rethinking the use of position change alarms by joanne...

Rethinking the Use of Position Change Alarms By Joanne Rader, Barbara Frank, Cathie Brady

January 4, 2007

Personal alarms are alerting devices designed to emit a warning signal when a person moves in a way perceived to put them at risk, usually for falls. The most common types of devices are:

• A cord attached to the person’s clothing with a pin or clip and ending with a magnet or pull- pin that activates when the person exceeds the length of the cord

• Pressure sensitive pads for chairs, wheelchairs and beds that activate when there is decreased pressure

• Pressure sensitive mats for the floor that activates when pressure is increased • Light beams on the bed or door that activate when the person crosses the beam.

The Omnibus Reconciliation Act of 1987 (OBRA 87) implemented in 1990, resulted in a dramatic shift in thinking and practice related to the use of physical restraints and falls. The Quality of Care regulations to implement OBRA 87 require that there be no decline in a person’s physical, mental, or psychosocial well-being, unless such a decline is an inevitable consequence of the person’s disease or condition. Restraints cause declines in a person’s physical, mental, and psychosocial well-being. By keeping people from moving, restraints adversely affect people’s respiratory, digestive, circulatory, and muscular systems, contribute to depression and isolation, and inhibit sleeping as well as independent eating, drinking, toileting, and natural repositioning. As nursing home staff came to understand the detrimental affects of restraints and changed practice, the use of position change alarms became wide spread. However, just as restraints cause harm by keeping people from moving, so do personal alarms. Meanwhile, there is no evidence to support alarms’ usefulness in preventing falls or injuries. In fact, in most cases, falls continue to occur. In spite of that, staff, and sometimes families, gravitated to the use of alarms, and surveyors in many states began looking for them as part of the documented safety plan. Quite often, staff respond to the alarm by directing a resident to sit back down instead of assisting residents with whatever is generating their movement (discomfort with the current position, a need for a drink, the bathroom, or simply a need to move). Often staff respond to the alarm and not to the person. In addition to the harm alarms cause by immobilizing residents, and having no evidence that they prevent falls or injuries, they are difficult to utilize in a consistent way for a variety of reasons:

• Many persons dislike them and repeatedly hide or remove them • The device can malfunction (cord breaks or detaches, battery dies, alarm fails to go off or is

slow to respond) • If too many are in use, the warning signal loses its effectiveness at alerting staff.

Rethinking the Use of Position Change Alarms

For the person, there can be numerous negative consequences to his/her quality of life and mobility:

• Alarms create noise, fear and confusion for the person and those around them. For example, one gentleman would duck down when he heard the alarm as he was interpreting the sound to mean incoming missiles, bullets from his World War II experience

• If staff tell the person to sit down when the alarm goes off, the underlying need causing them to want to move is not being address

• As the use of the alarm decreases the person’s overall mobility, he/she may be more at risk for fracture when he/she falls since the person may have increased weakness and osteoporosis and decreased balance and endurance

• The alarms can be experienced as embarrassing and an infringement of freedom, dignity, and privacy

• Skin break down can occur from being immobilized, and afraid to shift position or body weight while sitting for prolonged periods of time, or while lying in bed at night

• Sleep may be interrupted, or even impossible when residents lie still for fear of setting off the alarm if they shift their position or being awakened by the alarm

• Loss of independent bowel and bladder function can occur. Clearly there are many people in LTC who are at risk for falls and injury and who need to have a safety plan in place. These plans need to be highly individualized and based on a thorough assessment of the risk factors that exist within the person and her/his clinical condition, in the physical environment and also the organizational environment. The alarms provide a clear example of an intervention that by attempting to prevent the risk of falling may actually increase the risk of serious injury from falling. They give a false sense of security and at the same time, absorb an inordinate amount of staff time responding to the alarm. In most cases, the best way to prevent the risk of falls with injury is to promote residents’ balance, endurance, and overall mobility. The residents’ wishes and preferences have to be considered. If persons do not have cognitive impairment and are informed of the risks, they have a right to be mobile, even if that involves falling. If the person is cognitively impaired, his or her expressed wishes must be factored in. These wishes may well be expressed through behaviors that demonstrate any discomfort from the person’s perspective. For people who are cognitively impaired, the alarms are particularly upsetting. They have been found to induce agitation during the day and interrupt sleep at night. Lack of deep sleep compounds agitation, and contributes to loss of appetite, and decreased balance and endurance. The medications used to treat agitation and sleeplessness often pile on to the problems.


For people who have had a recent change in health and ambulatory status (e.g., amputation, hip replacement, stroke or debilitating acute illness), there may be some value in using an alerting device temporarily as a reminder of the need to call for assistance. In a sense it acts as a substitute call light for at risk people who may not remember to use a call light. It might also be helpful in assessing the needs and patterns of newly admitted residents. Given that there is no clear evidence of the efficacy of the devices in reducing falls or injuries, any prolonged use should be very carefully and routinely assessed against the multiple adverse consequences that can inhibit healing. In some cases, premature and prolonged use of alarms contribute to such a severe decline in a resident’s function that it may unnecessarily turn short-term residents into long-term residents. People who came to the nursing home to recover may never go home. Originally alarms were designed for very short-term use to learn a resident’s patterns. These patterns can more easily be learned through individualized care. Staff would have time for individualized care if they were not responding to so many alarms. However, when an alerting device is documented as being part of the short-term safety plan, staff have a responsibility to assure that they are being used as indicated in the plan (e.g., placed correctly on the person, length of cord adjusted properly, in good working order). If this is not done or if the resident consistently tries to remove it, the facility will be viewed as having not followed the person’s safety plan and be at risk for deficiencies. So the reasonability of the plan has to be considered. It makes no sense to create a plan that you know the resident will consistently foil. Since our culture tends to be over-protective of elders and to seek solutions in technology, and our traditional nursing home culture tends to focus on risk prevention instead of health promotion, it is easy to over rely on these devices. Because there is potential for harm, we need instead to find the underlying causes of falls and instability, and develop individualized approaches that take into account the strengths, possibilities, wishes and needs of each person. So when considering using personal alarms, it is important to ask, “Will this cause immobilization and isolation for this person?” “Will this really increase the person’s safety or is it more to help the caregivers (family and professionals) feel they are doing something?” As a culture we need to come to terms with the fact that in our long-term care settings we are working with the frailest of the frail much of the time. Some are going to fall, get injured and even die as a part of normal life and risk taking. There is no way to prevent all falls and people coming into new settings have an increased risk of falls. We certainly don’t want to contribute to their risk of injury from falls by immobilizing them and causing their decline. The best we can do is work to strengthen balance and endurance and know as much as we can about the person. By doing so, we can respond to his/her needs and help him/her sleep, drink, shift, and move as safely, freely and comfortably as possible with our assistance when needed. With this approach, we can try to create plans of care that meet the unique needs of each person.


As with any significant change in clinical practice, it is important to start slowly. In order to remove position alarms, identify residents who can most easily have a decrease in the amount of time alarms are in use for them. Remove the alarms a few hours at a time. Have all staff involved in watching and learning together, identifying any possible concerns, as well as possible strategies. Make sure to give staff the help and support they need as they proceed. Work together to mitigate risks and put in place the necessary interventions to meet residents’ needs and build their capacity to function without alarms. Each success will teach you more about how to take on the next challenge. You may want to start by putting an alarm on yourself, and having all who will be involved in an alarm elimination effort do the same. Wear the alarm for 30 minutes and then discuss the experience together. You’ll be surprised by how uncomfortable it is and how much it has the psychological effect of restricting your movement. This kind of personal experience is a great teacher. Essential ingredients for a successful process include:

• Consistent staffing so that staff know residents well and work well with each other • Daily meetings on the unit where you are changing practice to discuss what staff are doing,

learning, and needing • Consistent communication across shifts to share information, ideas, and experiences • Interdepartmental communication so that all who are on the floor can be knowledgeable

partners in the effort • Coordination with care planning processes • Inclusion of the physician • Review of factors contributing to risk of falls (e.g. medications, diet, activity, footwear, etc.) • On-going communication with resident and family throughout the process and full inclusion

of their input into decision-making. For more information on how to eliminate alarms, see Nursing Home Alarm Elimination Program: It’s Possible to Reduce Falls by Eliminating Resident Alarms by Brenda Davison, DON, Jewish Rehabilitation Center of the North Shore, Swampscott, MA. The article is available at www.MassPRO.org. Brenda shares her story on the CMS Surveyor Training web cast, From Institutional to Individualized Care, Part One: Integrating Individualized Care and Quality Improvement, November 3, 2006, available from http://cms.internetstreaming.com. Copies of this program, and the accompanying train-the-trainer manual and handouts, can be obtained from the National Technical Information Services at 5285 Port Royal Road, Rm. 1008, Sills Bldg. Springfield VA 22161. Phone number: (703) 605-6186. This material was prepared by Quality Partners of Rhode Island, the Quality Improvement Organization Support Center for the Nursing Home Quality Initiative, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. Publication number: 8SOW-RI-NHQIOSC-072208-1.

CONSISTENT ASSIGNMENT—having the same caregivers con-sistently caring for the same

patients on at least 85 percent of theirshifts—sounds like a simple enoughconcept.

But while it has proven to be a foun-dational first step in moving facilitiesfrom an institutional model of caretoward a person-centered model, stud-ies show that it is currently practicedin only about 10 percent of the nation’snursing facilities.

Recently, a group of 254 nursingfacilities completed a one-year pilotprogram as part of a Centers forMedicare & Medicaid Services (CMS)-funded study called “ImprovingNursing Home Culture.”

Participants presented their resultsat an outcomes congress held inOctober 2005, and many identifiedconsistent assignment as an essentialelement of their successful improve-ment in both quality of care and staffretention. The results of the CMSstudy confirm the findings of 11 otherin-depth studies that cite evidence forconsistent assignment as foundationfor quality improvement.

Turnover Affects QualityWhile providers, working with qualityimprovement organizations (QIOs)over the past three years, have madesignificant progress on the qualitymeasures, it is clear that nursing facili-ty staff turnover and high staff vacancyrates are significant barriers preventingbreakthrough levels of sustainedimprovement.

The American Health Care

Association estimatesthat there are more than100,000 vacant full-timenursing positions—including registerednurses (RNs), licensedpractical nurses (LPNs),and certified nurse assis-tants (CNAs)—and anaverage turnover rate ofmore than 70 percent in the nation’snursing facilities. Turnover leads to

staff instability and vacant shifts,which, in turn, result in rushed, deper-sonalized care. Providers with severestaffing issues are unable to focus onquality improvement until they canstabilize their staffing.

To address this concern, QualityPartners of Rhode Island and theColorado Foundation for MedicalCare recently concluded the aforemen-tioned CMS-funded study to explorestrategies for improving the nursingfacility culture.

Nursing facilities worked with theirlocal QIOs in an effort to shift frominstitutionally driven care to more per-

son-directed care andfound that they neededto establish consistentassignments to struc-turally hard-wire therelationships needed forcaregivers to knowpatients’ individualneeds.

A Holistic ApproachConsistent assignment, also known asprimary or permanent assignment,means that RNs, LPNs, and CNAs aregiven the opportunity to get to knowtheir patients intimately.

The more prevalent approach toscheduling is to assign caregivers on arotating basis, so they move from onegroup of patients to the next after acertain period of time, usually weekly,monthly, or quarterly. Experts estimatethat 90 percent of nursing facilitieshave policies that require staff to rotatetheir assignments.

The pilot demonstrated that the onekey to transformational improvementin patient care and quality of lifeinvolves a holistic approach to qualityimprovement that embraces the qualityof work life of nursing facility staffwith a commitment to individualizedcare. This holistic approach focuses on

Focus On CAREGIVING

A Case For Consistent AssignmentWhen caregivers get to know their patients more intimately, it opens the wayfor improved quality and a reduction in staff turnover.

Provider • June 2006 47

DAVID FARRELL, BARBARA

FRANK, CATHIE BRADY,MARGUERITE MCLAUGHLIN,

AND ANN GRAY

Peoplechoose to workin long term carebecause they careabout their workand the people theycare for.

DAVID FARRELL, MSW, andMARGUERITE MCLAUGHLIN, MA, areproject managers and ANN GRAY is anintern with Quality Partners of RhodeIsland, Providence, R.I. BARBARA FRANK,

MPA, and CATHIE BRADY, MA, are con-sultants with B&F Consulting, Warren,R.I.

key areas that impact organizations andindividuals, including the nature of theenvironment, care practices, workpractices, leadership, family and com-munity, and government.

A key tenet of quality improvementsays that “every system is perfectlydesigned to achieve the results it gets.”

In order to have different outcomes, itis necessary to examine the root causesof current outcomes and examine thesystems that produced them. It turnsout that low staff morale and high ratesof turnover are often directly related tothe longstanding practice of rotatingstaff assignments. In long term care,

the work has inherent meaning forpeople attracted to caring for others.Yet management systems such as rotat-ing assignment can interfere with,rather than support, the caring connec-tion with patients that often drawsindividuals to caregiving work in thefirst place.

Building RelationshipsAccording to research published by thelate Susan Eaton, in “What aDifference Management Makes,”retention is all about relationships, andrelationships are at the heart of a goodworking environment. This includesrelationships with co-workers; acrossdepartments; with supervisors; with theorganization; and, most importantly, inthe case of long term care, withpatients and their families.

The National Citizens Coalition forNursing Home Reform has confirmedthat patients and their families valuethe quality of the relationships theyhave with the frontline caregivers morehighly than the quality of the medicalcare and the quality of the food.People choose to work in long termcare, and stay in the field, because theycare about their work, the people theycare for, and the people they workwith. They want to make a differencein people’s lives.

Time and again, studies show thatleaders who implement systems thatfoster and support these caring rela-tionships have an easier time retainingstaff. With consistent assignment, ithas been found that staff not onlydevelop closer relationships withpatients for whom they are caring, butwith co-workers as well. Conversely,the system of rotating staff assignmentcontinually severs relationships andinhibits caregivers’ ability to recognizepatient declines and consistentlyaddress care needs.

What The Literature ShowsThere are many reasons that long termcare managers believe rotating staffassignment is effective. Some of the

48 Provider • June 2006

Focus On CAREGIVING

most common reasons center on issuessuch as fairness, preventing staffburnout, and the need for all staff tobe somewhat familiar with the needs ofall patients.

In other facilities, managers discour-age strong relationships between staffand patients to shield staff membersfrom experiencing grief when patientsdie. Finally, some are opposed to con-sistent assignment because they do notwant individual staff members to beunfairly “stuck” with “hard-to-care-for” patients.

However, these reasons for rotatingassignments are not supported byresearch. In fact, rotating assignmentsactually exacerbate low staff morale,leading to staff burnout, call-outs,quitting, and overall instability. A thor-ough review of the literature found 11research articles that support the prac-tice of consistent assignment overrotating assignment, including:

n Barbara Bowers, in “TurnoverReinterpreted: CNAs Talk About WhyThey Leave,” found that rotating staffmade CNAs feel less valued for theirskill, experience, and knowledge of thepatients. “CNAs defined good caregiv-ing as based on the establishment andmaintenance of good relationships withresidents,” Bowers wrote. “CNAs feltany disruption to these relationshipswas detrimental to the quality of thecare provided and the quality of resi-dents’ lives.”

n Suzanne Campbell, in “PrimaryNursing: It Works in Long TermCare,” evaluated the effectiveness ofprimary nursing, another term for con-sistent assignment, and found that forpatients:

— One year after implementation ofprimary nursing there was a 75 percentreduction in the incidence of decubitusulcers.

— After implementation of primarynursing, rates of patient discharge to alower level of care increased by 11 per-cent, while in-patient death ratesdecreased by 18 percent.

— Two years after institution of a

primary nursing system there was a 36percent increase in the number ofambulatory patients.

Campbell also recorded the effectson nursing staff and found that:

— One year after implementation ofprimary nursing, the turnover rate wasreduced by 29 percent.

— One year after implementation,nurses reported feeling more account-able by 26 percent, more able to makeand implement nursing decisions by 40percent, and more able to plan andimplement nursing care by 22 percent.

When switching from rotating

Provider • June 2006 51

Focus On CAREGIVING

Focus On CAREGIVING

assignment to consistent assignment,managers should expect some concernfrom staff, who have generally beentold in the past that the rotating staffmodel is best. Managers should informstaff that based on a number of studiesthere is new information and that thefacility must make changes to reflectthis new knowledge and implementbetter practices. Addressing staff con-cerns will be the key to success in mak-ing the transition. Following is aprocess that managers can follow wheninitiating the transition to consistentassignment:

1.) Call separate meetings on eachnursing unit with all of the CNAs fromthe day shift and with all of the CNAsfrom the night shift.

2.) Begin the meetings by explainingthat nursing facilities that haveswitched to consistent assignment have

improved quality of care and life of thepatients and the quality of work life forthe staff.

3.) Place each patient’s name fromthe unit on a Post-it note and place allof the Post-it notes on the wall.

4.) Ask the group of CNAs to rankeach of the patients by their “degree ofchallenge,” with No.1 being relativelyeasy to care for and No. 5 being verydifficult (time-consuming and emo-tionally draining, for example). Let theCNAs agree on a number for eachpatient and write that number on thepatient’s Post-it note.

5.) Allow the CNAs to select theirown assignments. Assignments areconsidered fair when each CNA in thegroup has amassed the same degree-of-challenge total. For example, one No.4 patient is equal to two No. 2patients. Therefore, the CNAs may

not end up with the same number ofpatients to care for. Relationships withpatients are important and also shouldbe part of the decision-making process.The sequence of rooms is less impor-tant. However, proximity of the resi-dents is important.

6.) Continue meeting every threemonths, or more frequently dependingon the facility, to reexamine the assign-ments in order to ensure staff feel thatthey are fair and relationships with thepatients are going well. ■

52 Provider • June 2006

■ For additional material on consis-tent assignment, see the change ideasheet on consistent assignment atwww.riqualitypartners.org/nursing_homes/wfr_train_3.php.

For More Information

HATCh Holistic Approach to Transformational Change

Consistent Assignment

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

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

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

• Staff that care for the same residents form

a relationship and get great satisfaction from their work.

• When staff care for the same people daily

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

• When staff and residents know each other

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

• Relationships form over time – we do not

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

• When staff routinely work together, they can

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

• Consistent assignment forms the building

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

Change Idea Sheet-Consistent Assignment Page 1 of 6

Consistent Assignment-Page 2

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

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



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

tionships • To stabilize staffing and establish strong

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

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

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

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

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

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

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



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

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

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

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

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

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

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



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

Example: For one unit CNAs Week 1 Week 2 Week 3 Total Mary 3/5 5/5 4/5 12/15 Jay 5/5 4/5 5/5 14/15 Sam 4/5 4/5 5/5 13/15 Maria 3/5 5/5 2/5 10/15 Total= 49/60 82% of the times the full-time CNAs care for the same residents on this unit. Note: This assumes that the leadership team is not rotating the CNAs quarterly. Questions to Consider: • How does familiarity and routine help in-

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

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

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

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

each day? • What do residents experience when they

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

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

Change Ideas: • Make a mutual commitment to consistent

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

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

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

vide back-ups and substitutes for when

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

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

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

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

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

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

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

2. Begin the meeting by explaining that nursing

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

3. Place each residents name on a post it note

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

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



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

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

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

6. Meet every three months to reexamine

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

Resources: 1. Centers for Medicare & Medicaid Ser-

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

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

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

Health and Human Services Report to Con-gress.

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

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

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

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

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

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

Created and distributed by:

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


B & F Consulting www.BandFConsultingInc.com

Communication Map For a Resident’s First 24 Hours Staff Experience

What Information Do Staff NEED to

know about a New Resident? Who has that Information? How can staff who need it

get it in time? From arrival til bedtime

The first night

The first morning

First full day

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Person-Directed Care Model

Leadership

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Leadership

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is a night owl

drove a hook and ladder for the fire department

wife was Shirley

wife died a while ago

has a picture of roses in a garden in his shadow box

used to love the smell of bacon cooking

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Leadership

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Catholic

admitted thru short term

fell his second night here

sleeping pills PRN

came to B two months ago

sometimes has a few choice words in the

morning

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Leadership

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incident report on him for hitting the night aide

constipated

has a UTI

is taking meds for anxiety and agitation

can toilet himself

widower for 12 years

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Leadership

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lation

s

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gets easily agitated

needs incontinence checks at night

his daughter visits, usually on the weekends

recovering from a broken hip

bed alarms

ambulate 2X daily

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Leadership

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lation

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worked the evening shift at the fire department

male aide o night shift usually has him for

assignment

incident occurred while giving him a suppository

has Red Sox sticker in his shadow box

this is third incident

incident occurred during morning care

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Leadership

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Leadership

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his grandkid brought him a potted plant and it's

doing pretty well

sometimes the night maintenance guy talks

with him while he's doing the floors

hates incontinence briefs

has lived alone a long time and developed his

own ways about him

used to keep a bird feeder

incident occurred during bathing, while in

Hoyer lift

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Leadership

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recommend increase meds for agitation

he's lost 5 pounds

he talks back at the overhead pager

used to love to make breakfast

was very sweet when he first came in

hums when he gardens

HATCh Holistic Approach to Transformational Change

Background: A facility’s care routines can sometimes unwittingly deprive residents of deep restful sleep. These care routines are at the heart of the nursing home’s culture. All work and assignments are organized around these routines. To change them will have an impact on the facility as a whole. The care routines continue because staff is not aware of the iatro-genic affects of sleep deprivation. Typical Issues: Residents are awakened and put to bed according to the facility’s schedule. To ease the burden on the in-coming day staff, the night shift awakens some residents and gets them ready for the day. Sleeping residents are awakened during the night to take tempera-tures, give medications, monitor for inconti-nence, insert suppositories, or even to hydrate them. Some homes have gone so far as to have the night staff provide care such as clipping toenails. Sleep, for many residents, is compro-mised by bed alarms. Facility floors are cleaned and shined with noisy machinery during the night when hallways are clear.

Residents who are sleep deprived experience a range of typical effects of sleep deprivation in-cluding: lethargy, loss of appetite, depression,

anxiety, agitation combative behavior, and other declines. Medications given in response to these effects, or to help residents sleep, often times exacerbate the situation. Barriers: There are many “organizational effi-ciencies” that prevent organizations from pro-viding residents with a good, full, restful night’s sleep. Providing a climate where resi-dents can sleep through the night and awaken-ing based on their biological clock would re-quire a great deal of rethinking about common ingrained institutional behavior. The changes have been successfully managed by many or-ganizations that began the dialogue with the question, “What would it take to sleep through the night here?” People realized that the nightly skin checks, floor buffing schedules, and sup-pository schedules, to name just a few organ-izational efficiencies, would need to be redes-igned. Regulatory Support: OBRA ’87 fully supports this area of change. The regulatory interpretive guidelines for F240 Quality of Life, found in OBRA ’87 states, “The intention of the quality of life requirements specify the facility’s responsi-bilities toward creating and sustaining an envi-ronment that humanizes and individualizes each resident.” F242 Self-Determination and Par-ticipation includes language that gives the resi-dent the right to “choose activities, schedules, and health care consistent with his or her inter-ests, assessments and plans of care….” It also provides the resident the right to, “make choices about aspects of his or her life in the facility that are significant to the resident.” F246 Accommo-dation of Needs also has language in the interpre-tive guidelines that states, “The facility should

The Sleeping & Waking Experience

Change Ideas-Waking & Sleeping Page 1 of 5

The Sleeping & Waking Experience -Page 2

attempt to adapt such things as schedules, call systems, and room arrangements to accommo-date residents’ preferences, desires, and unique needs.” Implementing care schedules around the natural rhythms of a resident’s waking and sleep-ing routines are clearly supported by these regu-latory requirements.

Additionally, the resident assessment process and requirements outlined in F272 Resident Assess-ment also provide support for structuring care giving around the preferences and routines of each individual resident. This regulation requires nursing homes to use the Minimum Data Set (MDS) assessment to gather information neces-sary to develop a resident’s care plan. Section AC. Customary Routines of the MDS includes three areas regarding a resident’s sleeping routine that should be assessed and considered when de-veloping a care plan:

Section AC. Customary Routine

1. Stays up late at night (e.g., after 9 pm) 2. Naps regularly during the day (at least

1 hour) 3. Wakens to toilet all or most nights

Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 2.0 Manual includes the following lan-guage to explain the intent of gathering this in-formation from residents upon their admission to a nursing home: “…The resident’s responses to these items also provide the interviewer with “clues” to under-standing other areas of the resident’s function. These clues can be further explored in other sec-tions of the MDS that focus on particular func-tional domains. Taken in their entirety, the data gathered will be extremely useful in designing an individualized plan of care.” Some nursing homes have voiced concerns that the requirement for frequency of meals served to residents is a barrier to implementing care sched-

ules based on a resident’s customary waking and sleeping routines. F368 - §483.35(f) Frequency of Meals requires each resident to receive and the facility to provide at least three meals daily. It also includes that there must be no more than 14 hours between a substantial evening meal and breakfast the following day. Some providers have interpreted this language to mean that all resi-dents must actually eat promptly by the 14th hour, which makes it difficult to honor a specific resi-dent’s request to refuse a night snack and then sleep late. Based on this interpretation, nursing homes are often hesitant to implement an indi-vidualized, resident-centered approach to waking and sleeping for fear of being noncompliant with this regulation. However, this interpretation is not necessarily intended by the regulation.

In December 2006, the Centers for Medicare & Medicaid Services (CMS) provided the following language clarification regarding frequency of meals:

The regulation language is in place to pre-vent facilities from offering less than 3 meals per day and to prevent facilities from serving supper so early in the afternoon that a significant period of time elapses un-til residents receive their next meal. The language was not intended to diminish the right of any resident to refuse any particu-lar meal or snack, nor to diminish the right of a resident over their sleeping and waking time. These rights are described at Tag F242, Self-determination and Participa-tion. It is correct in assuming that the regu-lation language at F368 means that the fa-cility must be offering meals and snacks as specified, but that each resident maintains the right to refuse the food offered. If sur-veyors encounter a situation in which a resident or residents are refusing snacks routinely, they would ask the resident(s) the reason for their customary refusal and would continue to investigate this issue only if the resident(s) complains about the food



items provided. If a resident is sleeping late and misses breakfast, surveyors would want to know if the facility has anything for the resident to eat when they awaken (such as continental breakfast items) if they de-sire any food before lunchtime begins. This clarification clearly promotes a resident’s right to choose and to exercise his or her auton-omy. It also provides nursing home providers with some assurances that the regulations and regulatory agencies are supportive of individual-ized care that provides options for resident choice of waking and sleeping routines and meal times. To view the entire CMS clarification go to CMS’s website at: http://www.cms.hhs.gov/SurveyCertificationGenInfo/downloads/SCLetter07-07.pdf For more information in creating individualized care-giving schedules, see the CMS broadcast, “From Institutional to Individualized Care, Parts I and III” at http://cms.internetstreaming.com. Goal: To support residents’ health and well being by helping them have deep sleep through the night, by shifting from institutionally driven routines to routines that follow people’s natural rhythms of sleeping and waking. Another goal is to support better relationships between resi-dents and their caregivers by allowing caregiv-ers to respect people’s individual routines and set their care giving schedules around what works for each resident. Infrastructure Helpful to Support the Change: Establish a work group with staff from all departments to identify and implement the changes needed in order for residents to re-turn to their natural patterns for sleeping and waking. Adjust clinical care, staffing schedules, and routines for food service, housekeeping and maintenance to accommodate individual resi-dents’ needs and preferences related to sleeping

and waking routines. Establish a system for learning about people’s patterns as part of the welcoming in to the nursing home for new resi-dents. Making the Change: There are many ways to undergo the change process. A good start is to think about who can help and to plan in a sys-tematic way the necessary steps. Ensuring that its not a top-down edict but a shared commit-ment on the part of the community based on need creates a climate ripe for change. With your committees and groups ask: • Number of residents who sleep through the

night • Number of residents who wake of their own

accord • Pre and post data on agitated behavior;

anxiety meds; bowel and bladder conti-nence; UTIs; skin care; weight change; mo-bility; social engagement; staff-resident re-lationships; staff workload.

PDSA Cycles: The Plan – Do – Study – Act Cycle is a way to systematically go through quality improvement in a thoughtful way. With your committees and groups ask: 1. What are we trying to accomplish?

(Greater choice for residents, better sleep hygiene, a less institutionalized setting, resident choice over their desire to stay in bed, go to bed late) Naming and articulat-ing what it is that you are trying to accom-plish will help you months from now (when you are in the thick of things!) to remember the original intention of the change.

2. How will we know a change is an im-provement? This is the question that begs a measurement response. (We had low satis-faction in the area of resident choice and now look!; as a result of this change we


http://www.cms.hhs.gov/SurveyCertificationGenInfo/downloads/SCLetter07-07.pdf

http://www.cms.hhs.gov/SurveyCertificationGenInfo/downloads/SCLetter07-07.pdf

http://cms.internetstreaming.com/


have more people able to ask for things and have their needs met!; our resident feel more rested, there are fewer combative in-cidences, less frequent falls )

3. What changes can we make that will result

in an improvement? (Eliminating a harsh bed-check process in the night with lights on etc; Implementing a “gentle awakening process”; changing the way we think about breakfast to allow people to sleep. Go study your subject-find out what others have done, take a road trip, phone a friend, go to a Pioneer conference, talk with ex-perts-ask others to do the same.

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

direction. Even finding that one is heading in the wrong direction can offer valuable feedback to a committed team. The next step then, is the study phase. Study: Test the hypothesis out. Stay open to the possibilities. There are many things you might find happen that you didn’t expect. Be sure to note these unexpected gains. Act: Once you have completed the process identified above you have a more complete un-derstanding of the challenge or problem. Now armed with very specific information and data you have three options: • Adapt the change • Adopt the change • Abort the change This entire process can be done in a very public way by using storyboards to journey the proc-ess. Remembering to celebrate the success of the process is an important feature of the story helping staff, families and resident alike to wit-ness the ongoing efforts made to improve the home. Plan: Engage a committed group of people to consider, discuss and explore better sleep hy-giene for residents based on residents obvious sleep deprivation and associated problems. Do: Track the sleep of five resident volunteers who have minimal medical, hydration or treat-ment needs. These volunteers will be given the opportunity to awaken by their own natural body clock for two weeks. Study: What time they awaken over the two weeks, mood, and appetite using simple tools. Determine if residents have a greater sense of rest and peace. Act: Consider a small group of people who have incontinence to initiate the next cycle.



Explore how to maintain skin integrity while allowing for better sleep. Innovative Change Ideas: Homes that have undergone change in the do-main of waking and sleeping consider these questions in their change process: • Would you be comfortable sleeping here?

With this bed and pillow? • How can sleep be made comfortable? • Where could you start your change proc-

ess? • What are all the factors that must be con-

sidered from each department in order to make this change?

• What could be improved in the following: lighting, noise, bed comfort, privacy, and clinical care to help with sleep?

• What evening activity and food do people who like to stay up want available?

• If it the process changed how would staff and residents benefit?

• What are the medical consequences of sleep deprivation on health and well-being?

• What negative outcomes are we causing by constantly interrupting the sleep of our resi-dents?

• How would residents and staff benefit from how awakening happens?

• What is the importance of sleep hygiene for physical and mental well-being?

Resources: 1. Cruise PA, Schnelle JF, Alessi CA, Sim-

mons SF, Ouslander JG. The nighttime en-vironment and incontinence care practices in nursing homes. J Am Geriatr Soc 1998 Feb; 46 (2): 181-6.

2. Esser S., Wiles A., Taylor H., et al. The sleep of older people in hospital and nurs-ing homes. J Clin Nurs 1999; 8: 360-8.

3. O’Rourke DJ, Klaasen KS, Sloan JA. Re-designing nighttime care for personal care

residents. J Gerontol Nurs 2001 Jul; 27 (7): 30-7.

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


rethinking the use of position change alarms by joanne...

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