CareTrust REIT

It’s hard to put in words what the last 12.5 years at The Ensign Group have meant to me (though I’ve tried many times to share bits and pieces on this blog) …

20 days ago, Ensign completed the spin-off of its real estate into a new, separate, independent real estate investment company specializing in senior housing & healthcare called CareTrust REIT.

CareTrust Logo Black-02

The CEO of CareTrust is Greg Stapley.  He’s an Ensign founder, primarily responsible for acquiring the portfolio Ensign has today.  Early last year, as we were headed towards a sale of Doctors Express, Greg told me about the plans for the REIT and his likely departure from Ensign to run it.  He asked me to join him.  At that time, I joked that I still had PTSD from the prior 12 months (moving my family to Baltimore to run a business that we ended up selling a year later … and all the accompanying ups and downs) and that I needed time to clear my head before making a long-term decision.

Immediately after the sale of DRX, I went to work for Ensign in skilled nursing operations again in Colorado to fill in for a couple guys who left their buildings in Denver at the same time.  What was to be a 30-60 day interim project turned into an 8 month assignment — that I absolutely loved (except for the commute).  It was GREAT to be back in daily operations, especially with the devoted and talented “Ensignistas” in Denver.  Ensign asked me to move to Colorado and oversee operations there after a short time but I felt like I needed more time to decide.  I genuinely didn’t know what I wanted to do next.

After our relatively short time in Maryland, my wife and I wanted to stay here for many years to come.  By the end of the summer, I had narrowed down the decision to 1) join Greg and build CareTrust together or 2) open a new market for Ensign’s operations here on the east coast.

Ultimately, I concluded that CareTrust was the right course for me and my family.  Even though it’s based in So. Cal. like Ensign, I’ll be the east coast office as we look to acquire senior housing and healthcare properties nationwide.

When it comes to real estate, they say its location, location, location.  But when it comes to skilled nursing real estate, its really operator, operator, operator.  In a way, my role at CareTrust is similar to one of my roles at Ensign for those 5 years I led the new leader selection & training (AIT) efforts.  Ensign’s growth strategy depended on the pipeline of homegrown talent to lead its new acquisitions.  My role(s) at CareTrust will be to build a bullpen of exceptional operators across the country who we can confidently lease our new acquisitions to.  After a couple of operator “interviews” its pretty clear to us that it “takes one to know one.”  I commonly hear, “You’re the only REIT that’s asked us about X, Y, Z (In-house rehab, centralization v. decentralization, RU%, Culture, turnover, clinical support, PPDs, readmission rates, etc.)” So, I’ll be working on operator relations, business development, investment underwriting, and oversight of our 3 operating independent living facilities in Dallas and Salt Lake.

When I made my decision last fall to go to the REIT, I did so with mixed emotions.  I have and will retain deep, meaningful friendships at Ensign.  Today, I’m thrilled for this opportunity to build on what we built at Ensign with new partners, in new places, and in a new way.

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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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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?

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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.

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.

“Systems In Place”

I had never heard that phrase until I got to long-term care.  Gotta get your systems in place.  Do you have systems in place?  Huh?

Our admissions process is broken.
Collections are killing us.
Our falls have increased every month for the past 4 months.
Patient satisfaction for food is low.
Our census is struggling.  We’re not really marketing.
Etc.

I’m not a naturally organized person.  In Myers Briggs terms, I’m an ENTP.  Much more of a dreamer/spontaneous preference than a structured/organized type.  So, when constantly pressed with the notion of having systems in place, I struggled to really get into it.  That difficulty caused me problems.

AND, when you combine a natural disinclination for structure with the ignorance of a rookie, my first facility was a disaster.

Or more accurately put, I was a disaster.

It wasn’t until my third facility when a certain light turned on.  Turns out to be one of the most important lights to turn on in my career.  How to get “systems in place.”

Of course, as you read on you’ll be tempted to think, “Really?  You didn’t know this?  This can’t be that big of a deal.”  Nevertheless, it has been a career changer for me.

Here’s how I can help get systems in place regardless of my experience or knowledge with the “system” or problem or poor outcome we’re trying to solve.

Systems-In-Place
The system tool

With this framework, I now have a way to solve problems in a systematic way – in a way that will stay solved long-term – regardless of my lack of experience or knowledge.

This isn’t the be-all, end-all.  You have to dig deep to the core problem you’re trying to solve.  But, once it’s time to set the system in place, you have to have answers for each of the boxes above in order to do it.

In other words, the more answers you have for the boxes in the system framework above, the stronger in place your system becomes.

I don’t need to be an expert in every department in the facility to effectively run the facility.  I just need to think critically & satisfy the framework above by asking the experts in the facility questions until I’ve filled in the system framework.

I usually start from the bottom up, with the scoreboard.  Stephen Covey famously taught to “begin with the end in mind” and that’s spirit of this.  I begin with the outcome we need and who, how, and when we’ll measure and “scoreboard” it.  Then, we work our way up to fill it in together with your staff.

That’s it.  Hope it helps.

Do you share financials w/ staff?

3 legged stool

 

I am all about analogies.  It’s a curse.  It’s my go-to.  I have a problem.  But, sometimes it really just works.  (I’ll get to it … hang with me).

Nursing Home Administrators are easily seen by their care-giver/clinician staff as only caring about the financial aspects of the facility.  Years ago I became very reluctant to share financial information with my staff out of fear that they would think that’s all I cared about.  I also feared they would mishandle the information.

As though they weren’t sophisticated enough to appreciate the need for the facility to ‘make money.’

So, instead of educating staff on the financial fundamentals and enlisting their help to eliminate waste and be efficient as co-owners of the facility and their departments, we ration out just enough information to get them to do what we want.  We give them a budget for hours or expenses for the month based on our projected census.  They toil away under your close management, trying to hit that budget WITHOUT understanding the larger picture.  I’m not saying that doesn’t ‘get the job done’ b/c in many cases it does.  But, they deserve more.  And with the trust you give them (along with the education), something powerful happens … they come alive and take MORE ownership of their responsibilities.  They take pride in their new understanding and they become more creative problem solvers, now that they see the whole problem to solve and not just their little piece.

Here’s what I’ve concluded …

… if presented properly, sharing the financial realities (challenges and successes) are an empowering, trust-building lever administrators should pull in their management of the facility.

The key phrase, of course, is ‘if presented properly.’  I’ve been burned by sharing facility financial information.  So … the best way I’ve found to empower my staff with this lever is to use the analogy of the 3 Legged Stool.  Here’s how the conversation went at a recent all-staff meeting at a facility that has been losing money ….

Me: What do you think I care most about?

Them: [Thinking: I’m not stupid enough to answer that question … Suspicious smile … long pause]

Me: Really.  It’s ok.  What do you think I care most about in running this facility?

Them: [Still Thinking: I don’t know him well enough to be honest.  He’s just like all the rest, probably.  Money.  The answer is money].  “Patient Care.”

Me: Yes.  What else?

Them: [Oh, there’s more than one answer.  I’ll say it …]  Profits.

Me: Yes.  What else?

Them: [What a dork.  He can’t care MOST about more than one thing!] Ummm … Customer Satisfaction?

Me: Yes.  But, how can I care MOST about more than one thing?  Have any of you ever seen a 3 legged stool?

Them: Yes, of course.

Me: Which leg is most important?  Which leg do you care most about when you sit on it?

Them: The one that’s going to break.

Me: Put yourself in my shoes.  If you were me, what would you say make up the 3 legs holding up our facility?

Them: Money, Patient Care … and … ?

Me: And … customer & employee satisfaction.  Which one do you think I think is most important?

Them: Whichever is weakest?

Me: That’s right.  That’s exactly right.  You’ve heard me talk a lot lately about some our financial challenges.  You’ve seen me tighten up our processes around approving overtime and tightening our belt in other ways too.  We’ve had to flex staffing to appropriate levels that match our lower census.  Our patient care is great.  Our customer satisfaction is high.  Our turnover is low.  But, financially, the facility has been losing money for a few months in a row because we haven’t adjusted our spending appropriately to our low census.  Right now, the leg that’s weakest … the leg’s that’s breaking is the financial one and we have to strengthen it.  Here’s what we’re doing (overview of efficiencies we’re trying to regain).  What else do you suggest we try?  What can you do to help?

(I then asked if any of them had ever been ‘cancelled’ or sent home early from a shift.  100% of their hands shot up.  I asked if they understood the rationale for flexing hours.  If they understood nursing hours PPD and the state minimum requirements.  They did not.  I explained how the hours PPD number is calculated and we calculated it for our facility).  They saw – and understood – how high we were staffed.  They began to ask insightful questions about staffing for acuity and skilled mix and how we derive our goals/staffing targets (which the director of nursing determines based on acuity, by the way).

The feedback from the meeting was very positive.  They went to work the next day with a sounder understanding of what makes me/us tick and WHY we’re managing the financial side of things so tightly right now.  I finished the meeting focusing on the other two legs.  I reaffirmed to them where my heart/passion lie … in creating an environment where they are free to thrive as caregivers.  An environment that creates a surprising experience for our patients and their families.  I concluded with the Cab Driver story.  That’s at an all staff meeting.

1:1 meetings with department heads allow for deeper education on the financial management of the facility and their departments.  I recommend we stop rationing crumbs to the ‘leaders’ of the facility.  Let’s let them eat at the table.  (See?  I had to throw in another analogy!)  Let’s be more transparent with our P&Ls so they can take ownership, and eventual PRIDE in the successful operation they’re responsible for shaping.

EnsignPrize! – judging behind the scenes

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

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