Spending Smart for Staff Stability

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Spending Smart for Staff Stability

• BF Consulting
• Cathie Brady Barbara Frank
• cbrady01_at_snet.net bfrank1020_at_aol.com
• Quality Partners of Rhode Island
• www.riqualitypartners.org
• October 7, 2008
• American Health Care Association Annual
  Convention

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Why is Staff Stability Important?

• For financial stability
• For clinical improvement
• For employee morale
• For resident and family satisfaction
• For occupancy and revenue
• For culture change

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HATCh Holistic Approach to Transformational
Change
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Basic Premise

• Use your resources to your best advantage

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Use your resources well by

• Understanding the nature, extent, and root causes
  of your problems
• Targeting resources to support your goals
• Redirecting resources that are undermining your
  goals

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• cms.internetstreaming.com
• Archived by date
• From Institutional to Individualized Care
• Nov. 3, 2006 Individualizing Care
• May 4, 2007 Transforming Systems
• May 18, 2007 Case Studies
• Sept. 14, 2007 How of Change
• Purchased from Pioneer Network _at_
• www.Pioneernetwork.net
• or from
• National Technical Information Services
• 5285 Port Royal Road, Rm. 1008, Sills Bldg.
• Springfield VA 22161
• Phone [phone]

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Staff Stability Tool kit

• www.riqualitypartners.org
• Nursing Home QIOSC
• Workforce Strategies

Thank you David Farrell!!!
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Staff Stability Tool Kit
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Process Framework
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Root Cause Analysis Information Gathering Ask
Staff
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Cause Specific Intervention
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Management Practices
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Spending Practices
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Using Training StrategicallyGrow Your Staff
Grow Your Organization
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Advancing Excellence Technical Assistance Webinar
Staff Stability Learn to manage your resources
and improve staff retention!

• September 25, 2008
• Audio and Materials available at
  www.nhqualitycampaign.org

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Stepping Away from the Wall

• The first thing we had to do was to admit that
  what we were doing wasnt working.

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A Vicious Cycle of Turnover, Vacant Shifts, and
Stress
Vacant Shifts

• Working short staffed

• Financial burden

• Resentment

• Instability

• Overtime

• Poor outcomes

• Agency use

Turnover in 2002 National 70

• Lack of trust

Stress

• Vacant Shifts

• Errors

• Poor judgment

Turnover

• Injuries

Eaton, What a difference management makes!, 2002
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What a difference management makes! Five
Management Practices Associated
withLow-Turnover, High Attendance and High
Performance
High quality leadership at all levels of the
organization
Valuing staff day-to-day in policy and practice,
word and deed
High performance, high commitment HR policies
Work systems aligned with and serving
organizational goals
Sufficiency of staff and resources to care
humanely
Eaton, 2002
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BJBC Case Study

• Daily Instability
• Vicious cycle Turnover, absenteeism, care load
  too heavy, high stress, harsh environment
  contention
• Leadership
• Administrator in crisis mode (washing windows)
• Front-line supervisors stretched thin, worn-out
• Feeling unappreciated and disengaged
• Small raises, empty brag board, uncomfortable
  break room, pizza but not enough supplies
• We were so busy plugging holes, that we werent
  stepping back to look at what was happening and
  what we could do about it.

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Operating in Crisis Mode Perpetuated the Crisis

• For call-ins
• Bonuses for taking last minute assignments
• Lots of agency
• Deals for doubles
• For turnover/hiring
• Hiring bonuses
• Inexperienced new hires paid almost same as long
  time staff
• Piecemeal hiring to fill holes
• Hiring any warm body
• No time for orientation, right out on the floor,
  and then right out the door

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When employees are absent, there is a strong
effort to get replacements
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Teamwork in my department is good
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Management cares about me as a person
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I would recommend this to a friend as a good
place to work
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Employee Survey Findings

• Leaderships perceptions differed from rest of
  staff about depth and nature of problems and
  efforts to resolve them
• Nurses lowest morale in building
• Not a welcoming place for new staff
• Concerns re communication, support, working
  short, lack of supplies
• Lots of concern about low pay rates
• Issues about favoritism

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• First nationwide report
• 1,933nursing homes in 49 statesand D.C.
  participated in 2006

NOTE Alaska not included
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106,858VOICES HEARD
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TABLE 5
FACTORS THAT DRIVE WORKFORCE RECOMMENDATION
Ranked correlations (p lt 05) between employee
workplace recommendation and employee
satisfaction items
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TABLE 6
PRIORITY ITEMS FOR NURSING STAFF
Ranked by average scores and correlations with
workplace recommendation
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June 2005 Drilldown Snapshot of Current
Situation

• Composition of staff by work status

Whats the impact on quality care and retention?
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Incentives
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Composition of staff by Length of Service
How does this affect retention of new employees?
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Terminations by Length of Service

• Losing new employees within first month, 3 mos, 6
  mos. (sign-on bonus, poor hiring, poor welcome)

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Incentives
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Turnover Costs

• Includes higher hourly wage sign-on bonus
  filling vacant shift through agency or overtime
  recruitment screening training and orientation

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Instability vs. Stability
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Turnover reduced
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If you always do what youve always done, youll
always get what youve always gotten. Definition
of insanity Trying the same thing over and over
and expecting a different result.
Youve got to do something different to get
something different
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Staff Stabilization Plan

• Break the Cycle Spend smart to make your money
  work for you
• Goals
• Increase of staff who are full-time
• Improve of new hires who stay
• Improve attendance and of fully-staffed shifts

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Goal 1 Spending SmarterInvesting in your
loyal staff

• How did he do it
• Raises to FT and PT employees using money from
  last minute bonuses
• Converted per diem employees back to guaranteed
  hours

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New Wage Package
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As a result Increase in FT Staff
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Goal 2 Improve percent of new employees who
stay

• Improved recruitment, hiring and welcome
• Administrator/DoN mentor dept. heads in interview
  and hiring skills
• Provide a supportive environment to help new
  staff stay
• Dept. heads, supervisors support new employees
  track progress and needs first days, weeks
• CNA trainer follow-up from class to floor

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HR Policies and Practices

• Recruiting
• Hiring
• Welcoming

• better pool of candidates better hires
• better hiring process better welcome
• better welcome better retention

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Strategies to Increase Percent of New Hires that
Stay

• Recruitment
• Selling points
• Refer a friend
• Sources of candidates
• Reputation in community

• Hiring
• Make people come more than once
• Include supervisor and staff
• Direct hiring by unit
• Traits
• Interview and resume reading skills

• Welcoming
• Team support and rewards
• Supervisor, Dept heads, HR check-in, follow-up
• Extended orientation
• Picture, bio
• Celebrate

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Hiring Smart

• Make hiring a good screen 2 or 3 visits
• Tour (see how they are with residents, see what
  your staff thinks of them)
• Make hiring the start of a good welcome
• include staff and supervisors then staff are
  invested in that person making it
• Look for character traits - the skills can be
  learned
• Teach interview and hiring skills

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Refer-a-friend Bonus

• Word of mouth is best advertisement its
  happening all the time try to generate positive
  word of mouth
• Actively promote refer-a-friend bonus
• Personally approach your best employees
• Pay as soon as you hire its up to you then, to
  have them stay

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Former Recruitment Ads
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Former Recruitment Ads
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New Recruitment Ads
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New Recruitment Ads
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Recruitment Getting the Right Pool of Candidates

• What are your selling points as a place to work?
• Refer a friend bonus who are your best staff,
  who are their friends?
• What are good sources of candidates where do
  you recruit?
• Whats your reputation in the community as an
  employer?

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Compare current practices with human development
needs

• Current practices for
• Applicant arrival
• Interview process
• First day
• First week

• Human needs for
• Identity
• Intimacy
• Emotional Connection

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Welcoming Applicants

• Make a good first impression
• Receptionist is key make sure she has postings,
  applications, info on benefits, and shes tuned
  in to welcoming
• Make it a priority to meet new applicants
• Give them a tour
• see how they are with residents
• see what staff think
• Interview and screen when they come in

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Screen before hire, not after

• Focus on character traits
• Create opportunities to interact with residents
• Include others in interview (with prep on
  legalities)
• co-workers
• supervisor
• resident and/or family
• Farrells five smile rule for friendly people

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Orient for Retention first few weeks

• Protect learning time 3 days to 2 weeks
• Extend the orientation til theyre solid
• Stable assignments with supervision
• Mentors do it right
• Training re how to teach
• Give time and pay for this extra work
• Protect mentor time and assignment
• Welcome system on the floor
• Pair up during class or interview with mentor
• Pizza party on floor to welcome
• Picture of new person on their wing
• Administrator personally tune in to new person
• Team Rewards when new employees stay

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A Warm Welcome A supportive environment helps
new staff stay

• Team welcome and rewards
• Supervisor takes personal responsibility
• Daily Check-in at unit
• Daily Check-in at leadership stand-up
• Follow-up by HR
• First day, first week, first month
• Extended orientation
• Pictures, bio, balloons
• Pizza party after successful probation

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Goal 3 Improve attendance, percentage of
shifts fully-staffed

• What he did
• Track attendance by person, unit, shift, dept.
• Analyze absences for patterns.
• Communicate at dept. head meetings, put record in
  paychecks, and discuss absences with employees.
• Recognize and reward units and individuals with
  good attendance.
• Support employees adjust schedules, link to
  employee assistance services.

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Perfect Attendance Bonus

• Time Period
• Amount
• Pay-out options
• Lump sum
• Increase the hourly rate for next pay period
• Non-monetary (gas cards, grocery cards)
• Raffle
• Team rewards

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Longer term Retention

• Young staff need structure and guidance develop
  them take them under your wing
• Timely teaching of skills teachable moments
• Work-based learning
• Rookie of the month recognize progress
• Recognize co-workers who give good support
• Wow rewards

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Reward Longevity

• Longevity rewards make it worth staying and a
  loss to leave
• PTO
• Cumulative bonuses
• Recognition on anniversaries
• Opportunities for classes, advancement

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Improving Attendance

• No-call, no shows from average of 4 a day in
  2005 to 0 for last several months of 2006
• 25/month perfect-attendance bonus, paid out at
  end of year (paid out 13,000 in 2006)

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Three months later Progress in Stabilizing
Staff

• New Wage Package in Place
• Raises given to full-time staff
• Staffing stabilized
• Evening and night shifts fully staffed
• Fewer call-outs on evenings and nights
• Better retention of new employees
• New CNA class about to start on the floor
• Dept heads coach, support new employees

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Concurrently Leadership Development

• Administrator developing leadership skills of
  department heads
• I expect more from them and Im working with
  them to meet my expectations.
• DoN learned that
• Leadership is all about relationships. Anyone
  can be a leader. You have to understand your
  impact and bring out the best in the staff.
• Urges nurses to pursue further education.
• Meets weekly with nurses to problem-solve,
  mentor, guide

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Leadership on the FloorHow 2 charge nurses start
their day
I gather my staff in the morning and I tell them
we have to work together. Were like sticks. If
we work apart, each of us can be broken. If we
stick together, we cant be broken. Weve got to
stick together to get the work done. And lets
have fun doing it. Then I just pitch in and we
get through the day.
I am overwhelmed by what I have to do when were
working short. If I start doing the CNA's job,
Ill never get all my meds passed and my charting
done. Its just too much. Im not going to do the
personal care. I just keep my focus on my work
and get as much done as I can.
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Essential Practices for Effective Leadership at
all Levels

• Nursing/dept head meetings on work flow and
  workforce
• Managing by Walking Around
• All Hands on Deck
• Start of Shift Stand-up
• Mid-shift Huddle, Check-in
• End of day check in howd your day go?
• Intershift communication/rounds
• People Development

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Key Systems for Effective Teamwork
Inclusion at unit and department level ask how
can we get this done?
Inter-shift Communication So Staff have 24/7 view
of residents
Start of Shift Rounds So Staff Work Together,
Share Information
Consistent Assignment So Staff Know Residents
Individually
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Leadership Pyramid from Stephen Covey
Hearing
Teaching
Mentoring
Feeling
Seeing
Modeling
Leading by Example, Franklin Covey Co., 1998
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Supervision

• Structure
• Guidance several times during shift
• Show them the way
• Establish a mentoring relationship
• Take people in hand and guide them
• Encouragement, positive feedback
• Strength-based
• Be the supervisor staff want to work for
• Our employees have hard lives. I want work to be
  a place where they succeed.

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Using Training Well

• Look at what youre spending for what results
• Find out what topics people need
• Pay attention to teaching methods
• Use what you teach teachable moments
• Method also teaches (problem-solving discussions
  instead of to-do lectures)
• Use resources of Workforce Development
• Grow your people grow your organization

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Decrease in Turnover
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Increase in Percent of Nurses and CNAs Working
Full-time
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Its so much fun coming to work. We laugh here
all the time.

• - Director of Nursing

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Cautionary note
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Instability vs. StabilityShort term vs. Long Term

• Staffing to census
• Opt out of benefits
• Sign-on bonus
• Last minute assignment bonus
• Rotating assignments
• New schedule each month

• Steady staffing
• Affordable insurance
• Longevity Bonus
• Individual and Team Attendance rewards
• Consistent assignments
• Regular schedule of workdays

VS.
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Hiring PracticesInstability vs. Stability

• Any warm body hiring
• Plug-in-the-hole Hiring
• Inadequate orientation
• Rotating new employees to every unit

• High standards take time to hire right
• Hiring Full-time Employees
• Thorough orientation
• Creating a stable environment to help new
  employees settle in

vs.