Creating a Positive Chain

of Leadership

David Farrell, MSW, NHA

What Matters the Most?

Systems

Equipment

People

High Performing Nursing HomesThree Common Elements - Culture – person-centered care Workforce commitment Leadership practices

All three are interdependent

Grant, L. 2008

Results are Interrelated Implement principles of culture change

Enhanced leadership practices Employee satisfaction Workforce stability

Low turnover, high retention, low absenteeism Consumer satisfaction Clinical outcomes Regulatory compliance Occupancy rate and mix

Grant, L. 2008

Kind Caring Staff

Know me as an individual

Quality Care

A Consumer Perspective on Quality Care: The Residents’ Point of View

NCCNHR 1985

Drivers of Consumer Satisfaction Caring staff Competent staff Choices and preferences Nursing care Responsive management Respectfulness of staff

MyInnerView, Inc. 2010

Better Census and Resources for More

Improvement

Improved Quality and Satisfaction

Staff Stability and Engagement

Path to Improvement

© B&F Consulting Inc. 2011 www.BandFConsultingInc.com

People and Systems Development

Drivers of Staff Engagement

Management cares about employees Management listens to employees Help with job stress

MyInnerView, Inc. 2010

Building Trust and Making a Statement Presence

“You go into the rooms?” Asking and delivering Listening Speaking with conviction Painting the graffiti

Adapted from Albert Einstein Health Foundation, Philadelphia,

PA., 1990

Leadership Practices Matter Most

Leadership Practices

Process Improvement

Performance Improvement

Person-Centered

The Impact of Leaders

Healthcare organizations Fragile ecosystems Leader’s actions influence:

Culture Relationships

Staff engagement Clinical outcomes Quality of life

CompassionPerformance

Person-Centered Care Leadership

Relationships and Quality

14

People ParadigmW. Edwards Deming: Quality, the result, is a function of quality, the

process Essential ingredients of the process:

Leaders and their people Cannot improve interdependent systems and

processes of care until you progressively improve interdependent, interpersonal relationships

Theory of Relational Coordination

The effectiveness of care and service is determined by the quality of communication among staff

Which depends on the quality of the underlying relationships

The quality of the relationships reinforce the quality of the communication

Gittell, et al, 2008

Relational Coordination in Healthcare

Task interdependence Uncertainty Time constraints

Gittell

Food Service

Physicians

NursesCNAs

Therapists

Healthcare Organizations

Nurses

CNAs

Therapists

Food service Physicians

Within functions Across functions

Gittell

Trigger Relational Coordination

Leadership actions Increase Communication

Frequency, timeliness Accurate, transparent, frequent Model problem solving

Enhance Staff Relationships Shared goals Enhance shared knowledge Model mutual respect

Relational Coordination Works Significantly associated with –

Enhanced resident quality of life Higher nursing assistant job satisfaction

Evident in SNFs implementing person-centered care

Gittell, et al, 2008

20

Quality is All About Relationships Between co-workers Across departments Between supervisors Frontline and supervisors Staff and residents Between residents Staff and resident’s family members

Eaton, S. 2001

Thank You Cards Cards are powerful

Send them to staff members’ homes Birthday cards Anniversary cards Excellent attendance “I appreciate you” “I am glad you work for us. On behalf of the

residents, their families and your co-workers – Thank you.”

Relationship Facilitation Strategies Ample supplies at hand Resident transfer equipment at hand Report between shifts Staffing configurations Staff composition

Relational Coordination in OaklandKey changes – New name badges Created efficiencies Mitigate conflict “Just in time” compassion

Tragedies in their lives

Enhancing Staff Relations

Karaoke Kids Day Heritage Days Senior Prom Weight Loss Challenge Safety Huddles

Manage Relational Coordination

Our systems and structures of communication create our relationships and our culture

Relational Coordination Applied to Staff Assignments

LOW:Rotating

Assignments

HIGH:Consistent

Assignments

Communication and Relationship Factors

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Relational Coordination Applied to Shift Hand-off

LOW:Tape

recorded

HIGH:Structured Person to

person discussion

with checklist

Communication and Relationship Factors

© B&F Consulting Inc. 2011 www.BandFConsultingInc.com

Relational Coordination Applied to Interdisciplinary Problem-solving

LOW:Conducted by 2 managers and solution rolled out via

in-service

HIGH:Root-cause

analysis conducted by PIP team led to successful pilot test and then facility-

wide adoption

Communication and Relationship Factors

© B & F Consulting, Inc.

Enhancing Relational CoordinationFollow QAPI systematic process - Charter Performance Improvement Projects Learn, teach and utilize

Ice breakers Root-cause analysis Brainstorming Flow chart Learning circle

30

Cause and Effect Diagram

Systems

Environment

People

Equipment/Supplies

First 2 Hours Checklist

People support what they help create

Empowerment

Humility Listen to others perspectives Stakeholders –

Who is effected? Who can help us understand this better?

Involvement = success of changes Spread Sustainability

Communication Builds Trust

Leadership Visibility

Rounds to trigger engagement Engage the heart and minds of staff What you do and say matters

Meet and greet, linger Observe – processes of care, handoffs Praise, build self-esteem Build trust Foster teamwork

Invisibility

“The problem is not motivation. It is theways in which we unintentionally de-motivate employees.”

Quint Studer

Community Meetings Performance data

Human resource Clinical outcomes Business results

Benchmark and compare Celebrate positives

Employee and rookie of the month Raffles Patient safety chain

Communicate

What?

How?

Why?

The “Golden Rule” Christianity

Do unto others, as you would have them do unto you Islam

No one of you is a believer, until he loves for his brother what he loves for himself

Judaism What you hate, do not do to anyone

Hinduism Do nothing to thy neighbor, which thou would not have them do to thee

Buddhism Hurt not others with that which pains thyself

Confucianism What you do not want done to thyself, do not do to others

Assume the Best

To bring out the best - Self-fulfilling prophecy Express confidence Spark optimism “I’m proud of all of you.”

Sutton, R., 2010

Bad is Stronger Than Good

Eliminate the negative Interdependent work = larger negative effect Grumpiness is contagious

Felps, W. 2001

Human Beings are FlawedWhat exposes the flaws?

Workload, fatigue Broken systems Lighting, noise, distractions Personal issues Coworkers behaviors Equipment, supplies

41

Who are the CNAs?

Total 1.47 million Deliver 80% of hands-on care 90% are women 51% are non-white Average age is 38 50% are near or below the poverty line 41% rely on public benefits

GAO, 2001National Clearinghouse on the Direct care Workforce, 2006BLS 2006, FHCEF 2010

Common Forms of Feedback Silence Negative Positive Deliver feedback to individuals and teams:

Timely Be specific Be sincere End on a positive

CompassionPerformance

Person-Centered Care Leadership

“We missed you yesterday…and the residents did too. I hope your son is feeling better. We are a better place when you are here.”

Small Wins are the Path

People Energized

Steps forward

Visible results

Contact Information

David J. Farrell, MSW, LNHA

Director of Organizational Development

Regional Director of OperationsSnF Management

dfarrell@snfmgt.com(510) 725-7409