Archive for category: Leadership Practices

Embracing Change in Tough Environments

Change is difficult for most people. It usually feels easier and less risky to keep the status quo. People settle into certain procedures and relationships to accomplish work, and, over time, these patterns become expectations and rules for all to follow.

When making changes in organizations, it’s important to manage both socio-technical change– the changes of people and work processes– and emotional change– the change process itself as experienced by the people involved. If you are implementing a new dining program, the socio-technical changes would be the menu changes, the different roles of staff, new food items needed, etc. The emotional changes would involve how CNAs feel about serving in the dining, how department managers feel about increased responsibilities, how the foodservice director feels about less oversight over the food program, etc.


Change Management in 8 Steps

John Kotter, a well-known leadership professor from Harvard Business School, has studied change initiatives extensively. Specifically, he has looked at why some change efforts succeed while many other change efforts fail. (Kotter estimates that 75% of large organizational change initiatives fail.) Based on his extensive research, Kotter has developed an eight-step model for improving change processes. (Kotter, Leading Change, 2012) The steps are:

1. Increase the sense of urgency: People need to understand why they must change. Whether it’s a new payment model or different resident expectations, it’s important to make the case for change. A common example is to imagine you are on a burning off-shore platform. While jumping into the ocean seems terrifying, it is the only way forward with a chance at survival.

2. Build the right team: Once again, the team is crucial to success with changes. Make sure you work hard at building a strong, committed team. In the old days, it may have been important to have staff that followed instructions and didn’t rock the boat. Now, however, we need people who can problem solve independently and aren’t afraid to speak up when they notice a way to better serve residents.

3. Get the right vision: Know where you are trying to go. For most organizations, focusing on the needs of the person served is at the core of their mission, and it’s usually fairly easy to align the vision with this mission.

4. Communicate for buy-in: Communicate, communicate, and communicate. Use a variety of methods and materials, be frequently present, and engage staff to ensure understanding. Rarely has a change initiative in any organization been over-communicated. Remember that communication is a two-way street, too: don’t just shovel out memos and information—listen to feedback and make sure to engage all in the process.

5. Empower action: Leaders cannot do everything themselves. Instead, work hard to empower staff to make decisions, and support them, even if the decisions turn out to be wrong. Mistakes are usually the best way to learn how to do better, so take those opportunities to mentor staff rather than punishing them.

6. Create short-term wins: Don’t begin with a giant, long-term overhaul, as people will tend to lose interest and commitment to progress. Focus on small, visible goals first to build excitement and engagement. One of the reasons why 5S is a great starting place is that it’s both easy and plain to see. People see and experience the change and are much more likely to work on larger projects.

7. Don’t let up: Once a change begins, understand there will be peaks and valleys. Don’t give up on the goals and vision. Push forward with focus and dedication to the team.

8. Make it stick: For change to be successful long-term, it has to become part of the culture. This is as true for Lean and improvement as anything else. Build improvement thinking into every part of the culture, from orientation to evaluations to celebrations. Ensure that respect for people is practiced by everyone in the organization and that everyone spends time thoughtfully reflecting on how to do better. (Kotter, Getting Change to Stick, 2011)

Emotional Transitions

William Bridges, in Managing Transitions, developed a model for managing the emotional impact of transitions (Bridges, 2009, pp. 4-5):

1. Letting go, losing, endings:
When implementing change, it’s important to recognize the loss associated with letting go of old ways. Oftentimes, the people who struggle the most with this will be the best employees—after all, they have been the most successful in the old system. Spend time preparing for the transition by talking about the reasons for the change and how it will benefit residents. Build up the need for improvement. Also, understand that people are generally more likely to take a risk to minimize a loss (holding on to the status quo, for instance) than to take a risk to obtain a gain (a better process or outcome). That’s why even a positive change can be hard for people to accept.

2. The neutral zone:
The neutral zone describes the uncertain area between the old and new. Things are different, but not quite settled. Staff experience confusion and uncertainty in what’s happening and where the organization is going. Communicating a strong vision, encouraging people to try even if mistakes occur, and finding short-term goals to mark success are all crucial waypoints to guide the team through the neutral zone.

3. New beginnings:
New beginnings can be exciting, but there is often a tendency to slide back. To fight this tendency, active engagement from leaders is a must! You must work hard to build the new way of working into the very culture of the work area, from training new staff to ensuring that resources and rewards are aligned with the new way.

Moving Forward

TeamworkThe need to change is neither going away nor slowing down. But applying a good change management framework, along with proven tools and techniques, can help ‘grease the wheels’ that will lead to better adoption, less frustration and better outcomes for residents.

Embarking on a change initiative in your organization? Feel like you are stuck in the mud? Get in touch and learn how we’ve helped organizations just like yours move ahead of the pack.

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.

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.


Harness the Power of Information with Governance

“[Information governance is] an organization’s coordinated, inter-disciplinary approach to satisfying information compliance requirements and managing information risks while optimizing information value” – The Sedona Conference Commentary on Information Governance

Governance is the practice of aligning an organization’s values and goals with its operations and structures. Like other crucial resources in healthcare, information is a high level asset that requires management and oversight to ensure it can be used effectively. Information governance, a rapidly growing concept in healthcare, allows an organization to create reliable structures and processes to manage, maintain and act upon information in a way that supports organizational goals and ensures compliance with applicable rules and responsibilities.

Most, if not all, healthcare organizations have at least a simple governance structure in place around privacy and security of health information, driven by the requirements of HIPAA. But information governance is a much deeper concept, addressing not only security but also the quality of information and how effectively it can be used and shared (when necessary). As the use of information in and across healthcare organizations grows, the quality, reliability and availability of that information will become almost as important as actual care routines. For long-term and post-acute care organizations, now is the ideal time to think hard about information governance structures.

AHIMA (The American Health Information Management Association) provides a wealth of resources on information governance (, including an excellent primer on the eight principles of information governance. These eight principles (depicted below) offer a framework to understand the full cycle of information use within an organization.

In a 2014 survey of healthcare organizations, AHIMA found a wide range of organizational approaches to information governance:

Tellingly, 34% of organizations either didn’t think there was any need for governance or didn’t know their organization’s position, while another 22% have not started any program. As this survey represented a wide range of healthcare providers, long-term and post-acute care providers can be expected to fall disproportionately in these underdeveloped camps.

An information governance program should begin at the Board level, typically in the form of a Board oversight committee. In smaller organizations, information governance may be adequately situated within the corporate compliance and risk management program. A cross-functional team should be comprised of Board representatives, the CIO, the IT Director, clinical and administrative leadership, and other relevant stakeholders. Once organized, the information governance committee can develop an organizational information governance strategy and structure to address several components:

  • Key roles and responsibilities
    • Who is responsible for program development and oversight?
    • Who will manage training? Auditing? Communication?
    • How will oversight and accountability survive turnover and succession?
  • Information standards, definitions and expectations
    • How will information be used and what requirements are necessary for these uses?
    • What dimensions govern the acceptability of information?
  • Policies and procedures that govern information management
  • An audit and oversight program
    • How will the organization ensure compliance and identify opportunities for improvement?
  • Workforce training
    • How will employees in all job functions and at all levels contribute to the overall governance program?

Given the central place of health information and its importance to operations, the principle of information integrity oftentimes occupies the majority of a governance program’s ongoing work. A large part of information integrity involves ensuring data quality through the dimensions of accuracy, completeness, validity, timeliness and accessibility.

  • Accuracy: Is the information correct?
  • Completeness: Are all required elements present?
  • Validity: Does the information match the rules?
  • Timeliness: Is the information present when needed?
  • Accessibility: Is the information available?

To manage these dimensions, a governance committee should develop standards for each element, training to teach staff how to prepare and store information correctly, and audit mechanisms to verify data quality and identify problems.

As information needs become more complex, the role for information governance will only grow. Organizations should lay the foundation for a strong information governance program now or risk not having the infrastructure required to compete in the future healthcare marketplace. Begin by setting the governance structure, define roles and responsibilities, train all stakeholders, and sustain through oversight and continuous improvement.

For more information on setting up an information governance program, visit AHIMA’s website:

I will also be speaking about the important of information governance, along with EHR adoption and succession planning at the Long-Term Post Acute Care Heath IT Summit in Baltimore June 21st-23rd. This is a fantastic learning conference for all those involved in long-term and post-acute care operations. Learn more at:

Ready to get started? So are we!