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Enhance employee satisfaction to improve family care and quality
Massages, celebrations, education are among strategies
Hospice employees and managers have probably felt at times that when staff morale is low, that's when more patient/family problems pop up.
Now, there's a little more evidence showing that employee satisfaction is closely linked to hospice family satisfaction, and that if a hospice improves the former, the latter will follow.
A Nashville, TN, hospice found that when its employee satisfaction was high, so was family satisfaction, which in turn, led to more referrals by families, a greater revenue growth.
"We noticed that as our employee satisfaction improved statistically, our family evaluation of hospice care improved also," says Janet L. Jones, RN, BSN, chief executive officer of Alive Hospice Inc. of Nashville, TN.
Alive Hospice began surveying employees five years ago, contracting with the Center for Nonprofit Management of Nashville. For the patient/family satisfaction measurement, the hospice uses the National Hospice and Palliative Care Organization's (NHPCO's) survey tool, Jones says.
"We looked at roughly three different years, 900 patients, and 300 employees," says Stan York, EdD, an assistant professor of strategic management of Belmont University in Nashville, TN.
"These employees are very loyal to the company, and the turnover is low," York says. "The more satisfied they are, the more loyal they are, and these loyal employees also are more productive."
With York's help, the hospice was able to take individual results from the employee survey and use these to predict outcomes on the family evaluation survey, Jones notes.
"Most people know intrinsically that happy employees make for happier hospice families," Jones says. "Now we know that the quality of patient care is better when employees are happy with their work environment."
The employee satisfaction survey contains about 30 questions, with scaled answers, in a variety of dimensions, including task significance, competency, support, integration, structure, execution, and strategy.
It is distributed to staff through their payroll envelopes, and it contains a self-addressed, self-stamped envelope they can return to the survey contractor. The response rate has ranged from 49% to 75%, and the hospice now has more than 300 employees, Jones says.
Among the questions asked were these:
"We feel that if there's burnout, we expect it will be reflected in the overall satisfaction of employees, and this will lead to more turnover," York notes.
Researchers reviewed the literature about family satisfaction in hospice care and found that the volume of studies on this topic was small, he says.
They also compared hospice employee satisfaction and patient satisfaction with the relationship between employee satisfaction and patient satisfaction in hospitals and Veterans Administration hospitals, he says.
"We found that the correlation between employee satisfaction and quality of the family was higher in the hospice industry than it was in the hospital or VA system," York says.
This is probably because the hospice industry is the most relationship-oriented of all health care industries, York says.
"We related these attributes of employee satisfaction back to the domains of care that were described in the family evaluation of hospice care, and we found a strong relationship between employee satisfaction and overall family satisfaction," York says. "We found that certain attributes of family satisfaction were more highly significant than others."
For instance, task orientation was highly related to quality of work, York says.
"We took some statistics we had about dimensions of satisfaction, like task significance, and the fact they're in hospice and it's very meaningful to them," York explains.
"We followed this linkage through the entire process, looking at various attributes of satisfaction and comparing these to coordination of care and symptom information," he adds.
So the quality improvement aspect of the survey was to address this question: "What do satisfied families do, and how does that help us as a company?" York says. "We know there are two outcomes: one is you have repeat business, and the other is they will refer us to other people."
Survey results showed that highly satisfied families were more likely to refer the hospice services to other people, he notes.
"What we did then is we compared that referral rating to improvement in the bottom line in terms — we compared it, for example, to their total revenue and to their total return on the equity and return on investment," York says. "And we found a very high positive correlation to the fact that these families will refer us to the organizational performance."
Here is how higher staff satisfaction might result in bottom-line business improvements:
Investigators found that the correlation between family referral and revenue growth was 0.96 statistically, very close to a perfect correlation of 1.00, York says.
The relationship between employee satisfaction and overall family satisfaction was 0.95, and the relationship between family satisfaction and family referral was 0.83 — still very high, York adds.
"So that tells you satisfied families are likely to refer hospice services to others," he says.
The survey results also were used for the purpose of identifying quality-of-care deficits and correcting them.
The first survey's scores were not bad, but they showed some room for improvement, Jones recalls.
"We take the results from the staff survey and go over them with a statistician to see if there are areas that are red flags for us," Jones explains. "Then we engage an employee committee to look at those areas."
In some cases, the committee needed to investigate to find the root cause of a problem and what this means to the staff and the agency, she adds.
Employees' answers suggested that the hospice focus on several key areas for improvement, including the following:
Based on these answers, the hospice made various improvements in these three areas, Jones says.
Another use for the data will be to develop a tool to help hospices design their service delivery systems to improve quality-of-life care for patients, York says.
"We have developed a cross-walk that looks at the dimensions of employee satisfaction and then correlates this to dimensions of patient satisfaction," York explains. "So if you want to improve in one area of patient or family satisfaction, you can use this cross-walk to say, 'These are the dimensions of employee satisfaction I need to work on.'"
Although the pilot study with Alive Hospice suggested the cross-walk could work, it can't be generalized to the hospice industry just yet, York says.
"Our next step is to do something on a national level so we can do a more generalized pool," York says. "We know some hospices have employee satisfaction surveys, and some do not, and NHPCO is trying to develop a standard employee satisfaction survey."
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