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”

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).

Secret Service

One of the biggest complaints in hospitals and nursing homes is how long it takes to get the help you need. A fanatical commitment to world class service is the right way to solve this symptom. AND, there’s a way to cut call light/wait time in half while improving morale between direct-care staff — join the secret service!

Picture it … you’re a patient recovering from surgery. You are experiencing severe pain. You push your call light for the nurse. 3 minutes later, a nurse’s aide walks in and asks what you need. She tells you that she’ll go get the nurse for you. Unfortunately for the nurse aide and for you, the nurse is in her secret hiding spot in the facility where she can actually get some of her documentation done. The aide looks up and down the hall. No nurse. She goes to the med cart. No nurse. How is the aide feeling toward the nurse? More importantly, how are you feeling about the aide, the nurse, and the whole facility?

The best solution I’ve found to that (and hundreds of other) scenarios is a pretty simple technology that the secret service uses to protect the president. And … of course, we have a lot of fun telling the hospitals, doctors, and prospective residents that “if it’s good enough for the president of the United States, it’s good enough for our residents.”

Imagine having each of your nurses and aides with the secret service ear piece in one ear while they work. Then, that scenario above plays out like this … you ask for pain meds. The aide immediately presses her microphone button under her scrubs and says, “Roxanne, Mr. Jones needs a pain pill.” (Everyone hears that in their ear) Roxanne — in her secret hiding place — responds on her undercover mic, “Tell him I’ll be right there.”

Let’s do the math together to drive the point home:

Let’s take a 99-bed facility with 90 residents (high acuity). The day shift has the following in nursing: 5 licensed nurses, 10 nurse aides, 1 RNA. How many times during her shift does the nurse or CNA look for someone for assistance (ie, help with transfers, pain pills, showering, ADLs, wound care, room change, etc., etc., etc.)? Let’s say 20 times. On average, how much time does it take to find the person you’re looking for? Sometimes 20 seconds. Sometimes 10 minutes. Let’s say 5 minutes. Now let’s do the math …

– 16 staff in nursing x 20 searches for help x 5 minutes per search = 1,600 minutes/60 minutes = 27 hours.
LET THAT SINK IN! On one shift alone, your nursing staff is spending a collective 27 hours “looking for someone to help.” It’s insane! That equals:
– 54 hours/day (treating the next two shifts like one day shift due to fewer staff)
– 68 days/month
– 818 days/year

If you really want to pull your hair out, calculate the wage cost of that “looking for someone to help.” When I show this to Directors of Nursing, they have heart attacks. If your nursing staff/DNS is pushing back at all to the idea, do that math with them and you’ll see a change of heart. Just think of how much more care can be delivered if you had 54 hours/day more of nursing time available?!

The radios & headsets we use have benefited us in several ways …
– improved communication between nursing staff
– more efficient use of our time
– created buzz in the patient & labor market
– eliminated the hated/annoying overhead paging

Externally … this has been HUGE for us in our community for marketing. The DC planners, doctors, vendors, etc. are thrilled that a SNF is so progressive/pro-active to this very common problem in healthcare. If you preach/market customer service as your distinguishing characteristic and are able to back it up with the secret service ear piece action … buzz, buzz, buzz.

Post a comment/question or email me to find out more details about this solution. I have no vested interest in any technology solution provider by the way. I just can’t imagine delivering healthcare any other way anymore.

"Buy A Bus"

In October of 2004, we acquired a facility in Orange County, CA. It was there that the idea of “becoming the Ritz Carlton of skilled nursing facilities” first struck us …

A couple weeks before we took over the facility, the Dept. of Health called us in to their office to talk. It was there that we first realized what type of facility we were getting … a train wreck. DHS informed us that it was among their worst facilities in the county in terms of complaints and surveys (annual inspections). When I asked them why they thought it struggled so much for so long, their response surprised us … mainly a problem of geography – that our affluent area limited the number of strong employees.   When I asked what they recommended, they said “buy a bus and bus them in from Santa Ana and Anaheim.” After years of “dealing” with that facility, DHS saw buying a bus as the most feasible option.  What immediately followed, ALMOST made me take up their advice …

A few weeks after we took over, DHS showed up for our annual survey. And, in keeping with tradition, we failed it. Fines, penalties, and denial of payment for new admissions … not to mention the stress in preparing for a re-survey.  By the start of the second quarter, we were in the hole and tired. Looking back, that thrashing was really necessary to “prepare the soil.” Because of that experience, we were desperate not to repeat the same failure year after year and we started looking for what would address these pains we were feeling:

– Survey/Department of Health
– New Management
– Growing Census
– Feeling “Stuck” (internally & externally)
– What makes our building different from our competition?
– Recruiting
– Staffing
– Morale
– Financial Stress
– Survival Mode
– Customer Complaints

I think most SNFs experience these to one degree or another. We just happened to feel them all intensely at the same time 🙂

We identified something that would, theoretically, address all of those pains — and we found it at a training offered by the Ritz Carlton hotels. I attended their training that summer of 2005 in Los Angeles and was blown away. The initial skepticism (“We don’t look or smell like a Ritz”) and (“Their customers actually chose to be their customers — unlike our patients/residents”) started to melt away as the day went on. My “yeah but” turned into “I wonder if” to “why not?” In addition to the Ritz, we studied Disney and the Four Seasons …

We knew that radical change/commitment would be needed in order to become the ritz carlton of SNFs. But, frankly, we couldn’t see any other way out. We developed our own framework — including our Mission, Employee Promise, Motto, Customer Communication Guidelines, Service Definition, Guardian Angel Program, and Standards. We also developed training modules for each of these which included a test at the end of the training that every employee/and new hire had/has to pass in order to continue employment.

I’ll go into more detail later about the model … but, the results have been awesome as we’ve seen major improvements in the following:

– Staffing/Recruiting
– Reduced Complaints
– Improved Surveys
– Reduced Turnover
– Stronger Reputation & Census
– Provided hard, written standards to hold staff accountable and promote excellence
– Improved communication flow through Q Shift stand-ups
– Improved Financial Performance

What sounded good/right on paper turns out to be good/right in practice in this case. No remodel, re-landscaping, re-naming, re-anything could have the powerful impact on an organization that a fanatical commitment to world-class customer service standards can and does.

I hope this blog will serve both you and me to discover proven strategies and principles to bust out of the mediocrity in healthcare and achieve world class results.