David Farrell, MSW, NHA Project Manager Quality Partners of Rhode Island

1. David Farrell, MSW, NHA Project Manager Quality Partners of Rhode Island I will address the question that you will likely face � �Isn�t this too idealistic. Come on, I have bottom line objectives to meet. I answer to the owners. I answer to Wall Street. Things are going pretty well. We are making money. We give good care. Our survey results were at the state average. We have not had a citation in the past 14 months. Our QMs are at or a little below the state average. I think our staff morale is ok. Residents and families seem happy. No one has complained lately. So why should I embark on this transformational change?� This is a legitimate question. You have heard the altruistic reasons. Not everyone will respond. Let me arm you with the business case that you may consider using to recruit facilities to participate. However, you may need to use these facts to prompt individuals to change after you recruit them.I will address the question that you will likely face � �Isn�t this too idealistic. Come on, I have bottom line objectives to meet. I answer to the owners. I answer to Wall Street. Things are going pretty well. We are making money. We give good care. Our survey results were at the state average. We have not had a citation in the past 14 months. Our QMs are at or a little below the state average. I think our staff morale is ok. Residents and families seem happy. No one has complained lately. So why should I embark on this transformational change?� This is a legitimate question. You have heard the altruistic reasons. Not everyone will respond. Let me arm you with the business case that you may consider using to recruit facilities to participate. However, you may need to use these facts to prompt individuals to change after you recruit them.

2. AHCA recently published the following 2002 data regarding LTC staff turnover and vacancies and the numbers are staggering. Nationally: Turnover Calc. = # of terms divided by total FTEs AHCA estimates that 10 states have turnover rates which exceed 100% and two states have DON turnover which exceeds 100% Also, DON turnover rates increased from 2001 compared to 2002 to where half of the DONs left their positions in 2002. Turnover rates for Admins. Is 40% and there ahs been a 40% decline in the number of potential admins. Sitting for the lic. Exam. Regarding vacancy rates � SNFs reported that they had a easier time finding CNAs last year primarily due to a downturn in the economy. Avg is 71% Sadly, according to UCLA research data, 50% on CNAs do not renew their certificate after 3 years of their initial certification. According to the US Dept. of Labor - Nursing homes employ 1.8 million people � more that the auto and steel industries combined Our poor public image contributes to our inability to recruit new people to join the ranks of LTC. AHCA recently published the following 2002 data regarding LTC staff turnover and vacancies and the numbers are staggering. Nationally: Turnover Calc. = # of terms divided by total FTEs AHCA estimates that 10 states have turnover rates which exceed 100% and two states have DON turnover which exceeds 100% Also, DON turnover rates increased from 2001 compared to 2002 to where half of the DONs left their positions in 2002. Turnover rates for Admins. Is 40% and there ahs been a 40% decline in the number of potential admins. Sitting for the lic. Exam. Regarding vacancy rates � SNFs reported that they had a easier time finding CNAs last year primarily due to a downturn in the economy. Avg is 71% Sadly, according to UCLA research data, 50% on CNAs do not renew their certificate after 3 years of their initial certification. According to the US Dept. of Labor - Nursing homes employ 1.8 million people � more that the auto and steel industries combined Our poor public image contributes to our inability to recruit new people to join the ranks of LTC.

3. SNF Statistics 16,100 SNFs 15,000 free-standing 75% for-profit Top 10 chains dropped 20% of their beds 1.68 million beds Average occupancy 85.6% Serve 3.5 million per year Total U.S. spending $99 billion in 2001 Let�s take a broad view of the current state of SNFs as we build the case for transformational change Occupancy rates vary widely from state to state Look at how many people we serve per year. 70% of those over the age of 70 will spend at least one day in a SNF in their lifetime.Let�s take a broad view of the current state of SNFs as we build the case for transformational change Occupancy rates vary widely from state to state Look at how many people we serve per year. 70% of those over the age of 70 will spend at least one day in a SNF in their lifetime.

4. SNF Statistics continued Net profit margin for-profits 2.2% Net profit margin of non-profits 0.3% 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% Most of these figures are based on 2002 cost reports. Starbucks � 70% margin In 2002, 37 states either froze or reduced their Medicaid reimbursement rates for SNFsMost of these figures are based on 2002 cost reports. Starbucks � 70% margin In 2002, 37 states either froze or reduced their Medicaid reimbursement rates for SNFs

5. Why Culture Change? Connecting the Dots Intrinsic motivation Satisfaction Stability Quality of Life Quality of Care Financial

6. Institutional Model Low morale Great responsibility Little autonomy Emotional demands Inadequate orientation Lack of flexibility Environment Stress! Lack of supplies Lack of systems RN/CNA conflicts Inadequate leadership Listed here are some of the internal causes which contribute to a lack of staff due to constant turnover. In the inst. Model, we have a PP for everything. In a sense, we tell our staff to check their judgment at the door. The bottom line is a lack of TRUST.Listed here are some of the internal causes which contribute to a lack of staff due to constant turnover. In the inst. Model, we have a PP for everything. In a sense, we tell our staff to check their judgment at the door. The bottom line is a lack of TRUST.

7. 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 You face numerous explanations as to why high turnover exists in the long term care profession. Very rarely do the leaders refer to their organizational structure or their own actions, or other factors within their control, as the cause. However, we have a significant growing body of research based evidence that negates many of these explanations.You face numerous explanations as to why high turnover exists in the long term care profession. Very rarely do the leaders refer to their organizational structure or their own actions, or other factors within their control, as the cause. However, we have a significant growing body of research based evidence that negates many of these explanations.

8. 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 Wage pass through is an additional allocation of funds provided through Medicaid reimbursements for the express purpose of increasing compensation for direct-care workers. Most states required participation and monitored the providers for compliance through random audits. 21 states have implemented wage pass through legislation with the stated expectation that doing so will help address the shortage of direct care staff employed by LTC facilities. A review of the current data does not support the efficacy of wage pass through programs. There may be a variety of reasons for this including the lack of a common methodology to measure turnover. However, one state legislator said it best � �A wage pass through is a down payment � the first step toward a more comprehensive effort to sustain a competent and stable LTC workforce.� The summary of the study indicated that low wages are not the sole cause of high vacancy rates and high turnover. An increase in wages cannot by itself, resolve recruitment and retention problems. Retaining a stable workforce is complex and requires multi-faceted solutions. Numerous research studies, conducted in a variety of states, indicate other factors are also correlated with job satisfaction.Wage pass through is an additional allocation of funds provided through Medicaid reimbursements for the express purpose of increasing compensation for direct-care workers. Most states required participation and monitored the providers for compliance through random audits. 21 states have implemented wage pass through legislation with the stated expectation that doing so will help address the shortage of direct care staff employed by LTC facilities. A review of the current data does not support the efficacy of wage pass through programs. There may be a variety of reasons for this including the lack of a common methodology to measure turnover. However, one state legislator said it best � �A wage pass through is a down payment � the first step toward a more comprehensive effort to sustain a competent and stable LTC workforce.� The summary of the study indicated that low wages are not the sole cause of high vacancy rates and high turnover. An increase in wages cannot by itself, resolve recruitment and retention problems. Retaining a stable workforce is complex and requires multi-faceted solutions. Numerous research studies, conducted in a variety of states, indicate other factors are also correlated with job satisfaction.

9. Cost and Quality Marilyn Rantz research findings: Retention translates into increased efficiency Retention leads to better quality outcomes Better quality outcomes lead to lower costs On average - $13.50 less PPD Annual savings (90 residents per day) = $440,000 Excellent study by Marilyn Rantz � randomly selected 90 facilities in 90 MO. Then she picked out the 23 delivering the best clinical care. And low and behold, it turns out that these homes were also the most profitable Here�s more regarding the cost of poor outcomes � Ross labs estimates that the cost associated with healing a stage 3 PU on a MediCal recipient can cost a facility over $10,000 to heal the stage 3. Interesting to note that a research study conducted by Jane Straker at Miami U. found that facilities with high turnover offered higher full-time starting salaries than low turnover facilities. This is a landmark study � for the very first time a researcher found that providing great care and profitability are not two mutually exclusive goals � in fact they are very closely linked. Most providers and LTC corps agree � their best performing facilities from a clinical perspective are also the most profitable. Excellent study by Marilyn Rantz � randomly selected 90 facilities in 90 MO. Then she picked out the 23 delivering the best clinical care. And low and behold, it turns out that these homes were also the most profitable Here�s more regarding the cost of poor outcomes � Ross labs estimates that the cost associated with healing a stage 3 PU on a MediCal recipient can cost a facility over $10,000 to heal the stage 3. Interesting to note that a research study conducted by Jane Straker at Miami U. found that facilities with high turnover offered higher full-time starting salaries than low turnover facilities. This is a landmark study � for the very first time a researcher found that providing great care and profitability are not two mutually exclusive goals � in fact they are very closely linked. Most providers and LTC corps agree � their best performing facilities from a clinical perspective are also the most profitable.

10. Cost of Turnover Nationwide $2,500 per employee $2.5 billion nationwide Direct costs Advertisement costs Staff time to interview, check references, etc. Drug screen, pre-employment physical Classroom orientation Unit orientation Cost of coverage of the vacant position Indirect costs Vacant shifts, lower quality, slower service, lost new admissions, workers compensation, lost revenue, stress leading to errors An excellent study was just published titled � �� Turnover is not an inevitable cost of doing business. At a much lower cost, is the expense of investing in keeping and retaining frontline staff. However, beyond the dollars is the human toll turnover imposes on organizations. With every quit or termination, the care giving relationships and quality of the services provided to elders is disrupted. At the extreme, staffing can become so compromised that the well-being of both residents and the caregivers is neg. affected. With the stated goal in the 8th scope of 15% improvement, we are looking at a potential cost savings of $20,000. An excellent study was just published titled � �� Turnover is not an inevitable cost of doing business. At a much lower cost, is the expense of investing in keeping and retaining frontline staff. However, beyond the dollars is the human toll turnover imposes on organizations. With every quit or termination, the care giving relationships and quality of the services provided to elders is disrupted. At the extreme, staffing can become so compromised that the well-being of both residents and the caregivers is neg. affected. With the stated goal in the 8th scope of 15% improvement, we are looking at a potential cost savings of $20,000.

11. Injury Perils of LTC Staff Lost-time injuries are twice the US average More likely to be injured on the job than: Construction workers Policemen Firefighters Coal miners Manufacturing plant employees Primarily due to short staffing Significant cost Workplace injuries are a byproduct of short staffing, lack of training, lack of a team approach (trust) CNAs alone average 200,000 injuries per year SNFs experienced 79,000 lost time injuries in 2002 In second place was truck drivers at 36,8000Workplace injuries are a byproduct of short staffing, lack of training, lack of a team approach (trust) CNAs alone average 200,000 injuries per year SNFs experienced 79,000 lost time injuries in 2002 In second place was truck drivers at 36,8000

12. Assaults by Residents on CNAs 59% assaulted at least once per week 16% assaulted daily 51% have been injured Confident in recognizing agitation Lack of knowledge and skill to prevent Surveyed 138 CNAs in six nursing homes in the Midwest. Surveyed 138 CNAs in six nursing homes in the Midwest.

13. �What a Difference Management Makes� Paired 4 high vs. 4 low turnover facilities Similarities 159 on-site interviews Vicious cycle Similar to the approach by Jim Collins in G to G, Professor Susan Eaton from Harvard, conducted a very interesting research study. The burning question for her was � why do we have such extreme variation in turnover rates among SNFs located within the same geographic regions (who re essentially just down the street from one another), offering the same starting salaries, employing the same types of people, offering the same staffing ratios and what difference does management practices make. She looked for and found a total of eight facilities, 4 with high rates of turnover and 4 with low rates of turnover, each of the contrasting pairs were located within the same labor market. She then went on-site and conducted 159 interviews and made observations seeking to explain the variation. She identified 5 distinct areas � High quality leadership and management, offering recognition, meaning, and feedback as well as the opportunity to see one�s work as valued and valuable; managers who built on the intrinsic motivation of workers in this field An organizational culture, communicated by managers, families, supervisors, and nurses themselves, of valuing and respecting the nursing caregivers themselves as well as residents Basic positive or �high performance� Human Resource policies, including wages and benefits but also in the areas of �soft� skills and flexibility, training and career ladders, scheduling, realistic job previews, etc. Thoughtful and effective, motivational work organization and care practices Adequate staffing ratios and support for giving high quality care The best part about her research study is the specifics, the how-to, regarding the actions that leaders must take on a consistent basis. Similar to the approach by Jim Collins in G to G, Professor Susan Eaton from Harvard, conducted a very interesting research study. The burning question for her was � why do we have such extreme variation in turnover rates among SNFs located within the same geographic regions (who re essentially just down the street from one another), offering the same starting salaries, employing the same types of people, offering the same staffing ratios and what difference does management practices make. She looked for and found a total of eight facilities, 4 with high rates of turnover and 4 with low rates of turnover, each of the contrasting pairs were located within the same labor market. She then went on-site and conducted 159 interviews and made observations seeking to explain the variation. She identified 5 distinct areas � High quality leadership and management, offering recognition, meaning, and feedback as well as the opportunity to see one�s work as valued and valuable; managers who built on the intrinsic motivation of workers in this field An organizational culture, communicated by managers, families, supervisors, and nurses themselves, of valuing and respecting the nursing caregivers themselves as well as residents Basic positive or �high performance� Human Resource policies, including wages and benefits but also in the areas of �soft� skills and flexibility, training and career ladders, scheduling, realistic job previews, etc. Thoughtful and effective, motivational work organization and care practices Adequate staffing ratios and support for giving high quality care The best part about her research study is the specifics, the how-to, regarding the actions that leaders must take on a consistent basis.

14. A Vicious Cycle A you recall from the first LS, Eaton identified the following vicious cycles that occurs in facilities. This can happen fast.A you recall from the first LS, Eaton identified the following vicious cycles that occurs in facilities. This can happen fast.

15. The Impact of Vacant Shifts C.N.A.�s report what gets neglected: Range of motion Hydration Feeding Bathing Example � Braintree Manor Relationship to clinical care � most fac. Tie their skin check system to the shower schedule. Therefore, even if a fac. Is only short staffed two days in a week, if those days happen to fall on Mabel�s shower day, she may go ten days without a full body check. This is where a stage one is not identified and turns into a stage two. Example � Braintree Manor Relationship to clinical care � most fac. Tie their skin check system to the shower schedule. Therefore, even if a fac. Is only short staffed two days in a week, if those days happen to fall on Mabel�s shower day, she may go ten days without a full body check. This is where a stage one is not identified and turns into a stage two.

16. High Turnover = Poor Outcomes Interrupts continuity: Incontinence Facility acquired pressures sores Urinary Tract infections Falls and fractures The link between turnover and quality has been empirically established.The link between turnover and quality has been empirically established.

17. Staff Stability Tacit knowledge: Lifting and turning safely Who has grandchildren Who wears glasses for what Individual preferences Studied 20 SNFs to determine how HR management and quality of care are linked in a systematic way. It means a lot to the elders and their families when the staff remember their preferences. When Ms. Jones prefers a cup of tea at 7 am and she takes it with 2 scoops of sugar and a little milk, and her caregiver gets it for her before she asks for it and its just right it makes her feel special. Studies have repeatedly confirmed that consumers� perception of the quality of their care is deeply rooted in the quality of their relationship with their caregivers. They value these relationships higher than medical care and the quality of the food. Studied 20 SNFs to determine how HR management and quality of care are linked in a systematic way. It means a lot to the elders and their families when the staff remember their preferences. When Ms. Jones prefers a cup of tea at 7 am and she takes it with 2 scoops of sugar and a little milk, and her caregiver gets it for her before she asks for it and its just right it makes her feel special. Studies have repeatedly confirmed that consumers� perception of the quality of their care is deeply rooted in the quality of their relationship with their caregivers. They value these relationships higher than medical care and the quality of the food.

18. Abuse and Neglect Causes: Inadequate training Short staffing Stress Burnout Frequent thoughts of quitting In this study they surveyed staff who abused residents. Those who abuse and neglect come from all walks of life, there is no correlation with job title, income level, professional education or years of experience. Abuse and neglect are directly related to stressful working conditions, including those which induced frequent thoughts of quitting and high levels of burnout. By focusing on Org CC � You can mitigate those instances which made lead to abuse or neglect.In this study they surveyed staff who abused residents. Those who abuse and neglect come from all walks of life, there is no correlation with job title, income level, professional education or years of experience. Abuse and neglect are directly related to stressful working conditions, including those which induced frequent thoughts of quitting and high levels of burnout. By focusing on Org CC � You can mitigate those instances which made lead to abuse or neglect.

19. Litigation Only 8% go to trial 50% lead to payment of plaintiff 92% settled out of court 88% payment to plaintiff Average payment = $406,000 Initiated in reaction to: Death Pressure ulcers Weight loss Emotional distress 63% of claims were initiated by the child of a resident Half of all claims were initiated due to wrongful death Other reasons for claims � emotional distress, falls, iproper use of restraints and med errors Nursing homes collectively paid out $1.4 billion in claims in 2001 Of course, SNFs do not make only a one time payment for a claim, they pay for it for years through higher liability insurance premiums. Despite the higher number of claims and size of compensation payments in Texas and Florida, these two states do not look worse than other states when comparing OSCAR data or QM rates.63% of claims were initiated by the child of a resident Half of all claims were initiated due to wrongful death Other reasons for claims � emotional distress, falls, iproper use of restraints and med errors Nursing homes collectively paid out $1.4 billion in claims in 2001 Of course, SNFs do not make only a one time payment for a claim, they pay for it for years through higher liability insurance premiums. Despite the higher number of claims and size of compensation payments in Texas and Florida, these two states do not look worse than other states when comparing OSCAR data or QM rates.

20. Revenue Growth Marketing Public relations Occupancy rates Improved quality mix Sub-acute Having enough staff allows facilities to admit more acutely ill residents. Many facilities deny new admissions due to short staffing. Better QMs = new admits. The most powerful public relations force any facility has is their satisfied residents, family members and staff. Org. CC improves their sat. levels. Regarding subacute care � the person directed care model embraces an approach that is required for success in the sub-acute wing of any nursing home. These short stay residents need consistently assigned caregivers and expect high levels of response and service. They want �choice.� The principles and values fit very well here. Also, these residents are the new ltc residents. You do not want to run two different wings of a facility under different sets of values. Having enough staff allows facilities to admit more acutely ill residents. Many facilities deny new admissions due to short staffing. Better QMs = new admits. The most powerful public relations force any facility has is their satisfied residents, family members and staff. Org. CC improves their sat. levels. Regarding subacute care � the person directed care model embraces an approach that is required for success in the sub-acute wing of any nursing home. These short stay residents need consistently assigned caregivers and expect high levels of response and service. They want �choice.� The principles and values fit very well here. Also, these residents are the new ltc residents. You do not want to run two different wings of a facility under different sets of values.

21. Very Satisfied Staff V. Tellis-Nayak � Research studies - The power of staff satisfaction Staff satisfaction is a key performance indicator Analysis of 30,000 responses in 520 facilities from 1995 thru 2001 Used a 4 point Likert scale which forced respondents to make a choice � Very Dis, Dis., Sat., Very Sat. They clustered the 520 nursing homes into 3 groups labeled above � Facilities which averaged 8% of very sat. staff Facilities which averaged 18% of very sat. staff Facilities which averaged 36% of very sat. staff V. Tellis-Nayak � Research studies - The power of staff satisfaction Staff satisfaction is a key performance indicator Analysis of 30,000 responses in 520 facilities from 1995 thru 2001 Used a 4 point Likert scale which forced respondents to make a choice � Very Dis, Dis., Sat., Very Sat. They clustered the 520 nursing homes into 3 groups labeled above � Facilities which averaged 8% of very sat. staff Facilities which averaged 18% of very sat. staff Facilities which averaged 36% of very sat. staff

22. Agency Staff Usage and Staff Satisfaction

23. Survey Deficiencies Compared to State Average and Staff Satisfaction 

24. QI Index and Staff Satisfaction QI index = 0 to 100 (100 = best) It is composed of 5 care outcomes collected monthly on HCFA form 672: acquired Pus, restraints, anti-psych drug use, wt. Loss, and falls. Correlation with Family Satisfaction and vice versa Correlation with occupancy levels, revenue and AR Strong correlation with turnover � Replacing staff is extremely expensive QI index = 0 to 100 (100 = best) It is composed of 5 care outcomes collected monthly on HCFA form 672: acquired Pus, restraints, anti-psych drug use, wt. Loss, and falls. Correlation with Family Satisfaction and vice versa Correlation with occupancy levels, revenue and AR Strong correlation with turnover � Replacing staff is extremely expensive

25. Staff Satisfaction = Family Satisfaction 12 states publicly report family satisfaction Staff satisfaction key predictor of family satisfaction Satisfied employees report: Better supervision Better training Better work environments Satisfied families report: Quality of life Quality of care Quality of service

26. Retention Issues Only 60% of facilities measure turnover Less than 50% use satisfaction surveys Largest obstacle to quality care - vacancies C.N.A. focus groups - relationships Listen, recognize, respect, trust So, you figure if staff sat. and turnover are such key performance indicators with a strong correlation to other key performance indicators, it must be something that we would diligently measure in LTC. But � we do not. All of the not-for profit facilities in this study had budgeted for adequate ratios, however, all the key staff from the administrator to the CNAs pointed to vacancies caused by call-offs and turnover as their greatest obstacle to providing high quality care. In addition, the OIG recently released a final report on the analysis of nursing home complaint data reported in the National Ombudsman reporting System. From 1996 to 2000, nationally, one of the most prominent changes is that of complaints regarding staff turnover increased by over 200%. So, you figure if staff sat. and turnover are such key performance indicators with a strong correlation to other key performance indicators, it must be something that we would diligently measure in LTC. But � we do not. All of the not-for profit facilities in this study had budgeted for adequate ratios, however, all the key staff from the administrator to the CNAs pointed to vacancies caused by call-offs and turnover as their greatest obstacle to providing high quality care. In addition, the OIG recently released a final report on the analysis of nursing home complaint data reported in the National Ombudsman reporting System. From 1996 to 2000, nationally, one of the most prominent changes is that of complaints regarding staff turnover increased by over 200%.

27. The Critical Domainof Workplace Practice

28. Transformative Work Place Practice

29. Average Hours PPD Total hours per patient per day = 3.32 Only 3 states under 3.00 HPPD Only 1 state above 4.00 HPPD Increase of .21 HPPD since 1999 RN hours have decreased by .05 HPPD LPN hours have increased by .05 HPPD C.N.A. hours up by .21 HPPD Recently, AHCA published the following data. As you can see, despite the acute shortage and high turnover, SNFs nationwide have actually increased the avg. HPPD since 1999. Primarily, these increases have come from increasing the number of C.N.A. hours.Recently, AHCA published the following data. As you can see, despite the acute shortage and high turnover, SNFs nationwide have actually increased the avg. HPPD since 1999. Primarily, these increases have come from increasing the number of C.N.A. hours.

30. 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 Why do they enter this field � based on the research, they intentionally choose LTC, not because they do not have other options, but because they have a desire to help others. Single moms at or near the poverty line have limited resources to fall back on when their kid is sick or their car won�t start. In addition, we know that most are uninsured. In fact, most for-profit chains encourage it by offering as much a $1 more per hour to entice staff to waive their right to coverage. 25% have no health insurance Avg. age is 37, 10% are over 55, 50% have at least one child under 18 20% are below the poverty line 75% have a high school diploma Avg. rate is $9.85 = $ 20,500 per year. Cashiers make $7.60 All occup. Avg. is $13.50 Four major causes of stress � Pillemer - lack of time, lack of good supervision, lack of staff, lack of training in psych/social aspects of care giving. NOT unskilled labor. Example - Philome These are the people I worked with at Braintree Manor on PMs and NOCs. I was not welcome into the group. In fact, I ate all of my meals alone. Looking back, I realize now how poorly I was trained and how alienated I felt. It was only the residents that kept me coming back. Ironically, I was fired for visiting the residents when I was not on the clock � I policy I ignored.Why do they enter this field � based on the research, they intentionally choose LTC, not because they do not have other options, but because they have a desire to help others. Single moms at or near the poverty line have limited resources to fall back on when their kid is sick or their car won�t start. In addition, we know that most are uninsured. In fact, most for-profit chains encourage it by offering as much a $1 more per hour to entice staff to waive their right to coverage. 25% have no health insurance Avg. age is 37, 10% are over 55, 50% have at least one child under 18 20% are below the poverty line 75% have a high school diploma Avg. rate is $9.85 = $ 20,500 per year. Cashiers make $7.60 All occup. Avg. is $13.50 Four major causes of stress � Pillemer - lack of time, lack of good supervision, lack of staff, lack of training in psych/social aspects of care giving. NOT unskilled labor. Example - Philome These are the people I worked with at Braintree Manor on PMs and NOCs. I was not welcome into the group. In fact, I ate all of my meals alone. Looking back, I realize now how poorly I was trained and how alienated I felt. It was only the residents that kept me coming back. Ironically, I was fired for visiting the residents when I was not on the clock � I policy I ignored.

31. Key Reasons C.N.A.�s Select Nursing Home Work The opportunity to help others Makes me feel meaningful It is useful to society Offers a lot of contact with people

32. Stand Up and Tell Them Views from the Frontline in Long-Term Care Produced by Better Jobs Better Care, a national program supported by The Robert Wood Johnson Foundation and the Atlantic Philanthropies, with direction and assistance provided by the Institute for the Future of Aging Services, American Association of Homes and Services for the Aging.

33. C.N.A.�s Four Major Causes of Stress Lack of: Staff Time Good supervision Education

34. 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

35. 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 Excellent study in Michigan completed by professors at Michigan State. Over 1,100 direct care workers completed an anonymous survey. These are workers who left direct care work and are no longer employed in the field. Includes SNF and home health. The largest obstacle to delivering excellent care and service is vacancies/vacant shifts. If poor supervisory behavior is one of the primary reason people leave, this needs to be turned around to be the primary reason people stay. Last on the list of reasons they left was lack of child care and transportation problems. However, oftentimes, I hear providers considering the provision of child care and offering transportation as the answer to their turnover and staffing problems.. Thus � we have a Gap � providers need the facts. We need more anonymous surveys of the front-line caregivers like this one in order to provide ltc leaders with information which allows them to customize their interventions. Exit interviews conducted by Administrators do not allow for the candid response an anonymous survey does. Excellent study in Michigan completed by professors at Michigan State. Over 1,100 direct care workers completed an anonymous survey. These are workers who left direct care work and are no longer employed in the field. Includes SNF and home health. The largest obstacle to delivering excellent care and service is vacancies/vacant shifts. If poor supervisory behavior is one of the primary reason people leave, this needs to be turned around to be the primary reason people stay. Last on the list of reasons they left was lack of child care and transportation problems. However, oftentimes, I hear providers considering the provision of child care and offering transportation as the answer to their turnover and staffing problems.. Thus � we have a Gap � providers need the facts. We need more anonymous surveys of the front-line caregivers like this one in order to provide ltc leaders with information which allows them to customize their interventions. Exit interviews conducted by Administrators do not allow for the candid response an anonymous survey does.

36. CMS Special Study on Workforce Retention Quality of work life measures: Staff satisfaction/experience Attendance Shifts worked short Turnover rates By shift By unit By discipline By LOS Resident and family satisfaction What to do with data � first collect good data Turn data into information, turn information into knowledge, turn knowledge into action Understand it Simplify it Trend it Convert it to positive Post it Promote improvement See your own correlations between satisfaction and quality outcomes Regarding turnover � some is to be expected. With high standards and with an eye toward retaining your top performers, it is important to get rid of your bottom 10%. Constantly be on the lookout to upgrade by keeping the applicant pipeline full and continuing to interview staff even if all your positions are full.What to do with data � first collect good data Turn data into information, turn information into knowledge, turn knowledge into action Understand it Simplify it Trend it Convert it to positive Post it Promote improvement See your own correlations between satisfaction and quality outcomes Regarding turnover � some is to be expected. With high standards and with an eye toward retaining your top performers, it is important to get rid of your bottom 10%. Constantly be on the lookout to upgrade by keeping the applicant pipeline full and continuing to interview staff even if all your positions are full.

37. CMS Special Study on Workforce Retention What does it feel like when understaffed? �Stressful; no lunch break, your back hurts.� �Hectic � finger nails do not get clipped, men don�t get shaved, people are left with empty cups.� �Hell.� What does it feel like when you have enough staff? �Relief � feel you accomplished something.� �Can do little things for the residents like give them a hug.� �Can give them a back rub, talk to them, you can take the time to be more human.� Part of the homework involved having the corporate staff visit the facilities and ask questions such as : �. �Can give them a back rub, talk to them, you can take the time to be more human.� What she did not say was that on the days she is understaffed, she shuts down � she can not be human. Those days, residents are served in a rushed, uncaring manner. This is true today just as it was ten years ago when Dr. Pillemer found that, in his focus groups, 40% of the C.N.A.�s reported feeling they have become emotionally hardened as a result of working as a C.N.A. and 60% reported that there were times when they delivered care in an impersonal way. Research gap � what is they link between working short and resident quality of life. For future research articles � The combination between data and quotes works well. It grabs me because it appeals to my head and my heart. Part of the homework involved having the corporate staff visit the facilities and ask questions such as : �. �Can give them a back rub, talk to them, you can take the time to be more human.� What she did not say was that on the days she is understaffed, she shuts down � she can not be human. Those days, residents are served in a rushed, uncaring manner. This is true today just as it was ten years ago when Dr. Pillemer found that, in his focus groups, 40% of the C.N.A.�s reported feeling they have become emotionally hardened as a result of working as a C.N.A. and 60% reported that there were times when they delivered care in an impersonal way. Research gap � what is they link between working short and resident quality of life. For future research articles � The combination between data and quotes works well. It grabs me because it appeals to my head and my heart.

38. Institute of Medicine Quality of care depends on the frontline Staffing levels are necessary Other key factors: Education Supervision Job satisfaction Turnover Leadership Organizational culture Quality of care depends largely on the performance of the care-giving workforce. Staffing levels are a necessary but not sufficient condition for positively affecting quality of life and quality of care. Quality of care depends largely on the performance of the care-giving workforce. Staffing levels are a necessary but not sufficient condition for positively affecting quality of life and quality of care.

39. National Commission on Nursing Workforce National Initiatives State and Local Initiatives Collaborate Create partnerships Develop workforce initiatives Facility and Provider Initiatives

40. National Commission on Nursing Workforce Facility and Provider Initiatives: Create worker-oriented workplaces Implement organizational change Develop supervisory training programs Organize peer mentor programs Encourage self managed work teams Promote career ladder opportunities Support professional and personal growth Increase salary and benefits Foster relationships

41. �What a Difference Management Makes� Low turnover vs. high turnover: Leadership visibility Cared for caregivers High performance human resource practices Primary assignments Rarely worked short Similar to the approach by Jim Collins in G to G, Professor Susan Eaton from Harvard, conducted a very interesting research study. The burning question for her was � why do we have such extreme variation in turnover rates among SNFs located within the same geographic regions (who re essentially just down the street from one another), offering the same starting salaries, employing the same types of people, offering the same staffing ratios and what difference does management practices make. She looked for and found a total of eight facilities, 4 with high rates of turnover and 4 with low rates of turnover, each of the contrasting pairs were located within the same labor market. She then went on-site and conducted 159 interviews and made observations seeking to explain the variation. She identified 5 distinct areas � High quality leadership and management, offering recognition, meaning, and feedback as well as the opportunity to see one�s work as valued and valuable; managers who built on the intrinsic motivation of workers in this field An organizational culture, communicated by managers, families, supervisors, and nurses themselves, of valuing and respecting the nursing caregivers themselves as well as residents Basic positive or �high performance� Human Resource policies, including wages and benefits but also in the areas of �soft� skills and flexibility, training and career ladders, scheduling, realistic job previews, etc. Thoughtful and effective, motivational work organization and care practices Adequate staffing ratios and support for giving high quality care The best part about her research study is the specifics, the how-to, regarding the actions that leaders must take on a consistent basis. Similar to the approach by Jim Collins in G to G, Professor Susan Eaton from Harvard, conducted a very interesting research study. The burning question for her was � why do we have such extreme variation in turnover rates among SNFs located within the same geographic regions (who re essentially just down the street from one another), offering the same starting salaries, employing the same types of people, offering the same staffing ratios and what difference does management practices make. She looked for and found a total of eight facilities, 4 with high rates of turnover and 4 with low rates of turnover, each of the contrasting pairs were located within the same labor market. She then went on-site and conducted 159 interviews and made observations seeking to explain the variation. She identified 5 distinct areas � High quality leadership and management, offering recognition, meaning, and feedback as well as the opportunity to see one�s work as valued and valuable; managers who built on the intrinsic motivation of workers in this field An organizational culture, communicated by managers, families, supervisors, and nurses themselves, of valuing and respecting the nursing caregivers themselves as well as residents Basic positive or �high performance� Human Resource policies, including wages and benefits but also in the areas of �soft� skills and flexibility, training and career ladders, scheduling, realistic job previews, etc. Thoughtful and effective, motivational work organization and care practices Adequate staffing ratios and support for giving high quality care The best part about her research study is the specifics, the how-to, regarding the actions that leaders must take on a consistent basis.

42. Communication Listening Consistent and regular communication Across shifts is planned Between leaders and staff Visibility � word and action Written � minutes, memos, notes Respect Eaton noticed that two of the low turnover facilities had union contracts. Within the contracts, it was clearly spelled out when, where and how often communication between the managers and the staff was to occur. This concrete practice existed due to unionization which increased the employees sense of fairness and consistency. Handout � meeting minutes � what�s the message.Eaton noticed that two of the low turnover facilities had union contracts. Within the contracts, it was clearly spelled out when, where and how often communication between the managers and the staff was to occur. This concrete practice existed due to unionization which increased the employees sense of fairness and consistency. Handout � meeting minutes � what�s the message.

43. Recognition Caregivers thirst for recognition Catch them in the act of compassion Recognize teams for quality improvement Recognize new employees Create positive feedback loops People are much more likely to improve their performance when they are consistently recognized for good behaviors than if they are consistently criticized for the wrong behaviors. Recognition is about acknowledging good resulted and reinforcing positive performance. It helps shape your culture in which contributions are noticed and appreciated A massive study by Gallup found the one of the major reasons for employee resignations was a lack of recognition for good work According to research conducted by Jones, workers who felt like they were appreciated by supervisors were 52% less likely to look for a different job Caregivers have a fundamental need to have their efforts on behalf of residents acknowledged and appreciated. When you catch and praise individuals for making residents, visitors and coworkers feel good, you triple the likelihood that the staff member will go above and beyond the call of duty. Pay close attention to new employees, for new staff, they need positive feedback even if they do something partially right before they do it completely right RIG THE Raffles.People are much more likely to improve their performance when they are consistently recognized for good behaviors than if they are consistently criticized for the wrong behaviors. Recognition is about acknowledging good resulted and reinforcing positive performance. It helps shape your culture in which contributions are noticed and appreciated A massive study by Gallup found the one of the major reasons for employee resignations was a lack of recognition for good work According to research conducted by Jones, workers who felt like they were appreciated by supervisors were 52% less likely to look for a different job Caregivers have a fundamental need to have their efforts on behalf of residents acknowledged and appreciated. When you catch and praise individuals for making residents, visitors and coworkers feel good, you triple the likelihood that the staff member will go above and beyond the call of duty. Pay close attention to new employees, for new staff, they need positive feedback even if they do something partially right before they do it completely right RIG THE Raffles.

44. Empowerment Foundation is trust High involvement Knowledge Skills and resources Positive feedback Opportunity to improve systems This is one of the most difficult and time consuming aspects of the CC journey if you are focused on deep organizational change. To go from a paradigm of control requires high levels of trust within the organization. You simply can not rush the process of laying a foundation of trust. When you build knowledge and skills you build self esteem in the frontline caregivers and confidence in the leaders that they can release control. It takes longer to ask the staff for their feedback and input. An empowered staff feels valuable and important. They come to work because they know they make a difference. It is difficult to pull CNAS off the floor for care planning meetings. However, research shows that low turnover facilities find a way to get their input and demonstrate that their opinion matters. the best decisions about how care should be carried out should be made by the front-line staff who know the resident. empower staff through extensive education, shared decision making and enhancing the critical thinking skills of the front-line staff. This is one of the most difficult and time consuming aspects of the CC journey if you are focused on deep organizational change. To go from a paradigm of control requires high levels of trust within the organization. You simply can not rush the process of laying a foundation of trust. When you build knowledge and skills you build self esteem in the frontline caregivers and confidence in the leaders that they can release control. It takes longer to ask the staff for their feedback and input. An empowered staff feels valuable and important. They come to work because they know they make a difference. It is difficult to pull CNAS off the floor for care planning meetings. However, research shows that low turnover facilities find a way to get their input and demonstrate that their opinion matters. the best decisions about how care should be carried out should be made by the front-line staff who know the resident. empower staff through extensive education, shared decision making and enhancing the critical thinking skills of the front-line staff.

45. Retention 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 In general, relationships were valued in the low turnover homes. This was noticeably absent in the high turnover facilities. Relationships are at the heart of good work environments. Studies have repeatedly confirmed that consumers� perception of the quality of their care is deeply rooted in the quality of their relationship with their caregivers. They value these relationships higher than medical care and the quality of the food. Management systems that support these caring relationships retain their staff.In general, relationships were valued in the low turnover homes. This was noticeably absent in the high turnover facilities. Relationships are at the heart of good work environments. Studies have repeatedly confirmed that consumers� perception of the quality of their care is deeply rooted in the quality of their relationship with their caregivers. They value these relationships higher than medical care and the quality of the food. Management systems that support these caring relationships retain their staff.

46. Primary assignments Improve: Teamwork Relationships Attendance Screening and assessment Quality of life Clinical outcomes Allows for person-directed care Low turnover facilities utilize primary assignments of their staff. Why is that empowering � Primary assignments allow staff to really get to know the residents. They become the experts on a group of residents and everyone knows that they can go to them for answers. This is empowering and boosts peoples self-esteem. In addition, primary assignments allow for staff to notice the clinical changes early before it�s too late. This is essential to reducing exposure and risk. Also, primary assignments reduce turnover because it allows staff to form close relationships with the residents. It also allows staff to provide more resident-centered care and enables them to follow the individual routines of their residents thus enhancing residents quality of life. You have to have a few floats. Ask the residents Low turnover facilities utilize primary assignments of their staff. Why is that empowering � Primary assignments allow staff to really get to know the residents. They become the experts on a group of residents and everyone knows that they can go to them for answers. This is empowering and boosts peoples self-esteem. In addition, primary assignments allow for staff to notice the clinical changes early before it�s too late. This is essential to reducing exposure and risk. Also, primary assignments reduce turnover because it allows staff to form close relationships with the residents. It also allows staff to provide more resident-centered care and enables them to follow the individual routines of their residents thus enhancing residents quality of life. You have to have a few floats. Ask the residents

47. Primary Assignments � The Evidence Residents � more control and choice, less agitation Staff � ability to provide high quality care Residents � better clinical outcomes Staff � able to provide better care and more aware of resident needs Lower turnover and lower absenteeism Residents � reduction in pressure ulcers, increases in functional ability Staff � felt more accountable Turnover dropped by 29% Preference of staff, residents and families Families � greater sense of comfort Staff � higher satisfaction Definition of PA vs. RA The small amount of existing literature on staff assignment is nursing homes reveals the following: Allows for PDC � can not do it without primary assign. Cox � Conducted a before and after study and found the following � Patchner � Examined the the effects of the type of staff assignment in isolation and found the � Campbell- also used a before and after design, after implementing PA in a facility that previously used RA, Campbell found � Goldman � Explored peoples perceptions of RA and PA and found � Of course � all the CC experts highly recommend PA. They argue you can not provide PCC without them. Why is that empowering � Primary assignments allow staff to really get to know the residents. They become the experts on a group of residents and everyone knows that they can go to them for answers. This is empowering and boosts peoples self-esteem. In addition, primary assignments allow for staff to notice the clinical changes early before it�s too late. This is essential to reducing exposure and risk. Also, primary assignments reduce turnover because it allows staff to form close relationships with the residents. It also allows staff to provide more resident-centered care and enables them to follow the individual routines of their residents thus enhancing residents quality of life. How to do it � meeting, assign numbers, let them choose. What are the barriers to switching to primary assignments?Definition of PA vs. RA The small amount of existing literature on staff assignment is nursing homes reveals the following: Allows for PDC � can not do it without primary assign. Cox � Conducted a before and after study and found the following � Patchner � Examined the the effects of the type of staff assignment in isolation and found the � Campbell- also used a before and after design, after implementing PA in a facility that previously used RA, Campbell found � Goldman � Explored peoples perceptions of RA and PA and found � Of course � all the CC experts highly recommend PA. They argue you can not provide PCC without them. Why is that empowering � Primary assignments allow staff to really get to know the residents. They become the experts on a group of residents and everyone knows that they can go to them for answers. This is empowering and boosts peoples self-esteem. In addition, primary assignments allow for staff to notice the clinical changes early before it�s too late. This is essential to reducing exposure and risk. Also, primary assignments reduce turnover because it allows staff to form close relationships with the residents. It also allows staff to provide more resident-centered care and enables them to follow the individual routines of their residents thus enhancing residents quality of life. How to do it � meeting, assign numbers, let them choose. What are the barriers to switching to primary assignments?

48. Eaton�s Findings on Scheduling Most common reason for termination Different practices in low vs. high Flexible Allow for different start times Consider personal lives Rigid In response to problems �Personal life is not my problem.� In Eaton�s study, she found that one of the most common reasons for termination were conflicts related to showing up at work not work performance. She found some significant differences in practices and systems in the low vs. high turnover facilities in her study. In low turnover homes, schedules were posted well in advance, sufficient notice was provided to the staff regarding open shifts or any changes to the schedule. The staff could rely on the consistency of it. In the high turnover facilities, the scheduling was very haphazard as if it was as simple as placing peoples names on a sheet of paper. The schedule was seen by the staff as very chaotic. Changes were made to the schedule without sufficient notice to the staff and, in the staff�s view, without justification. The first issue to identify is are the schedules rigid or flexible. The flexibly scheduled facilities in Eaton�s study had the least absenteeism and lowest turnover. Consider personal lives � of the front-line staff. Handle call-offs with compassion and concern for the well being of the person calling in. Then, they assisted the employee with the problem at a later date. In Eaton�s low turnover facilities, the managers had an understanding of what their employees lives were like outside of work. Rigid In response to problems � most facility leaders respond to attendance problems with more rigidity and disciplinary action. �Personal life is not my problem.� � was a pervasive attitude among the leaders of high turnover facilities in Eaton�s study. Yet, in the low turnover homes, they had the opposite attitude and it showed in the way they treated the employee�s who called off. Used as punishment � Changes in the schedule used as disciplinary action was a hated practice among the CNAs. In one example in her study, a C.N.A. was hired and requested day shift but accepted pm shift until a day shift position opened up. His attendance was fair but not perfect due working on pm shift did not fit his personal responsibilities outside of work. After working for a year, he found out that two new CNAs were hired to day shift. When he inquired as to why he was not moved to day shift as he had requested he was told he was not moved because of his attendance on . In Eaton�s study, she found that one of the most common reasons for termination were conflicts related to showing up at work not work performance. She found some significant differences in practices and systems in the low vs. high turnover facilities in her study. In low turnover homes, schedules were posted well in advance, sufficient notice was provided to the staff regarding open shifts or any changes to the schedule. The staff could rely on the consistency of it. In the high turnover facilities, the scheduling was very haphazard as if it was as simple as placing peoples names on a sheet of paper. The schedule was seen by the staff as very chaotic. Changes were made to the schedule without sufficient notice to the staff and, in the staff�s view, without justification. The first issue to identify is are the schedules rigid or flexible. The flexibly scheduled facilities in Eaton�s study had the least absenteeism and lowest turnover. Consider personal lives � of the front-line staff. Handle call-offs with compassion and concern for the well being of the person calling in. Then, they assisted the employee with the problem at a later date. In Eaton�s low turnover facilities, the managers had an understanding of what their employees lives were like outside of work. Rigid In response to problems � most facility leaders respond to attendance problems with more rigidity and disciplinary action. �Personal life is not my problem.� � was a pervasive attitude among the leaders of high turnover facilities in Eaton�s study. Yet, in the low turnover homes, they had the opposite attitude and it showed in the way they treated the employee�s who called off. Used as punishment � Changes in the schedule used as disciplinary action was a hated practice among the CNAs. In one example in her study, a C.N.A. was hired and requested day shift but accepted pm shift until a day shift position opened up. His attendance was fair but not perfect due working on pm shift did not fit his personal responsibilities outside of work. After working for a year, he found out that two new CNAs were hired to day shift. When he inquired as to why he was not moved to day shift as he had requested he was told he was not moved because of his attendance on .

49. The �Stop Doing� List Rotating staff Incentives to waive benefits Sick pay � use it or lose it No sick pay until second day of absence Filling vacant shifts with new staff Some facilities promote excessive absenteeism. They have the exact same policy as your other facilities. Like many of the clinical issues we face, the problem usually does not lie in the policy. However, your systems may be contributing to the problem. Incentives to waive benefits � this has become a common practice nationwide for corps. To encourage staff waive their right to benefits for $1 more per hour. While this appears to save the corps a lot of money, it actually costs them down the road. These costs simply shift to another line item. If staff members have no health insurance, they are less likely to seek medical treatment until it is too late. Or if they have no sick pay or vacation pay that they have accrued, they have nothing to tie them to the facility. A spell of illness for this individual is the equivalent of a financial catastrophe. Bonuses for working short � staff tend to have a field day with this one and start making arrangements for whose turn it is to call off so that they all may get extra pay. Scheduling overtime and double-time � in facilities where the scheduling of staff for OT and DT is the routine, you have a system where these individuals have a strong financial incentive to keep the facility short staffed because they are making more money because of it. They see new employees who appear on the schedule and take their OT/DT as a threat to their income. Also, offering OT to an employee who called off earlier in the week allows that individual to earn more money that week than if they had shown up for their scheduled shift. Rotating staff � this leads to call-offs the days after the rotation. Sick pay � use it or lose it policies encourage staff to use it. You are much better off paying a portion of it out as a reward to those with great attendance records. No sick pay until second day of absence � this is an interesting one. Are you encouraging the person to call off for two days instead of one? No incentives or disincentives � Ignoring the staff with issues and those with excellent attendance records is another way that a system, or lack of a system, encourages the problem to continue.Some facilities promote excessive absenteeism. They have the exact same policy as your other facilities. Like many of the clinical issues we face, the problem usually does not lie in the policy. However, your systems may be contributing to the problem. Incentives to waive benefits � this has become a common practice nationwide for corps. To encourage staff waive their right to benefits for $1 more per hour. While this appears to save the corps a lot of money, it actually costs them down the road. These costs simply shift to another line item. If staff members have no health insurance, they are less likely to seek medical treatment until it is too late. Or if they have no sick pay or vacation pay that they have accrued, they have nothing to tie them to the facility. A spell of illness for this individual is the equivalent of a financial catastrophe. Bonuses for working short � staff tend to have a field day with this one and start making arrangements for whose turn it is to call off so that they all may get extra pay. Scheduling overtime and double-time � in facilities where the scheduling of staff for OT and DT is the routine, you have a system where these individuals have a strong financial incentive to keep the facility short staffed because they are making more money because of it. They see new employees who appear on the schedule and take their OT/DT as a threat to their income. Also, offering OT to an employee who called off earlier in the week allows that individual to earn more money that week than if they had shown up for their scheduled shift. Rotating staff � this leads to call-offs the days after the rotation. Sick pay � use it or lose it policies encourage staff to use it. You are much better off paying a portion of it out as a reward to those with great attendance records. No sick pay until second day of absence � this is an interesting one. Are you encouraging the person to call off for two days instead of one? No incentives or disincentives � Ignoring the staff with issues and those with excellent attendance records is another way that a system, or lack of a system, encourages the problem to continue.

50. Gallup Organization Keys to improve retention: Recognition and praise Care about them as people Encourage personal development Value their opinions Encourage friendships Let them know they make a difference Most leaders in LTC are not cruel individuals. Very rarely do you find toxic cultures. However, what you do find is supervisors who ignore their staff. The majority of their hard-working committed staff members are invisible to them.Most leaders in LTC are not cruel individuals. Very rarely do you find toxic cultures. However, what you do find is supervisors who ignore their staff. The majority of their hard-working committed staff members are invisible to them.

51. Basic Human Needs To Live To Love To Learn To Leave a Legacy

52. Culture Change = Stability Eden LEAP Meadowlark Hills Mt. St. Vincent Less absenteeism Lower turnover rates AND � as a result, research supports, they have better clinical outcomes.AND � as a result, research supports, they have better clinical outcomes.

53. Basic Change Model Primarily � in the 7th scope of work, QIOS focused on behaviors. In the 8th scope the focus shifts to leadership paradigms. Provoke people to examine their paradigms. And the greatest challenge in the 8th scope will the fact that culture change requires that leaders change what they say and what they do. Whereas in the 7th scope, the focus was primarily on changing what the nurses and CNAs did. When Susan Eaton interviewed Bill Thomas in 2000, she asked � �What�s the biggest cost?� Bill�s answer was � �The biggest cost is changing your mind.� If your faced with the question of �Is this too idealistic?� What the individual may really be asking is �Can I change?� Well, the leaders of SNFs ask the nurses and CNAs to change their all the time. Human beings can change. Ultimately, what we learned from Jim Collins was that moving organizations from good to great is never a matter of circumstance. Going from good to great is always a matter of concise choice.Primarily � in the 7th scope of work, QIOS focused on behaviors. In the 8th scope the focus shifts to leadership paradigms. Provoke people to examine their paradigms. And the greatest challenge in the 8th scope will the fact that culture change requires that leaders change what they say and what they do. Whereas in the 7th scope, the focus was primarily on changing what the nurses and CNAs did. When Susan Eaton interviewed Bill Thomas in 2000, she asked � �What�s the biggest cost?� Bill�s answer was � �The biggest cost is changing your mind.� If your faced with the question of �Is this too idealistic?� What the individual may really be asking is �Can I change?� Well, the leaders of SNFs ask the nurses and CNAs to change their all the time. Human beings can change. Ultimately, what we learned from Jim Collins was that moving organizations from good to great is never a matter of circumstance. Going from good to great is always a matter of concise choice.

54. �For every thousand hacking at the leaves of evil there is only one striking at the root.� Henry David Thoreau