McKnight’s Guest Column: Bundled Payments

McKnight’s is a leading skilled nursing industry news source that I’ve written for in the past.  This is my first guest column since moving to the REIT side of the business.  We meet with investors and analysts a lot and one of their most pressing questions lately is around bundled payments/comprehensive care for joint replacements (CJR) so I wrote about my take on it for McKnight’s.  Click on the article below to read the full text.

Dave Sedgwick McKnight's CJR Skilled Nursing article

 

Or read it below …

“What’s your take on bundled payments?”

About a year ago, investors and analysts would occasionally ask us some form of that question. Now, virtually every time we talk with investors, analysts, and bankers, they ask. At the end of answering questions on the topic for 45 minutes during one of these recent meetings, the investor laughed and incredulously said, “So, basically you’re the only ones saying, ‘No big deal. Nothing to see here. Business as usual.” Well, yes. And, no.

There’s a lot of hand-wringing in the post-acute world these days as observers try to predict just how material the constant changes to reimbursement will be for the operators. It seems generally believed that bundled payments expansion is a net-negative for the industry since it partly exists to lower Medicare payments. There will be “losers” who don’t adapt to the changes. But, there will also be “winners.” There always have been. As a former operator and current investor in the space, I have a positive view on what these changes mean for the profession.

Context Is Key

Viva-La-Evolution

I entered the skilled nursing profession as an administrator-in-training at The Ensign Group in California in 2001. Back then, one of the first themes I picked up on from the seasoned ED/DNS/DORs around me was that, “this isn’t your grandmother’s nursing home anymore.” “No, you see, while we still provide long-term custodial (I will always hate that term) care, we now specialize in providing short-term rehabilitation for Medicare and HMO patients.”

For the last 15 years, the best operators have been adapting to the demands of the hospitals (higher acuity, readmission rates), CMS (MDS/RUGS changes, 5 star ratings, compliance), and HMOs (shorter length of stay, case management, collaboration).

“So are you worried about this Joint Replacement thing?

On April 1, 2016, the Comprehensive Care for Joint Replacement (CJR) went into effect in 67 markets. Briefly, the CJR holds the participating hospitals financially responsible for the episode of care from the day of admission until 90 days later for major joint replacement or reattachment of lower extremity joint replacements (LEJR), hips and knees. If a hospital can lower the cost of that 90 day episode of care below targets set by CMS, they will reap the financial rewards with a bonus. The opposite is also true. Some warn that allowing hospitals to waive the required three night hospitalization before discharging CJR patients to SNFs rated 3 star or better will crush the 1-2 rated facilities. Others warn that hospitals will be incentivized to send CJR patients directly home with Home Health, bypassing SNFs altogether, because of the cost savings. In my opinion, these predictions have been overblown. The sky is not falling.

Now sing it with me … “You Tell Me That’s It’s Evolution”

evolution-darth-vader

I understand why outside observers worry that this as a seismic shift for skilled nursing (and HH for that matter). How, then is CJR not the end of the world for post-acute facility providers? Again, I see CJR as a positive step for post-acute care because it advances trends that level the playing field for stronger operators, ultimately benefiting the patients. Here’s what I mean.

  • Length of stay: HMOs have been pressuring SNFs to shorten length of stay for many years. The last facility I personally ran was 100% short-term rehab. Our combined Medicare/HMO average length of stay was in the mid-teens. Strong providers have been equipping themselves to shorten length of stay for years. They will employ similar practices on these LEJR Medicare patients that they have been using on HMO patients, thus gaining CJR market share from those who don’t.
  • Case Management/Data Reporting: Try competing in a market where your competitors employ the hospital Discharge Planners as part-time Social Workers on the weekend or pay kickbacks for referrals. What? It happens. Today. I’ve competed against it. The only way we could “level the playing field” was to be BETTER. We had to build strong, data-driven (readmission rates, satisfaction scores, survey results, clinical outcomes) relationships with the hospitals that earned our admissions. We had to reach out to hospitals years before ACOs or BPCI to “show them the data!” How does CJR impact this? It should put a vice on the unethically influenced placement of patients and make the market for post-acute patients more merit based. For the many hospitals that didn’t care about their post-acute discharge system, now they will. Stronger operators are poised to gain CJR market share because of it.
  • CMS Star Rating: As soon as the star ratings came out years ago, we complained because the system doesn’t necessarily reflect quality care. In the short-run, hospital may use star ratings in their discharge calculus. But, they’ll evolve as well. SNFs who are 1 or 2 stars can still receive joint-replacmenet patients. And, here’s the thing, patients who are ready to be DC’d from the hospital after a night or two have already been heading home with HH for years. Patients that have to go to the SNF have an initial hospital stay past 3 days anyway.
  • Readmission Rates: At the end of the day, the cost of caring for that patient for 90 days depends greatly on whether or not the patient is readmitted to the hospital. Hospitals are going to be very sensitive to which post-acute location gives them better odds of not having a re-hospitilization. Where would you send them? To the strong SNF provider with 24-hour RN coverage, a medical director, in-house therapists, wound care professionals, etc. or the patient’s home with her elderly husband to care for her in between the hour or so/day she gets from HH. Both graphics below from Avalere, show hospitals the need to partner with SNFs with the lowest readmission rates. It’s no wonder CMS is adding readmission rates to the star rating system this summer.

Screen Shot 2016-03-27 at 3.09.39 PM Screen Shot 2016-03-31 at 3.49.54 PMWhile there may be a slight tightening on the flow of LEJR patients for the general industry (only for 67 markets for now), the strong providers will be able to capture greater share of that theoretical smaller piece. But, let’s not forget the rest of the pie! Sometimes it seems that outside observers focus so much on the joint-replacement piece of the patient pie that they forget a few key points:

  • SNFs are taking care of sicker and sicker patients every year (the kind that absolutely require 24-hour nursing care)
  • Seniors demographics haven’t changed. The numbers of SNF-age patients is growing and will continue to grow for many years to come. While a piece of the pie might shrink, the overall pie will be expanding for years to come.
  • As a general rule, the highest Medicare reimbursement occurs at the start of the SNF stay, sometimes “stepping down” towards the end. So, as providers shorten length of stay, they may see a slight increase to their average medicare reimbursement rate.

So, What?

So, what does this all mean for investing in skilled nursing real estate? It has always been true that in healthcare real estate, the operator matters most. The playing field has been changing for the last 15 years. BPCI/CJR actually has the potential of slightly leveling the playing field in behalf of stronger operators. BPCI/CJR can’t be ignored and should be a factor in underwriting acquisitions. Higher lease coverages and cap rates are in order for facilities with lower star ratings and higher readmission rates as those metrics become more and more impactful on a provider’s ability to shift patient mix and capture short-term rehab market share.

Today (and tomorrow), more than ever before, your SNF real estate investment will hinge on the quality, sophistication, and culture of the operator running it.

Love, Part 3: “This isn’t for you”

I’ve written about Pat Lencioni’s books before.  Really good stuff.  Weighted heavily towards the so-called soft stuff.  The same stuff, I believe, that creates separation from the pack and great companies.  I bring him up because the last two posts about “love” in the workplace or “love” as a leader remind me of a story he tells.  I think its a good illustration of what I tried to convey in Part 2

Pat’s POV — January 2014
When Meg Whitman Loved Me

No, this is not a tabloid headline. It’s a true story, and not a steamy one.

It was more than twenty years ago, long before Meg Whitman became the CEO of Hewlett–Packard, or candidate for governor of California, or CEO of eBay. I was just out of college in my first job as a research analyst for the management consulting firm, Bain & Company, and she was the lead partner on one of the projects I was working on, which made her something of my boss.
As a senior in college, I had decided that management consulting sounded really interesting. Management had always fascinated me, and being a consultant seemed like a wonderful way to help people. It was a perfect fit. So I applied for one of the most coveted jobs available to me and my classmates, and somehow was hired.

After about eighteen months on the job, Meg invited me to her office for a meeting. She said something pretty close to this: “Pat, I think you’d be a really good partner some day, but I don’t think you’re a great analyst.” Meg wasn’t one for fluffy conversation or saying things she didn’t mean. I knew that she was being sincere about both of her comments, and while I was simultaneously flattered and wounded, I was a lot more wounded. But I had to confront the fact that in the competitive world of big consulting firms, I was not on the fast track, and needed to find a new track.

Looking back and understanding my Myers–Briggs and DiSC profiles, I can see that I was never cut out to be a research analyst (I’m an ENFP and a high I and high D). My attraction to management consulting had to do with the work that partners did, but the only way to rise to that level in a big firm was to be better at quantitative analysis and number crunching than my peers. Meg made clear what I already knew, even if I didn’t want to admit it: I wasn’t ever going to love or be good at that kind of work.

I won’t say that I took the news easily. I certainly didn’t stand up and hug Meg (I don’t remember her being a big hugger). I probably agreed with her assessment a little sheepishly, and slinked back to my cube to begin pondering the future of my career (which would eventually take a new turn that has been a great blessing in my life). As I look back at that moment today, I realize it may have been the kindest thing anyone did for me in my career.

Let me be clear. I’m sure that Meg didn’t particularly enjoy having that conversation with me. But she did it anyway. She was gracious enough, direct, and most important of all, honest. And that’s a form of love. Love is not an emotion; it is a verb. What Meg did is take responsibility for helping me, regardless of whether she felt like it or how it would make me feel about her.

More leaders need to understand the power of honest feedback, because they would better serve their organizations and the people who work there. Keeping people in jobs or situations that are not suited to them is almost never an act of kindness, even when intentions are good. In most cases, it only prolongs suffering and prevents the pursuit of a better life. That’s not an argument for abruptly dismissing people who need to move on, but rather an invitation to have difficult conversations that give them clarity early and help them begin to take responsibility for their own success.

Ultimately, kind but direct feedback reduces the number of painful and expensive surprises that too often result in lawsuits for companies and personal scars for employees. If this seems like a simple message, that’s because it is. Unfortunately, this kind of love is all too rare.

So here’s to loving our people enough not just to hug them, but to tell them the kind truth. And here’s to Meg (I promise not to hug you).

Yours,
Pat Lencioni

You can read/follow Pat on his website here: https://www.tablegroup.com/pat/povs/

Love, Part 2: Wuv, Twooo Wuv

princess bride marriage love

In my last post, I talked about how important it is for leaders to not allow a void of communication to be created.  I want to drill down a bit on this with what and how we fill that void. I certainly didn’t intend to say in part 1 that we should only praise or shower people with love. What I believe is that we, as leaders, need to communicate honestly, clearly, directly, and … kindly. Depending on the employee’s performance, those conversations can be threatening, rewarding, or stabilizing.

“Tough Love” is really a misnomer.

If you really care about the individual as a person and you see him/her as a human being with hopes, dreams, fears, and responsibilities every bit as important as your own, you see beyond the job or task they may be failing at.  You see them and their happiness.  Nobody is going to thrive, over time, if they’re in a job that’s a poor fit with their strengths, values, and/or desires.

Here’s a real-life example (some details have been ‘vagued’ out to protect the innocent) …

“It’s evident to me that you’re unhappy here.  I say that because I’ve observed that in your demeanor but I also have some new concerns about the work you’re doing (Here’s what I’ve observed: X, Y, and Z).  Job satisfaction and job performance are usually pretty connected so I’m not surprised to see things that concern me on both fronts at the same time.  Life’s too short to spend most of your waking hours doing something you’re unhappy about or find unfulfilling.  If this is something you really want to do, then I will do everything within my power to help you be successful at it.  What are your thoughts?

[Whoa.  Do I answer him honestly?  He’s not attacking me, but he’s also forcing me to deal with the issues that I’ve been trying to avoid.  Do I answer him honestly?]  

I think the answer to that question, Do I answer him honestly?, depends a lot on your intent as a leader.  If your intent is to “performance manage out” this problem child, that will come across.  You may not think so, but sincerity is something that is really hard to fake.  If someone is being genuine with us we can generally tell, can’t we?  It’s a feeling we get.  Let’s continue with the feedback conversation:

In order for you to really be successful here, though, I’ve got to see the following changes (1, 2, 3).  Here’s the thing, I want two things.  I want you to be happy and I want you to be happy here.  And, because that’s what I want, I’ll do everything I can to help you be successful.  I’ll be more clear about my expectations.  I’ll follow up with you about your progress and I’ll listen to your concerns.  I won’t hold back my opinions.  IF, however, you disagree with my concerns and counsel and therefore disregard it, I can pretty much guarantee we’ll be having a difficult discussion like this again very soon.

The choice is completely yours.

To me, that conversation shows true love (twooo wuv as he says in Princess Bride).  We’re deceiving ourselves when we avoid the honest and direct conversations with employees.  We’re not being more kind.  We’re not doing them any favors.  We’re actually doing more harm than good.

The longer you wait, the harder the conversation becomes.

Don’t wait.  If you make it a common practice to give direct, corrective feedback as close to the issue as you can, you bring clarity to your team and you avoid mole hills turning into mountains.  Show the love.  Don’t wait.  Tweasure your wuv.

Love, Part 1: “Have I told you lately that I love you?”

 

 

Who knew that Rod Stewart was such a management guru?  He doesn’t look like one.  But let’s judge the man by his words not his appearance, huh?

Rod_Stewart_and_Ron_Wood_-_Faces_-_1975

 

“Have I told you lately that I love you?”

And with that simple question, Rod does more good in the world of “performance management” consulting than most consultants ever could.

Have you ever wondered what you’re boss was thinking about you and/or your performance?  I have.  I’ll get to that in a second.  I was speaking with a colleague the other day whose performance over the course of the last 24 months has been staggering.  As a new leader in the industry he has assembled a team, collaboratively defined its vision, elevated care and customer service, and has achieved fantastic financial, clinical, compliance, and regulatory results.  Can I paint a more successful picture?

And yet, after another record breaking month of results were posted, he was concerned that his boss wasn’t happy with him.  Why?  Because he hadn’t emailed him or called him to comment on his performance.  It had been a few months now.  No thank you.  No Attaboy.  Silence.  So, instead of appropriately celebrating or feeling satisfaction, this top performer’s strongest emotions were concern and doubt.

I experienced something similar several years ago.  My boss was on the road almost all the time.  Not only that but he had the weight of the organization on his shoulders and hundreds of people wanting a piece of his time.  As the weeks, then months went by I tried to just give him (AND MYSELF) the benefit of the doubt …

I’m sure he would call or email me about my performance if he had any concerns.

I know he’s just really busy.

He hired me because I don’t need the supervision or direction.

But, given enough time, its natural to FILL THE VOID with the worst case scenario.

I began to do what my colleague was doing.  I began to not only doubt my boss’ appreciation of my work but I began to doubt if he thought my role was even important to the organization.  After all, if nobody’s talking to you about your work (good or bad), your work must not be that important to people.

The benefit of the doubt turns into the TYRANNY OF THE DOUBT.

Maybe its just me and my colleague, but I don’t think so.  I’ve had people I’ve managed express similar feelings during overdue conversations with me as well.

A few months ago, I kept missing a 1:1 with one of my department heads.  Things kept getting in the way.  One postponement after another.  Sure, we’d talk briefly in our daily department head meeting or in the hallway but we missed quality 1:1, focused time to talk about her department (employees, goals, challenges, etc.)  When we finally met, I told her how impressed I had been by her improvements and resident/patient satisfaction I was seeing.  She was stunned.  She fought back the tears.  You see, she thought I was avoiding her because I was unhappy with her.  I had inadvertently created a void and she filled it with the worst case scenario.  Shame on me.

As leaders, we can way too easily fall victim to the illusion that silence creates.  “All is well.”  We can forget that even (especially) our top performers need regular feedback. Ironically, too often we spend an inordinate amount of time with under-performers at the expense of quality time grooming, coaching, rewarding, and recognizing those whose work we rely on so very much.

Let’s make the time.

–> Let’s set reoccurring appointment reminders on our calendars to reach out and fill the void with true conversation that builds loyalty and reaffirms mission.

McKnight’s Guest Column: Show Me The Money!

Happy Thanksgiving!  I just realized that another guest column was posted to McKnight’s.  This topic of whether or not staff should EXPECT a raise with their review came up when a friend of mine, Josh (new administrator) asked my opinion about it.  His question reminded me of when a CNA taught me a valuable lesson years ago at my first facility … You can read the entire article by clicking HERE or on the article image below.

Guest Column for McKnight's regarding annual reviews and raises
Guest Column for McKnight’s regarding annual reviews and raises

McKnight’s Guest Column & Attack of the Killer Email Monkeys

I recently wrote a guest column for McKnight’s that was apparently really well received according to their editorial staff.  You can read the article here:

McKnight’s Guest Column: The “Leading Cause of Death” of LTC Leaders

There are several really good comments at the bottom.  One comment, along with my reply, I’ll post here below.  I literally had this very same Q&A yesterday with a colleague who is fighting to get a handle on his workload/monkeys and establish a stronger method of follow-through.  Here’s the back and forth for the comment and I’ll include a little more from my email exchange with my colleague …

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Avatar
TryHaggis
2 days ago
Dave, nice job. Speaking as a casualty (or fatality) of this very issue, I can attest to the principles here 100%. I’m always curious about what people use to “know” their monkeys, tasks, etc. Given the close relationship between time management & monkey management, have you discovered a great time management tool / system that effectively discharges monkeys?

Avatar

A colleague of mine shared with me his secret for seeing his EMAIL MONKEYS a few years back. And this usually takes a bigger leap of faith, but it is HUGE for my ability to SEE my monkeys and act quickly on them. “A monkey is whatever the next move is when dialogue between two parties ends,” right? Therefore, emails become a massive collection of monkeys.
So, here’s what I do … I delete EVERYTHING that doesn’t REQUIRE a response. My Trash folder becomes my massive archive if I ever need to review an email from before. I TRY to keep my inbox below 10. I have 8 in there right now (I have 24,985 in my Trash Folder). Again, I delete everything that doesn’t require a response, a next move. So my inbox are only monkeys that need my attention. I’ll sometimes put on my calendar an email/monkey to address if it can’t be done immediately or if I’m in the middle of other more important things. It gives me a tremendous sense of control and organization.
I breathe/sleep easy knowing that I don’t have monkeys hidden in an inbox of 10,000 emails (those hidden/forgotten monkeys are the ones that undermine my credibility with people who are WAITING forever for me to respond). I do not use folders to organize emails from So-And-So or emails on a certain topic. I’ll use Evernote to record emails on a certain topic of a project I’m working on. Folders are just more hiding places for monkeys. It could take a weekend to thin out your inbox depending on the size. So, you may just want to rip off the bandaid and delete everything older than two months and thin from there.
I go into more depth here (caution: don’t click unless you’re really interested in the “nitty gritty” of handling monkeys AND I’m fully aware what works for me won’t necessarily fit you): Monkey Nitty Gritty or “It’s About Time”

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.

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

A Leader’s Downfall (mine)

One of the most frequently asked questions I get regarding new facility leaders is …

‘Why do they stumble or fail?’

While we can ‘see’ what’s going with a struggling leader (analysis paralysis, mistaken priorities, taking on too much, bad hiring, inattention to details, etc.), it’s practically impossible to discern what’s really going on in one’s heart/mind/motives that might be causing the shortcomings we see … unless, of course, I’m talking about myself.

My first facility was in AZ and was a ‘beast.’  Huge campus.  Tough part of town.  Tough patients/residents.  Horrible reputation (newspaper named it the 2nd worst facility in the state shortly before I arrived).  And, I was brand new.

Here’s a sample of why I refer back to my time in AZ as Desert Storm …

  • Evening call at home: Hi Dave.  I think you should come in.
    Why is that?
    Scott’s (patient’s name has been changed) passed out on the floor.
    How can I help?
    The police want to know why he’s got a homemade crack pipe next to him.
    I’m on my way.
  • Evening call at home: Hi Dave.  I think you should come in.
    Why’s that?
    Because I just worked a double, and I’m not working a triple and my replacement isn’t here and I’m going home so you need to find someone to replace me.
    I’m on my way.
    (Repeat that phone call about 20 times in the first few months)
  • Evening call at home: Hi Dave.  I think you should come in.
    Why’s that?
    Because they’ve got the place surrounded.
    Pardon me?
    Yeah, the Burger King across the street got burglarized and they think he’s in the facility someplace.
    I’m on my way.
  • Call from the nurses station: Dave, can you come help?
    What do you need?
    You can’t hear that?
    (I hear screaming in the background)
    I’m on my way.
    I see a 30-something patient screaming at the *bleeping* grandmas to get out of his way so he can get his pain medication.  He continues to yelling profanities at my nurses who are trying to explain why the MD has indicated that he has to wait a few hours in between doses.  I escort him away as he’s screaming at me in my face and threatening bodily harm.
  • Nurse walks in my office: Dave, we have a problem.
    What’s that?
    Jose is missing.
    Jose?
    Yeah.  Jose, from our locked unit is missing.
    Locked unit.  Right.  Locked.
    Dave, if we don’t get to him in the next couple hours, he may die (it gets hot in Arizona)
    We canvas the entire area/neighborhood for 3 hours – extending the radius every 30 minutes.  No luck.  After 4 hours I’m about to call the media (local news) to have them run a picture of him so people can find him – thus, debunking the myth that we’re the 2nd worst facility in AZ.  Clearly, we’re the 1st worst.  I receive a call from an ex-employee who says Jose is sitting in his living room.  He recognized him and invited him in.
    I’m on my way.
  • Phone call: Hi Dave.  This is Dr. Thornton
    Hi, how can I help you?
    I’m just calling to make sure you’re aware of the sexual activity in the facility?
    (Now curled in the fetal position) Tell me more.
    Right.  So … a couple of my male patients in Assisted Living say that they occasionally have relations with a female patient from the SNF side.
    Right.  Thanks, Doc.  We’re working on that one …
  • I walk in my office and there’s a couple waiting to see me.
    How could you let that happen to my mom last night?
    I’m sorry, what happened?
    Nobody called you?
    No (the one time I don’t get a call) I’m sorry nobody called.  What happened?
    Your *bleeping* nurses gave my mom insulin last night when she shouldn’t have and almost killed her.  She’s at the hospital now in ICU and the doctors aren’t sure she’s going to make it.  What kind of place are you running here?
    (I had no idea)

And, that was just week #1.

That’s a small sample of stories from Desert Storm.  9 months after starting there, I was dismissed.  When people ask me why I was let go there, I usually say flatly, ‘failure.’  That’s true on one level.  But, the WHY behind the failure is something that I learned months later.  I was given a second chance.  A fresh start.  A Do Over.  I was really lucky.  Although burned out and pretty much over skilled nursing after 9 long months, I accepted the merciful gift of a second chance and lived a very different story at the subsequent 2 facilities.

With a bit of distance from the storm, I was able to see more clearly in the mirror.  I wasn’t happy with what I saw.  I call it the dirty under belly of my motives.  I realized that at the core of my mistakes, problems, failures was pride.  Let me explain …

The type of pride that motivated me in AZ was that I wanted to be seen as the best leader they ever had.  Any time, in your heart of hearts, you want to be seen as, viewed as, admired as, thought of as, believed to be, etc. you’re doomed to fail.  When you make decisions, like I did, to be liked/popular instead of making decision based on what needs to be done because it’s the right thing, period, you’re going to fail.  Period.  It was that desire to be liked and highly esteemed that led to the outward signs of failure: analysis paralysis, second guessing, not saying ‘no’ enough, etc. that my partners saw.

When you combine that dirty little under belly of pride with the inherent insecurity that comes from your first facility … yikes.

I changed my style (and motives) at each subsequent facility … becoming more and more assertive and demanding — setting higher and higher expectations.  Requiring more and more of my staff in terms of customer service and quality care.  The irony, of course, is when I replaced my interest in popularity with interest in excellence, the esteem of my staff took care of itself (not to say I was beloved by all.  Not at all).

I see different versions of that same theme in a lot of brand new administrators.  Proverbs 16:18 warns that “Pride goeth before destruction, and a haughty spirit before a fall.”  If you’re lucky, you’ll learn the easy way this lesson that I learned the hard way (and seem to need to re-learn over and over).

And … for those of you who made it this far, a tribute to all of our spectacular professional ‘wipe outs …’

Honesty, Humility, & Domino’s Pizza

We’ve all had those moments when a truly unhappy, disappointed, angry customer lets us have it. Many of you run operations that have poor reputations (earned over the years one unsatisfied patient/resident at a time). How do shake the bad rep? How do you deal with the consistently negative feedback? Domino’s Pizza demonstrates some keys to taking the criticism, owning up to it, empowering their people to fix it, and inviting the customer into the solution.

Some key takeaways:

  1. Listen to the criticism
  2. Own up to it
  3. Empower your best people to solve it
  4. Invite the customer in on the solution

Because our daily plates are so full (pardon the Pizza pun), we often see complaints as To Do items.  We see our dealing with them (ie, calling back the complainer) as things we have check off a list.  I assume that’s how Domino’s treated the complaint about cardboard crust for years.  “Someone write this guy back.”  I’m not sure what woke them up to just how bad the problem is, but I assume it was the numbers.  Is it safe to assume that their numbers finally caught up to their poor quality?

The wisdom, of course, is to recognize that for every 1 complaint there are 10+ more people who feel the same way.  Let’s act with more urgency to see the complaints not as isolated incidents but as a choice EXCUSE to own up to our systemic deficiencies, empower our best people to solve it, and to invite our residents and patients in on the solution.

What Domino’s did here makes me want to try their pizza again.  I’m a straight Pepperoni guy myself.