last-minute assignment but no reward for being reliable Bonus Last minute assignment Perfect attendance Extra Per Hr. Annual RN, LPN --$10 $360, 000 CNA -- $5 $0 $0 What impact does this have on staff stability and care continuity? ©B&F Consulting 2017 www. bandfconsultinginc. com

What matters most to staff to recommend their nursing home to others as a place to work CNAs NURSES My Inner. View 1 Help with job stress and burnout 2 Management listens 3 Management cares 2 Management cares Today’s stressed employee is tomorrow’s call-off. Pitch in through all hands on deck. . . ©B&F Consulting 2017 www. bandfconsultinginc. com

VIDEO All Hands on Deck ©B&F Consulting 2017 www. bandfconsultinginc. com

Leadership on the Floor How 2 charge nurses start their day “I gather my staff in the “I am overwhelmed by what I morning and I tell them, ‘we have to do when we’re have to work together. We’re working short. If I start doing like sticks. If we work apart, the CNA‘s job, I’ll never get each of us can be broken. If all my meds passed and my we stick together, we can’t be charting done. It’s just too broken. We’ve got to stick together to get the work done. much. I’m not going to do the personal care. I just keep my And let’s have fun doing it. ’ Then I just pitch in and we get focus on my work and get as through the day. ” much done as I can. ” ©B&F Consulting 2017 www. bandfconsultinginc. com

Which of your nurses are Nurse # 1? Nurse # 2? Make individualized plans to develop your nurses ©B&F Consulting 2016 www. bandfconsultinginc. com

Take a Break 81

Relationships Determine Outcomes: People Paradigm Your systems create your outcomes • Quality, the result, is a function of quality, the process • Cannot continuously improve interdependent systems and processes until you progressively improve interdependent, interpersonal relationships Your systems for supporting good working relationships create your outcomes Deming, and Covey 1991 ©B&F Consulting 2017 www. bandfconsultinginc. com

Theory of relational coordination: Gittell, et al, 2008 • The effectiveness of care and service is determined by the quality of communication among staff • Residents’ relationships with staff are shaped by staff’s relationships with each other. • It is the community of staff’s relationships that shapes the resident experience ©B&F Consulting 2017 www. bandfconsultinginc. com

Dimensions of Relational Coordination Interdisciplinary ~ Interdepartmental Across Shifts and Days Communication Frequent Timely Accurate Problem-solving Relationship Shared Goals Shared Knowledge Mutual Respect Eaton, Bishop, Gittell ©B&F Consulting 2017 www. bandfconsultinginc. com

Relationships Closest to the Resident Matter Most Interdisciplinary and Interdepartmental Collaboration within and across units and shifts Nurses CNAs Residents Housekeeping, Food Services, Activities, Social Work Eaton, Bishop, Gittell Quality of work Quality of care ©B&F Consulting 2017 www. bandfconsultinginc. com 85

Bundle for Engineering High Quality Care An Infrastructure for Communication and Problem-solving Among and With Staff Closest to the Resident • Consistent Assignment • Huddles • CNA Involvement in Care Planning • QI Closest to the Resident ©B&F Consulting 2017 www. bandfconsultinginc. com

Mutually Reinforcing Bundle Consistent Assignment Care Conference Meetings Infrastructure for Communication, Engagement, and Continuous Improvement ©B&F Consulting 2017 www. bandfconsultinginc. com Shift Huddles, QI Huddles, Management Stand -up with Staff

Mutually Reinforcing Bundle Rounds Community Meetings Infrastructure for Communication, Engagement, and Continuous Improvement ©B&F Consulting 2017 www. bandfconsultinginc. com Notes

“The single biggest problem in communication is the illusion that it is taking place. ” George Bernard Shaw ©B&F Consulting and David Farrell 2017 www. bandfconsultinginc. com and djfarrell 1963@yahoo. com

Communication Challenges • Communication is spotty • Staff instability • Task-centered policies • Siloes of departments = siloes of communication • Left to a few key people to inform many • Changes in patient are reported but not acted on • Not noticing the change in the patient until it is too late • No system to review changes together • Steep hierarchy stifles sharing information • Lack of team approach • Those who know most are not • Staff do not understand how or what information to asked to share ©B&F Consulting and David Farrell 2017 www. bandfconsultinginc. com and djfarrell 1963@yahoo. com

Systems of Communication • Stand-Up morning huddles with department managers, IDT and staff • IDT and staff start of shift huddles • IDT and staff mid-shift safety huddles • Standing root-cause analysis • IDT and staff end of shift check in huddles ©B&F Consulting and David Farrell 2017 www. bandfconsultinginc. com and djfarrell 1963@yahoo. com

Facilitate Patient Safety Huddles • Purpose – catch clinical changes early • Build comfort and competence – Write down all the ideas – Prompt people – Compliment people – Set Rules - “No blame” – Promote constructive engagement – Redirect and keep it positive ©B&F Consulting and David Farrell 2017 www. bandfconsultinginc. com and djfarrell 1963@yahoo. com

Huddles - Keys to Success • Be prompt, start on time • Be prepared – discuss a productive meeting • Designate people to cover call lights during the meeting • Keep notes • Check medical records in real time • Get back to people who offered input ©B&F Consulting and David Farrell 2017 www. bandfconsultinginc. com and djfarrell 1963@yahoo. com

Huddle What to Cover – New patients – “At Risk” patients – Changes in condition – Unplanned discharges, rehospitalizations – Pending care transitions – discharges and room moves – Incidents and accidents, safety hazards – Clinical focus areas, QAPI PIPs – Key information, news, announcements – Kudos – New staff members ©B&F Consulting and David Farrell 2017 www. bandfconsultinginc. com and djfarrell 1963@yahoo. com 94

A huddle with a white board of the most important timely pertinent information needed to care for the residents today. ©B&F Consulting 2017 www. bandfconsultinginc. com 95

Most frequently cited deficiency is: “Failure to follow care plan” How valid are your care plans? Is there a disconnect between what your paper says and what your people do? If so, why? Is what your people are doing what the paper should say? ©B&F Consulting 2017 www. bandfconsultinginc. com 96

New requirements for participation: • Involve CNAs in care planning • More specificity about individualizing care • Focus on preventing avoidable adverse events ©B&F Consulting 2017 www. bandfconsultinginc. com 97

Change can be scary, or it can be approached as an opportunity for improvement • When we have to do something different, it can make us revisit what we are doing and challenge ourselves: • Is this the way we want it to be? ©B&F Consulting 2017 www. bandfconsultinginc. com

Involving CNAs in Care Planning Use this as a time to assess your Care Plan Meetings – Are they a check-off? – Does real problem-solving happen? – do people come on time, prepared, productive? – Are meetings person-centered? – Is the meeting held where it is easy for the resident and CNA to get to? (Move meeting to neighborhood; consider holding it in resident’s room) Make sure they are well-functioning meetings before you include CNAs. ©B&F Consulting 2017 www. bandfconsultinginc. com

How to Involve CNAs in Care Planning Prepare CNAs to Contribute: • When CNAs routinely share at shift huddles, this helps them know how to share in care plan meeting • Have a training to introduce CNAs to meeting format • Let CNAs know what to share – ADLs, meals, mood, activities, share with families what residents’ need B&F Consulting 2017 www. bandfconsultinginc. com

How to Involve CNAs in Care Planning Plan for their participation: • In huddle let CNA's know which residents are in ARD window and which are scheduled that day for care plan meeting B&F Consulting 2017 www. bandfconsultinginc. com

Video: Involving CNAs in the care plan meeting ©B&F Consulting 2017 www. bandfconsultinginc. com 102

Table Discussion: If you’re already involving CNAs in your care planning process, share with your tablemates. If this is on your to-do list, share your thinking. ©B&F Consulting 2017 www. bandfconsultinginc. com 103

FREE TOOLKIT: Shift Huddle and QI Huddle tipsheets, video clips and starter exercises at www. pioneernetwork. net Look under Provider resources at Engaging Staff in Individualizing Care

At www. pioneernetwork. net A N INFRASTRUCTURE FOR QUALITY Pioneer Network is pleased to announce that the Implementation Handbook for Engaging Staff in Individualizing Care, developed by B&F Consulting through our National Learning Collaborative funded by The Retirement Research Foundation will be available soon at pioneernetwork. net. This Handbook will support implementation of a communication infrastructure essential for effective care delivery to ensure positive resident and staff experiences, and good organizational performance. Forty-nine nursing homes, five state culture change coalitions and four corporations worked together with the Pioneer Network and B&F Consulting to share how-to’s from their successful pilot of these foundational organizational practices.

Making Decisions ©B&F Consulting 2017 www. bandfconsultinginc. com

Vicious Cycle –Compounding Errors Mentally Checks Out Increased Supervision, more forms, more audits Something went wrong Counseled and corrected instead of asking what happened ©B&F Consulting 2017 www. bandfconsultinginc. com 107

JUST CULTURE The single greatest impediment to error prevention in the medical industry is “that we punish people for making mistakes. ” Dr. Lucian Leape Professor, Harvard School of Public Health Testimony before Congress on Health Care Quality Improvement 108 ©B&F Consulting and David Farrell 2017 www. bandfconsultinginc. com and djfarrell 1963@yahoo. com 108

Factors that contribute to errors • • • Workload, fatigue Ineffective systems Environmental factors - Lighting, noise, distractions Broken or not enough equipment and supplies Ineffective or out of touch leadership Have systems to learn about these issues 109 right away and mitigate them ©B&F Consulting 2017 www. bandfconsultinginc. com

Multiple Choice A CNA assisted a resident by herself even though she was care planned as a “two person assist. ” The resident fell and broke her hip. What do you do (choose as many as apply): • if it’s a first offense, warn the CNA with a note in the record • in-service the staff on the lift policy • Fire her • Do a QI exercise with the staff to identify the systemic issues that contributed to the CNA's decision to go 110 forward alone. ©B&F Consulting 2017 www. bandfconsultinginc. com 110

Multiple Choice A CNA told a resident to urinate in her bed because she couldn’t help her to the bathroom. What do you do (choose as many as apply): • if it’s a first offense, warn the CNA with a note in the record • in-service the staff on care policies • Fire her • Do a QI exercise with the staff to identify the systemic issues that contributed to the CNA's decision to go forward alone. 111 ©B&F Consulting 2017 www. bandfconsultinginc. com 111

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Reflection: How did I react last time I faced an employee error? If another staff person faces the same situation, will she be able to do anything different because of my actions? Action: How can I react in a way that allows us to prevent it from recurring by getting to the root cause so we get a real fix? © David Farrell and B&F Consulting 2017 dfarrell@ncbcapitalimpact. org & www. Band. FConsulting. Inc. com

Make it easy to do the right thing: • Standardize (e. g. checklists) • Frequent integrated huddles and white boards for consistent communication • Keep it simple –avoid cascading effects – stop creating stress • Alarms - Stop putting in interventions that create more problems • Bottleneck because breakfast is only served at limited times ©B&F Consulting 2017 www. bandfconsultinginc. com

Questions to Consider: • What do your staff know, about conditions on the floor, that you don’t? How can you find out? • What practices do you know happen every day – day or night, weekday or weekend, etc? • What are you doing to be grounded in the reality of your staff’s working circumstances? • How safe does your culture make it to talk about near misses, challenges and concerns? • Do you problem-solve as a team? ©B&F Consulting 2017 www. bandfconsultinginc. com

Stop Doing List • Don’t Use “In-service” as THE go-to strategy. It’s insulting. – Usually staff know what to do. Find out what’s in the way. • Don’t create a new form or a new procedure. It creates more work and makes you more vulnerable to noncompliance with your own form. - Find out what’s in the way of your current processes. ©B&F Consulting 2017 www. bandfconsultinginc. com

Psychological Safety ©B&F Consulting and David Farrell 2017 www. bandfconsultinginc. com and djfarrell 1963@yahoo. com

Huddle Scenario A CNA assisted a resident by herself even though she was care planned as a “two person assist. ” The resident fell and broke her hip. You’ve learned that she isn’t the only one who has helped someone by herself. It’s a systemic issue. You, as huddle facilitator, call the staff on the unit together in a huddle because you want to understand what happened so that you can fix the systemic issues 118 that contributed to it happening. ©B&F Consulting 2017 www. bandfconsultinginc. com 118

Huddle Instructions Groups of 5 Role 1 – Facilitator Roles 2 -5 staff on the floor with varying perspectives Facilitator, your goal is to engage the staff in identifying and fixing systemic issues that contributed to the problem. Take a slip of paper out of the envelope and read it. This is a 10 minute stand-up. ©B&F Consulting 2017 www. bandfconsultinginc. com 119

What did the facilitator do well? Share facilitation tips ©B&F Consulting 2017 www. bandfconsultinginc. com

©B&F Consulting 2017 www. bandfconsultinginc. com

Staff Meeting and In-service • Call Lights: We have recently had several complaints of call lights going off for long periods of time, some state as long as 1½ hours before their needs were met. This is totally unacceptable. The Federal Government gives you a MAXIMUM of 3 minutes to respond to a call light. All staff members can answer call lights and will be expected to. This will be monitored closely. ©B&F Consulting 2017 www. bandfconsultinginc. com

Staff Meeting and In-service • Ancillary Stickers: Ancillary stickers are being found EVERYWHERE. Ancillary charges are a large revenue for this facility. Would you leave your own money lying around on the nurses’ station, the floor, in the parking lot on the ground or even in the trash? Those stickers influence your pay rates, raises, benefits, employee activities, etc. So in a matter of speaking you are leaving your own money lying around all over the place and it is going to waste. Please initial your stickers as you place them in the charge book. ©B&F Consulting 2017 www. bandfconsultinginc. com

Staff Meeting and In-service • Inappropriate discussions with residents: We have received reports from alert and continent residents that 11 to 7 staff are telling them to urinate in their attends. This needs to stop immediately. If a resident competent enough to tell you he/she needs to go to the restroom, then they need to be gotten up and taken. Our job is to MAINTAIN or IMPROVE our residents’ level of function. Not to encourage them to be more and more dependent on us. Also complaints of personal discussions amongst staff while providing care. ©B&F Consulting 2017 www. bandfconsultinginc. com

Staff Meeting and In-service • Care issues: Trays have been observed to be left for several minutes before being passed while staff are noted to be standing around gossiping with each other. Scheduled showers are not being done consistently. ©B&F Consulting 2017 www. bandfconsultinginc. com

Staff Meeting and In-service • Assignments: All employees are hired and expected to work. Regardless of the unit or assignment that you are given, you are expected to be on time, take your breaks when you are supposed to, complete your assignment and do it without complaining for 45 minutes or in some cases, all day. ©B&F Consulting 2017 www. bandfconsultinginc. com

Staff Meeting and In-service • Accountability: As nursing assistants you will be expected to arrive to work on time, take the assignment that you are given and promptly begin your work. You will be held accountable for all tasks on your assignments, shaves, showers, personal care etc. There has been too much idle time observed and not enough patient care being done. ©B&F Consulting 2017 www. bandfconsultinginc. com

Staff Meeting and In-service • Hoyer Lifts: Any resident who is care planned as a 2 person transfer on their (pink) care plan is required to have the hoyer lift used on them for ALL transfers. This is company policy and has to be incorporated into your daily routine. If you attempt to transfer someone without the hoyer or by yourself and injure them, that is considered abuse. ©B&F Consulting 2017 www. bandfconsultinginc. com

Staff Meeting and In-service • Trash and Linen Carts: Dirty trash/linen carts must be at least 6 feet away from clean linen carts at all times, this is an infection control issue. Also, all dirty trash and linen carts need to be put in the shower rooms whenever meal trays are out on the floor. When out on the floor, all carts and equipment must be kept on one side of the hallway. AND each shift needs to empty their own carts BEFORE they leave. This has been a daily complaint from your coworkers so please address it. ©B&F Consulting 2017 www. bandfconsultinginc. com

Staff Memo: Discuss • What do you think is going on for the person who wrote this? • How would you react if you were employed by this facility and you read these minutes? • Is this memo likely to solve the issues being addressed? • Have they ever been on the receiving end of something of this sort, either verbal or written? What impact did it have? ©B&F Consulting 2017 www. bandfconsultinginc. com

At Your Table Act as the management team How would you address these concerns in a better way? ©B&F Consulting 2017 www. bandfconsultinginc. com

Building Trust • Positive Presence • Listening - Asking and delivering – Let your staff know what you’ve done • Consistency • Being Transparent ©B&F Consulting and David Farrell 2017 www. bandfconsultinginc. com and djfarrell 1963@yahoo. com

Leadership Systems for Consistent Presence: • Rounds – to check in on people, not to check up on people • Shift Huddles, QI huddles, just-in-time teaching huddles • Regular Meetings with all staff • Everyone Stands Up Together ©B&F Consulting and David Farrell 2017 www. bandfconsultinginc. com and djfarrell 1963@yahoo. com

VIDEO A Leadership Presence Staff Can Depend On Meeting With Staff Closest to the Residents ©B&F Consulting 2017 www. bandfconsultinginc. com

My Inner. View Priority Items CNAs NURSES 1 Help with job stress and burnout 2 Management listens 3 Management cares 2 Management cares For staff stability, people need to know you care ©B&F Consulting 2017 www. bandfconsultinginc. com 135

Contact Information: Cathie Brady cbrady 01@snet. net Barbara Frank bfrank 1020@aol. com www. bandfconsultinginc. com