Staff Stability David Gifford MD MPH Sr VP for Quality & Regulatory Affairs 1 Workforce Trends 2 1
Top Workforce Concern 3 Balancing the Supply and Demand Retain Staff Recruit New Staff 4 2
Jan May Sep Jan May Sep Jan May Sep Jan May Sep Jan May Sep Jan May Sep Jan May Sep Jan May Sep Jan May Sep Jan May Sep Jan May Unemployment Rate Increasing Need for Caregivers The U.S. will need between 5.7 million and 6.5 million nurses, nurse aides, home health, and personal care workers to care for the 27 million Americans who will require long term care by 2050. Department of Health & Human Services and Department of Labor 5 Unemployment Trends Past 10 yrs 8 7 6 5 4 3 2 1 0 Current Unemployment Rate = 3.8% 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 Year and Month Unemployment Rate Current Rate 6 3
P = I D Prevalence = Incidence Duration Prevalence = # of people with a disease at a given time Incidence = # of people who develop a disease over time (10 per yr) Duration = # how long people have the disease (e.g. 10 yrs) P = 10 per yr * 10 yrs P = 100 people 7 P = I D Applied to Staffing Availability (prevalence) of RNs in the community Prevalence = # of RNs in a community Incidence = # of new graduating RNs in the community, or new RNs moving into the community Duration = length of time RNs stay in the community Center RN staffing level (prevelance) Prevalence = # of RNs employed by a Center Incidence = # of new RNs hired by the Center Duration = length of time RNs stay in the Center 8 4
Increasing the Workforce Supply 9 Increasing Incidence How do you recruit new staff into your community? #1 Attract staff from neighboring Communities States Countries #2 Train more citizens in your community or proximity Young people as they finish high school Retrain adult workforce looking for new opportunities #3 Expand the labor pool 10 5
Population Over 65 per RN (2015) Grand Forks, ND-MN NW Nonmetropolitan NE Nonmetropolitan KEY No Data 28-40 13 - <28 4 - <13 Fargo, ND-MN Duluth, MN-WI St. Cloud, MN Mankato- North Mankato, MN SE Nonmetropolitan SW Nonmetropolitan Minneapolis-St. Paul- Bloomington, MN-WI Rochester, MN SE Nonmetropolitan La Crosse- Onalaska, WI-MN 11 What attracts new workers? Salary Most Important Financial Benefits Healthcare Retirement Paid Time Off Workplace Flexibility Day care Wellness Program (gym membership) Tuition Reimbursement Pay Raise or Performance Bonus Life Insurance Workplace Perks Professional Development, Training & Advancement Equally as Important Quality of Services Delivered Rewarding experience Nice place to work Community reputation Current worker s satisfaction Non-financial Benefits Flexible and Family-Friendly Schedules Work hours Ease of commuting Work flexibility Telecommuting Day care options 12 6
RN Mean Hourly Wage (2015) Grand Forks, ND-MN Fargo, ND-MN NW Nonmetropolitan NE Nonmetropolitan KEY No Data $26 <31 $31 <32 $32 $37 Duluth, MN-WI St. Cloud, MN Mankato- North Mankato, MN SE Nonmetropolitan SW Nonmetropolitan Minneapolis-St. Paul- Bloomington, MN-WI Rochester, MN SE Nonmetropolitan La Crosse- Onalaska, WI-MN 13 Invest in the Future Start a high school nursing internship Partner with colleges and technical schools Adult basic education and ESL partnerships Research scholarship opportunities and communicate these to potential staff 14 Workforce Toolkit, Care Providers of Minnesota 7
Expand the Pool Older Adults 1. Flexible schedules 2. Focus on altruism 3. Capitalize on existing skills 4. Offer learning opportunities Men 1. Change the narrative 2. Recruit family caregivers 3. On the job training 4. Support Older Workers and the Direct Care Workforce, PHI, 2018. 15 Prevelance = I X D Increasing Incidence is hard and unlikely P = XI x D If increasing incidence enough to meet demand, then you Can try and decrease demand, and Increase duration 16 8
Decrease Demand for RN & CNAs Develop new positions to perform work that is not require to be done by nursing Hall monitors Bed-aids Feeding assistants Med techs 17 Staffing Turnover & Retention 18 9
Retention is Key but often. While an overwhelming majority (84.8%) of hospitals view retention as a key strategic imperative it is not evident in operational practice/planning. Although viewed in such a strong light, only half or 51.5% have a formal retention strategy. Response from 138 hospitals out of 4300 surveyed (including LTACHs & IRFs). 2016 National Healthcare Retention & RN Staffing Report Published by: NSI Nursing Solutions, Inc. www.nsinursingsolutions.com. 19 Staffing Turnover Relationship to Quality 20 10
Quality (higher value = lower quality) Quality Impact of Instability High Figure turnover 1: Hypothesized negatively affects Quality-Turnover quality & customer Relationship experience 140 120 100 80 Turnover Targets based on Quality 20% 50% 60 40 20 21 0 0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100 Turnover (percent) Castle, 2011 Turnover Linked to Quality Outcomes * Castle N & Engberg J. Staff Turnover and Quality of Care in Nursing Homes. Medical Care 43(6): 616-626 2005. 22 11
Staff Levels vs Turnover Impact on Quality* Nurse Level CNA Level RN Turnover LPN/CNA Turnover Restraints NO NO YES YES Catheters NO NO YES YES Contractures NO NO YES YES Pressure Ulcers NO NO YES YES Pyschoactive Med NO NO YES YES Survey Deficiencies NO NO YES YES * Castle N & Engberg J. Staff Turnover and Quality of Care in Nursing Homes. Medical Care 43(6): 616-626 2005. 23 Cost Impact of Instability Average cost to replace a CNA: $4,000 (range $1,000-$5,500) Average cost to replace an RN: $6,000 (range $2,300-$9,000) Higher turnover contributes to: Need for agency staff and overtime = increased costs Survey deficiencies & potential remedies = increased costs Poor reputation as place to work and place to receive care = decreased census, difficulty recruiting new staff 24 12
25 Measuring Turnover & Retention 26 13
Tools to Measure Turnover AHCA resources Long Term Care Trend Tracker Submit turnover and retention annually for CY Cost of turnover calculator (AHCA website) Other Free resources Advancing Excellence website has calculator CMS PBJ plans to add turnover & retention to Five Star 27 Turnover & Retention Upload staffing data and receive instant feedback on rates Benchmark against peers Examine 7 different staff positions: 1. Administrator/Executive Director 2. Director of Nursing/Director of Residential Care Services 3. Staff RN 4. LVN/LPN 5. CNAs (SNF) 6. Aides (AL) 7. Total All-Staff Turnover 28 14
Turnover & Retention: Sample Report 29 Staff Engagement 30 15
Three Types of Employees Engaged Not Engaged Actively Disengaged State of American Workforce Gallup 31 Brand Ambassador 32 16
Are you driving employees away? What is impact of recruitment strategies on your existing staff? How do you feel when as a loyal customer your Bank or Credit card Phone or Cable TV provides sign-on bonuses available only to new customers? How will your staff feel when you offer new hires sign-on bonuses Higher pay Better benefit packages More flexibility in scheduling More or better 33 How do utilize staff to recruit? Your staff are the best ambassadors to find new employees? What are they saying to friends and family about your organizations Do they use We or Us vs They or Them Provide all staff with business cards Involve staff in interview process Make staff responsible for on-boarding Split sign-on bonus for existing staff Provide payment differential during on-boarding period 34 17
Involuntary terminations Problems with attendance is often the leading reason for involuntary terminations What are reasons? Most are for personal needs (childcare, sick family member, car repair, house repair, attend child s sports event, etc) Accommodate personal needs Fair but flexible schedule plan Allow phone calls to check on home needs Evening/night shift (e.g. check to see if kids home safely) 35 The Vicious Cycle of Instability -- S. Eaton 36 18
Strategies to increase attendance Attendance incentives Financial bonuses (~$25/month perfect attendance) Public recognition for attendance Fair and flexible attendance Allow time off without explanation Set maximum number that trigger a meeting with supervisor but no automatic penalty Explore reasons for high absenteeism to help address reasons Involve staff in schedule design Allow staff to switch shifts but track overtime 37 Drivers of Engagement 1. Transparency of information 2. Connection to purpose 3. Effective supervision 4. Opportunity for growth 5. Recognition 38 19
Transparency of Information Goals of the organization are shared Employees know what s important Data and dashboards are shared 39 Connecting to a Purpose Feeling connected to the mission and vision Contributing ideas to the organization Participation in performance improvement teams 40 20
More Effective Supervision Traditional Raise performance problems in context of disciplinary action or serious adverse events Discuss rules and consequences Offer or mandate possible solutions Penalize non-compliance Coaching Establish a trust relationship Raise performance concerns in context of just in time feedback Consider the employees perspective Engage the employee to generate solutions Help the employee implement action steps Provide frequent positive feedback Make sure high performing staff hear positive feedback from you Growing a Strong Direct Care Workforce: Recruitment and Retention Guide PHI 41 Opportunity for Growth Peer mentoring for new employees Career ladders and lattices Succession planning Professional development Specialty Training 42 21
Recognition Has to be personalized Needs to be frequent and authentic Recognize people based on specific results and behaviors Implement peer-to-peer recognition Share recognition stories Make the programs easy and frequent Coordinate with company s values or goals Source: Forbes http://www.forbes.com/sites/joshbersin/2012/06/13/new-research-unlocks-the-secret-of-employee-recognition/ 43 What Matters Most to Your Employees (SNF survey)? Management cares about employees Management listens to employees Help with stress and burnout Workplace is safe Supervisor cares about you as a person Supervisor shows appreciation Source: My Interview survey & interviews with employees 44 22
Ways to Recognize Staff Traditional Formal Certificates of Achievement Company apparel Recognition in front of peers/residents/family VIP parking spot Free lunch who doesn t love a pizza party! Employee of the week/month/year More Personal Hand written note Personal verbal feedback when you see Share feedback from Families and residents Other staff Peer-to-Peer recognition 45 Employee Satisfaction linked to Outcomes Skilled nursing facilities with a high rate of employee satisfaction also have: fewer survey deficiencies a higher Five Star quality rating higher levels of resident and family recommendation Nurses as a stand-alone group of workers, have a slightly stronger correlation between nurse satisfaction and a SNF's rate of deficiencies than all-employees National Research Corporation: announced at AHCA 2013 annual convention 46 46 23
Empower Staff (increases engagement) Pilot test Let staff design make decisions How new programs or processes will be implemented and pilot test their ideas Let them pick types or supplies to purchase Ask staff to visit other centers to learn Provide time for staff to work on projects Let them make mistakes Respond to their feedback & make changes they recommend or explain why you can t 47 Consistent Assignment Purpose: Residents consistently have the same caregivers caring for them every time. Residents are more comfortable with staff they know and who know them, their personal preferences and their needs Staff assignments are consistent when staff care for the same residents every time they work 48 24
Evidence supporting consistent assignment Greater staff satisfaction and lower staff turnover Quality of care improved related to Earlier detection of subtle changes in resident s condition Addressing individual needs of resident Greater family & resident satisfaction Focus groups show families rate the quality of the relationship staff have with residents more valuable than the quality of medical care or quality of food Focus groups found family members and residents want staff that know me (my mom) as a person Financial performance improves (occupancy, liability, turnover) 49 Consistent assignment permanent assignment Revaluate assignments regularly (~3 months) Involve staff, resident and family input Change an assignment if it is not working Designate a consistent back up staff for every consistent assignment to provide continuity when the primary person is out Encourage team work and help when a staff person is overwhelmed 50 25
Tips to Success Increase Staffing 51 Know your turnover & retention rates and set goals Review your recruitment strategies Review your strategies to retain new hires Focus on strategies to retain current staff Measure employee satisfaction Implement Consistent assignment MAGNET status Quality Award silver or gold level Access readily available free resources AHCA/NCAL Resources 52 26
AHCA/NCAL Resources Workforce Resource Center Gero Nurse Prep LTC Career Center ahcancaled LTC Trend Tracker 53 54 27
Staff Stability Resources AHCA Toolkit: 4 Key Strategies to Retain New Hires and Reduce Employee Turnover Cost of Turnover Calculator A Guide to Staff Stability for Leaders Consistent Assignment A Resource Guide Improving Staff Satisfaction What Effective Leaders are Doing The Staff Stability Toolkit (w/ CD-ROM) 55 http://qualityinitiative.ahcancal.org Staff Stability Toolkit This toolkit, from Healthcentric Advisors, is a "how-to" guide to stabilize staffing with practical tools for both immediate and long-term use. It combines concepts, practices, exercises, and tools to assist you in the systematic process of determining the root cause of a problem and identifying potential interventions. Can order from AHCA book store www.ahcapublications.org/productdetails.asp?productcode=8281 56 56 28
https://educate.ahcancal.org/ Resources for Workforce 57 58 29