June 20, 2006

I have three quotes that can transform your organization. Two came from a study that our Institute for the Future of Aging Services did for the Department of Health and Human Services (HHS) and the Department of Labor (DOL). The other is from a study by CNA, AAHSA's affinity insurance carrier.

The HHS/DOL study is entitled "Measuring Long-term Care Work." It's filled with a variety of validated tools — many developed by and with AAHSA members — on how to measure things like job satisfaction, worker-client relationships and organizational culture.

The CNA study, "Comparison of Claims Data in Long-term Care — January 1996 through March 2005 — Not-for-Profit, For-Profit" (a catchy title, don't you think?), contains an excellent analysis of the major reasons we suffer liability claims and a detailed guide that can fit nicely into your Quality First tool belt on what to do to prevent liability.

The HHS/DOL study is about 400 pages. The CNA study is about 30 pages. Both belong on your bookshelf and are worth operational planning time with your staff. They ain't sexy, but are essential resources for all of us.

Here are the three quotes—

1. "In a study of nursing home assistants, worker-resident relationships were identified as the most important work issue, and the major reason for worker retention."
2. "The importance of considering worker-supervisor relationships when attempting to maximize retention and limit turnover cannot be overstated... Supervision has been cited as a primary reason for leaving an organization..."
3. "Effective communication among providers, residents and families can foster realistic expectations related to resident care and services. The quality of the relationships and the ability to freely address concerns is the single most effective deterrent to litigation."

I recently had the opportunity to hear an inaugural presentation by Ed Kinney, the new CEO of Life Care Services. LCS is based in Iowa, but serves in 29 states as owners, managers and developers. Ed said to the assembled group, "you know, in the final analysis, we're fundamentally in the relationship business, aren't we?"

John Outler, a human resources guru I worked with, said many times, "you have to go through relationships to get to the work." Then he'd add, "people have been known to hang high-voltage wire in a hurricane if they have trusting relationships."

Mike Moore, AAHSA board member and CEO of the United Presbyterian Home in Iowa, wrote me last week about a resident who died recently. A deathbed conversation with her son included her gratitude for the home's staff. Her son quoted her at the funeral, "they were more than my caregivers. They became my friends."

A medical study a couple of years ago concluded that the relationship between certified nursing assistants (CNAs) and residents is often so close that they are the most likely folks to pick up on subtle changes that result in a health crisis. Observations of a resident like, "she doesn't seem like herself today..." can make all the difference.

I wonder how deeply we really understand the depth, power and quality of the relationships between staff and residents. Mike Moore said he sat in the pew at that funeral, beamed inside, and teared up as he shared this individual's perception of her relationships with staff members. If we asked, we might be amazed at staff's level of knowledge about resident needs, disappointments, hopes, fears and joys ... yes, the relationship context of deep friendships.

The resident-staff relationship is a sacred experience when it's done right. How does that happen? It happens by selecting the right people. Making sure that every staff member is in care-team meetings. Developing consistent staffing patterns and vigilance about burn-out or unusual stress in the lives of staff. Using staff satisfaction surveys. Hosting fun events. Being accessible to staff. Managing by walking around. Creating policies and programs that allow staff to spend quality time with residents.

Research from our Better Jobs, Better Care program has also given us some hard evidence on what works: Things like cultural competency training that focuses not just on teaching staff English, but on understanding the customs and cultures of those being served and those doing the serving. Dedicated staff retention specialists whose job goal is to reduce turnover. Direct care worker peer-mentoring programs and organizations that budget for the time required for them to participate in training and to support each other.

Early in my career as administrator of the Wesley Woods Health Center, an old Hill-Burton nursing home, we participated in one of the Great Society job training programs. Though a success, I remember a young CNA who was unusually gifted. She was bright, warm and had a good work ethic, and a lot of promise. Well, one day, she slapped a resident, out of the blue. Stunning; naturally, we had to discharge her immediately.

The person who cried most was Doris Kittle, a registered nurse who was a gifted mentor, among her other talents. One of the greatest nurses I've ever known. She thought she'd failed one of her residents and this young woman terribly. When we rooted out the cause of the behavior, the young CNA had just found out she was pregnant and had a sexually transmitted disease. She had gone home from work the afternoon before to find all of her belongings piled out on the street, and her boyfriend had left her. She came to work the next day and took it out on a resident. If we'd only known ...

The care and feeding of the resident-staff relationship and the staff-supervisor relationship within the context of healthy teamwork is the crucible from which a successful human resources culture is forged. That's what the Pioneer Network, Eden Alternative and Wellspring are all about. And there are people like Anna Ortigara of LEAP, Michelle Holleran, Clint Maun, Fran Battisti and Robyn Stone—and many of our members who are successful culture keepers—who can help us develop such a culture.

The aging-services airwaves will be increasingly filled with the concept of "person-centered" or "resident-directed" care. I can't prove it, but I'd bet that far too much of what we do is provider-centered care done for our convenience, or to mollify surveyors, or because "that's the way we've always done it." Order the video "Stand Up and Tell Them" and view it with your staff. It realistically addresses where we are and where we need to go in terms of person-centered care.

Genuine person-centered care isn't new. Hospice developed on that core principle for almost two generations. It is based on open communications with the patient about their condition, keeping family in the loop, tailored approaches to treatment that the patient wants to try and flexible schedules of basic services like meals and sleep and bathings and visitors.

Just ask some of our business friends like Aramark, Morrison Senior Dining or Sodexho about the effect of replacing a tray line assembly approach to meals with a dining experience with cafés, buffets and flexible hours. Resident satisfaction is up and weight loss is down.

Why? Choice. Control. Variety. Ambience. Relationships.

What do the people we serve and those who serve them expect of us? A good place to start is to make sure you ask them. Drew Gackenheimer of Joseph L. Morse Geriatric Care Center in Florida has a well-thought-out approach to family expectations from the early stages of the relationship. If families expect a cure or a return to health that is impossible, the Morse people help families honestly deal with the reality.

The science behind jury decisions in liability cases reflects that the key to favorable outcomes is the perception that we've done the best we know how to do, that we have a positive relationship with residents and families about expectations. And, yes, even when we make mistakes, we aggressively try to respond to problems when they arise, and honor requests when we can. People are less likely to sue people they know, like and respect. Mark Thomas of the Ebenezer Society in Minneapolis told a group of AAHSA leaders, "Culture eats strategy for lunch." Relationships should be the number one responsibility and concern of leadership.

The key to a future of health and viability for our organizations, and the improved quality of life the elders in our communities deserve, is Relationships! Relationships! Relationships! In the final analysis, Ed Kinney and Mike Moore are right. We're in the relationship business, and we enable deep friendships through caregiving.

Larry

William L. Minnix, Jr., D.Min.
President and CEO

Learn more about Better Jobs, Better Care.
Learn more about the Aon risk management training.
Read the ASPE/DOL Report.

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