Service Design in a Skilled Nursing Facility
Improving breakdowns in communication and ownership of tasks among employees in a Skilled Nursing Facility during the COVID-19 pandemic.
Project Information
During the global COVID-19 pandemic I was finishing my master’s degree by completing a full-time internship in a skilled nursing facility (SNF). My daily tasks involved learning and performing the duties normally completed by my supervisor, the Director of Social Services. I worked directly with residents and employees of the two-floor facility to contribute, in whatever ways possible, to the residents’ health and happiness.
As an unpaid intern, I had the privilege of providing direct services and examining the systems within the facility with a unique ability to uncover insights and gain trust quickly (more elaboration on this below). I was a half-time social worker and a half-time “investigator.” I wanted to use my time in the facility to understand those service delivery factors that “worked” and make at least one positive impact based on what I discovered.
The SNF operated like a living, breathing organism with priorities that changed every day due to resident and employee needs, state and local laws and reporting requirements, and of course, the COVID-19 pandemic. These factors seemed to exacerbate both the strengths and weaknesses of service delivery in the SNF. It is normal for a social work intern to go through an adjustment period, adapting to the service delivery methods at their placement site but almost every aspect of healthcare delivery was impacted by the pandemic which created a challenging work environment. This project is not intended for the purpose of highlighting the shortcomings of my previous internship; instead, the insights I gained showed me just how competent my fellows were in coping with “unprecedented times.”
Details
Methods: Contextual Inquiry, Interviews, Service Blueprint, Policy & Procedure Review
Timeline: January 2021 - May 2021
Deliverables
This mini service design project resulted in:
A Social Work Service Blueprint
An updated Employee Contact & Role Description intended for all employees of the SNF
A searchable Social Work Guide intended for new social workers at the facility learning on the job
Short term and long term Resident Cheat Sheets that captured the most essential notes a new SW would need to have if a replacement SW was needed immediately
Why Think Like a Designer as a Social Work Intern?
I have been interested in design thinking for many years now but felt a new conviction when I read the NASW Standards for Social Work Services in Long-Term Care Facilities, which outlines duties for social workers in practice settings like SNFs. Essentially, social workers are responsible for thinking about service delivery at all levels:
“The social work director shall carry primary responsibility for social work services, including the development of organizational plans and administrative policies and procedures and coordination of services.”
“Establishment and administration of quality assurance procedures and modification of these procedures where appropriate”
As an intern, I had the privilege of 1) being trusted with direct service provision and 2) being expected to think like a service designer by examining the policies and procedures of the facility and asking questions about the larger healthcare system.
Initial Observations
A handful of repeating themes circled in my head early on during my work in the facility. Before I’d formally decided to pursue a project, I made notes about these observations:
The employees were determined to deliver great care to residents and there was a general “hustle” in the building; I saw a lot of motivation to perform well.
Challenging situations were quickly addressed and much seemed to happen behind the scenes to “put out small fires.”
Problems, while they were addressed at the surface level, seemed to come up several times and there was seldom a pause to address the root causes if it would take too much time out of a busy employee’s day.
The issues that came up seemed to be largely related to communication practices.
On top of what I observed around me, I noticed that I was having difficulty completing certain parts of my duties; I hypothesized that this was due to multiple factors and I wanted to understand them.
Problem Statements
Employees are vocalizing frustrations about lack of communication and ownership in several processes (like coordinating “courtyard visits” or scheduling off-campus medical appointments) and have commented that the same problems present themselves in different circumstances
As the social work intern learning to provide services during the COVID-19 pandemic, I am unsure of each employee’s role and how they can help me deliver the best services to residents
Research Plan
I created a research plan that would allow me to complete the requirements of my internship and gather insights about healthcare service delivery before graduating in May. I did not expect to deliver a cure-all solution for complex and multi-level issues. I did seek to provide some insight on how employees interacted with the resident journey and where there were opportunities for better cross-department collaboration.
I knew the project could address both problems; the research and insight generation itself would answer my own questions about employee roles and I was confident that articulating those insights would address some of the challenges for my team.
I used my privilege as an unpaid intern to conduct contextual inquiries and interviews that would inform the Service Blueprint, updated Employee Contact & Role Description, the Social Work Guide, and Resident Cheat Sheets. I also planned to use morning meetings, Medicare meetings, psychotropic medication audits, care plan meetings, and other scheduled interactions with residents and employees to inform my deliverables.
The distinctions made by the individuals in leadership positions helped me differentiate the common challenges in senior healthcare provision which “came with the job” and the challenges that were specific to this SNF.
Insights & Opportunities
Eventually my notes showed how the different employees interacted with each other, residents, and within their roles at the SNF. Although my contextual inquiry and interviews highlight areas for improvement, I was amazed at how each person I worked with assumed responsibility without question, valued the residents and their happiness, and generally gave their peers the benefit of the doubt. I worked with an amazing team.
Insights I drew from my contextual inquiries and interviews included:
Employees often said “That’s just the way we do it;” many tasks they completed each day were not documented formally or outlined in a specific procedure, especially if the change was related to COVID-19
Employees had to adapt to provide services during the COVID-19 pandemic; for example, the therapy department had moved out into an open dining area because their office was considered too small to be safe
The most salient concern they voiced to me was that others were not trained in how to complete the tasks these employees undertook daily - I observed that although the SNF had a dedicated employees who were willing to take ownership of tasks, these tasks (and how to complete them) were not outlined and informal. Many employees feared that others would not be able to replace them.
Employees noted that there is a different way they are to communicate about each task they complete during the day - modes of communication ranged from texting on personal phones, sending emails, passing a message in the hallway, bringing the subject up in a scheduled meeting or writing a clinical note.
One employee said: “We are not 3-deep, meaning, if I’m unable to complete this, there aren’t at least 2 other people here who know what the task is, why it’s important, how to do it… they wouldn’t know who to ask for help.”
Ideation
The combination of my daily duties, the contextual inquiries, and the scheduled interviews gave me enough insights to start producing the deliverables discussed above. I knew the Service Blueprint would serve the dual purpose of generating insights and being a final deliverable, so I started as soon as possible so I could answer my own follow-up questions with employees during work.
Deliverables
Service Blueprint
To review, one of the frustrations that employees voiced was lack of communication between employees and lack of clarity around who owned different tasks. I made a service blueprint to highlight potential breakdowns and areas for improvement in one common process, the courtyard visit.
It would be out of scope for this project to break down every process in the facility, but the courtyard visit was particularly interesting because it was the SNFs unique adaptation to allow residents to see their friends and families during the global pandemic. COVID-19 brought concerns for resident safety which, in turn limited their contact with loved ones. Employees of the SNF were obligated to comply with the larger continuing care retirement community campus policies as a whole, as well as ever-changing mandates and recommendations at the community, county, and state levels. The blueprint highlights the roles and communication methods for employees during each step of the visitor’s journey. If you’d like to take a closer look, you can open it in another tab here.
I wanted to demonstrate to SNF employees that their frustrations could be captured with documents like this, which would allow them to use their own expertise in senior service delivery to brainstorm solutions together.
A Service Blueprint I created to represent the interactions between policy, employees, residents and visitors.
The Service Blueprint revealed these insights:
There are some tasks for employees which could occur less often; for example, the SW is responsible for answering any questions about the courtyard visit policy. The blueprint helped to highlight that this could be prevented if a) reception had a clear understanding (and ability to educate families) on the policy or b) the original communication (or follow-up communications) highlighted the answers to frequently asked questions.
Reception and Social Work often take ownership of remedying oversights or mistakes, in part because ownership of tasks is not clearly communicated to visitors. Calls directed to the social worker could be avoided if visitors understood that the Administrative Assistant was the owner of this task.
Extra work is created when the receptionist has access to documents but no authority to educate families or make updates to calendars.
The blueprint (and my time in the facility) confirmed my suspicion that the most vulnerable time for a successful scheduling of a courtyard visit happened after 5pm. After 5pm the Social Worker leaves the “Family Visitation List” at the nurses station where it could be misplaced. Additionally, if a visitor calls to schedule their next courtyard visit after 5pm, the Administrative Assistant or Social Worker could miss their message and the visitor’s experience will be negatively impacted.
Social Work Guide
I created the Social Work Guide to address the issue that came up during research: if the Social Worker was absent, other employees or replacements would not know the full extent of their duties and service delivery would be negatively impacted. I created and printed this document using the various resources discussed above, with continuous support from my supervisor.
The document is organized according to the resident’s journey in the SNF, is keyword searchable, and specifically highlights all the areas where the social worker and resident paths cross. I am not able to share the document here, as the information is very specific to the SNF where I was interning, but the Table of Contents is visible below.
The full Table of Contents for the Social Work Guide I created
Updated Employee Contact & Role Description Document
One of my obsessions during my internship was knowing who did what. I felt frustrated because although I had a general knowledge of the services the different departments provided, I did not have a grip on those nuanced tasks which had unique ownership.
Some employees had left the SNF in the last year and our contact information was not up-to-date. Additionally, the document we had which did describe some of the daily tasks did not go into detail and I noticed that we all wasted time with emails and phone calls to figure out who could help us.
My type-A personality fueled this endeavor and I made a comprehensive, printable spreadsheet which outlined up-to-date contact information by department as well as task descriptions next to employee names with repeated, searchable keywords that didn’t leave anything to question. I confirmed the document and its accuracy with each department lead to make sure I was not spreading misinformation and finally made the document available to my peers. You can see an example of one of the entries below.
One entry example from the updated document I created.
Resident Cheat Sheets
Although I was amazed at the ownership my supervisor took in claiming certain jobs to be done in the facility, my research showed that the facility would not be prepared if she left her position, even temporarily. I wanted to make a small impact by creating updated, COVID-19 friendly “cheat sheets” that would reflect the statuses and needs of all residents for a new social worker in the position.
The cheat sheets were not “high-tech” but provided a simple short cut appropriate for the demands of the social worker’s tasks.
The content of the sheets was influenced by the conversations around resident care that I encountered in my work most often. My intention was to save future social workers’ time by eliminating the need to look something up in our patient care software since the social worker spends so much time walking around the SNF and away from the computer. You can see parts of the two printable cheat sheets below.
Summary
I was so grateful to have the opportunity to think like a social work intern and a service designer with this project. If I had the time, I would have loved to create a more in-depth service blueprint in collaboration with other employees and administration within the SNF, as well as facilitate a workshop to brainstorm possible solutions where breakdowns occurred.
I felt that the project deliverables I was able to hand off in a short period addressed my original goals because they were grounded in context and created with employees (current and future) in mind.
My investigation and articulation of insights strengthened my ability to deliver social work services in the following ways:
I made fast friends with the direct care employees because I valued their opinions and insight and asked them the same questions I asked of the employees with masters and doctorate degrees
I was attentive in the multiple meetings I participated in each day and felt engaged with my peers; my questions were targeted to complete my service delivery blueprint but ended up sparking productive conversations
Every clinical record, grievance report, employee lunch, or care plan meeting became a tool for me to use - I became accustomed to using each tool with the intent of uncovering insights about service delivery
I felt curious about all the levels of service delivery that affected my clients
I gained confidence in presenting my insights into digestible, usable formats specifically for employees on the job