Long-Term Care Survey Alert

Follow this staffing path to stellar resident - and survey - outcomes.

Expert staffing management not only improves clinical outcomes, it gives surveyors and plaintiff attorneys one less way to nail your facility for a pressure ulcer or fall.

But keep in mind that staffing is more than numbers. "Adequate staffing is ... also measured by the facility's outcomes and operations," says attorney Harvey Tettlebaum, partner with Husch & Eppenberger in Jefferson City, MO.

In other words, simply investing in high staffing ratios may not give you the bang for the buck you think it will. Instead, find ways to staff that make sense for residents' wellbeing - and the facility's bottom line. Follow these four field-tested rules:

Rule No 1. Implement A Data-Driven, Defensible Staffing Method

Use your quality assurance process to find a way to adjust staff to residents' conditions or case-mix (and have the documentation to show you do), advises Tettlebaum. "The 'adjustment process' doesn't necessarily mean the facility hires more staff," says Tettlebaum. "For example, the facility could reassign more experienced nursing staff to a wing containing sicker residents," he suggests.

Facilities can use the RUGs to some extent to get an idea of staffing requirements, advises Patricia Boyer, RN, MSM, a consultant with BDO/Heritage Health Group in Milwaukee. "That's easier to do in RUG-based Medicaid states where the facility is RUGing every patient," she adds. "But you can use the nursing case-mix index for the RUGs to give you an idea of the number of nursing hours you should have. Or look at residents' RUG activity of daily living scores to give you an idea of the CNA staffing requirements." Or as an alternative, look at the number of patients in Extensive Services and Special Care, as these patients will usually require more skilled nursing care, advises Boyer.

Staffing tip: Maximize staffing effectiveness (and prevent errors) by identifying and targeting staff members' strengths and personality traits to various care tasks.

"For example, some people are very detail-oriented and good at math," observes Diane Brown, CEO of Brown LTC Consultants in Boston. "So assign those people to tasks that require absolute accuracy like weighing people, adding I&O sheets, calculating ADL scores or making sure medications are given  correctly." Other staff may be better at seeing the big picture or enjoy developing creative care plans.

Rule No 2. Tame Temp Agency Use

Temp agency nursing staff may get your staffing ratios in the safety zone in a crunch. But these caregivers can also cost you big in myriad and often unforeseen ways.

"Temp staff not only become a costly habit, but temp agency staff sometimes receive what almost constitutes a 'bounty' for getting other caregivers to sign on with the temp agency, which can deplete your staff," cautions Rick Carter, CEO of Care Providers of Minnesota in Minneapolis. "And temp staff can create higher survey and malpractice liability because they don't know the residents and facility procedures like the regular staff do," he adds.

Yet many facilities don't even try to get their own staff to cover for call-ins before dialing the temp agency, Carter notes.

Solution: Facilities can actually create their own "agency" or pool of staff willing to work extra hours. For example, recruit your own caregivers for a pool - or network with sister facilities in the area to share staff.

"Even if you pay these staff overtime wages, you will still spend less than if you use a temporary agency," Carter adds. Tap your staff's creativity: Ask your staff how the facility can eliminate or reduce use of temp staff, Carter suggests.

Some facilities are using Web-based systems where staff can put in dibs for certain days off - or the management posts a notice when the facility is short staff on a shift, and caregivers can sign up online, says Carter.

Other facilities have had good luck training CNAs or LPNs to manage day-to-day staffing rather than the DON. Front-line staff have a harder time saying no to working extra or on a holiday to someone whom they view as an "in the trenches" colleague, in Carter's experience.

Rule No. 3. Recruit, Recruit, Retain

Keep an eye on your facility's salary and benefits (available from cost reports) to remain competitive in a tight nursing market, advises Celia Strow, RN, MPS, CNHA, FACHCA, CEO of MyZiva.com in Lake Success, NY. "If a facility is experiencing high turnover, or is using a lot of agency staff, its care may be poor," Strow warns.

And a facility with a reputation for poor care can end up with a poor census, she adds, which means less revenue to improve care or staffing.

Also maintain a constant recruitment effort. Be prepared to show surveyors your efforts in that regard, if they question staffing levels. "The facility should have a list of potentially available new hires to replace staff who terminate employment," says Tettlebaum. "Explore creative models with your frontline staff for recruiting and retaining quality staff," adds Carter. (To find out how one facility went from "famine to feast" with its nursing applicant pool, read the case study in the September 2004 Long-Term Care Survey Alert)

Rule No 4. Develop Top-Notch Communication Systems

Your staffing numbers may look stellar, but your resident outcomes won't if staff fail to communicate and coordinate their assessments and care. "Lack of communication between nurses and attending physicians and between nursing shifts is a major risk management problem in nursing homes," says Stephen Trosty, JD, MHA, CHMA, a risk management expert in East Lansing, MI. So ask the interdisciplinary staff for input in thinking through what  information they want to communicate about residents, including emergent care issues, advises Trosty.

Then figure out how best to share information in your particular facility. Options include a 24-hour report book, end-of-shift reports, or reports during the shift, he says.

"Train staff in the communication procedures and process - and do QA audits to check for compliance," Trosty suggests.