BEST PRATICES… Are Never What the Masses Do

It seems that someone is always trying to sell something. I grow weary of it…unless it is something I need. May God strike down MVI if we ever sell something to a hospice that is not needed! HOWEVER, as a leader, whether a CEO, CFO, Clinical Leader or any other asset manager, you are constantly selling ideas. I sell ideas hard if I am convinced the direction is more than marginally beneficial. That’s my job. It’s your job too. In fact, it is the 1st Duty of a leader. 

What I mean by 1st Duty is that the primary responsibility of a leader is the development of the people they lead. In effect, teaching methods, mindsets and the culture of your organization in order to replicate operational excellence is the 1st Duty (a phrase I use when I teach the Model). We will circle back to this later.

In this article I want to cover a few Best Known Practices or BKPs (I don’t like the term “Best Practice” as it has the connotation that the practice is final, the ultimate, done, complete – all of which are an illusion). Though the Model as we define it is “the creation of a high-quality, predictable experience…that is financially balanced,” I want to offer another definition. The Model is really simply

“The deliberate concentration of the practices of outliers.”

Now you may or may not like the term “Model,” but please recognize that is simply a term we use to convey the ideals of order and process. In addition, all hospices that “do the Model” desire to become outliers or become even further outliers! However, the fact is that ALL hospices have a “model” or a way of conducting operations. Most, the vast majority, have an organic model that has evolved over time. However, rarely – if ever, is it enough to raise a hospice beyond mediocrity. It is far better to be deliberate and intentional.

I have spent most of the last 2 ½ years traveling and facilitating proprietary Model Workshops. It has been hard work. The results have ranged from modest improvement to phenomenal, even breathtaking. I can say without hesitation that the variance of outcomes is directly tied to the CEO’s ability to focus and manage with tenacity by upholding the established standards. It takes the quality of “grit” (Hire people with “grit” and you won’t be sorry. Leave the jellyfish on the beach!).

If you have 100 people, you have 100 personalities. However, you should have one set of standards which all people working within your system (Model) adhere. Measuring quality is always a challenge, but it is a no-brainer to correlate that if you design every aspect of the way a hospice performs its visits and answers the phones, a higher quality, predictable experience will be created. Financial measurement is much easier. However, it is a mistake to overemphasize it as you will lose many people. It is about purpose first with fantastic economic results as a natural by-product. The fact is that the most aggressive hospices have increased profitability by 30% of NPR (Net Patient Revenue)! That is, if the hospice was losing 10%, now they have a 20% profit! No serious bitching about the measly 2% sequester!  With this said, there are limits to profitability in terms of percentages of Net Patient Revenue as you can’t reduce costs to zero. However, you can increase patient volume. The point is, reimbursement is still excellent and the times now dictate that we really learn to manage our hospices, allocating resources as effectively as possible…and only OUTLIERS are managing this way! You can’t call up the hospice next door and find out how to do this. They don’t know. Best Practices are only used by the MINORITY!  It is our job (each hospice, MVI, others) to copy, invent, reimagine and become the outliers of tomorrow…

Let’s start by going down the Model trail looking at the most BASIC areas of design work and discuss each briefly so this article does not become a 450 page MVI manual!

People Development
Embracing People Development is the most no-brainer, but discounted strategic decision a hospice can make. It is a lie to say that “people are our most important asset” if your hospice doesn’t put extreme emphasis on People Development. It is IMPOSSIBLE for a hospice to be extraordinary without having an extraordinary People Development system. Teaching well is a skillset. It is not something “everyone knows how to do.” Assuming that people naturally know how to teach is just as bad as assuming everyone knows how to run a business (“Yeah, you take income, subtract cost and what’s left is profit!). If we lead hospices and have at least a 10% profit (without community support), you know how to run a hospice. If ALL clinicians are doing their visits to a high, “common-ized” standard and a “complaint” is an almost alien term to you, then I would say we are teaching well. You may say “Andrew, you press too hard!” Do I? Our return policy in hospice is not exactly stellar. Make People Development a priority! In fact, make it the most important thing your hospice does and the area where you excel!  You will be amazed at the results. I have documented 100+ specific practices and grouped them into 4 major processes (People Attraction, People Selection, People Development and People Retention) that any hospice could use. A People Development system could be improved by several hundred percent with the inclusion for only a handful of these methods. This is way too much for a FlashPage article and even too much for a Model Workshop. This is why we have a 2-day event devoted to this most important topic. Many practices are exotic. Some seem obvious, but if they were obvious, why don’t hospices use them? The point is, MOVE in this direction with all the force you can.

Visit Design
This is the basic widget of hospice. It is one thing to have a visit structure designed. It is quite another when you can pull ANY clinician at random and have the person recite as well as demonstrate your visit system! So the BKP here is (1) Design your visit structure (including each task associated with each phase of the visit) and (2) train your staff in the habits of doing every visit according to your standards. This would include use of your point-of-care devices and documentation. The visit is where documentation takes place…and it has to be perfect. 100% is the only acceptable standard in this area (or really any other area)! Anything less must not be tolerated. But this will only happen if every clinician is working according to a well thought-out visit structure. Make structures simple and do not tolerate deviation…that is unless you want an unpredictable, unsatisfying and sloppy care experience. Failure to do this is the main reason many hospices are in trouble and why our movement’s reputation has been damaged. We owe it to our patients and families to examine EVERY aspect of the care experience. You want to create an extraordinary experience for every patient, every time.

Phone Interaction Design
As we advance into the future, more and more care will be provided via telecommunicative means. Therefore, if we want to be an extraordinary hospice, we must be extraordinary on the phones. This starts with designing BASIC structures for common interactions. How to answer the phone, how to transfer a call, what not to say, how to put a person on hold, what the hold music/message should convey and many other things. To start, simply find your best phone person and emulate what they do! Take the materials MVI has already produced and modify them with your own ideas.

Team Design
This basic topic is often taken for granted. We have the “classic” hospice disciplines and most hospices are STUCK there and do very little if anything else. What else could be added, augmented or deleted to create an exceptional experience? What could be done by volunteers? Could the classic disciplines be redesigned to create a vastly superior experience? Of course the answer is a resounding YES to all of these questions! Let’s go back to basics. What is the most valued discipline once pain is addressed? Of course, it is the Hospice Aide. So where is it in your value proposition? In fact, how much attention do you give your Aides? How well are they trained in your “system?”

Patient-Related Design
With the selection of two or three vendors, a hospice can get this category of cost to 16% of NPR or less. What vendors? Look at the data grids in the FlashPage or simply query the MVI Benchmarking Application by vendor. This will take all of 15 minutes. Then analyze the results and MAKE A DECISION! I am amazed at hospices that could reduce their Patient-Related costs by 3-4% (which is a lot of money) with a couple of vendor choices that don’t. When hospices don’t take action, I wonder why? Are they afraid of the clinicians or what? What keeps a hospice from making an obvious choice that is supported by data and client satisfaction? Hospices, in general, are slow moving entities. Outliers take advantage of this fact.

Supporting Service Design
A typical hospice spends $.35 cents of EVERY dollar or 35% of NPR on Indirect Costs. With some effort, a hospice can get this to 30%. The first thing that has to be done is to “draw a line in the sand” as to what percentage will be allowed at your hospice (I recommend the same when establishing profitability levels). This is more than a goal. It is a mandate. Any area leader that can’t meet this standard will be replaced. I always encourage a hospice to link every leader’s compensation to performance as this is the quickest way to create a healthy and productive culture. To your surprise, people will not quit in droves. To your surprise, in 4 months you will be “in” the Model. To your surprise, your hospice will become easier to manage. However, this move requires overcoming fear. Money is emotional…but a leader in charge of resource allocation (this is what every manager does) must learn to use compensation as a tool. It is one of the most powerful tools available. Of course, you need to link pay to measures of quality, but I think you will be surprised how FEW measurements are needed to pull this off.

Marketing Design
Typical hospices are complaining about low census levels. Yet there are hospices where census is up several hundred percent that have been in communities for 25 years. What’s changed? What has changed is that they now have a product that actually works as promised! With an ultra-high level of confidence, marketers can promise that a high-quality experience will be created for every patient, every time. Sound like a fantasy? Then beware. This is the competitor you WILL face in the future. I will guarantee that. We were going to hold a Marketing & the Model Workshop last summer. However, it really was not needed if you have an extraordinary People Development system. Yes, there are specific things that marketers need to know and utilize. However, they pale in comparison to a rock-solid service promise where every time marketers make a commitment, IT WILL HAPPEN. Glitz and a good personality will only get you so far. You have to BE an extraordinary hospice in order for marketers to have something to market! To be an extraordinary hospice, you have to have extraordinary People Development (said it again…this must be a considered opinion).

Bereavement Design
The public assumes that we are experts in this area. I think many hospices believe they are as well. Based on personal and professional experience, I disagree. IF we are experts, then why don’t we incorporate modern methods and technologies? 99% of our movement uses traditional cognitive approaches, which are good, but are limited. Why not incorporate techniques and technologies used by the most advanced experts in grief, loss and PTSD?  I am referring to the use of EMDR, Hemi-Sync, IADC and the exploration of REM or the dream state. Why so much emphasis on these? Because to RESOLVE grief, a positive “direct personal experience” must be experienced. These direct experiences can be facilitated…and it has be found that more can be done in 1 hour using these approaches than in 30 years of counseling alone. Counseling is necessary, but it is not enough when someone has experienced a devastating loss. Counseling must be integrated with approaches that facilitate a highly personal direct experience. Why not use these techniques and technologies if they are available and cost very little? Are we scared to challenge our Bereavement staff? I think you may be surprised how many Bereavement staff will welcome the attention as this area is becoming increasingly undervalued and overlooked. Loss is all around us. It’s part of our business. Let’s meet the public and community expectations and be great at it!

The 1st Duty 
Ah yes. We need to complete the circle. As stated previously, in our humble opinion, the 1st Duty of a leader is the development of the people they lead. Staff members take their behavior cues from their immediate supervisors. They imitate their examples. This goes for all leaders. A leader self-replicates automatically. In hospice, there is no more important leader than the Clinical Leader as clinicians learn the culture and most of their practices from this critical position. Clinical Leaders are teaching by virtue of the position. But are they teaching well? Has the position been built to provide enough time to intentionally teach?  This 1st Duty applies to the CEO and all executive leadership as well. This would translate into the CEO teaching and making the important strategic decision to make People Development the center of the universe.  
If your hospice wants the same results as mediocre hospices, then simply do what the majority of hospices do. No problemo. Just call around and ask some questions regarding practices. Share complaints about what is right and wrong with our movement. Use “preceptors” and put everyone through orientation (Bore-ientation at many hospices) where we all go to the basement or some back room to watch a parade of people from different areas of the hospice. This type of “people development” will get you to average or below. IF you want to be an extraordinary hospice, you will do what other hospice are afraid of or won’t do. Prepare to be ridiculed and mocked. Welcome to the world of the outlier…

Your Objective Friend ~ Andrew