ABC Regional Hospital 1234 Medical Center Dr. Anywhere, NC 28394 www.abcregional.com

September 13, 2014

President, Board of DirectorsABC Regional Hospital1234 Medical Center Dr.Anywhere, NC 28394

Dear Sir,

I have enclosed my report for improving employee motivation and moral to increase patient safety and quality of care. The report was prepared in effort to remedy declining patient satisfaction scores, decrease adverse patient safety events and prevent future findings on Joint Commission surveys.

Employee interviews, viewpoint survey results, increasing turnover rates and feedback given during town hall meetings indicated that stress levels are high and satisfaction levels are low. Research shows a direct correlation between employee morale and engagement, patient safety and satisfaction, hospital rankings, and profitability.

Provided in the report are recommendations for programs and methods to improve employee morale and reduce turnover rates, along with a timeline for implementation. Please take into consideration these recommendations. ABC Regional Hospital has always been a provider of top quality medical care. I am confident that by retaining our highly trained and qualified staff, and motivating them to increase their level of engagement and commitment, ABC Regional Hospital will move forward and continue to be a pillar in the healthcare community.

Sincerely,

Steve Gubenia

Enc

Cc: Vice President, Board of Directors Board members, Executives Hospital Administrators Patient Care Managers

Patient centered quality care!

Improving Morale

Improving Morale to Reduce Employee Turnover and Enhance Patient Safety and Satisfaction

Prepared for:

President, Board of Directors

ABC Regional Hospital

Anywhere, NC

Prepared by:

Stephen Gubenia

September 12, 2014

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Improving Morale

Table of Contents Table of Contents i

List of Tables ii

Executive Summary iii

Introduction 1

Purpose 1

Background 1

Scope 2

Discussion 3

Why Employee Morale Matter 3

Factors Affecting Morale 5

Factors Driving Employee Turnover 6

Advantages to increasing morale 8

Disadvantages of not increasing morale 10

Methods 11

Conclusion 15

Recommendations 16

Appendices 20

Appendix A: Employee Viewpoint Survey Results 20

Appendix B: Introduction to Relative Value Units 22

References 24

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List of Tables

Table 1: Factors Affecting Morale................................................................................................................5

Table 2: Top 10 Reasons Employees Would Quit........................................................................................7

Table 3: Reported Relationships and Outcomes from Literature Review....................................................9

Table 4: Methods to Impact Engagement from Literatur Review..............................................................11

Table 5: Timeline for Implementation.......................................................................................................19

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Executive Summary

Employee motivation and morale has a profound effect on any organization’s productivity and

quality of work. In the healthcare industry, low productivity and work quality leads to low

patient satisfaction, increased adverse patient safety events, costly litigation, higher malpractice

insurance premiums, and lost revenue. ABC Regional is no exception. Declining patient

satisfaction scores, recent adverse patient safety events, and the findings on the most recent

survey from The Joint Commission, indicate issues with quality of care in this organization.

Employee feedback gathered through surveys, interviews, and meetings indicate that low

employee morale is a major contributing factor. There is a need to address this issue now to

improve our quality of care and enhance the future of our organization.

Research shows a direct correlation between employee morale and patient satisfaction. The top

rated hospitals in the nation, which are ranked based on several quality control metrics, score

high on both patient satisfaction and employee satisfaction surveys. Implementing programs to

improve employee morale will enhance quality of care, increase patient safety and satisfaction,

and increase profitability. Several methods to improve employee morale and satisfaction are

outlined in this report. Recommendations are made using cost-benefit analysis from research

data and employee feedback obtained through surveys and interviews. The outlined

recommendations will save the hospital money, improve our image within the community, and

ultimately lead to higher revenue. Most programs require very little resources and can be

instituted within the next 30 days, with two exceptions. The management certification program

will require 90 to 120 days to complete and cost $1,999 per Department Administrator. The

supervisor development program facilitated by the Department Administrators will require one

year for completion and few resources.

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Introduction

Purpose

This report will show that implementing programs to improve employee motivation and moral

will lead to better quality care and higher patient safety and satisfaction. Increased patient safety

and satisfaction will have positive financial gains for the hospital through higher revenue from

increased patient enrollment, and less money spent on litigation and malpractice insurance. This

project will demonstrate that instituting programs to improve employee motivation and morale

will save the hospital money, improve our image within the community, and ultimately lead to

higher revenue.

Background

In the past year there has been a decline in patient satisfaction and quality of care at ABC

Regional Hospital, this is reflected by declining scores on patient satisfaction surveys. Poor

work quality and low productivity is the number one contributing factor. This decline in work

quality led to several findings during this year’s Joint Commission survey that had to be

addressed before the hospital could receive full accreditation, as well as some patient safety

concerns and adverse events. Recent employee surveys, interviews, feedback given at town hall

meetings, and an increasing employee turnover rate indicate that low employee motivation and

morale is the major contributing factor. “The management of health care personnel takes place in

a complex environment involving a variety of professionals, extensive use of materials and

equipment, and an array of services that extend beyond health care to include food, hospitality

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and instruction. This challenging environment places a great deal of stress on employees”

(Bailey, 2009).

Budget cuts and subsequent layoffs have increased employee workload and stress. More than

half of the staff survey cited increase job stress and an increase in workload in the past year.

With the continuing financial shortfall this situation will not likely be remedied soon. This fact

makes it paramount that ABC Regional Hospital takes measures to boost employee morale and

motivation to maintain current staffing and increase productivity. Downsizing cuts human

capital which a high performance work system (HPWS) like a hospital relies heavily upon. A

study conducted by Iverson and Zatzick (2011), showed that “organizations with more extensive

HPWS can reduce productivity losses from downsizing by heightening their consideration for

employees’ morale and welfare.”

Scope

Various methods to boost employee morale were researched to assess the feasibility of

implementation, and the effectiveness of such programs at other organizations. An employee

viewpoint survey (adapted from the Office of Personnel Management Federal Employee

Viewpoint Survey) and interviews were used to assess current employee satisfaction rates and to

allow employees the opportunity to rate and give feedback on proposed programs. The survey

results can be viewed in Appendix A. This report examines various methods and programs to

boost employee morale. Recommendations are made based on evaluations of advantages and

disadvantages, and employee feedback of each method.

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Discussion

Why Employee Morale Matters

Employees are the foundation of every organization. Everyone from senior executive, to the

entry level staffer, has a key role in the function and overall success of the organization. The

healthcare industry relies heavily on the ability of every staff member to perform their duties to

the best of their ability in order to take care of patients, and ultimately save lives. Hospitals

especially rely on teamwork and trust that every team member is performing to the best of their

capabilities. If any member is not performing at their peak, the results can be disastrous. Low

employee morale leads to:

Loss of motivation,

Decreased productivity,

Employees taking shortcuts,

Careless mistakes (Incorrect coding/medication administration/dosing/procedure, etc.)

High employee turnover,

Increased hiring and training expenses,

Inexperienced and undertrained staff,

Wasted supplies,

Decreased patient safety and satisfaction,

Increased mortality rates,

Decreased patient enrollment,

Poor public image,

Costly litigation,

Increased operational costs,

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Loss of revenue, and

Potential loss of accreditation.

Employee morale is the driving force behind motivation and ultimately productivity. “Employee

disengagement is the single most important factor in declining productivity, which leads to

higher absenteeism, higher costs of doing business, and all around poor performance” (Cowart,

2014). Currently, at ABC Regional Hospital, productivity is measured by Relative Value Units

(RVUs), which Medicare and insurance companies use for reimbursement. These RVUs are

calculated using the nationally regulated Current Procedural Terminology (CPU) codes (see

Appendix B). This is the primary system that healthcare organizations use to measure

productivity and the metric used for commercial and federal reimbursement (Rodak, 2013).

Careless mistakes made in coding, and declining patient enrollment because of low satisfaction

rates, lead to lost RVUs and thus lost revenue. Some hospitals are moving away from the

volume-based healthcare model for physician compensation to a value-based model. This value-

based model combines quality metrics and patient satisfaction scores with productivity, which is

measured by acuity-adjusted panel size and clinical activities to determine physician

compensation (Rodak, 2013). This system is equally affected by the issue of employee morale.

The bottom line is that employee morale drives productivity, and productivity controls revenue.

Declining employee morale means a drop in revenue. In a survey conducted in 2009, “Twenty

percent, or one in five, of the more than 350 healthcare employers reported low morale.

Meanwhile, 38 percent of healthcare workers cited lack of motivation and nearly 25 percent

reported no loyalty to their employers” (Enrado, 2009). Despite this news, many healthcare

employers recognize the need to keep their highly trained staff. The costs to hire and train new

staff far outweigh the costs of keeping current employees happy. Of the 8 employees

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Improving Morale

interviewed during the research phase for this report 4 employees or 50% indicated low morale.

These employees included providers, nurses, medical support staff, and administrative staff.

Survey results were consistent with this percentage with approximately 51% indicating low

morale (See Appendix A).

Factors Affecting Morale

There are various factors that affect employee morale and job satisfaction. In a study to assess

what factors most affect morale and job satisfaction, employees were asked to rank 10 items that

they wanted from their job in order of importance. Their employers where then asked to rank the

items base on how they thought their employees would rank them. The surprising results are

outlined in the table below.

Employees'

RankItem

Employer's

Rank

1 Interesting work 5

2 Appreciation and recognition 8

3 Feeling "in on things" 10

4 Job security 2

5 Good wages 1

6 Promotion/growth 3

7 Good working conditions 4

8 Personal loyalty 6

9 Tactful discipline 7

10 Sympathetic help with problems 9

Table 1

(Niebrugge, Vicki, Declining Employee Morale: Defining the Causes and Finding the Cure, NOVA Group.)

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The data shows that interesting or challenging work, appreciation and recognition, and a feeling

of belonging are the top motivational factors for employees. Money is not the primary factor for

job satisfaction, which means that methods to improve employee morale do not have to be

costly. “Communicating appreciation to staff is critical in healthcare settings today. Five

specific Languages of Appreciation have been identified that can be communicated in

individualized ways in the workplace to affirm, encourage, mediate stress, and improve

employee morale. In tight budget environments, such an employee recognition program doesn’t

require financial resources or a line item in the budget” (White, 2012). Everyone wants to feel

appreciated and know that their work is valued. If an employee does not have a sense of being

valued they start to feel like a resource. If their commitment to a job well done goes unnoticed,

eventually their motivation will decrease (White, 2012). When employees do not feel valued,

they will:

• “experience a lack of connectedness with the mission of the organization; performance

declines.

• become discouraged; willingness to persevere through difficulties will diminish.

• complain about their work, colleagues, and supervisor.

• dislike coming to work; attendance may become inconsistent.

• consider leaving the organization and start to search for other employment

opportunities” (White, 2012).

Unfortunately, expressing appreciation is not always as simple as a verbal statement. Managers

must learn how to effectively communicate their appreciation to each unique individual.

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Factors Driving Employee Turnover

Evaluation of the data shows that low wages or lack of promotion and growth potential are not

the main reasons for employee turnover. The top 10 reasons that employees would leave the

organization were determined through surveys and interviews.

Top 10 Reasons Employees Would Quit Poor relationship with their boss, Bored or unchallenged by their work, Poor relationships with co-workers, Underutilization of skills and abilities, Lack of understanding the relevance of their job in connection with organizational

goals, Lack of accountability, empowerment, autonomy, and independence, Feeling that job is meaningless, Financial instability of organization, Organizational culture that doesn’t foster teamwork and a sense of belonging, Lack of recognition.

Table 2

“Studies suggest that the number one reason why people leave their jobs is their boss” (Cowart,

2014). The fact that supervisors and managers play a major role in employee satisfaction is both

good and bad news. The bad news is that a poorly trained manager can have a profoundly

negative effect on an organization. The good news is that by properly training managers to

effectively coach, counsel, and mentor their subordinates, and organization can ensure high

employee satisfaction, and lower turn-over rates. In a report published by McGilton et al.

(2013),

“Work conditions were a salient element affecting nurses’ intention to stay and included

impact of regulations on nurse role flexibility and professional judgment, an underfunded

system contributing to insufficient resources and staffing, and a lack of supportive

leadership. Factors promoting nurses’ willingness to stay included the development of

meaningful relationships with residents and staff and opportunities for learning and

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professional development. Nurses also considered personal and life circumstances (e.g.,

marital status and seniority) when discussing intention to stay.”

The report stressed the urgency to focus on creating better working conditions for staff,

especially nurses. The report concluded that developing a more individualized approach may be

the most successful strategy to improve retention of highly skilled staff (McGilton et al, 2013).

Advantages to Increasing Morale

A study conducted at a major urban hospital showed a direct and positive relationship between

employee satisfaction and the quality of the patient experience. The study used “review of

current literature on health care performance, primary data collection through an online forum

and interviews with key hospital staff, and an empirical analysis of employee and patient

satisfaction data” (Dahl et al., 2009). In a paper written by Newman et al (as cited in Dahl et al,

2009), “literature on nurse recruitment and retention, service quality, and human resource

management” was used to outline the impact of human resource management practices such as

employee engagement and empowerment on employee satisfaction and retention, and ultimately

how these might impact patient satisfaction.”

“Newman shows a chain of connectivity such that (a) internal conditions and

environment affect (b) the service capability of staff which influences (c) nurse

satisfaction which, in turn, affects (d) retention of nurses. All of those factors can reduce

(e) quality of patient care and ultimately (f) the level of patient satisfaction. In other

words, health care organizations that provide a good working environment which

enhances the service capability of staff through empowered decision making will lead to

more satisfied nurses who are more likely to remain loyal to the organization and provide

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a higher level of care resulting in higher patient satisfaction. Organizations that desire to

improve patient satisfaction must therefore be concerned about internal issues related to

employee satisfaction and view their employees as customers too. A connection appears

to exist between how engaged an employee is with the employee’s role in the patient care

process and the level of patient satisfaction. This interrelationship affects not only

satisfaction levels but also patient loyalty and financial performance” (Dahl et al., 2009).

Ultimately satisfaction in staff members leads to higher levels of engagement which translates to

increased patient safety through fewer errors. It also translates into decreased length of stay for

patients and lower variable costs (Dahl et al., 2009). This all helps to move more money to the

bottom line. The table below provides a summary of the effects of employee engagement.

Reported Relationships & Outcomes from Literature ReviewEffects of Higher Employee Engagement Levels

on EmployeesEffects of Higher Employee

Engagement & Satisfaction on Patients

Effects of Higher Employee

Engagement/Satisfaction on Financial Performance

• Improves employee productivity• Improves relationships with management• Reduces job stress• Increases employee satisfaction• Increases retention & turnover

• Improved care quality• Increased patient satisfaction• Increased patient loyalty

• Lower employee recruitment/retention and training costs• Higher patient loyalty to organization• Possibly lower costs related to the delivery of patient care (because of shorter patient stays)

Table 3

(Dahl et al., 2009)

In a report published by Griffith in The Journal of Healthcare Management (as cited by Bailey,

2009), “attributes of 34 community hospitals in nine states that have earned the Health Care

Sector Malcolm Baldrige National Quality Award, a nationally recognized quality benchmark for

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various industries,” were examined. Griffith’s findings indicated that the number one factor

affecting patient satisfaction is hospital employee morale, and that this started with creative

thinking by top level management (Bailey, 2009). The hospitals with the happiest patients and

caregivers used creative methods such as welcome letters to patients from the CEO, and visits to

patients from their units nurse manager who provided cell and office numbers. This level of

personal service has a price tag, but Griffith says (as cited in Bailey, 2009) “these hospitals kept

costs low enough to thrive financially on standard Medicare and insurance payments, despite

paying employees "extremely well." Griffith’s report found that “34 hospitals emphasized a

broadly communicated mission, a supportive learning culture, universal measurement and

benchmarking, and systematic process improvement” (Bailey, 2009). In addition the 34

hospitals frequently ranked in the nation’s top 10 percent and scored in the top 50 percent in all

satisfaction and quality measures (Bailey, 2009).

Disadvantages of Not Increasing Morale

A study conducted by Atkins et al. (as cited in Dahl et al., 2009) “showed that employee

dissatisfaction negatively impacts the quality of care and ultimately has an adverse effect on

patient loyalty and in turn hospital profitability.” Ignoring the issue and not increasing

employee morale is not an option. Action must be taken to improve morale, or patient

satisfaction and safety will continue to decline. If patient safety continues to decline we will see

an increase in adverse patient safety events which can lead to more costly litigation. Declining

patient satisfaction will negatively impact our public image and lead to declining patient

enrollment ultimately leading to loss of revenue. If patient safety and other quality control

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measures fall below an acceptable level we can expect possible loss of accreditation. These

issues are all preventable if action is taken now.

Methods

There are many inexpensive methods to boost employee morale. Most of the methods simply

involve additional training for management and supervisors to change their management styles

and foster a culture of belonging. “The ability to inspire morale in staff is a fundamental

indicator of sound leadership and managerial characteristics” (Stapelton et al, 2007).The

methods are summed in the table below.

Methods to Impact Engagement from Literature Review

• Empowerment in decision making• Management accessibility & leadership styles• Recognition programs• Workplace culture• Organizational communication• Trust & respect• Company reputation• Access to resources, training, information, & opportunity

Table 4

(Dahl et al., 2009)

More detailed explanation of these methods follows:

1. Give employees as much control over their job and work experience as possible.

“Decades of stress research with humans and lab animals shows that the #1 factor

determining an individual’s stress level when faced with adversity is the degree of control

they believe they have. Thus, the more control your employees experience on the job and

in their overall work experience, the greater their ability to handle the demands,

pressures, and uncertainties they face.” He says that if employees have little control over

their jobs they will develop “learned helplessness” and a “passive, victim mentality”

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(Lee, 2009). Empower employees to point out inefficiencies, remove barriers, and

streamline process. Make them feel that they have a voice and the power to make

changes. To facilitate employees feeling in control management must:

“Make sure you supply your employees with the tools, training, and resources to

do their jobs well… so they feel a sense of control and mastery in their work.

Give them as much decision-making authority as possible over their work.

Remove obstacles that make it hard for them to feel “the thrill of victory”, but

instead, set them up for “the agony of defeat.”

Don’t do things TO your employees. Involve them in decisions that affect their

day to day work experience.

Involve employees in generating solutions and new ideas. Involvement and action

create the experience of positive control, and are tremendous antidotes to fear”

(Lee, 2009).

2. Keep employees in the loop. Let employees know what is going on to reduce anxiety.

This may seem simple, but many employees rate their employer low in this aspect. To

facilitate this:

“Find out from your employees if they feel “kept in the loop” or “kept in the

dark.”

Ask them what information they want to be kept apprised of and act on this.

Be sure to explain the “Why” behind decisions. When people understand “Why”

they can deal with almost any “What.”

Share from the heart. In a recent interview with employees from another

organization lead by an authentic, transparent leader— Jøtul North America,

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winner of a Best Place to Work award—without exception the first thing

employees shared was the impact their leader’s authenticity and genuine concern

had on them in keeping morale and trust high, despite the difficult news he had to

bring them” (Lee, 2009).

3. Bring out their best. Let each employee know how they contribute to the overall

organizational vision and mission. To facilitate this:

“Make it a practice to share stories of the impact your healthcare organization is

having due to the contributions your employees make.

Celebrate examples of employees “going above and beyond.”

Make these both a regular component of your employee newsletter” (Lee, 2009).

4. Make gratitude a regular part of the organizations culture. Gratitude has profound

effects on individuals. “Experiments involving people who practiced reflecting on all

they had to be grateful for, showed that they developed greater levels of happiness, better

health, and an increased capacity to notice the positive in their lives” (Lee, 2009). To

foster a culture of gratitude:

“Model this. Express gratitude, not only to your team members, but to your peers, and

your manager. Bosses often get even less gratitude than front line workers.

Start each meeting with the opportunity for members to express their gratitude, such

as the great service they received from another department, or an “above and beyond

the call of duty” performance from a team member.

If you don’t already have a formal process where employees can express thanks to

each other, work with your employees to come up with one. At Northeast Delta

Dental, you can send a Team Gram to another employee who has been exceptionally

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helpful. (Note: such tangible expressions of appreciation only work if they are a

sincere, congruent reflection of the culture, and are not a replacement for face to face,

verbal expressions of gratitude).

Make sure your presence at work is something that others can truly be grateful for. In

other words, continually ask yourself: “Am I bringing my Best Self to Work” and

“Am I treating others the way I would like to be treated?” (Lee, 2009).

5. Expand patient safety programs to include employee safety (Lockton, 2012).

Improving work site safety helps employees feel secure and helps to improve morale.

6. Implement a strategic collaborative quality management program. “A well

developed, well introduced and institutionalized quality management model can improve

employees’ job satisfaction. However, the success of quality management needs top

management commitment and stability” (Mosadeghrad, 2014).

7. Treat employees like people. Treating employees like a resource or commondity is a

sure fire way to kill morale.

8. Make sure management is available, engaging and listening. Employees should have

access to management from their first line supervisor up through the highest level of

management. Having open door policies, town halls, or other forums for employees to

speak with management helps employees feel that their opinions are valued and take

pride in their work (Powers, 2013).

9. Offer training. Lack of developmental opportunities is in the top ten reasons why

employees leave a job. Start by “partnering new employees with more-seasoned

veterans, bringing in experts for training sessions, and paying for employees to attend

local trade conferences” (Powers, 2013).

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10. Give small perks that have big personal impacts. Allow employees to have flexible

hours once in a while. Give employees access to “executive” parking spots for a job well

done. Many managers will resort to giving a cash bonus to reward hard work, instead

give an employee an experience. Rueben Estrada of Estrada Strategies says, (as cited in

Powers, 2013), “When you give an employee money, his attitude is grateful, but the

feeling is, 'I earned it,' and thus the impact is short-lived. When you give an employee an

experience, you're giving them something they would call their mother to brag about."

11. Make the office fun. Promote interdepartmental competitions such as which department

can get the highest patient satisfaction survey scores, or the department with the lowest

number of safety incident reports. Implement best recipe contests or potluck employee

luncheons. No one wants to leave a place where they are having fun.

12. Start wellness programs. Employee exercise programs, weight-loss or other fitness

contests, or other wellness related programs can boost morale and help improve the

health and wellbeing of employees and their families, increasing organizational

performance (Bowden et al, 2010).

13. Ask employees what motivates them. This report has outlined many methods to boost

morale, but periodic surveys or sit down meetings with employees to assess their

changing needs and desires can help keep morale and motivation levels high.

Conclusion

ABC Regional Hospital must implement measures to boost employee morale and retain highly

trained and qualified staff. Failing to do so would be detrimental to the organizations success. If

employee morale continues to stay low then it is inevitable that staff turnover will continue to be

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high and patient satisfaction will continue to drop. The long-term effects of such a decline will

mean continued lost revenue and eventually possible loss of accreditation.

Recommendations

The recommendations made in this section are made based on evaluation of all research data and

employee feedback obtained through the employee viewpoint survey and interviews.

ABC Regional Hospital should institute a supervisor development program to train all managers

and supervisors in techniques to boost employee morale and foster a positive work environment

and culture of belonging. Effective communication is the foundation of all of these methods. I

suggest starting by requiring each department administrator to complete the Healthcare

Management Certificate program through the University of Georgia Center for Continuing

Education. This certificate is a 90 hour self-paced online program. The course offers complete

flexibility so that management can fit completion of the modules into their busy schedule. The

modules are fully supported by experienced mentors who check in on each student’s progress

every 72 hours. The cost of the course is $1,999 per enrollment.

The modules covered are:

Human Resource Development and Staff Relationships

Cultural Competency and Diversity Issues

Leadership Skill Development for the First-Time Supervisor

Management Ethics and Values-Based Decision-Making

Finances and Accounting for the Non-Accountant Manager

Systems Thinking and the Management Team

Project Management Fundamentals for Healthcare

Healthcare Reform: Managing Effectively in a Changing Environment

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A suspense date of January 30, 2015 should give all Department Administrators adequate time to

complete the course. After all department administrators complete the course I suggest

implementing supervisor development workshops in which the certified administrators would

lead interactive, scenario based workshops to help first-line supervisors develop new skills in

problem solving, effective communication, and building positive employee relationships.

Administrators can use these workshops to identify supervisors that they feel would both benefit

from and appreciate the opportunity to complete the certification themselves. The hospital could

offer a limited number of seats each year to qualified and motivated supervisors to enroll in and

complete the certification. A start date of May 1, 2015 would allow 3 months of planning time

to design and implement the program. There are a large number of first-line supervisors at ABC

Regional Hospital so I estimate a time frame of 12 months to be able to have all supervisors

attend the training program.

In addition to instituting a management training program I suggest that a monthly employee

recognition program be instituted starting in October. The program will consist of a “Wow” pin

to be awarded to a staff member that made a significant impact on a patient or the organization.

Any staff member or patient can submit a form detailing the deeds of the staff member they are

nominating. The Director of Human Resources (HR) will review all submissions and award pins

to deserving staff members.

Suggestion boxes should be placed in each department by the end of this month. These boxes

will give employees a chance to voice opinions on how to improve practices and procedures.

Forms for submission to the suggestion box will be formatted to allow employees to give an

explanation of areas of improvement as well as a suggested solution. Employees will have the

option to remain anonymous if they choose, but and awards program can be instituted to

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recognize the employee who makes the greatest impact on the organization through there

suggestion.

The daily hospital bulletin email should start to include a “hunt the good stuff” section.

Employees should be encouraged to email positive stories about co-workers impacts on the

organization, contributions to the community or personal accomplishments. The launch of this

section can advertised in the bulletin in the upcoming weeks with a go live date of October 15,

2014 to give HR time to review and compile submissions.

A quarterly letter from the hospital CEO should be included in the bulletin. This letter should

outline recent success and organizational goals. The tone of the letter should be positive to give

staff satisfaction and hope about the future of the organization. The letter can begin in second

quarter of fiscal year 2015 (FY15) with publication date of 2/1/2015. This would allow the CEO

a period of one month to compile data from the first quarter and compose the letter.

Seasonal healthy recipe contests should begin with submissions for Halloween, Thanksgiving,

and the winter holidays. Recipes can be featured in the bulletin and then staff will vote on their

favorite recipe. An article soliciting submissions can begin to run in the bulleting in mid-

October.

Wellness initiatives should begin with a “stay in shape for the holiday’s competition.” The goal

of the first contest will be to prevent holiday weight gain. Initial weigh-ins should be conducted

the last week of October. The employee who remains closest to their original weight, or loses

the most weight by January 2nd will win. The prize can be a day off, gift certificate, or even a

trophy or plaque. Other wellness initiatives can be determined throughout the year. All

initiatives can be headed up and managed by volunteers within the organization.

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The employee viewpoint survey used to assess current levels of employee satisfaction should be

given on an annual basis starting in the last quarter of each fiscal year.

Other long-term initiatives should be evaluated for possible implementation next calendar year.

Timeline for implementation is below.

Healthcare Management Certification for Department Administrators

Certify supervisors through Supervisor Development Program

Suggestion boxes in place

Quarterly letter from hospital CEO

Stay in shape for the holidays9/1

3/2014

3/12/2

015

9/8/2

015

Table 5

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Appendix AEmployee Viewpoint Survey Results

My Work Experience Percent Positive

Response1. I am given a real opportunity to improve my skills in my organization. 602. I have enough information to do my job well. 703. I feel encouraged to come up with new and better ways of doing things. 564. My work gives me a feeling of personal accomplishment. 705. I like the kind of work I do. 836. I know what is expected of me on the job. 797. When needed I am willing to put in the extra effort to get a job done. 968. I am constantly looking for ways to do my job better. 909. I have sufficient resources (for example, people, materials, budget) to get my job done. 4410. My workload is reasonable. 5711. My talents are used well in the workplace. 5712. I know how my work relates to the agency's goals and priorities. 8313. The work I do is important. 9014. Physical conditions (for example, noise level, temperature, lighting, cleanliness in the workplace) allow employees to perform their jobs well.

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15. My performance appraisal is a fair reflection of my performance. 6816. I am held accountable for achieving results. 8117. I can disclose a suspected violation of any law, rule or regulation without fear of reprisal.

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18. My training needs are assessed. 5019. In my most recent performance appraisal, I understood what I had to do to be rated at different performance levels (for example, Fully Successful, Outstanding).

68

20. The people I work with cooperate to get the job done. 7321. My work unit is able to recruit people with the right skills. 4022. Promotions in my work unit are based on merit. 3223. In my work unit, steps are taken to deal with a poor performer who cannot or will not improve.

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24. In my work unit, differences in performance are recognized in a meaningful way. 3125. Awards in my work unit depend on how well employees perform their jobs. 3826. Employees in my work unit share job knowledge with each other. 7227. The skill level in my work unit has improved in the past year. 5228. How would you rate the overall quality of work done by your work unit? 83My Agency29. The workforce has the job-relevant knowledge and skills necessary to accomplish organizational goals.

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30. Employees have a feeling of personal empowerment with respect to work processes. 4331. Employees are recognized for providing high quality products and services. 4632. Creativity and innovation are rewarded. 3533. Pay raises depend on how well employees perform their jobs. 1934. Policies and programs promote diversity in the workplace (for example, recruiting minorities and women, training in awareness of diversity issues, mentoring).

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35. Employees are protected from health and safety hazards on the job. 7636. My organization has prepared employees for potential security threats. 7637. Arbitrary action, personal favoritism and coercion for partisan political purposes are not tolerated.

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38. Prohibited Personnel Practices (for example, illegally discriminating for or against any employee/applicant, obstructing a person’s right to compete for employment, knowingly violating veterans’ preference requirements) are not tolerated.

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39. My agency is successful at accomplishing its mission. 7440. I recommend my organization as a good place to work. 6341. I believe the results of this survey will be used to make my agency a better place to work.

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My Supervisor/Team leader

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42. My supervisor supports my need to balance work and other life issues. 7743. My supervisor/team leader provides me with opportunities to demonstrate my leadership skills.

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44. Discussions with my supervisor/team leader about my performance are worthwhile. 6145. My supervisor/team leader is committed to a workforce representative of all segments of society.

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46. My supervisor team leader provides me with constructive suggestions to improve my job performance.

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47. Supervisors/team leaders in my work unit support employee development. 6448. My supervisor/team leader listens to what I have to say. 7449. My supervisor/team leader treats me with respect. 8050. In the last six months, my supervisor/team leader has talked with me about my performance.

77

51. I have trust and confidence in my supervisor. 6652. Overall, how good a job do you feel is being done by your immediate supervisor/team leader?

68

Leadership53. In my organization, leaders generate high levels of motivation and commitment in the workforce.

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54. My organization's leaders maintain high standards of honesty and integrity. 5455. Managers/supervisors/team leaders work well with employees of different backgrounds. 6356. Managers communicate the goals and priorities of the organization. 6157. Managers review and evaluate the organization's progress toward meeting its goals and objectives.

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58. Managers promote communication among different work units (for example, about projects, goals, needed resources).

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59. Managers support collaboration across work units to accomplish work objectives. 5660. Overall, how good a job do you feel is being done by the manager directly above your immediate supervisor/team leader?

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61. I have a high level of respect for my organization’s senior leaders. 5262. Senior leaders demonstrate support for Work/Life programs. 54My Satisfaction63. How satisfied are you with your involvement in decisions that affect your work? 5064. How satisfied are you with the information you receive from management on what's going on in your organization?

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65. How satisfied are you with the recognition you receive for doing a good job? 4566. How satisfied are you with the policies and practices of your senior leaders? 4167. How satisfied are you with your opportunity to get a better job in your organization? 3468. How satisfied are you with the training you receive for your present job? 5069. Considering everything, how satisfied are you with your job? 6570. Considering everything, how satisfied are you with your pay? 5471. Considering everything, how satisfied are you with your organization? 56Work/Life Programs79 - 84. How satisfied are you with the following Work/Life programs in your agency?79. Telework 7680. Alternative Work Schedules (AWS) 8981. Health and Wellness Programs (for example, exercise, medical screening, quit smoking programs)

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82. Employee Assistance Program (EAP) 4083. Child Care Programs (for example, daycare, parenting classes, parenting support groups)

35

84. Elder Care Programs (for example, support groups, speakers) 3085 – 97 How important is the following to you? Percent

Important85. Recognition (verbal) 8286. Recognition (award or gift) 6787. Recognition (financial) 4488. Forum for your opinion to be heard. 8589. Knowing how your work contributes to organizational goals. 9190. Training opportunities. 9291. Professional growth. 79

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92. Higher Salary. 6493. Wellness programs (for example exercise classes, quit smoking programs, fitness contests)

71

94. Child Care Programs (for example, daycare, parenting classes, parenting support groups)

61

95. Elder Care Programs (for example, support groups, speakers) 6096. Fun at work (Friendly competitions, Potluck luncheons) 7297. Availability/Transparency of Management 97

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Appendix B

Introduction to Relative Value Units and How Medicare Reimbursement is CalculatedMedicare pays physicians for services based on submission of a claim using one or more specific CPT® codes. Each CPT® code has a Relative Value Unit (RVU) assigned to it which, when multiplied by the conversion factor (CF) and a geographical adjustment (GPCI), creates the compensation level for a particular service. To understand this more fully, the calculations can be broken into three components – RVUs, the geographical adjustment and the conversion factor.Relative value units (RVUs) – RVUs capture the three following components of patient care.1. Physician work RVU – The relative level of time, skill, training and intensity to providea given service. Each CPT® code is targeted for review at least every five years todetermine the work RVU for a particular service and consider if it remains the same asthe value previously set. Code values can increase or decrease if the components ofservice have changed during the preceding years. A code with a higher RVU work takesmore time, more intensity or some combination of these two. Some radiation oncologycodes, such as treatment codes, have no associated physician work.2. Practice Expense RVU – This component addresses the costs of maintaining a practiceincluding rent, equipment, supplies and nonphysician staff costs. The practice expenseRVU is now calculated using a “bottom up” methodology where the direct costs ofproviding a service are calculated (staff time, supplies and equipment time) and indirectcosts are allocated. Indirect costs are those that cannot be directly attributed theprovision of a service, such as having a waiting room or a billing service. Direct costsare those that can be assigned to a specific service; a direct cost would be the actualsupplies, equipment and staff time used for a given CPT code. Frequently, a CPT® codewill be assigned a practice expense RVU for a facility setting, such as a hospital, and adifferent practice expense RVU for a nonfacility setting, such as a freestanding center.Generally, freestanding radiation oncology centers receive more practice expensecompensation than hospital-based centers, since the practice expense of owning andoperating equipment and providing staff resources are significantly more than thepractice expenses covered by the physician in a hospital setting. As an aside, the hospitalis paid under Hospital Outpatient Prospective Payment System (HOPPS or OPPS) for theradiation oncology equipment and services. Hospital-based physicians are paid under theMedicare Physician Fee Schedule (MPFS) in the same manner as freestanding-basedphysicians. 2009 is the third year of transition to a new methodology for calculatingpractice expense. The new methodology will be fully implemented in 2010. Therefore,the 2009 practice expense RVUs are often described as “transitioned” or “transitional.”3. Malpractice RVUs - These are generally the smallest component of the RVU values andrepresent payment for the professional liability expenses. RUC and CMS rules suggestthat these expenses are to be reviewed and updated on a bi-annual basis, but in practice,that has frequently not occurred.Geographic Practice Cost Indices (GPCI) - Geographic Practice Cost Indices account for thegeographic differences in the cost of practice across the country. CMS calculates an individualGPCI for each of the RVU components -- physician work, practice expense and malpractice.GPCIs are reviewed every three years.Conversion Factor (CF) – The conversion factor converts the relative value units into an actualdollar amount. The dollar multiplier (CF) is updated on an annual basis according to a formulaspecified by statute. Congress has the ability to override the statutorily defined formula, as it hasdone in the past several years. In 2009, the Conversion Factor adjusted for budget neutrality is$36.066.Budget Neutrality (BN) – CMS is prohibited from changing its overall budget by more than $20

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Improving Morale

million. Should RVUs shift in such a way that the CMS budget is impacted by over $20 million,CMS must use a budget neutrality factor to bring its total payments back in line. CMS first usedthe BN in 2007 by applying it solely to the physician work RVUs, since a revaluation ofphysician work RVUs for evaluation and management codes lead to the expected overage. In2009, CMS changed its BN application moving it to the conversion factor instead.Facility/NonFacility – This designation identifies where services are provided. The Facilitypricing amount generally covers services to inpatients or in a hospital outpatient clinic setting, but can include other settings. Off-site hospital-owned sites are also considered as “facilities” in the context of payment. NonFacility services are generally provided in a freestanding physician’soffice, but can include other freestanding settings. The formulas that reflect the above components and result in the 2009 physician fee schedule payment amount for each CPT® codes are:

2009 Non-Facility Payment Amount = [(Work RVU * Work GPCI) +(Non-Facility PE RVU * PE GPCI) +

(MP RVU * MP GPCI)]* [Conversion Factor adjusted for budget neutrality]

2009 Facility Payment Amount = [(Work RVU * Work GPCI) +(Facility PE RVU * PE GPCI) +

(MP RVU * MP GPCI)]* [Conversion Factor adjusted for budget neutrality]

Key:

Conversion Factor adjusted for budget neutrality - dollar amount used to convert RVUsinto a payment amount adjusted for budget neutrality to ensure that total Medicarepayments comply with allowed total Medicare funding.

Facility – Reflects the site of service designation, facility services generally are providedto inpatients or in a hospital outpatient clinic setting, but can include other settings.

GPCI – Geographic Practice Cost Index, used to reflect the variations in the cost ofproviding services between different geographic areas. There are different GPCI’s forwork, practice expense and malpractice.

MP – The portion of reimbursement associated with malpractice expenditures.

NonFacility – Reflects the site of service designation, nonfacility services are generallyprovided in a freestanding physicians office, but can include other freestanding settings.

PE – The portion of reimbursement associated with practice expense includingreimbursement for supplies, equipment and nonphysician staff.

RVU – Relative Value Unit, used to provide relative comparisons between CPT® codes.

Work – The portion of reimbursement associated with physician work.

Retrieved September 12, 2014, from http://www.acro.org/washington/rvu.pdf

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