Archive for category: Leadership Practices

Using Lean and PDSA to Reduce Employee Injuries


For many aging services providers, employee injuries are a costly reality of the workplace. In addition to workers compensation costs, however, employee injuries can cause scheduling challenges and lower worker morale. Lakeville Management, a small regional provider of assisted living and memory care communities, decided to tackle employee injuries as part of their commitment to deepening their respect towards employees.

To begin, administrators held several small focus groups to solicit information about the current safety culture, the employee injury reporting process, and barriers to implementing changes. With this initial information, the leadership team was able to construct a company-wide survey and identify opportunities to improve their processes.



The company safety committee (composed of multi-disciplinary representatives from each member community) first examined their current incident reporting process, which was used to report both actual injuries and near misses. Staff reported that the process was somewhat difficult, and, as a result, very few employees bothered to submit near misses. In addition, by examining the type of injuries that occurred most frequently, the committee decided to focus education and interventions on muscle strains, which accounted for almost 60% of all employee injuries.

The committee began by mapping out the incident reporting process. By dialoguing with supervisors tasked with completing parts of the process, the committee identified pain points, unclear forms, and burdensome back-and-forths. Using this knowledge, the committee tested several process and form updates, refining methods after 30 day trials in a single community.

The organization also created a temporary contest to build awareness about the value of near-miss reporting, including incentives for reporting near-misses and a transparent process in each community where near misses and interventions were displayed on a visual control board located in the staff break room. Staff were able see the results of reporting dangers before they led to injuries and could weigh in on interventions to help ensure that proposed changes were realistic within work routines.



After six months of work and four rounds of the PDSA process, Lakeville reevaluated the incident reporting process ease and short-term results. Supervisors reported that the updated processes were much easier to follow, and the leadership team noted a strong increase in the number of near miss reports. After twelve months, the results were dramatic: almost $200,000 in avoided worker compensation costs, 63% fewer lost days, and 15% fewer modified work days. In addition, managers at Lakeville became accustomed to including a review of staff injuries and near misses as part of their daily work, increasing accountability and awareness for the importance of worker safety to the organization.


Learn more about how Lean can help your organization improve performance, including reducing the number and severity of costly employee injuries, here.











Five Qualities of Role-Based Leadership

An important piece of adaptive leadership is the ability to apply different skill-sets to address different types of problems. Just as you (hopefully) wouldn’t use a hammer to fix a leaking pipe, you shouldn’t rely on one style or approach of leadership to meet every challenge. This complex understanding is oftentimes overlooked in leadership literature, where many authors propose more static models of “what a leader looks like.” In contrast, Ester Cameron and Mike Green, in Making Sense of Leadership: Exploring the Five Key Roles Used By Effective Leaders, propose a five quality leadership model that I find very helpful in understanding adaptive approaches. The five qualities they propose are:

  • The Edgy Catalyzer: Creates discomfort to promote change

    This quality is crucial when the status quo is an impediment to change or when an organization has become too complacent with its current structure and processes. By asking uncomfortable questions and pushing employees to examine held beliefs, the edgy catalyzer can help create a sense of unease that leads to a desire for change.

  • The Visionary Motivator: Focuses on engagement and buy-in to energize people

    A great deal of leadership literature focuses on the role of the visionary motivator in leading teams. This quality builds engagement and participation from team members and helps to create a coalition capable of moving change forward. Communication and positivity are essential traits of this quality.

  • The Measured Connector: Promotes a sense of purpose and connectivity between people

    Measured connectors work to align people with stated goals and targets. At times change can move uncomfortably fast, and this quality focuses on keeping team members together and committed. As organizations and care delivery systems become more complex, the importance of aligning not only internal employees but also external stakeholders grows.

  • The Tenacious Implementer: Focuses on projects, timelines, deliverables and targets

    In the article “What Leaders Really Do,” John Kotter creates a useful distinction between management work and leadership work. One common trap that leaders fall into, however—especially those skilled at building visionary coalitions– is failing to stick around and ensure that goals and projects are actually implemented. The quality of tenacious implementer is particularly important when managing the change required to implement regulatory fixes and large-scale IT projects, like EHRs.

  • The Thoughtful Architect: Envisions frameworks and system design to support needed change

    When working on system change or long-term strategic planning, leaders need to understand how to construct structural and process-oriented objectives to bring into existence an engaged vision. Indeed, many thought leaders are exceptional at building a strong coalition around a hopeful vision for the future, but then struggle to actually redesign an organizational structure or business line that brings this vision to life. The thoughtful architect quality is the most introverted of the qualities, and benefits from time to reflect and consider.

Cameron and Green constructed the following chart around some basic questions to highlight the differences between the qualities:

In considering the challenges facing your organization, different qualities of leadership are necessary in differing amounts to enable the organization to deliver the best results. Like many models of leadership, these five qualities are all considered “positive,” in the sense that they are all necessary to accomplish goals, though, as shown above, the amounts of each quality can vary considerably based on the specific aim. Put into the context of aging services, I’ve offered a visual depiction of the relative amounts of each quality useful in responding to the following challenges:

For each quality, too, there is a risk of using too much or too little of it, and it’s for this reason that I find the model most useful. The problems and challenges facing healthcare organizations today are myriad and diverse, and a one-size-fits-all model of leadership risks sacrificing the particular advantages of skills that might be necessary on one project but not on another. By understanding and embracing this complexity, adaptive leaders are much more effective in responding to a wide assortment of challenges and much more successful in leading a diverse range of change initiatives.

Using Plan-Do-Study-Act to Remove Alarms from a Skilled Nursing Home


Since the late 1980’s, nursing homes nationwide have taken dramatic steps to reduce the use of physical restraints among their residents. For many, this meant replacing lap belts and limb ties with bed and pull-tab alarms. These alarms attempt to alert staff to a resident about to fall, although studies of their effectiveness are inconclusive, at best. Many professionals now consider alarms to be unneeded, anachronistic, and disruptive to a resident’s wellbeing and quality of life—although removing them can be challenging, as Greenville Manor discovered.


When administrators at Greenville first proposed the idea of removing alarms, staff, family members and even some residents worried about the effect on resident safety and security. Although they were excited about eliminating the alarms to improve the atmosphere in the nursing home, the administrative team decied to utlize a Plan-Do-Study-Act (PDSA) cycle to test whether alarms could safely be removed without jeopardizing residents. A small, interdisciplinary team convened to work on the problem. By talking with staff and residents, and conducting online research, the team determined a number of root causes behind resident falls. The team also examined the process by which a nurse added an alarm to a resident’s care plan, and noted that very little investigation typically occurred. By organizing fall causes in a Pareto chart, the team was able to target the top 3 reasons and develop an education program to address those causes.


The team developed a test plan to remove an alarm from one resident and measure the results. After two weeks of no increased falls, the test was expanded to include seven additional residents (one nursing section). The team met frequently to analyze fall data and check in with staff involved in the test pilot. During the test, an alarm was discovered on one of the residents. The team quickly investigated and discovered that one of the night shift employees had been absent from a recent team meeting and did not receive the pilot notice in her mailbox. After correcting the issue, the team made a note to follow-up with a night shift focus group to talk about communication challenges and ways to better communicate between shifts.


After one month, the team determined that removing the alarms had actually resulted in a slight decrease in the number of falls in that section. (Later, the team learned that this result was not uncommon in communities that were successful in removing alarms.) The team decided to move forward with expanding the pilot, but to adjust the communication plan to ensure all staff and other stakeholders received adequate notice of the change.


At the next all-staff meeting, the team shared the results of the test, and solicited reactions from other team members. Staff who were involved in the pilot, along with the project team, responded to questions and helped to allay remaining fears about removing alarms throughout the community. Over the next three months, successive neighborhoods removed alarms while staff carefully monitored fall data. A community-wide party celebrated the removal of alarms, and a record of the before and after fall data was prominently displayed in the staff conference room.

The CMS Nursing Home Compare Five Star Update

Nursing Home Compare Five Star Rating

Since the Nursing Home Compare Five Star rating program was first launched in 2008, providers have approached it with a mix of trepidation, envy and awe. Using a set of complex statistical models, CMS awards between one and five stars to every nursing facility, with the goal of helping consumers make more informed and better care decisions. Unfortunately, its reliability is somewhat suspect, as most providers experience fluctuation in their star rating. According to a five-year analysis prepared by Abt Associates, only 3% of providers had the same star rating over the entire period, although 28% ended up with the same rating as when the program started. Almost 40% moved up or down one star over the five year period, while 20% moved two stars. Recently, CMS announced changes to the quality measure content and scoring methodology, costing about 8% of nursing facilities their five-star rating and creating unhappiness in the provider ranks:

LeadingAge Supports Transparency, But Still Finds Flaws in the CMS 5-Star Nursing Home Rating System
New Government Rating System Forces Nearly 1 in 3 Skilled Nursing Centers to Lose Coveted Quality Star
CMS’s confusing kick in the teeth

To understand what happened, first we need to understand how the score is calculated. You can read the CMS Technical Users Guide, or just follow along:

Health Inspections Five Star Rating

The health inspection rating is calculated from the number, severity and scope of deficiencies in the past 3 annual surveys, along with deficiencies from the last 36 months of complaint surveys. There is an aging component, as well, so that more recent surveys are weighted more than older ones. CMS then stratifies the star rating so that the lower 20% of nursing homes in each state receive one star, the middle 70% receive between 2 and 4 stars, and only the top 10% receive 5 stars. The actual state-by-state distribution looks like this:

Nursing Home Compare Five Star Rating

Staffing Five Star Rating

The staffing rating is based on reported staffing during the more recent annual survey, and looks at RN staffing and total nursing personnel (licensed nurses and nurse aides) adjusted by case-mix based on the RUG-III group. The star rating is determined according to the grid below:

Star ratings based on nurse staffing

And the state-by-state distribution looks like this:

Nursing Home Compare Staffing Star Rating

Alaska is excluded from the chart above. Why? Because 100% of Alaskan facilities received five stars for staffing.

Quality Measures Five Star Rating

The quality measure star rating is based on how the facility performs during the previous 3 quarters (9 months) on 11 of the 18 quality measures currently calculated by CMS:

Long-Stay Residents:
• Percent of residents whose need for help with activities of daily living has increased
• Percent of high risk residents with pressure ulcers (sores)
• Percent of residents who have/had a catheter inserted and left in their bladder*
• Percent of residents who were physically restrained
• Percent of residents with a urinary tract infection
• Percent of residents who self-report moderate to severe pain*
• Percent of residents experiencing one or more falls with major injury
• Percent of residents who received an antipsychotic medication

Short-stay residents:
• Percent of residents with pressure ulcers (sores) that are new or worsened*
• Percent of residents who self-report moderate to severe pain
• Percent of residents who newly received an antipsychotic medication

* Risk adjusted

The scoring methodology is somewhat complex, but essentially point values are assigned for each measure based on the nursing home’s performance compared to other nursing homes in the same state. Each quality measure is given equal weight, so the individual scores are simply summed. The total score is then applied to a scale to determine the star rating.

The current star distribution for quality measures, by state, looks like this:


Overall Five Star Rating

With the complicated math behind, calculating the overall star score is easy. Begin with the health inspection rating. Next, add one star if the staffing rating is a four or five stars *and* the staffing rating is higher than the health inspection rating. Subtract one star if the staffing rating is one star. Finally, add one star if the quality measure rating is five stars,  or subtract one star if the QM rating is one star.

Special note: If a facility has a one star health inspection rating, its maximum overall rating is limited to two stars. Also, if the facility is in the Special Focus Program, its overall star rating cannot be more than three stars.

Why was the Recent Rebasing Done and Why are Providers Unhappy?

Since the fundamental methodology is intended to stratify facilities relatively evenly, but the actual scoring is based on a known point system, a gradual drift towards higher star ratings occurred over the past five years. Part of this is probably due to overall care improvements, and part of this is probably due to providers gaming (or at least selectively improving) parts of the system.

There is also a slight issue of state imbalance. Consider the District of Columbia:



More than 50% of DC facilities hold a five star rating. Does this mean that DC providers provide phenomenal care? Perhaps, though it’s unlikely they provide significantly better care overall than providers in many other states. So how did so many providers get this coveted rating? As you can see above, the majority of DC providers received either four or five stars for staffing and five stars for QMs, which would lead to either one or two stars added to the health inspection rating. This points to a core problem with the five star system: CMS selectively stratifies measures by state, attempting to account for differences in state Medicaid policy and surveyor quirks, but this ends up causing some parts of the measure to reflect best-in-a-state results and others to reflect best-in-the-country results. Since the methodology isn’t standardized, it creates a real problem when comparing the five star rating of facilities located in different states.

What Does This Mean for Providers

CMS has clearly stated that it will continue to update measures and rebase scoring to promote continual improvement in nursing homes. While providers are understandably frustrated, this is simply the reality of healthcare today. Complaining about being ‘kicked in the teeth’ only furthers the perception that the nursing home field is behind the times. Instead, providers should see this as an opportunity to excel, not only in Nursing Home Compare rankings, but in service and care as well.

Understanding the methodology behind the five star rating system, as well as the state-level distribution, is a crucial first step to responding to this recent change. It should be clear that the health inspection score is the biggest driver of the overall score, and to reach a five star rating, a provider must be at or below the state average for survey deficiencies. Thus, it is critical, now more than ever, to build effective systems that embed quality processes into daily work. Customer service is also key, as most complaint surveys begin from unhappy residents or family members. Second, staffing hour cutoffs make it easy to compare current staffing metrics to the star rating system. For some facilities, adding slightly more staffing hours is an easy way to improve the star rating. Third, since quality measures are equally weighted, facilities can determine what measures are close to a higher point cut-off and work to improve those specific measures.


Building a Culture of Continuous Improvement with an Idea-Driven Approach

Ideas are the fuel of innovation, but many senior housing communities and long-term care operators struggle to engage their front-line employees in idea generation. This is both unfortunate and short-sighted. As Alan Robinson and Dean Schroeder note in their book, The Idea-Driven Organization, a steady stream of ideas can lead to competitive advantage, better service and higher quality—three things that aging services providers, now more than ever, must maximize. For nursing homes, an idea-driven culture is a crucial component to any successful QAPI program. For other providers, rapid growth and development is squeezing margins and increasing calls for enhanced regulation around quality and service.


Ideas are crucial to performance and quality improvement in long-term care

Generating Ideas

Generating ideas isn’t hard and it doesn’t have to cost a lot money. In fact, more employees will offer them for free. Why? Humans love to make things easier—it’s hardwired into our biology. In a typical workplace, however, rules, bureaucracy, and hierarchies all work to hamper employee engagement and reduce the flow of new ideas. An employee with too many ideas is often ostracized or, worse, accused of being trouble and offered the door. Other employees learn that it’s better to be quiet and keep ideas to themselves.

To break this cycle, build a culture where ideas are welcomed. Reward employees for sharing ideas. Create safe spaces when employees’ voices aren’t overshadowed by louder colleagues or discounted by management. (The nominal group technique can help with this!) Make it easy by ensuring that management spends time with front-line staff in their own work areas. When there, leaders should probe employees, ask questions and encourage contrarian views. Include idea generation and testing in job descriptions and performance evaluations to reinforce its value and importance.

Some organizations try suggestion boxes to solicit ideas. These rarely work; ideas becomes disconnected from their source, and are pre-judged to be undoable, or forgotten about in an ever-growing mountain of executive to-dos.  Instead of closed (or locked!) boxes, try open boards, instead, where ideas and follow-ups are shared openly. Open boards are also useful for aligning ideas with strategic priorities and organizational goals; list specific topics with known barriers or challenges on the board to help harness the wisdom of staff. Technology tools can be useful, too, such as idea management software and enterprise social networking tools.

Generating ideas in a nursing facility or assisted living is a team process

Managing Ideas

Generating an idea is only the first step. Once an organization starts to truly encourage an idea culture, it’s important to have a system to manage them. Countless idea programs fall into quick disuse as employees learn that the systems are of little value in enacting change.

Idea management takes energy and resources, but it shouldn’t be complicated or hidden from view. Track ideas openly, and allow for feedback, evolution and improvement. Many organizations limit the flow of ideas due to a lack of perceived bandwidth to accomplish goals. Instead of parking ideas or telling staff that there isn’t time to work on something, look for ways to enable and empower staff members themselves. While prioritization of ideas is important, of course, but don’t get trapped into creating so formal a system as to require every action be approved by three levels of management. Decentralization is key to an idea-driven culture. The vast majority of ideas should be tried and tested by front-line staff and supervisors, who are then supported in sharing both successes and failures.

There are many examples of organizations that have successfully done this, such as Ritz Carlton permitting any employee to spend up to $2,000 to make a guest happy. (Compare this to some nursing homes where staff struggle to have enough pens and thermometers.) Brasilata, described in The Idea-Driven Organization, authorizes front-line supervisors to spend up to 100 reals and managers up to 5,000 reals implementing an idea.

However the system is designed, the most crucial point is to not let ideas linger. Static action plans, known issue lists, and problem trackers that are not acted upon serve to stifle innovation and reassure staff members that the organization cares little about their ideas.

Here again, managing ideas through a visual board or an open, collaborative software system enables open lines of communication, frank discussions of challenges and impediments and innovative problem solving approaches.

Kaizen Idea board showing quality improvement ideas

Ideas Lead to Success

Lean organizations thrive on a constant, substantial flow of ideas. By building a culture that not only allows, but actively supports, idea generation, and then managing the flow in an efficient and transparent manner, companies can accelerate their improvement practices and develop a more robust and agile organization. When combined with a fervent improvement mindset, these organizations can far outshine their competitors.

Have more time? Listen to a wonderful podcost with Dr. Dean Shroeder & Dr. Alan G Robinson, authors of the Ideas Driven Organization, and visit their website, Idea Driven.

Ready to get started? So are we!