Monday, February 26, 2007

The Subtle Effects of Turnover
by Sharon Brothers, MSW

This morning I had an interesting conversation with a colleague, Benjamin Pearce, author of one of the best known books on the subject of developing and managing retirement and assisted living communities (Senior Living Communities), as well as himself a knowledgeable, experienced senior care community operator.

Ben asked if I knew what the current turnover rate in Assisted living happens to be – he believes it to be close to 90%. That means out of 100 caregivers in assisted living communities hired this year, 90 of them will leave before the end of the year.

For every family who is dependant on those individuals to provide care to their loved one, this is nothing short of a crisis.

Imagine if your mom has Alzheimer’s disease (the primary reason most individuals must seek assisted living or nursing home care). She is having difficulty finding the right words to express her feelings. Her caregivers learn to watch her behavior to see how she is acting, since they can’t rely on her words to express how she feels. The caregivers who have known your mom for months are able to instantly see when her behavior is different from usual. Perhaps she’s feeling pain, but can’t express it. Perhaps she is hungry or thirsty. Those experienced caregivers will notice that she is grimacing; that she’s fidgeting or restless. They’ll know that these subtle signs mean something isn’t right and they can quickly get to the bottom of the problem.

But what happens to your mother when all the caregivers who know her usual behavior leave? When the new caregiver interprets her restless behavior as agitation and asks the doctor for calming medication? When, instead of a simple over-the-counter pain medication – or a glass of water - your mother is prescribed a major psychotropic medication like Ativan.

Caregiver turnover suddenly becomes no longer an abstract “industry” problem, but a very personal problem.

We know some of the keys things we can do to reduce caregiver turnover: things like quality training, empowerment in decision-making, and improving the skills of mid-level supervisors to increase frontline workers’ job satisfaction.

It’s time to step up to the plate – to change those industry statistics so we can confidently talk about quality of care of our residents – and mean it.

When It Comes to Training, Invest Wisely, Not Cheaply
by Ed Hansen, MBA

When it comes to training, it pays to spend. Companies that invest in training reap the benefits of increased employee satisfaction, competence, and confidence, happier residents and families, increased census and reduced turnover, and mitigation of risks of all types. Some studies indicate that when training funds are spent wisely, more is better. For example, the Pennsylvania’s Frontline Long Term Care Workers report, published in 2001 by the Polisher Research Institute at the Philadelphia Geriatric Center, found that companies in the top 25% of training spenders reported fewer problems with turnover.

You may wonder, then, what constitutes a significant investment in training. The American Society of Training and Development (ASTD) 2005 State of the Industry Report notes that in 2004, mid-size companies – averaging 8,000 employees – spent an average of $955 annually per employee for training. This represents an increase of 16% over the previous two years. In the sample of large organizations – averaging 58,000 employees – spending on training was even higher, at an annual rate of approximately $1,368 per employee. Finally, in a sample of what ASTD ranks as the “Best of Breed” learning companies, spending per employee averaged $1,554 per year.

More recent data is available through Bersin & Associates Corporate Learning Factbook 2007. Bersin & Associates found that healthcare organizations spent, on average, $948 per employee on training. The biggest spender – the technology sector – came in at $2,763 per employee. The lowest spending was in the retail sector at $519 per employee.

Approaching training expenditures from a slightly different angle, several studies have uncovered average training costs in the senior care industry. The Polisher Research Institute report found that average annual training costs per nurse aide, were as follows:

Government Nursing Homes - $1,604
Private Nursing Homes - $1,066
Licensed, Certified Home Health Agencies - $955
Large Personal Care Homes - $455
Unlicensed, Non-Certified Home Health Agencies - $442

Another report, The Role of Training in Improving the Recruitment and Retention of Direct-Care Workers in Long Term Care relied on an informal questionnaire sent to AHCA affiliates. This questionnaire uncovered costs ranging from $150 to $2000 per trainee, with a majority of states reporting costs ranging from $500 to $1000 per trainee.

So, how much should you spend on training the most visible, highest customer contact employees in your organization? I can only speak for myself, but when I am finally dependent on others to care for me, I would prefer that they receive more training than the person who rings up my groceries.

View the 2005 Executive Summary at

Order the Corporate Learning Factbook 2007 at

View Pennsylvanian’s Frontline Workers in Long Term Care at

View the Workforce Strategies report at

Friday, February 23, 2007

The Sandwich Generation: Good enough isn’t good enough anymore

For the past 20 years, I have taught about, written about, and thought I understood the Sandwich Generation experience: the adult children, still caring for children of their own, and also caring for aging parents.

Now, however, I do more than understand – I am living the role. Last night, standing in the checkout line at Target with all the essentials needed to set my mom up in her new retirement apartment, I realized that I had done the exact same thing just a few months ago with my eldest daughter, who was moving into her first apartment.

I had the same exact cart contents, too: shower curtain, laundry soap, kitchen essentials, sheets and towels.

As I rushed from unloading my mother’s purchases to pick up my youngest daughter at dance class – 15 minutes late . . . again – I thought, “I am living the Sandwich experience.”

I, and nearly every one of my friends and acquaintances.

Melanie has been sitting at her dying mother’s side for the past two weeks, leaving only to attend her high school daughter’s performances. She’s learned more about hospice, caregiving, and end of life choices in the past two weeks than I have in the past two decades.

Carol, a professional with a thriving private practice, has gradually reduced her work week to three days as her kids have completed college. Last week, Carol started working five days a week again to help cover the costs of two parents in need of high-level assisted living care.

My husband is taking tomorrow off work to accompany his parents to the doctor to learn how his 87 year old mother’s recently diagnosed cancer will be treated, and to support his 93 year old father in handling the news.

Clearly, we’re not alone. Both CBS and NBC are currently airing segments during their evening news broadcast that focus on this exact challenge which is facing millions of Americans today.

Many of our parents need care in assisted living communities, nursing homes and retirement centers. And you can bet your last dollar that every one of us will be picky, annoying, and demanding. We’ve grown up demanding more, and we’re accustomed to getting it.

A promotional announcement for the upcoming Assisted Living Federation of America conference featured a Disney University past executive speaking on the topic of “Learning from Disney, Where It's Not About Satisfaction.”

While Disney seeks loyalty by offering the best vacation experience imaginable, we in senior care have felt smugly successful if our clients are merely “satisfied”.

As my generation of self-centered Baby Boomers enters the long term care system – as advocates for our parents or as consumers ourselves – beware: We’ll be looking for an experience that far surpasses simply “satisfactory.”

Yesterday I interviewed a young woman for an office position. She told me of an earlier job she’d had in a care setting where she had been excited to help, but left after just three months.

“I was thrown right into the work with no training at all – just another employee to get me started,” she said. “I would have loved the job, but I couldn’t do it without training.”

No wonder our turnover rate is so high – over 70% annually, according to the most recent survey by the American Health Care Association (AHCA), as reported by the National Clearinghouse on the Direct Care Workforce.

This one thing I know: As a profession of senior care providers, we are not going to be ready to meet the high demands of my generation if we don’t aim higher.

Higher in our training of frontline staff.

Higher in our own expectations of happy customers.

Because for me – and for millions like me – it is no longer just a job; it’s personal.


ALFA Conference (May 15-17 in Dallas, TX):

Fred Lee, author of If Disney Ran Your Hospital (Amazon link)

Direct Care Turnover Statistics:

Thursday, February 15, 2007

Who Will Care for Your Mom?

Even though I’ve been in the business of senior care for the past 20 years, it all took a personal turn for me recently.

Last fall, my parents were in an auto accident that left my mother severely injured. After several weeks in the hospital, she was ready to be discharged. With oxygen, IV medications and a three-person transfer requirement, we had no option but to find the best skilled nursing center available to her.

We had a choice of three nursing homes that had contracts with her insurance provider. Having been in the business of long term care for two decades, I called a few of my contacts and picked the best option – I thought.

Over the next two months, I realized on a personal level what I’ve known on a professional level for years: Good training of staff is NOT optional if you want good care – it’s a requirement.

This week, NBC Nightly News is airing a special series on “Trading Places: When kids care for aging parents” ( Clearly, I am not alone in realizing that training – of the people caring for MY loved one – is a very personal matter. Over 36 million Americans over age 65 feel this need personally, as do the families of some 5 million Americans over age 85. By the year 2020, over 10 million disabled seniors will present the largest disabled group in the history of this country.

As America’s Baby Boomers age, the system of care will be taxed beyond what we can currently conceive. How will we adequately staff these care settings, let alone train and retain qualified workers?

Who will care for YOUR mom – and mine?

Developing systems that train, motivate, engage and excite the people providing this care will no longer be optional, it will be essential.

We have begun a journey to help create this system; more importantly, we have begun our journey as individuals – and as a company – to work to improve the lot of caregivers throughout this system of care.

Join us. (

Wednesday, February 14, 2007

The 5th P of Marketing: People

When was last time you got a massage without a masseuse present? Or a filling without someone else’s fingers in your mouth?

Massage and dentistry are two examples of service industries, and in service industries the employee and the offering are many times one and the same--it’s just more difficult to find the barcode.

This inseparability (as us smarty pants MBAs call it) has led some marketing scholars to refer to people as the 5th P of marketing (you might recall the original gang of four: product, price, promotions, and place).

Senior care is also a service industry and staff, especially frontline staff, are definitely a key piece of the marketing mix. Their appearance, attitude, and skills in large part define the service experience and, in an age where the battle cry seems to be “differentiate through customer service”, the service experience is king.

Because of the importance of the service experience, it would be wise to know how customers determine and compare service quality.

The authors of Understanding, Measuring, and Improving Service Quality make the case that customers use their perceptions of the traits of reliability, responsiveness, assurance, empathy, and another group of characteristics called tangibles (all things physical, from clothing to paint color) to gauge their service experience.

Reliability refers to how consistently and accurately a service is performed. Variety can be a bitter spice if it means a new and unexpected hair style every time you visit the barber.

Responsiveness speaks to not only an employee’s ability to provide prompt service, but their willingness to do so. For example, we can assume that all cabbies know how to drive, but getting a cabbie to stop is an entirely different issue.

Assurance, another key piece of the service quality puzzle, is a measure of how well employees create a sense of confidence through their knowledge and courtesy. Courtesy and knowledge must go together: in the TV show House, Dr. House’s knowledge is supreme, but his manner is abysmal. The result is an initial dislike from his patients. That’s fine if you’re trying to create drama, but it’s very bad if you’re trying to fill rooms or sell service.

Empathy is a little more touchy-feely. It’s about showing individualized, caring attention. Some would argue we are born with the capacity for empathy, that it cannot be trained into someone. There are factors, however, that can help or hinder the expression of empathy, including employee satisfaction and engagement, the level of confidence in one’s skills, and simply having the time to develop an understanding of individual needs.

Finally, tangibles are all the physical clues that can be used as evidence of quality. Sights, sounds, smells, and tastes are all fair game. Focusing on the 5th P, an unpublished Willamette University study of hospital customers found that role-appropriate dress (e.g., suit on executives, sweats on physical therapists) and cleanliness were the top appearance-related indicators of quality.

So where does training fit in? Effective training, training that engages the learner and sets the stage for long-lasting retention of knowledge leads to competence and confidence, allowing employees to respond quickly, accurately, and consistently.

Confident in their knowledge, direct caregivers are also more willing to respond and more likely to respond with courtesy. Faster and more accurate responses mean more time is available, and less time is needed, to provide individualized attention. Buoyed by the positive feedback of supervisors, residents, and families, employees take pride in their work and themselves and are more likely to meet, or exceed, appearance standards.

The bottom line? Quality service starts with quality training, an investment that pays big dividends in, among other things, increased census, reduced turnover, and higher productivity.

Signaling Theory Gives a Green Light to Training Investments

We call them red flags, signs, indicators, omens, or the writing on the wall. Whatever you call them, signals are used in every part of life. From the rain forests of the Amazon Basin to the marble floors of Wall Street, signals are relied upon as cheap, easy, or safe indicators of things too difficult, costly, or risky to assess directly. As is turns out, investments in employee training can send a signal of its own to an important customer group: investors.

Investment in training is a powerful signal that wise investors look for when evaluating opportunities. That’s the conclusion reached by the American Society of Training and Development (ASTD) in a study of 575 U.S.-based, publicly traded.

The ASTD study of training practices and outcomes found that:

-Companies that invested $580 more in training per employee than the average company in the study improved their total shareholder return (TSR) the next year by 6 percentage points.

-Top training spenders had an average TSR the following year of 36.9 percent, while more frugal firms had an average TSR of only 19.8 percent. The TSR for top spenders was 45% higher than the market average.

-Firms that invested on average $1,595 per employee in training experienced 24 percent higher gross-profit margins and 26 percent higher price-to-book ratios than firms in the bottom quarter that invested on average $128 per employee.

-Knowing a firm's education and training investment improves the power to predict its future TSR by 50 percent.

ASTD’s Director of Research Mark Van Buren called the information “powerful” and that “both investors and companies will benefit by tracking and reporting on training expenditures.” Bottom line: investing in your employees is a capital idea.