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Having been in the long-term care business for more than 20 years, I've developed one skill set more fully than almost any other: the ability to argue the opposite point. This is partly borne of my exposure to the adversarial survey process and partly due to being mired in the murky grayness of middle management for so many years. With that I turned my attention to the notion that all employee turnover is negative and avoidable.

THE BUREAUCRATS SPEAK

At some point in the past two years, the state of Ohio, in her infinite wisdom, decided to tweak the reimbursement system for Medicaid.

One of the components of this was to offer a boost in reimbursement to facilities with an employee turnover percentage below a certain threshold. In the eyes of the state, this system basically rewards facilities that are doing things right and punishes those that are doing things wrong. 

When I first glimpsed this novel creation of our regulatory/reimbursement system, I was reflexively suspicious. As time passed, and my wife stopped listening to my impassioned arguments, I resigned myself to accept as fate this bureaucratic dictum. Plus, my facility wasn't affected as our costs were in excess of the reimbursement rate that the state had set, and therefore ineligible for the bonus payment.

ACADEMICS AND CONSULTANTS CHIME IN

I then became aware of a consultant who has been peddling a neatly wrapped, sure-fire solution to the turnover ailments of our industry. Consultants peddling solutions to real-world problems is an all-too-familiar development in the world of business.

This particular consultant was armed with a litany of dire consequences that employee turnover would visit on the unsuspecting operators of nursing homes. They ran the gamut from compromised quality of care to economic ruin. This consultant was able to divine an exact dollar cost associated with the turnover that occurs whenever an employee leaves the employ of a nursing home.

I would never dispute the notion that turnover costs a nursing facility, but I do dispute two major assumptions that are commonly accepted. First, that turnover is always negative and second, that it's entirely avoidable.

Many questions came to my mind as I considered this turnover conundrum: Who can control a person making an informed decision to pursue other employment especially when it is closer to home? Who can stop an employee from making a decision to go back to school? Who can stop a person from moving out of state, or out of the area for that matter, and being unable to continue to work? Who can stop a person from retiring or leaving at the end of a seasonal job, such as that of a landscaper?

WELCOME TO MY WORLD

I recently developed a report that listed the employees who left my current facility during the past year. As of December 31, 2007, we had 106 employees. Of those, 70 left during 2007. This would translate into an annualized turnover rate of 66.98 percent. 

On the surface this would appear to be an unacceptable level of turnover. But when I looked deeper, I saw some interesting patterns and realities. First, 37 of the 70 employees were fired for things like performance issues, insubordination, resident abuse/neglect, attendance problems, failing a drug test and falsifying the employment application.

I believe strongly that a certain percentage of turnover is necessary and may even be good for a nursing facility. Employees who had their employment terminated and were not meeting the expectations of the employer and were failing to meet the needs of the residents constitute addition by subtraction. 

UNAVOIDABLE INVOLUNTARY TERMINATIONS

I'm sure that someone could make a case that these 37 involuntary terminations were ultimately a reflection on the quality of the management and leadership in this building. But I would argue that, short of intervening in a prospective employee's life when they are at the impressionable age of four, it is impossible to change behaviors and avoid situations that occur when employees are willfully acting in a way that compromises the delivery of quality care and services. 

When employees undercut the delivery of quality care and services, there is a duty to act.  Often, that duty is to coach, cajole, re-educate and progressively discipline. But there will always be times when termination is the last or best option available to a manager. 

Going back to my original point, I can posit with a great deal of certainty that not only is turnover not always a negative, but it is an integral and necessary element of the employment equation.  If done properly, consistently and fairly, termination of employment can help assure quality care and preserve employee morale and performance.

UNCONTROLLABLE VOLUNTARY TERMINATIONS

But employees also leave on their own. In my facility, 10 of 33 employees who voluntarily terminated their employment did so for unavoidable reasons such as health issues, seasonal employment, relocation, life situation changes and retirement. Three employees quit and were ineligible for re-hire because of poor performance. Of the 33 employees who quit, six took comparable jobs with another employer and were eligible for rehire.  One of these six took a position with a sister facility in a community five minutes from her home.

Fourteen employees quit their jobs without so much as a phone call. I am sure that in a percentage of these cases, our facility played a part. But I would like to believe that any employee worth salvaging would have the common courtesy to call to announce their intentions to quit, or ask a supervisor to intervene in whatever situation is bothering them.  How any manager can be held accountable for employees simply not showing up for work and never returning is beyond my ken.   

SELECTION SIDE OF THE EQUATION

The academics and consultants would no doubt assert that my facility's turnover problem lies in the failure to adequately screen and evaluate prospective employees. Unfortunately, this is quite possible. However, many times the hiring-time horizon in a long-term care facility is reduced to the thinnest of margins owing to the immediate need to provide care and services. 

The academicians, bureaucrats and consultants formulate their plans for testing, evaluating and hiring the ideal candidates on a bright sunny Monday morning. Those responsible for providing care and services are faced with the reality of call offs and no call/no shows on a very cloudy Friday afternoon when the looming weekend calls for some quick thinking and sleight of hand to get through another in a long line of short-staffed weekends.

BOTTOM LINE

Hopefully, I've been able to demonstrate the faulty logic in using a gross turnover number as a basis for judging the quality of a long-term care facility's operation. Using turnover as a proxy for quality care or quality management simply does not stand up under the light of the specifics we saw in my facility's turnover statistics. 

Kevin R.  McMahon the administrator at the Merriman, Akron, Ohio, part of the Provider Services family. He can be reached at kmcmahon@the-merriman.net.

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Involuntarily Terminated Employees