Happy Thanksgiving! I just realized that another guest column was posted to McKnight’s. This topic of whether or not staff should EXPECT a raise with their review came up when a friend of mine, Josh (new administrator) asked my opinion about it. His question reminded me of when a CNA taught me a valuable lesson years ago at my first facility … You can read the entire article by clicking HERE or on the article image below.
I recently wrote a guest column for McKnight’s that was apparently really well received according to their editorial staff. You can read the article here:
There are several really good comments at the bottom. One comment, along with my reply, I’ll post here below. I literally had this very same Q&A yesterday with a colleague who is fighting to get a handle on his workload/monkeys and establish a stronger method of follow-through. Here’s the back and forth for the comment and I’ll include a little more from my email exchange with my colleague …
2 days ago
Dave, nice job. Speaking as a casualty (or fatality) of this very issue, I can attest to the principles here 100%. I’m always curious about what people use to “know” their monkeys, tasks, etc. Given the close relationship between time management & monkey management, have you discovered a great time management tool / system that effectively discharges monkeys?
Yesterday, I ran into an “old” former colleague. It had been years. First thing he said: “How is that we look so old now?” I never liked him. Ha! :)
The truth is that it was great to reconnect. Coincidentally, he’s in the midst of solving some of these same cultural puzzles for his new organization. We talked about Part 1 over lunch.
A couple key points when beginning this new culture adventure …
There’s a huge difference between the sugar-rush, Diet Dr. Culture & Built-To-Last Cultures.
Most staff have seen the Mission/Vision/Whatever that comes down from the Ivory Corporate Tower. They are forced to attend the meetings and trainings, often delivered by corporate types or half-heartedly by facility leaders. During those meetings, they are very quietly grabbing each others hands with a knowing nod: “This too shall pass.” And, they’re right. It won’t last because they (the staff) didn’t give birth to it.
The GIVING BIRTH metaphor.
I’m a guy. I’m no expert. I know. But, I’m a father of 5, does that count for anything?! Here’s the metaphor that fits so well here: Establishing your company/facility’s culture should be like giving birth. There’s power in the creative process. There’s a massive difference psychologically (for buy-in/commitment) if I’m able to participate in defining the culture (expectations, standards, rewards, etc.) as opposed to having Know-It-Alls present it to me. If I go through the “labor“ of wrestling with the words, values, mottos, standards, and behaviors that we want for our workplace, and then the “delivery“ of agreeing to and training new hires in it, then I will be committed to the final product in a way that I simply can’t if it’s presented to me … let me illustrate:
- Several years ago I went through this creative process for the first time at a building I ran in Orange County, CA. Our before and after scoreboard made many in the organization take note and ask me to share our “secret sauce” as we went from worst to first in some key metrics like EBITDAR PPD. I was more than happy to share. It felt like I was on tour as I presented to more than 1/2 of our facilities. I would spend an entire day with a facility’s leadership team – presenting to them the what, how, why, and when of World Class Service, which is what we labeled the culture we gave birth to. The immediate response from those many facility teams was, by-and-large, enthusiastic. They wanted to do the same thing at their buildings. They wanted to do it right away. I gave them our Mission & Standards documents. I gave them our Orientation packet. I gave them our Daily, Weekly, Monthly system for making the culture take root.
And, then I left to the next facility. I hit rewind and repeat. Over and over again. I personally felt tremendous excitement about making a difference beyond my facility. I felt appreciation from ED/DNS partnerships who were looking for that missing thing to take them to the next level. They found it. They believed. And, except for a handful of facilities, most of their efforts fizzed out within 3 to 6 months.Why? I’ve thought a lot about that. Ultimately, I believe two things are absolutely required in order to transform your culture into a transformative force:
The Executive Director must be a “true believer” (not the regional or the divisional or the owner at the home office)
S/he must lead her/his facility through their own creative process. They must reinvent the wheel instead of adopting someone else’s wheel (no matter how successful that wheel made that someone else).
If this is true, then the questions become what, why, how, and when to recreate the wheel. The Birds And The Bees, if you will, of how cultures are made (I couldn’t resist). Culture Birds & Bees. That’ll be part 3 next.
It’s ironic that I spend as much time as I do here and with colleagues on time management. Ironic because I’m not naturally a very organized person. The opposite is true.
I’ve learned the hard way (and the incredibly rewarding way) that the only way I can get to the VERY IMPORTANT x NON-URGENT stuff that will either transform a facility or take it to the next level is to become great at time management.
There’s a great thought in scripture that goes like this: Where your treasure is, there will your heart be also (Matthew 6:21). Adapted to the nursing home administrator, we can say …
What you spend your time on, that’s what matters most to you.
You may protest. You may say, “No, Dave. The reality is I can’t get to what matters most to me because I have to spend so much time on this other stuff that keeps coming at me.” As we climb up to the balcony and look down at our operations and at ourselves, we’ll probably see way too much work that is reactive vs. proactive. Reversing that pattern is what separates the great leaders/facilities from the pack. So …
- First things first = First who, then what. Let’s first surround ourselves with people more talented and driven than ourselves. They’re there. In every position. If we settle for less than “A” talent, we will be settling for mediocrity and burnout.
- Second (simultaneously), get the fundamentals in place. Apply our Daily, Weekly, Monthly system approach to marketing, expense management, labor, clinical metrics/outcomes.
- Third, control the monkeys before they lead to your downfall.
- Fourth (and finally!), you now have time to dedicate to the fine-tuning, pro-active, culture building work that ONLY YOU can lead.
This post is the first of a series that I’ll dedicate to what I believe is the most important work of a healthcare leader: to create a powerful, unique culture.
DOWNLOAD PDF Version Here: Culture Model
The title for this post, Stooping To Greatness, is stolen from a similarly themed article by Patrick Lencioni. I’m a big fan of his books that illustrate simply and powerfully that what matters most to create lasting, quality success is the SOFT stuff. The attention to people and culture.
I asked: How do you know you’re doing a good job?
: No complaints.
I wrote on the white board in front of all the staff: Silence = Approval
I asked: Is that right? Can anyone argue an opposing explanation for silence?
: They’re frustrated. They don’t believe you’ll do anything. They’re tired of talking/asking. They don’t trust you.
Man, I could take this several directions, huh? (That happened about 7 years ago in a very different setting than a skilled nursing facility, but it applies as you’ll see in a bit)
But, the reason for tonight’s post is to illustrate the oft-untapped power of scoreboarding in our skilled nursing facilities.
I get too preachy. So, tonight (while writing at 35,000 feet on my way home to Baltimore), I’ll try to be brief and let the case study do the preaching.
At a recent facility, we had a problem with the food. The main problem was it didn’t taste very good according to our patients. Yep. That’s a problem.
Here’s how scoreboarding helped to fix that …
First, data is power. It’s one thing to have a lot of anecdotal evidence (often by other complaining department heads, second hand). It’s a totally different ball game when you’re able to say, “last month we conducted 70 discharge satisfaction surveys. On a scale of 0-10, satisfaction with food scored a 6.25 while nursing and therapy and everything else scored in the 8s and 9s.”
So, do you do DC satisfaction surveys for all your Discharges?
Now that we have data, we can set objective goals to celebrate successes and judge our decisions by.
I asked our Dietary Supervisor to put up a scoreboard of the things she wants to perfect in the kitchen. Her team needs to be able to see it. There should be Daily, Weekly, Monthly things that get scored. There should be accountability, celebrations, etc. You come up with it. I want to see it up on the wall next week.
In addition to the scoreboard we changed the menu completely and added a few hours to the department each day to allow the cooks to give a little bit more attention and time to their meals.
The dietary department now knew that they were being measured (for the first time) on objective key factors for satisfaction. They knew their supervisor was stressed about the patient satisfaction. They knew their jobs may be affected if they don’t score well too.
But, they had no idea that I cared.
And, the rest of the facility (particularly the department heads) didn’t know that I really cared about this and that the dietary manager was taking this so seriously.
So, I decided to go all food critic on them. I channeled my inner Chef Ramsey. I began to ask for test trays for lunch and dinner. I created my own version of a scoreboard that ended up meaning a lot to them. Why? Because they see that I actually cared. Silence can mean a lot of things to your staff. But, it rarely means what you really intend. We all fill in the void/the silence with our own fears/worries.
After a meal, I would send an email to the entire department head team with my Chef Ramsey Food Critic review. My dietary manager braces herself when she sees an email from me about the meal and shares the usually-good news with her staff right away. I’ve noticed a massive change in the morale and level of engagement of the dietary department — for the better.
Here are some of my reviews …
Laura (and team),
I just wanted to let you know that dinner was great tonight! The ham was moist (it’s really easy to make dry ham) and the taste was really good. Rice done perfectly. Spinach … well, cooked spinach is cooked spinach. The biscuit was tasty too. Presentation was appealing, as you can see. When I went down there to ask for a test tray tonight, I also noticed their scoreboard up in their break room. I LOVE it. Getting food to be loved by so many different palates is a serious challenge. Our scores are sometimes really high. Sometimes really low. We still have a ways to go, but in talking with Laura, I’m confident that we’re headed in the right direction.
Ok … I won’t do this anymore for the whole team (yeah right) but here’s my food critic column for tonight’s dinner at the Sloan’s Lake restaurant.
Tonight’s food presentation was really good again! The chicken … the taste was good but it was dry and chewy. I thought about our patients maybe having a hard time cutting/chewing (don’t know if there’s a way to tenderize the chicken but that would probably help a lot. The mashed potatoes and gravy were really good and masked the dryness of the chicken well. The corn was pretty good and the roll was perfection. The desert was also good. On the sugary/sweet side, but good.
Before and after photos included.
The kitchen is on a roll!
Lunch was very good today. Thought you should know. The meal: cod. The fear: dry and overcooked or undercooked. The result: perfectly cooked. Moist. Layers of fish fell away from each other easily. Flavor? Good. I had to add salt to the whole plate, but would’ve been satisfied without doing so. I add salt to just about everything. Fish could’ve used a little more seasoning since the cod probably wasn’t caught yesterday in Alaska. Nevertheless, very enjoyable. I loved the cous cous and peas and carrots too. The portion of fish could’ve been larger but I’m full after eating everything on my plate. The dessert … some sort of cream puff cake. Ummm, Yum. I had to stop after two bites because I have a wife that I go home to, but it was surprisingly good. As you can see the appearance was also very nice. Hats off to Scott today.
What if I didn’t do this? The whole food critic thing? What would the dietary staff think mattered to me as the Executive Director?
I don’t know. But, I’m pretty sure they wouldn’t think that I cared much for their food or much about their work.
PS: August’s patient satisfaction scores hit 8! The entire staff applauded the kitchen staff at our all staff meeting for their progress this week. I just got the chills. You?
I had never heard that phrase until I got to long-term care. Gotta get your systems in place. Do you have systems in place? Huh?
Our admissions process is broken.
Collections are killing us.
Our falls have increased every month for the past 4 months.
Patient satisfaction for food is low.
Our census is struggling. We’re not really marketing.
I’m not a naturally organized person. In Myers Briggs terms, I’m an ENTP. Much more of a dreamer/spontaneous preference than a structured/organized type. So, when constantly pressed with the notion of having systems in place, I struggled to really get into it. That difficulty caused me problems.
AND, when you combine a natural disinclination for structure with the ignorance of a rookie, my first facility was a disaster.
Or more accurately put, I was a disaster.
It wasn’t until my third facility when a certain light turned on. Turns out to be one of the most important lights to turn on in my career. How to get “systems in place.”
Of course, as you read on you’ll be tempted to think, “Really? You didn’t know this? This can’t be that big of a deal.” Nevertheless, it has been a career changer for me.
Here’s how I can help get systems in place regardless of my experience or knowledge with the “system” or problem or poor outcome we’re trying to solve.
With this framework, I now have a way to solve problems in a systematic way – in a way that will stay solved long-term – regardless of my lack of experience or knowledge.
This isn’t the be-all, end-all. You have to dig deep to the core problem you’re trying to solve. But, once it’s time to set the system in place, you have to have answers for each of the boxes above in order to do it.
In other words, the more answers you have for the boxes in the system framework above, the stronger in place your system becomes.
I don’t need to be an expert in every department in the facility to effectively run the facility. I just need to think critically & satisfy the framework above by asking the experts in the facility questions until I’ve filled in the system framework.
I usually start from the bottom up, with the scoreboard. Stephen Covey famously taught to “begin with the end in mind” and that’s spirit of this. I begin with the outcome we need and who, how, and when we’ll measure and “scoreboard” it. Then, we work our way up to fill it in together with your staff.
That’s it. Hope it helps.
I just heard one of our patients say that. He had been sitting in a chair outside my office for about an hour. Quietly fuming inside.
About an hour earlier, he had pushed the elevator button when a therapist intervened. It went something like this …
Where are you going?
No, you can’t do that.
You have to stay on your floor.
Oh, and why’s that?
Well, because we have to know where you are. We’re responsible for your safety.
Ok. I’ll tell you where I’m going. Outside by the entrance. I want to go outside.
No, you can’t leave this floor. If something happens to you, we’ll get in a lot of trouble.
An hour later, his nurse and CNA both tried to get him to go to the dining room. This time he was resolute. He wouldn’t budge. He called himself a prisoner b/c the staff wouldn’t let him leave. I would’ve been the same way. After a few back-and-forths about whether he would or would not go to dinner or even ever leave that chair, I stepped out of my office and said,
You want to go outside?
They won’t let me.
Who won’t let you?
The people here.
There must be some misunderstanding. They probably meant that you needed to go with someone.
No. They said, “You can’t leave this floor.”
Well … let me see what I can do. [I went to the gym and asked the therapists about him. They were thrilled with the idea of me escorting him outside. They just didn't want him to go alone as he still has a ways to go to get his strength back and is at risk for falling. I came back with the good news. He couldn't believe it.]
We went down together and I pulled the bench into the sun. Gorgeous day. We talked for about 45 minutes. WWII veteran. married to a ‘saint’ for 60+ years. A few kids. He’s the last surviving child of 8 kids in his family. He told me about his ‘crooked’ father in law who died with $500,000 in the bank. We laughed. I teased him. He teased me back. We talked about religion and faith and cashing in his chips after 92 years on the earth. After a while, he said, “Well, is it time for dinner?”
Yeah, are you ready to go back in?
He literally had a large smile on his face when he sat down to eat dinner (after everyone else had already eaten by this time). It struck me as I sat back down in my office how differently that could’ve gone (and sadly too often does) … the nursing/therapy staff get frustrated by the patient’s “behavior” and start to treat him as an object more than as a person. He becomes a problem. Stubborn. ”Non-compliant.” A pharmaceutical intervention is ordered and the man, the WWII veteran, loses a little bit of his identity and dignity and control.
As a facility leader, it’s my role to establish a culture within the facility where that latter scenario is avoided — when it’s avoidable. We have to create a mission, a purpose for our staff that is larger than a paycheck or a task to constantly motivate them to SEE their brother, sister, mother, or father in the eyes of the patient sitting in that chair. I saw the difference tonight in being task-driven/objectifying and human-driven/personalizing.
Our great challenge is to systematically enable our great staff to personalize their residents’ and patients’ experience …