SPEAKER 1: Question for you. I love your use of daily huddles. I'm a big believer in them. I've been doing them for years. Do you run them throughout your hospitals? On every floor at every unit, is that sort of the structure?
SPEAKER 2: Yeah, sure. Yeah. So we have tiers. There are tiered huddles. So we have huddles on every floor, and every shift, there's a huddle. Those floor huddles then get fed down to the patient care director or manager on that floor who meets with all the other patient care directors and managers. And they talk about that question, are we ready for the next patient? And they share what's happening on their floor. This happens every shift seven days a week.
SPEAKER 1: How long have you been doing this for?
SPEAKER 2: We have been doing this now for a little less than a year.
SPEAKER 1: And have you been able to measure any outcomes from implementing that practice, or is it kind of too soon?
SPEAKER 2: It's too soon, but we are now tying it to outcomes. When we first set it up, we didn't really tie it to anything. We're actually tying it to-- one of those areas is patient safety and employee safety-- using this format to then determine, are we seeing a reduction in patient safety adverse events? And are we seeing reduction in employee injuries that are taking place?
So we're starting now to put the objectives that we want to measure and really add more and more rigor to this, combining goal boards that are on the units. And there's a whole series of sort of belts and suspenders that have to be put together to make this successful. But at a minimum, you get people talking, and you have people talking a common language and solving problems in a common way.
SPEAKER 1: That's awesome. I've been telling health care companies for 10 years the power of the huddle. So you're doing it, so good for you. Yeah.
SPEAKER 3: So it might be interesting-- so for those of you who are also in the same kind of sphere, I was telling [INAUDIBLE] her title maybe should really be vice president of hospitality services facility manager [INAUDIBLE]. Kind of like [INAUDIBLE] at [INAUDIBLE].
But any thoughts from [INAUDIBLE] or any of the other folks that work in these sort of support services areas? Because I think that the things that you're all are doing to try and empower and engage the staff, I think, has a big impact on things. But I'm just kind of curious, if you don't have specific questions for them, if you have any other comments.
SPEAKER 4: No, I actually would like to add, in Jeff's presentation, he's spent a lot of time talking about creating that culture, building the foundation, the credo, the respect. Because those are the foundations, the fundamentals that any society is built on, any good corporation is built on. Without those structures in place, then it's pretty hard to start talking about creating experiences that wow or engage in if you don't have a platform on which you're built.
So I do encourage, and I can't stress enough just how important it is to really have a culture. The code says culture eats strategy for breakfast, right, something like that, for a reason.
SPEAKER 5: I think also, Brooke, I think in senior housing specifically, and I'm sure the hospitals are dealing with the same, is the idea of this labor shortage. And obviously, with unemployment at an all-time low, it only seems to be a problem that will get bigger before it's resolved. And so I listened to what John was saying this morning, and I pulled up the article to read for later. But the idea is robotics.
And I'll never forget the quote from the founder of Sunrise. And I said to him-- to try and understand what his perspective was on technology, and he said, you know, Meredith, in senior housing, the best we'll ever be are surrogate daughters. Nobody's coming to be treated by machines. People come and move into senior housing because they need to be cared for, and they're looking for that human touch and that human experience.
And so I think the home health business is a one-on-one sacred relationship when done very well, like many people in this room do. But for senior housing, there is this question of how quickly we can recruit-- and not just recruit, but people who have the heart and soul that are capable of embodying the values, right?
It's one thing to say I'm fully staffed. It's one thing to say that. Something very different to say I'm staffed with the right people that are doing the right thing at the right time and buy into the culture and subscribe to the values. And so I'm just wondering, in this age of labor being an issue, what people are doing, knowing that the right people are now going to be even harder to come by?
SPEAKER 6: I was wondering, actually, to this whole concept of robotics and the whole concept of this image that we had earlier today with the robot delivering the food. And I think everyone that's spoken today has talked about the importance of that personal connection. And how are we going to meld those two things together successfully so we don't lose that personal connection?
SPEAKER 4: I honestly think that the way we recruit today has to change. A couple months ago, I was having a conversation with our recruiting team. Gone are the days where you could just post a position, and you would have thousands apply for it. Nobody's waiting. The unemployment rate is going down every single time the report comes out.
So what are we doing differently? And how are we engaging the millennials? Because those are the employees coming into the workforce. So we have to look at what they're looking for.
Recently, I think it was two years ago, three years, now, I, two years at [INAUDIBLE], implemented a career ladder program in environmental services. And what it is is we created-- everyone coming in comes in as an environmental services aide one. And then after being in the organization for three years without any disciplinary action and getting really high scores, scoring in the top percentile on your performance reviews, you would go up to EVS aide two.
What that gave you, the opportunity-- we gave them a $0.50 increase going up to EVS aide two. And also, they could sit for what's called a CHESP certification, which AHE came out with this certification internationally where environmental services aides were treated as professionals. So they had to go through a 24-hour training program. They had to sit for an exam that's accredited by AHE. And upon passing that exam, they would get the CHESP certification distinction.
The cost of it is $150, but we absorb the cost in the department. And once they pass that, then they would then become senior EVS aides, and they would get an additional $0.50. So that actually created interest in our department, and we saw that we started losing less of our team members who would get recruited by other departments and would go on to other things.
Actually, this year, one of my team members won the Heart of Healthcare award nationally. And he said when he actually came into the department three years ago, his thought was, this was my entry into health care. Within a year, I'm going to another department. So I just wanted to enter.
But now, he says, I'm never leaving. I have a career path. I have an ability to grow and to develop through it. So why would I want to leave?
And that just shows that if you think differently and think outside on what can you do differently to retain the talent-- and then once you have the talent there, do you have them engaged properly so you can get more out of them? And then how are we looking at different ways? Are we partnering with schools, vocational high schools, so we can start them when they're at that age and we can train them and set the mindset versus taking them from another institution with probably habits that we don't so desire and then trying to rewire them? What are we doing differently to create that pipeline within our operations and also to get new blood into the operations?
I think there's a lot of things that we could do differently. But just figuring out how to start.
SPEAKER 3: So I'm curious if anybody has an example of this. One of the things I've heard anecdotally from a lot of people is that some of the support functions staff, particularly if they're engaged and empowered by the clinical staff, too, to be early warning systems when they notice something going wrong. But that always has seemed to me to be a wonderful way of making their job much more meaningful to them, too. And I've just heard a lot of these things anecdotally, but maybe some of you folks who have staff could share some of those things
SPEAKER 2: We have a great example. And our support service teams are part of the huddles that take place. We were seeing a number of-- on our OB units across the campuses, and this is something that occurs across the country-- mothers falling asleep with their newborns, and the newborn falling out of their arms while they're sleeping. Obviously, a new family, very sleep deprived.
And what we have done-- of course, you have the nursing teams that are continuously rounding on patients and checking in. But it's not enough. And every minute counts to be able to check in. We have trained all of our food and nutrition employees, all of our environmental service employees to be part of this program that empowers them if they see something in the room, such as a mother who is holding their child and the mother is sleeping, to immediately take action.
And since we have done this and expanded out and created more of an army of problem solvers, of individuals that can help and identify, and making them feel that they are truly part of the care team, we've gone to zero. So I think that this is a really, really important area to hit on is to make sure that we are engaging the support service functions. They play a much bigger role in satisfaction than I think any of us realize.
SPEAKER 7: Would it be OK to add to that? Just to piggyback, through the Eden Alternative, we work with organizations all over the world and mostly in the US. And what we see repeatedly is engagement on steroids. So we have lots of organizations that work hard to create self-directed work teams right down to team scheduling themselves. And what this involves is a flattened hierarchy so that everybody has a voice in problem solving.
So if there is a care plan that needs to be looked into or just a particular problem, everybody is brought into what we call a learning circle or a huddle, right, to be a part of the conversation. So then you get the people closer to the individual, instead of people who really aren't that engaged with the individual, making the decisions about the course of that care. And frankly, what those self-directed work teams need to be doing is empowering that individual to be in charge of the course of their own care entirely, regardless of what abilities they live with.
So when you have employees that are on the maintenance team engaged in a circle sharing what they observe what they see and building a strong sense of ownership in any process, people want to keep those jobs. We find our turnover rates have gone down in the organizations that practice our approach significantly. And there are waiting lists. People want to work in those organizations.
So John's right. It's about culture. It's about the culture you create. So the more we push toward that person-directedness, I think, the more we'll see people excited about being involved.
SPEAKER 8: So my question is for Jeff. And I get really excited when I see securities, because I'm from the army. You oversee emergency services at Presbyterian. Along the lines of satisfaction, how does the element of security impact not only staff satisfaction but also patient satisfaction generally, but more so now in a climate of biocontainment? I'm interested to hear how you leverage that, how you market that, and what sort of impact does that have? Also, for the architects in the room, how are we designing to ensure security and use that as a measure of satisfaction in health care?
SPEAKER 2: So security is a feel, and it's a different feel for everyone. And what that means-- we really try and strike a balance between maintaining an open, patient-friendly environment and one where, when you enter the doors, you feel like you're in a safe place.
And we've made a lot of enhancements over the last two years in light of what's going on around the country and in light of our various different risk assessments that we are constantly looking at. But every enhancement that we've made, we have looked at through the lens of the patient.
We're not perfect. We have recently rolled out rapid scanners at our entrances to scan everyone who is coming into the building for any metallic or weapons. And right now, there are some queues that are created. We've rolled out visitor management systems at our entrances to identify everyone who is entering our building and making sure that we know who's where at all times, again, also creating a queue.
And we're now studying to try and lessen these queues and improve the experience. But what we are finding is that while there may be some people that are unhappy they have to wait in general, there's a tremendous reaction to, thank you for doing this, and thank you for being proactive to care for my safety and, more importantly, the safety of my loved ones.
And our employees feel tremendous benefit in this, as well. And a lot of the ideas, a lot of the programs are coming from our employees who are being injured and on the front lines. What else can we do to improve their safety? And the two go hand in hand. When you feel safe, you feel engaged, and you're more likely to provide that better experience.
SPEAKER 6: So I have an example of a design change that we have made recently in our exam rooms. So we always have a physician desk in the area that is usually curved to encourage communication between the patient and the physician, the provider. But typically, it was in the back of the exam room. And the physicians have come to us and said, from a safety perspective, sometimes, we don't feel safe in the environment, and we feel that sometimes the patient or the family member who may be angry or disturbed is between us and the door.
And so we've moved the physician desk right adjacent to the door with security measures that are embedded into the computer system so that there's not a big, red button there or anything. But they feel much safer in that setting. And of course, it's a very, very small percentage that we're talking about, but it only takes one.
SPEAKER 3: So anybody have an example of a housekeeper, dietary aide, whatever who's been instructed to kind of be observant and notice somebody pre-code where they could alert the nurse's station? Any examples that you could share? I've heard a lot of these things myself, I just--
SPEAKER 4: I can actually share one that happened earlier this year. It wasn't necessarily in a coding situation. But earlier this year, we had one of our environmental services aides on the unit. And she noticed that there was a gentleman at one of the stations or walls, and he was using an ID to try to get into the computer. But he was having challenges, so he kept trying.
And she noticed it, so she walked up. And she asked, is there anything I can assist you with? And he says, no, no, I'm fine. And she says, are you sure? And then she walked over to find a nurse to say, I think we have a situation here.
And by the time she turned around and the nurse-- they walked over to the area-- the gentleman had disappeared only to find that the ID he was using was-- a nurse had had that. It was stolen from her two days before.
So all this to say is that during that process, they contacted security. All of that happened. But it was through that whole vigilance and being aware of the environment, what was happening. Because had he been able to access our system, that could certainly have put our hospital at a great risk. And we all know what that's like in this type of an environment.
So those are examples that happen all the time, not just in our facility. But I know it happens in many facilities across the US that support services team members, as Jeff says, we now include them in the units, and they're an active part of all huddles that happen on the units. And they're actively involved in that team, so that builds that sense of pride and ownership, as this is their house. And they will protect it at all costs. Yes.
SPEAKER 2: Just to add onto that, our security officers are all certified in basic first aid and in CPR. And not too long ago, we had a security officer who was on their way home on the A train from our Columbia campus. Someone passed out and required CPR.
Our security officer began chest compressions while a resident happened to be on the train, as well, doing mouth to mouth. And the two of them resuscitated the patient all the way down to 57th Street, where they were met by paramedics. And it was thanks to the intervention from a security officer that this individual's life was saved.
So it's really important to make everyone feel part of that team. And everyone who is in health care, we always tell our employees, you are always on. Off work, on work, unfortunately, it's the profession you chose. And you never know.
SPEAKER 5: I think it's important, though, in this case that I was part of last week, the way in which we define the caregivers, particularly in senior housing. So what my observation was is interesting, that the community felt that they had sufficient caregivers, because everybody was cross trained to provide care. So if you're in the marketing office, if you're in the business office, if you're the general manager, executive director, everybody is qualified to provide care.
Yet from the family's perspective, those that actually are there doing one-on-one care and that's what they're trained to do specifically and that's their function and reason for existence at the property, it is perhaps far too few. So we have to be a little bit careful, because the state regulations in senior housing are not as stringent as nursing, right? So we were talking about it at lunch.
In a lot of the states, it says at a minimum, if you have anybody in the community, you need at least one caregiver. But that's, frankly, never enough. And then the regs go on to say, but you need to step up to the level of care that you are providing.
And so it's very interesting. That is a very gray area of what is the appropriate staffing for the care needs that exist of our resident population, which is always changing. So I just think we need to be careful. Yes, I would absolutely love everybody to be able to save a life. But in terms of passing meds, you need a certain level of certification and credentialing. To toilet and bathe the resident, you need a certain level of training and familiarity with that task.
I just think we need to be a little bit careful, because it's not like the hotel business, where you're-- I laughed in business school. We did the People's Express case. Did anybody ever fly People's Express? So the person who checked you in was the pilot who also did your luggage who helped you off the plane, right? And so the business school case was like, that is an optimal staffing model, because everybody's cross trained to do everybody else's job.
But when you're in the air buying the ticket, you don't want the guy who's supposed to be flying the plane running your credit card like they used to have to run the credit card. So there's a fine line, and I think senior housing has to be careful where we cross. We want to make sure everybody is trained or prepared for every situation, but there is no substitute for the caregivers that are necessary on the front line that do this job day in and day out.
SPEAKER 3: No, that's a good point. Obviously, you still need to have the basic level of staffing to do the right job for clinical care. Did you want to say something, Jeff?
SPEAKER 9: Yeah, no. They're right. It's the balance of those two things, right? I mean, day two orientation for us, everyone goes through our culture of care, our team steps. And it's very much, if you see something, say something, right?
SPEAKER 5: Or do something.
SPEAKER 9: And do something about it. And with some people, please do not operate outside of your clinical license that you've been given or not given. So I shouldn't be going to the OR saying, how can I help today, right? That's not me taking care of people.
But we all take care of patients, right? And that's something part of our culture of care is we all say everyone has the exact same job. We all take care of patients. It just looks different for everyone.
So in each of those examples, right, it's just what their version looks like. But you want everyone to be equally as empowered, because you never know who's going to see something first. And we know, from an acute setting, every minute matters.
And sometimes people get very hesitant of, do I say something? Do I do something? That's not what I do-- my lane. Everyone's very litigious, and you don't want to just do anything to disrupt anything. But think of how many things you're kind of allowing, then, to happen if people aren't empowered just to say something, right?
And that's all part of the culture. I mean, it's hard to get there to have an environmental services worker go up to a nurse practitioner or a resident and say, hey, this IV doesn't look good. It's like, really? What do you know about this IV? But maybe there's something there. So it's hard.
SPEAKER 5: But we all have to be in the business of risk management, right? And so when we're in the business of risk management in these clinical settings or in residential settings, I love what you're saying. This is a matter of awareness and notifying. Maybe that's right.
SPEAKER 9: Just escalate, escalate, escalate.
SPEAKER 5: Right. But the last thing you want is someone who's not qualified or certified to do something to cross that line and get out of the lane.
SPEAKER 9: And I mean, this came up at our table. Sorry. I mean, it was just that the amount of timing spent on training, right?
SPEAKER 5: Yeah, this is important.
SPEAKER 9: This is what we were talking about. I mean, think of, how long does each of our organizations spend? How many hours or minutes do we spend training people on the ask as an employee, right? However you want to define that-- your employee value proposition, your employee musts, your service standards. Whatever it is that you want to call it, how many minutes do we spend doing it, right?
I mean, if we really think about it. It's usually minutes, right? Oh, they get 30 minutes. They get 15 minutes. People don't get hours, nor do you get days in training people in that environment. Yet you throw them right into it, right?
I mean, literally. I mean, it's like, why are we doing that? And you wonder why people don't know how to react in those situations, because you haven't seen it enough.
And that's something that I question. Patient experience training gets two hours with every new employee, and that was a fight from the 30 minutes we had two years ago. And I think that is nowhere near enough of what we need. Things like this, how much more time should we spend doing this?
And I joke-- I don't know who's got Kronos, but every new nurse manager and assistant nurse manager goes to a two-day Kronos training to make sure they can clock people in and out of work. And two days for Chrome River, our accounting system. Two days training for there. But what's the training for experience for managing other people, managerial courage of when to say something? What training exists for those folks?
SPEAKER 6: There's also just the awareness of people. So a lot of times in health care, there's a challenge with wayfinding. And nobody brought that up today, but I know it's just-- because there's so many interconnections going from place to place, and it's so overwhelming.
And I can't tell you how many times you can see a patient, and they're just looking around, trying to figure out where to go. Anybody. You don't have to have a clinical experience. Anybody that works at the institute should be able to stop and give direction.
And I see that every single day. And I think that's a great example of just being able to do what you can to help a patient not in a clinical way, but in just having an engagement.
SPEAKER 8: I agree. So I want to piggy back a little bit on the security story but also to be very mindful to the fullest extent of your licensure conversation, because I have an example to share. So with the onset of Ebola, we were appointed a level two facility, one of two in New Jersey.
So we are required to do quarterly drills, which include clinical personnel and support personnel. So on one of our most recent drills that we had-- and I use my soldiers to act as actors. So they go in through guest services. They pretend to do different scenarios unknown to our team members to see what the responses are.
And I had my soldier pretend to elope after she had given several cues, went into the bathroom at Guest Services, throw up, come back outside, hold onto Guest Services-- I mean, giving all the cues. Then she pretended once they recognized, and they asked her to wait, because security was a concern for us. How do we stop a patient from leaving? Not one that's contained in our biocontainment room, but one that's on the outside.
So she pretended to leave, and our security that was right there instinctually jumped in front of her and said, no, you are not. Over my dead body, you are not leaving. This is our security personnel.
So I understand the danger, the level of danger, but there is that level of value. There is that extreme value that empowered support team member feels when he is connected to something that he was willing to put his life at bay for the organization. So I'm seeing both ends of this conversation. But I was just thankful that I had a really engaged team member.
SPEAKER 3: Great. Any other comments? But yeah, I've heard a lot of these anecdotal comments. And I love your patient experience boot camp that you do. Maybe that's some we should take the students to see at some point.
But yeah, I think there's-- to Meredith's point, you obviously can't have people giving care. But I think that empowering those support staff to be the eyes and ears and the early warning system, the kind of telemetry, if you will, for the clinical staff is very powerful. Because I do think, to your point, having those people who are engaged, it just makes a difference in seeing things and helping to prevent problems and just being more part of the real team. So all of your comments are great.
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Discussion on other services in a health care setting, including housekeeping, maintenance, guest/resident relations and patient services. Part of the Healthy Futures Roundtable held on October 10th, 2018.