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A 'Care Plan' for Staffing

Clint Maun, CSP

This is a reprint from an interview that first appeared in SNALF.com, July 25, 2001

"I started my life in health care as a nursing assistant because I needed a job to get off the farm," says speaker and consultant Clint Maun. "They hired me because I was big." He stuck with it through high school and college, then moved into health care management, regional management and eventually health care ownership positions.

In 1985, Clint chose to take his extensive industry background and channel it into his own consulting and speaking company, Maun-Lemke Inc. From only two employees, the company has grown to include more than 30 affiliates and associates and partners. "We specialize in people issues in health care," he says.

Clint is a nationally known speaker and health care expert and has received the designation of distinction, Certified Speaking Professional, from the national Speakers Association. He holds a bachelor’s degree in clinical and industrial psychology, an educational background he describes as "a terrible mix of trying to fix the world." We spoke to him from his office in Omaha, Neb.

Here’s my finely tuned and profound theory on this whole long-term care recruitment and retention issue: it’s a problem.

Why else ask me my expert opinion? That’s brilliant.

How did we get to this crisis point?

I think there are three ways we got there. One, we’ve had an explosion of need for health care workers, not only at hospitals as they continue to put other nurses and nursing assistants on board, but also in home care, assisted living and skilled nursing. The rules and regulations, the requirement for staffing, and the fact that we now take care of sicker patients in nursing homes has increased the demand. Second, because of the image issues associated with being a health care professional, a lot of people have chosen not to go into that profession, or in some cases have even tried to escape from it. They leave with a very negative opinion.

The third reason is that a lot of providers didn’t start paying attention to this issue until recently. Until they were in trouble with quality, service and cost, they didn’t put staff recruitment and retention in the top two or three strategic goals for the organization. So I think the explosion of the need, a negative image and a lack of attention.

So you spend a good part of your time advising long-term care operations on how to solve this problem.

Yes, we are speakers, consultants and researchers, and I would suggest that over 50 percent of our business practice is in speeches and seminars at associations and companies on this topic of recruitment, selection and retention. The rest of my time is spent in actual hands-on consulting on the development of a proactive and positive plan to deal with this issue. We also write articles, and develop tool kits, video and audiotape products and technical assistance programs by conference and video streaming to deal with this. So we’re very involved.

On the topic of recruitment and retention, let’s start with the money. How much does it cost to find and retain an employee?

In terms of what you can actually track on the profit/loss statement of a long-term care facility, it would cost at minimum $2,500 to replace a person at the beginning wage level. Most organizations think it’s higher than that. That’s how much it typically costs to advertise, coordinate the hiring, certify, train, get up and running, human resources and cost, etc. And it goes all the way up to $20,000-$25,000 for a specialist position, an RN or a higher-level management person. If you have 100 people who work in your building and you have 100 percent turnover, you can count on the fact that the turnover cost at minimum is $250,000. That doesn’t take into account service level issues, regulatory/ compliance issues, morale issues, unemployment costs and agency or outside employment costs. It’s a big dollar amount.

You’ve developed the concept of the "Superteam." Is it safe to say that most of what you recommend fits under that umbrella?

Yes. We believe you can’t fix any problem in health care anymore, and in fact you can’t deliver a day of service in health care, unless you’re using a team concept. The days of using vertically integrated programs or top-down, parent-child models are over. It doesn’t work to staff a building, to get you the revenue you need collaboration. If you’re not forming Superteam guided with the leadership of the administrator, and with key people working at cross-functional levels, you’re not going to get it done.

I recommend Superteam as the most proactive help for people. Instead of focusing on " Woe is us, there’s a shortage, no one wants to be a nurse or nurse aide," you have to decide to go the other way with a different paradigm.

What is a Superteam?

A Superteam is made up of a group of dedicated people who find it an honor to be on the team, and usually includes ten to 12 people. The administrator probably, in a typical health care facility, chairs it. The director of nursing must be on the team, and if you have a human resources professional, they should be on it. It might include the scheduler, the in-service coordinator, a couple of unit managers or charge nurses, and some nursing assistants, as well.

That team is going to work on a vigorous "care plan," if you will. Think of staffing as the patient, and the problem needs to be care planned, just as we would for an actual patient in a health care facility. They’re going to write a 12-week plan. We believe that’s the longest period of time you can hold people together for a purpose. Otherwise it turns into a committee, a policy-writing group and a bunch of mandatory in-services.

That’s an interesting metaphor, comparing the patient care plan model to the problem of staffing.

It allows people to see clearly that fixing the staffing problem is very similar to what we’re trying to do every day with Mrs. Johnson in Room 113.

What happens to the plan after it’s developed by the Superteam?

You have to have an action team that will dedicate themselves to a 12-week plan, with numerical, outcome-based written goals. They also have to agree to sign the plan and then report weekly on what they’ve done to be successful in accomplishing the 12-week plan. That report goes to the higher-level board or management structure. They keep score of their efforts, of outcome-based achievements in areas such as reducing absences and tardiness, getting people to pick up extra shifts, hiring, turnover reduction agency count diminishing and other specific goals that are tied to the plan.

What does the plan include?

There are three areas of the plan - the recruitment area, finding people; the selection area, picking people; and retention area, keeping people. We believe most facilities have some problems in recruitment and selection and need to work on that, but the major focus should be in retaining people. They’ve got to stop the revolving door. They have a core group of people who have been there forever, but they continue to have turnover of certain positions, shifts, or sections of the building.

Retention starts with how you conduct formal orientation. It needs to change from a 1959 grade-school approach to training - an approach that’s lethargic, boring and basically a mandatory whipping - to a more invigorating, involved process. It has to include the informal orientation, how you take them out in the unit. It has to include giving the new employee a customized checklist to that position, and providing a passionate mentoring program with an assigned mentor who finds it an honor to be a mentor. The mentor must be someone who is recognized for mentoring people, not per person mentored, but by how many people he or she mentored who are still there after three months, six months, and a year. So the mentor’s recognition is based on retention. The mentors are also required to do return demonstrations and give the new employee positive and improvement-oriented feedback about how he or she is doing.
We make sure the orientation process for a new employee is just like bringing a brand-new baby home from the hospital. We’re going to take care of them and not just leave them with the neighbors. We would treat a spouse we just married in a passionate way, and we would treat a brand-new baby in a passionate way. We have to do the same thing with our brand-new coworkers.

When you use the word "passionate," what do you mean by that?

That you don’t just throw them out there and say, "Who wants to take them, who’s stuck with them?" You don’t let the wolves get a hold of them and eat the young. You don’t let the chronic negative people interact with them in the wrong way. You don’t juggle them around the whole building and shift the mentor on them from one day to the next. You don’t wait to give them any feedback until they’ve been there 90 days and tell them you’re disappointed in them. You don’t get on their case the wrong way on their first day. In other words, you don’t bring a brand-new baby home from the hospital, a baby you waned so much, and leave it alone or let just anybody take care of it, and it’s the same thing with new coworkers.

Because a new employee makes a judgment very quickly on whether they want to stay.

Our research indicates that in two to three days, the employee has already made up their mind whether they think they can acclimate into this place. Are they treated well, have they met new friends? Do they get good answers to simple questions, or are they being impugned and swallowed up into a hellhole? They might stay three weeks, we’ve even seen them stay three to six months, but they’ve already made the mental decision of whether they like this place or not very early. In fact, of that $2,500 minimum turnover cost, we are able to calculate that anywhere from 35 to 40 percent is directly related to how you create passionate orientation.

Beyond orientation, how do you go about creating an environment that’s conducive to improve retention?

People who work in health care want to be able to get the work done, take care of the residents, and be able to enjoy the work too. The younger workers especially are not going to wait for fun. They don’t want to say, "Let’s work hard and then go to the bar and gripe about what happened at work today, and in only four more months we can wear a rubber nose for Halloween." They want to have fun now. They want to enjoy work right now. They want to have it be meaningful and they want to be involved.
If you’re going to put them on teams to improve things, today’s coworkers want to be involved in real teams on real issues, not fluffy feel-good committees. They want to know they’re making a difference. They want to discuss real issues, like scheduling and time off. They want to talk about how to fix clinical problems and deal with issues associated with turf and territory, with collaboration problems on the unit. So the more you involve them in real stuff, in real fixes at the real level where the real problems are, the more you have a chance to keep people.
Schedules especially are a very, very big deal. Time off is very important to all people, particularly young workers. A lot of us of my age grew up with work being very important to us. In contrast, the young coworkers today don’t mind working hard, but they don’t get their entire value out of work. They want to be able to also enjoy their lives and have time off to do other things. And if you don’t let them get involved in some kind of team-based scheduling conversations on the unit, but are still using an old parent-child model of scheduling where everybody runs to one nut in a hut who’s supposed to plan the time off, you’re going to have a lot of disenfranchised people. The young employees never get a break in that model, because the senior coworkers already have their pact with the scheduler on time off.

What about the role of data gathering? How important is it to gather data on retention?

You have to be able to go out into the unit and into the building and dig for data and it has to be specific. How much call off behavior do we have? How many absences do we have? How much turnover? Do we have one position on A- wing of the morning shift that we replaced four times, and it turns out that the reason we replaced that person four times is because we train them badly or treat them badly or give them the heaviest care load or don’t teach them how to handle the toughest customers?
You can sit around and say you have 87 percent turnover, but that doesn’t mean anything to anybody. It’s when you can say that its position on this shift has been replaced six times this year, a 600 percent turnover rate that you can get to the real reasons that’s occurring. It could be bad supervision, the old eating the young, horrible care load, lack of training, people who were forced to work a unit or shift they didn’t want to work. But once you start analyzing the big pressure ulcers on the patient of staff retention, so to speak, you get a chance to really drive home meaningful action.

How does the team concept apply to the data gathering process?

You can start on a specific unit. You can work together to set goals and targets, like we’re going to track and try to improve our tardiness, our call-off behavior, and our pick up ability. You have to set measurable targets and amounts of time, like over one week or two weeks. Break it down into small intervals. Put scoreboards up on the unit. Talk about the scores every day at the start of the shift. Celebrate success as a team when the unit hits those scores.

Once you start doing in-depth analysis, almost like an MDS for a patient, you start to find the thresholds, the triggers so to speak, of what’s going to create the need to fix the stuff on that unit. That’s what empowers the team. The unit can also work together to keep the new employees and mentor them and even recruit, from a unit-based perspective with assistance from human resources, rather than waiting for somebody else to bring them in.

Let’s talk a bit about the recruitment process. How can you most effectively spread the word to prospective employees?

Well, I think the mistake that’s made is people wait for the corporate office or HR person or the administrator or the DON to put an ad in the paper. Then the next thing you find is we’re in a retail mode, where we’re sitting, waiting, hoping somebody drives by slow and puts in an application. The problem with that retail approach is that you’re counting on magic and fairy dust for that to happen. You’ve got to go to make it happen, and the way to do that is not by putting an ad in the paper that says, "Wanted: Hundreds! We’re desperate! We need a boatland right now!" That makes your ad look like everybody else’s.
You have to go instead to interviewing your talented people in the building, the people who show up, work extra, have great attitudes, which have been there for a while and are super people. Even in the worst staffed buildings in America, there are great people who do a great job, and you have to interview them and ask them why they work there and what makes them keep working there. You’ll find out some good things. First of all, you’ll find common themes. You’ll find out themes of people of a certain age or a certain living location or a certain background. We’ve even found that eight of our greatest people all went to this church or had kids in this school or ride this bus.

Then, you target that area specially. The ads and the ad campaign need to be talent based. They need to say something like, "What makes Mary special?" There might even be a picture of her. "Mary works at our facility because…" Then you put down three bullets with quotes from her, followed by three more bullets that say, "We like Mary at our building because…" And then at the bottom it says, "If you enjoy what Mary likes and have these qualifications, call this number for a professional interview." Then, put that ad in the paper or on the radio. Make copies of the audiotape form the radio or the flier from the newspaper and get 40 people in the building to distribute five to ten copies of it to their friends and acquaintances. That way, you get three to four hundred distributions targeted to what makes people good in our building rather than sending the message that we’re desperate.

How would you involve employees in the hiring and interviewing process?

Well, the other mistake is that the crowd is always sitting on the unit hoping they’ve got a new application, or worse yet, the wolves are sitting there hoping they’ve got a new one to eat up. So instead of using the old parent-child model of one or two people doing the interviewing, we prefer to have teammates from the unit be involved in the interviewing. We can teach them behavioral interviewing techniques, questions that are specific and outcome-based about what the candidate has done in the past, in order to get at what they’re going to do in the future.

For instance, questions along a theme of dependability are important. You’d want to know that about a coworker in health care. So you’d ask them to describe a situation in the past at school or work when you aren’t going to be able to make it in when you are scheduled to be there. Then you shut up, which is the key to interviewing, and you let them talk. You teach co-workers how to ask those questions on dependability, initiative, willingness, creativity, problem solving skills, handing complex resident issues, family concerns. You put them in planned files, ready to use for certain types of jobs and positions, and you teach several staff members how to be involved in those interview processes.

The advantage there is that if they help pick them, they’ll help keep them. If they turn them down because they don’t meet the qualifications, it’s not like management turning them all down. Now what can happen is the crowd goes back to the unit and says, "Alright, ladies and gentlemen, we had an interview today and it didn’t go well. They weren’t that good, so we’re just going to have to continue to work with who we have and pick up extra shifts, because we don’t want that type of person on the unit". And if they did pick them, they’ll go back to the unit and say, "Gosh are we excited, we have a new one, they’re starting next, and they look really good. HR is checking their references, and when they come on the unit we’ll all welcome them".

So the best way to keep the wolves from eating the young is to get them involved.

The wolves back off of the wolf behavior if they have something to do with the process. Of course, there are some wolves who don’t really want us to ever fix the staffing problem in the building, because then they can’t be the queen or king of chaos anymore, holding the building hostage with their hissy-fits and moods. And that’s another part of this program. The Superteam has to address those three or four people in the building who might be holding the building hostage.

That’s as simple and straightforward a solution for the staffing crisis as we’re ever likely to hear: teamwork.

We have dozens of teams up and running at any given time. It’s not about us coming in as consultants with a magic solution. It’s simply this team deciding they’re sick and tired of being sick and tired. They’re not going to be held hostage to bad moods and bad attitudes and old practices. They can attack this as a team, and accomplish success. We’ve seen buildings that were in terrible staffing shape and in last place in their marketplace, place that were using all kinds of outside help at high price with little service quality. With the Superteam approach, they’ve been able to stabilize themselves in a short period of time to become the new positive place to be in the area.
It’s kind of like turning the rocks in a kaleidoscope. If you turn those rocks just a little bit, you get a whole new pattern. And that’s all we’re creating, a different way of looking at things. If the team gets busy on that, supported by the leadership of the building using cross-functional endeavors and focused plans, there’s no question they can be successful.