Friday, December 21, 2007

Matthew, Mark, Luke, and Waugh -- bless the bed that I fall on

I've finally finished listening to all 6 hours (actually 5 and a half hours) of Diane Waugh's most excellent series. I can sum her teachings up into 3 points:
(1) You've got to know each resident's life story well, and spoon feed back their long term memories to them.
(2) Empower CNAs -- treat them as equals on the care team, get rid of meaningless tasks for them to do, teach them how to properly interact with people (perhaps via scripts).
(3) 80% of falls are due to social causes, like triping on loose carpet or their shoelaces, or trying to get to the bathroom or bed, etc., and only 20% of falls are due to medical issues.
Take these three pearls and treasure them; use them every day. Listen to the mp3s (remember -- they're free) and apply them.

Wednesday, December 19, 2007

Waughing the Dog

Horribly cheesy title, I know. Here are some more pearls gleaned from the 3rd and 4th hours of Ms. Waugh's most excellent discussion:
1. The rationale for using restraints is: They keep 'em SAFE, keep us from getting SUED, and we don't have enough STAFF. This rationale is a bunch of horse baloney because it's all lies.
2. There are two kinds of residents who fall from the bed: Getter uppers and roller outers.
3. Roller outers are rare; best interventions are low bed and/or a bigger bed (Queen size bed is smaller than regular bed + mat). Mats are bad -- don't use them.
4. For getter uppers, teach them how to get off the floor. Identify why they might be getting up (toilet, hungry, they heard a noise, they are finished sleeping). Make sure residents know the call system is working.
5. Notice I said call system and not call light; CMS allows any system to be used as long as it enables the resident to summon for help. Technically, residents could be taught to "holler real loud" and it would be legal. The 3rd hour describes techniques for getting residents to use bells ONLY when they're needed. People often use the call system because they're lonely.
**6. If someone is getting up and is going to fall, DON'T YELL. Call them by name in a normal tone without excitement, say "Before you go, do you have time to share with me...", and insert something they can share from their short term memory. This is the absolute best intervention and it takes advantage of the resident's very short attention span.
7. Before someone moves in to the facility, go to their home for about an hour for a preadmission evaluation. Find out 7 things: What do they like to hear, taste, smell, touch, and see? What do they like to sit in? (The most worn out chair -- have it sent to facility) Where do they sleep? (Sometimes the chair or the couch due to CHF/COPD/etc. -- that's okay and it isn't neglect on their kids part). This is where you find your falls interventions.
8. Care plan meetings should be 20/80 medical vs. social information about the resident.

Tuesday, December 18, 2007

Tidbits on Falls aka Blog about Waugh

I have just finished listening to the first two hours of the falls program I found yesterday. Here are some take home points:
1. Wheelchairs are bad. They should be used ONLY for transport. Residents should be assisted to sit in real chairs and couches. These transfers can be used part of a restorative nursing program.
2. In dining rooms, the centerpieces on the table should be potted herbs.
3. Get rid of alarms NOW as they do absolutely nothing but irritate residents and staff via noise.
4. CNAs should have scripts for interacting with strangers in the facility so they don't say anything you don't want them to.
5. The definition of a restraint depends on the resident's point of view; if it enables a resident in some way, it isn't. If it limits a resident, it is. Merriwalkers may or may not be a restraint.
6. Whoever responded first to a fall should be the one to call the family and explain what happened and that someone was there when it happened. They should then let the charge nurse explain all the "medical" details.
7. Bedside water pitchers are NOT required unless the resident requests one. Have a hydration cart where the residents are actually at and offer them drinks from a 4 ounce cup instead.
8. There is nothing in the State Operations Manual (the federal rules) that prohibit restraints as long as there is an order. They are bad, however, because they kill.

Monday, December 17, 2007

Painless culture change resources

I just found a set of mp3s from a Diana Waugh conference on restraint reduction. Her method seems to lead to culture change, but in a painless sort of way. I was very much impressed, and of course they're free. The conference title was "Managing Falls and Behaviors in LTC without the use of restraints". Much kudos to Ms. Waugh and the folks at IPro. UPDATE: The link will be on your left under "Falls Audio"; I couldn't get the link to come out right in this post.

Sunday, December 9, 2007

Support Services Evaluation

To quote Quint Studer from page 201 of Hardwiring Excellence, "To reach the 99th percentile in patient satisfaction...every employee must own service, not just those with direct patient contact." Here is his method for ensuring the quality of departments that don't necessarily have direct patient contact: Have the nurses to evaluate them. Nurses are the frontline providers of care, and they rely on all these other departments, laundry, dietary, maintenance, housekeeping, and such, in order to do their jobs. Nurses are also customers of the ancillary staff for this reason. For the support services evaluation, use a grid that matches each department with a variable you want to measure. Variables might include phone etiquette, accuracy, timeliness, and so forth. Also have some performance standards available so that the nurses know what expectations that these departments should be living up to. Have the nurses to rate the departments on a numerical scale. Then provide timely feedback to the appropriate department heads. These leaders need to be held accountable for their department's improvement, otherwise things will never improve. And that kinda defeats the entire purpose of quality improvement.

Thursday, December 6, 2007

QIO's 9th Scope of Work

Earlier today I received a set of powerpoint slides from a conference CMS had late last month regarding the 9th scope of work contract for the state quality improvement organizations. The QIO contracts aren't up for renewal until sometime in the summer of 2008, July I think, but it wouldn't hurt to start getting in the mindset a little bit early. The two primary focuses are going to be on continuity of care and resolving health disparities (apparently they weren't resolved in the 8th scope of work). Some of the QI focus areas are pressure sores (both nursing home aquired in high risk residents AND hospital aquired), medication safety (don't know yet what setting this will be for -- definitely hospital, maybe others), physical restraints, and MRSA (big suprise there). If you want a copy of the slides, go to and click on "Presentations" under 2007 QualityNet conference.

Saturday, December 1, 2007

...and McKendree makes 21

CMS has revoked their provider agreement with McKendree Village, a very large SNF/ICF/ALF in Hermitage. It is the 21st nursing home in Tennessee this year to endure such a fate. I'd like to get a copy of the statement of deficiencies on Monday if I have time. I'd also like to find out what kind of quality improvement program they had (or didn't) in place.

Tuesday, November 27, 2007

The Five Organizational Pillars

Studer thinks that outcomes should be based upon 5 key pillars: Service, Quality, People, Finance, and Growth. Service includes things like patient satisfaction and decreased numbers of lawsuits. Quality focuses on clinical outcomes. People is the HR stuff, like decreased turnover and increased morale. Finance is similarly self-explanatory. Growth focuses on things like more admissions and faster throughput (an example being patients in the ER getting out quicker). Studer recommends that meeting agendas be grouped by these 5 pillars. This is a great paradigm to use for the daily standup department head meetings. He also suggests that a bulletin board be on each unit that shows staff the measurable progress that is made under each pillar. It's a wonderful tool to use.

Monday, November 26, 2007

Rounding for Outcomes

It is a well known fact that the overwhelming majority of employees don't quit their job, they quit their bosses instead. Outcome-based rounding builds positive relationships with employees, and is thus destined to reduce turnover while improving quality. You've got to start off by building personal relationships with staff. When you see them, you know they've got a daughter who's about to start school, so you ask how the first day of kindergarten went. You know his father died, so you ask how he's doing. You get the picture. After you've talked to employees about life outside of work, say: "Tell me what's working well today". Don't focus on what's broken, but what isn't. If the nurse mentions how good the food is, go tell the kitchen and let them know. GOSSIP THE GOOD. The next question to ask is who should I (the NHA/DON) be recognizing. When you find out, tell them. GOSSIP THE GOOD. Then ask what can do better. This is what quality improvement is. The final question is, "Do you have everything you need to do your job?" I once worked for a facility where this was never asked, but the administrator would always get up at staff meetings and tell us we had everything we needed. Of course we didn't, and her comments lowered her staff's perceptions of her abilities as a leader. Don't tell, but ask. Outcome based rounding can also be used with residents. In Tennessee, the Standards for Nursing Homes require that the DON visit every resident, every day. Before rounding on patients, tell the staff and ask if there is anything you should know beforehand. After introducing yourself to each resident, tell them you want them to be satisfied with their care. Ask if they are satisfied and find out why or why not. Then ask which employees need to be recognized. GOSSIP THE GOOD. Finish off by asking if there is anything else you can do for the resident while you're there. Don't forget to mention that you have the time. Of course, this is only the brief version of the technique. You have to read the book (Hardwiring Excellence, by Quint Studer) to find out the details. And one last suggestion: schedule all meetings after 10 in the morning and do all of your rounding before that time.

Post-discharge phone calls

Another technique available to you is 80post-discharge phone calls, that is, calling the resident two or three days after they're discharged. Obviously this is something best suited for short-term skilled patients. I could also see, however, calling the families of deceased residents about a week or so after they passed away and asking how they are and if you can do anything for them. But back to the post-skilled calls. After calling the person, you want to start up by showing empathy - "Mr. X? This is so-and-so from Generic Nursing Home and you were discharged from my unit the day before yesterday. I just wanted to call you and see how you're doing." Then ask about discharge orders or any kind of physician follow-up. Make sure they understand the orders. The next thing to do is to tell the person that you like to recognize your employees and ask who did and excellent job while they were there. Try to get specific details on what makes any employees they mention good, and then mention this to the employee. Finally ask the person if they were satisfied with their care and solicit suggestions on how the facility can improve. During these calls, make sure to spend 20% of the time asking questions and 80-90% of the time shutting up and listening. And don't make these calls before you round for outcomes, which will be what the next post is all about.

Saturday, November 24, 2007

AIDET: The 5 Fundamentals of Service

Page 94 of "Hardwiring Excellence" has Studer's wisdom on what is known as "key words at key times". The purpose is to let your patient (or resident, as the case may be) what is going on. I have often heard that the #1 cause of physician and hospital malpractice lawsuits is lack of communication. Key words are summed up as AIDET. First off, acknowledge the resident, preferably by last name. Next, introduce yourself with name, training, and experience. The D is for duration - how long the procedure or whatever it is is going to take. Then explain what is going to happen. Finish off by thanking the person. This is a good time to say "thank you for choosing [our facility]". So acknowledge, introduce, describe the duration, explain, and thank. Simple. It could be used by a RN before a complex wound care procedure on your new subacute patient, or the neophyte CNA could use it before giving a resident a shower. AIDET is one of those things that might need to be on the back of badges, like RACE. Especially if you want to create a resident centered culture.

Yet Another Rant

I've got to rant again. Sometimes I'm afraid I'll never get back to "Hardwiring Excellence" because so many others thing are pissing me off. Anywho, I was in Nashville yesterday and about 3 in the afternoon, I finally had a chance to read the daily paper, the Tennesseean. The front page story was on nursing homes; specifically how 20 nursing homes in the state have been ordered by survey agencies to halt admissions. You can read the article here:

What really pisses me off is this quote from Ron Taylor: "We think they [CMS] are looking at violations more harshly". No shit, Ron. I simply can't join THCA's agenda to deregulate long term care. JACHO did wonders for improving the quality of care in hospitals, because they don't have minimum standards, they have optimally achievable outcomes. Why can't something like that happen to SNFs? Nursing homes have no quality. But why should they? There is absolutely no motivation. All CMS requires is a quarterly QA meeting. For the record, let me state that quality assurance is retrospective, while quality improvement is prospective. What good is a quality program if it can't keep problems from happening? Why aren't facilities using the resources the state QIOs have developed? Why aren't NHAs held accountable for their facility? (But they are, you say. Bullhockey!!! When DOJ shut down Life Care Center of Lawerenceville, Georgia they were no able to go after the administrator's license). The lack of quality in nursing homes really bothers me, and sometimes keeps me from sleeping. I just really had to get this off my chest.

Wednesday, November 14, 2007

Rants about CNAs

I need to take a second and rant. I was recently told by a client facility that they couldn't understand what was up with the CNA turnover -- they established a CNA council and it didn't do squat to keep people from quitting. I firmly believe that the reason most nursing homes can't keep CNAs is because there is a tremendous cultural barrier. And that cultural barrier is related entirely to the gap between the socioeconomic classes of direct care staff versus everybody else above them in the organizational chart. The average CNA is a poor single mother roughly between the ages of 25 to 50. "We can get them to stay by offering just a little bit more money," I've heard. Not true. People want more from a job than just money. Social relationships, for one (just look at the turnover in facilities where folks aren't allowed to work together). Feeling like part of a team is another. Having a CNA council defeats that purpose because you are in essence telling these folks they aren't part of the team, even though they typically make up at least 60% of your workforce. And the arbitrary rule about no CNAs behind the nurses desk. "But Matt," you say, "They have no business being behind there. All they'll do is just waste time reading a newspaper." How many times have you seen a LPN doing that? Your CNAs are already isolated by their poverty; isolate them at work and you've just lost another one or three.

Thursday, November 8, 2007

Hourly rounding

One of the specific tools that Studer describes is HOURLY ROUNDING. In the hospital setting, this means that every hour the nurse makes a quick visit to each of his/her patients, and runs through some variation of this script: (1) How are you feeling? Are you in pain? (2) Let's change your position. (3) Do you need to use the restroom? (4) Is there anything else you need? I HAVE THE TIME!?! (That last bit was tacked on because patients are usually reluctant to ask a nurse to do something for them if they perceive the nurses as being rushed). So pain, position, and potty are what you're addressing in these hourly rounds. You're also making sure that nobody's fallen (On a side note, it's becoming pretty well recognized that no matter what or how much you do, you really can't prevent falls. All you can do is screen for risk and reduce hazards as much as possible. But more on that later). So what's keeping your facility's CNAs from doing hourly rounding? Rounds q2h are already the norm (and in Tennessee, the law). Can you find some way to reorganize the status quo so that patients are being looked in on more frequently? If the status quo isn't all about the patient, then the status quo must go. If this sounds like something you want to adapt, I would recommend starting on your skilled units first and then crossing over to the intermediate care units as well. And it's not necessary to do rounds hourly from 10P to 6A; every 2 hours or so have been found to be just as effective.

Monday, November 5, 2007

Why would I want to burn a nursing home down?

Yesterday morning I finished reading a most excellent book by Quint Studer called Hardwiring Excellence. The book describes a paradigm of techniques that hospitals can utilize to improve patient satisfaction, reduce employee turnover, and enlarge the size of the bottom line. So my response to this book is, why can't we adapt these techniques for use in nursing homes? Over the next, well, however long it takes, I'm going to be presenting my little bastardized version of Studer's ideas here. Except that they'll be geared for long term care. Oh, and about the bit about setting fires -- even though Studer is a consultant, he prefers to be called a fire starter because that's a more accurate description of what he does.