The Ralph H. Johnson VA Medical Center Community Living Center (CLC) was recently recognized as a 5-star CLC for Quality Measures and Staffing.
To reach this level of achievement, the CLC team worked hard to develop and implement numerous patient safety initiatives. These initiatives include: enhanced team communication through nursing huddles; shift-to-shift patient care report hand-offs; intentional rounding; and the establishment of a nursing Unit Based Council (UBC) for Charleston VA frontline staff to use to address nursing care issues at the unit level.
The UBC was responsible for researching the staffing methodology to ensure appropriate staff levels in the CLC. Through this analysis, a 12-hour staffing plan was piloted and initiated leading to improved nursing coverage, consistent caregivers and decreased use of overtime, as well as improved staff morale and satisfaction.
The CLC is a restraint free, no-lift home-like environment that has an identified Nursing Falls Reduction Champion for the unit, a Wanderguard alarm system throughout the home, ceiling lifts in all resident rooms as well as mobile equipment for safe transfers and fall mats in place for fall risk reduction.
The CLC staff utilized High Reliability Organization (HRO) principles to realize improved quality of care for Veteran patients. Below are specific examples for each principle:
Preoccupation with Failure – The CLC reached a 5-star rating in Quality Measures but continues to focus on areas of potential vulnerabilities to avoid complacency. For example, some residents with difficult diagnoses and treatment plans may cause a CLC quality measure to trigger. The interdisciplinary team reviews the residents on a weekly basis to ensure the care provided meets the needs of the resident and adverse events are avoided.
Sensitivity to Operations – The CLC front line staff implemented a nationally recognized tool, “Stop and Watch,” for identifying residents whose functional or medical status may begin to decline if action is not taken. The staff use the “Stop and Watch” tool as part of their daily routine while empowering nursing assistants to quickly speak up if a concern is observed. This notification results in immediate action taken by the registered nurse and CLC provider. Additionally, CLC leadership encourages staff to participate in the Unit Based Council, Shared Governance monthly meetings, and during monthly staff meetings. Staff members are encouraged to collaborate with management to provide solutions for issues raised.
Reluctance to Simplify – Decreased Activities of Daily Living (ADL), falls with injuries, and indwelling catheters are problematic with long-term care and hospice residents. Our CLC has utilized a full-time restorative care aid who provides therapies recommended by the physical therapist for maintenance of ADLs. Residents who function at their highest level tend to have decreased falls, therefore decreased opportunity for injury. The CLC staff inquire about the use of indwelling catheters on all residents who do not have a diagnosis of obstructive uropathy or neurogenic bladder and discuss this with the CLC provider and interdisciplinary team. Employees report and track all falls and utilize post-fall huddles to update the plan of care and prevent further falls for a resident. The CLC has had no falls with major injuries with these interventions.
Commitment to Resilience – A best practice action plan for all CLC quality measures was developed with by the Charleston CLC, with input from regional VA leadership, to identify actions for improvement with sustained compliance. This action plan is utilized by the interdisciplinary team to ensure each resident receives the highest quality of care in a safe environment. For example, one resident was identified as a high risk for falls. This resident was assessed, and unconventional methods were utilized to maintain his safety and prevent falls. Also, pressure injury is more likely to occur in residents who have decreased functional status as their baseline. A wound care team was developed to assess high risk residents weekly and guarantee proper interventions are in place. The CLC has had zero instances of pressure injury since this process was implemented.
Deference to Expertise – Pain management in the elderly can be challenging to ensure pain is controlled and the resident is functioning at their highest capacity. The CLC staff completes frequent pain assessments on all residents. The CLC provider uses various methods for pain management; utilizes the pain clinic; collaborates with the CLC pharmacist; utilizes manual therapy and hot/cold compresses provided by the physical therapist; and has coordinated volunteers to visit the CLC and provide middle-eastern, non-invasive, pain management techniques.