OHCA

Staff Retention Toolkit

Education and training of staff, supervision, environmental conditions, attitudes and values, job satisfaction and turnover of staff, salaries and benefits, leadership, management, and organizational capacity are all essential elements affecting quality of care to residents. -IOM, Improving the Quality of Long-Term Care

INTRODUCTION
As our population ages Oregons long-term care facilities will increasingly start to feel the significance of the growing demand in the delivery of quality health and personal care services. To achieve this demand our states care facilitys need to address one of our biggest concerns of the ability to retain direct care staff. Results of the 2002 AHCA Survey of Nursing Staff Vacancy and Turnover Nursing Homes reports, the national turnover rate of CNAs is 71%[1]. The high rate of turnover not only decreases the quality of care due to inefficient and in experienced staff but also increases cost because of the need for continual recruiting and training. The range of indirect and direct cost per direct care worker is estimated between $2,000 - $6,400 [2]. The following is a tool kit to be used as a quick practical reference to develop best practices to retain direct care workers essential for quality long term care. The toolkit looks beyond the barriers of inadequate wages and benefits and focuses on organizational practices and policies to develop a direct care workforce which is satisfied, qualified, and highly motivated. The toolkit addresses each of the following themes: Tracking Cost and Turnover Employee Satisfaction Surveys Cultural Competence Leadership Development Employee Recognition and Respect Performance Evaluation Training and Continual Education Opportunities Behavior Based Interviewing Orientation and Mentorship Recruitment Practices Becoming an Employer of Choice

The toolkit is not to be used as a single reference but as a quick introduction to the issues and potential solutions to successfully manage your direct care workers. In addition the toolkit offers a facility leadership assessment which acts as a working document to continually assess the quality and attention given to various aspects of the facilitys working environment. The toolkit also serves as a resource guide of available information to gain further insight or detail on each presented theme.

TABLE OF CONTENTS
Quick Guide to Best Workplace Practicespage 1 Leadership Assessment Tool page 3 Leadership Developmentpage 12 Leadership Tools and Practices....page 16 Tracking Turnover and Cost...page 19 Recruitment...page 24 Creating an Appealing Job..page 25 Evaluating Potential Direct Care Workers....page 33 Orientation.page 38 Peer Mentoring.page 43 Employee Recognition ...page 46 Tips to Generate Employee Respect and Value.page 49 Employee Evaluations.page 50 Cultural Competence...page 55 Employee Satisfaction Surveys..page 61 Attachments (A) Employee Opinion Survey Check-in...page 67 (B) Cause-and-Effect (Fishbone) Diagram..... page 69 (C) Honeymoon Quiz...page 71 (D) Staff Satisfaction Survey..page 73 Resource List....page 74

Quick Guide to Best Workplace Practices

High Turnover Homes

Low Turnover Homes

Innovative leaders High turnover in leadership team New staff expected to jump in fully without help in acclimating Seeing employees as problem people and punishing them for not adhering to rigid rules Stability among leadership team Ways of integrating new staff and supporting them as they acclimate Seeing employees as people with problems and helping them cope (flexible scheduling, emergency loans) High performance human resource policies including skills development, flexibility in assignments, career development, and realistic job reviews tied to supporting people development Meaningful involvement of staff in care planning Decentralization of care giving and decision-making to the units Arbitrary changes without involvement or explanation Persistent short-staffing Inter-departmental turf battles at leadership and line staff levels Enough staff to do the job Good work across departments from the leadership and from the line staff

Persistent call-outs, inflexibility in schedule Self-scheduling and trade-offs in scheduling, infrequent call-outs

No visible positive presence from administration and managers A mission on paper that is not reflected in daily work

Managing by walking around

A living sense of mission among leadership and staff that is reflected in the workplace culture and how leaders handle difficult or emotional moments Staff have empowerment to match their accountability Honoring staff's grief over deaths of people they've cared for

Staff are blamed for problems they have no power to resolve

Blame and hostility across shifts, units and Regular communication and collaborative departments problem-solving across shifts, units, and department Supervisors who direct but don't help Supervisors who pitch in, are willing to get their hands dirty Employees have a sense of fairness from management Good understanding across race and culture Managers support innovation and creativity Managers create an environment that supports people working together Recognizing workers for their good work, and seeing them as people in their own right Scheduling that accommodates employees' needs; self-scheduling Respect for caregivers Attention to concerns and consistent follow-up to take care of concerns

Employees feel there is favoritism

Racial and cultural conflict

Managers require strict adherence to rigid ways of doing things Managers are ineffective in dealing with problems A sense of anonymity about the staff, interchangeable

Random, impersonal, inflexible scheduling; favoritism; punishment Contempt for caregivers Lack of follow-up and responsiveness by management

Resource: U.S. Department of Health and Human Services [3]

LEADERSHIP ASSESSMENT TOOL

This assessment is a tool to be used by leadership to assess areas of concern within your care facility. The assessment should be filled out by your facilitys leadership team and be used as a working document to continually assess the quality and attention given to various aspects of the facilitys working environment. Please circle the number or fill in the answer which accurately rates the frequency the action takes place.

ORGANIZATIONAL CULTURE
1. Is the care facility a personal place to work? Is it like an extended family where people feel comfortable sharing their ideas, values, and concerns? 1 Not at all 2 3 Occasionally Sometimes 4 Frequently 5 Routinely

2.

Can your employees recite the care facilitys vision and mission? 1 Not at all 2 3 Occasionally Sometimes 4 Frequently 5 Routinely

3.

Is your care facility a fun place to work? Are employees excited to come to work (what is your employee attendance)? 1 Not at all 2 3 Occasionally Sometimes 4 Frequently 5 Routinely

4.

Is there a feeling of team work within the care facility among leadership and employees? 1 Not at all 2 3 Occasionally Sometimes 4 Frequently 5 Routinely

ORGANIZATIONAL LEADERSHIP
1. Does the leadership in the care facility nurture, mentor, and coach and promote excellence in employees? 1 Not at all 2 3 Occasionally Sometimes 4 Frequently 5 Routinely

2.

Does leadership teach and model good communication and listening skills? 1 Not at all 2 3 Occasionally Sometimes 4 Frequently 5 Routinely

3.

Does leadership establish relationships with the employees? Does leadership know employees personally (family, career goals, personal stressors)? 1 Not at all 2 3 Occasionally Sometimes 4 Frequently 5 Routinely

4.

Does leadership use a supportive problem solving approach to supervision that empowers staff in making decisions and solving problems? 1 Not at all 2 3 Occasionally Sometimes 4 Frequently 5 Routinely

5.

Does leadership engage employees to gain suggestions on what is and is not working with their daily job tasks? 1 Not at all 2 3 Occasionally Sometimes 4 Frequently 5 Routinely

6.

Does leadership clearly articulate the care facilitys vision and inspire employees to make it a reality? 1 Not at all 2 3 Occasionally Sometimes 4 Frequently 5 Routinely

7.

Does leadership refer to employees by their professional titles, such as our CNA, Jane Smith (as opposed to calling staff my girls etc.)? 1 Not at all 2 3 Occasionally Sometimes 4 Frequently 5 Routinely

RESIDENT CARE
1. Are residents enabled to make decisions such as meal time, bathing, recreational activities, or time spent out doors? 1 Not at all 2 3 Occasionally Sometimes 4 Frequently 5 Routinely

2.

Does care facility leadership support staff in getting to know residents, the residents family, medical history, and current wishes? 1 Not at all 2 3 Occasionally Sometimes 4 Frequently 5 Routinely

3.

Does leadership encourage consistent assignment for staff to bring their personal knowledge of residents into the care giving process? 1 Not at all 2 3 Occasionally Sometimes 4 Frequently 5 Routinely

4.

Does the care facility have a system in place to ensure the residents choices are elicited, valued, and met? 1 Not at all 2 3 Occasionally Sometimes 4 Frequently 5 Routinely

RECRUITMENT
1. Does the care facility leadership involve staff in the interview process of new hires? 1 Not at all 2. 2 3 Occasionally Sometimes 4 Frequently 5 Routinely

Does the care facility use behavioral interviewing techniques? 1 Not at all 2 3 Occasionally Sometimes 4 Frequently 5 Routinely

3.

Does the care facility use exit interviews with employees who are leaving? 1 Not at all 2 3 Occasionally Sometimes 4 Frequently 5 Routinely

4.

Does the care facilitys job description accurately reflect the traits of the employees that are targeted? 1 Not at all 2 3 Occasionally Sometimes 4 Frequently 5 Routinely

5.

Does the care facility have a volunteer or internship program targeted at high school or college students to introduce them to the long term care field? 1 Not at all 2 3 Occasionally Sometimes 4 Frequently 5 Routinely

6.

Does the care facility utilize sign on bonuses for new hires? 1 Not at all 2 3 Occasionally Sometimes 4 Frequently 5 Routinely

TRAINING AND EVALUATION

1. Does the care facilitys orientation incorporate non technical skills such as problem solving, critical thinking, communication, and team building? 1 Not at all 2 3 Occasionally Sometimes 4 Frequently 5 Routinely

2.

Does the care facility provide (pay for) ongoing training opportunities to employees, such as certifications, licenses, career ladders / lattices? 1 Not at all 2 3 Occasionally Sometimes 4 Frequently 5 Routinely

3.

Does the care facility have a process in place to follow up with new employees to assess their skill development? 1 Not at all 2 3 Occasionally Sometimes 4 Frequently 5 Routinely

4.

Does care facility leadership regularly evaluate employee performance? 1 2 3 4 5 Not at all Occasionally Sometimes Frequently Routinely

5.

Does the care facility provide new employees with mentors? 1 Not at all 2 3 Occasionally Sometimes 4 Frequently 5 Routinely

6.

Does the care facility provide diversity training for all employees? 1 Not at all 2 3 Occasionally Sometimes 4 Frequently 5 Routinely

SUPPORT OF STAFF
1. Does care facility leadership invite employees to participate in decision making in the following areas? (circle options) a. b. c. d. Scheduling Hiring Future planning / goal setting Resident care planning 2 3 Occasionally Sometimes 4 Frequently 5 Routinely

1 Not at all

2.

Does the care facility have an employee recognition program or worker appreciation events such as? (circle options) a. b. c. d. e. f. g. Gift cards Thank you notes Employee lunches / BBQ Merit increases Service awards Spirit awards Attendance awards 2 3 Occasionally Sometimes 4 Frequently 5 Routinely

1 Not at all

3.

Does care facility leadership empower staff to make decisions in regard to their own work and responsibilities? 1 2 3 4 5 Not at all Occasionally Sometimes Frequently Routinely

4.

Does the care facility provide employees with the appropriate work environment, tools, and resources to do their jobs at a quality level? 1 Not at all 2 3 Occasionally Sometimes 4 Frequently 5 Routinely

5.

Does care facility leadership provide clear job expectations to their employees? 1 Not at all 2 3 Occasionally Sometimes 4 Frequently 5 Routinely

6.

Does the care facility offer support service resources or information addressing the daily living needs of employees? (circle options) a. b. c. d. childcare housing transportation community resources 2 3 Occasionally Sometimes 4 Frequently 5 Routinely

1 Not at all

7.

Does the care facility acknowledge, accept, and celebrate the individual and cultural diversity of its employees? 1 Not at all 2 3 Occasionally Sometimes 4 Frequently 5 Routinely

MANAGEMENT OF EMPLOYEES
1. Does care facility leadership encourage creative ideas / innovation from employees, residents, and families? How? ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ 1 Not at all 2 3 Occasionally Sometimes 4 Frequently 5 Routinely

2.

Does the care facility gather frequently to express concerns, celebrate, and plan for future goals? How often does the facility gather? ____________________________ What occasions or reasons prompt the care facility to gather? ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ 1 Not at all 2 3 Occasionally Sometimes 4 Frequently 5 Routinely

3.

Does the care facility leadership encourage open communication with employees? How is open communication encouraged? ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ 1 Not at all 2 3 Occasionally Sometimes 4 Frequently 5 Routinely

4.

Does care facility leadership track employee turnover? 1 Not at all 2 3 Occasionally Sometimes 4 Frequently 5 Routinely

5.

Does care facility leadership survey employees to gain feedback on employee satisfaction? 1 Not at all 2 3 Occasionally Sometimes 4 Frequently 5 Routinely

COMMUNITY INVOLVEMENT
1. Does the care facility invite residents families to be part of the organizational community? 1 Not at all 2 3 Occasionally Sometimes 4 Frequently 5 Routinely

2.

Does the care facility provide opportunities for the residents to be active in the local community? 1 Not at all 2 3 Occasionally Sometimes 4 Frequently 5 Routinely

3.

Does the care facility stay abreast of what other long term care facilities are doing in the area? 1 Not at all 2 3 Occasionally Sometimes 4 Frequently 5 Routinely

4.

Does the care facility invite the community (religious group, schools, animal shelters) into the organization? 1 Not at all 2 3 Occasionally Sometimes 4 Frequently 5 Routinely

Scoring the Assessment:

Remember the assessment should be used as a working document to bring attention to your facilitys areas of concern or progress. Scoring can be done by each individual section to address specific areas of concern or as an overall rating. Anything scored below a 4 frequently rating should be addressed within your facility. The goal is to strive to incorporate each theme into your care facilitys routine working environment. On areas where you may not have scored highly you can refer to the corresponding sections of this manual for tips and additional information for improvement. Add each question Total Score:__________________ 172 215 171 129 128 86 85 43 Quality Performance Above Average Satisfactory Below standards

*This tool should be used along with employee surveys and turnover tracking records to provide an accurate picture and assessment of the working conditions of your facility.
Resource: Organizational Culture Assessment Instrument [4]

LEADERSHIP DEVELOPMENT
Most care facility leadership positions are recruited from within; however, field experience does not necessarily assure competency in supervisory skills, the art of communication, active listening, counseling, mentoring, and knowledge of the day to day activities is central to managing an individual, team, department, or facility [5]. The role of leadership in a care facility has a major impact on staff retention and the overall culture of an organization. Leadership has the ultimate responsibility of aligning the organizational goals, strategies, and work priorities. A key factor in moving employees in a common direction is creating a work environment where there are open and transparent communication practices. One of the top reasons staff leave is that they are dissatisfied with their supervisors [6].

WHAT MATTERS MOST TO EMPLOYEES: Leadership cares about employees Leadership listens to employees Leadership believes that employees can be successful Supervisor cares about you as a person Supervisor shows appreciation [7]

RELATIONSHIP BUILDING IS KEY TO GOOD LEADERSHIP Low turnover care facility leaders take measures to nurture relationships Between co-workers Across departments Between supervisors Staff and residents Between residents Staff and residents family members

KEY LEADERSHIP PIECES CRITICAL TO CULTURE CHANGE IN LONG-TERM CARE FACILITIES Transparency- the state of being easily understood, candid, frank and open. Trustworthiness creditability, competence, benevolence and integrity Connectivity - ability to invite feedback and collaboration with others Accountability are able to continually show progress and respond to the request and needs of others Empowerment able to share power with others, regardless of official position or title within the organization. Optimism - the tendency to expect the most favorable outcome of events or conditions, as well as seeing the best in others [8].

COACHING SUPERVISION IN LONG TERM CARE Coaching supervision is a relational approach to managing and supporting direct care workers. It offers direct care workers the skills to: Problem Solve Think Critically Communicate Effectively Prioritize [6]

THE BENEFITS OF COACHING SUPERVISION: Increased employee retention and lower termination rates Improves the likelihood that both conflicting parties are satisfied Time savings - less supervisory time spent disciplining employee, fewer problems and quicker and easier resolution of problems [6]

WHY PRACTICE COACHING SUPERVISION: Most individuals in leadership positions find it difficult to address the negative aspects of managing employees. Often times these situations are time consuming and sidetrack the more important vision on hand. Coaching offers support in resolving performance issues while holding the employee accountable for their actions. When a performance problem arises, coaches try to understand the employee perspective and work with him/her to analyze the problem and come up with a solution, ensuring the employee takes responsibility for solving the problem. The coach is there to provide support and follow up to ensure progress [9],[6].

FOUR PRIMARY COACHING SKILLS TO LEARN AND PERFECT: Active Listening - Using skills such as body language, paraphrasing, and asking clarifying questions to listen attentively and ensure understanding. As a coach you need to be aware of what blocks or distracts you from listening fully Self Management Setting aside emotional reactions and other listening blocks that can get in the way of hearing an employees perspective Self Awareness Being aware of your assumptions and bias that may lead to prejudging the employee. The coach must be aware of what their personal management style is and be willing to change or accommodate the style needs to their employees, for example introvert vs. extrovert. Presenting the Problem - Using objective language and open ended questions to identify performance problems and hold workers accountable [6].

FIVE BASIC STEPS OF COACHING SUPERVISION: 1. Create a relationship with your employee 2. Clearly state the problem without placing blame or judgment 3. Understand the problem from the employees perspective. It is important for the coach to know the complete story to be able to respond more effectively 4. Problem solve, find potential resolutions with the employee. As a coach you need to learn the valuable skills of pulling back and listening rather than immediately proposing solutions. 5. Help the employee commit to action steps. As the coach you need to provide clear and direct steps, with suggestion that the employee can be successful [6], [9].

REQUIREMENTS OF SUCCESSFUL COACHING: A solid investment of time to successfully implement and practice coaching principles Belief that all workers have the capacity to succeed at their jobs Respect for all employees and an understanding of their daily realities Belief that your employees are held at high standards and are able to be held accountable for their actions [6],[9].

TAKING A LEADERSHIP APPROACH TO EMPLOYEE RETENTION: Provide compelling reasons for employees to be a part of the care facility Satisfy the personal and practical needs of employees Demonstrate the value of each employee Execute management processes that provide daily engagement and advancement for employees Provide focused reward and recognition Act on unacceptable performance, dealing equally with technical and behavioral deficiencies [10].

LEADERSHIP TOOLS AND PRACTICES

LEADERSHIP VISIBILITY Leadership visibility is a way to demonstrate your commitment to excellence and engage the heart of your staff [11].

STRATEGIES TO IMPROVE LEADERSHIP VISIBILITY?

EMPLOYEE ROUNDING is an important method used by facility leadership to get to know staff individually, inspect their quality of work up close, praise staff for their accomplishments, build employee self-esteem and moral, and build a more stable and trust worthy relationship with your staff.

HOW TO IMPLEMENT EMPLOYEE ROUNDS Schedule a block of time with each staff one time annually Five key questions to ask staff: 1. Relationship building How is your family? 2. Focus on the positive What is working well for you today? 3. Positive feedback loop Is there anybody who has gone above and beyond the call of duty today? 4. QI- system focus Is there anything we can do better? 5. Needs Do you have the tools and equipment to do your job better? Follow-up and/or address all employee concerns [12]

LESS TIME CONSUMING METHODS OF INCREASED VISIBILITY WITH STAFF: All staff meetings Taking walks down the hall Monthly department meetings Newsletters Communication boards Thank you notes Walking staff to their cars Lunch with staff in the break room [12]

THE IMPORTANCE OF LEADERSHIP AND THE CARE FACILITY VISION Staff Retention is enhanced by a reason for being, and vision is the motivator and driver. If there is no shared vision in place employees come to work, do their individual duties, and go home. Without a shared vision there is nothing that unites or excites the employees. No direction, motivation, or nothing to work toward. Without a vision staff are unclear of expectations, what they should do or how the should perform. Visioning is the process of creating a dream organization without restraint of money or time. A well developed vision includes laying out how things will work in all departments, and how it will feel and operate as a whole. The vision needs to be created and supported by all staff, all departments, and all shifts. It should be reviewed by the perspective of the residents, families, and community. Once the vision is created it should be a topic of conversation that takes place will all employees on a continual basis and even more emphasized if the organizations seems to be struggling to ensure a positive direction is maintained. The vision should serve as a basis for all decision making [13].

ADDITIONAL RESOURCES

Paraprofessional Healthcare Institute Coaching supervision: Introductory Skills for Supervisors in Home and Residential Care
http://www.directcareclearinghouse.org/download/Introduction_Coaching.pdf

My InnerView Quality Care Begins with Satisfied Committed Employees Working Together To Achieve Success
http://www.myinnerview.com/downloadPDF.php?pdf=miv/research/Oct07ProviderSupple ment.pdf

American College of Healthcare Administrators Principles of Excellence for Leaders in Long-term Care
http://www.achca.org/content/pdf/POEbrochure-june2004.pdf

American Association of Homes ad Services for the Aging (AASHA)

http://www.aahsa.org

TRACKING TURNOVER
Each time a direct care worker decides to leave a long-term care organization there is a considerable loss in both finances and quality. Cost include recruitment and training, overtime paid out to an already stressed workforce, often times temporary staffing agencies are used to fill vacancies, or care hours simply go undelivered. In addition, with every quit or termination, the care giving relationships and services provided to clientsthe core commodity of long-term careat a minimum are disrupted and sometimes are so compromised that the well-being of both clients and workers is negatively affected due, for example, to increased injury rates on both sides [2],[14]

COSTS OF TURNOVER
Disadvantages of Turnover from the Organizational Perspective: Cost Due To person Leaving Temp agency / other staff who fills in (overtime cost) Lost productivity of departing employees Exit interview time and cost Cost of administrator / manager who arranges to cover work Impact on departmental productivity Lost knowledge skills and contacts Recruitment Cost Advertising job postings Internal HR time Reviewing resumes Conducting interviews Drug screens, educational and criminal background checks, reference checks Hiring bonuses or pay out Training Cost (largest training cost) Orientation Departmental training - trainer, trainee, materials and equipment New Hire Cost Administrative cost - payroll, benefits, uniforms

INDIRECT ORGANIZATIONAL COST

Lost Productivity Cost 75% of salary for first 2-4 weeks 50% of salary for weeks 5-12 25% of salary for weeks 13-20 Time of co-workers and supervisors coaching Increased mistakes Lost department productivity Reduced productivity of manager Reduced Service Quality Residents experience a loss of service or unprovided care hours Increases errors by overworked staff Deterioration in Organizational Culture and Employee Moral Staff feel tired and overworked Communication patterns start to break down Higher risk of employee injury Turnover breeds more turnover Loss of residents to other nursing facilities Organization has developed a community image of high turnover or constantly being under staffed\ Low staff rates may result in longer wait list or the turning away of potential residents.

ARE YOU TRACKING YOUR TURNOVER COST? Overall the cost of employee turnover can have a considerable impact on your organizations bottom line. Best practice is to carefully track turnover costs and know the true cost of employee turnover, make informed decisions about how much your organization can invest in retaining employees, and assess if such retention investments are improving your bottom line Nursing Facilities already under tight budgets do not want to invest large amounts of money on creating retention programs that do not guarantee positive outcomes. The first thing to do is to look at what the facility is losing during turnover by explaining how the costs are compiled. There is not just one specific cost of turnover. There are costs due to a person leaving, recruitment costs, training costs, lost productivity costs, and new hire costs [14].

1. The costs of the person or persons, including overtime pay for current nursing assistants / agencies, which temporarily fill in during the search for a new employee. 2. The costs of lost productivity. This is calculated at 50 percent if the position is being temporarily filled or 100 percent if it is not filled. 3. Costs of an exit interview and paperwork for stopping payroll and benefit deductions. The cost of training that has been invested in the employee, along with an extra certifications and programs the facility may have paid for. 4. The impact on the productivity of others based on who will fill in and how that will affect the work of others. Some service or care giver hours may go unmet. 5. The cost of leadership discussing reactions to the vacancy. 6. The cost of continuing benefits for eligible employees 7. The cost of lost knowledge, skills and contacts that the person takes upon departure. 8. The cost impact of unemployment insurance and the time spent to prepare for an unemployment hearing, otherwise the cost paid to a third party to handle the unemployment process for the company; 9. Subtract the cost of the person who is leaving for the amount of time the position is vacant [2].

RECRUITMENT COST ARE CALCULATED THROUGH: 1. The cost of advertisements mostly ranging from newspaper classifieds to a display advertisement; employee referral costs, Internet posting costs; 2. The cost of the time for Human Resource Department to learn the position requirements, develop and enact a sourcing strategy, review backgrounds, prepare and conduct interviews, make reference checks, notify unsuccessful candidates. 3. Costs of developing candidate interview schedules and making any travel arrangements for candidates out of the area; 4. The administrative cost of handling, processing and responding to the average number of resumes considered for every position; 5. The time spent by management and staff interviewing candidates; 6. The cost of drug screens, educational and criminal background checks and other reference checks. This can be very costly if you have outside entities providing these services; 7. The cost of pre-employment tests to evaluate skills, abilities, aptitude, attitude, values and behaviors [15].

TRAINING COSTS ARE CALCULATED BY: 1. The cost of orientation, orientation salary, the cost of the person who conducts the orientation along with any materials used; 2. The cost of departmental training, and departmental training salary; 3. The cost of the person or persons who conduct the training; 4. The cost of various training materials needed including company or product manuals, computer or other technology equipment used during the training; 5. The cost of lost productivity of the supervisor spent in assigning, explaining and reviewing work assignments and output [15].

LOST PRODUCTIVITY IS CALCULATED THROUGH PRODUCTIVITY WEEKLY: When the new employee is learning, he or she is not fully productive. 1. Upon completion of training, the employee is contributing at a 25% productivity level for the first 2 - 4 weeks. This turns out a 75% lost cost of the new employee's full salary during this time 2. At 5 -12 weeks, the employee is contributing at a 50% productivity level. This makes 50% of the full salary during this time; 3. At 13 - 20 weeks, the employee is contributing at a 75% productivity level. This cost loss is 25% of the full salary during this time; 4. Calculate the cost of coworkers and supervisory lost productivity in terms of the amount of time spent to bring the new employee "up to speed." 5. Calculate the cost of mistakes the new employee makes [15].

NEW HIRE COSTS INCLUDE: 1. The costs of a new employee including putting the person on payroll; 2. Establishing computer/security passwords and identification cards; 3. Uniforms Employees are the greatest expense for companies, yet it is the area where the least amount of investment is placed. Replacing a worker can cost 2-3 times as much as retaining one. Spending money on creating retention programs for your organization will pay for itself in the long run [15].

ADDITIONAL RESOURCES

CNA Replacement Cost Tracking Tool:

http://www.acumentra.org/downloads/nursing-home/turnover-replacement-cost.doc

Tunover Tracking Tool:

http://www.acumentra.org/downloads/nursing-home/turnover-rate-worksheet.doc

RECRUITMENT
KNOW YOUR WORKFORCE? The typical direct-care worker is a low-income woman between the ages of 25 and 54, often a woman of color, who is a single mother of young children. Many were, or still are, dependent on some form of public assistance. Most direct-care workers are motivated to become caregivers by a desire to make a difference in the lives of those they serve. More often than not, individuals choose to remain at their jobs because of their close relationships with those they care for not because of their wages or work environment. These workers give much more than they receive and are the lifeline for your care facilitys residents [16].

PRIMARY CHARACTERISTICS OF THE DIRECT CARE WORKFORCE CHARACTERISTICS Female White, nonHispanic Unmarried with children Mean age Some College
Resource: Scanlon (2001), [17]

NURSING HOME AIDES 91% 57% 32% 37 27%

HOME HEALTH AIDES 89% 49% 25% 41 38%

ALL WORKERS 52% 74% 11% 45 50%

QUALITIES OF AN IDEAL DIRECT CARE WORKER Interest in the elderly and disabled population Able to handle physical and emotional demands Reliable Mature Sensitive to other peoples preference Able to prioritize task Able problem solve and negotiate uncertain situations Basic language and math skills Maintain a relative stable home life [18]

DIRECT CARE STAFF TRAITS Employee Appearance Employee Work Ethic: Attendance and Tardiness Employee Honesty and Integrity Employee Attitude

THE CHALLENGES OF RECRUITMENT Low wages and poor benefits Limited advancement opportunities The job is not highly valued or respected The physical and emotional demands of the work Family / personal needs do not balance with job requirements Competition from acute care settings [2]

CREATING AN APPEALING JOB

In most situations an increase in pay and benefits is not an option. However, money is not always everything, to attract good employees you need to become a good employer. Becoming an employer of choice is about the care facility adapting to the needs of the employees. This may include providing opportunities for advancement, recognition, flexibility, and offering services that relief the daily burdens of an employees home and work life [19], [20],[21].

WHAT DOES IT MEAN TO BECOME AN EMPLOYER OF CHOICE? It is when your care facility is recognized for its leadership, work environment, best practices, ability to attract and retain top employees, and the ability to continually achieve its vision. Employees are choosing to work for your care facility Employees are loyal, committed the vision and mission, and willing to take the extra step to see the care facility succeed [19], [20], [21].

THE BENEFITS TO YOUR CARE FACILITY? Enhanced recruitment opportunities Employee pride, loyalty, and commitment Improved absenteeism, less turnover, higher retention rates Improved employee morale and performance Improved resident satisfaction [19], [20], [21]

WORK LIFE INITIATIVES Work life initiatives are actions taken by the employers to help employees effectively handle the growing pressures of both work and personal life. The introduction of work life initiatives allow employees to work up to their fullest potential by stabilizing their work environment and easing daily stress. The goal is to help employees become more self supporting which in turn will build their self determination, self esteem, and confidence [19], [20], [21].

STEPS TO BECOMING AN EMPLOYER OF CHOICE Focus Area: What programs and policies are in place at our care facility that focuses specifically on direct care worker needs? Is our care facilitys management of direct care workers considered flexible or rigid? Is our care facilitys culture supportive of its direct care workers? Are the care facilitys business management and direct care worker leadership in agreement? Is our care facility connected with our local community? Does our care facility leadership know the needs of our direct care workers (their home and work life)?

Potential Work Life Initiatives / Programs Childcare Assistance financial assistance, resources, referral Pregnancy maternity and paternity leave, lactation programs, county liaisons for WIC / food stamps Health and Wellness onsite and off fitness, weight loss, stress reduction, prevention, smoking cessation, discounted gym passes, visiting massage therapist, conduct health screenings onsite, re-educate your employees about body mechanics, develop a back program and feature it at a work retraining session, insist on pre-work stretches. Housing Assistance HUD, Section 8, set up county connections, relocation services Offer facility-sponsored counseling services. Examples include six free hours of counseling for each employee after the 90-day probationary period, pastoral counseling for staff, and/or small group rap sessions with supervisors. Informational Materials- regarding parenting, divorce, drug, alcohol abuse, and financial planning [19].

EXAMPLE WORK LIFE INITIATIVE: Monthly Brown Bag Lunch Sessions: Use a paid guest speaker possibly from the local business community to present brief in-services during employee lunch hours. Direct care workers and other staff can listen and learn about topics related to their position such as stress management. The session could include quick yoga techniques, massage, deep breathing, community resources, and potential discounted group rates to the local yoga studio.Other educational inservices could include topics such as parenting, budgeting, loss, death, family conflict, assertiveness, and motivation.

ADDITIONAL PROGRAMS: 1. Flexibility Flex-time around established core hours Part-time hours Job sharing Self Scheduling Flexible work schedules Modified duties Compressed work schedules Summer hours Parental hours 2. 3. Educational Counseling and Tuition Reimbursement Dependent Care Sick pay while caring for sick family members Leaves of absence for the birth of a child, adoption, or care of an ill family member New mother phase-in program Paid Time Off Vacation Vacation buy Personal days Holidays Sick days Paid leave Bank Buy vacation days Family Medical Leave Act (FMLA) [19], [21]

4.

REFERRAL SERVICES OFFERED TO EMPLOYEES One option is to implement an onsite comprehensive program to help employees manage their individual lives. Whatever stage of life or commitments they have parenting, caring for an elderly parent, handling a two-career household, parttime educational pursuits, or any other responsibilities resources would be available. The care facility could contract with a confidential third-party provider of referral and consulting services, available 24 hours a day, seven days a week. Whether someone needs a plumber or someone to walk the dog, or has a question about a sick child or elder care services, they can get help. They have extensive resources, trained consultants and experience in many social services areas [22].

A COMMITMENT TO WORK LIFE INITIATIVES There needs to be a clear commitment by the care facility to create a flexible and supportive work environment that empowers the leadership and direct care workers to find solutions that meet both the care facilitys vision and individual needs: The care facility needs to commit to providing an environment that recognizes and respects that satisfying work and personal lives are important for all employees. The care facilitys work life strategy and resources are consistently and effectively promoted in communications, both internally and externally. Management of work and personal life effectiveness is a shred responsibility between the care facility and the employee, for which both are held accountable. The care facility needs to develop core work life programs, with flexibility to meet unique job, individual, and location needs. The care facility will continual strive for continuous improvement towards individual work and personal life effectiveness through ongoing measurement of its work life strategies, including: evaluation, assessment, feedback, and response [21], [22].

TIPS FOR SUCCESS: The key is to know the needs of your direct care workers and tailor the trainings accordingly. Provide programs specific to women's needs and women's issues Provide various modes of training (visual impact) and activity Provide onsite speakers Provide the opportunity for offsite classes at no cost to the employee Make connections with technical schools. Utilize an employee assistance program (EAP) and encourage its use Provide a good explanation of the benefit package. Training should be geared to employee learning needs and disabilities. Consider providing audio tapes and video tapes for reinforcement as well as providing additional one-on-one training as needed

Invite families to attend these educational offerings Provide employees with professional career assessment; encourage employees to pursue interests; help employees determine their abilities. Set up special interest groups where discussion could take place on breaks or outside of work; examples include wellness programs, budget planning. Be considerate of time, offer support groups before or after work; brown bag lunches [23]

RECRUITMENT: CONNECTING WITH YOUR COMMUNITY Traditionally direct care worker candidates have been women with little job or formal education experience. The idea here is to think outside the box and look beyond the norm. Potential employees may be students, retirees, laid off workers, parents of young children, and second income earners who all want to work with and help other people. Recruitment needs to occur not only through internet and newspaper ads but at the community level as well [24],[18],[25].

WHERE THE CANDIDATES ARE? Churches, synagogues, and other places of worship Faith based and other human service agencies The local welfare department Local offices for the federal or state Housing and Urban Development, local housing authority Supermarkets, shopping centers, and other stores Community based organizations that serve immigrants or underserved populations Neighborhood associations Cultural Centers GED and other educational programs Health clinics Laundromats

Unemployment offices Senior centers Local colleges w/ nursing, social work, or other human service programs [18], [24] RECRUITMENT IDEAS Ask one of your employees to speak at a high school health occupations class. Create a video describing the role of the person you hope to hire. Utilize this video for pre-employment purposes. Require job applicants to view the video prior to hiring them. Incorporate employees at every level in your recruitment program at local career fairs. Provide shadowing opportunities in addition to your verbal explanation of the direct care worker position [23], [25],[18].

ADDITIONAL RESOURCES

Wisconsin Association of Homes and Services for the Aging

http://www.wahsa.org/empch6.htm

Families and Work Institute: http://www.familiesandwork.org Center for Work and Family Boston College: http://www.bc.edu/centers/cwf/

EVALUATING POTENTIAL DIRECT CARE WORKERS

WHAT IS BEHAVIOR BASED INTERVIEWING? Behavior based interviewing targets the potential employees previous experiences and responses on the premise that their behaviors demonstrated in the past are likely to be repeated. Behavioral interviewing is also designed to help minimize subjective impressions by focusing on previous experiences. Behavior-based interview questions focus on specific examples that target behaviors needed for success in the position.

TRADITIONAL INTERVIEW vs. BEHAVIORAL INTERVIEW In a traditional interview the questions asked typically have straight forward answers such as Tell me about your background? "What are your strengths and weaknesses?" or "What major challenges and problems did you face? or "Describe a typical work week?" In a behavioral interview, the care facility has decided what skills are needed in the individual they hire and will ask questions to find out how the individual has used the skills in previous work experiences. The interview team is looking at how the potential employee handled a situation, instead of what they might do in the future. Questions asked may be Describe a time when you were late for work? or Describe a situation where you had a difficult client and explain what you did to work with him/her?

WHY BEHAVIOR BASED INTERVIEWING? The most accurate predictor of future performance is past performance in similar situations. Behavioral-based interviewing provides a more objective set of facts to make employment decisions than other interviewing methods. Increased chances of successful integration and fit with care facilitys culture The ability to interview effectively the first time saves the care facility resources (reduced turnover, less advertising cost, less training cost, less overtime paid).

PREPARING FOR AN INTERVIEW Prepare an Interview Team The interview team should consist of both leadership and employees who currently hold the position. Decide on Selection Criteria (basic competencies) - The role of the interview team is to identify job-related experiences, behaviors, knowledge, skills and abilities that are desirable for a direct care worker position. Think about adaptive, technical, self management and transferable skill sets. Questions should be based on core competencies. Develop Interview Questions Questions asked should be based on past situations where the potential employee demonstrated desirable behaviors. Question should be open ended, specific, and start with an action verb.

WHAT TO LOOK FOR IN INTERVIEWEE RESPONSES The potential employees answer should include 4 parts, often referred to as a S-T-A-R statement Situation what was the specific event, situation or stetting Task what needed to be accomplished Action taken what steps were taken to handle the situation Result - What happened? How did the event end? What was accomplished? What was learned?

ASK QUESTIONS TO EXPLORE BEHAVIOR, WORKSTYLE, & PROBE FOR CONSISTENCY: Can you give me an example? What did you do? What was your role? How did you feel in that situation? What were you thinking when that happened? What was the end result?

INTERVIEW TEAM EVALUATION AND DECISION Each team member completes their own evaluation Compare evaluations among team members Discuss differences in ratings Allow for changes and open discussion Summarize feedback Assess each competency area individually Consolidate interview notes and final comments Final decisions should be based on evaluation rating, core competencies, overall fit, and future potential

EXIT INTERVIEWS When an employee decides to leave or is terminated from a care facility it cost money not only in resources but losses in productivity. If this happens often the impact can be a significant cost to the quality of care that is provided. Preventing turnover is difficult. One way to better understand why your employees leave is to conduct exit interviews before their departure. YOUR EXIT INTERVIEW FORM: An exit interview form should contain questions that will allow you to collect objective information about your care facilitys environment. You should develop an exit interview form that allows for yes and no questions so data compiled over several interviews is easier to manage. Open-ended questions leave room for interpretation of data. To make changes in the care facility based on the responses collected in exit interview forms, you have to show the data supports your actions. The form should allow for a variety of responses including, multiple choice and blank fields. Allow the individuals to choose more than one answer

Ask your employee why they are leaving the care facility. If their response to the question is salary, ask if they would have stayed if they received a raise? Ask about the work environment, leadership, communication patterns. How did it relate to their job satisfaction Do not get personal or defensive of comments. Ensure the employee feels comfortable and can be honest with their answers. Thank the employee for their time and honesty. Respect the employees confidentiality. Do not share specifics of the comments or point fingers at other employees

ADDITIONAL RESOURCES

ORIENTATION
Effective orientation programs get new employees up to speed faster, have higher retention rates, and achieve better agreement between what employees consider productive and the performance standards the care facility expects. In addition, new employees have an accelerated learning curve, increased productivity and a smoother transition into the care facilitys organizational culture [26], [27].

THE PRIMARY PURPOSE OF NEW EMPLOYEE ORIENTATION: To introduce employees to the work environment To ensure employee achieves a sense of belonging Create a positive impression Prevent uncomfortable feelings of isolation and frustration Help new employee understand his/her role and how it fits into the total facility Help new employee achieve objectives and shorten learner curve Help new employee make a successful adjustment to the position [26],[28].

THE BASIC COMPONENTS OF NEW EMPLOYEE ORIENTATION: History of the care facility Familiarity with the facility or campus layout Increased knowledge about the organizational mission, vision, core values, and its diversity Employee policies and procedures Explanation of Employee Benefits and services Core Facility Trainings Introduction to care facility leadership and staff

BEFORE THE EMPLOYEE ARRIVES: Notify everyone in your unit that a new person is starting and what the person's job will be. Ask the other staff members to welcome the new employee and encourage their support. Prepare interesting tasks for the employee's first day. Make a copy of the job description card, job performance standards, care facility organization chart, and your specific department's organization chart. Enroll the employee in the New Employee Orientation Make sure a copy of the appropriate personnel policy manual or contract handbook is available for the employee. Have a benefits information package available. Identify a more senior direct care staff to act as a peer mentor Put together a list of key people the employee should meet and interview to get a broader understanding of their roles Draft a training plan /checklist for the new employee's first few months [27]

WHAT TO COVER: Organizational history Market niche - how the care facility sets itself apart in the marketplace and in the community ( why do residents choose to receive care here) Mission, vision, values, philosophy and goals Organizational structure - Interrelationships between departments / functions - Names of department heads - Organizational Culture - Management style - Dress Code - Emphasis on teamwork, group interactions, diversity, quality, communication styles - Work arrangement policies flexibility in scheduling, etc. - Career development opportunities such as training courses, mentoring options, career ladder / lattice - Explanation of the performance evaluation system - Overview of work place polices related to equal opportunity, nondiscrimination /non-harassment, health and safety, confidentiality, Internet and computer usage, holidays and grievance procedures - Organizational events and activities, such as holiday parties, staff meetings, special events and fund raisers Facility tour [27] ,[28]

ORIENTATION KIT: In addition to the orientation it is a good idea to put together a folder/kit of written materials that new employees can refer to at a later time. Organizational literature, including flyers and newsletters A map of the building / campus An organizational chart A glossary of agency specific terminology and acronyms A list of contact names for specific inquires Instructions for accessing the care facilitys intranet and operating email, voicemail, etc., as appropriate Work-related computer and internet policies A calendar of training events, meetings, conferences, fund raising events A current job description A comprehensive employee handbook that details the care facilitys polices, procedures and standards [27]. THINGS TO REMEMBER: Spread the orientation out over a period of time Avoid information overload Assign mentors to assist in acclimating employees Make it a habit to frequently interact with the new workers. Understand that new employees are normally reluctant to ask questions. Create ready-made opportunities. Make orientation fun and welcoming

ORIENTATION PROCESS Beyond First Week: Elicit feedback from the new employee to ensure everything is running smoothly Probe for difficulties and improvements made by the new employee Ensure orientation checklist is completed by direct supervisor and new employee Complete a three month performance evaluation [28]

Results of a Successful Orientation: Excited employee, who quickly becomes well adjusted to the organizational culture

Employee who understands the care facilitys mission and vision and how he/she fit into them More productive employees Employees have developed positive impression [28]

ADDITIONAL IDEAS FOR ORIENTATION IMPROVEMENTS: A welcome lunch for new employees with co workers, mentors and care facility leadership. This is the best time of the day for an informal interaction. Incorporate interactive ideas for orientation and entry level trainings such as role plays, case studies, and team discussions Offer non technical skill training specifically on critical thinking, problem solving and effective communication. Allow trainees to practice each skill, learning how to think objectively about an interpersonal conflict, communicate clearly, and find solutions without allowing emotions to overwhelm rational thinking. Allow ample time for on the job training where new employee receives support from mentors, peers, and close oversight by leadership. Follow-up - Allow new employees opportunities to gain feedback, ask questions and do an assessment of additional training needs ( See attachment C).

ADDITIONAL RESOURCES: The Importance of Good Employee Orientation - AAHSA White Paper
http://www.wahsa.org

PEER MENTORING
Research reflects that a considerable amount of employee turnover of direct care staff takes place during the first three months of employment. More senior staff tends to leave based on lack of opportunities for advancement or growth. Peer mentoring is a strategy that can be used to address both issues by reducing turnover among new employees and creating opportunities for more experienced workers [29]. The primary role of the peer mentor is to help new employees become comfortable at their new position and ease into the care facilitys organizational culture. The mentor acts as a confidant who can answer questions, give advice, model best practices, and provide emotional support. The peer mentor not only serves as an instructor to new employees but also as a link between new employee and supervisor, providing a better understanding of the employees skill development and addressing their needs earlier [30],[31]. A good peer mentor needs to have outstanding clinical, knowledge base, problem solving, and interpersonal skills. When training peer mentors the primary focus needs to be placed on relational skills which include: Leadership skills the ability to be a role model and motivate new employees Interpersonal communication skills - the ability to actively listen, ask questions, and understand the employees perspective Teaching and coaching skills the ability to asses skills, create a supportive learning environment, and provide constructive feedback Problem solving the ability in helping new direct care workers develop decision making and conflict resolution skills [31],[32],[33].

DEVELOPING A PEER MENTORING PROGRAM: Job Design -How will the mentor manage their new responsibilities along with current care giving responsibilities? Mentor compensation Decide if mentor will receive wage adjustment

Management buy-in Do you have organizational support?

Organizational orientation to the mentors role Ensure that all staff is aware of the mentors role and how mentors are assigned mentees. Who is responsible for oversight of the program? Mentor Selection - Develop a fair and accessible system for aids to apply to become mentors. Think about what the incentive is to take on the added responsibility Mentor Training should focus on interpersonal skills Mentor Oversight and Support ensure mentor has identified leadership support Mentor to Mentee Matching ensure good fit by trying to match u personalities as well as skill area. If a mentee has weak clinical skills match her/him with a mentor who excels in this area Mentee Orientation should be part of the new employee orientation where new employees are introduced to their mentors. Mentees should be made aware of the role of their mentor and the limits of their responsibilities [32],[33], [31].

ADDITIONAL RESOURCES

EMPLOYEE RECOGNITION
Employee recognition should be part of the organization's culture as it contributes to both employee satisfaction and retention. The key to successful employee recognition is that rewards must be meaningful to staff and used effectively in acknowledging excellence [34],[23]. THE BENEFITS OF RECOGNIZING & REWARDING DIRECT CARE STAFF: Tells direct care staff what standards their job performance must meet When direct care staff know that the care facilitys, residents, families, and leadership expect a particular level of performance, theyll be more cooperative about performing at that level than if a performance standard seems to be based on a managers whim. Rewards improve direct care worker job performance and satisfaction. The need to discipline or correct direct care staff is reduced because employee job performance meets the care facilitys expectations more often. This creates a more pleasant work environment. Residents and their familys expectations are more likely to be met by direct care staff job performance even when facility leadership is not present [25], [34].

There are many ways to reward employee job performance. A successful employee recognition program requires a balance between financial and non financial rewards to provide motivation to all employees regardless of their priorities. In addition you need to consider the difference between team rewards and individual rewards. Some rewards encourage partnerships and teamwork while others personal interest [25]. Appreciation: Saying thanks or expressing appreciation to an employee. Example: I appreciate how quickly you Bankshot: Asking someone of higher rank, status, or authority to reward an employee instead of giving the reward yourself. Example: A nurse manager asking the administrator or care facility management to praise an employee. Body Expressions: Hand signals or facial expressions that mean approval. Examples: Smile, thumbs up, hand shake Praise: Complimenting an employees job performance. Examples: Well done! Super job! Excellent work!

Preferred Work Assignment: Tasks an employee likes to do. Examples: More freedom to make decisions, greater variety of assignments. Incentives: Rewarding employees with small gifts, gift certificates, paid days off, bonuses [34],[23]

DESIGNING A SUCCESSFUL REWARDS PROGRAM: Solicit input from facility leadership, residents, and resident family members to determine expectations of care delivery and professionalism. For example, ask residents what they feel is the most important aspect of their care and how they expect to be treated. Know what the industry standards are and what is happening through out the state. Care facility expectations should be achievable and not out of reach by employees. Staff should be fully aware and reminded periodically of expectations and standards of job performance Observe job performance of an individual employee or group and solicit comments from coworkers, residents, family members, and facility leadership. Job performance decisions should be based on welldefined standards that have been developed using observable achievements. When expectations are met, tell individual employees or groups exactly what was done well and how their job performance benefits the care facility Recognition should be visible to all members of the organization. Rewards / Recognition should have meaning and value for the recipient. Rewards / Recognition can be based on an event (achieving a designated goal) or based on a time frame (performing well over a specific time period). Rewards / Recognition can be spontaneous (sometimes called on-the-spot awards) are also highly motivating and should also use a set criteria and standard to maintain credibility and meaning. Non-monetary rewards, if used, should be valued by the individual. For example, an avid camper might be given a 10-day pass to a campsite, or, if an individual enjoys physical activity, that employee might be given a spa membership. The non-monetary rewards are best

received when they are thoughtfully prepared. Be creative! Rewards should be appropriate to the level of accomplishment received [25], [35].

TYPES OF EMPLOYEE RECOGNITION: Formal Employee of the year Various Awards: years of service, perfect attendance, demonstration of leadership, demonstration of innovation Informal Care facility picnic Holiday party Monthly meeting acknowledgement Birthdays Employee appreciation week Day to day Notes from co workers or facility leadership Emails Postings on break room bulletin boards

THREE RULES TO EFFECTIVE REWARD AND RECOGNITION OF JOB PERFORMANCE If-Then rule: If an employees job performance meets or exceeds care facilitys expectations, then reward the employee. On the other hand, if an employees job performance does not meet expectations, then do not reward the employee. Quick rule: Reward job performance that meets customer expectations as soon as practical after the performance occurs. Variety rule: Change what you do to reward an employee for job performance that meets or exceeds expectations. Using a variety of rewards prevents any one reward from losing its effectiveness due to overuse [35].

FUN WAYS TO RECOGNIZE & ENCOURAGE STAFF

1. Display photos of your direct care staff with notes about favorite foods, hobbies or families 2. Plan an awards ceremony and invite your mayor. 3. Create a poster consisting of "thank you" notes from family members and staff. Include pictures of your nurse assistants. When complete, enlarge your poster to 5X8 feet and post it in a prominent place 4. Provide computer training for nursing assistants and encourage them to connect with resources and nursing assistant groups in other areas 5. Nurse Aide Olympics develop teams to participate and receive prizes in participating in various events including wheel chair races, bed races, bedpan toss, blind-fold feeding, bed making, balloon shavings, and other games. The event encourages fun, and team building 6. Ask your local newspaper to write a story about staff member who has the most years of service 7. Collaborate with the Ombudsmen or other local groups to plan an Award or Recognition Program 8. Ask your residents to provide insights about how important the direct care staff is to them. 9. Ask resident families to provide stories that reflect the caring and wisdom of direct care staff employed at your care facility 10. Form a direct care worker Excellence Committee (or some aptly named group) that develops in services/presentations all year long. Collaborate with other local facilities- to share and inform. 11. Host an open house to highlight what your direct care staff does [35]

TIPS TO GENERATE EMPLOYEE RESPECT & VALUE SUGGESTIONS TO BUILD RESPECT Continue working to educate the public regarding the role of long term care employees. Invite the public into you care facility. Host an open house, bring your child to work day, internship programs Develop an environment of respect for all disciplines in long term care. Mandate zero tolerance for disrespect. Encourage employees, family and residents to provide positive feedback related to the performance of individual employees. Encourage employees to mingle with other employees during break time.

Accept and seriously consider employee suggestions for problem solving. Develop levels of advancement and growth for all staff positions. Encourage all employees to attend staff meetings and other employee gatherings [23].

SUGGESTIONS TO BUILD SELF-ESTEEM Encourage all employees to provide positive feedback. Select an Employee of the Month or celebrate special staff recognition days. Include line staff on facility committees. Create a staff council for suggestions and problem solving. Integrate the direct care workers as part of the resident care planning team. Encourage employee participation in your quality improvement program. Insist all employees show common courtesy related to the basics of life. Offer training for specialty programs. Provide literature and guest speakers on self-esteem [23].

EMPLOYEE EVALUATIONS Employee performance evaluations are an extremely important tool for developing and maintaining successful employees.

PERFORMANCE EVALUATIONS: Improve communication Help to motivate employees by allowing them to be part of their professional development decisions. Improve productivity Help to identify and correct performance deficiencies Develop employee skills by setting goals and establishing action plan Performance evaluations should be viewed as a positive and useful tool for involving employees in their development. The periodic evaluations help remind employees of expectations already set for them, serve as an avenue for responding to concerns, and provides continuing opportunities to update employees on their progress and to give and receive feedback on work issues.

PERFORMANCE EVALUATION TIPS FOR SUPERVISORS Be honest and fair in evaluating all employees. Be certain that you as the supervisor have reviewed all of your employees in an objective and consistent manner as individuals and relative to other employees in the group. The purpose of performance evaluations is to take a realistic snapshot of the employee's performance. Don't say the employee is improving if (s)he is not performing well. Be consistent in your approach. Don't create a situation where it appears that you create excuses for one employee while holding another employee accountable. Define your criteria for each level of ranking and use the same criteria for every employee. Don't set separate criteria for certain employees. Give your comments. A ranking or number used to rank an employee's performance is useless without a written comment. Comments are required for any ranking that is less than "3 or meets expectations" and also for the highest ranking of "5 or exceeds expectations." Comments may confirm achievements or be constructive depending on the nature of the ranking. Make your comments consistent with the rankings. Don't give someone a "meets expectations" ranking if your comment describes a substandard performance. Be realistic. Don't inflate ratings. Inflation of ratings only inflates an employee's expectations. Rate the employee's performance, not the employee's "attitude." Keep your comments job related and based on the employee's ability to perform his/her job. Avoid phrases like "bad attitude," "he's not a team player," and other subjective type comments. Explain the behavior that is a result of the "attitude." Set goals with the employee. Don't just criticize a deficient performer; set goals for follow up and for improvement or development. Work together to create a plan of action to help the employee in deficient areas and to establish goals for the coming year. Set a follow up period and be sure to reevaluate the employee at the appropriate time. A performance evaluation should motivate an employee to want to improve. The employee should feel excited about the challenges and his/her ability to meet them. If employees hear only about their failures and weaknesses, they'll start to believe they can't succeed. If employees get support and encouragement from their supervisor, they'll gain the desire and confidence to keep trying. When the supervisors' suggestions for improvement bring results and recognition - employees are even more likely to listen to future suggestions
[36].

THERE SHOULD BE NO SURPRISES The evaluation should be a review of the past year's performance. Through previous counseling and other communications, the employee should be aware of any concerns you might have about their job performance. The annual evaluation should not be the first time the employee learns of your concerns [36]

ADDRESS DEVELOPMENT NEEDS BOTH PROFESSIONAL & CAREER Don't forget to allow space for identifying and establishing training goals. Ideally, training and career development activities should be tied to the performance of goals and to improving performance of specific competencies. Depending on the type of assessment, the training can be tied to the employee's current role, but should also help prepare him/her for career aspirations or progression within the organization.

DEVELOP S-M-A-R-T GOALS Specific, Measurable, Attainable, Realistic, Timely Prompt leadership and direct care to be specific. Provide detailed descriptions of each goal, link the goals back to the mission /vision of the facility, how will the goal be measured, identify any training or resources required for success, and the expected completion date. Also be sure that the overall number of goals is reasonable. You may want to limit the number of goals an employee and/or leadership can create. Providing an example of a SMART goal can be particularly helpful.

PROVIDE FEEDBACK Close the loop: Employees need detailed and specific feedback on performance of competencies and goals in order to develop and improve. Identify times when feedback will be given and in what format.

ADDITIONAL RESOURCES

CULTURAL COMPETENCE
The term cultural competence refers to the ability to work effectively with individuals from different cultural and ethnic backgrounds, or in settings where several cultures coexist. It includes the ability to understand the language, culture, and behaviors of other individuals and groups, and to make appropriate recommendations. Cultural competence exists on a continuum from incompetence to proficiency. Cultural sensitivity, which is a necessary component of cultural competence, means that long term heath care professionals make an effort to be aware of the potential and actual cultural factors that affect their interactions with residents and their co workers. It also means that the care facility is willing to design programs and materials, to implement programs, and to make recommendations that are culturally relevant and culturally specific [37].

STEPS TO BECOMING MORE CULTURALLY COMPETENT Cultural competence is something that develops over time with continued learning and active engagement. Individuals working with different ethnic and cultural groups can become more culturally competent by addressing three main stages: developing awareness, acquiring knowledge, and developing and maintaining cross-cultural skills. Developing Awareness -Developing cultural awareness includes recognizing the value of population diversity. It also means an honest assessment of one's biases and stereotypes. Acquiring Knowledge - One can never learn everything about another culture. However, acquiring knowledge about other groups is the

foundation of cultural competence. In addition to understanding other cultures, it is essential to understand how different cultural groups view one's own culture. Knowledge of another culture includes assessments of facts not only about relevant norms, values, worldviews, and the practicality of everyday life, but also about how one's culture and the services one provides are viewed. Developing and Maintaining Cross-Cultural Skills - Even though the United States is a very diverse society, most health care professionals have been trained in a monocultural tradition. In addition, many continue to practice as if ethnic and cultural differences are insignificant. Crosscultural skills are developed through formal coursework, informal interaction and networking, and experience [37].

ORGANIZATIONAL RESPONSIBILITIES It is important for long term care facilities to voice a commitment to cultural competence. Care facilities need to provide cultural competence and/or cultural sensitivity within their training programs, in-services and seek out outside workshops. In addition organizational policies and procedures need to reflect the diversity of the care facility [37].

STEPS TO BECOMING CULTURALLY COMPETENT 1. Developing Awareness Admitting personal biases, stereotypes, and prejudices Becoming aware of cultural norms, attitudes, and beliefs Valuing diversity Recognizing comfort level in different situations A willingness to extend oneself to different cultures and ethnic groups [37] 2. Acquiring Knowledge Knowing how your culture is viewed by others Attending classes, workshops, and seminars about other cultures

Reading about other cultures Watching movies and documentaries about other cultures Attending cultural events and festivals Sharing knowledge and experiences with others Visiting other countries [37] 3. Developing and Maintaining Cross-Cultural Skills Making friends with people of different cultures Establishing professional and working relationships with people of different cultures Learning another language Learning verbal and nonverbal cues of other cultures Becoming more comfortable in cross-cultural situations Assessing what works and what does not Assessing how the beliefs and behaviors of the cultural group affect the client or family Learning to negotiate between the person's beliefs and practices and the culture of your profession Being more flexible Attending continuing education seminars and workshops Learning to develop culturally relevant and appropriate programs, materials, and interventions Learning to evaluate culturally relevant and appropriate programs, materials, and interventions Ongoing evaluation of personal feelings and reactions Overcoming fears, personal biases, stereotypes, and prejudices [37] The Office of Minority Health and the Department of Health and Human Services made specific recommendations for culturally effective health care in the document, "Assuring Cultural Competence in Health Care: Recommendations for National Standards and an Outcomes-Focused Research Agenda." Some of these recommendations include: Developing and implementing a strategy to recruit, retain, and promote qualified, diverse, and culturally competent employees and administrative staff Promoting and supporting the necessary attitudes, behaviors, knowledge, and skills for staff to work respectfully and effectively with residents and each other in a culturally diverse work environment Developing a comprehensive strategy to address culturally and linguistically appropriate services, including strategic goals, plans, policies, and procedures

Hiring and training interpreters and bilingual staff Providing a bilingual staff or free interpretation services to residents with limited English skills Translating and making available signage and commonly used educational materials in different languages Developing structures and procedures to address crosscultural ethical and legal conflicts, complaints, or grievances by residents, their families, and staff Preparing and distributing an annual progress report documenting the care facilitys progress in implementing these standards, including information on programs, staffing, and resources [38].

HOW TO INCORPORATE CULTURAL DIVERSITY WITHIN YOUR CARE FACILITY Host a diversity panel discussion capturing best practices in your care facility. Include staff, residents, family members, diversity practitioners from your area. Have a focus session to enhance knowledge of diverse communities, demographic trends, languages, communication patterns of your service area. Include implications for future service needs. Explore the diversity within your offices by asking for volunteers to share experiences, customs, cultures. Organize presentations, potlucks, or panel discussions. Recognize the languages spoken in your service area by having volunteers write names or phrases in the languages spoken by office staff. Extend an invitation to the local Native American community to come and speak about the history and the needs of the area. Invite an expert of Middle Eastern cultures to give an overview of the culture and what it means for Arab Americans living in the USA now.

Partner with local Office of Vocational Rehabilitation Services to bring Windmills training or disability awareness training to staff. Contact Centers for Independent Living for more information on presentations regarding serving people with disabilities. Have a session on working with people in poverty. Provide examples of how to improve communication skills and deliver services in a respectful manner. Get volunteers from staff and outside participants to create a display portraying family diversity. The goal would be to emphasize the message that families come in different forms, with a breadth of diversity and family configurations. If you need help with this let me know and remember not to use client photographs. Bring in diversity practitioners from the county, university, community college, non-profits, schools or the private sector to share what they are doing to make programs or services more cultural competent. You will be amazed as to how willing people are to come and share best practices. Contact your local Chamber of Commerce, diversity groups, churches, schools, higher education to find out about art, crafts, musical groups, dance groups, that would be willing to come to your offices or share their diverse crafts and art. Native American dance groups, Mexican folkloric dance groups, African American choirs, Asian and Pacific Islander dance or musical groups come to mind as possible offerings. Create a work environment that reflects the multi-cultural setting of your service area. Take one of your lobby areas as a project and include feedback from your staff, residents and family members. Identify opportunities to engage or collaborate with diverse communities in your local area. Contact the DHS Training Unit, your local library, or college to obtain resource information on diversity training, displays, posters, books, tapes, and articles. Create a display bulletin or table and update on a monthly basis depending on the celebration of the month, e.g., Black History Month, Disability Awareness Month, and so forth. Resource: Oregon DHS Celebrating Diversity

ADDITIONAL RESOURCES

Think Cultural Health - www.thinkculturalhealth.com U.S. Department of Health - Office on Minority Health - www.omhrc.gov The Cross Cultural Health Program - www.xculture.org/index.cfm Health and Literacy Special Collection - http://healthliteracy.worlded.org Race the Power of Illusion - www.pbs.org/race/000_General/000_00-Home.htm

EMPLOYEE SATISFACTION SURVEYS Satisfied, motivated employees facilitate higher resident satisfaction and, in turn, positively influence organizational performance. Care facilities that establish a feedback process to measure employee opinions and attitudes through Employee Satisfaction Surveys are able to develop such a workforce. An employee satisfaction survey is a tool to ensure that employee perceptions and perspectives are taken into account when making organizational decisions.
(See Attachment D)

BENEFITS OF EMPLOYEE SATISFACTION SURVEYS

More Accurate Perspective Care facilities can attain clearer perspective on how their employees prioritize and rank the importance and value of topics such as benefits, versus compensation, versus career development. Increased Employee Loyalty By quantifying and analyzing employee attitudes and opinions, care facilities can identify problem areas and develop solutions that create a supportive work environment and foster a motivated, loyal workforce. Training Needs Assessment Employee Satisfaction Surveys help to develop individual goals and career potential. With more insight into employee opinions and attitudes, leadership can establish effective professional development programs. Improved Resident Service Because motivated direct care staff is critical to improved organizational programs, such as increasing resident satisfaction, care facilities that value and strive for greater Employee Satisfaction ultimately create higher resident satisfaction.

ADDITIONAL BENEFITS Foster commitment instead of compliance Identify managers in need of leadership development Determine your care facilitys readiness and its ability to accomplish its mission Identify organizational weaknesses and strengths Identify best practices Create a rich working environment Improve employee collaboration and team work Collect data and track progress over time Identify areas of opportunity

FOUR STEPS FOR USING STAFF SURVEY RESULTS Data collected is the voice of your direct care staff. The data should be considered valuable as it is the reality of your care facility and its operations. Just as important as the data it self is how the data is shared with staff and what happens as a result of the survey. STEP 1: Promptly post the results. This can be done in an all staff meeting or posted in a visible area. Results should be discussed and staff can be asked to

participate on a multi-disciplinary team whose charge is to improve the results. Note some issues may not have a feasible resolution. In this case always state specific reasons why concern can not be addressed and ask for additional input. STEP 2: Right after the results are posted, either the administrator can hold an all staff meeting or each department leader can hold meetings with their staff to discuss the results. The department leaders should prepare talking points to facilitate meetings. The following questions can be addressed: What are the strengths in our care facility that we should celebrate? What are the areas in which we need to improve and how have we prioritized them? Where do we want to be in six months relative to where we are today? How can we use process improvement to get there? What ideas do you have for addressing our needs? (Make sure to solicit feedback and gather ideas.) During these meetings, staff will share issues that can be immediately addressed by leadership. Listen carefully to what is frustrating your staff. Demonstrate that you are listening by acting. Often, there are quick successes you can implement. Some examples of quick successes include purchasing extra supplies or installing additional glove holders. Implementing changes such as this will build trust and help you address more challenging opportunities as the process continues. Note during all meetings specify someone to assist in note taking who is not direct care staff. STEP 3: Hold the first of many meetings of multidisciplinary team from all levels of the care facility who signed up to discuss the results and work on implementing improvements. During these meetings, care facility leadership should serve as facilitators and seek to understand the specifics: what problems are occurring, how often they are occurring, when and where they are occurring. Then you can move to understanding why they are occurring, using root cause analysis techniques. For each individual item that did not score well, lead the group in a brainstorming session to: Identify and document all possible causes. Look for the relationship between them. Examine the ones over which you have influence and those over which you do not.

You may want to use a fishbone diagram to guide this discussion

(See attachment A and B)

Your goal is to move the merely satisfied staff (the ones who rated the facility as "fair" for each statement in the survey) to becoming very satisfied ("excellent"). If you get 33% who rate you as "excellent" or "good" on a given item, you are in good shape. This is because being very satisfied (not just merely satisfied) correlates strongly with resident and family satisfaction, low turnover and even clinical outcomes such as a reduction in falls, pressure ulcers and catheter utilization. So note the items where you got close to or above 33% "excellent" or "good" marks. Celebrate these successes and build off of them. The most important items in the survey are in the "Supervision" section. If you can improve your scores in this section, you will see spillover to many of the other items. For example, your ratings for performance evaluations and orientation should improve. Furthermore, your score on "What is your recommendation of this long-term care facility as a good place to work?" should also rise. That question is the best way to judge the overall level of staff satisfaction. STEP 4: Once the team has some potential solutions in mind, start your pilot tests of solutions designed to improve staff perceptions related to the questions. For example, if only 10% of the staff indicated that management listens to them. You may want to have department heads start learning circles and begin a suggestion box, then conduct a follow-up survey to ask staff what they perceive as the barrier to management listening. You will want to learn quickly what works and what doesn't. So, after you have implemented some solutions: Take the items from the survey that you were attempting to improve and re-survey the staff on only those items Compare these results to the previous results to the same items on the original survey to determine is the solutions are effective Reflect on the results of every change, paying close attention to any glitches that arise Determine whether to table it or spread it to more staff. Most of all, appreciate this opportunity to improve the work-life of your facility, for the good of your staff AND your residents. Making your facility a better place for your staff to spend the bulk of their day can only lead to positive changes for everyone [39].

GALLUP 12 INDICATORS TO MEASURE EMPLOYEE SATISFACTION 1. Do I know what is expected of me at work? 2. Do I have the materials and equipment I need to do my work right? 3. At work, do I have the opportunity to do what I do best every day? 4. In the last seven days, have I received recognition or praise for doing good work? 5. Does my supervisor, or someone at work, seem to care about me as a person? 6. Is there someone at work who encourages my development? 7. At work, do my opinions seem to count? 8. Does the mission/purpose of my care facility make me feel my job is important? 9. Are my coworkers committed to doing quality work? 10. Do I have a best friend at work? 11. In the last six months, has someone at work talked to me about my progress? 12. This last year, have I had opportunities at work to learn and grow [40]?

ADDITIONAL RESOURCES Measuring Long-Term Care Work: A Guide to Selected Instruments to Examine Direct Care Worker Experiences and Outcomes - Institute for the Future of Aging Services - U.S. Department of Labor and U.S. Health and Human Services US http://aspe.hhs.gov/daltcp/reports/dcwguide.htm#satisfaction of health and human servicesUS

ATTACHMENT (A)

Activity: EMPLOYEE OPINION SURVEY CHECK IN Purpose: Use this activity to conduct interim checks on your employee opinion/engagement survey results and identify where you are doing well, and what can be improved. Facilitator Notes: Group Activity 45 minutes One hour Supplies: Flip Chart Sticky dots 1 package red, yellow and green Process: Place the top 3 5 priorities from your employee opinion/ engagement survey on a flip chart. Provide each participant with a red, yellow and green sticky dot for each question. For example, if you placed three priorities on the chart, each participant should have 3 red, 3 yellow and 3 green sticky dots. Ask participants to review each priority and place a dot next to the priority. The dots represent the following feedback: Green: You are doing a great job, we are making progress as a department on this priority Yellow: Our progress is coming along, it is OK, but not great, we have opportunities to still improve Red: No progress or improvement in this area. We have much work to do. Leave the room and provide participants with time to place their dots on the priorities. 1 dot per statement per participant. (15 minutes) Upon returning to the room, review the priorities and facilitate a discussion in the following order: Green Dots: What have we done to make progress on this priority? Whats working well and what do we need to keep doing to ensure we continue to do a good job. Yellow Dots: What have we done to make progress on this priority? Whats working well? Where do we still have opportunity to improve? What are our next steps to move this priority from yellow to green? Red Dots: What are our obstacles to making progress on this priority? Lets look back at our original action plan. What is working on the plan? What is not working and needs to improve? What additional actions should we be taking? What are our next steps and timeframes for making progress on this objective?

Conclude the session by reviewing wins and action steps. Commit to a time when you will follow up with the team. Consider placing as an agenda item in your staff meeting. Thank team for their time, honesty and participation.
Resource: Studer Group 2008 http://www.studergroup.com

ATTACHMENT (B)

Cause-and-Effect (Fishbone) Diagram What is it? A Cause-and-Effect Diagram (also known as a "Fishbone Diagram") is a graphical technique for grouping people's ideas about the causes of a problem. Who uses it? The team, the users, the leadership. Why use it? Using a Cause-and-Effect Diagram forces the team to consider the complexity of the problem and to take an objective look at all the contributing factors. It helps the team to determine both the primary and the secondary causes of a problem and is helpful for organizing the ideas generated from a brainstorming session. When to use it? It is used after the causes have been grouped by relationships. It is a useful diagram for problem analysis. Therefore, a Cause-and-Effect Diagram should be used before deciding how to deal with the problem. How to use it: Before constructing the Cause-and-Effect Diagram, you need to analyze the causes. The steps are as follows: 1. Re-examine the problem by asking: What is the problem? Who is affected? When does it occur? Where does it occur? 2. Brainstorm the team's ideas about the causes of a problem using the Causal Table or "Why-Because" Technique. 3. The list of causes should be grouped by relationships or common factors 4. You can now illustrate graphically the causes grouped by relationships by using a Cause-and-Effect Diagram where: The problem under investigation is described in a box at the head of the diagram.

A long spine with an arrow pointing towards the head forms the backbone of the "fish." The direction of the arrow indicates that the items that feed into the spine might cause the problem described in the head. A few large bones feed into the spine. These large bones represent the main categories of potential causes of the problem. Again, the arrows represent the direction of the action; the items on the larger bones are thought to cause the problem in the head. The smaller bones represent deeper causes of the larger bones they are attached to. Each bone is a link in a Cause-and-Effect chain that leads from the deepest causes to the targeted problem.

ATTACHMENT C

THE HONEYMOON QUIZ The Studer Group suggests that you schedule follow-up meetings at the 30- and 90-day marks. Somewhere in this timeframe, the honeymoon ends and reality starts to set in. Again, these meetings are more than casual conversations about how things are going. The Studer Group also suggests going in with a structured list designed to discover not only whats not going well, but also what is going well. The following is an outline leaders can use for both 30- and 90-day meetings. Start by letting the new hire know that you are glad she/he is part of the team. Let her know that you care about her and that you value her input and ideas. Then ask: 1. How do we compare to what we said we would be like? When expectations arent being met, employees may feel as though you have misrepresented the situation. They may even feel lied to. This question will open a dialogue for clarifying the new hires expectation level and will give you a good perspective on whether you are delivering what you promised. 2. Tell me what you like. What is going well? In long-term care, we are often trained to focus on what is going wrong. By asking what is going well, you give the new hire a chance to focus on the positive aspects of the job. As a manager, you will gain a unique perspective on what matters to people. 3. What employees have been helpful to you in your first 30 days? By asking this question, you can discover which employees are valuable in the retention process and recognize and reward them for helping new hires learn the ropes. Once other employees see that the employees are being rewarded, they too will become involved in the process. Employee turnover affects everyone and everyone should have a stake in tackling the problem. 4. I noticed you came to us from _____. Are there things you did there that might be helpful to us? Asking this is a great way to harvest intellectual capital. Current employees may not be good at taking input from new employees, even if the advice is sound. Plus, new hires may be reluctant to offer input for fear of alienating co-workers. By asking the question, you create a win-win situation. You get great new ideas for process improvement, and the new employee feels as though she made a valuable contribution. 5. Is there anyone you know who might be a valuable addition to our team? At this point, your new employee is likely still in touch with former co-workers. If he is having a good experience with your organization, encourage him to let former co-workers know. This is a very effective

Resource: Studer Group 2008 http://www.studergroup.com

Attachment D

Staff Satisfaction Survey

Facility: ________________________________ Date: ________________ For each statement, please circle the number that best reflects your level of agreement. 1 = Strongly Disagree II. 1. Work Environment 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. For the type of job, my workload is reasonable. I have enough equipment and supplies to do my work well. Compared to other facilities I am paid fairly. My performance evaluations are done fairly. There is communication between shifts. Co-workers work well together. I like the type of work I do. Supervision I get recognition for good work. My supervisor cares for me as a person. My job expectations are made clear to me. Managers care about the staff. Training New staff receives a good orientation. Staff receive good ongoing training. I got training to deal with challenging residents. I got training to deal with challenging families. Caregiving 16. 17. 18. 19. 20. The staff cares about the residents. This facility gives good care. In General Overall, I am satisfied with this long-term care facility. I would recommend this long-term care facility as a good place to receive care. I would recommend this long-term care facility as a good place to work. 1 1 1 2 2 2 3 3 3 4 4 4 1 1 2 2 3 3 4 4 1 1 1 1 2 2 2 2 3 3 3 3 4 4 4 4 1 1 1 1 2 2 2 2 3 3 3 3 4 4 4 4 1 1 1 1 1 1 1 2 2 2 2 2 2 2 3 3 3 3 3 3 3 4 4 4 4 4 4 4 2 = Disagree 3 = Agree Strongly Disagree 4 = Strongly Agree Disagree Agree Strongly Agree

Adapted from V. Tellis-Nayak, Customer Satisfaction in Long Term Care: A Guide to Assessing Quality. American Health Care Association (AHCA). Resource: For the Leading Edge survey, visit http://www.acumentra.org/healthcaresettings/nursing-homes/tools-person.htm.

RESOURCE LIST
ECLEPS- This project builds capacity for long-term care (LTC) facilities to be excellent clinical learning sites for nursing students in the Oregon Consortium for Nursing Education (OCNE). Through community-academic partnerships, we are developing a model training and support program that provides LTC staffs with essential knowledge and skills to enhance their practice setting and support students learning. The product of this proposal will be four enriched LTC clinical education sites for nursing students, two in nursing facilities and two in community-based LTC facilities (e.g. assisted living, residential care). The program will be available for replication by other schools and LTC facilities throughout Oregon and the Northwest. This project is funded by the Northwest Health Foundation (NWHF). http://www.oregonhwi.org
Advancing Excellence- Advancing Excellence in America's Nursing Homes is a

coalition-based campaign to improve the quality of life for residents and staff in America's nursing homes. The campaign's unprecedented coalition includes long-term care providers, caregivers, medical and quality improvement experts, consumers, government agencies and other quality-focused organizations. The campaign will strengthen the public trust in nursing home care by focusing on quality improvement and self-regulation. The campaign acknowledges the critical role of nursing home staff and consumers in improving quality of care and quality of life for nursing home residents. http://www.nhqualitycampaign.org Leading Edge Network Working with nursing homes to create a learning community to address staff and resident satisfaction, direct care worker turnover, and clinical issues related to Medicare Quality Measures. http://www.acumentra.org/healthcaresettings/nursing-homes/network.htm MOVE (Making Oregon Vital for Elders) MOVE is a coalition of long term care organizations, public agencies, academia, and other interested parties whose mission is to promote person-centered care in Oregon. http://www.orculturechange.org/ Better Jobs, Better Care BJBC is a 4-year $15.5 million research and demonstration program, funded by the Robert Wood Johnson Foundation and The Atlantic Philanthropies. The program seeks to achieve changes in long-term care policy and practice that help to reduce high vacancy and turnover rates among direct care staff across the spectrum of long-term care settings and contribute to improved workforce quality. http://www.bjbc.org

Local - Better Jobs, Better Care The lead organization of the Oregon BJBC Demonstration project, called Oregon Works!, is the Oregon Technical Assistance Corporation, a nonprofit organization promoting independence for persons with disabilities through training, technical assistance and organizational development. The Oregon Works! Coalition, made up of a collaborative partnership of more than 20 organizations, has focused on improving recruitment and retention of direct care workers through intensive workplace change efforts in eight long-term care sites. Culture and Medicine Project Acumentra Health's Culture & Medicine QI Project assists medical practices in assessing and improving their compliance with standards for culturally and Linguistically Appropriate Services. The project provides free educational resources for providers, using a self-paced online curriculum from the federal Office of Minority Health. Although the QI project is no longer recruiting participants, the online curriculum remains available. The Health Careers Access Project (HCAP) HCAP is a new 3-year demonstration project of the Transitions/Transiciones Program at Mt. Hood Community College. The project will a) assist low-income, minority and non-native English speaking women to prepare for successful entry into nursing and other Portland-area healthcare training programs and b) establish a model for dissemination to other Oregon community colleges through a statewide network of Transitions programs Pathways to Advancement State of Oregon Pathways to Advancement is a student-centered, demand-driven statewide initiative. The initiative is focused on increasing the number of Oregonians attaining degrees, certificates and credentials in demand occupations and easing student transitions across the education continuum. Oregon's community colleges are developing model programs that realign curriculum, provide alternative delivery methods as well as flexibility for adults to gain skills and advance in the labor market more quickly to address employer and student needs. Career Pathways approaches in four transition arenas across the education continuum: secondary to postsecondary, pre-college (ABE/GED/ESL/DE) "bridges" to credit postsecondary, postsecondary education for skills upgrading and career changers and community college to university. Work Source Oregon Work Source Oregon is a network of public and private partners working together for businesses and workers to: Ensure businesses have a ready supply of trained workers whose skills and talents are aligned with the expectations and needs of business and industry; Connect businesses with the resources they need to grow their workforce and their business; and Provide the resources to help Oregon's unemployed and underemployed get connected with the employers that are right for them, find the jobs they're looking for and get trained for jobs they want. Website has links to workforce, economic development, and training information

and information on the governor's Workforce Initiative, including Regional Workforce Teams, and a new training fund. http://www.worksourceoregon.org Pioneer Network - Pioneer Network, based in Rochester, N.Y., is at the forefront of changing the culture of aging and long-term care of elders in America. A growing coalition of organizations and individuals from across the nation, Pioneer Network advocates for public policy changes, creates communication, networking and learning opportunities; builds and supports relationships and community; identifies and promotes transformation in practice, services, public policy and research; develops and provides access to resources and leadership; and hosts a national conference to bring together interested parties with a desire to propel this important work. http://pioneernetwork.net/ Acumentra - (Local area networks for Excellence) Acumentra Health is a nonprofit organization dedicated to improving the quality and effectiveness of healthcare. We collaborate with practitioners, providers, public agencies, and private organizations on a wide range of healthcare improvement projects and programs. Our work reaches all age and economic levels, and all delivery settings. http://www.acumentra.org

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