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

IMG_2505

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

IMG_2506

IMG_2507

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.

image

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?

Advertisements
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.