HCM 700 Module 3 Milestone One Example

Milestone One: Breaking the Turnover Cycle at Willow Creek Care Center, Problem Statement and Literature Review

[Student Name]

Southern New Hampshire University

HCM 700: Healthcare Administration Capstone

Module Three Milestone One

[Instructor Name]

[Date]

The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.

Milestone One: Breaking the Turnover Cycle at Willow Creek Care Center, Problem Statement and Literature Review

The organizational assessment found that Willow Creek Care Center's weak ratings, losses and high rehospitalization rate share a common root in workforce instability. This milestone defines that problem precisely, states the capstone's purpose and question and reviews the research on turnover, agency staffing, retention and avoidable hospital transfers. The review is organized by theme and gives particular attention to studies whose findings conflict.

Problem Statement

Willow Creek Care Center, a 120-bed nonprofit skilled nursing facility, lost 94% of its nursing staff to turnover last year, with nearly half of departing aides leaving within 90 days of hire. To cover 22 vacant aide positions, it spent $1.9 million on agency staff, 21% of nursing labor costs, contributing to a 3.1% operating loss. Workforce instability is associated with a two-star rating, 14 inspection deficiencies and a 25.8% short-stay rehospitalization rate, and it limits admissions. Without intervention, the cycle of turnover, agency cost and declining quality is likely to deepen.

Purpose and Capstone Question

The purpose of this capstone is to design an affordable, evidence-based workforce and quality plan that reduces turnover and agency dependence while lowering avoidable rehospitalizations. The guiding question is: which combination of retention, staffing and clinical strategies, feasible within Willow Creek's finances, would most reduce nursing staff turnover and agency use over three years while improving resident outcomes?

Scope and Assumptions

The capstone focuses on certified nursing assistants and licensed nurses, who account for most turnover and agency spending. It does not address dietary, housekeeping or administrative staff. It assumes the Medicaid rate will rise only modestly, that the regional labor market will remain tight and that the board will consider using reserves for a multiyear plan if the case is strong.

Search Method

PubMed, CINAHL, Business Source Complete and Google Scholar were searched for studies published from 2000 onward using combinations of nursing home, skilled nursing facility, turnover, retention, certified nursing assistant, agency, contract staff, consistent assignment, minimum staffing and rehospitalization. Priority went to large multi-facility studies, systematic reviews and trials. Of about 140 records screened, 31 were read in full and 18 are central to this review.

Theme 1: Turnover and Quality

Research consistently links turnover with poorer care. Castle and Engberg (2005) reported that facilities losing more aides, practical nurses and registered nurses scored worse on a range of quality indicators. Gandhi et al. (2021), using federal payroll data for nearly all U.S. nursing homes, found average annual nursing staff turnover of about 128% and that star ratings sagged as turnover climbed. Bostick et al. (2006) concluded from a systematic review that higher staffing levels, especially of registered nurses, were associated with better quality. These studies are observational, so they cannot prove turnover causes poor quality, but their consistency across decades and data sources is persuasive.

Theme 2: Agency Staffing

Castle (2009) examined nearly 3,900 nursing homes and found that about 60% used at least some agency staff and that lower agency use was strongly associated with better quality for both aides and registered nurses, with clinically meaningful differences at the highest levels of use. The mechanism is plausible: temporary staff do not know residents' routines, preferences or baseline condition. For Willow Creek, where agency hours make up 18% of nursing time, the literature suggests that reducing agency dependence is a quality strategy as well as a financial one.

Theme 3: Why Aides Leave

Castle et al. (2007) linked nurse aides' job satisfaction to both their stated intent to leave and actual turnover, identifying satisfaction with supervision, workload and rewards as important. Squillace et al. (2009) described the National Nursing Assistant Survey, which gathered the views of about 3,000 aides nationally and was designed to inform policy on recruitment, training and retention. Together, these sources suggest aides leave for reasons that facilities can influence, including supervision quality and workload, not pay alone. Willow Creek's exit interviews, which cite unsafe staffing, schedules and lack of recognition along with pay, fit this picture.

Theme 4: What Helps Aides Stay

Castle (2013) studied consistent assignment, in which aides care for the same residents most days, and found it associated with lower turnover and absenteeism. Consistent assignment also builds the familiarity that the agency literature suggests matters for quality. Other retention strategies, such as career ladders, peer mentoring and predictable scheduling, appear often in practice reports but have weaker research support. A plan built on them should therefore include careful local measurement.

Theme 5: Staffing Standards

Bowblis (2011) studied state minimum direct care staffing requirements and found they raised staffing levels and were associated with better performance on some quality measures, particularly in facilities that had been below the new standards. Harrington et al. (2016) argued that existing standards were too low and called for higher federal minimums. A federal minimum finalized in 2024 was later blocked and then rescinded, so Willow Creek cannot rely on regulation to set its staffing and must make its own case to its board.

Theme 6: Avoidable Rehospitalizations

Mor et al. (2010) documented how often Medicare patients bounce from a skilled nursing stay back into the hospital within a month, roughly one in four, and how much those returns cost. INTERACT, a program of tools and training to help staff recognize and manage changes in residents' condition, has been evaluated twice with differing results. Ouslander et al. (2011) reported a 17% reduction in hospital admissions across 25 facilities in a six-month quality improvement project, and a 24% reduction among the 17 most engaged facilities. Kane et al. (2017), however, in a larger randomized implementation trial, found no significant overall reduction in hospitalizations, with benefits limited to facilities that used the tools extensively.

Making Sense of the Conflict

The INTERACT results are less contradictory than they first appear. The early project involved volunteer facilities with intensive facilitation, while the randomized trial measured the program as it was implemented in ordinary conditions. Both point to the same lesson: the tools work where staff actually use them, and staff use them where they are stable, trained and supported. For Willow Creek, this means an INTERACT-style program is unlikely to succeed while turnover remains near 94%, so workforce stability should come first.

Evidence Summary

Table 1 summarizes the central studies, their designs and their implications for the capstone.

Table 1. Central Evidence and Implications

Note. Appraisal by the author.

Gaps in the Evidence

Few studies test retention strategies in randomized or strong quasi-experimental designs, and fewer still measure their financial return. Most research uses data from before 2020, when labor markets were different. And little is known about how best to combine strategies or in what order to introduce them. The capstone plan will need to be explicit about which elements rest on strong evidence and which require local testing.

Implications for the Solution

Five implications follow. The plan should target turnover as the root problem. It should focus on the first 90 days, when most aides leave. It should address supervision, workload and schedules alongside wages. It should use consistent assignment to build stability and familiarity. And it should add a rehospitalization program only once staffing stabilizes, with close monitoring of how thoroughly staff use it.

Conclusion

The literature supports the assessment's diagnosis: turnover and agency dependence are associated with poorer care, and aides leave for reasons a facility can influence. Evidence on specific retention strategies is thinner, and the INTERACT studies show that clinical programs depend on a stable workforce. Milestone Two will design the solution and implementation plan on this foundation.

References

Bostick, J. E., Rantz, M. J., Flesner, M. K., & Riggs, C. J. (2006). Systematic review of studies of staffing and quality in nursing homes. Journal of the American Medical Directors Association, 7(6), 366-376. https://doi.org/10.1016/j.jamda.2006.01.024

Bowblis, J. R. (2011). Staffing ratios and quality: An analysis of minimum direct care staffing requirements for nursing homes. Health Services Research, 46(5), 1495-1516. https://doi.org/10.1111/j.1475-6773.2011.01274.x

Castle, N. G. (2009). Use of agency staff in nursing homes. Research in Gerontological Nursing, 2(3), 192-201. https://doi.org/10.3928/19404921-20090428-01

Castle, N. G. (2013). Consistent assignment of nurse aides: Association with turnover and absenteeism. Journal of Aging & Social Policy, 25(1), 48-64. https://doi.org/10.1080/08959420.2012.705647

Castle, N. G., & Engberg, J. (2005). Staff turnover and quality of care in nursing homes. Medical Care, 43(6), 616-626. https://doi.org/10.1097/01.mlr.0000163661.67170.b9

Castle, N. G., Engberg, J., Anderson, R., & Men, A. (2007). Job satisfaction of nurse aides in nursing homes: Intent to leave and turnover. The Gerontologist, 47(2), 193-204. https://doi.org/10.1093/geront/47.2.193

Gandhi, A., Yu, H., & Grabowski, D. C. (2021). High nursing staff turnover in nursing homes offers important quality information. Health Affairs, 40(3), 384-391. https://doi.org/10.1377/hlthaff.2020.00957

Harrington, C., Schnelle, J. F., McGregor, M., & Simmons, S. F. (2016). The need for higher minimum staffing standards in U.S. nursing homes. Health Services Insights, 9, 13-19. https://doi.org/10.4137/HSI.S38994

Kane, R. L., Huckfeldt, P., Tappen, R., Engstrom, G., Rojido, C., Newman, D., Yang, Z., & Ouslander, J. G. (2017). Effects of an intervention to reduce hospitalizations from nursing homes: A randomized implementation trial of the INTERACT program. JAMA Internal Medicine, 177(9), 1257-1264. https://doi.org/10.1001/jamainternmed.2017.2657

Mor, V., Intrator, O., Feng, Z., & Grabowski, D. C. (2010). The revolving door of rehospitalization from skilled nursing facilities. Health Affairs, 29(1), 57-64. https://doi.org/10.1377/hlthaff.2009.0629

Ouslander, J. G., Lamb, G., Tappen, R., Herndon, L., Diaz, S., Roos, B. A., Grabowski, D. C., & Bonner, A. (2011). Interventions to reduce hospitalizations from nursing homes: Evaluation of the INTERACT II collaborative quality improvement project. Journal of the American Geriatrics Society, 59(4), 745-753. https://doi.org/10.1111/j.1532-5415.2011.03333.x

Squillace, M. R., Remsburg, R. E., Harris-Kojetin, L. D., Bercovitz, A., Rosenoff, E., & Han, B. (2009). The National Nursing Assistant Survey: Improving the evidence base for policy initiatives to strengthen the certified nursing assistant workforce. The Gerontologist, 49(2), 185-197. https://doi.org/10.1093/geront/gnp024