Mothers in long-term care

I was asked to speak in church today.  Mother’s Day.  No pressure.

As I prepared for my talk, I remembered a classic, inspiring, true story of a taxi driver who picked up somebody’s elderly mother late one night to take her to a hospice facility.  It didn’t end up fitting into my talk, but I wanted to share it here.  I’ll be sharing it with the staff at the two facilities in Denver I’ve been helping with this week.  Enjoy.  And, pass it on.

“Twenty years ago, I drove a cab for a living. One time I arrived in the middle of the night for a pick up at a building that was dark except for a single light in a ground floor window.

Under these circumstances, many drivers would just honk once or twice, wait a minute, then drive away. But I had seen too many impoverished people who depended on taxis as their only means of transportation. Unless a situation smelled of danger, I always went to the door. This passenger might be someone who needs my assistance, I reasoned to myself. So I walked to the door and knocked.

“Just a minute,” answered a frail, elderly voice.

I could hear something being dragged across the floor. After a long pause, the door opened. A small woman in her 80’s stood before me. She was wearing a print dress and a pillbox hat with a veil pinned on it, like somebody out of a 1940s movie. By her side was a small nylon suitcase.

The apartment looked as if no one had lived in it for years. All the furniture was covered with sheets. There were no clocks on the walls, no knickknacks or utensils on the counters. In the corner was a cardboard box filled with photos and glassware.

“Would you carry my bag out to the car?” she said. I took the suitcase to the cab, then returned to assist the woman. She took my arm and we walked slowly toward the curb. She kept thanking me for my kindness.

“It’s nothing,” I told her. “I just try to treat my passengers the way I would want my mother treated.”

“Oh, you’re such a good boy,” she said. When we got in the cab, she gave me an address, then asked, “Could you drive through downtown?”

“It’s not the shortest way,” I answered quickly.

“Oh, I don’t mind,” she said. “I’m in no hurry. I’m on my way to a hospice.”

I looked in the rear view mirror. Her eyes were glistening.

“I don’t have any family left,” she continued. “The doctor says I don’t have very long.”

I quietly reached over and shut off the meter. “What route would you like me to take?” I asked.

For the next two hours, we drove through the city. She showed me the building where she had once worked as an elevator operator. We drove through the neighborhood where she and her husband had lived when they were newlyweds. She had me pull up in front of a furniture warehouse that had once been a ballroom where she had gone dancing as a girl.

Sometimes she’d ask me to slow in front of a particular building or corner and would sit staring into the darkness, saying nothing.

As the first hint of sun was creasing the horizon, she suddenly said, “I’m tired. Let’s go now.”

We drove in silence to the address she had given me.

It was a low building, like a small convalescent home, with a driveway that passed under a portico. Two orderlies came out to the cab as soon as we pulled up. They were solicitous and intent, watching her every move. They must have been expecting her. I opened the trunk and took the small suitcase to the door. The woman was already seated in a wheelchair.

“How much do I owe you?” she asked, reaching into her purse.

“Nothing,” I said.

“You have to make a living,” she answered.

“There are other passengers.”

Almost without thinking, I bent and gave her a hug. She held onto me tightly.

“You gave an old woman a little moment of joy,” she said. “Thank you.”

I squeezed her hand, then walked into the dim morning light. Behind me, a door shut. It was the sound of the closing of a life.

I didn’t pick up any more passengers that shift. I drove aimlessly, lost in thought. For the rest of that day, I could hardly talk. What if that woman had gotten an angry driver, or one who was impatient to end his shift? What if I had refused to take the run, or had honked once, then driven away?

On a quick review, I don’t think that I have done anything more important in my life. We’re conditioned to think that our lives revolve around great moments. But great moments often catch us unaware—beautifully wrapped in what others may consider a small one.”

– http://kentnerburn.com/archives/391

Act 2, Scene 1

Take your pick of metaphors …

Shifting gears
A clean slate
Starting a new journey
Passing the baton

 All of those metaphors apply to what I’ve decided to do … help grow a new Ensign-backed venture in a new segment of the healthcare industry: URGENT CARE.

I started this blog in 2007 to share lessons learned the hard way in healthcare administration in the long-term care setting.  I had run 3 skilled nursing facilities in Arizona and California.  Then I was asked to help reshape our Administrator in Training (AIT) program where we select, train, and place around 20 AITs per year.  Having not-too-long-ago gone through my own learning curves/new facility and having a small part in the training of over 100 AITs has given me a unique viewpoint of the ‘new healthcare leader.’ I’ve really enjoyed the platform and really appreciate the many friends, acquaintances, and opportunities that have come from it.  In some cases, it has helped people make the decision to join the industry.  In others, it has convinced people that it’s not for them.

During Q4 of 2010 I was getting very antsy to get back into the thick of operations.  My wife and I flew out to Boston (from California) several times looking at homes, facilities, the industry, etc. to see if I would attempt to open up a new Ensign-affiliated market there.  After 4 months of a roller coaster of emotions, we decided to stay put … I love what I do.  I love who I do it with.  I love where I do it.  Once I put that decision behind me, I re-engaged in a big way and 2011 became for me one of my favorite years at Ensign ever … The eprize! being a key ingredient in that.

2012 started as 2011 ended … incredibly excited about the year and the work on my plate: a re-design of our AIT program (3.0?), eprize! encore?, making HR a bigger force for good, etc.  Then, one morning everything changed …

My friend and colleague, Mike, recently branched away from skilled nursing to take Ensign into Urgent Care.  He met two urgent care industry giants: John Shufeldt and Glenn Dean.  Mike was the catalyst that brought John and Glenn and Ensign together to form a joint venture.  The original plan was to open up a handful of centers in one market.  While that’s still progressing, the ‘plan’ has expanded.  The joint venture acquired Doctors Express on March 1, which is the nation’s first and only franchise system of urgent care centers.  It has currently about 50 centers in 25 states (and counting).  The corporate office is near Baltimore, MD.

John/Glenn/Mike asked/offered me to join them in the joint venture by having primary responsibility for the franchise system.  At first I laughed it off.  It didn’t really register as real or possible.  I was so locked in to what I/we’re doing and have been doing for the last 10 years, I couldn’t really imagine it.  But, after a few days I started to feel like it was the right thing to do … much to my and my wife’s surprise!  What was really shocking was to see her feel the same way.  Whereas the Boston indecision was a 4 month roller coaster, this was a 4 day natural, fast decision.

It’s hard to articulate why the decision came so quickly.  It just felt like the right thing for me and my family.  We’re excited to move to Maryland and have some more elbow room for the family (5 kids).  I’m excited to be back at square 1.  I feel like an AIT again.  Having to learn a new industry — quickly (although 10 years of healthcare management experience helps).  I’m excited to be part of a very small new venture that has HUGE potential.  I’m worried about my ability to be/do what’s needed.  I’m, at times, overwhelmed by everything that needs to happen in a very short amount of time.  For the last couple months, life/work has been running at a frenetic pace.  I’m loving it.

I’ve replaced myself at Ensign someone who I call ‘The Upgrade.”  Talk about luck.  Once everything is squared away for his transition, he’ll be announced.

This Blog …

I’ve decided to continue this blog for the time being.  The title of “Transforming Long-Term Care” will have to change to something else.  But, I expect that the lessons I continue to learn the hard way in urgent care management will translate to any/all healthcare leadership as has been the case with the skilled nursing stuff.  I hope you’ll continue to value the thoughts, experiences, links, and mistakes I share here going forward.

On to Act 2 …

Act 2, Scene 1

EnsignPrize! – judging behind the scenes

This has been one of my favorite weeks in YEARS in skilled nursing.  I’ve had the privilege to judge, in person, some of the finalists of the eprize in California and Colorado.  Below are a few photos from my time behind the scenes.  Unfortunate realization … I didn’t have many regrets about my time as an administrator until this week.  Seeing the great work that these leaders have inspired in their staff has been humbling.

Serious Tilapia. Administrator say, “Dave you don’t have to eat it all.” I say, “I wouldn’t if I didn’t want to. This is great.”
“Cheesecake Factory” quality cream of broccoli soup.
Wouldn’t believe it if I didn’t see it. Alzheimer’s facility in Colorado that I was afraid of years ago when we acquired it. Now, didn’t want to leave. What a great feeling. These people have become legit experts in meeting the needs of the cognitively impaired. There, “behaviors” is a bad word. Quote: Behaviors are simply unmet needs.  To have 8 residents with extreme dementia peacefully sitting together engaged in meaningful activities compared to how it was years ago was jaw-dropping.
Organic garden w/ help from local organic gardeners. Chef uses the produce in soups, dishes all the time. Residents help cultivate/grow.

The EnsignPrize! home stretch

At Ensign’s 2011 annual meeting I spoke about some personal feelings re: hitting 10 years with the organization and in skilled nursing. It was a time of deep reflection. It was then that I developed some of the thoughts I’ve shared here about burn out, empathy, and a hunger to do more after surviving industry-common career crushing experiences. Some of those thoughts are found here.

As “luck” would have it, while I was in that very reflective mood, I was hit by some new, related ideas during a couple early morning rides. I love to listen to NPR podcasts during those runs/rides and back then I listened to a Freakonomics podcast that was like lighting a fuse in my mind. When I got to the office that morning, ideas started to crystalize, as seen on my whiteboard:

I don’t expect you can follow the train of thought there. But, with the help and input of my colleagues at Ensign, what started as some 10-year angst turned into the eprize! … our organization’s $150,000 competition to transform the industry by transforming the day-in-the-life of our residents. At that 2011 annual meeting, I shared with my friends and colleagues the story of how the idea of the eprize! was born and then challenged them to run with it. And … they did.

The executive directors and directors of nursing upped the ante to $150k and all agreed to put money into the ‘pot’ from their own facilities to fund the award. For more details about the competition and why we did it the way we did it, see this “halftime talk” I gave to the organization about it:

Well … the applications are finally in and uploaded onto the EnsignEprize.com website and the contestant facilities are lobbying their communities hard to have them ‘vote’ for their application. The eprize! award winner will be announced in early April. As I’ve read through and watch the videos of some of the applications I’ve gotten emotional to see the small and big improvements in the systems we use to care for our residents and patients with more dignity, humanity, and choice. I hope you take a minute to go to the website and see what we’ve been up to for the last year as a group. And, please, by all means … share this with your friends. Better yet, challenge your own organization to do something similar!

Nursing Home Institution vs. Resident Centered Approach

The Next 10 years …

This all started about 2 months ago when my wife and I were on a walk, talking about my short career in long-term care.  I marveled that I had been with the same company (The Ensign Group) for 9 years.  AIT-Administrator of 3 facilities-AIT Program/Leader Development/Support guy …

That walk/talk stimulated a lot of reflection in what I want out of my next 10 years.  A strong desire (maybe need?) has risen to the surface to take my (and our company’s) experience and do something transformative with it for the benefit of today’s and tomorrow’s long-term care residents.  That could sound a little quixotic (side note: Don Quixote: One of my all time favorite stories/inspirations and a great motivating tool for staff) but I think it’s actually a pretty common experience for people in long-term care.  As I looked in the 9 year mirror I see myself on this curve:

Empathy Curve in Healthcare
Empathy Curve in Healthcare

 

As an AIT I started out like most — fired up, wanting to treat each resident like family, eager to learn and improve this embattled industry.  The empathy I felt was very high.  Feeling sorry for a lot of the long-term residents who had no family support.  Feeling a bit shocked at the scene of a resident being wheeled down on a PVC pipe roller chair to the shower room covered only with a sheet — leaving a trail of diarrhea.  Feeling nauseated by the smells during certain procedures.  How do I, having never worked in a nursing home before, get used to that?!  Feeling pretty impotent to change things for the better until I learn why they’re done this way in the first place.  What have I gotten myself into?

So what happens/happened?

You start to cope.  I suppose we all cope differently.  But as you cope, you ‘fall’ not just on the empathy curve but into a too-casual relationship with the profession.  Some signs of the coping fall …

  • You call Virginia in room 24 bed A by a different name: 24-A, ‘the hip’, Medicare Patient, etc.  This dehumanizing of ‘Virginia’ helps you cope with all of the residents you’ve let down some way.  It also speeds up communication with the others at the facility who don’t really know Virginia.
  • You are less shocked by the sights, sounds, and realities of life as a nursing home resident.
  • You rationalize away your loss of empathy as not a loss of empathy but as a better understanding of why things are always done that way.
  • You spend your time on delivering the things your company measures regardless of how in line with your values or vision those measurements are.
  • You don’t smell the smell that first-timers do.  🙂

You survive for a while and then you begin to thrive.  Your experience and success builds confidence to experiment, to find YOUR VOICE.  You begin to need more than simple survival.  Maslow’s Hierarchy of Needs illustrates a theory of the different levels of human need that you see in yourself as an administrator.  This analogy is a bit forced but you’ll get the idea.

You first need to survive.  That ‘Physiological’ need means you have to not lose your job 🙂  You need to learn, perform to how your measured, fit in, etc.  With some time and success your needs graduate to the ‘Safety’ need.  Here you pass some surveys; you put a team together; you learn from your mistakes; you change your style to be more effective.  You start to float between Safety and ‘Belonging’ as you find some balance in your life. you perform well financially; you’re recognized in your organization as an important partner.  The trouble is … this is the bottom of the Empathy Curve.  You may stay here for the rest of your career, quite comfortable.

Maslow's Hierarchy of Needs
Maslow’s Hierarchy of Needs

But with time, you start to feel a need to do more with what you’ve received.  You feel a need to not only run an outstanding facility, but to transform long-term care in the eyes of the residents.  You wrestle with some tough questions as you confront the brutal facts …

  • What truly makes us different from our competition (in the eyes of the community)?  Wouldn’t our competitors say that they are nice and caring just like we say?  What can only we say about being a resident here that our competition cannot?
  • Is it a significantly better experience to be a resident in my facility than at an average facility elsewhere?  In other words, is sleeping, waking up, getting dressed, eating breakfast, going to activities, going to therapy, receiving medications, etc. a significantly better experience than your average facility?

You feel a higher need pulling you up from the coping gravity to see things (again) from the residents’ perspective.  You are extremely proud of surviving and then succeeding at one of the most difficult jobs anywhere.  You are proud of how you’ve treated your employees (for the most part).  You are proud of the company you’ve helped grow.  You are proud of the facilities that have improved qualitatively and quantitatively under your leadership.  Now what?

Now you feel a new, familiar need to change the industry.  You feel a need to fight the CALF PATHS and the gravity that limits our vision of what we can and should do.

The difference between that need/empathy today vs. when you began is that now you have the knowledge and wherewithal (what a great catch-all word) to do something about it.

There are a handful of companies and leaders in long-term care that are ‘ahead of the curve’ (get it?) when it comes to changing the industry.  BUT, it seems like the movement is way too slow.  One major initiative is the resident-centered approach as illustrated here.

Nursing Home Institution vs. Resident Centered Approach
Nursing Home Institution vs. Resident Centered Approach

I love the concept.  I think it is on target to where we need to take long-term care.  But, the cultural, financial, and regulatory obstacles are real and in many cases prohibitive for an administrator to experiment with.

For my next 10 years I want to work at clearing those obstacles away.  AND, more importantly, I want to figure out how to lessen the slope and duration of the drop and bottom of the empathy curve for others.  Skilled nursing companies have to find the right people, find the right measurements and establish a culture of entrepreneurship and innovation in order to do more than simply survive.  We and our residents ‘need’ it.

Technology, Part 2

In Part 1, I subtly (in huge print) wrote:

We identified a problem.  We looked outside our industry for a solution.  It looks high-tech but is actually low-tech analog.  You might be tempted to do this too.  If you did, you very well maybe throwing your money down the toilet.

Captain Kirk w/ an evolved Secret Service radio

So, before you go Captain James Kirk on me (I don’t refer to Star Trek nearly enough) and start incorporating the latest tech, consider what another Jim says on the subject …

Jim Collins’ Good to Great is used by many companies today for obvious reasons.  Its a compelling premise … what do these companies have in common that went from good to great?

G2G Page 152:

“This brings us to the central point of the chapter.  When used right, technology becomes an accelerator of momentum, not a creator of it.  The good-to-great companies never began their transitions with pioneering technology, for the simple reason that you cannot make good use of technology until you know which technologies are relevant.  And which are those?  Those–and only those–that link directly to the three intersecting circles of the Hedgehog Concept.”

When it comes to the secret service radios I’ve seen facilities throw money down the toilet as they hope for the internal and external momentum described in part 1 from the radios without going through a Hedgehog type conversion BEFORE bringing in the new technology.

BEFORE introducing the ‘math’ or before dreaming of increased census or community buzz that can and has come from the secret service investment, you MUST wrestle together with your staff to identify your identity.  Defining your culture and then drawing a line in the sand CULTURALLY speaking.

That is the basis for the an enduring momentum to build and without it whatever ‘pop’ you experience from the technology will be short-lived and after 3 months your radios will be in a closet somewhere in your facility and you will curse my name.

Idaho Healthcare Association

I thoroughly enjoyed the Idaho Healthcare Association convention in Boise during in  July.

I was invited to speak on how to create your own unique culture within your facility or company.

Thank you to Robert & Jill for the invite and warm welcome.  I was totally impressed with the organization and our colleagues in Idaho … making a difference!

My presentation consisted of a few case studies on the topic.  We discussed what we learned from each and ended with a how-to-map for repeating the steps at your company/facility.

The phrase, “I’m passionate,” is certainly over-used.  Nevertheless, I’m passionate about this topic.  It goes far beyond theory or academics for me.  I’ve seen amazing results from getting serious about owning the culture for myself and for others.  I shared cases at USA Olympic Hockey (The Miracle), The Ensign Group’s (my company) ‘anti-corporate’ office, my most recent facility, and we ran out of time to share the Johnson & Johnson case.  All these cases teach us …

  • The How-To: Pain, Engage, Define, Commit, Flywheel.
  • The culture starts and stops with ‘the’ leader.
  • Cultural transformation requires hard work and pain.  There are no shortcuts.
  • Team chemistry is better than a group of individual all-stars.
  • You have to draw lines in the sand and commit to not cross (or let anyone else cross) that line.
  • Cultural transformation is too-often treated (by the leaders and the employees) like a new program.  Programs fade in 2 to 3 months.  For the transformation to ‘take root’ it must be treated more like a conversion to a new religion.  The most outstanding organizations are those who have a fanatical commitment to their stated culture.
Download presentation PDF here

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.

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.