Event ID: 2624612Event Started: 5/28/2015 1:53:00 PM ET

TIEBREAKER

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GOOD AFTERNOON, EVERYONE. AND WELCOME TO THE LEADING AND SUSTAINING SYSTEMIC CHANGE COLLABORATIVE, NO. 1, LEADERSHIP AND TEAMWORK. I AM ONE OF THE QUALITY IMPROVEMENT ADVISORS FOR ATOM ALLIANCE, ALABAMA. ON BEHALF OF ATTAM ALLIANCE, I WOULD LIKE TO THANK YOU FOR TAKING THE TIME TO JOIN US BEFORE WE GET STARTED I WOULD LIKE TO INTRODUCE MY COLLEAGUE FROM KENTUCKY, SCOTT GIBSON, WHO WILL RUN THROUGH A FEW HOUSEKEEPING ITEMS FOR TODAY'S MEETING. SCOTT?

THANK YOU VERY MUCH! WE DO HAVE ALL THE PHONE LINES MUTED AT THIS TIME. THIS IS GOING TO PROVIDE A BETTER LISTENING ENVIRONMENT FOR ALL OF US. AND IT'S GOING TO EMIT ALL OF THE BACKGROUND NOISES. WE'LL NOT BE OPENING THE PHONE LINES ON TODAY'S WEBINAR. DURING TODAY'S WEBINAR, WE DO HAVE THE CHAT BOX FEATURE. IT IS EITHER LOCATED ON THE RIGHT SIDE OR AT THE TOP OF YOUR SCREEN. SEVERAL OF US WILL BE MONITORING THE CHAT FEATURE AS WE MOVE THROUGH THE PRESENTATION TODAY. IF YOU HAVE ANY QUESTIONS OR COMMENTS, CAN YOU POST THAT IN THE CHAT. IF YOU DON'T WANT FULL-SCREEN, YOU CAN GO UP TO THE TOP OF THE SCREEN AND HIT RETURN OR YOU CAN CLICK THE CHAT BUTTON. OUR PRESENTERS MAY BE ASKING YOU TO USE THE CHAT FEATURE AT DIFFERENT TIMES DURING TODAY'S WEBINAR. IF YOU'D LIKE YOUR QUESTION OR COMMENTS OR PARTICIPATION ANSWERS TO BE PRIVATE, YOU CAN CHOOSE MY NAME. THAT'S SCOTT GIBSON. OR YOU CAN CHOOSE ALL OF THE PARTICIPANTS HOWEVER YOU FEEL THE MOST COMFORTABLE. THAT WAY THE CHAT BOX WILL ONLY APPEAR IN MY WINDOW IF YOU CHOOSE MY NAME. WE CAN VIV EVERYONE UNDERSTANDS HOW TO USE THE CHAT FEATURE. PLEASE POST IN THE CHAT BOX WHAT STATE YOU'RE CALLING IN FROM TODAY! I'D ALSO LIKE TO ITEM YOU TODAY'S PRESENTATION, YOU BE ASKED TO PARTICIPATE IN SOME POLING QUESTIONS. MAKE SURE YOU'RE -- POLLING QUESTIONS. WHEN YOU DO THE POLLING QUESTIONS, MAKE SURE YOU CLICK YOUR ANSWER, AND DOLLAR THAT, HIT THE "SUBMIT" BUTTON SO WE CAPTURE THAT. I WILL NOW TURN THE FLOOR BACK OVER TO BETH.

THANK YOU, SCOTT. FOR TODAY'S WEBINAR, WE HAVE HAD OVER 400 REGISTRANTS REPRESENTING HOSPITALS, HEALTHCARE, TRANSITION OF

COMMUNITIES, NURSING HOMES, STAKEHOLDERS, FAMILY MEMBERS, AND BENEFICIARIES. YOUR REPRESENTATION TODAY JUST GOES TO SUPPORT THAT WE CAN NO LONGER WORK IN SILOS. IN ORDER FOR US TO ACCOMPLISH THE GOALS OF THE NATIONAL QUALITY STRATEGY, AND THE POSITIVE OUTCOMES FOR THE BENEFICIARIES AND THEIR FAMILIES, WE MUST UNITE AND WORK TOGETHER. TODAY IS THE BEGINNING OF A NEW AND EXCITING JOURNEY. FOR YOUR REFERENCE, TODAY'S WEBINAR IS BEING RECORDED AND WILLING POSTED ON THE ATOM ALLIANCE DEDICATED WEBSITE WITHIN THE NEXT WEEK. NEXT SLIDE. IN AN EFFORT TO FURTHER ENHANCE THE QUALITY OF SERVICES FOR MEDICARE BENEFICIARIES, THE CENTERS FOR MEDICARE AND MEDICAID SERVICES LAUNCHED THE REORGANIZATION OF THE QUALITY IMPROVEMENT ORGANIZATION, QIO PROGRAM. THEY REDESIGNED THE QIO PROGRAM THROUGH REORGANIZING WITH NEW REGIONAL CONTRACTORS BEGINNING ON AUGUST 1ST, 2014. SO AS A RESULT OF THIS REORGANIZATION, WE NOW HAVE THE ATOM ALLIANCE WHICH IS ONE OF 14 NEW QUALITY IMPROVEMENT ORGANIZATIONS WORKING WITH PROVIDERS, STAKEHOLDERS, AND MEDICARE BENEFICIARIES TO IMPROVE THE QUALITY OF HEALTHCARE FOR TOP TARGETED HEALTH CONDITIONS. AS YOU CAN SEE FROM THIS, THE ATOM ALLIANCE PARTNERS INCLUDE THE STATES OF ALABAMA, MISSISSIPPI, TENNESSEE, KENTUCKY, AND INDIANA. THE FIRST PART OF OUR WEBINAR WILL BE HIGHLIGHTING HIGH-LEVEL CONCEPT, WE WOULD LIKE TO GO AHEAD AND INTRODUCE YOU TO THE NURSING HOME CHAIN WHO WILL SERVE AS THE FACULTY AND BEHIND THE SCENES FACILITATOR FOR TODAY'S WEBINAR. THE NURSING HOME TEAM. FROM ALABAMA, LIZ PROSCH, WHO SERVES AS THE SUBJECT MATTER EXPERT FOR THE ATOM ALLIANCE NURSING HOME TEAM. BETH GREENE, ALSO FROM ALABAMA. KATHY HYBARGER AND KARA DAWSON FROM INDIANA. FROM TENNESSEE, BETH HERCHER AND JULIE CLARK. FROM KENTUCKY, WE HAVE SCOTT GIBSON AND MISSISSIPPI MAE MCDANIELS. PLEASE NOTE THAT FOR THOSE PARTICIPATING IN THE LEANING AND SUSTAINING SYSTEMIC CHANGE NURSING HOME COLLABORATIVE, THESE INDIVIDUALS SERVE AS YOUR STATE-SPECIFIC POINTS OF CONTACTCONTACT. WE HAVE LEARNED THAT EFFECTIVE LEADERSHIP WILL BE CRITICAL TO THE SUSTAINING IMPROVEMENT EFFORT. THE LEADING AND SUSTAINING SYSTEMIC CHANGE COLLABORATIVE IS A LEADERSHIP-DRIVEN COLLABORATIVE. IT'S ALL ABOUT LEADING AND DEVELOPING HIGH-PERFORMING TEAMS TO DRIVE AND SUSTAIN SYSTEMIC IMPROVEMENT. SPECIFICALLY THE PURPOSE IS DESIGNED TO CHARTER, LEAD, AND DEVELOP SELF-DIRECTED, HIGH-FUNCTIONING CHANGE TO DRIVE AND SUSTAIN SETTLEMENTIC IMPROVEMENT USING -- SYSTEMIC IMPROVEMENT USING QATI TECHNOLOGY. AS I MENTIONED EARLIER, THE FIRST 30 MINUTES OF OUR WEBINAR IS GOING TO BE HIGH-LEVEL, BROADER CONCEPTS AROUND LEADERSHIP AND TEAM-BUILDING. WHICH COULD BE APPLICABLE TO ANY SETTING. HOSPITAL, CARE TRANSACTION, COMMUNITIES -- CARE TRANSITIONS, COMMUNITIES, ETC. STEPS 1 AND 2 INCLUDE ESTABLISHING A SENSE OF URGENCY AND CREATING A GUIDING COALITIONSTEPS 1 AND 2 INCLUDE ESTABLISHING A SENSE OF URGENCY AND CREATING A GUIDING COALITION. THE LATTER PART OF THE WEBINAR WILL BE NOR NURSING HOME

SPECIFIC. KOTTER IS MORE ABOUT BEHAVIORAL CHANGE WHERE QATI IS MORE ABOUT SYSTEMIC CHANGE. SO IN THIS MODEL, YOU SEE THREE INTEGRATED CIRCLES. AT THIS POINT I WOULD LIKE TO TURN THE PROGRAM OVER TO JULIE CLARK, QUALITY IMPROVEMENT ADVISOR WITH TENNESSEE. JULIE WILL SPEND THE NEXT FEW MINUTES TALKING WITH US ABOUT HIGH-LEVEL LEADERSHIP AND HIGH-FUNCTIONING TEAMS.

THANK YOU, BETH. NEXT SLIDE, PLEASE.

We will be using this evidence-based material during our collaborative work, because implementing and sustaining change is very difficult. Kotter's set provides a comprehensive strategy to help with implementing and sustaining change within your organization to. Better illustrate the eight steps of change, Kotter and his colleague wrote a fable about a penguin colony in Antarctica that has lived on the same iceberg for many years. When one curious bird discovers signs of a problem inside the iceberg, the penguins want to listen to him. They -- don't want to listen to him. They are fine with the way things are. But a small group of penguins come to understand that their iceberg actually was melting. And they knew they had to do something or they would be without a home. So they created a sense of urgency in the colony to help them focus on how to resolve that problem. Then they carefully built their guiding team, making sure the best penguins with the best skills were members of that team. Next they developed a sensible vision for a better future. Moving forward, they communicated that vision so others would understand and accept it. The guiding team then began to empower others in the colony celebrations were enjoyed by all. The colony kept pushing forward changes by never letting up on new ways of doing things. And the final step was to ensure the colony's new culture was sustained. During our learning sessions, we'll cover these steps in more detail. Today's Webinar will focus on the first two steps of creating a sense of urgency and building a guiding team. The other evidence-based material we will be using during the LSSCC learning sessions will come from the team step program. You will see the team step logo on the slide as we share the program information. You'll also see penguins on the slide, this is due to the class action of teamSTEPPS with Kotter's eight steps of change. These identify different roles and personalities that exist in the work environment. And these penguins represent those personalities and roles. They'll be introduced through the the teamSTEPPS and Kotter's material we'll be sharing with you. The first penguin, his role is leadership. There are two types of leaders within an organization, a designated leader who is assigned to lead and organize a core team. They will establish clear goals and facilitate open communication and teamwork among team members. A situational leader can be any team member who still has to manage a situation based on their knowledge and expertise. A situational leader may include a therapist if your team is working on decreasing falls or CNA if you are working on consistent assignments. This list is recognizing that effective team leaders should be able to organize the team and keep them on-task. Articulate clear goals, make decisions through input from other team members, empower team members to speak up and challenge ideas appropriately. They should also actively promote and facilitate good teamwork by being a good role model of strong teamwork behavior. Finally they should have the skills needed for possible conflict resolution. An effective leader should promote model desired team behaviors with their own behavior. Leaders should provide open sharing of information. They should use role models and effective cuing to promote team members to use prescribed teamwork behaviors and skills that were established for the team. Leaders need to provide constructive and timely feedback to their team members. Leaders can also provide

facilitation of briefs, huddles, and debriefs, and conflict resolution in an effort to cultivate desired team behaviors. Resource management is a big responsibility for the leader of a guiding team. The leader may be able to identify team member skills and knowledge so they can be utilized to assist in the success of the task. The leader should also have a clear understanding of the materials that may be needed to accomplish the task. And they should be aware of the amount of time the team will need to spend on the task in order to accomplish it. By having these resource management skills, the leader will be able to avoid the possibilities of work overload of the team members, and that may -- that may cause compromised situational awareness that could lead to the team having errors or failures of the task. Here we see our leader delegating to two team members, using the resource management skills we just recovered to identify appropriate team members to compete a task or assignment. Now the leader needs to decide exactly what should be delegated to the team members. Then the leader will need to communicate clear expectations of what needs to be done. And an effective leader will also make sure his team members understand to request feedback if needed. The role of the leader will be very important in the first step of Kotter's eight steps of change. The leader will need to create a sense of urgency in the organization to help start the process of change. In order to create a sense of urgency, the leader will need to get people's attention. They may need to decide to host a staff meeting or change celebration to spread the word. The leader should be ready tosome the need for change and even the pain and consequences of what may happen if the change is not implemented. Sharing data and how information from that data indicates a need for improvement is just one idea on how to sell the need for change. Leaders should find ways to I merpeople within -- immerse people within the change. This will bring a chance for brainstorming with the staff. Leaders can empower people to solve the problem W. More people empowered working on the change, you will find more ideas on how to accomplish it, and the staff will be invested. And sharing a sense of urgency among people is crucial to getting cooperation for change. Unless individuals understand the urgency of a situation, complacency sets in, and change becomes difficult if not impossible. leaders need to be aware of possible barriers that may arise during change efforts. Listed on this slide are some common barriers that may happen, including complacency of staff, not having a powerful, guiding coalition. Not integrating the vision. Allowing for obstacles. Not celebrating short-term wins. DeClair victory too soon. And neglecting to anchor changes into the organization's culture. In order to counter these possible barriers, Dr. Kotter identifies ways to institutionalize change. Leaderships should find ways to build new habits and skills with their staff. They will need to provide opportunities for discussion so that staff can express their thoughts and feelings around the change effort. New tools may need to be created. Rewarding change is a fun way to keep change on the leader's mind. And encouraging mutual leadership with appropriate staff members. Here is our first polling question. Remember to hit the submit button at the bottom of the polling window so we can capture your answer. The question: The first step in Kotter's eight steps of change is announce you are a leader, create a sense of urgency, or establish a meeting room. that completes my section on leadership and how it can drive change efforts in your organization. Leadership must drive the change efforts for it to be successful. But there is also a need for high-functioning teams to help with the leader. During this next section of the Webinar, I will share with you on how to build your guiding coalition. What characteristics the team members should posses, and why teamwork is needed in change effort. We've got the majority of you saying creating a sense of urgency is the first step. And that is correct. Next slide. Looking at the iceberg, you can see that the second step is going to be building a guiding team. Building a strong guiding team will be

crucial in change efforts. These teams will be responsible for helping the leader drive change efforts in the organization. When a leader pulls together a guiding team, they'll launch and ensure the team members have expertise in the change topic, the multidisciplinary mix so all voices in the organization can be heard. They should have strong communication skills and be credible. They should also have Elementary skills to help drive -- leadership skills to help drive the change process, and management skills that will help control the change process. Teammate members should have the same sense of urgency the leader has. Regarding team structure, it's important to know that teamwork cannot occur in the absence of a clearly defined team. Another role of the leader will include choosing team members and defining roles of the team members. Leaders must commit to being an active member of the team so they can create a climate conductive to effective team functioning and ensure there is mutual accountability and recognition of professional respect. This shows us some of the goals of teamwork in organizations like nursing homes and hospitals. When staff work as a team, improvements may be accomplished with reducing clinical errors. Improving resident outcomes, process outcomes, resident family and staff satisfaction, reducing staff turnover, and reducing resident and family grievances and complaints. High-performing teams tend to have a shared mental model that contributes to their success. Members can anticipate each other's needs, coordinate without the need to communicate overtly, know when explicit communication is best, and know where to look for expertise. Other traits of high-performing teams included on this slide are that these teams will have clear roles and responsibilities that have been provided to them by their leader. They will have a shared vision or common purpose that the leader promotes. They will optimize resources and have strong team leadership. They will engage in a regular discipline of feedback to all team members and leaders to establish and revise team goals and plans. And this will help them differentiate between higher and lower priorities. They will develop a strong sense of collective trust and confidence, create mechanisms to cooperate and coordinate with each other, and they will manage and opt myself performance outcomes. They will have mechanisms for anticipating and reviewing issues of team members by periodically diagnosing team effectiveness, including its results, processes, and vitality, which may include morale, energy, and retention. Improvements in your organization will most likely impact the experiences your beneficiary and their family may have when they need your services. You may include them in appropriate team meetings or meet with them on an individual basis, things to consider when you are utilizing their input is to listen to their thoughts and ideas. Find out how involved they'd like to be in your change efforts within your organization. Ask them about any concerns they may have, speak to them in lay terms, ask for feedback on a regular basis. Give them access to relevant information. And encourage them to participate in their care so they can bring these experiences to the team for discussion. There are many variables they r that may -- that may affect team performance. These are things the leader needs to be aware of in order to reduce the risk of barriers within the team. Some barriers may include inconsistency in team membership, lack of time to work on change effort, lack of information sharing to understand the needs for change. And how the change efforts are progressing in the organization. Varying communication styles of the team members not being met, conflict between team members or staff, lack of coordination and follow-up provided by the leader, work overload not being controlled by the leader, misinterpretation of cue, and lack of role clarity provided to them by their leader. Now that we've examined the structure of team, we're going to look at the team leaders and members' characteristics. The penguins represent various leaders and team members and various personalities within an organization. Let me introduce you to some of the penguins' personalities to help you understand

who should be on your team. These are the penguins in Kotter's fable, titled "our iceberg is melting." They have various personalities, including Alice, who is focused and knows her colony! She is smart and goal-oriented. Fred is open to new ideas and observant. Buddy who may not have ideas to share, but he is trusted and well liked. Lewis, the leader, wise and respected. Nono is closed-minded and resistant to change. And the professor is intelligence and loves -- intelligent and loves data and solutions. You will need various personalities and skills represented. Two or more people who interact dynamically, independently, and adaptively toward the common and valued goal and have specific roles that have been defined for them, by their leader Swhat defines -- is what defines a team. A leader should look for individuals who are able to predict the needs of other team members, provide quality information and feedback. Engage in higher level decision-making, conflicts skill flee if it arises. Understand the roles and responsibilities, and reduce stress on the team as a whole through their performance. Did the team members communicate essential information with the entire team? Did all the the team members contribute and change efforts? Was there mutual respect within the team? Did the team members bring concerns to their attention? And what are some specific actions that could have been taken to improve the team's outcome? This is my last polling question. And this question is the second step in Kotter's eight steps of change is: Assign a day and time for meetings, create a storyboard, or build the guiding team. And I would like to thank you for your attention and participation in this overarching high-level leadership and teamwork information. Atom Alliance hopes this will help you understand crucial roles in developing and cultivating your organization's guiding coalition team. Let's see what the answers are on this poll. There they are, you are so smart! 190, build the guiding team, and that's absolutely correct. And the leader within your organization is going to have the to be -- to have to be the person that puts that together. I will turn the floor back over to Beth Greene.

Thank you, great job of covering high-level consuspects around leadership -- concepts around leadership and high-functioning teams. What you should have heard thus far is that the foundation of the learning organization rests upon exceptional leadership. And that exceptional leadership equips and helps develop high-functioning teams. While you may not be a representative of a nursing home, we invite you to stay on the Webinar as we now shift to a more nursing home specific focus around QAPI methodology. Utilization of QAPI will help our nursing homes support your goal, for example reducing 30-day hospital readmissions and unnecessary hospitalizations. Next we will hear from Beth Hercher, quality improvement advisor with Tennessee. Beth will review steps 1-3 of QAPI methodology, which includes leadership accountability and responsibility, developing a deliberate approach to teamwork, and step 3, taking your QAPI poll. Beth's discussion will reenforce how QAPI aligns with Kotter's steps of change previously discussed by Julie.

Thank you, Beth. Before I begin my presentation, I want to share with you a well known quote around the QIO community, regarding performance improvement. While all changes do not lead to improvement, all improvement requires change. As Beth shared with you, what I plan to share with you for the remainder of the Webinar, are the first three implementation steps for QAPI. If you're probably asking yourselves right now, how are we going to take Kotter's change steps, creating a sense of urgency, and building a guiding coalition and maker that fit into -- make that fit into our nursing home environment? We feel that QAPI implementations steps 1-3 would be a great place for you to start. Step 1 is all about leadership, responsibility, and accountability. Step 2 will walk your team through how to develop a deliberate approach to teamwork. And then

most importantly, the third step, and that's where you will be taking your QAPI poll. Kotter suggests that leadership is responsible to create a sense of urgency. So when we think about this implementation step for QAPI, step No. 1, that suggests that leadership is responsible for setting the tone. That leader is to help staph identify how to meet -- staff identify how to meet the organization's mission, vision, guiding principles, and even standards and expectations. Your leadership within your facility may be your medical director. It could be your administrator, it could be your director of nursing or perhaps it's a great nurse unit manager. Some of the ways that this leadership can take action and create this sense of urgency is by developing a steer committee. And that's going to provide QAPI's leadership, by providing resources that could be equipment, training pertaining to QAPI, it could be to -- business office staff has a basic knowledge of QAPI. This is going to establish that climate of open communication and respect. And also a better understanding of your home's current culture and how it will promote performance improvement. Following this session, we will make available QAPI steps 1-3 worksheets. These are going to serve as a checklist or action steps, and other questions like the probing questions you see on this slide around leadership, that will help your team in further discussion and assessment on how your current leadership functions. And also areas that you can look to improve. In addition to this worksheet, we encourage and you your team to review some of the change concepts from the stem as change package. This change package was developed from a series of ten site visits to a select group of high-performing nursing homes across the country. CMS did a pilot and conducted these interferes and onsite -- the latter part 2011, 2012. And from those onsite interviews of these high-performing nursing homes, important themes emerged regarding how these facilities approach quality, and you how they carried out their work. The change package is a menu of these strategies, change concepts, and specific actionable items that you come your team may choose to begin testing from. Each strategy will be supported by change concepts and action items. And really just think of change concepts as general approaches to stimulate creativity and critical thinkingthinking. We encourage to you look at strategy No. 1, lead with a sense of purpose as you walk through that QAPI implementation step No. 1. This aligns with Kotter's create a sense of urgency. At this point, I want to pause to introduce to you one of my colleague, Mae McDaniels, who will introduce to you one of her nursing homes from within her state. And you'll be hearing a live success story around creating this sense of urgency.

Good afternoon, everyone. And thank you, Beth, for an excellent explanation of the role of leadership in QAPI, and ways to use the best practice change packet. I want to congratulate camush Ashe has completed her batch ler's -- bachelor's degree in nursoth 16th. And I love -- nursing on the 16th of this love. And I would like to thank her for sharing today. She will also share the benefits of consistent assignment for her residents and staff.

Hello, everybody. I have with me Jennifer, my assistant, Brenda Grayson, who just stepped out for another meeting, but she's staff development. I talked to you all about consistent assignments. This was -- I guess started here about two months ago. We were having problems with basically staff shortage. And we called a team in, we spoke with the nurses, but we met with the CNAs SEPARATE, AND ASKED THEM WHAT did they think about the issue? They came up and worked for all. They were saying that they never really got a weekend off, but every five or six weeks or so. So that was one of the biggest complaints. Another complaint was money, they wanted a raise. So what could we do to get the raise and the weekends? This is the problem, what can we do to fix it? So we went all the way up the chain, we got answers to that. That really

wasn't the answer they wanted. So we told them let's figure out what we can do to make it work with what we have. The CNAs came in, they suggested why can't they go to 12 hours and work with us nurses? So the nurses agreed that would be a grad GD thing. And this is how our consistent assignment came about. Not being Ms. Mae would call it a consistent assignment, but we liked the terminology. They came on board and said they would work the 12-hour shift to do this, and the nurses wanted them to be called a team. So we built teams! Most people are working 12. We have some CNAs that could not. The majority of the ones wanted 12-hour shifts. And the nurses also work 12 hours. The same team for the day shift and night shift. Some days we have eye different team on one holiday than on the other. But for the most part, everybody is in the same section taking care of the same residents, and every day it's the same team. It ensures that the nurses and the CNAs air good fit for each other. Good relationships. The relationship building, you have the same people dedicated to a group of residents all the time. That's a positive for the staff to know that what they suggested was actually what we went along with and agreed to. So they felt empowered as people themselves,ad aides, that we listened to them, and they made a decision that would actually help and change the comfort here candidate great Oaks. -- at Great Oaks. Like I said, we started about two months ago, CNAs and their major roles, and we interviewed several family members in regards to a consistent assignment. And we had no negative feedback. The benefit of it was relationship building, the bonding, and one thing they pointed out was that the elderly rarely can keep up with everybody's name that comes through here to work. So they enjoyed the fact that they were able to identify faces, and a lot of them have not learned the names of their team members. That was one benefit that was a good benefit. They really don't have to keep up with so many names of who's coming in and going out all the time. And another thing that myself and the assistant realized, we're able to have more accountability with the team. And with the same people working with the same residents every day. You're able to -- you don't have to go -- you don't have to dig so far. Because it's one team. We have two different teams through the the week, and you can identify issues and concerns. Can you address things and handle things better when it's a team. And it's not three shifts, you have to go back and research through three shifts, and it's much easier with the team put together. If a patient says mom is saying something, or dad is saying something, they know who to go to. They don't have to look who it is they need to talk to. Because they are well aware of who the team members are for that patient.

Has it decreased your call-in and turnover rate?

Yes, yes.

That's great. So how are you tracking? Do you have a tool that you're using to track the number of staff to residents?

We do. Our staff development keeps it -- a tracking system daily. We pull it for every shift. We put it out at the beginning of each shift and collect it the next day. But we do track it. And the assignments are basically made before the shift even starts. Because you know what aide and what nurses are going to be assign ed to which resident.

Okay. I'm sorry, go ahead.

Go ahead N.

No, we have some questions in chat for you. Okay. Did this help attract new staff members? Sally -- I want to says s OsaidHeimer.

Yes, it did. We have four new CNAs coming on board because of the 12-hour shift, and because they will be working on a team. They're not coming and it's just them by themselves. They know they'll be on a team.

That's great. Okay. Here's another question. Judy said from the start, how did you begin to assign -- I'm sorry, from sale. How did you begin to assign, if all wanted the same area?

Well, actually we were not confronted with that problem. Our CNAs work sections that they wanted to keep, and the nurses wanted to keep the same aides. So we haven't run into that problem yet. So we didn't have five or six that wanted one section. The section that they were in, they were happy there, and they wanted to stay in that section.

Okay. Then I have another question. How many days are they on and off?

They work 12 hours, Monday, Tuesday, off Wednesday and Thursday. They work Friday, Saturday, Sunday. And the next week, they only work Wednesday and Thursday. And they're all Tuesday, Friday, Saturday, Sunday.

Oh! How large is your facility?

60 beds.

Okay. Is it hard to replace a staff member that works 12 hours versus one that works 8 hours when there is call-ins?

No. Usually we have a call-in which has been -- very rare since the CNAs agreed to go to 12 hours. And one thing we addressed upfront before we even entertained that position, we had to have the agreement that you all want more money, and you want more weekends off. Can we all agree that the weekend call-ins will stop, and you are here on time, and you are assigned? And that has not been a problem!

Great. That is great. I have another question for you. Explain how the pay raise came into effect.

Okay. Actually, they really got two pay raises. If you look at it technically. Once they agreed to go to 12 hours, our shift used to be 6:00 to 2:00, 2:00 to 10:00, CNAs. Now the shift changes at 3:00. So when they moved to 12 hours, they got a shift increase. And then a few weeks later, our corporate office went ahead and game them an overall increase.

You got plenty of questions. What is your beginning CNA hourly rate?

It is $9.50 currently.

Okay. And do you ever rotate to prevent staff burnout?

We can rotate. And that's something that we asked the staff often. Let us know if one section gets too hard for you because we do have issues that may come in. Maybe five or six left in one section. So to avoid the staff call-in or saying I'm tired, I can't do this, sometimes we'll double them up to work a section that's harder or rotate them out. We like them to move out of that position.

They're not alone in a section.

Yes.

How do you schedule vacation and time off?

We ask that it is presented -- requested by the 10th of every month prior. And we usually don't have a problem with staff picking it up. And they take turnings really doing vacations. They usually talk amongst themselves. The assistant can tell you usually how they do it. She basically works with them when it comes to vacation or whatever.

Okay.

Sometimes they swap the other days with the opposite RN. And we've seen that a lot go on because one of ours is a tool, so it worked out better for her to have inconsistent days, and her office partner agreed to that. So a lot of times our problems are solved within the own staffing themselves.

And the next question goes along with -- go ahead, I'm sorry.

I was going to ask, what Jennifer just said -- the -- if they want vacations, a lot of them know that they have a 2-day week that they only work. One week they only work a Wednesday and Thursday. So usually they work amongst themselves to swap out that Wednesday and Thursday which will give them a 7-day off period. Because they don't like to lose their time. So they usually will work an extra day before they go on vacation, and an extra day when they come back. And it still gives them a 7-day off period because they're only working two days in one week. That's better for the nurses and the CNA. They don't have to give up so much of their time.

The next question, if your staff has set workdays, how do you work around school schedules? You may have answered that already.

Jennifer did. They usually talk amongst themselves. One of them went back to RN school. She talked to her teem mate on the opposite ro-- teammate on the opposite rotation, and they worked it out so every day is covered.

Great. Next question, what is your staff to CNA ratio?

CNA to resident or nurse to CNA?

Well -- it should have been staff to resident ratio.

Okay. We do 10-12 on day shift. 10-12 residents to one CNA.

Okay.

And the nurses work 1 to 30.

And how did you integrate the 8-hour staff members into your schedule?

They follow eight hours. If you're 12 hour, you always follow 12 hours. You stay in a rotation of 12 hours. And 8-hour staff members always follow an 8-hour rotation. And they keep the hall and the nurses consistent on that hall.

How much overtime does this create?

None. [ LAUGHTER ]

Okay. And how do you handle holidays?

Holidays are usually worked out amongst the staff before we even know about it. They usually talk amongst themselves. We do ask that they turn in -- when it comes down to Thanksgiving, Christmas, new year's, we put out what do you prefer first? We put out three lists. And they can give us three holidays that they prefer to have off first, second, and third. And they turn it in, and usually before we work it out, the staff ends up coming back saying, well, you know, I have so-and-so going to work for me on Thanksgiving and I'm going to work for her on Christmas. Usually our staff creates that and speaks it before we have to handle it.

For the sake of time, and you have plenty more questions, I think this is great, I'm going to ask a couple more questions, and then we're going to move forward. And at the end, we'll come back to you, okay?

That's fine.

And Mae, is this Julie, another way -- this is wonderful. You have so many great questions. We appreciate this. And we want to make sure to answer all of them. So what we can do is after the Webinar, we will get the report from the polling questions. And we can put those together and have her provide some answers and give this information to you after the Webinar. Even posting it on the dedicated site. Please feel free to keep going with your questions and we'll make sure that we capture those and provide you with some answers.

So do we have time for a few more questions?

I think probably. Go ahead and do a couple more.

Okay. Someone wants you to repeat what days that your CNAs and nurses work.

One week Monday and Tuesday, Friday and Saturday, Sunday. The second week, they only work Wednesday and Thursday.

Do you have a shower team?

Yes, ma'am.

Okay. And how do the 12-hour shifts affect your PPD?

It doesn't. The shower team works 5:00 to 1:00 or 6:00 to 2:00. So they don't -- they're not working 12-hour shifts.

Okay. Someone says I realize you said no overtime. How are you able to arrange that?

The overtime with the 12 hours, the CNAs are only scheduled for 7.5 hours a day. That's the 8-hour shift. And for the 12-hour shift, it's 11.5. So they would have to -- one week they will have 84, and one week I think they have 76. One week is 84, and one week is 76 I do believe. But they have a 30-minute difference over the two weeks. It balances out.

Okay, thank you very much. And you did an excellent job. And congratulations on receiving your bachelor's degree. And I will now give it back over to Beth Hercher. And if you have anymore questions, please place them in the chat. Thank you.

Thank you.

Great. Thank you Mae, that was excellent, and thank you to everyone for those wonderful questions that you posted in chat. We've got a lot more. And we will definitely capture those for you and put those -- either send them out to you or get them posted on our dedicated web pagepage. I want to move onto QAPI implementation step No. 2, and that's thinking about your approach to teamwork. And that implementation references effective teams because we know that it is so important to have action-oriented teams in place. And you have to have active members who are on board with making positive change. That's just imperative. So this whole implementation step kind of will walk your team through those thoughts and ideas. Some action steps you may need to think about are accessing steps within your organization. Especially in our nursing home environments we're always thinking about a performance improvement project. So that's where you're going to begin to think about and determine who of the direct staff needs to be on that team, do residents and families have a role? And lastly, that whole implementation step asks you assess your modes and methods of communication. That is so important. And a lot of failure happens with teamwork because there's just improper communication structure within your facility. So that again -- this whole worksheet that we'll be providing you will help you and your team work through these questions like you see on this slide. Do we have effective teamwork, do we know that, what does it look like? How does our leadership support the effectiveness of development teams? And your leader will be working on these steps with you. We encourage you to look at the whole package around this teamwork concept. There's a specific change strategy that aligns back to the COMLECHLTation step No. 2, and that is to nourish teamwork and communication. That whole concept is around effective communication with staff and between staff. That is so important. This whole change concept is going to offer your team

examples such as including all shifts and communication. You might start to think about learning circles. You might start thinking about some huddles and develop that communication that uses multiple approaches. Some facilities incorporate newsletters, they do an e-mail chain or -- of that nature. The other concept is be a collaborator among collaborators. That is going to provide your team with examples the importance of celebrating a successful CLAKZ. Have you cross -- class collaboration. Have you cross-trained your staff? Encouraging staff to support one another on and off the job. And lastly teaching and modeling offering and accepting help. So we hope these change strategies along with the worksheets, that's going to help your team become more effective and high-functioning. We feel that hearing from your peers is so much more meaningful to you than just us talking to you around these concepts. So I am very excited to introduce to you Emily wit com, an administrator for Tribeca medical center in Nashville, Tennessee. And she's going to share with us this whole ladder focus around building a guiding coalition. And she's going to share with you how she was able to do that within her facility and how that has impacted staff stability within her nursing home. So Emily, start off by sharing the benefits of that. Then if you don't mind to kind of finish up our sharing time with you today, I would like to ask you three questions. Does that sound like a good plan?

Sure. That's great. On the training the coalition, I'm just going to name some things that we have done in-depth, and service-wise. But we always recognize nursing week, social services week, administrative week. And we have had team-building exercise outside the facility. We've brought our management team together and rented out the whole laser tag downtown Nashville. That was lots of fun. And it was lots of team-building in that you had -- drew names and it wasn't one department against the other. Of course we have had potlucks. But the difference is that the facility would furnish the entree, whether it's chicken or the barbecue. So they certainly -- the staff certainly wanted to get together and have that potluck since the facility was paying for the barbecue. We've done games on the floors. And when I say on the floors, units, they're communities. We've done a game, we've invited the housekeeping staff that's assigned to the floor, the activity staff assigned to the floor. All the nursing assigned to the floor. And they would participate in the trivia games. In eye down time, you -- a down time, you call everybody from the desk, it probably takes five minutes to ask a question. Of course it's important that that question spans all ages, all ethnic groups, so everybody has a try. And it would take maybe five minutes. And everybody enjoyed Thad lots of fun, and I think that helped us knit together. We also have community meetings, and staff meetings, where there's a problem identified on the floor. And we bring everybody from that floor, that unit together. And try to seek out the solution with everybody's input. So it's important that everybody be recognized. And first of all, management states we have a problem and this is what it is and ask every participant to contribute to that. So it's important that every member be heard, no matter if the solution is off the wall or not. And tell them thank you and try to figure out a way where part of that solution could be viable. So that brings them together and creating solutions and then they figured out the solution and they implement it. Generally an administrator is not smart enough to do that. They need to do that. Of course we have had in nursing and therapy, I call it fighting. We have both departments meet, in a conference. I would choose a spokesperson from each diameter that was nonconfrontational. Nondefensive. Let each diameter explain -- department explain their job and how it relates to the problem. And 90% of the time, the problems resolve with both parties understanding oh, I didn't know they had to do it like that. And reaching a solution. We notice what each -- try to notice -- management notices what each staff member excels at. If for

instance a housekeeper was doing -- was not cleaning her tables but instead she was helping them assist the residents, so she had a great rapport with the residents. She was also a good housekeeper, unless she was doing that job. So we talked to her and offered her an activities assistant training program, if she would like to move. And a job came available, she moved to activity assistance, she excelled at it. She was so much better at that than housekeeper, and much happier at her job. So Beth, you want me to -- I can continue on that vein.

You're doing great. You were kind of talking about the ways that you nurture that whole growth and innovation when you talked about the promotion of your housekeeper. I think that is excellent. And then when you were talking about maybe three things that you've done in your facility to develop effective team, I heard you say your community meetings that you spoke of, and then that conflict resolution which was great. And you had one more, did I miss that?

Well, to me, it is so important on the problem-solving, when we say create urgency, the way I see that, you're stating a problem. We have a problem on the floor. And you put it out there. Very graphically. Then you say listen -- I tell them I'm not smart enough to solve this problem. You know your job as a CNC, you know your job as a nurse. I don't know it. Help me help you solve this problem! And what happens, you have to be a fairly strong leader because what happens is inVAESHably, someone is -- invariably, someone is going to say something that's in18, and you have to support them -- inane, and you have to support them and stop anyone else from interrupting, and say thank you for that. I can see where that might help in some situations or whatever. And if boosts the other people up, if nobody is put down, interrupted, run over. Then you can physically see people rise up in their seats. Because they know they can state some solutions. That team-building, they have -- they have figured out or therapy or nursing needs to do, and they're the ones that made the rules. So it's administration's job to write it down, support it, pass the information onto other departments and that kind of thing. So that's been a great team-building experience. I think more than anything.

That's great.

We have -- when we talk about -- and do I want to get into the families and how they're supported?

Yeah, I do want to -- I see that there's a great comment for you from Chad. And it's talking about great ideas that you provided. Sounds very helpful, and allowing voices to be heard from all staff. And I think that is so important. That's from Judy parton. And thank you. That's an excellent comment.

And another problem that we had, of course we survey family, conduct meetings with families and residences, we all do. And we have our tray cards in dietary, some selective menus for lunch, which we have had for sometime. And we all know that when you don't have selective menus, and breakfast, you have scrambled eggs on there, and they will get scrambled eggs for many, many weeks to come. Until they draw it to somebody's attention, I am sick of scrambled eggs, then we give them fried eggs for many days to come. [ LAUGHTER ]

So it was brought to my attention again, or recently, say, and I said oh, yes. We need to work on this. So I brought it to the morning meeting where all our staff is in. And explained to them, you

know, I've had another -- I've had an issue with a resident, it was too difficult to change the menu. I change it, my tray card, and I get scrambled eggs. And until I get a hold of somebody, I still have them. So it's time to get a selective menu going. What do you think? First of all I said nursing, anybody in this room, social services, anybody had a problem expressed, residents expressed a problem, that they want to be able to have Brek fast differently. Change the men use. And I have four or five people, managers and social services say yes. So the dietary manager, you know it's scary because you have a tray line. It's like a factory in a way. And when you have selective men use, it stops that -- menus, it stops that process. Or it delays it. So of course everybody else would like to have selective menus, and activities has to help out with marking the selective menus of certain residents. But the main problem is the kitchen. So my kitchen menu was there. And he looked at me, and I said it's okay, I understand that's a big, big deal in the dietary line. And I ran dietary for a while. And you can have -- it's all right, you can have -- if you need, you can look at your labor hours if you need more, we can do that. Seif you would look at your situation -- so if you would look at your situation and let me know what you need to take care of this. It turned out that he didn't need anymore staff. It took him 15 minutes. So it was -- but I was ready. But it was great that -- he wants also to make the residents happy as we all do. When he heard that the residents all wanted it, and there was 19 of them, he was certainly willing to do it.

Well, I think that's a great example of just that whole involving direct care staff. Into performance improvement projects. That's excellent. One quick question, what size is your facility?

It's a 240-bed facility.

So you're a pretty good size.

Right. we'll share with our audience regarding that.

And part of that, I -- I guess -- what happens in that situation, when we have meetings with families, and I have meetings with patients. I'm probably more remiss in that they explain to me what they wish for. And I try to fulfill it. Although I have solicited their help in certain areas. Like I found clothes in my closet that aren't labeled. I said if you can help me, please help me monitor that situation. Would you mind? And I say no, if you wouldn't mind when you visit, would you look through there their and see what's not labeled, then maybe we can figure out what friend is bringing it in. And we can get that labeled. So if you could monitor that and report back to me, I'd appreciate it.

Excellent.

Most of the them, I have asked them from a call like situation, if you have any situation, if you see call lights that aren't answered, please let me know. If you ran a restaurant and something wasn't right, you would want to know from your customers. Was everything all right? Yes, it was fine, then you murmur under your breath you'll never come back. [ LAUGHTER ]

So I do solicit the family members to please talk to me, give me ideas. We have had them help out, building things in the past.

We're going to wrap it up and move O. You've given us some excellent information. There's a couple other questions I want to answer offline. One comment that I think is great, when residents have concern, then they get to be part of the performance improvement project. That's just an amazing thing. Great job.

Thank you, Beth.

Thank you, Emily. Let's move on. And we will capture these questions and get it all out to you. I'm going to move to the third implementation step. You're also going to get to hear from one of our nursing homes here in Tennessee around that. This is a very important step to take. The QAPI self-assessment is just a way for your facility to gauge where you are with your whole journey around QAPI. So I am excited to introduce to you Brenda Underwood, the director of nursing with lake shore Harlan here in Tennessee. And I'm going to turn it over to you now to talk about how you completed with your team, completed QAPI self-assessment. And some of the things that you discovered along the way.

We have been on quite a journey implementing QAPI. But it's been an amazing journey. When we got started, we really started at the top. The administrator and I sat down, took a look at all of our processes with our adequate A process and what we could -- adequate QA process, and what we could do differently by implementing QAPI. We rolled that out with our leadership team, we met every morning, and we talked about what the differences would be, some of the concepts, what are some of the language. For about six months, it'll be QAPI and having that topic change and discussion. After that we set our timeline. We knew we wanted to start small. So we took a calendar and mapped out a year, and made ourselves some benchmarks. And by this time, we want to see in, and by this time we want to see that. So we started implementing our QAPI that direction. We added performance improvement plans to our attendance policies. When we started asking our staff to be involved in their performance improvement, we saw call-ins and call-out reduction by 40% overfour months. So we said we're onto something. So let's just keep growing this. Now we look at it, and we said every month we're going to roll out another piece of this QAPI. So a new form, process, some of it was trial and error. But we read out a little every month just to keep that sense of urgency, keep things going. Now we're looking back, and we did completely implement QAPI starting January 1st of this year. And we found that it is involve our residents and our staff in the performance improvement project. It has really boosted us to the next level. So it's been a lot of fun, it's been amazing to seat changes. Learning circles is one of my favorite. We still incorporate QA into our QAPI. But now our forms and processes incorporate cause analysis into what we do every day. T kind of where we are, and how we blended it into our building. Now we're looking at this process every corner, and seeing where we are, and if we need to tweak something or change something or do something differently.

Excellent. It's just amazing when we hear the stories around the QAPI self-assessment. And you've done an excellent job by keeping it on the radar. It sounded like you had it as a standing agenda item for that standup meeting. And so you just kept it out there. THOFRP. I don't think we've got any questions in chat for you. If we do, we will certainly get those answered and send them your way. But thank you so much. We appreciate it. Notoriety sake ever time, we're -- for the same of time, we're going to move forward. Excellent job.

Thank you thank you.

So we're going to wrap things up. And we appreciate you hanging on I failed to mention each one of these nursing homes that just shared are part of our peer coach program. Each one of them are high-performing nursing homes, and they're a part of our peer mentoring program, and we're just delighted to have them. So again, to all of you, great job. And thank you. We are moving into action period 1. And that is going to be June, July, and August. What does that mean for you? It means that during this three-month action period time, you're going to be taking those worksheets that I had talked about, taking a look at that change package, and assembling your team establish your leader. Start going through those assessments and working through those first three implementation steps. If you have not done so, go ahead and conduct your QAPI self-assessment. Each point of contact within your state will be getting that assessment tool out to you. We're going to start sending that out to our folks in Tennessee following this first learning session, and through the that action time. So watch out for that. You may have already done it. But those are some things that we're hoping you're going to do during the action period time. And that is in between this first learning session and then when we meet again for the next virtual learning session too. The worksheets, I just wanted you to know we will be posting them on the dedicated web page for you to download after this session. And those will be available for you. And they're really good because they not only put out some action items for you to document, but they also have some questions that are more of like a self assessment or a check list, if you will. They even go into some of the hurdles that you may have with the implementation steps. And then the last page, ideas how to implement the steps. So those are around leadership, responsibility, teach work, and the third -- teamwork, and the third is around QAPI self-assessment. Coming very soon, we're planning to do a very informal Webinar, if you will. We think we may do it in June. But it could be more around the first or second week of July. But we're going to be doing a Webinar to talk about improve your quality measures. Just having a discussion around composite scores. And during that Webinar we'll be sharing expectations for you around the second learning session which will be in September. All of these evidence-based resources are posted on your Atom All dedicated web page. And at the bottom of the screen, you can see that specific URL. You'll just copy and paste that into your browser, and it will take you right to this page so that you can download those resourceresources. Do we have any questions I need to address before closing remarks?

No questions in chat.

Great! Thank you, ma'am. Our long-term care world and environment is rapidly changing. With the QAPI regulation pending as well as paper performance upon our horizon, wean that we've got to create a sense of urgency in the way we handle and manage change. And as you heard earlier, the Kotter change concept helps leaders begin to think about how they approach change from the more traditional change management to a more powerful change leadership. Management is about coping with complexity, causes us to bring things in order. Staying within a budget. But thet change leadership concept is how we begin to think about learning how to cope with rapid change. And we feel these concepts hopefully will be useful to you. As you begin to build your coalition and begin to work on your teamwork skills, we hope that you think about the differences between traditional change management and begin to think about the change ladder -- leadership. Management involves planning and budgeting, leadership very muches setting direction. Management involves ownershiping and staff -- organizing and

staffing. But leadership involves arc lining people -- aligning people. Management provides control and solves problems. But change leadership provides motivation. So we hope that as you build your teams and work through your QAPI implementation steps, you begin to lead and guide your team of behalf of atom alliance, we want to thank you for your commitment to our collaborative. We look forward to our next learning session for you, with you, and for now we want to say so long, and we'll see you guys again very soon! [Event Concluded]