SNFs Get Ready – Claims Audits Start Soon!
Recently, CMS announced that its Medicare Audit Contractors (MACS) would soon commence (June 5) a five-claim audit process for every nursing home in the nation participating in the Medicare program. The reviews are set to occur on a rolling basis whereby each MAC in its region, will begin by pulling five Medicare claims from each provider in their region, assessing the claims for billing errors. The genesis of this program is a Health and Human Services report that noted that (approximately) one-fourth of all SNF claims were improper as supported by documentation. In CMS language improper means overbilling vs. underbilling.
The goal of the claims review program is purportedly a combination of recoupment when payment is too high combined with education. It is likely that providers with prior bad history of ADR (Additional Documentation Requests) or probes, if their performance on this review is poor, will receive additional follow-up attention. The claim reviews are pre-payment vs. post-payment.
From the Medicare FFS (Fee for Service) Improper Payment Report (all provider types) for 2022, I included two pages with data, illustrative of the SNF improper payment issue and the reasons why. The pages are located here:2022 Improper Payment Report – SNF The most common cause of impropriety was insufficient documentation. Some of this continues to relate to PDPM as SNFs in many regards, lag in terms of MDS coding knowledge and billing education. COVID did not help. Other issues are as simple as improper certification times, illegible signatures, improper Section GG (therapy coding) and improper diagnosis codes. Per CMS, the improper payment amount for 2022 is estimated to be $5.8 billion.
My caution here for all post-acute providers but especially for SNFs and Home Health Agencies, claims audits are here to stay. According to Altarum’s Health Economic Sector Index, SNFs spending increased 11.6% YoY (March) and Home Health spending increased 8.7%. Outlays, within programs with known billing impropriety issues, beget claims reviews. The full Altarum brief is here: https://altarum.org/publications/may-2023-health-sector-economic-indicators-briefs
As I have written before, compliance is a fairly new requirement for SNFs. Within the ethics and compliance Condition of Participation found at 483.85 (F- 895) SNFs must, among a number of requirements, implement a system (reasonable with policies and procedures) to find and correct, improper billing practices such that the same, could be fraudulent or could be in violation of federal law. The last element, violation of federal law is tricky. It is against the law to bill Medicare for care that is rendered improperly or is sub-standard. Technically, care provided to a resident, billed to Medicare, later determined to be harmful via a survey (G level violation or worse) is a violation of federal law. A decent overview of the compliance requirement is available here ComplianceandEthics 483.85
Essentially, post-acute care providers, particularly HHAs and SNFs need to develop a comprehensive ethics and compliance program that INCLUDES regular claim audits. The difficulty, however, is for the audits to be useful and proper, the same should be conducted by an independent auditor. This can be costly and often, non-helpful when the auditor is not uniquely familiar to normal provider operations and typical survey and certification processes. The goal of the audit process is detection and then, education. Incorporated properly within a well-developed ethics and compliance framework, the audits can be completed efficiently and wrapped within a proper QAPI (Quality Assurance) function. Done right, the ethics and compliance program dovetails into a QAPI program and vice-versa. This reduces separate work, enhances process improvement, focuses on resident/patient care and how the same is effectively provided, properly documented, and properly billed. Watch this site for more on this topic and for additional tools that I have developed and effectively used with H2 Healthcare clients.
A bit of travel awaits so I will not offer new posts/updates until next week. Until then, Vaya con Dios!
Wednesday Feature: Summer’s Here!
This past weekend was the official, unofficial start of summer as Memorial Day weekend typically ushers-in the summer faves of barbecue, fireworks, picnics, parades, and warm days. I hope you all enjoyed the weekend and took a bit of pause from your fun to remember those special men and women that lost their lives in service to our country (USA).
There are so many summer traditions that I am fond of or fondly recall as part of my youth (a long time ago). Foods of course, cooked on the grill, never go out of style. These days, I am a fan of farmer’s markets, fairs (local and state), and drives on country roads in our Mustang convertible. When I was young, a summer ritual was packing the car with food and drink and heading to the drive-in movies. For a while, the drive-ins were in steep decline, but I’ve noticed a renaissance occurring and within an hour’s drive, we can hit a drive-in theater. The problem for me now, is that there just isn’t the summer blockbuster, got to see, movies that typified my younger years (and memories). Sure, the comic book adaptations are kind of fun, but I really miss the kingpins of my youth.
I’m going to date myself with this post but so be it. I grew up in the 60s and 70s. My young adult years were the 80s. I spent many days in my youth in movie theaters, Saturday matinees with cartoons! I grew-up in the city so getting to the movies on a Saturday was as simple as scrimping together some change (50 cents was more than enough), hopping on your bike (weather permitting), and hitting a local theater – the old-fashioned kind with a balcony, single screen, drawable red and gold curtains, etc. I was a big Tarzan fan, any kind of western, and some of the creepy, old monster movies like Dracula and the Mummy.
As I got into my teen years and early 20s drive-ins were great as were the multiplexes that had just started to populate shopping malls. Movies were great for dates, followed by a pizza or ice cream. Seeing a blockbuster at a drive-in was a real treat and I have many memories of nervous jumps and audible shrieks at a drive-in theater where I saw Jaws. The enormity of the screen and we, as always, were fairly close, was a perfect venue to see a flick like Jaws.
As I have gotten older, I no longer have a big desire to go to the movies via a theater. My wife and I will try to conjure-up a date night at a drive-in this summer, provided we can find a movie we both will like. A couple of places we know of, occasionally pull-out an oldie, worthy of our attention. I guess we’ve fallen into a routine where, we can find something on-demand for a few bucks and be comfortable at home with a glass of wine and some snacks – definitely cheaper and more practical when it comes time that either of us needs a pitstop.
As I migrate into summer in the great Midwest, I can’t help but recall my favorite summer flicks, the blockbusters of a few years back. My ten favorites are below including the year of their release. I hope this post stirs some fond summer memories for you. Happy Hump Day!
- Jaws – 1975
- Star Wars, Episode IV (A New Hope) – 1977 (this was the original Luke, Leia, Han Solo, et. al. flick)
- Star Wars, Episode V ( The Empire Strikes Back) – 1980
- Raider of the Lost Ark – 1981
- Star Wars, Episode VI (Return of the Jedi) – 1983
- Ghostbusters – 1984
- Back to the Future – 1985
- Top Gun – 1986
- RoboCop – 1987
- Total Recall – 1990
And, last to mention, an all-time guilty pleasure film of mine from the summer of 1996 – Twister! Still a must watch when I can catch it.
Friday Feature: SNFs Still Make Sense
For some recent years, enhanced by the pandemic, the role of SNFs in the post-acute/senior living industry has tarnished. Residents and families often view the SNF as a “negative place” to reside, even if for short-term recuperation. Clinical staff take a dim view of the care complexity such that the SNF is a downgraded clinical setting, less than a hospital or outpatient setting. Providers, struggling with reimbursement inadequacy and advancing regulation, have reduced beds or closed locations. Some organizations like CCRCs, have minimized bed capacity or completely eliminated the SNF and moved to advanced Assisted Living care as the highest available care option for residents. Yet, in spite of these trends and the tarnish, SNFs have a place in the continuum and in some regards, and advancing place.
What challenges the SNF industry and thus, its reputation, are more external forces than flaws in the core purpose of an SNF. External forces such as onerous and increasing regulation, below cost reimbursement, and labor shortages are the most common forces providers deal with. Gone are the days where nursing homes were locations of long-term stays, typified by years of residency. Where and when this still occurs is for residents with early-age disabilities, or for residents that have minimal financial means such that Medicaid nursing home benefits are the primary level of support for care. With Medicaid supports via waiver programs expanding, long-term skilled nursing care includes primarily the most complicated residents, those with multiple conditions requiring skilled nursing interventions weekly or even, daily. Examples include ventilator care, dialysis, tube feedings, ostomy care, etc. While these services can be provided in the home or a non-SNF setting, location challenges often make an inpatient environment (SNF), the best place for consistent care when required.
The demographics forward, favor a post-acute, SNF setting. Despite the push for post-acute care to migrate to home settings with home health the reality remains, this is not the answer for every patient. The older the patient, the number of comorbidities involved, the nature of the comorbidities, the presence of an aging spouse with health challenges, etc. all are a predicate to whether or not, home care via home health is viable. Today, even access to home health can be challenging if not, impossible. The staffing challenges all health care providers face are particularly daunting for home health agencies where, acceptance of cases, especially complex cases, comes down to having available staff to meet patient needs. As home health care by its nature is inefficient, facility-based care can be more feasible when complexity of the case is at issue and the availability of staff is challenged. In other words, staffing one location that can accommodate say 60 residents, is easier than staffing a caseload of 60 separated by travel with distances expressed in miles.
The SNF industry and the facilities within tend to be some of the oldest classes of assets in the senior living industry. The cost of new construction is high and without access to a very high-quality payer mix, the returns are challenging. For providers than can maintain solid occupancy and high-quality payer mixes (Medicare, insurance, private pay), the returns are solid and the access to capital is there. Medicare Advantage plans are starting to create solid value-based care propositions for good providers with exceptional quality records AND great care coordination partners. For example, an SNF that has a relationship with a Home Health Agency, either owned or in partnership, has the ability to package price disease management approaches by common clinical conditions that include SNF care and HHA care, all bundled, and care coordinated. If the pricing is mapped with overall savings, reductions in re-hospitalizations, improved patient outcomes and satisfaction, the opportunities going forward are significant. I have a number of pathways/algorithms that fit this example. A few can be downloaded here.
What headwinds lie ahead fall mostly around staffing, regulation, and reimbursement. Oddly enough, the failures that will inevitably occur necessitating closures and bed reductions, will make good SNFs stronger going forward. The demand by demographics and patient needs is only increasing. There will be a significant role for SNFs to play in meeting the market needs. The questions that beg are around reimbursement keeping up with increasing costs and how disconnected will new staffing regulations be to the reality of the labor markets. As I have said in other posts, mandates make no sense when in all reality, the mandate cannot be met now, or anytime in the near future.
Bottom-line: Banks are still willing to lend to good providers. REIT capital is available as is private equity for facility improvements and modifications. Demand is decent and recovering. There is a lot of pent-up demand as well, post-COVID. Valuations have remained stable for SNFs as well. Plenty of partners exist, more so than other senior living segments (hospitals, Med Advantage plans, health systems, Home Health Agencies, etc.).
Litigation risk is still an issue but a recent court case in Washington involving Life Care Centers of America concerning COVID and the liability for infections obtained in an SNF was found favorably for Life Care Centers. One case, however, is not a trend but it is a good sign that perhaps, the SNF industry will not be overwhelmed by COVID litigation pertaining to outbreaks and occurrences in facilities. A synopsis of the case is available here: https://www.mcknights.com/news/life-care-centers-vindicated-in-early-covid-wrongful-death-case/?utm_source=newsletter&utm_medium=email&utm_campaign=NWLTR_MLT_DAILYUPDATE_052323&hmEmail=IjP1GPaY%2BJ2uvsLxTJ79bVeRWY7ycbnr&sha256email=aa4cb7c695037c31a216b9562788596b6fcd012145d566f31440b6fcd139c8a9&elqTrackId=2c80aade4c3647c8ab5b85f72fb85138&elq=8a824ff9b15249a9bf296d2d2c1be9e8&elqaid=4134&elqat=1&elqCampaignId=2746
Well-run, well-capitalized SNFs with more modern physical plants have a solid opportunity in the evolving post-acute industry. Challenges exist but opportunities do as well and, in my opinion, the opportunities outweigh the challenges for operators that understand value-based care models, are willing to develop partnerships, can maintain staff, and have great quality and service records.
Wednesday Feature: Memorial Day
Aside from the holiday and the weekend immediately prior marking the start of summer, Memorial Day is a significant holiday for many. Officially, it is a national holiday set aside to remember and mourn the deaths of service members, killed in the line of duty (while serving in the U.S. Armed Services). It is unlike Armed Forces Day and Veteran’s Day which exist to honor and recognize, all who currently serve or have served, in the Armed Services (alive or deceased).
Originally, Memorial Day was known as Decoration Day. The first holiday version was created by John Logan, Commander of the Army of the Republic to honor fallen Union Civil War soldiers. The day spread across the states as a day of honoring fallen soldiers via grave remembrance decorations. By 1890, every Union state celebrated the holiday. With the onset of World Wars (I and II) the day’s recognition expanded to all fallen soldiers, regardless of the war.
In 1971, Congress officially designated “Decoration Day” as Memorial Day and marked the national holiday to occur on the last Monday of every May. It is a day which includes many celebrations ranging from religious services at Veteran’s cemeteries to parades and festivals, etc.
This upcoming Monday is Memorial Day in the United States. I am grateful to be a resident and citizen and forever in debt to the brave men and women who fought for the freedoms I enjoy – daily. I will certainly pause and reflect on Monday. Until then, Happy Hump Day. Below is a favorite Memorial Day poem from Henry Wadsworth Longfellow – “Decoration Day”.
Sleep, comrades, sleep and rest
On this Field of the Grounded Arms,
Where foes no more molest,
Nor sentry’s shot alarms!Ye have slept on the ground before,
And started to your feet
At the cannon’s sudden roar,
Or the drum’s redoubling beat.But in this camp of Death
No sound your slumber breaks;
Here is no fevered breath,
No wound that bleeds and aches.All is repose and peace,
Untrampled lies the sod;
The shouts of battle cease,
It is the Truce of God!Rest, comrades, rest and sleep!
The thoughts of men shall be
As sentinels to keep
Your rest from danger free.Your silent tents of green
We deck with fragrant flowers;
Yours has the suffering been,
The memory shall be ours.
Friday Feature: 5 Important Leadership Principles
Every successful organization shares a common trait – good or great leadership. I’ve written numerous articles on this topic and how the same is connected to employee retention, market share increase, brand dominance, and organizational wealth (balance sheet and cash flow). Fundamentally, organizations flourish under good leaders and flounder when leadership is poor or not present.
I’ve worked with many, many organizations in turn-around situations whereby, prior executives failed to provide solid leadership and operational performance demonstrated that lack of proper leadership. In senior living, the common signs of poor leadership include staff morale, too many unidentified supervisory or management positions generating bureaucracy but not results, weak financial structure expressed via marginal cashflows, census challenges, rate imbalances, no growth plan, marginal quality and service, etc. The structural imbalances are evident even if the basics get done.
There are only three business strategies: grow, milk, or sell. Selling occurs when a business decides that it either cannot exist on its own or it’s time to return capital to its investors. Milking often occurs before selling if the business has been successful. Milking entails skimming profits and cash, generally prior to selling. For non-profits, milking and selling are pretty much, moot strategies. Frankly, most businesses choose to adopt a growth strategy. Growth however, requires good, solid leadership and governance. Without these elements, a strategy for growth may be discussed or even outlined but implementation will not occur successfully.
I am a fan of Peter Drucker and Steve Jobs in terms of how leadership and growth are operationalized. From both, I’ve developed and maintained a set of leadership principles that tested, over time, work and facilitate growth and business success. Below are the first five principles.
- Remember Occam’s Razor/KISS: Leaders should keep things as simple as possible and focus on relentless incrementalism. Growth comes via a learned set of behaviors that if properly simplified, and rewarded, become habits. Likewise, it easier for the operational leaders to put into place, simple goals and objectives that forward the growth strategy. I’ve watched so many strategic elements fail not due to a bad concept but due to too much complexity. How do you eat an elephant? One bite at a time!
- Measure what Matters: This ties to one above but it is a bit more nuanced. Organizations talk about KPIs, etc. and throw out reams of data, often meaningless to growth. I like a simple set of core metrics. For example, care breaks down to only so many things that matter to the patient and the organization. Outcomes are key. Financials are relevant only such that the same paint the desired picture. I like a focus on cash, especially in relationship to the expenses. This is often called, ROI.
- Play a Long Game: Leaders should focus on a long view, one that embraces an ongoing picture of what growth and success looks like. Short views frustrate management and staff. The short stuff is about progress toward a longer, bigger picture. Paint this picture, evangelize it, reward it and growth will occur.
- Create Succes via Humanness: In service organizations like healthcare, people are the capital. They are the most precious commodity and a renewable resource. Leaders build teams like coaches. Treating people with respect, caring about them and for them, affords them the comfort and willingness to do great things. I like what Steve Jobs said about doing great things in business: “Great things in business are never done by one person; they’re done by a team of people.”
- Create Constant Forward Momentum: Leaders are and always should be, ahead of any point in time. They sell and exhibit a forward vision and work constantly, to keep momentum going forward (e.g., growth). A good leader looks to simplify, keep obstacles to progress minimalized, rewards activity and growth, recognizes performance, and when necessary, eliminates people that are barriers to the team and its accomplishments.
TGIF!. I’ll have more on leadership in future posts!
Wednesday Feature: Here’s Comes Summer!
I can feel it and smell it…. summer is coming. Every year at this time, it feels like it’s taken forever, but soon, the warmer days and the longer days (hours of sunlight), erase the darker memories of dreary, cold days. Winter becomes a distant memory, replaced by a joyous desire to romp outside.
Where I primarily live, the celebration of summer is almost a ritual. Winters can be long and springs, short. Some years, spring is almost unrecognizable, and summer becomes, a quick jump into warm, muggy days. This year though, winter was relatively mild marked by a decent amount of snow but no real prolonged frigid, sub-zero periods. Just north of me, the snowfall was righteous and the melt, the cause of major flooding along the Mississippi. The transition to summer can be brutal at times.
Early summer is also storm season or can be. When I lived in the Great Plains, this timeframe marked the sweet spot of tornado season. I’ve seen my share of tornadoes, fortunately not up-close. Still, I love watching storm systems and cloud formations as warm fronts clash with upper air cold fronts, etc. The views can be breathtaking and soul filling.
Soon, next week in fact, the summer season kicks into high gear. Most schools will be closed or soon to close. Memorial Day marks the official/unofficial start of summer with picnics, a long weekend, the Indy 500, and maybe, the first family camping trip. While the official first day of summer will remain two weeks away, Memorial Day is a perfect weekend to begin in full force, the rituals of summer. County fairs start along with various festivals. Farmer’s Markets awake (a favorite for me) and early produce like asparagus, some lettuces, rhubarb and onions become available. My summer planting is also done so now, I can wait for the flowers and the first tomatoes and peppers that will add (wonderfully) to my summer meals.
I now will spend almost every evening on our open porch or deck. We’ll eat outside nearly every day. When time permits, we’ll hop into our Mustang convertible and take long(ish) jaunts to various favorite spots for lunches or ice cream. We’ll hit parades and firework events as often as feasible. The Farmer’s Market will become a weekly stop, one or more locations. Suffice to say, I will be outside as much as I can, charging my batteries for what I know, will be another winter. Summer gives me the memories and energy to hold-off against the northern winds and frigid, dark days in January.
With Memorial Day next week and the marking of another summer season right along with it, feel free to share your memories in a comment to this post. I’ll try to retain as many as I can! Happy Hump Day!
Wednesday Feature: Happy Mother’s Day
This upcoming Sunday is Mother’s Day. Despite its commerciality, it does have a history dating back to the early 1900s. In 1908, Anna Jarvis in honor of her deceased mother, Ann Reeves Jarvis created the first U.S. version of Mother’s Day. Ann Reeves Jarvis was an activist who founded Mother’s Day Work Clubs. A staunch Episcopal Methodist woman, she taught Sunday school. It was during a Sunday school class that her daughter supposedly, came up with the inspiration for Mother’s Day via a prayer. Notably, as the holiday took on a greater focus toward gifts and cards for moms, Jarvis became unfavorable to the day as now commemorated. The actual holiday as we know it became nationalized in 1914.
Celebrations related to “mothers” date back to ancient Greek and Roman times. Festivals were held in honor of the mother goddesses of Cybele and Rhea. Mothering Sunday is a Christian festival that started in the United Kingdom and Europe. It occurred on the 4th Sunday of Lent, Laetare Sunday, where Christians returned to their mother church – the main church in their locale for a special worship service. This tradition ultimately became more secular, focused on gifts to mom and then more or less, merged with the American tradition in the 1930s and 1940s.
Below are some fun Mother’s Day facts that most people probably don’t know.
- Mother’s Day is typically the busiest day of the year for restaurants.
- More calls are made on Mother’s Day than any other day of the year.
- Mother’s Day is the third highest sales day of the year for plants and flowers.
- President Woodrow Wilson signed Mother’s Day into law in 1914.
- Last year (2022), $31 billion was spent on Mother’s Day with the average gift amount of $245.
- The most popular gift on Mother’s Day is a card and 41% of folk buy jewelry for mom.
- Mother’s Day is a worldwide holiday.
As we approach this weekend and our honor and celebration of moms, I think very much about mothers, mine of course (who has passed) but also of the role of “mother”. Being a mother is not solely, a biologically driven title. Mom is a title more universal than just related to a person that gave birth. My wife is a mother, but she never gave birth. Parents of adopted children are moms and dads, just the same. I’ve known many adoptive parents and they are just as attached, just as loving, just as committed, and yes, just as hopeful, frustrated, excited, etc., as biological parents. Mom is sometimes nature but always, nurture.
The universality that I attribute to “mom” comes from my own history. My grandmother served in many ways, as a surrogate mom when I was growing up. I spent many, many days with my grandmother and she in turn, nurtured me in the same ways as my mom. She was a kind but a pious and serious woman; the matriarch of the family. She was about chores, reading, and always, amazing food. My mom somehow, never got the cooking or baking gene from my grandmother. She passed away just shy of 102 and I will always, have cherished memories of her as an “additional” mom in my life.
So, on this Hump Day, I wish all the moms, grandmoms, and mothers to be, a joyous and cherished Mother’s Day. You deserve all the honor and appreciation you receive on Sunday as mom is and always will be, universally symbolic of nurture and care.
Pastoral Care and Risk Management
In 2001, the Association for Professional Chaplains honored me with their Distinguished Service Award for my work in expanding the impact of professional chaplaincy and programs of pastoral care/ ministry in specialized healthcare settings. This was (and remains for me) a huge honor. Yet, since that time, a little over twenty years ago, programs of pastoral care, Clinical Pastoral Education, and chaplaincy are struggling for a concrete place in healthcare. Sadly, instead of watching these programs expand, I’ve seen contraction. Even more sad, I’ve watched geometric increases in management positions in risk management, etc., often while chaplaincy positions were eliminated.
Entering the “way back machine”, the core of my work which was recognized by the Association of Professional Chaplains, was that chaplaincy and programs of pastoral care make good business sense. The clear revenue picture isn’t present – I get it. The payback however, expressed as ROI via reduced risk, reduced litigation, improved employee retention, and patient satisfaction is enormous. One needs to however, understand and live, the work of chaplains in a healthcare setting to understand how the benefits are manifested.
I have literally sat in exceptionally contentious family meetings, dealing with issues of death and dying, where years of anger, hostility, sometimes abuse, come forward. The patient gets lost. Staff get frustrated and no common ground appears visible. In this midst, a professionally trained chaplain enters and when introduced, the dialogue begins to change. The issues remain but in short order, a sense of calm and a sense of order begins to emanate. The anger drops as the chaplain listens differently, redirects conversations, asks probative questions, and turns the focus to core beliefs and values. Ultimately, almost all important, life altering decisions have as their basis, a person’s core beliefs and values. Even for folk not identifiably religious or denominationally, spiritual tradition faithful, a series of beliefs and values can be found and from there, a decision framework can be built.
What we know about litigation risks, patient and staff, is that the desire to litigate is often born in a search for an answer. Something less desirable happened or questions posed, were not answered or the answers were obtuse. Healthcare of course, is not an exact science and bad things happen for no particular reason, even with adequate protections in place. For example, and I know this one well as my firm via my wife’s practice, handles complex litigation matters for defense counsel; old people fall. Save physical restraints, prohibited by law, old people will fall and sustain injury, sometimes that same leading to death or being associated with death. Falls beget lots of litigation in post-acute care yet, when the organization is heavily invested in pastoral care and the approach of the care team is “transdisciplinary” and the care coordinated, litigation risk can be minimized. I know, I’ve seen it in action.
Healthcare phraseology loves the words, multi-disciplinary or interdisciplinary. Pastoral care and care coordination done right (see yesterday’s post on care coordination here: https://wp.me/ptUlY-xO) is transdisciplinary. Transdisciplinary process and teams occur when roles are shared beyond traditional boundaries (removing the silo effect) and people collaborate among themselves beyond their specific discipline and restrictions. The patient becomes the center and his/her values and beliefs are the focal point for decisions and plans. Incorporating the patient’s key stakeholders into this process is where pastoral care has power and risks are reduced. Bad outcomes, if they occur, are no longer viewed as something to litigate as all along, the patient had clear value, the team was collaborating in the patient’s best interest, familial stakeholders were present, and the need to find flaw and extract some sort of retribution, diminished. Is it a perfect process? Of course not. Is it a process that better handles the ambiguities and the imperfections of healthcare outcomes, especially among the oldest with comorbidities and fragility? I believe it is and again, I’ve seen it work.
Among the defined dimensions of human care, spiritual care is a specific dimension. Providers need to address the physical, the emotional, the psychological, the social, and the spiritual dimension of human existence if care is to be complete. Staff have the same needs in many regards. As direct witness to suffering, grief and loss, the meaning of their work is often only reconciled spiritually. Their own feelings manifest in the milieu with the patient, the family and each other and they too, require care. An excellent White Paper, funded by Bristol-Myers Squibb covers the role of Chaplaincy in healthcare. Its link is here: https://citeseerx.ist.psu.edu/document?repid=rep1&type=pdf&doi=6a559606ee9814ea4e9b6a39f677ad9114dd7386
The role pastoral care plays in risk management is evident in literature as well but, the words risk management specifically, are not always present. Managing risk is about reducing negative outcomes or for patients and staff, dissatisfaction with what has occurred or is occurring. For example, in the journal Supportive Care in Cancer, an article titled, “Unmet spiritual needs impact emotional and spiritual well-being in advanced cancer patients”, the authors noted: When spiritual needs are not met, patients are at risk of depression and reduced sense of spiritual meaning and peace. Spiritual care should be matched to cancer patients’ needs. The risk management that is evident is the reduction of depression and an increase in a sense of peace. Reductions in frustration, sense of loss, anger, etc., all are reductions in risk and without question, lessened frustration begets better outcomes for patients and their loved ones and lower levels of litigation risk.
Wednesday Feature: Lessons from a Cat
Happy Hump Day! I am a cat fan and a cat dad. Ever since I can remember, cats have been part of my life. I love dogs too and have had a number as pets, but I am partial to cats. My wife and I share our spaces with two cats: Mac and Cheese. You can guess what color they are.
Mac and Cheese are brothers. They have never been apart. Though they share a resemblance, being around them for any length of time, you could separate them quickly. And as cats go, they are both different yet, in many ways the same. Their lives are somewhat separate as each has his own routine and personality but, they are interconnected. They play together, sometimes sleep together, share food together, call for each other at night to play, etc. Mac is dominant, bigger and more social. Cheese is more traditional cat-like: sleeps more and is kind of aloof.
What I marvel about cats is their grasp of the world around them and their distinct ownership of all that enters this world. Cats are phenomenal athletes, evidenced by their grace in contorting into tight spots, contorting into sleep positions, and navigating ledges and rims without falling or disturbing things in their path. And, while a housecat is domesticated, they never lose the predatory heritage. Even Mac and Cheese will prowl, seek bugs, destroy toys, etc.
There is much to learn from being around cats and observing their lives within the spaces they inhabit, including with people. In almost a Zen way, cats can teach us important things – things we should adopt as beneficial to our own lives, success, and fulfillment. Below are fifteen things that cats can teach us, adopted from care.com: https://www.care.com/c/15-things-cats-teach-us-about-life/
- Indulge Your Curious Spirit
- Choose Your Friends Wisely
- Get Plenty of Rest
- Maintain a Well-Groomed Appearance
- Don’t Forget to Show Appreciation
- Eat More Fish
- Stay Aware of Your Surroundings
- Spend Time Soaking Up the Sun
- Take Time to Sit Still and Really Notice Things
- Don’t Sweat the Small Stuff
- Stretch Regularly
- Ignore the Little Things that Tend to Irritate You
- Look Before You Leap
- Don’t Lose Your Playful Energy
- Don’t Get Discouraged
I hope this message makes your day – Happy Hump Day!
Top 5 Staff Retention Tips for a Tough Labor Market
Recently, I wrote a post on recruitment in a tough labor market. Suffice to say, I have not in my three decades plus career, seen a tougher labor market for clinical staff (all staff in many regards). COVID had a lot to do with the shifting supply of labor, but I’ll offer that health policies and economic policies during the prime pandemic period and since, had far more to do with where staff went – and clearly, stayed. Societal and government responses to COVID are in my opinion, primarily to blame for the largest impact on staff disengagement from direct care environments. Dissecting the policy side is a topic for another post on another day. The recruitment strategy post can be found here: https://wp.me/ptUlY-vj
The opposite of recruitment is retention. Arguably, the better an organization does at retaining its employees, the less it needs to invest in recruitment. Healthcare has notoriously been an industry prone to turnover, especially among para and non-professional staff. Back in the day (I sound like a codger), I knew some long-term CNAs, ten to even thirty years in one company (one I was running at the time) and similar for housekeepers, laundry staff and maintenance. I simply don’t see that kind of tenure any longer, save a few of the folk almost at retirement. Once the final generational shift occurs, primarily the folk in my age cohort (aka “Boomers”), new outlooks on longevity in one career and one employer become fully operable. Simply, length of service regardless of retention strategy will be shorter. Long-term may evolve to any service in one place between 5 to 10 years. Outliers will be those working in the same place for ten plus years, without a shift in position or level within the organization (e.g., move to management or some other promotion).
Combatting turnover is a function of understanding why people leave, voluntarily. Some of the primary conditions are symptoms of what is going on in the healthcare industry. For example, hours and workload are often cited as primary drivers yet, providers have (often) little choice but to mandate overtime or have folks work short, covering more patients (or cases) than ideal. There is a bit of a circular (dog chasing his/her tail) phenomenon about workload when overall, open positions exist. Staff get tired of working short or covering for call-offs, etc., and thus, turn over. Problem is perpetuated. A somewhat universal list of the top reasons staff leave is below.
- Supervision: Bad managers/supervisors create turnover.
- Recognition: This is different from reward. This is appreciation or acknowledgement of the work being done within the conditions/environment that it is being done in.
- Schedule/Workload: This involves everything from how much patients/cases are on the shift to when shifts change or rotate to length of shifts to weekends to on-call to overtime mandates, etc. Extra hours can sometimes be absorbed without too much difficulty but too often as of late, extra hours are the norm and staff burnout.
- Limited Promotion/Growth: Healthcare is very layered and often, the jobs stagnate. For example, lateral movement is difficult at a professional level. RNs in one area can’t always jump to another clinical area without additional training or without taking a back-step in schedules, etc. If the view is that the only promotion is to management, a couple of realities need to be considered. First, not all (or even most) clinical staff make good management/supervisory staff. The industry definitely does not need more weak managers. Second, taking good clinicians away from patient care is self-defeating to the organization and to the patient.
- Bureaucracy/Regulation: This I’ll call paper before patients. Healthcare as I often hear, is neither fun nor rewarding in the way it used to be. Too much regulation takes the clinicians who went into the industry away from patient relationships. Staff have tons of work to do and on top, supervisors crab constantly about keeping paperwork up to date (documentation). Meetings and in-services are constant and rarely, of any value (per staff). Don’t forget too, the industry lost untold numbers due to COVID mandates (vaccine, PPE, testing) that created massive burnout and frustration.
In a recent survey of post-acute and senior housing executives conducted by NIC (National Investment Center) only 30% of organizations noted retention of 80% of their new hires longer than a month. A year ago, this number was 46%. When looking out a year, only 7% of organizations retained more than 80% of their new hires for more than a year. I can only think of one word to describe this data – YIKES!
No magic bullets are available to remedy this issue. Turnover has lots of causes and organizations can only do so much. We have a supply problem in the industry and until the supply is increased, by societal value shifts and proper public policy, turnover will continue to be an issue. I do, however, know organizations that have made an impact and with the implementation of certain strategies, performed better in terms of turnover. These strategies comprise my top five tips/recommendations for improving staff retention.
- IMPROVE MANAGEMENT: This is not easy, but it does immediately and over the longer term, bear real results. Staff don’t work for companies; they work for leaders. Hire leaders that have proven track records in building teams and retaining staff. Don’t promote people without a prior, successful training program in management/supervision. Provide ongoing training in management and supervision.
- RELEASE AS MUCH CONTROL AS POSSIBLE OF THE SCHEDULE: Give staff say in what hours they work, when they work, etc. Of course, parameters are required but if any one major gripe can be alleviated, scheduling is a prime complaint. Staff need to be engaged directly and provided opportunity to address their own work /life balance. Team scheduling is awesome as are incentives around team performance in this regard. Likewise, stop thinking about shifts and how many staff per patient. Look at work blocks and patient needs and when duties really need to be done and by whom.
- RESTRUCTURE REWARD AND COMP: To the extent possible, flex everything and create for new staff, a very stepped process of achieving ongoing rewards/increases in pay and certain benefits like time-off, during that first year. Gainshare as much as possible as well. This is not about pay per se but about recognition and engagement. Everything needs to be on the table. Start with the total comp budget and note, “what’s the best way to spend it” – ROI v. wages and benefits. The more staff feel connected such that what they do correlates to a reward, a benefit or recognition to them (individual and team), the more they are likely to stay.
- ALGEBRA/SIMPLIFY: For decades, I have worked with and led organizations in healthcare that simply can’t stop themselves from doing dumb things. Often, the excuse is “regulation”. My answer: B.S. Rarely is all of the paperwork, forms, redundancy, etc., required or if it is, it can be simplified. Healthcare loves paper, regulations, rules, etc. Staff get trapped here and supervisors use bureaucracy like a hammer – a blunt instrument. My advice, deconstruct. Remove as much needless and redundant chores, paper, etc. from staff. Look acutely at who has to do what by when and then, look at how it is currently being done. Improvement is definitely possible. Pay very close attention to how much additional, non-nursing work nurses and nursing staff are doing.
- INJECT FUN INTO WORK: Healthcare is too serious and too bureaucratic. Give staff a chance to create an environment that encourages team, fun, fellowship. This is within the workplace and outside of work as well. The reality is that staff that feel part of something bigger, committed to each other, enjoy being part of a cause, etc., work harder and stay longer at their place of employment. This requires a culture shift for most healthcare organizations and a definite shift in management style.
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