1. 1 CONNECTING THE DOTS: WHAT CAUSES QUALITY IN NURSING HOMES? REGINALD CARTER

2. 2 INTRODUCTION Reginald Carter Past President/CEO (1984-2006) Health Care Association of Michigan reginaldkcarter@aol.com Georgia Health Care Association, Ritz Carlton, Amelia Island, Florida (June 18, 2008).

3. 3 TRANSPARENT GOVERNMENT: PATHWAY TO TRUST All institutions (schools, churches, government, business, military) need to be accountable and transparent in order to be trusted. It is easier to be successful if you are trusted. Nursing homes which share outcomes with consumers are an example of both transparency and accountability. The Georgia HCA’s sharing family satisfaction information creates public trust.

4. 4 CONNECTING THE DOTS Explains the factors causing quality in nursing homes. It is a way of telling your story so that the customer knows you know what you are doing. It reassures them. They need to trust you because they do not know how to judge your performance and they have entrusted their family member to your care. They want to trust you because it is easier on them if they have a basis to trust you. You need to earn their trust.

5. 5 WILLIAMS NEWS SERVICE Finding a new Russian military plant by connecting the dots.

6. 6 NATIONAL HIGHWAY TRAFFIC SAFETY ADMINISTRATION “Click it or Ticket” safety belt campaign increased the use of seat belts from 11% in 1985 to 80% in 2004 by a combination of paid media advertisement and periodic police enforcement of safety belt use. This strategy connected the dots between auto fatalities and factors which reduce fatalities (seat belt use). NHTSA is now focused on lowest safety belt use by drivers of pick-up trucks.

7. 7 HEAD START PROGRAM There was a healthy curiosity about what factors caused children to perform better at school. Researchers look backward until they could identify the earliest signs during the first 6-18 month period when the successful student was talked to by an adult. The Head Start program was created based on “connecting these dots.”

8. 8 GENERAL PRINCIPLES Define quality. Identify most important causal factors of quality. Do not get lost in the detail of specific cases. Let the data talk to you. Listen to various sources (research studies, resident and family feedback, observation, gut feeling, professional training and education). Be open to revisions based on new information. Explore alternative stories and have your story assessed by others to verify your set of factors.

9. 9 ASSIGNMENT Define quality. Select the three most important factors causing quality in nursing homes. Write the three factors down and pass them to me so that at the end of the session we can discuss your factors identified as causing quality.

10. 10 SOURCES FOR MY STORY Family satisfaction surveys for Michigan nursing homes (31,000 from 1996-2005). OBRA survey results for 450 homes (1984-2004). Medicaid cost reports. Nursing home employee salary and benefit surveys by HCAM. Telephone interviews with administrators and DONs of 50 high quality homes. Daily communication with various stakeholders during 24 years as staff at HCAM. Other research and public policy studies of quality.

11. 11 THE STORY: FACTORS CAUSING QUALITY Quality defined as both high family satisfaction and OBRA compliance. Sustained strategy for high quality. Small facility in rural location. Continuous community involvement. Longevity of key staff. Health benefits for employee and family.

12. 12 IMPLICATIONS OF THE STORY Having a strategy for quality is different than implementing the strategy. Most homes have a system for monitoring quality but the greatest challenges are in sustaining quality 24/7. Ferdinand Fournies wrote a powerful book entitled Why Employees Don’t Do What They’re Supposed To Do and What To Do About It.

13. 13 FOURNIES LIST OF WHY They do not know what they are supposed to do. They don’t know how to do it. They don’t know why they should do it. They think your way will not work. They think their way is better. They think something else is more important. They anticipate future negative consequences. Personal problems. Personal limits. Obstacles beyond their control.

14. 14 FOURNIES: WHAT TO DO Let them know what they are supposed to do. Find out if they know how to do it. Let them know why they should do it. Convince them that your way will work. If their way is not better, explain convincingly why it is not better. Let them know the work priorities. Convince them that anticipated future negative consequences for attempting to perform will not occur. Work around personal problems or give the work to someone else. Verify that the work is not beyond their personal limits. Verify that there are no obstacles beyond their control. Verify that it can be done.

15. 15 RIGHTSIZING Large urban homes should be changed to smaller units ( 50 beds). Green Houses. Neighborhoods within large facilities to promote sense of smaller with dedicated staff to promote continuity of care (Autumn Woods of Warren – suburb of Detroit).

16. 16 COMMUNITY INVOLVEMENT Expand visiting hours. Increase special events for community. Increase volunteers at facility. Increase media coverage. Hire staff from community. Encourage staff to move to community. Recognize vendors’ role in perception of facility. Encourage staff to participate in community (Yale Miss Sausage award).

17. 17 LONGEVITY OF STAFF Financially reward all staff who commit to longevity. Provide health benefits for all staff and family. Employment longevity data is not easily relieved. Nor is community involvement information.

18. 18 THE HIGH PRICE FOR NOT BEING TRANSPARENT Airline security post 9/11/2001 terrorist attack. Catholic Church protecting priests who were sexual predators (2002). Enron and Anderson Accounting Consultants (2002). FEMA management after Katrina hurricane. All four were unprepared for public scrutiny

19. 19 TRANSPARENCY MATTERS Lessons in transparency from Consumer Guide to Michigan Nursing Homes (1996- 2006). Fear of low results. Fear of high results. Fear of litigation. Fear of no or negative press coverage. Not knowing how good you are (Randy Jordan).

20. 20 WHY BOTHER? Transparency is important because it creates trust in the consumer and it is the right way to treat customers or potential customers. Some hospitals are now telling patients if there was an error in their treatment. Only 1% of patients pursue litigation and they appreciate the honesty of the hospital in admitting error. Hospitals were choosing this approach because of high medical mal- practice insurance premiums.

21. 21 WHY BOTHER? Creating and telling your story provides you with confirmation about the effectiveness of your strategy for quality and provides confidence in you by your consumers and their families.

22. 22 Q & A How did you define quality? What factors would you use to define quality? Tell us your story? Do you believe in transparency for the customer? What is your biggest fear about transparency?

23. 23 THANK YOU