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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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.

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

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?

Why we sold the franchise

Turbulence

Almost 12 months since my last entry.

I find myself on a plane headed back to Maryland after meeting with my partners in SoCal about my short- and long-term plans now that the sale of Doctors Express has been finalized.  We announced the sale of the franchise business to American Family Care (AFC), based in Birmingham, AL a few weeks ago.

What took me away from doing what I love with and near the people I love in the place I love?  One of my best friends and Ensign partner, MikeD, started a new venture within the org. in a new sector of healthcare – urgent care.  He had already brought on a couple urgent care veterans to accelerate his learning curve as he planned to build several centers de novo.  Quickly after the venture got off the ground, their plans expanded into a couple new paths including the acquisition of the only urgent care franchise in the country – Doctors Express, based in Maryland.  Mike asked me to lead that business and they made it worth my bet.

Personally, it was a high risk/high reward proposition.  Much to my surprise (and the surprise of my family and friends and colleagues) my wife and I decided to go for it after just 4 days.

By the time I could transition my role to “the upgrade” BHulse, my new partners were already underway with Doctors Express.  10 months after I joined … at our annual conference in March in Vegas, I told the franchisees that the best word that I could think of to describe the last 12 months is TURBULENT.  Turbulent because even though there were bumps along the way, the plane kept moving forward and the system made huge improvements in terms of number of centers, patient count, and revenue.  2013 is definitely poised to continue its upward trajectory.

So why sell?

Good To Great

You have to understand Ensign’s culture to understand the answer.  The book Good to Great teaches a lot of the same values and strategies that have been part of the Ensign Way for years …

“The pivot point in Good to Great is the Hedgehog Concept. The essence of a Hedgehog Concept is to attain piercing clarity about how to produce the best long-term results, and then exercising the relentless discipline to say, “No thank you” to opportunities that fail the hedgehog test. When we examined the Hedgehog Concepts of the good-to-great companies, we found they reflected deep understanding of three intersecting circles: 1) what you are deeply passionate about, 2) what you can be the best in the world at, and 3) what best drives your economic engine.” (source)

hedgehog and fox

Mike and I (both 11 years with Ensign-related businesses) concluded that, in spite of the promising future for the Doctors Express franchise, being a franchisor was a significant departure from our hedgehog.  I found myself in the peculiar position of recommending that we sell the business I lead – making my future uncertain – b/c I believed it was the 1) right thing for Ensign and 2) the right thing for the franchisees.

A cornerstone to the culture at Ensign is the independent/interdependent nature of the facilities, agencies, and companies.  Franchising requires strong (sometimes rigid) corporate control to retain brand standards among franchisees who bring a vast range of values, motives, and competencies to the system.  At Ensign, the word “corporate” is a ‘bad word.’  I constantly wrestled with the misfit between my/our approach/culture and the approach/culture a franchise system requires.

square peg round hole

Fortunately, we became acquainted with AFC and quickly saw their huge corp. infrastructure and decades of urgent care experience AND TRADITIONAL CENTRALIZED CORPORATE structure to be a better fit for franchising.  Could we have continued the upward ramp of the last 12 months?  Yes.  No doubt.  I think many, if not most, organizations are driven principally by the numbers.  In our case, no matter how pollyannish this may sound to outsiders, Ensign’s success is largely attributed to our hedgehog-based discipline to say no to seemingly great financial opportunities that are only attractive because of the numbers but do not fit with who and what we are.

I admire many of the franchisees and staff I worked closely with and I will be cheering AFC and Doctors Express on for years to come.

Gratefully, I will be returning to what I know and love: senior care/skilled nursing. In the coming weeks & months I’ll be writing about lessons learned 1) at DRX and 2) from returning to skilled nursing.  Good to be back …

Idaho Healthcare Association

I thoroughly enjoyed the Idaho Healthcare Association convention in Boise during in  July.

I was invited to speak on how to create your own unique culture within your facility or company.

Thank you to Robert & Jill for the invite and warm welcome.  I was totally impressed with the organization and our colleagues in Idaho … making a difference!

My presentation consisted of a few case studies on the topic.  We discussed what we learned from each and ended with a how-to-map for repeating the steps at your company/facility.

The phrase, “I’m passionate,” is certainly over-used.  Nevertheless, I’m passionate about this topic.  It goes far beyond theory or academics for me.  I’ve seen amazing results from getting serious about owning the culture for myself and for others.  I shared cases at USA Olympic Hockey (The Miracle), The Ensign Group’s (my company) ‘anti-corporate’ office, my most recent facility, and we ran out of time to share the Johnson & Johnson case.  All these cases teach us …

  • The How-To: Pain, Engage, Define, Commit, Flywheel.
  • The culture starts and stops with ‘the’ leader.
  • Cultural transformation requires hard work and pain.  There are no shortcuts.
  • Team chemistry is better than a group of individual all-stars.
  • You have to draw lines in the sand and commit to not cross (or let anyone else cross) that line.
  • Cultural transformation is too-often treated (by the leaders and the employees) like a new program.  Programs fade in 2 to 3 months.  For the transformation to ‘take root’ it must be treated more like a conversion to a new religion.  The most outstanding organizations are those who have a fanatical commitment to their stated culture.
Download presentation PDF here