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

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

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    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.

    3. Turnover and Vacancies Nationwide Turnover RNs = 50% LPNs = 50% CNAs = 70% 96,000 Vacant FTEs 52,000 CNAs 25,100 LPNs 13,900 RNs First, a quick review of some of the evidence. There are 16,100 SNFs nationwide. Serve 1.7 million on any given day. Avg. 5.5 vacant positions per facility. Average turnover rate is 71% AHCA published the following 2002 data regarding LTC staff turnover and vacancies and the numbers are staggering. 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. Example C.N.As turnover – if have 40, 54% = 21 left According to the US Dept. of Labor - Nursing homes employ 1.8 million people – more than the auto and steel industries combined Our poor public image contributes to our inability to recruit new people to join the ranks of LTC. Frontline workers play an impt. Role in monitoring the daily well-being of the residents allowing for more personalized care according to the elder’s wishes. High turnover causes a loss of impt. Knowledge about resident well-being. Turnover cause staff shortages which result in rushed, de-personalized care. First, a quick review of some of the evidence. There are 16,100 SNFs nationwide. Serve 1.7 million on any given day. Avg. 5.5 vacant positions per facility. Average turnover rate is 71% AHCA published the following 2002 data regarding LTC staff turnover and vacancies and the numbers are staggering. 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. Example C.N.As turnover – if have 40, 54% = 21 left According to the US Dept. of Labor - Nursing homes employ 1.8 million people – more than the auto and steel industries combined Our poor public image contributes to our inability to recruit new people to join the ranks of LTC. Frontline workers play an impt. Role in monitoring the daily well-being of the residents allowing for more personalized care according to the elder’s wishes. High turnover causes a loss of impt. Knowledge about resident well-being. Turnover cause staff shortages which result in rushed, de-personalized care.

    4. 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.

    5. 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. When staff leave – they do not go to fast food restaurants – they go to other healthcare organizations. 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. 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. When staff leave – they do not go to fast food restaurants – they go to other healthcare organizations. 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.

    6. Institute of Medicine Quality of care depends on the performance of the workforce 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. Below a certain threshold, you are guaranteed poor quality. Above that threshold, all of these other factors come into play. Thus far, we have primarily focused on the others, now let’s focus on stabilizing staff and the how tos regarding that. In the 8th scope, many of the homes you work with will need these practices right up front if we are to make any headway within the other circles. 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. Below a certain threshold, you are guaranteed poor quality. Above that threshold, all of these other factors come into play. Thus far, we have primarily focused on the others, now let’s focus on stabilizing staff and the how tos regarding that. In the 8th scope, many of the homes you work with will need these practices right up front if we are to make any headway within the other circles.

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

    8. “What a Difference Management Makes” Paired 4 high vs. 4 low turnover facilities Similarities 159 on-site interviews Areas that distinguished low vs. high Leadership visibility Cared for caregivers Orientation, career ladders, scheduling 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.

    9. The Impact of Leaders Nursing homes – a short history Research-based evidence Administrator and DON influence Leader’s actions Culture Retention Quality outcomes In researching the links between quality leadership and quality of care I have found some clear patterns emerge. It is important to note that, the modern nursing home , as we know it today, has been around for less than 40 years. Now, there is a growing body of research-based evidence that supports the fact that leaders of successful nursing homes engage in certain activities on a consistent basis that the leaders of unsuccessful nursing homes do not. It’s more about practices than personality. There is some thing about the organizational makeup of these fragile ecosystems we call SNFs that make them very susceptible to poor leadership practices. However, because of their fragility, they are also very responsive to excellent leadership actions. Administrators and DONs have an extremely strong influence on the performance of Skilled Nursing Facilities As the research evidence grows, we will come to know these certain leadership activities of successful facilities to be universal truths – unarguable natural laws related to creating a culture of excellence and improving quality of care.In researching the links between quality leadership and quality of care I have found some clear patterns emerge. It is important to note that, the modern nursing home , as we know it today, has been around for less than 40 years. Now, there is a growing body of research-based evidence that supports the fact that leaders of successful nursing homes engage in certain activities on a consistent basis that the leaders of unsuccessful nursing homes do not. It’s more about practices than personality. There is some thing about the organizational makeup of these fragile ecosystems we call SNFs that make them very susceptible to poor leadership practices. However, because of their fragility, they are also very responsive to excellent leadership actions. Administrators and DONs have an extremely strong influence on the performance of Skilled Nursing Facilities As the research evidence grows, we will come to know these certain leadership activities of successful facilities to be universal truths – unarguable natural laws related to creating a culture of excellence and improving quality of care.

    10. This diagram presents a visual model of the core components of a strategic framework designed to create a high-retention culture. Consider this a strategic plan to create the culture which will allow you to retain your top performers. As you can see here at the bottom of the model – everyone comes into this profession or your facility with some common shared vales which they hope to act on and live out. Values such as compassion, service or care. Solid structures are built with a solid foundation. And here that foundation is a commitment to quality of care and service for the residents. The pillars reflect broad categories of leadership practices identified by researchers to have the most the most positive impact on the culture in nursing homes. Consider these pillars the eight areas of action in which you will get the greatest mileage for your efforts. By simultaneously working within these specific management/leadership domains, you will retain staff and create a C of E. Again, researchers and LTC experts around the nation agree that leaders who focus their efforts within these pillars of success will achieve great results. You can not ad lib excellence. Consider this a strategic plan based on sound research. This diagram presents a visual model of the core components of a strategic framework designed to create a high-retention culture. Consider this a strategic plan to create the culture which will allow you to retain your top performers. As you can see here at the bottom of the model – everyone comes into this profession or your facility with some common shared vales which they hope to act on and live out. Values such as compassion, service or care. Solid structures are built with a solid foundation. And here that foundation is a commitment to quality of care and service for the residents. The pillars reflect broad categories of leadership practices identified by researchers to have the most the most positive impact on the culture in nursing homes. Consider these pillars the eight areas of action in which you will get the greatest mileage for your efforts. By simultaneously working within these specific management/leadership domains, you will retain staff and create a C of E. Again, researchers and LTC experts around the nation agree that leaders who focus their efforts within these pillars of success will achieve great results. You can not ad lib excellence. Consider this a strategic plan based on sound research.

    11. Pillar #1 Recruitment Community Outreach Employee Referral Be proactive Pay bonus ASAP Recruitment brochures Community outreach – sometimes you have to go out and find the hard-working, good hearted people who are stuck working in fast food restaurants but would be a great fit in LTC – BK example, Jamba Juice Sign on bonuses do not work Structure and promotion of the employee referral bonus is key Be proactive with referral bonuses – target new staff and your top 25% PHI has found that turnover rates are higher among those who apply and are hired via response to newspaper ads than for those who are hired via referrals from current employees. Community outreach – sometimes you have to go out and find the hard-working, good hearted people who are stuck working in fast food restaurants but would be a great fit in LTC – BK example, Jamba Juice Sign on bonuses do not work Structure and promotion of the employee referral bonus is key Be proactive with referral bonuses – target new staff and your top 25% PHI has found that turnover rates are higher among those who apply and are hired via response to newspaper ads than for those who are hired via referrals from current employees.

    12. Looking in the Right Places Effective job postings ESL classes Department of Labor WIB career centers C.N.A. training classes Human service agencies Health clinics Community colleges GED classes Laundromats Unemployment offices Newspaper advertising – bad ads vs. good adsNewspaper advertising – bad ads vs. good ads

    13. 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 The receptionist is a key player in the recruitment formula. Make sure the receptionist is part of the R&R Committee. Keep him or her informed of current openings. Inform the receptionist to interrupt the hiring manager when the applicant completes the application. The hiring manager must drop everything and interview on the spot or meet and greet and set up a date for the interview. Do not allow applicants to drop off the application and leave. Recruitment never ends. Never stop recruiting.The receptionist is a key player in the recruitment formula. Make sure the receptionist is part of the R&R Committee. Keep him or her informed of current openings. Inform the receptionist to interrupt the hiring manager when the applicant completes the application. The hiring manager must drop everything and interview on the spot or meet and greet and set up a date for the interview. Do not allow applicants to drop off the application and leave. Recruitment never ends. Never stop recruiting.

    14. Interview Tips High standards Involve front-line Ask the right questions Open ended Behavior based Facility tour observations Let employees help solve short staffing The next 7 pillars of success focus on retaining the employees you have successfully recruited into your facility. Research based evidence supports the fact that effective leaders within our profession spend a considerable amount of time and effort focused on retention. Screen for personal characteristics: Maturity Compassionate Sensitivity Critical thinking Ability to communicate, learn Friendliness, smiles Good to Great – first who…then what Let employees help solve short staffing The next 7 pillars of success focus on retaining the employees you have successfully recruited into your facility. Research based evidence supports the fact that effective leaders within our profession spend a considerable amount of time and effort focused on retention. Screen for personal characteristics: Maturity Compassionate Sensitivity Critical thinking Ability to communicate, learn Friendliness, smiles Good to Great – first who…then what

    15. Careful Selection Screen for personal characteristics: Maturity Compassionate Sensitivity Critical thinking Ability to communicate, learn Friendliness, smiles Personal characteristics are more important than experience or skills. SNFs routinely violate the very basics of HR practices and then wonder why they are in staffing dilemmas. Some of my best hiring decisions came from individuals with no experience in LTC. To meet the 8th scope goal of reducing turnover of new hires, SNFs must do a much better job of hiring right.Personal characteristics are more important than experience or skills. SNFs routinely violate the very basics of HR practices and then wonder why they are in staffing dilemmas. Some of my best hiring decisions came from individuals with no experience in LTC. To meet the 8th scope goal of reducing turnover of new hires, SNFs must do a much better job of hiring right.

    16. Red Flags Does not interact with residents during tour Is not courteous to staff Does not smile Long commute “Bad mouths” former employer Reveals confidential information You are their “second” job Regarding selection – Disney example, 5 smile rule example Regarding selection – Disney example, 5 smile rule example

    17. Pillar #2 Leadership Development Self Department Heads, Charge Nurses, C.N.A.s Coaching and counseling Performance appraisals Conflict management The top admins. and dons look at themselves as a work in progress. They read leadership books and listen to the tapes. Then they take the time to share this knowledge with the leaders within their facility. Leaders improve when they are exposed to new knowledge whereby they can examine their own actions against the information provided in order to gain a perspective on their effectiveness as a leader. Self reflection is key. The performance of Charge nurses and Dept. heads is a key to NH success and quality resident care. Front-line supervisors make or break our organizations. The relationship the employee has with their supervisory determines 50% of their work-life satisfaction A considerable amount of effort needs to be invested in developing their supervision skills. According to a massive study by Gallop, an employee’s direct supervisor has the greatest impact on performance. Lack of recognition or appreciation is one of the top reasons for for employee resignations. Hold dept. managers accountable for turnover within their department and facility-wide.The top admins. and dons look at themselves as a work in progress. They read leadership books and listen to the tapes. Then they take the time to share this knowledge with the leaders within their facility. Leaders improve when they are exposed to new knowledge whereby they can examine their own actions against the information provided in order to gain a perspective on their effectiveness as a leader. Self reflection is key. The performance of Charge nurses and Dept. heads is a key to NH success and quality resident care. Front-line supervisors make or break our organizations. The relationship the employee has with their supervisory determines 50% of their work-life satisfaction A considerable amount of effort needs to be invested in developing their supervision skills. According to a massive study by Gallop, an employee’s direct supervisor has the greatest impact on performance. Lack of recognition or appreciation is one of the top reasons for for employee resignations. Hold dept. managers accountable for turnover within their department and facility-wide.

    18. Pillar #2 Leadership Development Effective praise Retention strategies Interpreting data Critical thinking Improving leadership behaviors is the key Leadership skills, more than management expertise, impact turnover Low turnover = better quality outcomes Critical thinking – lead with questions not with answersImproving leadership behaviors is the key Leadership skills, more than management expertise, impact turnover Low turnover = better quality outcomes Critical thinking – lead with questions not with answers

    19. Pillar #3 Communication The big picture – Mission, vision, values Provide staff with direction, purpose Express high expectations Key values: Excellence Service Respect Teamwork Caring and compassion Successful leaders in our profession make an extraordinary effort to communicate their vision, values and the facilities Mission at every opportunity. They also understand that the staff is looking to them to demonstrate their commitment to the words through action. Shared values encourage teamwork, provide staff with a sense of direction, and spell out how you want staff to act in order to achieve the mission. Miracles happen every day in SNFs – capture those stories because those are clear examples of employees living out the mission and values. Throughout history – humans have perpetuated their cultures through stories. Successful leaders in our profession make an extraordinary effort to communicate their vision, values and the facilities Mission at every opportunity. They also understand that the staff is looking to them to demonstrate their commitment to the words through action. Shared values encourage teamwork, provide staff with a sense of direction, and spell out how you want staff to act in order to achieve the mission. Miracles happen every day in SNFs – capture those stories because those are clear examples of employees living out the mission and values. Throughout history – humans have perpetuated their cultures through stories.

    20. Visibility Demonstrate your commitment to excellence Engage the Heart of staff Rounds – nothing is more important Meet and Greet Inspect Praise Build self-esteem Build stability and trust Leadership presence and visibility on the units and in resident rooms modeling excellent customer relations is key. Communication during rounds allows you to catch your staff doing something right and let them know they have been caught. Every hour, employees are committing acts of compassion. Let them know you saw them and appreciate it. Nothing is more important to creating a culture of excellence than rounds. Talking to your people and taking action based on what you hear.Leadership presence and visibility on the units and in resident rooms modeling excellent customer relations is key. Communication during rounds allows you to catch your staff doing something right and let them know they have been caught. Every hour, employees are committing acts of compassion. Let them know you saw them and appreciate it. Nothing is more important to creating a culture of excellence than rounds. Talking to your people and taking action based on what you hear.

    21. Becoming Visible Smile Make eye contact Use the other person’s name Be calm and positive Listen Offer condolences Inquire about employees personally Hand them a granola bar The single most noticeable and important behavior is to establish eye contact, smile, and say “hello” to employees, residents, physicians, visitors as you walk along instead of being absorbed in your own thoughts with a concerned look on your face. It is important to be a positive force. The key is to do rounds religiously because visibility must stay a priority. It is not the first priority to eliminate when other demands arise.The single most noticeable and important behavior is to establish eye contact, smile, and say “hello” to employees, residents, physicians, visitors as you walk along instead of being absorbed in your own thoughts with a concerned look on your face. It is important to be a positive force. The key is to do rounds religiously because visibility must stay a priority. It is not the first priority to eliminate when other demands arise.

    22. Engage the Heart of Staff Use every opportunity and every avenue – Frame your mission and value statements Start meetings with - “why are we here?” Hand out reminders and refreshers Post reminders on bulletin boards Tell heartwarming stories Build pride in the organization Consistently remind staff in sincere ways of the value of what they do beyond the mechanics of the job. It is so much more than tasks to be checked off or charted. What you and your staff do on a daily basis is a deeply humanistic endeavor. Frontline caregivers need to understand how important they are. All staff need to understand what your values look, feel and sound like in action. Tell heartwarming stories of success at the meetings – consider “chicken soup for the _____ soul.” Stories help create a picture of the culture in action and help to create an emotional connection. Throughout history, humans have used stories to perpetuate their cultures. Nursing is intrinsically meaningful in terms of it’s effect on the lives of people. It is up to the leaders to creatively and consistently remind the staff that their contribution is important. Hand out examples of methods to remind staff in sincere ways that what they do matters – it matters a lot. Read vision statement.Consistently remind staff in sincere ways of the value of what they do beyond the mechanics of the job. It is so much more than tasks to be checked off or charted. What you and your staff do on a daily basis is a deeply humanistic endeavor. Frontline caregivers need to understand how important they are. All staff need to understand what your values look, feel and sound like in action. Tell heartwarming stories of success at the meetings – consider “chicken soup for the _____ soul.” Stories help create a picture of the culture in action and help to create an emotional connection. Throughout history, humans have used stories to perpetuate their cultures. Nursing is intrinsically meaningful in terms of it’s effect on the lives of people. It is up to the leaders to creatively and consistently remind the staff that their contribution is important. Hand out examples of methods to remind staff in sincere ways that what they do matters – it matters a lot. Read vision statement.

    23. Communication Strategies Monthly dept. meetings All staff meetings Quarterly town hall meetings Mini-inservices Learning circles Communication boards Lunch with Admin. Lunch in break room Newsletters Quality updates Post quality data Be creative and mix your methods – people learn in many different ways. Communication demonstrates caring and respect for your staff and their commitment to the facility. Brief nsg. station stand-up meetings are an excellent way to communicate. People do read bulletin boards. Make sure the information is changed each week and place the boards in strategic areas that staff members can’t miss. Communicate the “score” – people want to know progress reports about quality of care indicators. Highlight improvements and achievements. People want to know they are part of a winning team. Research shows that repetition is the key to behavior change. What are some other vehicles do you use to communicate to your employees?Be creative and mix your methods – people learn in many different ways. Communication demonstrates caring and respect for your staff and their commitment to the facility. Brief nsg. station stand-up meetings are an excellent way to communicate. People do read bulletin boards. Make sure the information is changed each week and place the boards in strategic areas that staff members can’t miss. Communicate the “score” – people want to know progress reports about quality of care indicators. Highlight improvements and achievements. People want to know they are part of a winning team. Research shows that repetition is the key to behavior change. What are some other vehicles do you use to communicate to your employees?

    24. Pillar #4 Recognition Caregivers thirst for recognition Catch them in the act of compassion Recognize teams for quality improvement Recognize new employees Create positive feedback loops The power of “thank you” cards 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 An analysis of the action plans the facilities developed at the C of E workshops revealed that the #1 plan of action involved stepping up their recognition of front-line staff. If you want folks to work as a team you must reward the team. RIG THE Raffles.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 An analysis of the action plans the facilities developed at the C of E workshops revealed that the #1 plan of action involved stepping up their recognition of front-line staff. If you want folks to work as a team you must reward the team. RIG THE Raffles.

    25. Thank You Cards Cards are powerful Send them to staff members’ homes Birthday cards Anniversary cards Excellent attendance “I appreciate you” “I am glad you work for us. On behalf of the residents, their families and your co-workers – Thank you.” Cards are a powerful way to reinforce positive behavior Send the cards to their homes. This sends a powerful message to their families that their place of work is proud of them. Their families knowledge reinforces the positive feeling that comes from praise. Send b day cards, anniversary cards, congratulations and condolences. Get to know your staff as people and you will learn what's going on in their lives which is significant. Cards say, “I care about you.” At Department head meetings, pass out blank cards and have them write them during the meeting. Then mail them and 10 –12 will go out that day. Pass out blank cards at family council meetings. Action – write a card now. And, we’ll get you started by giving you a box. At this point during our workshops we stopped, handed out thank you cards, and had the participants take the time to write a thank you card to a C.N.A. We encouraged them to send the card to the staff members home as this is more powerful than handing them the card at work. Cards are a powerful way to reinforce positive behavior Send the cards to their homes. This sends a powerful message to their families that their place of work is proud of them. Their families knowledge reinforces the positive feeling that comes from praise. Send b day cards, anniversary cards, congratulations and condolences. Get to know your staff as people and you will learn what's going on in their lives which is significant. Cards say, “I care about you.” At Department head meetings, pass out blank cards and have them write them during the meeting. Then mail them and 10 –12 will go out that day. Pass out blank cards at family council meetings. Action – write a card now. And, we’ll get you started by giving you a box. At this point during our workshops we stopped, handed out thank you cards, and had the participants take the time to write a thank you card to a C.N.A. We encouraged them to send the card to the staff members home as this is more powerful than handing them the card at work.

    26. How to Praise Effectively Praise should be: Timely Specific Sincere Proportional Positive Timely – do not wait. Give praise as soon as possible after good performance takes place. Praise tends to lose its effectiveness with the passing of time. Specific – tell the person exactly what the did that was good. Avoid generalities like a simple – “good job” Being specific lets the person know what behaviors to repeat Sincere – insincere or manipulative praise is worse than none at all. Be honest and open. Tell the person what their performance means to you personally. Proportional – match the amount and intensity of the recognition to the achievement. Going overboard for small stuff will make people question your motives. Require dept heads to praise 5. Have dept heads praise each other. An example “Maria, I couldn’t help but notice that you skipped your lunch break in order to stay with the new admission. You noticed how upset she was after her family had left and you showed great compassion and service in how you calmed her down and used some of the distraction techniques we talked about at yesterdays in-service. Thank you. It means a lot to me to see your compassion is action and I am proud you work here. Keep up the great work.Timely – do not wait. Give praise as soon as possible after good performance takes place. Praise tends to lose its effectiveness with the passing of time. Specific – tell the person exactly what the did that was good. Avoid generalities like a simple – “good job” Being specific lets the person know what behaviors to repeat Sincere – insincere or manipulative praise is worse than none at all. Be honest and open. Tell the person what their performance means to you personally. Proportional – match the amount and intensity of the recognition to the achievement. Going overboard for small stuff will make people question your motives. Require dept heads to praise 5. Have dept heads praise each other. An example “Maria, I couldn’t help but notice that you skipped your lunch break in order to stay with the new admission. You noticed how upset she was after her family had left and you showed great compassion and service in how you calmed her down and used some of the distraction techniques we talked about at yesterdays in-service. Thank you. It means a lot to me to see your compassion is action and I am proud you work here. Keep up the great work.

    27. Pillar #5 Empowerment Empower employees by giving them: Knowledge of what is expected Skills and resources Feedback on how they are doing Feedback on how the facility is performing Opportunity to improve work processes Opportunity to provide feedback (surveys) Primary Assignments When you build knowledge and skills you build self esteem 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. Fundamental to the Wellspring model is the managers belief that the best decisions about how care should be carried out are made by the front-line staff who know the resident best. Under the Wellspring Model – they empower staff through extensive education, shared decision making and enhancing the critical thinking skills of the front-line staff. When you build knowledge and skills you build self esteem 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. Fundamental to the Wellspring model is the managers belief that the best decisions about how care should be carried out are made by the front-line staff who know the resident best. Under the Wellspring Model – they empower staff through extensive education, shared decision making and enhancing the critical thinking skills of the front-line staff.

    28. Career Ladders Competency Based Model C.N.A. Level 1 C.N.A. Level 2 – Advanced C.N.A. Level 3 – Geriatric C.N.A. Level 3 – Restorative C.N.A. Level 3 – Dementia C.N.A. Level 4 - Mentor

    29. Primary assignments Improve teamwork Enhance relationships Improve attendance Improve screening and assessments Allows for resident-centered care Improves quality of life Improve outcomes Low turnover facilities utilize primary assignments of their staff. MAK from Wellspring speaks to the power of primary assignments. 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. Low turnover facilities utilize primary assignments of their staff. MAK from Wellspring speaks to the power of primary assignments. 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.

    30. 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?

    31. Pillar #6 Train or Hope Key Elements – What Works: Interactive/hands-on A safe environment Multi-faceted approaches Individualized, small and large group English and Spanish versions Reminders and refreshers Resource binders Videos, pocket cards, posters, pay check stuffers People learn in many ways and the bombardment method works. Interactive Education – Make sure you incorporate the basic concepts of adult learners – real world case studies, discussions, practice sessions and return demonstrations. Use case studies as examples Create a safe environment – for example – do not require C.N.A.’s to read out loud. Respect staff by making it interactive. In order to make sure your staff know “why” you may need to translate material to the native language. Reminders and refreshers help reinforce your key messages. Use your bulletin boards. Resource binders need to be made available at the nursing stations and in employee break rooms. ESL specific to LTC vocabularyPeople learn in many ways and the bombardment method works. Interactive Education – Make sure you incorporate the basic concepts of adult learners – real world case studies, discussions, practice sessions and return demonstrations. Use case studies as examples Create a safe environment – for example – do not require C.N.A.’s to read out loud. Respect staff by making it interactive. In order to make sure your staff know “why” you may need to translate material to the native language. Reminders and refreshers help reinforce your key messages. Use your bulletin boards. Resource binders need to be made available at the nursing stations and in employee break rooms. ESL specific to LTC vocabulary

    32. Important Topics Orientation Assessment Dementia care Hospice Customer service Internal and external The only thing worse than training your staff and then they leave is not training them and they stay. Here are some of the key topics that have been identified by researchers which high quality NHs train their staff on and low performing facilities do not. Performance is based on people and only improves when people improve. Performance does not improve after training completed. Performance improves only if people adopt and implement what they learned into everyday practices. Hold staff accountable to demonstrate that they learned the material Department heads and clinical champions must be assigned to go out on the floors and help people use the skills and knowledge shared during training sessions. A NH rich with opportunities to acquire new knowledge and skills fosters high performance and lowers turnover. The only thing worse than training your staff and then they leave is not training them and they stay. Here are some of the key topics that have been identified by researchers which high quality NHs train their staff on and low performing facilities do not. Performance is based on people and only improves when people improve. Performance does not improve after training completed. Performance improves only if people adopt and implement what they learned into everyday practices. Hold staff accountable to demonstrate that they learned the material Department heads and clinical champions must be assigned to go out on the floors and help people use the skills and knowledge shared during training sessions. A NH rich with opportunities to acquire new knowledge and skills fosters high performance and lowers turnover.

    33. Building Skills Critical thinking Extending sympathy Conflict resolution Handling complaints Easing the stress of long waits Easing anxiety through conversation Empathic listening To move and organization from a control paradigm to empowerment/release requires skill building of both the leaders and the frontline staff. Providing frontline staff with specific training on these topics makes their job easier and more gratifying. Learning how to provide great service and putting it into action gives employees immediate feedback from pleased family members. It fulfills the intrinsic motivation of nurses and nursing assistants - and it allows them to improve their caring and compassionate approaches with people. Distraction away from embarrassment is a key skill and leads to enhanced relations between staff and residents. Is there a lot of un-learning that must also take place? Un-learning takes more time than learning new skills. It is important that we stress build-up – the accumulation of knowledge and know-how- when working with the pilot facility leaders. The list of the new skills that leaders must acquire in the new culture are these and a whole bunch more. To move and organization from a control paradigm to empowerment/release requires skill building of both the leaders and the frontline staff. Providing frontline staff with specific training on these topics makes their job easier and more gratifying. Learning how to provide great service and putting it into action gives employees immediate feedback from pleased family members. It fulfills the intrinsic motivation of nurses and nursing assistants - and it allows them to improve their caring and compassionate approaches with people. Distraction away from embarrassment is a key skill and leads to enhanced relations between staff and residents. Is there a lot of un-learning that must also take place? Un-learning takes more time than learning new skills. It is important that we stress build-up – the accumulation of knowledge and know-how- when working with the pilot facility leaders. The list of the new skills that leaders must acquire in the new culture are these and a whole bunch more.

    34. Pillar #7 Measurement Staff satisfaction Attendance Shifts worked short Turnover rates By shift By unit Resident and family satisfaction Quality Measures Quality Indicators 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.

    35. Process to Collect Satisfaction Data Survey design – questions to ask Timing Cover letter Encourage all to respond Explain what you will do with the results Anonymous Return to a front-line staff member Do not assume you know what the morale is. Collect your own data just as you would with any clinical issue before you begin the quality improvement process. Design – ask questions related to the issues researchers have identified which influence a persons perception of workplace satisfaction and decision to stay with you: Questions related to the work environment -Training,, Communication, Supervision, Care Giving, And General – such as “I would recommend this facility as a good place to work” Consider using a four point Likert scale – Strongly Disagree, Disagree, Agree, Strongly agree. Translate the survey in order to increase the response rate. Research has shown that the response rate of staff satisfaction surveys is a good indicator of how well a facility is run. You can expect a higher response rate from from facilities with better quality outcomes. When it comes to Sat. Surveys – 20% is the survey tool 20% is the process to administer and collect the surveys 60% is what you do with the resultsDo not assume you know what the morale is. Collect your own data just as you would with any clinical issue before you begin the quality improvement process. Design – ask questions related to the issues researchers have identified which influence a persons perception of workplace satisfaction and decision to stay with you: Questions related to the work environment -Training,, Communication, Supervision, Care Giving, And General – such as “I would recommend this facility as a good place to work” Consider using a four point Likert scale – Strongly Disagree, Disagree, Agree, Strongly agree. Translate the survey in order to increase the response rate. Research has shown that the response rate of staff satisfaction surveys is a good indicator of how well a facility is run. You can expect a higher response rate from from facilities with better quality outcomes. When it comes to Sat. Surveys – 20% is the survey tool 20% is the process to administer and collect the surveys 60% is what you do with the results

    36. Results of Satisfaction Surveys Personally respond to a signed survey Promptly post the results Recruit a multi-disciplinary team Analyze the results Focus on “hot” issues Root Cause Analysis PDSA Post the action plan Re-survey Personally respond to a signed survey with low ratings Promptly post the results Recruit a multi-disciplinary team Analyze the results Focus on “hot” issues PDSA – Root cause analysis Post the action plan Re-survey Personally respond to a signed survey with low ratings Promptly post the results Recruit a multi-disciplinary team Analyze the results Focus on “hot” issues PDSA – Root cause analysis Post the action plan Re-survey

    37. Pillar #8 Quality Improvement A Paradigm Shift Deming’s 85% Rule Poor quality comes from poor work processes Workers want to do a good job Generally, healthcare leaders recognize quality improvement as a strategic asset and competitive advantage. However, executing plans and actions that incorporate quality improvement on a consistent basis remains an ongoing challenge. W. Edwards Deming – was a businessman looking to improve business results. They utilized the principles we hold dear in order to improve business results – profit. These same foundational principles of CQI that we embrace in LTC also lead to bottom line results. his principle theory was that most product defects and quality failures result from management failures rather than worker failures. Deming’s advice – don’t try to change your workers until you first change yourself. He said - 85% of the problems within our organizations are the fault of the leaders. However, 85% of leaders blame their problems on the personnel short coming of their staff. LTC employees are miserable when working in organizations that provide lousy care and service. Generally, healthcare leaders recognize quality improvement as a strategic asset and competitive advantage. However, executing plans and actions that incorporate quality improvement on a consistent basis remains an ongoing challenge. W. Edwards Deming – was a businessman looking to improve business results. They utilized the principles we hold dear in order to improve business results – profit. These same foundational principles of CQI that we embrace in LTC also lead to bottom line results. his principle theory was that most product defects and quality failures result from management failures rather than worker failures. Deming’s advice – don’t try to change your workers until you first change yourself. He said - 85% of the problems within our organizations are the fault of the leaders. However, 85% of leaders blame their problems on the personnel short coming of their staff. LTC employees are miserable when working in organizations that provide lousy care and service.

    38. Addressing Absenteeism Retention is a complex problem that requires multi-faceted solutions. I like to think of improving retention and stabilizing staff as a jigsaw puzzle with at least a hundred pieces that need to be put in the right place to solve the challenging puzzle. Addressing absenteeism is a key piece of the puzzle. Working short staffed is strongly associated with staff turnover. First – we will take a quick look at the data Then- we will explore strategies identified by researchers and LTC experts regarding how to lower absenteeism rates. In addition, we will talk about scheduling because scheduling errors lead to absenteeism.Retention is a complex problem that requires multi-faceted solutions. I like to think of improving retention and stabilizing staff as a jigsaw puzzle with at least a hundred pieces that need to be put in the right place to solve the challenging puzzle. Addressing absenteeism is a key piece of the puzzle. Working short staffed is strongly associated with staff turnover. First – we will take a quick look at the data Then- we will explore strategies identified by researchers and LTC experts regarding how to lower absenteeism rates. In addition, we will talk about scheduling because scheduling errors lead to absenteeism.

    39. Absenteeism Complex Morale Quality Service Safety Retention Facilities with chronic absenteeism usually have high turnover. Therefore, we must address the issue of absenteeism. A Complex Organizational problem– There is no perfect plan. The root causes in each of your facilities is different. Therefore, they require careful analysis before deciding on interventions. However, there are best practices out there. Some organizations actually have systems that encourage absenteeism. Company-wide attendance problems are the sign of a sick system, not a sick employee. Oftentimes, we react to the problem as if getting tougher on the violators will solve the problem. In this sense we are blaming the problem on the personal short comings of the staff rather than looking at our own organizational or leadership practices as the cause. Morale – facilities with absenteeism problems have morale problems. Quality – absenteeism leads to tired staff or vacant shifts – both of which have a negative effect on q of care and life. Service – absenteeism leads to delayed, or worse, denied service. Safety – tired staff and vacant shifts leads to workplace injuries. Retention – often, the vicious cycle of turnover starts with flawed organizational systems related to scheduling and absenteeism. Facilities with chronic absenteeism usually have high turnover. Therefore, we must address the issue of absenteeism. A Complex Organizational problem– There is no perfect plan. The root causes in each of your facilities is different. Therefore, they require careful analysis before deciding on interventions. However, there are best practices out there. Some organizations actually have systems that encourage absenteeism. Company-wide attendance problems are the sign of a sick system, not a sick employee. Oftentimes, we react to the problem as if getting tougher on the violators will solve the problem. In this sense we are blaming the problem on the personal short comings of the staff rather than looking at our own organizational or leadership practices as the cause. Morale – facilities with absenteeism problems have morale problems. Quality – absenteeism leads to tired staff or vacant shifts – both of which have a negative effect on q of care and life. Service – absenteeism leads to delayed, or worse, denied service. Safety – tired staff and vacant shifts leads to workplace injuries. Retention – often, the vicious cycle of turnover starts with flawed organizational systems related to scheduling and absenteeism.

    40. 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.

    41. Findings from WFR Collaborative 40% of all shifts understaffed No difference between weekends and weekdays Average number of call-offs per month = 45 Licensed staff called off as often as C.N.A.’s Most common reason for termination

    42. WFR Findings Continued What does it feel like when understaffed? “Stressful; no lunch break, your back hurts.” “Unsafe for patients and self.” “Hectic – finger nails do not get clipped, men don’t get shaved, people are left with empty cups.” “Hell.”

    43. WFR Findings Continued What happens that leads your co-workers to call-off? “Just tired mentally. Overwhelmed and can’t overcome it.” “Burn out if you worked 7 am to 11 pm.” “Stress – someone is always asking you to stay late.” Top reasons for call-offs: Sickness of self Sick family member Baby sitter problem Car problem Domestic crises What happens that leads to call-offs? It sounds like they are answering for themselvesWhat happens that leads to call-offs? It sounds like they are answering for themselves

    44. WFR Findings Continued 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.” More human – Does this imply that when they are understaffed you can not be human. That you shut down your human emotions in order to get through the shift. In no case did the answers indicate that money was a factor.More human – Does this imply that when they are understaffed you can not be human. That you shut down your human emotions in order to get through the shift. In no case did the answers indicate that money was a factor.

    45. The “Stop Doing” List Incentives to waive benefits Bonuses for working short Scheduling overtime and double-time Rotating staff Sick pay – use it or lose it No sick pay until second day of absence No incentives or disincentives 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.

    46. The “To Do” List No-fault attendance policy Measure and track Educate leaders Reward reliability Reward improvement Proactive replacement plan Wellness Scheduling

    47. No-Fault Attendance Policy No more qualifying absences Removes inequity No need for physician notes Absences are simply measured Promotes trust Bear in mind that the process of qualifying whether or not an absence is excused or not is important and those decisions can make or break the foundation of trust in an organization. Some facilities have adopted a “no-fault” attendance policy – this takes the guess work out of trying to qualify absences. You are either here or you are not. No need for M.D. notes to justify an absence. Absences for any reason are all treated the same. Bear in mind that the process of qualifying whether or not an absence is excused or not is important and those decisions can make or break the foundation of trust in an organization. Some facilities have adopted a “no-fault” attendance policy – this takes the guess work out of trying to qualify absences. You are either here or you are not. No need for M.D. notes to justify an absence. Absences for any reason are all treated the same.

    48. Collect Data Single point person Review individual records monthly Individual’s and facility trends By day of the week By unit, shift Average number of call-offs per employee per quarter “Sick pay” dollars Leaders attendance records Number of call-offs per month Alert supervisors to alert individuals First and foremost, an effective program starts with collecting good data. Collect data for each individual employee, department, facility both for absenteeism and the number of shifts worked short staffed. Usually, having one person (and one back-up) coding and tracking absenteeism works best. In terms of effective systems – this single point person would then review all of the attendance records monthly and alert supervisors of trends (both positive and negative) by making a copy of employees attendance records and sending them to their supervisors. Also, make a copy of the each employee’s attendance record on a quarterly basis and include it in the employee’s paycheck in order to provide them with regular and consistent feedback. Letters example. In addition, as part of the process of employee evaluations, they would make a copy of the employees attendance record and attach it to the appraisal forms to be completed. These simple processes related to data collection and alerting supervisors are important and tell the staff you take the problem very serious.First and foremost, an effective program starts with collecting good data. Collect data for each individual employee, department, facility both for absenteeism and the number of shifts worked short staffed. Usually, having one person (and one back-up) coding and tracking absenteeism works best. In terms of effective systems – this single point person would then review all of the attendance records monthly and alert supervisors of trends (both positive and negative) by making a copy of employees attendance records and sending them to their supervisors. Also, make a copy of the each employee’s attendance record on a quarterly basis and include it in the employee’s paycheck in order to provide them with regular and consistent feedback. Letters example. In addition, as part of the process of employee evaluations, they would make a copy of the employees attendance record and attach it to the appraisal forms to be completed. These simple processes related to data collection and alerting supervisors are important and tell the staff you take the problem very serious.

    49. Educate Leaders Accountability Set the example Discuss absenteeism during meetings Rewards and recognition Individuals and groups Show data Meet with staff as problems arise Help staff solve the problem Fair and firm Beyond that – leaders are charged with keeping the issue at the forefront of everyone. It should be a standard agenda item during dept. meetings. Recognition – there needs to be both public and private recognition for excellent attendance. On a quarterly basis, leaders should send thank you cards for good attendance. Reward reliable staff – allow staff to cash out one sick day per quarter for no call-offs. There are many other incentives facilities have designed. The key is, are you rewarding the right behavior. Consider raffles and include only those staff in the raffle who had perfect attendance for a specified period of time. Reward improvement – for those who had poor attendance and received counseling, oftentimes, when they improve, it’s ignored. Therefore, leaders must seek out those who have had improvement and let the employee know that they noticed it and appreciate it. Reward new staff and allow them to cash out a sick day if no call offs in the first six months. Leaders are the key and they must set the example by having excellent attendance records themselves. Using the system I just described, leaders must meet with their staff as problems arise. Being concerned for the welfare of the employee and showing it and expressing it. Exploring how they may assist the staff member to solve the problem. Leaders should be fair yet firm. There will be individuals who have no legitimate excuse and they must be dealt with. But collecting good data allows you to identify these individuals. However, this must be balanced with a genuine care and concern for the well being of the staff and their families.Beyond that – leaders are charged with keeping the issue at the forefront of everyone. It should be a standard agenda item during dept. meetings. Recognition – there needs to be both public and private recognition for excellent attendance. On a quarterly basis, leaders should send thank you cards for good attendance. Reward reliable staff – allow staff to cash out one sick day per quarter for no call-offs. There are many other incentives facilities have designed. The key is, are you rewarding the right behavior. Consider raffles and include only those staff in the raffle who had perfect attendance for a specified period of time. Reward improvement – for those who had poor attendance and received counseling, oftentimes, when they improve, it’s ignored. Therefore, leaders must seek out those who have had improvement and let the employee know that they noticed it and appreciate it. Reward new staff and allow them to cash out a sick day if no call offs in the first six months. Leaders are the key and they must set the example by having excellent attendance records themselves. Using the system I just described, leaders must meet with their staff as problems arise. Being concerned for the welfare of the employee and showing it and expressing it. Exploring how they may assist the staff member to solve the problem. Leaders should be fair yet firm. There will be individuals who have no legitimate excuse and they must be dealt with. But collecting good data allows you to identify these individuals. However, this must be balanced with a genuine care and concern for the well being of the staff and their families.

    50. The Foundation is Trust Trust is essential Leaders reveal priorities daily Respect vs. contempt Micro-inequities Covering shifts Elders are the priority Leaders must set the example in order to gain trust. Therefore, corps need systems to track their leaders absenteeism records. If they call-off, the staff will call-off. Trust starts with believing what the employee says. This is difficult some times. However, not believing the employee for the reason they were not at work can have serious consequences. Leaders who express negative attitudes toward the frontline staff, or contempt, on the whole were those who had had high turnover and absenteeism. Eaton found that those who showed respect had lower absenteeism It is what we call a micro-inequity. A serious micro-inequity is the way we typically treat Dept Head call-offs compared to frontline staff call offs. Gaining trust is essential to tackle the absenteeism problem and for covering shifts to prevent short staffing. In Eaton’s study, she found that the vicious cycle of turnover and short staffing in the low performing facilities was primarily due to a lack of trust among the staff members themselves. They would not cover shifts for one another because they could never trust that if they agreed to cover a shift for someone that they would be there for them when they needed a favor. Certainly, leaders must keep the elders and their safety and wellbeing, at the forefront of their discussion about the need to reduce absenteeism and short staffing. Leaders must set the example in order to gain trust. Therefore, corps need systems to track their leaders absenteeism records. If they call-off, the staff will call-off. Trust starts with believing what the employee says. This is difficult some times. However, not believing the employee for the reason they were not at work can have serious consequences. Leaders who express negative attitudes toward the frontline staff, or contempt, on the whole were those who had had high turnover and absenteeism. Eaton found that those who showed respect had lower absenteeism It is what we call a micro-inequity. A serious micro-inequity is the way we typically treat Dept Head call-offs compared to frontline staff call offs. Gaining trust is essential to tackle the absenteeism problem and for covering shifts to prevent short staffing. In Eaton’s study, she found that the vicious cycle of turnover and short staffing in the low performing facilities was primarily due to a lack of trust among the staff members themselves. They would not cover shifts for one another because they could never trust that if they agreed to cover a shift for someone that they would be there for them when they needed a favor. Certainly, leaders must keep the elders and their safety and wellbeing, at the forefront of their discussion about the need to reduce absenteeism and short staffing.

    51. Involvement = Commitment Multi-disciplinary committee Sets attendance standards Input on recognition Guidance on scheduling Employee Assistance Programs Involvement is key – create a committee to oversee and set parameters regarding attendance and scheduling. High involvement means high commitment. Transforming a stagnant recruitment and retention team to have input on real issues like absenteeism and scheduling – key component of retention. Today’s employees want to be involved on teams that focus on real issues. They want to know they are making a difference. So the more you involve them, the more likely that you will gain their commitment. Employee Assistance Programs not only help to foster a sense of community within a SNF, they work. Estimates are that for every dollar invested in EAPs, an organization can save between $5 and $16. Companies with EAPs in place that are advertised and utilized report fewer accidents, lower turnover and lower absenteeism rates.Involvement is key – create a committee to oversee and set parameters regarding attendance and scheduling. High involvement means high commitment. Transforming a stagnant recruitment and retention team to have input on real issues like absenteeism and scheduling – key component of retention. Today’s employees want to be involved on teams that focus on real issues. They want to know they are making a difference. So the more you involve them, the more likely that you will gain their commitment. Employee Assistance Programs not only help to foster a sense of community within a SNF, they work. Estimates are that for every dollar invested in EAPs, an organization can save between $5 and $16. Companies with EAPs in place that are advertised and utilized report fewer accidents, lower turnover and lower absenteeism rates.

    52. Proactive Replacement Plan Short term: Clear policy regarding who and when Allow for last minute coverage for each other Call employee who called off Show concern Replace for next shift? Replacement priority list No overtime Voluntary overtime no double time Voluntary OT/DT Agency staff Short term: Clear policy regarding who to call and when to call off Call employee who called off – must have high levels of trust Show concern – “Hope you are feeling better soon.” Replace for next shift? – “In order to prevent short staffing, we want to be proactive and replace you now if you think that you will not be in for your next shift.” Replacement priority list – in order No overtime- for the replacement Voluntary overtime no double time – 4 hours during peak time Voluntary OT/DT – eat the expense to prevent working short Agency staff – if needed, but only if good and reliable (next slide) Staff member who previously called off in pay period – ask this person last. Do not reward them for calling off for a regular shift by providing them with OT/DT. If you do, they earned more that week by calling off. Short term: Clear policy regarding who to call and when to call off Call employee who called off – must have high levels of trust Show concern – “Hope you are feeling better soon.” Replace for next shift? – “In order to prevent short staffing, we want to be proactive and replace you now if you think that you will not be in for your next shift.” Replacement priority list – in order No overtime- for the replacement Voluntary overtime no double time – 4 hours during peak time Voluntary OT/DT – eat the expense to prevent working short Agency staff – if needed, but only if good and reliable (next slide) Staff member who previously called off in pay period – ask this person last. Do not reward them for calling off for a regular shift by providing them with OT/DT. If you do, they earned more that week by calling off.

    53. Staff Vacancy Long term: Agency Only selected agencies Repeat hire agency staff Orientation, extended written and verbal report Drop everything to interview Sign-up for extra shifts Meet with staff regularly Update on progress Do not allow employees to work over 60 hours per weekDo not allow employees to work over 60 hours per week

    54. If Working Short Staffed Pre-shift meeting Relieve licensed staff or C.N.A.’s of certain duties Housekeepers pass trays and make beds Dietary staff pass trays, pick up trays, pass water pitchers D.O.N. complete some treatments Managers assist on the floor Feed the staff Pats on the back

    55. Wellness Health and dental insurance Flu shots for staff and families Free vitamins Healthy snacks and food Discounts to health clubs Smoking cessation classes Stress and work/life management Wellness – encouraging staff to accept benefits is key. Benefits – ground people to organizations and keep them with you. No benefits = no committeemen. Also, those with no health insurance do not see physicians. Vitamins, food, health clubs – consider offering you staff a nice break room that is clean and comfortable. Offer free vit. C, healthy food, low cost lunch, discounts on memberships to health clubs, stress counseling, educational speakers on women’s issues. Notice – there is nothing on here that reflects getting tougher is the answer because it is not. Often, when attendance problems arise, we tend to place immediate blame on the individuals who are calling off and identify their personal issues as the problem. However, many times we, the leaders of the organization are contributing to the problem. Wellness – encouraging staff to accept benefits is key. Benefits – ground people to organizations and keep them with you. No benefits = no committeemen. Also, those with no health insurance do not see physicians. Vitamins, food, health clubs – consider offering you staff a nice break room that is clean and comfortable. Offer free vit. C, healthy food, low cost lunch, discounts on memberships to health clubs, stress counseling, educational speakers on women’s issues. Notice – there is nothing on here that reflects getting tougher is the answer because it is not. Often, when attendance problems arise, we tend to place immediate blame on the individuals who are calling off and identify their personal issues as the problem. However, many times we, the leaders of the organization are contributing to the problem.

    56. Eaton’s Findings on Scheduling Most common reason for termination Different practices in low vs. high Communication Flexible Allow for different start times Consider personal lives Rigid In response to problems “Personal life is not my problem.” Used as discipline 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 .

    57. Staffing Coordinators Complex task Requires education Recognition and rewards Character traits: – integrity, fairness It is interesting to note that both the high and low turnover facilities had full time scheduling coordinators. However, how this key, powerful individual handles this responsibility can make or break the organization. Scheduling is complex and requires education. In addition, this individual should be carefully selected. If this individual appears to act with favoritism, the morale of the facility will sink to new depths. If they are rigid, turnover and absenteeism become more common. Favoritism damages morale – Thus, the scheduler needs to be someone who is fair, flexible, friendly and focused on the elders. They are the most harassed person in the facility and they hold tremendous power. It is interesting to note that both the high and low turnover facilities had full time scheduling coordinators. However, how this key, powerful individual handles this responsibility can make or break the organization. Scheduling is complex and requires education. In addition, this individual should be carefully selected. If this individual appears to act with favoritism, the morale of the facility will sink to new depths. If they are rigid, turnover and absenteeism become more common. Favoritism damages morale – Thus, the scheduler needs to be someone who is fair, flexible, friendly and focused on the elders. They are the most harassed person in the facility and they hold tremendous power.

    58. Scheduling Success Master posted well in advance Allow staff to trade days Honor requests for time off Increase FT and decrease PRN and PT Avoid every other weekend off Primary assignments and primary days Indicate assignment on the master schedule Allow staff to trade days – the schedule may look like a mess and you may get some OT. But, the shifts are filled, you allowed the staff to do a favor for one another (trust). Engage the Director of Social Services – we must start using or DSS in a more effective way. Especially, as a professional who assists the staff with matters pertaining to their lives. Attendance is complicated by transportation and childcare issues. We can and should assist staff to solve these challenges. Primary assignments and primary days – if you can set days and set assignments, you are well on your ways to improved attendance. Rotating days leads employees to guess when they may be off. In the last facility I managed, it worked great and our top performers worked almost every weekend. Indicate assignment on the master schedule – by indicating which assignment a C.N.A. is working on the master schedule, you have eliminated that chaotic moment at the beginning of each shift when the C.N.A.’s are standing around the nursing station waiting for the charge nurse to give them their assignment. Reward and educate staffing coordinators – consider meeting with your staffing coordinators, providing education and rewarding them. In our small corp. we did this and gave them each a nice wristwatch. They were thrilled. And, we accomplished a lot regarding education. For example, a common error that was occurring with our staffing coordinators was an inability to identify how many positions were vacant. We found that facilities were turning down FT applicants because they believed that they only had a PT position available. However, the PT position was caused by numerous PRN and 2 day a week part-timers all over the schedule. The more FT staff you have the better off the facility. Thus, the facility should interview and potentially hire this person. Weekend on/weekend offs staffing systems are detrimental to the facility. It results in half your FT staff being off every weekend. Have a contingency plan for call offs. Allow staff to trade days – the schedule may look like a mess and you may get some OT. But, the shifts are filled, you allowed the staff to do a favor for one another (trust). Engage the Director of Social Services – we must start using or DSS in a more effective way. Especially, as a professional who assists the staff with matters pertaining to their lives. Attendance is complicated by transportation and childcare issues. We can and should assist staff to solve these challenges. Primary assignments and primary days – if you can set days and set assignments, you are well on your ways to improved attendance. Rotating days leads employees to guess when they may be off. In the last facility I managed, it worked great and our top performers worked almost every weekend. Indicate assignment on the master schedule – by indicating which assignment a C.N.A. is working on the master schedule, you have eliminated that chaotic moment at the beginning of each shift when the C.N.A.’s are standing around the nursing station waiting for the charge nurse to give them their assignment. Reward and educate staffing coordinators – consider meeting with your staffing coordinators, providing education and rewarding them. In our small corp. we did this and gave them each a nice wristwatch. They were thrilled. And, we accomplished a lot regarding education. For example, a common error that was occurring with our staffing coordinators was an inability to identify how many positions were vacant. We found that facilities were turning down FT applicants because they believed that they only had a PT position available. However, the PT position was caused by numerous PRN and 2 day a week part-timers all over the schedule. The more FT staff you have the better off the facility. Thus, the facility should interview and potentially hire this person. Weekend on/weekend offs staffing systems are detrimental to the facility. It results in half your FT staff being off every weekend. Have a contingency plan for call offs.

    59. QE Foundation - Scheduling Impacts turnover, attendance, quality Effective practices Consistency Continuity Cohesiveness Flexible Communication Effective practices – Priority #1 In high turnover/low quality facilities the scheduling of staff was clearly not a priority of the leaders. In low performing facilities scheduling was almost random or delegated to a receptionist as if it was just a matter of placing peoples names on pieces of paper. Yet, scheduling is anything but this. In fact, schedules, as much as any single item in a CNAs or nurses life besides their assignment, determined what their life would be like both at and outside of work. It can be a big area of contention if handled poorly. High performing facilities utilize the following practices - Consistency – Use the same number and mix of staff each day. They do not attempt to adjust to acuity and do not staff down on weekends. Continuity – They use primary assignments. They do not use registry and they are top heavy on full-time staff. Cohesiveness – The same staff work together on the same units. They are not rotated. This creates teamwork. Flexible – the Leaders and Staffing Coordinator are empathetic and trust what staff tell them. They immediately explore attendance issues in a respectful way showing concern and the willingness to work with their people. Communication – Schedules are posted well in advance and vacant shifts are clearly communicated. Effective practices – Priority #1 In high turnover/low quality facilities the scheduling of staff was clearly not a priority of the leaders. In low performing facilities scheduling was almost random or delegated to a receptionist as if it was just a matter of placing peoples names on pieces of paper. Yet, scheduling is anything but this. In fact, schedules, as much as any single item in a CNAs or nurses life besides their assignment, determined what their life would be like both at and outside of work. It can be a big area of contention if handled poorly. High performing facilities utilize the following practices - Consistency – Use the same number and mix of staff each day. They do not attempt to adjust to acuity and do not staff down on weekends. Continuity – They use primary assignments. They do not use registry and they are top heavy on full-time staff. Cohesiveness – The same staff work together on the same units. They are not rotated. This creates teamwork. Flexible – the Leaders and Staffing Coordinator are empathetic and trust what staff tell them. They immediately explore attendance issues in a respectful way showing concern and the willingness to work with their people. Communication – Schedules are posted well in advance and vacant shifts are clearly communicated.

    60. Emile Durkheim “When mores are sufficient, laws are unnecessary. When mores are insufficient, laws are unenforceable.” Mores = customs and rules of a social group Strict attendance policies and disciplinary action are not the answer. Remember, the frontline staff at the facilities in Eaton’s study were not fundamentally different kinds of people with different work ethics. They were, however, acting in a different org. setting, being treated and trusted differently. Both groups of facilities in the study had attendance policies. If the mores in a SNF are sufficient, people have better attendance rates. If the mores are insufficient, stricter policies will not improve the problem. This is where the issues of deep organizational culture change comes into play. Mores = customs and rules of a social group Strict attendance policies and disciplinary action are not the answer. Remember, the frontline staff at the facilities in Eaton’s study were not fundamentally different kinds of people with different work ethics. They were, however, acting in a different org. setting, being treated and trusted differently. Both groups of facilities in the study had attendance policies. If the mores in a SNF are sufficient, people have better attendance rates. If the mores are insufficient, stricter policies will not improve the problem. This is where the issues of deep organizational culture change comes into play.

    61. Contact Information David Farrell dfarrell2@riqio.sdps.org Phone: (401) 528-3265

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