Work. PUB DATE 87 76p. PUB TYPE - ERIC · 2013-11-23 · Preface. There are 957 nursing homes in Illinois. The vari-ations among the homes are as great as the people who live and

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Balgopal, Pallassana R.; And OthersQuality Assurance in Nursing Homes.Illinois State Dept. of Public Aid, Springfield.;Illinois Univ., Urbana. Jane Addams School of SocialWork.87

76p.

Books (010) -- Reports - Evaluative/Feasibility (142)

MF01/PC04 Plus Postage.Community Support; Facility Guidelines; HealthFacilities; Medical Services; Needs Assessment;*Nursing Homes; Organizational Development; *PersonalCare Homes; *Program Effectiveness; ProgramEvaluation; *Quality Control*Quality Assurance Programs

This manual, developed for the nursing home employee,examines the concept of quality assurance in nursing homes, describesthe benefits of an effective quality assurance program, and providesguidelines to aid nursing homes in developing an appropriate qualityassurance program. After a brief introduction, a working definitionof quality assurance is provided, and the four steps in the qualityassurance cycle are delineated: identifying needs, planning,implementing changes, and evaluation of results. The next chapterdiscuss the quality of life mission of nursing homes; this isfollowed by guidelines for administrators and supervisors in dealingwith staff. The next three chapters provide specific suggestions forquality assurance in various aspects of nursing home management:building a positive community image, addressing the needs offamilies, and improving the nursing home environment. Costs ofquality assurance are next considered, and two types of qualityassurance program--informal and formal--are described and compared.The manual concludes with guidelines for developing such a program,and sample documentation is appended, along with a list ofreferences. (TE)

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Reproductions supplied by EDRS are the best that can be madefrom the original document.

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E QualityAssurancein Nursing Homes

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0CDC.) U.S. DEPARTMENT OF EDUCATION

Mar of Educational Research and Improvement

EDU ATIONAL RESOURCES INFORMATIONCENTER (ERIC)

This document has been reproduced asrecerved from the person or organrzahonoronating 4Minor changes have been made to improvereproduction Qualrty

Points ofvreworoprnions stated in thrsdocumeet do not necessarily represent offroatOE RI position Or poky

"PERMISSION TO REPRODUCE THISMATERIAL HAS BEEN GRANTED BY

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TO THE EDUCATIONAL RESOURCESINFORMATION CENTER (ERIC)."

Pallassana R. Balgopal, D.S.W.Michael. A. Patchner, Ph.D.

2

QualityAssurancein Nursing Homes

Pallassana R. Balgopal, D.S.W.Michael A. Patchner, Ph.D.

withDebbie J. BarnettMary M. DarbesJo Schmidt

School of Social Work

University of Illinois at Urbana-Champaign

This project was funded by

the Illinois Department of Public Aid

1987

3

This project was funded by the Illinois

Department of Public Aid

Copyright © 1987 by Tha School of Social Work

University of Illinois at Urbana-Champaign

All rights reserved. No part of this book maybe reproduced in any form or by any means,electronic or mechanical, including photocopy-

ing, recording, or any information storage and

retrieval system, without permission in writ-ing from the authors.

Library of Congress Catalog Card Number:87-062428

4

Dedicated to all the residentsin Long Term Care Facilitiesin Illinois

5

Acknowledgements

The writing of this volume involved assistance frommany people. Although it is impossible to identify all ofthem individually, we do want to acknowledge our ap-preciation to the following Individuals and institutions.

We are deeply grateful to the Illinois Department ofPublic Aid for their interest and the funding that madethis research project possible. For their special commit-ment and contribution, we would like to thank ConnieCheren, Jo Ann Day and Mary Gober.

Gratitude is also extended to the University of Il-linois, School of Social Work for its support. In particular,thanks is expressed to Degr, Daniel Sanders, AssociateDean Charles Cowger, and a special recognition is ex-tended to Assistant Dean Jar.ice Hartman for her invalu-able input that helped bring the project to its successfulcompletion. Bill Morgan of the Grants and Contracts of-fice at the University of Illinois provided assistance, andour appreciation is extended to him.

This project could not have been initiated withoutthe participation and cooperation of the administrationand staff of exemplary Illinois nursing homes. Specialappreciation is due to the following: Cathy Moses, PastAdministrator, Katherine Stanfield, DON and SherryBailott, ADON at Americana Healthcare Center of Ur-

bana in Urbana, Illinois; Robert Knobloch, Administratorof Apostolic Christian Home for the Handicapped in Mor-ton, Illinois; Leona Hughes, Administrator, ShirleyStone, Assistant Administrator, Nancy Finley, DON ofArthur Home in Arthur, Illinois; Jacqueline Mason,Owner and Joanne Fishcher, Administrator of BurgessSquare Healthcare Center in Westmont, Illinois; MarshaReardon, Administrator and June Bishop, Social ServiceDesignee of Fondulac Manor in Peoria, Jllinois; JamesBowden, Administrator, Patricia Miller, DON and PatOtteney, RN of Lake Bluff Healthcare Center in LakeBluff, Illinois.

This volume has profited by the incisive and thoroughcriticism provided by Sherry Bailott, Connie Cheren,Leona Hughes, Ruth Schankin, and Katherine Stanfield.Their instructive criticisms helped us clarify and reviseour ideas.

Our gratitude is expressed to Jo Schmidt, the ProjectDirector, for her dedication and commitment to this re-search endeavor. A successful research project cannot beundertaken and completed without a committed andhardworking staff as a foundation. It is our pleasure tocommend our project staff for their diligence, insight andhard work which contributed very significantly to thesuccess of this project: Debbie J. Barnett, Emer DeanBroadbent, Mary M. Darbes, Debbie Gilpin, Ronald Hast-ings, Priscilla Purcell, Chathapuram S. Ramanathan,Jerry Ringenberg, Wes Stevens, and Becky Witt.

7

Preface

There are 957 nursing homes in Illinois. The vari-ations among the homes are as great as the people wholive and work in them. Each facility reflects a uniqueblend of residents and staff whose individual strengths,needs, and values are combined to form the home's owngeneral character and personality.

Fundamental to the character and personality of anursing home is its approach to providing service andcare to the residents. Some homes are successful in meet-ing the residents' needs. Some fail. Some homes are ableto create a working and living environment that signifi-cantly contributes to the quality of life for the residentsas well as the staff. Other facilities must struggle to meetthe minimum standards set by the State.

What are the factors that yield success for facilitiescommitted to delivering quality service? Examination ofnine exemplary facilities in Illinois revealed three gen-eral areas that, when thoroughly developed andstrengthened, form a solid foundation for quality servicedelivery. A set of three manuals discussing and outliningtechniques that have proven effective in upgrading ser-vice delivery in these facilities has been developed for thepurpose of providing fresh and innovative ideas to homesthat are struggling as well as those that have achievedexcellence in service delivery.

Data for the manuals were collected from a carefulexamination of the nine facilities in addition to a thoroughreview of the research literature. Each manual was de-veloped independently and focuses on a specific dimensionof service delivery in the nursing home. Yet they areinterconnected and can serve as a comprehensive packageof information for delivering quality care to the resident3in addition to improving the working environment forpersonnel. The manuals are available under the followi,igtitles:

Personnel Management in Nursing HomesQuality Assurance in Nursing HomesCare Planning Process in Nursing HomesThis manual, Quality Assurance in Nursing Homes,

is intended to define in concrete and practical terms themeaning of quality assurance in the nursing home, de-scribe the benefits of an effective quality assurance pro-gram, and provide guidelines to aid a facility in develop-ing a quality assurance program appropriate to its ownunique character and personality. Quality assurance willbe examined from a systems perspective. This means thatjust as quality assurance has a direct effect upon everyoneassociated with the nursing home, everyone associatedwith the home has a direct effect upon quality assurance.This duality of people and quality assurance ultimatelydetermines the quality of life for the facility's residents.It is to this end, improving the quality of life for nursinghome residents, that this manual is directed.Pallassana R. Balgopal, D.S.W.Michael A. Patchner, Ph.D.September 1987

9

Contents

Introduction 1

What is Quality Assurance? 3

Does Quality Assurance Mean Quality Care'? 7

How Does Quality Assurance AffectManagement and Staff? 13

How Does Quality Assurance Create aPositive Community Image?

How Does Quality Assurance BenefitFamilies?

21

25

How Can Quality Assurance Improve theNursing Home's Environment? 33

Is Quality Assurance Cost Effective? 37

Is Quality Assurance Attainable? 41

Appendices 57

References and Suggested Reading 69

I0

1

Introduction

Health care in nursing homes has traditionally fol-lowed the "medical model". Staffed with medical person-nel in hospital-like buildings, facilities have tended tofocus primarily on the medical needs of "patients". Thismanual proposes that facilities take a more holistic ap-proach to resident care by developing and implementingquality assurance programs. This means that in additionto medical needs, the social, cognitive, and spiritual needsof the residents are also addressed. An effective qualityassurance program can help nursing home personnelidentify problems in meeting the needs of residents andprovide an organized approach to resolving those prob-lems. The outcome is an improved quality of life for theresidents and, because quality of life issues have a directeffect on the families of residents, an effective qualityassurance program also benefits families who can takecomfort in knowing that the facility is delivering the bestpossible care to their loved ones.

The benefits of a successful quality assurance pro-gram are not limited to nursing home reside Its and theirfamilies. Working conditions for staff are enhanced byproviding them with clearly defined expectations for jobperformance, by encouraging them to participate in deci-sions that affect their jobs, and by creating an atmosphere

11

2 Quality Assurance in Nursing Homes

of cooperation in accordance with the home's philosophyof care.

This manual has been designed to provide you, thenursing home employee, with information about qualityassurance in nursing homes. A working definition of qual-ity assurance will be developed, two types of quality assur-ance programs will be discussed, the benefits of a goodquality assurance program will be assessed, and variablesin the makeup of a facility that determine the selectionof an appropriate quality assurance program will besuggested. As you read, consider quality assurance inyour facility, and how your job contributes to quality as-surance.

12

3

VVhat isQualityAssurance?

Quality assurance in nursing homes is the set of pro-cedures a facility uses to promote excellence in the provi-sion of care.

Quality refers to the specific performance standardsor goals a facility sets as levels of achievement to bemaintained.

Assurance refers to the process of guaranteeing thatquality is achieved and maintained. Assurance proce-dures consist of these four steps:

1. Identifying needs and formulating goals for meet-ing needs and then identifying reasons for thedifference between actual performance and de-sired quality performance.

2. Planning what needs to be done to bring perform-ance up to quality standards.

3. Implementing changes that help bring perform-ance up to quality levels.

4. Evaluating the extent to which the desired qualityof performance is achieved.

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Quality assurance procedures are ongoing anddynamic. This means that quality assurance is not a one-time or stop-and-start effort. It is a cyclical process thatmust be maintained to achieve the desired excellence inservice.

The Quality Assurance Cycle

Identifying

Evaluating Planning

kiImplementing

Quality assurance in nursing homes takes the formof systematic programs designed to identify problems incare delivery, formulate plans to correct the problems,implement the plans, and evaluate the outcome to deter-mine if the plans were effective in eliminating the prob-lems. An effective quality assurance program maintainsthe cyclical process described above.

To give the definition of quality assurance utility,the remainder of this manual is devoted to examiningthe impact of quality assurance by considering andanswering the following questions:

Does quality assurance mean quality care of resi-dents?How does quality assurance affect administrators,supervisors, and staff?

14

What is Quality Assurance? 5

How does quality assurance create a positive com-munity image of the nursing home?How does quality assurance benefit the familiesof residents?How can quality assurance improve the nursinghome's physical environment?Is quality assurance cost effective?Is quality assurance attainable?

15

7

Does QualityAssurance MeanQuality Care?

The Quality of Life Mission

The first step in developing a successful quality assur-ance program is to identify the specific standards thefacility desires to achieve. Research on organizationaldevelopment and success has found a strong relationshipbetween an organization's sense of purpose or missionand the quality of the organizational culture and the ser-vice it delivers. When goals are clearly interwoven andreinforced within all aspects of an organizational climate,employees naturally begin to internalize the value systemof the mission and to function more smoothly as an integ-rated unit.

Mission goals of nursing homes are usually developedby the owner, administrator, and directors of the variousdepartments. However, innovative facilities may want toask all staff, volunteers, residents, and families to partici-pate in offering their suggestions for mission goals. Thisway, a diversity of valuable ideas are obtained, and many

16


persons are uplifted as their self-worth is enhancedthrough the process.

A careful and thorough assessment of the characteris-tics, expectations and needs of the residents can help thefacility develop a mission statement of quality of life stan-dards which staff and residents can aim for and achieve.For example, .:sing home residents typically have awide range of medical, physical, psychological, emotional,cognitive and spiritual disabilities and needs. Their inde-pendence and social and environmental activities are lim-ited as well. They are characteristically single, have nochildren living close by, and are poorer than the popula-tion in general Taking the example further, from thisdescription of res;dent characteristics, disabilities andneeds combined with a basic ethical sense of human needs,several general qv ali .37 of life standards for residents canbe generated. It is i: 'portant that residents:

Feel a ser a of well-being, self-worth, and self-esteem.

a Feel a sense of satisfaction with their care.Enjoy a medically sound and safe physical envi-ronment.Have the opportunity to have .lose and meaning-ful relationships with others.Are able to achieve desired goals and exercisechoice.Enjoy a sense of privacy, dignity and reasonablecontrol over life decisions.

This list, of course, is only partial. Many holistic qualityof life standards for residents will be generated by eachfacility. Each facility will also reflect its own unique sense

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Does QA Mean Quality Care? 9

of mission and philosophy of quality of life for its resi-dents.

Nursing home mission clearly stated will becarried out by staff.

Translating the Quality of Life Mission

A facility that delivers excellent service to its resi-dents is one that is able to enthusiastically translate itssense of quality of life mission to its entire staff. Ideals orgoals of quality of life for residents are not static or con-tained merely within the pages of a notebook. Rather,they are enthusiastically conveyed to the staff and resi-dents by the administrator and department heads. Theyare conveyed:

In a positive, uplifting manner.On a day-by-day, ongoing basis.In a dynamic way that is continually open tochange, input, and growth.

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In a trusting sense that staff will carry out theirgoals in a responsible way.

The quality of life goals or mission statement of afacility can be kept alive and fostered through creativeways of expressing them on an ongoing basis. Some ideasthat have proven successful include enlivening the socialclimate of the facility by expressing the mission goals in:

Memos to department heads concerning proce-dures.

Describe how new procedures support thegoals of the facility.

Show how deleted procedures no longer sup-port the goals.

Staff meetings.The general foundation for discussions can

be the home's mission goals.Show how problems detract from facility

goals and ask for solutions that supportthem.

Ways of showing appreciation.Send flowers or a plant to a department

that is doing an outstanding job. Includenote describing how the work promotes themission of the nursing home.

When giving individual employees "pats onthe back" tell them how their good worksupports the home's mission.

A general statement on facility stationery thatsummarizes the home's mission goals.Goals engraved on a plaque hung in the receptionarea.

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Does QA Mean Quality Care? 11

Statements of the mission goals given to all jobapplicants and to new personnel during orienta-tion.

Give job applicants a printed copy express-ing goals.Verbally explain the goals during the firstday of orientation.

In the nursing home, quality assurance means deliv-ering quality care and service to the residents. Staff whounderstand, agree with, and appreciate the overall mis-sion of their-facility will be better able to work togethercooperatively to provide the best possible care and serviceto the residents.

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13

How Does QualityAssurance AffectManagement andStaff?

In many long term care facilities, it is the adminis-trator in conjunction with department supervisors whosets levels of expectations for all the different jobs thatmust be done if quality care is to be delivered to theresidents. Administrators and supervisors are necessarilyinfluenced by external regulatory agencies to set stan-dards that are in harmony with laws that govern licensureand certification. Standards of care that go above andbeyond those laws may be set by managers either in oroutside the facility. In facilities where job expectationsare set by someone outside the facility, such as boardmembers or corporate executives, it is still the responsi-bility of the administrator and the supervisors to ensurethat those expectations are being met. Meeting expecta-tions in care delivery means that problems or potentialproblems must be quickly and accurately identified andresolved. Problem identification, assessment, and resolu-tion are largely managerial tasks; however, all staff canparticipate in the problem solving process. A successful

21


quality assurance program encourages staff to speak upwith new ideas and to becoine invoi --,,c1 in solving prob-lems that affect their own jobs as well as other depart-ments in the facility. Administrators and sup rvisors ben-efit from the fresh insight and start' are g'- ...n a sense ofpower and control over their jobs.

The grand objective of a quality assurance programis to eliminate problems in resident care. It is unrealisticto expect that all possible problems that can ()Calf in anursing home can be eliminated. However, a sound qual-ity assurance program can significantly reduce thenumber and severity Gf the problems that inevitably ariseso that excellence in care as defined by the facility isachieved and maintained.

Administrators and supervisors can help staff to dotheir best possible work by following these fourguidelines:1. Make job expectations clear to staff.

During orientation give each new employee a writ-ten and clearly defined job description that in-cludes performance standards acceptable to thefacility. (See Appendix A for a sample job descrip-tion.)Make clear to each employee the consequences ofnot meeting job performance standards.Consequences should include, but not be limitedto, disciplinary or termination issues.Explain to each employee how his or her job con-tributes to quality care of the residents and howfailure to meet facility standards not only resultsin poor quality care, but can also jeopardize the

P2

How Does QA Affect Management and Staff? 15

employee's well-being.Give all employees access to copies of the variousjob descriptions throughout the facility with qual-ity performance criteria.

2. Schedule regular meetings between staff and manage-ment.

Encourage employee input regarding problemsand solutions or innovative ideas in care. Use theirvarious perspectives and talents to gain fresh in-sight into care delivery.Invite employees to role-play problems and solu-tions as a fun way of creating and developing newideas. (See Appendix B for an example.)Give verbal "trivia" quizzes on facility policies,standards, and procedures. Give a prize to the em-ployee who answers the most questions correctly.Record and post minutes from the meetings for allemployees to read. (See Appendix C for an exam-ple.)

3. Give employees incentives for contributing to qualityassurance.

Recognize good work with "pats on the back" andplenty of verbal thank-yous.Put a suggestion box in the employees' lounge orother place where employees eat or take breaksand reward employees whose suggestions are im-plemented. (See Appendix D for examples of sug-gestions contributed by employees.) Suggested re-wards include:

--Small monetary rewards.Time off from work with pay.

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16 Quality Assvrance in Nursing Homes

Recognition by putting employee's pictureand suggestion on a bulletin board in aprominent place in the facility.

Celebrate successful evaluations by supervisorswith parties or gifts such as new plants or flowersfor the departments.

4. Schedule regular employee evaluations.Schedule evaluations in addition to the evalua-tions done for the purpose of increasing wages togive employees feedback on how well they are per-forming their jobs. (See Appendix E for sample jobevaluation.)Evaluations should emphasize strong as well asweak points in job performance.Leave space on the evaluation form for employeesto respond.Evaluations can be written by a team of super-visors so that no one supervisor must carry theresponsiblity if negative comments must be made.If evaluations are discussed between the adminis-trator or the DON and the employee, give the writ-ten evaluation to the employee a day before theconference so that he or she will have time to thinkabout and react to the evaluation.Have an "employee of the month" election. Em-ployees can vote using ballots that include spacefor why the employee is being nominated. Put win-ners' names on a bulletin board in a prominentplace in the facility along with a list of the qual-ities from the ballots that make him or her anoutstanding employee.

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Now Does QA Affect Management and Staff? 17

Quality assurance is a team effort.

Employees can significantly contribute to quality as-surance in a facility if they are allowed to become animportant and integral part of the facility's quality assur-ance program. Employees who have a clear understand-ing of what needs to be done and how to do it will be lessat risk for making mistakes because of ignorance of jobstandards and procedures. Supervisors and adminis-trators will benefit because they will need to spend lesstime disciplining employees who have created problems,and, with the additional input of the employees, less timetrying to identify and solve problems. Also, when employ-ees are allowed to contribute to decisions effecting theirjobs, either verbally in meetings or by seeing their writtensuggestions implemented, the resulting sense of pride andownership in the facility will promote an atmosphere of

2 5


teamwork and rapport among the employees making thefacility a happier place to be for everyone.

Employees who feel that they are members of a teamsharing the responsibilities of quality care delivery to theresidents will naturally work together more cooperativelythan employees who feel isolated in their jobs. A senseof teamwork and community within the facility can befostered by Administrators and supervisors who presentthemselves as rr -tubers of the team by their actions. Man-agers who are perceived as "doers" by staff, i.e. as par-ticipating members of a team with a common objective,will help staff to achieve high quality job performancebecause:

Staff are more comfortable interacting with man-agers with whom they have daily contact thanwith managers they see only occasionally.Staff feel that managers understand their jobs ndcan appreciate the difficulty and stress that acc n-panies their work.Staff are more inspired to work when they seetheir managers working.Staff can get to know managers on a more personalbasis, making them more approachable whenproblems need to be discussed.

Encouraging staff to interact with managers can helpinvolve staff in decision making and problem solving pro-cedures. The following ideas may help to integrate man-agement and staff into a comfortable, cooperative, andmutually respectful working relationship:

Managers and staff can take coffee or lunch breakstogether.

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How Does QA Affect Management and Staff? 19

Managers can keep an "open door policy" whichmeans that they are always available to staff.Managers and staff can be encouraged to greeteach other by name in and outside of the facility.Have at least one task that management and staffdo together such as feeding residents or makingbeds.

These ideas can help to create an atmosphere of team-work in the nursing home. Sharing activities and respon-sibilities with their managers can help to increase staffmorale. Staff and residents alike will benefit from thehappier and more home-like environment.

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How Does QualityAssuarance Create aPositive CommunityImage?

By moving away from the medical model of nursinghomes to a holistic-care plan model, the nursing homebecomes more of a home to the people who live there andless like an institution in which they are housed. Becausethe residents of the facility are also citizens of the commu-nity in which it is located, quality of life issues analyzedfrom the perspectives of the residents must not fail toconsider the relationship between the nursing home andthe community.

How the facility is perceived by the community canhave bearing on the residents' feelings of well-being, self-worth, and self-esteem. At some point before moving intothe facility each resident was most likely to have beenliving independently in a community setting, freely in-ter acing with the other members of that community.While it may not be realistic to expect that residents areable to remain as active in the community as they oncewere, it is possible to create and promote feelings of com-munity membership by developing a positive and active

28


relationship between the community and the facility. Thiscan help to alleviate the feelings of abandonment andisolation that residents report experiencing when theymove from their own familiar homes to the new and oftenfrightening facility environment. Developing an activerelationship between the facility and the communitymeans more than simply transporting the residents fromthe facility into the community. While this is indeed cru-cial to establishing good facility-community relations, itis also important that members of the community interactwith the residents in the facility.

Nursing home is an integral part of the community.

To encourage citizens of the community to visit, thefacility should present itself not as an isolated entity butas a vital and dynamic member of the larger communitysystem. To achieve this image the facility must informand educate the community about the residents who live

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How Does QA Create a Positive Community Image? 23

there, its philosophy of care, and the interesting programsthat are being developed or implemented. In addition, theneeds of the facility and how community people can con-tribute to and benefit from visiting the facility eithercasually or as participants in a formal volunteer programmust bE ommunicated. The following are suggestions foreducating and informing the community about the nurs-ing home:

Link up the facility with the community socialservice network. Workers may be interested orknow clients who are interested in volunteeringservices or donating material goods to the facility.Also, agencies may be willing to include informa-tion about the facility in their newsletters andbulletins.Look for someone in the facility who could givetalks on aging, long term care, or other topics re-lated to the facility.Publish articles in the local newspapers about thefacility and what is happening there. (See Appen-dix F for topic ideas.)Advertise volunteer opportunities on grocery storebulletin boards or on flyers posted in churches orwith other prominent community organizations.Develop an educational program with schools sothat students can learn about the aging processby interacting with the residents in the facility,by telephone, through letters, or by visiting.Children can make valuable contributions to thefacility's volunteer program and add a special di-mension to the lives of the residents. Encourage

30


children to volunteer time and service to the homeby sending someone from the facility to the schoolsto describe to the chilck . en what jobs they can doto help the residents and staff. Also, encouragethe children to create their own ideas for volunteerservice.Sponsor a local Retired Seniors Volunteer Pro-gram (RSVP) so that volunteers work out of thefacility or have the facility serve as a volunteerstation where RSVP members can volunteer.

There are many other ways a facility can create commu-nity interest; these are only a few suggestions. By takinga public relations approach the facility can actively andsuccessfully recruit volunteers, educate the public aboutthe aging process, promote a positive attitude toward thenursing home, and, most importantly, enhance the livesof the residents who have made the facility their home.

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25

How Does QualityAssurance BenefitFamilies?

What responsibilities does a nursing home have tothe families of residents? Although the primary commit-ment of care is to the resident, facilities that adopt theholistic-care plan model suggested in this manual willstrive to create a facility environment in which familiescan feel comfortable expressing concern and loving sup-port for their family members.

Families typically make the decision to in-stitutionalize their relatives only after exhausting allother resources. Because families tend to have strong de-sires to maintain their relatives at home, the in-stitutionalization process is often experienced as a crisis.Families are forced to confront the harsh realities of aloved one's illness, the pain of a separation that restruc-tures the family, and the inevitable mortality of theirrelative and themselves.

At the height of this crisis the family admits theirrelative to a nursing home for care that they cannot giveat home. Nursing home staff first encounter the new resi-

Q o


dent's family during this pivotal point in the family's life.At this critical time the needs of the family must be rec-ognized and met so that their relative's transition intothe home is made as easily and as smoothly as possiblefor everyone involved in the process. Staff can help theresident's family by providing them with:

Kind and gentle emotional support.Recognize that the family is experiencing

a crisis.Find out what expectations the family has

of the facility and reassure them that rea-sonable expectations will be met.

Remain aware that families often experi-ence conflicting feelings about placing theirrelatives in nursing homes and their be-havior may reflect the conflict.

Respect for the care they have given their relativeso far and the opportunity to remain involved incaring.

Encourage families to visit the facility.Tell them about activities they can partici-

pate in such as helping to feed residents orother volunteer opportunities.

Invite them to participate in the care plan-ning process.

Put their names on mailing lists for anynewsletters or bulletins put out by thenurs-ing home.

Families can be valuable contributors to the well-being of residents and the nursing home in general. Onthe other hand, if proper care and attention are not given

`,1 3

How Does QA Benefit Families? 27

to families, they can become effective saboteurs of staffand resident morale. For example, management problemsarise when there is conflict between residents and familymembers, and intervening staff may often wind up asconvenient scapegoats. Family members may also experi-ence considerable denial or guilt which cart result it, emo-tional over-reactions, rejections and distortions of theresident's behavior, illness, and/or reduced prospects fortheir relative's recovery.

Families are valuable contributorsto the well-being of residents.

Family members can have unrealistic expectationsof both resident and staff behavior that will lead to furtherconflict. If families do not understand the reasons for staffactions, or feel put off and without input, the resultingpoor family-staff interaction will have unfortunate conse-quences for everyone, especially the residents.

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Nursing homes that strive for excellence in holisticcare can create quality assurance programs in the areaof family care. The optimum quality assurance programfor enhancing family crisis resolution and family/staff/resident integration is one that actively recruits and servesthe family as a client of the nursing home. Policies thatpromote family well-being are also likely to have positiveeffects on residents and staff members alike.

Implementation of a quality assurance program thatactively involves the families of residents as clients neednot be viewed as a costly endeavor. Most aspects of afamily quality assurance program are not costly, can ac-tually increase staff efficiency, improve the communityimage, and promote resident/family satisfaction.

The first step in setting up a family quality assuranceprogram is to carefully and thoroughly identify thecharacteristics and needs of the families. Characteristicsand needs can be surveyed through:

ObservationInterviews with residents and their familiesSurveys or questionnairesRelevant books and articles

The second step is to plan policies and specific pro-grams and procedures to meet family needs. Some exam-ples of programs and procedures that actively involvefamilies in resident care are:

Family group counseling sessions which optimallyinclude all members of the newly admitted resi-dent's family. These sessions are usually con-ducted by trained social workers and are designedto allow families to express their feelings regard-

5


ing the placement of their relative in the nursinghome. The sessions help both the resident and thefamily adjust more easily to the new situation anddecrease conflict and guilt that can make the sep-aration seem more extensive.Inclusion of the family in a comprehensive psychi-atric assessment of the newly admitted resident.Inclusion of the family is essential for a completeunderstanding of the resident. This collaborationvalues family input and involves the family inimportant considerations of resident care. Collab-oration can also help families to come to termswith unresolved issues and can lead to greateradaptation and emotional openness within the en-tire family.Community support groups for families engagedin decision making about the care of the frail el-derly. Lead by nurses or social workers, thesegroups help families make difficult decisions, dealwith anxiety and negative emotions, and cope ef-fectively with their concerns. These groups can bepurely supportive and/or educational and social,and can help families alleviate some of their feel-ings of isolation, guilt, grief, frustration, confu-sion, and helplessness. They can also trainfamilies in care skills, quality visitation skills,and in understanding the developmental issues ofthe aging process.Periodic written communication to families con-cerning the progress of their relatives to reduceanxiety, especially for families who are unable to

96


visit the facility on a regular basis. Personalizedletters sent out two or three times a year keepfamilies informed about and help them to feel in-volved in the lives of their relatives. (See AppendixG for an example of a letter to a family.)

Research indicates that most families need and wel-come programs and classes that can increase their com-munication and visiting skills as well as their under-standing of the aging procesL. Examples of specific educa-tional program topics include:

Organic brain diseaseMood disturbancesMental and physical deteriorationThe process of aging and institutionalizationDeath and dyingAlzheimer's diseaseMedicationActivities and exercise

Scheduled activities for families are an importantaspect of dynamic family involvement. Some suggestionsfor family activities are:

Monthly coffee houses for family and staff.Resident/staff/family parties on holidays.Invite families to attend community outings forresidents.Create a committee of family members to helpdesign facility policies.Use surveys and questionnaires to solicit familysuggestions and/or complaints concerning thenursing home.

9


The particular components of a family quality assur-ance program will, of course, differ according to the par-ticular strengths and needs of each facility. Once thosestrengths and needs are identified, activities and pro-grams can be designed and implemented. The final stepin creating a family quality assurance program is evaluat-ing the effectiveness of the activities and programs.Evaluative measures that may indicate the success of aprogram include:

Decrease of staff/family/resident conflicts.Increase in family visits.Decrease in family complaints.Decrease in unrealistic expectations of families.Increase in family participation in facility events.Increase in special attention, affection, and sup-plemented services by families.

Implementing a family quality assurance programthat aggressively recruits and serves the family as a clientof the nursing home will increase the quality of familyrelationships and increase the quality of family/staff re-lations. Also, it is not costly to the facility, and will tapfamily resources to enrich the lives of the residents andthe nursing l'xne as a whole.

33

How Can QualityAssurance Improvethe Nursing Home'sEnvironment?

The delivery ofquality care to nursing home residentsbegins with the identification of the residents' health andsafety needs. Residents should feel secure in the facilityas well as during trip., into the community. State andfederal laws governing the home's physical environmenthave been established to protect the safety of the residentsand personnel in the facility. While these laws supply asound foundation for safety, they do not take into accountindividual needs. The means of identifying these indi-vidual needs can be incorporated into the home's qualityassurance program. Some suggested ways to identify in-dividual safety needs are:

Consult with residents and their families aboutsafety issues. For example, if a resident is afraidof sleeping in a totally darkened room, make anote of his fear on the care plan and instruct theevening shift to turn on a night light at bedtime.Examine disruptive behavior to determine if thecause is rooted in fear. If, for example, a resident

99


The facility is a resident's home.

becomes combative while being fed, it may be dueto a daily rotation in volunteers that does not allowthe resident to recognize and establish a relation-ship with any one volunteer. Try to recruit volun-teers who will wcrk with the resident several daysin succession so that a relationship can becomeestablished before the resident must be fed bysomeone unfamiliar to him.Form a volunteer resident safety council whoseresponsibilities include detecting potential safetyproblems in the home, for example, slick spots onwaxed floors or paper in ashtrays. The council mayenjoy publishing a newsletter on safety for theother residents and staff.Bring in guest speakers ..;ch as firemen or police-men to give presentations on safety issues. En-courage residents and staff to ask questions andgenerate discussions after the presentations.

40

How Can QA Improve the Home's Environment? 35

Identifying and meeting the health and safety needsof residents and staff is crucial to quality service in nurs-ing homes. An effective quality assurance program cantake improvement of the facility's physical environmentone step further by creating an environment that is notonly safe and functional but also cheerful and home-like.Because the nursing home exists for the benefit of resi-dents and staff alike, a sense of home and family can becreated by allowing reasonable participation by residentsand staff in decisions concerning facility decor and pur-chases made for the home, such as plants, fishtanks, ormagazine subscriptions.

Some suggested ways to involve staff and residentsin decisions concerning the facility's physical environ-ment are:

Form a resident decorating committee.They will be responsible for choosing new

paint colors, placement of plants, pictures,posters, etc.

Rotate members periodically so thateveryone who wants to participate is able to.

Display crafts made by residents and staff.Make a name card for each craft item so itsmaker is recognized.Ask if any of the makers are interested ingiving a talk about their work: for example,residents and staff may enjoy hearing abouthow a quilt was made, the history of thepattern, etc.

Devote a few minutes to staff meetings to inquirewhat would improve the environment for staff.

41


Staff can vote for items to be bought fortheir benefit: for example, small appliancesfor the staff lounge.Reward implemented ideas for improve-ment with recognition such as telling aboutthe ideas in the facility's newsletter or bul-letin or displaying the person's picture ona wall along with a description of the idea.

Involving residents and staff in decisions concerningtheir nursing home promotes a sense of community withinthe facility, improves staff morale, makes residents feel"at home", and promotes a sense of ownership and controlfor everyone. Improving the facility's physical environ-ment in small ways can improve the quality of life forthe residents who have made the facility their home, espe-cially when they are allowed to take part in decisionsconcerning their home.

42

37

Is Quality AssuranceCost Effective?

The quality of care can suffer significantly whennursing homes are forced to reduce the costs of servicedelivery. Deciding how and where to make budget de-creases is an administrative task that will ultimatelyaffect everyone in the facility. Budgetary decisions canbe more easily made when there is a clear relationshipbetween the facility's standards for excellence in caredelivery and the costs associated with meetirg those stan-dards. Maximizing quality of service while minimizingthe cost of service delivery is the goal of an efficient andeffective budget.

To achieve an efficient and effective budget, admin-istration needs some way of describing the relationshipbetween cost and quality. As spending is reduced in thevarious departments, how is quality of service affected?Some suggestions for assessing the quality-cost relation-ship are:

Examine resident make-up and variation in needs.Can needs be met with fewer staff on certain

4 3


shifts?Which tasks require higher skill levels End which

can be performed by employees with less experi-ence or training? For example, how will qualitybe affected if an aide performs a task currentlybeing done by an LPN?

Volunteers are valuable resources.

Consider the facility's hiring practices.How is quality affected by hiring inexperienced

employees at lower wages and providing inhousetraining?

Would there be advantages to raising wage ratesfor nurses in order to compete for the best nursesand reduce the possibility of high turnover?

--Are there common characteristics to employeeswho have worked in the facility for the longestperiods of time? Perhaps these are characteristicsto look for in new employees that will reduce staffturnover.

4

Is QA Cost Effective? 39

Assess your volunteer pool.Does the community include many retired personswho might enjoy giving time to the nursing homeand who are able to perform tasks currently beingdone by paid staff?Set up an incentive program for employees to re-cruit volunteers.Are there merchants in the community who maybe willing to provide services or goods in exchangefor publicity?

Examine buying practices.-Are there other facilities or institutions with

which to join or form a cooperative buying groupfor bulk items?What would be the cost advantages to buying freshfood in season as opposed to canned?

Assess staffing patterns for efficiency.Weekends are primary visiting times for familieswho may have questions, concerns, or informationabout their relatives that cannot be answered byweekend staff. Would there be an advantage tohaving department heads available on weekendsso that Mondays are not spent fielding telephonecalls from family members?

The difficulty in making quality-cost tradeoff deci-sions is that while service costs are clearly defined andmeasurable, quality service is usually not. Definingachievable standards of excellence is, then, the first stepin making cost-related decisions. Planning the means ofachieving the standards is the second step. Maintainingthe cost of the means within the predetermined cost pa-

Q5


rameters (implementation of the plan) is the task of thethird step. Finally, an evaluation of the quality of servicedelivery in terms of cost must be done each time changesin staffing, procedures, or buying practices are made.From this cyclical pattern of defining, planning, imple-menting, and evaluating, qualit-, -cost relationships willemerge so that quality service, becomes measurable interms of cost and cost becom,2s a direct function of thefacility's performance standards.

/I 6

41

Is QualityAssuranceAttainable?

Quality assurance can be achieved in different waysdepending upon the needs, the pl- "osopy and the perspec-tive of the facility. Quality assurance can be achieved bya tightly structured program that uses checklists andheavy documentation procedures to measure the carebeing given and to make sure that staff members aremeeting the expectations of the home. Quality assurancecan also be achieved by a more informal program thatrelies on visual inspections by managers such as the ad-ministrator or the director of nursing. This type of pro-gram emphasizes vocal communication between manage-ment and staff to ensure that the care being deliveredmeets the facility's standards.

Although nursing home quality assurance programscan be very different, they share the common goal ofproviding quality care to the residents. Other propertiesof quality assurance that underlie all nursing home qual-ity assurance programs are:

Quality assurance is a process designed by the

d7


facility's management to guarantee that each in-dividual resident is receiving quality care.The quality assurance process is ongoing. Thismeans that an effective quality assurance pro-gram is not a stop-and-start or a one-time effort.A good quality assurance program is one that isbeing implemented at all times by all staff mem-bers.Quality assurance is closely tied to the facility'sphilosophy of providing quality care. Each facilityhas an idea of what constitutes quality care. Jobstandards are set and staff are expected to main-tain them.Quality assurance is an important part of the fieldof long term care and the field has certain ideasof what quality assurance should be like. Many ofthese ideas are the result of federal and state reg-ulations for long term care facilities. These gov-ernmental regulations are generally considered toset the minimal standards for acceptable levels ofcare. Regulations govern many areas affectingquality of care including the facility's physicalplant, the number and type of personnel, and infec-tion control policies.Facilities cail build upon the governmental regu-lations by raising expectations of what constitutesquality care above and beyond the minimal stan-dards. This results in a facility's definition of qual-ity assurance and definitions can vary widely fromfacility to facility.

a8

Is QA Attainable? 43

Quality assurance is continuity of care that cutsacross all departments, meaning that everyone inthe facility is responsible for the care of the resi-dents. Housekeepers, the DON, the top adminis-trator, nursing assistants, dietary aides, mainte-nance personnel, nurses, and anyone else em-ployed by the home all contribute in some way tocare of the residents and, therefore, contribute toquality assurance. Think about your job and howit contributes to care of the residents. How doesit contribute to quality assurance in your facility?Quality assurance includes interaction amongfamilies, residents and staff. Quality assurance ismore likely to be achieved when there is comfort-able and open communication outside as well asinside the facility. Do you talk with family mem-bers as a part of your job? How does talking withfamilies help you to help the residents? How doesthis contribute to your ideas about quality assur-ance?Quality assurance is a way of identifying and soh,-ing problems. What problems come up in your joband how are they solved? The problem solvingmethods of your facility are a very important partof your quality assurance program.

Quality Assurance Programs

A quality assurance program in a nursing home isthe means the facility uses to make sure that the residentsare being taken care of in a manner that meets the stan-

d 9


dards of the facility. The facility's quality assurance pro-gram is its system of identifying problems in the deliveryof care, formulating plans to correct the problems, imple-menting the plans, and evaluating the outcome to deter-mine if the plans were effective in eliminating or alleviat-ing the problems.

There are two broad categories of quality assuranceprograms, formal and informal, distinguished by the +ypeand amount of documentation involved. The two types ofprograms will be discussed and the variables a facilitywill want to consider in choosing the pi ogram most appro-priate to its needs will be suggested.

Formal Quality Assurance Programs

Formal programs apply systematic procedures tomeasure the quality of care being delivered and requirespecific documentation as evidence that standards ofcareare being met. These procedures along with the necessarydocumentation are used by designated facility surveyorswho are directly employed by the home or by the corpora-tion if the home is corporate owned. Surveys are conductedat regular time intervals and may be as frequent as onceper month or as infrequent as once per year. A singlesurvey can last anywhere from one day to three monthsdepending upon its structure and purpose.

Although there can be a large degree of variation inquality assurance programs categorized as formal, all for-mal programs have some ?nmmon charactenstics. All de-pend upon checklists that dcterm.ne what the surveyoris to look for or measure and ;'iow to do it.

50


Checklists consist of questions about the facility thatthe surveyor answers by marking the appropriate re-sponse on the checklist itself or by writing out an answerto the question. Here are some examples of questions thatmay appear on a checklist:

Are bedrails up for all bedfast residents?Are all call buttons within reach of bedfast resi-dents?How many non-bedfast residents are dressed innightwear?

Quality assurance can be attained.

In addition to checklists, formal quality assutanc,2programs use some sort of rating system to score or meas-ure the facility's delivery of care by assigning values toquestions that appear on the checklist. Nursing homesmust then score a certain numbers of points to pass theinspection.

51


Formal quality assurance programs usually requirethe surveyors to document problems encountered in thefacility and to make suggestions or help set up proceduresfor correcting the problems. Some formal programs alsorequire documentation of outstanding features of a facil-ity. Copies of the completed checklists and any additionaldocumentation is distributed to the home's managementpersonnel so that the necessary improvements can bemade and outstanding work recognized.

There is quite a bit of paperwork involved in formalquality assurance programs! To increase efficiency andreduce complications in the survey process, developers ofthe checklists should strive to cover all measureable as-pects of nursing home services in as few questions aspossible and with the simplest scoring or rating systemappropriate to the questions. The very simplest checklistwould be a series of questions all answerable either "yes"or "no". Questions answered "yes" would receive a scoreof 1 and questions answered "no" would receive a scoreof 0. Facility management would then decide how many"points" a home must score to pass inspection.

Formal quality assurance programs may sound likea lot of work, but there are advantages to having a formalprogram. Well-constructed checklists make facility stan-dards clear and deficiencies as well as strengths can beobjectively measured by surveyors. Employees in eachdepartment know exactly what they must accomplish topass inspection and are made aware of areas where theyfall short of the standards. Plans of correction will beformulated and implemented within a specified period oftime and the next inspection will determine if the plans


were effective in eliminating the identified problems fromthe previous inspection. The next inspection will mostlikely reveal new problems and the formal process willbegin again. This demonstrates how quality assurance isan ongoing and never-ending process in nursing homescommitted to providing the best possible care.

Informal Quality Assurance Programs

Informal quality assurance programs are much lessstructured than formal programs. Informal programs relymore upon subjective problem identification and opencommunication between management and staff as meansof problem solving than upon written checklists, measur-ing and scoring techniques, and documentation.

Problems may be identified by the administrator ashe or she makes daily rounds. The administrator willthen call the problem to the attention of the appropriatesupervisor and a solution will be sought on the spot, ifpossible, or at an arranged meeting of persons likely tobe able to provide a solution, ifnot. Problem identificationis not limited to the administrator or only to staff inmanagement posit ions, however. All staff are encouragedto speak up if they notice problems or potential problems,and innovative ideas in service are encouraged and dis-cussed. It is by means of verbal communication that facil-ity standards are made known to employees, problemsare identified, plans of correction are formulated and im-plemented, and effectiveness of the plans evaluated.

One advantage of an informal quality assurance pro-grat,-1 is that employees have the opportunity to contribute

N3


to procedures in the facility thus developing feelings ofpride and ownership in the home. A sense of pride andownership will be reflected by more conscientious workhabits which will benefit the residents as well as theemployees. Another advantage of informal programs isthat the different perspectives of the employees can pro-vide fresh ideas in approaches to care that can lead togreater effectiveness and efficiency in bervice as well asbeing cost beneficial to the facility.

To illustrate how the two different types of qualityassurance programs can be used to solve a common prob-lem in nursing homes, an example of a proble:.. will bepresented and solved using formal and informal qualityassurance methods. The approaches are different, but theobjectives of both types of programs are to:

1. Identify the problem.2. Formulate a plan to correct the problem.3. Implement the plan.4. Evaluate the plan for effectiveness in solving the

problem.

Nursing Home #1: Problem Solvingby Formal Methods

Once per month an aide from each of the facility'sthree floors is given the survey checklist used by thehome's owner corporation to make annual inspections ofits facilities. The aides switch floors and spend a dayinspecting the floor just as the corporate inspectors would.This procedure for quality assurance teaches the aidesfacility standards of excellence and is instrumental inidentifying and solving problems on a regular basis.

5 4


The aide assigned LA) survey the third floor recordson her checklist that three residents are lying in wet bedsat 3:20 p.m., just after the shift change. According tostandards set by the cooperation, all wet beds are to bechanged by the respective employees at the end of theirshift so that the new shift does not have to begin bychanging wet beds. The surveying aide documents thatthree residents are lying in wet beds near the shift change.At the end of her inspection, she tallies the score accordingto instructions on the checklist. Because of the three wetbeds, the floor does not score enough points to pass theinspection.

The checklists and additional documentation is pre-sented to the DON by the aides the -text morning. TheDON meets with the charge nurse from the third floor todiscuss the problem of the wet beds. The charge nurse isunaware of the problem so she schedules a meeting withthe aides from the day shift to lock for a cause and solu-tion. The aides complain that because they are busy giv-ing baths near the end of their shift, they are unable tocomplete other tasks, which include changing wet bedsbefore the next shift arrives. So the problem identifiedby the survey as wet beds is caused by too much work tobe done by too few aides in too little time.

The charge nurse consults with the DON and theydecide to try an earlier bath schedule so that the aidesdo not have so many tasks to complete near the end oftheir shift. Documentation of the plan is made and sentto the corporate office along with the original surveysused by the three aides. The new plan will be implemented

r5


for one month and then evaluated for effectiveness duringthe next survey.

The next month's third floor survey does not revealany wet beds at times near the shift change so the planof rescheduling the baths is determined to be successfuland is continued as a quality assurance measure. Thesuccess of the plan is documented and sent to the corporateoffice along with the new surveys. The new bath schedulebecomes a policy of the facility ar.d is implemented bythe other two floors as a routine procedure.

Nursing Home #2: Problem Solvingby Informal Methods

In this nursing home, the administrator and the DON...Ake daily rounds to monitor and evaluate care and to

determine if all is going well. One afternoon around 3:20they notice that three residents are lying in wet beds.Standards in this facility demand that all wet beds bechanged near the end of each shift so that residents arenot left lying in wet beds until aides from the next shiftare able to change them.

The DON responds to the problem by asking an aideto change the beds immediately. She also makes a noteto bring the inc_ _t up at the next staff meeting. Monthlymeetings are held by the administrator for all departmentheads and for any other staff who may wish to attend.The purpose of these meetings is to inquire about prob-lems or potential problems that anyone may be havingand to develop ideas to solve or ward off those problems.

At the next monthly meeting the DON mentions theproblem of residents lying in wet beds. An aide from the

6


3-11 shift remarks that wet beds are being left by the 7-3shift who leave without completing duties which includechanging all the wet beds.

The administrator prompts a discussion on whatcould be causing the occurrence of uncompleted work onthe day shift. It is agreed that the evening shift has certainresponsils"ities that are being delayed because they mustbegin their shift by changing beds left unchanged by theday shift.

Through discussion, it is decided that the aides arehaving trouble completing their assigned tasks becausethey are busy giving baths near the end of the day shift.The problem is identified as too much work to be com-pleted by too few aides in too little time.

The administrator asks for suggestions to eliminatethe problem. An aide from the day shift suggests re-scheduling the baths to an earlier time in the shift sothat there is not so much to do at the end of the shift.The other aides in attendance agree that the plan soundslike an effective solution to the problem so the adminis-trator asks the DON to reschedule baths in a way thatis comfortable for the residents and effi..ient for the dayshift. Staff vote to implement the plan for' two weeks andthen determine if the rescheduling of tasks helped theaides to complete their work by the end of the day shift.

During the .wo week trial period neither the adminis-trator nor the DON notice any wet beds as they maketheir daily rounds. Residents are no longer complainingabout wet beds, and there seems to be less tension duringshift changes. At the end of the two weeks the adminis-trator and the DON call a staff meeting to evaluate the


plan. Feedback from the aides suggest that they are satis-fied with the new bath schedule and desire to maintainit. Everyone agrees that the plan has been effective insolving the problem of too much work to be completed intoo little time by too few aides.

Comparisons of Formal and Informal Programs

QA Procedure Formal QA Program Informal QA Program

Problem identified using surjvey checklist through observation

Plan formulated by management by staff & management

Plan implemented by staff by staff

Plan evaluated using survey checklist through discussion

Formal QA Program Features Informal QA Program Features

Service delivery monitored bysurveyors using preprinted formsor checklists that quantify goalachievement or failure.

Service delivery monitored bysubjective observation of manage-ment

Plans for improving care deliverydeveloped by managers

Plans for improve care deliverydeveloped by managers in con-junction with staff

Relies upon objective measure-ment of data to determine effective-ness of implemented plans

Relies upon verbal communicationbetween staff and management todetermine effectiveness of imple-mented plans.

Helps large facilities integrateemployees of varying backgroundsand values and who have littlecontact with one another

Helps maintain casual and family-like atmosphere in small facilitiesin which most of the employeeshavedaily contact with oneanother.

In-services usually scheduled andformally presented by departmentheads.

In-services frequently presentedon the spot by the managers whodetect the problems.

C 8


The formal and the informal quality assurance pro-gram techniques in the above examples resulted in thesame outcomesa better quality of life for residents whowere no longer left lying in wet beds and more efficientworking procedures for staff. These are two goals thatshould be a part of the quality assurance program thefacility chooses to adopt or develop.

How to Develop a Quality Assurance Program

The first step in developing a quality assurance pro-gram that will be effective for your facility is to analyzethe variables that make your facility unique. Some ques-tions to be considered in the analysis:1. How large is your facility in terms of staff and how are

they alike and different?Is it small enough that management and staff havedaily contact and problems can be discussed onthe spot in a casual manner or is it so large thatscheduled in-services are more effective for train-ing staff?Are most of the employees recruited from the samearea such that they have similar backgrounds andare familiar with the community? A small facilityin which staff have similar backgrounds andvalues lends itself to easier communication thana large facility with staff of various backgroundsand value systems.

2.How large is your facility in terms of residents and howare they alike and different?

Do you have many residents with widely differing

59


medical and social disabilities requiring a diver-sity of staff skills or are you P small facility withresidents requiring similar care so that your staffis interchangeable and each employee can workwith any ..-esident?Are your residents from the same general areasuch that they have similar backgrounds andvalues and communicate easily with one anotheror are your residents from many different geo-graphical locations, of widely varying economicstatus, and with obviously different value sys-tems?

3.What is the geographical location of the facility like?Are you located in a rural community where thepace is relaxed or is your facility in a busy urbanarea?Is your location such that community membershave easy access to your facility or must theytravel several miles to get there?How easy or difficult is it to transport residentsoutside the facility and into the community?

4.How will your choice of a quality assurance programaffect staff morale?

Will a tightly structured program using strictmeasuring techniques create unrest and feelingsof competition among employees?Will a casual, loosely structured program resultin staff not demanding as much of themselves asis required to achieve quality work?

Having answered these and other questions appropri-ate to your facility you can decide whether a formal or

GO


an informal program will work best in your home toachieve your standards of quality care. After deciding onthe type of program, the next step in its development isto determine what aspects of care will be monitored andhow. Forms and/or checklists will be needed for formalprograms and clear ideas of what to look for will need tobe developed for informal programs.

Ways to translate facility standards into concrete andunderstandable working procedures for staff must beagreed upon by managers so that staff have a clear ideaof what is expected of them and how to meet the expecta-tions. Explain to staff what is being monitored, how it isbeing monitored, and why, so that they have an under-standing of how the quality assurance program works inrelation to their own jobs.

When service delivery does not meet facility stan-dards of excellence, correction procedures must be plan-ned and implemented as quickly as possible. Determinegeneral approaches to correction as a part of your qualityassurance program, such as on the spot in-services whenappropriate.

After deciding upon a formal or an informal program,developing monitoring tools and techniques, educatingstaff about the program and how it affects their jobs, anddetermining general approaches to problem correction,the final step in setting up a quality assurance programis to design evaluative methods for determining the suc-cess or failure of your program.

As you develop your own quality assurance programor if you decide to purchase a quality assurance package,

61


you will want to keep in mind that a successful qualityassurance program will:

Promote ongoing quality care of residents.Aid administrators, supervisors, and staff in iden-tifying and solving problems.Create a positive image of the facility as a homerather than an institution.Reassure families that their relatives are beinggiven the opportunity for a good quality of life.Encourage members of the community to volun-teer time and services to the facility as well asinvolve residents in activities outside the facility.Promote a clean and safe physical environment.Be cost efficient and effective.Be compatible with the facility's mission state-ment.Promote holistic care of the residents which in-cludes issues of self-esteem, self-respect, and inde-pendence.

Is quality assurance attainable?yes!!!

n 04,

57

Appendix A

Sample Job Description

Nurse's Aide 7:00AM - 3:30PMQualifications

Education: A minimum of a grammar school education with a high schooleducation or equivalent preferred Certificate from Certified Nurse'sAide Training program preferred.

Training and Experience: Previous experience with elderly preferable.Job Knowledge: Knowledge of procedures and techniques involved in

administering simple treatments and providing related bedside care toresidents. Must be familiar with the location of the various departmentsof the home. Understanding of standard techniques used in providingpersonal services for residents and in caring for equipment andsupplies. Must understand the basis of good sanitation and steriletechniques to avoid infection or spread of contagious illnesses.

Working Environment: Work indoors in well-lighted ana ventilatedareas. May be exposed to communicable diseases. Possibility ofstrains due to moving residents

Performance RequirementsResponsibility: Handling and caring for residents to ensure their safety

and comfort Adhering to instructions issued by nurse Performingduties in acco, dance with the methods and techniques which conformto the home's standards of quality. Providing maximum resident-careservice as directed. Maintaining good housekeepir.g standards withinassigned duty areas.

Physical Demands: Good physical and mental health Constant standingand walking during work periods. Turning, stooping, bending,stretching, and lifting to assist residents, make beds, move equipment,and perform other related tasks Finger and hand dexterity to handledelicate instruments and other equipment. Visual and hearing acuityto detect changes in resident's condition.

Special Demands: Must have a genuine interest in geriatric nursing.Willingness to work with the realization that errors may have seriousconsequences for residents. Patience and tact in dealing withresidents, their families and visitors Some initiative and judgment inrecognizing symptoms indicating a resident's adverse reactions totreatments Willingness to perform a variety of simple repetitive tasks,many of which involve unpleasant conditions

P3


Job Duties1. Set up clean and dirty linen carts daily.

2. Review your assignment of residents and their plan of care, includingyour cleaning assignment, break assignment, and any specialinstructions.

3 Receive report from the staff nurse about your residents, such as.a) anything that is different or special you need to do

for residelit.b) any new admissionsc) any job assignments not included in the written

assignment.

4. Make rounds to check all assigned residents. Be sure residents areprepared for breakfast Face and hands are to be washed. Oralhygiene is done, toileting or diaper change is completed, andresidents are set up for breakfast in bed, chair or dining room.

5 Pass breakfast trays, seeing that each resident receives proper dietand that the meal is hot Set up tray for eating, butter bread, openmilk carton, etc. according to resident's needs Note how much eachresident eats for documentation on patient care record and advisenurse of any decreased intake.

6 Trays of residents requiring spoon feeding or partial assistance withactual feeding shall be served last.

7 Collect all meal trays and place on diet carts. Clean overbed tables.Position residents according to turning schedule as needed anddocument on the turning schedule as you complete each turn.

8 Give bed baths and shower., as assigned daily including shampoosand nail care Record care done in the patient care record. Reportto the nurse any br_iises, cuts, scratches, rashes, or any change inthe resident's skin condition.

9 See that all residents are properly dressed and hair is combed neatly.Give priority to residents going into therapy Apply urinary leg bagsas ordered, use medical aseptic technique, cover large drainage bagtubing with a fresh sterile catheter cap and emptN the bag of urine.

10. Complete room, make beds, and see that cloth', ig is put away andtable tops and dressers are clean Put personal soiled clothes in dirtylinen cart and throw it in laundry chute by 11AM.

i4

Appendix A 59

11. Place soiled diapers in plastic bags, close by knotting and discardin garbage chute.

12. Incontinent residents are to be checked every two hours and changedas needed. Assist continent residents in toileting as needed.

13. Check and toilet residents on bladder training at 8am, 10am, no 1,

and 2 pm or according to the individual's care schedule Documenton the training schedule and the I&O sheet.

14. See that position of bedfast residents, those with restraints, and thoseat high risk of pressure sores is changed every two hours or moreDocument turning schedules as each turn is completed.

15. Report any unusual symptoms to charge nurse such as pain, fever,body rash, personality change, or any change in the resident'scondition whether physical, emotional or psychological

16. Pass fresh water to all residents able to take fluids by mouth Assistand encourage residents to drink fluids frequently unless otherwiseordered.

17. Pass morning and afternoon nounshments as assigned

18. Prepare residents for lunch. See that residents going to dining roomare taken on time. Repeat procedure as for breakfast.

19. Assist residents out of dining room after meal See that they areclean, neat, and comfortable. Assist those who require a nap to bed.

20. Any units of discharged residents are to be cleaned by housekeepingand the bed made with fresh linens by the nurses aide assigned tothat room. Pack belongings as instructed by the charge nurse

21. Assist in ambulating residents as requested by the RehabDepartment or charge nurse Do ROM and ADL on residentsassigned to you according to sheets and as requested, and completedocumentation.

22. Answer call lights promptly and courteously whether or not it is yourassigned resident. Answer call lights for other staff when they areon break. They will do the same for you. Keep the call light withinthe resident's reach.

23. Assist with admissions, including settling the resident in the roomand completing vital signs and the clothing list

P 5


24 Complete docut entation on 18,0, B&B, V S., Patient Care Record,and any other forms required.

25. Be sure safety restraints are on where needed. All restraints mustbe released at least every 2 hours and the resider 1positioneddnd/or ROM done as appropriate for the type of restraint used.

26 Make last rJunds by 2pm, changing diapers, toileting and turningresidents as needed.

27 Clean off your linen carts and put them at the linen room for next shift.

28 Report to the charge nurses on the resident's condition and whetheror not your assigned work was completed by 2:45pm.

I, have read the above jobdescription and fully understand the conditions set forth therein, and ifemployed as a Nurse's Aide, I will perform these duties to the best of myknowledge and ability.

Date Signature

*Adapted from forms used at Lake Bluff Health Care Center and ArthurHome.

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Appendix 13 61

Appendix B

Role-playing as a Problem Solving Method

At staff meetings, select employees from various departments torole-play the parts of residents and staff to find creative solutions toproblems in the facility.

ExampleThe nursing home is having a problem with Mrs Evans. an 88 year

old blind resident who complains of hunger even after meals Sh,complains by yelling very loudly. The only solution to the problem so fahas been to wheel her into her private room so that the other residentsand staff are not disturbed by the noise.

A dietary aide is selected to play the part of Mrs Evans. He sits in awheelchair and yells that he is hungry, just as he has heard Mrs Evansdo. A nurse's aide is selected to try to solve the problem as the otherstaff members watch.

First, the aide tries to reason with Mrs Evans. Sha tells the residentthat she cannot possibly be hungry since she has just completed dinnerand even left food on her plate Mrs Evans continues to yell The aidedecides to wheel Mrs. Evans from the hallway where she is parked inher chair to her room. Mrs. Evans yells even louder when the aide tellsher she is taking her to her room The aide decides to wheel Mrs Evansto a location near the nurses' station She tells Mrs Evans that sl e mustbe quiet so that the nurses' important work is not disturbed. The dietaryaide playing Mrs. Evans pretends to be curious about what the nursesat the desk are saying so he (she) stops yelling in order to listen

The staff watching the "play" decide to try parking Mrs Evans nearthe desk during the day to see if she will be so interested in listening tothe nurses' activity that she will no longer cause a disturbance by yelling

The solution is tried for several days The nurses and aides workingat the desk pay some extra attention to Mrs Evans as they work bysaying hello as theyrass by and comp' ,cro.,ng her on her appearanceMrs. Evans, who was a vex y lonely ar d unhappy resident, enjoys listeningto the activity she c. innot see and tr.: comp? lionship of the nurses andaides as they work She no longer .--impi-..ins or yells and the problem issolved.

I: 7

Sample Minutes from a Staff Meeting

Minutes: Utilization Review Meeting 6-15-87Present. Shirley Campbell (Administrator), Dr. Philip Ramsey (Medical

Director), Deborah Parsons (DON), Jerry Thorsen (SSD), CarolSimon (Activity Dr.), Maude Butler (Dietary Supervisor), RickBaxter (Maintenance Supenpsor)

Recording secretary: Deborah ParsonsStarting time: 10:00 AMEnding time: 11:30 AM

I. Announcements-Next scheduled meeting: 10.14-87, 10:00-11 30-Welcome to Carol, our new activity director;-Census: 123 residents (Medicaid -52. Private-71)

II. Old BusinessA. Decubitus Ulcers:

- At last meeting (2-13-87) there were 5 cases.- As of date (6-15-87) there are 3 cases.-What has been done. An inservice was held two months ago by

the DON for all aides. Discussion was held on the conditionssurronding decubitus ulcers and a new rotation schedule waspresented The new schedule was implemented by the aides onall three shifts A follow-up inservice was held one week later todiscuss how the new program was working.

-What will be done. Due to positive feedback from the aides usingthe schedule and the decrease in decubitus cases. the programwill continue to be used

III. New BusinessA. Medication Combinations

- Dr. Ramsey g, e a preser on on medication combinationswhich can be harmful to residents with certain diagnoses.

-As of yet there have been no incidents of conflicting combinationsin the facility, we would like to maintain our awareness.

B. Resident Involvement in Care Plan Meeting:-Jerry (SSD) presented a questionnaire he designed to be

completed by residents on attending their own care plan meeting.-After reviewing the questionnaire, staff prent voted on whether

the survey should be distributed Voting resulted in. 6 Yes, 1 No.-Jerry will make arrangements to distribute the questionnaire .

Meeting Adjourned

63

Appendix D

Examples of Suggestions from the Employees' Suggestion Box

Put non-skid mats or appliques in residents' bathtubs.

Use linen tableclothes instead of plastic for holiday or special ,neals

Have rezerved employee parking.

Give employees their birthdays off as paid holidays.

Install a juice machine in the employees' lounge.

Replace artificial plants with live plants.

Have an employee "best attendance" award penodically.

Replace harsh soap in dispensers with a milder soap.

P9

64

Appendix E

Sample Job Evaluation of Nurse's Aide

,1/4e

... ,z4, e ,.§`or'

ale, 0,, x....o i

Appearance and Conduct V . ,\ N>4 e v- co +e0 ae yep

uniform neat and clean, dressesneatly, good bociy hygiene --, ,-1

L__, rf,cooperates with peers r-1

cooperates with supervisors Saccepts corrections and is willingto improve 1

completes assigned tasksenthusiastic toward resident care _ __I

respects resident's privacyinteracts appropriately with

residents' significant others

Dependabilityreports to work on timereports to work per scheduleassignments are followed through

on a timely basis

Quality of Careresident rooms and work areaskept clean and neat

attends to residents' needs(feeding & elimination)

grooms residents appropriately(teeth brushed, shaved, handsand face washed and dean)interacts in a polite way with theresidents

Safetysafely handles equipment used(wheelchairs locked duringtransfer, restraints on, etc.)

consistently uses infection control(hand washing, linen care, etc )

70

LiC.]

Appendix E 65

...0

..o 4...\ a

b°o.Jam

. 6i) , c., ...1

V- V> 42 V- co

keeps cabinets and doorslocked (snackroom, storage,supplies, etc.)corrects or reports unsafeconditions

Documentation and Executionrecords daily charting L7

carries out programs per careplan objectives

Other Itemsattends staff meetings and

in-services regularlyability to establish workingrelationship with fellow employeesand residents' significant others

Overall EvaluationOutstandingVery Good_ SatisfactoryNeeds Improvement

_ UnsatisfactoryComments

Comment on employee's m ajor strengths, developments achieved sincethe last appraisal.

Ii overall evaluation is "Needs Improvement' or "Unsatisfactory, liststeps employee is to undertake to continue employment

Employee's comments on appraisal.

Prepared by (supervisor's signature)

Approved by (Administrator or DON)

This appraisal was discussed with me

(employee's signature) Date

71

66

Appendix F

Sample Newspaper Article Topics

Announcements of residents' birthdays

"Someone You Should Know" articles about residents

Upcoming craft shows presented by staff and residents

Awards to outstanding staff members

Resident-family activities or programs

Talks given by residents

Fund-raisers for the nursing home

"Why I Love My Grandparents" writing contest for children

A person from the community spends a di y as a resident and reportson the experience

Publish residents' poetry or short stones

7 2

67

Appendix G

Example of a Letter to Family Members

Dear

One of the most important goals of our nursing home is to strive to create

a facility environment in which families can feel comfortable expressingconcern and loving support for family members

As family members, you can be valuable contributors to the well-beingof your loved one, and to the facility in general. On the following page,please indicate the ways you would like to be involved You will be notifiedof the dates and times of the events and programs in which you areinterested.

Thank you for your involvement. We look forward to serving you in policies

and programs that enrich the quality of family relationships. the lives ofthe residents, and the nursing home as a wriole.

Sincerely,

Family of (resident's name) Date


Family of (resident's name) Date

Please place a check beside the activities in which you are interested inparticipating:

Resident Care Plans7., I would like to be notified of every care plan meeting involving my

relative so that I may attend.

,== I would like to be notified periodically of care plan meetings involvingmy relative so that I may attend.

I would like to be notified only of major problems or concern> regardingmy relative.

would like to be notifieo only in case of emergencies regarding myrelative.

Family ProgramsI am interested in attending a community support group to help familymembers make difficult decisions and to cope effectively with theirconcerns

I am interested in attending workshops that can enrich communicationand visiting skills with my relative as well as help in understanding theaging process

I am interested in attending the followng family activities

monthly coffee houses with staff and other families

resident/staff/family holiday parties

community outings for residents and families

family committees on facility policies

24

69

References and SuggestedReading

Alan, Lucille ACSW, UCSW. "The Importance of Includ-ing the Family in the Comprehensive PsychiatricAssessment of the Nursing Home Bound Person.Journal of Gerontological Social Work. 7(3), May1984.

Committee on Nursing Home Regulation, Institute ofMedicine. Improving the Quality of Care in NursingHomes. Washington, D.C.: National Academy Press.1986.

DiBerardinis, James and Gitlin, Dianne. "A Holistic As-sessment Model for Identifying Quality Care Indi-cators in Long-Term Care." Long Term Care andHealth Services Administration. 4(3), Fall 1980, pp.227-235.

Flood, A. and Scott. R. "Conceptual and MethodologicalIssues in Measuring the Quality of Care in Hospi-tals." Hospital Structure and Performance. John Hop-kins University Press, 1987.

Greene, Roberta. "Familiesthe Nursing Home SocialWorker." Social Work in Health Care. 7(3), Spring,1982.

'75


Hatch, R. and Franken, Mary.. "Concerns of Childr.m withParents in Nursing homes." Journal of Gerontolog-ical Social Work. 7(3), May, 1984.

Kane, Rosalie. ''Assuring Quality of Care and Quality ofLife in Long-Term Care." Quality Review Bulletin.Oct. 1981.

Komaroff, Anthony. "Quality Assurance in 1984." Medi-cal Care. 23(5), May 1985.

Kraft, Margaret Ross. "Quality Assurance." Journal ofGerontological Nursing. 9(6), June 1983. pp. 326-332.

Linn, M. and Gurel, L. "Family Attitude in Nursing HomePlacement." The Gerontologist. Part 1. Fall, 1982.

Montgomery, Rhonda. "Staff-Family Relations and In-stitutional Care Policies." Journal of GerontologicalSocial Work. 6(1), Sept. 1983.

Scott, R. and Flood, A. "Costs and Quality of HospitalCare: A Review of the Literature." Medical Care Re-view, 41, Winter, 1985. pp. 213-261.

Sorodo, K. "Group Family Counseling: An Aid to Long-Term Care." Journal of Long Term Care Administra-tion. 10(1), Spring, 1982. pp. 137-142.

7 6

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Work. PUB DATE 87 76p. PUB TYPE - ERIC · 2013-11-23 · Preface. There are 957 nursing homes in Illinois. The vari-ations among the homes are as great as the people who live and