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Post-Acute and Healthcare News and Topics

Insight: CEO Turnover

During the pandemic and continuing somewhat through current, healthcare turnover has been on the rise. Nursing turnover (from direct care) and retirements exploded by mid-pandemic. Burnout was high as was job dissatisfaction. What became evident is the linkage between staff turnover and staffing difficulties along with COVID policy, and CEO turnover. While 2021 turnover was proximal to prior year norms, 2022 is showing an increase as the pandemic wanes but other headwinds increase.

According to Challenger, Gray & Christmas (executive outplacement firm), there were 62 hospital CEOs that called it quits in the first half of 2022 versus 42 in 2021. The impact is actually a bit more pronounced as the overall number of CEO positions has declined due to consolidations and closures. This same source indicates that the primary causes of turnover are COVID burnout, rising capital costs, capital access constraints, and staffing. Financial pressures due to these factors, evidenced by multi-billion-dollar losses at even the largest systems (Ascension $4.7 billion, CommonSpirit $3.7 billion) further contribute to turnover.

Senior Living/Post-Acute care is walking an almost parallel line in terms of turnover at the CEO level. Longer term, large provider executives are at retirement ages. The industry has not generated younger executive leadership in proportion to the positions that are turning. Talking with some of the larger recruiting firms specializing in Senior Living (e.g., Witt/Kiefer), even prominent positions at large non-profit organizations are struggling to source qualified candidates. The experience levels across the expanding system offerings (e.g., hospice, home health, post-acute services) aren’t universally held in various areas. Demand is high but quality candidate numbers are lower than say, 10 years ago. Further, market challenges in some areas such as high litigation, (low) available staff numbers, and changing demographics (think Chicago, Detroit, Portland) place boundaries on candidate opportunities. Simply put, many candidates have no desire to relocate to challenged locations.

Looking at key position availability by title, LinkedIn shows over 6,000 executive director/C-level openings in senior living. By comparison, LinkedIn shows hospital C-level openings at 738. The average tenure today for any healthcare CEO is a smidge over 5 years. Twenty years prior, the average tenure was between 10 and 15 years. Below are some interesting CEO turnover data points from Becker’s Hospital Review.

The average hospital CEO tenure is under 3.5 years.

•    Fifty-six percent of CEO turnovers are involuntary.

•    When a new CEO is hired, almost half of CFOs, COOs and CIOs are fired within nine months.

•    Within two months of a new CEO appointment, 87 percent of CMOs are replaced.

•    Ninety-four percent of new CEOs without healthcare sector experience believe extensive healthcare knowledge is not necessary to replace senior management positions.

•    Eighty-nine percent of people involved in the hiring process believe a broad area of business expertise is beneficial in a hospital CEO position.

•    Most new hospital CEO candidates come from a venture capital/private equity industry background (42 percent,) followed by finance and accounting (40 percent,) banking (32 percent) and marketing and sales (19 percent.)

An element not often factored into CEO turnover is the ripple effect. According to the American College of Healthcare Executives, the departure of the CEO is followed by departures of 77% of Chief Medical Officers and 52% of Chief Operating Officers. I have seen wholesale executive staff departures (CFO, COO, CPO/HR, etc.) in less than six months post the departure of  a popular/effective CEO.  In rural settings, the loss of a healthcare CEO can be even more painful as the executive role within the community in terms of service on various boards and civic organizations is lost with the vacation.

Addressing CEO turnover today is a function of understanding the key contributing factors.  Below is a solid list that I have compiled over the past three or so decades of my work in the industry.

  • Difficult relationships between the CEO and the Board
  • The regulatory and reimbursement environment is becoming more challenging
  • Profit motives out rank care strategies and growth
  • Cultural misalignment
  • Geography/location
  • Challenges with helping board members understand their roles (often, board members are appointed/recruited from within, without proper training and onboarding)
  • Capital access challenges
  • Staffing challenges/building and maintaining a core team
  • Compensation and benefits (an inability to maintain competitive compensation) 

Given the above, and the fact that the majority of turnover is non-voluntary today, the industry volatility creates planning challenges.  With average tenure at right around 5 years, constant and consistent succession planning for the healthcare organization is required.  I’d argue, given the overall lack of qualified candidates that can be source externally, an internal leadership development process is preferable.  What I have seen is that internal candidates tend to create less ripple turnover and have an advantage such that they know the culture and organizational capacity.  The downside, however, is that internal candidates can have too many organizational biases and bred relationships such that creating change and new strategies that challenge the status quo (we’ve always done it this way), becomes difficult if not, improbable.


May 16, 2023 Posted by | Health Policy and Economics, Hospital, Senior Housing | , , , , , , , , , | Leave a comment

Friday Feature: Three Trends to Watch

TGIF! This Friday, I’m focusing on three trends that I think, will have a major impact on healthcare and senior living for the balance of the year and likely, at least the first half of 2024. These trends are in no particular order.

Banking and Credit Struggles: This past week, the Federal Reserve provided some not too encouraging data and outlook on the banking sector via their regular Fed Survey. According to the quarterly Senior Loan Officer Survey, the number of banks increasing loan terms of industrial and commercial loans rose from 44.8% to 46% at the end of 2022. No doubt, this percentage is higher (still) for the first quarter of 2023. Among the conditions driving this tightening are lessening liquidity (deposit level shrinkage), credit quality deterioration (poor performance on loans issued/held), and significant reductions in borrower collateral positions. Loan demand, principally due to higher interest rates, is also significantly trending down for 2023.

Credit tightening and fallow credit demand are typically, signs of weakening economy and a possible recession. The challenge for senior housing and healthcare is that these industries tend to be almost recession proof and always, in need of credit for primarily, plant, property and equipment investment. The senior housing sector is a large consumer of credit for ongoing improvements and for expansion or merger/acquisitions. Likewise, the sector is vulnerable somewhat to rising interest rates as a significant amount of current debt is variable vs. fixed. Quick rate increases place loan covenants at-risk for default.

While I see an end to Fed rate hikes, I don’t see an end to inflation in the near term. With recent CPI (Core inflation too) running around 5% and the Fed funds rate, at 5% to 5.25%, we may see a “hold” period while the Fed waits for the lag effects to further diminish inflation. What is for certain, the current economic conditions will be significantly impactful for the healthcare/senior housing industries for the balance of 2023.

Employment/Labor: For all of healthcare, this is a major concern as demand exceeds supply in nearly all categories of employment and most acutely, for bedside/direct patient care staff. A possible recession and other industry slowdown will benefit healthcare and senior living via increased numbers of non-clinical staff needing work, but that same effect won’t move the supply “needle” on clinicians, especially nursing.

The trend here that I am watching is a bit nuanced. I’m watching the regulatory responses around staffing mandates, particularly in senior living/skilled nursing. The Biden administration has said, along with the 2024 SNF PPS rule that a staffing standard is forthcoming. We have yet to see it but states, such as Connecticut are somewhat ahead of the Feds. But, as of late, reality is beginning to settle-in; namely, the funding cost reality. Connecticut posed a per day increase in hours per patient from 3 to 4.1, along with ratios for certain positions. Both long-term care associations lobbied against the bill stating that while desirable for the industry to accomplish these levels, the reality is that supply won’t allow it. The state Office of Fiscal Analysis said the bill would require an increase in Medicaid spending by $26.6 million in 2025 and $15.5 million in 2026 and 2027.

Pennsylvania ticked-up staffing levels from 2.7 hours per day to 2.87, starting July 1. In July of 2024, the hours per day requirement jumps to 3.2 hours (direct care) per patient. Even though Pennsylvania increased its Medicaid reimbursement by 17.5% in 2017, funding woes for providers still persist. The genesis of the staffing level mandate is a report completed by the Pennsylvania State Government Commission. It noted that working conditions, training and career development were sorely needed to combat negatives about work in long-term care. The report further noted that long-term care spending needed an annual investment of $99.9 million to cover the cost of services which, translates to $12.50 per patient day increase or a Medicaid reimbursement rate of $263.05.

Finally, within the employment/labor trend, I’m watching legislative activity around staffing agencies and specifically, a move to cap the mark-ups that agencies can charge providers. Pennsylvania, in its report (noted) above, noted the rapid increase in agency costs to providers resulting from the pandemic and yet, the limited impact the fee increases matriculated to staff in the form of wages. A recently passed Indiana law includes a provision limiting “predatory practices” by agencies, specifically, price gouing. Minnesota is also working on legislation to increase funding and to in some ways, attempt to address staffing inadequacies.

Patient Transitions/Care Transitions: I’m continuing to watch the post-acute flow dynamics or the admission/transition referrals from hospitals to post-acute providers. My specific focus is on home health which seems to be struggling the most to sustain a referral dynamic that has home care preference but can’t be accommodated by home health agencies. The benefactor of this referral trend is the SNF industry. In a report from Trella Health for 3rd quarter 2022, the SNF industry saw a referral increase of 5.8% (YOY) and the home health industry saw a 8.6% decrease. Hospice referrals remained essentially unchanged. The data is for Medicare Fee-for-Service patients (traditional Medicare), excluding Medicare Advantage referrals. With the growth of Medicare Advantage, I expect to see a continued preference toward home/community discharges yet, staffing levels will dictate how this preference is realized. While home health has a distinct advantage in cost and desire by the patient typically, the setting has challenges to accommodate volume. Productivity levels are currently near the max for many agencies and thus, referral denials are at record levels.

Happy Mother’s Day to all moms and expecting moms, everywhere!

May 12, 2023 Posted by | Health Policy and Economics, Home Health, Policy and Politics - Federal, Senior Housing, Skilled Nursing | , , , , , , , , , , , , , , | Leave a comment

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:

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.

  1. Supervision: Bad managers/supervisors create turnover.
  2. 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.
  3. 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.
  4. 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.
  5. 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.

  1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. 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.

April 27, 2023 Posted by | Health Policy and Economics, Uncategorized | , , , , , , , , | Leave a comment

Top 5 Tips for Recruiting in a Tough Labor Market

I’ve done a number of presentations on the staffing challenges facing providers and how, certain strategies work and others don’t in terms of recruitment and retention. Over my 30 plus years in the industry, I’ve had reasonable (ok, very good) success in building and retaining high-performing teams, including direct care staff. I’ve been fortunate to have many folks who have worked with me, follow me from assignment to assignment, some across the country. Leadership is no doubt key to recruiting successfully as people want to work with winning organizations. Likewise, really good recruiting strategies don’t use the same methodology as the past – namely advertise, incent (throw money at it), repeat. Steve Jobs said it best: “Innovation is the only way to win”.

Most healthcare providers can’t financially compete for staff, consistently. In reality though, staff only work for money when they see no long-term value in the employment proposition. I know travel nursing and agency nursing catch lots of news and sound sexy and high paying. I also know nurses (really, really well as the same are throughout my family) and, the lure of travel nursing is short, regardless of the money. Stability, home base, regularity, working with good colleagues and peers has more value to most nurses.

Before I offer my five “DOs” for recruiting, let me offer a few “DON’Ts” and a reminder. The reminder is recruiting is like marketing – it requires constant, incremental effort to achieve success. Superb marketing campaigns and brands build year-over-year. One misstep, however, can damage a brand significantly (see Bud Light). The “don’ts” mostly focus on money as in don’t think you can buy staff and don’t think, sign-on bonuses buy anything other than applications and temporary workers. Don’t focus on the economic alone but on the goal of recruiting. Like marketing, it’s about positioning the organization to attract workers. The sale or close comes via an H.R. specialist or someone exceedingly good in the organization of convincing people of the value of working for the organization.

My Top 5 tips for recruiting are….

  1. Focus on recruiting introductory, PRN workers first. Stop advertising for shifts, full-time, part-time, etc.   Focus on people who are interested in flexible work and are willing to take a role and see how it goes.  This is the “dip your toe in the water” insight.  Be prepared to pay well but not necessarily crazy. You won’t be dealing with many if any benefits for this group other than some soft stuff (meals perhaps, incentive rewards like a gift card now and then, t-shirts) so hourly rates can be decent.  Likewise, be prepared to pay weekly if not even more frequently.
  2. Have a killer, multi-media/onboarding/orientation program.  Little investment here but not much.  YouTube, Tik Tok (can’t believe I wrote that), a website, and other applications can be used to recruit (what it’s like to work for us) and to onboard and orient.  The more new staff, even your PRN, feel comfortable walking in the door, the easier it will be to get them and keep them.  Giving them a stack of policies and procedures, a big manual, a drone-on HR speaker or a computer-based checklist is a certain turnoff.
  3. Give the Bonus to the Staff. Turn your own staff into recruiters and pay them for it.  Nurses know nurses, CNAs know CNAs, etc.  Comp and incent them to bring referrals and comp them well.  Sign-on bonuses really don’t work but referral bonuses do.  Heck, do individual and team and create a bit of competition and fun.
  4. Create a Marketing Campaign and Have Accountability. Recruiting is marketing.  Stop thinking otherwise. Sure, many think it’s an HR function but most who do, are wrong.  It’s an organization function today requiring the best talent.  For people to join your organization as employees, they need to know “why” – what are the tangibles and intangibles.  Why should I work for you?  This is not about pay and benefits but about the value and benefit internally, of a person working for XYZ organization.  What’s the value proposition?  What’s the real reason people work and stay for an organization (trust me, it’s not money). Build the case and sell that case.
  5. Get out of your own way. I watch organizations fail as their message is all wrong – tired, non-descript, sounding like everyone else.  I watch organizations fail as their environment and their culture are all the same. Stop and align the incentives.  Reward what matters and differentiate.  Remember the Jobs quote in the first paragraph.  Innovate.  Stop looking externally at what everyone else is doing and stop going to the same conference sessions.  Direct care staffing has certain red rules but not as many as providers think.  In other words, stop the “can’t, regulations won’t let us” and start with WHAT can we do.  Maybe even bend a rule or two if the same doesn’t jeopardize patient care or quality.  Worklife for nurses and CNAs in terms of direct care has lots of negatives but many that I see are driven by provider foolishness – too much paperwork not necessary, too many meetings not necessary, and very few positive touches and rewards.  If your culture and the work create fun, ownership, and staff love their work and their company, recruiting others to join the team just got that much easier.

Upcoming, I’ll touch on the opposite of recruiting – retention.


April 20, 2023 Posted by | Home Health, Hospice, Senior Housing, Skilled Nursing, Uncategorized | , , , , , , , , , , , , , | Leave a comment

Litigation and Staffing: What to Know, What to Control

Following up from my last post regarding staffing and litigation risks, this post concentrates on “what we know” and “what we can control”. For example, what we know is that there simply is not enough staff (clinical and even non-clinical) to fill a provider’s vacant positions. The world in general knows this and the press, is oft to repeat a narrative where staff shortages cause negative outcomes, long service waiting times, delayed or deferred admissions, etc. Not a week goes by where I don’t see a news story, on-line, in-print, or on television focused on a health care staffing concern of one level or another.

As I mentioned in the prior post, the heightened alarmism and focus is not helpful, for the most part. For example, I’ve watched Union organizing activity in a number of markets, seeking to organize nurses, based on the staffing issue – not enough and thus, unsafe for nurses and patients. I get the issue, but I don’t see a solution. Raising the issue to a fever pitch, demanding that providers hire more staff that don’t exist, pay more for staff that does exist, etc., isn’t solving the problem. I get that management may even seem callous to the issues and some may be but most senior leaders I talk with are truly trying to do everything they can to improve bedside/patient-centric staffing levels. The simple reality is that there are more openings than bodies capable and willing to fill the positions.

A case in point is recent organizing activity in Wichita, KS (Sedgwick County). Union activity in health care in this area/community has been historically, very low. For professional nurses, it’s been virtually non-existent. At two Ascension hospitals (national Catholic health system) nurses voted within the last nine months, to organize. Here’s a short quote from the Union regarding the push for organization: “We need better staffing, we need Ascension to get serious about recruiting and retaining nurses and we need to have a better safety workplace violence program,” said registered nurse Sara Wilson. “Nurses are in danger when we go to work and Ascension needs to take care of their nurses.” As one would expect, there is truth within that statement but also, to be frank, very little that Ascension can do to create more staff. Provider resources are simply not robust enough to just see the staffing issues as economic. More money isn’t the answer. Ascension closed 2022 with a negative 3.1% margin on losses of $1.8 billion. Among the major health care bankruptcies, one quarter were senior care providers (last several years).

Knowing what we know regarding staff supply, the concern is can some things be done and what can we control. We know money won’t solve the staffing problem as this too, is of finite quantity. Likewise, we also know that money is a substitute concern for the real core issue of simply, not enough bodies for the tasks demanded in patient care. In other words, money becomes the tangible point, but we also know, that money won’t employ more bodies or staff. I know many providers that have RN openings that offer $100K in wage opportunities plus sign-on bonuses and benefits with no takers for these opportunities. A quick Indeed search of Chicago, IL using the job title “nurse” produced 9,133 positions within a 25-mile radius. Similarly, Google searches for nursing positions provide multiple, big dollar references, for travel positions ($5,500 to $7,850 per week). And, according to the Bureau of Labor Statistics, over 203,000 openings will occur every year for at least, the next decade (

What can be done primarily, for any provider, is first and foremost, a concentration on retention. The second thing is to listen to staff, not as a show, but as a real effort in understanding what their concerns truly are. Some are fixable, some are not but all providers should be honest. Open the books so to speak and share the economics. The third, as I have discussed repeatedly, is improve management and reduce bureaucracy wherever possible. An organization can significantly improve its bedside hours (actual) by reducing as many tasks as possible, that have nothing to do with patient care. Trust me, there are many things that health systems and providers require staff to do that has nothing to do with patient care or regulatory requirements. Fourth, analyze the work-flow and make sure that proper duties are assigned to proper staff. I have seen all to many environments where RNs are doing work that could and should be handled by techs, social workers, chaplains, therapists, etc. For example, I can’t even begin to count how many times I have heard about therapists dropping a patient back into his/her room and putting on the call light for nursing to come and toilet the patient or have other care needs met. Crazy. Unless the need was a medication administration, the therapist can and is qualified to assist the patient with a toileting need to get fresh water, transition the patient to bed, etc.

When I see litigation and I see a lot as my firm (H2 healthcare) has an active compliance practice and a nationally known expert in litigation support (defense, not plaintiff), the focus is nearly always on “nursing” not doing something or being somehow, the causation for the bad outcome. Now, with staffing coming to the surface as a root cause (not enough bodies), the question begs, what kind of staff and in what amount. No doubt the focus will be on nursing but perhaps, that focus is rather shallow. As I pointed out in the paragraph above, maybe the staff numbers are better than thought just poorly organized and used (health care is notorious for “silos”) and layers of management.

What a provider can control, aside from numbers of staff which, we know is difficult to totally control, is how staff are allocated especially in relationship to patients and their needs. Below are my top six things providers can control/do with regard to staffing and to reduce litigation risk.

  • Make sure staff in number and capability, match the generalize facility census trend. This means in number (patients) and care needs. I know providers like full beds with patients that garner high reimbursement but, there is a balance. Strike the balance as much as possible and let staff know it.
  • Work as teams – not just as nursing, and therapy, and social work, etc.
  • Stop employing managers that were the “best” clinicians. Employ managers that actually know how to manage, Likewise, give these managers true accountability and authority. They must be able to do their job and not have to “punch up” to get things done. Good management reduces litigation risk.
  • Put staff in positions where decisions are made and give them real results and a “piece of the pie”. Gain share for reduced call-ins, turnover, staff referrals (new).
  • Keep staff apprised of staffing levels and make sure they know how staffing decisions are made, etc. Don’t whitewash the issues. Staff complain about being short-staffed which is the “killer” when it comes to litigation. Too many depositions of nursing staff start with staffing level discussions. Focus on real conversations, daily, about team and everyone being engaged not just “CNAs and Nurses”.

In my next post, I’ll dig a bit deeper into this concept (risk and what can be done), especially concerning the evolving and expanding trend of litigation in Assited Living Facilities.

April 3, 2023 Posted by | Assisted Living, Skilled Nursing | , , , , , , , , , , | Comments Off on Litigation and Staffing: What to Know, What to Control

Better Productivity, Better Retention: Labor Strategy for 2010

For the vast majority of providers, productivity and retention are ongoing labor hassles.  Salaries and benefits are typically, the single largest expense item for health care providers and when analyzed by all of the components, a surprising percentage is allocated for labor related expenses that can and should be, reduced.  Expenses such as Worker’s Compensation, recruitment, turnover, lost productivity due to turnover, pool staff, etc. are resources spent with minimal to no return.

For nearly twenty-five years, I ran a very large multi-site, multi-corporation health system with nearly 1,000 employees.  A number of years back (ten or so), the organization decided to focus on our labor costs and our manpower strategy.  Our turnover was about the industry norm, we had some pool use, our recruiting costs were higher than they should have been, our Worker’s Comp premium was trending up and our overall comp and benefits package, while attractive, wasn’t strategically aligned with who we were trying to recruit – principally experienced, stable employees.  Altogether too often, we hired someone in a panic mode to fill a spot only to find out we hired the wrong people, termed them or they termed themselves,  and then went back to the drawing board.  In the interim, to fill the vacancies resulting from the revolving door, we used pool or temporary staff; premium dollars for no commitment, no real productivity.

By the time I retired in early 2009 and for the seven to eight years preceding, the organization had turned to become the employer of choice in the market area.  Our turnover was less than 10% of our total staff, the majority occurring in non-clinical staff.  Average staff tenure had exceeded ten years and our recruitment budget was less than $100K per year.  Our Worker’s Compensation “modifier” (the factor that correlates work related accident/injury loss experience to premium) was the lowest in the industry – so low that we annually received high five and six figure rebates on our premiums.  We never posted ads for management or administrative positions, never had any employment actions (legal) taken against us save unemployment claims which we universally won on appeal, and had totally eliminated pool or agency use.  Our productivity was extremely high and our Medicare, Commercial and Private Pay payer mix for our reimbursed businesses (SNF, Hospice, Outpatient Rehab, etc.) was fully 75% of our patient days and billed encounters.  We also ran multiple sites, completed multiple acquisitions, and had over a dozen complex service lines (vent, wound, inpatient hospice,, etc.) that required us to recruit and maintain, highly skilled clinical staff.

The point of this post for me, is not to brag but to share some common sense, workable strategies that will, if employed (pardon the pun) properly, increase productivity, increase retention, and reduce non-essential labor related expense.  I have actually used each tactic or strategy below and each has worked (in conjunction with the others) and produced real, tangible results that every provider organization can benefit from.

  • Change hourly and salaried compensation to a very flat scale that compensates each employee for the requirements of the core job – nothing more.  There is no real correlation between longer-term employees being paid more and their relative worth to the organization.  I know this sounds incongruous in light of a retention strategy but trust me, longer-term employees well compensated and performing will be just fine and as we all know, pay doesn’t keep or attract any key staff members.
  • In light of above, increases in hourly and salaried wages should be tied to “market” only or to skill levels.  Career ladders are fine provided they actually correlate to necessary skills, demonstrated competency and “jobs” that actually exist or need to be filled. 
  • Re-work job descriptions for all non-management and non-supervisory positions such that the core of the job description is divided into two thematic areas – job required competencies and behavioral standards.  Job required competencies are the core, functional requirements (demonstrable) that must be completed by the person doing the job, routinely (daily, weekly, monthly, etc.).  Behavioral standards are the requirements established by the profession and/or the organization and are essentially universal to every position or every position within a particular job category.  Examples of behavioral standards are attendance requirements, dress codes, CEU requirements, etc.  Behavioral standards are not things like, “treats co-workers with respect” – this should be an organizational given and the purview of management.  Eliminate from each job description, any non-demonstrable, non-verifiable requirement.
  • Change job or annual performance evaluations to nothing more than a competency based review, based on the job description.  Competency testing should be annual or as frequent as needed when job descriptions change or competencies are altered/added.  Eliminate “compensation” from the discussion as compensation or wages should be determined entirely based on the market, the organization’s budget and its manpower plan (a component of which should include a provision of how the organization determines what level of compensation it will offer in light of the market).  Include in the review, an optional discussion for employee development but such a discussion should only occur based on the desire or choice of the employee.
  • Re-work hiring and orientation practices (non-management, non-supervisory) such that new hires are essentially automatic if the candidate meets the essential requirements of the job.  Orientation thus becomes a very didactic, competency-based process during which, the new hire is fully tested and indoctrinated in his/her job and the organization’s standards for employees.  Require absolute attendance and use tests and/or other forms of demonstration to assure that the new employee has successfully grasped the knowledge and/or demonstrated the core competency of the position.  Be prepared to “terminate” employees that don’t meet the requirements or standards at a high level.  Past experience suggests that employees that “don’t get it” within the first ninety days or less will likely be problem employees throughout their career and certainly, take  far more organizational resources to supervise and manage than what their performance will be worth.  Lastly, don’t let any new hire “start” their full position until he/she has successfully completed every facet of their orientation.  The organization should view this phase as the most critical step toward long-term retention and success of a new hire.
  • With respect to benefits, I am a big fan of unbundling every possible, non-mandated benefit and creating a cafeteria or flexible benefit program that allows each eligible employee to “purchase” the benefits that fit their circumstance or lifestyle.  I am also a big fan of providing lots of choices or voluntary plans such as additional life insurance, extra disability income protection, hospital indemnity, etc.  We even allowed employees to buy additional days off.
  • Create an “employee activities” committee and provide the committee with a budget.  Encourage employees to create almost weekly activity programs and events, mostly simple.  I prefer breaking these activities into four categories: Fun, Education, Wellness, Community Involvement.  Examples of things that we did were food drives, walking programs, wellness fairs, sports themed lunches, ice cream float days, cookouts, etc.  The only requirement for these events is that they must be “open” to every employee on every shift.
  • Share as much information as possible with employees about operations including budgets, strategic plans, census, staffing, quality data, etc.  I also believe that getting employees (hourly especially) involved in quality and customer service/customer satisfaction activities is essential.  The more knowledgeable and involved employees are, the more committed to the organization they typically become.

Assuming the points above are implemented or are in the process of implementation, the next group or set of strategies is undoubtedly the hardest to implement as each involves organizational change and management acumen or competency.  Arguably, without these changes or strategies in-place, the results attained will be weaker and produce much less return for the organization.

  • Rewarding performance must become a group and an individual function, tied to true performance.  The organization should be willing to provide significant bonuses or other tangible rewards to individuals who demonstrate exceptional performance or to groups that demonstrate exceptional performance.  The organization must be exceptionally clear about how it determines performance (must be measurable) and what performance is (outcomes).  Examples of performance are census goals, payer mix, survey results/outcomes, budget/financial performance, clinical indicators and quality measurements and of course, customer satisfaction.  I am a fan of using “scorecards” on key performance outcomes and then posting these measurements for staff to review.  The organization should become willing to “gain share”‘; passing along a percentage of actual gained revenue or saved expense to employees. For example, we shared the dividend we received from our Worker’s Comp experience with employees. Employees knew that the safer we maintained the workplace, the gain we received as result of our safe practices benefitted them.
  • In light of the point above, rewards must be timely and personal.  We used cash, vacations, time off with pay, deferred compensation into retirement plans, etc. for larger rewards.  For small incentives, we used gift certificates, movie passes, flowers, pizza parties, etc.  The whole point here is that performance must be rewarded rapidly and tangibly and the behavior that is part and parcel to good outcomes needs immediate recognition. 
  • Management at every level is key and the organization must commit to developing professional management staff and developing core managerial competencies.   I like the following approach.
    • Require managers to complete an organization sponsored or conducted training program on key managerial competency.  Completion and demonstrated competency is required to maintain the management position.
    • Never promote someone into a management position simply based on tenure or job skill.  Make sure that each manager has managerial competence.
    • Tie managerial compensation to the achievement of organizational objectives, direct objectives of the job and employee/direct report outcomes.  Managers must know that their compensation and future is directly tied to how well their reports and staff perform.  Measure constantly, employee turnover, customer satisfaction, quality and financial outcomes.
    • Give managers the authority and a budget for rewards for their staff.  Measure how frequently the manager is using these tools to reward outcomes and behavior.
    • Make it difficult for managers to take job actions against employees without the involvement of a “higher authority” (senior management, human resources).  Organizational policy should reinforce that employees only get fired or suspended for not performing their job as detailed in their job description (competency) or for behavioral standard infractions (attendance, dress code, etc.).  Managers should understand and embrace the concept that their role is to coach, to plan, to develop and to implement organizational strategies and policies.
    • Create opportunities for managers to interact, to solve problems jointly, to develop new ideas and programs, and to be a part of the overall organization – not just their individual department or function.
  • At the organization level, set a clear standard and practice for very quick termination of employees, regardless of tenure, that do not meet expectations.  Consciously limit written and oral discipline tendencies so that managers know that their responsibility is to lead and to work on performance issues, not simply spend hour after hour disciplining poor performing employees that will likely never be terminated.  If the organization has clearly outlined performance and behavioral standards for each job, employees that don’t meet the standards should be quickly eliminated from the organization.  Documentation thus becomes very simple; a function of matching employee behavior or work product to the job description and the competency testing material that should be a part of each employee’s record.
  • Consciously reinforce to all levels of management that interaction with every level of employee is a necessity and that visibility and knowledge of the core business and the customer is critical.  To do this, the organization must commit to limiting non-essential meetings as well as to an ongoing review process of management that incorporates key performance outcomes that cannot be attained unless management is fully engaged with staff, with customers, and with the process and outcomes of the jobs they (management) lead and direct.

Putting these concepts into action is not an easy or quick process, taking at least a couple of years from start to finish.  Maintenance is also somewhat difficult as the organization must be disciplined to not let creep in, the natural tendencies of humans to want to short cut the steps or to not repeat the maintenance steps (training, orientation, performance monitoring, etc.) frequently – a must.  Without question, the first two or so years will be years with some additional turnover and necessary management turnover as managers will be the most resistant to their new levels of accountability and their new focus of “keeping” employees productive rather than “micro managing” conduct, etc.  What I do know is that when the steps above are flushed out on an organization specific level and implemented, the results in terms of productivity and retention are amazing – well worth the investment and the effort.

January 4, 2010 Posted by | Assisted Living, Hospice, Senior Housing, Skilled Nursing | , , , , , , , , , | Comments Off on Better Productivity, Better Retention: Labor Strategy for 2010

Holding onto Your D.O.N.

In our annual Healthcare Leadership Labor Market Report released in July, we presented some rather alarming trends regarding the long-term care and post-acute care industry’s retention of nursing executives.  For example, we noted that 71% of the Directors of Nursing in nursing homes leave their positions each year.  We also noted that the average tenure of a Director of Nursing is three years.  Within the report, we cited numerous reasons for the short-tenure and resultant turnover with the key take-away point being “job dissatisfaction”.  Of course some or a large amount of the job dissatisfaction within long-term care has to do less with the “job” and more with “what” the job has become as a result of what is going on in the industry today.

The purpose of this post is not to reiterate the informationin the report, rather to provide some key information to combat the trends presented; namely turnover of this incredibly key resource.  What is most important to note however, is why these positions turn and what an organization can and should do about keeping the right people working in the right positions.  The reality most apparent is that there are not enough good nursing executives to fill the voids that are created at the rapid pace at which they are occurring.  The depth of this labor pool is rather shallow, especially when skill and acumen are accounted for as key requirements over against the willingness of a registered nurse to put his or her life and license on the “line”.  To that end, the principal reasons “why” a nursing executive or as is commonly known,  a D.O.N. leaves his or her post are as follows.

  1. Job Dissatisfaction: To be specific, this means general feelings of an inability to adequately perform one’s job and to be recognized for the performance due to the role or positional requirements which are viewed as unreasonable.  In most cases, the demands and expectations are too great for any one person to consistently accomplish.
  2. Industry Dissatisfaction: This dissatisfaction is principally about the present state of the long-term care industry and often is categorized into regulatory and budgetary issues that impact the D.O.N.’s ability (real or perceived) to deliver care sufficient to meet organizational and professional standards.  Not too surprising, labor issues such as staffing are also a part of this factor (insufficient and inadequate staffing numbers).
  3. Hours and Working Conditions: The sheer time demands and the often physical and emotionally demanding role of a Director of Nursing simply takes a toll and lifestyles and personal health (emotional and physical) suffers to the extent that leaving a position is viewed as necessary.
  4. Organizational Dissatisfaction: Key components herein were dissatisfaction with immediate supervisors and dissatisfaction with perceived or real lack of organizational support and allocation of resources.  Important to note that for Directors of Nursing in nursing homes, dissatisfaction with the Administrator was frequently cited and generally, cited more often than overall dissatisfaction with the larger organization.
  5. Professional Needs Not Met (Compensation, Advancement, Autonomy): Somewhat lumped together but this catch-all is rarely the key reason (or reasons) alone for turn-over.  What is important to note however is that compensation in terms of straight salary and benefits in long-term care falls significantly below compensation levels in acute care settings and when viewed in light of the job demands is appallingly low compared to other executives in healthcare and out of healthcare, especially non-clinical executives in healthcare.

Taking the above into account, the key is to devise an overall program and plan that sufficiently reduces the dissatisfiers, where at all possible.  It may seem impractical to think that any organization can change the influence the industry has on a position however, there are strategies that can be used to significantly minimize the negative environmental factors that come to bear and produce turnover.  To be certain, the most important step to take is to create a list of factors that an organization controls directly and a corresponding list of the factors that an organization doesn’t directly control but can manage as a means of developing an overall retention strategy. 

Without going into a full-blown plan that may or may not be applicable to a particular situation, there are some very basic organization level steps that can and should be taken to improve the probability of  D.O.N. retention.

  1. Develop an organizational commitment to keeping goals and objectives extremely clear and focused, inclusive of the time expectations required to complete same.  Involve the D.O.N. directly in establishing these goals and objectives including gaining agreement on realistic time frames for completion and identification of resources required for completion.
  2. Make certain that no organizational expectations are formally or informally enforced regarding “time in office” versus performance.  Provide complete control to the D.O.N. to come and go and be present as necessary and judge performance strictly on agreed-upon goals and objectives – not on time in the office or on a set schedule.
  3. Reduce to a minimum the number of non-essential and often, counter-productive meetings and committees involving the D.O.N.  Meetings add busy work and create confusion and often, lead to endless additional tasks that should be handled elsewhere.  Help the D.O.N. process his/her schedule and assure that maximum time is provided to him or her to complete his/her objectives, not consumed by organizational meetings that are not relevant.
  4. Make abundantly clear to the Administrator that a key element of his/her performance requirements and ultimately, job retention is the retention of the D.O.N.  It may be necessary (and advisable) to have a qualified third-party work with both the Administrator and D.O.N. to forge a true partnership agreement and develop role expectations and a structured reporting relationship.  Long-term care tends to be backward here in so much that Administrators are presumed to be superior roles when in reality, the D.O.N. is often the de facto leader within the nursing home.  Good Administrators fully understand their role and how to complement this relationship and support the work of the D.O.N.
  5. Pay special attention to getting and receiving constant and consistent feedback from the D.O.N. regarding job and positional demands.  Encourage the D.O.N. to participate in external networking opportunities and to take advantage of continuing leadership and clinical educational opportunities.
  6. Provide external resources such as consultants to the D.O.N. pre and post-survey.  Most D.O.N.s don’t feel adequately supported in advance of a compliance survey and don’t have the resources necessary to dissect survey issues.  Surveys are horrendously stressful and are not a true reflection of the D.O.N.’s performance in many cases.  Organizations that are aware of how widely variable compliance surveys are and how inconsistent surveyor practices are understand that D.O.N.s have only so much control over the ultimate outcome.
  7. Increase the expectations of other clinical staff (and the accountability) including the Medical Director in terms of overall patient care and satisfaction.  Too much falls directly on the plate of the D.O.N. that belongs to other disciplines and most often, he/she is left “holding the bag” for what others should have done.  In a fully evolved organization, the D.O.N. and the Administrator should actually jointly oversee and partner in managing and planning the work, required performance outcomes and review of all other clinical/care disciplines.
  8. While financial resources are always tight in long-term care, the organization must make an overt commitment to providing the D.O.N. with sufficient dollars to build and reward an adequate staff and to have current clinical resources and support systems.  Make the D.O.N. aware of key financial issues and measurements but don’t place the onus on him or her to be accountable for other organizational financial matters beyond his/her scope of control.  Too often, D.O.N.s are brought into census and payer mix issues that are only sources of frustration and beyond the scope of what a D.O.N. should truly be concerned with.
  9. Create an overall organization compensation policy that allows for frequent recognition and reward, beyond the scope of standardized evaluation programs, bonus programs and wage increase programs.  These programs work best if they are totally person-centered, allowing for the compensation program of the D.O.N. to be personalized.  Rewards and recognition need to be frequent and not just monetary.  Programs that use paid time off as reward, gift certificates, movie passes, flowers, spa certificates, etc. are viewed by all staff as significant and personal and D.O.N.s need to be a part of these programs and have the programs at their disposal for use among their own staff.

There is a time worn saying that is appropriate: “Its cheaper to keep them than to lose them”.  In too many cases, a highly qualified D.O.N. leaves only to be replaced by someone lesser qualified, often at a higher cost and in all cases, at a higher organizational cost.  Rarely is the replacement of this position an “upgrade” and certainly, at the rate of turn-over (once every three years) nearly always at a strategic and financial disadvantage to the organization.

September 2, 2009 Posted by | Skilled Nursing | , , , , | Comments Off on Holding onto Your D.O.N.