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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

The 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.

by Sean Carey

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.

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.)
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.
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.

by Sean Carey

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:

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.

by Sean Carey

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?

by Sean Carey

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?’

Example:

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

Change Management in 8 Steps

Emotional Transitions

Moving Forward

Percent of Spending by Type, MS-DRG 470

Ready to get started? So are we!