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

Shift Huddles and Hand-offs:Assuring Continuity of Resident Care

April 2 - 4, 2012

Cathie Brady & Barbara FrankB&F Consulting

© B&F Consulting Inc. 2012 www.BandFConsultingInc.com 1

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

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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 GittellBrandeis University

© B&F Consulting Inc. 2012 www.BandFConsultingInc.com

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Dimensions of Relational Coordination

Interdisciplinary ~ InterdepartmentalAcross Shifts and Days

Communication FrequentTimelyAccurateProblem-solving

RelationshipShared GoalsShared

KnowledgeMutual Respect


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Relationships Closest to the Resident Matter Most

Within and Across Shifts and DaysInterdisciplinary and Interdepartmental

CNAs Residents

Charge Nurses and Nurse Managers

Quality of work Quality of care

Eaton, Bishop, Gittell© B&F Consulting Inc. 2012

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Relational Coordination: Shift Hand-off

LOW:Tape

recorder

HIGH:Person to

person with shift overlap

Communication and Relationship Factors

CNAs Residents

Charge Nurses and Nurse Managers


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Relational Coordination for Start of Shift

LOW:Everyone

just goes to their own

assignment

HIGH:Rounding/

Huddle review of each resident at start of shift



Relational Coordination for End of Shift

LOW:Everyone just

does their paperwork and goes

home

HIGH:Rounding/

Huddle review of each resident at end of shift



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


Agenda for Shift Huddle


Resident by resident by exception: •Risks & opportunities in quality of life & quality of care•MDS functional status, mood, customary routines•INTERACTII “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

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Agenda for Shift Huddle continued…


•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

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Two Central Activities:

1. Identify and challenge our assumptions

2. Explore and imagine options and act on them

CRITICAL THINKINGEnhanced ~ Expansive ~ Analytical Thinking


Critical Thinking vs. Routine CareCNAs

• 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


IndividuallyCNA

• Question things that you don’t understand• Tune in• Learn to read the charts


IndividuallyNursing

• Put on an alarm after a fall• Food supplements• Two hour night time checks• Why are we charting that?


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

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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:


STOPand

WATCH

If you see something,

say something!


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


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


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


What Can Happen When Residents Go to the Hospital?

• Confusion

• Immobility

• Deconditioning

• Bedsores

• Pneumonia

• Infections


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


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


Stop and Watch

• Seems different than usual

• Talking or communicates less often

• Overall needs more help than usual

• Participated in activities less than usual


Stop AND Watch

• Ate less than usual (not because of dislike of food)

• New concerns

• Drank less than usual


Stop and Watch• Weight change

• Agitated or Nervous more than usual

• Tired, weak, confused or drowsy

• Change in skin color or condition

• Help with walking, transferring, toileting more than usual


Mrs. JonesBackground:Mrs. Jones is a resident who has been in your carefor several months. You usually provide limitedassistance to help her transfer and she is able toambulate with her walker. In the mornings, you sether up and she is able to do most her AM careherself although you help her with putting on herTED hose and shoes. She then heads to breakfastwhere she eats independently and spends theafternoon reading and going to some of the scheduled activities.


Mrs. Jones

On Tuesday when you went in to help Mrs.Jones get ready, she told you her right kneewas hurting her. With your help, shemanaged to get out of bed and using herwalker went to breakfast where she ate aswell as usual. After breakfast though, shedidn't want to go to Bingo. She said she was tiredand instead asked you to help her get back intobed.


Mrs. Jones

What would you do for Mrs. Jones?


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.


Mrs. Jones

What would you do for Mrs. Jones?


Mrs. JonesBecause you reported, the nurses realized that herpain, likely caused by arthritis, wasn't respondingto her usual pain meds. They called the doctor,changed her meds and asked therapy to evaluateher. They also realized that her increased swellingmay have been related to her heart failure. Thegot an order for an increased dose of Lasix to helpprevent the fluid buildup from getting worse. Withbetter pain control, she was more able toparticipate in her usual activities.

By Friday, she seemed more like herself.


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


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


Documents

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