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Taking Aim at Number Four in the Quadruple Aim—Our Team
Leaders in health care delivery understand the significance of maintaining an effective workforce. This recognition of employees’ importance is what resulted in a proposed fourth dimension to be added to the Triple Aim1 (enhancing patient experience, improving population health, and reducing costs), as it was felt that achieving the Triple Aim2 is not possible without an engaged workforce. The additional fourth item—making the Triple Aim into the Quadruple Aim—specifically focuses on the work life and well-being of care professionals.1 The rationale behind this is that health care employees who believe that leaders are concerned about them as a whole person—not just an employee—are more productive, more satisfied, and more fulfilled. Satisfied employees lead to improved clinical and financial outcomes as well as healthier patients.3
Widespread burnout and dissatisfaction have been reported by physicians and other members of the health care workforce.1 Burnout is associated with lower patient satisfaction and reduced health outcomes, and it may increase costs.1 Burnout thus imperils the Triple Aim and may need to be considered alongside the other established aims.2 Unfortunately, it is common to find disengaged employees in long-term care (LTC) facilities despite their vital role in achieving the facilities’ objectives on improving the lives of their residents. The following strategies are suggested to help LTC leaders in achieving a happy and effective workforce in their facilities.
LTC Staff Education—Thinking Outside the Box
Benjamin Franklin said, “An investment in knowledge pays the best interest”; it is easy to see that this maxim is true, which is why staff education is foundational in health care. However, many agree that education for LTC staff has turned into a stale, check-the-box activity.4 Many facilities do not spend time and money on effective education, thus opportunities are lost that could have resulted in improved clinical and financial outcomes. In addition to the education itself being inadequate, the educational targets are typically far too narrow, ie, focusing only on nursing staff. Here again, there is an opportunity to go beyond traditional routines and to educate all staff—from nursing to aids to maintenance staff—as well as patients and family, and even the outside community as well. It is this type of thoughtful investment that will pay the highest interest for years to come.
The Role of Communication in Education
Any educational investment needs to begin with the end in mind, specifically what the end goal is. For nursing homes, this includes such measurable outcomes as maintaining physically and mentally healthy residents in the facility, building the facility’s census, and improving the quality of life for the residents. While education does involve formal teaching, effective communication strategies are also needed to accomplish these tasks; importantly, this communication should include staff feedback and exchanges. One powerful recommended tool is the establishment of a team huddle.5 For example, leaders can establish a short, stand-up huddle in the mornings to check-in with team members about what their day will look like. A morning huddle is also a chance for team members to share information with each other and deliver project status checks, or to solve problems concerning specific patients and the overall unit as well. It is helpful to keep team meetings brief and to the point, which is why standing discussions may be preferable to longer sit-down meetings.
Another tip that may be useful is to use a weighted ball. For instance, if one or a few people on the team consistently get off topic and never make it back to the initial point, make it a rule that the person speaking should be holding a 10-lb medicine ball. The weight of the ball will be a reminder to keep the meeting short and on topic.5 Everyone should have the opportunity to speak and to be heard. Vocalizing individual status updates on patients in front of the whole team will lead to greater commitment and task accountability from each team member. Team communication should not be merely reporting to the team leader but a chance for members to connect with each other, to pull together, and to better understand and coordinate what each should be working on.
Here are some ideas of what to share during team huddles:
• Top 3 priorities for the day (eg, for specific patients and/or the unit)
• Top 3 facility metrics (eg, readmission rate, census,
patient satisfaction scores)
• Barriers to care, so that team members can start
thinking about problem-solving and possible solutions
to discuss later
• Team member accomplishments and recognition
The Amazon Approach to Education
While the morning team huddle is a useful time to exchange information and connect, there are, of course, required skills that need to be taught to team members. Often this training is done through PowerPoint presentations, which can sometimes be distracting or, at worst, boring to learners, and leaders only have to check a box that staff were present. It is helpful to consider the approach that Amazon takes to education.
Amazon uses “narrative structure” in training, which has been found to be more effective than PowerPoint. Instead of reading bullet points on a PowerPoint slide, employees are asked to sit silently to read a 6-page memo that is narratively structured—with real sentences, topic sentences, verbs, and nouns—and then discuss what they have learned.6 Carmine Gallo, author of The Communication Secrets to Get from Good to Great, has identified several reasons to use this approach.6 Historically, narrative storytelling might not have been as critical for our survival as a species as food, but it comes close. People sat around campfires swapping stories of experiences, history, and knowledge. Stories served as instruction, warning, and inspiration. Neuroscientists’ experiments confirm what we have known for centuries: the human brain is wired for story. We process our world in narrative, we talk in narrative and—most importantly, from a leadership standpoint—people recall and retain information more effectively when it is presented in the form of a story, rather than chopped bullet points, for instance.6
Moreover, stories are persuasive. Aristotle, the father of persuasion, revealed the 3 elements that all persuasive arguments must have to be effective: character/credibility, logic, and emotion.6 Neuroscientists have found that emotion is the fastest path to the brain. In other words, if you want your ideas to spread, story is the single best vehicle we have to transfer that idea to another person.6
Finally, simply put, the brain is not built to retain information that is structured like bullet points on a slide. There is nothing inspiring about bullets. It is well-known in the neuroscience community that humans recall things much better when we see pictures of the object or topic than when we read text—physical images or mental images generated from narrative styles. Visuals are much, much more powerful than text alone. Thus, if you do choose to use slides, use more pictures than words and try to create mental images with your spoken words. Following these principles will transform your educational sessions into true learning experiences.
Employee-Focused Management Philosophy
While education and communication are foundational, an ongoing process encompassing these elements is also needed to keep any LTC organization functioning successfully. Here we can tap into the Toyota management philosophy, which is based on the 2 core ideas: continuous improvement and respect for people.7 These elements should be underlying values in the support for staff involved in direct care of our patients.
Supporting staff through these principles was brought to public discussion by Jeffrey Liker, PhD, a professor of industrial engineering at the University of Michigan, through his 2004 book, The Toyota Way.8 Dr Liker characterizes the Toyota Way as “a system designed to provide the tools for people to continually improve their work.”
Continuous Improvement
Dr Liker breaks down the idea of continuous improvement into 4 main principles for practical application to daily processes:
1. Think long term. Leaders’ focus should be on extended sustainability9 rather than short-term gain and fostering a sense of purpose in employees for productivity.10
2. The right process will produce the right results. Continuous improvement is promoted by eliminating the 7 “wastes” identified by Taiichi Ohno, the father of the Toyota Production System, which include overproduction, waiting, unnecessary transport or conveyance, overprocessing or incorrect processing, excess inventory, unnecessary motion, and defects. Employee empowerment in this area comes from the fact that any employee can call a halt to production when a problem is detected.11
3. Add value to your organization by developing your people. Leaders must adopt and promote the philosophy to employees; employees and teams must embrace the philosophy and teamwork should be recognized; the development of business partners and suppliers should be fostered similarly to the development of employees.
4. Continuously solve root problems to drive organizational learning. Managers must monitor operations personally to understand problems; solutions should be determined through consensus and implemented swiftly; the organization must consistently monitor and evaluate its own practices with the purpose of constant improvement.
While Toyota applies these principles to the production of great cars, this ideology can easily be applied to health care organizations to produce better outcomes, especially today as skilled nursing facilities (SNFs) are increasingly being held accountable for reductions in hospital readmissions and emergency room use as well as an ever-growing list of Centers for Medicare and Medicaid Services quality measures. This is only achievable through a supported workforce.
Respect for People
The second area of focus in the Toyota culture is respect for people. Although it is often pointed out, incorrectly, that the low wages in health care is what causes high staff turnover, it is in fact the feeling of respect much more than money that drives staff.12,13 Respect for employees can be communicated through these 3 science-backed ways14:
1. Reward efforts with experiences or prizes. In a recently aired NPR podcast, Nobel prize winner and behavioral economist Richard Thaler explained why organization leaders should choose to reward staff with gifts or experiences rather than cash.15 For example, rather than giving them a $500 bonus, he suggests giving them a $500 vacation. When people receive the vacation, they report being significantly happier than when receiving the cash. This is because when we receive cash, we are torn between saving and spending it. With a vacation, however, we can enjoy the gift without any guilt. Whether it is a gift or a team outing, spend extra effort identifying a non-cash way to show your employees that you care.
2. Communicate appreciation. According to psychology professor Robert Emmons, giving thanks at work should be mandatory.16 In addition to strengthening teams and corporate culture, gratitude motivates employees more than money. In one study, GlassDoor researchers found that 70% of employees would feel better about the effort they put in if they were thanked more regularly by their boss.17 In another Wharton experiment, researchers found that when fundraisers were given a pep talk by a director who thanked them for their efforts, they made 50% more fundraising calls than those who did not receive a pep talk.18 There are number of ways you can thank your employees for the same effect. Simply thank them in the hall or write them a personal thank-you card. On a larger scale, you might thank specific individuals in a company meeting or email.
3. Give compliments. In an experiment on employee motivation, behavioral economist Dan Ariely and colleagues compared how different incentives affected employee performance.19 On the first day of the experiment, workers were given either $30, a voucher for a pizza, or a “Well Done!” compliment from their boss. The voucher and compliment were equally effective in increasing performance, while the cash was less successful. As the week went on, the monetary reward actually led to a decrease in performance. It had a worse effect than giving employees no incentive at all.
Find a meaningful way to acknowledge your employees’ work. One way might be an employee recognition program where you spotlight specific employees and the work they have done. Another way might be to invite individuals to demo their work for others at the company who might find it helpful.
Conclusion
Supporting staff is a critical component for SNFs to be successful in the care of older adults. Without an engaged staff, all of the outcomes that SNFs are being held accountable for will come up short and, most importantly, impact the quality of care for older adults.
References
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