Job swap: boosting employee morale and resident care: from the staff of Talladega Healthcare Center, Talladega, Alabama.

The circumstances that led to our facility's focus on reducing CNA turnover included a desire to improve resident care outcomes tracked through our QA/QI process. We track key care indicators as well as employee turnover, and our QA/QI team determined that nursing staff turnover significantly impacted our ability to improve quality-of-care outcomes. Also, based on feedback from our residents and their family members, we learned that their comfort level with and confidence in the care being provided increase significantly when they feel as though they know staff members personally. We knew that for these relationships to reach a personal level, nursing staff turnover had to be reduced.

The Process

We quantified our objectives by reviewing our QA/QI data to choose the care outcomes that would indicate significant improvements in care delivery. We decided to focus on reducing falls, the number of residents transferred to the hospital as a result of fall-related injuries, development of pressure areas, and undesired weight loss, and on improving customer satisfaction. We surveyed residents on service satisfaction prior to planned discharges.

The Job Swap program. As we tracked resident outcomes, we also tracked nursing staff turnover. A program we call Job Swap was designed to help reduce employee turnover. It is based largely on W. Edwards Deming's "Fourteen Points" of Total Quality Management--primarily the principle of "driving out fear." We also used Stephen Covey's book Seven Habits of Highly Effective People. For example, Covey's habit of "seek first to understand, then to be understood" was the basis for having our employees literally "walk a mile in someone else's shoes," in the hope that this would improve mutual understanding and communication and increase job satisfaction--ultimately leading to reduced turnover.

In the Job Swap program, for an entire day staff from all departments swap jobs. Positions that are swapped include anything from floor technician to DON to facility administrator. Nursing assistants are scheduled to work in a department of their choosing. The event is advertised as a "Swap 'til You Drop" event, and staff look forward to it all year long.

A QA/QI team member coordinates the event with staff. The Job Swap date is posted throughout the facility. Staff wear T-shirts imprinted with our facility name and the "Swap 'til You Drop" theme on Job Swap Day and throughout the year on Casual Fridays.

Job Swap is a voluntary event. Interested employees agree either to do a different job or host someone in their role. Each department preselects a host to ensure sufficient staffing levels. A list of participants is posted next to our time dock and, this year, at least 60 employees participated.

The day before the Job Swap, participants make their requests or put their names in a hat to determine their assignments. All participants know their positions and hosts before they leave work the day prior to Job Swap. Employees report to work the day of Job Swap according to the scheduled hours for the job they will be working. The employee, accompanied by the host, works the entire scheduled shift in that position. All Job Swap participants eat lunch together that day, provided free by the facility.

Employees from all departments participate. Moreover, all management-level staff perform direct-care jobs as part of the event. Our staffing coordinator, along with all other department heads, coordinates assignments and schedules to accommodate the swap and still maintain routine facility operations. The only obstacle we faced in implementing this program was to coordinate staffing to ensure that routine facility operations continued with the job swapping in effect. To accomplish this, our staffing coordinator is permitted to schedule extra CNAs to maintain quality care, as well as to host employees who are job swapping with CNAs throughout their shifts. The permission to hire temporary staff is granted across all departments. The cost of this is minimal compared with the results we achieve.

Program Evaluation/Benefits

Tools we used to evaluate the success of our objectives were developed through our QA/QI data and feedback from residents, staff, and families, as well as employee turnover. We found that the QA/QI data demonstrate an improvement in the targeted care outcomes--falls were reduced by 17%, falls with injury and related hospital transfers were reduced by 50%, the number of residents who developed pressure areas stage II or higher declined by 50%, and residents experiencing weight loss declined by 63% (Figure).

Looking at staffing, national CNA turnover averages were determined from the American Health Care Association's 2002 AHCA Survey of Nursing Staff Vacancy and Turnover in Nursing Homes. To evaluate staff turnover, we included national and state averages from that survey to compare to our facility's results. Specifically, we compared CNA turnover from January 2002-June 2002 to CNA turnover for the December 2002-May 2003 time period.

During the same time period that QA/ QI data show that improvements were made in all chosen care areas, we found that CNA turnover at our facility was steadily decreasing. CNA turnover was reduced by 28%; from 58% in January 2002-June 2002 to 30% for the December 2002-May 2003 time period. The reduced turnover is even more impressive when compared with the AHCA study's 80.6% national average in 2002 and the 71.1% average in our state (Alabama).

A Customer Service Satisfaction Survey was implemented during the same month as the lob Swap. Residents or family members completed the surveys prior to discharge. We decided to start with our short-term stay residents for the survey; longer-term residents will eventually be included. Customers were asked to rate aspects of our facility as excellent, good, average, fair, or poor. Residents completed 25% of the questionnaires, families completed 67%, and friends completed 8%. Among the initial results, 92% rated our fulfillment of patient care needs as excellent or good; the same percentage had an excellent or good overall impression of our nursing facility. Every respondent said he or she would recommend our facility to others.

We use these surveys continuously to determine areas that need improvement and to measure the success of our improvement efforts through our QA/QI process.

Although we realize that other factors--such as acuity level, availability of necessary supplies, and staff training--affect resident care outcomes, we believe that CNA turnover is the most influential, with our Job Swap program playing a major role with its resulting cooperation, communication, and improved employee morale; improved job satisfaction; increased employee retention; and, ultimately, improved resident care outcomes.

Conclusion

An interesting question is: Why did this relationship occur?

The laundry worker who normally washes and distributes linen experienced working side by side with a CNA helping to care for the residents who use that linen. The cook in the kitchen who normally prepares the food experienced the challenge of trying--sometimes to no avail--to get a resident to eat 100% of the meal to prevent weight loss. The business office staff who bill for enterals, catheters, and wound supplies saw the actual benefits of this equipment while care was being provided. In short, this experience put caregiving and the resident at the heart of each employee's job and mission. In fostering understanding of what our care team is all about, this program has had a significant impact.

Figure. Improvements in targeted care outcomes are seen by comparing
data from Jan. 2002-June 2002 to Dec. 2002-May 2003. At the same time,
the staff turnover rate fell from 58 to 30%, and customer satisfaction
surveys had positive results.

Average number of resident falls
(17% reduction)

Jan. 2002-June 2002    30
Dec. 2002-May 2003     25

Average number of resident falls
resulting in injury (50% reduction)

Jan. 2002-June 2002    3.0
Dec. 2002-May 2003     1.5

Average number of residents who
developed pressure areas stage II or higher
(50% reduction)

Jan. 2002-June 2002    3.6
Dec. 2002-May 2003     1.8

Average number of residents
experiencing weight loss (63% reduction)

Jan. 2002-June 2002    12.5
Dec. 2002-May 2003      4.6

Note: Table made from bar graph.

RESIDENT/STAFF RESPONSES

I really enjoyed getting to know the girls in the Business Office and in other departments. I don't really get to see them much. I know them, but don't really spend a whole lot of time with them. Now when I see them, I remember their names.

I think having the same aides helps me feel better about being here. It makes it feel like they are your friends and fatality; not just some people. I Like getting to know people's ins and outs, you know, their peculiarities. We've all got'em. I like knowing them well enough to know a little something about them, too.

Resident

I enjoyed getting to know different people that I don't usually get to spend a lot of time with. Having the same girls to help me and not having a new person as much gives me peace of mind. It means a whole lot not to have a stranger earning in. That's how it feels when we lose somebody. You don't know what to say or do. You nave to Learn someone all over again. I worry less when I Know them already. The other day my daughter asked me, "Mother, do you really know all these people you name off?" I was naming the girls who help me. And I told her, "Why, of course I do."

Resident

This year I was a participant in our annual Job Swap Day. I requested to go into the kitchen; my request was approved. I had the experience of my life working with Ernastine Curry. Ms. Curry has worked in dietary for many years and I have to say she is very good at her job. It was an interesting and fun day. I had the opportunity to help prepare breakfast and lunch. I cooked fish, helped prepare macaroni and cheese, coleslaw, and desserts. It was a major change from nurse to cook, but I enjoyed every minute. It was interesting to see how such a large amount of food is prepared and all the different machines used.

LPN

This year I got a chance to "walk a mile" in Valerie Swain's shoes. Valerie is one of our facility's clinical nurse managers. I learned that Valerie not only looks after the CNAs but also is responsible for all the nurses on her unit. This position is very challenging! Throughout the day I learned the different reports Valerie has to complete. I also got to review the new ADL forms that our CNAs were going to start using. Between all the paperwork, you have to deal with other issues that may arise. You have to be a well-rounded individual to handle this position. We couldn't have chosen anyone better to handle this position. I'm excited to have had this chance to see what actuality goes on behind the scenes.

Payroll Clerk

Donna Adendorff is administrator of the Talladega Healthcare Center, Talladega, Alabama. For further information, phone [phone] or fax [phone]. For more information on the OPTIMA Award, visit www.nursinghomesmagazine.com. To comment on this article, please send an e-mail to [e-mail].