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.
    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.

Myers Briggs (MBTI) Personality Indicator

  • WHAT: I’m not going to take the time right here to repeat what’s already available.  To understand the basics of MBTI, click here:
  • WHEN: You’re ready to use MBTI with your team when you’re ready to start the very long, hard process of creating a high functioning team.  Don’t bother if you’re looking for the flavor of the month.
  • WHERE: Go offsite.
  • WHY: 2 Reasons … 1) Build Trust on your team and between you and those you lead and 2) Bring the Soap Opera season to an end.1) The foundation for a team to become effective/great is TRUST.  I love the approach Patrick Lencioni teaches in The 5 Dysfunctions of a Team.  Cick here to see his model:  When I work with a team, the first thing I work on is trust vis-a-vis the MBTI.  People who have been working for years together are startled by the things MBTI teaches them about each other.  I’ve found the MBTI to accelerate the establishment of TRUST faster than anything else.2) I’ve found most of the ‘drama’ that walks in my door as a leader is the soap operatic relationship problems among the people I lead.  I’ve also found that USUALLY the source of the drama is a misunderstanding, ignorance, insensitivity to the differences in other’s personalities.  Furthermore, my ability to win loyalty, manage effectively, and inspire is subtly yet totally undermined by my ignorance, inattention, and/or insensitivity to the individual team members’ different personalities.  THE most effective way to solve those people problems is to attack that source of the problems: misunderstanding each other.
  • HOW: There’s a couple ways to go with this.  And, as with all things, YOU GET WHAT YOU PAY FOR.1) Free: You do some research online; you put a powerpoint together on the history, basics, and application of MBTI; you have your team take a free online assessment like this:; you try your best to interpret the results; you try not to do psychological damage since you’re not certified to administer/interpret MBTI results 🙂  Besides the ‘psychological damage’ you cause, you’ll also be spending A LOT of time preparing for the do-it-yourself way.
    2) Expert: Pay a certified practitioner/facilitator.  Depending on the size of your team, you’ll be looking at around $3,000, give or take.  I know of a couple great facilitators.  Contact me if you need a referral.

Here’s a few slides from my MBTI sessions …


MBTI & 5 Dysfunctions Of A Team
MBTI & 5 Dysfunctions Of A Team
Extravert v. Introvert
Extravert v. Introvert
4 MBTI preferences
4 MBTI preferences