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: http://www.tennessean.com/apps/pbcs.dll/article?AID=/20071123/NEWS07/711230457/-1/ARCHIVES

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.