www.thegreenhouseproject.org

Creating a Patient Safety Chain

David Farrell, MSW, LNHADirector

High Performing Organizations

Three Common Elements -• Culture – person-centered care• Workforce commitment• Leadership practices

All three are interdependent

Grant, L. 2008

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

Low Performing Organizations

Three Common Elements -• Culture – task-centered care• Unstable workforce• Leadership practices

All three are interdependent

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

Vicious Cycle of Low Performer

Limited Resource

s

Staff Instability

Poor Outcomes

• Leadership turnover

• Correcting and in-servicing

• Low morale

• Poor attendance• Cut costs

• Crises

• Trim staffing

• Fewer higher paying patients

• Fewer physicians willing to recommend

• Clinical, Survey, HR, Q of Life

All Nursing Homes Have Tipping Points

Assume decline happens steadily…

but…itcan happen all

at once.

The Tipping Point -How Little Things Can Make a Big Difference

By Malcom Gladwell

Organizational Change and EpidemicsCharacteristics of Epidemics• Contagiousness• Little changes have a big impact• Tipping point

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

Three Agents of Change in Social Epidemics

1.) The Law of the FewLeaders that infect people

2.) The Power of ContextEnvironment

3.) The Stickiness FactorMessages that trigger action

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

“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

New York City Early 1990’s

• Murders dropped to 667• Felonies plunged to 3,000• Not a gradual decline• Crime plummeted – it TIPPED!

Gladwell, M., 2000

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

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

“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

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

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

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

The Impact of Leaders

Healthcare organizations• Leader’s actions influence:

– CultureRelationships

– Staff engagement– Clinical outcomes – Quality of life

CompassionPerformance

Person-Centered Care Leadership

“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

A Vicious Cycle

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 outcomes

• Financial burden

• Fractured relationships

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

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

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, 2001National Clearinghouse on the Direct care Workforce, 2006

BLS 2006, FHCEF 2010

Instability = Poor OutcomesEffects communication and

continuity:• Incontinence• Facility acquired pressures sores• Urinary tract infections• Falls and fractures

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

AbsenteeismComplex organizational problem -• Morale• Quality• Service• Safety• Relationships• Communication• Labor costs• Re-hospitalization rates

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.”

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

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.”

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

Environment

People

Equipment/Supplies

High absenteeism

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

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

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)

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

CompassionPerformance

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.”

To Be Expected

“Thanks for being here today. I’ll see you tomorrow?”

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

www.thegreenhouseproject.org

Nurse Ratchet

A Root-Cause of Absenteeism on the PM Shift?

Staffing Coordinators

• Complex task• Requires education• Support – meet weekly• Recognition and rewards• Character traits:

– integrity, fairness

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

4 on 2 off scheduleEven # of CNA assignments3 CNAs serve 2 resident assignments

M T W Th F S S M T W Th F S S

Maria1 1 1 1 O O 1 1 1 1 O O 1 1

Jen2 2 O O 2 2 2 2 O O 2 2 2 2

EllieO O 2 2 1 1 O O 2 2 1 1 O O

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

If Working Short Staffed

• Have a plan• All hands on deck• Managers and non-nursing staff assist

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

Staffing ModelsConsistent 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

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

Consistent Assignment:

Top Five Stressors

• Preventing Falls

• Stubborn Residents

• Terminal Residents

• Depressed Residents

• Death as Emotional Stress

Rotating Assignment:

Top Five Stressors

• Low Wage

• Abusive Residents

• Heavy Workload

• Disagreements w/ Coworkers

• Lack of Staff

Gruss, V. et al., 2004

Same SNF – Different Units

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

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

Relational Coordination in Healthcare• Task interdependence• Uncertainty• Time constraints

Gittell

Food Service

Physicians

NursesCNAs

Therapists

Healthcare Organizations

Nurses

CNAs

Therapists

Food service Physicians

Within functions Across functions

Gittell

Trigger Relational CoordinationLeadership actions -• Increase Communication

– Frequent, timely– Accurate– Model problem solving

• Enhance Staff Relationships– Shared goals– Enhance knowledge– Model mutual respect

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

Red Auerbach

Relational Coordination Tipping Points• Ample higher quality supplies • Resident transfer equipment • Staff composition • Consistent assignment• Systems of regular communication

– Report between shifts– Safety huddles

Systems of CommunicationKey changes –Change of shift huddlesStart of shift huddlesMid-shift safety huddles

Standing root-cause analysisEnd of shift check in and follow up

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

Infectious Agent - The Stickiness Factor• The message has to “stick”

– Trigger people to change• Increase volume • Consistent and optimistic

Effective Rounds

• Mood, posture and paradigm• Content – what you say and do• Timing• Following up

Mood / Posture / Paradigm

• Flip the switch• You are in the spotlight• Make eye contact• Praise, build self-esteem• Smile• Linger

Content – What You Say and DoTrigger 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…

Invisibility

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

Quint Studer

Timing of Rounds

Priority is Visibility• Before morning stand-up meeting• Lunch• Shift change• Last rounds• Weekends• Nights

Following Up

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

Drivers of Staff Engagement

• Management cares • Management listens • Help with job stress

MyInnerView, Inc. 2011

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

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

Notes to Staff – Make the Message stickMonday 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

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

PUSH tool adopted

New mattressesin place

All staff in-service

Root-causeAnalysis done

New admissions Plan implemented

Transparency

People Energized

Steps forward

Visible results

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?

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.”

What Matters the Most?

• Systems

• Environment

• People

Drivers of Consumer Satisfaction• Caring staff• Competent staff• Choices and preferences• Nursing care• Responsive management• Respectfulness of staff

MyInnerView, Inc. 2011

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

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

Wally Pipp

Lou Gehrig

Exercise

Who are your triple crown winners?

Who are your lowest performers?

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

First Who…Then What

Three simple truths -• Key to adapting to change• Motivation and management• Wrong people

Collins, 2001

Careful SelectionAsk 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

Environment Impacts PeopleSignals disorder: Not one living indoor plant Neglected courtyards Dead space Broken furniture Mismatched chairs

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

Care, Listen, Prevent Stress

Oakland - 70 Changes

• Some were small and simple• Some were big and complex

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%

Transparency

People Energized

Steps forward

Visible results

Paint the Graffiti Everyday

Contact Information

David J. Farrell, MSW, LNHA

DirectorThe Green House Project

(510) 725-7409