Shift Huddles and Hand-offs:Assuring Continuity of Resident Care
April 2 - 4, 2012
Cathie Brady & Barbara FrankB&F Consulting
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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
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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
Communication and Relationship Factors
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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
Communication and Relationship Factors
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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
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Agenda for Shift Huddle
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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…
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•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
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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
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IndividuallyCNA
• Question things that you don’t understand• Tune in• Learn to read the charts
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IndividuallyNursing
• Put on an alarm after a fall• Food supplements• Two hour night time checks• Why are we charting that?
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Developing Critical Thinking as an Organizational Norm
Welcome ideas
Appreciate divergent viewpoints
Make it safe to be challenged
Routinely seek participation when making
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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:
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STOPand
WATCH
If you see something,
say something!
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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
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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
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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
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What Can Happen When Residents Go to the Hospital?
• Confusion
• Immobility
• Deconditioning
• Bedsores
• Pneumonia
• Infections
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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
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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
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Stop and Watch
• Seems different than usual
• Talking or communicates less often
• Overall needs more help than usual
• Participated in activities less than usual
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Stop AND Watch
• Ate less than usual (not because of dislike of food)
• New concerns
• Drank less than usual
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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
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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.
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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.
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Mrs. Jones
What would you do for Mrs. Jones?
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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.
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Mrs. Jones
What would you do for Mrs. Jones?
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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.
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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
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