Veterans Health Administration (VHA) Community Living Centers (CLCs) are engaged in cultural transformation aimed at providing resident-centered, home-like environments that promote optimal outcomes for residents. One element of cultural transformation is use of consistent staff assignment, a scheduling practice thought to result in better staff-resident relationships and improved resident health and quality of life. Although VHA Geriatric and Extended Care (GEC) and CLC leadership monitor consistent staff assignment and actively encourage its implementation, the extent of its adoption in individual CLC care units ("neighborhoods") is not known. Nor do we know which CLC neighborhood characteristics are associated with more complete and more sustained implementation of consistent staff assignment.
We addressed these knowledge gaps by: (1) determining the progress of individual CLC neighborhoods in VHA nationwide in implementing consistent staff assignment, and (2) identifying specific CLC neighborhood characteristics associated with more complete and more sustained implementation of consistent staff assignment.
A total of 203 staff schedulers, representing neighborhoods across the network of 133 VHA CLCs, completed a Staffing Practices Survey (SPS). The SPS assessed the one-year history and current levels of consistent staff assignment, as well as structural, functional, and staffing policy and practices characteristics, and scheduler resources, of each neighborhood. Based on SPS results we categorized the neighborhoods as having: (a) full versus incomplete current implementation of consistent staff assignment, and (b) among those neighborhoods with incomplete implementation, the level of progress toward the full implementation goal. We graphed neighborhoods' consistent staff assignment levels over four quarters (October 2013 to July 2014), and (c) classified them into five groups based on one-year history of consistent staff assignment: stable high, improving, stable low, declining, and highly variable. To identify facilitators and barriers to full and more sustained implementation of consistent staff assignment, we compared the above groups on structural, functioning, and scheduling characteristics.
About half (51%) of VHA CLC neighborhoods nationwide have achieved the goal of full implementation of consistent staff assignment (i.e., during the past month, at least 85% of residents provided care by a maximum of 12 care providers). Of neighborhoods without full implementation, 42% have low (0-24%), 24% have moderate (25-50%), and 34% have higher (51-84%) levels of consistent staff assignment. Regarding one-year history of consistent staff assignment, 31% of neighborhoods had stable high, 15% had improving, 30% had consistent low, 11% had declining, and 13% had highly variable levels of consistent assignment from October 2013 to July 2014. Structural characteristics of the neighborhoods (e.g., larger size; more complex resident mix) were not related to full implementation, but staffing practices and policies were. For example, schedulers in full-implementation neighborhoods were significantly more likely to involve staff in troubleshooting scheduling problems than were schedulers in neighborhoods without full implementation (60% versus 39%). Neighborhoods with full implementation also were more likely to maintain stable care teams (61% versus 31%) and to have fewer problems with staff absences (9% versus 24%). Full implementation neighborhoods also had more scheduling resources than those without, including schedulers with more than 3 years' experience in that role (87% versus 77%). Schedulers in full implementation units endorsed more positive appraisals of consistent staff assignment scheduling. They were more likely to report that consistent assignment does not make staff absences more challenging to manage (85% versus 73%), that it positively affects resident functioning (69% versus 54%), and that it benefits staff's job satisfaction (51% versus 34%).
Among the neighborhoods that had not yet achieved the full implementation goal, staff schedulers' education and training were associated with higher levels of consistent staff assignment implementation. The percentage of staff schedulers with formal (academic and on-the-job) training in consistent assignment methods was 29%, 45% and 47%, in groups with low, moderate, and higher levels, respectively, of consistent staff assignment. Tools to support implementation of consistent staff assignment had been developed in 27%, 41%, and 53% of neighborhoods with low, moderate, and higher levels of consistent staff assignment.
Regarding correlates of one-year historical patterns of consistent staff assignment levels, neighborhoods that had stable high or improving historical patterns were more likely than those with stable low, declining, or highly variable patterns to maintain stable care teams (56% versus 40%), report having minimal problems with staff absences (24% versus 9%), to have staff who feel like a team (56% versus 41%), to hold team meetings to familiarize one another with residents' needs and preferences (67% versus 44%), and to have staff that frequently help one another (51% versus 36%).
These findings suggest that although VHA CLC neighborhoods nationwide have made considerable progress toward attaining the goal of full implementation of consistent staff assignment, there remains significant variation among them in achieving and maintaining this goal. Whereas staff scheduler inexperience and frequent staff absences pose barriers to full and stable implementation of consistent staff assignment, progress toward full and sustained implementation is facilitated by providing staff with focused, formal training in consistent assignment methods, use of more team-based and inclusive scheduling practices, and neighborhood work settings that emphasize teamwork and mutual support to achieve staffing and resident care goals.
Findings from this project will be disseminated to VHA CLC staff via national monthly conference calls and, together with staff-developed consistent assignment tools and documentation, made available to neighborhood staff nationwide on the VHA CLC SharePoint site. In addition, we plan to reach CLC staff and the broader national nursing home care provider community by publishing our findings about key factors that facilitate and impede implementation of consistent staff assignment practices. Results of this project have potential to improve implementation of consistent staff assignment in skilled nursing and long-term settings and thus to contribute to improved health and quality of life of Veterans obtaining care in both VA CLCs and non-VA community nursing homes.
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