Setting the Nursing Home on Fire

Policy Guidelines Online

2009-03-22T17:32:00.000-07:00

These two websites have policy and procedure manuals that you may find useful for developing your own.

http://nursing.uchc.edu/unit_manuals/

http://www.gplan.com.au/index.php?action=view&view=14273&pid=13761
(Scroll down to the RACF Clinical Resource Manual)

Inservice materials: Enteral nutrition care

2009-03-22T15:30:00.000-07:00

Rather than develop a slideshow, here are links to sites that will help you create your own staff development session for licensed nurses on enteral nutrition care.

http://www.grs.scot.nhs.uk/instantKB13/FileRedirect.aspx?FileID=1405

http://www.free-ed.net/sweethaven/MedTech/NurseCare/GastroNurse01.asp?iNum=42

http://allnurses.com/general-nursing-discussion/peg-tube-residual-356852.html

http://www.dbh.nhs.uk/Library/Patient_Policies/PAT%20T%2016%20v.2%20-%20Management%20of%20Patients%20following%20PEG.pdf

http://www.gplan.com.au/content/Document/RACF%20Resource%20Manual/Percutaneous%20Endoscopic%20Gastrostomy%20Clinical%20Management%20Flowcharts.pdf

http://www.virginiageriatrics.org/consult/Peg_tube_decisions/index.html

http://www.ambpeds.org/site/sp_int_groups/PHM2005/Troubleshooting1.ppt (for pediatrics but still has some valuable information on the latest research)

http://www.southbirminghampct.nhs.uk/_services/elderly/policies/enteral_feeding_nov07.pdf

http://210.125.93.14/lecture/PDFGuides/HCP24.pdf

QA/QI tools

2009-03-22T15:25:00.000-07:00

The Kansas Foundation for Medicare Quality has redesigned their website and now offer better access to the QA and QI tools they have available at http://www.kfmc.org/providers/nh/tools/index.html. The ADL decline section has some good stuff on restorative nursing, and there is also everything you need to set up a skills fair for staff development.

NAB Practice Exam

2009-02-09T11:06:00.000-08:00

The NAB practice exam I wrote is available at:
www.scribd.com/doc/8570144/Nab-Review

Finally back

2009-02-09T11:02:00.000-08:00

It's been about three months since I've blogged. I've been extremely overworked and also questioning if I want to stay in this insanity known as long term care. Fortunately, I've received a number of very supportive emails from some previously unknown followers of this blog and have decided to get to back to blogspot. Nursing homes are still very far from ideal, much less perfect, and I want to help change that.

Everytime a CNA becomes a NHA, an angel gets its wings

2008-11-13T09:40:00.000-08:00

I very rarely talk about myself, but I am going to make an exception just this once. I got my administrator's license!!! I went through the process in Michigan, because if you are a RN you don't have to meet any other requirements besides passing the state and national licensure examinations. I probably won't be running a facility anytime soon as I got the license primarily for enhancing my ever-growing list of credentials and qualifications.

As far as that something special I promised, I am going to put up a NAB test that I constructed myself when I was studying. I found that I can learn and retain information better if I act as if I'm having to teach it, so a mock exam was in order. I don't recall any of the questions I made actually showing up on boards, but it should serve its purpose well and it will save you however much you might otherwise pay for a practice test (I've seen them go for $15 to $75 apiece). Look for it to come out either tomorrow or saturday.

Once again, slides are late

2008-11-10T08:46:00.001-08:00

MDS inservices for both CNAs and LPNs is available at http://www.parragonhealth.com/slides.htm. They are over a week late, so watch out for the good thing I have promised.

All about IDR

2008-10-26T20:06:00.000-07:00

There are two processes in place for challenging surveyor findings: formal appeals (which is used primarily for getting rid of civil monetary penalties) and informal dispute resolution. Informal dispute resolution is used primarily to get F tags taken off the record when the allegation of deficiencies doesn't actually represent an actual deficiency. It can also be used to challenge the scope and severity of quality of care deficiencies. It cannot used to challenge deficiencies on a follow up survey that have been cited on a previous survey, for scope and severity on F tags that do not fall within the quality of care domain OR represent an immediate jeopardy, to challenge remedies levied by the state or federal government, procedural violations on the part of the surveyors, or alleged inconsistency in the way that two different facilities were surveyed. In order for an IDR to be successful (and they rarely are -- less than 20% of the time), you have to either show that the alleged deficiency is not actually a violation (although the state survey agency may label this as a procedural violation and then disqualify your claim) or that there is documentation to support the facility's position that was not reviewed by the surveyor at the time.

NHA without AIT

2008-10-15T19:18:00.000-07:00

If you want to become licensed as a nursing home administrator, almost all states require that you have a bachelor's degree and complete an administrator in training program, which is a 6 to 12 month preceptorship with an experienced administrator, all before you are allowed to take the state and national boards. There are two states that do not require an AIT for licensure, just a bachelor's degree OR licensure as a RN: Illinois and Michigan. A third state, Missouri, has relatively lax standards for licensure but they reserve the right to require an AIT if they think it is necessary.

Good news and bad news

2008-10-07T20:48:00.000-07:00

Good news: This month's powerpoint slides are up at http://www.parragonhealth.com/slides.htm. The topic this month is skin.
Bad news: Once again, I'm a week late getting them out. I promise to have next month's slides up by November 1, or I'll do something good to make up for it.

Life Safety Resource

2008-09-30T15:26:00.000-07:00

While trolling the web, I came across a very interesting document -- a fire and life safety toolkit. It has everything you might possibly need to prepare for a LSC survey. It's available at:
http://www.kahsa.org/content_new/pdfs/Toolkits/FireSafetyPreventionToolkit.pdf

Another long term care blog! Yay!

2008-09-25T14:13:00.000-07:00

A DON is blogging about her work at http://skillednursingthing.blogspot.com/. I really like her take on things; have a look sometime.

Wound care wisdom, part deux

2008-09-23T20:15:00.000-07:00

Here are some quick tidbits on dressing types.
-Hydrogels are the way to go for wet-to-dry; they work well for most applications
-Hydrocolloids are not appropriate for acute care, but might be okay for nursing homes
-Acrylics only have to be changed every 7 days (can sometimes last even longer)
-Foams are best for shallow wounds on the extremities; don't use on the sacrum
-Aliginates are used for lots of drainage
-Hydrofibers absorb 3x more than aliginates
-Xenaderm is good for progressive stage I/II ulcers
-Betadine keeps necrotic tissue dry and is best for heels and toes

Wound care wisdom, part 1

2008-09-15T14:22:00.001-07:00

-Juven is better than Boost or Ensure for residents with low albumin levels, and can be mixed with near anything, thus increasing compliance.
-Arterial ulcers need to be kept dry, preferably with Betadine.
-Venous incompetence with lymphedema: redness is most often reactive erythema and not infection, so don't give antibiotics.
-Betadine keeps necrotic tissue dry and is best for heels and toes.
-If there is a yellow ulcer, the red spots that are speckled throughout it are hair follicles and this indicates that it is a stage II.
-Heel ulcers are 100% preventable.

New Slides are Here

2008-09-05T14:53:00.001-07:00

The September staff development slides are finally up at http://www.parragonhealth.com/slides.htm. I apologize for taking so long to post them, and also for not writing any blog entries in a while. It's been a crazy month.

Note:
For the bathing slides, you need to also access this page to find out most of the information listed:
http://www.nhcqf.org/QI_Services/NursingHomes/Workshop4/Bathing_Without_a_Battle_Handouts_0506-541.pdf

Book Review: The Principles of Health Care Administration

2008-08-15T10:52:00.000-07:00

I've finally found a book on nursing home administration that I finally like. If you've seen my reviews on amazon.com, you probably know that I absolutely loathe James E Allen's Nursing Home Administration. I was at a used book store in Nashville on monday and I found a copy of Winborn Davis's The Principles of Health Care Administration for only $5, which is great because it sells for $103 new -- I think that's just a bit too much. The book is divided into four chapters, one for each of the four NAB domains. It almost reads like a commentary on the State Operations Manual because most, if not all, of the F tags are discussed at length. The chapter on financial management needs more practical advice on how the business office should be run, but other than that I was thoroughally impressed. I think it would be the perfect AIT text or study guide for the NAB boards. Although it's out of print on amazon, it can still be ordered here for $98.50.

New nursing home blog

2008-08-03T21:32:00.000-07:00

Nursinghomesurveyor.com is a new blog that shows a lot of promise. Check it out!

New Staff Development Slides Availble

2008-08-03T21:30:00.000-07:00

This month's staff development slides are now available at http://www.parragonhealth.com/slides.htm. The topics are "Feeding the Hard to Feed" and "Renal Failure".

F314: Pressure Ulcers

2008-07-24T13:56:00.000-07:00

Requirement:

The facility must prevent pressure ulcers and effectively treat those that are present.

Intent:

Pressure ulcer prevention must be promoted. Existing pressure ulcers must be treated appropriately, and the development of additional pressure ulcers must be prevented as well.

Common Reasons for Citing F314:

The lack of documentation and monitoring is the most common reason this tag is cited. Other causes include the care plan not being individualized for the resident with a pressure ulcer, failure of the communication process between CNA and nurse regarding the development of pressure ulcers, the lack of dietary intervention, failure of the nurse to notify the physician, the lack of pressure relieving devices even if not ordered, wound care not being provided per physician order, the nurse’s failure to maintain clean or sterile technique as indicated, using a shearing motion while turning and repositioning the resident, and providing wound care without cleaning up incontinence beforehand.

Preparation:

With the lack of documentation being the biggest factor with this citation, frequent chart audits are essential. It is also essential that nurses providing wound care be observed for their compliance with physician orders and established guidelines. Some facilities have had great success by having weekly skin rounds, in which an interdisciplinary team (including at a minimum the skin or wound care coordinator, MDS coordinator, DON or ADON, and dietician) shadow the treatment nurse as wound care is provided. This team based approach provides the opportunity for all of the above-mentioned audits to be done in a timely and efficient manner. It is also necessary to have an effective system in place for addressing CNA-nurse communication.

Reminder about restorative

2008-07-17T15:09:00.000-07:00

If a resident is receiving two different forms of restorative nursing at least 6 days a week, they will RUG into RLA or RLB (depending on the ADL score). This can mean up to an extra $75 per day, which amounts to roughly an additional 2K/month - 24K/year.

Profiting from Private Duty

2008-07-08T14:31:00.000-07:00

At the beginning of this month, the state of Tennessee enacted a new law that shifted a large portion of Medicaid's long term care designated funds from nursing homes to in home private duty care services. This has obviously caused nursing home providers a great deal of worry, a' la "We're gonna lose all our patients!" The new law is actually a blessing in disguise to nursing homes because it gives us a perfectly valid reason to expand our product lines. Having a nursing home to provide home care services is a winner. The biggest issue in private duty nursing is human resources (recruiting and retaining nurses and techs, credentialing, staffing, etc.). Nursing homes have been dealing with these same issues for years and have the tools to address them (although many choose not to use for whatever reason). Since most nursing homes have an existing CNA training program in place, training additional caregivers would not become a problem. Staff could (not should) be rotated in between private duty and nursing home divisions, and developing a PRN pool would be a little bit easier. Additionally, community relations could be maintained and/or improved, particularly in rural areas, and continuity of care could be taken to new heights.

New training slides

2008-06-30T14:57:00.000-07:00

This month's free staff development powerpoint shows are now available at www.parragonhealth.com/slides.htm. The topic is survey preparation.

The PHI books

2008-06-27T06:05:00.000-07:00

Although this has been posted here before, I have had some requests to repost the links to two manuals available for free from the Paraprofessional Health Institute. They are:

Coaching Supervision

Peer Mentoring

4 Thoughts

2008-06-27T05:58:00.000-07:00

I was in a most excellent training session with Dianne Harris earlier this week. Here are four little tidbits I picked up on:
1. Sliding scale insulin is no longer considered appropriate for the nursing home setting. I will do some research and write more about this later.
2. Nursing homes are an excellent place for BSN students to do nursing management/leadership clinicals. This is something you should consider doing, as it is a great recruiting tool for RNs.
3. When interviewing licensed nurses, be sure to ask some clinical questions to make sure that their level of competency is where you want it to be at. It is suggested that you ask these 3 questions, at a minimum: (a)What are the signs and symptoms of heart failure, (b)How would you recognize if someone was hypoglycemic, and (c)What would you do if someone was having a stroke in progress?
4. Post the list of emergency stock drugs by the phone, so the nurse doesn't take an order for a med that can't be administered right then. It will also save a nurse the time needed to retrieve the list from wherever it is usually kept, which also keeps her from looking incompetent in the doctor's eyes.

Thoughts on Nursing Home Reimbursement

2008-06-16T06:48:00.000-07:00

There is no business case for quality in long term care. There certainly is in the hospital industry, where compliance with evidence based practice practices was shown in a Premier demonstration pilot to save 11K per CABG patient. The reason that nursing homes can't afford quality is the current reimbursement system. Under RUGs, we are financially rewarded for keeping residents sick and maintaining utilization of resources as high as possible. While this is good for the bottom line, it is no good to residents. Perhaps we could look at going back to capitation, a system in which a facility is paid X amount of dollars per month per resident, with the dollar amount being determined by the average cost of care for nursing homes in that region. While this may not be the best system for skilled residents, it is certainly feasible for residents receiving an ICF level of care. Nursing homes would then have an incentive to maintain quality standards, because poor resident outcomes would result in nursing homes having to absorb that cost (ie, there would not be additional payments for in-house acquired pressure ulcers or other preventable complications). Hospitals have a list of no-pay diagnoses, inpatient acquired complications that they are not allowed to bill for. Third party payers should demand the highest quality of care from nursing homes, just as they do from every other provider type.

Free training slides

2008-06-05T08:30:00.000-07:00

I am offering free powerpoint slides for staff development, available at http://www.parragonhealth.com/slides.htm. New slides will be available by the first day of each month. Two different sets will be posted, one for CNAs and a second one for licensed nurses. This month's topics are abuse prevention and interpretation of laboratory tests. Enjoy.

Survey Paranoia

2008-05-30T07:49:00.000-07:00

Some time ago I bought a bunch of nursing home books on ebay and came into possession of a mini-manual from one of the state nursing home associations (which will remain anonymous) on how to effectively manage surveys. Some of it was quite good, such as making sure that staff did not acknowledge guilt. This would be evidenced by a surveyor's statement on the 2567 (Statement of Deficiencies) that stated "The DON admitted that the CNA should have never done that", for instance. Some of it was bad, such as the suggested method for doing mock surveys that I will not go into here. And some of was disturbing. One particular chapter of this manual was devoted to keeping tabs on the surveyors. It actually stated that "an unobtrusive surveillance system to keep tabs on the surveyors...is essential". If that is not possible, the manual states, a staff member should be placed outside the door with walkie-talkie access to the administrator. Now before I go any further, I want to make it clear that this manual was about 15 years old, and would probably no longer be applicable because the state this came from currently utilizes a different type of survey protocol. But is goes to perfectly illustrate the industry's ridiculously paranoid attitude toward regulatory compliance. Interestingly enough, a expose that came out in 1997 ("Patients, Pain, and Politics") described similar behavior going back to the 1960's, when nursing home regulation was nothing compared to what it is today. Even when I worked the floor just a few years back this same attitude was the rigor de norm. Everyone sneaked around, talked in hushed tones, and tried to predict which resident would be interviewed next. As a consultant, I still see this behavior.

Nursing home surveys are nothing to be paranoid about, unless you're trying to hide your substantial noncompliance. Survey protocol is clearly spelled out in the State Operations Manual. It should be no mystery who gets interviewed, because the manual tells you. "But the surveyor's don't do things by the book!", I can hear someone cry. If they don't, then appeal it. That's what IDR and the appeals process is for. The reason that deficiencies happen is primarily because nobody knows the rules of the game called survey. As I cannot emphasize enough, TEACH YOUR STAFF THE STATE OPERATIONS MANUAL!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
Of course this is a problem if you don't know it yourself. When a week long DON orientation attempts to cover everything about survey in 45 minutes, and the required text for virtually every AIT program in the country doesn't even mention the word 'survey', it's not entirely your fault. But if you haven't been taught it, you need to learn it for yourself. As anyone who has ever tried to read the watermelon book cover to cover can tell you (myself included), it's one hell of a boring book. Perhaps you could try this instead: Get the forms used in the quality indicator survey and do mock surveys through QAA committee with them. You will learn the rules as you go along because the contain the relevant F tags and the critical elements necessary for demonstrating compliance with them.

You can be paranoid about state if you want, but it's a waste of time and energy you probably don't have. If your facility is not survey ready when they walk in the door, there is only so much you can do to fix things while the surveyors aren't looking. Doing well on survey takes staff education and frequent mini mock surveys conducted over the course of the entire year. Waiting until you're already inside the window is uselsss.

RCA Tutorial

2008-05-26T07:02:00.000-07:00

There is a great tutorial on how to do a root cause analysis here. It is from the National Center for Patient Safety at the VA, which has a lot of other wonderful resources too, such as fall prevention tools.

Free Abuse Prevention Training Resources

2008-05-20T08:12:00.000-07:00

Get it here.

F281: Professional Standards of Quality Care

2008-05-20T08:04:00.000-07:00

Requirement:

Services provided or arranged by the facility must meet professional standards of quality.

Intent:

All services performed in the facility must conform to generally accepted standards of clinical practice. These standards may come from textbooks, current journals, position statements by such organizations as ADA, AMDA, ANA, etc., or clinical practice guidelines published by AHCPR.

Common Reasons for Citing F281:

Improper disposal of controlled substances

Failure to secure controlled substances

Leaving medications at bedside

Failure to assess for dehydration issues

Failure to carry out physician orders

Failing to add new interventions after a fall

No care plans or lack of care plan review for resident care issues

Not monitoring or assessing dialysis access site

Failing to date multidose vials when first opened

Pre-pouring of medications

Improper documentation of medication administration

Preparation:

Frequent education is necessary to make sure that nursing staff understand the standards to which they should be practicing under. Explanation of rationales is vital in this aspect. Working alongside nurses during medication passes is a useful technique for ensuring compliance with this tag and has the potential to improve staff morale if carried out in an appropriate manner. Having generic care plans available for frequently missed areas of care is another useful idea. Frequently missed areas include safe smoking, constipation, weight loss, hydration, fluid restriction, accident prevention and falls, skin breakdown, and hemodialysis.

Free self study modules for CNAs

2008-05-18T15:06:00.000-07:00

There is a collection of 16 self study modules here, designed for direct caregivers such as CNAs. Some of the topics include managing challenging behaviors 1 & 2, aspiration, dehydration, infection control, fall prevention, and documentation. It looks very promising and would make a great addition to any facility's staff development program, especially if you rely on self-study to help the aides meet their 12 hour continuing education requirement.

Training your CNAs

2008-05-15T09:00:00.001-07:00

In the vast majority of nursing homes, CNAs are taught from the immensely popular How To Be a Nurse Assistant. Published by the American Healthcare Association, it is one of their best sellers (right after their reprint of the CMS State Operations Manual). Irregardless of how good the book is, nurse aides quickly find it to be useless in the real world. Despite all of the skills taught in the book, it doesn’t adequately cover the three things that the average CNA spends 90% of their time doing: skin care (turning, positioning, changing, bathing), providing assistance with eating, and dealing with psychosocial issues.

It is no secret that training programs for nurse aides are not only irrelevant to what really goes on, but are also of an inadequately short length. Whatever notion you may have to the contrary, the CNA is not an unskilled worker. Although some of the physical tasks probably would be considered menial, that is not the point here. As Lori Porter pointed out in her autobiographical Everything I Learned in Life...I Learned in Long Term Care, a nurse aide has the power to either promote a resident’s physical, mental, and psychosocial well-being, or completely destroy it and take that individual’s last shred of dignity away from them.

Either we forget (or simply have never realized) the enormous power we have entrusted to these folks – power that oftentimes goes unchecked. If we are to fulfill our legal obligations as nurses and/or administrators to maintain the health and welfare of our residents, it is simply incomprehensible to think that we would delegate this enormous task to unskilled workers. Thus we must transform the workforce, which can be achieved in one of two ways.

The first way is to change the way that CNA classes are conducted. Consider lengthening the course from two weeks to three weeks. The current practice is to have the students spend a week in class, then a week on the floor. What I suggest is that you combine class time with floor time. After three days or so in the classroom dealing with non-clinical topics, slowly introduce the students to the residents. Let them know what is going on with them from a medical and from a psychosocial standpoint so that they can truly see in action the conditions they are learning about. Have the students spend time on the floor during its busiest times, and then during the lulls have them to return to the classroom to talk about clinical issues. Don’t be limited by the textbook – allow the student’s minds to go above and beyond the norm. It seems that every nursing home wants well trained staff but they don’t want to put forth any effort to achieve that dream.

Although some corporate owners and administrators may balk at this approach, citing increased costs, it is actually a worthwhile investment. It is common knowledge that the vast majority of CNAs quit soon after being hired so it is prudent to keep a proverbial safety net under them for an extended period of time. With this paradigm in place, the students will have a supporting framework when things get rough. During the latter part of the second week or the early part of third would be an excellent time to begin peer mentoring.

Happy Nursing Home Week!!

2008-05-13T05:24:00.000-07:00

I would like to just take a moment to wish everyone a happy national nursing home week. Thank you for all that you do. As nursing home providers, you take care of those who can't take care of themselves, despite being ridiculously overworked, underpaid, and sorely underappreciated. Thank you.

Acuity Based Staffing

2008-05-10T14:48:00.000-07:00

Sometimes staffing is based on resident acuity levels. This is usually calculated by averaging the RUG scores. However, this causes a big problem: Higher acuity levels don't necessarily mean that more CNA care is required, just more skilled nursing and/or rehab. CNA staffing should be based on average ADL scores. Doing so will eliminate complaints that you are being unfair about making assignments (ie, "on the ICF wing we've got 12 patients each that are all total care and Susie on skilled only has 8 patients that don't need a mother flipping thing").

F309: Quality of Care

2008-05-02T10:31:00.001-07:00

Requirement:

Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well being, in accordance with the comprehensive assessment and plan of care.

Intent:

It is the nursing home’s responsibility to make sure that residents either get better or stay the same (within the resident’s right to refuse treatment), within the limits of the resident’s medical condition and/or the normal effects of aging.

Common Reasons for Citing F309:

The most common reason this tag is cited is for failure to reposition. For example, a resident is observed sitting in the same position for 3 hours, even though they are care planned to be repositioned every 2 hours. Another common reason for this tag is missing lab work. Other reasons that have been used to justify this citation include failing to properly manage pain, noting that residents are not wearing TED hose that has been care planned, failure to protect fragile skin, and lack of foot pedals when their use is obviously necessary. F309 is a sort of catchall citation and is frequently cross referenced to other tags.

Preparation:

Because of the vague nature of F309, it is often difficult to adequately plan for this. Missing lab work can be oftentimes be prevented by requiring nurses to maintain a log of lab work or having all labs being coordinated through just one individual, usually a RN supervisor or administrative nurse. Issues with repositioning can be handled by educating and monitoring staff on its importance. Some facilities have attempted to tackle persistent repositioning problems by keeping underpads in three different colors and requiring direct care staff to change the existing pad to one of another color every two hours. The resident will be repositioned in the process of the pad change, and it becomes rather easy to monitor staff compliance by just checking to see what color the pad is. The other issues can be addressed by frequently walking around and observing how residents are cared for.

2008-05-02T10:31:00.000-07:00

Culture change on the cheap

2008-04-29T14:56:00.000-07:00

CMS and the Pioneer Network had a culture change conference earlier this month and now the presentations are online at http://www.pioneernetwork.net/news-and-events/creating-home-presentations.html. The most interesting one is "Low Cost Practical Solutions", which has some very good ideas on how to make things better with a minimum of both money and effort. Take a look.

Focus on the money part deux

2008-04-27T12:29:00.000-07:00

There are quite a few nursing homes that like to limit supplies in a well-intended effort to contain costs. This practice is pound foolish and penny stupid. Not only does it decrease employee morale and directly affect resident care in a negative way, but it is a waste of time and energy that most administrators don't have to begin with. Assuming that with volume discounts, an incontinence brief will run you anywhere from about 30 to 50 cents each. Limiting how many briefs can be used per day will save you a dollar, maybe a buck fifty, per day per resident. Maximizing the RUG score by educating CNAs on their part and by ensuring that MDS nurses are credentialed will increase your revenue by a minimum of several dollars per day per resident. I'm not in any way saying you should try to defraud third party payors, but you should go to great lengths to make sure that your assessments are as accurate as possible. In short, go after the many big fish instead of concentrating on the few small fish that are out there in the sea of finance.

Preparing for LSC inspection

2008-04-23T11:06:00.000-07:00

http://www.healthynh.com/nhha/nh_hospitals/ruralhealth/cah%20downloads/LSC%20Survey%20Form.pdf
is the form that surveyors use to ensure compliance with the Life Safety Code. Perhaps you could find it useful when preparing for inspections.

3 thoughts about employee behavior

2008-04-17T11:58:00.000-07:00

1. 90+% of the time, folks do the best they know how under the given circumstances
2. There are four primary goals of behavior: Power, revenge, attention, and display of inadequacy
3. http://www.paraprofessional.org/publications/coaching_supervision/ has "Coaching Supervision" pdf files for free (Normally $99 through AHCA)

Nursing Homes: Focus on the Bottom Line!!!

2008-04-15T07:53:00.000-07:00

You may be thoroughly convinced otherwise, but I think that nursing homes don't think enough about making money. Reimbursement is typically something that only the front office and the administrator are concerned about, but I would encourage you to get every single member of your staff in a money mindset. Teach them how nursing home finance works. Make sure that CNAs understand (I mean *really* understand) how the ADL and restorative documentation that they are responsible for raise the RUG levels. It is imperative that everyone in the facility appreciate the MDS. Insist that anyone who so much as breathes on the MDS gets certified so that they know what they are doing. Have an inservice for the licensed nurses on what they have to chart for skilled residents, and why. Conduct an open-house meeting as you are preparing the annual budget. Share your projections with all staff and get their feedback. By getting everyone in a money mindset, not only are you helping the facility but you are helping them. Although unconventional, it is empowerment at its best, because everyone can see that they are making a difference in the one thing that seems to matter most to corporate owners -- making a profit.

Free videos for staff development

2008-04-09T06:15:00.000-07:00

I've found some really good videos online on how to do nursing stuff, and of course they're free. They would make an excellent tool for a cash-strapped staff development office.
http://saddleback.edu/alfa/vid_index.aspx
http://lib2.hacc.edu/nursing/nursing103/

Book Review: Quality Management Integration in Long Term Care

2008-04-03T07:34:00.000-07:00

I was initially quite excited to get this book and it came with the full blessing of AHCA. After reading it, though, I am rather disappointed. I was expecting a book that actually explained practical applications of quality improvement in nursing homes, and this book was not that at all. It is a discourse explaining the need for quality improvement along with a very broad based overview of some statistical tools. It is not at all practical and seems to be geared more for students in a college-based NHA training program. I am not as enthusiastic about interviewing residents, staff, and families about quality as the authors, mainly because I feel that most folks in the nursing home are petrified of retribution and will tend to give answers that they think administration wants to hear. One bright spot of the book, however, is chapter 4, "Internal Critical Issues", which discusses barriers to quality improvement. Overall, the only truly good thing about the book is that it doesn't reference Allen's opus magnum which I detest. Although I commend the authors for being one of the very few to write a book on such an vital topic, I really have a hard time recommending it. A better QI text is "Quality and Performance Improvement in Healthcare", published by AHIMA, because it is extremely practical and does talk about long term care at length.

How to know when you have acheived quality

2008-03-31T07:30:00.000-07:00

AAHASA has put together a series of questions that are asked in order to determine how focused a nursing facility is on quality. Although designed for consumers, it is also a useful tool for using internally. Take a look sometime.

Are you a nursing home nazi?

2008-03-29T15:58:00.000-07:00

I read an interesting discussion on the allnurses.com forums called "Rounds, Falls, and Skin issues". What caught my eye is this:

"On another note, this same study revealed another "secret." In war days in the concentration camps the prisoners were subjected to various types of torture. Among these was that they were awakened every 2 hours during the night and forced to stay awake for about 10 minutes and then allowed to go back to sleep. This severely disturbed their sleep patterns and thus, made them clumsy and confused during the day due to lack of proper REM sleep. Hmmm, is this what we are doing to our elderly? Is this part of the reason for so many falls and inappropriate behaviors?"

Does the way your facility take care of residents actually cause more harm than good? This is something to really think about.

A most powerful excerpt from "Everything I Learned in Life...I Learned in Long Term Care" by Lori Porter

2008-03-26T06:20:00.000-07:00

"At that minute, I knew there was nowhere else a high school dropout could go and have that much power and influence...You see, we have the power to make an old person feel special, beautiful, worthwhile, needed, wanted, respected, revered, admired, and productive, but we also have the power to strip them of their every dignity. That power should come with a warning, and we should all be reminded of it everyday. None of us fully appreciate or comprehend the power of our own influence."
--------------------------------
Although this book has been out for some time, I just got the chance to read it last night and I was really touched by it. I especially appreciate the above-mentioned quote so much that I plan on printing up a copy and sticking it in front of my desk just to remind me how much power I really do have working in long term care. I think you should print off a copy too, and make sure that no one in your nursing home forgets that power either.

2 things to think about doing

2008-03-25T09:54:00.000-07:00

(1) Require all employees to initiate a conversation before touching a resident or doing something clinical to them
(2) Recruit volunteers to come in and write down the stories of resident's lives that they dictate to the volunteers. Share these stories with staff so they realize that the resident is a person with a rich, vibrant history and not just some inanimate object to feed, change, and bathe.

Occupational Hazards in LTC

2008-03-19T12:17:00.000-07:00

OSHA has an interactive nursing home set up at http://www.osha.gov/SLTC/etools/nursinghome/index.html where you can learn pretty much everything there is to know about occupational hazards in the long term care setting.

An interesting nursing home blog

2008-03-19T11:47:00.000-07:00

Barbara Mitenberger has created an excellent blog at http://www.longtermhealthlaw.com. It focuses on the legal aspects of nursing home administration and is highly informative. Thanks Barbara!

F371

2008-03-18T12:38:00.000-07:00

Depending on who you ask, anywhere from 1/3 to 1/2 of nursing homes are cited with a F371 tag in a year. F371 requires that kitchens be clean and sanitary. One way to verify that the conditions of F371 are being met is to have the dietary manager to conduct a weekly audit. The easiest way to do this is to make a list of all potential violations and have the manager to circle them as they occur. The possible violations are:

ANYTHING STORED ON FLOOR

DENTED OR SWOLLEN CANS NOT STORED SEPERATELY

INSECTS OR DROPPINGS

STREAKS ON WALLS ALONG SHELVES

LACK OF FIRST IN, FIRST OUT ROTATION

OPENED FOOD THAT IS UNSEALED AND/OR UNDATED

BULK FOODS IN CRACKED OR PEST-VULNERABLE CONTAINERS

UNUSUALLY HIGH OR LOW TEMPERATURE IN FOOD STORAGE AREA

REFRIGERATOR TEMPERATURE >41 DEGREES FAREINHEIT

HIGHLY PERISHABLE FOODS USED AFTER THREE DAYS OF BEING OPENED

(This means foods that are animal derived and/or high in protein)

EGGS IN UNBROKEN SHELL USED 4-5 WEEKS AFTER PACK DATE

RAW ANIMAL FOODS LOCATED NEAR OTHER ITEMS

FREEZER TEMPERATURE >0 DEGREES FAREINHEIT

FROST BUILDUP IN FREEZER OR EVIDENCE OF THAWING

SPILLS IN THE DAIRY CASE

DIRTY SHELVES, FLOORS, OR WALLS

CROWDED STORAGE SPACE

HOT FOOD HELD FOR MORE THAN 30 MINUTES BEFORE SERVING

ICE IN CONTACT WITH FOOD

HOT FOODS HELD <135>180 DEGREES

COLD FOODS HELD >41 DEGREES

LACK OF HAND WASHING/SANITIZATION

IMPROPER UTENSIL USE OR LACK OF CLEANING

IMPROPER OR LACK OF CLEANING OF EQUIPMENT AFTER USE

LACK OF COVER DURING TRANSPORTATION

FOODS TRANSPORTED NEAR SHOES OR FLOOR

Lectures on Pain Management

2008-03-15T13:39:00.000-07:00

IPro has a set of 6 mp3 files on pain management in nursing homes at http://www.providers.ipro.org/index/nhqi-conferences-pain-management. It's a good resource for audio learners.

SPIRIT: A rapid QI program that stays on the floor

2008-03-07T16:48:00.000-08:00

Beth Israel Deaconess Medical Center in Boston has recently launched a new semi-informal QI initiative called SPIRIT: Solutions Promoting Improvement Respect Integrity & Teamwork. I'm feeling a bit lazy right now so I'm just going to link to its description on their CEO's blog here. Nursing homes seem to never do anything innovative, so the next best thing is to steal ideas (steal? I really mean borrow ideas) and adapt them to the long term setting. One thing that really impresses me about the SPIRIT initiative is that it strives to empower employees to answer these 3 questions with a "resounding YES!":

"Am I treated with dignity and respect by everyone I encounter, regardless of role or rank in the organization?

Am I given the knowledge, tools and support that I need in order to make a contribution to my organization and that adds meaning to my life?

Did somebody notice I did it, i.e., am I recognized for my contribution?"

Can every single employee in your nursing home, administrator on down to the lowliest part-time laundry aide, answer these questions in the affirmative?

Quality Indicator Surveys

2008-03-03T12:42:00.000-08:00

The surveyor's manual for the quality indicator survey program can be found at http://www.uchsc.edu/hcpr/qis_manual.php. Under "Tab 9", you can find the phase II critical elements. These forms serve as a sort of "how to survey nursing homes for dummies". They tell exactly what to ask residents and staff, exactly what type of documentation needs to found in the chart, what needs to be observed, and which F tags should be cited and under which conditions. It seems that this could be a great tool for your facility's QA committee, as they would be able to take care of quality issues while preparing for surveys at the same time.

Lessons in Quality Management

2008-02-22T08:02:00.000-08:00

Here are some ideas I picked up from chapter 7 (Quality Management in Military Medicine) of Chip Caldwell's Handbook of Managing Change in Health Care:
1. "Throwing money at a problem usually only makes it worse"
2. Crisis management is bad. It is used to demonstrate that something is getting done. It causes processes to break down and for people to make shortcuts in order to save time. "Quick productivity takes precedence over quality".
3. "The fear or inability to say no in an organization is enormously destructive to any QM initiative. It immediately creates distrust and stifles productive feedback. Employees are fearful of being fired. Exposing any weakness or faults labels the employee as a troublemaker. Employees are then very distrustful of any management scheme that talks about empowerment. If they don't see empowerment or trust in action, they will correctly decide that it doesn't really exist. If their evaluations are based on the quantity of work performed, process improvement will be seen as a waste of time. Their view is, 'Why spend the time required to fix processes?' For them, management's over-focus on short-term tasks or projects give visible (but false) evidence that real work is being done."

I find this last item particularly true. It is interesting that this comes from a chapter about quality in military medicine, as I once heard someone say that calling CNAs the 'front line' makes it sound as if we are fighting a war. Perhaps we are.

Employee vs Patient Centered Healthcare

2008-02-21T15:18:00.000-08:00

Hospital Impact blog had a post on this recently. What are your thoughts on this delicate balance?

Why nursing homes have poor quality

2008-02-16T09:40:00.000-08:00

I was thinking about this last night and realized something quite obvious. JCAHO, the organization that accredits virtually every hospital in this county, has established standards for hospitals to go by. These standards are considered optimally achievable outcomes -- what a facility should aspire to be. CMS standards, the ones that nursing homes are required to comply with, are minimum standards -- the absolute bare minimum you can do to get by with. Literally every single nursing home I have worked with has regarded the CMS minimum standards as optimal achievable outcomes. The prevailing thought in the long term care industry is that a deficiency free survey is something you should aspire to. The problem with this thinking is that a deficiency free survey only means that you are providing a minimally acceptable level of care. Facilities must truly desire to go above the minimum standards, which requires blowing up the box and getting the hell away from the status quo. Unfortunately this is too scary for most providers and corporate owners. Nursing homes have the worlds worst case of "we have never done it this way before" that anyone has ever seen.

Medication Regimen Review Resource

2008-02-12T12:16:00.000-08:00

If your facility's QA committee needs some help with medication regimen reviews, there is a course page from the University of Washington School of Pharmacy here that you will find useful. There are a number of course handouts that address things like breakdown of drug delivery systems (ie, how things can and do go wrong), classification of med errors, how to actually do a drug regimen review, Beers criteria, drug delivery systems in nursing homes, and lots of stuff on the law.

Great new MDS site

2008-02-11T14:07:00.001-08:00

I found a great MDS site this morning, run by the state of Missouri's MDS help desk. Check it out here.

Handwashing, Semmelweis, and Quality Improvement

2008-02-11T06:47:00.001-08:00

Did you know that the best way to prevent infections is to wash your hands frequently? Apparently the only people who didn't know this worked in nursing homes. There was an article in this month's AHCA Provider about this suprisingly new concept that was just recently discovered about, what, 100 years ago by Semmelweis. Ironically, the so-called "Semmelweis Reflex" is an outright dismissal of any information that is radically out of sync with the status quo. Kind of like introducing *real* quality improvement to nursing homes (by real, I mean the prospective, quantatative kind that actually gets results, not some half-arsed PDSA crap). If you need proof that this truly non-existant, take a look here.

Testing interviewees for honesty

2008-02-04T11:47:00.001-08:00

Check out this idea from Service Untitled, "Find More Honest Employees". There might be some legal issues with this, as the author warns, but it is an interesting way to test prospective employees for honesty. I would certainly appreciate knowing who might and might not wind up being a thief.

Food for thought on suggestion boxes

2008-02-04T11:08:00.000-08:00

I was killing time at a used book store on saturday and bought a cheap copy of Nuts!, a book on how Southwest Airlines is driven by innovation. There was a blurb on suggestion boxes that I would like to share here: "One of our managers mentioned to me that he wanted to put up a suggestion box. I responded by saying, 'Sure--why don't you put up a suggestion box right here on this wall and then admit that you are a failure as a manager?' Our theory is, is you have to put up a box so people can write down their ideas and toss them in, it means that you are not doing what you are supposed to be doing. you are supposed to be setting your people up to be winners. To do that, you should be there listening to them and available to them in person, not via a suggestion box...I think that most people employed here know that they can call any one of our vice presidents on the telephone and get heard, almost immediately." The book then goes on to say that at Southwest, managers are expected to spend a minimum of 1/3 of their time walking around. That's exactly what the NHA and DON need to do.

Something to do during stand-up

2008-01-31T11:08:00.000-08:00

During the daily stand-up meeting (a.k.a. department head), assign each person to go 2 or 3 tasks in the facility that will only take 5-7 minutes total to complete. Tasks could include returning an empty oxygen tank to the tank holder out back, cleaning up a messy sink area, helping a CNA with rounds, or getting a resident a cup of coffee. Put each task on a card and have each person draw a couple. Everybody participates -- no exceptions. This will do a lot for improving staff morale.

If Nordstrom ran your nursing home

2008-01-31T10:56:00.000-08:00

Nordstrom's is a chain of upscale department stores famous for their customer service. They only have one rule for employees: "Use your best judgment". Let's play a quick game of what-if and imagine Nordstrom being hired to run a nursing home (this is just the ICF wing; Disney can run the skilled hall). Residents would be able to participate in the activities of their choosing, and it wouldn't just be groups like church and bingo. Nurses wouldn't have superfluous charting, aides wouldn't be assigned useless tasks like putting ice in water pitchers that everyone knows are never drank out of. Aides would pretty much run the place, in fact, and nobody would have a problem with it. There would be fewer med passes. Administration would never be in the office, and all the meetings would be condensed into one. There would be hot coffee and fruit for visitors to enjoy, and of course the residents would be partaking as well. Mutual cooperation between everyone would foster a genuine element of customer service, with customers being all stakeholders and not just visitors and residents. But now it's time to return to reality. What can you do today to bring the nursing home just a little bit closer to Nordstrom's?

Following up with new employees

2008-01-28T13:25:00.001-08:00

You need to meet with new employees either 30 or 90 days after they are hired. You still need to meet with them informally on a regular basis before this point in time, however. This needs to be a quick little 5 or 10 minute sit-down meeting where you work on these 4 vital questions:
1. Now that you've been here for a while, how do we compare to what we claimed to be when we hired you?
2. What are we doing that's good? Who here has been helpful to you?
3. At the last place you worked, what were they doing that we could do here to make things better?
4. Is there anything here you don't like? What can we do to make things better?
After this meeting, continue to meet with your staff. If the employee has any answers to ideas 3 or 4 that deserve recognition or reward, make sure they get it.

Random thoughts on customer service

2008-01-26T20:01:00.000-08:00

Nursing homes typically give a horrible initial impression, simply because, well, that's just how they are. How can you fix it? I'm not talking about what to get rid of (except for the a-hole staff), but rather what can you add. How can you make your staff more friendly? What can you do to foster relationships between families and staff? How can your on-hold messages be changed so that callers get to hear something other than really bad advertising for the facility? Honestly, who cares about the bingo schedule? Get some ideas from other industries at http://www.serviceuntitled.com/

Yesterday's MDS 3.0 Conference Call

2008-01-25T12:52:00.000-08:00

I didn't have a chance to listen in on the MDS 3.0 open door forum yesterday; I was urgently called out of town to deal with a pressing issue during the same time as the conference call. However, the topics that were discussed were posted online at http://www.cms.hhs.gov/OpenDoorForums/Downloads/MDS30Word012408.pdf
You can check out the results of the pilot projects and validation studies, which are now finished.

Open Letter to CEOs

2008-01-22T14:47:00.000-08:00

http://www.escapefromcubiclenation.com/get_a_life_blog/2006/05/open_letter_to_.html
is one management consultant's advice to all corporate executives. Although not directly applicable to nursing homes, or even healthcare, a lot of the same principles still apply, like, "If you want to see things change immediately, stop being an asshole". Check it out and apply it today.

MDS 3.0 Special Open Door Forum

2008-01-22T14:27:00.000-08:00

CMS is having an open door forum at their Baltimore office on Thursday to allow providers to give their 2 cents worth on MDS 3.0. However, it will be presented as a teleconference as well, since there were more people interested in participating than there were seats. You can register at the CMS website. If you don't want to, or can't, take the call, check back here on Thursday afternoon and I'll post the highlights. Otherwise, you can download an audio recording of the teleconference after January 30 at http://www.cms.hhs.gov/OpenDoorForums/05_ODF_SpecialODF.asp.

Thanks to the Tennessee State Veterans Home, Murfressboro

2008-01-20T20:12:00.000-08:00

Recently, I've had the opportunity to observe operations at the Tennessee State Veteran's Home in Murfressboro. Initially, I expected the worst. TSVH has gotten loads of bad press in the media, as they had 8 immediate jeopardies on their last survey. However, I was pleasantly suprised to find out that the facility was actually one of the best I have ever been in. I would especially like to commend the staff on the North Wing, which is the secure dementia unit. Robin Ronewicz, Gail Fish, and Annah Jones are truly exceptional staff members, and Diane Williams is one of the best house supervisors I have ever had the pleasure to meet. I would again like to express to them my thanks for the great work they do. I sent the administrator of the nursing home a short email expressing my kudos, and the staff couldn't believe that somebody would actually publically thank them as it had never happened before. I would like to present everybody out there with two pieces of advice: (1) Thank your staff, thank them often, because you have absolutely no idea how underappreciated they feel, and (2) Bad survey results don't necessarily mean that a facility is bad. Judge a nursing home by how compassionate and caring the nurses and techs are.

Random recognition

2008-01-18T05:53:00.000-08:00

Starting today, send an employee a thank-you card to their house. In it, say something along the lines of, "On behalf of the residents and your co-workers, I would like to thank you for the hard work you do. It is really appreciated, much more so than you can ever know." Have the administrator and the person's department head to sign it. Everybody should get one at random at least once during the year.

CMS SNF Open Door Forum Conference Call -- 1/17/08

2008-01-17T14:08:00.000-08:00

CMS has an open door forum conference call for nursing homes once a month, where providers have the opportunity to give feedback on proposed changes to CMS law and policies, as well as get general questions on billing and survey issues answered. Here is a highlight of today's call for those of you who didn't chance to listen in.
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1. After May 23, 2008 do not use the old legacy codes with your NPI # when submitting claims.
2. Due to a computer glitch that some of the fiscal intermediaries had, if you had denials on a no-pay bill at the end of the fiscal year, don't split it but instead resubmit.
3. AAPC offers CEUs to certified coders who complete any webinar or course sponsered by CMS or a carrier.
4. MDS 2.0 has had revisions as follows: (Chap. 3)I2J, I3, K2A, K3, L1E, M4, M4G, M5E, (App B).
5. MDS 3.0 will have a conference in Baltimore on January 24; it will also be presented via conference call at the same time. They will discuss the draft version and how the pilots went.
6. MACs (Medicare Modernization Act Contractors) will replace FIs and carriers. Meridian Services, Trailblazer, Wisconsin Physician Services, Highmark, and Palmetto have been awarded contracts for regions 3, 4, 5, 12, and 1, respectively. MACs for regions 2, 7, and 13 have not yet been awarded.
7. The therapy cap still remains at $1810/yr, but Congress is allowing the exception process to continue out through July 31, 2008.
8. Next Open Door Forum conference call will be on February 28, from 2-3 EST.

7 Questions to Ask Nurses

2008-01-14T08:56:00.000-08:00

The next time you're out making walking rounds, ask a nurse these 7 questions on patient safety:
1. Have there been any near-misses that nearly resulted in resident harm?
2. Have there been any incidents recently where a resident was harmed?
3. What things do you think will cause another resident to be harmed?
4. What can we do to prevent the next adverse event?
5. Can you think of a way the system here doesn't work?
6. What specifically can administration do to make the work you do safer?
7. What are we doing that works?

Website for QI in LTC

2008-01-14T00:09:00.000-08:00

http://mqa.dhs.state.tx.us/QMWeb/POR.htm
has some really nice QI stuff. The website's title is "Problem-Oriented Best Practices". Topics include ethics, geriatric syndromes, nutrition, organization and administration, medication prescribing practices, and preventive practices. Good stuff!

5 ideas on communication

2008-01-11T09:18:00.000-08:00

Here are some simple things you can do to improve communication in your facility:
1. Ask the employees what is going great on their unit
2. Bring an employee to the daily stand-up (also known as department head meeting), introduce them, and spotlight their successes
3. Let the residents know how good you know the direct care staff is -- be specific
4. When you speak at staff meetings, base everything around a story. If you need to talk about the importance of fall prevention, for instance, begin with the story of a resident who suffered undesirable consequences as the result of a preventable fall.
5. Have a communication board on each unit. Each week, have a white piece of paper titled, "What's Happening This Week". Keep it factual, short, and sweet. To quote Quint Studer from page 224 of Hardwiring Excellence, "We learned that employees define quality communication in terms of quick wins on what they really need to know about. Newsletters that feature executives in suits just don't do it."

Free CNA videos online

2008-01-01T11:51:00.000-08:00

http://www.health.state.mn.us/divs/fpc/videoindex.cfm has free training videos for CNAs on the survey process.

http://deptets.fvtc.edu/nursing/index.htm is a online video based CNA course. This is a great resource for new CNA classes or for staff development.

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

2007-12-21T14:30:00.000-08:00

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.

Waughing the Dog

2007-12-19T06:14:00.000-08:00

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.

Tidbits on Falls aka Blog about Waugh

2007-12-18T06:03:00.000-08:00

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.

Painless culture change resources

2007-12-17T10:35:00.000-08:00

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.

Support Services Evaluation

2007-12-09T11:22:00.000-08:00

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.

QIO's 9th Scope of Work

2007-12-06T14:46:00.000-08:00

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 www.qualitynet.org and click on "Presentations" under 2007 QualityNet conference.

...and McKendree makes 21

2007-12-01T15:34:00.000-08:00

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.

The Five Organizational Pillars

2007-11-27T08:57:00.000-08:00

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.

Rounding for Outcomes

2007-11-26T06:31:00.000-08:00

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

2007-11-26T06:15:00.000-08:00

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.

AIDET: The 5 Fundamentals of Service

2007-11-24T06:52:00.000-08:00

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

2007-11-24T06:10:00.000-08:00

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.

Rants about CNAs

2007-11-14T06:21:00.000-08:00

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.

Hourly rounding

2007-11-08T08:14:00.000-08:00

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.

Why would I want to burn a nursing home down?

2007-11-05T06:23:00.000-08:00

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.