An information-based approach to staff efficiency

The clock ticked 11:00 p.m. and still no nurse for the Medicare unit. The agency called and said the last bill had not been paid and they would not staff that shift. The director of nursing (DON) was called and was going to work that unit herself to cover the shortfall—in all, the sixth time this month we had a crisis on the night shift.

All kinds of incentives were used to get staff to show up: shift differentials, 40 hours paid for 26 hours worked, sign-on bonuses, days off for days worked, free passes to ballgames and movies, more money per hour for working off-shifts. Nothing seemed to work for any length of time.

This was occurring when I was running nursing homes 10 years ago. Everyone blamed it on a nurse shortage. In fact, aides just did not want to work in nursing homes. Is it possible to improve morale and attitudes to impact retention and attendance? The answer is an emphatic yes!

But why? Is it more money? Is it more time with the resident? Is it more authority? Is it better benefits? Is it more status? Is it a better future? Is it having better tools to get the work done? Is it knowing what the workload will be when they get there? Or is it just plain liking the job better? The experts suggest that it is all of these, but one will stand out as the primary impetus to cutting turnover and call-ins: the workload and the worker’s capacity to get it done to management’s satisfaction.

In my experience in turning around numerous poor performing facilities, the workers’ attitude toward their work was impacted more by how we delegated the tasks than anything else. When the method of assigning the work was restructured, the facility that had been decertified for poor quality turned around immediately. In three months it went from being targeted for closure to getting five of the six stars of quality given by the surveyors.

We have refined this concept over the last 10 years. In essence the technique is called Activity Based Analysis. As the name suggests, it starts with basic questions—for example, what does the typical certified nursing assistant(CNA) do during a shift and how do her/his qualifications match up?

In our studies, CNAs have been typically responsible for 20 to 25 tasks per shift for each resident. Of course they don’t get that workload done—not even close. They tend to do the easier tasks first and, if they have time left or are not pulled to cover the dining room or rounds, they may get some PROM (Positive Range of Motion) exercises done. Moreover, of the tasks that the CNAs perceive they are responsible for, only half require a certification to do. In other words, over half their day is wasted on busywork that someone less costly could do.

In my facilities when we took this busywork away and assigned it to hospitality aides, the CNAs’ work attitude improved immediately, as did retention and attendance. We also were able to get restorative and rehab programs done that weren’t being done before. This resulted in more residents ambulating, with fewer bedsores and better appetites. And the facility getting five stars for quality from surveyors and a growing census.

When we did a nursing task analysis, we found that of the 41 tasks that the nurse perceived she was responsible for, only 16 required a nursing license to do. A CNA or a hospitality aide could do the other 25. We also found that housekeepers were delivering a workload that was not meeting management’s expectations because they did what they could get done, not necessarily what needed to be done. Indeed, all functions had workloads that did not meet their job descriptions or management’s perception of what was needed.

This was, in sum, a certain indication of a fouled up business model.

Improved classifications

This revelation motivated a complete restructuring of the organization chart. We turned it upside down and put the patient at the top. We assigned different specialty units to Nurse Case Managers, utilizing our case management software, staffed the units with specialized case management teams, and did away with traditional departmentalization. Hospitality Services became the foundation for nonclinical resident services, encompassing housekeeping, laundry, dietary, and maintenance. Together with the Clinical Services, the Case Managers run their specialized units with their teams. The result is improved morale, improved work conditions, improved attendance, and improved retention of high-performing staff (Table 1).

The functional staffing breakdown

Alzheimer’s Unit

Respiratory Unit

Rehab Unit

Extended Care Unit

Chronic Care Unit

Case Manager

Case Manager

Case Manager

Case Manager

Case Manager

Psycho/Soc Tech

High Tech Nurse

Rehab Nurse

Unit Nurse

Restorative Nurse

Behavior Tech


Rehab Aide

Restorative Aide

Restorative Aide

Recreation Leader

ADL Aide

Restorative Aide

ADL Aide

ADL Aide

Hospitality Aide

Hospitality aide

Hospitality Aide

Hospitality Aide

Hospitality Aide

The functions relate to the services to be rendered and each function determines the job title, compensation level and relevant performance measurements. We used the PIE (Problem Intervention Evaluation) charting format for all care plans and progress notes. For example the Psycho/Social Tech is assigned a specific group of residents (up to six) who have similar emotional problems based on their MDS Schedule E triggers. Set standardized psycho/social programs are triggered by the psycho/social assessment and model program. Interventions are matched to the patient by the computerized templates from the case management library. Minutes of care are attached to the program interventions totaling at least 30 minutes each day. The programs are conducted by the Psycho/Social Tech in a classroom setting. For each participant, the outcomes are evaluated and documented at least weekly by a social worker comparing the current deficit level for each participant’s problem(s) to the baseline assessed deficit(s) and charting progress toward predetermined goals. We used a 0 to 4 scale (4 being profound, 3 impaired, 2 responsive, 1 needing supervison, 0 fully cognitive), so the evaluation was numerical and could be tracked and analyzed by the computer.

On the other hand a Behavior Tech performs one-on-one interventions daily for a caseload of residents who have exhibited episodic behavior problems. The social worker, psychiatrist and/or psychologist assist in the prescribing of medications and assessment of programmatic interventions with minutes of care attached, and then evaluate progress towards individualized outcome goals at least weekly.

The ADL Aides’ function is focused on the emotional and ADL needs of totally dependent patients in terms of response to medications and routine ADL interventions for continence, nutrition, skin precautions, weight, vital signs, I&O, and bowel movements. This applies to residents who are fully dependent and do not have restorative potential.

Another example of specialization is the High-Tech Nurse who specializes in post-hospital cases that involve high-tech equipment for respiration, tracheostomies, IVs, tube feeding, complex medications, post-surgical monitoring, and tests. This position is a step up from the Pharmacology, Treatment, and Unit Care Nurses. The high-tech nurse is trained and experienced in subacute care for the geriatric patient.

The goal

Once the organization is functionalized, standardized, and computerized in this manner, we can determine, based on the minutes of care attached to the triggered programs, how many full-time equivalent (FTE) staff we actually need for each shift.

This may seem like a dramatic leap of faith, but in the first facility I managed we accomplished the transition to functionalization over a weekend during a 16″ snowstorm. The storm prevented half of the scheduled staff from getting to the facility. We ran the operation for three days actually better with half the staff. During that weekend we changed the way we were organized and never looked back. It was the major catalyst to our getting recertified and earning five of the six stars of quality that the State Quality Incentive Payment Program awarded annually for performance.

Since turning around this and other troubled facilities using this technique, our company has consulted with more than 140 skilled facilities over the past 10 years, attempting to get a commitment from the owners to set up a Functional Outcome Universal Score, or “FOCUS on the Patient” program. However, it was not until the Prospective Payment System (PPS) entered the picture in the late 1990s that we started to get more interest.

Through this reengineering of systems, realignment of workload, and reorganization of workflow, the result—as we experienced 10 years ago—is a reduction of FTEs. How can this be, when every DON will tell you that he or she is short? It’s because the staff they think they need don’t show up as scheduled, nor do they work productively the whole shift. If, on the other hand, staffing is based on realistically assigned workloads and staff can get their real jobs done, they will show up as scheduled. And if the workload is focused on the real priorities, they will get the important tasks done first.

What is the impact on your labor costs for replacing certain CNAs twice a year? What does it cost to try to get staff to show up for the night and weekend shifts? Once a value is put on the waste that is caused by an unstable workforce, performance bonuses can be used to share in the elimination of these wasteful costs. Then you end up paying fewer people more money for better performance, and make more money the old fashioned way: by earning it with services delivered well and with enthusiasm. This level of quality will draw market share to your door and reduce the trauma caused by poor surveys, complaint follow-up, and civil money penalties.

With the restructuring and reengineering comes a new organization chart—putting the resident at the top but, even more importantly, building in a career ladder for the staff that starts at entry level and directs them into defined levels of nursing, therapy, social work or administration (Table 2).

Career ladder



Social Work


Hospitality Aide

ADL Aide

Activity Tech


ADL Aide

Restorative Aide

Behavior Tech

G/L Accountant

Restorative Aide

Rehab Aide

Psycho/Social Leader

Chief Accountant

Rehab Aide

Therapy Aide

Social Service Aide

Cost Accountant


Therapy Assistant

Social Worker



Registered Therapist

Dir. Admissions

Chief Financial Officer

Case Manager

Rehab Director

Dir. Human Services

CFO/VP Finance

Director of Nursing




In the real world of long-term care, remarkable stories are starting to emerge. At Robyn Wood in Oneonta, New York, we implemented FOCUS nine years ago, and saw a reduction in FTEs, increased wage rates from 4% to 23%, a cost savings of $150,000 that went directly to the bottom line, and improved outcomes. This year, at Golden Age Care Center in Centerville, Iowa, where the State is using MDS case mix as the basis for reimbursement, we trained the DON and clinical staff on optimizing staff productivity, efficiency, and reimbursement, based on case management principles. Not only has quality been improved, but Medicare is being billed for psycho/social and restorative programming that weren’t being done before. This more than doubled billings to Medicare Part A and increased case-mix scores dramatically, thereby improving profitability.


It is not more money that will fix our image problems and our financial shortfall. It is improved information technology and management systems for controlling staff performance and quality of services provided, as it was in the automobile industry in the 1980s after the Japanese learned TQM (Total Quality Management) from W. Edwards Deming and captured market dominance from the United States over the last four decades.

In my view, the future of our viability of our operations for managing the coming influx of seniors into long-term care rests on our correcting the following deficiencies:

  • only 0.5% of budget being spent on information technology

  • care plans printed but not used to direct staff operations or document care

The MDS is touted as the foundation for quality monitoring, care plan development and reimbursement, which means that:

  • software systems are focused on assessment, but not on assignment and management of the workload or measuring outcomes

  • Medicare reimbursement is based not on rules and regulations, but interpretive guidelines

  • Quality Indicators and Quality Measures don’t measure outcomes, but merely count mistakes

  • systems designed for case management, functional team development and PIE charting are not being used generally to direct care efficiently and cost effectively

Jerry L. Rhoads, CEO of Caregiver Management Systems, Schaumberg, Illinois, is a CPA, licensed LTC administrator, and Fellow of the American College of Health Care Administrators.

For further information, phone (847) 517-6710 or visit To send your comments to the author and editors, e-mail

Long-Term Living 2008 October;57(10):56-60

Topics: Articles , Facility management , Staffing