Maintaining quality in a union home: providing good resident care demands special attention in this setting.

Maintaining quality of care in a unionized home can be a challenge, but is achievable if you establish high standards, provide staff with clear direction, and follow-up with appropriate supervision and discipline when warranted. A necessary ingredient is a system of accountability.

Accountability

For each job duty, policy, and procedure, each employee must be answerable to judgement of his or her performance and compliance. This is particularly important in a union home, where clear directions must be proven to have been given to employees that should have resulted in consistent practices. This is because a claim by management that non-compliance to policies, procedures, and job descriptions should result in discipline almost always results in the filing of a union grievance. In this case, it will be necessary to prove to the union or an arbitrator that the employee was clearly informed of his or her responsibilities but failed to comply.

Accountability for each new employee must begin upon hiring where, in addition to all usual information given to new employees, they may be given the following document or similar statement that they should be required to read and sign:

"I understand that as an employee of (NAME) Nursing Center, I am fully responsible for reading the Policy and Procedure Manuals located on each nursing unit and further understand that I must periodically check these manuals for any changes and updates that may be added."

This signed document should be added to the employee's personnel file. It will eliminate the employee's being able to deny knowledge of written policies and procedures and job duties. It should be an established practice to conspicuously post policies, procedures, and memos for at least two (2) weeks before they are permanently entered in an appropriate binder on each nursing unit and department to be retained for future reference. All information related to the performance of work in the facility should be made readily available to staff at all times.

Accountability is further increased by documented resident assignments, and special duties that include cleaning dining rooms, putting away resident clothing, etc. Individual resident assignments should be specific and itemize each resident service provided by nursing assistants on each shift. They should be completed by charge nurses with input from nursing assistants on that unit to assure fairness and accuracy in resident assignments.

Supervision

In order to insure that policies, procedures and job duties are adhered to, it is necessary to closely monitor compliance, therefore, in a union home, supervision must be increased. Even if charge nurses are not in the bargaining unit, they may feel reluctant to discipline subordinates due to the possibility of harassment by the union. Such harassment might involve denial of the incident to the extent that the charge nurse must go to great lengths to prove non-compliance, or even threats to the charge nurse's person or property. Therefore, there is a greater than usual need for clear management support, as evidenced in more documented policies and procedures. High visibility of supervisors in work areas also demonstrates management support to charge nurses.

The probationary period for a new employee is a most important time to determine if this employee meets the standards of the facility, because this is when we are seeing them at their best. It is particularly important to closely observe the new employee because during this period the employee's termination is usually not subject to grievance or arbitration procedures. If poor work habits are observed during probation, the policy should be to terminate.

Charge nurses must be trained, developed and encouraged to enforce high standards of care by supervision of work performance of subordinates. Even if unionized, charge nurses must accept the responsibility for care delivered on their units because it is their professional and legal obligation.

Standards

A most useful policy establishing quality of resident care can be developed utilizing input from nursing assistants and charge nurses. This policy can focus on areas of resident care and environmental situations and specify a quality outcome in each area.

In conjunction with this "Quality Assurance policy," an audit form may be developed to address each area of resident care. The audit can be conducted on residents of a selected nursing assistant. The results of the audit can be included in the nursing assistant's personnel file and referred to in completing the annual evaluation. These audits should be unannounced and done regularly. They must be conducted by management and must include nursing assistants on all shifts. They may also be done in each department using the same system of policy development including quality outcome and audit.

Major violations of the Quality Assurance policy discovered upon audit should result in disciplinary action. The rationale for these actions should be nonspecific, categorized as "substandard care" or "substandard performance." This is helpful to avoid graduated discipline for each of the resident care areas.

For example: One of the areas reflecting quality resident care can be "clothing" and the standard or expected outcome can be that the resident has on underwear and footwear and is tastefully dressed. If the resident does not have on underwear, the nursing assistant assigned should receive a verbal warning for substandard care. The next audit may reveal that same nursing assistant did not meet the quality standard when he or she did not clean and manicure the assigned resident's nails. This warning will be written for substandard care, with progress through suspension and termination depending on the severity and number of occurrences of the violations.

Evaluation

In addition to the probationary evaluations, annual evaluations must be done on all employees. Evaluations for nursing assistants are usually done by charge nurses, while charge nurse evaluations are usually done by supervisors. Because it is not easy for anyone to give a bad evaluation, there is a tendency to rate employees as average or above. It may become necessary to review evaluations before they are given to employees to assure accuracy.

In a union facility it is more difficult to terminate an employee who has had consistent, above-average evaluations over a number of years. If evaluations are accurately reflecting below-average work habits, there will be accompanying warnings or poor audit results that will justify the evaluation and build a case for termination of a marginal employee. Accuracy in evaluations can be assured by objective documentation of observances throughout the year, with progress reports to nursing assistants to avoid the shock of a bad evaluation at the end of a work year.

Another evaluation tool that may be used is provided by the residents and/or family members. Marketing studies show that every satisfied customer tells 3 people of their satisfaction, whereas every dissatisfied customer tells 12-15 people of their dissatisfaction. If you resolve a complaint of a dissatisfied customer, that newly satisfied customer tells 9-12 people. If you are told of a complaint and do nothing to correct it, that complaining dissatisfied customer will tell 25 people. Our goal should be to become aware of dissatisfaction and try to correct it before the public at large becomes aware of it. Customer-oriented evaluations can therefore be very important. A form that is easily completed and that can be submitted anonymously will stand a better chance of being returned.

Evaluations of the facility should be solicited through out the year. Families and residents should be encouraged to communicate openly, without fear of reprisal. Unfortunately, this is more easily said than done. Through the cooperation of the local consumer group representing better nursing home care, meetings should be arranged involving the nursing assistants and residents; together, their addressing of perceptions and concerns related to living and working in the facility can encourage development of better understanding of the needs of both groups.

Separate evaluations from the staff regarding improvements and their opinions about the facility may reveal areas that need attention, as well. This should not replace regular meetings with staff where open communication with supervisors should be encouraged and ways to improve performance discussed.

Management Rights

As far as management rights are concerned, all union contracts usually have a provision with this title. Basically it says that management has the right to operate, manage, direct, and supervise operations within the provisions of the contractual agreement. It doesn't mean that the union will not challenge actions taken by management in this regard. Do not let any anticipated challenge from the union prevent you from taking action that you feel is in the best interest of resident care or your business. The philosophy should be to act and let the union react by filing a grievance.

However, the consequences and/or ensuing action should be seriously considered, particularly in regard to employee discipline where, if union intervention results in a reduced discipline, perception of the union strength and necessity will be increased among the employees.

In conclusion, establishment of high standards reflected in written policies, procedures and job duties that are clearly understood, carefully monitored, and evaluated will result in quality in any facility, whether unionized or non-unionized facility.

Discipline that is fairly administered and justified will be supported, publicized among staff, and in the end contribute to the maintenance of standards necessary to quality resident care.

Lucille Massemino, CMACHCA is a Registered Nurse and has been involved in health care for over 20 years, serving as Director of Nursing at a community general hospital before coming to Charlesgate Nursing Center as Administrator. She is also President and Treasurer of Davenport Associates. She is actively involved on several boards regarding long-term care and active in the American College of Health Care Administrators.