the cost of turnover : advancing excellence campaign washington, d.c. (september 27, 2011)

Graduate School of Public Health University of Pittsburgh

THE COST OF TURNOVER:

Advancing Excellence Campaign

Washington, D.C. (September 27, 2011)

Nicholas G. Castle, [email protected]


INTRODUCTION:

Introduction From ivory tower (in PA)

Tell you what you already know! Resident-to-resident abuse Patient Safety Culture Agency staff use Worker injuries Quality of care Deficiency citations Leadership TURNOVER (TODAY)


INTRODUCTION:

Introduction / Conclusion Bottom line

Need less turnover Turnover influences quality (Men’s Health: Research stating the

obvious!) More “refined” message(s)

Others need to understand importance of turnover

Many costs associated with turnover


INTRODUCTION:

What to expect! Research (what we know about turnover) Format (information)

No formula No prescription Some advice

AND Thank You!>20,000 surveys (10 years)

Provide Some Feedback


INTRODUCTION:

Research Sponsor The Commonwealth Fund

Staff Assist http://www.crhc.pitt.edu/StaffAssist/

o CAHPS Survey (Satisfaction)o U. Pitt Research Network


TOP MANAGEMENT TURNOVER:

How Much Turnover? (Study 1): TOP MANAGEMENT TURNOVER Administrators, average turnover rate of 43% per

year. Directors of Nursing, average turnover rate of 39%

per year. In most facilities one member of top management

leaves every year. Some facilities had 6 NHAs or 6 DONs in one year. Primary data from surveys of approx 3,000 top

managers (2005, 2007, 2009)



How Much Turnover? (Study 1): TOP MANAGEMENT TURNOVER More Details

NHA / DON probability of remaining in same position for 3 years < 33%

Administrators, average turnover rate of 43% per year.

Facilities with stable (>2 year tenure) NHA and DON = 23%.

Facilities with “excess” turnover (>4 NHA and/or DON) = 19%

TOP MANAGEMENT TURNOVER: Where do you go?

Time 0 6 months 1 year 1.5 years 2 years

OTHER NH 91 NHAs (12%)

NOT WORKING IN LTC 27 NHAs

(3.6%)


NOT WORKING IN LTC 23 NHAs (3%)




Retired 23 (3%) Retired 28 (4%) Retired 33 (4%) Retired 37 (5%)

SAME FACILITY 502 NHAs (67%)



Setting: 6 states, randomly chosen participants


Cohort of 748 NHAs SAME FACILITY 618 NHAs (82%)


Administrator Turnover (Cohort, N=748)

82

67

48

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Some questions of importance: Retire

Reasons Other nursing homes

Why Other LTC facilities

Same facility Why

Not working in LTC Why Good / bad



Why do you leave?

Able to answer some important questions

DEFICIENCY CITATIONS? Some association (fired or quit?)

Stronger over time (performance matters) Not so much with NHC QMs

DON Less able to work in acute care? Not true, frequent moves

Influence of age



Why do you leave?

Examine: Levels of job satisfaction SAME FACILITY

Most satisfied with rewards, work skills, coworkers, work load

Least satisfied with work demands OTHER NURSING HOME

Most satisfied with rewards and work skills Least satisfied with work demands, coworkers, and

work load NOT WORKING IN LTC

Most satisfied with rewards Least satisfied with work skills, work demands,

coworkers, and work load



What Helps? (Study 2): THE EFFECTS OF TOP MANAGEMENT

PROFESSIONAL DEVELOPMENT ON ADMINISTRATOR TURNOVER

Examines characteristics associated with professional development of the top management team and administrator turnover.

Primary data from 406 nursing homes.Professional development lowers turnover rate

(assumes lower top management turnover is important).

State Website Minimum Degree Additional Requirements

Alabama http://www.alboenha.state.al.us/ Associates Supervisor Experience; AIT ProgramAlaska http://www.commerce.state.ak.us/occ/pub/nha4020.pdf Baccalaureate-HC or Business Experience

Arizona http://www.aznciaboard.us/New%20rules%20effective%204-5-08.pdf Associates current RN; AIT program

Arkansas https://www.medicaid.state.ar.us/Download/general/units/oltc/regs/nhadmin.pdf Associates Coresework; internship or experience

California http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdph526.pdf (RN) Work experience; current RN; AIT

Colorado http://www.colorado.gov/oed/industry-license/300IndDetail.html Associates, HC related field Supervisor Experience

Connecticut http://www.ct.gov/dph/lib/dph/practitioner_licensing_and_investigations/applications/pdf/nha2000.pdfBaccalaureate Residency training

Delaware http://regulations.delaware.gov/AdminCode/title24/5200.shtml Associates Experience or AITFlorida http://www.leg.state.fl.us/statutes/index.cfm?App_mode=Display_Statute&Search_String=&URL=0400-0499/0468/Sections/0468.1695.htmlBaccalaureate AIT Program or Experience

Georgia http://rules.sos.state.ga.us/docs/393/3/02.pdf H.S. Diploma Experience; AIT

Hawaii http://hawaii.gov/dcca/pvl/programs/nursinghome/application_publications Baccalaureate Experience or AIT

Idaho https://secure.ibol.idaho.gov/IBOL/BoardAdditional.aspx?Bureau=NHA&BureauLinkID=100H.S. Diploma Experience; AIT

Illinois http://lmi.ides.state.il.us/licensure/n/239.htm 60 semester hours Experience

Indiana http://www.in.gov/pla/2813.htm Associates, HC AITIowa http://www.legis.state.ia.us/aspx/ACODOCS/DOCS/645.141.pdf Baccalaureate Coursework; Practicum

Kansas http://www.kdheks.gov/hoc/regs/28-38.pdf Baccalaureate Practicum

Kentucky http://www.lrc.ky.gov/KRS/216A00/080.PDF Baccalaureate Experience or internship

Louisiana http://www.labenfa.com/ 60 semester hours Experience

Maine http://www.maine.gov/sos/cec/rules/02/chaps02.htm#371 Baccalaureate Cert in LTC or credits in management; AIT

State Renewal CEUs Detail Cost

Alabama Annual 24 hours Only 6 hours can be NAB/NCERS approved self-study 125

Alaska Biennial Signed statement

Arizona Biennial 50 hours June 30th even years; board approved 300

Arkansas Annual 20 CEUs 100

California Annual 40 hours 10 hours in aging or patient care 190

Colorado Annual None 51

Connecticut Biennial 40 hours 200

Delaware Biennial 48 hours July 31 odd years mailed to individuals

District of Columbia Biennial 40 hours June 30th even years

Florida Biennial 40 hours 250

Georgia Biennial 40 hours Dec 31 odd years; 6 hours in ethics or resident rights 125

State Hours/etc Topics Substitutes

Arizona knowledge of proper needs to be served by nursing care institutions; background in the laws and rules governing the operation of nursings care institutions and the protection of the interests of the patients in nursing care insitutions; training in elements of good health care facililties administration

Arkansas 15 semester hours; 3 hours per topic

Accounting College or Vocational courses

Management Work exp (6 weeks = 1 credit hour)

Personnel CLEP

Writing CEU (10 contact hours = 1 credit hour

Resident Care

Connecticut LTCA study General Admin and Management

Financial Managementlaws and RegulationsPersonnel management and labor Relations

Patient Care and ServicesPlanning and Delivery Systems

Gerontology

3.5 million elders per year receive care in nursing homes. Much of this care is sub-standard and can cause harm (Almost all facilities received citations in 2008). Each state has minimum requirements for licensure (which includes education levels). States have extensive latitude in their licensure requirements. Increasing minimum education levels may improve management and in turn, improve quality.

Significantly, the point estimates show that moving NHA education levels from a High School Diploma to a Bachelors degree would be associated with: 45% reduction in Physical Restraint Use. 40% reduction in residents with Moderate to Severe Pain. 27% reduction in incidence of Pressure Sores in Low-Risk Residents. 24% reduction in incidence of Pressure Sores in High-Risk Residents.

DiscussionDiscussionFour Quality Measures were examined in this investigation (restraint use, inadequate pain management, and two measures for pressure sores). Prior research identified these Quality Measures to be sensitive to top management characteristics.

We find ALL four of these measures to be positively associated with NHA education. As the average age of the elderly increases, the complexity of care provided in nursing homes will rise, and additional educational preparation may prove to be critical to meet these ever increasing demands.

Impact of Education of Nursing Home Administrators on Quality Jessica Furnier & Nicholas Castle

Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh.

To determine the relationship between education level of Nursing Home Administrators (NHAs) and quality of care.

ObjectiveObjective

Methods and MaterialsMethods and Materials

ResultsResults

Public Health & Policy ImpactPublic Health & Policy Impact

Future DirectionsFuture Directions

Table 1: Results Examining the Influence of Education on Nursing Home Quality Indicators

IntroductionIntroduction

Educational data: Collected via mail survey with follow-up reminder postcards. (6,000 mailed; 4,003 returned) Additional data collected: gender, age, race, and tenure.

Quality data: Obtained from Nursing Home Compare Measures included: restraint use, inadequate pain management, and two measures for pressure ulcers.

Analysis: Linear regression analyses used to examine the association of education with quality measures.

As noted in the Institute of Medicine’s 2001 report, nursing home quality is poor. Research indicates an association between organizational performance and characteristics of top management in a variety of industries, including healthcare. The influence of top managers of nursing homes (i.e., NHAs), has been demonstrated by recent research linking high NHA turnover to deficiency citations and poor resident quality of care (Castle, 2005).

Research in other industries has shown that education is positively associated with organizational commitment. Higher levels of education have also been associated with increased performance (Chevalier, 2004).

We hypothesize that a higher educational background of NHAs will be associated with better quality of care.

Table 1 shows increased education is positively associated with better quality of care.

Examine the impact of: Minimum state training requirements on quality NHA and Director of Nursing Experience on quality Continuing education on quality

A total of 4,003 NHAs returned the demographics and job characteristics survey, giving a response rate of 67%. The response rate varied little across the states, and in general, most items on the questionnaire were answered.

NHA EDUCATIONHigh School, 4%

Associates, 9%

Bachelors, 55%Masters, 30%

Other, 27%

NHA TENURE

< 1 year, 24%

1-2 years, 19%

2-5 years, 25%

> 5 years, 32%

NHA AGE

< 30 years, 16%

30-40 years,

22%

41-50 years,

22%

> 51 years, 40%

(1) (2) (3) (4) Variables

Percent Physical Restraint Use

(LSR)^

Percent With Moderate to Severe Pain

(LSR)^

Percent Low-Risk Residents With Pressure Sores (LSR)^

Percent High-Risk Residents With Pressure Sores

(LSR)^ NHA Education

Associates Degree 28.5*** 27.3*** 14.5*** 10.8***

(vs. High School Diploma) (1.44) (1.53) (2.1) (2.25)

Bachelors Degree 45.1*** 39.9*** 27.2*** 23.8***

(vs. High School Diploma) (1.25) (1.33) (1.81) (1.95)

Masters Degree 47.7 42.5*** 30.5*** 27.8*** (vs. High School Diploma) (1.31) (1.39) (1.88) (2.03) > Masters Degree 47.3*** 42.7*** 28.9*** 25.9*** (vs. High School Diploma) (2.01) (2.14) (2.89) (3.1) *p < .05; **p < .01; ***p < .001.

NHA = Nursing Home Administrator; FTE = full-time equivalent, ADL = activities of daily living, RNs = Registered Nurses, LPNs = Licensed Practical Nurses; LSR = long-stay resident

^ Definitions can be found in Abt (2004). NOTE: Coefficients of interest are presented. The regression models also include as controls – Top Management Factors (Tenure, Turnover (past 3 years), age, member of a professional association) Staffing Factors (Nurse aide staffing (FTEs per resident), LPN staffing (FTEs per resident), RN staffing (FTEs per resident)) Resident Factors (Resident case-mix (ADL score), Psychiatric condition, Mental retardation, Dementia Organizational Factors (Medicaid resident occupancy, Size (number of beds), For-profit ownership, Chain member, Occupancy rate) External Factors (Medicaid reimbursement rate, Competition (Herfindahl Index), Elderly in county (per 1000 population), Per capita income ($))

ReferencesAbt Associates Inc (2004). National Nursing Home Quality Measures: User’s Manual. Cambridge, MA: Abt Associates. Retrieved August 25, 2010 http://www.cms.hhs.gov/NursingHomeQualityInits/35_NHQIArchives.asp#TopOfPageChevalier, A., Harmon, C., Walker , I. and Y. Zhu, 2004, “Does Education Raise Productivity, or just Reflect It?”, Economic Journal, Vol. 114, F499-517. Castle, N.G. (2005). Turnover begets turnover. The Gerontologist, 45, 186-195.

http://www.bjbc.org/content/docs/TOCostReport.pdf

(1) (2) (3) (4) (5) Variables

Physical Restraint Use

Inadequate Pain

Management

Low-Risk Residents With Pressure Sores

High-Risk Residents With Pressure Sores

Residents With Catheters

NHA Education

Associates Degree 27.9*** 27.8*** 14.5*** 11.6*** 7.8***

(vs. High School Diploma) (1.44) (1.53) (2.1) (2.25) (2.00)

Bachelors Degree 43.6*** 39.3*** 26.4*** 23.9*** 19.9***

(vs. High School Diploma) (1.25) (1.33) (1.81) (1.95) (1.74)

Masters Degree 43.5*** 41.4*** 29.3*** 27.3*** 23.3*** (vs. High School Diploma) (1.31) (1.39) (1.88) (2.03) (1.82) > Masters Degree 47.2*** 42.9*** 29.3*** 26.6*** 23.2*** (vs. High School Diploma) (2.01) (2.14) (2.89) (3.1) (2.79)

STATE Licensure

Education Score 3.8*** 3.4*** 3.3*** 3.4*** 3.9***

(1,2,3) (0.43) (0.43) (0.54) (0.57) (0.50) Training Score 0.11*** 0.12** 0.05 0.04 0.03

(0-100) (0.02) (0.03) (0.03) (0.03) (0.03) *p < .05; **p < .01; ***p < .001.


TOP MANAGEMENT TURNOVER: So What? (Study 3): ADMINISTRATOR

TURNOVER AND QUALITY OF CARE IN NURSING HOMES Study

Administrator turnover is associated with a higher than average proportion of residents who were catheterized had pressure ulcers were given psychoactive drugs and with a higher than average number of quality-of-

care deficiencies. Repeated with DON

Similar findings (different QMs)

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TOP MANAGEMENT TURNOVER: So What? (Study 4):

TURNOVER BEGETS TURNOVER Association between turnover of nursing home

administrators and staff turnover. 419 nursing facilities and the 1999 On-line Survey,

Certification, and Reporting System (OSCAR) 10% increase in top management turnover

21% increased turnover of Nurse Aides30% increased LPN and RN turnover

Confirms interviews with nurse aides“If management does not want to work here, why

should I?”

QUALITY

The Quality Porcupine

Quality

Parsimony vs. Completeness

Population

Orthogonal

Data Sources

Type:

Stru

cture

,

proce

ss, O

utcom

e

Degree of

“adjustment”

Scale

used

Understandability

Real-time information


FACILITY CONTEXT AND MARKET CONTEXT

FACILITY AND MARKET CONTEXT

(e.g., bed size, ownership, chain membership, occupancy, Medicaid occupancy, top

management)

(e.g., competition, unemployment)

+ = hypothesized positive influence on care processes (with increasingly more +’s indicating a stronger positive influence); 0 = no hypothesized influence on care processes; – = hypothesized negative influence on care processes (with increasingly more –’s indicating a stronger negative influence).

CARE PROCESSESTopManagement

QUANTITY OF CARE+++ Staffing levels0 Staff Stability0 Professional Staff Mix++ Agency staff+++ Consistent resident assignment

Staffing interactions^Staffing nonlinearities^^

CAREPRACTICES+ Staffing levels++ Staff Stability+++ Professional Staff Mix- Agency staff+++ Consistent resident assignment


0 Staffing levels0 Staff Stability+++ Professional Staff Mix--- Agency staff+++ Consistent resident assignment


COORDINATION

++ Staffing levels+++ Staff Stability++ Professional Staff Mix--- Agency staff+++ Consistent resident assignment


CONSISTENCY

ResidentOutcomes(Quality of Care)

Resident*Acuity*Demogra


STAFF TURNOVER:

High levels of staff turnover in nursing homes? Nurse Aides = 71% Licensed Practical Nurses = 49% Registered Nurses = 50%

Source: Decker at al. (2003)


STAFF TURNOVER:

So What?GAO (2001): turnover among nurse aides

working in nursing homes is:13-18% percent higher than the overall labor

force 20% higher than other service workers.

100,000 FTE vacancies at nursing homes½ this post recession?

Does vary by state

State

Number of Facilities in Sample

NA Turnover1

LPN Turnover1

RN Turnover1

DON Turnover2

NHA Turnover2

NA Vacancy

Rate3

LPN Vacancy

Rate3

RN Vacancy

Rate3

AL 119 82% 44% 50% 55% 47% 10% 10% 9% AR 124 121% 66% 51% 63% 55% 8% 11% 12% AZ 62 93% 72% 69% 67% 63% 7% 11% 13% CA 548 61% 42% 45% 51% 58% 10% 15% 14% CO 107 57% 40% 40% 44% 40% 8% 12% 11% CT 170 43% 33% 39% 35% 37% 9% 11% 14% DE 26 60% 27% 37% 21% 27% 12% 14% 15% FL 455 66% 57% 51% 53% 50% 12% 12% 12% GA 192 78% 55% 45% 56% 57% 10% 12% 14% IA 242 55% 32% 35% 32% 39% 7% 10% 9% ID 29 62% 47% 54% 37% 39% 8% 9% 10% IL 446 58% 40% 43% 42% 40% 8% 8% 10% IN 213 74% 57% 57% 50% 53% 11% 12% 15% KS 176 87% 59% 55% 46% 43% 10% 7% 9% KY 168 92% 53% 59% 53% 46% 8% 7% 8% LA 121 95% 43% 50% 28% 36% 10% 9% 8% MA 228 47% 45% 43% 36% 33% 9% 14% 15% MD 122 49% 38% 40% 29% 40% 12% 11% 12% ME 60 41% 30% 32% 23% 30% 9% 7% 8% MI 217 53% 32% 36% 26% 28% 11% 11% 10% MN 189 81% 26% 28% 21% 33% 10% 10% 9% MO 264 91% 53% 53% 52% 48% 9% 14% 13% MS 73 60% 56% 71% 55% 44% 12% 15% 14% MT 30 58% 44% 42% 37% 47% 13% 15% 16% NC 214 68% 50% 45% 33% 38% 9% 10% 10% ND 36 38% 22% 25% 24% 32% 10% 9% 6% NE 111 36% 24% 21% 25% 29% 11% 9% 8% NH 45 49% 34% 34% 28% 31% 12% 13% 14%

NOTE: data from 8,023 nursing homes collected in 2004 (Castle, 2005)

State

Number of Facilities in Sample

NA Turnover1

LPN Turnover1

RN Turnover1

DON Turnover2

NHA Turnover2

NA Vacancy

Rate3

LPN Vacancy

Rate3

RN Vacancy

Rate3

NJ 200 49% 36% 42% 31% 35% 14% 15% 16% NM 34 72% 57% 62% 46% 45% 10% 17% 16% NV 12 66% 67% 66% 29% 32% 12% 13% 15% NY 351 43% 35% 41% 37% 46% 12% 11% 12% OH 520 71% 41% 50% 40% 41% 12% 10% 13% OK 164 75% 59% 52% 57% 54% 13% 13% 10% OR 82 61% 39% 46% 34% 39% 11% 10% 9% PA 366 42% 35% 37% 30% 36% 13% 11% 12% RI 51 63% 36% 53% 23% 32% 10% 11% 13% SC 90 66% 46% 43% 31% 40% 10% 5% 9% SD 51 47% 24% 21% 36% 42% 9% 6% 7% TN 175 80% 50% 51% 41% 40% 11% 8% 9% TX 547 82% 52% 54% 62% 41% 11% 8% 14% UT 38 81% 46% 61% 48% 43% 11% 9% 12% VA 103 66% 51% 49% 54% 57% 7% 10% 11% VT 18 62% 24% 50% 24% 37% 8% 12% 12% WA 142 60% 39% 37% 44% 32% 7% 14% 13% WI 220 43% 27% 30% 35% 38% 9% 10% 11% WV 60 55% 31% 58% 32% 39% 11% 12% 14% WY 12 50% 37% 32% 36% 44% 8% 8% 9%

SUMMARY 8023 64% 43% 46% 39% 41% 10% 11% 12%

NOTE: data from 8,023 nursing homes collected in 2004 (Castle, 2005)


STAFF TURNOVER:

So What? Data used in this investigation came from

surveys of nursing home administrators (N=6,005), Nursing Home Compare; Online System for Certification and Administrative Reporting data, and, the Area Resource File.

From the 18 turnover variables of interest (i.e., 6 quality measures and NA, LPN, and RN turnover) 11 coefficients were statistically significant.


STAFF TURNOVER:

Figure 1: Hypothesized Quality-Turnover Relationship

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Long Stay Quality Factor and Nurse Aide Turnover and Agency Use

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STAFF TURNOVER (2):

Causal Analysis? Registered Nurses, Licensed Practical Nurses,

and Nurse Aides were measured quarterly from 2003 through 2007, and come from 3,939 facilities.

Generalized method of moments (GMM) estimation was used to examine the effects of a change in staffing levels on change in four quality measures (physical restraint use, catheter use, pain management, and pressure sores).


STAFF TURNOVER (2):

Causal Analysis? For staff turnover, 7 of the 12 coefficients

were significant, and in all cases increasing turnover was associated with decreasing quality.

Castle, Medical Care, 2011


STAFF TURNOVER (2):

VARIABLES

QUALITY INDICATORS

Physical restraint use

Catheter use

Pain management

Pressure sores

Δ NA Staffing Levels 0.73*** (0.03)

0.36 (0.48)

0.46** (0.17)

0.81*** (0.11)

Δ LPN Staffing Levels 0.17** (0.04)

0.49 (0.68)

0.15** (0.05)

0.16*** (0.04)

Δ RN Staffing Levels 0.12*** (0.03)

0.44*** (0.06)

0.53* (0.28)

0.46*** (0.17)

Δ NA Agency Staffing Levels

0.16 (0.07)

-0.38*** (0.09)

-0.32*** (0.02)

-0.19*** (0.08)

Δ LPN Agency Staffing Levels

-0.15 (0.26)

-0.11 (0.21)

-0.19 (0.08)

-0.67 (0.42)

Δ RN Agency Staffing levels

-0.46 (0.42)

-0.14*** (0.02)

-0.31** (0.11)

-0.32** (0.18)

Δ NA Turnover -0.65** (0.24)

-0.60** (0.20)

-0.24** (0.09)

-0.11*** (0.04)

Δ LPN Turnover -0.49 (0.68)

-0.31** (0.17)

-0.29 (0.27)

-0.16 (0.250

Δ RN Turnover 0.05 (0.12)

-0.52*** (0.13)

-0.27** (0.11)

-0.65** (0.19)

Δ Professional Staff Mix

0.16 (0.21)

0.03** (0.01)

0.15*** (0.03)

0.42* (0.21)

Dummy variables for quarters X X X X


COST Study:

IS THERE A BUSINESS CASE FOR LOWER IS THERE A BUSINESS CASE FOR LOWER TURNOVER?TURNOVER?

Caudill and Patrick (1991)Caudill and Patrick (1991)Replacing CNA = $2,000Replacing CNA = $2,000Replacing RN = $7,000Replacing RN = $7,000

Seavey, D., “The Cost of Frontline Turnover in LTC.” (2004)

Replacing CNA = $2,500Replacing CNA = $2,500 Better Jobs Better CareBetter Jobs Better Care http://www.bjbc.org/content/docs/TOCostReport.pdf

$3,500 per employee$3,500 per employee Employee turnover's nationwide cost is roughly $4.1 Employee turnover's nationwide cost is roughly $4.1

billion annuallybillion annually

http://www.bjbc.org/content/docs/TOCostReport.pdf


COST Study:

Data Primary data (2010) Random sample Nursing Homes (N=2,344)

Nationwide sample

Cost Questionnaire Nursing Turnover Cost Calculation Methodology

(NTCCM) (Jones, 1990, 2005).

Used in business and nursing professions


COST Study:

Includes Pre-Hire and Post-Hire costs Pre-hire = advertising and recruitment post-hire = orientation and training

Include both direct costs (newspaper advertisements) and indirect costs (time spent interviewing)


COST Study:

Replacement Costs Pre-employment administrative expenses Cost of attracting applicants Cost of entrance interviews Pre-employment information gathering

Cost Category Description of calculation and adjustments Pre-hire Costs Advertising & Recruitment Costs

The sum of (1) labor and travel and other expenses associated with job fairs, student visitation, community recruitment; (2) newspaper and internet advertisements, and other media purchases; (3) paper and other supplies associated with advertising and recruitment.

Vacancy Costs The sum of (1) labor and expenses linked to overtime due to understaffed conditions; (2) missed or denied transport revenue due to understaffed conditions.

Hiring Costs The sum of (1) labor and expenses linked to interviewing candidates; (2) processing paperwork for candidates and new hires; (3) bonuses for new hires; (4) expenses linked to use of employee search and hiring firms; (4) expenses linked to background checks performed on candidates and new hires.

Post-hire Costs Orientation & Training Costs

The sum of (1) labor and expenses linked to initial orientation of new hires; (2) precepting new hires; (3) expenses associated with printing orientation materials, supplying binders and company booklets and other materials to new hires; (4) expenses linked to providing company clothing and equipment to new hires, and providing health screenings or vaccinations for new hires; (5) and expenses associated with agency equipment purchases specifically for new hire training.

New-Hire Productivity Costs

The sum the productivity costs for new hires (the difference between 90% productivity and productivity during the learning curve period).

Pre-Turnover Productivity Costs

The sum of labor costs linked to time administrators or equivalent employees spend filling shifts that employees who turnover during the month in question end up missing for one reason or another.

Termination Costs The sum of (1) labor and expenses linked to time administrators spend conducting exit interviews of terminated employees; (2) expenses associated with producing and printing materials and processing equipment and clothing linked to the termination process (e.g. washing or replacing employee agency issued clothing and equipment); (3) and expenses linked to paying the terminated employee early retirement, unused vacation compensation, or other related payout expenses unrelated to providing them with a final check.


COST Study:

Results CNA

Cost per replacement $3,940 Range $1,056 -- $5,530

RN Cost per replacement $5,901 Range $2,306 -- $8,921

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2200

2400

2600

2800

3000

3200

3400

3600

3800

4000

0 50 100 150 200 250 300 350 400 450 500

Average Turnover

Cos

t per

NA

($)

Termination Costs


Implications / Further Research:

Cost “savings” for high turnover Even cheaper to “fire” someone Business of high turnover

Learning curve for high turnover BUT

Does not include lower Quality Does not include occupancy (loss) Does not include NHA/DON turnover Does not include absenteeism

2000

2500

3000

3500

4000

4500

0 50 100 150 200 250 300 350 400 450 500

Average Turnover

Cos

t per

NA

($)

Including Top Management Turnover Costs

Including Top Management Turnover Costs and Absenteeism Costs



Additional analyses By region (some differences) By chain (less than expected) Union (less than expected, some less

turnover) Use median values Weight by larger facilities Influence of fluctuations in turnover over

time More than 50% are stable (consistent)



Next step Assisted Living (n=>3,000)

Similar turnover levels Somewhat less expensive

For reference Hospitals 1% > turnover $300K costs RN turnover $60,000

But $42,000 = bed loss

SOURCE: David Farrell, MSW, LNHADirector, Care Continuum


HOW TO ACHIEVE IMPROVEMENTS?

Myths About High Turnover CNAs do not have a good work ethic CNAs are not reliable Have little support at home Have a lower commitment Will leave for 10 cents more per hour

Jervis, 2002



“…these individuals were not fundamentallydifferent kinds of people with different work

ethics. They were, however, acting in a different organizational and human setting, being treated differently …..”

Susan Eaton



Top Reasons for Leaving Too many residents Pay was too low Not valued by the organization Dissatisfaction with supervisor Lack of opportunity to advance Could not provide quality care

Mickus, M., Luz, C., Hogan, A., “Voices from The Front.” 2004



What Matters Most to Employees Management cares about employees Management listens to employees Help with stress and burnout Workplace is safe Supervisor cares about you as a person Supervisor shows appreciation

MyInnerView, Inc. 2005



Consistent assignment of Nurse Aides (NAs).


Definitions:

Consistent assignment is defined as “the same caregivers consistently caring for the same residents almost every time they are on duty” (Care Practice Work Place Practice Environment, 2010).

Synonymous terms include primary or permanent assignment.


Literature Review:

Many quality initiatives have advocated consistent assignment Advancing Excellence in America’s Nursing

Homes Campaign goals and objectives [Available at: www.nhqualitycampaign.org/files].

State Quality Improvement Organizations (QIOs) (e.g., Patient Safety Insights, 2011)

Advocates for culture change (Doty, Koren, &

Sturla, 2008). States Offices of Health Facilities and

Certification (e.g., DE, OH, RI, IL, CA).


Design: Data used came from a survey of nursing home

administrators, the Online Survey Certification and Reporting data, and the Area Resource File.

The information including consistent assignment and staffing variables of Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and NAs were measured in 2007, and come from 3,941 facilities.

Negative binomial regression and multivariate logistic regression models.


Results (1):

Table 1: Distribution of Level of Consistent Assignment

1.5%2.2%

3.4%

4.3%4.3%4.3%3.7%

2.5% 2.4%3.0%

4.3%

3.3%

5.7% 5.9%6.5%

9.2%8.8%

17.4%

7.3%

3.3%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

16.0%

18.0%

20.0%

1-5 6-10 11-15

16-20

21-25

26-30

31-35

36-40

41-45

46-50

51-55

56-60

61-65

66-70

71-75

76-80

81-85

86-90

91-95

96-100

Level of Consistent Assignment

Perc

en

t


Results (2):

Variable Percent (n)

Use of consistent assignment (yes) 68% (2,678)

If using consistent assignment: Average level of consistent assignment for Nurse Aides^ 62%

Distribution of average levels of consistent assignment: Facilities with 1-33% consistent assignment of Nurse Aides 19%+

(509) Facilities with 34-66% consistent assignment of Nurse Aides 32%+

(857) Facilities with 67-100% consistent assignment of Nurse Aides 49%+

(1,312) Distribution of average levels of consistent assignment at recommended level: Facilities with =>85% consistent assignment of Nurse Aides 28%

(749) ^ calculated by facilities using the methodology distributed by Quality Partners of Rhode Island (2007). + Three measures do not equal 100% due to rounding error Overall sample size = 3,941 nursing homes


Results (3): Resident

Quality of Life deficiency citations (Incident Rate Ratios [95%CI])

Staffing Quality of Life deficiency citations (Incident Rate Ratios [95%CI])

Facility Quality of Life deficiency citations (Incident Rate Ratios [95%CI])

Quality of Care deficiency citations (Incident Rate Ratios [95%CI])

J, K, or L deficiency citations (AOR [95%CI])

Staffing Characteristics: Consistent assignment 0.82*** 0.84*** 0.96** 0.97* 0.92 (=>85% vs. None) (0.78-0.96) (0.81-0.97) (0.90-0.98) (0.88-0.98) (0.87-1.07) Consistent assignment 0.89* 0.95 0.98 1.02 0.99 (<85%-1% vs. None) (0.75-0.98) (0.91-1.06) (0.69-1.01) (0.85-1.09) (0.97-1.11) RN staffing 0.88** 0.94 0.89* 0.93 0.97** (0.82-0.93) (0.85-1.01) (0.82-0.99) (0.80-1.02) (0.90-0.99) LPN staffing 1.11 0.83 0.97 0.77 0.96 (0.93-1.16) (0.78-1.01) (0.78-1.02) (0.56-1.00) (0.74-1.09) NA staffing 0.93** 0.91** 0.89 1.01 0.98* (0.83-0.97) (0.89-0.98) (0.78-1.01) (0.85-1.05) (0.90-0.99) Staff mix 0.92*** 0.98** 0.90** 0.86** 0.95** (0.86-0.94) (0.90-0.99) (0.82-0.97) (0.81-0.94) (0.91-0.98) RN turnover 1.02** 1.19** 1.02 0.98 0.91 (1.00-1.09) (1.02-1.26) (0.97-1.07) (0.96-1.16) (0.87-1.10) LPN turnover 1.21 1.10** 0.97** 1.05 1.03 (0.95-1.26) (1.06-1.19) (0.85-0.99) (0.94-1.09) (0.97-1.11) NA turnover 1.13*** 1.16*** 1.06** 1.03* 1.07 (1.07-1.19) (1.10-1.21) (1.01-1.11) (1.00-1.09) (0.99-1.14) RN agency 1.11** 1.12* 1.26 1.18 1.048 (1.01-1.15) (1.03-1.26) (0.99-1.33) (0.91-1.25) (0.99-1.15) LPN agency 0.95 0.75 1.01* 1.05* 1.09 (0.91-1.06) (0.68-1.16) (1.00-1.09) (1.00-1.11) (0.98-1.11) NA agency 1.20 1.13* 1.07* 1.11** 1.13*** (0.99-1.26) (1.05-1.29) (1.02-1.18) (1.07-1.21) (1.04-1.15) Psuedo-R2 0.27 0.31 0.26 0.25 0.17


Discussion:

• Our findings that a beneficial association of consistent assignment with deficiency citations exists may provide some further momentum to implementation of consistent assignment

– In turn may enable the use of other culture change practices.

– Improve overall quality of care of nursing homes.


Summary:

• Consistent assignment has developed as a preferred practice in nursing homes based on little empirical evidence. The findings presented here provide some tentative justification for the use of this staffing practice for Nurse Aides.

• Similar findings for TURNOVER• None vs. 85% = 32% reduction

• Similar findings for ABSENTEEISM• None vs. 85% = 41% reduction



DEMING (the quality Guru):“Cannot improve interdependent systems and

processes until you progressively improve interdependent, interpersonal relationships.”



“The problem is not motivation. It is theways in which we unintentionally de-

motivate employees.”

Quint Studer “Hardwiring Excellence”



Communication Strategies(For Example)

• Monthly dept. meetings • All staff meetings

• Quarterly town hall meetings • Mini-inservices• Learning circles • Communication

boards• Lunch with administration • Lunch in break

room• Newsletters • Post quality data

SOURCE: David Farrell



Recognition(For Example)

• Raffle off gifts every month

• Neighborhoods for quality improvement• New employees – Rookie of Month• The power of “thank you” cards

SOURCE: David Farrell


WE KNOW THIS!

"Every organization is perfectly designed to get the results that it gets".

“We can’t solve problems by usingthe same kind of thinking we usedwhen we created them”

Albert Einstein


Ms. Alabama Nursing Home

Ms. Hanceville Nursing & Rehab Center Crowned Ms. Alabama Nursing Home 2010

the cost of turnover : advancing excellence campaign washington, d.c. (september 27, 2011)

Documents

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