Quality is the administrator’s job #1

Quality is the administrator’s job #1 – nursing home administrators

George E. Molloy

A long-time consultant says don’t leave it up to employees – lead them!

Nursing home magazines are awash in articles about “T.Q.M.” and “C.Q.I.” Guest columnists and editorial writers alike rant the praises of W. Edwards Deming and practically deify him. Administrators and Directors of Nursing babble about “empowering their staff.” If you remember, “Quest for Quality” and “Quality Circles” received just about the same amount of frenzied attention and space just a few short years ago.

Don’t get me wrong. I am not saying that this current emphasis on quality care and service is misguided or inappropriate. Actually it is timely, needed and necessary from a management as well as a marketing perspective. It is very politically correct and hip. But where does the rhetoric end and the commitment begin?

Some facilities seem to be missing the point. They talk about quality but don’t do anything about it. They know all the words, phrases and slogans. They “talk the talk” but can’t or won’t “walk the walk.” Some administrators print new brochures that prominently feature their facility’s “commitment to excellence,” while deficiencies pile up and customer service on the units is seriously flawed or simply non-existent.

Quality care and superior service are not found on paper. Quality is the result of deep personal and professional commitment from each and every employee in each and every department. No amount of rhetoric can replace leadership, supervision and training of staff in the quest for quality. Quality is not a goal like passing a survey or even being accredited by the Joint Commission. Quality is a continuous journey of awareness, performance and evaluation. Quality is never an accident; it results from hard work and effort. Quality is not a sometimes thing; it is an every day, every shift thing. Quality does not come from slogans or buzz-words; it results from changes in attitude, behavior and performance.

Lessons from OBRA

OBRA mandates facilities to conduct evaluation activities and surveys to assess the level of family and resident satisfaction. Administrators, facing deficiencies if they don’t conform and comply, conduct such surveys periodically. (A few even go so far as to conduct them every 90 days !) But the real issue is not how often the surveys are conducted, but what is done as a result of the findings.

John Graham, President of Graham Communications, a marketing consulting firm in Massachusetts, has some pretty harsh things to say about the practice of conducting customer satisfaction surveys. Writing in Sales and Marketing Executive Report, he says:

“Surveys that ask customers to rate how the business or company (the facility) is doing in various areas are for the most part, useless! They are useless because they rarely ask the right questions. Even if they indicate where a business or company (facility) needs to improve, they don’t indicate how the improvement needs to be made. Customer satisfaction surveys are mostly window-dressing and public relations gambits. Real customer service satisfaction results from improving employee performance. Only when employees do their jobs well, will customers be truly satisfied. Most employees mistake fast service with good service; most employees mistake doing the job as praise-worthy. Customers expect not only the job to be done but done well! Managers know about quality failures before customers do. So why don’t they fix the problems instead of waiting for a survey?”

Part of the problem in dealing with family satisfaction levels is a fundamental misconception about the very nature of nursing home care. Unlike private-duty nursing, where families might hire a nurse or an attendant for one-on-one care, nursing home care is provided on a staff-to-patient basis. A certain number of residents are cared for by one assistant. All of their needs, requests, demands and requirements must be taken care of by one nurse’s aide who has that particular assignment for that particular day.

Nursing homes, of course, must schedule a sufficient amount of help to provide the care and service. Most, if not all, do. But what happens if the scheduled worker does not show up because she (or he) is sick? Someone who does not know these residents or their peculiarities might be assigned to them. Sometimes the residents themselves can be cruel and totally unreasonable with employees. They “tell on them” to their families, and the families are upset because their loved ones are upset. What it all boils down to is, it’s the aides’ fault.

Fingerpointing in the Right Direction

W. Edwards Deming (1900-1993) is revered by American business as the prophet and guru of quality. Mr. Deming was an obscure statistician in 1950 when some research he had conducted during World War II came to the attention of some Japanese industrialists. They were trying to not only rebuild their companies after the devastation of the war, but also compete in the global market. America had the capability to produce quantity; the Japanese saw an advantage in quality. One of Deming’s principal theories was that most product defects and quality failures result from management failures rather than worker failures.

How is it, then, that so many nursing home quality improvement programs are directed at having employees perform better rather than having managers manage better? Perhaps the consultants trying to peddle their T.Q.M. programs to the managers target the workers for improvement because, after all, better to finger the nurse’s aide than the Nursing Director.

Mr. Deming delighted in telling corporate chieftains, who had hired him to help solve their quality problems at fees often as high as $100,000, that “85% of your quality problems are the result of management failures! Don’t try to change your workers until you first change yourselves!”

Some companies listened to him. Ford Motor Company, for example — one of Deming’s top clients — found its over-all quality and ranking by J.D. Power’s Customer Satisfaction Survey soaring following those dark days of the early 1980s.

If nursing home quality problems are going to be seriously addressed and resolved, then all administrators and department heads must take a long look in the mirror. Instead of “empowering employees,” they should use their own authority and power to make needed and necessary changes. The industry doesn’t need more managers; the industry needs more leaders — people who lead by example rather than by memos.

Quality of Care Factors

There are many management failures that not only destroy the perception of quality and value, but negate the facility’s marketing efforts as well. From my experience as both a manager and a marketing consultant, I would say that there are three major areas of concern:

1. Absenteeism:

It is difficult, if not impossible, to provide consistently high-quality care if the facility suffers from an absentee problem. It is a quality care and marketing issue if the nursing staff is always short on Saturdays, Sundays and most holidays. Today’s residents are sicker and more acutely ill than ever before. They require care and supervision every day of the week, not just Monday through Friday. Residents need meals that are on time and housekeeping that is diligent, not sporadic.

It is exceedingly difficult to provide basic care, let alone high-quality care, if you are the only aide responsible for 18 elderly, very sick residents. It is rather foolish to talk about a “commitment to excellence” if you have one licensed nurse trying to cover two units, supervise staff, administer medications, answer the phone, give tours, address families’ concerns and complete all the charting.

Absenteeism is a management failure. Absenteeism has devastating effects on the quality of care and level of service, and results in poor employee morale and very dissatisfied customers. “Empowering” aides to work overtime is not the solution; using the disciplinary process effectively to get rid of malingers is. Remember what Mr. Deming told the executives at Ford Motor Company: “Nobody wants your cars if they were made on Monday or Friday – the two worst days for assembly line absenteeism.” Only when Ford got serious about worker performance and absenteeism did sales increase.

Administrators should stop reading books on “empowerment” and start reading the departmental schedules and determine who is not showing up for work when scheduled and fix the problem. How come everyone seeking a job is healthy, fit and able to perform, but suddenly becomes chronically sick, feeble and near death every Saturday, Sunday and holidays? Managers have the power to address this — they just don’t use it.

2. Tolerance of Mediocre Work Performance:

Some administrators are so delighted just to have employees show up that they ignore the performance of those who do. Some even confuse “longevity” with “performance.” Because an employee has been in housekeeping for 15 years doesn’t mean the floors are clean and the bathrooms are spotless. Also, there is a difference between doing a job and doing it well. People rarely remember how fast you did an assignment; they will always remember how well you did it.

Nursing homes that wish to remain truly competitive must pay more attention to employee performance and productivity. Today’s customers have become too sophisticated and educated to pay premium dollars for mediocre care and inferior service. Even Medicaid families who admit their loved ones into your facility because your marketing was good will just as quickly take them out if your performance is sub-standard.

3. Failure to Pay Attention to Grooming and Appearance:

Don’t blame the employees for how they look; blame the owners and the managers for allowing them to look that way!

Tom Watson, Sr., the founder of IBM, took over the company when it was a small, demoralized business and office supply company. And many of the employees “looked the part.” Mr. Watson told them, “Gentlemen, always remember that the image of the person is the image of the product. You will be calling on some pretty important people in the course of your day. Always bear in mind if you deal with very important people, you should dress like a very important person!”

The more you think about that statement — the image of the person is the image of the product — you can see how some nursing homes hurt their own image and negate the professionalism they seek simply through their employees’ appearance. Employees must be trained to realize what a critical role they play in both the public relations of a home and the marketing of a home. In short, they represent the product the facility markets and sells. Their performance, productivity, attitude and actions are visible every day.

Service Failures

Despite all that is and has been written about service, I don’t think that long-term care facilities understand what it is. They think that “Guest Relations,” “Customer Service,” and “Hospitality Training” are all the same things, just like they used to think that “Public Relations” and “Marketing” were the same.

“Smile therapy” programs are foolish, especially if the facility has absenteeism problems. What’s the use of getting employees to “smile” if they don’t show up for work on Saturday or Sunday? What’s the use of smiling at patients on Monday when you neglected them all weekend?

Many readers may remember my First Impressions Program. It was written in 1984 and has since been used by over 1000 facilities. I know a little bit about service-training for long-term care facilities because, unlike some consultants, I actually managed facilities and employees for almost 15 years prior to becoming involved in marketing. So let me explain service quality.

Two factors in service delivery are always considered by every customer: the process and the outcome. Both must match the customer’s expectations for the service to be judged merely satisfactory; both must exceed expectations for the service to be viewed as superior. If either one is substandard, the customer will be dissatisfied. Some examples:

* When the meal you ordered (outcome) is wonderful, i.e., delicious, nicely prepared, hot, flavorful, done exactly as ordered, but you had to go through hell to get it (process), i.e, the waiter was not attentive, was slow, had the original order confused, etc. – you were happy with the meal, but dissatisfied with the service, and probably won’t go back to the restaurant.

* When you are courteously treated by the customer service representative at the dealership when you bring your car in for a check-up — he greets you with a smile, calls you by name, arranges for transportation to your job, and promises to call you when the car is done — and then you later pick up the car, pull out into traffic and the car starts to lurch and hesitate again, you are not a satisfied customer at all. You’re an irrate one!

Quality control of a product involves precise measurements and evaluation comparing the finished product against an objective norm or standard. Quality control of service, on the other hand, entails depth of training, employee response, supervision, and some measurement. Customer-relations training is critical because it predisposes the employee to act, to respond to a problem, a request, or need. Employee response is critical because employees have to see service as part of their job, whatever their title or duties might be. Supervision is essential because, without it, how will anyone know that service is meeting and hopefully exceeding expectations?

Behind the Satisfaction Surveys

People who are dissatisfied with a service often vote with their feet and take their business elsewhere. Families and residents dealing with nursing homes are in a different position; most are in it quite literally for the long term. As a result, their responses to customer satisfaction surveys have to be looked at carefully. There can be more to those “highly positive” responses than meets the eye, for several reasons:

Fear of retaliation: Often they will write glowing reports to management praising everything. Meanwhile they’re writing anonymous letters to the state, making anonymous phone calls to the ombudsmen, or criticizing the facility unmercifully to neighbors and friends. If the word gets out to facility management, though, they’re afraid that they or their loved one will somehow be made to suffer.

Sheer gratitude: Families have often opted for nursing home care as a last resort, when all their other resources are exhausted. At this point they are grateful for any help they can get, “high-quality” or not.

Survey wording: Questions in any survey can be worded, inadvertently (and sometimes not), to gain a positive response. Lack of careful wording can lead to misleading findings.

Satisfaction only temporary: Maybe the family is pleased with the facility’s response to a particular problem, but finds other factors not measuring up over time. Quality is a continuous process — and so is maintaining customer satisfaction.

How do customers judge quality in health care? They judge by the things they see, experience, and understand. Many cannot understand, much less evaluate, the “mechanics” of quality (accurate charting, treatment protocols, etc.), but they can, and do, judge the human elements. You can have your JCAHO decal and a deficiency-free survey and still fail miserably with your residents, families and visitors. I know of many nursing homes that passed their survey with flying colors, created expensive brochures and even took out expensive newspaper ads praising staff and their efforts — and they had census, case mix and service problems galore.

A New Culture

What is needed in all of health care, but especially long-term care (because the residents remain in our care longer), is a service culture. We are good technically, but our service quality is too often, at best, mediocre-to-poor. Long-term care employees’ service culture can be improved if their managers insist that service performance is as important as technical performance.

I did a consultation recently for a large nursing home chain. It considered itself very progressive and was quite involved in subacute care. The facilities were very “mechanistic” quality-oriented. Their customer service program was written by the human resources department and consisted of nothing more than a variance of each facility having “an employee of the month”. There was no training or supervision relating to customer service, but there were endless “customer satisfaction surveys” sent back to the corporate office. Nothing was done to train staff because the administrators thought that was somebody else’s job. Even if the administrators were willing to train, they had no formal program for this.

The message: You can provide the best health care in the world only as long as you have customers. To get customers in the door it will help to have a reputation for high-quality care (the mechanistic quality), but to keep customers and attract more, you must also develop a reputation for friendly, attentive, responsive service.

George E. Molloy is President of M&M Associates, a long-term care management, marketing and training consultation firm based in Vero Beach, FL. For quality improvement, Mr. Molloy has recently developed a comprehensive employee training program called “The Pride Program.” For information: 407-690-2822.

COPYRIGHT 1994 Medquest Communications, LLC

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