Improvement Through a Quality Driven Organizational Model AHCA/NCAL Quality Symposium February 2009

1. Improvement Through a Quality Driven Organizational ModelAHCA/NCAL Quality SymposiumFebruary 2009 Susan Gilster, PhD, NHA Jennifer Dalessandro NHA susang@hcmg.com www.alois.com www.careleadership.com

2. Defining Quality • What is “quality?” • What is “quality care?” • What is quality of life?” Susan D. Gilster, PhD

3. Quality Driven Organizations • Quality is defined as: “degree of excellence, superiority in kind” • “Quality” and “Quality of life” in AL/LTC • Defined in terms of: • Number of pressure ulcers, restraints, pain management • More recently added, resident/family satisfaction and staff retention with permanent assignments • Goals to improve that “quality” Susan D. Gilster, PhD

4. Organizational Quality • Until the organization, all people, all departments are engaged, united and focused on quality, (excellence, superiority) develop sustainable systems the “quantity of care” will fluctuate and “quality of life” substandard Susan D. Gilster, PhD

5. Initiating Quality Model in Organizations • “The quality of leadership, more than any other single factor, determines the success or failure of an organization.” (Fiedler) • Leadership is not simply one person-improvement or change is initiated by one, must have the support of CEO, and in time includes leader + management team + all employees (resident/family too) Susan D. Gilster, PhD

6. What happens when leaders leave?Administrator Research • Castle 2007 article (N=696) • Turnover 43-70% annually in AL and NF • Administrator turnover: • Increased deficiencies/citations • Increased pressure ulcers • Increased resident catheters • Increased psychoactive drugs • Increased staff turnover-2.3 times higher RN’s at 76%, LPN’s at 78% and CNA’s at 107% Susan D. Gilster, PhD

7. NHA Staff Turnover • CCRC with 235 resident accommodations • 16 RN 12 @ 150% of $43,000=$784,320.00 • 28 LPN 22 @ 150% of $37,000=1,212,120.00 • 72 CNA 77 @ $5000=$385,200.00 • TOTAL=$2,381,640.00 per year Susan D. Gilster, PhD

8. Organizational Leadership Concerns • Lack leadership training in curriculums • Leaders desire better-don’t know how • Leaders in LTC traditionally have been “crisis management” driven • Lack systems approach, organizational structures, strategic plan, vision • Tasks and responsibilities overwhelming Susan D. Gilster, PhD

9. Susan D. Gilster, PhD

10. Organizational/Leadership Frameworks Business and Health Care Susan D. Gilster, PhD

11. Organizational Models-What do they say? All leadership models speak to quality-service All address education and learning as an ongoing necessary process Open, honest and routine communication Leaders are only as good as the people they select, prepare, educate, include, respect and value, trust, nurture, support and monitor Organizationally driven, staff take over tasks allowing leaders to lead and drive quality Susan D. Gilster, PhD Susan D. Gilster, PhD

12. S.E.R.V.I.C.E Model Development • Addresses staff research • Qualitative, historical case study • Extensive review of literature-business, health care, staff satisfaction • Leader/Administrator research 2002 • Grounded in business literature • Elements consistent with Baldridge Award and National Quality Award Susan D. Gilster, PhD

13. Susan D. Gilster, PhD

14. Organizational Leadership Model S.E.R.V.I.C.E. S ervice (Greenleaf, Kouzes, …) E ducation (Deming, Noelker, Teresi…..) R espect (Annison, Longest, Stone…) V ision (Senge, Buckingham, Dana…) I nclusion (Collins, Wheatley, Autry, Kemper…) C ommunication (Helgesen, Goleman, Olson..) E nrichment (Bennis, DuPree, Senge…) Susan D. Gilster, PhD Susan D. Gilster, PhD

15. Model as an Intervention • Two CCRC’s-200 + accommodations • Facility A-Administrator turnover q 1-2 years-new hire • Facility B-Administrator in various roles for 13 years • Leadership model was the intervention • One researcher conducted all sessions Susan D. Gilster, PhD

16. Organizational Model Intervention • Leader agreement with 7 domains of SERVICE • Implement all 7 at their own pace-own way • Staff and family survey, turnover, agency utilization, census, financials @ 3,6,(9),12 • Staff survey (54 questions) Scale 1=very unhappy, 2=unhappy, 3=happy, 4=very happy (no neutral category) Response rates 76-85% • One investigator all data Susan D. Gilster, PhD

17. Research Results • We know-staff satisfaction leads to resident & family satisfaction which leads to increased census, improved financials • Results for this session focus only on items identified consistently with staff satisfaction research, staff turnover, agency use, financials Susan D. Gilster, PhD

18. Respect from supervisor… Susan D. Gilster, PhD

19. Compliments from supervisor… Susan D. Gilster, PhD

20. Respect from my department… Susan D. Gilster, PhD

21. Respect from own shift… Susan D. Gilster, PhD

22. Respect from other departments… Susan D. Gilster, PhD

23. Know making a difference… Susan D. Gilster, PhD

24. Job prep at orientation… Susan D. Gilster, PhD

25. Frequency of ongoing inservice/education… Susan D. Gilster, PhD

26. Feeling part of team… Susan D. Gilster, PhD

27. Frequency of staff meetings… Susan D. Gilster, PhD

28. Availability of Administrators… Susan D. Gilster, PhD

29. Wages/pay received… Susan D. Gilster, PhD

30. Overall satisfaction… Susan D. Gilster, PhD

31. Would advise friend to apply… Susan D. Gilster, PhD

32. I think of changing jobs… Susan D. Gilster, PhD

33. Census and Finances • Facility A-end of the first year • Highest census ever • Decreased turnover, decreased agency use • Increased staff satisfaction-statistically significant at one year • Facility B • Maintained a high census, • Staff satisfaction continued on upward trend, • Cut turnover in half, decreased agency Susan D. Gilster, PhD

34. Facility C • Census has been maintained for years-currently undergoing second expansion • Staff satisfaction remains high-continuous effort (53 item survey, 90% response rate=3.4 average out of 4 “very happy” and 3.6 for overall satisfaction) • Family satisfaction very high (84 item survey,75% response rate=3.8 out of 4 “very happy” and 3.8 for willing to recommend) Susan D. Gilster, PhD

35. Impact of model on staffing costs • Facility A • Saved $688,000.00 staff turnover in one year • Decreased agency by tens of thousands dollars • Agency costs ranged ($10,000-50,000/mth) • Facility B • Cut turnover by more than half in one year with projected savings of $1,120,000.00 • Decreased agency use • Facility C • Turnover single digits for years • No agency use Susan D. Gilster, PhD

36. Quantity or Quality? • Organizational model intact for years-how staff defined “quality of life” • Happiness, acceptance, feeling loved, who we are as people, respect, humor, laughing, dignity, freedom of choice, communication, sharing joys, genuine love for each other, feeling valued and included, concern for others, listening to others, involvement, attachment, homelike and family feeling, compassion, trust, attentiveness, patience, individuality……… • Nothing mentioned about “care issues” Susan D. Gilster, PhD

37. Conclusion • Sustainable quality is organizationally driven • Quality Organizational models include: • Commitment to excellence-service driven • Vision-developed/interpreted with all parties • Education-organization and personal-ongoing • Respecting and valuing all • Including and listening to all • Communication-sustainable with systems perspectives • Enriching, planning, evaluating, monitoring, creating Susan D. Gilster, PhD