1. Shift Huddles and Hand-offs: Assuring Continuity of Resident Care April 2 - 4, 2012 Cathie Brady & Barbara Frank B&F Consulting © B&F Consulting Inc. 2012 www.BandFConsultingInc.com 1

2. Relationships Determine Outcomes Deming said: Quality, the result, is a function of quality, the process Cannot continuously improve interdependent systems and processes until you progressively improve interdependent, interpersonal relationships Covey, 1991 © B&F Consulting Inc. 2012 www.BandFConsultingInc.com 2

3. Theory of relational coordination: Relationships with the resident are shaped by the relationships among all those who are caring for the resident It is the community of relationships that shapes the resident experience Jody Hoffer Gittell Brandeis University © B&F Consulting Inc. 2012 www.BandFConsultingInc.com 3

4. Dimensions of Relational Coordination Interdisciplinary ~ Interdepartmental Across Shifts and Days Communication Frequent Timely Accurate Problem-solving Relationship Shared Goals Shared Knowledge Mutual Respect © B&F Consulting Inc. 2012 www.BandFConsultingInc.com 4

5. Relationships Closest to the Resident Matter Most Within and Across Shifts and Days Interdisciplinary and Interdepartmental CNAsResidents Charge Nurses and Nurse Managers Quality of work Quality of care Eaton, Bishop, Gittell © B&F Consulting Inc. 2012 www.BandFConsultingInc.com 5

6. Relational Coordination: Shift Hand-off LOW: Tape recorder HIGH: Person to person with shift overlap Communication and Relationship Factors CNAsResidents Charge Nurses and Nurse Managers © B&F Consulting Inc. 2012 www.BandFConsultingInc.com 6

7. Relational Coordination for Start of Shift LOW: Everyone just goes to their own assignment HIGH: Rounding/Hudd le review of each resident at start of shift Communication and Relationship Factors © B&F Consulting Inc. 2012 www.BandFConsultingInc.com 7

8. Relational Coordination for End of Shift LOW: Everyone just does their paperwork and goes home HIGH: Rounding/Hudd le review of each resident at end of shift Communication and Relationship Factors © B&F Consulting Inc. 2012 www.BandFConsultingInc.com 8

9. Huddle How-to Who: off-going and on-coming nurses first with off- going CNAs; then with on-coming CNAs What you cover: resident by resident quality of life and quality of care – by exception, from care card, risks and opportunities How long: Will take longer at first, then down to 10 – 15 min. How to do it: Keep it moving and constructive; know your residents, problem-solve together; not for blaming – for fixing and alerting © B&F Consulting Inc. 2012 www.BandFConsultingInc.com 9

10. Agenda for Shift Huddle © B&F Consulting Inc. 2012 www.BandFConsultingInc.com Resident by resident by exception: Risks & opportunities in quality of life & quality of care MDS functional status, mood, customary routines INTERACT II “Stop and Watch” at end of shift Anyone in their ARD Residents coming in and leaving New residents’ social history family medical needs customary routines special needs 10

11. Agenda for Shift Huddle continued… © B&F Consulting Inc. 2012 www.BandFConsultingInc.com Reportable Events, Incidents, Accidents for any resident Complaints and Compliments for any resident Follow-up on any issues – Stand-Down at end of shift Any clinical area that is being worked on (e.g., pressure ulcers) News from any department requiring staff knowledge or coordination Introduction of and check-in with new employees 11

12. Two Central Activities: 1. Identify and challenge our assumptions 2. Explore and imagine options and act on them CRITICAL THINKING Enhanced ~ Expansive ~ Analytical Thinking © B&F Consulting Inc. 2012 www.BandFConsultingInc.com 12

13. Critical Thinking vs. Routine Care CNAs Notes the difference in mood and asks the nurse about it Knows the time of day resident usually wants to take a nap and notes difference Spots slight change in skin and tells nurse Provides care Is pleasant May not note slight changes as anything different Takes pride in efficiency Works hard © B&F Consulting Inc. 2012 www.BandFConsultingInc.com 13

14. Individually CNA Question things that you don’t understand Tune in Learn to read the charts © B&F Consulting Inc. 2012 www.BandFConsultingInc.com 14

15. Individually Nursing Put on an alarm after a fall Food supplements Two hour night time checks Why are we charting that? © B&F Consulting Inc. 2012 www.BandFConsultingInc.com 15

16. Developing Critical Thinking as an Organizational Norm  Welcome ideas  Appreciate divergent viewpoints  Make it safe to be challenged  Routinely seek participation when making decisions © B&F Consulting Inc. 2012 www.BandFConsultingInc.com 16

17.  Lead with questions, not answers  Engage in dialogue and debate, not coercion  Conduct autopsies without blame  Build “red flag” mechanisms Jim Collins Four key practices: © B&F Consulting Inc. 2012 www.BandFConsultingInc.com 17

18. STOP and WATCH If you see something, say something! © B&F Consulting Inc. 2012 www.BandFConsultingInc.com 18

19. It’s All About Communication! CNAs are the EYES and EARS of the facility CNAs see the resident in every aspect of their daily lives No one knows your residents better than CNAs © B&F Consulting Inc. 2012 www.BandFConsultingInc.com 19

20. Trust your judgment! Your close relationship with your residents helps you know when “something’s not right” Value your observations Value your contributions When you notice changes and notify nurses, you help all of us to give better care © B&F Consulting Inc. 2012 www.BandFConsultingInc.com 20

21. The Sooner the Better Small changes can be early catches Act on small changes to prevent them from becoming big problems Keeping issues in check lets us keep our residents where they really want to be: with us and out of the hospital © B&F Consulting Inc. 2012 www.BandFConsultingInc.com 21

22. What Can Happen When Residents Go to the Hospital? Confusion Immobility Deconditioning Bedsores Pneumonia Infections © B&F Consulting Inc. 2012 www.BandFConsultingInc.com 22

23. Keep ERs for Emergencies Some people never rebound from hospital admissions As many as 1/3 of hospitalizations may be avoidable YOU can help prevent these unnecessary and potentially damaging trips Keep your eyes open for changes, notify nurses, and keep our residents out of the hospital © B&F Consulting Inc. 2012 www.BandFConsultingInc.com 23

24. To Whom, What, How, When and Where, do I report changes? Report to your charge nurse Any changes that you may observe, or hear Report changes verbally-not just in Care Tracker, or on a documentation log Report when you first observe or hear a change © B&F Consulting Inc. 2012 www.BandFConsultingInc.com 24

25. Stop and Watch S eems different than usual T alking or communicates less often O verall needs more help than usual P articipated in activities less than usual © B&F Consulting Inc. 2012 www.BandFConsultingInc.com 25

26. Stop AND Watch A te less than usual (not because of dislike of food) N ew concerns D rank less than usual © B&F Consulting Inc. 2012 www.BandFConsultingInc.com 26

27. Stop and Watch W eight change A gitated or Nervous more than usual T ired, weak, confused or drowsy C hange in skin color or condition H elp with walking, transferring, toileting more than usual © B&F Consulting Inc. 2012 www.BandFConsultingInc.com 27

28. Mrs. Jones Background: Mrs. Jones is a resident who has been in your care for several months. You usually provide limited assistance to help her transfer and she is able to ambulate with her walker. In the mornings, you set her up and she is able to do most her AM care herself although you help her with putting on her TED hose and shoes. She then heads to breakfast where she eats independently and spends the afternoon reading and going to some of the scheduled activities. © B&F Consulting Inc. 2012 www.BandFConsultingInc.com 28

29. Mrs. Jones On Tuesday when you went in to help Mrs. Jones get ready, she told you her right knee was hurting her. With your help, she managed to get out of bed and using her walker went to breakfast where she ate as well as usual. After breakfast though, she didn't want to go to Bingo. She said she was tired and instead asked you to help her get back into bed. © B&F Consulting Inc. 2012 www.BandFConsultingInc.com 29

30. Mrs. Jones What would you do for Mrs. Jones? © B&F Consulting Inc. 2012 www.BandFConsultingInc.com 30

31. Mrs. Jones On Wednesday, Mrs. Jones asked if she could eat breakfast in her room. You helped her get dressed because she seemed a little more tired than usual and noticed that her TEDS were more difficult to put on today than usual. Mrs. Jones then spent most of the day in bed reading or napping. © B&F Consulting Inc. 2012 www.BandFConsultingInc.com 31

32. Mrs. Jones What would you do for Mrs. Jones? © B&F Consulting Inc. 2012 www.BandFConsultingInc.com 32

33. Mrs. Jones Because you reported, the nurses realized that her pain, likely caused by arthritis, wasn't responding to her usual pain meds. They called the doctor, changed her meds and asked therapy to evaluate her. They also realized that her increased swelling may have been related to her heart failure. The got an order for an increased dose of Lasix to help prevent the fluid buildup from getting worse. With better pain control, she was more able to participate in her usual activities. By Friday, she seemed more like herself. © B&F Consulting Inc. 2012 www.BandFConsultingInc.com 33

34. Teamwork – Everyone Contributes Ordinary people can perform extraordinarily when they can contribute together; know their work has importance and meaning; and can feel competent to do it With huddles, aides work is valued People deserve to be trusted People are good and want to do a good job People are self- motivated Good Facilitation is key © B&F Consulting Inc. 2012 www.BandFConsultingInc.com 34

35. Listening Skills Tips Commit to improving listening skills Finding the time to stop and listen to the CNA Give eye contact Give feedback to the CNAs Use “teachable moments” help CNAs to grow and become star © B&F Consulting Inc. 2012 www.BandFConsultingInc.com 35