Closing the Backdoor to

Staff Turnover

September, 2018

2

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

3

4

Mission Impossible?

• Improve staff morale

• Retain committed productive staff

• Hire committed productive staff

• Maintain consistent high-quality care

• Earn high customer satisfaction

5

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%

7

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

8

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)

9

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?

13

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

jeffwe@qualishealth.org

206-288-2465

Brent Schneider, MHA LNHAQI Consultant

brents@qualishealth.org

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

paulap@qualishealth.org

206-288-2470