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Achieving Workforce Stability
andImproving Staff
SatisfactionDavid Farrell, MSW, LNHADirector of Organizational Development
SnF Management
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High Performing Nursing HomesThree Common Elements - Culture – person-directed care Workforce commitment Leadership practices
All three are interdependent
Grant, L. 2008
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Results are Interrelated Implement principles of culture change
Enhanced leadership practices Employee satisfaction Workforce stability
Low turnover, high retention, low absenteeism Consumer satisfaction Clinical outcomes Regulatory compliance Occupancy rate and mix
Grant, L. 2008
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The Opportunity - MHRC
Licensed administrator in California Four years studying Desire to implement Privilege
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June 2006
Nursing Department = 77% turnover rate CNAs = 94% turnover rate
$1,961 direct cost to replace one Average of 52 call-outs per month Long history of non-compliance
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June 2006
8 vacant FT nursing positions 1,200 hours of overtime per month Physical plant, grounds Average of 104 residents Culture
Lack of trust
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“I think that’d be good.”
Mr. Condee Watts
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The Impact of Leaders
Healthcare organizations Fragile ecosystems Leader’s actions influence:
Culture Relationships
Retention Clinical outcomes Quality of life
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Building Trust and Making a Statement Presence Asking and delivering Consistency Listening Speaking with conviction Painting the graffiti
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Turnover and VacanciesNationwide Turnover
RNs = 41% LPNs = 50% CNAs = 66%
110,000 Vacant FTEs 60,000 CNAs 24,100 LPNs 25,000 RNs AHCA, 2007
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Top Reasons for Leaving
Too many patients Pay was too low Not valued by the organization Dissatisfaction with supervisor Lack of opportunity to advance Could not provide quality care
Mickus, M., Luz, C., Hogan, A., “Voices from The Front.” 2004
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High Turnover = Low Quality Physical restraints Catheter use Contractures Pressure ulcers Psychoactive drug use Quality-of-Care deficiencies
Castle et al., 2005Castle, 2007
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Cost of Turnover Nationwide $2,500 per C.N.A. $2.5 billion nationwide Direct costs
Advertisement costsStaff time to interview, check references, etc.Drug screen, pre-employment physicalClassroom orientationUnit orientationCost of coverage of the vacant position
Seavey, D., “The Cost of Frontline Turnover in LTC.” 2004
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Satisfaction Surveys
Percentages to People Voices of people Perception is reality Selection bias myth Public relations force
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Power of Staff Satisfaction
Influences Turnover Relationships - co-workers, residents, families Quality of care Regulatory compliance
Castle et al., 2007
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Higher Employee Satisfaction Fewer resident falls Fewer pressure ulcers Fewer catheters Less nurse turnover and absenteeism Less CNA absenteeism Higher occupancy rates
MyInnerView, Inc. 2005
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Staff Satisfaction = Family Satisfaction Satisfied employees report:
Better supervision Better training Better work environments
Satisfied families report: Quality of life Quality of care Quality of service
Grant, L., “Organizational Predictors of Family Satisfaction in Nursing Homes.” Seniors Housing & Care Journal. 2004.
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Drivers of Workforce Satisfaction Management cares about employees Management listens to employees Help with job stress Fair evaluations Staff respect for residents Workplace is safe Supervisor cares about you as a person
MyInnerView, Inc. 2008
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Jim Collins
“Good is the enemy of great.”
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Confront the Brutal Facts Attribute of Level 5 Good decisions Distinctive process
Collected data Seek deep understanding Determine the truth
Right decisions self-evident
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Creating Climate Where the Truth is HeardFour key practices: From data to knowledge to action Conduct autopsies without blame Engage in dialogue, not coercion Lead with questions
Collins, J. 2001
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Uncover Root Causes
Identify all possible causes Focus is the “relationship” between Document all potential causes
Look for patterns in what staff do Keep asking why, when, how? Arrange these causes along “bones”
Vote on the most influential
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Cause and Effect Diagram
Policies
Environment
People
Equipment/Supplies
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Being an Administrator
Emotionally demanding “Look at my arm.”
Overwhelmed Buried by measures
Use power wisely Moving Mr. Watts
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Leadership PracticesTo demonstrate that management cares about
the staff: Implement evidence-based “best practices” Share clinical outcome data with staff Staff participate in identifying the “root-cause” Charts are audited to collect data - QI Commitment to person-directed care Quality is noticed - recognition
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Leadership PracticesTo demonstrate that management cares about
the staff: Staff schedules are honored Investments in staff satisfaction and safety Celebrate joyful events Staff are allowed to grieve Positive relationships are a priority
Facilitate relationship-building
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Theory of Relational Coordination
The effectiveness of care and service coordination is determined by the quality of communication among staff which depends on the quality of the underlying relationships
The quality of the relationships, in turn, reinforces the quality of their communication
Important in settings with high levels of task interdependence, uncertainty and time constraints
Gittell, et al, 2008
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Relational Coordination
Effectiveness Measured By:
Communication Frequent, timely, accurate, problem solving
Relationships Shared goals, shared knowledge, mutual respect
Gittell, et al, 2008
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Relational Coordination Works Significantly associated with both enhanced
resident quality of life and higher nursing assistant job satisfaction
Evident in homes on the culture change road
To foster relational coordination – select and train staff for relational competence and functional competence
Gittell, et al, 2008
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Relational Competence
The ability to see the larger process and how their work fits in
The ability to see the perspective of others, to empathize with their situation and respect the work they do even if it is of lower status
The ability to see how each individual’s work connects to others around the wants and needs of the residents
Gittell, et al, 2008
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People ParadigmFocus on Relationships
DEMING: Quality, the result, is a function of quality, the process Essential ingredients of the process:
Leadership and people Cannot improve complex, interdependent systems and
processes of care until you progressively improve interdependent, interpersonal relationships
Covey
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Quality is All About Relationships Between co-workers Across departments Between supervisors Frontline and supervisors Staff and residents Between residents Staff and resident’s family members
Eaton, S. 2001
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Characteristics of NH Service Work Necessity for internal service – Staff serve one another within the organization High degree of trust
Leaders with Social Intelligence – Create a positive climate for internal service Communicate – “it’s about we and me” Minimize stress Develop teamwork facilitation strategies
Peters,T., et al. 1982Bowers, B. 2001
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Teamwork Facilitation Strategies Consistent assignment Ample supplies at hand Resident transfer equipment Report between shifts Staffing configurations – Spa Aides Change employee name badges Build a sense of community
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CommunicationTHE BIG PICTURE: MISSION, VISION, VALUES Community meetings
Sincere reminders Provide staff with direction, purpose “Did you see their faces?”
Express high expectations Key values:
Respect Teamwork Caring and compassion
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Community Meetings Performance data
Human resource Clinical outcomes Business results
Benchmark and compare Celebrate positives
Employee and rookie of the month Raffles
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Winning is Contagious
Happy staff are productive staff
Productive staff are happy
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The “Golden Rule” Christianity
Do unto others, as you would have them do unto you Islam
No one of you is a believer, until he loves for his brother what he loves for himself
Judaism What you hate, do not do to anyone
Hinduism Do nothing to thy neighbor, which thou would not have them do to thee
Buddhism Hurt not others with that which pains thyself
Confucianism What you do not want done to thyself, do not do to others
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Culture is Improving
“I got your back.”Pam, CNA
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Leadership Visibility
Engage the heart of staff Rounds – nothing is more important
Meet and greet Observe – processes of care, handoffs Praise Build self-esteem Build stability and trust Build teamwork
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Five Key Questions To Ask Staff Relationship building
“How are your beautiful kids doing?” Focus on the positive
“What is working well today?” Positive feedback loop
“Is there anybody who has gone above and beyond the call of duty today?”
QI - systems focus “Is there anything we can do better?”
Needs “Do you have the tools and equipment to do your job?”
Studer, Q., “Hardwiring Excellence.” 2003
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Common Forms of Feedback Silence Negative Positive
Praise should be: Timely Specific Sincere Positive
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Thank You Cards Cards are powerful
Send them to staff members’ homes Birthday cards Anniversary cards Excellent attendance “I appreciate you” “I am glad you work for us. On behalf of the
residents, their families and your co-workers – Thank you.”
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Quint Studer
“The problem is not motivation. It is theways in which we unintentionally de-motivate employees.”
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“I See You”
Smile Make eye contact Use the other person’s name Hand them a granola bar Offer condolences
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Death and Dying
Shocked Condolences Packing up belongings Moments of silence
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Leadership PracticesTo demonstrate management listens to employees: Measure and act on satisfaction survey results Seek out individuals to “weigh-in” on decisions Conduct consistent, frequent rounds Create opportunities for individuals to lead Learning circles Community meetings, neighborhood meetings C.N.A.’s attend care conference meetings
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Communication - Key Changes Communication boards
Gentle, sincere reminders Weekly notes
No overhead paging Staffing organization Respectful rounds Weekly resident council meetings
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“What a Difference Management Makes” Paired 4 high v. 4 low turnover facilities Similarities 159 on-site interviews Areas that distinguished low v. 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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A Vicious Cycle
Turnover
Vacant Shifts
Eaton, Phase II Final Report, 2001
Stress
• Working short staffed
• Resentment
• Waiting
• Anxiety
• Errors
• Poor judgment
• Injuries
• Vacant Shifts
• Lack of trust
• Instability
• Poor outcomes
• Financial burden
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The Impact of Vacant Shifts
CNAs REPORT WHAT GETS NEGLECTED: Range of motion Hydration Feeding Bathing
Hawes, 2002
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Eaton’s Findings on SchedulingMost Common Reason for Termination Flexible in low turnover facilities
Allow for different start times Consider personal lives
Rigid in high turnover facilities In response to problems “Personal life is not my problem.”
Eaton, Phase II Final Report, 2001
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Who are the CNAs? Total 1.4 million 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
2007 Federal Poverty Rate = $20,650 30% - 35% receive food stamps
GAO, 2001National Clearinghouse on the Direct care Workforce, 2006BLS 2006, FHCEF 2007
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No-Fault Attendance Policy
No more qualifying absences Removes inequity No need for physician notes Absences are simply measured
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The “Stop Doing” List
Incentives to waive benefits Turning away FT applicants Sending staff home early Scheduling mistakes Rigid scheduling practices Discipline before intervention
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Scheduling Success
Allow staff to trade days Honor requests for time off Increase FT and decrease PRN and PT Indicate assignment on the master schedule Decrease shifts of unreliable staff Hire reliable people with relational and
technical competence
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First Who…Then What
Three simple truths - Key to adapting to change Motivation and management Wrong people
Collins, 2001
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Determining the “Right” People Rigorous process Focus on character traits
Example – Nucor
“Nucor built its’ entire system on the idea that you can teach farmers how to make steel, but you can’t teach a farmer work ethic to people who don’t have it in the first place.”
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Recruiting, Hiring and Selection Take the time to hire winners Enhance the pool of candidates Improve the screening process Provide a quality orientation
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Recruitment Process Problems Applicant is not greeted Receptionist in not aware of their role No one knows open positions Interviews are not conducted for walk-ins
“Come back Tuesday at 11:00”
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Interview Tips
High standards Ask the right questions
Open ended Behavior based
Ask to see their last performance evaluation Facility tour observations
Monitor interactions with people
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Careful Selection
Ask the right questions to screen for key character traits:
Maturity – self reflection Compassionate Sensitivity to others needs Self esteem Ability to communicate, learn Friendliness, 5 smiles
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What do you like to do with your free time?
“Well…I’m not much of a people person. I tend to stay at home and keep to myself.”
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MHRC Key Changes
Employee referral bonus Focus on referrals from your top 30% Structure of payout is the key
Peer Mentors Regular HR meetings Addressed poor teammates Hired good teammates
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“In a good to great transformation, people are not your most important asset. The right people are.”
Jim Collins
Never Stop Recruiting, Interviewing
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Care, Listen, Prevent Stress
OVER 130 DOCUMENTED CHANGES Some were small
New chairs for the nurses Softer toilet paper
Some were big Peer Mentor program Flu shots
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130 Changes: The Flywheel Effect
People Energized
Steps forward
Visible results
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MHRC
One Year Later
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May 2007
Ø vacant FT nursing positions Average daily occupancy rate jumped from 104
to 120 in March 2007 Quality mix increased by 30% 44 live indoor plants Overtime declined by 70% Resident’s at high risk with pressure ulcers
declined 55%
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May 2007
Nursing staff turnover declined from 77% to 28% CNA turnover rate declined from 94% to 31%
Saving $70,000 Call-outs declined by 40% Resident, family member and staff satisfaction
scores increased Best year of compliance Margin doubled
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Leadership’s Paradigm
“…these individuals were not fundamentally different kinds of people with different work ethics. They were, however, acting in a different organizational and human setting, being treated differently and being trusted and valued at a much higher level.”
Susan Eaton
Eaton, Phase II Final Report, 2001
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Formula for Individualized CareHigh satisfaction + Retention + Consistent
Assignment + High % of FT staff = Growth of Tacit Knowledge:
Lifting and turning safely Names of grandchildren Anticipating needs Reciprocity
Eaton, S., “Beyond Unloving Care.” 2000
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“No one has ever cared for me like you do.”
Mr. Condee Watts
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Contact Information
David J. Farrell, MSW, NHADirector of Organizational
DevelopmentSnF Management
[email protected](510) 725-7409