1. Staff Stability and Engagement: Practical Strategies for All Long-Term Care Communities June 10, 2016 Barbara Frank, B&F Consulting www.BandFConsultingInc.com

2. Ten Steps To Staff Stability articles in Provider Magazine Jan and Feb 2016 http://www.providermagazine.com/archives/ 2016_Archives/Pages/0116/10-Steps-To-Staff- Stability.aspx http://www.providermagazine.com/archives/ 2016_Archives/Pages/0116/10-Steps-To-Staff- Stability.aspx http://www.providermagazine.com/archives/ 2016_Archives/Pages/0216/Ten-Steps-To- Staff-Stability-Part-Two.aspx http://www.providermagazine.com/archives/ 2016_Archives/Pages/0216/Ten-Steps-To- Staff-Stability-Part-Two.aspx ©B&F Consulting 2016 www.BandFConsultingInc.com

3. ©B&F Consulting 2016 www.BandFConsultingInc.com In 2008 there were 7 people for every job opening Today there are 1.5 people for every job opening

4. USA Today, May 29, 2015 Raising pay Expanding benefits Listening to employees' gripes. To stem turnover, Smokey Bones Bar & Fire Grill, with 65 restaurants in the Eastern U.S., last fall began conducting "stay interviews" with managers to determine how to improve their work lives. "The single biggest reason people quit their jobs is they don't trust their boss," says Dick Finnegan, a consultant for the chain. ©B&F Consulting 2016 www.BandFConsultingInc.com

5. Employment PAY CHECK AFFILIATION ©B&F Consulting 2016 www.BandFConsultingInc.com

6. A Vicious Cycle of Vacant Shifts, Stress, and Turnover Turnover Vacant Shifts Stress Working short staffed Resentment Agency use Errors Poor judgment Injuries Vacant Shifts Lack of trust Instability Poor outcomes Financial burden Overtime Eaton, What a difference management makes!, 2002 Fractured relationships ©B&F Consulting 2016 www.BandFConsultingInc.com

7. What a difference management makes! Five Management Practices Associated with Low-Turnover, High Attendance and High Performance: High quality leadership at all levels of the organization Valuing staff day-to-day in policy and practice, word and deed High performance, high commitment HR policies Work systems aligned with and serving organizational goals Sufficiency of staff and resources to care humanely Eaton, 2002 ©B&F Consulting 2016 www.BandFConsultingInc.com It’s all about affiliation

8. Staff Stability – Why It’s Important Prevent avoidable hospitalizations and other adverse events Provide consistent care so staff know residents better and can individualize care Improve resident and staff satisfaction Promote better teamwork ©B&F Consulting 2016 www.BandFConsultingInc.com

9. Staff Stability in Six Steps - How Step 1. Look at your data Step 2. Improve your pool of candidates Step 3. Improve your Hiring Process Step 4. Provide a Good Welcome Step 5. Reduce Stress and Provide Support Step 6. Engage and Develop your staff ©B&F Consulting 2016 www.BandFConsultingInc.com

10. Composition of staff by work status: PositionFTPTPer diemBaylor RN27%13%47%13% LPN55.5%0%18.5%26% CNA48%10%9%32% What impact does this have on staff stability and care continuity? ©B&F Consulting 2016 www.BandFConsultingInc.com

11. Incentives Bonus for last-minute assignment but no reward for being reliable BonusExtra Per Hr.Annual Last minute assignment RN, LPN --$10 CNA -- $5 $360,000 Perfect attendance$0 What impact does this have on staff stability and care continuity? ©B&F Consulting 2016 www.BandFConsultingInc.com

12. Position1 day – 1 mo 1 – 3 mo 3 - 6 mo 6 mo – 1 yr 1–2 yr> 2 yr RN18% 27%18%0% LPN7%13%33%27%20%0% CNA23%30%23%16%3%5% Other8%27%39%12%14%0% What impact does this have on staff stability and care continuity? ©B&F Consulting 2016 www.BandFConsultingInc.com

13. Incentives BonusAmt OfferedQuarter - Annual Sign-on bonus Paid after 6 mos. RN -- $2000 LPN -- $500 CNA -- $250 $12,500 - $50,000 Referral bonus Paid after 6 mos. RN, LPN --$1000 CNA -- $500 $6,000 Longevity$0 RaisesAverage 2%$90,710 What impact does this have on staff stability and care continuity? ©B&F Consulting 2016 www.BandFConsultingInc.com

14. Turnover Costs Includes higher hourly wage; sign-on bonus; filling vacant shift through agency or OT; recruitment; screening; training; orientation PositionPer PersonAnnual Cost RN$4,899$53,889 LPN$4,193$62,895 CNA$3,207$205,248 Other$2,692$131,908 Total 2004$453,940 ©B&F Consulting 2016 www.BandFConsultingInc.com

15. Instability vs. Stability Last minute bonus $360,000 Perfect attendance $ 0 Baylors $268,994 Raises @ 2% $90,710 Sign-on bonuses $50,000 Referral bonuses $6,000 Turnover costs $453,940 Longevity bonus $0 Total: $1,132,934 Total: $96,710 ©B&F Consulting 2016 www.BandFConsultingInc.com

16. ©B&F Consulting 2015 www.BandFConsultingInc.com Recruitment Hiring Process Welcoming Map your current processes Identify areas for improvement 16

17. Step 2. Improve your pool of candidates Don’t cast a wide net... Be Targeted to the people you want to hire ©B&F Consulting 2016 www.BandFConsultingInc.com

18. ©B&F Consulting 2015 www.BandFConsultingInc.com Recruitment Seek Triple Crown Winners: – Reliable – Good interpersonal skills – Competency in job skills Use Your Triple Crown Winners to recruit: – Micro-target advertising – Refer a friend – Nursing schools 18

19. Grow Your Skills - Grow Your Career Join our family environment and staff longevity Join a group that loves to work together and loves our residents Our company has advancement opportunities to help you grow Excellent benefits – low cost health, Paid tuition for nursing school Work as a CNA and get paid to get your nursing license “I came here because I can use my skills and they’re invested in my future” – Brett, RN We pride ourselves in our high quality care and our great work environment We have an opening for an LPN or RN for a charge nurse position – call us if you are a good match for our team. ©B&F Consulting 2015 www.BandFConsultingInc.com 19

20. Chris Schmidt, Co-owner Schmidt Wallace Health Care Management Company, Alabama

21. Chris Schmidt, Co-owner Schmidt Wallace Health Care Management Company, Alabama

22. Refer-a-friend Bonus Word of mouth is best advertisement Actively promote refer-a-friend bonus ~Personally approach your best employees Pay as soon as you hire – it’s up to you then, to have them stay ©B&F Consulting 2016 www.BandFConsultingInc.com

23. Nursing School Students Word of mouth from current students and recent graduates Offer flexibility so people can continue school and fill in shifts Offer a good on-boarding process to help new nurses settle in to their new career ©B&F Consulting 2016 www.BandFConsultingInc.com

24. Monitor: Which of your recruitment efforts generates good staff who stay?...No more postcards Need new approaches Chris Schmidt, Co-owner Schmidt Wallace Health Care Management Company, Alabama

25. ©B&F Consulting 2016 www.BandFConsultingInc.com Step 3. Improve your Hiring Process

26. Screen before you hire, not after Take the time to hire someone who will be value added to your team Make hiring process a good screen – have a multi-layer process “Measure twice – Cut once” ©B&F Consulting 2016 www.BandFConsultingInc.com

27. Focus on Character Traits Maturity – self reflection Compassionate Sensitivity to others needs Self esteem Ability to communicate, learn Friendliness - Five smile rule _______________ ©David Farrell and B&F Consulting 2016 www.BandFConsultingInc.com

28. Welcoming Applicants Make a good first impression Receptionist/person at front door is key – Make sure she has postings, applications, info on benefits, and she’s tuned in to welcoming Make it a priority to meet new applicants ©B&F Consulting 2016 www.BandFConsultingInc.com

29. Screen, tour, interview right when they come in Facility tour observations –Walk quickly and see how they keep up –Go up and down stairs if you have them –Place them next to residents who will engage them – see how they respond (resident ambassador) –Monitor interactions with people – afterwards, ask staff what they know about person ©B&F Consulting 2016 and David Farrell www.BandFConsultingInc.com

30. Include others in interview Teach interview and hiring skills Include: co-workers, supervisor, resident and/or family Once Talladega unit managers were involved, they wanted them to succeed Give training on how to interview and legal prep on what’s acceptable This starts the process of a warm welcome – builds confidence in the new employee and starts the relationship ©B&F Consulting 2016 www.BandFConsultingInc.com

31. Interview Tips High standards Ask to see their last performance evaluation Where have they been trained? (Does it make a difference?) Do they have experience? Do they have realistic expectations about the job? Ask the right questions – Open ended – Behavior based; scenario based – Character based ©David Farrell and B&F Consulting 2016 www.BandFConsultingInc.com

32. Interview Questions Who is the nicest person you know, and why? What are you most proud of? Tell me about your prior experiences in caregiving? Tell me about a time that you’ve had a conflict with a co-worker. What did you do? Tell me the names of three elders you had a close relationship with in your past job? ©David Farrell and B&F Consulting 2016 www.BandFConsultingInc.com

33. Loomis House Involves Residents What do you do when you are stressed? What made you decide to become a CNA? If a 96 year old resident was going toward the door to leave and told you that she was waiting for her mother to pick her up, how would you respond? If you were going in to care for a resident who was agitated, how would you handle it? ©B&F Consulting 2016 www.BandFConsultingInc.com

34. Increasing Percent of Newly Hired Staff Who Stay MEASURE!! ©B&F Consulting 2016 www.BandFConsultingInc.com Step 4. Provide a Good Welcome

35. A Warm Welcome from Management and Co-workers Helps New Staff Stay Leadership –Administrator personally tune in to new person Supervisor responsibility for welcome –Frequent check-ins Co-workers –Invite to lunch and to go on breaks together Remember: It takes 3 months to be comfortable ~ 6 months to feel competent in a new job ©B&F Consulting 2016 www.BandFConsultingInc.com

36. Friendships at Work People stay in places where they have friends ©B&F Consulting 2016 www.BandFConsultingInc.com

37. ©B&F Consulting 2015 www.BandFConsultingInc.com Welcoming Active learning instead of a check-off. Adults retain more as active, engaged learners than as passive learners. Add engagement to the required content. Break up the sitting still with moving around Scavenger Hunt Pay attention to the classroom atmosphere. Decorate it - make it welcoming. Act as warmly as you would if you are welcoming someone into your home. Serve food and drinks. 37

38. ©B&F Consulting 2015 www.BandFConsultingInc.com From Classroom to Floor Establish relationships right away. –Lunch with administrator and with co-workers –Have a resident be a part of the welcome process. –Have nurses have individual time with DoN as they learn so that they have a relationship and feel they can come back to the DoN with questions. Stable assignments – DON’T MOVE NEW STAFF AROUND 38

39. Mentor for Retention – Do it Right Take it seriously Make sure you have the right people as mentors –Application, interviews and recommendations Training –How to teach to other people’s strengths –How to handle conflict and give feedback Clear lines of responsibility –how to handle deficits in new staff developmentally –Who’s accountable for what ©B&F Consulting 2016 www.BandFConsultingInc.com

40. Team Rewards when new employees succeed ©B&F Consulting 2016 www.BandFConsultingInc.com

41. Younger Employees You may be their first real employer Young staff need structure and guidance – develop them – take them under your wing Maximize sense of affiliation – they love connection and are very social ©B&F Consulting 2016 www.BandFConsultingInc.com

42. Today’s Stressed Employee is Tomorrow’s call-off...and next week’s term All Hands on Deck Rounds, to check in on people, not up on people Stand-up Staff meetings Personally tune in – one to one’s Intercede Step 5: Reduce Stress and Provide Support ©B&F Consulting 2016 www.BandFConsultingInc.com

43. From Absenteeism to Attendance Track and Analyze Address Absences: enforce policies provide help Create accountability Reward Attendance – incentivize what you want to have happen ©B&F Consulting 2016 www.BandFConsultingInc.com 43

44. ©B&F Consulting 2016 www.BandFConsultingInc.com Step 6: Engage and Develop Staff

45. Employee Engagement The amount of discretionary effort and care that employees put into their jobs above and beyond the minimum required Want the organization to succeed Feel connected – –Emotionally –Socially –Spiritually © David Farrell 2015 djfarrell1963@yahoo.com 45

46. Employees are Engaged When - Leaders’ are engaged Understand the business and their role in its success Trust leadership is making good decisions Feel valued and appreciated Are well informed © David Farrell 2015 djfarrell1963@yahoo.com 46

47. How do you promote staff engagement? Your Systems Create Your Outcomes ©B&F Consulting 2016 www.BandFConsultingInc.com 47

48. From Conference Room to Rounding  ©B&F Consulting 2016 www.BandFConsultingInc.com Use What They Know Management Stand-up Engineer Engagement

49. Everyone Stands Up Together ©B&F Consulting 2016 www.BandFConsultingInc.com A shift huddle with the management team Takes the morning stand-up or daily clinical 24-hour report to CNAs and nurses, to share and discuss information and determine together action to be taken. Stand-up works best early enough in the day to be able to act on items identified. Stand-down in the afternoon closes the loop on action items. Takes 10-15 minutes in each area of the home. It can occur daily or weekly, on a regular schedule.

50. A huddle with a white board of the most important timely pertinent information needed to care for these residents today. B&F Consulting 2016 www.BandFConsultingInc.com

51. Matt Garcia Western Home Communities 420 E. 11th St Cedar Falls, IA 50613 p: 319-277-2141 matt.garcia@westernhome.org

52. Huddle How-to What you cover: – By exception, any red flags How long: – 10 - 15 min. How to do it: – Problem-solve together and make a game plan – Close the loop Focus on new residents - heads up before they come; check in the next day B&F Consulting 2016 www.BandFConsultingInc.com

53. How to Involve CNAs in Care Planning Prepare CNAs to Contribute: When CNAs routinely share at shift huddles, this helps them know how to share in care plan meeting Have a training to introduce CNAs to meeting format Let CNAs know what to share – ADLs, meals, mood, activities, share with families what residents’ need Plan for their participation: Hold care conference where CNAs can get to it In huddle let CNA's know which residents are in ARD window and which are scheduled that day for care plan meeting B&F Consulting 2016 www.BandFConsultingInc.com July 16, 2015 regs require CNA involvement in care plan meetings!

54. QI Closest to the Resident Adverse Events Investigations in response to an incident or series of incidents, or for a resident who is at high risk 24 Hour Report Huddles to closely monitor residents who are on a “watch” list Clinical Rounds of committees such as weights, wounds, antipsychotics QAPI huddles that bring the team guiding a Performance Improvement Project (PIP) together with the staff caring for the residents whose situations are being addressed ©B&F Consulting 2016 www.BandFConsultingInc.com

55. QI Rounds Huddle Questions What are possible causes? What causes can you do something about? What’s the easiest to change that has a big impact? What help do you need? How will you know it worked? Who do you need to involve? 55 ©B&F Consulting 2016 www.BandFConsultingInc.com

56. FREE TOOLKIT: tipsheets, video clips and starter exercises at www.PioneerNetwork.net Look under Provider resources at Engaging Staff in Individualizing Care

57. AN INFRASTRUCTURE FOR QUALITY Pioneer Network is pleased to announce that the Implementation Handbook for Engaging Staff in Individualizing Care, developed by B&F Consulting through our National Learning Collaborative funded by The Retirement Research Foundation will be available soon at pioneernetwork.net. This Handbook will support implementation of a communication infrastructure essential for effective care delivery to ensure positive resident and staff experiences, and good organizational performance. Forty-nine nursing homes, five state culture change coalitions and four corporations worked together with the Pioneer Network and B&F Consulting to share how-to’s from their successful pilot of these foundational organizational practices. At www.PioneerNetwork.net www.PioneerNetwork.net

58. Reduce Stress Rounds to check in on people, not up on people All Hands on Deck Community Meetings Stabilize Staffing Identify and support your best employees Improve attendance and schedule Hire for character and give new employees a good welcome Develop a Positive Chain of Leadership People development Develop Nurses as Leaders Help people improve/hold people accountable Promote Relational Coordination and Critical Thinking Consistent assignment Shift Huddles and Inter-shift communication CNAs active in care planning QI among staff closest to the resident Achieve Quality Improvement through Individualized Care Transform from Institutional to Individualized Care Delivery Systems to support customary routines such as waking, sleeping, eating, bathing, and daily activity, to promote mobility and reduce psycho- active meds and hospitalizations The Cumulative Effect of Many Changes Addressing the Many Interrelated Root Causes TIPPING POINT FROM Vicious Cycle of InstabilityTO Positive Cycle of Steady Improvement Relational Coordination and A Positive Chain of Leadership 58 ©David Farrell and B&F Consulting 2015 www.BandFConsultingInc.com

59. Contact Information: Barbara Frank bfrank1020@aol.com www.BandFConsultingInc.com