​​If one thinks of a nursing facility as a fragile ecosystem in which each policy, department, staff member, and patient is systematically connected, it is easy to see how a seemingly small change might affect the whole.

Such is the case with consistent assignment, an alternative staffing model that, when put into practice, has been shown to significantly impact such factors as staff retention, resident and family satisfaction, and even clinical outcomes.

Specifically, the term consistent assignment refers to a staffing model in which patients are cared for each and every day by the same staff members, rather than having the clinical staff rotate its assignments from one group of patients to another. The implementation of consistent assignment is the eighth and final goal in the Advancing Excellence in America’s Nursing Homes (AE) campaign, and it may well be the linchpin for the entire initiative.

Recent Achievements

By way of example, a large urban nursing facility in California implemented more than 130 changes in its quest to move from an institutional care model to an individualized, or person-centered, model of care.

But of all the changes made, according to the facility’s administrator, it was the switch to consistent assignment in the first month of the process that helped pave the way for a host of positive results. 
“We built off of relationships that developed and created a sense of community,” said the administrator. As a result, he said, over the past year:
  • The annualized turnover rate for certified nurse assistants (CNAs) declined from 94 percent to 38 percent;
  • The turnover rate for licensed nursing staff declined from 43 percent to 11 percent;
  • The nursing staff only worked with less than the optimal number of staff (“short staffed”) on 10 occasions in 280 days—less than a 3 percent chance a neighborhood would work understaffed on any given day;
  • Nursing department staff call-offs declined by 40 percent;
  • Patients at high risk with pressure ulcers dropped from 25 percent to 11 percent;
  • Residents at low risk with pressure ulcers declined from 4.5 percent to 0 percent; and
  • The overall occupancy rate of the facility increased from 82 percent to 94 percent.
“I am proud of these numbers,” said the administrator. “These percentages are people. By creating a better quality of work life for our staff, we enhanced the residents’ quality of life, and we gave their families greater peace of mind.”
This is by no means an isolated case. In fact, facilities that change from rotating staff assignment after a period of time to consistent assignment have reported an impact on key quality indicators that is profoundly positive. Studies have documented a solid evidence base that consistent assignment lowers turnover (AE Goal 7), improves resident and family satisfaction scores (AE Goal 6), and improves the ability of staff to recognize and address clinical issues at their earliest, most preventable stages (AE Goals 1 – 4).

Why It Works

There is nothing particularly complex or magical about consistent assignment. The key is in allowing caring relationships between staff and patients to develop and flourish over time. In long term care, the work has an inherent meaning for people attracted to caring for others. Yet, management systems such as rotating assignment can interfere with, rather than support, the caring connection with patients that draws people to caregiving work.
Fundamentally, the implementation of consistent staff assignment creates work situations that build on the intrinsic motivation of many staff members—the opportunity to form and sustain close relationships with the patients.
In her article, “Beyond ‘unloving Care’: Linking Human Resource Management and Patient Care Quality in Nursing Homes” (International Journal of Human Resource Management, June 11, 2000), researcher Susan Eaton notes that staff retention is all about relationships. Good relationships are at the heart of good work environments, she says, including relationships with co-workers; across departments; with supervisors; with the organization; and, in the case of long term care facilities, with patients and their families.

Further Confirmation

The National Citizens Coalition for Nursing Home Reform has further confirmed that patients and their families consider the quality of the relationships they have with their frontline caregivers as more valuable than the quality of the medical care and the quality of the food that’s served at the facility. Relationships are the cornerstone of individualized, person-directed care.
Researcher Mary Lescoe-Long studied the family members’ perspective in six Kansas nursing facilities and found that family members were keenly aware of staff members who displayed personal empathy toward their loved ones. She discovered that family members wanted the CNAs and nurses to “know my mom as a person.” And when family members see and feel that personal empathy, it gives them “peace of mind.”
When staff care for the same people daily, they become familiar with their needs and desires, and their work is easier because they are not spending extra time getting to know what each patient prefers.
Knowing the patients’ routines and preferences, as well as their family members, can only come about through consistent personal exposure over time.
As staff members remember the patients’ routines, they are likely to be praised by more satisfied patients and families, thus enhancing their own self esteem and, perhaps, lowering their thoughts of leaving a facility. Therefore, consistent assignment fuels success in AE Goal 6 (satisfaction) and Goal 7 (staff turnover).

Better Patient Care

Long term care researcher Lou Burgio compared two nursing facilities with consistent assignments to two nursing facilities that employ rotating assignments. Patients living in consistent assignment facilities received significantly higher ratings on patient grooming and personal appearance than patients in rotating assignment facilities.
In addition, Burgio found that CNAs working in consistent assignment facilities reported higher job satisfaction than those working in rotating assignment facilities.
The Centers for Medicare & Medicaid Services (CMS) recognizes that consistent assignment is key to individualized care.
In a recent CMS surveyor training broadcast, staff members at a facility that uses consistent assignment talked about how they are able to notice and treat small red spots before they become pressure ulcers (AE Goal 1) and how they are able to recognize and address pain in their patients because they know them so well (Goal 3). This is the case even among short-stay patients because the facility is now geared toward establishing solid relationships as soon as a new patient is admitted (Goal 4).
A geriatric psychiatrist in this training broadcast described how, through individualized care, staff know their patients better and can use alternative means of preventing falls and addressing challenging behaviors, thus
reducing their use of restraints (AE Goal 2).
Many of the culture change pioneers contend that individualized care depends on having consistent assignment in place.
Leaders who implement systems that foster and support caring relationships between patients and staff have an easier time recognizing and addressing clinical issues while they are still small. Their staffs feel a greater sense of satisfaction and responsibility, as reflected in a higher rate of retention. The system of consistent assignment allows staff to develop close relationships with patients they are caring for and with co-workers they are providing care with.
Clearly, the system of consistent assignment, backed by research-based evidence, is the foundation for individualized care and a first step toward a more stable workforce, improved clinical care, and enhanced quality of life for patients process.
David Farrell, MSW, NHA, is director, Care Continuum Lumetra (California’s quality improvement organization), San Francisco, and a member of the American Health Care Association’s QI Committee. Barbara Frank, MPA, is with B&F Consulting, Warren, R.I.