Research has uncovered common threads of quality impacts among the largest hospices nationwide as providers employ a range of initiatives to uproot the underlying causes of staff and family caregiver dissatisfaction.

Strong communication, streamlined operational processes and an encouraging organizational culture are three significant drivers of positive end-of-life experiences for families and staff alike, according to Diana Franchitto, president and CEO of HopeHealth.

Taking this three-pronged approach to growth can help drive both retention and quality, Franchitto stated.

“Patients, families and staff benefit from really sticking to good internal operating processes,” Franchitto told Hospice News. “We have a very rigorous review of our processes that has really helped us. We’ve had staff mention that having tight, strong processes is a satisfier. Our multidisciplinary teams wholly depend on one another for the benefit of their patients, so having open communication is critical to strong caregiver satisfaction as well. Those processes drive workflow protocols, so it allows staff to have a sense of urgency in getting to our patients quickly, which is really critical to strong caregiver satisfaction.”

Established nearly 50 years ago, Rhode Island-based HopeHealth provides hospice, palliative care, and dementia and grief support services in Massachusetts and in its home state. The nonprofit has narrowed the focus of its retention initiatives toward reducing staff turnover.

HopeHealth’s retention initiatives have included establishing a steering committee to help guide the organization’s internal processes. The committee has aided in the development of standard operating procedures related to the organization’s referral and admission processes, clinical guidelines, and billing and revenue cycle management.

HopeHealth recently lowered its staffing vacancy rate to 5.4%, after initially setting a goal of under 8% of all positions organizationwide. Having a low vacancy rate has improved the hospice’s clinical capacity and helped with timely access for patients and their families, Franchitto said.

Other sticking points for retention and quality have been a focus on developing organizational culture and encouraging employee engagement and staff recognition, she added.

“Probably the most important challenge for hospice leadership to address is the balance between staffing and your bottom line,” Franchitto said. “There’s nothing more unnerving and unsettling to a team than not having enough staff to care for patients. There needs to be a commitment to making sure teams are appropriately staffed. And, from an employee perspective, having a palpable sense of mission, culture and purpose is really important. It’s leadership recognition of the seen and unseen things that they do while caring for terminally ill patients, and it’s a hard job.”

Insufficient staffing a large quality challenge

HopeHealth ranked second in caregiver and employee satisfaction in a recent study published in the American Journal of Hospice and Palliative Medicine (AJHPM). The study examined areas such as pain and symptom management, emotional and spiritual support, communication and respect.

The research examined Consumer Assessment of Healthcare Providers and Systems (CAHPS) scores among 50 of the largest hospice providers across the country. Researchers employed a natural language processing methodology which dug into various caregiver and staff online review channels such as experiences provided in Google reviews and employee feedback from Glassdoor.

Insufficient staffing was among the common reasons for lower quality ratings, according to AJHPM researcher Jason Hotchkiss, who is part of the psychology faculty at Cornerstone University. Hotchkiss is also an author, chaplain and psychologist.

“Staffing is so vital to all of this. If your staffing is insufficient, people are not going to get timely help,” Hotchkiss told Hospice News. “And that’s one of the most alarming things that has come out of this data analysis. Poor staffing was a common complaint among more than 20% of for-profit hospices and about 5% to 6% of nonprofits, so it’s a chronic issue. That means hospices have to work harder at keeping their employees and keeping them happy.”

For families, dissatisfaction may be tied to a lack of understanding around the nature of interdisciplinary hospice services, Hotchkiss stated. The data analysis found that many family caregivers did not have clarity or held misconceptions about hospice, which led to unmet expectations, he explained.

The research findings indicated that hospices have room for improvement when it comes to public education and clear communication with patients and their families, according to Hotchkiss.

“The most important thing that can be done at the bedside is to make sure the patient and family are not extremely distressed when providing information,” Hotchkiss said. “It’s that caregiver conference with the family that allows hospices to clear up unrealistic expectations and confusions about how they’re going to help manage symptoms. There’s a whole breadth of needs that humans have, spiritually, emotionally and it’s listening to people to guide how you care for them.”