2. Personnel Management

HIRING AND RETAINING EMPLOYEES

        Traditional employee screening as practiced in the industry by most firms is not effective in finding persons least likely to be injured on the job. Most home care providers are low wage, older and high turnover positions. HHC companies are reluctant to conduct extensive evaluations, including physical capability assessments, when skill requirements are low and turnover is likely. Professional employees are typically hired for professional and relationship skills, not for patient handling ability. Even where the employer spends the money to screen employees, screening, at least of physical capabilities, only addresses prospective/new employees. Unless a company conducts annual fitness for duty testing, they need to employ other methods to control losses.

        Screening of potential employees is necessary (criminal background checks are mandated) and physical examinations may be beneficial, but the jury is out regarding the most effective – physician provided or evaluations conducted by testing facilities using isometric examinations. Some research indicates psychological profiles to examine such things as honesty, work ethic and motivation may be just as or even more effective in preventing injuries than physical examinations.

        Who a company hires has a significant bearing on the possibility of future claims of employee injuries, motor vehicle collisions and potential liability claims related to patient care. In home healthcare, as with any profession, the employee selection process starts with the basic process of identifying the requirements for the job and matching an employee to the job requirements. Beyond this basic requirement, employee selection practices can also be used as a risk mitigation opportunity. Where can a company experience a loss, and what can be done to improve the possibility that an employee won’t put the company at risk and/or injure themselves or others?

• Job description– Begin with an accurate description of job requirements, including “essential functions.” Essential functions are those aspects of the job that must be done for the job to be accomplished at a minimum. Employment practices suits are often related to aspects of the job being defined as essential that were in fact not. Job descriptions need to reflect realistic performance requirements. “Must be able to transfer clients to and from beds, chairs, toilets, baths etc.” is an unrealistic expectation. Caveats need to be added that consider client assessments, transfer devices and client characteristics (physical, mental etc.). With regard to client transfers, the ideal is to eliminate the need to manually move clients without mechanical assistance. Before writing the job description, start by making the job as safe as possible to do.
• Job application – Prospective employees need to be required to complete, sign and date a formal written job application. In addition to standard application questions, signing the application should serve as a notice to the prospect that what they have said is true and accurate, and they understand the company has permission to verify the information through checks of references, criminal background and motor vehicle records. If the company provides post offer, pre-employment physical examinations or assessments, drug tests or other examinations, such as a written personality or behavioral test, the signature should also authorize the company to conduct these evaluations.
• Interview – A key objective of the interview process is to accurately match the prospective employee with characteristics of a successful employee. In home care, honesty, judgment, decision making ability and commitment to the profession are critical. Situational questions are important parts of the behavioral interview. How would they respond to things like customer complaints and personality conflicts? Can they provide examples of situations where they have encountered situations like this? How did they respond?
• Criminal background check – Since the caregiver may have access to personal valuables and finances, obtaining a criminal background check is a recommended practice. Doing so may also be a legal requirement in the state where the organization operates. Prospective employees should provide a written acknowledgement the company will conduct such a check as a condition of employment and subsequent to employment commencement. Before making a decision to refuse an employment offer, or for terminating employment, consult with legal counsel if it is discovered the employee or applicant has been convicted of a crime.
• Reference checks and skills – Check the references and verify education and technical qualifications. While some employers may be reluctant to provide details about previous employment, most will not hesitate to respond honestly to the question “would you hire them again?” Ask specific questions about what the person did from business references, and try to get a sense of who the person is (integrity, honesty, passion for the work etc.) from personal references.
• Post offer, pre-employment screening – Employers are allowed to screen employees regarding their ability to perform “essential functions” of the job. When applied consistently to specific classifications of employees, these tools can be applied to help the employer match the employee with the job. They are referred to as “post-offer, pre-employment” because they are conducted after a conditional offer of employment has been made.

        These types of screens, consisting of physical examinations or functional capacity tests, can be conducted in a variety of settings and by different sectors of the healthcare industry. For the employer, the question is not who performs the testing and the cost, but the effectiveness and track record of the company doing the tests. In home healthcare, this is one of the few ways of preventing a company from “hiring a claim,” or a person with pre-existing physical limitations or limited capacity to conduct essential functions, which may include client transfers.

        Not all home healthcare agencies require physical examinations. Some have been successful in controlling loss experience through effective background checks, reference and skill verification and effective patient assessment and care management planning.

        Drug testing– Another type of post-offer, pre-employment screen is drug testing. Prior to testing for drugs, it is important to establish a company policy regarding impairments on the job. Consider if you will only be testing applicants or current employees as well, and under what conditions (random, for cause etc.)

        Driving skills – When employees drive company vehicles, or drive on behalf of the company, it is important to understand if they drive, what they do will reflect on the company. Should an employee cause a serious collision, the plaintiff may seek to access the financial resources of the company. If the driver has a history of poor driving and the employer should have known and should have done something to prevent the loss, they may be found financially responsible.

        Evaluating driving skills can be as simple as riding along with the employee or as complex as requiring mandatory defensive driving training.

• Employee handbook – Explains who the company is, what they do and what is important to the organization. Because the handbook can spell out details of benefit plans, rules and regulations and disciplinary procedures, it should be reviewed by legal counsel before implementation. All employees should sign off to verify that they have reviewed and understand the material. Sign-off should include a confidentiality agreement to protect personal information about patients. GIFT GIVING, NOT ASSISTING CLIENTS ON THEIR PERSONAL TIME, FOLLOWING CARE PLANS, NOT DIRECTLY HANDLING CASH OR CREDIT CARDS.
• Orientation – the orientation process helps the new employee understand what the organization is about. What are the values and principles the company works off of? What is the mission statement and scope of what the company does? What are the expectations of the new employee? What can the employee expect of the company?
• Probation – Probation provides the organization with an opportunity to see how well the new employee actually fits with the culture of the company. It can also provide a chance for learning, correction of mistakes and an opportunity for growth. A key consideration is that even with successfully passing the probation period, employees need to be held to a standard where serious misconduct will not be tolerated.

Employee Retention

        One of the most significant challenges faced by many home healthcare organizations is high employee turnover. Organizations achieving the highest levels of success in the industry often credit the quality and loyalty of their employees for their success. Companies experiencing problems with profitability, liability and workers compensation claims are also frequently plagued by high levels of turnover. When turnover is high, everything costs more. Companies experiencing high turnover may not be able to justify extensive and through background checks or screening practices. Probationary periods are out of the question, the employees are needed yesterday.

        While not every aspect impacting turnover is under the control of every home healthcare agency, there are some consistent characteristics of companies that have a good deal of success in keeping good, productive employees.

        Basic motivation – People who do well in healthcare have a genuine love for the work they do. They get high levels of personal satisfaction from helping others in need, and from the relationships they form.

        Recognizing and appreciating employees – One of the greatest motivators is feeling that your work is valued; that you contribute. People that get into healthcare want to do something that makes a difference. They want to help and most genuinely care. Gratitude from the client or the family goes a long way to motivating someone to stay in the profession. Failing to be recognized by the employer and that they value your contributions opens the door for finding greener pastures to practice the profession in.

        Job and Career opportunities – Despite a love of work, everyone has bills to pay and personal responsibilities to take care of. Retention does depend on compensation. Organizations that don’t offer competitive wages and benefits are not selecting from the pool of the best available employees. Retention is also a factor when the best employees look down the line for promotion opportunities.

MANAGEMENT CONTROL PRACTICES – KEEPING THINGS UNDER CONTROL TRAINING

        Training is an essential tool in ensuring that employees understand their jobs and perform them in a safe and efficient manner. Training may also be required by law for some occupations. Unfortunately, in the realm of finding ways to control losses, training is often regarded as the “silver bullet.” Training is relatively cheap to purchase, develop and provide in comparison to other, more effective measures that eliminate or reduce the hazard because these types of controls may be more difficult to apply.

        In workers’ compensation, general lift training (lift with the legs and not with the back) is ineffective. The science of biomechanics demonstrates that you cannot teach a 125-pound home care provider to safely lift a 300-pound client from a bed to a wheelchair without mechanical assistance. In fact, research conducted by the Veterans Administration and others to develop patient handling algorithms and teaching scenario specific transfer techniques, such as bed to wheelchair transfers, resulted in, at best, only a slight reduction in the risk of injury. Findings from the research led to the development of “zero lift” policies being implemented in hospitals and nursing homes across the country. Unfortunately, these policies are more difficult to implement in the home healthcare environment.

        If all client transfer tasks cannot be engineered out, training needs to focus on task specific techniques based on best practice methods.

WRITTEN PROCEDURES AND DOCUMENTATION

        Company policies and practices designed to achieve client satisfaction, and prevent losses, are worthless if not verified. Document everything. In the event a situation end up in front of a judge, “if it wasn’t documented it didn’t happen” is all too often the deciding factor in assigning liability. Procedures and related documentation should address:

• Physician orders
• Care plans
• Verification that care plans were discussed with the client, family and caregiver
• Any physical hazards
• Observations made at visits regarding changes in the client’s physical condition or psychological state. Document notifications to the physician and/or family
• Anything that interrupts or prevents the ability to provide services contracted for. This could include hazards around the home, threats from family members, dangerous animals, or patient refusal to accept services.
• Any situation where there was an injury or suspected injury to the client, your employee or anyone else

SUPERVISION

        The organization should have specific practices in place to routinely evaluate both customer satisfaction and employee potential for client abuse and injury to themselves or others. In addition to scheduled performance evaluations against established criteria, another approach is to periodically contact the client and their family members. What you discuss should be recorded.