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AE-5 Consistent Assignment, Satisfaction and Turnover: What’s the Connection David Farrell, MSW, LNHA Director, AE-5 Consistent Assignment, Satisfaction and Turnover: What’s the Connection David Farrell, MSW, LNHA Director, Care Continuum

The Opportunity • Licensed administrator in California • Four years studying • Desire to The Opportunity • Licensed administrator in California • Four years studying • Desire to implement • Privilege

Baseline Measures Medical Hill Rehabilitation Center (MHRC) Oakland, California Baseline Measures Medical Hill Rehabilitation Center (MHRC) Oakland, California

June 2006 • 8 vacant FT nursing positions • 1, 200 hours of overtime June 2006 • 8 vacant FT nursing positions • 1, 200 hours of overtime per month • Physical plant, grounds • Average of 104 residents, 10 Medicare • Culture 4 Lack of trust

June 2006 • Nursing Department = 77% turnover rate • CNAs = 94% turnover June 2006 • Nursing Department = 77% turnover rate • CNAs = 94% turnover rate 4 $1, 961 direct cost to replace one • Average of 52 call-outs per month • 5. 5% in-house PU rate • 14 falls per month • Good survey - 8 deficiencies in May 2006

“I think that’d be good. ” Mr. Condee Watts “I think that’d be good. ” Mr. Condee Watts

Principles NATURAL LAWS OR FUNDAMENTAL TRUTHS: • Universal, timeless • Produce predictable outcomes • Principles NATURAL LAWS OR FUNDAMENTAL TRUTHS: • Universal, timeless • Produce predictable outcomes • External to ourselves • Operate with or without our understanding FP-06

The Impact of Leaders Healthcare organizations • Fragile ecosystems • Leader’s actions influence: 4 The Impact of Leaders Healthcare organizations • Fragile ecosystems • Leader’s actions influence: 4 Culture – Relationships 4 Retention 4 Clinical outcomes 4 Quality of life

What Matters Most to Employees • Management cares about employees • Management listens to What Matters Most to Employees • Management cares about employees • Management listens to employees • Help with stress and burnout • Workplace is safe • Supervisor cares about you as a person • Supervisor shows appreciation My. Inner. View, Inc. 2005

Myths High Turnover FRONTLINE WORKERS: • Do not have a good work ethic • Myths 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

Top Reasons for Leaving • Too many patients • Pay was too low • 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

“What a Difference Management Makes” • Paired 4 high v. 4 low turnover facilities “What a Difference Management Makes” • Paired 4 high v. 4 low turnover facilities • Similarities • 159 on-site interviews • Areas that distinguished low v. high 4 Leadership visibility 4 Cared for caregivers 4 Orientation, career ladders, scheduling 4 Primary assignments 4 Rarely worked short Eaton, Phase II Final Report, 2001

A Vicious Cycle Vacant Shifts • Financial burden • Instability • Working short staffed A Vicious Cycle Vacant Shifts • Financial burden • Instability • Working short staffed • Resentment • Poor outcomes • Waiting • Lack of trust • Anxiety • Vacant Shifts Turnover Stress • Errors • Poor judgment • Injuries Eaton, Phase II Final Report, 2001 FP-05 b

The Impact of Vacant Shifts CNAs REPORT WHAT GETS NEGLECTED: • Range of motion The Impact of Vacant Shifts CNAs REPORT WHAT GETS NEGLECTED: • Range of motion • Hydration • Feeding • Bathing Hawes, 2002

Instability = Poor Outcomes INTERRUPTS CONTINUITY: • Incontinence • Facility acquired pressures sores • Instability = Poor Outcomes INTERRUPTS CONTINUITY: • Incontinence • Facility acquired pressures sores • Urinary tract infections • Falls and fractures Dresser et. al. 1999; Harrington et. al. 1999

2006 National Survey of NH Staff Satisfaction • Completed by 106, 858 employees in 2006 National Survey of NH Staff Satisfaction • Completed by 106, 858 employees in 1, 933 SNFs • Overall satisfaction = 4 16% excellent 4 39% fair/poor • Scores decrease as tenure increases • Priorities 4 “Help reduce the stress, listen, care about and appreciate me, and please make sure I have the supplies I need. ” My Inner. View, 2007

Staff Satisfaction = Family Satisfaction • Satisfied employees report: 4 Better supervision 4 Better Staff Satisfaction = Family Satisfaction • Satisfied employees report: 4 Better supervision 4 Better training 4 Better work environments • Satisfied families report: 4 Quality of life 4 Quality of care 4 Quality of service Grant, L. , “Organizational Predictors of Family Satisfaction in Nursing Homes. ” Seniors Housing & Care Journal. 2004.

Studies have repeatedly confirmed that residents and their family members value the quality of Studies have repeatedly confirmed that residents and their family members value the quality of the relationships they have with the frontline caregivers higher that the quality of the medical care and the quality of the food. NCCNHR, PHI

MHRC Principles Into Practice • Presence • Asking and delivering • Consistency • Listening MHRC Principles Into Practice • Presence • Asking and delivering • Consistency • Listening • Speaking with conviction • Physical labor

MHRC Changes OVER 130 DOCUMENTED CHANGES • Some were small 4 New chairs for MHRC Changes OVER 130 DOCUMENTED CHANGES • Some were small 4 New chairs for the nurses 4 Softer toilet paper • Some were big 4 Peer Mentor program 4 Flu shots

Science of Change: Psychology of Change: Quality Improvement Practices Relationship-Based Practices • Evidence-based solutions Science of Change: Psychology of Change: Quality Improvement Practices Relationship-Based Practices • Evidence-based solutions • Small pilot-tests • Evaluation and re-evaluation • Mid-course adjustments • PDSA Cycles • Build on intrinsic motivation • Holistic approach • Start where people are • Build capacity for change • Trust, trustworthiness

Being an Administrator • Emotionally demanding 4 “Look at my arm. ” • Overwhelmed Being an Administrator • Emotionally demanding 4 “Look at my arm. ” • Overwhelmed 4 Buried by measures • Use power wisely 4 Moving Mr. Watts

People Paradigm Focus on Relationships DEMING: • Quality, the result, is a function of People Paradigm Focus on Relationships DEMING: • Quality, the result, is a function of quality, the process • Essential ingredients of the process: 4 Leadership and people • Cannot improve interdependent systems and processes until you progressively improve interdependent, interpersonal relationships

Retention is All About Relationships Low turnover facility leaders take measures to nurture relationships: Retention is All About Relationships Low turnover facility leaders take measures to nurture 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

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

Recruitment Process Problems • Applicant is not greeted • Receptionist in not aware of 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 4 “Come back Tuesday at 11: 00”

Interview Tips • High standards • Involve front-line • Ask the right questions 4 Interview Tips • High standards • Involve front-line • Ask the right questions 4 Open ended 4 Behavior based • Facility tour observations

Careful Selection SCREEN FOR PERSONAL CHARACTERISTICS: • Maturity • Compassionate • Sensitivity • Critical Careful Selection SCREEN FOR PERSONAL CHARACTERISTICS: • Maturity • Compassionate • Sensitivity • Critical thinking • Ability to communicate, learn • Friendliness, smiles

“In a good to great transformation, people are not your most important asset. The “In a good to great transformation, people are not your most important asset. The right people are. ” Jim Collins

MHRC Key Changes • Employee referral bonus • Peer Mentors • Regular HR meetings MHRC Key Changes • Employee referral bonus • Peer Mentors • Regular HR meetings • Goal – 450 nursing hours 4 Not HPPD • Addressing poor performers • Hired the right people

Leadership Development • Self • Department heads, charge nurses, CNAs • Coaching and counseling Leadership Development • Self • Department heads, charge nurses, CNAs • Coaching and counseling • Performance appraisals • Conflict management

Leadership Development (cont. ) • Effective praise • Retention strategies • Interpreting data • Leadership Development (cont. ) • Effective praise • Retention strategies • Interpreting data • Critical thinking

High Quality Leadership • A strong vision or mission • Set high standards and High Quality Leadership • A strong vision or mission • Set high standards and develop trust • Listen to others, communication • Values contributions • Builds on their intrinsic motivation Eaton, S. , 2001

Communication THE BIG PICTURE: MISSION, VISION, VALUES • Community meetings 4 Sincere reminders 4 Communication THE BIG PICTURE: MISSION, VISION, VALUES • Community meetings 4 Sincere reminders 4 Provide staff with direction, purpose 4 “Did you see their faces? ” • Express high expectations • Key values: 4 Respect 4 Teamwork 4 Caring and compassion

The “Golden Rule” • Christianity 4 Do unto others, as you would have them The “Golden Rule” • Christianity 4 Do unto others, as you would have them do unto you • Islam 4 No one of you is a believer, until he loves for his brother what he loves for himself • Judaism 4 What you hate, do not do to anyone • Hinduism 4 Do nothing to thy neighbor, which thou would not have them do to thee • Buddhism 4 Hurt not others with that which pains thyself • Confucianism 4 What you do not want done to thyself, do not do to others

Visibility • Demonstrate your commitment to excellence • Engage the heart of staff • Visibility • Demonstrate your commitment to excellence • Engage the heart of staff • Rounds – nothing is more important 4 Meet and greet 4 Inspect 4 Praise 4 Build self-esteem 4 Build stability and trust

Five Key Questions To Ask Staff • Relationship building 4 “How are your beautiful Five Key Questions To Ask Staff • Relationship building 4 “How are your beautiful kids doing? ” • Focus on the positive 4 “What is working well today? ” • Positive feedback loop 4 “Is there anybody who has gone above and beyond the call of duty today? ” • QI - systems focus 4 “Is there anything we can do better? ” • Needs 4 “Do you have the tools and equipment to do your job? ” Studer, Q. , “Hardwiring Excellence. ” 2003

Communication Strategies • Monthly dept. meetings • Communication boards • All staff meetings • Communication Strategies • Monthly dept. meetings • Communication boards • All staff meetings • Lunch with • Quarterly town hall meetings administration • Lunch in break room • Mini-inservices • Newsletters • Learning circles • Post quality data

MHRC Key Changes • Communication boards 4 Gentle, sincere reminders • No overhead paging MHRC Key Changes • Communication boards 4 Gentle, sincere reminders • No overhead paging • Celebrate diversity 4 Name badges • Staffing organization

Eaton’s Findings on Scheduling Most Common Reason for Termination • Flexible in low turnover Eaton’s Findings on Scheduling Most Common Reason for Termination • Flexible in low turnover facilities 4 Allow for different start times 4 Consider personal lives • Rigid in high turnover facilities 4 In response to problems 4 “Personal life is not my problem. ” Eaton, Phase II Final Report, 2001

Who are the CNAs? • Total 1. 4 million • Deliver 80% of hands-on 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 4 2007 Federal Poverty Rate = $20, 650 • 30% - 35% receive food stamps GAO, 2001 National Clearinghouse on the Direct care Workforce, 2006 BLS 2006, FHCEF 2007

The “Stop Doing” List • Incentives to waive benefits • Turning away FT applicants The “Stop Doing” List • Incentives to waive benefits • Turning away FT applicants • Sending staff home early • Scheduling mistakes • Rigid scheduling practices • Discipline before intervention

Scheduling Success • Allow staff to trade days • Honor requests for time off Scheduling Success • Allow staff to trade days • Honor requests for time off • Increase FT and decrease PRN and PT • Avoid every other weekend off • Consistent assignments and primary days • Indicate assignment on the master schedule

Recognition • Caregivers thirst for recognition • Raffle off gifts every month • Neighborhoods Recognition • Caregivers thirst for recognition • Raffle off gifts every month • Neighborhoods for quality improvement • New employees – Rookie of Month • Quiet, steady performers • The power of “thank you” cards

Thank You Cards • Cards are powerful 4 Send them to staff members’ homes Thank You Cards • Cards are powerful 4 Send them to staff members’ homes 4 Birthday cards 4 Anniversary cards 4 Excellent attendance 4 “I appreciate you” 4 “I am glad you work for us. On behalf of the residents, their families and your co-workers – Thank you. ”

Invisible “The problem is not motivation. It is the ways in which we unintentionally Invisible “The problem is not motivation. It is the ways in which we unintentionally de-motivate employees. ” Quint Studer “Hardwiring Excellence”

“I See You” • Smile • Make eye contact • Use the other person’s “I See You” • Smile • Make eye contact • Use the other person’s name • Boost self-esteem • Hand them a granola bar • Offer condolences

Death and Dying • Shocked • Condolences • Packing up belongings • Moments of Death and Dying • Shocked • Condolences • Packing up belongings • Moments of silence

MHRC Empowerment • Empower employees by giving them: 4 Knowledge of what is expected MHRC Empowerment • Empower employees by giving them: 4 Knowledge of what is expected 4 Skills, resources and supplies 4 Feedback on how they are doing 4 Feedback on how the facility is performing 4 Opportunity to improve work processes 4 Opportunity to provide feedback (surveys) 4 Consistent assignments

Support for Consistent Assignment • Results from 12 research studies: 4 Improved teamwork 4 Support for Consistent Assignment • Results from 12 research studies: 4 Improved teamwork 4 Enhanced relationships 4 Improved attendance 4 Improved staff, resident, family satisfaction 4 Lower turnover 4 Improved screening and assessments 4 Improved clinical outcomes 4 Improved quality of life • Allow for individualized care

Same SNF – Different Units Consistent Assignment: Rotating Assignment: Top Five Stressors • Preventing Same SNF – Different Units Consistent Assignment: Rotating Assignment: Top Five Stressors • Preventing Falls • Low Wage • Stubborn Residents • Abusive Residents • Terminal Residents • Heavy Workload • Depressed Residents • Disagreements w/ Coworkers • Death as Emotional Stress • Lack of Staff Gruss, V. et al. , 2004

Evidence Against Rotating Assignment Experts estimate 90% of SNFs nationwide rotate staff from one Evidence Against Rotating Assignment Experts estimate 90% of SNFs nationwide rotate staff from one group of residents after a duration of time. HIGH RATE OF BURNOUT • 70% feel burned out some of the time • 60% feel they sometimes treat the residents impersonally • 40% feel that they have become hardened emotionally Pillemer, K. “Solving the Frontline Crisis in LTC. ” 1996

Burnout “The true cause of burnout is the deadening effect of closing one’s emotions Burnout “The true cause of burnout is the deadening effect of closing one’s emotions to people who are in obvious need of a human connection. Human life is sustained by affection. ” Dr. Bill Thomas, W. , “What Are Old People For? How Elders Will Save The World. ” 2004

Formula for Individualized Care High satisfaction + Retention + Consistent Assignment = Growth of Formula for Individualized Care High satisfaction + Retention + Consistent Assignment = Growth of Tacit Knowledge: • Lifting and turning safely • Names of grandchildren • Who wears glasses • Individual preferences • Anticipating needs • Reciprocity Eaton, S. , “Beyond Unloving Care. ” 2000

MHRC Environmental Changes • FT painter 4 Research-based color selections • Live plants • MHRC Environmental Changes • FT painter 4 Research-based color selections • Live plants • New chairs for nurses • Courtyards • Deep cleaning • Home Depot

130 Changes: The Flywheel Effect Steps forward Visible results People Energized Eaton, Phase II 130 Changes: The Flywheel Effect Steps forward Visible results People Energized Eaton, Phase II Final Report, 2001 FP-05 b

MHRC One Year Later MHRC One Year Later

May 2007 • Ø vacant FT nursing positions • Average daily occupancy rate jumped May 2007 • Ø vacant FT nursing positions • Average daily occupancy rate jumped from 104 to 120 in March 2007 4 Medicare occupancy increased from 10 to 24 • 44 live, potted plants are in the building • Overtime declined from 1, 200 hours to 450 hours per month • Overhead paging eliminated

May 2007 • Nursing department turnover rate declined from 77% to 28% • CNA May 2007 • Nursing department turnover rate declined from 77% to 28% • CNA turnover rate declined from 94% to 31% 4 Saving $70, 000 • Average of 32 call-outs per month • 3. 5% in-house PU rate • 10 falls per month

Valuing and Respecting Caregivers CARING PRODUCES RESULTS: • High trust • Empathy • Understanding Valuing and Respecting Caregivers CARING PRODUCES RESULTS: • High trust • Empathy • Understanding • Respect for caregivers • Support staff Eaton, S. , 2001

“No one has ever cared for me like you do. ” Mr. Condee Watts “No one has ever cared for me like you do. ” Mr. Condee Watts

Contact Information David J. Farrell, MSW, NHA Director, Care Continuum dfarrell@caqio. sdps. org (415) Contact Information David J. Farrell, MSW, NHA Director, Care Continuum [email protected] sdps. org (415) 677 -2054