Working short again?

Healthcare units that are working short because of unplanned absences present performance and morale issues that can directly influence patient outcomes. Given the widespread shortage of skilled healthcare workers, effective staff management has become an absolute must in todays environment, and will likely present the greatest challenge in years to come. Weak leadership style is linked to poor employee morale, which results in withdrawal behaviors that include absenteeism. 

At the Department of Pathology at the Medical Center of Louisiana at New Orleans, we measured the use of unplanned sick leave in our laboratory units and discovered a striking difference between low- and high-performing units. We then adapted a tool called the Unit Climate Profile to measure the leadership climate in our units and found an inverse relationship between leader score and absenteeism. In our lab, we noted that the low-scoring leader was perceived as not respecting the mission core values, not enforcing policies, and not setting a good example. The employees of this unit called in sick at a rate far higher than the average. While we typically measure employee competency, the Unit Climate Profile offers a view of manager competency that could directly affect staffing and unit performance. 

In the summer of 2000, our lab received a complaint of a delayed cardiac panel on a patient in the emergency room. It seems that the result was delayed by more than two hours. We found that the initial result was produced in a timely fashion, but that it required a dilution because the value was out of the reportable range. The dilution was prepared and run, but the repeat result was not released because the bench had been left unattended. The shift was working short an all-too-common occurrence because an employee had called in sick, and backup coverage had not yet been obtained. 

The new focus on human issues

Mounting evidence shows that the management of human resources has become the focus for people interested in quality improvement. The website (www.jcaho.org) for the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) is rich with planning documents and new standards which address the issue of staffing. The most telling of these is a new standard (HR.2.1, effective July 1, 2002), which says that organizations must assess staffing effectiveness by using clinical or service indicators in combination with human resource indicators. The JCAHO is also modifying standards in both Performance Improvement and Leadership chapters to include references to the new standard.

The Institute for Healthcare Improvement (IHI) is also very interested in staffing issues, and it dedicated its 2001 forum to the human side of healthcare. A quote from the forum announcement states, The people who serve patients cannot possibly do that job well unless they, themselves, feel healthy, valued, optimistic, and energized. From the viewpoint of improvement, a healthy workforce is not just an ethical and moral imperative, it is a strategic imperative.

The IHI goes on to say that the new wave to overtake our industry is the staffing dilemma, and its message is a call to action. But what are we to do? We typically measure biological
analytes, but how are we to measure staffing effectiveness and such a fuzzy thing as morale?

What is morale?

Merriam-Websters Collegiate Dictionary says morale is, a: the mental and emotional condition (as of enthusiasm, confidence, or loyalty) of an individual or group with regard to the function or tasks at hand; b: a sense of common purpose with respect to a group.¹ Given this definition, it is easy to understand why people issues have become a strategic must.

Echeverria describes a direct link of morale to leadership, citing that the key difference in leadership lies in the kinds of emotions that it generates people often refer to these emotions as motivation or morale,² he said. Our performance improvement question became one of leadership competency that is, do our leaders promote good morale?

But how do we measure morale?

Numerous studies describe a positive correlation between job satisfaction and attendance.³ Studies show that absenteeism is but one of several withdrawal behaviors that can be predicted by job satisfaction.⁴ With that in mind, our team conducted a comprehensive review of sick leave utilization. Planned medical absences and Family Medical Leave were excluded so that we measured only unplanned (unexpected) sick leave. In other words, we measured the level of calling in sick the kind of event that can result in short staffing. We were interested in unit culture differences, which would point to the managers skills.

In this review, two of our units stood out from the rest, and the variance was striking. In one case, we found a unit that used 61 percent less sick leave than the departmental average, and on the other extreme we found a unit that used 73 percent more sick leave than the average
(Table 1). Expressed another way, the best-performing lab called in sick 1.3 percent of scheduled time, whereas the poor-performing lab called in sick 5.9 percent of the time. The overall lab call-in rate was 3.35 percent.

We were very surprised by these findings, and we were even more surprised that the two units were very similar. Both were specialty units of about nine people that operated only on the day shift, and each lab shared space and ventilation systems with other labs in the study. Our team wondered whether unit leadership might explain the differences, and if an employee survey might reveal the reasons for the disparity in the unplanned sick leave usage. One team member with military experience suggested a tool used in the armed forces called the climate profile.

The Unit Climate Profile

The Unit Climate Profile (UCP) is a method used by Army commanders to assess and establish what they call a positive command climate. The tool deals with morale issues, probing the soldiers perception of the leadership, training, job satisfaction, social climate, food, and morale. In total, the Army measures 21 climate areas and collects data on the soldiers perception by using an anonymous questionnaire. The Atomic Energy of Canada Limited Research has developed a similar tool, called Upward Feedback, to gauge the performance of managers.5 Both the UCP and Upward Feedback tools probe the feelings and perception of employees. We decided to use this approach to see if we could understand the reasons for the sick time disparity.

Questionnaire design

We designed our questionnaire to focus on two areas: issues impacted by unit leadership5 and the overall organizational climate. We wanted to know if our unit managers:

• Exhibited respect for our mission, core values, and policies. 
• Set a good example.
• Enforced policies. 
• Were helpful and respectful of employees.
• Were forward-thinking and open to suggestions. 
• Could tell the difference between honest mistakes and poor performance. 

We were also interested in the perception of the overall organization: We wanted to know if we provided a safe, clean work environment; if the organization was moving forward; and if people were proud to say that they work here. The complete questionnaire is seen in Figure 1.

Our survey consisted of 30 statements, with the first 20 focusing on the unit manager and the last 10 focusing on the organization. Following the Army model, we used a scaled answer sheet . We wanted the survey to be truly anonymous, so the statements were read out loud by a facilitator to small groups of employees. The employee had only to circle the appropriate qualifier to each statement and then seal the questionnaire to ensure anonymity. The facilitator recorded the unit name when the answer sheets were distributed so that no handwriting was required of the employee. In all, we surveyed 100 technical employees, approximately 60 percent of our professional technical workforce.

Scoring 

For each statement, we asked the employee to indicate if the statement reflected his perception always, mostly, moderately, poorly, or seldom. We assigned a numerical grade of 5 to 1 for each answer respectively. An always answer was scored 5, whereas a moderately answer was scored 3, and a seldom answer was scored 1. The average score for the first 20 questions determined the unit manager grade, and the average of the last 10 questions determined the organization grade. By averaging the manager scores from each unit, we determined the manager score and organizational score by units. All grades were then expressed as a percentage.

Results

Unit manager grades are represented in Table 1. Most of our unit managers scored in the range of 71 percent to 84 percent, but two unit managers stood out, one for having a near-perfect score of 96.7 percent and one for having a very low score of 52.8 percent. Not
suprisingly, these were the same two labs that represented the extremes in sick leave usage. We then tested the correlation of the managers UCP score with the current years sick leave utilization and found a correlation of 0.68. One must note, however, that this is not a perfect tool, as unit 8 scored low on the UCP but had the second-best attendance.

The organization scores were more uniform, but generally low, ranging from 46 percent to 65 percent, meaning that the employees generally rated the statements about the organization as moderate when it came to support. The lowest-rated organizational question concerned the work environment (temperature, cleanliness, noise, etc.), which was rated at 2.5 of a possible 5. It is interesting to note that the highest-rated organization question was the question about pride in the organization. Our employees report that they are mostly proud to say that they work here (3.8 of a possible 5).

Discussion

In our laboratory, we identified two very different unit managers. In the best case, the employees report that the manager always exhibits support for our core values, mission, and policies. They report the manager always sets a good example and always enforces policy. Further, they report that the manager is helpful, resourceful, forward-thinking, and respectful. These employees rarely call in sick. The model set by this manager is one that we would like to follow in order to maximize productivity, retain employees, and improve our staffing effectiveness.

In our worst case, the report is nearly the opposite, and these employees call in sick frequently. This is one management model that we do not want to duplicate.

A recent survey of veteran laboratory technologists at our facility indicated that we could lose 27 percent of our workforce to retirement in the next five years. A statewide survey of laboratory workers indicated that 24 percent of the workforce anticipates retiring within the next five years and 47 percent within the next 10 years.⁶ This means that our staffing situation is likely to get worse. 

With severe staffing shortages in laboratories at a national level, we recognize that performance-improvement efforts must be focused on productivity, recruitment, and retention of our most-skilled employees. We see both the UCP and leave-utilization measurements as indicators of lab manager competency, which previously may not have been included in competency assessment strategies.⁷ We believe that manager-competency measurements, like these, can be used to counsel managers, make organizational changes, and ultimately improve morale, attendance, and performance. In our lab, these scores have been delivered to our administrative director to be discussed during personnel evaluations. The scores and absenteeism rates are useful starting places to begin the discussion about the importance of good morale and leadership. Whereas previous competency and training efforts focused on our technical workforce, we suggest that efforts focused on manager competency might be more fruitful.

Daniel Haun, Rita Viviero, Argie Leach, and Gerald Liuzza are all associated with the Department of Pathology at the Medical Center of Louisiana at New Orleans.

References

1. Merriam-Websters Collegiate Dictionary. Available at www.webster.com. Accessed March 14, 2002.

2. Echeverria R. Emotions: At the heart of business practice. Ctr Qual Mgmt J. 1997. Available at
cqmextra.cqm.org/cqmjournal.nsf/reprints/rp08400. Accessed March 14, 2002.

3. Ensman RG. Combating employee absenteeism: What really works. Dietary Manager. February 1997. Available at www.dmaonline.org/articles/97hr6.html. Accessed March 15, 2002.

4. Harrison D, Martocchio J. Time for absenteeism: A 20-year review of origins, offshoots, and outcomes. J Mgmt. May-June 1998;24(3):305-350. 

5. Pinsonnault JF. Grading the bosss performance: Upward feedback process developed by Atomic Energy of Canada Limited Research. CMA. June 1992;66:10-13.

6. Lawrence L, Jarreau P. Effect of attrition on clinical laboratory workforce. Lecture presented at Medical Center of Louisiana; June 12, 2001; New Orleans, LA.

7. Howanitz PJ, Valenstein PN, Fine G. Employee competence and performance-based assessment: A College of American Pathologists Q-Probes study of laboratory personnel in 522 institutions. Arch Pathol Lab Med. 2000;124:195-202.

© 2002 Nelson Publishing, Inc. All rights reserved.