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Here are the instructions for the assignment.
You should already have read the introduction section of the document. Before completing the assignment below, read the Staff Stability Toolkit Sections I, II and III.
Imagine that you are running a long term care organization that employs staff in each category. Complete Worksheet #4 – make up the number of staff for each category. You will need to turn in this worksheet so please make sure you have included your name on the document.
Charley shared in class his turnover rate at Riverview. Be prepared to discuss why your turnover rate calculated in your worksheet is more or less than what Charley is experiencing at Riverview and what impacts this is having on your organization.
The reference documents for the assignment are under “Files” and are also listed below.
Staff Stability Toolkit
Worksheet 4 – Turnover Rates.xls
Keeping and
Growing Your
Staff
Setting the
Stage for
Success
Management
Practices that
Support
Stability
Drilling Down:
Gathering and
Analyzing Data
Achieving Staff
Stability
Using Training
Strategically
Staff Stability Toolkit
Version 1.2
235 Promenade Street
Suite 500, Box 18, Providence, RI 0290
8
T: 401-528-320
0
W: www.healthcentricadvisors.org
1
Table of Contents
TABLE OF CONTENTS …………………………………………………………………………………………………………………………….
1
ACKNOWLEDGMENTS ………………………………………………………………………………………………………………………….. 3
ORIGINS AND SOURCES …………………………………………………………………………………………………………………………………. 3
PURPOSE AND USE ………………………………………………………………………………………………………………………………
4
TAKING INSTABILITY IN HAND ………………………………………………………………………………………………………………………….. 4
BACKGROUND ……………………………………………………………………………………………………………………………………………. 4
FISCAL PRACTICES ………………………………………………………………………………………………………………………………………..
5
ORGANIZATIONAL AND MANAGEMENT PRACTICES …………………………………………………………………………………………………. 5
ACHIEVING STABILITY AND STAYING THERE ………………………………………………………………………………………………………….. 5
SECTION I. SETTING THE STAGE FOR SUCCESS …………………………………………………………………………………………..
7
FRAMEWORK FOR ACTION: A COMPREHENSIVE APPROACH……………………………………………………………………………………….. 7
THE HOW OF CHANGE: USING BOTH THE SCIENCE AND PSYCHOLOGY OF CHANGE …………………………………………………………….. 8
USING A HIGH INVOLVEMENT APPROACH ………………………………………………………………………………………………………….. 11
SECTION II. MANAGEMENT PRACTICES THAT SUPPORT STABILITY ……………………………………………………………. 18
RECRUITING, HIRING, AND WELCOMING …………………………………………………………………………………………………………… 20
ATTENDANCE, SCHEDULING, AND ASSIGNMENTS …………………………………………………………………………………………………. 32
“A POSITIVE CHAIN OF LEADERSHIP” ……………………………………………………………………………………………………………….. 42
SECTION III. DRILLING DOWN: GATHERING AND ANALYZING DATA …………………………………………………………… 49
WHAT IS “DRILLING DOWN” AND WHY DO IT? …………………………………………………………………………………………………….. 49
WHAT DRILLING DOWN CAN DO FOR YOU. …………………………………………………………………………………………………………. 49
WORKSHEET 1: EMPLOYMENT STATUS – THE COMPOSITION OF YOUR CURRENT STAFF …………………………………………………… 51
WORKSHEET 2: CURRENT STAFF BY LENGTH OF SERVICE ………………………………………………………………………………………… 52
WORKSHEET 3: VACANCIES………………………………………………………………………………………………………………………….. 53
WORKSHEET 4: TURNOVER RATES …………………………………………………………………………………………………………………. 54
WORKSHEET 5: THE COST OF TURNOVER …………………………………………………………………………………………………………. 5
6
WORKSHEET 6: TERMINATIONS (VOLUNTARY AND INVOLUNTARY) BY LENGTH OF SERVICE ………………………………………………… 57
WORKSHEET 7: ABSENTEEISM ………………………………………………………………………………………………………………………. 58
WORKSHEET 8: MONTHLY CALL-IN LOG …………………………………………………………………………………………………………… 58
WORKSHEET 9: FINANCIAL INCENTIVES ……………………………………………………………………………………………………………. 60
SECTION IV. CASE STUDY: ACHIEVING STAFF STABILITY …………………………………………………………………………… 61
USING DATA-DRIVEN DECISIONS TO RE-EXAMINE INDUSTRY NORMS ………………………………………………………………………….. 61
INTRODUCTION ………………………………………………………………………………………………………………………………………… 61
THE PROBLEM: STABILIZING STAFFING ……………………………………………………………………………………………………………… 61
THE INTERVENTION ……………………………………………………………………………………………………………………………………. 64
A NEW APPROACH ……………………………………………………………………………………………………………………………………. 69
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RESULTS ………………………………………………………………………………………………………………………………………………… 73
CONCLUSION: A LESSON LEARNED …………………………………………………………………………………………………………………… 75
SECTION V. USING TRAINING STRATEGICALLY ……………………………………………………………………………………….. 76
GROW YOUR PEOPLE, GROW YOUR ORGANIZATION …………………………………………………………………………………………….. 76
TRAINING ON YOUR OWN DIME: GETTING YOUR MONEY’S WORTH …………………………………………………………………………….. 77
OPTIONS FOR USING WORKPLACE EDUCATION TO ADVANCE ORGANIZATIONAL GOALS ……………………………………………………….. 79
FUNDING SOURCES TO SUPPORT WORKPLACE: ……………………………………………………………………………………………………. 81
TIPS FOR WRITING A GRANT PROPOSAL FOR FUNDING …………………………………………………………………………………………… 86
FINDING AND SELECTING THE RIGHT TRAINING PROVIDER ……………………………………………………………………………………….. 87
KEYS FOR SUCCESSFUL WORKPLACE EDUCATION PROGRAMS …………………………………………………………………………………….. 88
TECHNICAL ASSISTANCE ……………………………………………………………………………………………………………………………….. 93
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Staff Stability Toolkit
Keeping and Growing Your Staff
Acknowledgments
B & F Consulting developed this Staff Stability Toolkit under subcontract with Healthcentric Advisors
with generous funding from the Commonwealth Fund Contract 20060687/20070013.
Origins and Sources
This toolkit incorporates experiences and lessons
learned
in over 400 nursing homes. It is designed to
serve as a resource for homes just getting started with efforts to reverse turnover as well as employers who
have already started to address recruitment and retention and need further assistance in a specific area.
This toolkit applies concepts and practices based on the work of Susan Eaton, Ph.D. who, in 2002,
completed a CMS funded study, What a Difference Management Makes! Dr. Eaton’s study compared
practices at high and low turnover nursing homes in the same labor market. Strategies and techniques
based on her findings have been successfully piloted in Better Jobs Better Care – Vermont (BJBC-VT); a
Centers for Medi
care
& Medicaid Services (CMS) funded Improving Nursing Home Culture Pilot (INHC);
with nursing homes nationally through the Quality Improvement Organization (QIO) program and in
New England through workforce development programs. These methods are currently being used among
approximately 100 nursing homes in New Orleans and Lake Charles, Louisiana.
The INHC core faculty developed HATCh (available at www.medqic.org), a model for a Holistic Approach
to Transformational Change. HATCh identifies six domains: the environment, care practices, and
workplace practices, leadership, family & community, Government/Regulatory National Stakeholders
each of which affects the other, and all of which have an impact on both the quality of care and the quality
of the work environment.
Using the HATCh model, participating nursing homes focused first on stabilizing their workforce through
high impact management practices using evidenced based tools and strategies. Recognizing the link
between management and fiscal practices, a “drill down” tool was developed through BJBC-VT and
provided to assist the INHC nursing homes in analyzing how particular financial practices were
contributing to its staffing inst
ability.
The drill-down exercises are worksheets designed to allow individual nursing homes to customize them to
focus on the precise issues of concern in their workplace. The current version was developed by Dave
Johnson of IPRO, the New York QIO. The excel worksheets are easily downloaded from
www.riqualitypartners.org or as stand-alone tools.
Section IV of the Tool Kit provides a case study of Birchwood Terrace Healthcare in Burlington, Vermont.
With assistance provided under the BJBC-VT project,i Birchwood was able to achieve staff stability by
first gathering and analyzing their data and then applying the principles and practices described here. The
http://www.riqualitypartners.org/
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case study is part of a series being published nationally by BJBC capturing the great work done under that
impressive initiative.
Section V discusses the strategic use of training to stabilize staff, state workforce development resources,
adult education and literacy programs. Contributors to this section include Geri Guardino, an
independent consultant with extensive experience in health care workforce development, Carolyn Blanks
of the Massachusetts Extended Care Federation and Carol Kapolka, of the Extended Care Career Ladder
Initiative, a program of the Commonwealth Corporation of Massachusetts. Other workforce development
sources include workforce projects in Connecticut, Massachusetts, and Rhode Island: a U.S. Department
of
Labor
grant in CT administered by Capitol Workforce Partners; the CT Culture Change and Career
Ladder Initiative, funded through the state of CT and administered by the CT Women’s Education and
Legal Fund; grants from ECCLI, the Extended Care Career Ladder Initiative operated by Commonwealth
Corporation of MA; and grants to Healthcentric Advisors through the RI Department of Labor and
Training and the Department of Education.
The experiences and ideas from pioneering nursing home administrators have greatly informed this
toolkit. They include David Farrell, Medical Hill, Oakland, CA; Bill Graves, St. Camillus Health Center,
Whitinsville, MA; Connie McDonald, Maine General at Glenridge, Augusta, ME; Loren Salvietti, Quaboag
on the Common, West Brookfield, MA; Lori Todd, Loomis House, South Hadley, MA; and Scott West,
Birchwood Terrace, Burlington, VT.
The Appendix to this toolkit contains references to additional reading on staff stability and
leadership
development (Appendix A). Also available are “homework” assignments (Appendices B & C) that help
readers learn about root causes of instability and assist in implementation of the practical tools contained
in the following pages.
Your suggestions regarding possible improvements and additions to subsequent editions of this toolkit are
most welcome. All sections of this toolkit are reproducible without charge if appropriate attribution is
included.
Direct all inquiries to:
Marguerite McLaughlin, Project Manager
Healthcentric Advisors
mmclaughlin@healthcentricadvisors.org
Purpose and Use
Taking Instability in Hand
High turnover of staff at all levels and departments in nursing homes has been a persistent problem for
decades. Turnover has been shown to undermine the continuity of care and consume financial resources
that could otherwise be allocated to improving care and services. The purpose of this toolkit is to provide a
“how-to” guide to stabilize staffing, with practical tools for immediate and long-term use.
Background
It is ironic that practices used by many fiscal and organization/management companies deal with chronic
staffing instability actually contribute to and accelerate the instability. These practices are such common
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responses to instability that they have gone unquestioned and been assumed to be working. As
“conventional wisdoms” that have become industry norms, they bear closer scrutiny.
Reversing instability brings immediate benefits. It allows organizations to improve the effectiveness and
efficiency of how employees work together. The more stable an organization’s staffing is, the more
opportunity it has to improve its operations. Deeply rooted stability gives homes a solid foundation to take
on initiatives such as Advancing Excellence in America’s Nursing Home Campaign, quality improvement,
culture change, or career ladders. Staff stability is the foundation for good outcomes by clinical,
regulatory, and business measures. Two forces at work that perpetuate the cycle of turnover in most
nursing homes are fiscal practices and management
practices.
Fiscal Practices
The fiscal practices specifically refer to the wages, benefits, bonuses, incentives, and differentials available
to a worker. Wages and benefits for most CNAs and other non-supervisory staff in nursing homes are not
enough to live on. It is inevitable that the economically related struggles many lower-wage staff
experience daily affect their work attendance and performance. Nursing homes often feel helpless to
address this economic reality because wage and benefit levels are affected significantly by public
reimbursement rates. Yet, each nursing home’s systems for bonuses, incentives, and differentials, as well
as policies related to attendance, schedules, assignments and employee assistance, all have an impact on
retention outcomes. Learn how you can spend smarter and use found resources to support better wages
and benefits, as well as, promote better attendance and retention.
Organizational and Management Practices
Organizational and management practices include staff composition, hiring, orientation, attendance,
scheduling practices, consistent assignment, and leadership practices. Fiscal and management practices
go hand-in-hand. Management practices, wages, benefits, incentives and bonuses affect your hiring and
your retention. You operate at your best when your fiscal and your management practices work in the
same direction, not against each other. These practices shape the way people work together and how
people feel valued and appreciated, which in turn shape retention outcomes. The draw of current staff, to
work in a field where they can make a difference in others’ lives by helping them, can be supported
through management practices like consistent assignment. Building stability into the schedule has a
ripple effect – on attendance and in care. See how to implement leadership practices that build morale and
performance.
Achieving Stability and Staying There
This toolkit will provide you with the information needed to achieve sustained stability. It will help you
identify the root causes of your instability and give you proven strategies to reverse it. It is based on
rapid-cycle quality improvement practices that lead to sustained improvement through measurement,
root cause analysis, pilot testing, and spread. The same practices that help you improve clinically can help
you improve operationally, in stabilizing staffing in your building. The toolkit combines concepts,
practices, and tools to support you in a systematic process of determining the root cause of a problem and
identifying potential remedies. It offers ways for you to gather information by collecting data and listening
to your staff. For maximum success, take a comprehensive approach that you can maintain over time. If
you use piecemeal temporary programs that fall by the wayside so will your stability. Whether you are
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fine-tuning your efforts or just getting started, this toolkit offers suggestions on what to do, how to do it
and why.
Retention of current staff is the best place to start. Many organizations make the mistake of
focusing mainly on recruitment. Recruiting new staff does not help if your nursing home is not able to
retain them. The place to start for stability is learning how to keep and support the good staff you have.
Recruitment is always more successful when new employees come in to a more stable organization. Your
current staff’s word of mouth will be your best selling point. As you have more stability, you can be more
selective and targeted in your recruitment. But as long as you have instability, you will feel pressure to
lower your standards and recruit indiscriminately. Stabilize through retention and the rest will follow.
So what makes your staff stay? My InnerViewii reports on results of over 106,000 respondents to staff
satisfaction surveys in nearly 2000 nursing homes in 49 states. Employees said what is most important to
them in staying and recommending their workplace to others is that:
Management cares,
Management listens, and
Management helps with job stress.
Management efforts to reduce stress, listen to and support staff will have an immediate positive impact on
staff stability. Creating conditions that allow employees to get their work done at a reasonable pace will
contribute to their feeling good about working for your organization. You will be better able to
make/create these conditions by looking at your data and listening to your employees about their
experiences and ideas.
Section One of the toolkit describes a process for getting started and outlines how to include employees
from every department in your efforts.
Section Two provides tips on management practices that support stability related to:
Recruiting, Hiring, and Welcoming Staff
Attendance, Scheduling, and Consistent Assignment
“A Positive Chain of Leadership”
Section Three introduces a tool for “drilling down” into the data to learn more about your current state
of stability or instability. It explains how to gather and analyze data about turnover, absenteeism, and
financial incentives. Step-by-step instructions are included.
Section Four is a case study describing how Birchwood Terrace applied these tools and practices to
achieve staff stability. It shares how they used the drill down process to identify the root causes of their
instability and re-allocate their financial and management resources to support stability.
Section Five explains how to use training to support stability and improve organizational performance.
It provides information about workforce development and other resources available to help employers
provide training. This section has tips on writing grants for funding, choosing the right training partner,
and successful workplace training programs. It also includes information about state-based technical
assistance resources to aid in stabilizing staffing.
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The Appendices offer additional resources, including a bibliography of articles that reflect the research
about these practices. It contains the change package and homework assignments from the INHC pilot
project, as well as a facility self-evaluation tool based on Dr. Eaton’s work. It has a primer on the
workforce development and adult education systems and a checklist for organizational readiness for
workplace training.
Section I. Setting the Stage for Success
Framework for Action: A Comprehensive Approach
Overview
Staff stability and instability affects all aspects of your operation, while all aspects of your operation affect
your staff stability. The good news is that as you stabilize, you will gain the ability to achieve
improvements in key performance measures – clinical, regulatory, and financial.
Temporary programs or shotgun approaches – pizza parties, employee trips, even career ladders or
mentor programs (when not combined with other proven strategies) – are difficult to sustain, easily miss
the mark, and often go by the wayside. Stability requires a comprehensive approach because all aspects of
operations impact how staff feel valued and contribute to the stability of the work environment.
But fear not. You do not have to take it all on at once. Experience has shown it is best to start where you
can have easy wins with rapid positive results. As soon as you are able to change the direction toward
stability, you will be able to build on that momentum.
Nursing homes have been described as fragile ecosystems, highly sensitive to
change.
Losing a good
supervisor can throw staffing in disarray as long-time staff struggle with agency nurses if the nurses do
not know staff or respect their knowledge of residents. Sending a reliable employee home because you are
staffing to census can lead that person to leave for a more reliable job. Any one factor can set a spiral in
motion – short staffing breeds turnover and absenteeism, both of which contribute to increased staff
in
stability.
Nursing homes are also highly responsive to positive change. Helping a supervisor become a good leader
can have an immediate positive effect. Implementing an effective attendance reward system for
individuals or, better yet, for units as a team, can positively affect attendance without having to employ
punitive approaches. Positive management practices – such as gathering staff at the start of each shift to
reinforce teamwork, and establishing consistent assignments so CNAs regularly work with the same
residents, co-workers, and supervisors – can have a galvanizing affect that contributes to a sense of unity,
cohesion, and stability.
Stability is not just affected by workplace practices. All too often, nursing homes work separately and
concurrently on clinical measures, culture change, business objectives, and workforce retention, without
recognizing their inter-relatedness. For example, staff stability is the cornerstone of quality of care. If you
doubt this, do a quick analysis of any quality measure and compare times when you are working short or
have a lot of agency use with times when you have stable staffing. Whether it is falls, pressure ulcers, call-
lights not being answered, even obtaining correct weights – you will see when you have stable staff; you
do better in these measures. A staff member who works with the same resident regularly will notice a red
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Holistic Approach to Transformational Change
HATCh
Leadership
Government & Regulations
Community
Family
area before it becomes a pressure ulcer. And will have time to notice it during a shower, rather than
having to skip the shower because of working shorthanded.
The Holistic Approach to
Transformational Change (HATCh)
The importance of staff stability for clinical,
regulatory, and financial outcomes was
demonstrated through the INHC pilot,iii
which used a framework called HATCh to
illustrate the interconnection of workplace
practices, care practices, and the care
environment.
HATCh places the resident and the care-
giving relationship at the center, as noted
by the heart, because this is at the heart of
what we are all doing. The three inner
circles that most closely affect the quality of
the care-giving relationship are the 3
domains of Workplace Practices,
Environment and Care Practices.
The domain of workplace practice sits at the
bottom of the three circles because
workplace practices that create workforce stability are the foundation necessary to achieve quality
outcomes. The second domain is the domain of care practice. This is about how clinical care is provided
within the daily rhythms of nursing home life. The third domain is that of the environment. We include in
this domain both the physical and social environment in which residents live. All three of these domains
depend on the circle of leadership, which surrounds them. HATCh also notes the roles played by
communities and families, as well as the regulatory and governmental policies that oversee and financially
support the nursing home.
The How of Change: Using both the Science and Psychology of Change
The Science of Change includes the following basic quality improvement practices:
Root-Cause Analysis (RCA) – Why is it happening?
Evidence-based solutions – What has been proven to work?
Small pilot tests – What will it take to make it work here?
Mid-course adjustments – How do we need to tweak it for our situation?
Evaluation – How will we know if it is working?
Spread – Now that it is working, how can we make it the new norm?
The Science of Change has more likelihood for success when it is coupled with the Psychology of Change.
The Psychology of Change builds on what truly motivates staff, their commitment to residents, and what
brings them into the change process as contributors. It is an approach to change that:
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Core questions every employee should consider…
From your own experiences, what makes a job good?
What keeps you in your current job?
What drew you to care-giving work and to your current
organization?
What do you need to feel good about your job?
Builds on intrinsic motivation – How can we make this work better for you and your
residents?
Starts where people are – What are your trouble spots and how can we work to fix them?
Builds on people’s experience – How is this working for you now, what have you seen
work
elsewhere?
Builds the capacity for change – Each change is a building block to the next as employees
learn skills in working together and performance improvement.
Creates a climate of full and open exchange – People’s ideas and concerns are treated as
valuable information for the success of any endeavor.
The following are core elements of what your employees need to function at their highest possible level as
direct-caregivers. Think about how you would answer the questions.
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When examining the answers to the above questions, use the tools provided in this toolkit to:
Look at the current situation
Being as objective as possible, step back and look at what you are doing now.
Examine turnover, hiring, and attendance to give you a picture of what’s happening
Collect data on who is leaving and who is staying.
Gather information about your employees’ experiences working in your organization; ask them
about their perspective on what is working, not working, and what changes are needed.
Decide what needs to change
Reinforce and keep strategies, programs, practices that are identified as working well.
Evaluate those things that have been identified as not working. Think about it both from a
personal perspective – what would you need – and from the perspective of your employees –
what are they telling you they need?
For each area that needs to change, determine if it still needs to be done, and if so, how can it be
done in a better way that will support stability.
Make changes in stages to build momentum in a positive direction
As a team, review the list of areas where change is needed. Determine what is easy to do and what
is complex. Identify areas that will have a strong positive impact.
Prioritize to start where you can easily have the best chance of success and have a positive impact.
For example, rewarding good attendance is fairly easy to do and will have an immediate impact by
improving
attendance.
Enlist staff participation. Get input from staff about what rewards for good attendance would be
meaningful to them.
Explain to all employees what you are doing and why. For example, if your focus is on
attendance, explain that you do not want anyone to work “short” because scheduled staff is
frequently missing their shift. Your goal is that every shift be fully staffed by scheduled
employees.
Collect data to measure your impact. At the beginning, post your attendance rates, and then post
your progress weekly.
Evaluate each effort and make mid-course adjustments as you go along.
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Announce progress and celebrate positive results.
Take on the next area. Build on the gains you have achieved. As you go forward, maintain your
previous efforts, or you may soon experience a backward slide.
Using a High Involvement Approach
It is not just what you do, but how you do it. A process that involves a wide spectrum of staff is a key
ingredient for success. Guidance from your current staff will help ensure that you target your efforts
effectively.
Important Reminders
Involve employees in identifying what is going on and identifying solutions, implementing
solutions and evaluating whether they are working.
Make this an educational experience in which employees learn how to use their problem-solving
skills for organization improvement.
These efforts should not be designed or implemented by the management team in isolation. You
will be more effective if representatives of the entire staff are involved along the way.
Consider forming a Retention and Recruitment Committee
Identify employees throughout the organization who have an interest in and are willing to work to
make a difference in this area.
Identify someone as a formal decision maker such as the Administrator or the Director of
Nursing, or select a leader of the committee who has been given decision-making authority by
administration.
Make the work meaningful. Participants will be hesitant to join in future efforts if their work is
later vetoed.
Be clear about what the committee is charged to do, what permission it has, and its operating
parameters.
Operate it in a way that gives everyone an opportunity to contribute and everyone an opportunity
to learn and grow.
Key steps for good participation in a Retention and Recruitment Committee
Make personal invitations to your front-line and supervisory staff to encourage their
participation.
Communicate facility-wide that you are recruiting for this committee and all are welcome to
participate.
Schedule meetings when members can attend, especially those on evenings and nights.
Make sure everyone knows when the meetings are scheduled.
Arrange coverage so staff can participate without adding to their or their co-workers’ stress. One
option is to have someone from management cover responsibilities on the floor during the
meeting. While management staff routinely go to meetings, staff with hands-on responsibilities
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who do not will be worried about what they did not get done, left for others, or awaits them when
they get back. They may not be able to attend, unless they know their responsibilities are covered.
Make it worth people’s time – listen to what they have to say, act on their suggestions, and follow-
through on what you say you will do
Learn what assumptions committee members have about the cause of turnover
The committee’s first actions should involve finding out more about the root causes of turnover and
absenteeism by looking at the data and talking to the staff.
Step 1: Break your group up into pairs or threes. Ask them to list on poster paper all of the reasons that
they think turnover is happening. Give sufficient time for people to really think this through. (Note:
People will be more engaged and voice their opinions in a small group conversation rather than in a large
one.)
Step 2: As a whole group, talk about the lists that each group has generated. Look at areas where there
seems to be a lot of agreement, and also areas that only a few people have mentioned.
Take the conversation out to the whole
organization
Step 1: Give each committee member an assignment of which people to talk with to explore these areas
further.
Step 2: Inform supervisors and managers that committee members have these assignments and will need
time to complete them.
Step 3: Let others on staff know that this is happening and encourage them to participate in interviews to
give their input.
Helpful Hints
One administrator recognized the hesitancy of front line staff in speaking up when participating in
meetings with management staff and identified a way to overcome this barrier. He placed a basket in the
middle of the table and as participants came in to the meeting, he asked everyone to put their name
badges in the basket, explaining that he wanted everyone at the table to feel that their contribution
would be given equal weight and wanted everyone to feel free to contribute. This highly symbolic
gesture helped to put people at ease and able to fully participate in the meeting.
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See Box 1.0 for a list of assignments that your committee could consider.
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Box 1.0: Retention Committee Discovery Assignments
Have each member of the committee talk with one to three people from among your reliable, core
staff – who have been employed. Ask them why they came to work at the home, and why they have
stayed. Have committee members talk to peers (i.e. nurses talk to nurses, CNAs to CNAs).
Have each committee member talk with someone employed less than a year. If you have many new
employees, divide the list so that as a committee, you talk with each of them. Ask how they heard
about the job opening, what made them choose this place to work, what has helped them stay, what
has been hard for them, and if they have any suggestions for ways to help new staff settle in.
Review the competing ads in the local paper for positions comparable to what you have available.
Look at which ads are the most appealing. Do your ads stand out in a positive way? Do they capture
what is good about working here?
Call area nursing homes and ask about their wages and benefits for new and experienced staff in
various positions (best accomplished by someone in management).
Sit in the employee break room for 30 minutes and objectively evaluate. (Best accomplished by
someone on the management team) Consider the following: Is the space comfortable? Is it clean?
Does it give staff a place to relax and recharge during their breaks? Ask employees who come in what
would make the space better for them.
Collect data (Worksheet 6) on who is leaving by their length of service. Consider the following: Are
employees leaving after they collect a sign-on bonus? Are your long-time employees leaving?
Look at the causes of involuntary terminations. How many were due to disciplinary action related to
attendance?
1
2
3
4
5
6
7
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Collect data on other factors that could be affecting working conditions, such as, in the past three
months, how many shifts were worked with fewer people than scheduled?
Get in touch with five people who resigned in the past year that the retention team identifies as
people who were good co-workers. Explain to them that you are implementing improvements to
make your home be one where people stay and that you are trying to understand why people leave.
Ask them why they left and what they would suggest be done differently to make your organization a
better place to work. (Best accomplished by someone on the management team, but can be done by
several people if your home is large, or if you have had heavy turnover.)
Look at what you have learned
Step 1: Give the committee enough time to complete these assignments before meeting again.
Step 2: Check in with committee members between meetings to make sure they are progressing.
Step 3: At the next meeting, ask everyone to share what he or she has
learned.
Step 4: After everyone has shared, the group facilitator will lead the group in creating two lists: why
people stay and why people leave. A third list will inform the committee what members learned about
what your competitors offer and how you compare to them.
Analyze the information and set priorities for action
Step 1: Review the lists of why people stay and the top reasons people leave.
Step 2: When the group has agreed on these reasons, identify action that can be taken to strengthen and
preserve what keeps people here.
Step 3: Look at ways to incorporate these strengths into your advertising and other recruiting.
Step 4: Then generate ideas for action that can be taken to address why people leave.
Step 5: Identify where you will take action first – what is realistic and easy to do that can have an
immediate positive result.
8
9
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Model for Implementing Change
The “Plan – Do – Study – Act”, is a model for us to systematically go through quality improvement in a
thoughtful way. It starts with three questions.
Helpful Hints
Some areas, like relationships between supervisors and their staff, may take longer to address.
Keep these in mind so that as you take your first actions, you do so in a way that begins to
address the larger issues as well. For example, if you identify that people leave because of
having to work “short” and your action is to reward good attendance, use team rewards that
strengthen relationships within work units, instead of individual rewards that could add to
strains in relationships.
Plan
1.
Objective
2. Questions & Predictions
Plan to carry out the
cycle (who, what, where,
when)
Do
1. Carry out the plan
2. Document problems &
observations
3. Begin analysis of data
Act
1. What changes
are to be made?
2. Next cycle?
Study
1. Complete the analysis
of the data
2. Compare data to
predictions
3. Summarize what was
learned
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The first question is what are we trying to accomplish? Have you ever attempted to take a trip
without asking “Where are we going?” The best way to answer this is to set up a goal statement. The goal
statement forms the team’s expectations to accomplish in the quality improvement project. It will act as a
guide to help keep you on track.
An example of a goal statement might be: To improve satisfaction level of the residents we will commit to
consistent staff assignments on Unit 1 within 30 days AND we will spread this change throughout each
unit within one quarter. This goal statement is pretty clear and reflects the goal, who they are going to
work with, what the measurable goals are, and the hope to spread it beyond their team.
The second question is how will we know that a change is an improvement (and not a set
back)? We will know a change is an improvement if . . . . . (just fill in the blank).
The third question is what change can we make that will result in improvement? This can be
done through developing strategies aimed at reaching an improvement. A strategy may be just a simple
idea someone has for making things better. It doesn’t have to be some big “rocket science” thing. Don’t
forget there is also a larger community to pull from for ideas. The Long Term Care Community has many
other resources, standards of care, and providers. Embrace them in your efforts.
As outcomes improve, you move closer to an optimal quality of life of both the residents and your staff.
The two work very closely together.
Use this toolkit as a resource:
Use this toolkit as a way to educate and energize the committee. Have different members read different
sections and then share what they have read with the group or target certain sections that cover the area
you have decided is your place to start. Remember to contact the state resources identified in Section V
for additional information.
Key steps to remember:
Start with small pilot tests of change-incremental actions that can be put in
place and sustained.
Have the committee be a part of implementation and checking in with people
about its usefulness.
Make adjustments as needed.
Make the change more widespread and build on it.
Have committee members check in – with core staff and with new employees.
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Section II. Management Practices that Support Stability
One administrator who cut her turnover nearly in half routinely asks herself when she is making a staffing
decision: “By doing this, am I contributing to staff stability or to staff turnover?” Evaluating her day-to-
day management decisions in this way has helped her reduce turnover. Her practice of questioning and
reframing common management traditions has been a key component in her nursing home’s staff
stability.
The vicious cycle of turnover, vacant shifts, and stress
iv
Many management practices in high turnover homes perpetuate a vicious cycle of turnover, vacancies and
stress. Although these practices are widely used, they are not good management practices. The practices
provide perceived short-term gains at the expense of long-term stability. In fact, even in the short term,
many of these practices undermine stability. The result is a vicious cycle in high turnover nursing homes
of:
High absenteeism
Short staffing
High overtime
Staffing agency usage
Increased injuries
Financial drain
Poor clinical quality
Helpful Hints
Use Learning Circles to facilitate conversation. The purpose of a learning circle is to hear from
everyone, including those who are comfortable speaking in groups and those who are not.
In a learning circle, everyone, in turn, addresses the topic of the discussion. One person speaks
at a time and others follow in turn. While one person is speaking, everyone else listens intently
without interrupting, asking questions, or offering opinions. Anyone can volunteer to start.
When the first person is done speaking, the person to the left or right goes next. If someone is
not ready to speak when their turn comes, they can “pass.” After everyone has gone around,
the first person returns to anyone who passed to see if they would like to speak. After everyone
has spoken, the conversation opens up for discussion!
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How homes deal with their staffing problems can make their situation better or worse. Below are five
key management practices consistently present in low turnover homes. These practices deal positively
with staffing problems, contribute to staff stability and generate high levels of performance:
1. High quality leadership at all levels of the organization:
Cultivate leadership among mid-level supervisors and non-supervisory staff
Build skills and systems to support and encourage self-direction and shared decision-making
2. Valuing staff in policy and practice, word and deed:
Manage by walking around
See where staff need help and pitch in; answer call bells and help out at meals
Give genuine appreciation for a job well done
A Vicious Cycle of
Turnover, Vacant Shifts, and
Stress
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
Turnover in 2002:
National: 70%
Five Organizational/Management Practices
Associated with High Retention, Attendance, and Performance
From What a difference management makes! by Susan Eaton, 2002
“A Positive Chain”
of high quality
leadership
throughout the
organization
Organizational
practices that
value staff in
policy and
practice, in word
and deed
Human resource
policies and
practices that
invest in and
support staff
Organization and
work design to
reinforce intrinsic
motivation of staff to
care for residents
Sufficient staffing
and resources to
provide humane
care
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Show real understanding for the challenges staff face in their personal lives
3. High performance, high investment human resource policies and practices:
Show, through your human resource policies and practices, that you trust and respect staff
Make sure your wages, benefits, hiring practices, training opportunities, and attendance
policies reflect an investment in staff
Have attendance policies that take into account the challenges staff face in real life
Help new employees settle in and become acquainted with the staff and the environment
Offer workplace training programs to help staff grow in their skills and professional
opportunities
4. Work design that supports staff’s intrinsic motivation:
Implement consistent assignment (staff and supervisors work with the same residents and co-
workers) to support teamwork and staff-resident relationships
Rely on staff input and judgment, and support staff to problem-solve together
Support employees to exercise more responsibility and they will
5. Sufficient staff and resources to do the job humanely:
Reduce call outs so there are fewer shifts worked short
Maintain staffing levels that allow staff to provide the quality of care that draws them to this
work
Provide sufficient supervision and support
Ensure adequate supplies are available for employees to complete their jobs
Recruiting, Hiring, and Welcoming
1. Take the time to hire right.
2. Hiring right starts with having a good selection to hire from.
3. Have a good screening process so that you hire people who are a good fit.
4. Provide a quality orientation and help new employees feel welcomed and they will be much more
likely to stay. v
Helpful Hints
Use Facilities that use the “any warm body” approach to fill vacancies often lose more new staff than they keep.
Staff will tell you “anybody is NOT better than nobody.” Staff will be more willing to welcome and mentor new
employees if they have trust that the newly hired employees are likely to succeed. A cycle of turnover among new
employees can become self-perpetuating as current staff becomes more jaded and less helpful to newcomers, and
managers become more desperate and less selective in their hiring. Who can afford such wasted effort, especially
in times of a decreasing selection from which to recruit staff?
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Helpful Hints
Be specific about the position for which you are advertising. An ad that covers several positions indicates
desperation and instability. If you are hiring for a 3-11 CNA on the Alzheimer’s unit, talk about the unit being
one in which staff are highly engaged with residents and work well together.
Focus on character traits: Indicate that you are looking for someone who likes developing relationships and
works well with others, someone who is caring, creative and takes initiative.
Share selling points for working in a nursing home such as independence and responsibility. Focus on nurses in
long-term care as being Gerontological Nurses, with an expertise in a specialized field of c
are.
Use the ad to sell yourself as a potential employer. Emphasize the benefits of working in your nursing ho me.
Include quotes from your staff about what they like about working here.
Keys to Hiring Right
Attract the right people.
Target your advertising.
Start by examining what draws people to nursing home work. When long term employees of
nursing homes are asked why they stay in this field they quite often say they stay because of their
deep connection and commitment to residents for whom they provide care; the sense of
satisfaction they get from the relationships they form at work with the people they care for and
the people they work with; and their desire to make a positive difference in the lives of others.
Review your ads: Are they focused and geared to draw on what attracts people to this work? Will
they reach the employees that you want to hire?
Create an ad that captures the benefits of working in your nursing home.
Be creative in where you advertise:
o Ask your staff their suggestions on where to post ads
o Consider non-traditional places to post
o Advertise in small weekly papers, not just large newspapers
o A one page flyer that can be posted in laundromats, supermarkets or churches
o Some younger workers use the internet when job searching, so consider using
www.Craigslist.com or www.monster.com to advertise an opening
o One-Stop Centers – every state funds career centers through the Department of Labor.
They assist jobseekers find jobs and are eager to partner with employers looking to hire.
Give them a list of qualifications and they will screen applicants for you. They may be
able to offer free CNA training to prospective employees. See Section V for more
information.
http://www.craigslist.com/
file://riqnfp01/data/deptdata/9SOW/QI%20Fair-January%202008/Staff%20Stabiliyt%20Toolkit_1.2_CD_010909_smm/ARCHIVE/www.monster.com%20
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Refer-a-friend bonuses instead of sign-on bonuses
Targeted “refer-a-friend” bonuses are a smarter way to spend than sign-on bonuses. Refer-a-friend
bonuses targeted to your good employees have a double benefit: they reward your good staff, they have a
built-in screen, and they target people your staff would like to work with.
Sign-on bonuses are so popular that nursing homes feel they have to offer them to stay competitive. Yet,
sign-on bonuses have many negatives: they reward people merely for accepting employment, who might
leave as soon as they get the bonus; they draw people attracted to the bonus, without a screen for whether
they would be good co-workers; and they send a bad message to full-time, regularly committed staff that
has been holding things together with no extra compensation.
Go to Worksheet 6, Drill-down on Terminations by Length of Service, to see how many employees are
leaving after they get the bonus:
Try this….
Gather a group of six to nine long-term, valued employees. Tell them that you would like to
improve recruitment by hiring more employees like them. Ask them: what makes them stay
employed in your home and what is better about your home than the home down the street?
Ask what drew them into care-giving work in the first place. Having this conversation using a
learning circle (see Section II) is an effective way to hear from
everyone.
Use the information
you gather to write a job advertisement that highlights the desirable features identified by
your staff. Ask an employee if you can quote them in the advertisement.
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Collect data on staff turnover by length of service (see Worksheet 6).
Identify how many left at the six-month mark when they received sign-on
bonuses.
Compare how much you spend on sign-on bonuses with how much you spend on refer-a-friend
bonuses.
Compare the results – how long do people stay who got sign–on bonuses and how long do people
stay who were referred through the refer-a-friend bonus?
Researchvi shows that having friends at work makes people more likely to stay employed in a particular
place and is a key ingredient in retention. If you are finding that your staff is hesitant to recommend your
home as a place of employment to their friends, ask your reliable employees why. The top answers in over
106,00 employee satisfaction surveys show that the key to staff recommending their home to friends as a
place to work are that they feel management cares about them, listens to them, and helps them with their
job stress.vii You may have to adjust your organization’s management style and approach to be successful
with a refer-a-friend bonus program. Part 3 of this section has some tips on effective management
practices.
Make a good first impression
Your receptionist contributes to a perspective employees’ first impression and plays a key role in the
hiring process.
Helpful Hints
To improve your refer-a-friend bonus, consider the following:
How much do you pay? Make it comparable to what you would pay for a sign-on bonus. Consider
combining it with team retention bonus (see A Good Welcome).
Pay the full amount of the refer-a-friend bonus at the time of hire. Paying this bonus in increments is not
motivating. If an employee refers someone that you then hired, they have done their part.
Actively promote the program in the break room, by the time clock, and by talking it up at department
head and staff
meetings.
Make a personal appeal to top employees:
The administrator should personally approach your best employees to ask for their help in
recruiting additional staff.
Explain that you are asking your best workers to recommend other good workers to hire. You trust that
they have friends with similar good character traits that you want for people working in your NH.
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Always be prepared for the walk-in applicant and, if possible, interview them immediately. When
someone is looking for employment it means they need to find work. If they are good candidates, you do
not want to lose them because another organization was quicker to respond. Quickly ascertain whether or
not this person is a fit for your organization. Do this by taking the applicant on a walk-through of the
building. See how he/she interacts with residents and whether any of the staff know the applicant.
Helpful Hints
Strengthen your receptionist’s role with job applicants:
Your receptionist is your first impression and plays a key role in the hiring process.
Have a designated area at the reception desk with everything needed for applicants and a
receptionist check-list for handling walk-ins or potential employees with an appointment.
Make sure your receptionist:
o Knows the key role she plays and is prepared to put the home’s best foot forward to potential
employees.
o Knows when active recruitment is happening.
o Knows which positions are available and has copies of each posting.
o Has applications, pens, and benefit information available at the desk.
o Has a clear plan for notifying a designated person from administration whenever an applicant
comes in, for a walk through and an interview on the spot.
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Sample note to have at the reception desk….
When someone comes in to apply for a job:
Warmly greet them
Give them an application and pen
While they are completing the application, notify the Administrator
and/or DON) that an applicant is in the lobby
Be hospitable – tell them where the restroom is and offer a beverage
Always get their contact information and which position they are
interested in
Supplies to have on Hand: Applications, pens, and recent advertisements
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Take time to hire right, using high standards
An immediate need to fill vacancies may tempt you to put aside hesitation about a potential new employee
and “just give it a try.” This will make things harder in the long run. Poor hiring decisions compound
stress and instability. Even though your employees are voicing a need for help, they really want you to hire
reliable, dependable co-workers. When new employees are not reliable and dependable, current
employees end up working even harder and with resentment. Hiring people who do not meet your
standards will likely result in termination in short order. When you take time to hire right, you are more
likely to hire someone who will stay. A good employee that stays and does a good job provides a boost to
everyone.
Consider the following when interviewing:
What are they looking for in a job?
Are they warm and friendly?
Will they fit in well with other staff?
Do they have a good sense of humor?
How do they deal with change? With stress?
Do they take initiative?
Do they have solid common sense?
Remember ~ Skills can be taught; caring can not!
The Five Smile Rule: One administrator looks for smiles from prospective employees as he
walks them around the building as part of the initial interview. He checks off each smile
until he has at least five noted. He is looking for friendly people. Residents and co-workers
like friendly people.
Helpful Hints
To hire good employees:
Focus on character traits.
Ask for input from residents, families, and staff.
Look for evidence of reliability, caring, good temperament, and the ability to work well with
others.
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Have an effective screening process with multiple appointments
Start with a more informal conversation while walking through the building. There are a number of
reasons for doing this:
Your employees get to see the person being considered and can tell you what they know about the
person.
You get to see how this person reacts to residents, and
You give the prospective employee a feel for your organization.
Next, have two or three mandatory appointments to test timeliness and reliability. The appointments can
span a very short time period so the hiring is still timely, both for the organization and for the person
seeking
work.
Involve others in the hiring process
Help others learn the necessary skills by teaching them the essentials of hiring.
Involving your managers:
In a department head meeting, discuss the benefit of the managers becoming involved in hiring so
they know potential staff from the beginning, can help make a good selection, and can be better able
to help the new person settle in.
Help develop skills in hiring. Some of your managers may have experience in hiring, and others may
not. Have your managers share tips from their
experiences.
Go over basic dos and don’ts of what can and cannot be asked in an interview.
Work on skills for reviewing applications. As practice, review applications of recent employees who,
for whatever reason, did not work out. Have your managers work in groups of three to review a few
applications. Some things may be immediately clear to them as “red flags.” (For instance, does the
applicant have a history of being able to be on her feet and working at a fast pace? Does the applicant
have experience working with people?)
After they have reviewed applications of employees who did not stay, have them review the
applications of recently hired employees that have been employed more than six months. See if they
can spot indicators of success. This process of reviewing and discussing together will help managers
get more comfortable knowing what they are looking for in an employee.
Use this same process to debrief after hiring someone who did not work out. Discuss if there were
“red flags” that may be helpful to know in future hiring.
Work together to develop interview questions: some that are for everyone and some that are specific
to each department. Think about typical situations encountered in the job where an individual’s
One administrator built three separate appointments into the interview process over a very
short period of time. The first was an open house that also involved a walk- through. The
second visit was an interview with the manager for that position. The third visit was for
medical requirements. By requiring these three visits, he screened upfront those who are
not serious about working for that nursing home. After all, if they want a job, and cannot
make three visits, then how can he rely on them to meet their work schedule?
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character traits and judgment make a difference. Use these as discussion points in an interview.
Practice interviews with co-workers, so managers who are not comfortable doing interviews gain
experience and feedback.
Conduct real interviews in pairs to provide support, perspective and feedback.
Discuss a game plan for walking a prospective employee through the building. What do you want to
look for during a walk-through and how do you want to provide opportunities to see applicants
interact?
Develop a “score sheet” that managers can easily use to capture their observations after the walk-
through and interview.
In management meetings, ask how new employees are doing. Also, spend time reviewing who worked
out, who did not, and why, so that you can improve your hiring practices going forward. You
especially want to find out if it was a poor employee or an insufficient welcome. New employees
should be reviewed and their needs discussed. High investment and involvement in their staying will
pay off.
Consider including direct supervisors, co-workers, residents and families in interviewing. They provide
important perspectives in evaluating a candidate. Interviews with the direct supervisor and co-workers
gain input from people who know the job. Residents and families can offer valuable insights and questions
as well. Since the residents are the ones being cared for, they should be involved and have a say in who is
hired. There will be times when a resident picks up on something important that staff had not. This
additional screening before hiring saves time and money in the long run. You will be able make better
hiring decisions that contribute to retention.
When co-workers invest time and effort to screen and interview a potential employee, they are more likely
to have positive expectations of the new employee and offer a warmer welcome. Since the staff and
residents are involved in hiring, they start to form relationships with the new staff member even before
the person starts working. These relationships help to retain staff because those who have been involved
in the hiring are already committed to helping the new employee succeed.
Helpful Hints
Include residents, families, and staff in interviewing. Have them:
Ask their questions in ways that stay within the limits of legal standards.
Gather people who want to be part of this process and ask them to think about what they would want to
know about a potential new employee.
Write down their questions. Have someone with HR expertise review the questions and modify them,
keeping the essence of the question, while meeting legal standards of what can and cannot be asked.
Develop a uniform set of questions (see sample below) that staff, residents, and families can use to
interview prospective employees.
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Use Your Money Well
Offer affordable benefits and encourage employees to take benefits. Providing an option for employees to earn higher
pay, in lieu of benefits, began as a way to allow staff whose spouse provided their health coverage to opt out of the
costly benefits and share in the financial savings. It worked well for employees who received insurance from a spouse.
However, the approach creates a potentially harmful trade-off for your employees.
When employees do not have other options for health care insurance, this practice has serious
consequences. When employees are put into a forced choice between slightly higher wages or health care,
and their wages are not adequate to meet their needs, they are in a no-win situation. They often choose the
slightly higher wage, gambling on their good health, because the higher wage better meets their most
imminent need.
A compounding component is some employees with low income qualify for Medicaid, for themselves or for
their families. They may therefore, opt for more pay in lieu of benefits. However, they may be close enough
to the income eligibility level that if they receive a raise, take extra hours, or even get a bonus of some kind,
they become ineligible for Medicaid.
A better way is to offer an affordable health benefit to all employees. Here is why:
When your employees have health insurance, they can take care of their medical needs before they become
emergencies. Scheduled absences are far less costly than unscheduled absences due to emergencies.
Your employees will be in better health with better attendance when they have routine access to preventive
care and treatment for chronic injuries and illnesses.
You will be an attractive employer, which will allow you to be more selective in your hiring.
This will be one more positive factor in retention.
When we take good care of our staff, they are better able to take good care of the residents.
Sample questions
viii
What do you do when you are stressed?
Tell us about a stressful situation that happened while working and how you handled it.
What made you decide to become a CNA?
What do you feel you do very well? (What do you feel are your strengths?)
What do you feel you would like to do better? (What are your challenges?)
Can you tell us what you consider to be abusive?
If you were to witness abuse, or had been told by someone about an abusive situation, what would you do?
What do you feel you would bring to our nursing home if you were to be hired?
What do you expect from our nursing home if you were to be hired?
What would you do if you were in a situation with a resident(s) and you should not leave, but asked by a
person of authority to handle another situation? (Example: you are the only CNA in the second floor dining
room with 15 residents and a nurse asks you to assist Mrs. K. in the bathroom.)
If a 96-year-old resident was going toward the door to leave, told you they were waiting for their mother to
pick them up for lunch, how would you respond?
If you are going in to care for a resident and they are agitated, how would you handle that?
These questions help the interviewers see the critical thinking skills, judgment, and character of the
interviewee. The situations depicted are real, and the answers that are given can be revealing. A benefit of
having uniform questions is when you are asking everyone the same questions giving you a common
ground for comparison, along with any new questions that rise during the interview.
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Helpful Hints
Support your employees’ health:
Flu shots for your employees and their families. (If an employee’s child gets the flu then the
employee will not be coming to work.)
Vitamins, free healthy meals, and healthy foods in vending machine.
Physicals or screenings for staff through your medical staff.
Health promotion opportunities such as smoking cessation programs, weight loss clinics, and team
contests such as a “biggest loser” can be an entertaining way to your staff’s good health.
Use Your Money Well
Reward Longevity with Raises and Bonuses
Reward longevity. Avoid ceilings on raises for long-time employees. If your home caps hourly
wages, at a certain point, your most reliable, long-term employees stop receiving raises. If the
cap is not continuously adjusted for inflation, it can prevent wages from staying current with
buying power. Newly hired employees may get a pay rate close to what your long-time employees
are earning, negating their years of experience and loyalty.
If a long-time employee leaves because she does not feel adequately compensated, the home will
lose institutional memory and the consistency of care that longevity brings. Long-time
employees know people, have relationships, and know how to do their job. Their years invested
in your home give them a deep commitment. This once stable position may become unstable and
can cost thousands in turnover.
Spend Smarter: A better way is to reward long-time staff with regular raises, the ability to bank
or cash in PTO, and longevity bonuses. Give raises that reflect inflation. Give longevity bonuses
in dollar amounts per year of service on employees’ anniversary date.
Go to Drill down Worksheet 5 to calculate your turnover replacement costs. Count the positions
that turn over several times in a year. For each of these unstable positions that you can convert
to a stable one, calculate your savings in a year. Go to Drill down Worksheets 2 and 6 to calculate
your current staff and your terminations by length of service. For greater stability, increase the
percentage of your staff that remain with your for a long time.
o Hire full-time employees instead of plugging holes in the schedule.
o Part-time staff cannot follow-up on clinical issues, be there for a return call from a doctor,
answer questions from families, or recognize subtle changes in a resident’s condition that
may be early signs of a more significant problem.
o Part-time staff is less able to participate in facility-wide efforts.
o It is better to maximize your percent of full-time positions. The larger your percentage of full-
time staff, the greater your stability will be.
o In advertising, make it a selling point that you are looking for full-time people who want to
join and contribute to a good stable work environment. Emphasizing stability and continuity
in the work environment attracts applicants looking for full-time work.
o Continuity reduces stress, supports good communication, and builds positive momentum.
Full-time employees can participate in organization-wide and unit-wide improvement efforts.
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Go to Worksheet 1 to review the composition of your current staff. Do you have the right mix for your
organization’s needs? Worksheet 9 lets you see if any of your current financial incentives are
contributing to an out-of-balance staff composition.
Piecemeal to full-time: Instability to stability
In June 2005, Birchwood Terrace had more per diem and Baylorix nurses than full-time and part-time
positions. By using the drill down tools, they saw that they were creating financial incentives for people to
work Baylor schedules and per diem by having a bonus for taking last minute assignments. At the same
time, they were not rewarding full time reliable employees with longevity. They made it a goal to increase
their percent of full-time employees and reached a point where they were only hiring full-time nurses.
They did this by giving a substantial wage increase to only those who worked guaranteed hours. They paid
for the raise by eliminating the last-minute bonus. After Birchwood stabilized its staffing, it got the
reputation in the community as a place people wanted to work. It improved their relations with hospitals,
medical staff, and families, because people could rely on their continuity. Now they have a waiting list of
nurses who want to work full-time for them. See Section IV Case Study for more information.
A Good Welcome
Providing new employees with a thorough orientation to residents, co-workers, and the organization is
essential to retention. Nursing homes “working short” often forgo solidly orienting a new staff person.
Instead, they move a new person from wing to wing, wherever the need is that day. The shortage for the
day is relieved but the new person is floundering without a way of getting to know the residents, routine,
or co-workers. The difficulties of starting a new job can become overwhelming. It is not unusual to see a
new employee leave during break because they do not know anyone and do not develop connections.
This is especially true for people new to the CNA world. CNA classes do not adequately prepare people for
the real-life challenges of working with residents with dementia, disabilities, the range of personalities, or
those who are dying. Without help in setting care priorities and managing their day, new CNAs are
overwhelmed and unable to provide the care that attracted them to the job.
Go to Worksheet 6 to calculate how many new employees are leaving quickly, and let you see if you need
to improve your welcome. Multiply the number of new employees who leave by your turnover
replacement costs (Worksheet 5) and that is money you can reinvest in orientation. With Worksheet 9,
look at what you are spending for sign-on bonuses and redirect those funds to team retention bonuses.
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Attendance, Scheduling, and Assignments
Eaton found in homes with high turnover that most involuntary terminations came from attendance
issues. High turnover homes had strict and punitive responses to absences. Staff with personal needs
affecting their attendance were often viewed with suspicion and met with punitive action.
A better way is to invest in attendance and help people meet their schedule. Employees with good
attendance want the poor attendance of co-workers addressed. No one wants to work short-staffed;
however, a punitive approach may lead to termination of an otherwise good employee. Adjustments,
assistance, and rewards usually work better for employees you want to keep. Assess your current level of
Use Your Money Well
Allow the new worker the time for a solid orientation in the area where s/he will be working. Focus
on continuity and stability for new employees. Give them time to gain confidence, apply their skills,
and learn the ropes. With a solid orientation to their job, residents, co-workers, and their care unit,
new employees have the greatest likelihood of success.
Elements of a successful orientation process include:
o Continuity of assignment: Give new employees the same assignment for at least two
weeks so they have time to get to know residents and co-workers. Start the new employee on
what will be their regular assignment. If the regular assignment will be weekends or nights,
orient on weekdays when supervisors and managers are available to provide support. Then
shift the new employee to their regular assignment when they are comfortable and confident.
Pay attention during the transition.
o Regular oversight by management and supervisors: Have supervisors and managers
introduce new employees to their duties, their co-workers, and the residents. Make sure
supervisors and managers are “checking in” a few times a day the first week, and daily for the
rest of the month.
o Mentors help new staff learn the ropes: Train mentors in communication and
sensitivity to the different learning styles. Provide mentors support from their supervisor and
a regular avenue for giving progress reports on new employees. Compensate staff for this
extra responsibility and factor the time demands into the mentor’s assignment. Recognize
that new employees turn to their mentors long after they have settled in, so make this a
position with an on-going higher hourly wage. Many workforce development programs will
fund the cost of mentor training (see Section V).
o Team retention: Give the co-workers mentoring the new employee a bonus when the new
employee stays (usually after 3 months). When current employees see so many new
employees come and go, they often hold back support and connection until they see if the new
person is going to make it. With a financial incentive to help new people settle in successfully,
employees reach out more readily. A team retention bonus rewards the whole group for
teamwork and promotes stability.
o Timely teaching: Provide new staff with information as issues and questions arise at the
start of a job. Have the in-service director coordinate with mentors and supervisors to give
new staff the information and skills training they need to succeed.
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absences and its cost to your organization (Click here to go to Worksheet 7 on Absenteeism Costs and
Worksheet 8 on Absence Log.) Estimate what resources you can convert to support attendance. Make a
realistic effort to improve attendance. As you make progress, you can take on a comprehensive approach
for sustained good
attendance.
Basic elements of a comprehensive approach to sustained good attendance are:
Clear, fair, and flexible attendance policies and practices will play a significant role in promoting good
attendance.
Fair and flexible.
Hold staff to a high standard and provide assistance and adjustments so staff can meet that
standard.
Reward good attendance rather than rewarding last minute assignments.
Effective attendance policies and practices:
Accommodate requests for time off: When staff require a day off, accommodate their need. Treat
your employees like responsible adults. Understand that if people still need the day, they will have
to take it anyway. Then, instead of an absence you can plan for, you will have an unscheduled
absence that is harder to cover.
Allow employees to switch days: Usual rules for co-workers switching include limits on overtime,
written documentation of the agreement, and holding the originally scheduled employee
responsible for the substitute’s attendance.
Anticipate needs after stressful times: Sometimes, employees call out because they need a rest
after working short-handed, filling in for an absent staff member, or working a double shift.
Instead of penalizing such absences, anticipate that the staff will need a break and schedule a
substitute so they can get some rest.
Respect an employee’s reality: Have a specific number of absences trigger concerned intervention
rather than triggering disciplinary action. Some homes have a “no-fault” policy: no reason is
asked for and once the number of absences reaches a certain level, no reason is accepted. Instead,
find out why absences are occurring and see what can be done to help a good, caring staff person
be able to have a schedule she can meet.
If a staff member or her family member is sick, ask if he/she expects to be out for more than one
day and plan for the second day’s absence ahead of time.
Hold staff to a high standard and provide assistance and adjustments where needed:
Track attendance by employee, department and shift. Click here to go to Worksheet 8, the call-in
log.
Report the employee’s attendance record with their paycheck. Show the number of absences in
the pay-period and absences year to date. This tracking and reporting shows you are serious
about attendance. It will make a difference for some employees when they know their attendance
is being monitored.
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Offer help and make adjustments. Meet personally and confidentially with staff with high
absenteeism. Explore the causes of absences and what can be done to help. Offer employee
assistance and make adjustments to the schedule. Questions to ask:
o Would a different schedule help?
o Is the shift not working?
o Are there some days that are harder than others?
o Would the person do better with fewer hours on the schedule?
o Does the employee need assistance with issues that are contributing to absences?
Most employees going through difficulties in their personal lives will, over time, even out and work
regularly again. Adjusting a schedule or providing some help often makes a big difference. The resources
to support attendance often pay for themselves in salvaging employment for good employees having
difficult times.
Enforce the rules:
Those who do not improve their attendance through these accommodations will be easy to identify. Take
action with them to protect the stability of your daily schedule.
Have a sympathetic understanding of staff’s problems:
Employees struggle to make ends meet, without much cushion to handle any problems related to illness,
childcare, transportation, or even basic shelter. Normal everyday problems are compounded by low
wages. Homes that allow for and assist employees with their problems end up with employees who are
better able to get to work, and who develop a deep commitment and loyalty to their employer. Yet in the
field of long-term care, the prevalent attitude is to “leave your problems at the door”, as if employees can
put problems totally aside. Instead, simply being able to take a moment to say what is happening often
allows the employee to get into work mode.
One administrator said, “We’re dealing with their problems, because they’re dealing with their problems.
It’s just a question of whether we deal with them up front or we force staff underground with what they
are dealing with. When we force their issues underground, we wind up dealing with the problems in
other ways, when they can’t come to work, or are carrying their worries without any help or
recognition from us as their employer. That’s when we can lose a good worker who’s having a bad time
of it.”
Ways to help include:
Short-term loan programs: Many low-wage earners do not have access to short term loans from
banks for sudden expenses, such as a costly car repair. Many homes have started to address this
kind of need with in-house short-term loans. While there is currently no hard data on payback
rates, the anecdotal evidence is that the payback rate is quite high. Employees are grateful for the
assistance and loyal to the employer that they can count on.
Employee assistance programs (EAPs) offer a wide array of services, counseling, support and
referrals, and are a cost-effective investment.
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Avoid micro-inequities. Think about the disparities that exist in your nursing home. When
someone from the management team gets a call that her daughter is sick, she lets you know she
needs to leave now to pick her up at school and take her home. You tell her you hope her daughter
feels better and you will see her tomorrow. A CNA gets the same call. Do you have the same
response? In most nursing homes, the response is different. This is called a “micro-inequity.” In
the mind of the CNA, it is simply “unfair.” They do not take their responsibilities lightly at work or
as parents. Have equal trust in staff, and allowance for family needs, regardless of an employee’s
position in the organization.
Make accommodations. A simple example is rethinking the ban on cell phone use. Many evening
staff who are parents want to know their children are safely home from school, doing their
homework and finding dinner. One nurse manager adjusted the cell phone ban to make it clear
that cell phones should not be used in a way that interferes with resident care. She invited staff to
use her office to make their calls home to check on their children.
One administratorx put it like this: “Many who work in long-term care have hard lives. I want this job to
be a place of stability for them. I hope it can anchor life for them.”
Reward reliability and good attendance instead of paying bonuses for last minute
assignments
Many homes pay a significant hourly bonus to staff for taking a last minute assignment when there is an
unscheduled or unexpected absence. Rewarding last minute assignments instead of rewarding attendance
creates many problems:
Employees who reliably come to work receive less pay than those who take the last minute
assignment.
Scheduled staff never knows whom they will be working with or whether they will be working
short-handed.
The stress and financial inequity can cause full-time staff to opt, over time, to become part time or
per diem and then wait for the last minute call.
Staff becomes more casual about their attendance, figuring that if they miss a shift, they can
always pick up work later in the week, with a bonus.
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Use Your Money Well
Reward full time work and good attendance by targeting resources to people who commit to a
regular schedule and who have good attendance.
Reward guaranteed hours with better pay:
o Make full-time and guaranteed part-time hours a better financial deal than working per diem
with bonuses for last minute
assignments.
o Target substantial wage increases to people who guarantee hours so their pay rate is better
than the hourly rate for per diem staff. Fund the wage increase by eliminating the last minute
assignment bonus.
o Encourage per diem staff to convert to full-time status. Have one-on-one meetings with per
diem staff that you want to convert. Explain to them that you are moving towards more full-
time committed staff to create more stability, and you want to offer them the option of
coming on staff full-time.
o Spell out the financial advantages to them of converting to guaranteed hours.
“Perfect attendance” bonus:
o Give individual and team bonuses for those with perfect or the best attendance for a specified
period of time.
o Effective time periods are short, because when the time period is too long, the attendance
bonus can become irrelevant as soon as someone misses a day. Month-by-month or pay
period-by-pay period are good time frames.
o The bonus amount can be a lump sum payment (ex. $25 per month), an addition to the
hourly rate for the next pay period (ex. $0.25 more per hour), a non-monetary reward such as
a gas card or grocery card, or eligibility for a raffle with a substantial prize. Adding the payout
to the base rate gives an employee a concrete incentive to maintain the higher level in their
next paycheck. Gas cards or grocery cards are not taxable and also do not affect income levels
for staff that rely on their eligibility for public benefits such as Medicaid or food stamps.
o Combine attendance and longevity incentives. Those who earn a bonus in any given time
period can also be eligible for a cumulative or special bonus collectable at the end of the year.
For example, for each month someone earns a perfect attendance bonus, they can also have a
bonus amount banked for them and collectable in December.
o Paid time off: Offer an extra paid day off per quarter for those with no call-outs, or pay out all
or a portion of unused sick time at the end of the calendar year.
o Rules for eligibility: Rules should be fair, not punitive. The goal is to encourage attendance.
Rules that are too strict or unfairly applied will cause resentment. Require staff to work every
shift they are scheduled and to be on time. Do not disqualify staff for absences when they
have a medical note and call in with ample time to get a replacement or make acceptable
arrangement to switch with another employee.
o Team attendance bonuses: In addition to individual rewards, reward every member of the
work group with the fewest shifts worked short-handed in a given month or pay period. Team
rewards help everyone pull together.
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One home’s path to a fair and flexible attendance policy:
Loren Salvietti, administrator at Quaboag-on-the Common in West Brookfield, Massachusetts, completely
overhauled her attendance policies. She told her staff “You are all adults. I trust that you are responsible.
If you are unable to come to work, I know you must have a good reason. I’d like to work with you so you
can attend to what you need to in your life and I can still be sure that we aren’t counting on you on the
schedule when you can’t come in.”
Attendance problems were the leading cause of terminations. They often found that they were letting go
people who otherwise were very good employees. They decided to do something different. First, they
called other administrators to see if anyone had a policy that was working for them. No one she talked to
did so they put together a policy they thought would work. It was agreed upon to be a one-year to pilot
after which they would evaluate their outcomes. The results were astounding. They reduced the
terminations due to attendance from 40 in one year to 1 in the next year by shifting from a punitive policy
to a constructive, helpful, and flexible policy. The daily attendance also improved significantly. After
quietly using this policy for one year, they held open staff meetings to discuss the policy. In these
meetings, which were held over a period of several days, at different times, so that all employees could
attend, they introduced the policy and asked for staff reaction and input. The policy, as modified based on
those staff discussions, was then formally put in place.
Stable schedule and consistent assignments
As attendance improves, put more stability into your schedule and assignments. Three key areas that will
have a positive impact on attendance are:
Steady daily staffing rather than staffing to census.
Regular 8-hour shifts rather than long “Baylor” shifts.
Consistent assignments.
Maintain steady daily staffing rather than staff to census
Staff depend on steady wages from scheduled workdays. Yet, it is a common practice to send CNAs home
on shifts when the census is low. For many CNAs, losing a day of pay is a hardship that may drive them to
leave for another job where they can count on their hours. Once employees realize they can not count on
the schedule, they begin to see the schedule as something they can adjust from their end as well. Sending
people home leads to people deciding at the last minute not to come in.
Helpful Hints
Fairness is crucial in scheduling and awarding attendance bonuses. If your staff experiences favoritism in
scheduling, they will resent attendance bonuses and view it as unfair. This happens if they are not
accommodated when they need days off but other “favorite” staff are given their days off. If staff loses out
on an attendance bonus that they would otherwise qualify for because of unfair scheduling practices, a
good incentive program is undermined.
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Use Your Money Well
Maintain steady daily staffing. Steady staffing provides stable employment and earnings that staff
can count on. Maintaining steady staffing during the ups and downs of census allows staff to have
days with less stress. Employees appreciate those times for the way they can better focus on the care
and needs of their residents.
Helpful Hints
Anticipate when typical low census periods are. Look back at census data over the last year to see what
patterns emerge. If it is clear that your census is low during certain times of the year, build this into your
budget and plan for it.
Manage with stability in mind to maintain stability.
A Cautionary Tale: The Price of Staffing to Census
One nursing home administrator had worked hard to stabilize staffing and cut her turnover by
50% over three years. When her corporate manager directed her to save money by staffing to
census, she resisted, to no avail. Within three months of having instituted the practice of staffing
to census, she began losing some long time, loyal staff that told her they could no longer count on
their jobs with her and they had to go elsewhere. They felt that their loyalty to her had not been
returned.
The problem got worse. Employees began to look at the schedule, see that “too many staff” were
scheduled given that the census was low, and decided on their own to call out rather than be sent
home. Two or three scheduled staff members each doing this on a given shift left her short-staffed,
even though enough people had been scheduled.
Her savings of $80 per CNA sent home was erased by the extra costs of replacing staff on shifts
she was now short, and then replacing staff that had left permanently. Some were irreplaceable.
By showing her corporate manager the numbers, she convinced them to let her reverse the
practice and return to steady staffing, but the damage had been done. She lost good staff, and
worse, she lost the trust of some who remained. It took a long time to win that back.
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Use regular 8-hour shifts rather than long “Baylor” shifts
To meet the needs on hard-to-fill shifts such as week-ends, evenings or nights, many homes schedule
employees to work 12–hour shifts and be paid for more hours than they work. For example, work two 12-
hour shifts and get paid for thirty hours, or work double doubles and get paid for forty hours. This is
commonly referred to as a “Baylor” position. At times of overall staffing shortages, variations on Baylor
positions have been offered during the regular weekday shifts as well. The down side to this practice is
tremendous.
One problem is exhaustion. Employees working such long hours are sleep deprived. This makes them
vulnerable to errors and injuries, short-tempered, and unable to carry the same workload as those coming
in fresh. Other staff may feel burdened working with these co-workers because it leaves them carrying
more of the load and having potentially negative interactions. Employees can get hurt, residents can
suffer, and co-workers can be disheartened.
This arrangement can create a separation between weekday and weekend staff where weekend employees
have little opportunity to interact with weekday staff. Working concentrated shifts makes staff unavailable
for regular communication, follow-through, and collaboration with the rest of the staff during the week.
Weekend staff working long shifts can be very task focused and not able or predisposed to look at the big
picture in care of a given resident, supervision of staff, or initiatives that the nursing home may be
undertaking.
Can you really afford to pay people to stay home?
Baylor salary pays staff for hours they do not work. Paying staff for hours they do not work, and paying
them to work past the point of exhaustion is not a long-term solution to staffing problems. Exhausted
employees call out, generating replacement costs, or are difficult to work with, leading to turnover costs.
Use Your Money Well
Pay better wages, with a substantial pay differential for hard-to-fill shifts. Limit the
number of successive hours an employee can work. Instead of paying people for hours they
are not working, use those funds to enhance pay for the hours worked. Make sure that no
schedule leaves staff isolated from the rest of the organization.
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Have consistent assignments
Assignments are consistent when CNAs care for the same residents every time they work. Whenever an
assignment change is built into the schedule, whether daily, weekly, monthly or quarterly, it is considered
staff rotation. There is a mounting body of evidence that consistent assignment improves clinical,
workforce, and organizational outcomes. Many consider it the foundation of quality improvement, culture
change, and workforce retention. Advancing Excellence in America’s Nursing Homes has made
consistent assignment one of eight goals participating nursing homes are asked to work toward during the
campaign.
Reasons for consistent assignment (for the Consistent Assignment Change Idea Sheet, see Appendix D):
Consistent assignments build relationships between residents and staff.
Attendance is better and turnover is reduced. Caregivers report feeling a greater sense of
responsibility to come to work because they know best what “their” residents need.
Family members feel more comfortable with the care when they know the caregiver.
Teamwork improves. When CNAs work consistently with the same residents, they also have the
same co-workers, and teamwork develops.
Quality of care improves when CNAs care for the same residents consistently. They are able to
notice subtle changes in a resident’s individual needs, conditions, and characteristics. Staff
familiar with residents know better how to help them and are more accountable for care
outcomes.
Helpful Hints
An Idea for Weekend Coverage
If you must consider offering a Baylor schedule, consider a different kind of Baylor program consisting of
four, eight-hour days on Friday, Saturday, Sunday, and Monday that pays the equivalent of 40 hours for
this 32-hour shift. It provides continuity and a tie-in with regular weekday staff, and ensures a
manageable work schedule for employees.
Go to Worksheet 1 in the drill down to track the composition of your current staff and see how many
people work long shifts. On Worksheet 9, calculate your incentives. How much are you paying people to
work these long shifts and how does their per hour wage rate compare with what you are paying others?
Can that money be re-allocated to support higher wages and differentials for these shifts, so you have
coverage, without exhausting your employees?
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Getting started with consistent assignment:
Pilot consistent assignment on a unit that has the best chance of success.
Ask staff to rate residents by degree of assistance needed and then divide up the assignments
evenly. Some residents might seem difficult to some staff and not to others. Match staff to
residents in a way that feels fair to everyone.
Ask residents and families their preferences and include them in making assignments.
Revisit assignments as the resident population changes to maintain fairness.
Change an assignment if it is not working. These are “consistent” assignments not “permanent”
assignments.
Pair staff with residents who are hard to care for so no staff person is left alone with such a
challenge.
Have a consistent back up for every assignment to provide continuity for the other days and
shifts, for days off, and if a staff person leaves.
Have consistent assignments for other departments – activities, housekeeping, laundry,
maintenance, food service, and social work. You will build consistency and teamwork for
residents’ total needs.
Build teamwork and a sense of being in it together. Bring staff together at various points in the
shift to check-in and share the load.
“Model” teamwork and that every resident is everyone’s job by having an “all hands-on deck”
approach where all department heads, nurse managers, charge nurses, and non-nursing staff
answer call bells, help at meal times, and provide support through busy times.
“But I’m Only Brushing Your Teeth”
Anna Ortigara, the author of Learn, Empower, Achieve, Produce (LEAP), a leadership-training
program for nurses, developed an exercise for corporate nursing home leaders participating in
the CMS pilot Improving Nursing Home Culture. Participants paired up and given: a toothbrush,
toothpaste, bib, glass of water, and spit cup. One person in the pair brushed the other’s teeth. If
you are cringing at the thought of this, you should know that it was not easy for the participants
either. But they realized that even this is not the most intimate care nursing home residents
receive.
After the exercise, they discussed what it was like to receive personal care. They thought about the
difference between receiving such care as a task from a staff member, with whom they have no
attachment, compared to receiving such care in the context of a warm consistent relationship and
strong connection.
At the end of the pilot, as they reviewed turning points, this was one. The move to consistent
assignment turned out to be a key factor in their success in reducing turnover.
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Calculating your current rate of consistent assignment:
Mary Tess Crotty at Genesis Corporation developed a simple way to calculate how consistently you are
staffing. For a sample of residents, count the number of CNAs who initial the CNA flow sheet for a month.
If you are 100% consistently assigned, you should have 6-9 CNAs (this includes a FT CNA and her back-
up on each shift, and a weekend CNA per shift). If you have more than 6-9 CNAs, then figure out why.
“A Positive Chain of Leadership”
Good leaders bring out the best in others. Dr. Eaton noted that low turnover homes support and develop
leaders at every level of the organization. She saw strong leaders among supervisors, managers, and peers,
which she called “a positive chain of leadership.” This positive chain of leadership builds on staff’s
“intrinsic motivation” — what most people who work in long-term care describe as a “calling” to care for
others. This “intrinsic motivation” drives people to overcome the difficulties and stresses of the work to
take care of the residents they know are depending on them. When you manage in a way that encourages
and supports this motivation, employees do their best.
Yet the long-term care field has historically had a top down, punitive approach to management that
dampens staff’s intrinsic motivation. Many managers and supervisors have not had training in
supervision, and follow the rule-oriented, punitive approach they see around them. Employees experience
the punitive, “command and control” approach as disrespect. Many cite it as a reason they leave a job, or
the field. It certainly does not bring out the best in employees. A better way is to establish a positive chain
of leadership in your organization:
Expect the best from the staff, and help them do their best.
Develop and support leadership skills among supervisors and managers.
Have regular workforce-workflow meetings with supervisors and managers.
Have regular systems to promote teamwork, communication and collaborative problem-solving.
Develop and support direct care staff in exercising good independent judgment
Expect the best and help people perform at their best
Expect people to perform at their best and help them get there. Most people step up into their own
personal best when they know that there is an expectation of high standards. It is hardwired into our
human nature to want to excel. By having high expectations, we are tapping into a basic human desire for
mastery. When management believes employees want to do a good job and provides support, this
generates an environment of mutual support. In Encouraging the Heart, Kouzes and Posner outline steps
for bringing out the best in employees:
Set clear standards – people need to know what is expected of them.
Expect the best – it will be a self-fulfilling prophesy.
Pay attention – tune in to people individually.
Personalize recognition – group appreciation is good; specific individual acknowledgement is
better.
Tell your story – share successes; this is a way of teaching what you are aiming for and
acknowledging when you achieve it.
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Celebrate together – have fun; spend at least as much time acknowledging what has gone well as
is spent correcting what has not.
Set the example; employees learn far more by what you do than what you say. Model the way.
People development
Good managers develop others. For supervisors to lead well, management needs to spend time developing
supervisors’ leadership skills. Do this through individual coaching and group meetings with supervisors
about workforce issues. Actively involve managers in supporting their supervisors.
Leadership is a skill to be developed. Assess your managers and supervisors individually and determine
how to help them be their best. Have high expectations. Help supervisors and managers take on
challenges and grow.
Help your managers and supervisors develop trust in their own decision-making abilities. When
supervisors come to you for a decision, use this as an opportunity to help them develop. If a staff member
comes to top management to intercede in situations where they do not have trust in how their direct
supervisor is handling the situation, use this also as an opportunity to develop the supervisor.
Help the supervisor think through how to approach the situation and follow-up with her on what
happened. At first, tell her how you are thinking about it, what you see as options and what are
the advantages and pitfalls of each option. Spell out your thinking about the situation and why
you think the way you do. Ask her how they are seeing it.
Over time, ask them what they see as the options instead being the first to share how you see the
situation and what options you see. Ask what they see as advantages and disadvantages to each.
Talk together about how each option would play out. Teach them how to think options and
develop their executive decision-making.
Spell out the permissions and parameters of their decision-making. Do not leave them frustrated
because they put effort into something that you are not comfortable having them do.
As they get more comfortable in taking on decision-making, you will also have more confidence in
the decisions they are making and be able to support them. If you have concerns about their
thought process, spell the concerns out.
Eventually they will come to you just to let you know what was done in a given situation. You will
feel comfortable because the line of thinking that went into it is one that you had a hand in
developing.
Let people know that you are there to support them, and that you are not leaving them out on a
limb.
Follow-up with them, and teach them how to follow-up. Many decisions need continued
maintenance or occasional adjustments. This kind of follow-up is another skill for effective
management.
It may be easier to do it yourself, but it is better in the long run to help your employees develop this
ability.
Workflow/Workforce meetings with charge nurses
You probably spend far more time than you would like on people problems. Be pro-active about your
people management and you will easily cut that time in half. Develop your supervisors’ leadership skills
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by having regular meetings about workforce and workflow issues. Spend time pro-actively on these issues
and develop your staffs’ skills in problem-solving together.
An example: At one workflow meeting, the Director of Nursing learned that the pharmacy delivered the
meds at 10:45 p.m. every night, just as the evening supervisor was trying to finish things up to go home.
Instead of being able to put everything in order and have a good report with the night supervisor, she had
to check and distribute all the meds. It was fairly simple to tell the pharmacy to get the meds there by 9:00
pm. Use these meetings to discuss progress related to new employees, tension on the floor, attendance
issues, or other workforce issues.
Regular systems for teamwork, communication, and problem solving
Systems for communication
Systems that support regular communication provide the structure for teamwork and contribute to
stability – both in the day-to-day and in the overall work environment. Bring people together on an
organizational level and at the unit level to ensure that, everyday, people have the information they need,
when they need it. Having information about individual residents, new admissions, events in the building
or other matters relevant to care, actually saves staff time. Regular ways of putting heads together for joint
problem solving can save time and improve how people work together.
During times of staffing challenges, organizations often see time spent in meetings as a luxury that can no
longer be afforded. Staff meetings where issues can be talked through are postponed or cancelled.
Administration may fear that meetings will be “gripe” sessions instead of being productive. Employees
have no way of learning what is being done to alleviate the situation, and no where to voice concerns,
identify problems, or engage in productive problem-solving. In the absence of real information and
communication, they perceive that management is either unaware or unconcerned about the problems
they face.
A better way is to bring everyone together and open lines of communication. Bringing everyone together
to determine how to work together to get everything done is even more necessary. It lets employees know
what efforts are underway and it gives management valuable information from them about where the
trouble spots are that need to be kept in mind. If it has been the home’s practice to bring people together,
that should continue in hard times. If it has not been the practice, hard times create additional need for
meetings.
Here are some proven, effective, simple communication systems for supporting communication that does
not take much time, but give people needed information:
Quick, change-of-shift meetings are an important way to support stability and a smooth hand-off.
Start-of-shift stand-up meetings get everyone on the same page about their responsibilities for the
day. Let people know the situation, and what is expected of them. You can hear from employees
and get them working together. Speaking with people individually is also good, but having them
all together reinforces teamwork.
Mid-shift huddles refocus the team on what is needed on their shift and a way to “check-in” on the
days events. Inquire if anyone is behind and needs more help and get them to put their heads
together on how to help out. This is especially a good practice if you are working short-handed. It
is also useful if you have younger employees.
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A quick on-the-spot huddle to problem solve is a good way to work together when an issue arises.
Anyone can call a huddle and everyone then comes together. If you have fewer people than
expected at work, have a quick huddle to determine how you will work together, who should do
what to cover. If you have a new admission, quickly huddle to free the staff person who will be
caring for the new resident. If you have some contention among staff, quickly huddle to resolve it.
If a resident is having difficulties, quickly huddle to get ideas on how to handle the situation. The
huddle helps staff work as a team, and draws on their ideas and problem-solving skills. When the
solution is theirs, they will have more faith in it and more energy to make it work.
End of shift check in. Ask how did the day go? Give people a pat on the back for a job well done.
Find out what issues need to be passed to the on-coming shift.
Daily or weekly team meetings are useful in every department, for updates, check-ins and
problem solving. Include housekeeping, activities and others assigned to your neighborhood in
your meeting.
Hold all staff meetings monthly or quarterly in a way that everyone can attend. Ideally they
should be held several times a day so everyone can attend and you can maintain staff on the floor.
Prime times for one-hour meetings are 7:15, 1:45, and 3:15 so people can come just after or just
before their shift.
Hold workforce and workflow meetings with charge nurses to look at issues such as how new
employees are doing, how contention is being resolved, how to address a clinical matter being
missed – such as obtaining all the weights, or how to help out on a unit that is working short-
staffed.
Manage by walking around: Top administrative staff routinely walk through the building during
the day, and especially during stressful times, to be available, see what is going on, lend a hand,
and voice appreciation.
Managing by walking around – rounds for retention
xi
Make it a daily routine to walk through the building in slow, lingering rounds for retention. This kind of
walk through is not to be confused with micro-managing. Micro-managing is checking on people, and
Helpful Hints
Managing Younger Workers
The executive function in the brain does not fully develop until people are in their mid to late 20’s. Before
executive function develops, young adults do not have as much ability to see ahead and organize their time.
They need regular structured guidance at intervals throughout their shift to complete their responsibilities.
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Walking-around to see what is being done wrong. Forget the clipboard – this is very different. Use this as a
way of supporting people, by being closely in touch with what they need. Set a positive tone for the day.
Be available, visible and in touch with staff. By this conscientious act of being out and about, greeting staff
personally, you generate warmth and positive energy.
Hear and see what people need to do their jobs, how new employees are faring, and where the trouble
spots are that need attention and assistance. A daily early morning walk around actually saves time later
in the day because you are aware of the needs early in the day to do something about them, rather than
being caught off guard by a situation when you finally hear about it much later in the day. When you hear
concerns, it is essential to do what you say you will do, and to follow-up with the people involved.
Sometimes you take action but do not tell the staff what you have done – and then they do not know that
their talking with you did any good. Make sure to coordinate your actions with others responsible that
may already be working on the issue.
Catch your employees doing the right things. During a late day walk-through, speak with employees about
what has gone well that day. This is not to be done to suppress concerns, but to know who deserves a pat
on the back. After you hear what has gone well, give the pat on the back and spread the good will.
For instance, if you ask a charge nurse what has gone well and she tells you the meals went out
smoothly and the residents enjoyed the lasagna, then when you are in the kitchen area, you can tell the
staff that you were just on unit two, and Sue, the nurse, said that everything went smoothly today and
that the residents loved the lasagna—good job!
This builds relationships among the staff, and creates an environment where people feel appreciated, by
you and by their co-workers. Telling food service staff that the compliment came from nursing builds
goodwill between two work areas.
Encouragement and Feedback
In, The Leadership Challenge, Kouzes and Posner tell a story about an army experiment. Participants in a
special training program had gone through a rigorous few weeks that were to culminate in a long march.
On the day of the march, the soldiers were divided into four groups.
The first group was told exactly how long they had to march – 20 kilometers – and were given
regular progress reports along the way.
The second group was told, “This is the long march you heard about.” Nobody knew how far he or
she would march, nor were they informed of their progress along the way.
The third group was told they would march 15 kilometers. When they got to 14 kilometers, they
were told they really had to march 6 more, to 20.
The fourth group was told they had to march 25 kilometers. At 14, they were told they would only
march 20, and that they only had 6 more to go.
So how did each group do? It is no surprise that the first group did the best and finished first. Blood tests
for stress indicators were taken during the march and again 24 hours later. The first group scored better
in their stress indicators as well.
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It is also no surprise that group two came in last. They had no information to go on, and no feedback
along the way. They were left in the dark and their performance reflected it. These soldiers were all in
comparable shape with comparable ability. How they were encouraged by regular feedback made the
difference in their performance.
On-going regular ways of letting people know what is expected of them and how they are doing to meet
those expectations make a big difference in people’s performance. If leaders provide people with a clear
sense of direction and feedback along the way, they encourage people to reach inside and do their best.
Regular information and feedback reduces stress and improves performance. (See communication
systems section for opportunities to give encouragement, feedback, and appreciation.)
Simple ways to give encouragement, appreciation and feedback include:
Thank you notes: Ken Blanchard, in the One Minute Manager, says effective praise is timely,
specific, sincere, proportional, and positive. Never follow a thank you with a “but”.
Brag boards and other visible ways of acknowledging good performance or showing progress in a
particular area of
focus.
Merit-grams that can be given by anyone to anyone so employees thank each other. Tie the merit-
grams to gift cards for gas, groceries, movies, or a prize.
Pats on the back while making walking rounds.
Special mentions of accomplishments in start of shift stand-ups, staff meetings, and manager
meetings.
Consider both group rewards and individual rewards. Individual rewards are extremely important. People
need to know that you see what they are doing and appreciate it. Group rewards provide the extra benefit
of helping teamwork and cohesiveness flourish. For example, reward the unit that has the best attendance
or a work team that retains a new co-worker.
Helpful Hints
Recognition and Feedback
Appreciations and celebrations that are an extension of positive relationships are enjoyable for everyone. Supervisors
who are hands-on and involved interact regularly with staff and give appreciation as part of their daily interaction. In
homes where the regular contact is not good and employees are not getting along well with each other, signs of
appreciation such as a pizza party or an employee recognition event will not make up for the negative feelings.
Difficulties of the working situation will overshadow their ability to receive the appreciative gesture being offered.
While the gesture may have been truly a heartfelt way of showing gratitude, when employees feel the continued stress
of working short-staffed, or are working doubles, or there is harshness in interactions on the floor, a pizza party may
not be able to overcome those negative feelings. It may be better received if it is not done as a party, but to help them
get through long hours, acknowledging that that they did not plan on working this many hours and need nourishment.
For this type of appreciation to work, it has to happen when people see it as a genuine gesture of thankfulness. It will
fall short if it is perfunctory and not heartfelt or if the negatives on the floor are overwhelming.
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Independent judgment and decision-making
Today’s nursing homes are highly structured, with policies and procedures for every situation. Often a
blanket approach designed to protect the organization is not necessarily the best approach for an
individual resident. Employees are discouraged from using critical thinking and then have to enforce
policies they know are not working, with little avenue for raising a concern, let alone, resolving it.
A better way is to support staff’s independent judgment, critical thinking, and decision-making through a
developmental process. It is important that both you and they feel confident in their decision-making
abilities.
Regular means of communication get employees used to meeting together and talking things
through. Use start of shift stand-up, mid-shift huddles, or end of shift check-ins to talk over any
issues and involve them in problem solving together.
When employees bring issues to you, ask their thoughts and talk through the options and issues
to be weighed, so they learn how you are thinking about it and develop their own critical thinking
skills.
When issues need to be addressed, take staff through a problem-solving process. Have them
identify why it is important. Have them talk about what is working now and what is not, barriers
and options. Be sure to lay out any regulations and other requirements to be considered.
Turn decisions over to employees that you feel they can make, with proper guidance, support, and
oversight.
A Closing Thought from Steve Covey’s Leading by Example:
The foundation of good leadership is leading by example and modeling the way. Employees respond to
what they see you do than what they hear you say. If you say that residents come first, but you walk by a
call bell without answering it, you are modeling that whatever else you are doing comes before whatever
Leadership Pyramid
from Stephen Covey
Teaching
Mentoring
Modeling
Hearing
Feeling
Seeing
Leading by Example, Franklin Covey Co., 1998
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the resident needed. Once you are modeling good leadership, the next step is to mentor your staff. Let
them feel your support and your belief in them. Help them shine. Then whatever they hear from you,
whatever you teach, will just be a confirmation of the rest. This is the model for a good positive chain of
leadership. This will provide a stable environment and the base for high performance.
Section III. Drilling Down: Gathering and Analyzing Data
What is “drilling down” and why do it?xii
“Drilling down” is a performance improvement tool that helps you understand the root causes of your
staffing instability and then implement cause-specific interventions. Use this “Drill Down” to examine
your use of financial resources to determine if you are spending in a way that supports retention or you
are spending in a way that inadvertently may be contributing to your turnover.
This tool is best used in conjunction with the management practices discussed in Section II. As you put
new practices in place, you can measure their impact and compare your results. This helps you ensure that
your fiscal and management practices are supporting stability, quality care, and financial viability.
Drilling down works best as an on-going process, not just a one-time activity. As you succeed in
stabilizing your staffing, you will need to continue your efforts to maintain your results. Make it part of
your routine to maintain oversight and analysis of your situation and to measure the impact of your
management decisions.
While it is possible to complete only one part of the tool now, it is best used in its entirety to ensure the
full benefit and gain a complete picture of the situation. The information and data you obtain will become
the basis for your blueprint for action.
What drilling down can do for you.
The “drilling down” tool allows you to:
Take an in-depth look at the facts. You may have a sense that your turnover is an enormous
expense, but do you know what exactly it is costing?
Understand what is working and what is not. For example, are employees resigning shortly after
receiving a sign-on bonus? Would your money be better spent on perfect attendance bonuses?
Examine the root cause of the problem.
Pinpoint where a problem is occurring. Is your absenteeism greater on a particular unit? Are
people resigning very shortly after beginning employment?
Examine how you provide incentives. Are bonuses for picking up a shift at the last minute actually
giving staff an incentive to call out knowing that they can pick up a shift later in the week and
receive a bonus?
Evaluate data on the costs and benefits of your current practices. Do you cut costs by staffing to
census but increase turnover costs at the same time?
Make and monitor management decisions about staffing and allocation of resources.
Gather and understand the business case for your decisions in a way that will allow you to explain
and obtain buy-in from your board, regional manager or owner.
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Format and design:
Although it may look intimidating, you will find the Drill Down tool easy to use. This guide will walk you
step by step through the fields and provide ideas on how to use the information you learn. The excel tool
in the following section:
Contains built-in drop down boxes to guide you through each step. The boxes tell you what to
input and where to locate the information to use.
Generates graphs as you input the data. This provides two visual ways of seeing the information.
Provides a sample data sheet that you can use to understand how the table and graphs can look
when completed.
Automatically populates additional tables where it is needed. Having all this information linked
on the worksheets will allow you to analyze how the information is linked within your nursing
home. For example, the worksheet that calculates the rate of turnover and the cost of individual
turnover automatically populates the worksheet that calculates your total turnover costs.
You are now
ready to
begin
Worksheet 1!
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Worksheet 1: Employment Status – The Composition of Your Current Staff
Purpose: To determine if the current composition of your staff is optimal to meet your facility’s goals.
The more full time employees you have, the more you have built-in continuity, consistency, and stability.
If you have too many part time or per diem employees, you may want to explore why and examine ways to
reverse this trend. Completing this worksheet will allow you to identify where you have daily continuity
and where you have piecemeal staffing coverage.
Completing Worksheet 1: Employment status
Enter how many of your current employees are: full time, part time, or per diem. An extra box is
provided so you can include other types of employment arrangements such as 12-hour shifts,
doubles, Baylor programs or
other.
A comments section is provided so you may make notes on how you chose to count other
employees such as those that span different shifts or nursing administration.
As you complete each section, you will see both a graph and percentages automatically calculated.
Date the worksheet. It is suggested that you complete this worksheet monthly initially and move
to quarterly as you become successful in making positive changes in your staff composition. Once
you are satisfied with your staffing composition, you may want to complete this worksheet 1–2
times per year to monitor the sustainability of the changes you have made.
Questions to consider:
Do you have the optimal staffing composition?
How does your staff composition relate to performance, retention, or morale?
How does the staff composition among your supervisory staff affect continuity, consistency,
teamwork and organizational commitment?
How are your CNAs affected by having different part-time nurses supervising them?
How does your current staffing composition affect your hiring? Are you looking for several part-
time employees instead of full-time employees?
Next steps:
Examine whether you reward full time or piecemeal positions.
Review your financial incentives (Worksheet 9) to determine if you can make working guaranteed
hours a better deal than any other employment arrangement. This will allow you to use your
resources in a way that is best for your organization.
Conduct interviews with some of the part-time or per-diem employees to determine how you
could make working full-time appealing to them.
Evaluate whether or not you are turning away potential full-time employees during your hiring
process.
Examine staff composition on any unit that is of particular concern.
See Section II, Part I, for tips on hiring practices.
Go to Worksheet 1.
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Worksheet 2: Current Staff by Length of
Service
Purpose: To allow you to examine your staff mix by length of service.
Every organization has a mix of employees; some who have been employed a long time, some a short time
and others somewhere in the middle. Organizations with a greater percentage of long-term employees
have more continuity in the care of their residents, as well as stability in their workplace.
Completing Worksheet 2: Current staff by length of service
Using current information, enter your data on length of service in the following categories:
o < 6 months
o 6 months → 1 year
o 1 year → 2 years
o 2 years → 5 years
o 5 years → 10 years
o > 10 years
Drop down menus will guide you through this data entry for each department.
Graphs will provide you with a picture of how long employees have been with your organization.
Date the worksheet. You should consider doing this at least every 6 months to determine if your
staff mix is moving in the right direction with a higher number of long-term employees.
Questions to consider:
Do you have a solid group of long-term employees who can provide steady mentorship for new
employees?
Do you have longevity among your supervisory staff?
Are employees leaving very shortly after they are hired?
Is this the staff mix of length of service you desire?
Next steps:
Examine, by department, how long employees have been employed in your organization.
Examine the data by unit and ensure that you do not have too many new employees all in one
area.
Review your financial incentives on Worksheet 9 to determine if you are rewarding longevity.
Review your pay raise structure. Consider revising if:
o your raise structure does not keep your long-term employees at a higher rate than new
employees
o you are not providing raises that are keeping pace with inflation
If you determine that you have many new employees resigning, interview some that have left and
determine why new employees are not staying.
Call long-term employees who have recently left and ask them what contributed to their decision
to leave.
Conversely, speak with a few long-term employees and ask them to discuss about what makes
them stay.
Refer to Section II on Rewarding Longevity for suggestions on what activities to include in your
action plan. Refer to Section V for information about programs your organization can become
involved in that can give your long-term employees opportunities to grow and advance.
Go to Worksheet 2.
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Worksheet 3: Vacancies
Purpose: To inform you about the vacancies in your organization by shift and department.
Having this information will allow you to target your attention to units or departments that need your
immediate focus. It will highlight potential trouble areas as well as where your organizational strengths
are.
Completing Worksheet 3: Vacancies
To complete this worksheet, you will need to know how many shifts currently have vacancies. To
obtain this information, look at your staffing budgets compared to what you currently have for
staff.
Part-time positions should be added together to create full-time FTEs to understand vacant FTEs.
If a shift is usually covered by a per diem employee, it is not counted as a vacancy, nor is an
employee that is currently assigned to “light duty”.
Date the worksheet. You should complete this worksheet monthly to quickly identify where your
vacancies are and where you might be vulnerable to low staff morale or poor quality due to
vacancies.
Questions to consider:
Do you have repeat vacancies on one shift, one unit, or in a particular department?
Are you allocating adequate resources to encourage longevity?
Do you utilize “Refer a Friend” programs to encourage your long-term employees to recommend
people they know for employment?
Next steps:
Speak with your current employees and ask them to advise you about what the facility leadership
can do to help new employees succeed and want to stay.
Review your hiring practices. Consider if you are recruiting and hiring the employees that are a
good fit with your organization.
Assign new employees to stable work areas, not to areas with high levels of instability.
Go to Worksheet 3.
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Worksheet 4: Turnover Rates
Purpose: To allow you to calculate exactly how many people left, by position and by month during the
past year. This rate will provide your baseline from which you can work to improve.
Completing Worksheet 4: Turnover rates
This calculation is the total number of terminations (voluntary and involuntary) divided by the
average number of employees.
This worksheet has separate tables for calculating turnover of CNAs, RNs, LPNs, and the facility
overall.
Automatically calculates a combined turnover rate for the entire nursing department and for all
non-nursing staff.
There is an additional table for any non-nursing department or unit. It is not linked to the other
tables and will not affect the rest of the worksheet. You can calculate your rate of turnover and
your costs for that specific department or unit by importing this information to the table in
Worksheet 5.
Turnover is recorded by month in order to review any seasonal variations.
The calculation is completed by indicating the month’s total number of terminations and the total
number of active employees on the payroll on the last day of each month.
Different organizations have different systems for keeping this data. Some places to consider
looking are: payroll reports, and forms completed when an employee terminates
It is recommended that you complete this worksheet both retrospectively and for the current year.
This will give you the ability to benchmark your work going forward.
Complete this worksheet at the end of each month so you have a current accurate picture of your
turnover rate. You will be able to chart your progress as you realize improvements.
Frequently asked questions when completing this worksheet
1. What about agency staff? Do they count in any of the calculations?
No. Agency staff is not included.
2. Why does a part-time or per diem employee termination count equally as a full-time
employee termination?
The calculation is a measurement of all turnover, regardless of employment status.
3. What about an employee who changes his/her job title and stays in the organization? Does
that count as a termination?
No. Do not count this individual as a termination.
4. What if an employee works at two facilities owned by the same corporation and leaves one of
the facilities but stays at the other?
The employee would be coded as a termination by the facility from which he or she
departed.
5. What if an employee cuts his/her hours from full-time to per diem? Does that count as a
termination?
No. They are still employed by the facility.
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6. What about an employee who goes on unpaid leave or who is still employed but did not work
any hours in the month or pay period?
Employee is still employed and continues to be included in the denominator.
7. What if an employee leaves (termination) and then is re-hired three weeks later?
Employee counts as a termination if the calculation is done prior to re-hire.
8. If a home has 130 budgeted positions but only 125 of the positions are filled, is the average
number of employees 125 or 130?
The average number of employees is 125.
Questions to consider:
Are the turnover rates higher among any specific group of employees?
Are turnover rates higher at a particular time of the year?
Have you taken the time to ask people why they are leaving? Do you routinely conduct exit
interviews?
Do you see a connection between turnover and clinical quality i.e. number of falls, number of
pressure ulcers, increased weight loss?
Next steps:
Review the turnover rates in relation to the information you learn from Worksheet 6, to
determine who is leaving and how long they were employed.
Conduct a root cause analysis about who is leaving and learn why.
Go to Worksheet 4.
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Worksheet 5: The Cost of Turnover
Purpose: To calculate exactly how much the turnover in your facility is costing on an annual basis and
by position.
Quite often, turnover cost is estimated using a formula that is popular in the literature. This tool will give
you YOUR costs utilizing your specific information. Once you know what turnover is actually costing, you
will be able to reallocate these resources to retention initiatives.
Completing Worksheet 5: The cost of turnover
Included in the cost of turnover are the costs associated with:
o Replacing an employee
o Advertising
o Screening
o Interviewing
o Physical exams
o Vaccines
o Training
o Orientation
If your facility incurs additional costs, the worksheet provides space for you to include them.
Questions to consider:
How much are you spending on turnover?
How could you better spend those resources?
How much does it cost if you lose an employee because of the practice of staffing to census?
What are the hidden costs of turnover? For example, does your turnover create more turnover?
Is your turnover creating quality problems that are expensive such as increased pressure ulcers?
Next steps:
Identify strategies to reallocate some of the money spent on turnover into programs and practices
that support retention.
Go to Worksheet 5.
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Worksheet 6: Terminations (voluntary and involuntary) by
Length of
Service
Purpose: To calculate who is leaving by their length of service.
This will help you pinpoint where your instability is occurring and where to target your retention efforts.
If you have many people leaving in the first days and weeks of employment, you will know to target your
efforts at improved hiring and retention of new employees.
Completing Worksheet 6: Terminations by length of service
Worksheet allows you to enter data by employee category and length of employment.
Terminations are defined as any employee departure regardless of whether the employee was
fired or quit.
Questions to consider:
Of the employees terminated, how many were fired? Are you using sound hiring practices or have
you resorted to hiring “any warm body”?
How many were terminated for attendance issues?
Do you have more employees quitting or more being fired?
Are there any patterns by unit or shift?
Is there a correlation between pay out of sign-on bonuses and terminations?
Next steps:
Review your attendance policies and procedures and determine if they are contributing to your
loss of good employees.
Review your hiring and welcoming if you are losing new employees.
Ask people who leave why they left.
Determine if your supervisors need to improve their leadership skills.
Use tips in Box 1 of Section 1 to learn about your turnover.
Go to Worksheet 6.
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Worksheet 7: Absenteeism
Worksheet 8: Monthly Call-In Log
Purpose: To collect information about your rate of unscheduled absences.
These logs allow you to calculate how much you are spending for these absences. You will be able to
analyze data on absenteeism including:
Rate of absenteeism by person, unit and shift.
Cost.
Incentives and practices that can improve attendance.
Completing Worksheets 7 & 8: Absenteeism/Monthly call-in log
Worksheets allow you to track absences by employee type, shift, and unit by month.
For each call-in you are able to calculate the total of replacement costs for agency staff, overtime
or bonus expenses.
You are able to calculate if call-outs were received with sufficient notice (i.e. 2–4 hours).
Total of worksheets is 13 pages long because it contains tables and graphs by type of nursing staff,
non-nursing departments, and shifts for all employees. There are 6 blank “user defined” sections
for tracking other miscellaneous departments or job categories.
Questions to consider:
How are you supporting your employees when they are working without a full complement of
staff?
Are you staffing to census? Is it contributing to absenteeism?
Are you inadvertently rewarding absenteeism by paying bonuses to employees for picking up a
shift at the last minute? Have you considered attendance bonuses instead?
When someone calls in sick, do you ask them if they are likely to be out again the next day?
If someone works an extra shift to cover for someone else’s absence, do you use that time to find a
replacement for their next shift so they can rest?
Do you adjust schedules to accommodate employees’ personal
needs?
Do you have an employee assistance program (EAP) to assist employees who are struggling with
issues that affect their attendance?
Do you provide health insurance, sick leave, and flu shots?
Are you tracking attendance? Do your managers have one-on-one discussions with employees
that are having attendance issues?
Next steps:
Track attendance by employee and give them a record of their monthly attendance.
Have you looked at ways to reschedule employees who stay an extra shift to ensure that they are
not contributing to the absenteeism problem by calling in because they are exhausted?
Review the absenteeism log and determine if call outs are frequently from the same unit. Is there
a problem in a particular area that is contributing to absenteeism?
These two worksheets
should be used
together!
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Consider an attendance bonus; determine if implementing this type of bonus is improving the
problem.
Review Section II for more information on management practices that support good
attendance.
Go to Worksheet 7.
Go to Worksheet 8.
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Worksheet 9:
Financial Incentives
Purpose: To determine what incentives, bonuses, and differentials you offer and what employees are
taking advantage of benefits, as well as the costs associated with these benefits.
Completing Worksheet 9: Financial incentives
Worksheet 9 is designed to help you evaluate what incentives you are currently using.
To complete, you will need access to data from the last quarter on what types of incentives are
used, the frequency of use and the amount distributed to staff in the last quarter.
One quarter’s data will be utilized to estimate annual expenses.
Questions to consider:
Are employees resigning after receiving the sign-on bonus?
Are you rewarding and encouraging longevity or placing greater value on recruitment?
Are you spending more on incentives that contribute to instability? Can you shift resources to
support more staffing stability?
Next steps:
Shift resources to create or strengthen perfect attendance bonuses; evaluate whether or not this
has an impact on attendance.
Increase or create team bonuses if new employees stay a certain length of time; evaluate if team
bonus costs lower turnover costs.
Increase the pay rate of full time staff; evaluate if the costs are justified by lower turnover and
absenteeism.
Refer to Section II for additional ideas on how to implement programs that invest in stability.
Go to Worksheet 9.
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Section IV. Case Study: Achieving Staff Stability
Using Data-Driven Decisions to Re-examine Industry Norms
xiii
“The first step is that you have to be big enough to say what you’re doing isn’t working. Then you can fix
it, do it better and move forward.”
– Scott West, Administrator, Birchwood Terrace Healthcarexiv
Introduction
This is the story of how one nursing home, Birchwood Terrace Healthcare, achieved and sustained staff
stability. It is also the story of how, through a classic improvement process, Birchwood used data to
examine its current practices and institute new approaches that led to positive results. Birchwood used
the tools in this kit to see how its fiscal incentives were contributing to its instability. By retargeting its
resources, Birchwood broke its vicious cycle of turnover and stress and put its money to work to support
workplace stability and harmony.
The problems Birchwood faced, and the fiscal and managerial practices it used, are common across the
country. What is uncommon is that Scott West, the Administrator, and Sue Fortin, the Director of
Nursing, were willing to acknowledge that what they were doing was not working, and they had to do
something different. They asked Better Jobs Better Care–Vermont (BJBC-VT)xv for assistance to address
their high rate of turnover.
Through a six-month BJBC-VT intervention, Birchwood made substantial progress toward stability.
Birchwood collected data to determine its current status and the impact of its incentives. Leadership
analyzed the data and put new fiscal practices in place that had an immediate impact in stabilizing
staffing. At the same time, Birchwood’s managers focused on strengthening supervisory and management
practices and putting systems in place to solidify relationships among staff. Two years later, the progress
has been sustained.
Workers who left 2/15/04 – 2/15/05 2/15/06 – 2/15/07
LNAs 92 30
RNs 18 3
LPNs 10 6
The Problem: Stabilizing Staffing
Located in Burlington, VT, Birchwood Terrace is a Medicare- and Medicaid-certified nursing facility
owned by Kindred Nursing Centers East, LLC; a subsidiary of Kindred Healthcare, Inc. Birchwood has a
capacity for 160 residents and has 186 employees. It has a sub-acute unit, a dementia unit and a long-term
unit. Scott West, the administrator, and Sue Fortin, the director of nursing, are recognized leaders in their
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field. They asked BJBC-VT for assistance with their high rate of turnover. Contractors B & F Consulting
gathered information from staff about the nature of the turnover and then developed an intervention
process that included:
Collecting and analyzing data to determine the nature and extent of the turnover and
absenteeism.
Developing and implementing a three-pronged plan to stabilize staffing by increasing the
percentage of full-time and part-time staff, improving attendance and retaining a greater
percentage of new employees.
Providing leadership training for managers and supervisors.
Information Gathering (Qualitative)
The information-gathering process included three days of one-hour meetings with employees on all shifts,
units and departments during two weekdays and one weekend day. Employees reported that because of
absences and turnover, they often worked short and there was an inconsistent team of co-workers on each
shift. Supervisors were feeling extremely stressed, some to the point of tears. The stress was causing
conflict, interfering with teamwork, causing some to quit, others to shift to per diem and others to call out
the next day after having worked a double or worked shorthanded.
Birchwood’s corporate employee opinion survey found similar concerns. It was tabulated for three groups:
department heads, licensed staff and non-licensed staff. This separate tabulation allowed management to
see differences in how different groups of staff experienced the workplace. Department heads were very
aware that there were serious problems and were working diligently to address them. But, as is often the
case, management was unaware of just how depleted and demoralized their staff members, and especially
their nurses, were. Birchwood management learned from the survey that:
Department heads had different perceptions than the rest of the staff about the depth and nature
of the problems. The managers’ responses were much more favorable in areas related to
communication, teamwork, and support when working shorthanded and other morale-related
areas.
Nurses’ responses indicated their morale was the lowest in the building.
There were sometimes wide swings, with a significant number of staff responding positively and
a significant number responding negatively, indicating unevenness in the work experience in the
building.
When employees are
absent, there is a strong
effort to get replacements.
Strongly
Agree
Agree
Neither
Agree nor
Disagree
Disagree
Strongly
Disagree
Department heads 29% 57% 14% 0%
0%
Licensed nurses 14% 36% 14% 29% 7%
Hourly staff 17% 17% 17% 17% 33%
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Teamwork in my
department is good.
Strongly
Agree
Agree
Neither
Agree nor
Disagree
Disagree
Strongly
Disagree
Department heads 57% 43% 0% 0% 0%
Licensed nurses 13% 13% 27% 20%
27%
Hourly staff 33% 33% 0% 0% 33%
Management cares about
me as a person.
Strongly
Agree
Agree
Neither
Agree nor
Disagree
Disagree
Strongly
Disagree
Department heads 43% 57% 0% 0% 0%
Licensed nurses 7% 13% 27% 13% 40%
Hourly staff 17% 50% 0% 0% 33%
I would recommend this to
a friend as a good place to
work.
Strongly
Agree
Agree
Neither
Agree nor
Disagree
Disagree
Strongly
Disagree
Department heads 43% 43% 14% 0% 0%
Licensed nurses 20% 13% 20% 27% 20%
Hourly staff 33% 17% 0% 17% 33%
Management was trying to provide support, promote morale and plug the holes. West, as administrator,
was washing windows, passing trays, making beds, and transporting residents. While staff appreciated his
active support, they still felt overwhelmed. Attempts to improve employee morale, such as pizza parties,
were unsuccessful and poorly received. Management was consumed by the daily struggle to plug holes in
the schedule and unable to step back to develop a strategy to address the big picture.
The practices they were using to plug the holes in the schedule were inadvertently making matters worse:
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Not taking time to hire right: Feeling the urgency to hire, they brought on new people they
might not have hired had they felt they could wait.
Inconsistent assignments: New employees were often given different assignments each day,
to plug that day’s hole, without having the opportunity to get to know their co-workers, residents
or supervisors. Many new staff left immediately, so the home had to start a new hiring process.
Piecemeal hiring: They tried to fill holes on certain days and shifts and accepted new
employees only willing to work certain days and shifts. Their schedule was a daily jigsaw puzzle,
filling holes and fitting people in as they could.
Sign-on bonuses: Birchwood offered sign-on bonuses. This was hard for current staff who felt
undervalued by comparison. Too many new employees left soon after collecting their bonus.
Baylors: To allow full-time staff to have more weekends off, Birchwood used a Baylor program—
staff who worked two 12-hour shifts got paid for 30 hours. Eventually, the program took on a life
of its own, expanding to weekday use.
Last-minute assignment bonus: Another common practice used at Birchwood was a bonus of
$5 per hour for CNAs and $10 per hour for licensed nurses to cover for staff who called in absent
at the last minute. Still, it faced daily instability, with absences, turnover and stress at all-time
highs.
These efforts were industry norms meant to stem the tide of instability. They were generating hard
feelings among core reliable staff and accelerating the instability.
The Intervention
Data Collection Tools
xvi
: The “Drilldown”
Birchwood collected data to capture a snapshot of the current picture of staff and find any causal links
between its financial incentives and its staff instability. The tool asked for the following information for
RNs, LPNs, CNAs and non-nursing staff.
The Snapshot of the Current Situation
Composition of staff.
Current staff by length of service.
Terminations by length of service.
Turnover replacement costs.
Financial Incentives
Bonus for accepting last-minute assignment.
Differentials.
Baylor.
Per-diem status.
Perfect attendance bonus.
Holiday bonus.
Sign-on and Employee Referral bonuses.
Annual average wage increase.
Longevity bonus.
Preceptor bonus.
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Data Analysis
The data was compiled in June 2005. The next step was to analyze the data to see if there were any links.
The data suggested a link between staff instability and financial incentives.
The Composition of Current Staff showed that full-time status employees made up the lowest
percentage of staff, particularly in supervisory and management positions. Of 57 licensed staff, only 23
were full-time.
Composition of Current Staff (June 2005)
Position Full-time Part-time Per diem Baylor
RN
Total – 30
8
27%
4
13%
14
47%
4
13%
LPN
Total – 27
15
55.5%
0
0%
5
18.5%
7
26%
CNA
Total – 77
37
48%
8
10%
7
9%
25
32%
Having fewer than half the supervisory staff working full-time helped explain significant problems in
leadership, morale and communication. Nurses were not available to follow-up on resident or staff issues
or on facility initiatives. CNAs had different supervisors each day, each with their own way of doing
things, their own expectations of the staff and, in many cases, limits on the degree to which they engaged
with the teamwork and communication issues on the floor.
A third of the CNAs and a quarter of the LPNs were Baylors. Working two 12-hour shifts left many people
worn out. Working with people during their second 12-hour shift was often a very trying experience.
Clearly there was a link between the composition of the staff and the instability Birchwood was
experiencing. Was there a link between the composition of the staff and the financial
incentives?
The data highlighted that there was no financial benefit to being reliable – working full-time, committing
to a schedule the facility could count on, and having good attendance. It was a better financial
arrangement to work per diem and get a bonus for taking a last-minute assignment than to have
guaranteed hours and good attendance. It was also financially better to work as a Baylor than a regular
shift. Birchwood was paying its staff for hours they did not work. Baylor nurses made more per hour than
the director of nursing, with far less responsibility.
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Financial Incentives – Bonuses (June 2005)
Bonus Extra Per Hour Annual
Baylor Work two 12’s,
paid for 30 hours
$268,944
Per diem $1 add-on to regular
hourly wage
$51,012
Last-minute assignment RN, LPN: $10
CNA: $5
$360,000
Perfect attendance $0 $0
Birchwood was rewarding the behavior it was trying to stop and not rewarding the behavior it sought to
encourage. They grappled with the question: Why should we reward people for doing what they are
supposed to do—coming to work? until they looked at the data and realized their current system
rewarded people for picking up last-minute assignments when it fit into their individual schedule to work.
Birchwood had lost control of its schedule as staff had converted from full-time to per diem and Baylor.
When West and Fortin analyzed the data, what they saw “blew our minds!” It was at this point that is was
very clear to them that they needed to make a change.
The Current Staff by Length of Service and Terminations by Length of Service also showed
disturbing data that made them question their practices.
Current Staff by Length of Service (June 2005)
Position < 6 mos. 6 mos. – 1 yr.
1 – 2 yrs. > 2 yrs.
RN 10% 50% 20% 20%
LPN 11% 41% 33% 15%
CNA 12% 14% 68% 6%
The data showed that:
Many nurses in charge were new (60 percent of RNs and 52 percent of LPNs had been there less
than a year).
There was greater stability among CNAs than nurses.
A few long-time staff members were hanging on.
Non-nursing departments had more longevity than nursing.
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The smallest percentage of staff was the long-time core staff. Among the nurses, the largest percentage
had been there less than a year.
So, who was leaving and when were they leaving?
Terminations by Length of Service (June 2005)
Position 1 day – 1 mo. 1 – 3 mos. 3 – 6
mos.
6 mos. – 1
yr.
1 – 2 yrs. > 2 yrs.
RN 18% 18% 18% 27% 18% 0%
LPN 7% 13% 33% 27% 20% 0%
CNA 23% 30% 23% 16% 3% 5%
Of 66 CNAs who had left in the last two years, 15 had left in the first month and another 19 had left within
the first three months. Clearly, something was not working well in the hiring process or in the orientation.
While some nurses were leaving within the first few months, the bulk of the departures were occurring at
or just after the six-month mark.
Could there be financial incentives that were contributing to this?
Financial Incentives – Bonuses (June 2005)
Bonus Amount Offered Quarter Paid – Annual
Estimate
Sign-on bonus
paid after 6 months
RN: $2,000
LPN: $500
CNA: $250
$12,500 –
$50,000
Referral bonus
paid after 6 months
RN, LPN: $1,000
CNA: $500
$1,500 –
$6,000
Longevity $0 $0
Raises Average 2%
$90,710
Birchwood’s sign-on bonus kicked in at the six-month mark. So did its turnover of licensed nurses. Its
data showed it was putting more emphasis on recruitment and hiring than on retention. While it had paid
out $50,000 for sign-on bonuses, it had no longevity bonus in place, and it was paying an annual raise
averaging two percent. Here again, Birchwood was rewarding behaviors that were hurting its stability and
not rewarding behaviors it sought to encourage.
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What was all this turnover costing? In 2004, it cost $3,207 for each CNA who left and more than $4,000
for each nurse who left. Its total cost for turnover in 2004, for all positions, was $453,940.
Turnover Costs (calculated in June 2005)
Position Per Person Annual 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
How did that measure up with what it was spending on retention? What if these funds could be reinvested
in retention efforts? Putting all the incentives together, Birchwood was able to look at what its instability
was costing compared to what it was spending to increase its stability.
It turned out that Birchwood was spending more than $1 million per year on turnover and
practices that accelerated the turnover. By contrast, it was spending one tenth of that amount on
investments in stability. No wonder it was getting the results it was getting.
Instability vs. Stability (June 2005)
Costs of Instability Investments in Stability
Last-minute bonus
$360,000
Perfect attendance
$ 0
Baylors
$268,994
Raises at 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
The good news was there were resources available that could be redirected to serve its organizational
goals. The data provided the information necessary to take the next step—develop a plan of action.
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A New Approach
Once West and Fortin looked at the data, they saw that what they were doing was not working. They
needed a new approach. They focused on three goals for a six-month effort (from July 1 to Dec. 31, 2005)
to stabilize staffing:
Increase the percentage of full-time staff.
Increase the percentage of new employees who stay.
Improve attendance and decrease the number of shifts with last-minute absences.
Increase the percentage of full-time staff
To increase the percentage of full-time staff, West worked with his district office on a wage package that
made working full-time with guaranteed hours the best deal in the house. By eliminating the last-minute
assignment bonus and phasing out the Baylor program, West was able to free up considerable resources.
He redirected those resources to a wage increase that only full-time staff and part-time staff in the nursing
department were eligible to receive. Staff members who work 24 hours per week are eligible for benefits,
so with the wage package, it was a good deal for staff to switch from per diem to become a regular part of
the staffing team.
Raises for Full-Time Nursing Department Staff (August 2005)
Position Old Wage Range New Wage Range Raise Amount
CNA $9.25 to $10.50 $11.50 to 12.75 + $2.25
LPN $15.00 to $16.70 $18.00 to $20.50 + $3.00 to $3.80
RN $18.00 to $20.50 $23.50 to $26.00 + $5.50
West and Fortin began an aggressive internal marketing campaign. They sat down one-on-one with each
part-time, per diem and Baylor staff member to talk about what the raise plus benefits would mean for
them. By December 2005, they had gone from 60 full-time employees in the nursing department to 80.
Some staff members converted from per diem to full- or part-time. Some former employees returned. As
Birchwood brought on new staff, it almost exclusively hired for full-time positions. A year later, in
December 2006, they had 96 full-time employees in nursing, an increase of more than 50 percent.
The shift had been cost-neutral; dollars that were going to Baylors for hours they did not work were now
going to full-time employees for hours worked. They had not anticipated the increased cost of benefits for
the increased number of full-time employees, yet the investment in their staff was still a better deal than
what they were spending before.
Now, not only does Birchwood tell applicants it is looking only for people who can work full-time, but for
the first time in her five years as director of nursing, Fortin has applications in her desk drawer of nurses
who want to work full-time for her and are waiting for openings.
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There were two dynamics to the wage bump that West and Fortin had to deal with. One they anticipated—
that the advantage of the wage increase would be short-lived and their competitors in the area would
quickly move to match their wages. The other, they had not been prepared for. While they had the
advantage in the labor market, they suddenly had a large pool of applicants, not all of who were well-
suited for work at Birchwood and many of whom were attracted primarily to the wage rate. After a few
false starts with new employees that led to quick terminations, they revamped their screening and hiring
process to increase the percentage of new employees who stay.
Increase the percentage of new employees who stay
Increasing retention of new employees involved both an improved hiring process and welcoming process.
B & F Consulting, along with David Farrellxvii, facilitated training sessions with department heads to talk
about screening and interviews. West changed his screening and hiring system to involve his managers
and worked with them to develop their skills.
Hiring skills: To develop their skills, managers did mock interviews with people posing as
applicants. Those posing as applicants played out particular scenarios or personalities, so
managers had practice managing difficult situations—a shy person, one with latent anger,
someone not quite straightforward enough. Together they looked through applications of new
employees who had not worked out and discussed red flags to beware of. For example, an
applicant whose previous work history involved much sitting might not work out in a job on her
feet all day.
Hiring system: West and Fortin decided to focus their hiring efforts on new entries to the field
rather than on people who had worked at other facilities in the area and perhaps not performed
satisfactorily. So they hired through their own training class.
To get the right people into the class, they set up a three-part screen, each requiring attendance
and timeliness. First is an open house that includes an information session and a tour of the
building. Each manager takes two or three applicants on the tour, invites their questions and
encourages them to interact with residents. Applicants are told this is their chance to convince the
manager to have them back for an interview. While applicants are getting to see the building,
managers get to see how the applicants relate to residents.
After the tours, the managers met and decided which applicants to interview. They made three
piles—yes, no and maybe. They looked over the applications, looking for red flags. They identified
areas to be probed in the interviews or reference check. Applicants then had two more
appointments to keep—the interview and a pre-employment physical. If applicants made it to the
class, they were hired.
Welcoming system: Birchwood has worked equally hard to revamp its welcome, so new
employees settle in well. On the evening shift, the entire staff takes responsibility for helping new
co-workers succeed. The experienced staff members work one-on-one with the new staff and take
them on breaks and to meals. Sometimes the staff members have pizza together to welcome their
new workmates.
New staff members have a two-day orientation. On day two, the nurse in charge of the mentor program
sets up each new employee’s schedule, teaches them how to read it, connects them with their mentor and
follows up throughout the first few weeks. Managers and supervisors now have it as a priority to check
how new staff are doing, the first day and onward. They discuss new staff at morning stand-up.
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These efforts were successful in increasing the percentage of new employees who stayed. In June 2005, 34
of the 66 CNAs who had left in the previous 12 months had left within their first three months of
employment. By December 2005, they were still losing new employees. They were attracting more
applicants because of their higher wages and improved reputation as a workplace, but they had not yet
instituted the careful screening process. They put the screening process in place in 2006. As of
December
2006, their long-time staff members were staying and their new employees were staying through the first
six months and beyond.
Staff by Length of Service (2004 compared with 2006)
Length of Service 2004 May 2006 Dec
2006
< 6 mos. 12.00% 23.00% 31.51%
6 mos. – 1 yr. 14.00% 5.19% 15.07%
1 – 2 yrs. 68.00% 35.00% 20.55%
> 2 yrs. 6.00% 36.36% 32.88%
Reflecting on the change in practice, Fortin remembers their desperation to plug a hole in the schedule,
even when it meant hiring someone who had been “no-call, no show” at another facility. “We’d hire them
and hope they’d work out,” she said. Now, they have high standards in their hiring. They do not hire
people they have doubts about. They hold each other to the high standard.
It has caught them by surprise how much their reliable staff members supported them and wanted
management to hire reliable staff. As they have held to the high standard and hired people they have
confidence in, they are no longer facing desperate moments when they have to plug a hole. While their old
practice, so common in the field, had perpetuated the instability, their high standards, careful hiring and
good welcome, built and maintained stability.
Improve attendance and decrease the number of shifts with last-minute absences
Birchwood began to embrace high standards for attendance. The first step was to track attendance, by
individual and by department. West, being a firm believer in process improvement, told his managers,
“You collect what’s important to you. When we focus on something, we make it work.”
So they started monitoring employee attendance. Employees received their monthly attendance record
with their paychecks. Managers analyzed the absences for patterns and met one-on-one with each
individual with significant absences to communicate their concern. Rather than a strictly punitive
approach, managers worked with employees with multiple absences to reduce their hours to a more
manageable schedule or made other adjustments in their assignment to help them succeed. They also
took action when it became apparent staff could not be depended on, and rewarded those with good
attendance.
In June 2005, they were dealing with three to four call-outs every day, they were constantly focused on
that day’s staffing. Managers, the scheduler and supervisors were playing a daily game of “let’s make a
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deal” to do anything they could to get staff to come in or stay over. They were constantly plugging holes
everywhere without getting control of the schedule.
Birchwood’s management took control of the schedule, and they now hold each other to their
commitment to expect and reward attendance and not tolerate excessive absences. In a meeting to reflect
what they accomplished, they could not remember the last time in the previous year that there had been a
“no-call, no-show” except for a new staff person who had misread her schedule. “You’re never going to get
to perfection,” Fortin said. “There’ll always be staffing issues. But now things are steady enough that when
something comes up, we can deal with it.” They now have many days without last-minute absences.
They have changed their bonuses to be able to reward attendance and staying power. If an employee
works all scheduled hours in a given month, she receives a $25 bonus credit for that month. At the end of
the year, all the bonus credits are paid out. The maximum payment is $25 for each month of perfect
attendance or $300 for the year. In December 2006, Birchwood paid out $13,000 in attendance bonuses.
By contrast, in their June 2005 data, they had paid out $360,000 in bonuses in the previous year for
people to pick up last-minute assignments to cover for others who were absent.
By the fall of 2005, Birchwood was already feeling the positive effects of its stabilization efforts. As it
slowed its vicious cycle of turnover and absenteeism, West and Fortin asked their managers and
supervisors to assume their leadership roles with more confidence. Now that staff could be counted on
each day, supervisors needed skills in how to work with staff to bring out the best in them.
Leadership development: Building skills and systems
Birchwood participated in a three-part leadership development training program offered by BJBC-VT and
by B & F Consulting. The training drew from two texts: What a Difference Management Makes! by Susan
Eaton and The Leadership Challenge by James Kouzes and Barry Posner. Each identifies key practices for
effective leadership that bring out the best in others. The training focused on building skills and systems
that support good working relationships.
The training programs included experiential learning opportunities to explore these concepts and
homework assignments that guided participants to apply these concepts in their workplaces in between
sessions. In addition, B & F provided on-site assistance with teamwork and facilitated problem-solving for
Birchwood’s nursing management and supervisors. These meetings focused on workforce and workflow
issues. As staffing stabilized, supervisors were struggling with how to guide staff to work better together.
Supervisors voiced concern that they were either too lenient or too harsh. Talking it through together,
nurses explored ways of being neither lenient nor harsh, but instead holding their staff to high
expectations and helping them meet those expectations. They also brainstormed ways of resolving
problems each was facing.
In their collaborative problem-solving on workforce issues, one nurse discussed a new employee on the
short-term rehab unit who was not keeping up. Another nurse volunteered to have the new employee
switched to the slower pace of her unit. In problem-solving on workflow issues, a nurse said she cried
when she saw the breakfast cart come because she was not ready to pass out the trays. Another nurse
offered to have the cart come to her floor first and then Fortin said she would talk with the food service
director about holding the trays for that unit until they were ready to receive them. The nurses began to
problem-solve together and became a support group to each other, with Fortin playing a key role in
facilitating the process.
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After one such meeting, in which employees had been particularly creative in brainstorming solutions,
West wrote a congratulatory note to all who had participated, saying:
“We had a great meeting with the people from Better Jobs Better Care Grant. 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 … 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!”
Birchwood was experiencing a new energy. Staff members were able to shine. They were working better
together in thinking things through and finding new ways moving forward.
Results
By the following May (2006), Birchwood had created a new norm—daily stability. It had broken the
vicious cycle. It had seen a 33 percent increase in full-time staff. With high retention and attendance, it
was more fully staffed each day, so care became manageable and the environment more positive and
supportive. West had begun working with department heads to grow their leadership skills. He said, “I
expect more from them, and I’m working with them to meet my expectations.” Fortin said she had learned
that “leadership is all about relationships. Anyone can be a leader. You have to understand your impact
and bring out the best in the staff.” Her staff was stable enough that she could invest in helping them
develop, and she was supporting a number of her nurses in pursuing further education.
As West and Fortin reflected on what was different a year after the drilldown, they noted:
Now that we have more staff, people are not as stressed. They are more able to help each other
out. We do not hear “not my hall.”
Nurse Managers “modeled teamwork instead of conflict.
We have trust among the team; we can say “time out, let’s look at this.”
Now they are hiring for full-time positions, and they take their time to hire right.
The schedule runs smoothly now—no favoritism—and now we have consistent attendance.
Consistent attendance is allowing us to move to block assignments.
There is better team problem-solving on the units.
Now we can take on individualized care.
The concurrent efforts of fiscal and management practices paid off. Birchwood broke its vicious cycle of
turnover, vacancies and stress. It reduced its overall turnover, as well as its turnover of new employees.
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In 2004, its turnover rate was 61.5 percent and by 2006, its turnover had a relative decline of 16 percent,
to 50.53 percent.
Birchwood’s staff composition steadily shifted to full-time, long-term employees.
Employment
Status
RN LPN LNA
2005
May
2006
December
2006
2005
May
2006
December
2006
2005
May
2006
December
2006
Full-Time 27.00% 56.00% 70.83% 55.50% 67.88% 84.38% 48.00% 65.75% 82.61%
Part-Time 13.00% 18.75% 16.67% 0.00% 7.14% 3.13% 10.00% 13.70% 2.90%
Per Diem 47.00% 18.75% 8.33% 18.50% 7.14% 3.13% 9.00% 5.48% 4.35%
Baylor 13.00% 6.25% 4.17% 26.00% 17.86% 9.44% 32.00% 15.07% 10.14%
RN LPN LNA
Length of
Service
2004
May
2006
December
2006 2004
May
2006
December
2006 2004
May
2006
December
2006
< 6 mos. 10.00% 6.25% 22.73% 11.00% 16.67% 24.24% 12.00% 23.00% 31.51%
6 mos. – to 1 yr. 50.00% 0.00% 4.55% 41.00% 0.00% 18.18% 14.00% 5.19% 15.07%
1 yr. – 2 yrs. 20.00% 18.75% 18.18% 33.00% 16.67% 12.12% 68.00% 35.00% 20.55%
> 2 yrs. 20.00% 75.00% 68.18% 15.00% 66.60% 45.45% 6.00% 36.36% 32.88%
In 2005, its licensed nursing staff, who had been there less than a year, was predominantly per-diem and
Baylor. Eighteen months later, its licensed nursing staff is predominantly full-time and staying for the
long term. Birchwood is now a place people want to work. Their experience debunks the myth that nurses
really prefer part-time work. Once it is a good place to work, nurses are eager for full-time positions.
Birchwood’s most recent numbers reflect that their positive results have been sustained.
Turnover 2004 2005 2006
RN 62.6 54.2 50.7
LPN 37.5 30.4 19.5
LNA 84.4 95.8 81.4
Average 61.5 60.13 50.53
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2/15/05 2/15/07
Open LNA positions 14 2
Open staff nursing positions 6 0
Full-time LNA 31 51
Full-time nurses 18 31
Per diem employees 22 6
These results are not just because of the changes in financial incentives, but also because of changes in
management practices. The stability brought by the fiscal practices allowed management to put in place
key practices to promote and support that stability. For example, once experienced staff shifted back to
full-time and reduced their absences, they stabilized. Once they stabilized, they had a manageable
workload because they were fully staffed on most shifts. Once they had a manageable workload, they were
able to provide a better welcome to new employees. Each practice reinforced the others and built on each
other.
The end result was a better environment for everyone. In January 2007, the brag board was full of thank-
you notes from staff to each other for how they had all pitched in to help through the holidays: “You guys
are awesome.” “Thanks for the great and positive attitudes.” “Thanks a million for the team you are
creating.” “Thanks to all who pitched in.” “You rock the house.” People covered for each other, so they
could each have time to celebrate the holidays and still maintain good staffing. In day-to-day exchanges
around the building, staff members voluntarily helped each other. A beautiful hand-painted sign in the
lobby said, “Live well, love much, and laugh often.” Indeed, Sue Fortin said, “It’s so much fun coming to
work. We laugh here all the time.”
West notes that now “our goal is to not lose focus of where we were and how we got where we are. I had a
team meeting yesterday to focus on some key areas as a management team. One area is to continue to
improve retention. I have a great nurse that is going to run this committee. No one wants to go back to
where we were—great motivation.”
Conclusion: A lesson learned
When asked to share lessons from his experience, West wrote:
The other really important message from our work with you is to remember to take the time to
sit and reflect on the positives. I remember when you were coming up to talk about “our story.”
I thought “what story?” But by taking the time and talking about the changes, we were able to
see we were moving in the right direction. I feel that is a very important message. While we try
to be proactive, often we are reacting to something during the day and that tends to be the
focus.
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Long-term care work is so demanding and fast-paced that there is often little time for reflection. It is
important to step back and see what is happening. When it is not working, the reflection provides a
chance to change. When changes bring positive results, the reflection is an opportunity to recognize what
has led to the success and purposefully continue it.
A word of caution: As remarkable as the achievements at Birchwood are, they can be undone easily.
Typically, success lulls people into thinking the problems are gone forever. As soon as a provider starts to
cut corners again—perhaps to lower the amount of the bonus for perfect attendance—any short-term
savings from such a measure will likely start to cost, before too long, in slippage. With a 10:1 ratio of
investment in instability to investment in stability, any cut in stability will cost tenfold. Our field cannot
afford such a “penny-wise and pound foolish” approach. Taking the time to reflect on results allows the
opportunity to integrate success into everyday practice for sustained stability.
Section V. Using Training Strategically
Grow Your People, Grow Your Organization
Training is something you do now, but do you make the most of it? Can you use it more strategically? Use
education as the engine for better organizational performance. Invest in effective training for your
employees; your organization will benefit. Use your current training time more effectively as one of your
stabilizing strategies. As you stabilize, use training for improved performance. Training can be a
recruitment tool if you establish yourself as the “go-to” employer for workplace-supported education.
Significant local public resources are available in many states to support the cost of training and
development of your employees.
Many nursing homes have found education to be an important tool in their effort to stabilize staffing
because:
It is an investment in employees, which they appreciate.
It can help staff improve their skills and job performance.
It can improve the work environment.
It can help individuals improve their earning power and their ability to support their families.
It can improve their confidence and morale.
It can be a factor in recruitment, if your workplace supports people who want to advance in their
careers.
Providing educational opportunities to your employees has many benefits. Benefits for employers include:
Decreased CNA vacancy rates.
Improved CNA retention rates.
Significantly reduced expenditures spent on agency fees.
Reduced recruitment costs.
Improved relationships, communication and teamwork.
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Employees benefit by:
Gaining new skills and confidence to provide better care to their residents.
Receiving a wage increase after successfully completing training.
Improved communication, morale and job satisfaction.
Opportunities to advance their education and careers.
In fact, good training can be a win-win:
Employees gain skills, access to new education, job advancement opportunities
Employers gain more committed workers, reduce turnover and fill critical vacancies.
Residents benefit from a skilled, productive and committed workforce in place to provide
consistent care
Organizations benefit when decreased turnover reduces stress on line staff and supervisors,
and results, in a more positive and functional care-giving environment
This section will help you make the most of the training you do now; help you expand and focus your
training; and identify possible funding sources to help you do so. It includes:
1. Training on Your Own Dime: Getting Your Money’s Worth
2. Options for Using Workplace Education to Advance Organizational Goals
3. Funding Sources to Support Workplace Education: Accessing Workforce Development Resources,
Adult Education and Literacy Programs, and State Grants through Civil Monetary Penalty Funds.
4.
Tips for Writing a Grant Proposal for Funding
5. Finding the Right Training Partner
6. Keys for Successful Workplace Education Programs
7. Accessing Technical Assistance Resources, including Quality Improvement Organizations, Culture
Change Coalitions, and LANES – state-based coalitions supporting the Advancing Excellence
campaign.
We are currently developing a drilldown tool – A Training Cost-Benefit Analysis – with nursing homes
participating in two CT projects administered by Capitol Workforce Partners, The CNA Advancement
Initiative, a U.S. Department of Labor grant, and Promoting Work-based Learning for Quality Care,
funded by the Robert Wood Johnson Foundation.xviii
Training on your own dime: Getting your money’s worth
First, look at what you are doing now and what you are getting for your effort. To do this:
Calculate what you are spending now on training.
Determine how useful your current training is.
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Next, figure out how to get more benefit for your current training expense. To do this:
Identify ways training can help your organizational efforts.
Find out your employees’ training needs. (Appendix E: Organizational Readiness Checklist –
Determining your organization’s needs, will help you do this)
Then, improve your current training and your attendance so you maximize the benefit of the time your
employees spend in training.
The cost for each staff member includes their hourly wage and the fringe rate. For example, an employee
may earn $10.00 per hour, but the fringe benefits afforded that individual may equate to an additional
$4.00 per hour for a total of $14.00 per hour.
To calculate what you are currently spending on training, for each required training you
do, such as monthly CNA in-service:
Multiply the number of staff involved in training by their per hour wage for
the amount of time spent in training.
Add the cost of the instructor (hour wages x amount of prep and class
time).
Add any costs for extra employees hired for coverage and/or extra pay for
attending class outside of scheduled work time.
To find out how effective your current training is and what more your employees need:
Ask your core reliable staff:
What’s the most useful training they have received from you in the last
year and why it was useful?
What topics would they like for training in the future?
What can we do to make the training more useful for them and for
others?
Ask new employees, who have been with you at least a month:
In what areas do they need additional training?
What training would you suggest we provide to new employees during
their first month on the job?
Ask supervisors what they see as the training needs for:
Staff they supervise.
Themselves.
Nursing as a group
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Improve your current training:
Use it as an opportunity for group discussion:
Problem-solve real situations staff are currently struggling with about a resident, a care issue, or
any other job related topic.
Discuss questions and issues employees have about a new policy or a treatment approach.
To find out what is working or not working in relation to a clinical topic, like falls, or a workflow
topic, such as communication.
Use good educational methods to teach a topic:
Focus on how to put the information to use.
Have interaction with group discussion. You do not need to have all the answers – it is often
better when the group learns together how to go forward.
Build on what people know about the topic; what is happening now and what is needed for things
to work better.
Be prepared for suggestions about what is needed from management. Follow through on what you
say you will do. It is okay to say you will take information back for a decision and meanwhile, ask
the group to focus on what they can do under the current circumstances.
Improve your attendance at training sessions:
Schedule training during employees’ regular work time, so they do not have to come in off shift, or
when they would normally be sleeping.
Provide coverage for employees’ work while they are in class so they can concentrate on the class
with the assurance that their work is taken care of.
Serve food and drinks.
Consider strategies to promote attendance and timeliness, such as a raffle at the start of the
session that people have to be in attendance to win.
Options for using workplace education to advance organizational goals
xix
Use workplace education strategically to give your staff the development and guidance they need to get
you to your organizational goal, whether it is stability, clinical improvement, culture change, or other
organizational performance. You can give staff basic education, skills development, opportunities for
advancement, and ways of working better together. Investing in your employees through education can
contribute to better morale.
Here are some examples of types of educational programs and potential classes:
For clinical improvement, have a series of classes on:
Problem solving: Teach about problem solving by solving problems. Help employees think
through an ordinary, every day stress point and come up with their own solutions about how to do
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it better. At first, fix a very specific problem, such as making sure weights are done or that the
dispensers in residents’ rooms do not run out. Then target broader goals with more elements,
such as reducing falls.
Clinical knowledge and skills: Teach staff the clinical information related to the area you are
working on. Connect the information to their direct work experiences. Discuss skills needed and
how they can be used more effectively. Have employees practice and reflect on their practical
experiences.
Quality Improvement Processes:xx Learn about performance improvement by having a
direct experience with a specific area of concern. Explain and discuss why the area of concern is
important. Show staff the current data. Discuss what that means and discuss strategies for
improvement. Ask staff what barriers they face and come up together with strategies for
addressing them. Together set targets for improvement. Meet regularly to assess how it is working
and what needs to be done.
Create a mentor/team leader or neighborhood coordinator program, with classes in:
“Soft skills” such as communication, teamwork, collaborative problem-solving, conflict
resolution, how others learn, leadership, and facilitation.
Areas of new responsibility can include clinical, administrative, or operational skills and
processes. These can relate to new responsibilities such as interviewing new employees,
scheduling, mentoring new staff, record keeping, or being the point person for information or to
make sure certain things are done.
Generate efficiencies in operations by having employees learn how to identify and remedy trouble
spots:
Operational knowledge and skills: Teach “Work Redesign” – which involves identifying and
analyzing how work happens now and then redesigning the flow to work better. For example, how
is the kitchen notified about residents who go to the hospital? Teach staff how to analyze the steps
involved, where the process works and where it breaks down. Teach skills in creating new ways
that work better, including skills in assessing improvement and making needed mid-course
adjustments. Learn by taking on real situations.
If culture change is your goal, hold classes for all staff in areas such as:
Teamwork and problem-solving: described above. Additional focus on building day-to-day
systems to support working better together. Examples include having a start of shift stand-up and
good shift-to-shift hand-offs as ways of bolstering communication and teamwork.
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Quality improvement/process improvement: described above with additional focus on
how to analyze the workflow of care practices. Examples include: how meals are delivered and
what systems could support wider flexibility regarding when and what residents eat.
Individualizing care: Everyone on staff can take part in a series of classes looking at what they
would need for themselves if they were to live in their nursing home. Through personal and
shared exploration, staff members could see their work tasks through the eyes of residents.
Examples include bathing, waking, sleeping through the night, eating. The classes would bring
new sensitivity and perspective to staff. Class could be an avenue for redesigning care systems to
support individual rhythms of daily life.
Reward learning and provide opportunities for advancement:
Upgrade skills: Give staff an opportunity to improve basic education skills such as reading,
writing, and math, through Adult Basic Education (ABE) courses; provide English language
courses at a range of levels, from the most basic to pre-college, if you have staff with the interest
and need; offer a series of advanced clinical skills in areas such as dementia, hospice, restorative,
behaviors, or other clinical area; basic computer skills or skills for electronic record keeping.
Reward staff for growth: Offer a range of classes in areas that serve your organizational goals.
Reward staff for completing an individual class, a certain number of classes, a set of topics, or
some assignments. Create a ladder of achievement. For example, if someone takes 10 classes, they
are a shooting star and earn a raise of $0.25; with another 10 classes, they are rising stars with
another raise.xxi
Bridge to nursing: Staff may need refresher courses in math, science, or other areas. Host
classes in your workplace, or make arrangements with a local educational provider to customize
classes for your employees or a group of employers. Accommodate academic schedules into your
work schedule. Consider offering tuition assistance.
College bound: Offer preparatory courses for college to employees. Link with a community
college or another educational provider to bring classes to your workplace, or accommodate your
employees in their classrooms. Include academic counseling.
Funding sources to support workplace:
xxii
Fortunately, as you work to stabilize your staffing, you do not have to go it alone. Many financial and
technical assistance resources are available in each state. Programs vary widely from state to state in what
they offer and how their services can be accessed. Three state programs that may fund training for
employees are: the Workforce Development System, Adult Education and Literacy Programs, and the
Civil Monetary Penalty Fund.
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The Workforce Development System
For information about resources available in your area, contact your local Workforce Investment Board
(WIB). Locate yours through your State Workforce Investment Office – a list is available at:
http://www.doleta.gov/usworkforce/statecon.cfm. Find out what resources or funds are available for:
Recruitment: Most states’ department of labor offices will assist businesses by posting job
openings, hosting job recruitment events and screening potential employment candidates.
On-the-Job training opportunities: Typical categories include English for speakers of other
languages (ESOL), “soft” skills such as communication and teamwork, occupational skills classes,
academic remediation, total quality management, workplace literacy, college prep and college
courses, cross-skills training, technology application, supervisory and management leadership
skills, and new employee training.
Career ladders: Career advancement initiatives include programs to help people advance within
their current workplace, such as from housekeeping or food service into CNA or for CNAs into
peer mentor, team leader, or clinical specialties. In a few states, programs support CNAs to
become nurses.
Innovation: In a few states, the Workforce Development system has given funds to nursing homes
to pay for training and consultation to promote workplace efficiencies or improved performance,
including culture change.
Often, the employer is asked to match grant monies by giving workers paid time off for training, providing
training facilities or contributing some other type of in-kind match to show a commitment to the effort.
Training is often arranged at the beginning or end of an employee’s shift since they are already on-site.
Many nursing homes schedule the training from 2-4 p.m. to catch the day and evening shifts. In most
cases, the employer will pay for the hour in class that the employees are scheduled to work and the
employees will attend the other hour of class on their own time.
An example of how one grant program can work
Rhode Island’s Comprehensive Grants provide up to $50,000 per company for incumbent worker
training programs. This grant process usually takes place once or twice a year. To apply for a grant, a
business must pay into the state’s Job Development Fund (JDF). The JDF represents a 0.21 percent
assessment of the employer’s payroll tax and makes available between $6-8 million annually to finance
workforce development initiatives in Rhode Island.
Announcements are placed in the local papers that a “Request for Proposal” (RFP) has been made public
from the Governor’s Workforce Investment Board. Applicants are invited to an orientation event where
the grant guidelines and application process is explained. All applications are then submitted, read, and
graded by an independent group of volunteers that have been trained to review proposals. Individual
grant agreements are written between the grantee and the board for a specific scope of work and
accompanying performance measurements.
Similar grant programs are often set up for smaller training requests of $10,000 or less with rolling
application deadlines, by which applicants can apply all year and applications are reviewed on a one-on-
one basis.
http://www.doleta.gov/usworkforce/statecon.cfm
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Grant time lines vary as does time spent in training. Most grant contracts are for a year and can be
extended if necessary. Grants can support training at the work-site or at a training site. Employers can
hire a part-time trainer or pay an outside trainer on a consultant basis.
In Rhode Island, grant applicants are asked to explain:
What type of training they will offer in what time frame?
Why the training is necessary to improve the skills of the employee and the competitiveness of the
company?
The proposed curriculum and training provider.
How the training is to be evaluated and specific anticipated results.
Budget and budget narrative where all proposed expenses and matches need to be documented:
The proposed expenses need to be reasonable and reflect prevailing community costs. All costs
need to be tied to the proposed scope of work.
The budget narrative describes and justifies all expenditures and the proposed match so that
further clarification can be provided
Most programs require the employer to provide a cash or in-kind match toward the cost of training. The
cost of employees’ wages for the time they are in training classes is often accepted as a match. Other areas
often accepted for matching funds include the costs of space, material or equipment.
Once a grant agreement has been reached, training can begin. In RI, payments for the state-funded
portion of training are processed and paid quarterly after receipts are approved by the staff of the
Governor’s Workforce Investment Board.
Types of job training programs
Ask your WIB what types of training programs have been funded in the past and what the WIB looks for
in determining whether a training proposal is acceptable. Typically, WIBs fund training that results in
new responsibilities and higher wages or in skills needed to improve employee or organizational
performance. Programs usually need to result in measurable improvements, such as resident or staff
satisfaction, turnover rates, and clinical outcomes. Classes can be a single course or a series, can occur at
the worksite with an in-house or outside training provider, or at a training site away from work.
Types of training programs that may be supported in your state include:
“Soft Skills” – Classes for staff in teamwork, communication and other aspects of work are often
funded as long as the grant shows how these skills will improve operations.
Supervisor and Manager Leadership Skills – Classes that help supervisors and managers be better
leaders are often funded in conjunction with training for front-line staff.
Occupational Skills – A nursing home could host a CNA class open to the public or for its own
non-certified staff.
Academic Remediation – Bridges gaps in skills that affect job performance.
Total Quality Management (TQM) – Provides grants for performance improvement and
workplace innovation. A number of nursing homes have used these funds to support culture
change.
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Workplace Literacy – Workplace literacy programs are tailored to each workplace and its
workers. These classes can include ESL, Adult Basic Ed, and GED courses.
Cross Skills Training – This includes general skills such as medical terminology, or introduction
to aging, or training everyone in the “feeding assistant” program so all staff can help at meal
times.
Technology Application – This covers computer literacy. Staff can learn Word, Excel, and use of
the Internet. You can request funding to train employees for technological improvements such as
in-house email, electronic medical records, web-based in-service programs, and hand-held and
laptop computers.
Adult Education and Literacy Programs
Federal and state funding is available for adult education and literacy services. Many states also have
programs for employer-based literacy training. Often employers must contribute to the costs. Many
provide “functional literacy” or “functional English” classes tailored to the functional requirements of jobs
at your workplace. You can get information on literacy providers, classes offered and the availability of
funding for employer-based programs from your local Workforce Investment Board or Department of
Adult Education.
Invite literacy providers to hold a program in your building. Hosting literacy programs can help with
recruitment. If a literacy provider is housed in an agency that provides support services to people, partner
with them for a win-win. Recruit well-prepared employees and refer employees to the social service
network for help with issues affecting their ability to work.
Adult literacy classes are designed to be flexible. Many programs allow students to start and stop
instruction as needed and are scheduled at night or on weekends. Literacy programs are delivered in
many venues including; the worksite, community colleges, community based organizations, universities
and libraries. Classes are often made available at the worksite and can be coordinated with job skills
training.
Three types of literacy are necessary for employees to be able to function in a work environment: prose,
document and quantitative literacy.
Prose literacy – The ability to read and understand instructional manuals, brochures, and safety
signs.
Document literacy – The skill to read and understand so as to complete a task. For example, being
able to read care plans or diet orders.
Quantitative literacy – This includes the ability to compute math, such as being able to calculate
and document the percent of a meal eaten or amount of fluid intake. It also includes financial
literacy.
The classes are often available through federal funding include: adult basic education (ABE), high school
completion through the General Education Development (GED) examination, and English for speakers of
other languages (ESOL) programs. The amount and focus of state and federal resources is driven by the
size of the minority population and the status of the waiting lists for various services.
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Adult Basic Education (ABE) programs are designed for adults who read at the eighth-grade level
or below.
General Education Development (GED) prepares a student to take the GED exam, which involves
five tests that show general knowledge and thinking skills. This credential often substitutes for a
high school diploma.
Adult English as a Second Language (ESL) programs teach English to adults whose native
language is not English.
There are many advantages to offering literacy training for both the employee and employer. Many
employers have enjoyed better individual and team performance, willingness on the part of staff to
embrace change, and better work with residents. Employees have shown greater capacity to read orders,
use numbers and problem solve. Also, employee morale and self-esteem have been improved.
Here are websites with state information about Adult Education and Literacy Programs:
Educational Resources by State – State Adult Education Directors
http://wdcrobcolp01.ed.gov/Programs/EROD/org_list_by_territory.cfm
State Workforce Investment Boards – National Association of Workforce Boards
http://www.nawb.org/WorkforceBoardWebSites/tabid/167/Default.aspx
Civil money penalties: An underused resource
Civil monetary penalties could fund your staffing retention program. Imagine that! You could
be the beneficiary of the fines and penalties paid into this program. The money that has been collected
through these fines is held in a fund designated to be used exclusively in and for nursing homes to
improve care for residents. Civil Money Penalties in some states have been used to support culture
change, staff development, staff training or quality improvement projects in nursing homes.
Every state is different in how they are using these funds.xxiii Of the fifty states, only six states collected no
fines: AK, CT, ID, MT, PA, SD and WY. All other states collected penalties associated with fines imposed
for deficiencies. The fund has been commonly used to fund state conferences and training, and individual
provider proposals for culture change activities, staff retention projects, and training projects for direct
care staff.
Several states place information on their website (Nursing Home Regulatory) about how to apply to use
the funds, but most states have not yet developed criteria for use or formal mechanisms for applying for
funds.
Decisions about how the funds are used are done primarily through the licensing and certification agency.
Contact your state association or licensing and certification agency to inquire about the funds. Ask how
funds have been used historically, and what the process is for application. If there is no formal process,
ask about writing a letter requesting use of the funds.
Each funding organization has its own format, terminology, and questions. For different funders, you may
need to use different terminology to explain similar activities. For example, for a civil monetary penalty
http://wdcrobcolp01.ed.gov/Programs/EROD/org_list_by_territory.cfm
http://www.nawb.org/WorkforceBoardWebSites/tabid/167/Default.aspx
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“POME”
Problem
Objective
Methodology
Evaluation
proposal, link stable staffing with continuity of care and better quality of care. For a workforce
development proposal, link stable staffing with opportunities for your staff to learn new skills.
Remember to be clear about what you intend to do, and how it fits within the purpose, goals, and grant
guidelines of the funder. Check funders’ websites for information and to see what they have funded
historically. For workforce development funds, show how your proposal will support staff retention and
advance employees’ skills and earning power. For civil monetary penalty monies, show how your proposal
improves care and life for residents.
Tips for Writing a Grant Proposal for Funding
Answer each question asked in the funding guidelines. Use the funder’s words and show how what you are
proposing to do will advance their aims. A simple way to think about elements in a proposal is the
acronym POME….
Problem: In the problem statement, explain what problem or
need you have, what you propose to do about it, and why. Explain
how you assessed the needs of your organization and staff. Assess
needs through: staff discussions (called focus groups), staff or
resident satisfaction surveys, turnover data, and other
information gathering activities. Use the discovery process
described in Section I as your needs assessment process.
Objective: Spell out what you hope to accomplish. It is usually
quantifiable, for example, reducing turnover or improving
resident or staff satisfaction in a particular area. Then explain
why the approach you want to take will help you meet this
objective. Many of the tools throughout this tool-kit will help you
make your case for the direction you want to take.
Methodology: Explain step by step what you will do, who will
participate, how you will implement your plan. Be clear and
detailed to show funders that you have a sound proposal and you will likely succeed in what you have set
out to accomplish.
Evaluation: Say how you will know if you have accomplished what you set out to do. Measures can
include turnover rates, attendance rates, cost of pool use, staff or resident satisfaction data, and clinical
data. Use evaluations of each class. Use pre- and post-project data and focus groups.
Budget and timeline: Be realistic about what costs you will incur. Follow the funder’s guidelines for
allowable uses of the funds and requirements for matching funds and in-kind contributions. In-kind
contributions are non-cash resources that you provide, such as classroom space and supplies. Matching
funds are costs you contribute to the effort, such as the cost of staff time to administer the grant. Most
workforce development funders expect you to pay for staff time for training and will not allow the grant to
cover those costs. However, they may allow you to count that as your “matching funds.” Quite often, after
a grant is approved, the funder will meet to review the budget and ask for adjustments or explanations.
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Billing and payment schedule and other financial issues: Some funding sources give you the money up
front but most require you to spend the money first and then bill for it. Some make monthly payment,
others quarterly, and others when an objective is completed. Find out how long the wait is between when
you bill and when you will get paid. Knowing this will be important to your own cash flow and may help
you schedule classes and activities under the grant. Find out what receipts are required for expenditures.
The accounting systems you have in place for your regular payment sources may not be sufficient for this
grant. You may need a new accounting process for the expenditures related to this grant. This will take
some time to set up. Meet with the funder’s accounting staff to get information about what they will need
to issue payment and any help you might need in setting up a good system from the start. Once you have a
system in place, and the payment cycle is working, cash flow should go fairly smoothly.
Reporting requirements: Find out what the reporting requirements are and get a system set up from the
start so that you do not have to scramble afterwards to gather all the information you need. Ask to see a
final report the funder considers of high quality so you know what is expected. Report on outcome
measures and evaluation results. Workforce development grants often require reports on how many
employees have attended classes and what impact the classes have had on their wages. Some need regular
attendance sheets, and some want evaluations of each class by each participant. Some need this
information as you go along and others will look for it in a final report.
Getting Help: If your proposal is for a substantial amount, consider hiring a grant writer with experience
in that area. Sometimes educational providers will write the grant and then do some of your training. If
you decide to write your own proposal and are unfamiliar with grant writing, ask your provider
association for assistance and to refer you to colleagues who have successfully written grants. There are
articles on the web and books on the subject.
Finding and Selecting the Right Training Provider
Employer Guide to Selecting Training Partners by the Commonwealth Corporation of Massachusettsxxiv
highlights six key areas to explore when interviewing training providers:
1. Business objectives: How will you develop an employee-training program that is tied to my
company’s business objectives?
2. Workplace requirements: How will you develop an employee-training program that reflects
my workplace and its requirements?
3. Employee needs: How will you craft an employee-training program tailored to our employees’
needs?
4. Employee assessments: How will you ensure that the employee assessments you use will be
high quality?
5. Qualified staff: How will you ensure that your staff members involved in the development and
delivery of training programs are highly qualified?
6. Evaluation: How will you use evaluation to ensure training quality?
This excellent resource will guide you through the selection of a training provider and the collaboration
for development of training programs that meet your organization’s and your employees’ needs.
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Keys for successful workplace education programs
xxv
Bringing education programs into your workplace, for your employees, has many benefits. It also has
many challenges. If you are experiencing daily instability, scheduling time during the workday for people
to go to class can be difficult. You will want to make sure that you have a basic level of stability before you
attempt to schedule classes. Classes can also be a boost to stability. If the classes meet employees’ needs,
they will not want to miss them so their attendance will likely improve.
Many nursing homes that have hosted classes have found that if classes are open to a significant
number of staff, they will pull together with co-workers to make sure people are able to go. One
nursing home that held ESL classes, with different fluency levels scheduled on different days of
the week, had over a third of its employees attending. On the days when it was their turn to go to
class, employees reported that their co-workers helped out with tasks to make sure they would not
miss the class. They, in turn, were happy to return the favor the next day. The supervisors led by
example and everyone cheered each other on.
As you implement a workplace-training program, consider the following:
Determining your organization’s needs.
Employee participation in educational opportunities.
Operational issues.
Determining your organization’s needs
Key steps for success include:
Use a high involvement approach. Involve department heads
and managers, supervisors, and line staff in assessing needs,
designing the schedule, identifying operational issues, and reviewing
how it is going.
Communicate every step of the way, including individual and
group discussion and clearly written information.
Check your gut. Make sure the organizational decision-makers
and all levels of the organization are fully committed to this
undertaking.
Financial support is essential. Corporate budget pressures to
tighten staffing levels can impede the success of a workplace
learning initiative.
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Consider what you need staff to learn and how you will be able to function better because of their new
skills. Focus classes in areas related to current and projected organizational needs. Investing in your
staff’s growth is reason enough to sponsor workplace classes. There is an added benefit if the classes also
support organizational goals. The burdens created by classes will be easier to handle if the benefits
outweigh them. Set the schedule of classes at a pace that does not overburden your current staffing
capability.
Match courses to organizational needs: Involve department heads, supervisors, and non-
supervisory staff in discussions about which courses are most needed. Talk very specifically about
what knowledge and skills your organization needs these courses to provide and how staff could
put them to use. Talk about goals for the courses, what you would like staff to learn and what
improvements in care you expect as a result. Discuss potential trouble spots and strains on the
organization as staff goes to class.
Customize classes: Work with educational providers to customize courses to the specific needs
of your organization. Make sure the courses use approaches that are consistent with your policies
and the standard of practice you follow. Content should be relevant and examples should ring true
for participants. Tie content to real job duties, such as CNA flow sheets.
Instruction methods and content should be at the right levels for the people taking them, and should build
on existing knowledge and competencies. Instructors should be knowledgeable about how what they are
teaching applies to situations staff currently face. Instructors should use good adult education methods
that engage staff and maximize their ability to transfer this new knowledge into their daily practice.
Metrics: Identify ways to know if the education is having a positive effect on organizational
performance. Define what improvements you hope to achieve and a way to measure these
improvements. For example if you select a course on behaviors, you could measure the rate of use
of PRN medications for agitation. Create measures based on the skills and competencies you want
staff to be able to do and then measure staff’s ability and frequency of use of a skill or practice.
Measure at the beginning and the end of the course, and three or six months later.
Staging and scheduling: Set up a projected calendar of courses over the period of the grant,
based on organizational need and capacity. Determine how much coverage you can provide while
people are in class and use this information to determine the calendar of courses, scheduling of
classes, and how many people can go to a class at one time.
Pick class times that have the best chance for good attendance. Allow flexibility in class times and in
employees’ schedules to make it work for people to attend class and the work to be covered. Allow at least
two months between courses for employees to have time to become comfortable using what they have
learned.
Employee participation in educational opportunities
Market the opportunity to generate interest. Think strategically about who can participate in courses and
in any selection process, how staff will use what they have learned, and how staff will be compensated for
what they have learned and can now do. Have a fair, clear, application/interview process open to
everyone.
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Marketing the opportunity: Use positive marketing that emphasizes the opportunity for staff, the
benefits of participating, and the value of the courses. Show that leadership is fully in support of the
classes. Talk about the growing professionalism of the CNA job. Include personal testimonials from
employees who have had success going to class. Encourage word of mouth, peer-to-peer promotion of the
program. Ask informal peer leaders to help spread the word. Include clear and concrete information about
the courses, the selection process, and how work and class time will happen. Have both a personal
approach and a way of reaching everyone. Send personal notes of invitation to participate in the courses
to staff at their home address from management. Convene a range of meetings to reach as many people as
possible in a way staff can ask questions. Possibilities include:
An education fair.
Small group/mini-meetings in people’s work areas.
Informational socials.
Meeting with people in the break room.
Staff meetings.
In addition to meetings, make clear, written information available through:
Paycheck flyer.
Posters in lobby, by time-clock, in break room, in elevator, and in bathroom.
Employee newsletter.
Motivate employees to participate: Let staff know that the whole organization is behind their
participation. Stress the advantages of participation:
Educational and Professional Advancement
o Preparation for entrance into college.
o Preparation for other avenues for professional growth.
o Investment in yourself.
Growth Within the Organization
o Promotion or other opportunity to grow in role within the organization.
o Increased professionalism as a CNA.
o Opportunity to be a leader among peers.
o Opportunity to share what you learn with peers.
o Short-term advancement goals.
Financial Rewards
o Increased pay.
o Bonus for completion.
Many adults hesitate to go back to school. This is especially true if their prior school experiences were not
positive or successful. In addition, many adults have multiple demands on their lives that can easily
interfere with taking classes. Give much encouragement and support. Make sure classes are an enjoyable
and positive experience.
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Communication: Give information consistently along the way. Let everyone know what classes are
offered, when, any new roles or responsibilities related to the classes, any additional compensation, and
how they can apply. Get input from staff initially and find out how the program is going along the way.
Have regular meetings to check-in and give progress reports. See marketing bullet for suggestions on ways
of communicating in person and in writing.
Selection: Decide who is eligible to apply for classes. Develop criteria for applying and being selected.
Criteria can include factors such as a minimum length of service in your organization, satisfactory
performance and good attendance. Use a fair and open process. Explain it well and make it widely known.
Be clear about expectations for participation.
Talk one-on-one with each employee interested in taking a course to find out why they are interested and
what barriers they may have to participation that you can work to resolve. Employees’ other
responsibilities can interfere with attendance in class, as it sometimes does with attendance in work.
Maximize participation by being pro-active in developing supports for staff.
Seek out employees who may not volunteer or initiate interest, but who you know will benefit from the
classes. In selecting employees for participation in courses, give consideration to employees who are most
likely to complete the course and use what they learn, as well as ones who need the course in order to
meet their current basic job responsibilities.
Support for course participants: Work with the educational providers and with supervisors to
provide whatever supports participants need to be successful in the classroom. Anticipate that supporting
participants will require dedicated resources. You can provide support in-house through your staff
education coordinator or the point person for the initiative. You can also enlist outside support through a
case manager or a mentor. Some workforce grants include funding for employee supports. Participants
may need a range of supports:
Some participants will need academic preparation through the adult basic education and English
for Speakers of Other Languages courses before they are able to take on clinical specialty courses.
Provide educational counseling to support individual plans based on staff’s needs and abilities.
Address factors that can make an employee feel intimated about going to class. Testing,
homework, reading, math, just being in a classroom can be difficult. Find out what concerns
employees have and help alleviate them.
Provide childcare while employees are in class for staff who participate in class during hours they
would not normally be working.
Have an orientation kick-off for participants to explain how the courses will go and help
participants prepare for this educational undertaking.
Throughout the course, have brief meetings with groups or individuals to check on their progress
and any issues they are having.
Case management is an important program component. It helps individuals make, feel confident
about, and get excited about career and education choices. It limits false starts and early
terminations from class.
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Look for ways to make it stress-free for employees. They are taking on a new responsibility and will need
support and encouragement to be successful. Giving employees support maximizes their participation.
Supervisor participation: Supervisors will support employee participation in a course they believe is
worthwhile, will benefit care, and will not place too heavy a burden on the remaining staff. Ask
supervisors about employees’ capabilities and educational needs. Have supervisors participate in selecting
participants for courses. Work with supervisors on scheduling so they can manage the work while
employees are in class. Have meetings with supervisors to gauge how employees are doing with classes
and to guide supervisors in how to support their staff’s participation in class.
Using what employees learn: Work with supervisors and managers on how employees will use their
new competencies and on any changes in responsibilities. Lack of opportunity to utilize what participants
learn in class can sour them to the experience and dampen interest in further participation. Give
supervisors guidance on how to help employees use their new skills. Consider how to sustain use of new
job skills and knowledge.
Compensation: Determine whether you will compensate for time in classes, and whether you will give a
wage increase or a monetary bonus for completion of classes. Provide certificates of completion and
recognition for accomplishments. Have a recognition board to post employees’ classroom
accomplishments. While even a small wage increase helps, the respect, support and appreciation that
workers feel from employers who invested in them is PRICELESS.
Operational issues
Workplace education presents operational challenges. Have a positive program champion/point person
who can coordinate and trouble-shoot operational issues. Coverage is a key operational issue. Lack of
coverage can hinder participation in class and create resentment among co-workers.
Program champion: Assign someone to manage the program that has the authority to
coordinate scheduling, link content with organizational needs, support employees during the
classes and in applying what they learn to their work responsibilities. Running the program
requires administrative as well as managerial skills. The point person needs to be detail oriented,
flexible, organized, strong communicator, cheerleader and champion, and someone who works
well with the DoN, CNAs, charge nurses, and the scheduler. The program point person will need
to work closely with the Director of Nursing to coordinate how staff is selected, how classes are
scheduled, and how employees put their new skills and knowledge to use.
Coverage: Draft a plan for floor coverage. Work with supervisors, schedulers, and employees to
determine how you will cover shifts for employees who are in class. Do not make going to class
stressful for employees. Typical trouble spots in workplace education occur when employers do
not provide coverage. When employees not going to class have to work shorthanded, they will
understandably resent it. Participants will naturally hesitate to leave their co-workers short-
handed. Do not allow lack of coverage to prevent someone from attending class, and do not pull
someone out of class. Be prepared to call in per diem employees if needed to assist with
assignments. Have supervisors and managers help employees manage the time on class days, and
pitch in to help provide coverage. Co-workers will pitch in when they see that supervisors are. Co-
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workers will be more willing to help out if they know what an employee learns will help them all,
and that they will have their own chance to take a class.
Supervisor support: Help supervisors support employee participation and trouble-shoot any
tensions among staff related to the initiative. Provide guidance to supervisors on how to integrate
what employees learn into their regular work duties and how to facilitate sharing what they learn
with their co-workers. Support by supervisors and the tone they set for support among co-workers
will keep participants focused and motivated.
Logistics: Have consistent times and places for classes so participants know where they are
going and can plan accordingly. Flexibility is also important. Stuff happens – expect the
unexpected. Scheduling problems, staff turnover, maternity leaves, etc. often affect training. Be
able to adjust scheduling and/or content of training as needed. Communicate any changes clearly.
Review and adjustments: Set up a process for early and regular check-ins with employees
taking the classes and with their supervisors and managers. Find out how the classes are going
and how staff is able to use what they are learning. Ask about any scheduling and operational
issues. Make adjustments as necessary.
Organizational updates and celebration: Make sure people have a regular way to know
what is going to happen and what they may need to be doing. Celebrate success! Involve
residents, families, community officials, employees’ families, and non-participating employees,
who you want to thank and recognize for their support. Promote the positive changes that occur.
Technical assistance
There are several sources of technical assistance available in states for nursing homes seeking help to
stabilize staffing. These include:
Quality Improvement Organizations (QIOs): Every state has a QIO, funded by the federal
government, to provide free tools and educational resources to providers of Medicare services. Each QIO
has staff with expertise in nursing homes and most QIOs have developed expertise in workforce retention.
QIOs will likely have technical assistance materials available to support your efforts to stabilize staffing
and can refer you to other nursing homes that have successfully stabilized their staffing. To contact the
QIO in your state, go to www.ahqa.org and look for the QIO locator.
Culture Change Coalitions: The Pioneer Network supports individuals and organizations seeking to
transform traditional models of nursing home from an institutional model of care to individualized care.
Many participants in the Pioneer Network have worked hard to build stable staffing. Over 30 states have
Culture Change coalitions. The coalitions sponsor educational sessions and help individual providers
network with each other. To contact the Pioneer network, go to their website: www.pioneernetwork.net.
To contact your state’s culture change coalition, go to www.Pioneerexchange.org.
Advancing Excellence Coalitions, called LANES: Advancing Excellence in America’s Nursing
Homes is a new coalition-based, ongoing campaign that launched in September 2006 to improve the
quality of care and quality of life for those living or recuperating in America’s nursing homes. Over 6000
http://www.pioneerexchange.org/
http://www.nhqualitycampaign.org/star_index.aspx?controls=about
http://www.nhqualitycampaign.org/star_index.aspx?controls=about
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nursing homes are participating. Homes agree to work on improvement goals in a number of clinical and
operational areas. Two of the areas for improvement are increasing staff retention; and improving
consistent assignment of nursing home staff, so residents regularly receive care from the same caregivers.
Local Area Networks, called LANES, exist in every state to coordinate and support provider efforts. To
find the LANE for your state, go to www.nhqualitycampaign.org.
i
Better Jobs Better Care, funded by Robert Wood Johnson Foundation and Atlantic Philanthropies, supported initiatives in 5 states to improve
direct care jobs in long-term care. The Community of Vermont Elders (COVE) was the lead agency for these activities in Vermont.
ii
June 2007, My InnerView Inc., 2006 National Survey of Nursing Home Workforce Satisfaction
iii
Healthcentric Advisors coordinated Improving the Nursing Home Culture, funded by the Centers for Medicare and Medicaid Services. Over 15
months in 2004 and 2005, 254 nursing homes participated either in a Workforce Retention or a Person-Directed Care arm of the pilot. Aggregate
data showed a 9% relative improvement in retention, and improvements in several quality measures.
iv
What a difference management makes! Eaton, 2002
v
This section draws from the work of David Farrell, Scott West, and Lori Todd
vi
Gallup Poll 2002
vii
June 2007, My InnerView Inc., 2006 National Survey of Nursing Home Workforce Satisfaction
viii
Loomis House, South Hadley, MA
ix
Baylors work long blocks of hours and receive extra pay beyond the hours worked. For example, a Baylor might work two 12-hour shifts and
be paid for 30 hours.
x
Connie McDonald, administrator with Maine General Rehabilitation and Nursing Care in Augusta, ME
xi
David Farrell was a source for this section.
xii
Excel spreadsheets were originally developed by Healthcentric Advisors and B & F Consulting. They were updated and enhanced by Dave
Johnson of IPRO, the QIO for the state of NY.
xiii Adapted from case study written by Cathie Brady and Barbara Frank of B&F Consulting, through funding from Better Jobs Better
Care-Vermont; available through www.bjbc.org.
xiv
Birchwood Terrace Healthcare is owned by Kindred Nursing Centers East, LLC, and a subsidiary of Kindred Healthcare, Inc.
xv
BJBC-VT contracted with B&F Consulting to provide technical assistance to Birchwood. B&F Consulting subcontracted with Healthcentric
Advisors for assistance from David Farrell related to data collection and analysis.
xvi
The drilldown tool used for Birchwood became the prototype for the drilldown tools in this Toolkit. It was designed by B&F Consulting with
David Farrell from Healthcentric Advisors.
HCP’s Healthcare Quality Care Improvements, Contraindications and ICD-10
http://www.bjbc.org/
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xvii
Farrell drew on his work on the Pillars of Retention, published in Provider, 2006
xviii
Available September 2008
xix
See Appendix F for more information about these programs.
xx
Also known as Performance Improvement or Process Improvement.
xxi
Adapted from an initiative by Loren Salvietti, Administrator, Quaboag-on-the-Common, and West Brookfield, MA, funded by the Extended
Care Career Ladder Initiative operated by Commonwealth Corporation of Massachusetts.
xxii
See Appendix F for more information about these programs.
xxiii
The Commonwealth Fund supported research that examined the federal and state fines collected and how states were using the funds. The
research resulted in an article entitled, The Collection and Use of Funds From Civil Money Penalties and Fines From Nursing Homes published
in The Gerontologist, Vol. 46, No. 6, 2006 by Tsoukalas, et al. It includes a table that summarizes the fines and penalties for noncompliance
collected in all fifty states in the year 2004.
xxiv
Available at www.commcorp.com under Industry Sector Strategies as part of the ECCLI Virtual Library
xxv
Developed for Capitol Workforce Partnership by B & F Consulting for the CNA Advancement Initiative funded by the U.S. Department of
Labor
http://www.commcorp.com/
- Staff Stability Toolkit_Cover_120111_dam_Healthcentric Advisors
- Staff Stability Toolkit_120111_dam_Healthcentric Advisors
INSTRUCTIONS
Click here to begin Worksheet 4 –
Turnover Rate
s
Click here to begin Worksheet 4 – Turnover Rates
Turnover Rates
| Facility Name- | Date Completed- | ||||||||||||||||||||||||||||||||||||||||||||||||||||
| Period Being Studied- | |||||||||||||||||||||||||||||||||||||||||||||||||||||
| To calculate OVERALL FACILITY Turnover Rate, indicate the total number of ALL Employees / ALL Departments on the last day of each month to be studied. |
OVERALL FACILITY TURNOVER STATISTICS |
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| JAN- | FEB- | MAR- | APR- | MAY- | JUNE- | ||||||||||||||||||||||||||||||||||||||||||||||||
| JULY- | AUG- | SEPT- | OCT- | NOV- | DEC- | ||||||||||||||||||||||||||||||||||||||||||||||||
| Total of monthly #s above- | 0 | ||||||||||||||||||||||||||||||||||||||||||||||||||||
| Average # of Employees- | 0.00 | ||||||||||||||||||||||||||||||||||||||||||||||||||||
| Total # of ALL Terminations (for same period) | |||||||||||||||||||||||||||||||||||||||||||||||||||||
| OVERALL Turnover Rate- (# Term/Ave. # of Employees) | 0.00% | ||||||||||||||||||||||||||||||||||||||||||||||||||||
| To calculate RN Turnover Rate, indicate the total number of RNs on the last day of each month to be studied. |
RN Turnover Statistics | ||||||||||||||||||||||||||||||||||||||||||||||||||||
| Average # of RNs- | |||||||||||||||||||||||||||||||||||||||||||||||||||||
| Total # of RN Terminations (for same period) | |||||||||||||||||||||||||||||||||||||||||||||||||||||
| RN Turnover Rate- (# RNs Term/Ave. # of RNs on payroll) | |||||||||||||||||||||||||||||||||||||||||||||||||||||
| To calculate LPN Turnover Rate, indicate the total number of LPNs on the last day of each month to be studied. |
LPN Turnover Statistics | ||||||||||||||||||||||||||||||||||||||||||||||||||||
| Average # of LPNs- | |||||||||||||||||||||||||||||||||||||||||||||||||||||
| Total # of LPN Terminations (for same period) | |||||||||||||||||||||||||||||||||||||||||||||||||||||
| LPN Turnover Rate- (# LPNs Term/Ave. # of LPNs on payroll) | |||||||||||||||||||||||||||||||||||||||||||||||||||||
| To calculate CNA Turnover Rate, indicate the total number of CNAs on the last day of each month to be studied. |
CNA Turnover Statistics | ||||||||||||||||||||||||||||||||||||||||||||||||||||
| Average # of CNAs- | |||||||||||||||||||||||||||||||||||||||||||||||||||||
| Total # of CNA Terminations (for same period) | |||||||||||||||||||||||||||||||||||||||||||||||||||||
| CNA Turnover Rate- (# CNAs Term/Ave. # of CNAs on payroll) | |||||||||||||||||||||||||||||||||||||||||||||||||||||
| These statistics reflect an automatic calculation of the statistics entered in the 3 categories above. (RN, LPN & CNA) |
Nursing Staff Combined (RNs, LPNs and CNAs) Turnover Statistics |
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| Average # of All Nursing Staff- | |||||||||||||||||||||||||||||||||||||||||||||||||||||
| Total # of All Nursing Staff Terminations (for same period) | |||||||||||||||||||||||||||||||||||||||||||||||||||||
| All Nursing Staff Turnover Rate- | |||||||||||||||||||||||||||||||||||||||||||||||||||||
| These statistics reflect an automatic calculation based on the statistics entered above. (“Overall Facility Statistics” minus “Nursing Staff Combined”) |
All Other Staff Turnover Statistics |
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| Average # of All Other Staff- | |||||||||||||||||||||||||||||||||||||||||||||||||||||
| Total # of All Other Staff Terminations (for same period) | |||||||||||||||||||||||||||||||||||||||||||||||||||||
| All Other Staff Turnover Rate- | |||||||||||||||||||||||||||||||||||||||||||||||||||||
| User-Defined Turnover Calculators | The “calculators” below may be used to customize and help analyze turnover statistics. The “User-Defined” nature allows you to isolate statistics by such specifics as individual department, unit, or even specific job description. | ||||||||||||||||||||||||||||||||||||||||||||||||||||
| To calculate Turnover Rate, indicate the total number of identified staff on the last day of each month to be studied. The data entered should ONLY be specific to the group of employees identified for this isolated table. | Enter the description of the specific group below. | ||||||||||||||||||||||||||||||||||||||||||||||||||||
| Average # of identified staff- | |||||||||||||||||||||||||||||||||||||||||||||||||||||
| Total # of Terminations (for same period) | |||||||||||||||||||||||||||||||||||||||||||||||||||||
| Turnover Rate- (# Term/Ave. # of identified staff on payroll) |
&L&”Arial Narrow,Bold”&
2&F&R&”Arial Narrow,Bold Italic”Enter Information ONLY IN the SHADED Cells. All others will be calculated automatically.
&L&8&A&C&”Arial Narrow,Regular”&P of &N
Turnover Rates
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