Author Archive for: scarey

Psychological Safety: A Missing Ingredient for Effective Teams

The manager has an open office policy. He involves staff in decision making, asks for feedback about new programs and initiatives, and helps out on the floor often. Still, he frequently finds staff are hesitant to speak openly about problems they see and challenges they face in their everyday work. He oftentimes doesn’t find out about issues until they become big problems, and there is a steady stream of bickering among many of the staff members.

The manager has held meetings to talk with staff about his desire for everyone to communicate openly and proactively. He assures staff they can drop by his office anytime—he almost always arrives early and leaves late. He walks the halls to check in with staff and asks how he can help. Still, the fundamental challenges remain. So what is missing? Why are his staff still reluctant to engage?

A key ingredient to high functioning teams is “psychological safety,” a term that describes individuals’ perceptions about the risks of their actions on interpersonal relationships. Amy Edmundson, a professor at Harvard Business School, has researched psychological safety and its impact on team performance extensively: “It consists of taken-for-granted beliefs about how others will respond when one puts oneself on the line, such as by asking a question, seeking feedback, reporting a mistake, or proposing a new idea. One weighs each potential action against a particular interpersonal climate, as in, ‘If I do this here, will I be hurt, embarrassed or criticized?’” (An excellent read is Edmundson’s recent book, “Teaming:How Organizations Learn, Innovate, and Compete in the Knowledge Economy“.)

This is crucial to understand. An open-door policy may sound great from a leader’s perspective; they just have to sit back and wait for staff to come talk. But if individual staff members worry about being judged for “going to the boss’ office,” or believe that their boss will overreact—or, worse, do nothing—they may be reluctant to risk the effort.

Psychological safety may sound like a familiar concept, especially if you work with one of the many organizations that has invested in developing a strong culture of trust and respect. Psychological safety is related to trust, as both involve perceptions about risk and vulnerability. But the differences between the two are important, too: trust involves perceptions about another’s future actions towards you, and generally considers a longer-term timeframe across many interactions, whereas psychological safety is an internal calculation about how others will perceive a specific action in the relatively immediate future.

These differences are important, in two key respects. First, the focus of psychological safety’s effect is a near-term calculation. This means a person may choose a course of action with negative long-term consequences to avoid a short-term embarrassment or reprisal. Consider the all-too-common example of a CNA who observes an unsafe condition but fails to speak up because she is fearful of being labeled “a troublemaker.” The long-term potential for harm should outweigh the short-term risk of standing out—but often it doesn’t. Second, trust involves holding a belief about how another person will treat you in the future, whereas psychological safety involves an assumption about how your own actions will be perceived by others. Individuals with lower self-esteem and self-confidence may struggle to take risks even in environments where there is trust. In addition, the experience of the group tends to influence psychological safety much more than trust; if you witness a team member being criticized or embarrassed, you are much more likely to censor your own actions in defense.

A lack of psychological safety manifests itself in myriad ways: employees are less likely to speak up if they have concerns or reservations; co-workers may observe mistakes, but fail to call attention to them; managers stick to the status quo, rather than attempt a risky innovation or improvement effort; teams are less capable of achieving goals that require communication and interpersonal interaction.

So, how can a leader combat these tendencies within their organization? Here are 3 practices to promote a culture of psychological safety.

  1. Be vulnerable and take risks. A secure leader can model vulnerability for the team. Embrace weakness, admit mistakes openly, and demonstrate a willingness to take interpersonal risks. Pay particular attention to actions you are hesitant to take: are you worried about another person’s reaction? The company’s response? Your reputation? Confronting these fears head-on can help you identify places where other team members may be struggling, too.In addition to taking appropriate risks, explain the context around your actions openly. Leaders often unwittingly harm psychological safety by making decisions without describing context or alternatives; by doing so, they create an illusion that every action should be “certain,” which reduces risk-taking confidence in staff. Similarly, make sure that you don’t unwittingly punish staff for failures that come from prudent risk-taking. When handled appropriately, failures and mistakes should be celebrated for the learning opportunities they provide. Doing so helps to normalize imperfection and lowers the risks for others to make mistakes. (A commitment to Just Culture helps balance accountability with support.)
  2. Develop team competencies that contribute to psychological safety. As noted earlier, psychological safety is related to trust, but also has some important distinctions. Typical trust-building exercises focus on peer-to-peer or employee-to-supervisor relationships. By contrast, building psychological safety involves whole team discussion about the barriers and roadblocks to speaking and acting openly, and requires diligence in establishing and maintaining norms for acceptable and desired behavior (which should include making mistakes). In this regard, leaders must also be mindful about cliques that exist within departments or units, as these tend to normalize behavior in ways that limit risk-taking. Calling attention to appropriate instances where individuals took risks to speak up or take action helps to reinforce expectations and build support.Practice is also important: sometimes team members may come to an administrator to share something “confidentially” or “off the record”— rarely, however, do these concerns really involve a confidential matter; rather, they are a symptom of a lack of psychological safety in the team. Take the opportunity to prepare the individual, and then gather the team for the individual to raise the concern directly to the group. Show your support for this type of behavior, and use the instance in an upcoming staff meeting to highlight the risk individuals face, the benefits of speaking up (to both the team and to the residents being served), and the commitment the team can expect from leadership.
  3. Identify your True North. Purpose-directed organizations build safety by creating a shared vision of what is trying to be achieved. The Cleveland Clinic, for instance, identified “Patients First” as their true north, and constantly asks team members at all levels of the organization to focus on “what matters most.” By striving for a shared purpose, staff are freer to take risks because they can mediate discomfort or conflict with someone else by appealing to that overall goal instead of focusing on a specific action or behavior.

Increasing the psychology safety in an organization takes time, commitment and courage. But the benefits– improved patient safety, increased employee engagement, and strong, more resilient teams are well worth the struggle.

The New Comprehensive Care for Joint Replacement Program (CJR) Begins; What Providers Need to Know

The Comprehensive Care for Joint Replacement Program, the first mandatory bundled payment program from CMS, began April 1. Under the CJR, almost 800 hospitals in 67 geographic areas will be partially at risk for all Medicare spending related to lower joint replacements (DRG 469 and 470), from initial admission to 90 days post-discharge. Hospitals’ performance will be compared to both their historical spending and regional spending levels, which regional spending becoming increasingly important over time. In addition to meeting target pricing, hospitals are responsible for meeting minimum quality and satisfaction measures. Here’s a breakdown the methodology:

CMS Bundle Payment Methodology

With responsibilities now extending beyond discharge, hospitals need to act quickly to understand the post-acute care process. Using that newly acquired knowledge, the challenge will be to reengineer care delivery outside of the hospital walls to optimize outcomes and reduce costs. According to an analysis by Avalere, 60% of hospitals will need to reduce costs in order to remain competitive with their regional competitors. Those organizations that wait to act could very well find themselves spending the next five years playing from behind, always trying to catch up with everyone else in the region only to find themselves continuously outpaced and losing money. As many analyses have noted, too, the vast majority of variation in LEJR payments occurs in post-acute care. As a result, post-acute providers must pay particular attention to their relationships with acute care partners during the CJR rollout.


(Analysis by DataGen)

It will no longer be sufficient for post-acute providers to compare themselves to others simply by looking at star ratings or occupancy. Instead, providers need to understand the current flow of Medicare patients from acute care partners through the post-acute journey, and begin benchmarking themselves against competitors based on rehospitalization rates, lower average lengths of stay, higher satisfaction, and access to preferred referral networks.

This example, from the Portland metropolitan market, shows post-acute flows from an area hospital. Using this information, PAC providers can better understand their competition and target hospitals that might benefit by referring more patients to their facility.

The April 1, 2016 start date has put pressure on hospitals to quickly ramp up. On the other hand, the fact that the first year (through December 31, 2016) has no downside risk may cause some organizations to take a slower pace understanding their downstream costs and challenges. This is a big mistake. Since the CJR applies to all hospitals in the geographic region, those that start early will have a continuing advantage over the life of the program.
As part of the CJR, CMS has waived certain restrictions on telehealth, gainsharing and patient support (including providing remote home monitoring technologies). PAC providers with extensive home health networks will be at a particular advantage to test out new technologies, such a tele-therapy, remote home monitoring, and active case management as an alternative to extensive skilled nursing stays and potential hospital readmissions.
For post-acute providers looking to excel in this new environment, here are some key considerations:


Without a doubt, the CJR is only the first of the mandatory bundles providers can expect in the near future. CMS will likely move very quickly to expand both the geographic reach and the DRGs of these value-based models as it looks to shift entirely aware from a fee-for-service-model. Post-acute care providers are a crucial component in the healthcare space, but they will only remain so by focusing on better outcomes at lower costs.


CMS Launches CCJR Bundled Payment Program for Hospitals and Post-Acute Care

The Centers for Medicare & Medicaid Services (CMS) recently finalized its rule for the Comprehensive Care for Joint Replacement Program (CCJR), a five year pilot program that will run in 67 regions across the country. Hip and knee replacements are the most common inpatient surgery for Medicare beneficiaries and can require lengthy recovery and rehab time. In 2014, there were more than 400,000 procedures, costing more than $7 billion for the hospitalizations alone, with the cost of surgery, hospitalization, and recovery ranging from $16,500 to $33,000 across geographic areas. This wide variation in cost, along with similar variation in quality and complication rates, led CMS to make the CCJR program mandatory for almost all hospitals within the chosen regions.

Percent of Spending by Type, MS-DRG 470

  • Index (hospital)
  • Post-Acute Care
  • Physician Services
  • Rehospitalizations
  • Other

The CCJR will hold hospitals accountable for cost variation and performance for the 90 day period beginning with the hospital admission for MS-DRG 469 and MS-DRG 470, inclusive of all related follow-up post-acute care and Part B spending.  The specific mechanism for payment places a high burden on hospitals to select high-quality, lower-cost post-acute care providers, and actively manage cases as patients move through the episode of care. While individual fee-for-service providers will continue to receive regular payments for services, CMS will prepare an accounting at the end of the year (beginning with year two of the pilot) of the actual spending versus the allowed spending based on a per-episode rate. Hospitals that exceed the allowed amount will see their year-end Medicare payment reduced by an equal amount, whereas hospitals that spend less are eligible for an incentive payment. In addition, CMS will set quality benchmarks that must also be met regardless of spending.

Many hospitals will struggle to navigate the post-acute care environment and select the most effective setting for patients. For post-acute care providers, this is a fantastic opportunity to provide leadership and guidance to local hospitals serving joint-replacement patients. PAC providers with extensive home health networks will be at a particular advantage, as this program provides an incentive to test out lower cost interventions, such a tele-therapy, remote home monitoring, and active case management as an alternative to extensive skilled nursing stays and potential hospital readmissions. For patients still within the 90 day window, skilled nursing facilities have the opportunity to provide a lower cost triage and stabilization environment for patients versus a repeat acute inpatient admission.

Initially, partnerships and narrow referral networks will likely be based on publicly available measures, like the Nursing Home Compare Five Star Rating System. This is only the beginning, however. As I’ve written before, narrow networks will soon give way to smart networks, built on actual value outcomes and cost data. CMS plans to share extensive spending and use data to eligible hospitals to help them navigate this new program before penalties begin to set in. Armed with this information, hospitals will likely shift their focus to outcome measures and quality factors that account for the biggest drivers of actual costs: least expensive setting, overall length of stay, functional improvement, and readmissions over the entire 90 day episode.

In the example to the right (taken from the Vantage Care Positioning System from Avalere Health), two area SNFs have significantly different LOS and rehospitalization rates, leading SNF A to cost more than $2,000 more per case, on average, than SNF B. As long as SNF B is able to maintain the necessary quality levels, hospitals will have a significant financial incentive to funnel patients to that location.

Going forward, there are additional avenues that offer even more potential to reduce costs and better serve patients, notably:

  • Respite care in assisted/ residential care communities, coupled with home health
  • Telerehab, with reduced frequency home health
  • Remote patient monitoring to increase security/ reduce risk for patients recovering at home
  • Incorporation of non-medical healthcare workers armed with clinical decision support and predictive analytics to guide services
  • Home care, meals services, and housekeeping support post-discharge to reduce risk of rehospitalizations or other complications.

The CCJR is likely the first of a new wave of mandated bundles from CMS, and may pave the way for similar moves by other payers. Hospitals, skilled nursing facilities, and post-acute care providers should view the joint program as a template to build upon in a value-based future rather than an aberration of fee-for-service to be minimized or ignored. Non-traditional players, such as home care, meal services, and other senior housing providers, should view the CCJR as a new market opportunity with significant growth potential ahead.

Wondering how the CCJR program will affect your organization?

Getting Started with a Performance Scorecard: “Nine Steps to Success”

With rapid changes to payment structures, increasing service demands from newer demographics, and fierce competition, aging services and long-term care organizations are turning towards more formal methods to drive strategy forward. Scorecards and performance dashboards offer a visual way to align strategic planning with management operations. This helps an organization organize work according to priorities and achieve strategic goals by creating transparent, measurable connections between programs, processes and people and their relationships with the mission, vision and strategy of the organization.

Commonly, scorecards are developed through a nine step process designed by the Balanced Scorecard Institute.

Step One: Assessment

The scorecard building process starts with a thorough assessment of the organization’s mission and vision, challenges, strengths and opportunities. Preparations also begin for the communication and implementation of the scorecard throughout the organization. Key questions to ask include, “Who are we serving and how?”, “What payment models can we expect going forward?”, and “How are we different from our competitors and other levels of care?”

Step Two: Strategy

Next, a strategic plan is developed based on the assessment findings. This three to five year plan lists specific goals to accomplish and high level strategies that will enable achievement.

Step Three: Objectives

The strategic elements developed earlier are broken down into strategic objectives, which are the basic building blocks of strategy and define the organization’s strategic intent. Objectives are first designed and categorized on the strategic theme level (aligned by perspectives), and then later merged together to produce one set of strategic objectives for the entire organization.

Step Four: Strategy Map

Next, the cause and effect linkages between the organization-wide strategic objectives are detailed to create a strategy map that showcases how the organization provides value to its constituents. The strategy map should answer two fundamental questions: ‘where is the organization?,’ and ‘why are we headed there?’




Step Five: Performance Measures

In Step Five, performance measures are developed for each strategic objectives. Leading and lagging measures are identified, expected targets and thresholds are established, and baseline and benchmarking data is developed.

Step Six: Initiatives

After developing measures, strategic initiatives are developed to achieve the strategic objectives. To build accountability throughout the organization, ownership of performance measures and strategic initiatives is assigned and documented.

Step Seven: Performance Analysis

In Step Seven, the implementation process begins by developing systems to get the right performance information to the right people at the right time. Automation, where possible, adds structure and discipline to implementing a scorecard, helps transform mountains of organization data into information and knowledge, and helps communicate performance information. In short, automation helps people make better decisions because it offers quick access to actual performance data.

Step Eight: Alignment

Now, the organization-level scorecard is cascaded down into business unit and department scorecards. Cascading translates high-level strategy into lower-level objectives, measures, and operational details. Cascading is the key to organization alignment around strategy. Team and individual scorecards link day-to-day work with department goals and the organization vision. Performance measures are developed for all objectives at all organization levels. As the scorecard management system is cascaded down through the organization, objectives become more operational and tactical, as do the performance measures. Accountability follows the objectives and measures, as ownership is defined at each level. The alignment process should be bi-directional, so that challenges and opportunities known at the ground level make their way up into higher level strategies.

Step Nine: Evaluation

Finally, an evaluation of the completed scorecard is done. During this evaluation, the organization tries to answer questions such as, ‘Are our strategies working?’, ‘Are we measuring the right things?’, and ‘Is this still the right track?’ The constantly changing nature of healthcare means organizations must continually re-evaluate strategy and execution to ensure success.

For a related overview on performance measures and balanced scorecards, see our earlier article: Balanced Scorecards and Key Performance Indicators in Long term and Post-acute Care

Three Ways to Improve Recruitment and On-boarding of New Staff

While a lot has been written about finding the “right” employees for aging services organizations, many providers still struggle with turnover of 40%, 50%– even 75%. The costs of high turnover are well known: direct orientation and retraining time, poor productivity, lower team cohesion, higher incidence of care problems and regulatory issues. So what’s the challenge? Providers need to look beyond just the search and selection process. In fact, many providers aren’t getting the right people in the door at all, or, when they do, don’t invest enough for talented, capable employees to want to stay.

Here are three overlooked areas to consider to help your organization hire and retain new staff better:

Build the Right Impression from the Very Beginning

Take a look at your recruiting and application processes. Do your job ads speak of the culture of your organization and the type of applicant you are seeking? Is the application process itself easy and straightforward? How are applicants greeted when they come into your community for the first time? The initial impressions set the stage both for the quality of people who will stick through the process and how seriously applicants will take your cultural messaging once they are hired.

Many job ads are little more than simply job descriptions, or, worse still, just a short list of requirements. This is a huge missed opportunity to connect with the heart and passion of potential employees. Instead, craft postings that highlight your organization’s character and flair, the warmth of your residents, and the opportunity available. Compare these three job postings for a similar position:







Which job are you more likely to apply for?

Some rigorous applicant tracking systems, in trying to make life as easy as possible for Human Resources, require applicants to wade through screen after screen of an application, entering information that will only be glanced at once or twice—previous employment information, skills inventory and the like— unfortunately, such a process can send the message that you don’t value the applicant’s time. Demographic information, a resume, and a brief statement from the applicant should be sufficient to determine if you want to know more; gather more in-depth information, like references and skills, after an initial screening.

When you invite an applicant to your community for an interview, think about their experience visiting for the first time. Many communities have invested heavily in the front entrances and grounds of communities. But what happens after they walk in the front door? Are they offered a beverage and a comfortable seat? Or are they greeted from behind a glass window and told to wait on an old bench in the hallway? When walking the applicant through the hallway, do you take time to introduce them to residents and staff that you pass? Or is the applicant walked in silence to the back conference room? These first impressions can solidify a community’s commitment to hospitality or reinforce the view that employees are simply another resource in a giant machine.


One of the best investments an organization can make is in its orientation process. Many communities, however, thrust new employees onto the floor as quickly as possible, oftentimes without completing even a rudimentary orientation process.

Start with a thoughtful and well-designed process instead. Give new staff sufficient time to shadow, practice, and finally demonstrate their knowledge of the work. Pick trainers that are positive and know their assigned residents well. Strive for consistency in trainers to help build mentoring relationships. Create position-specific new hire information to cover required skills and knowledge. A check-off list that new staff and trainers both complete can help encourage standard training and eliminate gaps and oversight.

Introduce new employees to not only to their own work area, but also the rest of the organization. Schedule time to visit with other departments so new employees understand how the entire team works together to serve residents. This also serve to build cross-functional relationships and lessons the natural tendency for departments to form silos and rivalries.

Make sure the orientation is long enough for new employees to understand the work they are expected to do and, even more importantly, how they can go about finding additional information later on. Many things won’t be covered during the initial few days, so it is crucial that new employees know where to find information– lest they resort to guessing or not completing certain work.

Evaluation (For Them and You)

Check in regularly with new employees throughout their orientation period. In addition to asking if the new employee has any questions, ask about their experience with the orientation and for feedback to improve it for others in the future. Ensure that they received enough training by checking in with co-workers and trainers. Ask if they are happy, and what they would like to change about their work so far. Creating a standardized check in process can be very helpful, too. After an initial orientation, schedule follow-up meetings at regular intervals. The administrator should conduct at least one of these meetings to help reinforce the vision they hold for their team and build strong relationships with new staff.

Here is an example of one organization’s orientation and evaluation approach:

Orientation Philosophy

Guiding Principle: To achieve our mission of providing quality continuing care to our residents, and in the spirit of our values of service and excellence, we believe new employees will best succeed with a structured, thoughtful, and extensive orientation to their work. Administration, current staff, and new employees all have important responsibilities to ensure this happens.

Goal: New caregivers will be able to perform all assigned job duties with their assigned resident group and have sufficient knowledge about community policies, practices and procedures to be successful in their employment here.

Process: New caregivers will be assigned at least seven days of orientation. Ideally, the first three days will be with one trainer and one group of residents. Subsequent days may be with other groups in the same level of care.

Trainers will give new caregivers feedback about their work during training. Any serious skill or work habit insufficiencies will be communicated during this phase to the staffing coordinator, who will ensure additional orientation time is scheduled.

After initial training is complete, new caregivers will have a check-in with the Staff Development Coordinator, and then work on the floor for approximately two weeks. They will then meet with the Administrator to review any issues during orientation and help identify any additional training needs at this time. New caregivers will also be scheduled off the floor for an additional day of orientation to review their training and ask any questions that may have come up during the first two weeks of solo work.

Regular check ins with team leaders and community administration are scheduled throughout the first 90 days to ensure a warm and thorough welcome, identify any orientation or training gaps, and ensure new caregivers are successful in their long-term work here.


Investing time and resources in training employees adequately can seem burdensome at first. Some current employees who had to learn by jumping into the fire may even feel resentful of the investment. Over time, however, most communities experience significant returns on the upfront investment, including lower turnover, better quality care and less administrative time spent resolving training and quality-related conflicts. By setting the stage from the first interactions, you can help ensure a stable and valued relationship with staff.


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