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How to Implement and Sustain Changes in Practice to Comply with Appendix PP Updates

As of October 24, 2022, nursing facilities must comply with updates the Centers for Medicare & Medicaid Services (CMS) made to the surveyor guidance in Appendix PP of the State Operations Manual. Although changes to facility policies and procedures have likely been initiated, changes to practice can be very difficult to operationalize, much less sustained. This article will explore three things the DNS can do to implement and sustain the changes in practice a facility must make to comply with Appendix PP updates.

Reduce the Hassle Factor

When designing a new way of doing things, the DNS should reduce “the hassle factor” as much as possible. Anything that gets in the way of doing the work expected by policy, procedure, or other standards of performance—such as duplication of work, confusing steps in a process, or unclear directions or assignments—creates unnecessary hassle for staff. For example, requiring the nurse to complete a new form in the electronic health record (EHR) in addition to completing old forms that could otherwise be eliminated impedes a new way of working. The nurse is being asked to complete an additional step and duplicate documentation, which requires more of his or her time and creates a hassle. When confronting such a situation, a nurse may choose to complete one form or parts of each form, but not both, due to the burden the additional hassle places on the workload. In contrast, when staff can consistently complete a process with five steps rather than ten, they will be more likely to achieve compliance.

To reduce the hassle factor and simplify changes in practice, involve staff who will be expected to perform work in a new way in the design of the change that is to be implemented. Staff have knowledge of what works, as well as what doesn’t. This insight is critical not only to streamlining steps, but also to fostering acceptance of changes needed for full implementation and sustainment.

Recognize that Change Is Personal

There are situations in which some staff may resist change. To implement changes that endure, the DNS must help staff through this resistance. When changes are initially discussed, staff, including leaders, usually first consider how the change will affect them personally. If they anticipate the change will be for the worse, they often react with skepticism or reluctance to change. Generally, this is because of concerns that the change will require them to do more work, be too difficult to achieve, or require skills they lack. For example, when the DNS and other facility leaders learned of the updates made to Appendix PP, their first responses were probably not excitement to conquer a new challenge; rather, it was likely feelings of frustration and being overwhelmed. Such hesitation may cause some staff to sabotage the change with negative talk to other teammates, trying to maintain the old way of doing things.

To overcome this, the DNS must remember that resistance to change is normal human behavior. Staff are not typically intentionally undermining the success of the facility or trying to be poor team players. This approach enables the DNS to connect with staff to learn why they are resistant to the change. The DNS should not ignore the behavior and hope the matter will resolve itself. Rather, the DNS should seek out staff who continue to resist the change and talk with them about what is wrong. Hearing why staff are struggling with the change gives the DNS an opportunity to clear up any misconceptions or misunderstandings. It also allows the DNS to work with staff to remove barriers they encounter that prevent them from doing things the change calls for. The DNS might open the conversation with the following examples.

  • I’ve asked you and the other CNAs to change how you (describe the change) to comply with a new regulatory requirement, but I know that is very difficult to do. Please tell me what is keeping you from doing (describe the change) in the new way?
  • You’re an important part of the team and an excellent nurse, so I need your input to figure out why (describe the change) to comply with a new regulatory requirement isn’t working for you and others.
  • I know that change can be really tough, especially when you’re already doing so much. Please help me understand what is keeping you from sticking with (describe the change) so that we can find a solution together.

Report Results

Imagine a person trying to lose weight because they have high cholesterol and are diabetic, but they never check their weight, cholesterol, or blood sugar levels. They don’t know if the changes they have made are working to produce the new desired results. Without this feedback, they may stop trying to lose weight. When asked to make a change, staff need to know why, but they also need feedback to know if what they are doing is working.

The DNS should have a method to measure if, in fact, the change has produced the desired result. For example, if the change requires staff to perform a procedure in a new way, the DNS might measure the number of staff who achieve a new level of competency to perform the procedure, but the DNS would also need to measure staff compliance performing the procedure in the new way. An additional measurement of the change can also include a resident outcome that is desired because of doing the procedure in the new way. After measuring these metrics, the DNS must share the results with staff in a way that highlights their contribution to the change. Essentially, staff need to know that because they put forth the effort to do things in a new way, they have made it possible for the facility to achieve the desired results.

To report results to staff in a way that is relevant to them, follow these four tips:

  1. Consider the target audience. What will resonate with them, or what will they be interested in knowing?
  2. Distinguish between what the condition was like before the change was made and what the results are after the change is made.
  3. Use visuals to complement numbers so staff can easily see the difference without having to interpret what the numbers mean.
  4. Connect what staff are doing, the new results, and how the change helps the residents and/or their teammates.

Creating and sustaining change are not easy, even when there is a clear requirement to do so, such as with the Appendix PP updates. To lead changes in practice and sustain improvements, the DNS must approach the situation by considering both processes and people. For more resources on the Appendix PP updates, regulatory compliance, and leading the nursing department, AAPACN offers the following resources:

Appendix PP Revisions in the State Operations Manual: Breaking Down Key Changes

The Road to Compliance Starts with a Gap Analysis

Survey Solutions on Demand Series

Nurse Leader Fundamentals

Director of Nursing Services–Certified

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