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BY: BRIAN E. FORSCHNER, PhD; JAMIE J. HOUSEMAN; BETH A. LUKEN; and TIMOTHY C. DRESSMAN

Dr. Forschner is president, Senior Health and Housing Services, Mercy Health Partners, Cincinnati; Ms. Houseman is executive director, Mercy St. Theresa Center, Mariemont, OH; Ms. Luken is executive director, Mercy Franciscan Terrace, Cincinnati; and Mr. Dressman, formerly executive director, Mercy Franciscan — best Park, Cincinnati, is now executive director, The Franciscan at St. Leonard, Centerville, OH.

Leaders of a Long-Term Care Organization Tell How They Eliminated the Need to Hire Temporary Staff

Like many other health care organizations, Mercy Health Partners of Southwest Ohio's Senior Health and Housing Services, Cincinnati, struggled in recent years with a shortage of professional staff. As a result, the organization (see below) found itself spending $2 million annually on temporary agency help. Such an expense was unsustainable. In early 2000, therefore, we who lead the organization decided to make it agency free. We set Labor Day as our target date.

Fortunately, we had a firm basis to build on, in that the organization was already well organized and well run. These characteristics lent themselves well to our effort to become agency free.

In kicking the initiative off, we formed 12- to 15-member teams in each of our four facilities. The teams met weekly from four to six hours, working over a period of 12 weeks to implement a performance improvement plan. Team members included administrators, directors of nursing, supervisory personnel, nursing assistants, housekeepers, maintenance employees, nurses, and other line staff.

Each facility's team was given considerable leeway in the techniques it chose to use to achieve the overall goal. The teams developed plans containing both weekly and 12-week goals. These goals were then incorporated in a performance contract that was signed by all committee members and approved by management. We leaders reviewed each facility's weekly report, which included graphs charting "call-offs" (occasions in which an employee scheduled for work calls to say that he or she will be absent), turnover, open positions, and spending. Accompanying each report was a narrative explaining the team's techniques and "best practices," as well as an assessment of its progress.

The organization's senior executives — the chief nursing officer, vice president of Human Resources, and vice president for Marketing and Public Relations — met once a month to support the teams and help them solve problems.

Project Implementation
The teams found that the most common causes of employee turnover were:

• Poor employee selection
• Inadequate orientation
• Lack of fun on the job
• Inflexible scheduling practices
• Negative employee attitudes

Consequently, the teams proceeded to focus on these areas.

Poor Employee Selection Studies done by Maun-Lemke, Inc., Omaha, a consulting firm engaged to aid the effort, indicate that 36 percent of all long-term care turnover results directly from poor job orientation; 25 percent of employees leave during their first 90 days on the job, for example.¹ In their book, First Break All the Rules: What the World's Greatest Managers Do Differently, Marcus Buckingham and Curt Coffman say national survey results show that employees need three things to succeed on the job:

• Knowing what is expected of them
• The materials and equipment necessary for doing the work correctly
• An opportunity every day to do what they do best²

Our four teams suggested ways to ensure that applicants were truly interested in the jobs they applied for. The facilities had hitherto relied on unfocused newspaper advertising to attract potential employees, most of whom simply walked in off the street. We began to improve our methods for recruiting staff.

In our advertisements, for example, we focused on what we called the "star employees" at each facility. The new ads — which featured photographs of the "stars" along with quotes from them — invited potential employees to visit the facility and meet them. An applicant responding to the ad would be greeted by one of these "stars," who in effect became a recruiter.

Applicants would typically spend time observing an employee at work to see if the job in question was one they were interested in. Sometimes this experience itself eliminated as many as half the applicants. Meanwhile, tours led by "star" employees or their colleagues allowed applicants to ask questions. This aspect of the process also permitted staff members to observe applicants and decide whether to urge management to offer them jobs. Partly because of this process, we were able to reduce hiring time, once a job candidate was selected, from three weeks to seven to 10 days.

Inadequate Orientation Our teams also revised the orientation process. We appointed mentors to meet with new employees daily for their first two weeks on the job. We launched an interactive orientation program that includes discussions of our passionate commitment to our residents, a scavenger hunt — like activity that gives participants an opportunity to explore the facility, skits on safety issues, and a presentation on disaster procedures. This approach conveyed our enthusiasm for our work to our new employees, enthusiasm we have found to be contagious.

Lack of Fun on the Job Realizing that our staff members generally spend more waking hours on the job than they do with their families, we decided that we must have a joyful atmosphere at work if we were to retain employees.

In this regard, exit interviews and staff discussions proved to be revealing. We found that, although our facilities were mission-oriented and well managed, they were not considered "fun" places to work. So our teams began looking for ways to change this. Each team appointed a committee whose job it is to celebrate birthdays and anniversaries and plan special events. It is now customary for our facilities to host pizza parties, "Hat Days" (when the dress code is relaxed and employees are allowed to wear their favorite hat on the job), "Survivor Days" (a scavenger hunt and summer cookout using the popular television show as a theme), and other special occasions. Even routine accomplishments, such as coming to work on time every day for a week, are recognized. All this has helped contributed to a more joyful atmosphere.

Inflexible Scheduling Practices Traditional work shifts do not always meet the needs of today's employees. Aware of concerns in this regard, our facilities' leaders first held employee focus groups, then followed up by experimenting with different types of scheduling. They introduced job sharing, established overlapping shifts and shifts of different lengths, and made accommodations for weekend preferences.

Negative Employee Attitudes To increase job performance, our teams also focused on attracting "positive" employees — individuals who, instead of simply complaining about problems, would suggest solutions to them. Those staff members who wanted to join what we called "High Performance Teams" promised to bring complaints or potentially troubling issues to the right venue and device potential solutions for them. When a group was commissioned as a High Performance Team, we gave its members buttons bearing the letters "BMG" and a slash across them, which meant "No bellyaching, moaning, or groaning!"

Outcomes
We had launched our campaign believing that reducing agency help would improve our resident satisfaction scores on the Parkside Associates' survey, increase staff satisfaction as measured by the Developing Organizational Capacity survey, strengthen our financial position, and reduce employee turnover.³

The day before Labor Day 2000, our facilities said good-bye to the last agency employee. In the next 30 days, we administered both employee satisfaction surveys and resident satisfaction surveys. A comparison of 1999 survey results with those for the first seven months of 2000 showed employee satisfaction scoring an excellent 60 percent. Improvement was particularly dramatic at Mercy Franciscan at Schroder, where employees embraced the new recruitment and retention concepts with extra effort and commitment.

We plan to use the results of the 1999 employee and resident satisfaction surveys as the benchmark for later surveys. New surveys were conducted in September and October 2001, and we expect those scores to indicate continuing improvement.

Meanwhile, survey results have shown that resident satisfaction improved at all four facilities in 1999-2000. In addition, all four showed significant financial improvement by the end of 2000. According to anecdotal evidence, staff members were more pleased with their work, residents and family members were happier, and the overall quality of the four facilities had increased. The health status of residents had also improved, as revealed by decreases in incidence of bedsores, falls, and urinary tract infections among residents. Across the four facilities, employee turnover rates were cut nearly in half, from 56 percent to 29 percent.

Staff's Cooperation Is Vital
Our campaign to become agency free was driven by our staff's desire to take better care of our residents, improve their working environment, and ensure the organization's financial solvency. The results seen since we reached our goal strongly suggest that the whole effort was worthwhile.

Permanent, facility-based staff members who are properly screened, oriented, and recognized for their work will stay in their jobs longer than those who are not. Moreover, staff members who are treated properly become committed to the organization's mission and values and provide residents with high-quality care. All this contributes to financial success because it helps the organization eliminate the use of costly temporary agency help.

NOTES

1. Clint Maun, Dale Lind, and Greg Efta, Recruitment, Selection and Retention of Top Quality Staff, Maun-Lemke, Inc., Omaha, 2001, p. 22.
2. Marcus Buckingham and Curt Coffman, First Break All the Rules: What the World's Greatest Managers Do Differently, Simon & Schuster, New York City, 1999, p. 27.
3. Parkside Associates, Inc., Partners in Quality: Long-term Care Survey, Park Ridge, IL, 2000; Jeff Monroy and Diane Fassell, Mercy Health Partners/Greater Cincinnati Region Employee Satisfaction Survey, Newmeasures, Inc., Boulder, CO, 2000.

Mercy Health Partners of Southwest Ohio

Mercy Health Partners (MHP) is an integrated, holistic health care delivery network with more than 80 care delivery sites in southwest Ohio. The system has a staff of more than 7,800 employees and more than 4,000 affiliated physicians representing a wide range of medical and surgical specialties.

MHP's Senior Health and Housing Services comprises four facilities in the Cincinnati area. They are:

• Mercy Franciscan Terrace
• Mercy Franciscan at Schroder
• Mercy Franciscan at West Park
• Mercy St. Theresa Center