It’s All about Always, part one

May 15, 2007

My “ah ha!” these last several months is the different impact the words always, most of the time, and sometimes have when it comes to performance.   We now have H-CAHPS, which will create the healthcare language of always, usually, sometimes, never.

Over the years, in many areas we have hardwired always.  If you are a member of a purchasing group, leaders always buy from a specific menu.   If you have a budget due, it is always done by the start of the new fiscal year.

In operations, the elusive ingredient which separates the perennial high performing leaders and organizations is consistency.  Consistency for patient experiences, employee work environment and physicians’ practice of medicine.  Many feel we run four organizations: the day, night, weekend and holiday organizations.

The implementation tools and techniques backed by evidence that achieve and sustain high performance results are what we at Studer Group call “evidence-based leadership.”  Evidence-based leadership helps create an always organization.  The foundation of evidence-based leadership is to begin with aligned goals, which are created by effective leader evaluations and a leadership development process that links to desired organizational outcomes.

Prior to visiting an organization I have leaders complete a survey.  It asks leaders to evaluate the effectiveness of these foundational aspects of evidence-based leadership.  The survey covers such things as, “Do you have a formal meeting with new employees on their 30th and 90th day?  If you are an inpatient nurse leader, what percent of patients do you visit (round on) each day? What percent of patients receive a discharge phone call?”

There are questions on the healthcare environment, too, so it gauges understanding of the leaders on the current and future healthcare environment and their readiness for success.   

We use this data combined with the organization’s results to implement the next steps to either achieve excellence and/or to sustain excellence.   After reviewing the results of these surveys from hundreds of organizations, we have learned a lot. 

When it comes to patients’ perception of care, it is all about always.  That is the topic of this blog.

When I review survey results, I ask the top leaders of the organization “Are the nurse leaders rounding on patients?  Are discharge phone calls being made? Are outpatients being contacted to remind them of their appointment to reduce patient no-show rate?”

The answer I get is “yes.”  It is a true answer.  It is what they hear when they ask leaders these questions.

So what separates the high performing leader and organization from the middle performing leader and organization from the low performer leader and organization? It is the impact of always.

High performing leaders and organizations have hardwired the tools and or techniques so they are always done.

The middle performing leader is a most of the time leader in using effective tools and techniques. 

The low performing leader is sometimes.

When the question is asked the answer is, “Yes, I round. Yes, 30- and 90-day meetings on new hires.  Yes, discharge phone calls.”

It is not until the verification of frequency system is put in place does it come to light that the difference is not who does the behavior, for almost all leaders or organizations can say they do it.  It is the hardwiring of the tool and technique so it is an always behavior; not a most of the time or sometimes behavior.

The other confusing issue is a leader who says they always do it. We find that this means it may take place five out of seven days.  For example, consider leader rounding on patients.  We find that patients’ and physicians’ experiences at the hospital during the weekday are much different than the weekends. So, for some practices, the hardwiring needs to be for seven days, not five.

Measuring “always”.  How can leaders assess whether they are an always organization?  One great way to find out is to ask your patients.  For the more than 3,000 organizations using the H-CAHPS survey, patients are already telling them.  The H-CAHPS instrument asks patients to describe their perception of the quality of their care by rating the frequency of events during their care (never, sometimes, usually, always).

By asking patients if they always see key events, leaders can quantify how hardwired those behaviors are from the perspective of the most important person in their organization . . . the patient.

Less is more.  Today, we know that doing more may get you less and doing less will get you more.  Our experience has taught us that it is better to have a leader implement one new tool or an adjusted technique until they achieve always, rather than doing more than one tool or technique most of the time or sometimes.  Then the leader, unit, department and division experiences success, the tool or technique is hardwired, and the maximum impact is gained so the leader can see if more has to be done.  And, if more needs to be done, the leader can choose the next step much more wisely.

At our June 11-13 What’s RIGHT in Health Care conference, organizations who are successfully building a culture of always will be presenting. Hope you can join us.



4 Responses to “It’s All about Always, part one”

  1. In your blog you stated, “When it comes to patients’ perception of care, it is all about always.” You later followed with, “The H-CAHPS instrument asks patients to describe their perception of the quality of their care by rating the frequency of events during their care.”

    Frankly, I have never agreed with “frequency” definition of quality that has pervaded patient satisfaction research for years. Quality is not limited to a perception of frequency. The only reason that patient perception of care is always about “always,” is because frequency is the only dimension they’ve been allowed to rate on for years. This method of assessing patient care quality in fact minimizes the feedback of each individual patient. There is a big difference between asking patients to evaluate an event and asking them how often it happened.

    But the biggest flaw implicit in the H-CAHPS approach is that each individual patient comes to a hospital as a blank slate with respect to expectations, prior-biases, or other issues that could infuence their perception of care. Is that really the truth? The H-CAHPS “world view” is that doctors, nurses and hospital staff are the only determiners of a patient’s perception of care. Each patient is a blank slate that the staff will mold like aluminum on a can-making assembly line. This allows them to excuse themselves from actually learning about individual patients’ needs, priorities, values, biases, or behavioral patterns, and working to shape the care experience accordingly. It excuses the institution from actually being “patient centered” because the only “patient” that matters is the abstraction defined by a collection of frequency ratings.

  2. Kitty Wrigley Says:

    One phrase in this article is “foundation of evidence-based leadership is to begin with aligned goals, which are created by effective leader evaluations and a leadership development process that links to desired organizational outcomes.” However, evidence-based practice (medicine or business) is founded on objective study, i.e., the literature. Here is a quote: Dr. David Sackett, the “father” of EBM wrote that it is “the conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient. It means integrating individual clinical expertise with the best available external clinical evidence from systematic research.” (BMJ 312:71-72, 1996) His concepts have influenced the business world, as seen in the publication of a book by two business professors at Stanford: Pfeffer, Jeffrey and Robert I. Sutton. Hard Facts, Dangerous Half-Truths & Total Nonsense:Profiting from Evidence-Based Management. The foundation of evidence-based anything is this: bigin with a search of the literature. This does not mean a Google search. Along the way, we develop goals and align them. Hopefully our goal development has included a thorough search of the literature. The practice of aligning goals is a good one, just not, in itself, evidence.

  3. Jay Tatum Says:

    One of the challengs of the “always” methodology is allowing the disciplined practice to become a part of one’s being. I agree that the small adjustment in one area makes a huge difference. Yet the comment I hear most often from senior and mid-level managers is consistently the same – “That’s not who I am.”
    I think when we seriously wrestle with our own personhood, defining our being from our doing, and writing and living that personal mission statement the “always” methodology always works. Whether one accesses, practices and participates in disciple-making determines what kinds of disciplines are important. The top performers always practice, practice, practice specific disciplines that produce results, always. Thanks for the upbeat vibe. Jay

  4. Bernie Henry Says:

    The key to healing is to realize that indeed time for emotional support and bonding lifts the human experience. The same is true in employee relations, The always manager makes sure that never, in the name of squeezing out variability to meet financial pressure, is the human presence and congeniality set aside. If emotional support and bonding is important to you it will always be on your calendar.

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