Jim Rome, John Wooden, Skilled Nursing “Success”

When I was in High School, my buddies and I listened to a new, up-and-coming, cocky sports talk radio guy, Jim Rome.  He constantly played his verbal trump card against people critiquing successful players/teams.  He would simply respond by saying, “Scoreboard!

Does anyone have a better scoreboard than John Wooden?  The best coach in sport.  Scoreboard? 10 national championships at UCLA.  But, why do I love and respect and listen to the man?  Because of how he won.  Coach Wooden came to mind today because of a conversation with another guy who’s the “best” at his sport, my friend David Howell, a facility CEO for The Ensign Group in southern California. In my opinion, Howell’s one of the best SNF EDs in the country.   It’s almost unbelievable to see what he’s built out of his small SNF in a very blue-collar neighborhood.  His facility won Ensign’s highest total quality award today and he shared with me what he was planning on saying at the ceremony … Wooden, “C.S. Wooden” 😉

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I want to share these two thoughts from a talk Coach Wooden gave and that Howell shared today as well.  But, you really ought to watch the whole talk below.

  1. Winning is not in the definition of success.  Here’s what C.S. Wooden said success is: Peace of mind attained only through self-satisfaction in knowing you made the effort to do the best of which you’re capable. I believe that’s true. If you make the effort to do the best of which you’re capable, trying to improve the situation that exists for you, I think that’s success, and I don’t think others can judge that; it’s like character and reputation — your reputation is what you’re perceived to be; your character is what you really are. And I think that character is much more important than what you are perceived to be. You’d hope they’d both be good, but they won’t necessarily be the same. Well, that was my idea that I was going to try to get across to the youngsters.”

  2. This.  Poem by George Moriarty, called The Road Ahead, Or The Road Behind.”
    “Sometimes I think the Fates must grin as we denounce them and insist the only reason we can’t win, is the Fates themselves have missed.

    Yet there lives on the ancient claim: we win or lose within ourselves. The shining trophies on our shelves can never win tomorrow’s game.

    You and I know deeper down, there’s always a chance to win the crown. But when we fail to give our best, we simply haven’t met the test, of giving all and saving none until the game is really won;

    of showing what is meant by grit; of playing through when others quit; of playing through, not letting up. It’s bearing down that wins the cup.

    Of dreaming there’s a goal ahead; of hoping when our dreams are dead; of praying when our hopes have fled; yet losing, not afraid to fall, if, bravely, we have given all.

    For who can ask more of a man than giving all within his span. Giving all, it seems to me, is not so far from victory. And so the Fates are seldom wrong, no matter how they twist and wind.

    It’s you and I who make our fates — we open up or close the gates on the road ahead or the road behind.”

Congratulations to David, Lito, and the entire Brookfield team.  You’ve been a stunning SUCCESS for many years before winning the Flag today.

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Stooping To Greatness, Part 2

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.

No longer collecting dust on the wall.
No longer collecting dust on the wall.  You can’t make this up.  In the basement of my facility, I was looking around for some equipment.  I turned on the light and saw these artifacts from the prior facility occupants.  I don’t know what caused them to fail.  But they did.  Anecdotally, I’ve seen this play out time and again.  Where there is no vision, the people perish.  Without a vision/culture that actually inspires (or at least captures their hearts and minds), you’re programs become artifacts.
  • 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.Poster-BWC-[Converted]-Outline
    • Poster-BWC-Standards-[Converted]-OutlineAnd, 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:
      1. The Executive Director must be a “true believer(not the regional or the divisional or the owner at the home office)

      2. 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.

Stooping to Greatness, Part 1

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.

Culture Model
My step-by-step, “how-to” reinvent the wheel. If you take your parent organization’s mission statement or use some other company’s culture stuff, you are missing the chance of a leader’s lifetime. There is a POWER that comes from the creative process. Or, the birthing process. What you collectively give birth to becomes your baby. You want to protect it. Nurture it. It becomes your competitive advantage that your competitors cannot replicate.

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.

The Silent Treatment vs. The Iron Chef

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.

The Kitchen's Scoreboard. Fires me up!
The Kitchen’s Scoreboard. Fires me up!  She did way better than I could’ve.  And, she owns it because she created it.

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.

Dave

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Team,

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!

Dave

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Laura/Team,

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.

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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?

The Biggest Bonus I Ever PAID

In a cluster of Colorado facilities I’ve been a part of these last couple months, we’ve been talking about how to create a culture — within our cluster/company and within our facilities.  It’s a topic I feel passionately about and one that I’ve personally participated in at a couple facilities and at a ‘corporate support office’ setting.  I’ve personally seen MASSIVE strides forward as teams dedicate themselves to a deliberate defining, planting, growing, and nurturing of a unique culture.  The process of creating that will be covered in another post.

Part of growing and nurturing a culture relates to where the rubber hits the road or when staff can see you put your carrot or stick where your mouth is.  The most powerful example of that is a story I’ve shared a lot in training settings about establishing a culture — a story of the biggest bonus I ever gave.

Several years ago, my new team and I had just defined our new culture.  Our mission, promise, motto, standards, etc.  It was time to show that it was real.
The culture was starting to do what it’s supposed to do — produce results (clinical and financial and resident/patient satisfaction).  After a solid month, I asked my department heads who “lived the culture in your departments the best.”  I received a handful of names and emailed my payroll manager the following:
On payday, please bring me the paychecks of Maria, Cathy, Jennie, Don, and Debbie. (names have been changed).  I’d like them to pick them up from me directly.  In addition, please create separate bonus checks in the following amounts:
     – Maria: $200
     – Cathy: $500
     – Jennie: $300
     – Don: $1,000
     – Debbie: $150
When payday came, Maria went to the payroll manager to pick up her check.  Here’s what went down …
Maria: Hi, can I have my check?
Payroll: Oh, no.  Sorry.  Dave has your check.
Maria: [struck with concern] But, why?
Payroll: You know … he didn’t say.  But, he wants to give it to you himself.
Maria: No.  Really.  Why?  What did I do?
Payroll: No idea, Maria.
     – Maria did not come to my office.  She spoke with the other housekeepers.  She confirmed her fear … they had all received their checks.  She was worried.  Was she going to lose her job?
     – Finally, after her shift was over, she came to my office.
Maria: Hello, Dave.
Me: Maria, come on in.  Have a seat.
Maria: Ok. Payroll tells me you have my check.
Me: Oh, right.  Yeah, have a seat.  [we sit down and I reach into my desk for her check(s)]
Me: Do you know why I have your check, Maria?
Maria: [Visibly worried] No.  Did I do something?
Me: [Smiling] … Sort of.  But, it’s not what you think.  See, last month was a very busy month here.
Maria: Yes.  Lots of room changes!
Me: That’s right.  You guys were very busy making room for the growing census.  Well, when we get very busy like that, we do better financially.  And when we do, we like to share it with those who were so important to making it happen.  So, last week I asked your supervisor, “who lived our culture [me pointing to the newly defined culture poster on my wall] this last month the best?”  Do you know who he said?
Maria: [Recognition coming to her of pending good news] Maybe me?
Me: Yes!  He said you.  In fact, here’s what he told me about you (related the specifics to the newly defined culture on the wall).
Maria is becoming visibly happy.
Me: So, yes … here’s your paycheck. And, here’s another check. It’s a small token of appreciation for being a great example of what we’re trying to become.
Maria: [she opens the bonus and immediately weeps.  As a housekeeper, she had never received a bonus before.]
We talked about what she’ll do with the money.  She’s SO grateful.  I tell her that compensation and bonuses are confidential so please don’t share this news with anyone.

This happens to be the best way to get the word out 🙂  Why?

= Her colleagues already know she didn’t get her paycheck and they’ll be anxious to hear why she had to get it from me directly.  She’ll tell them.  And, that’s exactly what I hope happens.
I hope that the message spreads fast that you can get a bonus when 1) we do well as a facility and 2) are modeling the behavior/culture we are striving to establish.
It’s the biggest bonus I ever paid as measured by its impact on our facility culture.  Here’s why:
  • Everybody was stoked for Maria
  • Communicating to Maria that she got it because of her supervisor built loyalty between her and her supervisor instead of between her and me.
  • Her supervisor, my direct report, was grateful that I made him look like a thoughtful, generous boss.
  • The staff began to believe that we really were committed to the mission we had collectively defined.

Now … multiply that by the other people who received bonuses that month and the subsequent 6 months and you can see how putting your money where your mouth is will ACCELERATE the momentum we need to as we’re looking to transform or strengthen the facility cultures we’re responsible for.

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!

The Speed of Trust

This is not a book review.

The Speed of Trust is a superbly TITLED book.

The writing itself was a bit too predictable, formulaic, and fluffy for my personal tastes.  I understand FranklinCovey is having success teaching its principles and I don’t mean to disparage the concepts or ideas expressed at all.  Just the opposite.  I believe deeply in what the title of the book, Speed of Trust, means to relationships and organizations.

Think about it in your own life.  I recently did.  Check out the quick back and forth between me and my wife about choosing a family photo to purchase from a recent family photo shoot.  Start from the bottom.

Thoughts?

Here’s how I see this exchange, through the speed of trust lens:

  • Even in the mundane communication(s), love is expressed, setting a positive, supportive, sincere tone.
  • My reply was honest and I thought it would be fun to have the kids ‘vote.’
  • Her response was SPEEEEEDY.  Cut to the chase.  No fluff.  No framing.  No setting the table.  No positioning statements.  Just her true, actual opinion.
How valuable, how precious to an organization or team or relationship to have true, actual, authentic, unfiltered, un-sugar-coated opinions and dialogue?!
If our relationship lacked trust, her response would’ve been very different.  And it would’ve been longer.  Maybe a little something like this …

You know, I really like the idea of printing them out.  I wish I could figure out how to do that myself.  Would you be able to do that for me this evening?  I wish I was as good with computers as you are [read: flattery leading up to a soft disapproval of your opinion to soften the blow] …. as far as the kids voting goes.  I love the idea.  On the one hand it could be really fun to see the differences in how they see the family.  On the other hand it might not turn out exactly as you/we might think/hope it would.  What do you think?  I could possibly see Caleb choosing the opposite of Madi just to be different.  You know what I mean?  I don’t know.  Maybe we can talk about it more tonight before dinner when you get home.  Maybe we could limit it or make it a blind test somehow so they don’t know which one they’re picking.  I don’t know.  You know?  I’d hate to see something that’s a positive possibly turn into a negative.  But, I love the idea of printing them out.  Can you do that for me from work or do you have to be home for that?  Thanks!

xoxoxoxoxoxoxox 

Now multiply the difference in the authenticity and speed of the response by the number of times you communicate as a team in department head meetings, in emails, in 1:1s and you come to realize just how critical it is to MAKE time to develop the trust as individuals and as a team.  A couple of books that I use and highly recommend to others (a lot less textbook feeling than Speed of Trust) are:

Leadership & Self-Deception (best for 1:1 relationship trust repairing/building)

5 Dysfunctions of a Team (best for team trust/dynamics issues)