1. Four Part CMS Satellite Broadcast From Institutional to Individualized Care This material was designed by Quality Partners, the Medicare Quality Improvement Organization for Rhode Island, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the US Department of Health and Human Services. Contents do not necessarily represent CMS policy. 8SOW-RI-NHQIOSC-072006 Part 4 The How of Change: What a difference management makes!

2. Marguerite M. McLaughlin Manager of Educational Development, Quality Partners of Rhode Island

3. 3 CMS Satellite Broadcast Series: From Institutional to Individualized Care Part 1, November 3, 2006: Integrating individualized Care with Quality Improvement Part 2, May 4, 2007: Transforming Systems to Achieve Better Clinical Outcomes Part 3, May 18, 2007: Clinical Case Studies in Culture Change Case Examples Today: The How of Change: What a difference management makes!

4. Cathie Brady Co-founder, B&F Consulting Consultant, Quality Partners of RI

5. Barbara Frank Co-founder, B&F Consulting Consultant, Quality Partners of RI

6. Quality Partners of Rhode Island 6 Thomas Hamilton Director, Survey & Certification Group Center For Medicaid and State Operations Centers For Medicare & Medicaid Services

7. Quality Partners of Rhode Island 7 Goals: 1.Describe a change process 2.Explore the importance of inclusive leadership 3.Identify workplace practices to achieve staff stability 4.Demonstrate why of individualized care is better care

8. Basic Premise Good care needs to be individualized That requires good relationships between residents and staff

9. Quality Partners of Rhode Island 9 Sections Section 1: The How of Change Section 2: A Positive Chain of Leadership Section 3: Achieving Staff Stability Section 4: Individualized Care: The Path to OBRA

10. Quality Partners of Rhode Island 10 The How of Change Personalize See how it is for residents and staff What’s working – keep it Open dialogue to change what’s not working Look at the data Pilot test Mid-course adjustments Spread Build this slide

11. Bathing Without a Battle www.bathingwithoutabattle.unc.edu

12. Quality Partners of Rhode Island 12 Ways to personalize the experience sit in a shower chair wear a chair alarm lie in a resident’s bed take a shower in the shower room eat a meal

13. Quality Partners of Rhode Island 13 Sources The Leadership Challenge by Jim Kouzes and Barry Posner What a difference management makes! by Susan Eaton Build

14. Quality Partners of Rhode Island 14 What a difference management makes! Five Management Practices Associated with Low-Turnover, High Attendance and High Performance: High quality leadership at all levels of the organization Valuing staff day-to-day in policy and practice, word and deed High performance, high commitment HR policies Work systems aligned with and serving organizational goals Sufficiency of staff and resources to care humanely Eaton, 2002

15. Quality Partners of Rhode Island 15 A Positive Chain of Leadership Encouragement and Valuing Positive Presence People Development Personal Growth as a Leader build

16. Quality Partners of Rhode Island 16 Facilities with higher employee satisfaction have: More residents without falls More residents without pressure ulcers More residents without acquired catheters Less nurse turnover Less CNA and nurse absenteeism Higher occupancy My InnerView 2007

17. Quality Partners of Rhode Island 17 Encouragement: Set clear standards Expect the best Pay attention and tune in to people Personalized recognition build

18. Quality Partners of Rhode Island 18 Effective praise is: Timely Specific Sincere Proportional Positive One Minute Manager Ken Blanchard

19. Quality Partners of Rhode Island 19 Achieving Staff Stability Maximizing Financial Resources to Invest in Staff Stability Attendance policies Hiring practices Consistent assignment build

20. Quality Partners of Rhode Island 20 Snapshot of Current Situation Composition of the current staff Position TotalFTPTPDBaylor RN - 3084144 LPN - 2715057 CNA - 77378725

21. Quality Partners of Rhode Island 21 Financial Incentives: BonusExtra Per Hr.Annual Baylor (work two 12’s, paid for 30 hours) RN -- $7 LPN -- $5 CNA -- $3 $268,944 Last minute assignment RN, LPN --$10 CNA -- $5 $360,000 Perfect attendance$0

22. Quality Partners of Rhode Island 22 Terminations by Length of Service Position1 day – 1 mo 1 – 3 mo 3 - 6 mo 6 mo – 1 yr RN18% 27% LPN7%13%33%27% CNA23%30%23%16% Other8%27%39%12%

23. Quality Partners of Rhode Island 23 Incentives BonusAmt OfferedQuarter - Annual Sign-on bonus Paid after 6 mos. RN -- $2000 LPN -- $500 CNA -- $250 $12,500 - $50,000 Referral bonus Paid after 6 mos. RN, LPN -- $1000 CNA -- $500 $6,000 Longevity$0 RaisesAverage 2%$90,710

24. Quality Partners of Rhode Island 24 Turnover Costs: PositionPer PersonAnnual Cost RN$4,899$53,889 LPN$4,193$62,895 CNA$3,207$205,248 Other$2,692$131,908 Total 2004$453,940

25. Quality Partners of Rhode Island 25 Instability vs. Stability Last minute bonus $360,000 Perfect attendance $ 0 Baylors $268,994 Raises @ 2% $90,710 Sign-on bonuses $50,000 Referral bonuses $6,000 Turnover costs $453,940 Longevity bonus $0 Total: $1,132,934 Total: $96,710

26. Quality Partners of Rhode Island 26 Stage 2: Staff Stabilization Plan Goals: –more full-time positions –Improve attendance –Improve percent of new hires who stay

27. Quality Partners of Rhode Island 27 New Wage Package For Full- time Staff Old Wage Range New Wage Range Raise Amount CNA$9.25 to $10.50 $11.50 to 12.75 + $2.25 LPN$15.00 to $16.70 $18.00 to $20.50 + $3.00 to $3.80 RN$18.00 to $20.50 $23.50 to $26.00 + $5.50

28. Quality Partners of Rhode Island 28 As a result: Increase in FT Staff Date# of FT nursing staff June 200560 Dec 200580 Dec 200696

29. Quality Partners of Rhode Island 29 RNLPNLNA Status2005 Dec. 20062005 Dec. 20062005 Dec. 2006 Full Time27%71%56%84%48%83% Part Time13%17%0%3%10%3% Per Diem47%8%18%3%9%4% Baylor13%4%26%9%32%10% Increase in Percent of Nurses and CNAs Working Full-time

30. Quality Partners of Rhode Island 30 Case Study and Tools Available on website for this broadcast and from: Better Jobs Better Care – www.bjbc.org COVE – Community of Vermont Elders – 802-229-4731 Quality Partners of Rhode Island – www.riqualitypartners.org

31. Quality Partners of Rhode Island 31 http://cms.internetstreaming.com

32. Quality Partners of Rhode Island 32 National Technical Information Services 5285 Port Royal Road Rm. 1008 Sills Bldg. Springfield VA 22161 (703) 605-6186