Always a Leader


“Always” Leadership

Consistency seems to be an elusive item in health care. Some shifts, some days, weeks, or months run well. Then issues arise that negate the gains. These methods to create and sustain those gains so interested Wiley publishing that they led to the publishing of my new book, “Results That Last.” In this article, Bob Murphy of the Studer Group has written excellent recommendations for how to become an “Always” leader.

We appreciate your feedback. I am so pleased many of you wrote regarding how helpful Debbie Cardello’s article on butterfly leadership was. Enjoy Bob’s article.

As I travel around the country, it constantly amazes me how much the same we are, how similar the issues are that we face. Right now, whether you are a leader in a hospital, health system, or medical practice you are facing the realities of financial pressures, competition, quality and service mandates, and labor shortages in critical positions.

When I ask leaders whether they think that health care will be more difficult in five years, everyone’s hands go up. Leaders know that if we do the same things we are doing now, in five years our results will be less than they are now. Just like when you’re promoted to a new role, the skills that helped you be successful to this point might not be the same ones you need to be successful going forward. For health care leaders looking to make an impact over the next five years, they need to become “always” leaders.

A recent challenge introduced by the Centers for Medicare and Medicaid Services (CMS), is destined to change the way we think about our roles as leaders. The Hospital Consumer Assessment of Health Care Providers and Systems (HCAHPS) “voluntary” survey of patients changes our fundamental language and attitude of leadership. The HCAHPS survey asks patients to rate us on the frequency of how often we do certain things. This is an important distinction from previous patient surveys which asked about satisfaction. Asking how often they saw certain things is very different than asking how satisfied they were with the same things.

Patients are asked: How often did nurses treat you with courtesy and respect? How often did doctors explain things in a way you could understand? How often were your room and bathroom kept clean?

The possible responses are “Never”, “Sometimes”, “Usually” and “ALWAYS.” When the results are compiled and published on the CMS website, the only results we will see is the percent of “Always.” When CMS uses the data in its calculation of our reimbursement, they will likely use the percent of “Always” to reward high performing organizations.

Because of these external pressures, we are being pushed from being “Sometimes” organizations to being “Always” organizations. That means we likely have to move from being “Sometimes” leaders to “Always” leaders.

What does an “Always” leader look like?

  1. An “Always” leader has a plan! High performing organizations and their leaders have leader performance evaluations that are measurable, specific, objective, weighted and time-sensitive. The goals set forth in the individual leader’s evaluation are linked to the organization’s overall goals. A good, measurable, specific goal aligns the leader’s behavior to the expectations of the organization. Most leaders really appreciate an evaluation like this because it helps set priorities and tells them in advance what is necessary for success. Leaders have told me that they want to know how they are doing and what else to do to succeed. High performing organizations use monthly report cards and 90-day plans to help a leader with all that is on their plate. A good evaluation provides a prioritization roadmap for the leader and keeps leaders focused on what is important. As a leader, I am pulled in many directions at the same time. A good evaluation tells me where to focus my time and helps when I am asked to do “other” work. I can bring my annual evaluation, monthly report card and 90-day plan to my boss and ask them to help me prioritize the new work. If it does not fit into my annual evaluation, I will likely not waste my time and energy. A good evaluation system allows senior leaders to continuously monitor eader performance and provides for organizational agility.
  2. An “Always” leader takes accountability for their own development. If we agree that health care is getting harder and we need to continue to grow our leadership muscle, an “Always” leader does not wait for their boss to tell them to get training. An “Always” leader evaluates their skills and seeks out new ways to learn. An “Always” leader asks their supervisor if they are on track, what are they doing well, and what could they do better.
  3. An “Always” leader uses evidence-based leadership (EBL) tactics when appropriate . An “Always” leader follows best practices in hiring,
    retention, communication, reward/recognition, re-recruiting high and middle performers and dealing with low performers.
  4. An “Always” leader has a balanced approach. Many organizations balance priorities and activities between the focus areas of Service, Quality, People, Financial Performance, Growth and Community. All too often our staff thinks that all we are concerned about as leaders are financial results.
  5. An “Always” leader connects the dots consistently to purpose, worthwhile work and making a difference. Many of the staff we work with have a calling. They choose to come to work every day because of the special feeling they get while taking are of patients or taking care of those who take care of patients. An “Always” leader taps into that core feeling of making a difference by the way we communicate, what we reward and how we lead by example. Methods include sharing stories from other parts of the organization that demonstrate worthwhile work, recognizing staff members when they demonstrate the behaviors we know make a difference to our patients. “Always” leaders use every opportunity to connect to the hearts of their staff. What we do is special. Our patients entrust us with their lives and that is special. We should take every opportunity to tell and show our staff that what they do is important.
  6. An “Always” leader follows a sequenced approach to improvement. Most everyone reading this article is familiar with CPR (Cardio-Pulmonary Resuscitation). If you were faced with a situation where CPR was necessary, you would follow the ABCs of CPR right? First is airway, then breathing, then circulation or compressions. It is understood that you may never get to compressions if you cannot open the airway. Why? Because the compression would not be as effective. The same thing applies to leadership in many ways. Some of the tactics we teach at the Studer Group are advanced techniques and require some foundations or basics in place first. Now, you can skip steps, but the likely outcome is that you will not be as effective, nor will you be as effective for long. We know that Hourly Rounding is a wonderful tool to implement to reduce decubitus ulcers, falls, call lights and the distance nurses travel during a shift, but we usually do not recommend it be the first tactic you employ. We usually first recommend Rounding for Outcomes on your staff and nurse leader rounding on patients before hourly rounding. Why? Rounding on staff and patients by the leader first role models the desired behavior. It helps the leader show that they are aware of the issues on the unit and what patients want before asking staff to do that. Rounding on staff helps improve the personal relationship between the staff and leader. Leaders find out what tools and equipment needs there are on the unit. Leaders find out what is going well and can reward and recognize staff for demonstrating desired behaviors. When rounding is done consistently by leaders, staff are less likely to push back.
  7. “Always” leaders take best practices and standardize across the organization. An “Always” leader is trying to find a way to do their job better and get great outcomes. We find in many organizations there are leaders already getting the desired results such as low turnover, great productivity, high service, but, for some reason, it is not well known throughout the organization. Sometimes other leaders in the organization are aware that there is a leader internally getting great results, but there is a reluctance to do what they are doing. An “Always” leader breaks down those silos and barriers and duplicates what is working well.
  8. Failure to always do desired behaviors. As organizations move to improve results, we commonly find that changing the behavior of hundreds of thousands of staff members is very hard to do. The easiest thing we can do is change our own behaviors first. That requires a good long look in the mirror. I’ve had to do that so many times in my career, and still do since I still make mistakes.

As health care leaders, it is our responsibility to move our organizations from “Sometimes” to “Always.” The journey will be hard work, but one that is achievable if we use proven tools and techniques to guide us.

Please add your comments to this blog and share your thoughts with our readers. We can all benefit from each other’s experiences.


Butterfly Leadership. Does It Keep You From Achieving Desired Results?


Debbie Cardello of the Studer Group, former COO of Baldrige winner Robert Wood Johnson University Hospital Hamilton (NJ), recently used the term “butterfly leadership.” I asked her to write more on this important topic. I hope you find her article interesting and helpful. Your comments are appreciated.

You are probably wondering, what is butterfly leadership? And what does it have to do with achieving results? Picture a butterfly as it flies from flower to flower, tree to tree, then quickly flutters away in search of sweeter nectar. As healthcare leaders, we face similar temptations.


I think back to days (I should say years) gone by when I was very frustrated that quarter after quarter, patient satisfaction scores stayed the same. Sometimes they even got worse, despite how hard we were working to improve. What I ultimately realized was that the team’s actions weren’t always aligned with goals and the “flurry” of activities prevented us from focusing on what mattered most . . . patients, employees, and physicians.


Good leaders in good hospitals experience these challenges every day. We also know that there is no magic bullet; and as caregivers, we will always find problems to solve and systems to improve. On the other hand, if our energy is consistently diffused, our ability to be an effective leader is at risk. We could experience a decline in performance, burnout, or worse yet – leader turnover.


What can we learn from the example above to help us focus and align our priorities, accelerate our performance, and avoid “butterfly leadership?”



Use the 90-Day Plan to identify what matters most. We’ve all heard this great advice: don’t confuse activity with results. It’s so easy to do in the busy world of healthcare. Begin by identifying what’s most important. This is where a good 90-day plan can help.


A 90-day plan that outlines three to four action steps is manageable and helps us focus on next steps that will move us closer to desired results. Review the plan monthly with your supervisor to ensure you stay on track, and to get and give feedback on how to best spend your time. Ask yourself on a regular basis, am I spending my time on value-added action steps, or is activity simply finding its way on my calendar?


Use Rounding to hardwire behaviors that matter most. We know that changing behavior is one of the most challenging aspects of being a leader. Behavior rarely changes by writing an email, sending a memo, implementing a policy, posting a flier on the bulletin board, or communicating it once at a staff meeting.


It is a process that happens one day at a time, and one person at a time through our rounding on staff and helping them connect their work to the mission and goals of the organization. Praise staff in the presence of others when you see them doing the behaviors that you are trying to hardwire. By doing so, you communicate what behaviors are most valued and important to patient care on our unit, and in our organization.


In order to reduce variation, we must manage performance. Most likely, you’ve already recognized your high and some middle performers for using desired behaviors. You also have a pretty good idea of who is not.

Next is a most important step if you are challenged by consistency issues. This is the time when many of us get frustrated and are tempted to “flutter” away, try something new, move on to another initiative, or throw up our arms in defeat and accept average results. Average results in healthcare could mean that a number of patients could still contract an infection in the hospital or be harmed by a medication error which consistent improvement efforts could have prevented.

Circle back and visit staff members individually to clarify that using the desired behaviors is not an option, it is a requirement. Give your staff an opportunity to discuss why he or she hasn’t complied – it may be due to a lack of understanding or training.

End the meeting with the understanding that the behaviors will need to become a regular practice to avoid further action. In my experience, a leader would have to do this with only a few staff – the rest figure out how serious you are, what’s negotiable, and what’s not negotiable.


Use Reward and Recognition to communicate what matters most. A simple rule to remember in communication is that once is never enough. We all need to hear information multiple times and in a variety of ways in order to truly understand.


Reinforce desired results with fun and interactive exercises that reward and recognize key behaviors. Share the top three organizational or department priorities at employee forums or department meetings. Ask employees to talk about one action they could take in their department to get the desired result. Encourage staff to share success stories. Give out fun prizes to volunteer participants. Employees are more likely to relate to important information when they can apply it to their own job.


While butterflies are most productive when they are “fluttering” from activity to activity, healthcare leaders could benefit from focusing their actions on identifying, rewarding, hardwiring and communicating what matters most. The result is so much more than meeting a goal or a score – it’s making a difference in the lives of those we serve.


Please add your comments to this blog and share your thoughts with our readers. We can all benefit from each other’s experiences.



Reflecting on What’s Right in Health Care


There were many reoccurring themes at this year’s national What’s RIGHT In Health Care conference. Two items were evident:

  1. Success depends on the combination of passion and well-executed prescriptions.
  2. There are tremendous financial pressures from many directions on health care organizations and, thus, on their CEOs. One of the pieces that resonated with our CEOs in attendance was the very specific return on investment tactics shared that overall had a $127 million return on investment. Of course, the ROI can only be replicated by combining passion with well-executed prescriptions.

Also presented last week were new toolkits with specific how-to’s that will help integrate safety into operations and collaborate with physicians. Additionally, attendees were provided with an action plan template so they can put new ideas into action when they return to their workplaces. Attendees also took home a new book featuring a story a day for the entire year to help connect each day to purpose, worthwhile work and making a difference.

You will soon be receiving very specific information on how to access presentations and other material from the conference.

As for me, I will be attempting to take July off to see children, grandchildren, spend time with my wife, Rishy, and by the grace of God, spend July 21st celebrating my father’s 87th birthday and my Aunt Mil’s 97th birthday. Every fire starter needs to rekindle their flame.

Thank you for your passion, willingness to make a difference and for answering the call to work in a field that has great purpose, allows us to do such worthwhile work and to make a difference. After last week’s conference, I received an e-mail from an attendee who, upon getting home, had a miscarriage. As she wrote of her and her husband’s heartaches, she described the staff that she interacted with and who now share a bond with her and her husband. She ended with a note thanking those who cared for her, her baby and husband for answering the calling to health care.

I also thank you for being difference makers. We must continue our journey to make health care better. We can make health care better. And we know how to make health care better.

Thank you.



Overcoming the Full Plate Syndrome Part 2: Tools to Create More Time


In my last blog, I talked about ways that organizations can reduce conflicting priorities for leaders and give them the skills they need to succeed for higher job satisfaction and better outcomes. Specifically, I recommended integrating measurable, objective goals into the organization’s evaluation system; weighting the goals to create clear priorities; and committing to leadership skill development. If you missed this blog, you can read it here.
In Part 2 on this topic, I’d like to urge leaders to proactively take charge of their own time by working smarter, not harder.

Not New, Better
Sometimes when Studer Group begins coaching an organization and introduces new leadership tools, leaders will tell us they don’t have time to do so many new things. We find that they feel more comfortable—and are even energized—once they understand that they are not being asked to do additional activities, but rather, to use a more efficient approach for current practices to get more satisfying outcomes.
Consider this list of practices most leaders already do and what works better to achieve outcomes:

Current Practices More Effective Approaches
1. Hold department meetings 1. Use Pillar Agendas at meetings
2. Talk to employees 2. Round for Outcomes
3. Employee reward and recognition 3. Write thank you notes
4. Employee selection and orientation 4. Use peer interviews and 30/90 day meetings
5. Retain employees 5. Hold individual employee meetings
6. Talk to patients 6. Use key words at key times
7. Pre- and post-calls to patients 7. Pre- and post-calls to patients
8. Evaluations 8. Leader evaluations
  9. Conduct leadership training

As you can see, the only new item on the list is leadership training. This is critical and necessary to ensure that leaders are growing the skills that move organizational performance and can manage their full plates. Aside from that, we recommend hardwiring more efficient tools that get better results for things leaders are already spending time on.

“Not New, but Better” also means that things leaders currently do on an occasional basis—say, holding a department meeting only when it seems urgent—now get done on a scheduled basis to ensure strong communication with an outcomes-oriented agenda that impacts organizational goals. Likewise, while some nurses may talk to some patients sometimes, we recommend standardizing the use of key words at key times. Remember—CMS will soon be publicly reporting on whether your patients say you “always, sometimes, or never” are responsive to their needs. When every nurse every time uses the key words, “Is there anything else I can do for you? I have time,” patients answer “always” on their surveys. Read my blog on always here if you missed it.

So, not new but better. Studer Group coach Tonia Breckenridge recently presented some excellent suggestions on how to manage the full plate at the third Leadership Development Institute of a Studer Group partner organization and received excellent feedback from leaders. So I wanted to share her suggestions with you:

  1. Regularly evaluate your activity versus your outcomes. Meet with your supervisor on a scheduled basis to review your annual goals and 90-day plan. Discuss what you are doing that does not contribute to your outcomes and whether to continue these activities.
  2. Develop people. When you delegate, you give others the opportunity to grow while opening up space on your own plate to take on key projects that will accelerate outcomes. Tonia cites a personal mentor who is masterful at identifying and capitalizing on the best strengths and skill sets of those he supervises, instead of trying to fix their weaknesses. As a result, his own capacity to achieve more is always increasing.
  3. Deal with low performers. Low performers eat up your time. Nobody ever wishes they waited longer to fire a low performer. Move their performance up or move them out of the organization quickly. It will save you time—and much pain—in the long run.
  4. Round for Outcomes. Even if you have as many as 60 direct reports, you can accomplish this in 30 minutes a day and connect with each individual at least once monthly. (This assumes you round on 3 individuals daily, spending five minutes with each person and allowing 15 minutes for follow-up on identified issues.) Hardwiring rounding will boost your employee retention and create a culture of problem-solving and recognition. You will get an unbelievable return on investment from this time spent with employees, physicians, and better patient outcomes.

Please add your comments to this blog and share your thoughts with our readers. We can all benefit from each other’s experiences.


Overcoming the Full Plate Syndrome Part I: How to Make Time for What’s Important


These are some words I hear a lot from leaders as I travel the country:
“I have too much on my plate. How can I possibly fit it all in?”

This is such an important issue that I’d like to address it in two parts. First, I want to share Studer Group’s experience on what organizations can do to increase the effectiveness of all leaders. In my next blog, I will share specific tactics for individuals that are highly effective.

In my seminars, when I ask attendees “How many of you have a full plate at work?”, almost all hands go up. In fact, I suspect that the people who aren’t raising their hands are feeling so overwhelmed they feel they don’t even have time to raise their hands.

Senior leaders in the C suite say that responding to financial pressures eats up their day. Managers say they just have too much to do. But here’s the thing…when I ask seasoned leaders if they feel they had a full plate 10 years ago, the same hands go up. I can see them thinking, “I had no idea know what a full plate was back then.”

A Brief Look at History
So what was keeping us so busy ten years ago? Well, we were coming off re-engineering and were trying to learn how to do more with less staff. The Balanced Budget Act and managed care pressures were requiring us to do more with less money. Then there was the physician issue: Should we employee them? Not employ them? We were also agonizing over the aging healthcare workforce and how to meet the needs of the aging baby boomer population. Sound familiar?

We may call some of these challenges by slightly different names, but the pressures today are really just the same and just as urgent. We feel pulled in too many directions and frustrated by our inability to use our time to meet our mission.

But here’s a secret: We will always have full plates because we are passionate about what we do in healthcare. We’re also achievers. So even if something falls off the plate, we’re quick to add something new. Because we’re compassionate in healthcare, we’re also not very good at saying no when people ask us to do something.

The thing is, once we accept that the plate is always going to be full, we can be more effective managing it. In his book, The Road Less Traveled, the late author Scott Peck noted that “Life is difficult. Once we accept that, life is not as difficult.” The Big Book of Alcoholics Anonymous says it too: Ones’ serenity is in direct proportion to ones’ acceptance.

So What Can We Do?

If we agree that our success is measured by our ability to realize the organization’s mission through specific organizational outcomes, then we have to find ways to spend the bulk of our time on the priorities that impact these outcomes. Sometimes our desire to accomplish a lot clouds our priorities with excess activity.

In working with many organizations to create evidence-based leadership, Studer Group has found that the keys to achieving outcomes are alignment, execution and accountability. In other words, goals and actions are aligned across the organization and consistently executed.

Leaders that we coach benefit from three key actions:

  1. Integrating measurable, objective outcomes into the evaluation system. When we begin working with a new organization, we frequently find they are using a subjective, competency-based evaluation system. By themselves, these systems do not typically achieve the organization’s desired outcomes. Here’s why: Competency does not assure consistent execution. Competencies are the “what” that we do. Measurable objectives, on the other hand, show leaders expected outcomes. As a result, they also reveal the competencies required to achieve those outcomes.Competency-based evaluation systems are no doubt easier to put in place and receive less pushback from some leaders than objective evaluation systems do, but in the end they frequently do not achieve the outcomes the organization desires. We find that when organizations implement our leader evaluation system there is an immediate breakthrough in results and performance gaps are quickly identified for swift action. Many organizations also find them to be an excellent succession planning tool. It becomes clear what a leader needs to accomplish to move up in the organization.
  2. Using a system to prioritize these measurable outcomes. I recently heard a hospital president in New York—Jon Schandler of White Plains Hospital Center—explain that leaders tend to gravitate to their comfort zones, which frequently do not match the organization’s needs. The way to deal with this: Weight outcomes on a leader’s evaluation so priorities are clear.Here’s a situation Studer Group coaches frequently see when reviewing evaluations: An organization is focused on improving patient safety. Leaders are familiar with the CMScore measures being reported on. And yet, leaders who can most impact these clinical outcomes do not have a goal on their evaluation that would make this a high priority for them. Weighted goals in objective leader evaluations are what aligns the time the leader spends to the desired outcome. In fact, a CNO I know recently credited the organization’s use of Studer Group’s Leader Evaluation ManagerSM for bringing the focus needed to cut ICU central line infections by 46% (a $432,000 annual savings). You can read another case study here.
  3. Building leadership skills. If we all agree the external healthcare environment will continue to get more difficult, then it follows that more skilled leadership at all levels of the organization is necessary for success. Developing skills in our leaders is the lynchpin to making gains and sustaining excellent outcomes. Just as many organizations host “skills days” to validate clinical competencies, so must we validate leadership skills.Senior leader teams that take the time to identify the skills their leaders need to achieve specific outcomes and have methods in place to attain and assess these skills will do well in the future. While it’s true that any new skill requires some extra time to master initially, the return on investment of time is huge as we improve. Rounding for Outcomes, for instance, requires a little time to become efficient, but it gives leaders back hundreds of hours when low performers move up or out and repetitive, routine problems are finally fixed once and for all.Isn’t reducing leadership variance at least as important as standardizing purchases through approved vendors? Or use of the corporate logo? I wonder, because I find that many organizations spend more time on these things than they do reducing leadership variance. High-performing organizations create clear leadership expectations for service and operational excellence and hold leaders accountable for meeting them. But they also provide a road map on how to get there with training on specific leadership competencies. From training managers how to hire the best employees to teaching strategic change leadership to senior leaders, leadership development matters.

Hardwire It

At Studer Group, we use the term “hardwiring” to describe the process of putting systems, skills, tools and techniques in place to assure consistent execution. Leadership training and an outcome-based evaluation are two of the most critical tools to hardwire. When an organization puts a structured management system in place with these elements, it creates the kind of accountability that assures the culture will outlast the people in the room.

The reality is that my plate and your plate will always be full. But we can manage it with confidence and success if we have the right tools.

As always, I am interested in your thoughts on this. Please share your comments.


Hardwiring those powerful letters we receive


We all need those letters.

In a recent survey of leaders we asked the question, “When was the last time you shared a patient letter in your department meetings with staff?” It turns out 60 percent of leaders had not done so in the past 6 months. Why? We can come up with a variety of reasons, but I find the two most often given are, “I don’t get copies of patient/family letters” and “I did not know I was supposed to, or could.”

Let’s hit the first reason. In our work we find almost all health care workers, whether they provide direct patient care, support services or any number of roles, went into and stay in health care for the same reason – they like what it represents. What is that? Their organization makes a difference in people’s lives. Employees love to hear about the impact their organization is having, the lives saved, and the end-of-life care that, while not saving a life, made such a positive impact. There are differences made in so many ways. We work in organizations surrounded by miracles.

Positive letters are printed in newsletters (after taking legal steps to protect writers or obtaining permission to use), which is good, but we can do more. Take time to send letters to all leaders. Even staff that don’t provide direct patient care enjoy the letters and feel good about the impact their organization makes. It also provides leaders the chance to connect staff back to the difference they make through their roles. When rounding on staff, have leaders show the letters and read them to staff. Ask leaders to read the letters at their own department meetings, too.

This hits point two. Most administrators read positive letters at department head meetings. But are we sure those leaders bring the letters and messages back to their staff? Most employee forums (town hall meetings) include letters from patients/family members thanking the organization, specific people and departments. This does not ensure that all staff hear these great letters for only those that attend the meeting receive the message.

I encourage organizations to hardwire the practice of leaders taking positive messages/letters back to their units from department meetings and employee forums as well as reading them out of the newsletter.

It’s easy to tell when the staff feels good about where they work. You see staff wearing the hats, shirts and buttons with your organization’s logo on them when you’re around the community. Heck, they even keep their name badge on when stopping at the grocery store on the way home.

This past year we have collected many stories about the difference makers in health care. These are now in a book, which contains a health care story for every day of the year. We will be providing this book complimentary to all people at the June 11-13, What’s RIGHT In Health Care conference. As I read the stories it reinforced how fortunate I am to be on this journey with you. Thank you.



It’s All about Always, part one


My “ah ha!” these last several months is the different impact the words always, most of the time, and sometimes have when it comes to performance. We now have H-CAHPS, which will create the healthcare language of always, usually, sometimes, never.

Over the years, in many areas we have hardwired always. If you are a member of a purchasing group, leaders always buy from a specific menu. If you have a budget due, it is always done by the start of the new fiscal year.

In operations, the elusive ingredient which separates the perennial high performing leaders and organizations is consistency. Consistency for patient experiences, employee work environment and physicians’ practice of medicine. Many feel we run four organizations: the day, night, weekend and holiday organizations.

The implementation tools and techniques backed by evidence that achieve and sustain high performance results are what we at Studer Group call “evidence-based leadership.” Evidence-based leadership helps create an always organization. The foundation of evidence-based leadership is to begin with aligned goals, which are created by effective leader evaluations and a leadership development process that links to desired organizational outcomes.

Prior to visiting an organization I have leaders complete a survey. It asks leaders to evaluate the effectiveness of these foundational aspects of evidence-based leadership. The survey covers such things as, “Do you have a formal meeting with new employees on their 30th and 90th day? If you are an inpatient nurse leader, what percent of patients do you visit (round on) each day? What percent of patients receive a discharge phone call?”

There are questions on the healthcare environment, too, so it gauges understanding of the leaders on the current and future healthcare environment and their readiness for success.

We use this data combined with the organization’s results to implement the next steps to either achieve excellence and/or to sustain excellence. After reviewing the results of these surveys from hundreds of organizations, we have learned a lot.

When it comes to patients’ perception of care, it is all about always. That is the topic of this blog.

When I review survey results, I ask the top leaders of the organization “Are the nurse leaders rounding on patients? Are discharge phone calls being made? Are outpatients being contacted to remind them of their appointment to reduce patient no-show rate?”

The answer I get is “yes.” It is a true answer. It is what they hear when they ask leaders these questions.

So what separates the high performing leader and organization from the middle performing leader and organization from the low performer leader and organization? It is the impact of always.

High performing leaders and organizations have hardwired the tools and or techniques so they are always done.

The middle performing leader is a most of the time leader in using effective tools and techniques.

The low performing leader is sometimes.

When the question is asked the answer is, “Yes, I round. Yes, 30- and 90-day meetings on new hires. Yes, discharge phone calls.”

It is not until the verification of frequency system is put in place does it come to light that the difference is not who does the behavior, for almost all leaders or organizations can say they do it. It is the hardwiring of the tool and technique so it is an always behavior; not a most of the time or sometimes behavior.

The other confusing issue is a leader who says they always do it. We find that this means it may take place five out of seven days. For example, consider leader rounding on patients. We find that patients’ and physicians’ experiences at the hospital during the weekday are much different than the weekends. So, for some practices, the hardwiring needs to be for seven days, not five.

Measuring “always”. How can leaders assess whether they are an always organization? One great way to find out is to ask your patients. For the more than 3,000 organizations using the H-CAHPS survey, patients are already telling them. The H-CAHPS instrument asks patients to describe their perception of the quality of their care by rating the frequency of events during their care (never, sometimes, usually, always).

By asking patients if they always see key events, leaders can quantify how hardwired those behaviors are from the perspective of the most important person in their organization . . . the patient.

Less is more. Today, we know that doing more may get you less and doing less will get you more. Our experience has taught us that it is better to have a leader implement one new tool or an adjusted technique until they achieve always, rather than doing more than one tool or technique most of the time or sometimes. Then the leader, unit, department and division experiences success, the tool or technique is hardwired, and the maximum impact is gained so the leader can see if more has to be done. And, if more needs to be done, the leader can choose the next step much more wisely.

At our June 11-13 What’s RIGHT in Health Care conference, organizations who are successfully building a culture of always will be presenting. Hope you can join us.



Celebrating National Hospital Week & National Nurses Week


I have learned much these past years in health care. The privilege of being in many organizations convinces me that we in health care share many common characteristics. One characteristic is that health care is more than a job. It is a calling.

In just one day last week I heard the same message from two people who were in very different situations and times in their careers. Kevin Lofton, the new chairman of the AHA, spoke of this calling in his talk on Sunday, May 6th when he assumed the chairmanship of AHA. On that day I also received the letter below written by a nursing student at Sacred Heart Hospital in Pensacola, Florida:

“I have no career experience in the field of nursing. This is just something I know I want to do. I would like to say that my goals are to gain tons of experience and working knowledge for the job, learn multiple areas and fields until I find the one that makes me the happiest. I would like to say just that. Because of a recent experience in my life, I have learned a valuable lesson. These things I have mentioned are not my goals at all. Yes they are important, but they are only necessities. My true goals are to care for those in need, to be compassionate and supportive, to provide comfort and treatment. For someone who is injured, frightened or confused I want to be that person who provides a safe and comforting environment, a way to ease their suffering and the knowledge and strength for them to carry on. If someone is alone and in their final hours I want them to know someone cares even if that person is a stranger who is fortunate enough to be their nurse. Of all the little things and big things that go on in a healthcare environment, I have recognized two things that happen constantly. One, people get sick, injured, suffer and die every minute of every hour. Two, they turn to a nurse for help in hopes that, that nurse is there just for them. I want to be that nurse and that’s my goal!!.”

The words from the nursing student brought me back to the beginning: purpose, worthwhile work and making a difference. Kevin’s talk keeps me there. It is our time and our responsibility to fulfill our social contract with those we serve. If not us . . . who? If not now . . . when?

I am an optimist in health care. Are there challenges? You bet. Can we be better? We have to be. So why am I optimistic? I see difference makers everyday. So do you. It starts when you look in the mirror. Never underestimate the difference one person can make.



Supporting and Appreciating Emergency Departments


Reading our professional journals, government releases and the variety of health care reports on problems, challenges, and failures in health care, I can at times fall into the trap of feeling sorry for myself or taking on a victim mentality.

After spending time on Saturday, February 24, 2007, with more than 1,400 emergency nurses at the Emergency Nurses Association meeting in Boston, I feel so much better. I saw such dedication to the health care calling, motivation to learn how to be even better leaders, and perseverance to keep striving to make a difference in health care. My flame got brighter thanks to these 1,400 difference makers.

At the session, I described something I was part of years ago that worked to improve outcomes. We had all department directors and members of the senior team spend one full shift working in the emergency department shadowing an emergency department staff member. At times working in an emergency department is similar to working at a desk at an airport. Both emergency staff and airport staff report delays, changes, and cancellations. While these are caused by other factors, the people at the desk take the brunt of others’ frustrations.

After experiencing a shift in the emergency department, many leaders went back to their own departments and fixed things to make service better for the emergency department; some leaders took ideas from the emergency department and improved their areas. All leaders left the emergency department with better relationships with emergency staff members.

Have leaders spend a shift in the emergency department and it will create better outcomes. Please let me know how it goes.

I meet many people in health care. There are many characteristics health care providers have in common. It is evident to me that health care providers are hard on themselves. One of my biggest challenges is helping health care providers be kinder to themselves. There is a lot of what’s right in health care. Never underestimate the difference you make.

What You Permit, You Promote


Liz Jazwick and I have been colleagues for more than 10 years. We first met at Holy Cross Hospital in Chicago, IL. Liz is a great presenter and a difference maker. My favorite thing I learned from Liz is, “What you permit, you promote.”

When I became president of a hospital in 1996, 23 percent of employees had late evaluations. I became aware of this issue when I mentioned to some employees our organization’s value of respect. An employee said, “If we are so respected, why is my evaluation late?” Thus, my search led me to find that 23 percent of our employees were waiting for an evaluation to be completed and some had been waiting for weeks and months. If an employee’s evaluation was late, nothing happened to the leader who did not complete it by the deadline.

I guaranteed all staff that in 60 days there would no late evaluations. I put in systems and consequences, positive recognition to leaders with no late evaluations, and connected the dots on why an on-time evaluation is crucial to show staff respect and retain employees. Sixty days later, there were no late evaluations nor were there any while I was there. I believe the system of on-time evaluations and results is still strong.

A few years back, we had a meeting with Studer Group staff members and posed the following question: “What are we permitting, thus promoting?” When people are asked that question, one will hear some good feedback and some ways to improve. For example, one may hear, “You are permitting us to hire our co-workers, thus promoting responsibility and ownership for new hires.” We also heard that we needed to do a better job walking the talk in some areas, and this caused us to tighten up. While the journey was not comfortable, it was worthwhile and made us better.

In our travels, we find that many organizations are not fully aware of what they are permitting, thus promoting. Here are some examples:

  • A leader who consistently is not meeting patient satisfaction goals is not dealt with, or worse yet, still gets a good review. We are promoting poor performance.
  • A vice president who is not sharing information that others are sharing. We are permitting inconsistent communication.
  • Staff not following agreed upon and signed standards of behavior (performance). We are permitting staff to not live the behaviors agreed upon, thus hurting the organizational results.
  • Allowing a physician to intimidate staff. We know from research that if staff are scared, they may not address patient issues with the physician. By allowing intimidation, we are not providing staff or patients the safest environment.
  • A leader keeps blaming the data for results. We are permitting, thus promoting, excuses.
  • A person is on his or her BlackBerry during a meeting. We are permitting lack of respect, thus promoting lack of attention.

You get the gist of it.

Ask yourself: “What am I permitting, thus promoting?” At your next senior leader meeting, put on the agenda “What are we permitting, thus promoting?” At the next department head meeting, take some time to ask leaders what they feel the senior leaders are permitting, thus promoting. At your next staff meeting, ask staff what is being permitted, thus promoted. While you may be disappointed in what you hear, you will not be disappointed in the opportunities presented to improve the organization or the outcomes that will be achieved.

Once you address what you are promoting, leaders may feel they need more training. It may be that at times leaders permit things because they do to not know how to handle them. For tips to help your team, click here to access the article Communication Transparency: Clarity Creates Trust by Beth Keane, a Studer Group expert.