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Leveraging Staff Engagement to Facilitate Organizational Change

June 6, 2019 – Presented by:

Jenna Tarara MSM, RNJennifer Theriault MSN, RN, COS-C Kathy Ruane MS, RN, CPHQ, COS-C

Leveraging Staff Engagement to Facilitate Organizational Change | June 2019

Objectives

● Understand essential components to establish organizational culture and priorities

● Understand how to utilize data to drive organizational change

● Identify methods to incorporate staff in decision making and implementation of processes to drive engagement

2Lahey Health at Home

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What has Home Care been up against?

In the last 10 years...

● Initiation of the Accountable Care Act● Creation of Accountable Care Organizations● Shift from fee for service to reimbursement for quality outcomes● Movement towards preventative care1

● Mergers and acquisitions● New F2F regulations (F2F Probe and Educate)● Introduction of Home Health Compare● Introduction of Value Based Purchasing● Introduction of Emergency Preparedness regulations● Significant revision to the CoPs ● OASIS B to OASIS D● Aging population and increase number of patients with chronic

comorbidities1

Lahey Health at Home

1https://www.bls.gov/ooh/healthcare/registered-nurses.htm


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What has Home Care been up against?

● Median turnover across the homecare industry was 66.7% in 20171

● Estimated increase in job growth for nursing is 15% (438,100) from 2016-20262

● 203,700 new nurses are required annually to cover new job creation and replace retiring nurses until 20262

● Home care workers (PCAs, HHAs, Nursing Assistants) are projected to add more jobs than any other occupation from 2014-20243


1https://homehealthcarenews.com/2018/04/median-home-care-turnover-hit-66-7-in-20172https://www.aacnnursing.org/News-Information/Fact-Sheets/Nursing-Shortage/

3https://phinational.org/wp-content/uploads/legacy/phi-home-care-workers-key-facts.pdf


5Leveraging Staff Engagement to Facilitate Organizational Change | June 2019

Why is Change Hard?

“Change, whether proactively initiated at the point of change or imposed from external sources,

AFFECTS PEOPLE”


Yoder-Wise, 2015, pg 309

6Leveraging Staff Engagement to Facilitate Organizational Change | June 2019

Employee engagement is the emotional commitment the employee has to the organization and its goals1


1https://www.forbes.com/sites/kevinkruse/2012/06/22/employee-engagement-what-and-why/#422b06817f379

Why is Change Hard?

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Organizational Culture

● Reflection of the norms or traditions of the organization and is exemplified by behaviors that illustrate values and beliefs

○ Examples:■ Behaviors that are accepted/tolerated ■ Customary forms of practice (celebrations of promotions,

professional performance, retirements, etc)

● Formal vs. day to day experiences can reinforce organizational culture or cause conflict


Yoder-Wise, 2015


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Organizational Culture

● Formal○ Written mission○ Vision○ Philosophy Statements○ Job Descriptions○ Policies and Procedures

● Day to Day (Agency Norms)○ Lived experience of staff and patients

Confusion, frustration and poor morale results when the formal and experienced organizational culture are incongruent


Yoder-Wise, 2015


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Organizational Assessment

● Evaluate staff perceived culture vs. formal culture

● Evaluate staff engagement○ Motivation○ Dedication○ Beliefs ○ Willingness to change○ Readiness to change

Lahey Health at HomeLeveraging Staff Engagement to Facilitate Organizational Change | June 2019

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Innovative Decision Process


Behavioral Response Characteristics

Innovators Thrive on ChangeDisrupt Stability

Early Adopters Respected by PeersStaff go to for advice and information on change

Early Majority Prefer to keep things the sameWill eventually accept the change

Late Majority Openly negativeAgree to the change only after most of everyone else has accepted the change

Laggards Prefer doing what has been done in the pastOpenly express their resistance to new ideas

Rejectors Oppose change activelyMay sabotage change efforts

Yoder-Wise, 2015

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Innovative Decision Process


http://sphweb.bumc.bu.edu/otlt/MPH-Modules/SB/BehavioralChangeTheories/BehavioralChangeTheories4.html


Establishing Organizational Culture


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Leadership

● Leadership buy-in is essential● Align the leadership team

○ Vision and Mission○ Agency goals

● Initial training and ongoing education● Standardized approach to:

○ Reporting○ Education○ Accountability○ Documentation

● Impact of informal leaders


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Just Culture

Foundation of a Just Culture :

● Provide structures for reporting● Understanding that system failures are the root cause of most errors● Constructive feedback

○ Collaborate with staff involved using the 5 Whys● Evidence-based practice● Fair and equal treatment● Always looking for way to improve


1

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3776518/http://www.ihi.org/resources/Pages/Changes/DevelopaCultureofSafety.aspx

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Quality Assurance Performance Improvement(QAPI)

● Systematic, comprehensive, and data-driven approach to maintaining and improving safety and quality

● Quality Assurance○ Standards for quality of service and outcomes○ Process for assuring care is maintained at acceptable levels

● Performance Improvement○ Continuous study and improvement of process○ Intent to provide better services and outcomes○ Prevent or decrease the likelihood of problems○ Testing new approaches to fix underlying causes of problems or

barriers


https://www.cms.gov/medicare/provider-enrollment-and-certification/qapi/qapidefinition.html

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QAPI

Use framework for all quality improvement initiatives for uniformity:

○ Internal agency processes ■ Intake■ Scheduling■ Equipment/Supplies

○ External processes■ Evidenced based practices■ Patient Satisfaction■ Patient/Agency Outcomes


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Plan Do Study Act (PDSA)


http://www.tribaleval.org/cqi/plan-do-study-act-pdsa/

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Driving Data

● Data sources○ OASIS○ HHCAHPS○ EMR Software○ Surveys

● Relevance of data○ Is the data recent?○ Does the data accurately capture intent of use?○ Is the data specific enough?○ Is the sample size large enough?○ Can you reproduce the data or can you use the same tool in the

future?


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Clinician Involvement with Data

How is data communicated?○ Town Hall meetings

○ Team Meetings■ Practice Committees

○ Individual performance reports■ Teams Monthly, Staff Quarterly

○ Quality Improvement meetings■ Hospice and home care representatives

○ Quarterly Performance Improvement meetings■ All quality, education and management present


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Sample QAPI Project

● Scheduling○ Problem: Inconsistent scheduling processes across branches and

team. Missed visits, delayed SOCs, incident reports○ Plan

■ Investigate current process for scheduling between the two branches

■ Created workgroup● Directors, managers, schedulers and staff from each

branch● Reviewed current processes and recommendations● Developed single process for both branches to follow

○ Do■ Education to schedulers, managers and field staff on new

scheduling process■ Set a definitive “Go-Live” date for new process


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Sample QAPI Project

○ Study■ Evaluate waitlists■ Monitor incident reports■ Monitor timely initiation of care

○ Act■ Scheduling successful for both branches


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Sample QAPI Project

● Medication Management○ Problem: HHCAHPS - seeing pill bottles was one of the lowest

responses○ Plan

■ Established goal rate■ Collecting data

● Interviewed field clinicians● Sent staff survey

■ Edited supervisory visit tool to include data collection point for medication reconciliation

■ Analyzed HHCAHPS responses■ Practice Committee engagement

○ Do■ Provided agency wide education on HHCAHPS results and best

practices for medication reconciliationLahey Health at HomeLeveraging Staff Engagement to Facilitate Organizational Change | June 2019

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Sample QAPI Project

● Medication Management○ Study

■ Analyzing HHCAHPS responses after training■ Evaluating medication reconciliation performance from

Supervisory Visit Tool

○ Act■ Improvement but agency goal not met■ Multiple PDSAs

● Trial patient phone call day Day 2 asking about medication reconciliation

● Software upgrade for medication list - proper utilization for accurate medication lists

● Collecting data from PT SOC med reviews



Resources


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Resources

● Employee Engagement: Who’s Sinking Your Boat○ https://www.youtube.com/watch?v=y4nwoZ02AJM○ 4 minute video illustrating the importance/value of staff engagement

● Home Health QAPI Fact Sheet○ http://www.homehealthquality.org/CMSPages/GetFile.aspx?guid=cce41e41-e796-43d7-bd4e-5d9963b82dc4

● Plan-Do-Study-Act Worksheet (IHI)○ http://www.ihi.org/resources/Pages/Tools/PlanDoStudyActWorksheet.aspx

● The Five Behaviors of a Cohesive Team○ DiSC/Team Building


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Organizational Assessment


References

27Lahey Health at HomeLeveraging Staff Engagement to Facilitate Organizational Change | June 2019

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References

● Baxter, A. (2018). Median Home Care Turnover Hit 66.7% in 2017. Home Care News. Retrieved on May 12, 2019 from https://homehealthcarenews.com/2018/04/median-home-care-turnover-hit-66-7-in-2017/

● Boysen P. G., 2nd (2013). Just culture: a foundation for balanced accountability and patient safety. The Ochsner journal, 13(3), 400–406.

● Institute for Healthcare Improvement. Develop a culture of safety. Retrieved May 15, 2019. http://www.ihi.org/resources/Pages/Changes/DevelopaCultureofSafety.aspx

● Kruse, K. (n.d.) What is Employee Engagement. Forbes. Retrieved on May 1, 2019 from https://www.forbes.com/sites/kevinkruse/2012/06/22/employee-engagement-what-and-why/#422b06817f37

● LaMorte W. (2018) Diffusion of Innovation Theory. Retrieved on May 12, 2019 from http://sphweb.bumc.bu.edu/otlt/MPH-Modules/SB/BehavioralChangeTheories/BehavioralChangeTheories4.html

● Nursing Shortage (n.d.) Retrieved on May 12, 2019 from https://www.aacnnursing.org/News-Information/Fact-Sheets/Nursing-Shortage

● PHI. US Home Care Workers: Key Facts. Retrieved on May 12, 2019 from https://phinational.org/wp-content/uploads/legacy/phi-home-care-workers-key-facts.pdf

● Plan-Do-Study-Act (2016). Retrieved on May 15, 2019 from http://www.tribaleval.org/cqi/plan-do-study-act-pdsa/

● QAPI Description and Design (2016). Retrieved on May 12, 2019 from https://www.cms.gov/medicare/provider-enrollment-and-certification/qapi/qapidefinition.html


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