Staff Stability: The Foundation for Quality Improvement Faculty: Cathie Brady & Barbara Frank April...

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


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:

© B & F Consulting, Inc. www.BandFConsultingInc.com © B & F Consulting, Inc. 2012


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

© B & F Consulting, Inc. www.BandFConsultingInc.com © B & F Consulting, Inc. 2012


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


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


Where to start

– Listen for quick wins– Build trust– Act fast – Visual– Symbolic – to let people

know you’re listening– Start with biggest irritants


We did the best we could, with what we knew,And when we knew better,we did better.

MAYA ANGELOU

Your experiences


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.


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


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


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.”


• 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


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?


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


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%


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


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


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


From Turnover to Stability

2005 2008

90% 28%


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.


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


Staff Stability Tool-kitwww.nhqualitycampaign.org

Resources Goal One – Staff Stability

www.healthcentricadvisors.orgHATCh

Workforce© B & F Consulting, Inc. 2012


http://www.nhqualitycampaign.org/

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


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


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)


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



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)


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”


Middle Class Experience

Abstract

Stable

Predictable

Can anticipate, isolate and solve problemsSafety-oriented


Society – and the workplace – is normalized to stability and planning


In poverty, life is falling apart

Without enough resources to fix it Bridges Out of Poverty

Poverty Experience

Concrete

Unstable

Tyranny of the Moment

Problem-solvingHyper-vigilance


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


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


Predisposing circumstances: Training and preparation for job


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


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


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


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”


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


Organizational Reinforcers and Enablers – Hidden Sanctions

Para-professionals

Reliable aides fill shortages, take up slack, have greater burden


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


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


Interpersonal ReinforcersMutual Lack of Interpersonal Skills


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


““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


No significant workhappens without a significant relationship.

James Comer



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


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


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


Contact Information:

Cathie [email protected]

Barbara [email protected]

www.BandFConsultingInc.comand

www.BandFConsultingInc.com/WhatYouDoMatters

© B&F Consulting Inc. 2012 www.BandFConsultingInc.com

mailto:[email protected]

mailto:[email protected]

http://www.BandFConsultingInc.com/

http://www.BandFConsultingInc.com/WhatYouDoMatters

http://www.BandFConsultingInc.com/WhatYouDoMatters

Staff Stability: The Foundation for Quality Improvement Faculty: Cathie Brady & Barbara Frank April...

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