Engage Your Front Line

The quality series continues with a look at facilities that have a strong caregiving staff

by Diane L. Dixon, EdD

Do you ever wonder about the origins of the term "frontline" staff? Terms such as line and staff are rooted in the principles of bureaucracy and authoritarian hierarchy developed by German sociologist Max Weber.¹ According to Weber, positions in the hierarchy are organized so each lower position is controlled and supervised by a higher one.

Formal organizational rules are used to ensure uniformity and improve efforts to regulate employee actions. The metaphor is that of a well-oiled machine.

Thankfully, we've begun to come to terms with this 20th century thinking in 21st century long-term care organizations. We now know that bureaucratic leadership doesn't lead to a culture of quality, but rather a culture of stifled, cynical employees.

The first step to engaging direct caregivers and other staff providing vital services, such as housekeeping, maintenance, and nutrition, is debunking the hierarchical model that causes leaders to look down on staff or to see themselves above them. If we envision a circle rather than a pyramid, everybody in the circle of caregiving is of equal importance.

Authentic engagement and gaining commitment begins with how leaders and managers view themselves in relation to their associates. They are partners in delivering quality care and creating an environment in which quality of life thrives.

Below, two long-term care experts share their thoughts on frontline caregivers. And in an effort to take a more in-depth look at evolving cultures of quality, we continue with our mini-case studies on Asbury Methodist Village and Friendship Manor.

Expert Insights

Sue Misiorski, RN, BSN, organizational culture change specialist for the Parprofessional Healthcare Institute, Bronx, N.Y., and president of the board, Pioneer Network, Rochester, N.Y.: Misiorski has vast experience working with nursing homes across the country. Recently she expressed concern about the number of unhealthy relationships between staff members in facilities.

Unfortunately, mistrust, fear, disrespect, and silence characterize relationships in too many nursing homes. Misiorski believes that before a facility can develop a culture of quality improvement and ultimately change its culture, the staff must first make healing these relationships a priority.

The long history of negative relationships in some facilities makes it difficult to move forward in a positive direction. Misiorski said that all levels of staff members must be in the same circle together and talk honestly.

When asked about how to engage employees in quality improvement processes, she indicated that simply inviting them onto a quality improvement committee is not engagement. Direct caregivers chosen for committees tend to be favored by the administrator or department managers. Important perspectives from staff who are either unhappy or soft-spoken often get overlooked.

Also, paraprofessionals who have never participated in a quality improvement committee will need to develop enough trust to believe that it is appropriate for them to share their views. In fact, they may need to learn how to participate. "A committee here and a committee there is not a culture of quality improvement; employee participation needs to be widespread and inclusive of decision making relevant to their work," stated Misiorski.

Real participation in quality improvement efforts depends on quality relationships.

Mary Ann Wilner, PhD, independent consultant, Brooklyn, N.Y., and member of the board of directors, Direct Care Alliance, Bronx, N.Y.: Dr. Wilner also emphasized the critical importance of relationships. "Quality improvement starts with the direct care worker" because the resident spends more time with them than with any other staff member, she said. Developing a culture of quality depends on what happens at this primary level to nurture relationships throughout the facility.

She suggested that vision also starts at the front line. Leaders and managers need to engage paraprofessionals in an ongoing discussion about shaping and supporting a vision for what a culture of quality needs to be in their facility.

Questions to prompt those discussions include:

• What matters most?
• What are we doing right?
• What are we doing that does not work well? Why?
• What do we want to change?

In addition, Dr. Wilner believed that leaders need to provide resources, training, and support to direct caregivers so they can do their jobs well. Her advice for providing that support is to offer education so supervisors enhance their communication and leadership skills. Supervisors can then become good problem-solvers, and model and promote healthy relationships in the facility.

Dr. Wilner also suggested that creating mentors by pairing experienced frontline workers with new employees enhances good relationships among direct care workers. Mentoring deepens their commitment to the facility's vision and practice of quality.

Case Examples

Asbury Methodist Village, Wilson Healthcare Center, Gaithersburg, Md.: Melissa Fortner is the assistant administrator and continuous quality improvement coordinator for the Wilson Healthcare Center, which is licensed for 285 residents. The center provides 24-hour care and employs nearly 300 people, whom they refer to as "associates." The center has a short-term rehabilitation and transitional care unit, and a 40-bed dementia special care unit.

"Quality is the way we do business," said Fortner. Everything they do is focused on quality of care and life.

Leaders at Wilson have developed multiple processes for engaging the frontline staff in the continuous work of developing a culture of quality improvement. The typical quality assurance interdepartmental program has been expanded to embrace continuous quality improvement. A monthly meeting provides a forum for discussing quality issues and processes for identifying key measures.

Wilson's Idea Generation Program has been in place for approximately three years. Boxes are all over the building so associates can place suggestions in them. An associate can focus on anything in their work area for potential improvement. Criteria for viable suggestions include:

• Requires no monetary commitment;
• Makes the job better; and
• Makes the job more efficient, saves time or money.

There is an incentive program associated with the Idea Generation Program. Every implemented suggestion is placed in a pool. Once the pool has eight names, a drawing occurs and five of the eight people receive $10 each.

Fortner indicated that the program has had varying degrees of success. Wilson is a large organization and while good ideas occur all the time, getting associates to formalize their ideas does not always happen. The quality improvement culture is still evolving and the intent is that as it matures more associates will participate.

Process Action Teams have been active at Wilson for approximately four to five years. These teams are episodic, meaning a team forms when quality process improvements are identified and disband once solutions are implemented. Improvement ideas come from sources such as the Quality Assurance/Continuous Quality Improvement Committee, satisfaction surveys, and the Idea Generation Program.

Associates closest to the process are invited to join Process Action Teams. Invitation is important because it gives associates the choice not to participate. This is different than putting someone on a committee, which usually results in resistance and lack of participation. Every associate receives an introduction to continuous quality improvement training so they understand how to use quality improvement tools and techniques. Once the team is formed, members develop a charter that includes the project purpose and desired outcomes. Evaluation of implementation progress is embedded in normal work processes.

Anthony Ingelido, vice president of Organizational Excellence for Asbury Services, Inc. suggested that the "best thing leaders can do is to help create an environment of trust."

Frontline workers are then more likely to actively participate. He also believed that frontline associates will participate if mistakes are treated as opportunities to learn. Listening to their stories and learning from them helps to develop a culture in which everyone focuses on quality improvement.

Friendship Manor Health Care Center, Roanoke, Va.: Friendship Manor leadership understands that developing a culture of quality begins at the front line. This is why Sue Jennings, CNA, assistant director of nursing for CNAs, dedicates her time to ensuring the full engagement of CNAs in decision-making and problem-solving processes.

Jennings and Libby Green, RN, vice president and director of nursing, believe that elevating the CNA role appropriately recognizes their importance as the primary caregivers.

Further, their experience suggests that the foundation for engaging the frontline staff is providing opportunities for growth and development.

To accomplish this, Friendship Manor has a Nursing Assistant Career Ladder. The steps in the ladder are briefly described below:

• Student Nursing Assistant: 70-hour classroom and 86-hour clinical training that lasts approximately four weeks.
• Student Graduate: Successful completion of classroom and clinical training.
• Certified Nursing Assistant (CNA): Requires a passing score on state certification test given upon completion of training.
• Geriatric Certified Nursing Assistant (GCNA): Contingent on minimum six months employment, passing score on the GCNA test, and satisfactory evaluation from supervisor.
• Unit Support CNA: Contingent upon placement in position.
• Lead Certified Nursing Assistant (LCNA): Contingent upon additional training, satisfactory evaluation from supervisor and facility needs.
• Senior Lead CNA (SR LCNA): Contingent upon additional training, satisfactory evaluation from supervisor, and facility needs.
• Assistant Director of Nursing (ADON): Demonstrated clinical expertise and leadership skills and dependent on facility needs.

Nursing assistants know that they are valued and will be recognized for their accomplishments. Jennings is responsible for the CNA performance management process and uses it to give feedback as well as recognition.

Involvement is also critical for engagement and gaining commitment from the front line. Jennings facilitates monthly meetings with the Lead CNAs, SR LCNAs, and Unit Support CNAs. Prior to the meetings, participants get input from their co-workers.

The typical agenda includes sharing input from staff across the nine nursing units. In addition, policy changes and new procedures are discussed. They also focus on staffing issues with the intent that staff members don't become overwhelmed. This forum builds teamwork and support.

To ensure that CNAs' points of view are represented and integrated into Friendship Manor planning and decision-making, Jennings participates in the monthly Friendship Management Group, which includes senior management and division and department heads. She is active in the Quality Assurance and Improvement Interdepartmental Committee meeting and follow-up processes.

In sum, Jennings provides a vital link between frontline leadership and the circle of leadership throughout the organization. It is evident that at Friendship Manor the front line is central to achieving its core mission.

Summary

The 21st century meaning of frontline staff is valuable people providing direct service to residents, patients, and families; they are critical to improving quality of care and life in the organization.

Before leaders and managers on all levels can expect frontline staff to actively participate in quality teams, taskforces, and/or committees, they must first have positive relationships with them.

Trust, respect, and communication form the foundation of engagement. The facility environment has to be open and supportive to eliminate fear. Direct service workers need to accept that participating in quality improvement processes is their job and not a separate activity. The front line must believe their contributions matter and that they will be recognized for doing a good job. These are the requisites for frontline partnership, with leaders and managers working together to develop a culture of quality.

Diane Dixon is a regular contributing writer for Caring.

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