By: Mary Griffin Strom, MSN, RN, Consultant, Creative Health Care Management
In the inspirational new book, See Me As A Person, authors Mary Koloroutis and Michael Trout define the practices that make up a truly authentic connection to patients and families. These practices are the essence of a therapeutic relationship. Koloroutis and Trout define a therapeutic relationship as one in which “the clinician offers care, touch, compassion, presence, and any other act or attitude that would foster healing, and expects nothing in return.” (Koloroutis & Trout, 2012.)
The “expects nothing in return” segment of that definition is what differentiates the therapeutic relationships we form with patients and their families from all other relationships. However, the elements that comprise the therapeutic relationship—presence through attunement, wondering, following, and holding—apply to all authentic relationships, personal or professional.
The therapeutic relationship practices that create authentic relationships with patients and families are something that we can think about, talk about, study, and DO. It takes intentionality, practice, reflection, and effort to move those practices from a way of thinking, to a way of doing, to a way of being.
The same holds true for servant leadership or caring leadership. We can talk about how important it is to be in service to those we lead or how important it is to be caring, but we seldom define those actions in a way that moves us to a new way of being a leader. Let’s explore what it looks like when we apply the therapeutic relationship practices to leadership.
Attunement
Presence through attunement is the container that holds the three essential practices. If we are not present and giving our undivided attention to the other, then wondering, following, and holding are not likely to be experienced by the receiver. First, we must be attuned.
As leaders, when we “round” on staff, are we attuned to them, focused on them, present for them, and with them? In other words, how do we show up? Are we working to meet our agenda or theirs? Are we with them to listen or to tell? If we are servant leaders, we might need to entertain how to set our agenda aside and be open to whatever their agenda is for that moment.
Wondering
Wondering begins then as soon as we are attuned. Wondering involves openness, curiosity, using wide eyes, and open ears. And perhaps most importantly, it means suspending conclusions. It means knowing that knowledge comes not from what we already know, but from what we might learn about our staff, the climate of the unit, and the staff response, as well as about the patients/families in our care that day on our unit.
Following
Following means we consciously decide to be guided in our discussions and our interactions with patients, families, and colleagues by whatever happens in the moment. It truly helps to know our staff as individuals, so that when they mention someone or something that has resonance to us, we pick up on that part of the dialogue and show respect and understanding of whatever conversation transpires. They are leading, and therefore, naturally you are the follower. This requires giving special attention to body language, tone of voice, choice of words.
Holding
Holding is the conscious decision to lift up, affirm, and dignify what you are hearing and learning from those who know the work the best: your team. Even if you encounter a strong emotional response in the moment, holding helps you as a leader to be a steady and nonjudgmental presence. Holding might mean that you convey that you have heard what was said, that you might need to get back to someone, and that you respect them enough to honor their concern. Holding also means that you keep your promise and return to them with an answer to their raised concern.
Just as these practices must be defined, practiced, and reflected on in order to be true elements of the therapeutic relationship with patients and families, the same holds true for these practices in our role as caring servant leaders. They do not come easily; they often come through trial and error and learning from our mistakes. Formal leaders would benefit from group/peer discussions centered on exploring these practices, putting them into practice, and then reflecting on how they worked and how it might become a way of leading. Staff will learn from you as they witness your steady intentional presence, your openness to their dialogue, your willingness to follow their train of thought and discussion threads, and your holding of their contribution as something valuable to you and to the organization.
I invite you to suggest at your next formal leadership meeting that you set aside some time to use See Me as a Person as part of your learning agenda for each of your meetings. As a leadership team, you will learn the language and definitions of its therapeutic practices and be able to role model the behaviors and practices such that caring servant leadership is demonstrated in actions more than words.
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Throughout her career, both as a nurse at the point of care and as an administrator, Mary has seldom used the word “patient” without the word “family” following right behind it. Currently, Mary is a consultant at Creative Health Care Management, where she partners with health care organizations on team building, patient safety and quality, leadership development at all levels, physician engagement, and patient experience. Mary can be contacted at mgriffinstrom@chcm.com
By Gwen Faust, RN, MS, Consultant (HCAHPS & Other Surveys), HealthStream
I live about 19 miles from Newtown Ct. One of my healthcare providers is a surviving sibling of one of the adults killed at Sandy Hook elementary school this past December. I saw him yesterday for a checkup and wasn’t sure how I was going to address his loss. I didn’t want to bring up something that I could only imagine was still extremely raw but I did want him to know I cared about him. When I saw him, I just touched his arm and said “Hello my friend.”
As I was leaving the office I saw him in the hallway… I wished him a good spring and told him to get out fishing (which I know is a lifelong passion of his). He began to talk about a trip he had just taken and how much it helped. We ended our conversation with a sincere hug. He went on to say that the best comfort available to him in these times is found in the caring touch from others. Words weren’t necessary… but the touch on a shoulder, arm, hand, or hug are now essential to getting through the day.
I have been thinking about the importance of touch since our conversation.
Touch is Valuable in Healthcare
In a society made keenly aware of abuse issues, sexual harassment and now impacted by technology to the nth degree… I fear that human touch in healthcare and elsewhere is limited at best and more than likely limited to task or procedure-related touch.
Touch was first recognized by Aristotle as one of our senses… right along with taste, smell, sight, and hearing. Infant survival depends on it. The positive and real impact of Touch Healing has long been studied and documented. Massage therapy is appreciated by many of you reading this, and hospitals are now starting to include integrated medicine in their programs for patients with cardiac issues, cancer, and chronic pain. Some hospitals have taught all levels of staff gentle hand massage as a rest-inducing or pain-relieving technique for the patients with whom they come in contact. Touch can be reassuring. When we are talking about being a team and “We’ll work on your cancer, heart failure as team”… how much more reassuring would it be to have that message accompanied with a hand being held or a hand on the shoulder? Communication, pain relief, healing (physical and emotional), stress management, improved circulation, and survival all are positively affected by human touch.
Touch is an Important Part of Effective, Caring Communication
So when we are with our patients and their family member, and we are speaking with them, we should use non-verbal communication techniques of looking at them, listening to them, and sealing the deal… with a human touch. I learned very early on in my nursing training that we can’t save everyone and that helping them through whatever their health care experience brings is the gift I could give as a nurse. One year I drew the cover for our Nursing School yearbook… I’ll spare you the art experience….but it was a drawing of two hands which were intended to portray the hands of a nurse—caring hands and hands that help heal.
While we may not return to PM care, complete with patient backrubs, we do need to revive touch as part of the care we give and the way we communicate.
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Few studies have been conducted on length of stay (LOS) and patient satisfaction, and studies of this type have mixed results. In the past, LOS has been associated with both higher and lower patient satisfaction. No studies have compared LOS and HCAHPS scores. The current study compared LOS with HCAHPS scores from inpatients of 602 hospitals. LOS was associated with HCAHPS scores. HCAHPS scores tended to decline as LOS increased across most HCAHPS categories, although discharge planning increased as LOS increased.
Examining the Relationship Between Length of Stay (LOS) and HCAHPS Scores
This HealthStream study, conducted by Research Analysts Jim Eggers, Chad Wrye, and Paul No, under the leadership of Randy Carden, Ed.D., Senior Research Consultant, examined the relationship between inpatient length of stay (LOS) and patient ratings of the hospital as measured by HCAHPS scores. LOS is defined as the number of days that a patient spends in the hospital as an inpatient and in this study is calculated as the difference between date-of-admission and date-of-discharge. While it is clear that patients should be in the hospital long enough to receive appropriate treatment, there is a push throughout the healthcare industry to reduce length of stay as much as possible through increased efficiency. Some open questions related to LOS are whether it is an appropriate measure of hospital performance, and how it is related to hospital quality and efficiency.
The source of the data for the current study was the 2012 HealthStream HCAHPS Database which contains 432,998 inpatient respondents from 662 hospitals. Of these 432,998 inpatients, 39,468 did not have LOS data and were eliminated. The remaining 393,530 patients, representing 602 hospitals, had an average LOS of 3.69 days with 2 days being the most common LOS. About two-thirds (65.8%) had a LOS of 3 days or less. Raw LOS values were then grouped into seven buckets: 1 day, 2 days, 3 days, 4 days, 5 days, 6 days and 7 or more days. Top box scores by the grouped length of stay were then calculated for each question and for each category in the HCAHPS survey. A mix of formal statistical testing accompanied by tables and graphs were utilized to analyze the data.
Findings of this analysis include:
- There was a relationship between LOS and HCAHPS Scores
- Lengthening of the patient stay affected some HCAHPS categories more than others
- There was a LOS threshold where scores changed significantly
- One HCAHPS category was outside the general LOS-dependent scoring trend
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By Suzanne Cleere, MSN, MSBA, RN, CENP; Consultant, Creative Health Care Management
Across the country there is a deep desire to elevate professional practice in nursing. It makes me wonder: Do we see the word “professional” as merely a label or does it help to define who we are? The age-old debate on “entry level into practice” surfaces in this conversation. But what I have discovered both in informal conversations and formal assessments in health care organizations across the nation is that even in organizations with a high percentage of bachelor-prepared RNs, there is a deficit of understanding nursing as a profession.
The Importance of Role Clarity
There are multiple strategies that have the potential to awaken professionalism in nursing including work in role clarity. Role clarity helps us to clearly define what it is that is nursing’s alone to own as well as to define the role of each individual nurse in each domain of practice. Within the profession of nursing we have three domains within which we function. They are:
- independent practice (separate from medical practice)
- interdependent practice
- delegated practice (which requires direction/decision making by another discipline)
Until we embrace that which is nursing’s alone to own (which can vary based on State Practice Acts), how can we appropriately enter into collaboration with individuals in any other discipline?
Standards of Practice for Nursing
It turns out that what we own is clearly articulated by the ANA in the ANA Scope and Standards of Practice (2010), along with the ANA Code of Ethics for Nurses with Interpretive Statements (ANA, 2001). Our professional organization provides us with firm ground to stand on and to build on. We own the nursing process. We own who we are in the provision of health care. As defined by the ANA, this is the work of the nurse:
Nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations.
Nursing’s boundaries are articulated by the ANA and the State Practice Acts. We are licensed to practice to the fullness of this definition, and we do this through the critical thinking model of the nursing process. Language has risen that describes our unique function, the interventions of nursing care, in Nursing Intervention Classification (NIC, 2013). Additionally we are called to a higher level of professionalism, well described in the 2nd Edition of Nursing, Scope and Standards of Practice:
The Standards of Professional Performance describe a competent level of behavior in the professional role, including activities such as quality of practice, education, professional practice evaluation, communication, ethics, evidence-based practice and research, resource utilization, environmental health, and leadership, appropriate to their education and position. Registered Nurses are accountable for their professional actions to themselves, their healthcare consumers, their peers and ultimately to society. (ANA, 2010)
The scope of nursing practice can be overwhelming unless we take the time to reflect on what it means in our own professional practice environments and in our individual practices.
Questions Useful for Creating Role Clarity
Where do we begin? Clarity requires dialogue. It requires time to pause, to reflect. The first step in creating the role clarity necessary for professional practice to really happen is to ask yourself and your team these questions:
- How do we, in this department or this hospital, live out the standards of professional performance? Are there barriers to living the standards fully?How can I engage in personal professional development?
- Do I (regardless of my role) provide my team with a professional role model?
- Do I (as a leader) provide my team with opportunities to reflect and dialogue on professional development?
- How does my state practice act define my practice?
- Who are the patients we serve?
- What is the intensity of care that this population requires? What aspects of that care are within my independent domain, the interdependent domain, and the delegated domain?
- Who within the team is qualified to provide the care?
When I know who I am in the work, what I am responsible for, and what you are responsible for, we are better together, a stronger team. We raise the level of care given, we improve the outcomes and metrics achieved, and we secure our role and legacy as professional partners in health care.
Reflection and dialogue are valuable first steps in establishing role clarity. Teams seeking further guidance may choose to work with a role clarity expert. The process is comprehensive, and therefore rarely fast, but working with a consultant can ensure that your team does its role clarity work as efficiently and effectively as possible. The most common response I hear from individuals in organizations who commit to the important work of role clarity is that they can’t believe they waited this long to do it!
Fostering connections at work and creating teams have always energized Suzanne, who is a consultant at Creative Health Care Management. She has Master’s degrees in nursing and business administration and is nearing completion of her DNP program, where her capstone project will explore “Reflective Practice: A Mechanism to Improve Relationship with Self, and Improve and Enhance Relationships with Patients and Peers.” All of her academic background is connected to real-world experience: she’s been a leader at every level, from 20-person nursing teams to VP and CNO. In every organization she’s been a force for positive change, leading by example.
Sources
American Nurses Association (ANA). (2001). Code of ethics for nurses with interpretive statements.Silver Spring,MD: Author.
American Nurses Association (ANA). (2010). Nursing: Scope and standards of practice (2nd Ed.). Silver Spring, MD: Author.
Bulechek, G., Butcher, H., Dochterman, J., & Wagner, C. (Eds.). (2013). Nursing interventions classification (NIC) (6th ed.). St. Louis, MO: Elsevier.
(This white paper is posted in conjunction with healthcare performance management expert and partner Baptist Leadership Group.)
In addition to establishing goals for clarity to achieve long-term outcomes and success, it is essential for an organization to establish clear behavioral expectations, often referred to as “Standards of Performance.” Standards of Performance are the day-to-day behaviors an organization expects everyone to live. Standards are not only important for staff, but also for leaders. These established behaviors allow each employee to live the values of the organization every day.
Standards of Performance are commo
n, observable behaviors that help achieve the organizational goals. At times they can be confused with the values of the organization. While values are important, they do not provide the clear and specific behavioral expectations. Standards are what ensure we live our values. Standards must first be clearly defined for everyone. This establishes consistent alignment of all leaders and employees. It also sets organizational expectations and interests to create loyal, cooperative, and willing employees who go above and beyond assigned duties. Without clearly defined behaviors, it will be difficult to make certain that everyone understands the expectations. This reduces the positive benefits for the organization.
They may consist of global behaviors everyone exhibits as well as jobspecific behaviors necessary to produce outcomes in a given role.
Standards in Action
For the Standards to permeate an organization’s culture and drive overall performance, it is imperative that these behavioral expectations are:
An accountable organization helps staff and leaders follow the standards of performance by assuring they are lived daily by everyone during every interaction. Standards are a tool to create consistent behaviors across the entire organization. These behavioral expectations support healthcare performance management and are the ways you can meet and exceed patients’ expectations.
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By Lee Ann Bryant, Associate Product Manager, HealthStream
According to a recent survey conducted by the Workgroup for Electronic Data Interchange (WEDI), an industry leader on the use of Healthcare IT to improve the exchange of healthcare information, healthcare facilities as a whole are not on track for a smooth transition to ICD-10 on October 1, 2014. Close to 1000 industry participants were surveyed on readiness in February of this year, including 778 providers, 109 health plans, and 87 vendors.
Stanley Nachimson, Director of the NCHICA/WEDI (North Carolina Health Information and Communications Alliance) stated “… it has become clear that many entities postponed their work until much later. It remains to be seen how this postponement will affect the progress to compliance. Indications remain that significant numbers of industry participants have a considerable amount of work to do in a very short time.”
Based on survey results, there was a shift in ICD-10 timelines across all facility types. Some contributing factors to this slow progress include the change in compliance dates, competing internal priorities and other regulatory mandates.
Some key results from the survey include: 
- Almost half of the health plans expect to begin external testing by the end of this year. In the 2012 survey all health plans had expected to begin in 2013.
- About half of the providers responded that they did not know when testing would occur and over two fifths of provider respondents indicated they did not know when they would complete their impact assessment and business changes.
- About two thirds of vendors indicate they plan to begin customer review and beta testing by the end of this year. This is similar to the number who expected to begin by the end of 2012 in the prior survey.
“The survey results show that projected timeframes for testing have shifted and many organizations will not begin this task until 2014,” said Jim Daley, WEDI Chairman. “Because of the magnitude of ICD-10 it is critical that organizations complete their remediation efforts as quickly as possible in order to allow adequate time for testing.” (For a full copy of WEDI’s letter to CMS, click here.)
It is critical that providers get started with their training right away. CMS has provided numerous timelines and checklists based on facility type and size. To access the ICD-10 Implementation Timelines and Checklists, click here.
If you have not yet begun your training for ICD-10 and want more information from HealthStream on the ICD-10 Solution Suite of products we offer through our partner, Precyse, click here.
By Bob Ogden, Senior Director Consulting
(Bob is a West Point graduate and retired from the Army as a Lt. Col. after a 22 year military career)
Lead and inspire people. Don’t try to manage and manipulate people. Inventories can be managed but people must be lead. —Ross Perot
Over the last seven years I’ve had an opportunity to interact with hundreds of healthcare leaders, from board presidents, to CEOs, to front line nurse leaders. During this time, I’ve been struck by the wide disparity in leadership skills; some “get it” and many clearly do not. I remember a comment a CNO made to me several years ago when asked to what she attributed the improvement in their physician satisfaction scores. She said “the new CEO is in the physician lounge every morning at 7:00 a.m. … he gets out of his office to meet the physicians and speak with them.” It was as if she was surprised that a hospital CEO would leave his office to greet physicians on their turf. Sounds to me like that CEO was one of those leaders that “gets it.” Unfortunately, though, I have met many leaders who do not.
Be a yardstick of quality. Some people aren't used to an environment where excellence is expected. – Steve Jobs
What is it that good leaders “get?” What are the traits of successful leaders? While there are many definitions and examples of good leaders, I like the five simple leadership elements of Paul “Buddy” Bucha, a 1965 West Point graduate and Medal of Honor recipient: honor, confidence, competence, compassion, and humility. I’ve often wondered why I see so many leaders in healthcare that struggle with some of the basics of leadership. Is it a lack of compassion or competency? The vast majority of healthcare leaders I’ve encountered are extremely compassionate and highly competent in their fields, so that’s not it. Is it because traits like honor, confidence and humility are missing, or is it something more fundamental? Could it be that what’s missing is the process of developing healthcare leaders like we see in the military or other industries?
Leaders aren’t born, they are made. And they are made just like anything else, through hard work. And that’s the price we’ll have to pay to achieve that goal, or any goal. – Vince Lombardi, legendary football coach
I agree with Coach Lombardi that it takes hard work to mold someone into a leader. As a graduate of the United States Military Academy at West Point, the foremost leader development institution in the world, and with 22 years as an Army officer, I have experienced leadership development up close. What’s missing in healthcare is a framework similar to the West Point Leader Development System the USMA faculty uses to develop 18-22 year old cadets into leaders for our Army. It is interesting to hear the insightful responses from a group of cadets when asked recently what leadership skills they had learned in their nearly four years at West Point. From this group of young men and women came observations such as genuine concern for others, being personable, providing consistent and honest feedback, empowering subordinates, delegation, emotional intelligence, patience, resilience, trust, and reflection. Do they “get it” already, even with their limited life experiences? 
Whatever you are, be a good one. —Abraham Lincoln
Some may argue that developing an Army officer preparing to lead soldiers in combat is completely different than preparing a nurse manager or CEO for their leadership challenges. However, if you look closely, there are a number of similarities between the two professions. Combat and healthcare leaders work in an environment where ambiguity is the norm, the daily pace creates chronic stress leading to burn out, and decisions that impact life and death are made daily. Technical competency is a requirement for both professions. While nurses may not be ducking for cover or lifting heavy rucksacks, many lift obese patients and walk miles every day in the course of taking care of their patients. We like to think the healthcare profession is unique, but I contend that there is a kinship with those protecting our freedom and there is much to learn about developing leaders from those in military uniforms.
I start with the premise that the function of leadership is to produce more leaders, not more followers. —Ralph Nader
A few healthcare organizations today have formal leadership development programs. Some incorporate programs like HealthStream’s Frontline Nurse Leader program for charge nurses, team leaders, and assistant managers, or the American Association of Critical-Care Nurses’ Essentials of Nurse Manager Orientation. For many organizations, however, leadership development consists of identifying the best clinician for the next open leadership position and then learning as you go. If that describes your organization, you may want to consider creating a leadership development program or formalizing the program you have in place already. A good place to start in creating a leader development program is to think what your end product should look like. The ten desired outcomes of the West Point Leader Development System provides a good place to start.
- Lead and inspire to complete the mission
- Embrace your role
- Demonstrate a broad perspective that is open to new ideas and experiences
- Understand ambiguous situations and solve complex problems
- Make sound and timely decisions under stress
- Communicate effectively with all audiences
- Demonstrate proficiency in (healthcare) skills required to succeed
- Demonstrate mental and physical toughness
- Demonstrate the respect for others and work effectively with different cultures and people
- Live the Army values
While the last outcome is unique to West Point and its Army mission, the first nine relate well to the role of healthcare leader. Whether you are developing charge nurses or future healthcare executives, the West Point Leadership Development System can be adopted and modified to provide a framework for a successful program.
In today’s healthcare environment, where transformation has become the norm, strong leaders are needed now more than ever at every level within the organization. It’s time to examine the process of creating leaders to ensure they will have the tools to face the challenges ahead of us. Will your organization be ready to meet the challenge?
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An interview with Lee Ann Hanna, Director of Education, TriStar Centennial Medical Center (HCA), Nashville, Tennessee
Currently the Director of Education at TriStar Centennial Medical Center (HCA), Nashville, TN, Ms. Hanna has over thirty years experience in healthcare settings; sixteen years experience in neonatal, pediatric, and adult critical care; and fifteen years experience in knowledge management and quality improvement. She is a Certified Professional in Healthcare Quality and a National Association for Healthcare Quality (NAHQ) Fellow. Lee Ann regularly presents at nursing and quality education conferences on the local, state, regional, and national levels.
We recently spent some time speaking with Lee Ann about her insights, challenges; and opinions, gleaned from her years of clinical education in a large hospital setting. Here is an excerpt from that conversation:
HealthStream: You have had a long and varied career, on both sides of the educational fence. What, in your opinion, is the biggest change in Pharmaceutical/Medical Device (PMD) training over the last five or ten years?
Lee Ann Hanna: Devices and drugs have been around for a long time; we implement new and/or we convert to the next. The biggest change over the last five to ten years has been that it’s coming at a faster pace. Implementations may come rapidly; sometimes this is based on outcomes data, regulatory directives, availability of products, and/or contract negotiations. Organizations are continuously moving to highest quality and best price. It’s not a good thing or a bad thing. It’s a reality of our economic environment.
While that is the biggest change, there are other changes that affect PMD training. Hospitals must work at higher productivity standards. Seldom do you find hospitals that budget for PMD training. It is usually absorbed by the patient care units. Although some hospitals allow for training cost centers, when all is said and done, training costs still hit the bottom line.
There is a shortage of bedside nurses. This may be due to intermittent shortages related to call-outs, leaves, and turnover, or long term shortages related to supply and demand. Patient care units staff for patient care. Unless a PMD training program is moderate to big and requires extensive training, most of this training occurs during the same hours that bedside nurses are scheduled to deliver patient care. As patient care is the priority, this may lead to distractions and missed training opportunities. There is nothing more frustrating than to be asked to use a device or administer a drug without training. According to the rules and regulations of registered nurses in our state, nurses should not perform nursing techniques or procedures without proper education and practice.
There is also a shortage of clinical educators. This affects the organization’s ability to develop and implement PMD training programs. I am aware of hospitals that do not have clinical education departments or centralized clinical educators. While this work has been decentralized to patient care units, those nurses may not have the knowledge and experience to develop and implement effective and efficient training programs. They may also have to be flexed to patient care to meet staffing needs, which may cause delays and quality issues.
PMD companies face the same challenges as healthcare organizations. Their environment is moving at a rapid pace. Competition and resources are just as challenging for them. These companies must also work in a cost effective and efficient manner, especially when it comes to training. Some PMD companies consider training a value-added service. Some PMD companies will not sell a product unless staff members are educated and competent to use their products. The latter understand that proper use of their devices and drugs will lead to improved outcomes and higher quality. If you take care of quality, everything else falls into place.
HealthStream: How is PMD training more cost effective today than it used to be?
Lee Ann Hanna: In my opinion, online training, alone or paired with classroom activities, is more cost-effective than traditional standup training alone. Online training may be completed on demand by participants and saves resources (class room space, human resources, time, travel expenses, etc.) for both the hospital and the device and drug companies.
By using online training, we can assign it and track it. If a PMD company sponsors the online training it can be updated with changes (appearance, function, label use, discontinuation, etc.). The hospital does not need to rely on clinical educators to develop and review programs, a resource intensive task. I advocate online training for small changes and online training in conjunction with hands-on training for medium to large changes. We call this blended learning or problem-based learning. It is efficient and effective.
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By Donna Wright, MS, RN; Consultant at Creative Health Care Management and author of Ultimate Guide to Competency Assessment in Healthcare
If you’re only using competency assessment just to assess skills, you have some missed opportunities. You can also use competencies as a way to articulate the current requirements of the job; it can be the second half of the job description.
Here is how you do it:
Competency assessment should reflect the current competencies needed in the job. It is not a static list of skills you repeat over and over again each year. An effective competency assessment is a dynamic, changing list that reflects what is New, Changing, High Risk, and Problematic (Wright, 2005*):
- New: new initiatives, procedures, technologies, policies, practices, patient/customer populations, etc.
- Changing: changes in procedures, technologies, policies, practices, patient/customer populations, etc.
- High Risk: High-risk job functions and accountabilities
- Problematic: problematic areas are identified by QI/PI data, patient surveys, staff surveys, incident reports, or any other formal evaluation process
This dynamic competency identification process can help you create a list of competencies that will reflect the current nature of the job and the technologies, knowledge, and concepts needed to successfully complete the work competently to ensure that patient and their families have the best experience and care possible.
When you have a dynamic system like this in place for your competency assessment, you also have achieved another aspect of performance management—articulating expectations. By stating what has changed and evolved in the job, you are explaining to an employee where their performance now needs to be. Our jobs are constantly changing; competency assessment can help leaders articulate these changes.
So now, competency assessment begins to be part of the job description. It is the dynamic, changing part of the job. If you think about it, the traditional job description is the basic part of the job that does not change much. It includes things such as do your basic job, come to work on time, be able to lift 25 pounds or more, etc. The second half of the job description should be current competencies that reflect the dynamic, ever-changing part of the job. In a way you are saying to the employees, “Now your job looks like this. You now need to know this piece of equipment, here is some new research that needs to be integrated into our work, and here is an area that we need to improve our outcomes by changing our practices in this way.”
When someone asks you if he/she can see a current job description, I recommend showing them two documents: the traditional job description and this year’s competencies. Next year if someone asks you the same thing, produce the traditional job description and that year’s identified competencies.
By using a dynamic competency identification process, you are automatically updating your job descriptions every year. You have created a wonderful performance management system that assesses competencies and articulates expectations at the same time.
Learn more about HealthStream's Competency Center and Performance Center.
A staff development specialist known for her irreverent wit, Donna brings a global perspective to her work. In this country and in the over two dozen others, Donna’s best known for the work she does based on two of her books, The Ultimate Guide to Competency Assessment and Relationship-Based Care (co-authored with several CHCM colleagues). The Ultimate Guide has become the industry standard for HR departments in establishing and assessing competency, and Donna specializes in setting up systems for organizations to ensure accountability and measure competency.
* Wright, D. (2005). The Ultimate Guide to Competency Assessment in Healthcare. Minneapolis, MN: Creative Health Care Management.
By Cyndi Tierney , Research Consultant (CG-CAHPS and Other Surveys), HealthStream
Setting Sights on Leadership in the Patient Experience
I
recently met with a hospital’s Patient Experience team. The team leader and hospital executive were committed to improving their results, passionate about the team of champions they assembled… and frustrated about their lack of progress. We talked about a few specific areas of opportunity, and then I asked where the initiative stood with department leaders. It was a long pause before they confided that it was a weak spot. Some department heads were on fire for the cause, while others weren’t supportive. Not dismissive either, they both quickly added. Just not pushing the agenda with the staff, and could I do something about that?
Dead in the Water
Hospitals and systems take varied paths in driving patient experience improvement efforts in their organizations. Some use a traditional top-down approach, some are de-centralized from corporate office and administered by leadership, while others run with a grassroots effort, using staff for the effort to take hold. No matter which route you’ve chartered, there’s a point (okay, sometimes multiple points) where you’re standing still. The water is dead calm and not a breath of wind in sight. Welcome to change.
A Riptide out to Sea
On my next visit, I met with the directors. As we started to talk, a few were brave enough to voice doubts about requiring staff to use catch phrases with patients. One or two even used the dreaded S word, “My staff members don’t like being scripted.” Now really, who does? Unless you’re in cement on Hollywood Boulevard, scripting feels like a small box in which to stuff your personality.
But enough commentary; let me get back to the point. This is classic resistance. There’s nothing wrong with it, this group is not dysfunctional, but they are not bought in. And if they don’t see the value of using key messages with patients, they sure can’t, or won’t support it. It wasn’t the staff who needed to look at scripting from another vantage point. It was the leadership. They hated the idea of forcing act one, scene one on their staff. No wonder it wasn’t catching on.
Swimming with the Current
I have a checklist I use whenever I travel. There’s nothing on the list that is so esoteric. It’s all basic stuff—toothbrush, shoes, phone charger, etc. I use it because when I don’t, I end up at Wal-Mart, hunting for a battery pack for my laptop. I’m not stupid, it’s just there are better things to do with my brain then remember all my travel items. That’s what the checklist is for.
Key words are a verbal checklist. Whether it’s teaching a medication, rounding in the rooms, or admitting a new patient to the floor, thereare a few critical points you want to cover. My colleague, Bo Hansen, calls them Word Tracks—essential words or concepts that help patients feel important and cared for and help them understand and remember what we are teaching.
That was easy for the group of directors. They got it. They liked it. They could get behind a verbal checklist.
A View from the Shore
You’d think this story would end here. Mid-level leaders had a change of perspective and change of heart. So, all is good, right? Well, no, it wasn’t all good. This wasn’t just a perspective problem; it was also a role problem. What exactly, are these leaders supposed to do? That wasn’t clear at all.
In this initiative, the Patient Experience (PE) team members were frontline staff from throughout the hospital. They were the change agents--the champions who introduced key words to their work areas and talked it up with their co-workers. In the units, on the floors, and around the hospital, they were role-modeling with colleagues.
And where should the leaders have been? On the sidelines, supporting the effort. This wasn’t a group of lazy leaders; it was a group of clueless leaders. They didn’t realize that was their job.
Too often, we are dazzled by a breath-defying best practice. Behind each of those, there’s a set of core leadership skills that ground the team. While the staff is center stage, the leader is encouraging behaviors into habits and publicly connecting those new habits to the changing results. This leader is the authority figure who sets the stage for this new way of life, as an expectation. He or she ultimately manages the group’s performance, rearranging priorities, removing or navigating barriers, and addressing stragglers or non-conformers.
Ships Ahoy
Healthcare professionals are far from lazy—in fact, our field is known for being dedicated and innovative. We are accustomed to learning new techniques, implementing new procedures, and operating new equipment. We learn it, and then we turn around and do it.
Without any guidance for seeing their role as a sponsor and understanding how they function to complement their champion, it’s no wonder these leaders are treading water. The lifeline we need to throw is a leadership checklist, a few key words, and this ship will be soon set sail again. Here’s to the champions who lead this effort, and their unsung leaders, who chart the course and steer the ship. Aye , Aye, Captain!
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