How We Know What Residents Really Want OCTOBER 26, 2011 ARKANSAS

Mary Tellis-Nayak RN, MSN, MPH Vice President of Quality Initiatives mary@myinnerview.com 773-942-7525

Outline» What do Arkansas residents and family members want?» How do residents wants align with families?» What do staff say about their work?» The importance of frontline caregivers in meeting residents wants and needs

To provide long-term care leaders evidence-based management tools to better achieve their organization s goals

Evaluate outcomes: measure variation Collect data: ensure validity, organize Turn plan into action: improve process My InnerView s evidencebased path to quality Turn data into information: benchmark, study variation Turn knowledge into plan: apply new wisdom to process Turn information into knowledge: study current process

Complaints that reach you: Tip of the iceberg! 5% complain to management 45% complain to frontline staff 50% have problem, yet don t complain Good quality is good business (TARP studies)

My InnerView» 9,500+ providers in all 50 states and District of Columbia use our tools» Skilled team of professionals with extensive senior care operational, clinical, regulatory and academic experience» Sent more than 2 million surveys in 2009» Recommended by: 5 national associations 41 state associations

Meeting the desires of residents

What matters most to patients?» What do you think are the issues related to patient satisfaction that have the highest correlation with their likelihood to recommend your home/community to someone else?

Understanding the patient s mind» Satisfaction and loyalty are not won on field of best clinical quality Clinical and process outcomes is not where battle for consumer s mind is being waged» Residents judge their experience by the way they are treated as a person, not by how they are treated for their disease» Perceptions of personal treatment are more highly correlated than clinical competence

I hope for the day when everyone who lives in any long-term care situation knows there is someone waiting for him or her each morning after the journey of sleep one takes each night. And I yearn for the day when each staff person most especially CNAs know that there are people who are waiting for a morning greeting, interested in learning how the CNA fared in the hours they were apart. CARTER WILLIAMS

When you don t remember anything, you re satisfied! Loyalty is generated by memorable things that happen that we didn t expect

The Law of Memorable Events» Though it takes somebody doing something special beyond what is expected, it doesn t take everybody doing something special all the time» It takes only one brief experience on only one day of a stay to determine dissatisfaction or loyalty

Loyalty comes from compassion What words on comment cards made the residents love the staff?

COMPASSION 2/3rds of adjectives used Compassion synonyms:» Caring, cares, cared +32» Kind, kindness +24» Compassionate +15» Help, helpfulness +15» Concerned +6» Listens +4» Loving +3» Empathy +3 Courtesy synonyms:» Friendly +8» Professional +9» Attention, attentive +7» Sweet +3» Respect +3» Polite +3» Patient +3» Smiling +2

If one were to pick out the synonyms for compassion, there is an amazing consistency in the qualities that have the greatest impact on patient loyalty

Compassion» Questions from survey companies that have questions with care, compassion or concern in them have the highest correlation with overall satisfaction and loyalty» Compassion dramatically influences overall satisfaction

Competence synonyms were the least mentioned

Courtesy and competency are expected Doing what is expected does not earn unsolicited raves

Loyalty is often expressed because of the actions of one nurse on one shift!

It is the compassionate connection between a caregiver and a resident that elevates common courtesy into something more tender and unforgettable than good, routine care

Compassion, caring, comforting and kindness these make up the bulk of the adjectives linked to loyalty they are all rooted in empathy The capacity for empathy is the ability to share in another s emotions or feelings When people receive empathy, they feel loved and cared about

For long-term care not to teach the role of empathy, or inspire compassion, is a colossal omission, because empathy has the capacity to heal by its effect on stress, and compassion is the primary influence behind patient loyalty.

What do residents want?

AN EXERCISE: What Matters Most

QUADRANT ANALYSIS: TWO KEY CONCEPTS 1. How residents, families and staff rate your care and services Your average score on each item: 0 3: Poor Fair Good Excellent Rank order all items by average score: 1 100: Lowest to highest ranking score 2. How much each item influences residents, families and staff to recommend to others Correlate each item with Recommendation: 0 1: No correlation to strongest correlation Rank order all items by correlational strength: 1 100: Lowest to highest ranking correlation

QUADRANT AND ACTION PRIORITIES Recommendation You can meet customer expectations 1 - Lowest to highest ranking score 100 A. Secondary strengths C. Secondary opportunities B. Primary strengths D. Primary opportunities Successes Challenges Item score 1 ----- Lowest to highest ranking correlation ------ 100 You have little control over customer expectations

ARKANSAS Voice of Residents and Family Members

RESIDENTS SAY: WHAT MATTERS MOST IN A NURSING HOME

SKILLED NURSING RESIDENT AND FAMILY Survey items 1 Choices/preferences 2 Respectfulness of staff 3 Respect for privacy 4 Resident-to-resident friendships 5 Resident-to-staff friendships 6 Meaningfulness of activities 7 Religious/spiritual opportunities 8 Quality of RN/LVN/LPN care 9 Quality of CNA/NA care 10 Quality of rehabilitation therapy 11 Adequate staff to meet needs 12 Attention to resident grooming 13 Commitment to family updates 14 Competency of staff 15 Care (concern) of staff 16 Responsiveness of management 17 Safety of facility 18 Security of personal belongings 19 Cleanliness of premises 20 Quality of meals 21 Quality of dining experience 22 Quality of laundry services

ARKANSAS RESIDENTS What matters most 14 - Competency of staff 15 - Care (concern) of staff 16 - Responsiveness of management 1 - Choices/preferences 17 - Safety of facility 5 - Resident to staff friendships 13 - Commitment to family updates 6 - Meaningfulness of activities 8 - RN/LVN/LPN care 21 - Quality of dining experience

ARKANSAS FAMILIES What matters most 14 - Competency of staff 8 - RN/LVN/LPN care 9 - CNA/NA care 17 - Safety of facility 15 - Care (concern) by staff 11 - Adequate staff to meet needs 16 - Responsiveness of management 1 - Choices/preferences 19 - Cleanliness of premises 12 - Attention to resident grooming

Why is willingness to promote your company such a strong indicator of loyalty and growth? FREDERICK RIECHHELD: THE ONE NUMBER YOU NEED TO GROW

Because when customers recommend you, they re putting their reputation on the line. They will take that risk only when they are loyal.

The importance of Recommendation» Provides crucial information Tells you loyalty of respondents Correlates to other quality outcomes: All items in survey Occupancy Quality indicators Employee satisfaction» That is why this question is used for Priority Action Agenda

If you want to grow your business exponentially, you must get serious about building and maintaining loyal relationships with your customers Loyal customers are easiest customers to serve Long-term customers tend to spend more with you than new customers Happy, loyal customers purchase other products or services in company s line Satisfied, loyal customers recommend company s products or services FREDERICK RIECHHELD: THE LOYALTY EFFECT

In most of the industries studied, the percentage of customers who were enthusiastic enough to refer a friend or colleague perhaps the strongest sign of customer loyalty correlated directly with differences in growth rates among competitors.

ARKANSAS Voice of Residents and Family Members

ARKANSAS RESIDENTS 2010 2009 2008 Response Rate 57% 52% 40% Facilities Surveyed 20 24 110 Surveys Received 94 143 836

Why look at Excellent?

Loyalty is generated by memorable things that happen that we didn t expect. These cause person to give score of Excellent, not Good

Research shows that, in most industries, there is a strong correlation between a company s growth rate and the percentage of its customers who are raving fans that is, those who say they are extremely likely to recommend the company to a friend or colleague. For My InnerView users, this is Excellent

ARKANSAS RESIDENTS 2010 2009 2008 Response Rate 57% 52% 40% Facilities Surveyed 20 24 110 Surveys Received 94 143 836

RESIDENT PERCENT EXCELLENT AND GOOD FOR GLOBAL SATISFACTION ITEMS Overall Satisfaction Recommendation to Others 90% 89% 91% 88%

RESIDENT GLOBAL SATISFACTION RATINGS BY DOMAIN

ARKANSAS FAMILIES 2010 2009 2008 Response Rate 39% 37% 38% Facilities Surveyed 22 27 121 Surveys Received 660 693 2,668

FAMILY PERCENT EXCELLENT AND GOOD FOR GLOBAL SATISFACTION ITEMS Overall Satisfaction Recommendation to Others 86% 87% 87% 87%

FAMILY GLOBAL SATISFACTION RATINGS BY DOMAIN

RESIDENT

FAMILY

PRIMARY STRENGTHS PRIMARY OPPORTUNITIES A B 18 7 11 20 13 19 22 RESIDENT 2 7 4 20 5 4 9 10 10 3 12 1 3 16 19 6 6 22 18 21 12 21 FAMILY 8 8 14 13 17 1 9 15 14 16 C D 2 5 11 17 15 SECONDARY OPPORTUNITIES SECONDARY STRENGTHS

RESIDENT Safety of facility Choices/Prefere nces 2 9 FAMILY CNA/NA care 8 1 Care (concern) of staff RN/LVN/LPN care 13 17 15 17 1 9 8 Competency of staff 14 15 14 B D PRIMARY STRENGTHS PRIMARY OPPORTUNITIES

RESIDENT FAMILY Adequate staff to meet needs Quality of dining experience Meaningfulness of activities Responsiveness of management SECONDARY OPPORTUNITIES C 7 11 20 18 22 6 12 3 22 18 20 21 12 21 19 5 16 6 11 9 15 14 16 D PRIMARY OPPORTUNITIES

Resident Satisfaction Studies have repeatedly confirmed that residents and their family members value the quality of the relationships they have with the frontline caregivers higher that the quality of the medical care and the quality of the food. NCCNHR, Public Health Institute

RESIDENT EXCELLENT, GOOD, FAIR OR POOR RANKED BY PERCENT EXCELLENT

FAMILY EXCELLENT, GOOD, FAIR OR POOR RANKED BY PERCENT EXCELLENT

Quadrant B RESIDENT Choices/Preferences (1) Safety of facility (17) Commitment to family updates (13) CAN/NA care (9) RN/LVN/LPN care (8) FAMILY Competency of staff (14) Choices/Preferences (1) Care (concern) of staff (15) RN/LVN/LPN care (8) Safety of facility (17) Respectfulness of staff

RESIDENT COMPARISON TO PREVIOUS SURVEY QUADRANT B

FAMILY COMPARISON TO PREVIOUS SURVEY QUADRANT B

Quadrant D RESIDENT FAMILY Competency of staff (14) Care (concern) of staff (15) Responsiveness of management (16) Resident to staff friendships (5) Meaningfulness of activities (6) CNA/NA care (9) Adequate staff to meet needs (11) Responsiveness of management (16) Cleanliness of premises (19) Attention to resident grooming (12) Quality of dining experience (21)

RESIDENT COMPARISON TO PREVIOUS SURVEY QUADRANT D

FAMILY COMPARISON TO PREVIOUS SURVEY QUADRANT D

Demographics and background information

FAMILY DEMOGRAPHICS AND BACKGROUND INFORMATION Gender of resident Female 70% Male 30% Age of resident 19 or under 0% 20 to 29 0% 30 to 39 0% 40 to 49 1% 50 to 59 4% 60 to 69 8% 70 to 79 16% 80 to 89 44% 90 or older 27%

FAMILY DEMOGRAPHICS AND BACKGROUND INFORMATION Homes visited None 30% Only this one 13% Two 31% Three 16% Four 5% Five or more 4% Reason for choosing Convenient location 32% Good reputation 28% Doctor or hospital 15% Relative or friend 11% Insurance requirement 1% Other reason 13% 54%

FAMILY DEMOGRAPHICS AND BACKGROUND INFORMATION Length of stay Less than 1 month 2% 1 to 3 months 11% 3 to 6 months 7% 6 months to 1 year 14% 1 to 3 years 36% 3 or more years 30% 66% Relationship to resident Spouse 15% Child 57% Brother or sister 11% Grandchild 1% Friend 3% Other relationship 13%

FAMILY DEMOGRAPHICS AND BACKGROUND INFORMATION Person visiting most Spouse 16% Child 55% Brother or sister 13% Grandchild 1% Friend 5% Another person 10% How often visited Less than one a year 0% Once a year 1% Once every 3 months 4% Once a month or more 12% Once a week or more 47% Almost daily 37% 83%

AVERAGE SCORES RECOMMENDATION TO OTHERS BY DEMOGRAPHICS Location type RESIDENT FAMILY

AVERAGE SCORES RECOMMENDATION TO OTHERS BY DEMOGRAPHICS Reason for choosing RESIDENT FAMILY

AVERAGE SCORES RECOMMENDATION TO OTHERS BY DEMOGRAPHICS RESIDENT How Often Visited FAMILY

AVERAGE SCORES RECOMMENDATION TO OTHERS BY DEMOGRAPHICS Length of Stay RESIDENT FAMILY

What does research have to tell us about the workplace?

Quality of leadership and quality of the workplace The voice of CNAs» Based on 2008 satisfaction surveys conducted by My InnerView: 78,547 CNAs/NAs 144,098 family members» 3,216 skilled nursing facilities ranked in four groups based on percentiles (lowest, 2nd lowest, 2nd highest and highest)

Indicators of quality workplace 1. Pay compared to other nursing homes 2. Safety of workplace 3. Adequate equipment and supplies to do your job 4. Work allows you to make a difference in people's lives 5. Co-workers work together as a team 6. Fair performance evaluations 7. Respect shown for resident by staff 8. Help you get to deal with job stress and burnout 9. Staff communication between shifts

Quality leaders produce a quality workplace 80 60 40 Group averge score: 1-4 Leadership Workplace Leadership Workplace Leadership Workplace Leadership Workplace 20 Lowest 2nd lowest 2nd highest Highest Based on My InnerView employee satisfaction surveys completed by CNAs/NAs in 2008.

Quality workplace earns staff recommendation 80 60 40 Group averge score: 1-4 Workplace Recommendation Workplace Recommendation Workplace Recommendation Workplace Recommendation 20 Lowest 2nd lowest 2nd highest Highest Based on My InnerView employee satisfaction surveys completed by CNAs/NAs in 2008.

Quality workplace earns family recommendation 80 60 40 Group averge score: 1-4 Workplace Recommendation Workplace Recommendation Workplace Recommendation Workplace Recommendation 20 Lowest 2nd lowest 2nd highest Highest Based on My InnerView employee satisfaction surveys completed by CNAs/NAs in 2008.

Quality workplace creates quality of life for resident 80 60 40 Group averge score: 1-4 Workplace Quality of life Workplace Quality of life Workplace Quality of life Workplace Quality of life 20 Lowest 2nd lowest 2nd highest Highest Based on My InnerView employee satisfaction surveys completed by CNAs/NAs in 2008.

As staff are treated, so will the elders be treated.

Quality workplace creates quality of care for resident 80 60 40 Group averge score: 1-4 Workplace Quality of care Workplace Quality of care Workplace Quality of care Workplace Quality of care 20 Lowest 2nd lowest 2nd highest Highest Based on My InnerView employee satisfaction surveys completed by CNAs/NAs in 2008.

Quality workplace creates quality of service for resident 80 60 40 Group averge score: 1-4 Workplace Quality of service Workplace Quality of service Workplace Quality of service Workplace Quality of service 20 Lowest 2nd lowest 2nd highest Highest Based on My InnerView employee satisfaction surveys completed by CNAs/NAs in 2008.

Quality workplace results in better state surveys 120 100 80 60 40 20 0 Group averge score: 1-4 Workplace Compliance Survey citations Workplace Compliance Survey citations Workplace Compliance Survey citations Workplace Compliance Survey citations Lowest 2nd lowest 2nd highest Highest Based on My InnerView employee satisfaction surveys completed by CNAs/NAs in 2008.

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

Thank you! Questions? 800-601-3884