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An information-based approach to staff efficiency

October 1, 2008
by Jerry L. Rhoads, CPA
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This software developer takes a systematic approach to staff structuring and operations

The clock ticked 11:00 p.m. and still no nurse for the Medicare unit. The agency called and said the last bill had not been paid and they would not staff that shift. The director of nursing (DON) was called and was going to work that unit herself to cover the shortfall—in all, the sixth time this month we had a crisis on the night shift.

All kinds of incentives were used to get staff to show up: shift differentials, 40 hours paid for 26 hours worked, sign-on bonuses, days off for days worked, free passes to ballgames and movies, more money per hour for working off-shifts. Nothing seemed to work for any length of time.

This was occurring when I was running nursing homes 10 years ago. Everyone blamed it on a nurse shortage. In fact, aides just did not want to work in nursing homes. Is it possible to improve morale and attitudes to impact retention and attendance? The answer is an emphatic yes!

But why? Is it more money? Is it more time with the resident? Is it more authority? Is it better benefits? Is it more status? Is it a better future? Is it having better tools to get the work done? Is it knowing what the workload will be when they get there? Or is it just plain liking the job better? The experts suggest that it is all of these, but one will stand out as the primary impetus to cutting turnover and call-ins: the workload and the worker's capacity to get it done to management's satisfaction.

In my experience in turning around numerous poor performing facilities, the workers' attitude toward their work was impacted more by how we delegated the tasks than anything else. When the method of assigning the work was restructured, the facility that had been decertified for poor quality turned around immediately. In three months it went from being targeted for closure to getting five of the six stars of quality given by the surveyors.

We have refined this concept over the last 10 years. In essence the technique is called Activity Based Analysis. As the name suggests, it starts with basic questions—for example, what does the typical certified nursing assistant(CNA) do during a shift and how do her/his qualifications match up?

In our studies, CNAs have been typically responsible for 20 to 25 tasks per shift for each resident. Of course they don't get that workload done—not even close. They tend to do the easier tasks first and, if they have time left or are not pulled to cover the dining room or rounds, they may get some PROM (Positive Range of Motion) exercises done. Moreover, of the tasks that the CNAs perceive they are responsible for, only half require a certification to do. In other words, over half their day is wasted on busywork that someone less costly could do.

In my facilities when we took this busywork away and assigned it to hospitality aides, the CNAs' work attitude improved immediately, as did retention and attendance. We also were able to get restorative and rehab programs done that weren't being done before. This resulted in more residents ambulating, with fewer bedsores and better appetites. And the facility getting five stars for quality from surveyors and a growing census.

When we did a nursing task analysis, we found that of the 41 tasks that the nurse perceived she was responsible for, only 16 required a nursing license to do. A CNA or a hospitality aide could do the other 25. We also found that housekeepers were delivering a workload that was not meeting management's expectations because they did what they could get done, not necessarily what needed to be done. Indeed, all functions had workloads that did not meet their job descriptions or management's perception of what was needed.

This was, in sum, a certain indication of a fouled up business model.

Improved classifications

This revelation motivated a complete restructuring of the organization chart. We turned it upside down and put the patient at the top. We assigned different specialty units to Nurse Case Managers, utilizing our case management software, staffed the units with specialized case management teams, and did away with traditional departmentalization. Hospitality Services became the foundation for nonclinical resident services, encompassing housekeeping, laundry, dietary, and maintenance. Together with the Clinical Services, the Case Managers run their specialized units with their teams. The result is improved morale, improved work conditions, improved attendance, and improved retention of high-performing staff (Table 1).

The functional staffing breakdown

Alzheimer's Unit

Respiratory Unit

Rehab Unit

Extended Care Unit

Chronic Care Unit

Case Manager

Case Manager

Case Manager

Case Manager

Case Manager

Psycho/Soc Tech

High Tech Nurse

Rehab Nurse

Unit Nurse

Restorative Nurse

Behavior Tech

Pharmacology

Rehab Aide

Restorative Aide

Restorative Aide

Recreation Leader

ADL Aide

Restorative Aide

ADL Aide

ADL Aide

Hospitality Aide

Hospitality aide

Hospitality Aide

Hospitality Aide

Hospitality Aide

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