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.