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Getting Beyond Blaming Staff: A Facility Example

      A telephone rings in a nursing home, far, far away:
      “Hello, this is Janet.”
      “It’s Sue on unit 100. I’m sorry to bother you, but Betty fell.”
      “What happened?”
      “She fell out of the Hoyer sling.”
      Attending physicians, administrators, and directors of nursing, you’ve all had calls like this, the calls that cause your heart to skip a beat and your pulse to shoot through the roof. As much as you don’t like getting them, the staff hates making them.
      Betty is not the patient’s real name, but this is a real story. Betty has quadriplegia. Two nursing assistants were transferring Betty from her bed to her electric wheelchair using a Hoyer lift, a procedure they had done dozens of times before, when she slipped out of the sling and crashed to the floor.
      Addressing a crisis, incident, or accident in the moment is something most nursing homes do well. Care is rendered, phone calls are made, and reports are written. But a crucial aspect of performance improvement is often missed in these scenarios. After the crisis, some facilities react by asking “why” at least five times just to find out “who.” Who should take responsibility, be written up, or even fired?
      Fear of disciplinary action does not motivate improvement — it subverts it.

      The Story Continues

      The physician happened to be in the facility at the time of Betty’s fall and immediately assessed her. It was clear that her shoulder was likely fractured, so she was sent to the hospital. Indeed, it was fractured, and Betty returned to the facility with her arm in a sling. The staff felt terrible, Betty felt terrible, and now Betty was terrified of transfers.
      However, the story also has a good side.
      Let’s start with Brian Joiner’s concept from Fourth Generation Management (New York: McGraw-Hill, 1993) of the three levels of fixes. The first-level fix is when an incident or accident is addressed immediately. Think of this level as damage control and cleaning up the aftermath. In Betty’s case, her condition was assessed promptly, and she received proper medical care for her injury. In many facilities, however, the process stops at this level, and the nursing assistants are blamed for the outcome, reprimanded, or even fired.
      Think of the popular carnival game Whack-a-Mole, in which the club-wielding gamer attempts to keep the moles in their holes by whacking them on the head when they pop up — truly an insane and fruitless game that never provides a satisfactory outcome. In nursing homes, this “Whack-a Mole” insanity is embodied in the question, “If we fired everyone involved in this incident, could it happen again with other staff?” Be truthful, and you’ll see that the answer is usually a resounding yes.
      So rather than stopping at a first-level fix (complete with disciplinary actions), make the choice to proceed to a second-level fix.
      Betty’s facility went to the second level: examining the process that led to the incident. Incidents do not happen in a vacuum; usually a sequence of events led to the event. In Betty’s story, several important contributing factors came to light during the investigation: the staff were using a sling that was too long for Betty; worse, the staff were not aware of what sling size was appropriate for each resident, so they used the slings interchangeably. Why were they doing that, you might ask? There weren’t enough slings in the facility, and slings were not assigned to each resident according to size. Furthermore, the labels on the slings were so worn from multiple washings that it was impossible to read the sizes or dates of purchase. Yet another problem was that the Hoyer lifts routinely acted up and ceased working. All these process issues culminated in Betty’s sad outcome.
      Some facilities react by asking “why” at least five times just to find out “who.” Who should take responsibility, be written up, or even fired? Fear of disciplinary action does not motivate improvement — it subverts it.
      The facility’s leadership could have stopped the investigation after identifying the process issues with the single Hoyer lift involved in this incident, but they did not. Instead, they looked beyond Betty’s unit and examined all the lifts in the facility. It’s a good thing they did — further investigation revealed that the instruction manuals for the Hoyer lifts were not in the facility, nor had there been consistent or documented inspections of the equipment. Leadership took immediate action: they removed all the lifts and replaced them with rentals, at which time the entire staff was trained on the new machines.

      The Next-Level Fix

      What is the most essential point of this story? Upon learning about the problems with Hoyer lift inspections and the overall safety program, the facility’s leadership took the improvement process a huge step farther to achieve a third-level fix. They asked two crucial questions:
      • 1.
        Is this the only process that causes harm to our residents?
      • 2.
        Is there a problem in the way we implement the protocol?
      Not surprisingly, there were other opportunities for improvement that, had those questions not been asked, leadership would never have known about — at least until there was another incident. The additional opportunities for improvement resulted in improved safety protocols for inspection and overall maintenance for all equipment, including the oxygen concentrators, intravenous administration pumps, and electric beds. By evaluating the entire system of safety, they improved many processes, which was a win-win for everyone.
      The facility’s leadership could have stopped at a level-one fix and simply fired the staff involved in the incident. They didn’t. They could have stopped at a level-two fix when they bought new slings, which they sized and labeled for each resident. They didn’t. Instead, they achieved the best improvement outcome possible by evaluating the entire system in which they worked each day. They didn’t succumb to a knee-jerk reaction and make an already difficult situation more problematic by merely blaming the nursing assistants who were involved in this incident. By improving the entire system, involving a variety of equipment and monitoring, they made their whole facility safer for both residents and staff.
      Ms. Hector is a clinical educator and speaker at health care conferences on diverse topics including end of life care, clinical operations for the interprofessional team, and process improvement. She is a member of the Annual Conference Program Planning Committee for AMDA – the Society for Post-Acute and Long Term Care Medicine, and the chair for the Spring Conference Planning Committee for the Arizona Geriatrics Society. We welcome Ms. Hector to Caring’s Editorial Advisory Board.