Archive for category: Leadership Practices

Balanced Scorecards and Key Performance Indicators in Long term and Post-acute Care

Are you struggling to accomplish your desired strategy? Thwarted by constant operational challenges? Your measurement systems might be able to help more– or they might even be part of the problem.

Many healthcare organizations track enormous amounts of data to guide their action and strategy. Sometimes, however, the pursuit of measures and metrics interfere with the implementation of strategy, and organizations struggle to move past the day-to-day business challenges to accomplish their long-term goals. Balanced scorecards and KPIs are two tool sets that, when used properly, can be used to facilitate both managing operations and preparing for future work.


Balanced Scorecard for LTC

Balanced Scorecards

The concept of a balanced scorecard was developed in the mid-90s by Robert Kaplan and David Norton (with help from  Art Schneiderman, et al.) as a response to the over-dependence on financial measures to guide organizational action. The purpose was to translate strategy into measures that could inform action by balancing financial measures with measures around the perspectives of customers, internal business processes and innovation/ learning. Over time, additional features were added, such as strategy maps to help visualize direction, and destination statements to provide more definition around goals.

A key challenge to implementing balanced scorecards is they take a significant investment of senior leadership’s time to develop. While financial measures are easy to translate across organizations (census, payer mix, days in AR and financial ratios would be common in long-term care), as well as some internal business measures (quality indicators, survey and cert. results), the customer and innovation quadrants needs to be more locally refined. Some organizations, for instance, serve specific populations, and the measures of success need to be closely aligned with those missions. Similarly, learning and innovation is important in every organization, but the actualization can vary from an interest in employee development to implementing evidence-based practices to technological adoption.

Sometimes, the challenge is having vague ideas about strategy but no clue about how to get there. I’ve worked for and with several organizations that have wanted to “be the best place to live and work” and “a teaching and learning organization.” They struggled year after year with making progress, however, because they didn’t hone in on specific measures to drive that strategy, nor did they have clear ideas about what exactly those lofty goals meant.

The Capital Care Group in Canada implemented a balanced scorecard, and there are some great lessons learned from research on that process:

“The balanced scorecard has focused on its role as a strategic management tool. The indicators and dimensions need to be customized to the organization. Senior management must be seen to be driving its introduction. It is worth spending sufficient time developing and implementing a scorecard rather than trying to rush its introduction. The scorecard needs to be integrated with existing management processes and sufficient resources must be assigned. However, success will ultimately depend on the culture of the organization being appropriate and receptive.”

Key Performance Indicators (KPIs)

KPIs were developed to focus attention on accomplishing organizational strategy by measuring discrete data points. Again, financial measures have been used successfully for quite some time, but KPIs expand the reach to things like productivity, marketing success, turnover, meaningful quality measures (ones that either impact action or reflect operational results) and the like.

When adopting KPIs, it’s important to choose a limited number so that staff don’t become overwhelmed with the measurement of data for its own sake. It’s also important to understand the tendency for measured indicators to pervert performance by allowing managers to manipulate action in promotion of measured activities even at the expense of organizational success. I frequently see this when organizations measure turnover without regard to other performance metrics. This tends to incentivize managers to keep staff regardless of performance or actions– even at the detriment of team morale and operational effectiveness. High turnover is a costly problem in long-term care, for sure, but not all turnover is bad.


Using Organizational Metrics Effectively

Whatever system of measurement you use, it’s important to understand the systems themselves don’t determine strategy. Measurement systems are oftentimes compared to an automobile’s dashboard or an airplane’s cockpit: but remember, you can’t tell where you’re going, or, even moreso, what you’re supposed to do when you get there, by looking at a dashboard; nor can you tell whether you should go through an intersection by staring at your dash. Instead, the dashboard helps keep you on track and can highlight problems that might interfere with your trip. Balanced scorecards and KPIs function in a very similar way: they guide action and help implement strategy– but you still need to know where you are going and what you want to do when you get there, and you must keep in mind that they are only a piece of the overall operational puzzle.


eSSee Consulting has extensive experience developing and implementing measuring and metric systems in long-term care organizations. If you’re unhappy with your current system, or don’t have effective dashboards at all, we would love to help simplify your life by focusing on measures that truly impact performance and push you towards your desired goals.

Policies and Practices Will Trump Your Rhetoric

The Atlantic recently published an enlightening article by veteran journalist Joe Williams, entitled, “My Life as a Retail Worker: Nasty, Brutish, and Poor,” where he writes about his experience working in a retail sporting goods shop after being laid off from Politico. It’s reminiscent of a phenomenal article Steven Lopez wrote in 2006: “Culture-Change Management in Long-Term Care: A Shop-Floor View,” which paints a similar picture of organizational rhetoric flatly denied by policy and practice.

Both articles highlight a common feature in highly bureaucratic organizations (which includes virtually all LTPAC providers): The rhetoric of person-centeredness, of genuine care about individuals, and of interest in the complexities of socio-economic conditions oftentimes falls flat in the face of organizational practices, strict “no-fault” policies, and unrealistic demands on individuals. In our work with providers, we constantly see discrepancies in the rhetoric of very caring leaders (We value our staff, we trust them to make good decisions, we put our residents first…) and the “machine” of the organization: inflexible attendance policies, collaborative discussions around all work issues except wages and working conditions, unrealistic labor demands on line staff… These two strong forces are like the legs of a person: if you don’t move too fast, you’ll probably drag each leg along without serious disruption. But try to run; try to walk quickly; try even to turn around: You’ll stumble and fall, like many well-intentioned providers.

Take this article published last month in McKnights. “Consistently assigning nursing home aides to particular residents could cause the aides to feel isolated and overburdened, suggests a study forthcoming in the Western Journal of Nursing Research.” Chris Perna, chief executive officer of the Eden Alternative, responded: “What the researchers can conclude is that the organizations involved did not do a very good job implementing these changes.” Pena went on to criticize the deployment of the program in the facilities studied, the sample size, and even that “the nursing homes in the study did not exemplify the principles of consistent assignment that Eden advocates.”

Pena is basically saying the organizations didn’t implement culture change correctly. It’s a common response to any criticism of the culture change framework, which intuitively feels right. And I get the feeling: my first job as a nursing home administrator was at a community lauded for it’s culture change practices, yet completely frenetic in staffing assignments. Through a long process, we developed a consistent assignment program that I felt was incredibly successful. From my vantage point as the administrator, I saw care outcomes were better (measure by incident numbers and the QI report), residents and staff were both happier (measured anecdotal and through satisfaction surveys), and absences were lower (measured through a detailed log we kept). But there was also roughness to this result. When a primary caregiver returned after a day off, they were invariably annoyed by small things the alternate did (or didn’t do). Teamwork was completely unaffected by consistency: those staff who helped extensive before consistent assignments continued to do so; and those who didn’t, didn’t. And the complaints about “certain groups of residents” intensified, as now it wasn’t luck if you were assigned “a hard group”– it was your fate. When we looked at outcomes on a microlevel, we found that one group consistently had lower staff satisfaction and higher turnover. Did we fail in our implementation? Did we not exemplify the principles well enough? No, I don’t think so. I think we discovered how life is infinitely more complex than a consistent assignment program can encapsulate. I think we discovered that our attendance policy was doing more harm to consistency than our staffing practices. And I think we discovered that not all CNAs want the same thing, not all residents want the same thing, and sometimes the competing priorities between administrators, staffing coordinators, line staff and residents mean that not everyone gets exactly what they want. And this is the heart of it.

The problem with culture change interventions, fundamentally, is that they are typically constructed in a vacuum of what could be. This is a great environment for designing a best practice, and a lousy environment for integrating real-world challenges. At the core of culture change philosophy is the tenet, “Know the person.” And it’s here where the tension is greatest. Know the person means consistent assignments are not best for all residents and all staff and all organizations. Neither is any other intervention. Programs must be designed locally and in context. And part of that context is the rest of the organization. What Lopez and Williams point out is that if your organization values people, don’t insist on policies that treat workers like criminals or children. If your organization demands loyalty, don’t stand behind policies that inflexibly respond to outcomes rather than processes. And if you care about doing the best work possible for residents, don’t create avenues for discussion that a priori exclude topics (like wages and working conditions).

Here’s a good way to start a more complex evaluation of culture change in your community: look at either your organization’s attendance or counseling policy. Does it reflect the person-centeredness of your organization? Does it reflect the values you expect line staff to show to your residents? Does it reflect your organization’s heart? Or is it formulaic, adversarial and reminiscent of the care processes your organization is committed to changing?

The Need for Management

It’s become vogue, particularly in the nonprofit field, to praise leaders and leadership as the needed remedy to challenges in the sector while vilifying bosses and management as outdated—or even backwards—modes of organizing. This follows a long trail of thought-leadership that began in 1977 when Abraham Zaleznik published his seminal article, “Managers and Leaders: Are They Different?” In the article, Zaleznik criticized the primary focus on managerial control that pervaded business schools at the time, and argued for the need to develop leadership practices aligned with inspiration, vision and innovation.

Through countless books, articles, and speakers on the subject since (Collins, Pozner and Kouzes, Maxwell, et al), the dichotomy of leadership versus management has grown stronger and, somewhat ironically, an inherent (and sometimes explicit) hierarchy of practices has formed. Indeed, Collins, in Good to Great, identifies managers as “level 3 leaders,” whereas there are two higher levels yet for those who practice traits of vision, humility, improvement and willpower.

Nonprofits, who traditionally have experienced greater difficulty in the basics of management to begin with, have leaped on to the leadership bandwagon with gusto, happily discarding the messy unpleasantness of “management;” in so doing, they jeopardize not only their organizations’ margins, but their entire missions as well. Many leaders in nonprofit aging services—executive directors, administrators, CEOs– actively campaign against “authoritative management,” citing their different “style of leadership” or “personality type” as their reasoning for glossing over the traditional facets of management. Leadership Institutes are now commonplace in trade organizations and professional societies, usually with a singular focus on leadership traits like vision and innovation and without regard to the duties and skills of a manager. In so doing, they throw out wholesale the lessons of the past and create real gaps in organizations’ abilities to actually effect the change they set out to create.

In 1990, John Kotter published an article entitled, “What Leaders Really Do.” The article’s first paragraph sums his entire thesis: “Leadership is different from management, but not for the reasons most people think… Nor is leadership necessarily better than management or a replacement for it. Rather, leadership and management are two distinctive and complementary systems of action.” In Kotter’s estimation, US businesses at the time were over-managed and underled. Unfortunately, the reality of aging services is that most organizations are both under-managed and underled, creating a disastrous combination that threatens their ability to survive.

Leadership is crucial, and we must continue to educate and train leaders in the practices that work. There is indeed still much work to do. Management, too, is critical to survival, however, and we must also stop vilifying the control of processes, the organizing of people, and the solving of business problems at the same time. As Kotter noted more than two decades ago, our success requires both.

Gerontologist: “Transforming Nursing Home Culture: Evidence for Practice and Policy”

The February 2014 issue of The Gerontologist contains a special supplement, “Transforming Nursing Home Culture: Evidence for Practice and Policy.” This 102 page volume contains a number of excellent publications, including, “What Does the Evidence Really Say About Culture Change in Nursing Homes?,” “Culture Change and Nursing Home Quality of Care,” “Who Are the Innovators? Nursing Homes Implementing Culture Change,” and “Building a State Coalition for Nursing Home Excellence.”

Overall, this supplement addresses the often-overlooked problem with research on culture change: it’s not yet clear what works and what doesn’t. Providers deep on a journey of culture change may object to this statement, pointing to numerous cases of anecdotal evidence that supports change practices. And, indeed, there is some evidence tying practices to improved outcomes (and less evidence tying practices to worse outcomes). Still, true lasting change will only broadly occur when we develop solid understandings of what will work, and many of the articles highlight areas where future research should be directed.

Some key findings:

  • Current evidence doesn’t give providers enough information to select interventions for specific outcomes.
  • The usage of control groups must be increased to develop a stronger evidence base.
  • Mouth Care Without a Battle offers specific guidance for improving the resident-centeredness of specific care tasks.
  • Culture change coalitions with broad stakeholder involvement can be successful catalysts for change.

Looking forward, an article entitled “Implementing Culture Change in Nursing Homes: An Adaptive Leadership Framework” by Corrizzini and Colleagues at Duke will be published in The Gerontologist soon. (Advance copy currently available online.) This paper, based on a qualitative, observational study of culture change practices in 3 nursing homes, highlights some crucial lessons for providers:

  • Administrators too often rely on technical management solutions that unknowingly promote a continuation of management-driven practices. Instead, administrators must learn to better develop an adaptive leadership framework to understand how relationship-driven processes can be supported.
  • Providers and proponents of culture change rely on technical measures of culture change, such as staff scheduling and resident involvement in care planning, rather than adaptive measures of staff empowerment and problem-solving capacity.
  • Culture change nursing homes continue to experience dramatic disconnects in understanding between various roles, and, significantly, between management and line staff. Further work is needed on developing tools to measure and reduce this gap.

Adaptive leadership practices, as noted in this study, are woefully underutilized in the LTPAC space, as there is a stong bias for leadership that manages the technical aspects of an organization, i.e. census and revenue-driven outcomes, staffing costs and labor usage, and proxy measures (turnover, satisfaction, compliance). Unfortunately, changing payment models will continue to support this bias.

Leadership practices aside, organizations can also look at adopting transparent mechanisms for communication, instilling a just culture, and using recognized focus group practices to gather quality data about challenges and develop a better framework for promoting culture change in their communities..

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