QI project cuts aide turnover
QI project cuts aide turnover
Turnover rate drops from 69% to 52% in year
Home care business at American Nursing Care in Milford, OH, was growing rapidly in 1996, and the agency could not hire home health aides quickly enough to meet demand.
But when administrators looked at the hiring statistics, they found that the agency had a rapidly revolving door when it came to hiring aides, says Terry Pope, RN, MS, regional administrator for the private company, which has 15 licensed freestanding offices in Ohio, Kentucky, and Indiana. The company employs more than 600 aides each year.
"We had some aides staying less than a couple of weeks, so we decided we needed to address that problem as much or more than our need for new staff," Pope explains.
When the norm isn’t good enough
An internal investigation showed that by the end of 1996, the company had lost 69% of its home health aides who were hired or already working during that year. Pope has seen statistics showing that the home care industry’s average annual aide turnover rate is between 50% and 75%. But she says she decided not to use that as an excuse. "We didn’t think we should be within the industry norm; losing 69% of the people you hire is very costly," Pope says.
Pope estimates it costs the company about $3,000 each time an employee quits. The estimate includes the cost of advertising for employees, recruiting efforts, training new staff, and the time lost in patient care that cannot be handled because of staff shortages, she says.
So the agency launched a companywide quality improvement project to increase its retention of home health aides. The project worked. By the end of 1997, the agency’s aide turnover rate had fallen to 52%, and the company continues to work toward a greater improvement. Pope says she hasn’t calculated how much money was saved by the reduction in aides’ turnover.
Here’s how it worked:
1. Create a clinical ladder for aides.
Hospitals have had clinical ladders for RNs for years, and it’s an idea that can easily be used for home health aides, Pope says. American Nursing Care created four levels for aides, with the fourth level reserved for aides with the most experience. Hourly wages would rise according to an aide’s climb up the ladder.
The ladder steps are:
• Level one: This is for newly hired home health aides. They are expected to have basic skills and be competency-tested. Everyone is hired at level one.
• Level two: Aides are trained with six different modules, including videotape sessions and RN-facilitated sessions. This is to make sure they understand the core aspects of care delivery and how the agency expects them to complete their tasks.
The modules focus on the needs of the elderly, personal care, nutrition, meal preparation, patient exercise, and professionalism.
The agency used teaching videos created by Instructional Media Network of Dayton, OH, Pope says. "We were a test site for them, and we were so impressed that we bought the videos the minute they were released."
One video, for example, shows a home health aide how to improve her poor work ethic and client relationships through a series of visits from nurse aide ghosts, in the tradition of Charles Dickens’ The Christmas Carol.
Aides who complete all six modules are advanced to level two.
• Level three: Level three sessions focus on specialization. Training is provided by nurses using some video instruction. These sessions include mental health, diabetic patients, cardiac patients, and pulmonary patients. "There are plans to develop more specialized programs," Pope says.
• Level four: This level is the mentor or preceptor level. Aides can work toward level four by invitation only. They must be recommended by a supervisor, who assesses their readiness based on the following criteria:
— professionalism;
— experience;
— performance;
— behavior.
"We give them a class in adult learning and teaching and how to evaluate people and how to give encouragement," Pope explains. Then the level four aides buddy up with level one aides and become mentors for them.
So far the agency has implemented the first three levels and is about to begin level four. More than 100 aides have completed level three and are eager to be referred to level four, Pope adds.
2. Determine what is most important to aides.
American Nursing Care conducted market research on what aides expect and need from a home care job because the company was considering developing a new business that would deliver home health aides to other companies, Pope says.
"We approached this by saying if we hire enough home health aides to have the market on home health aides, then we’d have to be a pretty darn terrific employer," Pope adds. "So we did a research study analysis on that concept."
American Nursing Care eventually abandoned the idea of starting the new business, but used the market research information to help improve staff retention.
Focus groups identify 11 job priorities
The research included holding focus groups of aides, asking them to name what they want from an employer. The focus groups came up with 11 job priorities. So the company sent out questionnaires to all aides, asking them to rank these 11 priorities according to their order of importance. The survey’s results gave the agency a good idea of where it needed to focus its time and resources.
"The last part of that research process shows how much bang for the buck each priority gives me," Pope says.
Here are the aides’ 11 priorities, listed in order from most important to least important:
• Give me the working hours that fit my schedule.
• Give me the information I need to perform my job.
• Value me and respect me for the work I do.
• Provide me with the number of working hours I need.
• Provide me with friendly and supportive people in the offices.
• Give me assignments close to where I live.
• Provide me with paid time off, i.e., sick and vacation time.
• Increase my pay relative to my seniority and performance.
• Offer me affordable health care insurance.
• Pay me more than other home health care employers.
• Provide me with convenient educational opportunities.
3. Make necessary changes when possible.
Pope views the 11 priorities as a pyramid, with the first item taking up the very bottom layer of the pyramid, and so on. This model shows how the very first priorities will have to be met before the aide will care about the middle priorities. And the least important priorities at the top of the pyramid would be icing on the cake.
This means the agency could postpone spending a lot of time and resources on the less important priorities and instead focus on the crucial ones.
"For example, our clinical ladder is a cool thing, and it’s one of the most important things we’re providing aides, but it’s number 11 on their list," Pope says.
However, the career ladder also touches on the eighth priority of increasing pay relative to seniority and performance, and it will continue to be an important part of the company’s program for aides, Pope adds.
The project showed administrators that aides first and foremost want enough hours to allow them to support themselves and their families. They also want consistent hours and flexible schedules.
"Most of our home health aides are single moms, managing families and households, and they can’t live on just a few hours a week," Pope explains. "We were giving them lots of itsy-bitsy assignments." The agency repackaged its aide assignments and turned the many little assignments into fewer assignments with more hours. This in turn allowed the agency to reduce its number of new aide hires.
"Instead of hiring lots of people who did a little bit for us, we employed fewer who did more," Pope says. This required administrators to analyze why they were making these schedules with few hours and how they could change it.
Administrators learned that the agency tended to schedule most aide visits in the mornings because that’s what patients requested. This meant an aide might be given two or three hours of work a day. In order to give aides more hours, the agency would have to schedule more afternoon visits. Administrators wanted customer satisfaction to remain high, so they proceeded cautiously.
First, the agency stopped asking patients whether they preferred a morning or afternoon visit. For example, they would instead ask patients if it would be alright for an aide to begin services tomorrow at 2 p.m. Most of the time, the patients would say that was OK. If they had a problem with the time, then the agency would change it, Pope says.
The tough part was changing schedules for patients who already were receiving services at a particular hour. These changes were eventually made but they required a lot of flexibility on the part of the aides, the patients, and the agency.
Changes keep aides and patients happier
Then administrators tried to give aides schedules that were sensible geographically, Pope says. Instead of being given a patient on one side of town at 8 a.m. and another patient clear across town at 11 a.m., the aides were given cases located in the same geographic area. This also helped them improve their productivity and wages. Aides now work an average of six to 12 hours more per paycheck, Pope says.
These changes led to a higher retention rate for aides and appeared to increase patient satisfaction, Pope says. "We used to get a lot more complaints relating to scheduling and timeliness and consistency of the caregiver, and we’ve seen those complaints decrease dramatically."
4. Acknowledge you can’t change everything.
American Nursing Care officials had to admit that they could not afford to make all the changes requested by aides. For one thing, they have not yet found a way to provide health insurance and some other full-time benefits. This will be especially hard under the interim payment system because of its reduction in reimbursement, Pope says.
While aides have more hours in their schedules, they still are considered part-time employees who work on an as-needed basis, Pope explains.
But the agency has continued to emphasize some of the aides’ other desires, such as staff support, friendliness, and respect.
"We tell all of our offices to be friendly, and we have staff celebration days and pizza parties," Pope says.
Sources
• Terry Pope, RN, MS, regional administrator, American Nursing Care, 300 South Technecenter Road, Milford, OH 45150. Telephone: (937) 328-5113 or (513) 576-0229, ext. 357. Fax: (513) 576-0381.
• Instructional Media Network, 22 Daniel St., Dayton, OH 45405. Telephone: (937) 226-9999 or (800) 591-6300. Fax: (937) 226-1554.
Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.