WHAT. drives. Satisfaction IN NURSING HOMES?

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1 news, views & ideas from the leader in healthcare satisfaction measurement The Satisfaction Snapshot is a monthly electronic bulletin freely available to all those involved or interested in improving the patient/ client experience. Each month the Snapshot showcases issues and ideas which relate to improving patient satisfaction and customer service, improving workplace culture and improving the way we go about our work in the healthcare industry. Customer WHAT drives Satisfaction IN NURSING HOMES? What drives aged care customer satisfaction? What steps can a facility take to improve challenging service issues? Strategies exist to improve customer satisfaction, embed trust and minimise the effects of a disappointing service experience. According to Press Ganey s most recent survey: Of all service issues surveyed, customers are most satisfied with staff courtesy. Of all service issues surveyed, customers are least satisfied with nursing aides responsiveness to call lights. The number one issue most highly related to a customer s likelihood to recommend a facility to others is management s responsiveness to customers. Overall, families are more satisfied than residents and there are significant differences between the perceptions of these two groups. Residents are less satisfied with admission, room, dining and nurses than are families. Families are less satisfied with housekeeping than are residents. If a nursing home desires word of mouth referrals, it must be serious about being responsive to its current clients. (See Table 1 on page 2) The Satisfaction Snapshot features: «relevant articles from healthcare industry experts «case study success stories «tips and tools for quality improvement «patient satisfaction and other industry research findings «articles with ideas to help achieve success in your role If you would like your colleagues to receive the Satisfaction Snapshot please send us their names and addresses. The Satisfaction Snapshot is published by Press Ganey Associates Pty Ltd. All material is copyright protected. Quotation is permitted with attribution. Subscribers are permitted and encouraged to distribute copies within their organisations. Subscription to the Satisfaction Snapshot is FREE! Please direct any comments, suggestions or article submissions to: Sharon Kerr Manager of Client Relations sharon.kerr@pressganey.com.au P: F:

2 page 2 TABLE 1 Percentage of customers who say the likelihood that they will recommend is very good 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Likelihood to Recommend by Management Responsiveness to Customer Ideas (Represents data collected between 1/1/2003 and 3/6/2003 from 12,263 customers at 303 nursing homes) 6% 5% 13% The top priorities for improving nursing home customer satisfaction reflect the importance customers place on receiving complete, useful and timely information about resident s care and feeling like the staff is responsive to their input (see Table 2 for the top priority actions). Action Steps What steps can a facility take to enhance customer service in areas that matter most to residents and their families? We can learn what it takes to enhance customer service by studying those who have mastered challenging service issues. Best practice managers, nurses and aides have taken bold and deliberate steps to listen to and involve residents and families. Their methods include: Implementing resident/family suggestions on how to make a more home-like environment. Taking concrete steps to create sincere connections with residents and families. 40% 94% very poor poor fair good very good Customers ratings of how receptive management is to their ideas Of the nursing home customers who rated their home s management most favourably in terms of being receptive to their ideas (very good), 94% rated the chance that they would recommend the home to others as very good. Of those who rated their home s management as good in terms of being receptive to their ideas, only 40% rated the chance that they would recommend the home to others as very good. In sum, if a nursing home desires word-of-mouth referrals, it must be very serious about being responsive to its current customers. Improving communication methods to educate residents and families. Actively seeking to collaborate with residents and families on all aspects of care. In addition to the previous steps, satisfaction measurement and strong leadership are critical factors in building a culture of excellence. The greatest quality improvements are made and sustained when performance excellence is mandated from the top and integrated into the facilty s culture. Therefore, every organisation should possess individuals with the following leadership characteristics: Demonstrates a recognisable commitment. Articulates a service vision. Role models a passion for service excellence. Exercises servant leadership. Rewards and recognises others. Connects the dots. Leaders communicate their visions loudly and frequently in meetings, writing and group settings. They are always willing to show who they are and what they stand for. They ensure that others know their skills, talents, values and priorities. Leaders are not afraid to show their colleagues and employees that they care about them as individuals. They take the time to find out who their staff are as individuals (e.g. their personal interests, family, etc.). They assess employee strengths and interest in developing new skills, and design training assignments accordingly. Leaders acknowledge that management does not have all the answers. They ask employees for insight to solve problems and give constructive feedback. Members of management who want to be leaders give their total attention to employees as they would any "customer" they want to WOW. Successful leaders empower their employees by allowing them to make as many decisions as possible. Leaders make recognition part of their daily job responsibilities by saying "thank you for doing a good job." They make team recognition a formal permanent and significant part of all standing meeting agendas through the creation of a peer-to-peer recognition program.

3 page 3 TABLE 2 Correlation w/overall NURSING HOME PRIORITY INDEX 2003 Mean Mean Mean Correlation Priority Priority Question n Score Score Rank Rank Index Rank F5. Explanation of your care (aides section) 10, F4. Responsiveness to your own ideas about your care 10, F3. How well aides kept you informed about your care 10, J2. How receptive management is to your ideas 9, F7. Aides responsiveness to call lights 10, F2. Technical skill of aides 11, G4. Promptness of eliminating odors from facility 11, H4. Staff receptiveness to your activity ideas 7, H2. Variety of educational activities 8, J3. Likelihood of your recommending this facility 11, F6. Likelihood of being treated with dignity (Aides) 11, D3. Likelihood of taking care of issues properly 10, E3. Responsiveness to your own ideas about your care 11, E4. Explanation of your care (nurses section) 11, C3. Assistance at meals (if needed) 9, G2. Skill of cleaning room 11, C1. Variety of food selection 11, E5. Likelihood of being treated with dignity (Nurse) 11, G3. Quality of laundry service 9, C2. Quality of food 11, D2. Skill of maintenance staff 10, B3. Cleanliness of your room 12, H1. Variety of recreational activities 9, J1. Availability of doctor 10, B1. Noise level around room 12, C5. How well meals met your special diet 10, F1. Friendliness of aides 11, E2. Technical skill of nurses 11, C6. Respect shown by dining staff 10, G1. Courtesy of housekeeping staff 11, I4. Appropriateness of monthly fee 7, J4. Treatment of visitors 11, H3. Variety of religious activities 8, J5. Security of the facility 11, I3. Billing procedures easy to understand 8, I2. Explanation of monthly fees 8, A3. Explanation of services 9, C4. Cleanliness of dining area 10, D1. Courtesy of maintenance staff 11, E1. Friendliness of the nurses 11, B2. How well things work 12, A2. Explanation of rights and responsibilities 9, I1. Friendliness of business office 9, A1. Courtesy of admitting staff 10, Press Ganey Associates, Inc. Based on 12,636 responses received in the first 6 months of 2003 from 376 facilities.

4 page 4 Leaders help staff understand how service excellence relates to why they went into health care. Finally, to achieve the ultimate level of responsiveness, every organisation must take a best practice approach by implementing the six key features of top service recovery programs. Awareness of expectations. Acknowledge mistakes. Apologise. Actively listen. Act to amend. Avoid future service failures. A well-developed service recovery program enhances continuous quality improvement efforts in resident care and customer satisfaction. It also contributes to workforce excellence by empowering employees to resolve complaints immediately. Effectively responding to customer concerns is the right thing to do. You are in the most important profession in the world. You are helping to save and restore the lives of families that have been torn apart by disease and injury. There is nothing more important than that, nothing. What Everyone in Health Care Needs to Know About Service Quality Gustafson and Stuedel Sharyl Wojciechowski, MA, Service Quality Consultant Sabina Gesell, Ph.D., Senior Research Associate Aimee Williams, Research Analyst

5 page 5 CultureChange = Customer Satisfaction in Aged Care Rose Marie Fagan Executive Director, Pioneer Network True customer satisfaction can seem as mythical and elusive as the Loch Ness Monster. Unfortunately, disgruntled residents, angry family members, staff turnover and increased costs are easier to find. But it does not have to be that way. By changing your facility s culture, customer satisfaction can be a pleasant, everyday occurrence. What is Culture Change? Many of today s senior residential/long-term care facilities are task-oriented, driven by schedules, rules, regulations, and of course, the bottom line. Elders often are forced to surrender their freedom and control in order to get the fundamental human support and services they need to live. By moving away from the medical model of care and embracing a more social model that is person-centred, we can create a culture of aging that is life-affirming, satisfying, humane and meaningful. Customer satisfaction is a natural by-product of this cultural transformation. Who Are Your Customers and What Do They Want? A good place to start the culture change process is to identify and understand the needs of your main customers residents and their families. Residents want what any of us want: a normal life in which they have control over their health, relationships, personal needs and home. They want acknowledgement from the people around them that their lives have meaning and value. Consistency, privacy and community involvement are understandably important to them. Family members needs are just as complex. By the time a family makes the difficult decision to bring their loved one to a residential care facility, they often are exhausted, guilty and afraid. They may be worried about medical, legal and financial issues. Family members expect the facility to be able to provide exactly the personalised type of care that they would provide their

6 page 6 that your staff have the necessary interpersonal skills to communicate well with family members. By changing your facility s culture to more actively include family members, you will increase their level of satisfaction. Invite them to planning meetings and events and ask them to participate in problem solving. Ask them to share their loved one s history with staff, so that they have a better understanding of this individual s talents, interests and habits. Make certain that they feel welcome when they visit their loved ones. For example, does each resident room have enough comfortable chairs for a few family members to enjoy a meaningful visit? Can residents bring their family members to a kitchen area and offer them coffee or a meal? Is there a private area that residents can use to entertain their guests? Results Culture change substantially improved resident outcomes at the Crestview Nursing Home. In 1998, 53 residents used incontinence materials. Today only three need to do so, thanks to staff members getting to know residents habits and needs. This alone can significantly raise the dignity and selfesteem of each affected resident. Since 1998, call-light usage is down 49 percent because staff members anticipate residents needs. Crestview also has cut down on wasted food by ordering smaller amounts of specific meals rather than ordering in bulk. In addition, the number of residents taking expensive food supplements dropped from 55 to 12. Since person-centred care was introduced, anecdotes about individuals improvement abound at Crestview. Here is one that demonstrates the power of culture change: one resident was bedridden and curled in the foetal position when he arrived at Crestview. Today, he s walking, shopping and active in Bible study and music sessions. Dollars and Sense For those of you who are saying, culture change sounds good, but we don t have the money or staff to make it happen or If only the regulators or reimbursement system would let us, there is good news. Many homes on the journey to culture change report that they have been able to reallocate money and make their budget cost-neutral. Also, many regulators are supportive of culture change and view it as a way to provide quality care for elders. By employing person-centred care, major cost savers appear, including a reduction in costly resident medication use. A decrease in staff turnover and the elimination of agency staff can contribute a significant savings annually for a facility. This money can be reallocated to a more meaningful and lasting investment, such as staff development opportunities. Culture change also can make your facility more profitable by increasing its occupancy rate and private-pay census. Crestview Nursing Home operates on the lowest Medicare rate in the state of Missouri $85 per resident per day. To make this work, they have cut costs without cutting corners. Residents don t need costly incontinence materials, for example, because aides keep track of when to take each resident to the bathroom. Less food gets wasted because residents have more meal choices. Crestview also spends less on their front staff. Highsalaried middle managers, such as an assistant administrator, PR person, HR director, marketing director and assistant director of nursing, aren t needed because there is a waiting list of residents, the facility enjoys a low staff turnover and aides have the authority to make care decisions. For example, an aide is in charge of scheduling staff members, ordering supplies and billing Medicare. That means that Crestview can get those tasks done for about $9 an hour instead of $18 an hour. Also, Crestview does not pay fees to a management company or home office, like so many of its peers. One final word on cost: Quality isn t expensive it s priceless. Pioneer Network Rose Marie Fagan is the executive director of the Pioneer Network. Formed in 1997, the Pioneer Network s mission is to advocate and facilitate deep system change and transformation in our culture of aging. In-depth system change requires change in our elder s attitudes towards themselves and their aging; change in individual s and society s attitudes towards aging and elders; change in the attitudes and behaviour of caregivers toward those they care for; and change in governmental policy and regulation. Our aim is nothing less than transforming the culture of aging for the 21st century.

7 page 7 Cultural Change=Customer Satisfaction (continued from front cover) loved one at home, if they could. They want to know that their family member is healthy and socially engaged when they visit or call. When family members are satisfied with the level of care their loved one is receiving, conflicts are significantly reduced. Person-Centred Care Case Study Person-centred care is the cornerstone of culture change, bringing satisfaction to both the resident and family. There are some fine examples of facilities that have been on the journey to culture change for three years or more. They are doing substantial deep-system change. The Crestview Nursing Home in Bethany, a bed not-for-profit centre, is one example of a facility that has successfully employed a person-centred model since This community has won national US acclaim and consistently posts near-perfect scores on accreditreviews. Crestview has a waiting list of 80 people, an anomaly in a state where nursing homes average 76 percent occupancy. Eric Haider, the facility s executive director, says that changing the facility to a person-centred model has increased resident satisfaction, boosted employee morale and cut costs. Unlike most long-term care facilities, Crestview does not make residents follow a rigid schedule that is designed to make a shift run more smoothly and efficiently. Instead, residents wake up when they want to, eat meals they choose, decorate their own rooms and enjoy their favourite extracurricular activities, such as bowling, shopping and attending religious services in the community. At Crestview, residents do not get awakened at 5:00 a.m. for a bath just so that it can be accomplished before the night shift goes home. If a resident prefers to bathe in the afternoon, then a staff member will assist them at that time. If a resident would like to make homemade spaghetti sauce, staff can shop with them for the ingredients and help them make it, if desired. If a resident wants to have a Big Mac for lunch instead of the offered meal, a staff member can bring the resident to the restaurant or pick it up for them. This rampant normalcy is the best way to ensure that residents feel at home and satisfied. Moving to a long-term care facility does not suddenly change someone s personality and interests after 85 years of life, said Haider. When residents are being forced to change fundamental qualities, they tend to fight and fight, until they finally give up. With person-centred care, rather than fighting, residents now are participating in decisions about their care. They are living. Staffing Residents aren t the only satisfied ones. While most facilities have sky-high staff turnover and cannot recruit aides fast enough, dozens of people are on the waiting list at any given time for jobs at Crestview. Although the pay is not high nurses aides start at $6.50 an hour working in a caring environment where you are valued is a big incentive for these professionals. Staff absenteeism is low and turnover is down to an amazing 9.4 percent annually. With 160 employees, Crestview has a direct-care staffing ratio of 1 to 4.5 on the daytime shift, 1 to 7 on the evening shift, and 1 to 10 on the night shift. Most facilities have a traditional staff structure, with aides relegated to the menial tasks while nurses and administrators make all of the decisions. All Crestview staff members are assigned to teams, no matter what their job title. Each team includes nurses, nurses aides, housekeepers, laundry workers, activities staff members, maintenance workers and kitchen help. Each team works with the same group of residents each day, to provide consistency and help build a community. Each staff member is empowered to make decisions and problem solve. For example, no staff member walks by a blinking call light without finding out what the resident needs. Focus on the Family Family is an important part of each person s life. Family bonds can get stronger as family members begin to take on an advocacy role for their aging loved one. A family member s fears and worries can quickly turn to anger and mistrust if they feel that their concerns are not being answered. An ongoing relationship with this family member can be marked with conflict and dissatisfaction, possibly jeopardising a resident s well-being. That is why it is critical