Sign Up For Email Updates   Submit

Consistent Assignment

Tip Sheet


WHAT IT IS:

Consistent assignment means residents have the same CNAs and nurses caring for them every day whenever these staff are working. Rotating assignment means that CNAs and nurses rotate to different groups of residents after a period of time, whether daily, weekly, monthly, or even after 3 months. Best practice is consistent assignment for housekeeping, activities, social services and therapies as well as CNAs and nurses.

WHY DO IT:
The research is now conclusive that consistent assignment of CNAs and nurses improves clinical, workforce, and organizational outcomes. Thirteen studies show that consistent assignments lead to enhanced relationships; improved staff attendance; improved staff, resident, and family satisfaction; lower staff turnover; improved accuracy and timeliness of screening and assessments; improved clinical outcomes; and improved quality of life. All the concerns frequently expressed as fears about implementing consistent assignment – staff burn-out, staff not knowing residents not on their assignment, unscheduled absences, and how to take care of the hardest people – already exist when staff rotate and can be handled better with consistent assignments.

Consistent assignments transform caregiving from "tasks" to relationship-based care. Residents know who is taking care of them and feel secure in the consistency of the relationship. They trust that "their CNA" knows just how to take care of them. Families share that trust and feel they are in a "partnership" with "their caregiver." Consistent assignment reduces grievances and complaints as staff are better able to meet residents' and families' needs. Staff are dedicated to their residents. Most CNAs come into this field because they care about people and want to make a difference in the residents' lives. Having a consistent assignment allows relationships to grow so that CNAs feel more satisfaction from their care-giving role.

Consistent assignments are the foundation for high quality individualized care and good teamwork because staff know residents so well they can anticipate individual needs and preferences. Consistent CNAs have finely tuned awareness of residents' needs and changes in their condition. They catch problems at the earliest warning signs and know how to respond. Staff know what has been tried, what worked and what didn't, and what is normal for each resident. This helps staff know how to approach a resident's current situation more effectively.

Consistent assignments provide stability – for residents and for staff. With consistent assignments, CNAs know how to plan their workday more efficiently, and can even have consistent break schedules. Staff establish a regular rhythm for their work and function better as a team throughout the shift. When CNAs spot subtle changes, nurses appreciate their contribution. Scheduling becomes simpler when it is built to support consistent assignments.

HOW TO DO IT:
Consistent assignment works best when it is supported by the other foundational organizational practices. To maximize consistent assignment, use shift huddles, QI huddles, and involvement of consistently assigned CNAs in care plan meetings so staff can share what they know about residents' needs and changes in condition and participate in designing the interventions they will implement. The care-giving relationship closest to the resident matters most. Consistently assigned staff serve residents best when they are supported by the rest of the nursing home team to accommodate residents' individual needs and preferences.

  • Measure the extent to which you currently have consistent assignments.
  • For a sample of residents, look at the CNA documentation for a month. Count the number of CNAs that have signed off on care. Compare that with how many CNAs would be involved in a resident's care if you were at 100% consistency. That number would probably be somewhere between 9 – 12 CNAs, depending on scheduling. 
  • For a sample of CNAs, count how many times they are moved from their consistent assignment to cover another area due to another employee's unscheduled absence. 
  • Use this information to set some goals for improvement.
  • Make it fair and sensible: The success of consistent assignments depends on the effectiveness of the implementation process. It needs to be put in place through a process that ensures staff involvement, fairness of workload, compatibility of assignments, and supervisory practices that foster teamwork and problem solving, particularly in regard to care for residents who staff find challenging. It needs to be accompanied by regular team meetings where information about residents is shared among staff so that anyone can be a back-up in caring for a resident.
  • Use a high engagement process: Assignments must be fair for staff and a good match for residents and for staff, playing to staff's strengths. For fairness and compatibility, staff members need to be involved in determining assignments, and supervisors need to facilitate adjustments when assignments do not work or the resident population changes.
    1. Pilot test where you have the best chance of success, with your best charge nurse and CNAs, so you can learn from the experience before you take it out to the rest of the organization.
    2. Meet: Hold a meeting with staff who will be working consistently together. 
    3. Play to Staff's Strengths: Some staff are naturally better suited to caring for people with dementia while others will gravitate to short-term rehab residents. Consider these factors in making assignments.
    4. Rate: Ask team to rate the level of difficulty for each resident considering both physical and non-physical factors.
 ResidentPhysical
 Non-Physical Total
    
    
    

  1. Select: Have staff select assignments, making sure that all assignments have a fair mix of residents by degree of difficulty, and are well-matched based on which staff have the best relationships with individual residents. Defer to any resident preferences. CNAs can split a double room (i.e. each work with one of the residents that live in the room) if that provides a better match and balance.
  2. Trouble-Shoot and Team Up: Create team assignments. Many homes use team assignments in which one CNA is primary for a resident, and a second CNA is the primary back-up on the same shift. This is helpful for residents who require two people to care for them, either because of physical or non-physical difficulty. Regularly talk through any situations that staff find challenging and what support is needed from care partners and other clinicians to develop effective strategies. Involve all departments in creating strategies to address these challenges.
  3. Have consistent staff breaks, meal assistance: Extend consistency in all aspects of the resident's experience, including meal assistance. Schedule consistent breaks. Staff will appreciate having a set time for breaks.
  4. Build schedule for consistent back-ups. Make staff schedules by resident assignments so the same CNAs always back each other up. Encourage them to work together to work out schedule substitutions for each other so that residents have consistency. Develop a pool of consistent back-ups who know the residents they will care for. Have per diem staff work in the same area so they are familiar with the residents and co-workers. Orient all staff serving as back-up, and introduce the staff member serving as back up to the resident.
  5. Adjust as Resident Acuity and Population Changes: Residents come and go, and their needs change. Assignments will periodically need to be rebalanced. Use a team process to monitor workload and make adjustments as residents move out, move in, or experience changes in condition.
  • Maintain consistency when there are staff absences: This is the time to walk the talk. If one group of assignments is affected by an absence, do not compound it by taking another CNA away from her assignment to fill the gap. This will create two groups of residents without their consistent caregiver. Instead, have an "All Hands on Deck" approach where department heads and nurse managers help out at the busiest times. Ask food service and housekeeping staff to pitch in at meal times. Your actions show your dedication to consistent assignments. Have a longer huddle at the beginning of the shift to help any CNA who is serving as a substitute become familiar with the residents they are caring for.
  • Make sure your scheduling and hiring practices provide a structure for consistent assignments. Below are two examples of how administrators "work the math" so that hiring and scheduling supports consistency of assignments. In both examples, administrators schedule in a way that pairs up CNAs to provide a consistent assignment and a consistent back-up, and then hires into those resident assignments. We include these examples to help you consider how to make your own math work.


A 4 on 2 off schedule: David Farrell, LNHA, has used a 4 days on, 2 days off schedule for CNAs, in which 3 CNAs cover two resident assignments with the third CNA having a split assignment. Here's how it looks:

 CNAMON
TUE
WED
THU
FRI
SAT
SUN
 MON TUE WED THU FRI SAT SUN
 Mary 1 1 1 1 Off Off 1 1 1 1 Off Off 1 1
 Jane 2 2 Off Off 2 2 2 2 Off Off 2 2 2 2
 Beth Off Off 2 2 1 1 Off Off 2 2 1 2 Off Off

Mary has resident assignment 1, Jane has resident assignment 2, and Beth has two days with assignment 1 and two days with assignment 2.

David suggests you invite staff to try this approach for 3 months. They'll likely love it and not want to go back because it provides consistency in care and among co-workers. Staff have fewer weekends off than in a traditional alternate weekend schedule but they get real rest with 2 consecutive days off. Everyone works weekends, rather than having a separate, disconnected, weekend staff.

Full-time/Part-time Paired Assignments: Connie McDonald at Glenridge Living Community in Augusta, Maine, uses 32 hour full-time and 24 hour part-time positions to establish continuity in assignments, and then hires for open positions by resident assignments. Here's how:

  • Each 8 hour shift x 7 days = 56 hours. These 56 hours are shared by 2 CNAs, one at 32 hours and one at 24 hours; they alternate weekends
  • Note that 32 hours is full-time with benefits at this home
  • Hire into 32 hr or 24 hr positions by assignment
  • Two CNAs who share a group of residents can switch days if they need to.
  • CNAs who want to pick up extra hours become the back-up pool for any co-workers working on the same neighborhood/household/unit 
  • 24 hr CNAs are eligible to apply for 32 hour positions when they become available
Resident Assignments
32 hrs
Days
24 hrs
Days
32 hrs
PMs
24 hrs
PMs
32 hrs
Nights
 24 hrs
Nights
 GroupOne
 CNA 1
 CNA 2
 CNA 3
 CNA 4
 CNA 5
 CNA 6
 Group Two
 CNA 7
 CNA 8
 CNA 9
 CNA 10
 CNA 11
 CNA 12
 Group Three
 CNA 13
 CNA 14
 CNA 15
 CNA 16
 CNA 17
 CNA 18

  • Support Consistent Assignments with Other Organizational Practices: Consistent assignment works best when it is supported by:
    • Leadership to trouble-shoot problems and foster teamwork within/across shifts.
    • Collaboration among clinical and operations staff, CNAs and nurses to problem-solve difficulties and maximize opportunities, identify effective interventions and work together to implement them.
    • Active involvement by CNAs in care planning and in QI (see tip sheets). When staff know residents well, they use and support what they know about residents to achieve optimal outcomes.
CAUTIONS:
  1. If CNAs are not able to use and share what they know about residents in ways that allow them to respond to their residents' needs and preferences, they will find consistent assignments too painful. For example, if a resident really does not want to get up early or have a shower that day, but the CNAs have to push through the residents' discomfort because they are required to provide care within a rigid schedule, it will be hard to have a deep relationship with residents and yet disregard what they know residents need. It forces them to break the trust consistency of assignments establishes.
  2. Grief: When staff develop deep caring relationships, they experience grief when residents they have cared for die. Make sure to acknowledge and honor their loss.


RESOURCES:
Pioneer Network
  • Pioneer Network's website provides links to many affiliate organizations with resources to support homes in implementing consistent assignment.
  • Pioneer Network National Learning Collaborative Webinars 1, 2, 3, and 12 available for a fee for five on-demand viewings of each webinar. All 12 webinars are also available for purchase as a set of discs, at a discounted rate. To purchase viewings of one or more of the webinars, or the entire package of 12 webinars, go to Pioneer Network store.
  • This tip sheet is from the Pioneer Network Starter Toolkit: Engaging Staff in Individualizing Care. The entire toolkit, with additional tip sheets, starter exercise and resources, is available at www.pioneernetwork.net/Providers/StarterToolkit
Advancing Excellence in America's Nursing Homes www.nhqualitycampaign.org
Data collection can help determine whether the changes being made are working, and continue to work. The Advancing Excellence in America's Nursing Homes campaign has the tools and excel sheets for collecting data on consistent assignment (are we REALLY doing this?) and on Person Centered Care (are the wishes and preferences of the residents actually being delivered, and are the direct care workers attending and participating in the care plan meetings?), as well as other organizational and clinical goals. www.nhqualitycampaign.org

For a comprehensive set of resources on consistent assignment, go to the resource section of the Advancing Excellence website under the process goal for consistent assignments at www.nhqualitycampaign.org


B&F Consulting www.BandFConsultingInc.comShort videos available under free resources at www.BandFConsultingInc.com


Download Consistent Assignment Tip Sheet (PDF)

Starter Toolkit Home          Step One          Step Two          Step Three          Self-Assessment
Prepared by B&F Consulting for Pioneer Network's National Learning Collaborative on Using the MDS as the Engine for High Quality Individualized Care. Funded by The Retirement Research Foundation.
All webinars in this series are available as archived recordings at http://eo2.commpartners.com/users/pioneerlive/all_series.php.
In addition, the full series is available as packaged DVD set in the Pioneer Network store.