2011-2012 n a t iona l surv e y o f c usto m e r and emp ... · c usto m e r and emp loy e e s ati...

© 2012 National Research Corporation

2011-2012 NATIONAL SURVEY OF

CUSTOMER AND EMPLOYEE SATISFACTIONIN NURSING HOMES

Table of Contents


INTRODUCTION

OVERVIEW AND DATABASE

• Overview

• Database

• Characteristics

i. Skilled Nursing Care Centers

ii. Customers

iii. Employees

LONG TERM CARE CUSTOMER SATISFACTION

• Overview

• Areas of Greatest and Least Satisfaction

SHORT-STAY SATISFACTION

• DifferencesandSimilarities

EMPLOYEE SATISFACTION

• Overview

• Top and Bottom Areas of Satisfaction

DEEPER ANALYSIS

• Overview

• Industry Variation by Provider Characteristics

• Relationships Between Measures

PERFORMANCE IMPROVEMENT

• Overview

• Key Drivers

• Possible Scores with Key Drivers

• Improvement Possibilities

CONCLUSION


INTRODUCTION


2

Introduction

INTRODUCTION

The challenges long term care organizations andleadersfindthemselvesfacingin2012arediverse,difficult,unpredictable,andcertainlycritical to both the short- and long term success of their business and potentially even for the professionasawhole.Multipleinfluencesarecontributing to this environment, including:

• Changes cascading through the entire healthcare system, such as the growth of integrated delivery models and an in-creased focus on cost management due in part to accountable care organizations and shared savings arrangements.

• Local and federal governments tightening regulatory expectations, decreasing reim-bursement, and continuing the movement toward value-based purchasing.

• Shifts in long term care drivers such as population demographics, the business economy, competition, and public image.

It’s no secret that healthcare expenditures in the United States are expected to nearly double between2009(whenthetotalbillwasalmost$2.5trillion,representing17.6%ofGDP)and2020(whenCMS,theCentersforMedicareandMedicaidServices,projectitwillhit$4.6trillionor19.8%ofGDP).Duringthatsamewindow,the Medicare budget will follow a similar tra-jectory,from$502billionspentin2009toaprojectionof$922billiontobespentin2020(Source:CMS,NationalHealthExpenditureProjections2010-2020).

These shifts in outlay will impact skilled nursing

care centers and other long term care providers by the sheer nature of their position in the healthcare continuum, but also because of the changes in population that are playing a role in the anticipated dramatic increase in health-carespend.Onesuchchange—therewere39.4millionAmericansovertheageof65in2009and CMS expects that number to increase to 54.2millionbytheendofthisdecade(Source:CMS, National Health Expenditure Projections 2010-2020).

Americans are living longer, with more chronic conditions and more functional limitations. Life expectancyforAmericanswhowere65yearsoldin2009was19.2years,andlifeexpectancyforAmericans75yearsoldin2009was12.2years(up1.6yearsand1.2years,respectively,fromthelifeexpectanciesin2000).Ofpeopleaged75andoverin2009,37%self-reportedthattheysufferfromheartdiseaseand20.5%reportedcancer(bothupalmost3%from2000).Ofpeopleage65andoverin2009,22%self-reporteddifficultywithatleastonebasicactivity(upfrom18.7%in2000)and12.1%reporteddifficultywithatleastonecomplexactivity(upfrom10.5%).(Source:CDC,Health,UnitedStates,2011).

Beyond the changes in population that are increasing the demand for various types of long term care, changes in healthcare utilization patterns can also be seen pointing in the same direction.In2010,24.3%ofhospitalpatientsaged65-84and44.3%ofhospitalpatientsaged85andolderweredischargedtoanursing


3

Introduction

homeafteranaveragestayofabout5.5daysinthe hospital. This demonstrates an increase in the rate of hospital discharges to skilled nursing homes as post-acute providers and a continu-ing decrease in the average hospital length of stay.In2000,20.2%ofhospitalpatientsaged65-84weredischargedtoanursinghomeafter5.8daysinthehospitalwhile40.7%ofhospitalpatientsaged85andolderweredischargedtoanursinghomeafter6.2daysinthehospital(Source:AHRQHCUPdatabase).

In this era of population management and heavyuseofanalyticstoefficientlyassessandmanage risks and costs in the healthcare arena, it’s easy to get caught up in the data. But mul-tiple individuals, organizations, and campaigns are working to do almost the opposite—to focus providers on the individual recipients of care and services. Person-centered care has been a hallmark of nursing homes, but it is one that continues to receive attention and investment in order to make it synonymous with the long term care profession. At the same time, across thecontinuum,effortstoimprovethecoordi-nation of care and services are not just about managing costs, but also about improving care experiences and health status.

There are many hurdles to long term success for long term care providers. Three that stand outare1)employeeengagement,2)residentandfamilyexperience,and3)publicperceptionand awareness. Intuitively, the three are tightly linked. The alignment of employees, the people at the heart of long term care, and their relation-

ship with their employers has tremendous influencetocreateandshapetheexperiencesof residents and their family members. The experiences of residents and family members translate to stories told and perceptions es-tablished of nursing homes and long term care providers across the healthcare continuum and in the population at large.

As a community, skilled nursing homes are gain-ing a stronger understanding of the importance of employee engagement and the customer ex-perience. In addition to understanding, nursing homes are still working to make the most out oftheinformationtheyalreadyhavetoeffectchange. The long term care profession’s suc-cess in ensuring person-centered care depends onhowfinelytuneditsleadersstaytothedistinct voices of the care recipients and other stakeholders.

Further, what is known about the experiences of immediate long term care stakeholders isn’t alwaysbeingeffectivelycommunicatedtothebroader collection of individuals and organiza-tionsthatshouldalsobeidentifiedasstake-holders in the long term health and well-being of the profession. Healthcare consumers still often hold a negative image of nursing homes, despite pervasive positive feedback provided by actual customers. This image can prevent popular buy-in with this critical segment of healthcare, which may inadvertently and indi-rectly impact payment policies. Other health-care providers may not be fully aware of the scope of services from nursing homes and


4

Introduction

ployeeSatisfaction(NationalResearchReport)with the intent to contribute to the profession’s understanding of the experiences and satis-faction levels of employees and the spectrum ofcustomers(short-stayresidents,long-stayresidents,andfamilies).Weendeavortoinformthe community’s leaders, managers, clinicians, and advocates about both broad concepts and nuanced education related to these critical aspects of the profession. We provide evidence and ideas that not only help individual organi-zations assess performance and direct improve-ment initiatives, but also provide objective datatoarmeffortsofprovidersandothersforcommunicating the value of long term care to policymakers, other healthcare providers, and individual consumers.

how they operate, potentially limiting the opportunity for nursing homes to participate as fully as possible in the evolving healthcare industry. Payers and legislators may not com-pletely understand or appreciate the value of the role that nursing homes play, either in managing overall healthcare costs or in the quality of life of residents and the satisfaction of their families. Such a lack of understand-ingmayalsocontributetofinancingdecisions,whichcouldhavethenegativeeffectoflimitingreimbursement of services, perhaps making the hospital stay longer or contributing to hospital readmissions.

National Research Corporation has produced this2011-2012SurveyofCustomerandEm-



• Overview

• Database

• Characteristics

i. Skilled Nursing Care Centers

ii. Customers

iii. Employees


6

The2011-2012NationalResearchSurveyofCustomerandEmployeeSatisfaction(NationalResearchReport)presentsfeedbackandinsightscollectedfrommorethan500,000stakeholders in the long term care community. These insights were gathered from residents, families, and employees through surveys ad-ministered by National Research Corporation through its My InnerView product line.

Typically called “satisfaction surveys,” these tools were designed to measure more than satisfaction. These measurement instruments collectinformationtosupportmultipleeffortswithin the long term care profession, includ-ing quality assurance, customer engagement, employee program development, performance improvement, referral source management, community outreach, and many others.

TheResidentandFamilyExperience(alsoknownastheMyInnerViewCustomerProgram)surveys asked residents and families to review 22skillednursinghomeexperiencesacrossthree broad areas:

1. Qualityoflife–iftheyfeltaffirmedaspersons in matters of safety, privacy, dignity, choice, and other aspects of well-being.

2. Qualityofcare–howtheyratedthestaffand care practices in regard to adequacy, competence, and a caring attitude.

3. Qualityofservices–howsatisfiedtheywere with meals, laundry, maintenance, and more.

Overview and Database


TheEmployeeEngagement(alsoknownastheMyInnerViewEmployeeProgram)surveysasked skilled nursing employees to comment on their experiences with the nursing home to provide an informed perspective to managers and leaders in three key areas:

1. Resources–iftheyhavethetools,training,equipment, pay, feedback, and safe environ-ment that allows them to be successful.

2. Relationships–howtheteam,supervisors,and management interact and work togeth-er on a daily basis and the support structure provided to the employee.

3. Commitment–iftheemployeeisalignedwith and integrated into the organization.

National Research Corporation hosts the largest collectionofdatareflectiveoftheviewsandopinions of residents, families, and employees across the long term care spectrum, including skilled nursing homes, assisted and indepen-dent living communities, adult day facilities, home health agencies, and continuing care retirementcommunities(CCRCs).Thisreportincludes observations limited to skilled nurs-inghomes,drawingondatafromthe2011My InnerView customer and employee database as well as from publicly available data released on the CMS Nursing Home Compare website.


7

feedback.And62%oftheemployeessurvey-ed returned responses, resulting in a database ofinputfrom44,819nurses,88,727CNAs,and108,998othernursinghomestaffmembers.

Characteristics of Skilled Nursing Care Centers

Skilled nursing homes that worked with National Research through My InnerView products largely mirror providers from across the nation in terms of key characteristics, includingprofitstatus,affiliations(beingbasedin a hospital, being part of a chain, or being partofaCCRC),thepresenceofresidentandfamily councils, and the number of licensed beds(seefigure2).

• Almost all skilled nursing care centers arenotlocatedwithinahospital(98%intheNationalResearchdatabaseand94%nationally).


Database

The2011-2012NationalResearchReportrepresents the nearly one out of three skilled nursing care centers in the United States (5,078)thatsurveyedcustomersandemploy-ees through National Research Corporation in2011.Italsorepresentsnearly220,000residents and family members and more than

240,000employees(seefigure1).Exactly

38%offamilies(123,384)and56%ofresi-dents(94,584)respondedtotherequestfor

SURVEY PARTICIPANTS

0 30,000 60,000 90,000 120,000

Nurse participants

Resident

Family

Other sta�

CNA participants

123,384

94,584

44,819

88,727

108,998

217,

968

Cus

tom

ers

242,

544

Emp

loye

es

Figure 1

NURSING HOME CHARACTERISTICS

37%46%

28%35%35%

18%

29%35%

64%65%

9%5%

91%95%

55%

81%

45%

19%6%2%

94%98%

120

or m

ore

80-1

19

Few

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0

Resid

ent a

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Fam

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ils

Resi

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Co

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ls

Not

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a CC

RC

Part

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CCR

C

Part

of a

Cha

in

Stan

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Loca

ted

with

ina

hosp

ital

Free

stan

ding

# of licensed bedsA�liations Resident & familycouncils

National

National Research Corporation

0%10%20%30%40%50%60%70%80%90%

100%

Figure 2


8

Characteristics of Customers

Data on the demographic characteristics of the customers provide context with which to frame interpretation of the results of the National Research Report analysis. The resident age and the length of residence inform our understand-ing of the individuals living in skilled nursing homes and the tenure of their relationship with the organization. The overview of the type of relationship the family member shares with the resident and the frequency of their visits tells us more about the perspectives of those responding to the survey. These demo-graphics have been similar each year that the National Research Report has been compiled, demonstrating consistency in the nursing home customer base.

• Welloverhalfofallresidents(61%)are80yearsofageorolder(seefigure3).

• VeryfewfacilitiesarepartofaCCRC(5%intheNationalResearchdatabase,9%nationally).

• Many skilled nursing providers have joint residentandfamilycouncils(35%intheNationalResearchdatabase,32%nation-ally),butmosthaveresidentcouncils(65%intheNationalResearchdatabase,64%nationally).Veryfewhavefamily-onlycouncilsornocouncilsatall(0%intheNationalResearchdatabase,4%nationally).

There are only two characteristics where the National Research Corporation database var-ies notably from the Nursing Home Compare database:

• Nursing homes that are part of a chain make up the majority of the profession, but are more predominant in the National Researchdatabasethannationally(81%vs.55%).

• Nationally, nursing homes are distributed fairly evenly in three groups that are based on the number of licensed beds (35%havefewerthan80,28%havebetween80and119,37%have120ormore. The National Research database has a lesser representation in the smallest sizedfacility(18%)andrelativelygreaterrepresentationinthemid-sized(35%)andlargerfacilities(46%).


Figure 3

80-89

70-79

60-69

less than 60

90 or older

RESIDENT AGES

38%

23%

9%

11%19%


9

• Overone-third(35%)haveresidedtherelessthanoneyear(seefigure4).Slightlyfewer(33%)havebeentherebetween1and3years;justslightlyfewer(32%)havebeen a resident for 3 or more years.

• Morethanthree-quarters(77%)offamilyrespondents visit their loved one at least weekly(seefigure5).

• Overhalfoffamily(52%)respondentsarechildrenoftheresident(seefigure6).Spouses and siblings are the next most frequentresponderstothesurvey(14%and13%,respectively).

Characteristics of Employees

While little variation is found in satisfaction scores among the various types of employees, whether segmented by job category, age, hours worked per week, or length of employment, knowledge about the composition of the work-force helps provide understanding about the employees that serve at the heart of the long term care profession.

• The workforce can be split into four evenly sizedgroupsbasedonagerange:25%arelessthan30,23%areintheir30’s,24%areintheir40’s,and28%are50orolder(seefigure7).


Figure 5

FREQUENCY OF FAMILY MEMBER VISITS

Once per year or less

Once every 3 mths

Once per month

Once per week

Daily

3%5%

15%

47%

30%

Figure 6

RELATIONSHIP TO RESIDENT

Grandchild

Friend

Other

Sibling

Spouse

Child

2%

8%

52%13%

14%

11%

Figure 7

EMPLOYEE AGES

less than 30

30-39

40-49

50-59

60 or older

20%

8%

25%

23%24%

Figure 4

less than 1 month

3-6 months

1-3 months

6 mths -1 year

3 or more years

1-3 years

LENGTH OF RESIDENCE3%

10%

8%

14%

33%

32%


10

• Whilemorethanoneinfour(27%)haveworked with their employer for less than ayear,morethanoneinthree(34%)haveworkedattheirnursinghomeforfiveyearsorlonger(seefigure10).

• Whilethenursingstaffmakesupthebulkof the workforce respondents, it is worth notingthat40%ofemployeesserveothercritical functions, including housekeeping, administration, social services, and food services(seefigure8).

• Only19%ofemployeesworkfewerthan30hoursperweek(seefigure9).Oneoutoffive(20%)reportedworkingmorethan40hoursperweek.


Figure 8

JOB CATEGORY

40%

20%6%

11%

9%

10%

4%

Other

Housekeeping

Social Services

Food

Administration

Nurse

CNA

Figure 9

HOURS WORKED PER WEEK

less than 10

10-20

20-30

30-40

40 or more

3%

6%

10%

61%

20%

Figure 10

LENGTH OF EMPLOYMENT

18%

24%

15%

17%

10%

16%

10 year or longer

less than 3 mths

3 mths - 1 year

1 - 2 years

2 - 5 years

5 - 10 years


• Overview

• Areas of Greatest and Least Satisfaction



12

Long Term Care Customer Satisfaction


bursement constraints, and an unsettling level of uncertainty due to the state of healthcare reform.

The overall customer recommendation rate of 88%isclosetothegoaloutlinedbytheAmeri-canHealthCareAssociation(AHCA)intheQual-ity Initiative. One of the four goals established intheQualityInitiativeistohave90%ormoreof nursing home customers recommend their communitybyMarch2,2015.Approximately56%ofskillednursinghomesincludedinthe2011-2012NationalResearchReporthavealreadyachievedthis90%goal.

Areas of Greatest and Least Satisfaction

While residents and families share a high over-all satisfaction level with their skilled nursing homes, their satisfaction with individual aspects ofcarerangesfrom69%(families’“good”and“excellent” ratings of the measure “adequate stafftomeetneeds”)to93%(residents’“good”and “excellent” ratings of the measure “safety offacility”).Thethreehighestratingareasofsatisfaction for both families and residents are respectfulnessofstaff,nursingcare,andsafetyoffacility(seefigure12).

Not only do customers’ scores vary between dif-ferentitems,theycanalsodifferslightlyonthesame items between residents and families. For example, the top area of satisfaction for resi-dentsis“safetyoffacility”at93%,wherethatsame items falls third on the list of top areas of satisfactionforfamiliesat90%.Conversely,

Year-after-year, the consistent message we hear from customers of the long term care profession is a clear appreciation of the quality of services and quality of life provided by skilled nursing care centers, in contrast to generally accepted negative images of nursing homes. This mes-sageisunchangedinthe2011-2012NationalResearchReportwith87%offamiliesand89%of residents indicating that they would recom-mend their nursing home as an “excellent” or “good”placetoreceivecare(figure11).Thesenumbers match the percent of families and residents that would provide the same ratings of their overall satisfaction with their skilled nursing homes.

These represent the highest recommendation scores collected since National Research Corporation(originallyMyInnerView)initiatednursing home satisfaction surveys, with the profession increasing scores—gradually but consistently—almosteveryyearsince2006.The profession has continued this trend despite the challenges of a weak economy, increased competition between long term care communi-ties, more options to facility-based care, reim-

Figure 11

TRENDED CUSTOMER RECOMMENDATION SCORES

ResidentFamily

82%83%84%85%86%87%88%89%

2006 2007 2008 2009 2010 2011


13

“respectfulnessofstaff”topsthefamilies’listofsatisfactionat92%,whileitisthirdforresi-dentsat90%.

Thesedifferencesarehighlightedevenmoreclearly when looking at the areas of lowest satisfactionamongcustomers.“Qualityofmeals” is the area that receives the lowest rate of“good”and“excellent”responses(71%)from residents, while it receives higher scores thanfiveotheritemsforfamilies(75%).Theitem that scores the lowest rating of satisfaction fromfamiliesis“adequatestafftomeetneeds”(69%).Residentsalmostmatchplacementwithsecond from the lowest raings, but still exceed thefamilyscoreby5%(74%).Anotherlow-scoring item, “security of personal belongings,” has similar placement on the relative scale for familiesandresidents,butdecidedlydifferent

Long Term Care Customer Satisfaction

ratesof“good”and“excellent”scores(2ndfrombottomforfamiliesat71%,4thfrombot-tomforresidentsat82%).

Relative to last year’s National Research Report, the areas of highest satisfaction have changed little. Families tallied the same three areas of highest scores along with the same scores. Residents increased their ratings in two of the threeareas(“safetyoffacility”and“RN/LVN/LPNcare”)by1%fromlastyear.

Rates on the lower-performing items have changed more notably—the resident scores for “qualityofmeals”hasimproved2%,from69%to71%,asdidthefamilyscoresfor“securityofpersonal belongings.” Plus, families scored “ad-equatestafftomeetneeds”69%inthisyear’sreportrelativeto68%inlastyear’s.

HIGHEST & LOWEST AREAS OF CUSTOMER SATISFACTION

0% 20% 40% 60% 80% 100%

Security of personal belongings

Quality of meals

Adequate sta� to meet needs

Safety of facility

RN/LVN/LPN care

Respectfulnessof sta�

% Excellent and Good Responses

Low

est

Satis

fact

ion

Hig

hest

Satis

fact

ion

Family Resident

92%90%91%91%

90%93%

69%74%75%

71%71%

82%

Figure 12


• DifferencesandSimilarities



16

vide a “good” or “excellent” rating of overall satisfactionand86%saythattheywouldrec-ommend their community as a “good” or “excel-lent”placetoreceivecare(figure13).

Many areas of highest and lowest satisfaction for short-stay residents are similar to their long-staycounterparts.“Respectfulnessofstaff”(93%,relativeto90%forlong-stayresidents)and“RN/LVN/LPNcare”(91%forbothshortandlong-stayresidents)bothmakethetopfivelistfor the short-stay residents, while they are in thetopthreeforthelong-stayresidents(figure14).Threeotherareastopthosetwofortheshort-stay resident population: “treatment by staff”(95%),“rehabilitationtherapy”(93%),and“helpwithadmissionsprocess”(also93%).

While“qualityofmeals”(69%forshort-stayresidents,relativeto71%forlong-stayresidents)isamongtheareasoflowestsatis-faction for both, “answering call lights” also receiveslowerscores(69%)fromtheshort-staypopulation.

Short-Stay Satisfaction


DifferencesandSimilarities

Short-stayresidentsdifferfromlong-stay.Theyaredifferentastothereasonwhytheycameto the nursing home, in the care plans that will dictate the services they will receive, and as tohowlongtheywillstay.Thesedifferencesappropriatelydrivespecificconsiderationsandinteractions with the short-stay residents that are not always paral-lel to the long-stay approach.

Despite these differences,the short-stay residents seem to share similar desires and expectations withthelong-stayresidents.Theyalsooffervery similar overall ratings of skilled nursing carecenters–87%ofshort-stayresidentspro-


Figure 14

HIGHEST & LOWEST AREAS OF CUSTOMER SATISFACTION FOR SHORT STAY PATIENTS

LowestSatisfaction

HighestSatisfaction

Treatment by sta�

Rehab therapy

RN/LVN/LPN care


Quality of meals

Answering call lights

Help with Admissions

63%95%

68%93%

58%93%

62%93%

61%91%

31%

31%69%

69%

0% 20% 40% 60% 80% 100%% Excellent % Excellent & Good

SHORT-STAY PATIENT SATISFACTION

% R

espo

nses

0%

20%

40%

60%

80%

100%

Excellent Excellent & Good

Recommendation to Others

Overall Satisfaction

50%

87%

52%

86%

Figure 13


• Overall

• Top and Bottom Areas of Satisfaction



18

Employee Satisfaction


positive scores for several of the individual areas assessed through the satisfaction survey. Nurses, CNAs, and the workforce as a whole agree on the four areas where their employers aremostsuccessful—“respectfulnessofstaff,”“sense of accomplishment,” “safety of work-place,” and “quality of in-service education” (figure16).

The groups agree on the top four items, but not theexactorderorspecificscoresofeacharea.Forexample,nursesofferthehighestscoresfor“respectfulnessofstaff”(86%)whileCNAsandthe workforce as a whole place “sense of ac-complishment”(85%and86%,respectively)atthe top of the list. As another example, nurses rate“qualityofin-serviceeducation”with72%positive scores, while CNAs rate the same mea-sureas“good”or“excellent”78%ofthetime.

% E

xcel

lent

and

Goo

d Re

spon

ses

0%10%20%30%40%50%60%70%80%

Reco

mmen

d-

ation

for c

are

Reco

mmen

d-

ation

for jo

bOv

erall

Satis

factio

n

Nurses CNA All Workforce

64% 62%67% 65% 65% 68%

75% 73% 75%

Figure 15

NURSING HOME WORKFORCE SATISFACTIONEmployees are at the heart of the long term care profession. They work to keep organizational operations running smoothly on a day-to-day basis. They care for residents and interact with families, creating and shaping the relationship between the nursing home and its customers. They perform tasks that are often physically, mentally, and emotionally taxing and carry a weight of responsibility for resident well-being and quality of life. Yet all of this often comes with a very modest wage and a lack of profes-sional image or status.

Top and Bottom Areas of Satisfaction

Alltypesofemployees(forthesakeofthisanalysis, divided broadly into three groups: nurses,CNA,andthefullworkforce)havecombined “good” and “excellent” ratings that rangefrom62%to67%foroverallsatisfactionand recommendation of the nursing home as a placetowork(seefigure15).Theworkforceasawholeoffersa67%positivescoreforoverallratingand68%positivescoreforjobrecom-mendation.Scoresfromthenursingstafftendto be a bit lower—nurses state that their overall satisfactionis“good”or“excellent”64%ofthetimeandCNAs62%ofthetime.TheCNAhasimprovedduringthelastfiveyears,upfrom57%in2006.NursesandCNAssharethesame65%positiveratingforrecommendationasaplace to work.

While employees’ overall satisfaction tops out atlessthan70%,theyofferahigherrateof


19

Employee Satisfaction

Opinions about the areas where skilled nurs-ing home employers are the least successful are less consistent. “Comparison of pay” is the lowest scoring item for the workforce as a whole(44%)andforCNAs(just29%),butitis the third lowest for nurses, who give it the highest percentage of “good” and “excellent” scoresofthethreegroups(46%).“Qualityoffamily-related training” is the measure second from the bottom in terms of relative satisfac-tionfornurses(46%)butisonlyfifthfromthebottomforCNAsandtheentireworkforce(53%and54%).

One low-scoring item is fairly consistent for all three groups, placing as the area of lowest satis-factionfornurses(41%)andsecondlowestforCNAs(43%)andthecomprehensiveworkforce

(46%)—“assistancewithjobstress.”Assistancewith job stress is an important aspect of the em-ployee-employer relationship. Not just because it presents a clear opportunity for the industry to improve, but nationally it is one of the pri-mary drivers of employees’ recommendations asaplacetowork,afindingthatiscoveredinthe Performance Improvement section of this National Research Report.

Unlike with the customer satisfaction scores, analysisconductedforthe2011-2012NationalResearch Report found no improvement in either the highest or lowest scoring measures from last year’s report. All of these positive rat-ings stayed the same or even decreased slightly in each of the measures, for each of the groups of employees.

HIGHEST & LOWEST AREAS OF WORKFORCE SATISFACTION


Figure 16

Low

est

Satis

fact

ion

Hig

hest

Satis

fact

ion

0% 20% 40% 60% 80%

86%83%83%84%

85%86%

77%75%

79%72%

78%76%

41%43%

46%46%

39%44%

46%53%54%

Assistance withjob stress

Comparisonof pay

Quality of family-related training

Quality of in-service education

Safety of Workplace

Sense of accomplishment


Nurse

CNA

Workforce


DEEPER ANALYSIS

• Overview

• Industry Variation by Provider Characteristics

• Relationships Between Measures


22

Deeper Analysis

DEEPER ANALYSIS

customer and workforce satisfaction scores. When looking at the rate of “excellent” recom-mendations(ofanursinghometoreceivecarefor customers, and as a place to work for em-ployees),thelowestandhighestscoringcatego-riesofprovidersdifferbyonly7%forcustomerscores(rangingfrom39%to46%)and8%foremployeescores(rangingfrom18%to26%)(seefigure17).Interestingly,lowandhighscores in one area of assessment do not always correlate with low or high scores in the other, despite the clear relationship between employ-ee and customer satisfaction that is presented in the next section of this report.

Wefindthemostvariationincategoriesofskilled nursing homes grouped by size. Small providers(thosewithfewerthan80licensedbeds)scorehigherinbothcategoriesthanmedium-sizednursinghomes(thosewith80-119licensedbeds),whichscorehigherthanlargefacilities(thosewith130ormorebeds).Customer “excellent” recommendation scores rangefrom39%inthelargenursinghomesto

Studying the high-level, nationwide feedback gathered from such a large representation of the long term care customer base and work-force provides tremendous value to better understand the people and perspectives that are so vital to the success of the profession. The databaseoffersconsiderablymoreopportunityto dig into this feedback for a more diverse and complete view; there are multiple approaches and angles to explore. For the purposes of this National Research Report, we have included two analyses:1)areviewofthedifferenceinscoresearnedbyprovidersofdifferentcharacteristics(forexample,ownership,affiliation,andsize),and2)ananalysisoftherelationshipbetweendifferingnursinghomesatisfactionandqualityscores.

Industry Variation by Provider Characteristics

Across various types of skilled nursing care centers,wefindonlymoderatevariationinboth

RELATIVE CUSTOMER AND EMPLOYEE SATISFACTION RATES

120

or m

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80-1

19

Few

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ina

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ital

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# of licensed bedsA�liations Resident & familycouncils

% Excellent Customer Recommendation

% Excellent Workforce Recommendation for job

Figure 17

0

10%

20%

30%

40%

50%41%

22%

46%

25%

43%

26%

40%

21%

41%

22%

41%

22%

40%

21%

46%

25%

39%

21%

43%

24%

39%

20%


23

Deeper Analysis

46%inthesmall;employee“excellent”recom-mendationscoresrangefrom20%inthelargenursinghomesto25%inthesmall.Infact,weconsistentlyfindlowerscoresforbothcustomerand employee satisfaction in larger and more complex organizations. Scores are higher in standalone nursing homes than in those that are part of a chain, and slightly higher in nursing homes that are not part of a CCRC than those that are.

As previously mentioned, higher and lower scores do not always pair within the same group of nursing homes. In fact, government-owned nursing homes have among the highest “excel-lent”customersatisfactionscoresat46%,butalso the lowest “excellent” employee satisfac-tionscoresat18%.

Relationship Between Measures

In this report, as in many organizations, we have focused on customer satisfaction and employee satisfaction as distinct issues. This is true, but they are also very much related, and neither ex-ists independent from the other, or in a vacuum, segregated from other quality measures and elements of facility operations.

In evaluating the relationships between various satisfaction and quality measures, we found that providers with higher employee satisfaction scores have clearly higher family satisfactionscores(seefigure18).

We evaluated this trend by segmenting provid-ers based on their average overall employee satisfaction scores into four groups, with those in the fourth quartile achieving the highest scoresandthoseinthefirstquartileachievingthe lowest. We then calculated the average overall family satisfaction scores for each group, and found that those skilled nursing homes with the lowest employee satisfaction scores had onlyanaveragefamilysatisfactionscoreof70,while those providers with the highest em-ployee satisfaction scores had an average family satisfactionscoreof80.

We took the same approach to evaluating the relationship between family satisfaction and resident satisfaction and found the same trend. Providers with the lowest levels of family satis-faction had an average overall resident satisfac-tionscoreof71,relativetothosewiththehigh-

NURSING HOMES WITH HIGHER EMPLOYEE SATISFACTION HAVE HIGHER

FAMILY SATISFACTION SCORES

Nursing Homes Grouped By Employee Overall Satisfaction Scores

Aver

age

Fam

ily O

vera

ll Sa

tisfa

ctio

n Sc

ore

66

70

74

78

4th Qu

artile

3rd Qu

artile

2nd Q

uarti

le

1st Q

uarti

le

7476

80

70

68

72

76

80

Figure 18


24

we know that some nursing homes are able to excel in both customer and employee satisfac-tion simultaneously. We also know that simulta-neouslyexcellinginbothisrare—only25%ofnursing homes have both higher than average employee scores and customer scores in the same year. Underperforming in both areas is morecommon,as42%arelowerthanaveragein both employee and customer satisfaction scores in the same year.

Similarly, we wanted to understand the rela-tionship between other quality metrics and satisfaction scores. For this, we turned to the Five-StarQualityRatingSystemavailableontheMedicare Nursing Home Compare website as a summarized representation of a range of nurs-ing home quality measurements. Again, there is a clear trend where nursing homes with higher star ratings also have higher “excellent” recom-mendations from family members, residents, andemployees(figure20).Five-starorganiz-

Deeper Analysis

NURSING HOMES WITH HIGHER FAMILY SATISFACTION HAVE HIGHER

RESIDENT SATISFACTION SCORES

Nursing Homes Grouped By FamilyOverall Satisfaction Scores

Aver

age

Resi

dent

Ove

rall

Satis

fact

ion

Scor

e

66

70

74

78

4th Qu

artile

3rd Qu

artile

2nd Q

uarti

le

1st Q

uarti

le

7577

81

71

68

72

76

80

Figure 19

RECOMMENDATION SCORES BASED ON OVERALL STAR RATINGS

% E

xcel

lent

0%

10%

20%

30%

40%

50%

60%

Employee ExcellentRecommendation for Job

Resident ExcellentRecommendation for Care

Family ExcellentRecommendation for Care

1 Star

2 Star

3 Star

4 Star

5 Star

Figure 20

est satisfaction scores achieving an average overallresidentsatisfactionscoreof81(seefigure19).

By looking at the scores of individual organiza-tions, instead of collapsing them into groups,


25

ationsin2011earned“excellent”scoresfrom50%offamiliesand51%ofresidentsasaplacetoreceivecare,relativetothe33%“excellent”scoresfromfamiliesand38%fromresidents earned by one-star organizations. Similarly,31%ofemployeesatfive-starnurs-ing homes said that they would recommend their organization as an “excellent” place to workrelativetojust16%ofone-starnursinghomes.

We compared satisfaction scores based on all of the star ratings available on Nursing Home Compare, including health inspections, nurse staffing,RN-onlystaffing,andqualitymeasures.The same trends generally held true—skilled nursing homes with higher star ratings also had higher “excellent” ratings in all three recom-

Deeper Analysis

mendation scores. The exception to this trend-was the employee recommendation scores basedonstaffingstarratings.Thegroupsofprovidersdefinedbythenursestaffingstarrating all had very similar employee “excellent” recommendationscores,rangingfrom21%to23%,withoutanycleartrend.ThegroupsofnursinghomesdefinedbytheRN-onlystaffingstar rating had “excellent” employee recom-mendationscoresrangingfrom20%to25%,withtheone-starnursinghomesachieving25%and the four-star organizations reaching only 20%.Theseresultsleadustobelievethathighquality in one area of long term care operations impactsorinfluencesperformanceinothers,but that not all commonly used metrics may be measuring the true or most important elements of quality.



• Overview

• Key Drivers

• Possible Scores with Key Drivers

• Improvement Possibilities


28

the data which areas of interaction are the most important to family members, residents, and employees and which drive an individual’s overall level of satisfaction with the nursing home.

We achieve this understanding by correlating theresponsestothespecificquestionswithsurvey respondents’ answers to the global “recommendation” question. This process tells us which measures “move” most tightly with the “recommendation” question. In other words, when people answer these questions with more positive responses, they are more likely to recommend a nursing home as a place to receive care or to work.

When we evaluate the data of all types of cus-tomers—short-stay residents, long-stay resi-dents,andfamilies—wefindalotofsimilarityamong their top drivers of recommendation. “Care(concern)ofstaff”and“competencyofstaff”topthelistasthetwobiggestdriversofrecommendationforallthreegroups(seefigure21).“Choices/preferences”isthethird

There is no shortage of incentives for all healthcare organizations, especially those in the post-acute and long term care segment, to focus on performance improvement. The evolution of the space from all angles pro-vides plenty of reasons for skilled nursing care centers to invest time, energy, and focus into performance improvement activities, in addi-tion to resources that will help nursing homes achieve success in their various performance improvement initiatives.

The bigger question then isn’t, “should we?” or, “why?” but, “how?”

The answer to that question can take many forms, from descriptions of performance im-provement models to prescriptions for culture change that will allow performance improve-ment to take root and change the fundamental operations of the organization. For the pur-posesofthis2011-2012NationalResearchReport, we want to explore how the data can help inform the decisions and the prioritiza-tion choices that are key components of any organization’s process, regardless of the tacti-cal approach taken.

Key Drivers

There are many dimensions to a customer’s or an employee’s relationship with an organiza-tion. We discussed the perspectives captured bythesatisfactionsurveysconductedin2011and where individuals rate skilled nursing homes higher or lower in some aspects of those relationships. We can further learn from

Performance Improvement


- Care (concern) of staff

- Competency of staff

- Choices/Preferences

- Responsiveness of management

3rd for families and short-stay residents

4th for long-stay residents

3rd for long-stay residents

4th for short-stay residents

TOP DRIVERS OF CUSTOMER RECOMMENDATION

Figure 21


29


biggest driver of recommendation for families andshort-stayresidents(fourthforlong-stay),and “responsiveness of management” is third forlong-stayresidents(fourthforshort-stayandfifthforfamilies).

None of the items that score lowest for custom-ers, “answering call lights,” “quality of meals,” oreven“adequatestafftomeetneeds,”areasimportant to these individuals as the way the employees of nursing homes interact with them and support their ability to get as close as pos-sible to the life they choose to lead. At the same time, none of the top drivers of satisfaction are among the highest scoring for any category of customers, which indicates they certainly pres-ent an opportunity to the profession.

The issues most important to employees follow a similar theme of valuing quality and intent of interaction. The top three drivers of recommen-dation among all three of the groups of employ-eesevaluatedwereidentical:“care(concern)ofmanagement,” “attentiveness of management,” and“assistancewithjobstress”(seefigure22).

Unlike with the customers, one of these drivers receives some of the lowest “good” and “excel-

lent” scores—“assistance with job stress.” This elusive and challenging function of support is so important to employees, and yet it is the item that receives the lowest or the second lowest positive ratings across all groups of employees. This presents a clearly important opportunity for the profession to make a distinct and posi-tive impact on its workforce.

Possible Scores with Key Drivers

An important question to consider when se-lecting performance improvement priorities is, “where are your opportunities to improve?” High and low scores are part of the answer to that question, as are the key drivers of perfor-mance. By identifying what elements of service are most important to your stakeholders, and then cross-referencing those against current strong and weak areas of performance, you may be able to identify areas that are opportunities forimprovement(whereperformanceislower)that will truly matter to your customers or employees(andaredriversofrecommendationscores).

Another component of the answer is, “what is possible?” If your performance in a key driver is alreadydefinitivelyabovethenationallevelofperformance, then it may not be an area where you want to focus. This is because it may be difficultforyourteamtoimproveperformancemuch in an area where you are already strong.

Again, we look to the data to inform our under-standing of what is possible. If we consider the top three drivers of long-stay resident satis-

- Care (concern) of management

- Attentiveness of management

- Assistance with job stress

TOP DRIVERS OF EMPLOYEERECOMMENDATION

Figure 22


30

faction—“care(concern)ofstaff,”competencyofstaff,”“responsivenessofmanagement”—wecan look to the database to see what individual organizations were able to achieve in these areas.

For the primary driver of resident satisfaction, “care(concern)ofstaff,”the50thpercentile“excellent”scoreis41%.Thistellsusthathalfof all skilled nursing organizations earned less than41%“excellent”responsesfromresidentsonthisitemandhalfearnedhigherthan41%.The75thpercentile“excellent”scoreis55%,andthe90thpercentile“excellent”scoreis


69%.Thesetwonumbersgiveusinsightinto“what’s possible” in terms of success with im-provingperformanceonthisspecificmeasure.Weknowthat25%ofnursinghomeshadascoreof55%orhigher,and10percenthadascoreof69%orhigher.While55%and69%are not unattainable goals to set, we know that nursinghomes(andnotjustoneortwo)havealready achieved them. In addition, we know that10%offacilitiesreceiveda98%orhigherpositive(“good”and“excellent”)scoreforthismeasure. Near-perfect positive marks are very possible.

RANGE OF “EXCELLENT” PERFORMANCE OF TOP THREE DRIVERS OF RESIDENT RECOMMENDATION

25th percentile

50th percentile

75th percentile

90th percentile

Responsiveness of management

Competency of sta�

Care (concern) of sta�

0 10% 20% 30% 40% 50% 60% 70% 80%

21%32%

46%63%

25%35%

49%67%

30%41%

55%69%

25th percentile

50th percentile

75th percentile

90th percentile

Responsiveness of management

Competency of sta�

Care (concern) of sta�

75%84%

92%97%

84%90%

95%99%

84%91%

96%98%

0 20% 40% 60% 80% 100%

RANGE OF “EXCELLENT” + “GOOD” PERFORMANCE OF TOP THREE DRIVERS OF RESIDENT RECOMMENDATION

Figures 23, 24


31

cludedintheanalysis(long-stayresident,fam-ily,short-stayresident,employee),andrangedfrom2to4pointsforthethree-yearviewofperformanceimprovement(figures25-28).

Lookingatthe75thpercentilescores,25%ofnursinghomesimprovedbetween5and7pointsormoreinasingleyear,dependingonthemeasure,andbetween7and9pointsor more over a three-year span. This partially answers the question, “what kind of improve-ment is possible and what should I expect?” Significantnumbersoforganizationshavemadenoteworthy improvements in performance over a relatively small amount of time. This doesn’t mean that all organizations can or will achieve the same results, but it is helpful to understand what others have done.

Improvement Possibilities

The other hot “what’s possible?” question in performance improvement activities is cen-tered around how much improvement can be expected or asked for in a given year or over time. To answer this, National Research evalu-ated nursing homes that have worked with us and surveyed at least annually every year since2007.Wetookalookathowoftenandhow much improvement was achieved within a singleyear(fornursinghomeswithaminimumnumberofresponses)andhowmuchimprove-ment was achieved over a three-year span.

It was discovered that the majority of nursing homes do improve each year and over three years.The50thpercentileforaone-yearim-provementwas1pointforallmeasuresin-

IN AVERAGE RESIDENT RECOMMENDATION SCORES

7

13

18

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14

-4 -20

5

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Figures 25, 26, 27, 28

IN AVERAGE FAMILY RECOMMENDATION SCORES

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IN AVERAGE SHORT-STAY RECOMMENDATION SCORES

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Single year change Change over 3 years

IN AVERAGE RECOMMENDATION FORJOB SCORES

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1 2-4 -4

25th percentile

50th percentile

75th percentile

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25th percentile

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75th percentile

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25th percentile

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90th percentile

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90th percentile

RANGE OF PROVIDER-LEVEL IMPROVEMENT



CONCLUSION


34

Conclusion

ority of the public. This function is one that positively contributes to many of the objec-tives of both the healthcare community and the healthcare recipient—aiding in the healing process, which not only contributes to quality of life but reduces other healthcare utilization (andthereforecost)andallowsthesetypesofpatients to return to live safely and indepen-dently at home.

We know more today than we ever have before about the bigger picture of customer and em-ployee satisfaction. National Research Corpora-tion is at the forefront of the activities involved in not only studying satisfaction in the long term care profession, but in marrying satisfac-tion data with other measures to have a more comprehensive picture of quality and in un-derstanding performance improvement around satisfaction, experience, and commitment. These activities have led to a deeper level of knowledge about what drives satisfaction and how organizations have improved and can im-prove going forward. They have facilitated the ability to demonstrate that the profession, as a whole, has been increasing resident, family and employee satisfaction steadily over the past several years.

There is value to individual providers as well as to the long term care profession as a whole if they and their advocates can focus on and improve upon the ability to tell this story. The facts presented in this National Research Report are some on which such communications could gain inspiration.

CONCLUSION

Between industry trends such as the Triple Aim from the Institute for Healthcare Improvement (IHI),regulatoryandcertificationrequirements,changesinpaymentpolicies(includingre-stricted reimbursement rates and value-based purchasingprograms),andbusinesspressureslike increased competition and a move toward consumer-driven healthcare, there is no short-age of pressures and competing priorities for leaders of skilled nursing homes. There is also a wealth of information to help support providers, leaders, and advocates in this work on behalf of their organizations and the profession.

Anecdotally, we know that nursing homes tend to have a public image that is less positive than they would like and less positive than they generally deserve. But it isn’t the resident or family experience that is actually driving this image. More likely, the trepidation that consum-ers feel related to nursing homes is more about the thought of being frail and elderly, losing autonomy, and having to leave their homes and be dependent on others in respect to life’s most basic activities. Despite the dramatic change in residents’ lives that nursing homes represent and the likely preconceived ideas that exist upon moving into a long term care community, residentsandfamiliescometobesatisfiedwith how they were cared for in a situation they would have preferred to avoid.

In addition, for many acute care patients, nurs-ing homes are actually places to go to and then to return home fairly quickly, which is a consid-eration that is likely not appreciated by the maj-

© 2012 National Research Corporation. All rights reserved. My InnerView is a product of National Research Corporation. My InnerView, the My InnerView logo, and the National Research Corporation logo are trademarks of National Research Corporation. All other trademarks mentioned herein are the property of their respective holders. All original data, analy-ses, and intellectual property presented herein cannot be duplicated or claimed as source material by parties other than National Research Corporation.

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