What is your Mount Everest?

Last month, I climbed Mount Everest, the world's tallest and most prominent mountain at 29,029 feet (8,850 meters). Well, sort of…I accepted the 29Zero29.com challenge organized by entrepreneur and extreme living specialist Jesse Itzler and his unbounded team. The event was at Mount Stratton, Vermont. We had 24 hours over three days to summit Mount Stratton 17 times. Each summit hike was 1,750 feet, 1.1 miles long and steep to equal the 29,029 vertical feet of Mount Everest in a weekend. Instead of resting overnight, I decided to push my outer limits to complete this event in 27 continuous hours. I climbed through the night and experienced the sunrise over the mountain. Everesting. One step at a time. I figure I have xxx days still ahead of me if Lady Luck is on my side. Every day, I ask myself “What is my Mount Everest?” What thoughts do I want to have and what actions do I want to take that will lead to achieving my goals and feeling fulfilled? I challenge you to explore your Mount Everest. What actions can we take to meet the challenges of the day and help others in their endeavors?

In considering this question in the health care industry, and especially in nursing and long-term care, one of our Mount Everests is how to continually improve the quality of care and the role of nursing home leaders in an ever-changing industry. Improving staff satisfaction is one “Mount Everest” challenge that will translate into higher levels of performance and service excellence. The AHCA Quality Improvement Committee assessed several key areas to improve staff perception and build a committed, motivated workforce. We can set and achieve these goals one step at a time. Notably, most of these objectives require little financial investment, although they may require some changes in leadership and management actions.

In order to prepare to climb a mountain, it’s important to learn as much as possible about it. Here are the key areas where nursing home leaders should focus to improve staff satisfaction.

What matters most to nursing home employees?
1.    Management cares about employees
2.    Management listens to employees
3.    Management helps to reduce job stress.
4.    Fair evaluations
5.    Staff respect for residents
6.    Workplace is safe
7.    Supervisor cares about you as a person

Once we understand the mountain, we can then develop the strategies to support each step we take. Following are the key areas for improvement and specific actions, practices and programs.

1.    Demonstrate that management cares about employees.

  • Regularly share evidence-based clinical “best practices” and assist staff with implementing changes in order to incorporate those practices into daily care.
  • Be transparent and share all data with staff – clinical outcomes, satisfaction survey results, occupancy trends and financial results.
  • When a measurable outcome is not up to par, allow and encourage staff to participate in a process of finding a solution. Identify the root cause, analyze all the possible causes and identify solutions that have the best potential to improve the outcome.
  • Move toward audited patient records to collect data and measure results instead of simply identifying those who missed documentation.
  • Ensure that individual employees’ schedules are honored. Employees should be informed ahead of time if their schedules and assignments need to change to meet the organization’s needs.
  • Work schedules and assignments should be clear, well-organized and posted well in advance.
  • Employees should clearly see the efforts made to fill vacant shifts and prevent understaffing.
  • Tip: Make sure your staffing coordinator is smart, fair and extremely organized. 
  • Employee evaluations should be conducted on or before the employee’s anniversary date. Employees should never be surprised by the information shared during the evaluation meeting regarding their areas for improvement. For the most part, employees should feel the evaluation was fair and, in many cases, they should feel great after the meeting.
  • Tip: Bring your employee master list to every stand-up meeting and announce upcoming employee anniversary dates. 
  • Recognize joyful events that occur in the employees’ lives and celebrate the event at the facility.
  • When tragedy occurs in employees’ lives, acknowledge it. Allow staff the opportunity to determine how they can help ease their co-workers’ pain.
  • When residents pass away, inform the staff that were closest to the person if they were off work. This will provide them the change to come to the facility if they choose. Don’t let them come to work after being off to a new resident in the room without adequate preparation.
  • When residents pass away, offer condolences to the staff that were close to the resident and allow them time to grieve, including attending the funeral or memorial service. Recognize that positive relationships are a priority and therefore facilitate relationship-building among all stakeholders in order to create a sense of community.
  • Bring people together regularly and engage them in relationship-building exercises.
  • Provide quality education and in-services that incorporate the principles of adult education. Offer educational topics beyond the mandatory in-services required by state regulations. Use data to drive your education agenda and use employees with subject matter expertise to participate in the training.
  • Pilot-test all changes and work out the kinks before spreading the change facility-wide. Never burden the staff with a new policy or procedure that has not been thoroughly pilot-tested.
  • When rolling out any change, stand alongside the staff during the rollout of the new process and provide responses and additional information that reflects your support.
  • Praise and recognize staff in public. Counsel and coach the staff in private.
  • Recognize and reward both individuals and teams for achieving and sustaining quality goals.

2. Demonstrate that management listens to employees.

  • Regularly measure and take action on staff satisfaction survey results. Share results with staff, celebrate successes and improvements. For areas that need further improvement, develop (with staff) and share the plan of action. Report back to the staff on progress and completion.
  • Consider sending a latter to each employee summarizing the actions being taken to enhance the areas of improvement gained from their feedback.
  • Consider using an employee newsletter or website to assist in promoting management and staff communication.
  • Facilitate a process to have CNAs attend and participate in resident care conference meetings. Formally invite the CNAs and help them prepare for the meetings by showing them important information to share.
  • Tip: Work with CNAs who are part of the interdisciplinary team to schedule care conference times that will work for everyone, including families.
  • Be honest with the staff. Don’t raise expectations and say “maybe” to suggestions that you know are unlikely to come to fruition. Professionally say “no” and explain why. Under promise and over-deliver.
  • Share the facility goals and strategic plans with the staff. Make a sincere effort to keep people informed of the big picture and how they fit into it.
  • Be transparent and share all data with the staff, such as clinical outcomes, satisfaction survey results, occupancy trends and financial results.
  • Seek individuals to weigh in on any decision involving them, including process changes, supplies and equipment.
  • Have facility leaders adopt an open-door policy, but recognize that most staff will not walk into a manager’s office unless they’re invited. Leaders need to get out among the staff in order to maximize their efforts to listen to them.
  • Conduct regular, frequent rounds to visit with and talk with the staff. Ask questions and be 100 percent interested in the answers.
  • Ask relationship-building questions to show that you see your staff as more than just workers and that you want their input.
  • Focus on them. “How are your beautiful kids doing?” or “How is your husband doing, I heard he was ill.”
  • Tip: Write the information down to remember it.
  • Focus on the positive. “What is working well today?”
  • Positive feedback loop: “Is there anyone you’re working with who went above and beyond today?” 
  • Tip: Pass on the positive responses.
  • Quality improvement/systems focus: “Is there anything we can do better?” or “what is frustrating you today?”
  • Tip: Consider the information they share is probably affecting more than one person. Bring this information to the next QI committee meeting.
  • Tip: Act on the information they share and always get back to them to let them know what you did or will do to make sure they have the right equipment and supplies to do their job well. 
  • Create consistent, formal, structured systems to receive employee insights and feedback, such as learning circles, community meetings and/or neighborhood meetings, regular employee satisfaction surveys and suggestion boxes. Be sure to check daily and post the suggestions and your responses on a bulletin board next to the suggestion box.
  • Know one thing about each staff member that you can talk about when you meet, perhaps something you share in common with them. 

3. Demonstrate that management works to reduce stress.

  • Make sure there are ample supplies at hand. Nothing frustrates CNAs more than a lack of clean linens. During every management rounds, open every linen closet to see what’s there.
  • When a resident passes away, acknowledge it. Personally offer condolences to employees who had a relationship with the resident. Allow the staff time to grieve and remind them of how proud you are of the positive contribution they made to the resident’s life. Hold memorial services and moments of silence at general staff meetings to honor those who have passed.
  • Tip: Develop systems to communicate with staff when a resident has passed away. Consider calling certain staff members who were close to the resident at their home (if they’re off that day) to let them know when a resident has passed. 
  • Address and take appropriate action with negative staff members that are contributing to their co-workers’ job stress. Pay close attention to who is on duty during unusually stressful times. Notice the dynamics between the staff.
  • Experiment with creative staffing configurations, such as spa aides, additional activities staff and clerks, to take stress off of nursing staff. Consider adding a concierge position at peak times to serve new admissions and their families, answer call lights, make beds, deliver nourishment and so forth.
  • Expand the activity program to individualize programs for residents and reduce their loneliness and boredom.
  • Explain to the staff that efforts are being made behind the scenes to prevent understaffed shifts and how they can assist.
  • Decrease the institutional environment. Create a home-like environment that is relaxing and pleasant to live and work in.
  • Offer more dementia care training for the entire staff. Be sure to include regular, consistent education regarding how to deal with combative and verbally abusive residents and families.
  • Offer wellness programs for the staff, such as smoking cessation classes or discount memberships to local health clubs. Bring in a massage therapist to provide staff with 15-minute massages. Change some vending machine items to healthy food choices.
  • Keep the facility sparkling clean and free of clutter.
  • Upgrade the employee lounge and create an area of peace, sanctuary and quiet. 
  • Intentionally create spontaneity and laughter on the job. Surprise staff by creating “fun” and laughter at every opportunity. Organize a facility choir made up of staff and residents.
  • Create a culture where everyone responds to call lights to first determine what the resident needs. 68 percent of the time anyone can handle the situation.
  • Minimize transferring an employee from one unit to another at the beginning of a shift. Staff find it stressful to start work in one unit and move to another in 10 minutes.
  • Create clear lines of communication so employees know who to turn to when stress is a problem.
  • When stressors are brought to management’s attention, be sure to both listen and do something to improve the situation.
  • Provide training to deal with difficult residents and families.
  • Provide a safe way for employees to remove themselves from problem situations when stress is overwhelming. Employees should be able to call for help or otherwise remove themselves before an adverse incident occurs between them and a resident. They should be empowered to do so.

4. Demonstrate management’s commitment to consistently fair performance evaluations.

  • Ensure that all job descriptions are up to date and in alignment with valid, credible performance evaluation tools.
  • Educate staff regarding how they will be evaluated and what different performance categories and ratings address.
  • Complete evaluations on time. An effective strategy to stay on top of timely evaluations is to announce upcoming employee anniversaries at every management meeting with a gentle reminder that evaluations are due. The goal should be to complete employee appraisals before or on their date of hire. Most employees remember that date and expect their evaluations. The importance of the evaluation is diminished when it is late.
  • Consider implementing quarterly mini-evaluations to provide more timely, constructive and positive feedback to employees. No employee should have to wait for their anniversary to learn that their work falls short.
  • Allow every employee the opportunity to complete a self-evaluation before the performance review meeting. Compare their evaluation with your own and discuss it with the employee.
  • Make an effort to collect more information and make sure to let the employee know of your diligent effort. Obtain other supervisory staff members’ opinions regarding line staff. For example, if a CNA has reported to multiple charge nurses over the course of the review period, ask each of them to provide feedback.
  • The reviewer’s approach should be to coach, build the employee’s self-esteem and move the employee closer to their potential. Therefore, conduct the review as an exchange of information, not as a report card. The evaluation form is only a tool, a means to an end. The goal should be no negative surprises for the employee receiving the review.
  • The review should cover subjects like job proficiency, working relationships with other employees and supervisors, relationships with the residents and their families, and how they fit into the facility’s culture.
  • When beginning the performance review, obtain the employee’s comments first. Look at their self-evaluation and highlight areas where your ratings match. Ask probing questions and promote self-discovery. Disagreements should be addressed through discussion and concessions on both parties. Complete your evaluation form in pencil and be willing to make adjustments during the review discussion.
  • At the end of the review, ask the employee felt the review was fair. If the answer is no, spend some time to work out the differences in opinion and come to a resolution. 

5. Demonstrate management’s commitment to treating residents with respect.

  • Implement consistent assignment of the same caregivers to the same residents. Abandon the practice of rotating staff assignments. Consistent assignment allows staff to form close relationships with residents.
  • Encourage staff to get to know the residents beyond their current diagnosis. Allow staff to read the extensive information collected about each resident by the activities and social service staff.
  • Inform family members of your consistent assignment approach and encourage them to get to know the caregivers.
  • Educate staff regarding why they should make the effort to form relationships with residents and their families, including how much those relationships ultimately make their job of caring for the residents easier and more meaningful.
  • Embrace person-centered care and begin the process of transforming the entire organization toward a person-centered care model.
  • Offer multiple opportunities for staff to learn how to deal with difficult resident behaviors. After a resident acts out, teach staff how to analyze the event to understand how to avoid triggering that behavior again.
  • Treat staff with respect. Staff will treat residents in the same manner they are treated by leadership.
  • Educate the staff on leadership’s philosophy on respect for residents, families, staff and visitors. Consider respect a core value of the facility and promote it at any opportunity.
  • Find ways to reward employees that demonstrate respect for everyone they come in contact with.
  • Ensure that the facility enforces strict policies on the respect shown to residents and family members.
  • Ensure that a system is in place for investigating reports of disrespectful treatment of residents.

6. Demonstrate management’s commitment to safety.

  • Make sure staff clearly understand your goal to keep everyone safe. Regularly discuss workplace safety at every general staff meeting. Express how much you care about the staff’s wellbeing.
  • Establish an active, involved safety committee. Include all disciplines and levels of staff as members of the committee. At meetings, report all incidents, including residents, visitors and employees. Regularly conduct a root cause analysis of every incident, including every near miss. Let those affectd participate in the root cause analysis.
  • Have safety committee employees participate in safety rounds and help them learn to identify and report unsafe practices and working conditions. Teach them to intervene without causing ill will among staff.
  • In the evenings, ensure that parking lots are well-lit and consider providing escorts to cars for employees.
  • Post employee safety tips throughout the facility, in the newsletter and in attachments to employee paychecks.
  • Consistently communicate through written word your commitment to staff safety through regular education and awareness. Dedicate certain weeks to an aspect of safe work practices.
  • Have safety contests and provide rewards to staff for working a certain number of days without a lost-time work injury.
  • Provide staff with training to deal with difficult residents. Conduct hands-on education regarding protecting oneself from combative residents at least three times per year. 

7. Demonstrate care for the staff members as people.

  • Regularly meet with staff to inform, educate and listen. Charge nurses should deliver a report to the CNAs at the beginning of a shift and hold a short “huddle” meeting at the end of the night.
  • Write personal thank you notes when staff members go beyond the call of duty.
  • Make sincere efforts to get to know each staff member as a person.
  • Monitor workflow and step in to assist staff when they need help. Charge nurses should provide regular, positive feedback to CNAs.
  • Consistently follow up when a staff member returns from being out sick to let him or her know that you’re concerned for their welfare and that he or she was missed.
  • Write personal cards to staff on birthdays and employment anniversaries. When a CNA is celebrating a joyful event in their life, the charge nurse should organize a pot luck get together for the employee.
  • Hold occasional appreciation gatherings for the department and have cake, pizza or other treats.
  • Provide the opportunity for employees to provide input on how their job is performed.
  • Provide a simple form in multiple locations that residents, visitors and co-workers can use to acknowledge employees for day-to-day acts of kindness.
  • Recognize and post achievements of units, teams and departments so residents, visitors and co-workers can see them.
  • Understand employees’ workloads and manage assignments accordingly.
  • Understand employees’ personal needs.

Recognizing the challenges encountered by leaders and managers in long term care including staff satisfaction, is the first step to enhancing quality of care especially as the acuity level of our elders continues to rise and funding decreases. With each step we take, the summit gets closer and the satisfaction is undeniable! Keep on climbing! 

Save the date for the 6th Annual Litigation Risk and Defense Strategies for Long-Term Care and Assisted Living Providers, Insurers and Brokers

Join me and my firm and co-hosts Cowan & Lemmon LLP, Horne Rota Moos LP and Kaufman Borgheest & Ryan LP for our annual conference, which will be held in Houston April 4-5, 2018. Stay tuned for more information on our program! Email me at radelman@hatlawfirm.com for updates.


Rebecca Adelman