Reducing employee turnover with a holistic focus

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Reducing employee turnover with a holistic focus

• Jeanie Mamula, MSHA, CPHQ
• Director, Clinical Quality Improvement
• April 17, 2007

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Disclaimer

• Much of the work presented here was developed
  by Quality Partners of Rhode Island, the Rhode
  Island QIO.
• Catholic Health Initiatives was involved in
  their collaborative to reduce workforce retention
  in 2004-05.

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Background

• (The following slides are excerpted from a
  presentation by David Farrell, Quality Partners
  of Rhode Island)

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Why Is Retention Important?

• Satisfaction
• Quality of Life
• Quality of Care
• Financial

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Institute of Medicine

• Quality of care depends on the performance of the
  workforce
• Staffing levels are necessary
• Other key factors
• Education
• Supervision
• Job satisfaction
• Turnover
• Leadership
• Organizational culture

Wunderlich G. S., Improving the Quality of Long
Term Care, IOM, 2000
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Turnover and Vacancies

• Nationwide
• Turnover
• RNs 50
• LPNs 50
• CNAs 70
• 96,000 Vacant FTEs
• 52,000 CNAs
• 25,100 LPNs
• 13,900 RNs

AHCA, 2002
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SNF Statistics

• 16,500 SNFs
• 15,000 free-standing
• 75 for-profit
• Top 10 chains dropped 20 of their beds
• 1.8 million beds
• Average occupancy 86.6
• Serve 3.5 million per year
• Total U.S. spending 99 billion in 2001

CMS Healthcare Industry Market Update 2002
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SNF Statistics continued

• Net profit margin for-profits 2.2
• Net profit margin of non-profits .3
• Average Medicaid rate 115/day
• 9.78 less than avg. daily costs
• Labor accounts for 60
• of total census / of revenue
• Private pay 20 / 30
• Medicare 10 / 25
• Medicaid 70 / 45

CMS Healthcare Industry Market Update 2002
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Who are the C.N.A.s

• Deliver 80 of hands-on care
• 90 are women
• 50 are non-white
• Single mothers aged 25-54
• 50 are near or below the poverty line

GAO, 2001
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Existing Explanations (wrong) for High Turnover

• Frontline workers
• Do not have a good work ethic
• Are not reliable
• Have little support at home
• Have a lower commitment
• Will leave for 10 cents more per hour
• If we could pay them more they would stay

Jervis, 2002
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State Wage Pass-Through Legislation

• Has it make a difference?
• 21 states passed legislation
• Analysis of 10 states
• 3 states reported no impact
• 3 could not determine
• 4 reported marginal positive impact
• Data does not support efficacy
• Simply a first step

PHI, Workforce Strategies No. 1, 2003
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Top Reasons for Leaving

• Too many patients
• Not valued by the organization
• Dissatisfaction with supervisor
• Could not provide quality care
• Unsafe working conditions
• Not enough support from peers

Mickus, M., Luz, C., Hogan, A., Voices from The
Front. 2004
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Very Satisfied Staff
In Three Groups of Facilities
Tellis-Nayak, V., Customer Satisfaction in Long
Term Care A Guide to Assessing Quality AHCA,
2003
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Agency Staff Usage and Staff Satisfaction In
Three Groups of Facilities
Tellis-Nayak, V., Customer Satisfaction in Long
Term Care A Guide to Assessing Quality AHCA,
2003
Very Satisfied Staff
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Survey Deficiencies Compared to State Average and
Staff Satisfaction in Three Groups of Facilities
Very Satisfied Staff
Tellis-Nayak, V., Customer Satisfaction in Long
Term Care A Guide to Assessing Quality AHCA,
2003
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QI Index and Staff Satisfaction In Three Groups
of Facilities
Very Satisfied Staff
Tellis-Nayak, V., Customer Satisfaction in Long
Term Care A Guide to Assessing Quality AHCA,
2003
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A Vicious Cycle
Working Short
Turnover/Absent
Stress
Eaton, Phase II Final Report, 2001
FP-05b
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What a Difference Management Makes

• Paired 4 high vs. 4 low turnover facilities
• Similarities
• 159 on-site interviews
• Areas that distinguished low vs. high
• Leadership visibility
• Cared for caregivers
• Orientation, career ladders, scheduling
• Primary assignments
• Rarely worked short

Eaton, Phase II Final Report, 2001
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The Impact of Leaders

• Nursing homes a short history
• Research-based evidence
• Administrator and DON influence
• Leaders actions
• Culture
• Retention
• Quality outcomes

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The CMS-QIO Collaborative
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Holistic Approach to Transformational Change
HATCh J
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Four Facets of the Improvement Strategy
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Building a High Retention Culture
Quality of Elders Care/Life
QUALITY OF WORK LIFE
P R O C E S S I M P R O V
M E A S U R E M E N T
T R A I N I N G
E M P O W E R M E N T
R E C O G N I T I O N
C O M M U N I C A T I O N
L E A D E R S H I P D E V.
R E C R U I T M E N T
COMMITMENT
VALUES
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Major Change Concepts

• Accessible and well-skilled leadership and
  management
• Deep personal value and respect of all staff,
  elders, and families
• Basic, high-performance human resource policies
• Thoughtful, effective, motivational work
  organization and care practices
• Adequate staffing ratios and support for high
  quality care

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Most-Adopted Changes During National Collaborative

• Improved hiring and orientation processes
• Consistent staffing
• Enhance workplace environment
• Provide more opportunities/focus on relationships
• Move to neighborhood concepts
• Changes in meals, bathing
• Leadership training for RN supervisors
• Increase in self-directed teams

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• So What Did CHI Do?

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CMS-Sponsored Collaborative

• CMS awarded a contract to Quality Partners of
  Rhode Island to lead the collaborative
• CHI was asked to partner with CMS as the only
  faith-based, not-for-profit corporation
• We brought in 6 nursing homes and 2 assisted
  living facilities
• The collaborative lasted one year, from December
  2004 to November 2005

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Process

• Four national meetings were held during the year
  3 training sessions, and one outcomes congress
• CHI staff attended the national meetings, then
  convened local meetings with the group of nursing
  facilities
• Each facility sent 1-3 representatives, who
  listened, then developed their own action plans
  see following examples

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Process

• Learning sessions centered on
• Current state of nursing facilities
• Homelessness
• High Turnover
• Institutional care
• Assessing our own facilities
• No assumptions
• Facing brutal facts
• Learning about Culture Change
• Focus on relationships
• Focus on Human Resource Policies

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Building a High Retention Culture
Quality of Elders Care/Life
QUALITY OF WORK LIFE
P R O C E S S I M P R O V
M E A S U R E M E N T
T R A I N I N G
E M P O W E R M E N T
R E C O G N I T I O N
C O M M U N I C A T I O N
L E A D E R S H I P D E V.
R E C R U I T M E N T
COMMITMENT
VALUES
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Recruitment

• Encourage promotion from within
• Establish hiring team
• Team interviews
• Senior VP set goal to become workplace of
  choice
• Red Carpet Program for new hires
• Personal greeting on first day spend time
  introducing
• Recognition ribbon attached to nametag all staff
  know this person needs welcoming, more assistance
  than others

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Leadership Development

• Established a Mastery Development Plan
• Identify strengths/weaknesses and plan
  development in weak areas
• Focus on individual, team, facility, organization
  intentions
• Align intentions
• Enhance and increase staff/leadership
  interactions
• Involve all employees in VIA (Values Impact
  Analysis) decision-making process

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Communication

• Consistent visibility/open door policy at all
  facilities
• Ongoing, structured leadership-staff interviews
• Staff-driven recognition program

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Recognition

• Family/Resident bulletin board for positive
  feedback
• Safety Bingo
• Personalized celebrations of important events
  (birthdays, anniversaries, etc.)
• Periodic celebration meals

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Empowerment

• Establish peer mentoring, especially among CNAs
• More self-directed teams
• More opportunities for training, advancement
• CNA participation in care planning
• Flexible schedules

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Training

• Re-vamped orientation for new employees
• Inter-facility groups established to
  problem-solve together, share best practices
• Allow staff to experience resident for a day
• CNA mentor becomes friend, resource, preceptor
  tries to resolve issues before they become
  problems

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Measurement

• Staff turnover
• Cost of turnover
• Resident satisfaction
• Employee satisfaction

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Process Improvement

• Re-visit how resident deaths are acknowledged
• Consistent staffing
• Resident meal service
• Resident bathing procedures
• Environmental changes

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Collaborative Homework

• Each facility had eight assignments, which
  ultimately drove future changes
• Review the cycle of turnover
• Interview staff regarding their feelings about
  understaffing
• Review costs of turnover, retention efforts, etc.
• Review retention incentives and how theyve
  worked (or not)
• Assess facility against high turnover/low
  turnover attributes
• Interview staff about their motivation to work
  (why did they choose healthcare, nursing homes?)
• Chart longevity in facility/talk to new and old
  staff about coming into facility as a new
  hire/observe whats really going on/review
  orientation practices
• Observe what happens during mealtime/interview
  staff about scheduling, relationships with
  residents, co-workers, supervisors

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Major Ahas during process

• New hires largely ignored or poorly treated
  Thrown to the wolves
• Every facility had a large number of new hires
  that left in less than 7 days
• Staff felt they werent allowed or didnt have
  time to develop relationships with residents
• Staff had no pride in the facility

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Actual changes made

• Employee lounges redecorated
• CNA councils created for problem-solving,
  attendance improvement, etc.
• New hiring processes hire for fit as much as
  skills and experience extended interviews
• Orientation and ongoing education schedules
  changed so staff didnt have to attend outside
  working hours
• Safety bingo promotes decrease in employee
  injuries

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Actual changes made, cont.

• Reflection rooms created for staff
• Created a soul space bulletin board where staff
  share family pictures, mementos
• Encourage staff to attend funerals of residents.
  Red Rose notification of death, memorial
  services held at facility for staff and families.
• Red Carpet welcoming program for new residents.

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Actual changes made, cont.

• Residents allowed to rise, breakfast on their
  desired schedule, more choices, some prepared on
  demand
• More special meals planned by residents
• Facilities beginning to explore neighborhood
  concepts
• Consistent staffing implemented
• Bath rooms redecorated to be more home-like, more
  like spas
• Re-focused resident activities to meet resident
  needs/desires

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Some befores and afters
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Before and After
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After
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Violas Story

• Viola before
• Kept to herself, did not initiate conversation
• Occasional one word response
• Appeared very demented and stoic without much
  expression
• Severely contracted hands, made no attempts to
  feed herself
• Slowly losing weight

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Violas Story, cont.

• Viola after
• This is the best oatmeal I have ever eaten.
• Initiates conversation with staff and peers
• Able to drink from a cup
• Weight has stabilized
• Even more amazing she is now able to walk
• She smiles more and appears happier

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This is a wonderful thing you are doing for us.
If we change the quality of one persons life
we have taken a step forward
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Results Two Years Later

• Most of the facilities have the processes still
  in place after two years
• At least three have gone forward with more
  culture change ideas
• One facility had gone more than 12 months with no
  turnover recent turnover due to promotions,
  moving none due to dissatisfaction
• One facility is working with their local AHSA
  organization to help the state develop their
  Pay-for-Performance program they are trying to
  build elements of culture change into the
  criteria

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Results Two Years Later

• Two facilities have seen CNAs advance their
  education to LPN, one of those is now working
  toward RN
• Two facilities have had RNs leave for other
  nursing homes and come right back
• Two facilities host CNA training classes, and
  have been able to hire best of class
• Two facilities have increased occupancy rates
• All facilities report much better relationships
  between leadership and staff

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CHIs Next Steps

• New collaborative effort going on with one
  free-standing nursing home
• Bi-monthly calls with DONs of all CHI facilities
  are increasingly focused on workforce-retention,
  culture change
• Intranet website established where nursing
  facilities can find, share best practices

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Contact information

• Jeanie Mamula MSHA, CPHQ
• Director, Clinical Quality Improvement
• Catholic Health Initiatives
• 303-383-2681
• JeanieMamula_at_catholichealth.net

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Questions