I’m pretty sincere

This video teaches a powerful customer service point – probably without intending to at all.  As I set expectations for the type of experience our patients and residents deserve and WILL receive at my facility, I share this video when talking about the reality of having to meet that standard even when we’re having a ‘bad day.’

I know cars don’t start.  Boyfriends can be jerks.  Kids can be sick.  People can cut us off.  My team could be playing while I have to be at work.  Life can totally get in the way of well … Life.  But, as far as our residents are concerned, they cannot have any idea, none whatsoever, that we are not 100% focused on their happiness, treatment, and recovery.  Does this mean we shouldn’t share our lives with our residents?  Yes.  It means we shouldn’t place our worries and concerns on residents who have serious worries and concerns of their owns.  Like in the commercial above, if we’re having a bad day or we wished we weren’t at work, we cannot let our resident have a clue.  Like the girlfriend in the commercial, she has to know that her boyfriend is sincerely devoted to her.

Don’t get me wrong.  I’m not advocating deception.  I’m advocating a customer satisfaction truth that we are always on stage when we are around our residents and patients.  The ‘floor’ is our stage.  And, no matter how bad your life is today or what great reasons you have to not smile, when you’re on the floor, you’re on stage and, in order to give the resident the best experience and best care, they need to see us at our best.

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Princess Story

Sometimes Usually a story is the best way to both teach a principle and persuade someone to believe it.  When I talk about ‘scripting’ in the facility – meaning there are words and phrases we shall and shall NOT say, I illustrate with a real-life story.  I also use this same story to talk about ‘being on stage.’

When my daughter was 5 years old we took her to Disneyland for the first time.  Like most 5 year old girls, she was totally ‘over’ Mickey Mouse.  Please.  She was there for one reason and one reason alone … to mix it up with her favorite princesses.  It’s all about the Disney Princesses.  Clothes, plates, utensils, tiaras, videos, etc.   It’s a racket.

We discovered that Pocahontas (yes, she’s an official Disney Princess.  Don’t fight it) was hanging out over by the Pirates of the Caribbean.  We clasped hands and booked it!  We were dodging and weaving through the mass of people … and, there she was.  We froze.  Oh my goodness.  She squeezed my hand.  She looked up at me.

Pocahontas ‘on stage’ for my daughter (and son)

There were a few girls in line to meet the princess and take a picture beside her.  My daughter couldn’t move.  She was too scared.  I leaned down and gave her some encouragement.  I promised her she could do it and that I’d take a picture for her.  I told her how sweet Pocahontas is …

She gradually made it to the line and expectantly stared forward.  Finally, her turn.  The Indian Princess greeted her, put her arm around her (and my son who was pretty oblivious to the whole coming of age moment for his bigger sister) and posed for the picture.  The princess asked my daughter’s name and thanked her for meeting her.

My daughter rushed to me and I showed her the picture.  We walked away holding hands and I knew what she was thinking … ‘my dad is the best dad in the whole world!’  Ok, maybe not.  She was probably marveling at her luck to meet the real Pocahontas.

[end of story]

Now, what in the world does that have to do with quality care in a nursing home?  In fact, it is helps me show one of the most important aspects of providing great care … that all of us in a SNF are always ‘on stage’ …

Can you imagine if Pocahontas acted like some of our staff?

Right after I take the photo, Princess P comments to another Disney employee (character)

‘Man, can you believe it?  Snow White called off AGAIN!  I’ve got to go be Snow White tonight.’ OR …

‘There’s too many visitors today.’  OR …

‘I’m going on break.’

Do you see the comparison?  How many times have our residents overheard something similar?

I’ll share a secret with you now … as long as you don’t share it with the wrong people (like my little girl).  Pocahontas is not real.  She’s an employee of Disneyland. Each of us is “on stage.”  Just as Pocahontas was/is.  While on stage, we have to act a certain way.   The little girl would not put up with that.  We are each Pocahontas for our residents.  We must act, speak, and look a certain way while on the floor/stage.  It’s up to us to DEFINE what is expected in terms of our actions, words, and appearance.  If you don’t define it how can you achieve it?

Of course, on those bad days that we all have, we have to “act” a little more than on the good days.  (Here’s a classic video I use to demonstrate this).  Nevertheless, we’ve got to make each resident/visitor interaction count with EVERYONE.

Working-the-floor hazards

In my first facility in Glendale, AZ, I was eager to prove myself as the best leader my staff had ever seen.  One problem with that was … that I wasn’t.  But, I’m getting ahead of myself.  In my AIT program (Administrator in Training) I learned as much as I could about the departments I was to oversee.  But, I failed to dive deep enough into the nooks and crannies of the facility which resulted in insecurity in me, the new leader, when it came to supervising department heads and holding them accountable and teaching them.

So, instead of investing in building a relationship of trust with my department heads who could then, in turn, do the same with their staff, I felt much more comfortable working out on the floor with the line staff.  I would show how much I cared for them and the residents by staying out of my office and walking around.  I would be visible.  I would get to know everyone by name.  I would get to know their lives.  It didn’t occur to me at the time but my department heads resented my behavior.  I’m saying they resented me being visible and out of my office.  We all should do that.  The ED who’s stuck in his office all day becomes out of touch, ineffective, and won’t be employed very long.

BUT … what they resented was that I was spending the necessary time to hold them accountable, invest in our relationship, and help them succeed.  Some of them felt like I was ‘going over their head’ or ‘undermining’ them.  What I learned, the hard way, was that when the ‘line staff’ feel so comfortable with you/me as the administrator, that can threaten their direct supervisor’s relationship with them.  And, their supervisor (your department head) feels it and trusts you less.

It happened to me.  Don’t let it happen to you.

Of course we should know everyone by name.  We should have an open door.  But, we should direct them to talk to their supervisors first before rushing in to solve problems.  And, we should make time, at least once a week, to have a meaningful status review with each department head.  That tweak to my management approach made a huge difference in my effectiveness and results in my next two facilities.

Tail wagging the dog …

A very troubling sign indeed.  For those of you well-versed in the CMS 5 star rating system for skilled nursing facilities, after reading this I’ll bet you say, ‘I didn’t see this coming.’

A nursing home administrator recently told me that his census was in the decline.  It didn’t fall off a cliff.  It’s been a gradual fall.  From an average occupancy rate of about 94%, he’s down to about 73%.  His Medicare census is also down about 33%.  His building is a leader in its market.  What happened?  A major side effect of the 5 star rating system.  Here’s the story …

A relatively new 50-ish bed, all private room facility in the market was unhappy with its low star rating.  The Quality Measure component was killing them. (For a 5 star rating system introduction, check this out.) They reasoned that since the 14 day MDS data was hurting their score, they would simply discharge their Medicare patients on day 14.  Their new message to the market, ‘We have beautiful private rooms and we get you home faster than anyone else.’

Of course they don’t mention …

  • the harm they cause by sending patients home too soon.
  • They don’t publicize what percent of their discharges end up in the hospital again.
  • They don’t emphasize that these medicare patients are being cheated out of their rightful benefit of receiving therapy/care so that they heal fully before going home.

Nope.  Instead, they are sucking the long-term care patients out of the market and everyone else is suffering.  What’s an administrator to do?  How do you compete with that?  We came up with a game plan to go on offense in his market.  The good news is there’s quite a bit he will do and he’ll be fine.  The point of this post is to call attention to UNINTENDED CONSEQUENCES.  I’m sure CMS did not intend for this side effect of the 5 star rating system.  This story proves again that ‘we perform according to how we’re measured.’  A primary concern, therefore, as a leader is to be sure that your measures and rewards promotes the type of behavior you want.  Unfortunately, clairvoyance, isn’t bestowed with title of ‘Leader,’ so we have to be attentive and willing to change our measures/rewards as we discover these things.

Will CMS change the measure to avoid this side effect?  I hope so …

‘Speed of the leader …

… is the speed of the team.’ I heard that phrase for the first time about a year and a half ago when a young, new nursing home leader stepped into his first opportunity to run a skilled nursing facility in San Diego, CA. The opportunity was daunting … the facility was old, beaten-down, beneath a freeway overpass, across the street from a strip club, and competing with some of the best looking and operated facilities in southern california. Takers?


This guy jumped in and ‘owned’ it from day one … running fast. He modeled what he expected and later required from his staff — putting customer service/satisfaction (for residents, patients, doctors, vendors, etc.) above everything but quality care. The census and financial performance naturally followed. A year and a half later, the facility is neck-and-neck with the competition — enjoying clinical, census, and financial success like never before.

The speed of the leader is the speed of the team … is true, but only part of the story.

The speed of the leader and team are both dependent on the quality of care. What this San Diego leader and team had going for them, that many in their situation don’t, is a stellar Director of Nursing and care outcomes. That is basic and fundamental before attempting any radical transformation.

One of the secrets to their success was the personal attention the leader gives to doctor relationships. He, along with his team, work hard to convince skeptical doctors to send them a patient to ‘prove’ the hype is not hype, but true. Once that doctor’s patient arrives, her satisfaction becomes priority #1 which leads to a changed reputation for the facility … 1 MD at a a time.

Thou Shalt Not!

One of the biggest challenges in providing the highest level of service in healthcare is to undo the years of phrases and vocabulary that is so common and so destructive. We’ve all heard the following:

“She’s not my patient”
“That’s not my job”
“The other shift didn’t do it”
“There’s no supplies”
“There’s no time”
“I’m in a hurry”
Etc.

When we started our transformation, we started here … with vocabulary. We introduced Communication Guidelines in the form of “THOU SHALT NOT SAY …” All of the staff could relate to saying or hearing each one of the 10 phrases at some point. Like with all our training, we made it fun/funny as we introduced the new requirement.

Then … we laid down the law. We stated that saying any one of those prohibited words/phrases would be cause for termination. We were serious. We don’t want to lose any of you. Etc.

When we termed a CNA for saying “She’s not my patient,” the entire facility found out about it and realized we were, in deed, serious about the experience our patients/customers receive. After the employee was termed, behaviour changed … big time. There was a noticeable difference in the verbal communication with people in the facility … more polite. More aware.

Everyone’s been told not to say those things before. But, it is the full committment of the leadership of the facility (meaning willing to lose people) that is required to see the change take effect.

Guardian Angels

The Guardian Angel program is a great way to accomplish several objectives at the same time:
* Provide an additional “friend” or contact for the patient
* Get to know the patients better
* Proactively solicit feedback daily from all patients
* Communicate with patients’ family weekly
* Check room for safety

Each department head is assigned as the “guardian angel” for a few rooms. Each day the GA is to visit the residents and patients in each of those rooms with the primary goal to build a good relationship. Get to know the patients, family members, etc. While there, the GA should be checking the room for safety and inquiring about customer service issues.

One great bonus for having this in place is during survey time. When the department of health asks you to arrange for a meeting with the patients of your choice, your guardian angels will be able to provide a broader perspective and deeper knowledge of the best candidates for that meeting due to the daily contacts.

A photo of each guardian angel is placed in the corresponding resident room with a brief description of the duties of the guardian angel (check out example above).