1.
Profound change. Sustainable results. 2
Profound change. Sustainable results. 2
Using Rapid Cycle Improvement
to Tackle Turnover
Presented by:
Janet Proctor Burgess, RN, BSN, CENP
Cooper Linton, MBA, MSHA
Duke Home Care & Hospice
Hosted by: Mark Graban
Value Capture Webinar
December 6, 2022

2.
Profound change. Sustainable results. 4
About Our Presenters
• RN for 33 years
• BS in nursing
• Certified Executive Nursing Practice
(American Organization for Nursing
Leadership)
• 20+ years in healthcare
• Co-host of a podcast “Edge of Aging”
• Masters in Healthcare Administration
• Graduate Certificate in Gerontology

3.
Profound change. Sustainable results. 5
Who is Value Capture? www.ValueCaptureLLC.com

4.
Using Rapid Cycle Improvement to
Tackle Turnover
Janet Proctor Burgess, RN, BSN, CENP
Director Patient Care Services Home Health
Cooper Linton, MBA, MSHA
Associate Vice President
Duke Home Care & Hospice/Duke University Health System

5.
Turnover Improvement
75%
19.73%
0%
10%
20%
30%
40%
50%
60%
70%
80%
Percent RN Annualized
Home Health Turnover Improvement
Jun-20 Jun-21
Before
After

6.
Home-based Care and Lean
Very limited penetration of lean principles in home-based care,
i.e. home health, home care, home infusion, hospice.
Challenges and perceived barriers:
• Highly dispersed work force and challenges of “lone workers”
• Incredibly heterogenous and uncontrolled care settings (literally
thousands):
• No standard design or condition for setting of care, i.e. no environmental services,
not ADA compliant, staff safety issues
• Care provider is a “guest” in the setting of care
• No security staff
• No ability to get immediate colleague support

7.
What Does Duke HomeCare & Hospice Do?
Three business lines:
• Home Health: nursing, therapies, social work, aide
• Hospice: In-home, free-standing hospice facility, and in-hospital
• Home Infusion and compounding pharmacy:
• Pharmacists
• Drug compounding
• Distribution warehouse
“Pressure relief value” for Duke University Health System

8.
Lean Timeline and COVID
• Began our lean journey 4-6 months before COVID with tiered huddle,
visual management system, leader training, and leader standard work
• Significant refinement of tiered reporting system during pandemic
• Provided a critical structure for rapid response
• Re-re-re-refining during endemic stage

9.
Symptom: 75% Nursing Turnover
AND Its TRUE Cost
Mission Impact: Mission failure for 2500 patients/year we
couldn’t accept. (Clinical harm)
The “hidden P&L” impact: >$20 M impact in revenue and
expenses
• Est. $4.5 M in annual expense directly tied to turnover
• Est. $17.5 M annual revenue opportunity cost
How would we respond if we received a
$22,000,000+ “turnover” invoice each year?

10.
PLUS Even More Financial Uncertainty…
• the loss of control for “attributed lives” on risk-based payor
relationships.
• the impact on unnecessary acute LOS and lost back-fill revenue for
DUHS.
• the impact of additional emergency department volume for DUHS.
• the impact on our other staff through overburden, dissatisfaction,
staff disengagement, and culture.
• inefficiencies and lower quality metrics resulting in waste.
• reduced care outcome metrics and their impact on value-based
purchasing payments.

11.
Analysis of Turnover
• Clinician Burnout
• Ineffective workflows
• Disengaged team members
• Ineffective Orientation, training and learning
• Leaders not eliciting feedback from front line staff
• Lack of support to front line staff

12.
Ineffective Workflows
• Time and money spent on non-valued added activities
• Increased cost due to uneven work and rework
• Frustration from frontline and leaders
• Staff feeling like their time didn’t mater

13.
Move from Transactional Leader to
Servant Leader
Build open and
trusting
relationships
Build culture of
inclusiveness and
consensus
Empower and
motivate
Focus on patient,
staff and caregiver
safety and
wellbeing

14.
Shift from being the
“Doer” to the “Coach”
• Establish workgroups to address problems
• Include team members doing the work at the front lines
• Allow group members to work through the problem and target
condition
• Do a better job listening and acknowledging
• Provide support and encouragement

15.
17

16.
Eliciting involvement in dispersed and remote workforce
• Use of Humble Inquiry to elicit feedback and identify current condition
• Use of technology to improve involvement in front line staff huddles,
improvement activities and work groups

17.
Why Rapid Cycle Learning?
• Ability to quickly test improvements and evaluate impact
• Encourages continuous improvement
• Provides timely information needed to make
decisions(nimbleness)

18.
Rapid Cycle Learning to Decrease Turnover
• Redesign of workflow towards achieving ideal state
• Reduction of wasteful activities in EMR/documentation
• Orientation process improvements
• Preceptor Learning and Training
• Workload and Productivity modifications
• Communication Improvements

19.
Keys to Rapid Cycle Learning Success
• Leader by-in and support
• Keep track of improvement activities, progress, and results
• Encourage and support engagement from staff at all levels
• Use information analyzed and collected from evaluation of improvement
activities to quickly pivot and make changes
• Use Rapid Cycle learning as a catalysis for continual change.
• Keep all staff updated frequently on improvement activities and outcomes

20.
Rapid Cycle Improvement Impact
• Improved workflows
• Elimination of wasteful activities
• Decreased frustration
• Improved work culture and environment
• Highly trained clinicians
• Decreased Turnover

21.
Turnover Improvement
75%
19.73%
0%
10%
20%
30%
40%
50%
60%
70%
80%
Percent RN Annualized
Home Health Turnover Improvement
Jun-20 Jun-21
Before
After

22.
Questions, Comments,
Observations?

23.
Profound change. Sustainable results. 25
Thank You / Q&A
Janet Burgess
• janet.proctor@duke.edu
Cooper Linton
• cooper.linton@duke.edu
Mark Graban
• mgraban@ValueCaptureLLC.com
More Resources:
Free eBooks, videos, white papers…
www.ValueCaptureLLC.com