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Here is a link to the published journal and article

Organization X Performance Improvement Project Analysis and Solutions for Improving Retention and Establishing Connections
Jennifer Graham and Zach Morgan

Graham, J., & Morgan, Z. (2017). Organization X Performance Improvement Project Analysis and Solutions for Improving Retention and Establishing Connections. Journal of Training, Design, and Technology, 1(1), 60-67.

Abstract

This project was based on an organization in the southeast region of the U.S. For purposes of this report, we will refer to them as “Organization X” to maintain confidentiality. In response to the UNCW team’s request, Organization X stakeholders identified two areas of potential improvement: 1) Individuals and families are more connected to their Direct Care Provider than they are to the organization at large, and 2) high turnover within the Direct Care workforce. The desired state of performance would be less turnover (which addresses the connection and potential lost revenue issue by default) and a greater sense of connection to Organization X among individual, families, and Direct Care Providers. Information obtained generated interventions designed to address the turnover and connection issues. Career Pathing (aimed at providing advancement opportunities for Direct Care Workers) and Community Engagement (aimed at enhancing Organization X’s reputation and increasing referrals and donations) were identified as the highest impact interventions. Other interventions included slight modifications to job descriptions, consistent application of hiring and onboarding best practices, and continued diligence in the area of injury prevention. 

Problem Statement

In 2015, one regulation of the Affordable Care Act, commonly referred to as the “Employer Mandate,” was enforced. Under this new mandate, all businesses with at least 50 full time employees are required to offer health insurance to at least 95% of their full time staff members and dependents up to age 26. If they do not offer health insurance to at least 95% of these employees, they are penalized with hefty fines that total $2,000 per month per employee. While the regulation was originally supposed to be implemented in 2014, it was actually delayed until 2015 with a timeframe to have this complete by all businesses within 1 year (to be fully implemented by 2016) (Internal Revenue Service, 2017). 

In response to this new rule, Organization X was the first healthcare provider of its kind to adopt the change in 2014 when the mandate was originally set to start. Organization X is a non-profit organization that relies on Medicaid funding for financial support and long-term sustainability. Realizing that the quality of services provided for individuals would be compromised if they had to allocate more funds for health insurance for the large majority of their direct care workers who worked full time hours, Organization X had to cut back on the number of hours employees could work. This meant that employees who were used to working 40+ hours per week, and some even up to 80 hours per week, were now limited to working no more than 29 hours per week. This shift caused many workers to either leave the organization entirely or take on a second or third job because they were no longer able to support themselves financially. Direct care staff are also paid lower wages ranging from around $8-9 per hour; these rates are set by their Managed Care Organization (MCO), not Organization X. High employee turnover results in the company having to spend more money on training resources for new employees. 

Since Organization X were such early adopters of this new regulation, they suffered a blow to their reputation as some members of the community felt that Organization X did not value their employees. This reputation hit has also caused staff members to feel disconnected from the organization. Because direct care staff members are the employees who interact with the clients and their family members most often, clients tend to foster more of a relationship with the worker and less with the organization. Therefore, when staff members leave to work with another healthcare provider, the client is likely to follow, resulting in a reduction of Organization X’s clientele.

Organizational Analysis

Organization X is a non-profit organization that has been working for over 90 years to provide a variety of services for adults and children living with disabilities and special needs. Some of these services include child development centers, rehabilitation, job training, summer camps for children, and in-home direct care services to help with individual daily life skills. They work to partner with individuals and families to reduce the impact of disability or health challenges and to enhance the quality of life. With specific regard to how their values, mission, and vision relate to the performance issue at hand, their values of shared purpose and stewardship play an important role. Shared purpose refers to all employees working together as a unified organization to meet their mission of partnering with individuals and families to reduce the impact of disability or health challenges and to enhance the quality of life. Organization X is experiencing a critical issue as it relates to their value of shared purpose because it appears that everyone isn’t working as a cohesive unit; staff seem to be experiencing a disconnect from Organization X as an organization and may not understand what it is exactly that Organization X provides to them apart from a source of income. Stewardship refers to Organization X building relationships with relevant stakeholders and there is also a critical performance issue here as well as it relates to the relationships being built between new and established clients, Organization X, and direct care staff.

Organization X is structured to provide services across two main regions: a Western region and an Eastern region. Across the Eastern region, there are 4 main programs that offer services within the community and in the homes of clients that each span approximately 5-15 counties. While the two regions within the organization used to be more autonomous, Organization X is trying to bridge the gap and offer more consistency between the two. There are a few summer programs in place throughout the regions as well, though they are not experiencing the same employee turnover issues that the year-round programs are. At each site within a county, there is a full time supervisor that oversees the direct care staff who are working in the homes and in the community of the client. Supervisors attempt to visit the homes of the clients and their families at least once a month and are the initial point of contact for clients and families when establishing service with Organization X as a provider. 

Environmental Analysis

For the purposes of this analysis, personnel of interest are: Direct Care Workers, their supervisors, and upper management (program directors and executive positions). Supervisors and upper leadership positions are full-time, salaried employees with insurance benefits. Leadership and supervisors will find themselves working Direct Care Workers (also known as Periodic Employees) work primarily in the client’s home and within the community where services are being provided. Our direct contacts for this project have been the Program Director for the Eastern Region and Organization X’s Chief Human Resources Officer. The goal is often to help the individual become more independent and to teach them skills that will benefit the client and their families. The vast majority of Direct Care Workers are not full time employees – they are hourly workers who are allowed to work up to 29 hours a week. 

A cap that limits working hours to 29 a week was not always in place. The world in which Organization X operates was directly affected by the 2010 signing into law of the Affordable Care Act (ACA). One of the provisions of the bill was a stipulation employers would have to provide health insurance to employees who worked over 29 hours per week. At the time, many of Organization X’s Direct Care Workers were working over 40 hours a week (and in some cases, close to 80 hours a week). As a 501(c)(3) non-profit organization, Organization X’s margins are incredibly thin and providing healthcare to all employees was not a feasible option. Most Direct Care Workers experienced a drastic cut in hours and Organization X went from being their primary employer to being a secondary or even tertiary employers. Some left the field entirely for other opportunities (such as big box/chain stores that would pay slightly better hourly wages and/or provide healthcare), while others started working for multiple agencies in order to reconstitute their former workload and income. In this environment, Direct Care Workers are frequently viewed by management as mercenaries and will frequently leave one agency if a slightly higher hourly wage is present elsewhere. Organization X was an early adopter of the new regulations and saw its reputation suffer as a result. For clients and direct care workers, the implementation of the new regulations resulted in a tarnished image and a damaged brand.

Direct Care Workers are front-line staff and are, in many ways, the face of the organization. Direct Care Workers are expected to have at least a high school diploma (or GED), a valid driver’s license, and a good driving record. Direct Care Workers also need to be able to work independently and maintain accurate records for their client (or clients) and should be comfortable assisting individual with personal care (baths, toileting, etc.). They are also required to complete training as required by the associated agency (in cases where Organization X is collaborating with another agency) or based on the type of service being provided. For a typical Direct Care position, the worker can expect to spend 25 hours with the client and reserve the remaining four hours for training.

Per a current Organization X job description, basic responsibilities for Direct Care Workers include (but are not limited to):

• Assists individuals with daily activities, personal care, home care and maintenance, and transportation.

• Participates in implementation of person centered plan.

• Provides direct interventions to build socialization, behavior management skills and daily/community living skills.

• Provides direct intervention to promote adaptive skill learning and development of leisure time interests/activities.

• Maintains documentation, progress notes, and other data as needed, including incident and accident reports.

• Communicates with other staff and supervisor on progress, needs, concerns, and changes.

• Demonstrates knowledge of agency policies and procedures.

• Attends staff meetings as required.

• Responds to individual safety needs, including reporting significant changes in behavior and health.

• Provides high quality customer service, serving as a positive representative for the agency with other professionals, families, and the community at large.

• Performs housekeeping duties as assigned.

• Assists in meal preparation in accordance with individual dietary needs and preferences.

• Attends individual and group supervision as required.

• Participates in ongoing Quality Improvement activities.

• Assists individuals we support with inclusion, respects the dignity and individuality of each individual and his/her right to confidentiality.

• Lifts and transfers individuals we support as needed.

• Assists individuals at learning and increasing skills in all areas of independence.

• Completes required paperwork accurately and as required by program.

Gap Analysis

Table 1

Performance Gap Analysis

Current State	Desired State	Gap
Organization X is still suffering from a diminished reputation after being early adopters of the ACA regulations. Families were strongly attached to the Direct Care Worker (or workers) assigned to them and in many cases saw this relationship diminished or abolished.	Organization X is perceived by the public as a leader in the field of providing services to individuals with developmental disabilities. Based on positive feedback from current and former clients, Organization X increases the amount of referrals they receive.	Organization X needs to re-establish itself as an agency that is perceived as a leader in the field due to well-trained staff and a wide range of services offered.
Direct Care Providers are still wary of Organization X and will frequently leave the organization for a marginal raise (even if the new employer does not have the same commitment to quality).	Organization X is a desirable employer for Direct Care Workers and has an excellent reputation that generates loyalty and longevity among staff.	Organization X needs to improve the connection between Direct Care providers and the organization. Whenever feasible, Organization X needs to reduce costly turnover.
Supervisors and Direct Care Workers are not consistent in the way they talk about the organization with clients. Organization X is still seeking to imbue their staff with a clear understanding and conversational knowledge of their brand.	Supervisors and Direct Care Workers are consistent in the way they discuss Organization X with clients. Clients and staff understand Organization X’s mission, goals, and identity.	Organization X needs to establish consistent messaging in all interactions between staff and clients. Supervisors and Direct Care Workers should be able to explain to clients the goals of Organization X and what makes it unique.

Cause Analysis

During Performance Analysis, the ultimate root cause of high employee turnover was identified as Organization X’s early (and inevitable) adoption of the Affordable Care Act’s (ACA) new Employer Mandate in 2014. The pressures of this new regulation combined with an already high turnover, low wage workforce is largely responsible for the current environment. Symptoms of this unstable workforce and non-profit financial constraints include: inconsistent communication initiatives, lack of knowledge about Organization X’s identity, a relative lack of organizational supports for Direct Care Workers, limited career advancement opportunities for Direct Care Workers, and high employee turnover. Organization X was an early adopter of the new regulation mandated by the ACA in 2014 and there is some evidence that by leading the way (and although there may have been strong business reasons for doing so), the agency suffered a disproportionately damaged reputation (in comparison to its peers). Consistently reassuring and forward-looking messaging was essential during this time, but in spite of these efforts, a segment of Direct Care Workers and individuals/families developed erroneous perceptions such as: Organization X did not care about its employees OR staying with Organization X was not worth enduring such a massive paradigm shift when other options were still available in the marketplace. The attendant tightening of resources (and available paid hours), reduced budgets, and climate of scarcity drove Direct Care Workers to separate from the organization for marginal gains and weakened the bond between Organization X and those it serves. 

The loss of a Direct Care worker can mean an interruption in services for individuals/families as they transition to a new Organization X staff member or to their current staff member’s new organization. In the latter case, the departure represented lost revenue for Organization X and the prospect that the individual may be transitioning to an agency that does actively facilitate the same quality of care. In either scenario, the departure of a Direct Care Worker meant additional strain on supervisory, HR, and training resources.  

Intervention Selection and Feasibility Analysis

Prior to considering implementation of any of the interventions listed below, a thorough review of current Direct Care turnover rates (using SHRM guidelines) is recommended. The initial goal of this review is to gain up to date insight into Direct Care Worker losses and to look for trends or outliers by comparing turnover rates across regions, programs, counties, and demographics. This data should also be compared against national and state benchmarks (when available). The next step is to use this data to calculate a reasonable estimate of what each Direct Care Worker’s voluntary separation costs Organization X. There are several turnover cost models available as resources, but ultimately key stakeholders must review the variables and their associated weights to determine an organizationally appropriate model. Presenting a current snapshot of turnover data as well as a thoughtful analysis of the total cost of voluntary separations may serve as an important financial and strategic justification for the interventions below.       
  

Pre-hiring and Onboarding Interventions

Hiring managers and supervisors should consider two key factors when reviewing potential Direct Care hires: Does the worker have previous Direct Care experience and do they have a history of longevity and loyalty with a previous employer? Workers with previous experience in Direct Care will have an understanding of the unique challenges and intrinsic rewards of the position. They may also require less training and may be able to begin providing quality services sooner during their tenure with Organization X. Longevity with a previous employer is often a predictor of future longevity and loyalty. Serial “job-hoppers” should not be automatically disqualified (especially if they have relevant experience), but they should be treated with additional caution. To implement, communicate these key factors to supervisors and hiring managers in the form of an interview checklist or hiring rubric. Also consider seeking feedback from supervisors and Direct Care workers regarding critical factors for longevity with Organization X. 

Confirm with HR generalists and supervisors that a robust onboarding program is consistently applied throughout all programs in the Eastern region. Prior to Day 1, ensure that the new Direct Care Worker is informed about necessary paperwork, upcoming trainings, and relevant policies and procedures. Upon starting work, make an effort to introduce them to relevant office and administrative staff (even it contact with them will be limited) and provide the new-hire with a small gift, card, or token that welcomes them to the organization. Consider relevant mentoring/job-shadowing opportunities (worthy training experiences that will have long-term benefits to the organization and the individual). To implement, HR, HR generalists, and supervisors should confirm that onboarding and follow-up checklists exist, are easily accessible, and are consistently followed. 

Establishing Identity Interventions
 

One of the major concerns expressed by stakeholders early on in the analysis and data collection phase of this project was that of the distant relationship between the organization and Direct Care Workers. As front-line employees, these workers may be less aware of the diligent work being done by management and administrative staff. Although typically an intrinsically motivated population, they may also feel less connected to Organization X’s mission and values (as opposed to their own internal motivation to serve).

To implement, consider updating the Direct Care Worker job description to include a one to two paragraphs about the identity of Organization X and what sets the organization apart from its peers. Information regarding why Organization X is a great place to work should be provided; advantages of working with the organization that may include flexible scheduling, rewarding work, and trainings that can help to gain NADSP certification. These and any other potential benefits should be added to Direct Care/paraprofessional job descriptions - as of this writing this introductory information is not present. The goal of this intervention is to establish Organization X’s reputation for excellent quality of service before the employee even begins working. The message should reflect that Organization X provides person-centered care while also caring deeply about its employees. The details of the current description are comprehensive and should be retained as a point of strength. 

Career Pathing Interventions
 

Lack of advancement opportunities is frequently identified as a root cause for Direct Care Worker job dissatisfaction and turnover (Butler, Brennain-Ing, Wardamasky, & Ashley, 2013). Starting with job postings (see above intervention) and continuing throughout the employee’s time with the organization, highlight opportunities that pave the way for career advancement. Of specific importance is the need to leverage and champion the DSP-Specific Curriculum within Relias Learning. Credentialed Direct Care Workers will be better able to embody best practices when interacting with individuals and families. A corresponding high quality of care allows Organization X to provide greater assurances to potential donors and families. Anecdotal evidence also implies that employees who make it through rigorous credentialing are more likely to stay on the job for an extended period of time. To implement, prominently display the benefits of Relias’s DSP-Specific Curriculum on the Organization X website and in corresponding job advertisements and communications for Direct Care Workers and Supervisors.    

Explore opportunities for Direct Care Staff to work in-office and assist with administrative tasks (likely initially paid as training hours but higher wages may be possible if significant ROI is demonstrated). The intended benefits of this intervention are:

●       A non-mandatory training opportunity that builds the Direct Care Worker’s resume and increases the potential for advancement within Organization X (Periodic with Benefits or supervisory/administrative roles)

●       Reduced administrative load on supervisors

●       More time for supervisors to call or visit with individuals/families and/or the Direct Care Workers they oversee

Although much of the existing research examines the benefits of apprenticeships for CNAs, there is some evidence that such programs may also boost retention among Direct Care Workers. To implement, identify leadership champions and use focus groups or surveys to develop a menu of potential administrative tasks. Participants should include Direct Care Workers, Supervisors, and relevant administrative staff. Consider scaffolding tasks to establish a logical progression for the apprentice and include a tangible benefit for individuals completing the program. Pilot the intervention in 2-3 locations, collect feedback, and evaluate expansion.

Injury Prevention Interventions

One of the leading causes of employee turnover in the Direct Care field are injuries sustained while working on the job (Lee & Jang, 2016). While ergonomic and workplace safety practices are important to establish in any line of work, they are especially important in this physically demanding role. In the recent past, Organization X has worked with a former Occupational Therapist (OT) to present information about safe working practices and techniques as part of the annual training session required of staff members (and held at each regional office). While this presentation is effective, staff may benefit further from consistent communications between Supervisors and the OT as specific work-related injuries arise. For example, upon noting an increase in lower back injuries, a supervisor or Program Director could contact the OT for an ad hoc refresher training on proper lifting. Preventing injuries while on the job not only helps to keep employees safe while at work, but also reduces overall operating costs incurred from fees related to worker’s compensation claims. Safety may already be an organizational strength - an increased and consistent focus on worker well-being has potential to truly differentiate Organization X from other agencies. 

Community Involvement Interventions
 

Some stakeholders have theorized that Organization X experienced a diminished reputation in the community due to being an early adopter of the cutbacks required to comply with the ACA and still provide quality care. In order to provide the same quality of services, widespread cuts in Direct Care hours were inevitable. Consequently (and as discussed earlier), some employees and members of the community felt disconnected from the organization. One possible intervention to re-establish the organization within the community (and drive referrals) is to host an annual (or bi-annual) festival within each Region (East & West).

Working closely with Organization X’s Events Committee, planners of this event would build on previous successes like “Walk with Me” and the “Eggstravaganza.” When feasible, individuals and their families should be highly involved with facilitating the event and the planning team should include input from supervisory and Direct Care voices. The committee responsibilities include but are not limited to: recruiting members of the community and other people with disabilities to help staff the event, contacting local media, securing monetary and material donations (tables, chairs, food, etc.), and making/ordering T-shirts and other items that increasing brand recognition. Booths can be set up for guests to play games, buy crafts, baked goods, and other products created by members of the community with disabilities. In addition to tickets granting admission to the festival, other fundraising opportunities could include a raffle of donated goods, a silent auction, and craft/food items produced and sold by individuals served by Organization X. 

Additionally, a portion of the proceeds ($100-$500) from the event (or an appropriate discretionary funding source) can be set aside as part of a “Direct Care Worker of the Region” awards ceremony. The staff member could be nominated by individuals, families, supervisors, members of the community, and other employees. With their efforts more publicly recognized, staff may feel more appreciated by the organization and employee motivation may be increased. In addition to enhancing Organization X’s reputation with the community, this intervention also serves to promote brand recognition, increase employee motivation and retention, and generate new streams of fundraising. It also supports Organization X’s mission of creating opportunities for people with disabilities by maximizing their potential to live, learn, work, and play in their communities. See Table 2 below for benefits, challenges, and feasibility rankings.  

Table 2

Feasibility of Interventions

Intervention	Benefits	Challenges	Feasibility
Establish Identity	●       Inexpensive ●       Not very time-consuming	●       May require more time to see ROI	1
Pre-Hiring and Onboarding	●       Inexpensive ●       Not very time-consuming	●       Consistency of implementation	2
Injury Prevention	●       Lowers litigation risk ●       Reduces frequency of worker’s compensation claims ●       Establishes more consistent communication channels	●       Cost of OT services ●       Accurate and timely reporting of injuries	3
Career Pathing	●       Boosts retention ●       Reduces employee turnover ●       Employee Development	●       May require additional funds ●       In-office learning may involve long drives for some workers	4
Community Involvement	●       Increases employee connection to Organization X ●       Enhances reputation ●       Allows for client involvement ●       Immediate and future fundraising streams ●       Increase awareness of brand recognition/identity	●       Time-consuming ●       May require start-up funds for first event ●       Direct Care Staff award nomination must avoid perception of favoritism ●       Resource intensive	5

Implications and Recommendations

To build momentum and gain quick wins, we recommend first addressing Organization X’s identity by updating the Direct Care job descriptions and re-examining the consistency of hiring and onboarding processes. Injury prevention is important and should be sustained, but this is currently less of a concern than other areas.

Although they are broader in scope and will require more resources, we believe that career pathing and large-scale community engagement initiatives have the greatest potential for positive impacts. Career Pathing interventions, especially those that foster potential advancement opportunities for Direct Care workers, will aid the organization in retaining and promoting top performers. A large-scale regional festival will require heavy logistical coordination and volunteer involvement, but could leave a lasting impression on the community where it is held. As these interventions (and others) take root, Organization X should continue to explore creative ways of involving Direct Care staff in organizational decision-making and strive to represent all facets of the organizational chart in public-facing events. Our team believes that progress in these areas will be hard-fought, but worthwhile, and will allow Organization X to publicize and improve upon the excellent work being done in communities across their Eastern Region and beyond.

References

Butler, S., Brennain-Ing, M., Wardamasky, S., & Ashely, A. (2013). Determinants of Longer Job Tenure Among Home Care Aides. Journal of Applied Gerontology. 33(2). 164-188.

Internal Revenue Service. (2017, April 20). Questions and Answers on Employer Shared Responsibility Provisions Under the Affordable Care Act. Retrieved April 20, 2017, from https://www.irs.gov/affordable-care-act/employers/questions-and-answers-on-employer-sharedresponsibility-provisions-under-the-affordable-care-act.

Lee, A.A., & Jang, Y. (2016). What makes home health care workers think about leaving their job? The role of physical injury and organizational support. Home Health Care Services Quarterly. 35(1).