leadership paradigm shift

1. Leadership Paradigm Shift Model Programs to Support the Working Poor The Critical First Six Months

2. Why do they enter this field � based on the research, they intentionally choose LTC, not because they do not have other options, but because they have a desire to help others. Single moms at or near the poverty line have limited resources to fall back on when their kid is sick or their car won�t start. In addition, we know that most are uninsured. In fact, most for-profit chains encourage it by offering as much a $1 more per hour to entice staff to waive their right to coverage. 25% have no health insurance Avg. age is 37, 10% are over 55, 50% have at least one child under 18 20% are below the poverty line 75% have a high school diploma Avg. rate is $9.85 = $ 20,500 per year. Cashiers make $7.60 All occup. Avg. is $13.50 30-35% receive food stamps. Four major causes of stress � Pillemer - lack of time, lack of good supervision, lack of staff, lack of training in psych/social aspects of care giving. NOT unskilled labor. Example - Philome These are the people I worked with at Braintree Manor on PMs and NOCs. I was not welcome into the group. In fact, I ate all of my meals alone. Looking back, I realize now how poorly I was trained and how alienated I felt. It was only the residents that kept me coming back. Ironically, I was fired for visiting the residents when I was not on the clock � I policy I ignored.Why do they enter this field � based on the research, they intentionally choose LTC, not because they do not have other options, but because they have a desire to help others. Single moms at or near the poverty line have limited resources to fall back on when their kid is sick or their car won�t start. In addition, we know that most are uninsured. In fact, most for-profit chains encourage it by offering as much a $1 more per hour to entice staff to waive their right to coverage. 25% have no health insurance Avg. age is 37, 10% are over 55, 50% have at least one child under 18 20% are below the poverty line 75% have a high school diploma Avg. rate is $9.85 = $ 20,500 per year. Cashiers make $7.60 All occup. Avg. is $13.50 30-35% receive food stamps. Four major causes of stress � Pillemer - lack of time, lack of good supervision, lack of staff, lack of training in psych/social aspects of care giving. NOT unskilled labor. Example - Philome These are the people I worked with at Braintree Manor on PMs and NOCs. I was not welcome into the group. In fact, I ate all of my meals alone. Looking back, I realize now how poorly I was trained and how alienated I felt. It was only the residents that kept me coming back. Ironically, I was fired for visiting the residents when I was not on the clock � I policy I ignored.

3. What Matters Most to Employees Management cares about employees Management listens to employees Help with stress and burnout Workplace is safe Supervisor cares about you as a person Supervisor shows appreciation

4. Business Case to Support Work/Life Issues Demonstrate the organization cares: Boost confidence and self-esteem Reduce stress Reduce communication breakdowns Improve loyalty and retention Reduce workplace injuries Decrease absenteeism Improve productivity Enhance relationships

5. Employee Assistance Programs (EAP) Employee Support: Marital and relationship Mental health/substance abuse Legal and financial issues Anxiety & mood disorders Balancing work and life Strong work/life programs are a powerful way for companies to attract and retain good employees.Strong work/life programs are a powerful way for companies to attract and retain good employees.

6. EAP Participant ServicesEmployees and Household Members Benefits of the EAP Confidential household benefit available 24/7 Pre-paid telephonic and in-person consultation Assessment, counseling (up to 6 sessions ) and referrals Work/Life information and resources Personal health on-line Psychologists Clinical social workers Counselors Marriage and family therapists Psychologists Clinical social workers Counselors Marriage and family therapists

7. EAP � How Much? Average = $3,500 per year $22 � 28 per employee per year Return on investment in EAP = $5 to $16 Companies with EAPs: 21% fewer accidents 35% reduction in turnover 59% reduction in absenteeism www.eaplist.com Marking is key to utilization. Remove the stigma.Marking is key to utilization. Remove the stigma.

8. Cost of Turnover Nationwide $2,500 per employee $2.5 billion nationwide Direct costs Advertisement costs Staff time to interview, check references, etc. Drug screen, pre-employment physical Classroom orientation Unit orientation Cost of coverage of the vacant position Indirect costs Vacant shifts, lower quality, slower service, lost new admissions, workers compensation, lost revenue, stress leading to errors An excellent study was just published titled � �� Turnover is not an inevitable cost of doing business. At a much lower cost, is the expense of investing in keeping and retaining frontline staff. However, beyond the dollars is the human toll turnover imposes on organizations. With every quit or termination, the care giving relationships and quality of the services provided to elders is disrupted. At the extreme, staffing can become so compromised that the well-being of both residents and the caregivers is neg. affected. With the stated goal in the 8th scope of 15% improvement, we are looking at a potential cost savings of $20,000. An excellent study was just published titled � �� Turnover is not an inevitable cost of doing business. At a much lower cost, is the expense of investing in keeping and retaining frontline staff. However, beyond the dollars is the human toll turnover imposes on organizations. With every quit or termination, the care giving relationships and quality of the services provided to elders is disrupted. At the extreme, staffing can become so compromised that the well-being of both residents and the caregivers is neg. affected. With the stated goal in the 8th scope of 15% improvement, we are looking at a potential cost savings of $20,000.

9. Earned Income Tax Credit (EITC) Offered through the IRS www.irs.gov/eitc Eligible employees complete IRS Form W-5 each year VITA program � free tax preparation Returns a portion of taxes paid On 2004 returns: Maximum amount $4,300 for workers with 2 or more children $2,604 for workers with one child $390 for childless workers Need help with the form.Need help with the form.

10. Low-Wage Model Programs and Policies FleetBoston�s Employee Emergency Loan Program No interest loans for emergencies � car repairs, utilities, rent Applications reviewed by committee Eligibility � six months of employment Harvard�s Learning and Literacy Program English as a second language Literacy, listening Eligibility � hourly staff, 3 months of employment

11. Low-Wage Model Programs and Policies continued TJX Companies Awareness Campaign Raise awareness about available government benefits Navigates through entitlement maze Eligibility � all employees Marriott�s Work Specific English Two courses � basic English Pre-test determines skill level Eligibility � all workers

12. Low-Wage Model Programs and Policies continued Bank of America�s Child Care Plus Reimbursement for a portion of child care expenses Assist employees to select the best providers Eligibility � base salary of $34,000 or less

13. ACHIEVE Goals: Retention Skill-building Reduce absenteeism Pairs MSWs with low-wage LTC staff Encourages advancement Work-site based Lunch and Learn Wellness Money matters Dealing with difficult people Cleveland OhioCleveland Ohio

14. No-Fault Attendance Policy No more qualifying absences Removes inequity No need for physician notes Absences are simply measured Bear in mind that the process of qualifying whether or not an absence is excused or not is important and those decisions can make or break the foundation of trust in an organization. Some facilities have adopted a �no-fault� attendance policy � this takes the guess work out of trying to qualify absences. You are either here or you are not. No need for M.D. notes to justify an absence. Absences for any reason are all treated the same. Bear in mind that the process of qualifying whether or not an absence is excused or not is important and those decisions can make or break the foundation of trust in an organization. Some facilities have adopted a �no-fault� attendance policy � this takes the guess work out of trying to qualify absences. You are either here or you are not. No need for M.D. notes to justify an absence. Absences for any reason are all treated the same.

15. Other Ideas Flexible scheduling Paid Time Off (PTO) Cash out vacation or sick pay Free or low-cost meals Free vitamins Free flu shots for staff and household Ride share

16. The �Stop Doing� List Incentives to waive benefits Bonuses for working short Scheduling overtime and double-time Rotating staff Sick pay � use it or lose it No sick pay until second day of absence No incentives or disincentives Some facilities promote excessive absenteeism. They have the exact same policy as your other facilities. Like many of the clinical issues we face, the problem usually does not lie in the policy. However, your systems may be contributing to the problem. Incentives to waive benefits � this has become a common practice nationwide for corps. To encourage staff waive their right to benefits for $1 more per hour. While this appears to save the corps a lot of money, it actually costs them down the road. These costs simply shift to another line item. If staff members have no health insurance, they are less likely to seek medical treatment until it is too late. Or if they have no sick pay or vacation pay that they have accrued, they have nothing to tie them to the facility. A spell of illness for this individual is the equivalent of a financial catastrophe. Bonuses for working short � staff tend to have a field day with this one and start making arrangements for whose turn it is to call off so that they all may get extra pay. Scheduling overtime and double-time � in facilities where the scheduling of staff for OT and DT is the routine, you have a system where these individuals have a strong financial incentive to keep the facility short staffed because they are making more money because of it. They see new employees who appear on the schedule and take their OT/DT as a threat to their income. Also, offering OT to an employee who called off earlier in the week allows that individual to earn more money that week than if they had shown up for their scheduled shift. Rotating staff � this leads to call-offs the days after the rotation. Sick pay � use it or lose it policies encourage staff to use it. You are much better off paying a portion of it out as a reward to those with great attendance records. No sick pay until second day of absence � this is an interesting one. Are you encouraging the person to call off for two days instead of one? No incentives or disincentives � Ignoring the staff with issues and those with excellent attendance records is another way that a system, or lack of a system, encourages the problem to continue.Some facilities promote excessive absenteeism. They have the exact same policy as your other facilities. Like many of the clinical issues we face, the problem usually does not lie in the policy. However, your systems may be contributing to the problem. Incentives to waive benefits � this has become a common practice nationwide for corps. To encourage staff waive their right to benefits for $1 more per hour. While this appears to save the corps a lot of money, it actually costs them down the road. These costs simply shift to another line item. If staff members have no health insurance, they are less likely to seek medical treatment until it is too late. Or if they have no sick pay or vacation pay that they have accrued, they have nothing to tie them to the facility. A spell of illness for this individual is the equivalent of a financial catastrophe. Bonuses for working short � staff tend to have a field day with this one and start making arrangements for whose turn it is to call off so that they all may get extra pay. Scheduling overtime and double-time � in facilities where the scheduling of staff for OT and DT is the routine, you have a system where these individuals have a strong financial incentive to keep the facility short staffed because they are making more money because of it. They see new employees who appear on the schedule and take their OT/DT as a threat to their income. Also, offering OT to an employee who called off earlier in the week allows that individual to earn more money that week than if they had shown up for their scheduled shift. Rotating staff � this leads to call-offs the days after the rotation. Sick pay � use it or lose it policies encourage staff to use it. You are much better off paying a portion of it out as a reward to those with great attendance records. No sick pay until second day of absence � this is an interesting one. Are you encouraging the person to call off for two days instead of one? No incentives or disincentives � Ignoring the staff with issues and those with excellent attendance records is another way that a system, or lack of a system, encourages the problem to continue.

17. �This is not corporate social work. It�s a business imperative.� Courtney Pratt CEO Toronto Hydro

18. Rhode Island Background State Statistics(see below for key to abbreviations) PC/HC Aide = Personal Care/Home Care AideHHA = Home Health AideCNA = Certified Nursing Assistant -- These charts include numbers for the BLS occupational group "nursing aides, orderlies and attendants."Avg DCW = Average direct-care worker wages -- calculated as a weighted medianUnited States and state abbreviations are used (ex: VT = Vermont)In 2000 152,402 (14.5%) of Rhode Island's 1,048,319 citizens were aged 65 or older, a 1.2% increase since 1990. Rhode Island has one of the highest proportions of older adults of any state. The US Census estimates that by 2030 Rhode Island's elder population will increase by 61.7%. By that year the traditional caregiving workforce (women aged 25 to 44) will decrease by 8.5%. The Bureau of Labor Statistics reports that in 2004 12,720 nursing assistants, home health aides, and personal care/home care aides worked in Rhode Island earning an average of $11.31 an hour. These numbers do not include many direct-care workers who are self-employed. According to a survey by the American Healthcare Association (AHCA) in 2002 the statewide vacancy rate for Rhode Island CNAs was 14.4% and the turnover rate was 82.7%. It is anticipated that the state's already high rates of direct-care worker vacancies and turnover will get worse as the population continues to age, and the 'care gap' between those needing care and those available to care for them continues to widen.Sources:Background State Statistics(see below for key to abbreviations) PC/HC Aide = Personal Care/Home Care AideHHA = Home Health AideCNA = Certified Nursing Assistant -- These charts include numbers for the BLS occupational group "nursing aides, orderlies and attendants."Avg DCW = Average direct-care worker wages -- calculated as a weighted medianUnited States and state abbreviations are used (ex: VT = Vermont)In 2000 152,402 (14.5%) of Rhode Island's 1,048,319 citizens were aged 65 or older, a 1.2% increase since 1990. Rhode Island has one of the highest proportions of older adults of any state. The US Census estimates that by 2030 Rhode Island's elder population will increase by 61.7%. By that year the traditional caregiving workforce (women aged 25 to 44) will decrease by 8.5%.

19. RI High Demand Occupations 2002 - 2012 Waiters and Waitresses Cashiers Retail Sales Registered Nurses Food Preparation Nursing Aides Nursing and Res care will add 5,000 jobs between 2002 and 2012Nursing and Res care will add 5,000 jobs between 2002 and 2012

20. Valuing and Respecting Caregivers Caring produces results: High trust Empathy Understanding Respect for caregivers Support staff Another key variable between the low and high turnover facilities was in how they looked at and treated the frontline caregivers. The low turnover facilities had leaders who had a genuine respect and a clear understanding of what the frontline�s staff lives were like outside of work.Another key variable between the low and high turnover facilities was in how they looked at and treated the frontline caregivers. The low turnover facilities had leaders who had a genuine respect and a clear understanding of what the frontline�s staff lives were like outside of work.

21. I will address the question that you will likely face � �Isn�t this too idealistic. Come on, I have bottom line objectives to meet. I answer to the owners. I answer to Wall Street. Things are going pretty well. We are making money. We give good care. Our survey results were at the state average. We have not had a citation in the past 14 months. Our QMs are at or a little below the state average. I think our staff morale is ok. Residents and families seem happy. No one has complained lately. So why should I embark on this transformational change?� This is a legitimate question. You have heard the altruistic reasons. Not everyone will respond. Let me arm you with the business case that you may consider using to recruit facilities to participate. However, you may need to use these facts to prompt individuals to change after you recruit them.I will address the question that you will likely face � �Isn�t this too idealistic. Come on, I have bottom line objectives to meet. I answer to the owners. I answer to Wall Street. Things are going pretty well. We are making money. We give good care. Our survey results were at the state average. We have not had a citation in the past 14 months. Our QMs are at or a little below the state average. I think our staff morale is ok. Residents and families seem happy. No one has complained lately. So why should I embark on this transformational change?� This is a legitimate question. You have heard the altruistic reasons. Not everyone will respond. Let me arm you with the business case that you may consider using to recruit facilities to participate. However, you may need to use these facts to prompt individuals to change after you recruit them.

22. Critical Components Quantitative assessment Drill down turnover rates by: Discipline Length of service Unit Employment status Qualitative � What�s it like being new? Individualized Orientation Peer Mentor Program

23. CMS Special Study: Workforce Retention Quantitative Drill Down In one Corporation: 37% of their turnover occurred in the first 90 days 53% in the first 6 months In another: 200% turnover rate of C.N.A. class participants In one individual facility: 50% of new hires left within the first 7 days As a result of collecting the dataAs a result of collecting the data

24. CMS Special Study: Workforce Retention Qualitative Assessment What is it like to be new? �Terrifying. People did not seem happy to see me.� �� I was moved around a lot which made it hard to get to know the residents.� �I did not receive training on proper transferring techniques until 3 weeks after I had started.� �It was great. The people were nice and I learned a lot.� One MPQ staff member who was interviewing an employee about their first experiences there indicated that the employee had tears in her eyes when she was answering the questions. � Another MPQ executive who asked the nursing home staff these questions indicated that she felt that �we� had let the employee down by not providing her with adequate training and the information she needed. � One MPQ staff member who was interviewing an employee about their first experiences there indicated that the employee had tears in her eyes when she was answering the questions. � Another MPQ executive who asked the nursing home staff these questions indicated that she felt that �we� had let the employee down by not providing her with adequate training and the information she needed. �

25. Being New What was it like for you? What was good? What was difficult? What is like for you new staff? What is good? What could be better? Think about a time your first few days on a new job were rough � what happened? Think about a time when your first few days on a new job went smoothly � why, what did the organization do to make you feel welcome? Do we make our new staff feel welcome? Think about a time your first few days on a new job were rough � what happened? Think about a time when your first few days on a new job went smoothly � why, what did the organization do to make you feel welcome? Do we make our new staff feel welcome?

26. Enhancing Orientation Collect the data Recruit a multidisciplinary team Include new and veteran Analyze the data Root-cause Design a new program Pilot test the new program PDSA

27. Components of Excellent Orientation Programs Individualized Brand new CNA�s or new grad�s vs. experienced Communication with veteran staff/mentors Participation of all Department Heads Formal welcome from Administrator Mission, vision, values, individualized care Make the first few days fun, interesting Have them do something meaningful and praise them Keep the paperwork to a minimum Remember, just cause they accepted the job does not mean they are loyal to your organization. The wrong first impression or a bad first day and many will not come back for the second day. It does not have to be boring � all paper work Remember, just cause they accepted the job does not mean they are loyal to your organization. The wrong first impression or a bad first day and many will not come back for the second day. It does not have to be boring � all paper work

28. Key Components continued Bite the bullet � work understaffed Orient them to their consistent assignment Gradual ramp-up for new grads and new certified Be aware of �hitting the wall� Frequent check-ins by supervisors, Administrator Free meals for first week Additional education interpersonal communication, dementia, death and dying Praise Formal Peer Mentor program

29. Peer Mentoring is� A process in which an experienced CNA: acquaints a new CNA to the customs, resources, and values of the organization serves as a clinical care role model It supplements, but does not replace, existing orientation Formal program: Application, interview, selection, wage increase Orientation and on-going education Oversight, support, evaluation

30. Effects of Peer Mentoring on Retention Program to promote excellent CNAs Step on a career ladder Supports new hires for first six months Critical for nurse aides who were recently certified Supports charge nurses Demonstrates management cares

31. Peer Mentors Key character traits: Positive Friendly, out-going Good teachers and communicators See the �big picture� Solid clinical skills Individualize care

32. Four Roles of Peer Mentors: Role Model Tutor Peer Resource Social Support

33. Success Factors of Mentor Programs Involve staff in the process of development Fairness of selection of peer mentors Formal job description Communication and education of all staff Designated coordinator New staff assigned before first day Have lunch the first day Works with new hire on the new hire�s assignment Frequent check-ins Measurement � retention bonus