6/27/2019 Triggering Staff Reliability David Farrell, MSW, LNHA This material was prepared by Telligen, the Medicare Quality Innovation Network Quality Improvement Organization, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. This material is for informational purposes only and does not constitute medical advice; it is not intended to be a substitute for professional medical advice, 1 diagnosis or treatment . 11SOW-QIN-C2-06/25/19-3472 Serving Colorado, Illinois and Iowa 2 1
6/27/2019 Meeting Norms • All lines have been muted • All lines will remain muted during this presentation • Type questions and comments in chat 3 Using The Chat Function • We will chat with each other today • David will ask you to do a short root cause analysis and chat in your organizations reply….. • Here is what you do: 1. Click on Chat icon at the bottom of the screen 2. You will be able to see the chat box come up and view the dialogue 3. To send a Message in chat, use reply to everyone and type your response at the Message Prompt 4 2
6/27/2019 David Farrell, LNHA, MSW 5 Why do Staff Call Off From Work? Identify all possible root-causes Brainstorming reasons why Avoid discussing solutions Keep asking - what else? Why? What have we missed? Are there other factors? Arrange the causes along “ bones ” 6 3
6/27/2019 Cause and Effect Diagram Systems People High absenteeism Environment Equipment/Supplies 7 Chat Time: Share you’re responses here React/Discuss responses Next Steps 8 4
6/27/2019 Social Determinants of Absenteeism Sick Days and Demographics of US Workers - • 5 = average sick days • 6 sick days for women and 4 for men • 3 = sick days college graduates • 8 = sick days H.S. diploma or less • 9 = sick days of divorced or separated • 4 sick days for married or never married • 13 = sick days of those on Medicaid • 3 sick days for those covered by insurance CDC 2016 Who are the Nursing Assistants? Total 1.55 million 90% are women 20% are born outside the U.S. Average age is 37 Injured 3.4 times more frequently Median hourly wage is $12.84 50% no formal education beyond high school 15% live below federal poverty line 37% rely on public benefits 13% uninsured and 25% on Medicaid PHI, 2018 5
6/27/2019 “ What a D Differe erence nce Manage gement ment Makes ” 4 high turnover vs. 4 low turnover SNFs Areas that distinguished low vs. high Leadership visibility Cared for caregivers Orientation, career ladders, scheduling Primary assignments Rarely worked short Eaton, Phase II Final Report, 2001 A Vicious Cycle of Staff Instability Vacant Shifts • Financial burden • Working short staffed • Instability • Resentment • Poor outcomes • Waiting • Lack of trust • Anxiety • Vacant Stress Shifts • Errors Turnover • Poor judgment • Injuries • Fractured relationships Eaton, Phase II Final Report, 2001 6
6/27/2019 High Turnover = Low Quality Catheter use Contractures Pressure ulcers Psychoactive drug use Quality-of-Care deficiencies Castle et al., 2005 Castle, 2007 Turnover + Absenteeism = Instability Inte terr rrupts s contin tinuity: ity: Incontinence Community acquired pressures sores Urinary tract infections Falls and fractures Dresser et. al. 1999; Harrington et. al. 1999 7
6/27/2019 The Impact of High Absenteeism Vacant shifts = more or different patients What get’s skipped – Range of motion Hydration Dining assistance Bathing Hawes, 2002 The Impact of Leaders Healthcare organizations Leader’s actions influence: Culture Relationships Staff engagement Clinical outcomes Quality of life 8
6/27/2019 Person-Centered Care Leadership Compassion Performance od - My Old and Ineffectiv ective e Met ethod Let department managers track attendance Discipline the very worst offenders when things got really bad Maybe fire someone to demonstrate that we are serious about this Forget about it until it get’s really bad again 9
6/27/2019 A Better Approach - Treat it like an organizational problem - Single point person tracks everyone Monitor the TOTAL number of unscheduled call-offs per month Share the total number with staff Demonstrate cause and effect on residents A Better Approach - Goal – Reduce the total number Focus efforts on staff in the middle Have critical conversations more frequently Examine environmental factors including co- workers influence 10
6/27/2019 A Root-Cause of Absenteeism on the PM Shift? Nurse Ratched Scheduling Success Meet with staffing coordinator twice a week Support, guide, monitor Care and be fair Allow staff to trade days Honor requests for time off 11
6/27/2019 Rule – Staff must provide a 30 day advance notice to request a day off A rule for a more predictable schedule Or… A rule that leads to a less predictable schedule Staff are just following the Rule… Does a staff member know before the hours of 11 PM – 1 AM that they are going to call off for tomorrow’s 7 AM shift? Then why do they wait and call so late? Did they know days ago that they were not coming in tomorrow? Why don’t they tell us earlier to give us a better chance of covering their shift? 12
6/27/2019 Goal – A More re Predict edictab able le Schedu hedule Please provide as much advance notice as possible (but at least 30 days notice) when requesting more than one day off Please let us know as soon as you can when you know that you can not work a scheduled shift Eaton’s Findings on Scheduling Most Common Reason for Termination Flexible in low turnover SNFs Allow for different start times Consider personal lives Rigid in high turnover SNFs In response to problems “Personal life is not my problem.” Eaton, Phase II Final Report, 2001 13
6/27/2019 No-Fault Attendance Policy If call-off – it counts as 1 No more qualifying absences They are all “excused” Removes inequity No need for physician notes Ask staff to tell the truth because you care about them Goal – A Perfectl ctly Staffed Day No call-offs No registry hours No modified duty assignments No employee orientation hours Fully staffed to budget – every shift/unit Overtime = less than 2% 14
6/27/2019 Consistent Feedback Leadership accountability Set the example Discuss attendance and its’ impact Rewards and recognition Show data Individual feedback Share their own attendance record Provide Respectful Feedback Analyze attendance records Two lists – over 6 callouts and 1 or less Meet with each staff member - “What happened to you?” Or… “Thank you for your reliability!” 15
6/27/2019 You Are Important “We missed you yesterday…and the clients did too. I hope your son is feeling better. We are a better place when you are here.” Performance Compassion Invisibility “The problem is not motivation. It is the ways in which we unintentionally de- motivate employees.” Quint Studer 16
6/27/2019 Proactive Replacement Plan Call employee who called off Show concern Replace for next shift? Replacement priority list daily Stand-by Pay confirmed to come in Name, phone number Best time to call Triggering Reliability - Root-Cause Analysis Organizational issue Collect accurate data Closely monitor Have timely critical conversations Change rigid policies Address other root causes Recognize improvement Public awareness campaign 17
6/27/2019 Mutually y Reinf nfor orci cing g Bundle e – Leadersh ship Rounds • Mood • Stories • Content • Strategic Plan • Timing • Data Notes • Content Community Meetings • Timing • Predictability Leadership Rounds 18
6/27/2019 Effective Rounds 1. Mood, posture and paradigm 2. Content – what you say and do 3. Timing 4. Following up Mood / Posture / Paradigm Flip the switch You are in the spotlight Make eye contact Praise, build self-esteem Smile Linger Hand out granola bars 19
6/27/2019 Five Key Questions To Ask Staff Relationship building “How are your beautiful kids doing?” Focus on the positive “What is working well today?” Positive feedback loop “Is there anybody who has gone above and beyond the call of duty today?” QI - systems focus “Is there anything we can do better?” Needs “Do you have the tools and equipment to do your job?” Studer, Q., “Hardwiring Excellence.” 2003 Rounds Content – What You Say and Do Do Trigger higher performance - Say - “ I ’ m worried about…I ’ m proud about…thanks for helping her with that…that was nice of you…the residents really love you…I notice that you really care…thanks for being here today…I really like working with you ” Do – Answer call lights…hold doors open…sit in the break room…sit at the end of a residents bed and talk to them…shake hands…carry a leftover food tray back to the kitchen…move a linen barrel to the right spot…slow down…go look everywhere… 20
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