Honored to have been part of the CARE Coalition of North East Ohio expert panel on "How Post Acute Care Providers Affect Star Ratings". Grateful to Bath Creek Estates SNF/LTC facility for hosting. Thank you Frank Gonzalez-Abreu for the invitation and thank you to each panel participant and attendee. Outstanding discussion and excellent questions. — with Roberta Brofman.
This interview was conducted by Shalom Plotkin of Right at Home and filmed through the courtesy of hChoices. In the interview Roberta Brofman, BSN, RN, MBA-HCM, tells us how and why she became a health care professional and what drives her passion for excellence.
Who you hire and how you train them are two of the most important decisions affecting your organization. This is true from entry level to the leadership team. The people you allow into your organization are the working capital that can mean the difference between success and failure.
If you are spending more time dealing with turnover and disciplinary actions, it is time to look closely at how you are selecting and training new employees.
Here are 11 areas of focus to consider in onboarding employees:
1. Determining qualifications per job level
It seems obvious that unless you know what you are looking for you will most likely never find it. However, it is not uncommon that candidates are selected based upon availability and a cursory look at qualifications. Human Resource (HR) departments may believe that this will be sorted out by the interviewer, but this is a waste of precious time that no one (including the candidate) can afford. Make certain that HR, hiring managers and interviewers have, in writing, the talents, education and experience solid candidates must have for every job level. It can be as simple as a checklist. While this may be labor-intensive on the front end, it will save cost and time in the long run.
2. Selecting Appropriate Candidates for Interview
Now that you know what you are looking for, you must know who fits that description. The checklist of minimum standards is only the beginning. Fitting the temperament, personality and soft skills into the hiring equation is critical. This is how you create culture within the organization. Anyone who has ever seen the movie The Internship where Vince Vaughn and Owen Wilson try to fit into the Google culture understands that the “fit” is critical to success. As Simon Sinek says, “Surround yourself with people who believe what you believe and great things happen.” Be aware that different parts of your organization may require different “fits.” For example the hospice team may be very different than the finance team.
3. Selecting the Proper Person to Conduct the Interview
How do you determine who conducts interviews at each level? Is it the director of that department only? Do you conduct peer to peer interviews? What qualifications do those who conduct interviews have to complete this very important task? Just because I am an expert in a particular area does not mean I know what questions to ask, how to evaluate the responses and what to look for. Do those conducting the interviews have adequate time set aside in their day? Providing training to those who are to conduct interviews is well worth the investment.
4. Determining the Interview Process
Taking the time to create a process is valuable to successful tracking of each candidate. We are all very busy and unless you have a specific process flow that candidates are guided through, it is easy to lose track of them. You want efficiency in the process so that good candidates do not move on to other opportunities. It shows respect to all candidates and indicates that your organization is efficient, well-organized and professional.
5. Asking the Right Interview Questions
The quality of the interview is directly related to the type of interview, as it will guide the questions and discussion. There are many options such as, behavioral interviews, case interviews, group interviews, phone and video interviews, second interviews, etc. The goal of the interview is not to determine basic qualifications as this should already have been completed. The goal is to determine the “fit,” the personality and soft skills which will match the role. I have often said that conducting an interview over lunch without asking a single question about the job would reveal the true candidate personality. Do they say thank you, are they patient; do they hold the door open; are they easily frustrated by the waiter’s error? You can train skills, but you cannot change the kind of person you hire.
6. Interpreting the Answers
It requires skill and experience to determine not only that responses were accurate but also what drives those responses. Are they nervous; are they too rehearsed; do they just need an opportunity despite the need for more experience? I can recall going back to work after years of raising my three sons. I had been away from Nursing for about ten years and applied for a home care position. I had never worked in homecare, had been away from direct care for years and was nervous. That hiring manager saw something in me that led to a fantastic career and I never disappointed her. To this day I thank her for looking beyond the resume and taking a chance on me!
7. Matching the Candidate with the Role
While a candidate may have applied for a role in one department, they may be better suited for another area. Matching the candidate with the role is about determining where they will be most successful. This means they will be fulfilled and will be more likely to stay with the organization. A happy employee makes a happy and successful organization.
8. Background and Reference Checks
Each organization has specific requirements for background and reference checking. I cannot stress enough the importance of checking these BEFORE the offer is made. I have seen situations where HR had to pull someone from orientation because a background check came back with an issue. Not the place anyone wants to be! While references may be seen as a formality, it is still important to follow through on them. Checking to see if the individual worked at a place where one of your trusted employees worked is also a way to check references.
9. A Proper Welcome!
Not much feels more like the first day in a new high school than the first day at a new job. We all feel a bit out of our element, stressed and unsure. The first impression you make on your new employee is crucial. How do you make them feel welcomed and a part of the culture? This should not be left to chance; you must have specific processes in place. A few ideas we have used successfully include: lunch with the leadership team during orientation; a picture of the new employee with their bio on the unit saying “Welcome”; follow up over coffee after one month; assigning a leadership mentor who stays in touch; a small welcome gift.
10. Orientation, Training and Assimilation
This is where we set the new employee up for SUCCESS! When they are successful, we are successful. Therefore, investing in a well-planned and executed orientation pays a massive return; not doing so will undo all the hard work that came before. It is also vital that those who provide training are star players. I have seen organizations where poor performers are responsible for training new employees. Is it any wonder that bad habits are then perpetuated? Recognize that proper training is going to cost money in the short-run, but poor training will cost in turnover and errors that increase risks and costs. Ensuring that the new employee is a positive part of the culture is part of their assimilation. Having that leadership mentor is key here.
11. Feedback Loop
Even the best onboarding process will not work 100% of the time. In order to determine where process improvement may be necessary you must establish outcome measures based upon the goals of the program. These outcomes must be reported on a regular basis to the quality committee or leadership board and also to those responsible for each part of administering the program. These should be opportunities for everyone to improve, not criticisms.
Examples of outcome measures include: Capture rate of candidates to employees; turnover rate within one year per job description/department; reasons for leaving organization; voluntary/involuntary termination; employee satisfaction per job category/department; success rates of interviewer in selecting successful candidates.
In summary, the importance of a strong onboarding program cannot be overvalued as employees are the backbone of who we are, what we do and how we are represented to the community. It is a critical part of the balance of operations, programs, people and service.
I recently attended an expert panel discussion entitled, “Handling Bundled Payments.” For anyone unfamiliar with the bundled payment system, it is defined as the reimbursement to health care providers, "on the basis of expected costs for clinically-defined episodes of care.” Costs (and risks) are shared based upon quality outcomes such as returns to acute care after service. It is a departure from the traditional “fee-for-service” reimbursement model in which a provider is paid per service rendered, regardless of outcome.
The bundled payment system basically puts all providers within the bundle into one boat—they either sink or swim—and if one fails they all suffer the consequences. Conversely, if they all succeed, all reap the cost benefits. The ultimate goal is to keep costs low and patient quality outcomes high.
Currently, bundled payment options are focused on joint replacement. However, in July 2016, the Centers for Medicare and Medicaid Services (CMS) announced three new bundles directed at cardiovascular care procedures, including acute myocardial infarction, coronary artery bypass graft and hip/ femur fractures. This new model was tentatively set to go into effect on July 1, 2017.
The expert panel discussion revolved around how to maximize patient outcomes, minimize risk and prevent patients from returning to the hospital.
Several recommendations surfaced:
There is something fundamentally wrong with this equation--
HOSPITAL + SKILLED NURSING FACILITY + HOME CARE AGENCY= SUCCESS is missing an essential factor--THE PATIENT!
The fact that the Medicare covered patient who goes home and does not follow instructions bears no financial responsibility in the equation whatsoever is absurd. The fact that the patient’s own irresponsible choices result in substantive costs for the providers significantly reduces the effectiveness of the bundled program in reducing costs.
Unless and until we include an element of patient responsibility into the bundle, costs will never effectively be controlled.
For the 15th consecutive year Gallop Poll has named Nursing as the most trusted and ethical profession. As a professional nurse, I could not be more proud of my fellow nurses.
I have seen first-hand the dedication of nursing professionals who sacrifice their own comforts to make certain that those entrusted to their care receive the attention they deserve.
I have also been fortunate enough to see the appreciation in the eyes of a patient in need. I’ve celebrated with joy at the birth of a newborn, held the hand of the dying patient and comforted loved ones after tragic loss. It is in these moments that I recognize how privileged I am to be part of the most intimate and vulnerable moments of another human being’s life.
This week as we celebrate National Nurses’ Week and the birthday of Florence Nightingale, the founder of professional nursing, I want to say thank you to nurses. Your dedication to excellence, knowledge and compassion sets you apart as a noble profession.
To my fellow nurses, I salute you for the respect, sacrifice and love you bring to every life you touch!
Happy Nurses’ Week!
United Airlines CEO, Oscar Munoz finds himself in the unenviable position of cleaning up the rubble that resulted from the now-infamous video of a passenger being forcibly removed from flight 3411. While viral video of the incident inflamed the outrage of the public, CEO Munoz’s initial comments regarding the incident was like adding gasoline to a raging fire. As stock prices plummet, the big question is how could this have been better managed, or better yet, avoided altogether?
Mentorship is an essential quality of leadership. However, in a profession plagued by chronic shortages, who has time for mentoring? The impact that nursing leaders have on an organization is far-reaching. Therefore, it is essential that resources are allotted to their mentorship and training.
Too often highly competent clinicians, recognized for their nursing expertise, are promoted into management roles with little or no training. They are given a new office, a title and it is assumed that they know how to lead. I refer to it as, “Poof, you’re a manager!” syndrome.
At best, these new leaders learn by trial and error. At worst, they leave the role feeling defeated and wondering what went wrong. Administrators are then left trying to figure out how such a competent clinician was unable to deliver in the new role.
It is not uncommon for these leadership roles to go unfilled, forcing administrations to place interim Directors of Nursing (DON) to fill the gap while they search outside the organization for talent. Had they invested in leadership training and succession planning for all nursing staff, this costly problem might have been prevented.
The investment is well worth the time and money because the return on investment (ROI) is substantive. Strong leaders who can develop talent, provide structure and create a culture of quality and caring are essential to the success of the organization.
Strong nurse leaders:
Skilled Nursing Facility (SNF) administrators are faced with some serious challenges when establishing policies for their admissions teams.
The drive to increase revenue by accepting any and all admission referrals in order to maintain census, can lead to short-term goals with serious long range consequences. Adopting a “never say no” policy regarding referrals to the SNF may make hospital discharge planners happy, but inappropriate admissions often leads to potential disaster.
The facility must be able to meet the needs of the patient and the patient. The family must accept the capabilities and resources the facility can provide. When there is a mismatch between these, prepare for rough times ahead.
For example, a 60-year-old patient is referred to the SNF status post fall and subsequent open reduction internal fixation (ORIF) of the femur. She is alert and oriented to person, place and time. Most SNFs can manage such a patient with little difficulty. However, a closer look at the referral indicates that the patient has a recent history of heroin abuse. Hospital social worker notes further indicate that family members have demanded the patient receive increasing doses of narcotics claiming that the patient is being denied the right to be free of pain. Nursing notes repeatedly refer to patient as non-compliant with safety instructions. Physician’s notes indicate a referral to psychiatry for a longstanding history of depression with multiple suicide attempts.
While every individual should be able to receive the care necessary for optimum quality of life, this patient is a ticking time bomb that places a SNF at very high risk:
The medical complexity of the average SNF patient has, and will continue to increase, placing significant demand on clinicians. Adding to the challenge by taking a “never say no” admissions policy is flirting with disaster.
Administrators, admissions teams and clinical leaders must come to an agreement as to the care they can provide and the risks they are willing to share.
What is the first impression your patients and their families have of your facility? As the saying goes, “You never get a second chance to make a first impression.”
A few years ago while I was working as a Director of Nursing (DON), a new patient was dropped off to our unit and the transport attendants failed to notify staff that she had arrived. They simply placed her in a room and left the facility. Fortunately, it was not long before staff realized the breakdown in communication and attended to the patient, but her first impression of us was certainly less than spectacular. For the remainder of her stay I felt as though we were always trying to make up for that first impression.
As a result of this incident we identified a need to create a more efficient admission process and as DON, I initiated a Kaizen event.
The Japanese word kaizen means "change for better" or improve. It is a process begun after WWII in the manufacturing industry however its application in healthcare is very valuable.
As part of the Kaizen event, I worked together with staff from every area of the facility to define the scope and purpose of the project. Our task was to:
The team then created an action plan complete with the responsible team members and completion dates, as well as a power point presentation and staff training manual.
To ensure that continuous progress was maintained, the team decided upon five outcome measures which were tracked, trended and reported to administration on a monthly basis. Those measures included:
An unexpected benefit of this process was that morale improved and staff members took personal responsibility and pride in providing improved services for their patients and families. Because staff was an integral part of the decision-making process, there was trust and respect shown to each of them.
The quality of health care operations and services is dependent upon efficiency in four areas:
Programs are the “what” of clinical operations. It can take months of hard work to establish excellent clinical programs for example in Heart Failure. However, if equal diligence is not spent on creating a process for implementation of the program, then inefficiencies will develop and render even a thorough, well designed program as ineffective.
Process is the “how” of operational logistics. It is the way in which programming will be delivered and is a critical element in the successful implementation of programs. Process also establishes consistency from one individual to the next. This is essential so that outcomes are reliable and consistent.
The People delivering well designed programs must have a full understanding of the part they play in implementation of the programs and processes. They are the “who” in the operations equation. It is essential that resources be allocated to ensure that all members of the staff are properly trained. This not only increases the likelihood of success, but it also shows respect for the role that your staff plays in day to day and overall operations, leading to quality results.
Last, but certainly not least, is the “why” of each of these portions of the operational puzzle—the Patients. The patient experience is central to why we do what we do. In the words of author and TED Talks speaker, Simon Sinek, “People don’t buy what you do, they buy why you do it.” In healthcare, this is our “why” and our passion—to ensure the patient has the best possible outcome and experience.
I recommend beginning with a review of each of these four critical areas to determine the proper course of action for process improvement. The following questions are helpful in the review process:
When operations run efficiently, leaders have more time to focus on additional opportunities for growth and development.
All this adds up to the simple equation listed below. If you ensure that your inputs on the left have QUALITY, then you can ensure that your outcomes on the right will have QUALITY as well.
Programs + Processes + People = Patient Experience
Sinek, S. (2010, May 04). Simon Sinek: How great leaders inspire action [Video file]. Retrieved from https://www.youtube.com/watch?v=qp0HIF3SfI