Change Ideas for Consistent Assignmentanha.org/members/documents/ConsistentAssignmentToolKit.pdfConsistent Assignment-Page 2 find it hard to have strangers caring for their intimate

Change Ideas for Consistent Assignment – September 2004 Page 1 of 4

Change Ideas for Consistent Assignment

Typical issues and evidence of discordance:

When employees are not given a consistent assignment they do not build relationships with their co-workers or with residents. Rotating staff means that each time there is a rotation or change in assignment the staff person has to take the time to figure out what the needs are of each new resident they are caring for and how to work with their co-workers for the day. This constant changing is hard for both residents and staff. Most of the care being done is very intimate personal care and residents find it hard to have strangers caring for their intimate needs, and to have to explain their needs time after time to new caregivers. When staff is unfamiliar with each other it is harder for them to have good teamwork together.

Barriers:

Many times frequent changes in shift and assignment are the result of short staffing. When there is not enough staff, the organization responds by plugging holes in the schedule with an available CNA. In other situations the policy of the nursing home is not to let people get attached to each other in the mistaken belief that if a close relationship develops and the resident dies the staff member will be inconsolable. Certain nursing homes don’t think friends should work together. Still others prefer that everyone is trained on every unit and available everywhere. Others do not want staff to be “stuck” with “hard-to-care-for” residents. Ironically, inconsistent assignment exacerbates instability in staffing and conversely, consistent assignment fosters stability. Call outs and turnover are reduced when meaningful relationships develop in which workers know they are being counted on and respond by making sure that the care that is needed is given.

Goal:

To strengthen and honor care-giving relationships To stabilize staffing and establish strong relationships between residents

and staff and among co-workers to provide continuity, consistency, and familiarity in care giving.

Infrastructure helpful to support the change:

Consistent staffing is stable staffing. Its implementation is hardest to achieve in homes that have high turnover and frequent call-outs. By instituting consistent assignment, homes will stabilize their staff because staff are more comfortable caring for the same people every day—they get to know their routines and form genuine bonds with them that enhance their working conditions.

To attain a consistent assignment the nursing home needs to build stabilizing influences into their workforce. Instead of utilizing “agency” or “pool” assistance when there are call outs the home can institute an in-house pool of people who agree to work in certain areas. The in-house pool is familiar with the residents. Monetary incentives are recommended to favor stable

Care practice Work Place Practice Environment

This material was designed by Quality Partners, the Medicare Quality Improvement Organization for Rhode Island, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the US Department of Health and Human Services. Contents do not necessarily represent CMS policy. 8SOW-RI-NHQIOSC-082006-2



Infrastructure helpful to support the change:

Consistent staffing is stable staffing. Its implementation is hardest to achieve in homes that have high turnover and frequent call-outs. By instituting consistent assignment, homes will stabilize their staff because staff are more comfortable caring for the same people every day—they get to know their routines and form genuine bonds with them that enhance their working conditions.

To attain a consistent assignment the nursing home needs to build stabilizing influences into their workforce. Instead of utilizing “agency” or “pool” assistance when there are call outs the home can institute an in-house pool of people who agree to work in certain areas. The in-house pool is familiar with the residents. Monetary incentives are recommended to favor stable assignments, instead of providing bonuses for per diem schedules or last minute work assignments. Supervisors need to create a team approach to the workforce. Management needs to provide employee assistance and flexibility when staff encounters family or financial problems that interfere with work attendance. These include employee loan programs and links with social support programs.

Measurement possibilities:

Number of shifts per week with unscheduled absences Number of shifts staffed below the scheduled staffing level Staff turnover Staff workload Resident and staff relationships

PDSA Cycles:

PLAN: Engage a team of staff, residents, and family to create an in-house “pool” to assist with any call outs. DO: Provide monetary incentive STUDY: Keep a log of facility call-outs for a set amount of time. Determine what is working and what is not working. ACT: Continue utilizing the in-house “pool” and take additional steps to provide incentive.

Questions to consider:

How does familiarity and routine help increase comfort and competence? How important are relationships to residents? To caregivers? To co-

workers? To quality care? How does teamwork help improve care? Would you like different people toileting and bathing you each day? Would you like having a different team each day? What do residents experience when they have frequent changes in their

caregivers? What do staff experience when their assignment is routinely changed? How

does that affect their relationship to their work?




Change Ideas:

Make a mutual commitment to consistent assignment – for staff that commit to a certain set schedule, commit back that they can count on that schedule.

Find out from staff what their preferred schedule and assignments would be. Create teams that work regularly together. Ask teams to work with each other to provide back-ups and substitutes for

when they need to change their schedule or call in on a scheduled shift. Find out who on staff enjoys floating or prefers various assignments rather

than destabilizing the whole staff by making everyone float. Have inter-shift communications among all staff from each work area, in

which personal information about how each resident did for the day is shared, so as to ensure a smooth hand-off.

Figure out when the busiest times are in accordance with the residents’ patterns, and adjust schedules to have the help that’s needed during those times.

Have regular housekeeping and food-service staff working with each care area.

When new staff is brought on, assign them to one work area so that they are familiar with a group of residents and co-workers well and acclimate to the work with them. Have the entire workgroup help welcome and mentor their new co-worker.

Associated principles

Relationships are the cornerstone of culture change. Residents who are cared for by the same staff members come to see the

people who care for them as “family.” Staff that care for the same residents form a relationship and get great

satisfaction from their work. When staff care for the same people daily they become familiar with their

needs and desires in an entirely different way—and their work is easier because they are not spending extra time getting to know what the resident wants—they know from their own experience with the resident.

When staff and residents know each other well, heir relationship makes it possible for care and services to be directed by the resident’s routines, preferences, and needs.

Relationships form over time – we do not form relationships with people we infrequently see. To encourage and support relationships, consistent assignment of both primary staff and ancillary staff is recommended.

When staff routinely work together, they can problem-solve and find creative ways to re-organize daily living in their care area.

Consistent assignment forms the building block for neighborhood-based living.

Resources: 1. Centers for Medicare & Medicaid Services (CMS). 5.0. What a difference




management makes! Nursing staff turnover variation within a single labor market [Online]. From: Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes. Phase II Final Report, Dec 2001. Available: http://www.cms.hhs.gov/medicaid/reports/rp1201-5.pdf, 15 Sep 2004.

2. Weech-Maldonado R, Meret-Hanke L, Neff MC, Mor V. Nurse staffing patterns and quality of care in nursing homes. Health Care Manage Rev. 2004 Apr-Jun; 29 (2): 107-16.

3. “What a difference management makes!” by Susan Eaton, Chapter 5, Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes (Phase II Final Report, December 2001). U.S. Department of Health and Human Services Report to Congress.

4. “PEAK: Pioneering Change to Promote Excellent Alternatives in Kansas Nursing Homes” by Lyn Norris-Baker, Gayle Doll, Linda Gray, Joan Kahl, and other members of the PEAK Education Initiative. http://www.ksu.edu/peak/booklet.htm


HATCh Holistic Approach to Transformational Change

Consistent Assignment

Definition: Consistent assignment (some-times called primary or permanent assign-ment) refers to the same caregivers (RNs, LPNs, CNAs) consistently caring for the same residents almost (80% of their shifts) every time they are on duty. The opposite of consis-tent assignment is the practice of rotating staff from one group of residents to the next after a certain period of time (weekly, monthly, or quarterly). Facilities who have adopted con-sistent assignment never rotate their staff. A few strong arguments for adopting consis-tent assignment include: • Relationships are the cornerstone of cul-

ture change. • Residents who are cared for by the same

staff members come to see the people who care for them as “family.”

• Staff that care for the same residents form

a relationship and get great satisfaction from their work.

• When staff care for the same people daily

they become familiar with their needs and desires in an entirely different way—and their work is easier because they are not spending extra time getting to know what the resident wants—they know from their own experience with the resident.

• When staff and residents know each other

well, their relationship makes it possible for care and services to be directed by the resident’s routines, preferences, and needs.

• Relationships form over time – we do not

form relationships with people we infre-quently see. To encourage and support rela-tionships, consistent assignment of both pri-mary staff and ancillary staff is recommended.

• When staff routinely work together, they can

problem-solve and find creative ways to re-organize daily living in their care area.

• Consistent assignment forms the building

block for neighborhood-based living. Typical issues: When employees are not given a consistent assignment they are not as likely to build relationships with their co-workers or with residents that create a deep sense of satisfaction and “knowing”. Rotating staff means that each time there is a rotation or change in assignment the staff person has to take the time to figure out what the needs are of each new resident they are caring for and how to work with their co-workers for the day. This constant changing is hard for both residents and staff. Most of the care being done is very intimate personal care and residents

Change Idea Sheet-Consistent Assignment Page 1 of 6

Consistent Assignment-Page 2

find it hard to have strangers caring for their intimate needs, and to have to explain their needs time after time to new caregivers. When staff is unfamiliar with each other it is harder for them to have good teamwork to-gether. Barriers: Many times frequent changes in shift and assignment are the result of short staffing. When there is not enough staff, the organization responds by plugging holes in the schedule with an available CNA. In other situations, the policy of the nursing home is not to let people get attached to each other in the mistaken belief that if a close re-lationship develops and the resident dies the staff member will be inconsolable. Certain nursing homes don’t think friends should work together. Still others prefer that every-one is trained on every unit and available eve-rywhere. Others do not want staff to be “stuck” with “hard-to-care-for” residents. Ironically, inconsistent assignment exacer-bates instability in staffing and conversely, consistent assignment fosters stability. Call outs and turnover are reduced when meaning-ful relationships develop in which workers know they are being counted on and respond by making sure that the care that is needed is given. Regulatory Support: There is no regulatory requirement mandating the practice of consis-tent assignment. However, this practice can contribute to successfully meeting regulations found under the Quality of Life and Quality of Care requirements of the federal regula-tions in OBRA ‘87. The interpretive guidelines for F240 Quality of Life states, “The intention of the quality of life requirements specify the facility’s respon-sibilities toward creating and sustaining an environment that humanizes and individual-izes each resident.” Additionally, regulatory

language found under F241 Dignity, F242 Self-Determination and Participation, and F246 Ac-commodation of Needs all include the nursing home’s responsibility to create and maintain an environment that supports each resident’s indi-viduality. The practice of consistent assignment provides staff and residents the opportunity to build strong relationships that result in staff knowing and supporting each resident as an individual. It helps create an environment that promotes staff to learn about and support a resident’s likes, preferences, and interests, which is directly sup-ported by the intent of the quality of life re-quirements. Strong caregiver-resident relationships can also lead to positive quality of care outcomes. Meet-ing the intent of the Quality of Care require-ments found in OBRA ’87 is heavily dependent on the direct caregiver implementing the resi-dent’s care plan (F282 Services provided by qualified person in accordance with each resi-dent’s written plan of care.) If staff has the op-portunity to work with residents on a consistent basis, then staff will be more familiar with care plan goals and treatment objectives. This can result in consistent implementation of care plan approaches. It also provides opportunities for staff to promptly identify when care plans need revision due to a resident’s refusal, preferences related to treatment, or a decline in the resident’s condition (F280 A comprehensive care plan must be – (iii) Periodically reviewed and revised by a team of qualified persons after each as-sessment.) The better that staff know each individual resi-dent that they work with, the more likely the in-tent of the Quality of Life and Quality of Care requirements will be met.



Goals: • To strengthen and honor care-giving rela-

tionships • To stabilize staffing and establish strong

relationships between residents and staff and among co-workers to provide continu-ity, consistency, and familiarity in care giving.

Making the Change: There are many ways to undergo the change process. A good start is to think about who can help and to plan in a systematic way the necessary steps. Ensuring that its not a top-down edict but a shared commitment on the part of the community based on need creates a climate ripe for change. A helpful tool can be the Model for Improvement that uses the PDSA Cycle (Plan-Do Study-Act). This is a way to sys-tematically go through a change process in a thoughtful way. With your committees and groups ask: 1. What are we trying to accomplish? (Better

relationships; less turnover of staff; greater satisfaction among families and residents?) Naming and articulating what it is that you are trying to accomplish will help you months from now (when you are in the thick of things!) to remember the original intention of the change.

2. How will we know a change is an im-

provement? This is the question that begs a measurement response.

3. What changes can we make that will re-sult in an improvement? Go study your subject-find out what others have done, take a road trip, phone a friend, go to a Pioneer conference, talk with experts-ask others to do the same.

Sometime, after having this conversation a committee will be energized and ready to try everything. After all, they are all great ideas that will benefit residents and staff in the long run. It’s also a homegrown solution to a problem or challenge faced by the organization. Though tempting, it is important not to try all of these ideas at once. Try one idea, roll it out on a small sample or pilot, test it, measure it. If it’s not working tweak it. This process is called a PDSA cycle. It looks like this. Plan: Each PDSA cycle has an objective and a measure. In this phase, create it. DO: Activate the plan & collect data using the method the team decided upon to measure your success. As much as possible do this on a small scale. Don’t try the change on the whole home; try it on a few people or a wing, unit or neighborhood. Small is better. You can keep tweaking and adding to your sample as you see success. Many teams go as far as Plan-Do. Some teams become very involved in the doing but some-times find themselves in the midst of many fail-ures without knowing what went wrong or why. The process invites the team to study their activ-ity to ensure they are heading in the right direc-tion. Even finding that one is heading in the wrong direction can offer valuable feedback to a committed team. The next step then, is the study phase. Study: Test the hypothesis out. Stay open to the possibilities. There are many things you might find happen that you didn’t expect. Be sure to note these unexpected gains. Sometime, after having this conversation a committee will be energized and ready to try everything. After all, they are all great ideas that will benefit residents and staff in the long run. It’s also a homegrown solution to a problem or



challenge faced by the organization. Though tempting, it is important not to try all of these ideas at once. Try one idea, roll it out on a small sample or pilot, test it, measure it. If it’s not working tweak it. This process is called a PDSA cycle. It looks like this. Plan: Each PDSA cycle has an objective and a measure. In this phase, create it. DO: Activate the plan & collect data using the method the team decided upon to measure your success. As much as possible do this on a small scale. Don’t try the change on the whole home; try it on a few people or a wing, unit or neighborhood. Small is better. You can keep tweaking and adding to your sample as you see success. Many teams go as far as Plan-Do. Some teams become very involved in the doing but sometimes find themselves in the midst of many failures without knowing what went wrong or why. The process invites the team to study their activity to ensure they are heading in the right direction. Even finding that one is heading in the wrong direction can offer valu-able feedback to a committed team. The next step then, is the study phase. Study: Test the hypothesis out. Stay open to the possibilities. There are many things you might find happen that you didn’t expect. Be sure to note these unexpected gains. Act: Once you have completed the process identified above you have a more complete understanding of the challenge or problem. Now armed with very specific information and data you have three options: • Adapt the change • Adopt the change • Abort the change

This entire process can be done in a very public way by using storyboards to journey the process. Remembering to celebrate the success of the process is an important feature of the story help-ing staff, families and resident alike to witness the ongoing efforts made to improve the home. Measuring Success: Here is a simple way to calculate/measure consistent assignment efforts. 1. Collect one week per month of staff assign-

ment sheets (filled out by the nurse on the unit at the beginning of each shift). Gather this information for each unit in the facility for both day shift and PM shift from the past 3 months.

2. Choose 4 full-time (5 shifts per week) CNAs to track, 2 from day shift and 2 from PM shift from one unit.

3. The goal is to measure how often these CNAs took care of the same residents. In or-der to determine which residents/rooms to track with each CNA, look at the first 3 days of assignment sheets and determine the group of residents/rooms each care giver has been assigned to. For example, if one of the CNAs was assigned to a group for two of the three days you were looking at, this would be the group that you would assume the care-giver is consistently assigned to. This will be the group of residents to track with the CNA.

4. Now, look at all 21 days worth of assign-ments and calculate how often each CNA was assigned to the same rooms that you es-tablished was their primary assignment.

5. Because there are seven days in a week but the CNAs only work five, caring for the same group of residents five out of seven days equals 100%. Four out of seven days equals 80%, etc.



6. Add up all four of the CNAs numbers over the three weeks you examined to get the total percentage of time the same CNAs care for the same residents.

Example: For one unit CNAs Week 1 Week 2 Week 3 Total Mary 3/5 5/5 4/5 12/15 Jay 5/5 4/5 5/5 14/15 Sam 4/5 4/5 5/5 13/15 Maria 3/5 5/5 2/5 10/15 Total= 49/60 82% of the times the full-time CNAs care for the same residents on this unit.

Note: This assumes that the leadership team is not rotating the CNAs quarterly. Questions to Consider: • How does familiarity and routine help in-

crease comfort and competence? • How important are relationships to resi-

dents? To caregivers? To co-workers? To quality care?

• How does teamwork help improve care? • Would you like different people toileting

and bathing you each day? • Would you like having a different team

each day? • What do residents experience when they

have frequent changes in their caregivers? • What do staff experience when their as-

signment is routinely changed? How does that affect their relationship to their work?

Change Ideas: • Make a mutual commitment to consistent

assignment – for staff that commit to a certain set schedule, commit back that they can count on that schedule.

• Find out from staff what their preferred schedule and assignments would be.

• Create teams that work regularly together. • Ask teams to work with each other to pro-

vide back-ups and substitutes for when

they need to change their schedule or call in on a scheduled shift.

• Find out who on staff enjoys floating or pre-fers various assignments rather than destabi-lizing the whole staff by making everyone float.

• Have inter-shift communications among all staff from each work area, in which personal information about how each resident did for the day is shared, so as to ensure a smooth hand-off.

• Figure out when the busiest times are in ac-cordance with the residents’ patterns, and ad-just schedules to have the help that’s needed during those times.

• Have regular housekeeping and food-service staff working with each care area.

When new staff is brought on, assign them to one work area so that they are familiar with a group of residents and co-workers and acclimate to the work with them. Process to change from rotating assignment to consistent assignment:

1. Bring together CNAs from each shift. This might require having a number of separate meetings. Be sure everyone is included.

2. Begin the meeting by explaining that nursing

homes that have switched to consistent as-signment have proven to the improve quality of care and life of the residents and the qual-ity of work life for the staff. Suggest that we pilot test consistent assignment and see how it works.

3. Place each residents name on a post it note

and place all of the post it notes on the wall. 4. Next, ask the group to rank each of the resi-

dents by degree of difficulty with number 1 being relatively easy to care, number 3 in the middle and number 5 being very difficult to



care for (time consuming, emotionally draining, etc…). Let the CNAs discuss each resident and come to an agreement. Write the number on the resident’s post it note.

5. Then, allow the CNAs to select their as-

signments. Assignments are fair when the numbers assigned to each resident add up to the other totals of the other CNA as-signments. Therefore, if one assignment has six residents and another has eight residents but the degree of difficulty num-bers total 27 then the assignments are fair. Relationships with residents are important and also should be part of the decision making process. The sequence of rooms is less important.

6. Meet every three months to reexamine

that the assignments, based upon degree of difficulty, are still fair.

Resources:

1. Centers for Medicare & Medicaid Ser-vices (CMS). 5.0. What a difference management makes! Nursing staff turn-over variation within a single labor market [Online]. From: Appropriateness of Minimum Nurse Staffing Ratios in Nurs-ing Homes. Phase II Final Report, Dec 2001. Available: http://www.cms.hhs.gov/medicaid/reports/rp1201-5.pdf, 15 Sep 2004.

2. Weech-Maldonado R, Meret-Hanke L, Neff MC, Mor V. Nurse staffing patterns and quality of care in nursing homes. Health Care Manage Rev. 2004 Apr-Jun; 29 (2): 107-16.

3. “What a difference management makes!” by Susan Eaton, Chapter 5, Appropriate-ness of Minimum Nurse Staffing Ratios in Nursing Homes (Phase II Final Report, December 2001). U.S. Department of

Health and Human Services Report to Con-gress.

4. “PEAK: Pioneering Change to Promote Ex-cellent Alternatives in Kansas Nursing Homes” by Lyn Norris-Baker, Gayle Doll, Linda Gray, Joan Kahl, and other members of the PEAK Education Initiative. http://www.ksu.edu/peak/booklet.htm

5. Burgio L.D., et al. Quality Of Care in the Nursing Home: Effects of Staff Assignment and Work Shift. The Gerontologist 2004 44(3): 368-377.

6. Campbell S., Primary Nursing: It Works in Long-Term Care. Gerontological Nursing 1985, issue 8, 12-16.

7. Cox, C., Kaesner, L., Montgomery, A., Marion, L. Quality of Life Nursing Care: An Experimental Trial in Long-Term Care. Journal of Gerontological Nursing 1991, is-sue 17, 6-11.

8. Patchner, M. Permanent Assignment: A Bet-ter Recipe for the Staffing of Aides. Success-ful Nurse Aide Management in Nursing Homes 1989, 66-75.

9. Grant, L. Organizational Predictors of Fam-ily Satisfaction in Nursing Facilities. Seniors Housing and Care Journal 2004, volume 12, 3-13.

Created and distributed by:

Quality Partners of Rhode Island designed this material under contract with the Centers for Medicare & Medicaid Services, an agency of the U.S. Department of Health and Human Services. Contents do not necessarily represent CMS policy. Updated: August 31, 2007 Contributors include: Quality Partners of RI RI Department of Health B&F Consulting


IF ONE THINKS OF A NURSING

facility as a fragile ecosystem inwhich each policy, department,

staff member, and patient is systemati-cally connected, it is easy to see how aseemingly small change might affectthe whole.

Such is the case with consistentassignment, an alternative staffingmodel that, when put into practice, hasbeen shown to significantly impactsuch factors as staff retention, residentand family satisfaction, and even clini-cal outcomes.

Specifically, the term consistentassignment refers to a staffing model inwhich patients are cared for each andevery day by the same staff members,rather than having the clinical staffrotate its assignments from one groupof patients to another. The implemen-tation of consistent assignment is theeighth and final goal in the AdvancingExcellence in America’s NursingHomes (AE) campaign, and it may wellbe the linchpin for the entire initiative.

Recent AchievementsBy way of example, a large urban nurs-ing facility in California implementedmore than 130 changes in its quest tomove from an institutional care modelto an individualized, or person-cen-tered, model of care.

But of all the changes made, accord-ing to the facility’s administrator, it wasthe switch to consistent assignment inthe first month of the process thathelped pave the way for a host of posi-tive results.

“We built off of relationships thatdeveloped and created a sense of com-

munity,” said the administrator. As aresult, he said, over the past year:

■ The annualized turnover rate forcertified nurse assistants (CNAs)declined from 94 percent to 38 percent;

■ The turnover rate for licensed

nursing staff declined from 43 percentto 11 percent;

■ The nursing staff only workedwith less than the optimal number ofstaff (“short staffed”) on 10 occasionsin 280 days—less than a 3 percentchance a neighborhood would workunderstaffed on any given day;

■ Nursing department staff call-offsdeclined by 40 percent;

■ Patients at high risk with pressureulcers dropped from 25 percent to 11percent;

■ Residents at low risk with pres-sure ulcers declined from 4.5 percentto 0 percent; and

■ The overall occupancy rate of thefacility increased from 82 percent to 94percent.

“I am proud of these numbers,” saidthe administrator. “These percentagesare people. By creating a better qualityof work life for our staff, we enhancedthe residents’ quality of life, and wegave their families greater peace ofmind.”

This is by no means an isolated case.In fact, facilities that change fromrotating staff assignment after a periodof time to consistent assignment havereported an impact on key quality indi-cators that is profoundly positive.Studies have documented a solid evi-dence base that consistent assignmentlowers turnover (AE Goal 7), improvesresident and family satisfaction scores(AE Goal 6), and improves the abilityof staff to recognize and address clini-cal issues at their earliest, most pre-ventable stages (AE Goals 1 – 4).

Why It WorksThere is nothing particularly complexor magical about consistent assign-ment. The key is in allowing caringrelationships between staff and patientsto develop and flourish over time. In

Focus On CAREGIVING

A Keystone For ExcellenceImplementing consistent assignment provides a strong foundation for achievingthe goals of the Advancing Excellence in America’s Nursing Homes program.

Provider • July 2007 35

DAVID FARRELL AND

BARBARA FRANK

DAVID FARRELL, MSW, NHA, is director,Care Continuum Lumetra (California’squality improvement organization), SanFrancisco, and a member of the AmericanHealth Care Association’s QI Committee.BARBARA FRANK, MPA, is with B&FConsulting, Warren, R.I.

The key is inallowing caringrelationships bet-ween staff andpatients to developand flourish overtime.

long term care, the work has an inher-ent meaning for people attracted tocaring for others. Yet, managementsystems such as rotating assignmentcan interfere with, rather than support,the caring connection with patientsthat draws people to caregiving work.Fundamentally, the implementation ofconsistent staff assignment createswork situations that build on theintrinsic motivation of many staffmembers—the opportunity to formand sustain close relationships with thepatients.

In her article, “Beyond ‘unlovingCare’: Linking Human ResourceManagement and Patient Care Qualityin Nursing Homes” (InternationalJournal of Human Resource Management,June 11, 2000), researcher Susan Eatonnotes that staff retention is all aboutrelationships. Good relationships are atthe heart of good work environments,she says, including relationships withco-workers; across departments; withsupervisors; with the organization; and,in the case of long term care facilities,with patients and their families.

Further ConfirmationThe National Citizens Coalition forNursing Home Reform has furtherconfirmed that patients and their fami-lies consider the quality of the rela-tionships they have with their frontlinecaregivers as more valuable than thequality of the medical care and thequality of the food that’s served at thefacility. Relationships are the corner-stone of individualized, person-direct-ed care.

Researcher Mary Lescoe-Long stud-ied the family members’ perspective insix Kansas nursing facilities and foundthat family members were keenlyaware of staff members who displayedpersonal empathy toward their lovedones. She discovered that family mem-bers wanted the CNAs and nurses to“know my mom as a person.” Andwhen family members see and feel thatpersonal empathy, it gives them “peaceof mind.”

When staff care for the same peopledaily, they become familiar with theirneeds and desires, and their work iseasier because they are not spendingextra time getting to know what eachpatient prefers.

Knowing the patients’ routines andpreferences, as well as their familymembers, can only come aboutthrough consistent personal exposureover time.

As staff members remember thepatients’ routines, they are likely to be

praised by more satisfied patients andfamilies, thus enhancing their own selfesteem and, perhaps, lowering theirthoughts of leaving a facility.Therefore, consistent assignment fuelssuccess in AE Goal 6 (satisfaction) andGoal 7 (staff turnover).

Better Patient CareLong term care researcher Lou Burgiocompared two nursing facilities withconsistent assignments to two nursingfacilities that employ rotating assign-ments. Patients living in consistentassignment facilities received signifi-cantly higher ratings on patientgrooming and personal appearancethan patients in rotating assignmentfacilities.

In addition, Burgio found thatCNAs working in consistent assign-ment facilities reported higher job sat-isfaction than those working in rotat-ing assignment facilities.

The Centers for Medicare &Medicaid Services (CMS) recognizes

that consistent assignment is key toindividualized care.

In a recent CMS surveyor trainingbroadcast, staff members at a facilitythat uses consistent assignment talkedabout how they are able to notice andtreat small red spots before theybecome pressure ulcers (AE Goal 1)and how they are able to recognize andaddress pain in their patients becausethey know them so well (Goal 3). Thisis the case even among short-staypatients because the facility is nowgeared toward establishing solid rela-tionships as soon as a new patient isadmitted (Goal 4).

A geriatric psychiatrist in this train-ing broadcast described how, throughindividualized care, staff know theirpatients better and can use alternativemeans of preventing falls and address-ing challenging behaviors, thus reducing their use of restraints (AEGoal 2).

Many of the culture change pioneerscontend that individualized caredepends on having consistent assign-ment in place.

Leaders who implement systems thatfoster and support caring relationshipsbetween patients and staff have an easi-er time recognizing and addressingclinical issues while they are still small.Their staffs feel a greater sense of sat-isfaction and responsibility, as reflectedin a higher rate of retention. The sys-tem of consistent assignment allowsstaff to develop close relationships withpatients they are caring for and withco-workers they are providing carewith.

Clearly, the system of consistentassignment, backed by research-basedevidence, is the foundation for individ-ualized care and a first step toward amore stable workforce, improved clini-cal care, and enhanced quality of lifefor patients process. ■

36 Provider • July 2007

Focus On CAREGIVING

■ David Farrell can be contacted [email protected].

For More Information

When staffcare for the same people daily,they becomefamiliar with theirneeds and desires.

Focus On CAREGIVING

38 Provider • July 2007

The first evaluative study of federalpaid feeding assistant (PFA) regula-

tion demonstrates that the quality ofcare provided in nursing facilities bystaff trained as PFAs is comparable tothe quality of care provided by indige-nous nurse assistants, according to theCenters for Medicare & MedicaidServices and the Agency forHealthcare Research and Quality.

“There were few to no significantdifferences in the adequacy and qualityof assistance provided by regular [cer-tified nurse assistants] versus PFAs,”the study’s authors concluded. “It isnoteworthy that licensed staff in thisstudy reported not only acceptance ofthe use of PFAs but even enthusiasmfor existing programs.”

Published in the April 2007 issue ofThe Gerontologist, the study seeks to

address the impact of the 2003 PFAregulation that allows a nursing facilityto hire single-task workers to providefeeding assistance to its patients.

In order to accomplish this goal,researchers observed PFA care at thefacility and individual level and con-ducted staff interviews at each of sevenselected nursing facilities in threestates. Data from these observationswere used to develop five care processmeasures relating to the adequacy andquality of staff assistance to encourageboth meal intake and patients’ inde-pendence in eating.

Interviews with multiple upper-levelstaff members, including administra-tors, directors of nursing, charge nurs-es, staff developers/trainers, and otherindividuals involved in PFA curriculumrevealed that, overall, they were satis-

fied with the PFA program in theirfacilities. All of the interviewees (100percent) reported that in addition tomaking no changes to existing certifiednurse assistant (CNA) or licensednurse staffing levels following PFAprogram implementation in their facil-ities, they planned to continue the PFAprogram and train additional staff.

Nearly all of the CNAs interviewed(96 percent) reported that they consid-ered the PFAs “helpful” for perform-ing one or more mealtime tasks inaddition to feeding assistance care pro-vision, while 92 percent reported thatthey had “no concerns” about the PFAprogram within their facility.

PFA interviews confirmed that theywere “comfortable” with their patientassignments and were able to “get helpfrom licensed staff when needed.”Some PFAs reported that they helpedwith additional mealtime tasks beyondindividual feeding assistance, such astransporting patients to and from thedining room; delivering, setting up,and picking up meal trays; and deliver-ing additional foods and fluids betweenmeals.

While the overall assessment of thePFA programs was positive, theauthors, nonetheless, suggested thatlicensed nurse supervision needs to beincreased for direct-care staff duringmealtime care to aide in the identifica-tion of patients in need of assistanceand to oversee the feeding of patientswith complicated needs.

With regard to the adequacy of stafftraining, almost all staff providingfeeding assistance had received at leasteight hours of formal training specifi-cally focused on feeding assistance,which included both written and per-formance-based competency evalua-tions. PFAs and CNAs, the authorsnoted, actually received comparabletraining relative to this specific careprocess.

—Meg LaPorte

Feeding Assistants Deemed Competent

22 Provider • June 2011

T

he Ties That Bind

Cons i st ent a ss ignment g i ve s r e s iden ts a s en se o f secu r i t y, f ami l y.

Provider • June 2011 23

I

Joanne Kaldy is a freelance writer and communications consultant based in Harrisburg, Pa.

T

he Ties That Bind

Cons i st ent a ss ignment g i ve s r e s iden ts a s en se o f secu r i t y, f ami l y.

magine this happening: A certified nurse assistant (CNA) accidentally drops a

resident during a transfer. The frail, elderly individual is bruised, sore, and has

a skin tear. When an investigation is conducted, the resident defends the CNA

and refuses to blame her for the accident. She says that the caregiver always is

conscientious and responsible and treats her with genuine care and concern.

She states emphatically, “I will not help you fire her.”

Or consider this story: A very elderly—over age 100—resident passes away.

She has no family. She leaves behind a box of belongings, including photos and

other personal items. Instead of discarding them and forgetting about a life and

what it meant, the resident’s assistant asks to keep the items. She says that she

wants to keep the woman’s memory alive. She says, “We are her family now.”

A Family Affair

These are true stories that epitomize the value of consistent assignment. A

growing number of long term care facilities have embraced this concept and

implemented it with great success, and the investment is reaping tremendous

dividends—happier residents and families, fewer behavioral problems, greater

staff stability and lower turnover, and more referrals. Staff, residents, and fam-

ily members alike are so enthusiastic about consistent assignment that facility

leaders are wondering, “Why didn’t we do this sooner?”

While establishing and maintaining consistent

assignment requires some work, many say it’s as

easy as teamwork, flexibility, and trust. These

elements not only help facilities move forward

with consistent assignment, they flourish as care

becomes a family affair with everyone working

together to create a caring, safe, and homelike

environment.

Joanne Kaldy


The benefits of consistent assign-ment seem obvious. “The CNA gets to know the resident very well and is familiar with the person’s habits, routines, and behavior. If the resident’s behavior changes—however subtly—the CNA is the first one to notice,” says Sister Pauline, administrator, Tere-sian House Center for the Elderly, a church-affiliated long term care facility in Albany, N.Y.

The CNA’s familiarity with the resident also can prevent behavioral

changes caused simply because an as-sistant doesn’t know about a resident’s routine, pet peeves, or preferences. Sister Pauline gives an example from her own family.

“My mother [who is a resident at Sister Pauline’s facility] always wore a scarf, and her CNAs know this, so they make sure she always has a scarf.”

She adds, “The aides spend a great deal of time with families and residents, and strong bonds are created. I get beautiful letters from families about

care CNAs provided to their loved ones.”

Residents, Families, Staff Like ItAccording to Barbara Baylis, RN, MSN, senior vice president of clinical and residential services for Kindred Healthcare in Louisville, Ky., “The residents and families like having some-one they can depend on every day. And they don’t have to tell their story over and over again.” As a result of consis-tent assignment, she says, facilities can

Plain Talk From Nursing Staff

Nursing staff from two facilities sat down with Provider and shared their thoughts and experiences regarding consis-tent assignment. Here are some of their insights:

n “I’ve been on one floor for six years. I like knowing where I’m going when I get to work. We have a routine, and we get it done. Everyone works together.”

n “Building a bond with families gives them a sense of security. I take care of a 104-year-old resident, and she doesn’t like anyone else to care for her. … Residents get to know when your days off are, and they like knowing who they will see and when.”

n “For the most part, each floor is the same here. We all get about the same number of residents. There’s a good balance between those people who need more hands-on care and those who are more independent.”

n “Team building is an important part of this concept [consistent assignment]. Mrs. Jones might be well on Wednesday, but you don’t know what will happen on Thursday. You have to build a strong team so that every-one can help out if there is a problem. We call it global duty. Everyone pitches in.”

n “You have to build a relationship with co-workers so that you can say, ‘I need a break from Mrs. Smith.’ We re-evaluate assignments from time to time to give people breaks as they need them. We try to work among our-selves to figure out assignments.”

n “I have one resident who declined when I went on a business trip for a week. She became very upset and would call my name. I have another resident who I take to my home for visits or out to lunch. My job is my home.”

n “I have one resident with a very involved family. Her daughter is happy to know that I can spot anything out

of the ordinary in her behavior or habits. She’s gotten to know me, and she feels much more confident and secure about her mother’s care. But you have to be careful not to give families the idea that you’re the only person who can care for their mother or father.”

n “I can count on the CNAs to detect even minor changes in residents. When residents leave for some rea-son, they often request to come back.”

n “Consistent assignment has helped with efficiency. We can determine what people want before they ask.”

n “It’s nice to have the same people caring for residents for even simple things like knowing what Mrs. Smith wore yesterday so she isn’t dressed in the same outfit to-day. You don’t have to bring in a tray and then take it back because you discover Mr. Jones doesn’t like scrambled eggs. You know this in advance.”

n “We have one resident with dementia. He would get agitated every time it snowed because he would think he should get out there with his plow. So we learned to close the blinds when it would snow, and he would stay calm.”

n “We actually have a long reservation list. People want to come here, and they want to come back when they leave. We get many referrals from families and others, and we’re very proud of that.”

n “We have a resident now who has been here sev-eral times for various reasons. She always tells me how comfortable she is here. There is not a ‘getting to know you stage.’ We just pick up where we left off, and she gets what she needs from the start.”

n “I took care of one resident for a long time. When she passed away, I was working on a different unit, but I requested to do her aftercare. Her family contacted me later and thanked me for what I did.”


expect to see a decrease in resident and family complaints and concerns.

The residents and families aren’t the only ones who benefit. “Consistent assignment makes it much easier and more pleasant to come to work,” Sister Pauline says. “They can plan their schedules according to their residents. They know who gets up early, stays up late, and so on. They know how their residents like their rooms and what they want on their beds. It makes for real harmony among everyone involved.”

Consistent assignment also enables staff to detect problems earlier and devise individualized solutions to chal-lenging situations.

For example, Barbara Frank, MPA, co-founder of B&F Consulting, a War-ren, R.I.-based company that works with nursing facilities and other orga-nizations on staffing, culture change,

and quality improvement, says, “I hear all the time from CNAs that they can anticipate residents’ needs all through the day and respond to them promptly and proactively.”

She cites a story from long term care physician Al Power, MD, who was try-ing to prevent pressure ulcer devel-opment in a high-risk resident. The nursing facility team kept attempting to turn the woman on her side facing the window, and she kept turning back on her other side toward the door. Her CNA observed that the resident was a bird lover and suggested hanging a bird feeder outside the window. The team did as she suggested, and it worked.

“Consistent assignment lets you intervene in a way that is likely to pro-duce positive outcomes. And staff have a real sense of personal accountability when they work this closely with their residents,” Frank says.

Starting on the road to consistent assignment is easier for most facilities than they realize. As Sister Pauline notes, “Many facilities have been doing it for awhile, but they didn’t have a name for it.” Baylis says, “We initi-ated this over three years ago when it became an Advancing Excellence Campaign goal [see box, page 28]. It is rooted in primary nursing and based on a staffing model that has been around for about 30 years.” Currently, about 99 percent of Kindred facilities have consistent assignment.

Assess, Stabilize, StartA first step to establishing consistent assignment, says Dwight Tew, vice president, talent solutions, for Brook-dale Senior Living in Brentwood, Tenn., is determining what staffing additions or changes are needed. Then it is essential to make sure that “you

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find the right people for each team and provide them with ongoing education.”

Robin Arnicar, RN, CDONA/LTC, director of nursing at the Renaissance Gardens, Silver Spring, Md., adds, “You have to conduct an honest evalu-ation of your staffing numbers. If you don’t have enough staff, you need to do a root cause analysis of why.” Then, she says, the facility needs to start recruit-ing and hiring needed staffers.

Establishing staff stability is key, agrees Frank, to improved perfor-mance. “It’s hard to maintain consistent assignment if you have to shift people around because you don’t have reli-ability. In addition, you need cohesive teams on each shift,” she says.

“You have to establish effective ways for teams to resolve issues as they arise,” Frank continues, “otherwise, CNAs can feel stuck and alone in a

challenging situation, and that is the kiss of death.”

Barriers May Crop UpWhile consistent staffing requires leadership support and staff buy-in, the concept needs little selling. Most lead-ers and staff inherently understand the benefits. However, this doesn’t mean that there aren’t barriers to implemen-tation. For example, says Frank, “CNAs may worry about being stuck with someone who is hard to care for. How-ever, if you support CNAs, it alleviates people’s fears that they will be left alone to deal with a difficult situation.”

Knowing that they have support can help give CNAs the patience and time to bond with and understand residents who—at first—may seem difficult. For example, Frank says, “There was a post-stroke resident in one facility whose stroke made it so she could only say ‘no’ to everyone about everything. When the organization established consistent assignment, the woman’s CNA got to know her and could tell from her eyes or other nonverbal cues when she actually meant ‘yes.’”

Frank stresses, “It’s critical to main-tain consistent assignments that staff perceive as fair. Staff have to trust the fairness of the process. You need to constantly trouble-shoot and make sure people get help when they need it.”

Another barrier that needs to be overcome up front is the myth that it is better for staff to know all assignments so that they can work anywhere. “This concept seems so anti-relationship,” says Frank. She adds that most staff like knowing what to expect when they come to work every day.

Baylis agrees. “CNAs don’t want to relearn everything all the time. They want to go to work and get started right away,” she says. “They like being ef-ficient and feeling confident about their work.”

Setting Up For SuccessOf course, preparation requires the res-ident’s involvement. As Sister Pauline

Advancing Excellence: Tools To Build Consistent Assignment

Consistent assignment is one of the eight goals that are part of the Advanc-ing Excellence in America’s Nursing Home Campaign, a national initiative designed to help nursing facilities achieve excellence in their residents’ quality of care and quality of life.

The campaign’s website offers a wide range of tools to assist facilities in moving toward successful consistent assignment (www.nhqualitycampaign.org/star_index.aspx?controls=resByGoal#goal2).

Among the tools are key articles on the topic, an implementation guide, a tool for calculating consistent assignment, fact sheets for consumers and staff, and a webinar program.

“I would advise going to the Advancing Excellence website and learning from the information there before they try to reinvent the wheel. This is a good starting place for facilities considering or just beginning consistent as-signment,” says Barbara Baylis.

The campaign offers several resources, including:n Consistent Assignment—The Practice and the Experience (www.nh

qualitycampaign.org)n Consistent Assignment: Where Do You Start and How Do You Do It!

(Video) (www.nhqualitycampaign.org)n Implementing Change in Long Term Care (www.nhqualitycampaign.org)n Campaign Goals and Objectives (www.nhqualitycampaign.org)n A Keystone for Excellence: Implementing Consistent Assignment Provides

a Strong Foundation for Achieving the Goals of the Advancing Excellence in America’s Nursing Homes Program (www.providermagazine.com/pdf/2007/caregiving-07-2007.pdf)

n A Case for Consistent Assignment: When Caregivers Get to Know Their Patients More Intimately, it Opens the Way for Improved Quality and a Reduction in Staff Turnover (www.providermagazine.com/pdf/ caregiving-06-2006.pdf)

n Change Ideas for Consistent Assignment (www.qsource.org/NHQI/ Consistent%20Assignment.pdf)

n Nursing Home Adopts Consistent Caregiver Assignment (www. internetifmc.com/downloads/NHQI/Wyndcrest%20Adopts%20 Consistent%20Assignment.pdf)


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11MCK1785_ProviderAd_June_FINAL.indd 1 4/21/11 12:13 PM

says, “Before the resident is admitted, we do a pre-admission assessment in which we ask many questions such as what time they get up, what side of the bed they get up on, and what they like to eat for breakfast. We try to mimic their regular schedule so that their admission is seamless.”

Later, the CNA and the resident make a care plan just between the two of them that is posted in the bathroom. The nighttime assistant does the same.

“On the first evening, the CNA calls the family and tells them how the resident is doing. Then the daytime aide calls in the morning to tell them how their loved one spent the first night. Immediately, they learn about this relationship with the caregiver; and it puts their minds at ease,” Sister Pauline says.

Arnicar suggests seeking out infor-mal facility leaders—people who are

influential in their units—and using them to establish a peer team. “These people can move a new program for-ward or be its demise. You need to rec-ognize that they are influential and ask for their help in explaining the benefits of consistent assignment,” she says.

Whatever plans a facility makes to implement consistent assignment, Ar-nicar suggests starting small and slow.

“Don’t do the whole building in one day. Start with one unit or neighbor-hood, make it work there, and then move on to the next neighborhood,” she says, adding, “Empower staff to come up with and share ideas along the way.” But don’t forget to set rules and structure, she cautions.

“I went to one building, and they had given staffing over to the staff but never gave them rules. They ended up with 55 different schedules, scheduling gaps, and tons of staff burnout and resident

complaints.” Finally, as the facility implements consistent assignment, it must plan a way to measure results. Ar-nicar suggests tracking outcomes such as staff, resident, and family satisfac-tion; number of complaints; number of staff call outs; turnover; and clinical issues such as weight loss, falls, and use of antipsychotics.

Plugging Into Smooth SchedulingSolid organization and strong processes will enable the consistent assign-ment program to move forward more smoothly. One option to manage staff-ing is the use of scheduling software, such as a program that enables users to create an active schedule. It enables facilities to track staffing and account for vacations and call outs.

These systems can be as simple or sophisticated as necessary. For example, they can be designed to send an auto-


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11MCK1785_ProviderAd_June_FINAL.indd 1 4/21/11 12:13 PM

matic message to only specific individu-als requesting coverage for a call out and enable a sudden absence to be filled by an appropriate substitute in 10 to 15 minutes.

Mark Woodka, chief executive officer of OnShift Software, a Cleve-land, Ohio-based scheduling software producer, says, “A facility can’t commit to consistent assignment and then implement the program in a disorga-nized way. People need to know the processes and trust that they will work. Otherwise, you will scramble when you run into conflict.”

He notes that his company maintains a template of the master schedule for clients and helps keep it consistent month in and month out.

Scheduling programs can help streamline scheduling and help facilities track staffing over time. They can con-tribute to cutting down on the use of

agency CNAs or nurses, and they can take the burden off of busy managers. However, facilities should consider the costs of these systems and weigh the expenses with their specific needs.

For example, facilities can purchase the license to use scheduling soft-ware for a few hundred dollars plus a subscription fee for regular updates. Or they can get the software subscription with a fully hosted service that includes customization, service, and support. Depending on the organization’s size, this could cost several hundred dollars annually or more.

Whether or not a facility chooses

to use specialized software or outside companies to manage scheduling, man-agers involved in setting and maintain-ing schedules need to be involved from the start.

“The people are crucial, and you really need their buy-in. You need to help them understand that consistent assignment ultimately will make their job easier,” says Arnicar. She suggests having this person talk to a scheduler at another facility that has implemented consistent assignment successfully.

Maintaining The MomentumTeamwork among the CNAs is essen-tial for consistent assignment. How-ever, it doesn’t always happen quickly and easily, especially when people come from different backgrounds and experi-ences. Sister Pauline says at her facility, CNAs “meet weekly and do huddles as a shift. As a result, they work together

and support each other.” They also make sure that new hires know what to expect and what is expected of them. She says, “When an employee comes in looking for a position, we first have them watch a video about working here.”

Hiring the right people in the first place is essential to maintaining con-sistent assignment. As Tew says, “We stress to interviewees that we focus on health and wellness and making residents as functional as possible for as long as possible.” He says that they listen for personal stories or other indications that prospective employees “have a desire to work for the greater good and serve the elderly.”

Tew talked to employees at one facil-ity who stressed that they liked their jobs because of the residents, the team-work, and the leadership. They enjoyed “an atmosphere where they’re caring for residents and having fun doing it. They look at it as something they want to do versus just a job they do for a paycheck,” he says.

Managers Must Take The LeadTew says supervisors and team leaders have a strong role to play in ensuring the success of consistent assignment.

“They need to create an environ-ment where associates feel rewarded, encouraged, and understand their jobs and what is expected of them,” he says, adding, “Managers need to be able to motivate staff and make them feel that they are part of the organization. They need to create a safe environment where staff can suggest improvements and changes and where they share the

same level of commitment as manag-ers.” Not only do team members need to feel that they can express opinions and share observations, they also need to know that management will act on them. “If you ask for CNAs’ input, you have to take it seriously and respond to it,” says Frank.

Busting BurnoutEven when facilities hire and keep great people, they need to protect them from burnout. There are many ways to ac-complish this.

For example, staff can volunteer to care for residents with whom they have established good relationships.

Elsewhere, full-time relief workers might work strictly for two people—for example, the person consistently handles Mary’s three days off and Bob’s two.

Facilities also should consider the demands of each resident in making assignments, Baylis says. “I may have nine residents, while you only have six because yours require more care and assistance. Assignments have to be equal not in number but in amount and level of care required. There needs to be equality and teamwork,” she says.

Another way to maintain staff satis-faction with consistent assignment is not to force caregivers to work with particular residents. As Baylis says, “Very rarely, we have situations where the caregiver and the resident don’t click, and when that happens, we switch them out and someone else cares for the resident. We always try to make accommodations.”

However, she notes, “team members usually develop strong bonds with the residents and families, and none of them want to change.”

Crowing About AccomplishmentsFacilities that have established consis-tent assignment successfully are wise to promote them as part of their culture. “It’s a core business strategy for us,” says Tew. “It’s a consistent message be-ing delivered from the top down.”

He says that his company uses “a lot of people pictures” in recruiting and marketing materials. “It may seem corny,” he admits, but he notes that it reinforces the person-centered ap-proach to care emulated by consistent staffing.

Tew also says that staff themselves are the best advertisement. “When you see that people are smiling, friendly, and happy as you walk through the facility, that says a great deal.”

Maintaining and promoting the in-dividualized approach to care is key to successful consistent assignment.

“If one resident leaves and that person showered in the morning, you don’t just put a new resident in the same routine just because it’s conve-nient. If you do, it can set you up for

residents and having fun doing it. They look at it as something they hey enjoyed a n a t m o s p h e r e w h e r e t h e y ’ r e c a r i n g f o r

want to do versus just a job they do for a paycheck.

T



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problems,” says Sister Pauline. “You need to involve the social worker and find the best place, the best routine for each resident.”

The facility also needs to prepare residents for staff vacations and absences. As Sister Pauline says, “The resident’s personality can change on a day the aide isn’t there.” She suggests having CNAs tell residents when they’re leaving for the day and remind them when they will be out the next day.

The relationships with the resident are so strong that even the family misses the caregiver when he or she is out. “Families will get upset if something happens and their family member has someone different caring for him or her. Often, they will visit more often and stay longer when the regular caregiver is out,” she says.

The sense of family that comes from consistent assignment is very real. As Karyn Leible, RN, MD, CMD, chief clinical officer, Pinon Management in Colorado, and president of AMDA—Dedicated to Long Term Care Medicine, says, “Residents love it when staff bring in their kids or grandkids. It becomes an extended nuclear family.” Leible, who first practiced consistent assign-ment as a nurse many years ago, adds, “My son used to round with me when he was two. When I was listening to a resident’s heart with the stethoscope, he’d be sitting on the person’s lap with a toy stethoscope.”

Another time, Leible brought her son into her facility on Christmas Eve. While she worked, he sang carols and baked cookies with the residents. “Many of these people don’t have anyone else. They like having someone special to care for them,” she says.

“Connecting to others is a human need. These relationships are key, and consistent assignment builds powerful, caring, and important con-nections that have a real impact on everyone involved.” n

Documents

Change Ideas for Consistent Assignmentanha.org/members/documents/ConsistentAssignmentToolKit.pdfConsistent Assignment-Page 2 find it hard to have strangers caring for their intimate