THE COST OF TURNOVER:
Advancing Excellence Campaign
Washington, D.C. (September 27, 2011)
Nicholas G. Castle, Ph.D.
CastleN@Pitt.edu
Graduate School of Public Health
University of Pittsburgh
INTRODUCTION:
 Introduction
 From ivory tower (in PA)
 Tell you what you already know!
 Resident-to-resident abuse
 Patient Safety Culture
 Agency staff use
 Worker injuries
 Quality of care
 Deficiency citations
 Leadership
 TURNOVER (TODAY)
Graduate School of Public Health
University of Pittsburgh
INTRODUCTION:
Introduction / Conclusion
 Bottom line
 Need less turnover
 Turnover influences quality
 (Men’s Health: Research stating the
obvious!)
 More “refined” message(s)
 Others need to understand importance of
turnover
 Many costs associated with turnover
Graduate School of Public Health
University of Pittsburgh
INTRODUCTION:
 What to expect!
 Research (what we know about turnover)
 Format (information)
 No formula
 No prescription
 Some advice
 AND Thank You!
>20,000 surveys (10 years)
 Provide Some Feedback
Graduate School of Public Health
University of Pittsburgh
INTRODUCTION:
 Research Sponsor
 The Commonwealth Fund
 Staff Assist
 http://www.crhc.pitt.edu/StaffAssist/
o CAHPS Survey (Satisfaction)
o U. Pitt Research Network
Graduate School of Public Health
University of Pittsburgh
TOP MANAGEMENT TURNOVER:

How Much Turnover? (Study 1):
TOP MANAGEMENT TURNOVER
 Administrators, average turnover rate of 43% per
year.
 Directors of Nursing, average turnover rate of
39% per year.
 In most facilities one member of top management
leaves every year.
 Some facilities had 6 NHAs or 6 DONs in one year.
 Primary data from surveys of approx 3,000 top
managers (2005, 2007, 2009)
Graduate School of Public Health
University of Pittsburgh
TOP MANAGEMENT TURNOVER:

How Much Turnover? (Study 1):
TOP MANAGEMENT TURNOVER
 More Details
 NHA / DON probability of remaining in same
position for 3 years < 33%
 Administrators, average turnover rate of 43% per
year.
 Facilities with stable (>2 year tenure) NHA and DON
= 23%.
 Facilities with “excess” turnover (>4 NHA and/or
DON) = 19%
Graduate School of Public Health
University of Pittsburgh
TOP MANAGEMENT TURNOVER:
Where do you go?
Cohort of 748 NHAs
Time 0
Retired 23 (3%)
Retired 28 (4%)
Retired 33 (4%)
Retired 37 (5%)
OTHER NH 86
NHAs (12%)
OTHER NH 91
NHAs (12%)
OTHER NH 106
NHAs (14%)
OTHER NH 90 NHAs
(12%)
SAME FACILITY
618 NHAs (82%)
SAME FACILITY
502 NHAs (67%)
SAME FACILITY 357
NHAs (48%)
SAME FACILITY 272
NHAs (36%)
NOT WORKING IN
LTC 21 NHAs (3%)
NOT WORKING IN
LTC 27 NHAs
(3.6%)
NOT WORKING IN
LTC 23 NHAs (3%)
NOT WORKING IN
LTC 20 NHAs (3%)
6 months
1 year
1.5 years
2 years
Setting: 6 states, randomly chosen participants
TOP MANAGEMENT TURNOVER:
Where do you go?
Percent
Administrator Turnover (Cohort, N=748)
90
80
70
60
50
40
30
20
10
0
82
67
48
36
6
12
18
24
33
36
Time (months)
30
42
28
48
26
54
TOP MANAGEMENT TURNOVER:
Where do you go?
Some questions of importance:
 Retire
 Reasons
 Other nursing homes
 Why
 Other LTC facilities
 Same facility
 Why
 Not working in LTC
 Why
 Good / bad
Graduate School of Public Health
University of Pittsburgh
TOP MANAGEMENT TURNOVER:
Why do you leave?
 Able to answer some important questions
 DEFICIENCY CITATIONS?
 Some association
 (fired or quit?)
 Stronger over time (performance matters)
 Not so much with NHC QMs
 DON
 Less able to work in acute care?
 Not true, frequent moves
 Influence of age
Graduate School of Public Health
University of Pittsburgh
TOP MANAGEMENT TURNOVER:
Why do you leave?
 Examine:
 Levels of job satisfaction
 SAME FACILITY
 Most satisfied with rewards, work skills, coworkers,
work load
 Least satisfied with work demands
 OTHER NURSING HOME
 Most satisfied with rewards and work skills
 Least satisfied with work demands, coworkers, and
work load
 NOT WORKING IN LTC
 Most satisfied with rewards
 Least satisfied with work skills, work demands,
coworkers, and work load
Graduate School of Public Health
University of Pittsburgh
TOP MANAGEMENT TURNOVER:

What Helps? (Study 2):
 THE EFFECTS OF TOP MANAGEMENT
PROFESSIONAL DEVELOPMENT ON
ADMINISTRATOR TURNOVER
 Examines characteristics associated with professional
development of the top management team and
administrator turnover.
 Primary data from 406 nursing homes.
 Professional development lowers turnover rate
(assumes lower top management turnover is
important).
Graduate School of Public Health
University of Pittsburgh
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Website
http://www.alboenha.state.al.us/
http://www.commerce.state.ak.us/occ/pub/nha4020.pdf
Minimum Degree
Associates
Baccalaureate-HC or Business
Additional Requirements
Supervisor Experience; AIT Program
Experience
http://www.aznciaboard.us/New%20rules%20effective%204-5-08.pdf
https://www.medicaid.state.ar.us/Download/general/units/oltc/regs/nhadmin.pdf
Associates
Associates
current RN; AIT program
Coresework; internship or experience
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdph526.pdf
(RN)
Work experience; current RN; AIT
Associates, HC related field
http://www.colorado.gov/oed/industry-license/300IndDetail.html
Baccalaureate
http://www.ct.gov/dph/lib/dph/practitioner_licensing_and_investigations/applications/pdf/nha2000.pdf
Supervisor Experience
Residency training
Associates
http://regulations.delaware.gov/AdminCode/title24/5200.shtml
Experience or AIT
AIT Program or Experience
Baccalaureate
http://www.leg.state.fl.us/statutes/index.cfm?App_mode=Display_Statute&Search_String=&URL=0400-0499/0468/Sections/0468.1695.html
Experience; AIT
H.S. Diploma
http://rules.sos.state.ga.us/docs/393/3/02.pdf
Experience or AIT
Baccalaureate
http://hawaii.gov/dcca/pvl/programs/nursinghome/application_publications
Experience; AIT
H.S. Diploma
https://secure.ibol.idaho.gov/IBOL/BoardAdditional.aspx?Bureau=NHA&BureauLinkID=100
http://lmi.ides.state.il.us/licensure/n/239.htm
http://www.in.gov/pla/2813.htm
http://www.legis.state.ia.us/aspx/ACODOCS/DOCS/645.141.pdf
http://www.kdheks.gov/hoc/regs/28-38.pdf
60 semester hours
Associates, HC
Baccalaureate
Baccalaureate
Experience
AIT
Coursework; Practicum
Practicum
http://www.lrc.ky.gov/KRS/216A00/080.PDF
http://www.labenfa.com/
http://www.maine.gov/sos/cec/rules/02/chaps02.htm#371
Baccalaureate
60 semester hours
Baccalaureate
Experience or internship
Experience
Cert in LTC or credits in management; AIT
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Renewal
Annual
Biennial
Biennial
Annual
Annual
Annual
Biennial
Biennial
Biennial
Biennial
Biennial
CEUs
24 hours
50 hours
20 CEUs
40 hours
None
40 hours
48 hours
40 hours
40 hours
40 hours
Detail
Only 6 hours can be NAB/NCERS approved self-study
Signed statement
June 30th even years; board approved
10 hours in aging or patient care
July 31 odd years
June 30th even years
Dec 31 odd years; 6 hours in ethics or resident rights
Cost
125
300
100
190
51
200
mailed to individuals
250
125
State
Arizona
Arkansas
Hours/etc
Topics
knowledge of proper needs to be
served by nursing care institutions;
background in the laws and rules
governing the operation of nursings
care institutions and the protection of
the interests of the patients in
nursing care insitutions; training in
elements of good health care
facililties administration
Substitutes
15 semester hours;
3 hours per topic
Accounting
College or Vocational courses
Management
Work exp (6 weeks = 1 credit
hour)
CLEP
CEU (10 contact hours = 1
credit hour
Personnel
Writing
Connecticut
LTCA study
Resident Care
General Admin and
Management
Financial
Management
laws and
Regulations
Personnel
management and
labor Relations
Patient Care and
Services
Planning and
Delivery Systems
Gerontology
Impact of Education of Nursing Home Administrators on Quality
Jessica Furnier & Nicholas Castle
Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh.
Objective
Results
Discussion
To determine the relationship between education
level of Nursing Home Administrators (NHAs) and
quality of care.
A total of 4,003 NHAs returned the demographics and job characteristics survey, giving a
response rate of 67%. The response rate varied little across the states, and in general, most
items on the questionnaire were answered.
Four Quality Measures were examined in this
investigation (restraint use, inadequate pain
management, and two measures for pressure
sores). Prior research identified these Quality
Measures to be sensitive to top management
characteristics.
NHA AGE
NHA TENURE
NHA EDUCATION
High School, 4%
<30 years, 16%
Associat es, 9%
Ot her, 27%
<1year, 24%
>5 years, 32%
Introduction
As noted in the Institute of Medicine’s 2001 report,
nursing home quality is poor. Research indicates
an association between organizational
performance and characteristics of top
management in a variety of industries, including
healthcare. The influence of top managers of
nursing homes (i.e., NHAs), has been
demonstrated by recent research linking high NHA
turnover to deficiency citations and poor resident
quality of care (Castle, 2005).
>51years, 40%
30-40 years,
22%
Bachelors, 55%
1-2 years, 19%
Mast ers, 30%
2-5 years, 25%
22%
Table 1 shows increased education is positively associated
with better quality of care.
Table 1: Results Examining the Influence of Education on Nursing Home Quality Indicators
(1)
(2)
Percent Physical
Restraint Use
(LSR)^
Percent With
Moderate to
Severe Pain
(LSR)^
28.5***
(1.44)
45.1***
(1.25)
47.7
(1.31)
47.3***
(2.01)
27.3***
(1.53)
39.9***
(1.33)
42.5***
(1.39)
42.7***
(2.14)
Variables
Research in other industries has shown that
education is positively associated with
organizational commitment. Higher levels of
education have also been associated with
increased performance (Chevalier, 2004).
We hypothesize that a higher educational
background of NHAs will be associated with better
quality of care.
NHA Education
Associates Degree
(vs. High School Diploma)
Bachelors Degree
(vs. High School Diploma)
Masters Degree
(vs. High School Diploma)
> Masters Degree
(vs. High School Diploma)
Methods and Materials
Educational data:
 Collected via mail survey with follow-up
reminder postcards. (6,000 mailed; 4,003
returned)
 Additional data collected: gender, age, race,
and tenure.
41-50 years,
(3)
(4)
Percent Low- Percent High-Risk
Risk Residents Residents With
With Pressure
Pressure Sores
Sores (LSR)^
(LSR)^
14.5***
(2.1)
27.2***
(1.81)
30.5***
(1.88)
28.9***
(2.89)
10.8***
(2.25)
23.8***
(1.95)
27.8***
(2.03)
25.9***
(3.1)
*p < .05; **p < .01; ***p < .001.
NHA = Nursing Home Administrator; FTE = full-time equivalent, ADL = activities of daily living, RNs =
Registered Nurses, LPNs = Licensed Practical Nurses; LSR = long-stay resident
^ Definitions can be found in Abt (2004).
Quality data:
 Obtained from Nursing Home Compare
 Measures included: restraint use, inadequate
pain management, and two measures for pressure
ulcers.
NOTE: Coefficients of interest are presented. The regression models also include as controls –
Top Management Factors (Tenure, Turnover (past 3 years), age, member of a professional association)
Staffing Factors (Nurse aide staffing (FTEs per resident), LPN staffing (FTEs per resident), RN staffing
(FTEs per resident))
Resident Factors (Resident case-mix (ADL score), Psychiatric condition, Mental retardation, Dementia
Organizational Factors (Medicaid resident occupancy, Size (number of beds), For-profit ownership, Chain
member, Occupancy rate)
External Factors (Medicaid reimbursement rate, Competition (Herfindahl Index),
Elderly in county (per 1000 population), Per capita income ($))
Analysis:
 Linear regression analyses used to examine the
association of education with quality measures.
References
Abt Associates Inc (2004). National Nursing Home Quality Measures: User’s Manual. Cambridge, MA: Abt Associates. Retrieved August 25, 2010
http://www.cms.hhs.gov/NursingHomeQualityInits/35_NHQIArchives.asp#TopOfPage
Chevalier, A., Harmon, C., Walker , I. and Y. Zhu, 2004, “Does Education Raise Productivity, or just Reflect It?”, Economic Journal, Vol. 114, F499-517.
Castle, N.G. (2005). Turnover begets turnover. The Gerontologist, 45, 186-195.
We find ALL four of these measures to be
positively associated with NHA education. As the
average age of the elderly increases, the
complexity of care provided in nursing homes will
rise, and additional educational preparation may
prove to be critical to meet these ever increasing
demands.
Public Health & Policy Impact
 3.5 million elders per year receive care in nursing
homes.
 Much of this care is sub-standard and can cause
harm (Almost all facilities received citations in 2008).
 Each state has minimum requirements for
licensure (which includes education levels).
 States have extensive latitude in their licensure
requirements.
 Increasing minimum education levels may
improve management and in turn, improve quality.
Significantly, the point estimates show that moving
NHA education levels from a High School Diploma
to a Bachelors degree would be associated with:
 45% reduction in Physical Restraint Use.
 40% reduction in residents with Moderate to Severe
Pain.
 27% reduction in incidence of Pressure Sores in LowRisk Residents.
 24% reduction in incidence of Pressure Sores in HighRisk Residents.
Future Directions
Examine the impact of:
 Minimum state training requirements on quality
 NHA and Director of Nursing Experience on quality
 Continuing education on quality
Variables
(1)
Physical
Restraint Use
NHA Education
Associates Degree
(vs. High School Diploma)
Bachelors Degree
(vs. High School Diploma)
Masters Degree
(vs. High School Diploma)
> Masters Degree
(vs. High School Diploma)
STATE Licensure
Education Score
(1,2,3)
Training Score
(0-100)
*p < .05; **p < .01; ***p < .001.
(2)
(3)
(4)
Inadequate
Low-Risk
High-Risk
Pain
Residents With Residents With
Management Pressure Sores Pressure Sores
(5)
Residents With
Catheters
27.9***
(1.44)
43.6***
(1.25)
43.5***
(1.31)
47.2***
(2.01)
27.8***
(1.53)
39.3***
(1.33)
41.4***
(1.39)
42.9***
(2.14)
14.5***
(2.1)
26.4***
(1.81)
29.3***
(1.88)
29.3***
(2.89)
11.6***
(2.25)
23.9***
(1.95)
27.3***
(2.03)
26.6***
(3.1)
7.8***
(2.00)
19.9***
(1.74)
23.3***
(1.82)
23.2***
(2.79)
3.8***
(0.43)
0.11***
(0.02)
3.4***
(0.43)
0.12**
(0.03)
3.3***
(0.54)
0.05
(0.03)
3.4***
(0.57)
0.04
(0.03)
3.9***
(0.50)
0.03
(0.03)
TOP MANAGEMENT TURNOVER:
 So What? (Study 3): ADMINISTRATOR
TURNOVER AND QUALITY OF CARE IN NURSING
HOMES Study
 Administrator turnover is associated with a higher
than average proportion of residents who were





catheterized
had pressure ulcers
were given psychoactive drugs
and with a higher than average number of quality-ofcare deficiencies.
Repeated with DON
 Similar findings (different QMs)
Graduate School of Public Health
University of Pittsburgh
QUALITY
Turnover
390
370
350
330
310
290
270
250
230
210
190
170
150
130
110
90
70
50
30
10
TURNOVER
Quality
100
90
80
70
60
50
40
30
20
10
0
QUALITY
Turnover
390
370
350
330
310
290
270
250
230
210
190
170
150
130
110
90
70
50
30
10
TURNOVER
Quality
100
90
80
70
60
50
40
30
20
10
0
QUALITY
Turnover
390
370
350
330
310
290
270
250
230
210
190
170
150
130
110
90
70
50
30
10
Quality
TURNOVER
100
90
80
70
60
50
40
30
20
10
0
TOP MANAGEMENT TURNOVER:
 So What? (Study 4):
 TURNOVER BEGETS TURNOVER
 Association between turnover of nursing home
administrators and staff turnover.
 419 nursing facilities and the 1999 On-line Survey,
Certification, and Reporting System (OSCAR)
 10% increase in top management turnover
21% increased turnover of Nurse Aides
30% increased LPN and RN turnover
 Confirms interviews with nurse aides
 “If management does not want to work here, why
should I?”
Graduate School of Public Health
University of Pittsburgh
The Quality Porcupine
Parsimony vs.
Completeness
Data Sources
QUALITY
Quality
FACILITY CONTEXT AND MARKET CONTEXT
(e.g., bed size, ownership, chain
membership, occupancy,
Medicaid occupancy, top
management)
(e.g., competition,
unemployment)
++ Staffing levels
+++ Staff Stability
++ Professional Staff Mix
--- Agency staff
+++ Consistent resident
assignment
Staffing interactions^
Staffing nonlinearities^^
0
Staffing levels
0
Staff Stability
+++ Professional Staff Mix
--- Agency staff
+++ Consistent resident
assignment
Staffing interactions^
Staffing nonlinearities^^
CONSISTENCY
COORDINATION
Resident
*Acuity
*Demogra
CARE PROCESSES
QUANTITY OF
CARE
+++ Staffing levels
0
Staff Stability
0
Professional Staff Mix
++ Agency staff
+++ Consistent resident
assignment
Staffing interactions^
Staffing nonlinearities^^
Resident
Outcomes
(Quality of Care)
Top
Management
CARE
PRACTICES
+ Staffing levels
++ Staff Stability
+++ Professional Staff Mix
Agency staff
+++ Consistent resident
assignment
Staffing interactions^
Staffing nonlinearities^^
FACILITY AND MARKET CONTEXT
+ = hypothesized positive influence on care processes (with increasingly more +’s indicating a stronger positive influence); 0 = no hypothesized influence on care processes; – =
Graduate
of Public
Health
hypothesized School
negative influence
on care
processes (with increasingly more –’s indicating a stronger negative influence).
University of Pittsburgh
STAFF TURNOVER:
High levels of staff turnover in nursing
homes?
 Nurse Aides = 71%
 Licensed Practical Nurses = 49%
 Registered Nurses = 50%
Source: Decker at al. (2003)
Graduate School of Public Health
University of Pittsburgh
STAFF TURNOVER:
So What?
GAO (2001): turnover among nurse aides working
in nursing homes is:
13-18% percent higher than the overall labor force
 20% higher than other service workers.
100,000 FTE vacancies at nursing homes
½ this post recession?
Does vary by state
Graduate School of Public Health
University of Pittsburgh
State
AL
AR
AZ
CA
CO
CT
DE
FL
GA
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
Number of
Facilities
in Sample
119
124
62
548
107
170
26
455
192
242
29
446
213
176
168
121
228
122
60
217
189
264
73
30
214
36
111
45
NA 1
Turnover
82%
121%
93%
61%
57%
43%
60%
66%
78%
55%
62%
58%
74%
87%
92%
95%
47%
49%
41%
53%
81%
91%
60%
58%
68%
38%
36%
49%
LPN 1
RN 1
DON 2
NHA 2
Turnover Turnover Turnover Turnover
44%
66%
72%
42%
40%
33%
27%
57%
55%
32%
47%
40%
57%
59%
53%
43%
45%
38%
30%
32%
26%
53%
56%
44%
50%
22%
24%
34%
50%
51%
69%
45%
40%
39%
37%
51%
45%
35%
54%
43%
57%
55%
59%
50%
43%
40%
32%
36%
28%
53%
71%
42%
45%
25%
21%
34%
55%
63%
67%
51%
44%
35%
21%
53%
56%
32%
37%
42%
50%
46%
53%
28%
36%
29%
23%
26%
21%
52%
55%
37%
33%
24%
25%
28%
47%
55%
63%
58%
40%
37%
27%
50%
57%
39%
39%
40%
53%
43%
46%
36%
33%
40%
30%
28%
33%
48%
44%
47%
38%
32%
29%
31%
NA
Vacancy
3
Rate
LPN
Vacancy
3
Rate
RN
Vacancy
3
Rate
10%
8%
7%
10%
8%
9%
12%
12%
10%
7%
8%
8%
11%
10%
8%
10%
9%
12%
9%
11%
10%
9%
12%
13%
9%
10%
11%
12%
10%
11%
11%
15%
12%
11%
14%
12%
12%
10%
9%
8%
12%
7%
7%
9%
14%
11%
7%
11%
10%
14%
15%
15%
10%
9%
9%
13%
9%
12%
13%
14%
11%
14%
15%
12%
14%
9%
10%
10%
15%
9%
8%
8%
15%
12%
8%
10%
9%
13%
14%
16%
10%
6%
8%
14%
NOTE: data from 8,023 nursing homes collected in 2004 (Castle, 2005)
State
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
SUMMARY
Number of
Facilities
in Sample
200
34
12
351
520
164
82
366
51
90
51
175
547
38
103
18
142
220
60
12
8023
NA 1
Turnover
49%
72%
66%
43%
71%
75%
61%
42%
63%
66%
47%
80%
82%
81%
66%
62%
60%
43%
55%
50%
64%
LPN 1
RN 1
DON 2
NHA 2
Turnover Turnover Turnover Turnover
36%
57%
67%
35%
41%
59%
39%
35%
36%
46%
24%
50%
52%
46%
51%
24%
39%
27%
31%
37%
43%
42%
62%
66%
41%
50%
52%
46%
37%
53%
43%
21%
51%
54%
61%
49%
50%
37%
30%
58%
32%
46%
31%
46%
29%
37%
40%
57%
34%
30%
23%
31%
36%
41%
62%
48%
54%
24%
44%
35%
32%
36%
39%
35%
45%
32%
46%
41%
54%
39%
36%
32%
40%
42%
40%
41%
43%
57%
37%
32%
38%
39%
44%
41%
NA
Vacancy
3
Rate
LPN
Vacancy
3
Rate
RN
Vacancy
3
Rate
14%
10%
12%
12%
12%
13%
11%
13%
10%
10%
9%
11%
11%
11%
7%
8%
7%
9%
11%
8%
10%
15%
17%
13%
11%
10%
13%
10%
11%
11%
5%
6%
8%
8%
9%
10%
12%
14%
10%
12%
8%
11%
16%
16%
15%
12%
13%
10%
9%
12%
13%
9%
7%
9%
14%
12%
11%
12%
13%
11%
14%
9%
12%
NOTE: data from 8,023 nursing homes collected in 2004 (Castle, 2005)
STAFF TURNOVER:
So What?
 Data used in this investigation came from
surveys of nursing home administrators
(N=6,005), Nursing Home Compare; Online
System for Certification and Administrative
Reporting data, and, the Area Resource File.
 From the 18 turnover variables of interest
(i.e., 6 quality measures and NA, LPN, and
RN turnover) 11 coefficients were
statistically significant.
Graduate School of Public Health
University of Pittsburgh
STAFF TURNOVER:
Figure 1: Hypothesized Quality-Turnover Relationship
Quality (higher value = lower
quality)
140
120
100
80
60
40
20
0
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
Turnover (percent)
Graduate School of Public Health
University of Pittsburgh
Long Stay Quality Factor and
Nurse Aide Turnover and Agency Use
Long Stay Quality Factor
0.6
0.4
0.2
0
-0.2
-0.4
-0.6
0
10
20
30
40
50
Percentage Agency Use
quality at low na turn
quality at mean na turn
quality at high na turn
Long Stay Quality Factor and
Registered Nurse Turnover and Agency Use
Long Stay Quality Factor
0.6
0.4
0.2
0
-0.2
-0.4
-0.6
0
5
10
15
20
25
30
Percentage Agency Use
quality at low rn turn
quality at mean rn turn
quality at high rn turn
STAFF TURNOVER (2):
 Causal Analysis?
 Registered Nurses, Licensed Practical Nurses,
and Nurse Aides were measured quarterly from
2003 through 2007, and come from 3,939
facilities.
 Generalized method of moments (GMM)
estimation was used to examine the effects of
a change in staffing levels on change in four
quality measures (physical restraint use,
catheter use, pain management, and pressure
sores).
Graduate School of Public Health
University of Pittsburgh
STAFF TURNOVER (2):
 Causal Analysis?
 For staff turnover, 7 of the 12 coefficients
were significant, and in all cases increasing
turnover was associated with decreasing
quality.
 Castle, Medical Care, 2011
Graduate School of Public Health
University of Pittsburgh
STAFF TURNOVER (2):


VARIABLES


Δ NA Staffing Levels

Δ LPN Staffing Levels

Δ RN Staffing Levels

Δ
Levels

Δ
Staffing

Δ
levels

Δ
NA Agency Staffing
LPN Agency
Levels
RN Agency Staffing
NA Turnover

Δ LPN Turnover

Δ RN Turnover

Δ Professional Staff
Mix

Dummy variables for
quarters

Graduate School of Public Health

QUALITY INDICATORS

Catheter
use
0.36
(0.48)
0.49
(0.68)
0.44***
(0.06)
-0.38***
(0.09)
-0.11
(0.21)
-0.14***
(0.02)
-0.60**
(0.20)
-0.31**
(0.17)
-0.52***
(0.13)
0.03**
(0.01)
Physical 
restraint use

0.73***


(0.03)


0.17**


(0.04)


0.12*** 

(0.03)


0.16


(0.07)


-0.15


(0.26)


-0.46


(0.42)


-0.65**


(0.24)


-0.49


(0.68)


0.05


(0.12)


0.16


(0.21)


X

X

Pain 
management

0.46**


(0.17)


0.15**


(0.05)


0.53*


(0.28)


-0.32*** 

(0.02)


-0.19


(0.08)


-0.31** 

(0.11)


-0.24** 

(0.09)


-0.29


(0.27)


-0.27** 

(0.11)


0.15***


(0.03)


X
Pressure
sores
0.81***
(0.11)
0.16***
(0.04)
0.46***
(0.17)
-0.19***
(0.08)
-0.67
(0.42)
-0.32**
(0.18)
-0.11***
(0.04)
-0.16
(0.250
-0.65**
(0.19)
0.42*
(0.21)

X
University of Pittsburgh
COST Study:
IS THERE A BUSINESS CASE FOR LOWER
TURNOVER?
 Caudill and Patrick (1991)
 Replacing CNA = $2,000
 Replacing RN = $7,000
 Seavey, D., “The Cost of Frontline Turnover in LTC.”
(2004)
 Replacing CNA = $2,500
 Better Jobs Better Care
http://www.bjbc.org/content/docs/TOCostReport.pdf
 $3,500 per employee
 Employee turnover's nationwide cost is roughly $4.1
billion annually
Graduate School of Public Health
University of Pittsburgh
COST Study:
Data
 Primary data (2010)
 Random sample Nursing Homes (N=2,344)
 Nationwide sample
 Cost Questionnaire
 Nursing Turnover Cost Calculation Methodology
(NTCCM) (Jones, 1990, 2005).
 Used in business and nursing professions
Graduate School of Public Health
University of Pittsburgh
COST Study:
Includes Pre-Hire and Post-Hire costs
 Pre-hire = advertising and recruitment
 post-hire = orientation and training

Include both direct costs (newspaper
advertisements) and indirect costs (time
spent interviewing)
Graduate School of Public Health
University of Pittsburgh
COST Study:
 Replacement Costs




Pre-employment administrative expenses
Cost of attracting applicants
Cost of entrance interviews
Pre-employment information gathering
Graduate School of Public Health
University of Pittsburgh
Cost Category
Pre-hire Costs
Advertising &
Recruitment Costs
Vacancy Costs
Hiring Costs
Post-hire Costs
Orientation &
Training Costs
New-Hire
Productivity Costs
Pre-Turnover
Productivity Costs
Termination Costs
Description of calculation and adjustments
The sum of (1) labor and travel and other expenses associated with job fairs,
student visitation, community recruitment; (2) newspaper and internet
advertisements, and other media purchases; (3) paper and other supplies
associated with advertising and recruitment.
The sum of (1) labor and expenses linked to overtime due to understaffed
conditions; (2) missed or denied transport revenue due to understaffed conditions.
The sum of (1) labor and expenses linked to interviewing candidates; (2) processing
paperwork for candidates and new hires; (3) bonuses for new hires; (4) expenses
linked to use of employee search and hiring firms; (4) expenses linked to
background checks performed on candidates and new hires.
The sum of (1) labor and expenses linked to initial orientation of new hires; (2)
precepting new hires; (3) expenses associated with printing orientation materials,
supplying binders and company booklets and other materials to new hires; (4)
expenses linked to providing company clothing and equipment to new hires, and
providing health screenings or vaccinations for new hires; (5) and expenses
associated with agency equipment purchases specifically for new hire training.
The sum the productivity costs for new hires (the difference between 90%
productivity and productivity during the learning curve period).
The sum of labor costs linked to time administrators or equivalent employees spend
filling shifts that employees who turnover during the month in question end up
missing for one reason or another.
The sum of (1) labor and expenses linked to time administrators spend conducting
exit interviews of terminated employees; (2) expenses associated with producing
and printing materials and processing equipment and clothing linked to the
termination process (e.g. washing or replacing employee agency issued clothing
and equipment); (3) and expenses linked to paying the terminated employee early
retirement, unused vacation compensation, or other related payout expenses
unrelated to providing them with a final check.
COST Study:
Results
 CNA
 Cost per replacement $3,940
 Range $1,056 -- $5,530
 RN
 Cost per replacement $5,901
 Range $2,306 -- $8,921
Graduate School of Public Health
University of Pittsburgh
Overall Costs
4000
3800
Cost Per CNA ($)
3600
3400
3200
3000
2800
2600
2400
2200
2000
0
50
100
150
200
250
Average Turnover
300
350
400
450
500
Overall Costs
4000
3800
Cost Per CNA ($)
3600
3400
3200
3000
2800
2600
2400
2200
2000
0
50
100
150
200
250
Average Turnover
300
350
400
450
500
Termination Costs
4000
3800
Cost per NA ($)
3600
3400
3200
3000
2800
2600
2400
2200
2000
0
50
100
150
200
250
300
Average Turnover
350
400
450
500
Implications / Further Research:
 Cost “savings” for high turnover
 Even cheaper to “fire” someone
 Business of high turnover
 Learning curve for high turnover
 BUT




Does
Does
Does
Does
not
not
not
not
Graduate School of Public Health
include
include
include
include
lower Quality
occupancy (loss)
NHA/DON turnover
absenteeism
University of Pittsburgh
Including Top Management Turnover
Costs
4500
Cost per NA ($)
4000
3500
3000
2500
2000
0
50
100
150
200
250
300
Average Turnover
350
400
450
500
Including Top Management Turnover
Costs and Absenteeism Costs
5500
5000
Cost per NA ($)
4500
4000
3500
3000
2500
2000
0
100
200
300
Average Turnover
400
500
Implications / Further Research:
 Additional analyses
 By region (some differences)
 By chain (less than expected)
 Union (less than expected, some less
turnover)
 Use median values
 Weight by larger facilities
 Influence of fluctuations in turnover over
time
 More than 50% are stable (consistent)
Graduate School of Public Health
University of Pittsburgh
Implications / Further Research:
 Next step
 Assisted Living (n=>3,000)
 Similar turnover levels
 Somewhat less expensive
For reference
 Hospitals 1% > turnover $300K costs
 RN turnover $60,000
 But $42,000 = bed loss
Graduate School of Public Health
University of Pittsburgh
SOURCE: David Farrell, MSW, LNHA
Director, Care Continuum
HOW TO ACHIEVE IMPROVEMENTS?
Myths About High Turnover





CNAs do not have a good work ethic
CNAs are not reliable
Have little support at home
Have a lower commitment
Will leave for 10 cents more per hour
 Jervis, 2002
Graduate School of Public Health
University of Pittsburgh
HOW TO ACHIEVE IMPROVEMENTS?
“…these individuals were not fundamentally
different kinds of people with different work
ethics. They were, however, acting in a
different organizational and human setting,
being treated differently …..”
Susan Eaton
Graduate School of Public Health
University of Pittsburgh
HOW TO ACHIEVE IMPROVEMENTS?
Top Reasons for Leaving






Too many residents
Pay was too low
Not valued by the organization
Dissatisfaction with supervisor
Lack of opportunity to advance
Could not provide quality care
 Mickus, M., Luz, C., Hogan, A., “Voices
from The Front.” 2004
Graduate School of Public Health
University of Pittsburgh
HOW TO ACHIEVE IMPROVEMENTS?
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
MyInnerView, Inc. 2005
Graduate School of Public Health
University of Pittsburgh
HOW TO ACHIEVE IMPROVEMENTS?

Consistent assignment of Nurse Aides
(NAs).
Graduate School of Public Health
University of Pittsburgh
Definitions:

Consistent assignment is defined as “the
same caregivers consistently caring for
the same residents almost every time
they are on duty” (Care Practice Work Place
Practice Environment, 2010).

Synonymous terms include primary or
permanent assignment.
Graduate School of Public Health
University of Pittsburgh
Literature Review:

Many quality initiatives have advocated
consistent assignment
 Advancing Excellence in America’s Nursing
Homes Campaign goals and objectives
[Available at: www.nhqualitycampaign.org/files].
 State Quality Improvement Organizations
(QIOs) (e.g., Patient Safety Insights, 2011)
 Advocates for culture change (Doty, Koren, &
Sturla, 2008).
 States Offices of Health Facilities and
Certification (e.g., DE, OH, RI, IL, CA).
Graduate School of Public Health
University of Pittsburgh
Design:



Data used came from a survey of nursing
home administrators, the Online Survey
Certification and Reporting data, and the Area
Resource File.
The information including consistent
assignment and staffing variables of Registered
Nurses (RNs), Licensed Practical Nurses
(LPNs), and NAs were measured in 2007, and
come from 3,941 facilities.
Negative binomial regression and multivariate
logistic regression models.
Graduate School of Public Health
University of Pittsburgh
Results (1):
Table 1: Distribution of Level of Consistent Assignment
20.0%
17.4%
18.0%
16.0%
14.0%
Percent
12.0%
10.0%
9.2%
8.0%
8.8%
7.3%
6.5%
5.7% 5.9%
6.0%
4.3% 4.3% 4.3%
3.4%
4.0%
2.2%
4.3%
3.7%
2.5% 2.4%
3.0%
3.3%
3.3%
2.0% 1.5%
0.0%
1-5 6-10 11- 16- 2115 20 25
26- 31- 36- 41- 4630 35 40 45 50
51- 56- 61- 66- 7155 60 65 70 75
76- 81- 86- 91- 9680 85 90 95 100
Level of Consistent Assignment
Graduate School of Public Health
University of Pittsburgh
Results (2):
Variable
Percent
(n)
Use of consistent assignment (yes)
68%
(2,678)
If using consistent assignment:
Average level of consistent assignment for Nurse Aides^
62%
Distribution of average levels of consistent assignment:
Facilities with 1-33% consistent assignment of Nurse Aides
19%+
(509)
32%+
(857)
49%+
(1,312)
Facilities with 34-66% consistent assignment of Nurse Aides
Facilities with 67-100% consistent assignment of Nurse Aides
Distribution of average levels of consistent assignment at recommended level:
Facilities with =>85% consistent assignment of Nurse Aides
28%
(749)
^ calculated by facilities using the methodology distributed by Quality Partners of Rhode Island (2007).
+ Three measures do not equal 100% due to rounding error
Overall sample size = 3,941 nursing homes
Graduate School of Public Health
University of Pittsburgh
Results (3):
Staffing Characteristics:
Consistent assignment
(=>85% vs. None)
Consistent assignment
(<85%-1% vs. None)
RN staffing
LPN staffing
NA staffing
Staff mix
RN turnover
LPN turnover
NA turnover
RN agency
LPN agency
NA agency
Psuedo-R2
Graduate School of Public Health
Resident
Quality of Life
deficiency
citations
(Incident Rate
Ratios
[95%CI])
Staffing
Quality of Life
deficiency
citations
(Incident Rate
Ratios
[95%CI])
0.82***
(0.78-0.96)
0.89*
(0.75-0.98)
0.88**
(0.82-0.93)
1.11
(0.93-1.16)
0.93**
(0.83-0.97)
0.92***
(0.86-0.94)
1.02**
(1.00-1.09)
1.21
(0.95-1.26)
1.13***
(1.07-1.19)
1.11**
(1.01-1.15)
0.95
(0.91-1.06)
1.20
(0.99-1.26)
0.27
0.84***
(0.81-0.97)
0.95
(0.91-1.06)
0.94
(0.85-1.01)
0.83
(0.78-1.01)
0.91**
(0.89-0.98)
0.98**
(0.90-0.99)
1.19**
(1.02-1.26)
1.10**
(1.06-1.19)
1.16***
(1.10-1.21)
1.12*
(1.03-1.26)
0.75
(0.68-1.16)
1.13*
(1.05-1.29)
0.31
Facility
Quality of
Life
deficiency
citations
(Incident
Rate Ratios
[95%CI])
0.96**
(0.90-0.98)
0.98
(0.69-1.01)
0.89*
(0.82-0.99)
0.97
(0.78-1.02)
0.89
(0.78-1.01)
0.90**
(0.82-0.97)
1.02
(0.97-1.07)
0.97**
(0.85-0.99)
1.06**
(1.01-1.11)
1.26
(0.99-1.33)
1.01*
(1.00-1.09)
1.07*
(1.02-1.18)
0.26
Quality of
Care
deficiency
citations
(Incident Rate
Ratios
[95%CI])
J, K, or L
deficiency
citations
(AOR [95%CI])
0.97*
(0.88-0.98)
1.02
(0.85-1.09)
0.93
(0.80-1.02)
0.77
(0.56-1.00)
1.01
(0.85-1.05)
0.86**
(0.81-0.94)
0.98
(0.96-1.16)
1.05
(0.94-1.09)
1.03*
(1.00-1.09)
1.18
(0.91-1.25)
1.05*
(1.00-1.11)
1.11**
(1.07-1.21)
0.25
0.92
(0.87-1.07)
0.99
(0.97-1.11)
0.97**
(0.90-0.99)
0.96
(0.74-1.09)
0.98*
(0.90-0.99)
0.95**
(0.91-0.98)
0.91
(0.87-1.10)
1.03
(0.97-1.11)
1.07
(0.99-1.14)
1.048
(0.99-1.15)
1.09
(0.98-1.11)
1.13***
(1.04-1.15)
0.17
University of Pittsburgh
Discussion:
• Our findings that a beneficial association of
consistent assignment with deficiency
citations exists may provide some further
momentum to implementation of consistent
assignment
– In turn may enable the use of other culture
change practices.
– Improve overall quality of care of nursing homes.
Graduate School of Public Health
University of Pittsburgh
Summary:
• Consistent assignment has developed as a
preferred practice in nursing homes based
on little empirical evidence. The findings
presented here provide some tentative
justification for the use of this staffing
practice for Nurse Aides.
• Similar findings for TURNOVER
• None vs. 85% = 32% reduction
• Similar findings for ABSENTEEISM
• None vs. 85% = 41% reduction
Graduate School of Public Health
University of Pittsburgh
HOW TO ACHIEVE IMPROVEMENTS?

DEMING (the quality Guru):
“Cannot improve interdependent systems and
processes until you progressively improve
interdependent, interpersonal relationships.”
Graduate School of Public Health
University of Pittsburgh
HOW TO ACHIEVE IMPROVEMENTS?
“The problem is not motivation. It is the
ways in which we unintentionally demotivate employees.”
Quint Studer “Hardwiring Excellence”
Graduate School of Public Health
University of Pittsburgh
HOW TO ACHIEVE IMPROVEMENTS?

Communication Strategies
(For Example)
• Monthly dept. meetings
• Quarterly town hall meetings
• Learning circles
• Lunch with administration
• Newsletters
• All staff meetings
• Mini-inservices
• Communication
boards
• Lunch in break room
• Post quality data
SOURCE: David Farrell
Graduate School of Public Health
University of Pittsburgh
HOW TO ACHIEVE IMPROVEMENTS?

Recognition
(For Example)
• Raffle off gifts every month
• Neighborhoods for quality improvement
• New employees – Rookie of Month
• The power of “thank you” cards
SOURCE: David Farrell
Graduate School of Public Health
University of Pittsburgh
WE KNOW THIS!
"Every organization is perfectly
designed to get the results that it
gets".
“We can’t solve problems by using
the same kind of thinking we used
when we created them”
Albert Einstein
Graduate School of Public Health
University of Pittsburgh
Ms. Alabama Nursing Home
Ms. Hanceville Nursing & Rehab Center Crowned Ms. Alabama Nursing Home 2010
Graduate School of Public Health
University of Pittsburgh