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Staff Stability: The Foundation
for Quality ImprovementFaculty: Cathie Brady & Barbara Frank
April 12, 2012© B&F Consulting Inc. 2012
www.BandFConsultingInc.com
Indianapolis/Marion County Nursing Home Leadership Collaborative
Share Shamelessly:Any action taken since March mtg:
What you didHow you did it
Results Challenges
Lessons
© B & F Consulting, Inc. 2012 www.BandFConsultingInc.com
Goal for today
To help nursing homes achieve staff stability
© B & F Consulting, Inc. 2012 www.BandFConsultingInc.com
Surveys are only the tip of the iceberg
5% complain to management
45% complain to frontline staff
50% have a problem yet don’t complain TARP Studies
Satisfaction Surveys
• Voices of people • Perception is reality• Selection bias myth• Public relations force
Power of Staff Satisfaction
Influences• Turnover• Relationships - co-workers, residents, families• Quality of care• Regulatory compliance
Castle et al., 2007
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
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.
Satisfaction and DPH Inspection Results
• More “excellent” = fewer deficiencies• Less “excellent” = more deficiencies• Areas with the strongest correlation
– Resident grooming– Choices/preferences– Staff care and concern for residents– Recommendation to others
Tellis-Nayak, V. 2010
Drivers of Staff Engagement
• Management cares about employees• Management listens to employees• Help with job stress• Workplace safety• Adequate equipment and supplies• Supervisor cares about you as a person
MyInnerView, Inc. 2010
From Data to Knowledge to Action
Satisfaction Surveys:
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It may be tempting to ignore the information, when it’s not what
you expected.
Better to know what you’re dealing with than to be in the
dark about it.
It’s a gift
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Focus on the Ends of the Scale
In general:• Only 3% register strong dissatisfaction• Common tendency to check “satisfied”• Will not admit “very satisfied”• “Very satisfied” good predictors quality• Combine “Dissatisfied and “Very
Dissatisfied”
Tellis-Nayak, V., 2003
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Express appreciation and indicate commitment to
act• Community Meetings• Focus Groups• One-on-ones with staff• Dept heads talk with
their staff• Unit-based meetings• All shifts
Conduct autopsies without blame© B & F Consulting, Inc. 2012
www.BandFConsultingInc.com
Where to start
– Listen for quick wins– Build trust– Act fast – Visual– Symbolic – to let people
know you’re listening– Start with biggest irritants
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Unit-based
QI
All Hands
on Deck
Nurse Leadership
Training
New ADoN, Charge Nurse
Changes
From NH in Need to NH in the Lead
Adm. & DoN
Rounds
77% Occ. 98% Occ.
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Strongly Agree
Agree Neither agree
nor disagree
Disagree Strongly Disagree
Department heads
43% 57% 0% 0% 0%
Licensed Nurses
7% 13% 27% 13% 40%
Hourly Staff 17% 50% 0% 0% 33%
Management cares about me as a person
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Strongly Agree
Agree Neither agree
nor disagree
Disagree Strongly Disagree
Department heads
57% 43% 0% 0% 0%
Licensed Nurses
13% 13% 27% 20% 27%
Hourly Staff 33% 33% 0% 0% 33%
Teamwork in my department is good
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Findings from Focus Groups
• Daily Instability:– Vicious cycle: Turnover, absenteeism, care load too
heavy, high stress, harsh environment; contention• Leadership:
– Administrator in crisis mode (washing windows)– Front-line supervisors stretched thin, worn-out
• Feeling unappreciated and disengaged– Small raises, empty brag board, uncomfortable break
room, pizza but not enough supplies
“We were so busy plugging holes, that we weren’t stepping back to look at what was happening and what we could do about it.”
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• For call-ins:– Bonuses for taking last minute assignments– Lots of agency– Deals for doubles
• For turnover/hiring:– Hiring bonuses– Inexperienced new hires paid almost same as long
time staff– Piecemeal hiring to fill holes – Hiring “any warm body”– No time for orientation, right out on the floor, and
then right out the door
Operating in Crisis Mode Perpetuated the Crisis
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Composition of staff by work status:
Position FT PT Per diem Baylor
RN 27% 13% 47% 13%
LPN 55.5% 0% 18.5% 26%
CNA 48% 10% 9% 32%
What impact does this have
on staff stability and care continuity?
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Incentives• Bonus for last-minute assignment but no
reward for being reliable
Bonus Extra Per Hr. Annual
Last minute assignment
RN, LPN --$10
CNA -- $5
$360,000
Perfect attendance $0 $0
© B & F Consulting, Inc. 2012 www.BandFConsultingInc.com
Terminations by Length of Service
Position 1 day – 1 mo
1 – 3 mo
3 - 6 mo
6 mo – 1 yr
1–2 yr > 2 yr
RN 18% 18% 18% 27% 18% 0%
LPN 7% 13% 33% 27% 20% 0%
CNA 23% 30% 23% 16% 3% 5%
Other 8% 27% 39% 12% 14% 0%
© B & F Consulting, Inc. 2012 www.BandFConsultingInc.com
Incentives
Bonus Amt Offered Quarter - Annual
Sign-on bonus
Paid after 6 mos.
RN -- $2000
LPN -- $500
CNA -- $250
$12,500 - $50,000
Referral bonus
Paid after 6 mos.
RN, LPN --$1000
CNA -- $500
$6,000
Longevity $0 $0
Raises Average 2% $90,710
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Turnover Costs
• Includes higher hourly wage; sign-on bonus; filling vacant shift through agency or OT; recruitment; screening; training; orientation
Position Per Person Annual Cost
RN $4,899 $53,889
LPN $4,193 $62,895
CNA $3,207 $205,248
Other $2,692 $131,908
Total 2004 $453,940
© B & F Consulting, Inc. 2012 www.BandFConsultingInc.com
Instability vs. StabilityLast minute bonus $360,000
Perfect attendance $ 0
Baylors
$268,994
Raises @ 2%
$90,710
Sign-on bonuses
$50,000
Referral bonuses
$6,000
Turnover costs
$453,940
Longevity bonus
$0
Total:
$1,132,934
Total:
$96,710
© B & F Consulting, Inc. 2012 www.BandFConsultingInc.com
From Turnover to Stability
2005 2008
90% 28%
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Goal # 3: Improve attendance, percentage of shifts fully-staffed
What he did: • Track attendance by person, unit, shift, dept. • Analyze absences for patterns. • Communicate at dept. head meetings, put
record in paychecks, and discuss absences with employees.
• Recognize and reward units and individuals with good attendance.
• Support employees: adjust schedules, link to employee assistance services.
© B & F Consulting, Inc. 2012 www.BandFConsultingInc.com
Perfect Attendance Bonus
• Time Period
• Amount
• Pay-out options:– Lump sum
– Increase the hourly rate for next pay period
– Non-monetary (gas cards, grocery cards)
– Raffle
• Team rewards
© B & F Consulting, Inc. 2012 www.BandFConsultingInc.com
Staff Stability Tool-kitwww.nhqualitycampaign.org
Resources Goal One – Staff Stability
www.healthcentricadvisors.orgHATCh
Workforce© B & F Consulting, Inc. 2012
www.BandFConsultingInc.com
St. Joseph County Bridges Out of Poverty 117 N Lafayette South Bend, IN 46601Phone
(574) [email protected]
Identifying Behavior Change Intervention Points to Improve Staff Retention in Nursing Homes
by Mary Lescoe-Long and Michael Long
July 1998
Study sponsored by:Kansas Association
of Homes and Services for the Agingand
Aging Research Institute
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KAHSA Project Keeping Front-line Workers
in Long-term Care
Looked into causes of turnover, absenteeism and negativity and determined that:
• they are driven by administrative and organizational culture and the interpersonal practices and interactions in the nursing home workplace
© B & F Consulting, Inc. 2012 www.BandFConsultingInc.com
KAHSA LTC Workforce Project:• Intrinsic job satisfaction among CNAs was heightened
when their nurse supervisors possessed good interpersonal skills and promoted aide autonomy in the daily processes of care
• Turnover rates among CNAs were significantly lower in homes where nurse supervisors listened and responded to aides’ recommendations and involved aides in resident care plans
• Poor interpersonal skills and a lack of mutual empathy among CNAs and their nurse supervisors affected communication, interfered with informal teamwork and were a root cause of turnover for both aides and nurses (Lescoe-Long and Long)
© B & F Consulting, Inc. 2012 www.BandFConsultingInc.com
No significant learning happens without a significant relationship.
James Comer
Building Relationships
Bridges Out of Poverty
No significant work happens without a significant relationship.
James Comer
Building Relationships
Bridges Out of Poverty
Looked at What Affected Retention, Job Satisfaction and Performance
• Among 3 groups: – paraprofessionals – front-line supervisors– managers/department heads
• Found 3 types of factors in play:– Predisposing circumstances (personal history
and experience)– Organization-Based Reinforcers and Enablers
(policies, procedures, practices)– Interpersonal Reinforcers (factors arising from
interaction with others)
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Predisposing circumstances: Personal Backgrounds
Para-professionals Front-line Supervisors Managers and Dept. heads
Severely economically disadvantaged Profoundly socially disadvantaged Lack of causal link between personal effort and success
Not severely disadvantaged or significantly advantaged Lower middle class Boot-strap – causal link between personal effort and success
Economically and socially advantaged Middle class “Robust sense of self-confidence and personal causality”
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Middle Class Experience
Abstract
Stable
Predictable
Can anticipate, isolate and solve problemsSafety-oriented
Bridges Out of Poverty
Poverty Experience
Concrete
Unstable
Tyranny of the Moment
Problem-solvingHyper-vigilance
Bridges Out of Poverty
Effects of Predisposing Circumstances on Motivation and Needs
Para-professionals Front-line Supervisors Nurse Managers and Dept. heads
Used to external factors controlling circumstancesExtreme, but fragile, need for internal rewards of self-development, self-esteem, mastery
Used to relying on own problem-solving skills Internal rewards come from pride in being a nurse; have worked hard to earn respect
Used to own abilities producing good results Looking for an environment in which they can have meaningful accomplishments
© B & F Consulting, Inc. 2012 www.BandFConsultingInc.com
TYRANNY OF THE MOMENT
“The need to act overwhelms
any willingness people have to learn.”
Source: The Art of the Long View by Peter Schwartz
Bridges Out of Poverty
Predisposing circumstances: Training and preparation for job
Para-professionals Front-line Supervisors Nurse Managers and Dept. heads
Incongruity between job and how it is depicted in training
Under-prepared for residents’ behaviors and disabilities
LPNs had little training in managing people
Little training in how to manage people, especially people with such different skills and circumstances
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Consider the contrasts…
• Instability• Lack of predictability• Stressful; hyper-vigilant• Tyranny of the moment• Survival mode
– Feels like constant crisis
• Concrete problem solving• Outside the norm
• Stable• Predictable• Emphasis on safety• Future focused • Stress is managed
– Emphasis on quality of life• Abstract problem solving• Politics, consumerism,
education – all normed to you
Poverty Middle Class
Bridges Out of Poverty
Work is based on middle class rules
Must know two sets of hidden rules
Must operate in two sets of hidden rules
Many of the behaviors that employees bring to work are necessary to help them survive outside of work
Those who work with people in poverty People in poverty
Bridges Out of Poverty
Organization-Based Reinforcers and Enablers:Sources and Use of Power
Para-professionals Front-line Supervisors
Many people tell CNAs what to do, few ask what they think and see Little room for CNAs to exercise own judgment
When CNAs don’t exercise judgment and initiative, nurses respond by being more directive and controlling Nurses resent having to direct, having to do CNA’s job, resent CNAs “behavior”
© B & F Consulting, Inc. 2012 www.BandFConsultingInc.com
Organization-Based Reinforcers and Enablers:Sources and Use of Power
• Without sanctioned avenues for power or control, left to informal uses of power including controlling or negative behaviors to co-workers or supervisors
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Organizational Reinforcers and Enablers – Hidden Sanctions
Para-professionals
Reliable aides fill shortages, take up slack, have greater burden
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Interpersonal ReinforcersLack of Mutual Empathy
Para-professionals Front-line Supervisors
Nurse Managers and Dept. heads
Most supervisors uninformed about what it means to come from and live in profoundly disadvantaged circumstances
Misunderstand source of CNA’s behavior; come to wrong conclusions about CNA’s motives and character; resent them; have decreasing tolerance for perceived bad behavior
Sympathetic but not empathetic to CNA’s personal circumstances or interpersonal dynamics’ impact
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Source: Meaningful Differences in the Everyday Experience of Young American Children (1995) by Betty Hart & Todd R. Risley
Number of words exposed to
Economic group Affirmations (strokes)
Prohibitions (discounts)
10 million words Welfare 1 for every 2
20 million words Working class 2 for every 1
30 million words Professional 5 for every 1
Research About Language in Children Ages 1 to 3
in Stable Households by Economic Group
Bridges Out of Poverty
Interpersonal ReinforcersMutual Lack of Interpersonal Skills
Para-professionals Front-line Supervisors Nurse Managers and Dept. heads
Meet stressful situations with conflict generating responses
Clinical education gives nurses excellent communication skills with patients but not with employees Respond to stress in ways detrimental to good employee relationships
Have good interpersonal skills but lack skills in how to deal with others who don’t have good interpersonal skills
© B & F Consulting, Inc. 2012 www.BandFConsultingInc.com
““Life is very rough for many who work in Life is very rough for many who work in long-term care. I want their workplace to be long-term care. I want their workplace to be
a place of stability and success for them.a place of stability and success for them.”” Connie McDonald, Administrator
Maine General Nursing and Rehab at Glenridge, Augusta, Maine
© B & F Consulting, Inc. 2012 www.BandFConsultingInc.com
No significant workhappens without a significant relationship.
James Comer
Building Relationships
Bridges Out of Poverty
Lescoe-LongKey Findings and Recommendations
• Go beyond sympathy to have mutual empathy, in word and deed
• Bring same level of caring for clients into caring for staff
• Develop interpersonal skills to support relationships
• Build in systems that reinforce caring for staff and teamwork – huddles and hand-offs
© B & F Consulting, Inc. 2012 www.BandFConsultingInc.com
My InnerView Priority Items
CNAs
1 Help with job stressand burnout
2 Management listens
3 Management cares
4 Supervisor appreciates
4 Adequate equipment/supplies
NURSES
1 Help with job stressand burnout
2 Management listens
2 Management cares
4 Training to deal with difficult residents
4 Training to deal with difficult family members
© B & F Consulting, Inc. 2012 www.BandFConsultingInc.com
Team PlanningGo to Tables with your co-
workers• Area you’ll focus on:• Goals• Preliminary action steps• Who needs to be involved• How will you know you’ve improved
© B & F Consulting, Inc. 2012 www.BandFConsultingInc.com
Contact Information:
Cathie [email protected]
Barbara [email protected]
www.BandFConsultingInc.comand
www.BandFConsultingInc.com/WhatYouDoMatters
© B&F Consulting Inc. 2012 www.BandFConsultingInc.com