When we talk about risk management, we often overlook one important aspect of how we provide care to our residents: staffing. So, let’s talk about staffing. How do you staff your community: are you staffing by acuity, census, or “clinical acuity”?
Notice there are two types of acuity. We often get lulled into thinking that the “subacute” unit has higher acuity, when in fact it's the long-term, high-ADL-need residents who require the most hands-on caregiver time.
In a report by the OIG, in 10 sample states, inadequate staffing levels were identified as one of the major problems in nursing homes. Guess what? We continue to have staffing challenges! So what are you doing about it?
Which Is the Best Staffing Model?
Using a Staffing Coordinator
Many centers use a designated staffing coordinator, which is great—but most staffing coordinators don’t staff by acuity as they aren't trained to do that. Staffing is not only a full-time job, but it requires assistance from someone who understands acuity, someone like the DON who doesn’t have the time to do this on a daily basis. It's a great idea to train your staffing coordinator before making them responsible for performing this function.
Staffing By Census
Are you staffing by census? You know the staffing “ladder”—census goes up or down by three residents and you add staff or send staff home. Statistics have proven that this practice doesn’t work! In fact, data has shown that staffing by acuity is the most accurate way to staff.
Staffing By Acuity
So take a look at “acuity” in your home. Are you over-staffing on the skilled units and not covering the basic needs of the long-term care residents?
A good tool to use is Section G of the MDS to determine ADL needs. You can breakdown the information any way that works for you, but make up a scoring scale—for example, if a resident is totally dependent on staff for mobility, then they would score a 4 in that category; if a resident only requires supervision for mobility, they would score a 1 in that category. Once each resident has been evaluated using Section G, find the average total score and staff based on the needs of the residents who fall below the average.
Covering Break Times
What about break times? Most breaks occur right after a meal. Morning breaks occur around 9:00-10:00, afternoon breaks around 1:00, and evening breaks around 7:00. If you look at the trending of incidents in your building, you'll probably see that these are the times when there's an increase in incidents.
Is it the chicken or the egg? Why not run a trial and see if you can identify which it is? Adjust break times for a month on one unit and see. It may be that you're staffed totally fine to meet acuity needs, but breaks and lunches are messing up your outcomes!
Or trial a unit with “hospitality” staff—managers are very capable of covering call lights when staff are on break. A more hands on-deck approach is also proven to be beneficial at reducing risk!
Permanent Assignment Staffing
Then we have permanent assignments. Everyone thought it wouldn’t work, remember? Technically, there should be lower risk for negative outcomes in communities with permanent assignments as it allows for staff to be intimately aware of each of their residents’ personal needs. But staff who are new to a resident may not be aware of their needs, yet they're still responsible for covering the permanent caregiver's breaks.
What is your process for educating the relief team on each resident’s individual needs? Remember, each resident in your care receives approximately 20 touches a day by a caregiver. If the resident knows their caregiver, and vice versa, and expects that caregiver on a daily basis, the care may be better and the resident may be more relaxed/compliant.
We all know that staff don’t work 24/7, so what is your back up plan? Do you have alternate primary caregivers? Some communities are moving to primary care where one nurse attends to all the resident needs (no CNAs). This is also effective, especially in the subacute arena.
We discussed acuity earlier, and it's important to remember that a resident’s acuity may change daily. There is no escaping declines and improvement that we see with our frail elderly population.
So say you have permanent assignments. Are you assessing the residents on a quarterly basis and with significant change in status? It's highly recommended that each assignment grouping be assessed for acuity creep. The burnout rate is high, both in permanent assignment situations and standard staffing processes. The key is to identify the subtle changes in resident behavior before the caregiver is burned out. Be proactive, identify the little things early, and adjust the assignments accordingly.
12-Hour Shifts
Another acute care-based option is the 12-hour shift but they are not without their downfalls. Think about a call-in, for example. You now have 1.5 shifts to cover, versus the traditional 8 hours.
But there are advantages, as there is less change for the residents throughout the day and ultimately more consistent care. There are no statistics regarding these outcomes—however, there are studies that indicate the average worker is only productive about 8 hours out of a 12-hour shift.
Remember breaks too. How many 30-minute breaks are the staff taking when they work 12 hours? It's a dilemma, so if you decide to try it, make the staff responsible. If one nurse wants 12-hour shifts, then make them identify their partner who will cover them when they are not on. This will give them some ownership in the process and hopefully prevent failure of the system!
Ensure You Aren't Caught Off-Guard
These are the things we look for when visiting a facility. The OIG and regulatory bodies also know the hot buttons and where to look for the bodies! It's always amazing when we review quarterly staffing reports and find no RN coverage in a skilled building for several days in a month.
- Are you monitoring the time clock use?
- Who is punching in and out?
- Are they doing it per the policy?
- Is there disciplinary action for staff who refuse to be compliant?
- How about staff interviews?
- Are staff being honest with you or do they fear for their jobs and hide things from you?
Remember, once a negative outcome is realized it's a little late to say, “Hmm, wonder how staffing was yesterday”?
So in summary:
- Ultimately, staffing is your responsibility. It's a delegated task, but the buck stops with you.
- Waiting for a negative outcome or hoping not to have one doesn’t relieve you of this responsibility.
- Meet with your staff, talk to them, LISTEN!
- Meet with your resident council—they'll have lots of suggestions. Document through the QAPI committee in a PIP. Evaluate and start over if needed.
- Never quit!
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