The Anatomy of a Change Process

A Case Study Coaching Through Systems Change This material was designed by Quality Partners, the Medicare Quality Improvement Organization for Rhode Island, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the US Department of Health and Human Services. Contents do not necessarily represent CMS policy. 8SOW-RI-NHQIOSC-082006-2

First Visit: What We Found

• Presenting Problem: High Turnover • Resulting Problems: – Sufficiency: • Vicious Cycle of regular understaffing and daily instability • A small core of staff committed to the organization but a high percentage of burned out staff • High rate of turnover among newly hired staff, and hiring of any warm body • Vacancies and high turnover rate in housekeeping - staff complained about how dirty the common areas, bathrooms, and resident rooms were.

First Visit: What We Found (cont’d)

• Valuing Staff: – High rate of conflict between CNAs and their supervisors, across departments, and among CNAs – Staff who took on extra assignments didn’t see promised bonuses reflected in their pay-checks.

– Bulletin board for recognizing staff was empty – Staff appreciation cruise had no sign-ups – Staff resented pizza appreciations when they didn’t have enough linens – On a given day, staff didn’t know where they would be assigned, or who they would be working with – A sense of favoritism and punishment in scheduling – Nurses who expressed contempt for their staff

First Visit: What We Found (cont’d)

• Leadership: – Administrator who is bright, capable, dedicated to supporting the growth and stability of his workforce, seen by staff as approachable, always out helping, had been there for a while – DON who is earnest and dedicated, has been there a long time, but is not fully trusted, not out on floors helping, not consistent in dealing with problems – Many front-line nurse supervisors who don’t want to be in charge, are frequently disciplining staff, and are near the breaking point themselves – Staff witnessed abusive action by co-workers and didn’t know if they are being held accountable – One outstanding nurse supervisor who rallies her staff daily and maintains good morale

First Visit: What We Found (cont’d)

• Organization of Work: – Assignments to residents, supervisors and co-workers varied from day to day – Staff had too many people to care for and couldn’t get it all done each day – Heavily routinized care with constant pressure to “pick up the pace” – Very little helping or teamwork, except on unit with one charge nurse who fostered teamwork – Poor communication across shifts and departments – Strained relationships throughout the building, lots of resentment and conflict

First Visit: What We Found (cont’d)

• HR Policies and Practices: – New hires given hourly rate almost the same as long time employees – Small raises, late evaluations and delayed raises, ceilings on raises for the few long-time staff left – Bonuses for taking last minute assignments so staff switched from full-time to per diem to choose when they would work, to get the bonuses for doing so – Many staff were bailers (work two 12’s, paid for 30) – Any warm body hiring practice. One new hire had been fired from another facility for “no-call, no show” – No time for orientation, right on the floor and then right out the door

First Visit: What We Found (cont’d)

• Urged administrator to take immediate action to build trust and accountability: – Let staff know abuse was being addressed – Make sure paychecks reflected promised bonuses – Work with DON on leadership and accessibility – Start managing by walking around; instead of being out there but too busy helping, be out there finding out how everyone is doing – Think about changing incentives from rewarding people for being part-time to rewarding people for committing to full-time work

Second Visit: What We Did

• Design customized drilldown to: – determine current picture -- nature and extent of turnover and vacancies – analyze current incentives

Second Visit: What We Did (cont’d)

• Develop plan to stabilize staff – Analyze composition of current staff – FT, PT, per diem, bailers, and length of service of current staff – Current percentage of vacant positions – Determine extent, nature, and impact of call-outs – how many, which units, shifts, departments, positions – Determine specifics on turnover – who by length of service, position, unit, shift and department; any seasonal patterns – Calculate turnover replacement costs – Analyze use and impact of current incentives: bonuses for last minute assignments, sign-ons, referrals, mentors, differentials, longevity, attendance

Third Visit: Findings

Analyze drilldown findings and initiate staff stabilization plan – Composition of staff: • too many part-time, per diem, and bailer • too few full-time nurses in charge Position FT PT Per diem bailer RN LPN CNA 27% 55.5% 48% 13% 0% 10% 47% 18.5% 9% 13% 26% 32% Goal: More full-time staff Action: Analyze incentives re FT/PT

Third Visit: Findings (cont’d)

• Incentives: – Best deal is bailer; – Next best PT/ per diem with bonus for last-minute assignment – No reward for being reliable Bonus bailer (work two 12’s, paid for 30 hours) Extra Per Hr.

RN -- $7 LPN -- $5 CNA -- $3 Last minute assignment Perfect attendance RN, LPN --$10 CNA -- $5 $0 Annual $268,944 $360,000 $0

Third Visit: Findings (cont’d)

• Recommendations: – Transfer funds from last-minute bonuses to pay for higher raises for FT. – Talk 1-on-1 to convert to FT. – Phase out bailers. – Establish individual, team perfect attendance rewards.

Third Visit: Findings (cont’d)

• Composition of staff by length of service: – Many nurses in charge are new (60% of RNs and 52% of LPNs have been here less than a year) – There is greater stability among CNAs than nurses – A few long-time staff are hanging on – Non-nursing departments have more longevity than nursing

Third Visit: Findings (cont’d)

Position

RN LPN CNA All Other

< 6 mo.

10% 11% 12% 15%

6 mo –1 yr

50% 41% 14% 27%

1 – 2 yr

20% 33% 68% 35%

> 2 yr

20% 15% 6% 23% Goal: Have a greater percentage of staff stay longer.

Action: Analyze turnover by length of service

Third Visit: Findings (cont’d)

• Turnover (voluntary and involuntary) by length of service – Losing a lot of new hires within first month, 3 mos., 6 mos.

– A lot of instability in nursing positions – Unstable supervision may be contributing to CNA turnover

Third Visit: Findings (cont’d)

Position RN LPN CNA Other 1 day – 1 mo 18% 7% 23% 8% 1 – 3 mo 18% 13% 30% 27% 3 - 6 mo 6 mo – 1 yr 18% 33% 23% 39% 27% 27% 16% 12% 1 –2 yr 18% 20% 3% 14% > 2 yr 0% 0% 5% 0% Goal: Keep new staff; don’t lose any more long-time staff. Action: Analyze cost of turnover and impact of incentives.

Third Visit: Findings (cont’d)

• Turnover Costs: $453,940 from Jan – Dec. 04 – Includes higher hourly wage; sign-on bonus; filling vacant shift through agency or overtime; recruitment; screening; training; and orientation

Third Visit: Findings (cont’d)

Position RN LPN CNA Other Per Person $4,899 $4,193 $3,207 $2,692 Annual Cost $53,889 $62,895 $205,248 $131,908 Recommendation: Reallocate money spend on turnover/recruitment to reward longevity

Third Visit: Findings (cont’d)

• Incentives – Sign-on bonus pay-out at 6 mos.; high rate of turnover at 6 mos.

– Referral bonus rarely used; in staff satisfaction survey, most said they wouldn’t refer a friend – No longevity bonus; Average Annual Raise 2%; no mentors paid

Third Visit: Findings (cont’d)

Bonus Sign-on bonus Paid after 6 months Referral bonus Paid after 6 months Longevity Raises CNA Mentor Amount Offered RN -- $2000 LPN -- $500 CNA -- $250 RN, LPN --$1000 CNA -- $500 $0 Average 2% $300 + $0.50/hr.

Quarter Pd - Annual Est.

$12,500 - $50,000 $6,000 - $24,000 $0 $90,710 $0

Third Visit: Recommendations and Action

Staff Stabilization Plan: • Goal 1: Change composition of staff to full-time – Action: Raises to FT and long-term employees; Convert staff to FT; Phase-out bailers and per diem (no new hires) • Goal 2: Improve percentage of new hires who stay – Action: Dept. heads and supervisors support new hires and track their progress and needs over first weeks, mos. Skills building and strategy sharing on interview skills and process, evaluating potential employees, and providing a supportive environment to help new staff stay. Administrator and DON take direct role in hiring.

Third Visit: Recommendations and Action

Goal 3: Improve attendance and percent of fully-staffed shifts • Action: Track attendance by person, unit, shift, dept. Analyze absences for patterns. Communicate at dept. head meetings, put record in paychecks, and discuss absences with employees. Recognize and reward units and individuals with good attendance. Support employees by linking them to employee assistance services.

Fourth Visit: Findings

• Progress: – New Wage Package in Place • Raises given to full-time staff • Several staff converted to FT – Staffing stabilized • Evening and night shifts fully staffed • Significant reduction in call-outs on evenings and nights – Better retention of new hires • New CNA class about to start on the floor • Department heads providing support to coach new hires – Nurse who had left returned

Fourth Visit: Findings

• Continuing Problems • Shortages and instability remain on one day-shift unit – One CNA’s child care hrs changed and she could no longer come in at 7:00 am - she was let go – Two CNAs who wouldn’t follow orders to float were let go • Dept. heads feel unskilled in interview process • One nurse supervisor reported continuing tensions on her day-shift unit – New hires not handling their care load – Working short – Unable to get residents up in time in the morning – “I cry when I see the food cart is here.”

Fourth Visit: Action

• Leadership: Coached DON on how to provide support to her nurses for their management dilemmas by modeling a facilitated problem-solving process that they could use regularly to address non clinical problems. Administrator to coach dept. heads on interviewing • HR Practices: Allowed longer orientation by reassigning new hires from fast-paced short-term rehab to slower-paced long-term unit; problem-solved ways to support new staff as they acclimate • Work redesign: Unit will call kitchen when they are ready for meal cart. Serve other units first.

Fourth Visit: Action

• Valuing staff: For CNA with child-care needs, allowed her to adjust her hours and come back to work • Sufficiency: Recognized that the unit with stress needed to have its vacancies filled as soon as possible. DON will work with nurse supervisor to assign full-time staff to her unit as soon as possible. In the meantime, others will help her shoulder her workload.

Fifth Intervention: Leadership Training

(off-site) • Agenda – Building Relationships – Myths and Facts about Leadership (Kouzes and Posner) – Eaton: What a difference management makes!

– Theory X and Theory Y as conceptual frame for management approaches – Exploring Power, understanding your impact

Fifth Intervention: Leadership Training

(off-site) • Homework – Read Encourage the Heart chapters from Kouzes and Posner – Complete Eaton self-assessment – Have conversations with three people who work for you about what brought them into care giving, what are their frustrations and their rewards, and someone who made them shine

Sixth Intervention: Leadership Training

(off-site) • Agenda – Work redesign – Your systems are creating your outcomes – Valuing Staff – Encouragement – Leadership in practice – how you communicate and motivate, and the impact you have – HR – welcoming new staff

Sixth Intervention: Leadership Training

(off-site) • Homework – Notice good leadership practices and their impact – Reward three instances of good leadership among supervisors – Send thank you cards to your staff – Target three areas for personal leadership growth, using the Leadership Practices Inventory or the Encouragement Index

Seventh Intervention: Meeting with Nurse Managers

• Progress: • Staffing had improved on day shift but was still a little short.

• New hires were settling in well.

• Kitchen now waits for call from unit before sending tray.

• CNA with child-care needs rehired.

Seventh Intervention: Meeting with Nurse Managers

• Presenting problem: • Nurses want training on how to get staff to work better together.

– Work is chaotic in the morning, hard to get everything done • Action: • Facilitated problem-solving process with DON and administrator

Seventh Intervention: Meeting with Nurse Managers

• Memo the next day from the administrator: • We had a great meeting Everyone brought insight and the reality of what we do. Honest discussion is what will move us forward and improves our system of delivering care for our patients and staff. Action steps: – Review

Bathing Without a Battle

(VHS)

Seventh Intervention: Meeting with Nurse Managers

(cont’d) • Identify at least 10 residents from each unit that are currently turned every two hours and can be switched to every three or more hours. Each nurse manager will review the list of 10 residents. That list will be dwindled down to five residents per unit. There should be some discussion on how we will care plan and the expectations to track these residents. • Samples or information on different attends incontinence products • If we have the opportunity we will discuss consolidating tasks and medication

Seventh Intervention: Meeting with Nurse Managers

(cont’d) • Remember the goal is to maximize sleep and maximize our care delivery system.

• I am impressed and thankful that we recognize that sometimes our systems are set up because “it is just the way that we have always done it.” Let’s break the mold, think outside the box, and make it happen! • Our committee will be called the Solution Committee since that is exactly what we are going to do!

• Thank you