closing the backdoor to staff turnover · • cna turnover = 95%-107% * number of facilities...
TRANSCRIPT
Closing the Backdoor to
Staff Turnover
September, 2018
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Qualis Health
• A leading national population health
management organization
• The Medicare Quality Innovation Network - Quality
Improvement Organization (QIN-QIO) for
Idaho and Washington
The QIO Program
• One of the largest federal programs dedicated to
improving health quality at the local level
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4
Mission Impossible?
• Improve staff morale
• Retain committed productive staff
• Hire committed productive staff
• Maintain consistent high-quality care
• Earn high customer satisfaction
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What A Difference Management Makes*Administrator from high-turnover nursing home: “Apparently, the previous administrator didn’t speak to
people. He just walked around the building and didn’t speak
to people, even the department heads.”
-What happened to him?
“He was promoted, to the corporate office, to be president of
a division.”
Administrator from low-turnover nursing home:“The staff will be a mirror of the supervisors. If the supervisors
treat staff with dignity and respect, and hold them
accountable, that empowers people.”
*Susan Eaton, “Appropriateness of Nurse Staffing Ratios in Nursing Homes Phase
II Final Report”, Chapter 5, December 2001
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Nursing Home Turnover:
Definitions and StatisticsTurnover =
Terminations ÷ employed staff in time period
Quiz 1: What is the 6 month turnover rate for an
organization that has 10 employees and 6
terminations?
A. 30%
B. 38%
C. 60%
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Options for Turnover Calculations• Numerator: (excludes agency)
• Voluntary terminations
• Involuntary terminations
• Both
• Denominator: (excludes agency)
• Employees• Summed over entire time period
• Averaged by month over time period
• Count only at end of one representative pay period
• Full Time Equivalents (FTE)• Averaged by month over time period
• Count only at end of one representative pay period
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Turnover Calculations:
It Makes a Difference How You Do ItTurnover Data for 6 Months Using Employees as Unit of Measure
Jan Feb Mar Apr May Jun
number of employees
at end of month 10 10 10 10 10 10
number of terminated employees
in month1 1 0 2 2 0
number of new hires in month 1 1 0 2 2 0
• If denominator is number of persons employed over the 6 months,
turnover rate = 38% (6÷16 = 0.38)
• If denominator is number of persons employed in the last pay period,
turnover rate = 60% (6 ÷10 = 0.60)
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Turnover Calculations:
It Makes a Difference How You Do ItTurnover Data for 6 Months Using FTE as Unit of Measure
Jan Feb Mar Apr May Jun
FTE worked 10 10 10 10 10 10
FTE termed 0.5 0.5 0.5 0.5 0.5 0.5
number of new hire FTE 0 0.5 0 1 0 1.5
If number of FTE worked in the last pay period is denominator,
turnover rate = 30% (3÷10 = 0.30)
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WA Turnover Rates2017 Schedule L of Medicaid Cost Report
0
10
20
30
40
50
60
70
10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
# o
f N
urs
ing
Ho
me
s
Annual Direct Care Turnover Rate
Distribution of 2017 Turnover RatesWA Nursing Homes (n= 226)
10th percentile = 17%25th percentile = 24%50th percentile = 36%
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How WA Medicaid Calculates
Direct Care Turnover • Includes: DNS, RN, LPN, CNA, and other “other
nursing with administrative duties”
• Denominator = total number of W-2’s for year for
selected job classifications
• Numerator = total number of W-2’s that exited the
selected job classifications
• Turnover cannot be higher than 100% using this
method of calculation
• Will derive a lower rate than methods using
denominator based on monthly average or end of pay
period count of employees (slide 7)
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A Deeper Look at WA Medicaid
Turnover DataFacility A
• 480 in denominator
• 316 in numerator
• Turnover rate of 66%
• 47 NH beds
Facility B
• 163 in denominator
• 102 in numerator
• Turnover rate of 63%
• 190 NH beds
• Which facility has the better staffing pattern?
• What don’t we know from just looking at this
data?
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Idaho Turnover Data
• Annual CNA turnover averaged 46%
based on voluntary reporting by 30
facilities
• AHCA Data Tracker reports 2015-2017*
• RN turnover = 75%-90%
• LPN turnover = 50%-70%
• CNA turnover = 95%-107%
*Number of facilities reporting 12,10, and 8 for 2015,
2016, and 2017 respectively
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Staff Retention
Staff retention = the percent of current
employees that meet a certain threshold
of tenure, e.g., 6, 12, or 60 months.
• What is the turnover rate in the non-
tenured portion of staff?
• Is it possible to have a core group of
long-tenured employees, but still
persistently high turnover overall?
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Turnover and Quality of Care
• Increased CNA turnover is associated
with
• Increased number of quality of care
deficiencies1
• Poorer Quality Measure results2
Not clear from cross sectional studies if
turnover leads to poor quality, or if poor
quality leads to turnover, or both1JAMDA 15 (2014) 102 -107
2The Gerontologist Vol. 47, No. 5, 650–661
3JONA Volume 43, Number 12, pp 630-636
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Turnover Costs Money
Estimates of turnover cost per employee
• 16% of annual salary4
• $4,000 for CNA (range $1,000-$5,000)5
• $6,000 for RN (range $2,300-$9,000)5
4Center for American Progress “There Are Significant Business Costs to
Replacing Employees” 2012
5AHCA Webinar 01/25/17 “Staff Stability”
https://educate.ahcancal.org/products/part-4-staff-stability
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Turnover Costs Money
Turnover contributes to:
• Agency staff and overtime pay
• Excess orientation and training costs
• Survey deficiencies with potential penalties
• Poor reputation as a place to work
• Poor reputation as a place to receive care
• Loss productivity due to poor morale
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The Contrarian View…
Turnover Saves Money
• Med Care. 2009 October ; 47(10): 1039–1045
• Study uses estimates of turnover based on
“instrumental variables”
Hybrid Cost Function Estimation Equation
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What Drives CNA Turnover?
• Lack of appreciation and professional
respect6, 7
• Appreciation judged by actions, not rhetoric• Think pay, bonuses, interactions with supervisor, ability to
contribute to care planning and execution
• CNAs treated as interchangeable cogs • Think rotating schedules, last minute reassignments, use of
agency staff, lack of recognition of individual skills and
performance
6Journal of Gerontological Nursing, 2003, 29(3): 36-43.
7Journal of Gerontological Nursing 29(3), 51-58.
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What Drives CNA Turnover?
• Lack of opportunity or support for job-
related growth7, 8
• Feeling excluded from care planning7, 9
• NHA and DNS turnover10
7Journal of Gerontological Nursing 29(3), 51-58.
8BMC Health Services Research 2006, 6:60
9The Gerontologist Vol. 36, No. 4, 512-517
10The Gerontologist, Vol. 45, No. 2, 186–195
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What About Pay?
• Low pay/benefits is a source of
dissatisfaction, but not strongly
associated with turnover among CNAs7
• Lack of differentiation in pay between
CNAs of differing skill contributes to
feeling disrespected and undervalued6
6Journal of Gerontological Nursing, 2003, 29(3): 36-43.
7Journal of Gerontological Nursing 29(3), 51-58.
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Top Factors Related to Job
Satisfaction Among CNAs8
Positive1. Feeling of
accomplishment
4. Co-workers
Negative2. Co-workers
3. Just hate the job
5. Dead-end job
8BMC Health Services Research 2006, 6:60
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Ranked Factors Related to CNA
Job Satisfaction7
1. Opportunity for advancement
2. Equal opportunity in hiring and
advancement
3. Supervisory support
4. Work schedule
5. Supervision competence
7Journal of Gerontological Nursing 29(3), 51-58
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Ranked Factors Associated with
Workplace Recommendation10
CNAs
1. Help with job stress
2. Management listens
3. Management cares
4. Supervisor appreciates
5. Adequate equipment
RNs & LPNs
1. Help with job stress
2. Management listens
3. Management cares
4. Training to deal with
difficult residents
5. Training to deal with
difficult family members
10June 2007, My InnerView Inc. 2006 National Survey of Nursing Home
Workforce Satisfaction
Comparison of pay ranked at bottom of factors driving workplace
recommendation overall.
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Tools for Organizational Assessment
• Staff Stability worksheets
• NNHQIC Staff Stability Tracking Tool
• AHCA LTC Trend Tracker
• AHRQ Culture of Patient Safety Survey
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Staff Stability Worksheetshttp://www.bandfconsultinginc.com/Site/Staff_Stability_Tool-kit.html
9 excel spreadsheets to help you take
a snapshot of current turnover1. Distribution of full time/part time/per diem by position
2. Staff retention by LOS and position
3. Vacancies by position/shift/unit
4. Turnover rate by position
5. Cost of turnover calculator (linked to turnover rate)
6. Terminations by LOS and job, voluntary & involuntary
7. Absenteeism by position and shift
8. Call-in log
9. Financial incentives affecting turnover and retention
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National Nursing Home Quality
Improvement Campaign
www.nhqualitycampaign.org
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Why Use Tracking Tools?
• Uncover hidden turnover patterns (if you
don’t look, you won’t see)
• Focus process improvement where it is
needed
• Create business case for action
• Establish ability to monitor improvement
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AHRQ Culture of Patient Safety Surveyhttps://www.ahrq.gov/sops/quality-patient-safety/patientsafetyculture/nursing-home/index.html
Perception of
patient safety is
strongly
associated with
job satisfaction
for nursing staff
AHRQ provides surveys, data
collection tools, planning
manuals and other supportive
materials
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Data from the Nursing Home
Culture of Patient Safety Survey
• NHAs more positive than CNAs
• Day shift more positive than night shift
• Newer staff more positive than staff with
longer tenure
• Lowest ratings were from survey:
• Overall staffing levels
• Management response to staff mistakes
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Recruitment and Retention Committee
• Recruit staff representative from all departments
and shifts
• R & R committee interpret information on staff
turnover (e.g., worksheets, patient safety survey)
• R&R committee can serve as key informants and
also interview peers
• “What do you like the most about working here?”
• “What are the main reasons you would consider
quitting?”
• You can also collect answers anonymously in a
suggestion box
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Scenario for Discussion
After you fill out the worksheets you discover the
following:
• 67% of your CNA positons are part time (< 40 hours/week)
or per-diem
• 75% of your CNAs have less than 1 year tenure
• A 20% vacancy rate among CNAs, a little higher on second
shift
• A 85% annual turnover rate among CNAs
• 41 CNA terminations in the last year, 66% of which were
employee initiated, half of those within the first 6 months
• (continued)
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Financial Incentives• In last year, the single largest financial incentive
expenditures for CNAs was a “New Hire Sign-On Bonus”
• No “Employee Referral Bonus”
• No “CNA Preceptor Bonus”
• Per-diem CNAs make $2.50 more an hour (no benefits)
• CNAs can waive health benefits for $2.00 more/hour if they
can prove they have health coverage
• Given the above information, what
else would you want to know?
• What would you suggest be done?
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Scenario Discussion
You have conducted a AHRQ Culture of Patient Safety Survey
and you notice that only 35% of respondents were positive
about the communication openness, i.e., the extent to which
staff can speak up about problems and their ideas and
suggestions are heard and valued
What do you suggest be done?
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Scenario Discussion
You have conducted a AHRQ Culture of Patient Safety Survey
and you notice that only 40% of respondents were positive
about teamwork, i.e., the extent to which staff treat each other
with respect, support each other, and feel like they are part of
the team
What do you suggest be done?
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Ideas to Try: Appreciation
• All Hands On Deck
• Daily Supervisor/Manager S2 P2 RE• Sincere Specific Personal Positive Recognition of Employees
• Incorporate into walking rounds, all shifts, all days
• No detail too small to appreciate
• Enhance the prestige of CNA involvement in
care-planning
• Staff huddles at beginning of shifts
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Ideas to Try: Incentives
• Use referral and retention bonuses
instead of sign-on bonuses
• Prioritize full time regular work over
per-diem or part time work
• Reward attendance at individual and
team level
• Reward tenure
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Ideas to Try: Supervisor Training• Provide training to supervisors on communication
skills and require skill checks
• TeamSTEPPS
https://www.ahrq.gov/teamstepps/longtermcare/index.html
• Teach Back
http://www.teachbacktraining.org/
• Reflective listening
https://www.workplacestrategiesformentalhealth.com/pdf/arti
cles/Building_Reflective_Listening_Skills.pdf
• Motivational Interviewing
https://en.wikiversity.org/wiki/Motivation_and_emotion/Book/2
016/Motivational_interviewing
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Ideas to Try: Staffing
• Don’t staff to census
• On a annualized basis, the gains in staff
morale and commitment may more than make
up for the short-term expense of keeping staff
on even when census dips
• Maximize FTE benefitted positions
• Consistent Assignment of care giver
• Associated with lower turnover and fewer
citations11, 12
• Support from www.nhqualitycampaign.org
11Journal of Aging & Social Policy, 25:48–64
12The Gerontologist Vol. 51, No. 6, 750–760
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Ideas to Try:
4-2 Schedule with 8 Hour Shifts
• Supports Consistent Assignment
• Supports work-life balance
• Avoids week-day vs. weekend
division of care teams
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Ideas to Try: Absenteeism
• Track absenteeism (worksheets) and look for
patterns
• Report individual and aggregate absenteeism
statistics to staff
• Seek to understand the reasons for absences
and collaborate to solve problems
• Reward perfect attendance
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Ideas to Try: CNA Career Ladders
• Career steps for CNAs with increase
in responsibility and pay
• Team Neighborhood Leads
• New Hire Preceptors
• QAPI leader
• Subject Matter Experts• Oral Care
• Feeding
• Bathing/hygiene
• Prompted voiding
• Dementia care
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Improving Hiring Practices:
A Bad Hire Is Worse than No Hire• Referral bonus with possibility of team retention
bonus
• Take applicants on tours and observe how they
interact with residents and staff
• Set up multiple interview appointments to test
dependability
• Use scenarios and behavior-related interview
questions
• Consider using team and resident interviews (HR
needs to screen questions for legality)
• Exemplify your person-centered culture
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Key Points to Remember
• Use staffing and payroll data, interviews,
and surveys to understand what is
driving turnover in your organization
• Involve staff in creating the kind of
community that attracts and retains the
best employees (closing the backdoor)
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ContactsJeff West, MPH RN
QI Principal
206-288-2465
Brent Schneider, MHA LNHAQI Consultant
208-383-5941
For more information: www.Medicare.QualisHealth.org/NHQCC
This material was prepared by Qualis Health, the Medicare Quality Innovation Network - Quality Improvement Organization (QIN-
QIO) for Idaho and Washington, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S.
Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. ID/WA-C2-QH-3538-09/18
Paula Parsons
QI Associate
206-288-2470