A negative culture within an organization can undermine the efforts of the strongest leaders. Negativity, disregard for rules, and lack of respect for authority can dissolve the core of an organization rapidly. Anyone who has struggled to change the culture of a failing organization will attest to the fact that it is one of the most challenging but critical keys to overall success. Unfortunately, you do not have the luxury of halting operations while assessing the problems and correcting them immediately. A systematic approach to recognizing the source of the problem, determining solutions, and implementing those solutions is essential. Begin the process of change by implementing the following recommendations:
A crucial key to preventing acute care readmissions from the Post-Acute Care setting is the use of clear and comprehensive communication between nurses and physicians.
A few years ago while working in my office as Director of Skilled Nursing, I overheard a nurse speaking on the phone with a physician indicating that her patient was short of breath. No additional information was communicated during the call. The nurse then proceeded to dial 9-1-1 to send the patient to the nearest hospital. When I inquired why the patient was being sent out emergently, the nurse replied that the patient was short of breath and the physician wanted her sent to the Emergency Room.
With my stethoscope in-hand, I went directly to the patient’s room to perform a physical assessment. My findings were as follows: the patient was alert and oriented; auscultation of her lungs indicated rales/crackles in her left lobe; she had a productive cough; pulse ox on room air was 90%; oral temperature was 101 degrees Fahrenheit; and respiratory rate was 28 per minute. All signs seemed to point to a developing pneumonia for which I believed the patient would benefit from a chest x-ray and blood work to rule out infection. I contacted the patient’s physician again and communicated the assessment and recommendations using a proven tool known as the SBAR (Situation, Background, Assessment, Recommendation). The physician was in agreement and results of testing indicated the patient had a developing left lower lobe pneumonia with an elevated WBC (white blood count) indicating infection. The physician ordered an intravenous antibiotic, and the patient was treated successfully in the skilled nursing facility, avoiding an unnecessary emergency room trip and admission to the hospital.
As a Director of Nursing, I immediately established additional assessment training for nursing staff and instituted the use of the SBAR tool for all nurse/physician communication. Acute care readmissions were reduced from 24% to less than 16%. Physicians expressed more confidence in the assessments provided to them by nursing staff, and patient satisfaction with nursing knowledge (as measured on a satisfaction survey) improved steadily.
This real-life case indicates how important it is for nurses to properly collect and communicate clinical information to physicians so that appropriate decisions can be made collaboratively for the benefit of the patient.
Not only did the confidence level of our nursing and physician staff improve, but hospital referral sources were also more likely to send patients from their hospitals because they were able to avoid readmission penalties mandated by the Affordable Care Act.
Great nursing skill combined with effective communication using the SBAR tool leads to fewer patient complications, improved patient satisfaction and increased referrals and revenue.
How will raising the minimum wage affect hiring and operations of long-term and skilled nursing facilities? While politicians, unions and protesters weigh in on this controversial subject, the fact remains that nursing home leaders must prepare for the real possibility of increased expense as well as the loss of direct care providers to higher paying, less stressful job opportunities. Attracting and retaining excellent aide staff is a daily struggle, and these care providers are critical to the patient experience, quality outcomes and the documentation which is so critical to reimbursement.
The role of the Nursing Assistant is physically and emotionally demanding. Many who were drawn to the profession are now looking elsewhere as they can obtain higher paying, less demanding entry-level positions. The number of qualified applicants for State Tested Nursing Assistant (STNA) training programs is down, as is the number of students who pass the Nurse Aide Training Competency Evaluation Program (NATCEP) and exam.
According to a report published in March of 2015 by He, Goodkind and Kowal; An Aging World: 2015, United States Census Bureau; “Growth of the world’s older population will continue to outpace the younger population for the next 35 years.”
Couple this with the fact that the nursing shortage as predicted by the Health Resources Service Administration (HRSA) is expected to fall 36% below anticipated need by 2020 unless serious interventions are put into place, and we have serious reason for concern.
Nursing home administrators and nursing leaders need to look for creative alternative methods of providing direct care. I believe that creating a hybrid LPN/STNA role is a very viable answer. In this model a new graduate Licensed Practical Nurse (LPN) would start at a rate of pay slightly higher than an STNA but below that of an experienced LPN. The new grad LPN would begin with a direct care assignment similar to that of the traditional STNA. As training progresses the LPN would begin to take on additional responsibilities for treatments, medication pass and other delegated duties within the appropriate level and scope of practice. As the LPN learns facility policies and procedures he/she would be evaluated and earn additional pay for successfully achieving at an increased level of responsibility.
This care model offers several instances of value. It attracts STNAs currently enrolled in LPN school and ensures that these new LPNs are trained and competent, based upon facility standards. This should lead to better overall compliance with regulatory and quality expectations, while providing incentives for staff fulfillment and retention.
Wan, He, Daniel Goodkind, and Paul Kowal
U.S. Census Bureau,
International Population Reports, P95/16-1,
An Aging Works: 2015, U.S. Government Publishing Office,
Washington DC, 2016.
Department of Health and Human Services, (2004). What’s behind HRSA’s projected supply, demand, and shortage of registered nurses? September 2004. http://bhw.hrsa.gov/healthworkforce/reports/behindrnprojections/index.htm
It is 2017, and “uncertainty” is the operative word for health care leaders. As we transition from the Obama White House to the Trump White House there is much that has yet to be determined with respect to how healthcare will change. President-Elect Trump has promised to “repeal and replace” the Affordable Care Act better known as Obamacare. With both houses of Congress dominated by Republican majorities it seems likely that change is coming. There has been little talk of exactly what that change will look like, except to say that a full repeal is unlikely because it would be too disruptive to those already on the exchanges who have no other options. It is said that markets hate uncertainty, and the same can be said of healthcare administrators, CEOs and nursing directors. So, what is a healthcare leader to do in order to prepare? As a former V.P. of Clinical Services for skilled, long term, inpatient rehab and home care facilities I recommend the following:
• Review your quality outcomes and develop process improvement plans in any areas that appear deficient
• Develop effective transition of care processes and communication
• Analyze information data sets such as MDS (Minimum Data Set) or IRF-PAE (Inpatient Rehab Facility-Patient Assessment Instrument) to ensure maximum reporting within guidelines
• Review all leadership positions within the organization for maximum effectiveness. Add or delete based upon need to address quality outcomes, education, regulatory compliance and cost containment. (Keep in mind that adding position(s) may lead to long-term cost reduction).
• Review last two years of health survey visit findings and perform audits on any areas with a history of deficient practice
• Perform staff satisfaction survey and develop additional methods to determine staff turnover rates and reasons for turnover then develop definitive plans to reduce turnover, increase recruitment and improve retention
• Perform resident/patient satisfaction survey (if not done within last 2 years) and develop action plan to improve to at least 95%
• Perform risk assessment analysis in areas that impact patient safety, returns to acute care and adverse events. Develop clinical programs that address any deficits.
It is unlikely that value-based purchasing (VBP) will fade. Therefore, a keen eye on quality outcomes is essential. As competition intensifies, this will differentiate your facility from the rest of the pack. Referral sources and patients are shopping for providers with the best results, so ensuring processes are in place which deliver clearly defined clinical programs to prevent readmission is critical to success. Mitigating risk and holding costs down while maximizing referrals is essential. The incoming administration is claiming to be serious about cost efficiency (Boeing learned that lesson before Trump even took office). A well informed, experienced leadership team is a must. Leadership needs to be prepared with a strong staff development program that keeps staff informed, in compliance with regulatory expectations and capable of providing quality customer service skills.
It is likely that legislation will be passed to ensure portability of insurance which will force not only competition between providers, but will also require better communication and cooperation amongst care providers across not only systems (hospitals, insurers, post-acute care providers), but states as well. Transitions of care will be a focus, and those who are prepared will be the clear winners. They will experience the most success, because their patients will reap the whole of the benefits of quality and efficient healthcare and isn’t this what we all want?