Quality Today
Primaris produces QualityTODAY, the premier source of healthcare quality improvement news in Missouri. QualityTODAY is published quarterly, sent to over 5,000 healthcare professionals and leaders statewide. E-mail Matt Heger (mheger@primaris.org) to get your copy or for reprint information.
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FALL 2007 |
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Retention: What's it worth?
Employee turnover is the scourge of the fast food, child care and – you guessed it – healthcare industries. Any job can leave workers longing for greener pastures, but healthcare adds long hours and a massive dose of stress. Lives hang in the balance. Good days can be amazing. Bad days are beyond comprehension.
Retaining employees is becoming more and more difficult as highly-skilled workers become scarce and costs for benefits and wages rise. Cost estimates of replacing a single employee range from around 25 to 50 percent of that employee’s yearly salary. These estimates don’t include the lost productivity among other staff, training and decreases in morale.
And worst of all, turnover begets more turnover. When one staff member leaves, it becomes more likely that others will follow close behind.
With all of these factors, how do you find the true cost of high turnover? There are a number of direct turnover costs that can be easily measured, including:
- Advertising
- Hours spent screening applicants
- Temp services
- Training hours
- Recruitment bonuses
In 2004, a study funded by the Robert Wood Johnson Foundation investigated these costs specifically in the long-term care industry. They found that direct costs add up to a bare minimum of $2,500 for every single front-line employee lost.
More difficult to measure are numerous indirect or “soft” costs. These include:
- Decreased productivity
- Reduced quality of care
- Lost company knowledge and history
- Increased risk of additional turnover
NEWS BRIEFSMoAHQ’s Distinguished Quality Professional AwardDr. Les Hall of the University of Missouri Hospital and Clinics has been officially announced as winner of the 2007 Distinguished Quality Professional Award from the Missouri Association for Healthcare Quality. Dr. Hall will be honored during a luncheon awards ceremony at the MHA Annual Convention and Trade Show and at the semi-annual Missouri Association for Healthcare Quality meeting. Pandemic Flu ResourcesTo help Missourians prepare for the next Just Culture GrantThe Missouri Center for Patient Safety has received grant funds to bring together Missouri regulators and healthcare providers to improve patient safety. This Just Culture Collaborative was made possible by the National Council of State Nursing Boards. Hospital HonorsBarnes-Jewish Hospital was named a consumer choice winner as the hospital with the most preferred overall quality and image in the St. Louis area, according to the National Research Corp.’s 2007-08 Healthcare Market Guide. Freeman Health System received the 2007 VHA Leadership Award for Clinical Excellence for its rapid response programs. Hospitals had to achieve at least a two percent decrease in patient codes outside of the intensive care unit to receive the award. St. Luke’s Hospital in Chesterfield was named among HealthGrades America’s 50 Best Hospitals for 2007. Primaris Quality Awards ApplicationsPrimaris is now accepting applications for Hospitals: Save the DateOn Jan. 15, 2008, the 5 Million Lives campaign will host their Boards on Board conference in the Kansas City area. For more information, e-mail rewhite@primaris.org. PQRIFor the latest updates on the Physician Quality Contribute:Do you have news to share with health care |
Both the soft and hard costs ignore the impact on human lives. A 2002 University of Pennsylvania study found that nursing turnover can indeed kill, as vacancies add to the workload of remaining nurses. For every additional patient on a nurse’s workload mortality increased by seven percent. Setting soft costs aside, there is a commonly-used quick estimate for determining the cost of turnover. This conservative rule-of-thumb estimate is derived from an employee’s total annual compensation, including all benefits, divided by four.
Using this, imagine an employee with $24,000 in wages and $4,000 in benefits. With a total compensation of $28,000, it would cost your business $7,000 to replace them. Simply considering this is a conservative estimate, it becomes obvious that it may be worthwhile to invest a little more into employees to improve their pay or their working environment. More in-depth tools are available to help analyze exactly how much turnover will cost you (read “Retention Resources”).
So what can employers do to increase retention? While employee turnover is a headache, retention doesn’t have to be. Determine an appropriate amount to invest in your workers and know what turnover really costs your organization. Hire with the long-term in mind and recognize the value of your employees.
Some turnover is inevitable. In fact, not all turnover is even bad. However, a revolving staff will not serve your organization well. Appropriate turnover will vary across industries. Physician offices may find a 20 percent turnover rate disastrous, while a large nursing home might be pleased with such a rate. But keep in mind, if employees are not satisfied, they will not provide their best performance. When their performance suffers, so does your organization.
Hiring for the long term
St. Andrew’s Management Services, St. Louis
Sheryl Steele knows it takes more than the swoop of a magic wand or a sprinkling of fairy dust to make turnover vanish, or even diminish for that matter.
“It’s hard work,” Steele said. “There’s no magic … it’s tracking exit interviews to know what issues staff are dealing with. It’s talking to your staff. It’s creating an environment where staff know they’re appreciated.”
Steele is the director of human resources for St. Andrew’s Management Services, a subsidiary of St. Andrew’s Resources for Seniors (STARS) in St. Louis. She works with leadership and human resources staff throughout approximately 20 senior care communities to ensure staff retention is addressed on a daily basis. Guaranteeing retention with carefully considered practices, Steele averts staffing crises.
Running the gamut from independent living communities to skilled nursing and home care, a St. Andrew’s community may have as few as 18 employees or as many as 250. But at least one thing is consistent across all facilities – turnover is tracked monthly and evaluated annually for major departments such as nursing, food and environmental services, Steele said. Tracking practices help detect abnormal “spikes” in current staff turnover and provide an opportunity to discover and solve the problem.
Equally important are the practices of staff retention that begin with hiring. This means not making “desperation hires,” but meticulously checking references and having at least two current staff conduct interviews with each job candidate at most facilities, Steele says.
Valuing staff once they’ve been hired is also key. St. Andrews’ staff orientation focuses on helping employees become comfortable with the community and the department in which they work and providing them with the tools they’ll need to do their job well and comfortably. At some of St. Andrew’s larger facilities, successful mentoring programs have been developed to help staff acclimate.
“We try to emphasize during orientation that each position is important,” Steele says. “We all know it’s hardest to hire nurses, but if your cooks don’t show up one morning, then you’re in hot water too.”
The organization continually self-evaluates through an annual salary survey and an employee satisfaction survey. Each St. Andrew’s community develops an action plan based on these surveys with the oversight of the corporate office.
“When we see a bad month or a bad year, we don’t panic, but we look at it and try to figure out why it was bad,” Steele says. “It might be as simple as a nearby big hospital is offering big sign-on bonuses.”
When problems are discovered, they are addressed. When one facility discovered higher-than-normal turnover, focus groups determined that employees were dissatisfied with their health insurance plan. Armed with that knowledge, the corporation worked to get a better one, Steele said.
And their corporation-wide efforts are having an effect. Steele said turnover has declined in her eight years with the company, which she attributes to efforts to pinpoint turnover and address it. Staff retention at each facility differs, but organization-wide, the cumulative average turnover for nearly 20 facilities in August 2007 was 28 percent.
Still, Steele isn’t satisfied – the organization’s philosophy is that there’s always room for improvement.
Retention resources
No healthcare provider has an identical environment, staff or culture. Likewise, no provider is in the same place when it comes to evaluating turnover and implementing practices to stabilize staffing. No matter where you’re at in your journey to staff retention, the list below can take your efforts further.
Primaris CD Toolkit
Find essential tools for “drilling down” to evaluate turnover and see staff retention ideas using this set of tools from Primaris. Order the CD “Developing and Retaining a Caring Workforce,” available here. This includes an indepth turnover calculator. Primaris resources are free.
Wellspring Change Model
Learn more about the Wellspring Change Model by the Wellspring Web site. Over a four-year period, 11 Wisconsin nursing homes using the Wellspring Model for improving nursing home quality decreased RN turnover by 6 percent, while state nursing home turnover averaged an increase of 7 percent.
Peer-Monitoring
Implement a peer-mentoring program for CNAs in home and residential care. A large percentage of CNAs quit during their first three to six months on the job. A mentoring program offers support and can reduce this early turnover. Download the eight-part course on establishing a mentoring program at www.paraprofessional.org.
Worker Barriers
Learn more about the challenges affecting direct-care workers that can also be barriers to job retention by visiting www.directcarealliance.org.
- Help workers with limited financial resources overcome barriers to staying employed. Promote the availability of an earned-income tax credit. Learn more at www.irs.gov/eitc.
- Consider establishing individual development accounts—organization-matched savings accounts for people with limited incomes. Learn more at www.idanetwork.org.
- Offer free financial education available through the Federal Deposit Insurance Corporation (FDIC)'s Money Smart program.
RN Leadership
Develop leadership in RNs using the Web-based education and resources available at the University of Minnesota Center for Gerontological Nursing: www.nursing.umn.edu/CGN/LTCNurseLeader/home.html.
Mather Lifeways LEAP Modules
Help nurses and CNAs in long-term care expand their roles using Mather Lifeways LEAP modules. Each course targeting charge nurses and managers is designed to help develop the roles of leader, care role model, clinical expert and care team builder.
Continuing Education
Provide employees with opportunities for continuing education and professional development. The Institute for Caregiver Education is a not-for-profit offering educational products and services based on Culture Change. For more information, visit www.caregivereducation.org.
Retention is like a box of chocolates
Putnam County Memorial Hospital
The average RN turnover rate in acute care hospitals is about 20 percent, but that number can be even higher in rural, critical access hospitals, such as Putnam County Memorial Hospital. In April 2006, Putnam County Memorial Hospital’s turnover rate was a whopping 66 percent.
It was at that point that Jeanie McLain, QA/UR Director, knew it was time to do something about it. And it began with the realization that with employees, much like with chocolate, you get what you pay for.
“Like chocolate, all nurses have the basic ingredients,” she said. “Then you have your better chocolate: your staff that desires to be superior, wants more education and comes to work every day with good attitude. You have that Godiva chocolate that’s really good. We want a Godiva staff.”
So the hospital began by implementing a new philosophy: “Quality Pay for Quality Staff.” Registered nurses received an eight dollar per hour pay raise. Certified nursing assistants and licensed professional nurses also received pay raises.
However, McLain knew that pay alone wouldn’t solve their turnover problem. It would also take redefining the orientation program and evaluations. Accompanying the pay hike was a 90 day probation period. Nursing standards were put in place and staff was evaluated to see where they needed to make improvements.
“Nursing requires more than just the basic skill set,” McLain said. “You have to be kind, caring and compassionate. Lots of hospitals just take a warm body and we were guilty of that for awhile.”
Putnam County stopped advertising for jobs and began to rely on word of mouth referrals. They also redefined the orientation and reorientation programs. A staff educator was hired to develop an orientation plan that included a longer, more consistent training.
Not all staff was on board. In the process Putnam County lost half a dozen staff members, some with twenty years of seniority. Located in a small town like Unionville, the situation was even more difficult.
The hospital also garnered plenty of positive community feedback. One measurement, McLain notes, is through a dramatic improvement in patient satisfaction surveys.
To help offset salary expenses, the hospital received a grant from the Missouri Foundation. However, the new culture generated a sound team of nurses. This reduced absences, which in turn reduced overtime salary costs and the hospital realized a financial benefit.
To date, Putnam County Memorial Hospital’s changes have been a huge success. Their turnover rate has been at zero percent since April 2007. In just one year, they had completely obliterated a 66 percent turnover rate.
McLain said that she believes other hospitals can implement similar programs to increase staff retention under one condition:
“You have to have support from management all the way down,” she said. “Management has to support it, and you have to be willing to cut bait if people aren’t going to change.”
Turnover at the top
The importance of leadership retention
Most supervisors are aware of the problems caused when front-line staff leave. However, when supervisors leave, their absence can create a staggering vacuum.
As an example, consider nursing homes’ turnover of facility administrators or directors of nursing (DON). As a state, the problem is disproportionately worse in Missouri. In 2002, the American Health Care Association estimated 42 percent turnover for Missouri administrative RNs (36 percent nationally) and 61 percent for Missouri DONs (50 percent nationally). A more recent study by Primaris showed that this turnover problem continues. Among a select group of nursing homes that represent 10 percent of Missouri facilities, 72 percent reported turnover of at least one leader during 2005 to 2006.
Follow the Leader
How does losing one leader affect nursing home staff? An increase in management turnover is associated with subsequent higher turnover among RNs, LPNs and direct care givers. Remaining staff are left with an even larger burden. This burden is then amplified by a lack of guidance from the supervisor that recently resigned.
Vision Impaired
Research also shows that nursing home administrator turnover can negatively influence the quality of care residents receive. Leaders, both administrators and DONs, have a vision and a plan to see organizational goals fulfilled. They inspire staff to share in this vision and to meet collective goals.
The loss of a leader often means the loss of that vision and the crumbling of plans and processes they have put in place. Clinical priorities lose their clarity, and knowledge related to improving quality of life is lost. Careful monitoring of quality measures and evaluation of care processes can go by the wayside.
What to Do?
To immediately address the loss of vision, Primaris studies have shown that declines in clinical improvement can be slowed by implementing care teams. These teams limit the negative effects of leadership turnover by maintaining a consistent focus even in the face of turnover.
However, it is far better to prevent leadership turnover whenever possible. When addressing turnover in your business, do not neglect management positions. Just as you would with front-line staff, analyze the costs associated with the absence of consistent leadership in your organization.
See "Retention Resources" above for more help, including useful links and resources to proactively address turnover.