When I took my first management job, I recognized that I was taking responsibility for the job performance of other people. It had became my job to achieve outcomes based on the work of other people. I had to figure out how to keep people motivated to do good work, motivate them to do better work in many cases, or move them out if they were unable or unwilling to do so. If I was a tyrant about the moving out part, then I probably wasn’t going to be very good at the motivating part, so I learned on the job how to manage myself in order to manage others. I learned on the job how to care about the people that I worked with because caring about them meant that I could see them as individuals and learn how to tailor my approach to their individual needs. I got training along the way, but that training built on my understanding and ownership of my role as a manager and the acceptance of increasing levels of responsibility for my own and others’ job performance. 

I’ve been reading lately about the idea of “radical candor”. It looks like this is being presented like a new idea, but it feels like it is just a re-packaging of common sense ideas for managing people. Of course, the book by this title was published in early 2017 so it’s still on the hot list and that’s why the idea is getting a lot of buzz right now.  

The premise of the book is that managers should “challenge directly” while also “caring personally”. Doing these things at the same time results in radical candor. Doing one without the other results in either “ruinous empathy” or “obnoxious aggression” and doing without either of them becomes “manipulative insincerity”. I’m sure we all recognize bosses from our past lives in one of these four phenotypes!

People who read a book and then say, “now I’m practicing radical candor” are most likely not doing that. I have observed people who said that they were bringing radical candor to their work (because they had just read the book and were inspired), but the observed experience was manipulative insincerity, because candor is hard. 

Managers have tough jobs. One of the hardest things managers have to do is give feedback and coach when they are trying to help improve performance or facing the need to move someone out of a role that they aren’t performing well in. It requires self-awareness, personal vulnerability, emotional intelligence, and the willingness to say difficult but honest things to people. It takes courage to say difficult things that are potentially going to impact a person’s livelihood, and it takes the ability to manage your own reaction and allow them to process what they are being told with devolving into “flight or fight” yourself. It requires practice and the acceptance that sometimes you are going to get it wrong.

Debbie was telling me recently about how she trained new managers. Relying on an adage that has stuck with her, she told them to ask themselves three things when they were considering feedback to their teams:  Is it kind? Is it true? Is it necessary? If the answer was “yes” to two out of three, then it was OK to say it. In fact, as a manager, they were obligated to say it, both the kind things and the necessary things. I had seen numerous examples of how Debbie applied this to her work as a manager and leader, but I had never heard the thought process behind it. Turns out these are a distillation of some ancient wisdom, all fully in the public domain now.

I saw one of the people who worked for Debbie flower into an effective manager because she had been given the tools and support to actively manage her team into both high performance and high engagement. This person started from the point of caring about her team – she just needed some tools to channel that caring into productive management. If you start from caring and learn how to do candor well, the result may be radical candor. If you didn’t “care personally” before you read the book, you aren’t going to after you’ve read it either – you may be candid, but it won’t be radical and it won’t lead to magical management results.  

In full disclaimer, I have to admit that I haven’t read the book – now I’m going to have to. We need more good managers in public service and in LTSS – these are people who do care and who may just need some training, tools and support to turn that caring into effective management. The book is identified on the website as having “launched a management revolution…” Per my last post, investing in management skills is a good thing and there is value in candor – I just wish it wasn’t seen as something radical! 

Sharing a new In a Nutshell on what we call ACE – when it comes to critical business process it’s all about accuracy, consistency, and efficiency.


#BeyondCompliance, #LTSSTransformation, #OperationalEffectiveness, #SageSquirrel

I recently read a LinkedIn post that I want to explore a little more deeply. It caught my eye because it was about turnover, but it went a different direction than most posts on turnover do. The writer makes a direct connection between turnover and the caliber of management skills and identifies high turnover not as a “people problem” or a “millennial problem”, but as a management problem and says that people aren’t investing any longer in high quality management skills.  

I have to quote here:  “Management is a humbling responsibility that is highly undervalued in business today. There is a difference between management and leadership; many want to lead, few want to spend the time to be great managers of people.” Agreed!

There is a difference between leadership and management and unfortunately, management gets the short end of the stick. Consider these quotes:  

  • If you want to get ahead, you have to show up as a leader – not a manager.
  • Managers have people who work for them, while leaders have a sea of talent ready to follow in their footsteps.
  • Managers rely on positional authority, whereas leaders exercise interpersonal influence.
  • Managers like to control, while leaders inspire trust.
  • Managers focus on execution, while leaders focus on developing and empowering others.
  • Managers dole out tasks, while leaders share a vision that‘s motivating and meaningful.

Do you see the theme here? Management is, at best, portrayed as leadership’s poor relation, toiling in the shadows, doing the grunt work. It’s a lot like Cinderella before the fairy godmother shows up. Leadership is the Prince Charming that everybody wants to be with. 

These present as a duality – that managers exist opposite and separate from leaders; that managers are autocrats barking orders to people who have to follow them because of job titles. I’ve met plenty of people through the years who did things that way, but called themselves leaders; I don’t know many who followed them willingly.

I would posit that this is more of a spectrum – there are  managers like the ones described above – and there are leaders who can inspire but who can’t manage their way out of a paper bag. There are leaders with no management skills and managers with no leadership skills, but the best are both.  

I have had the great good fortune to work with some incredible leaders, and yes, I’ve worked with managers that were a lot like the ones described above. The people who have inspired me have been the ones who were both, but the ones that I have admired the most are the ones who have been able to make things happen – the managers. 

Done well, managing people is HARD. Managers assimilate a lot of information, prioritize it and make decisions on what’s best for their organizations. They know how to both create a plan and work that plan in order to execute what needs to be done. They don’t do all of this on their own – most importantly, they understand that the people they work with are their best resource, and they know how to deploy those resources to make things happen. They are like a pilot flying a plane but their instruments are people – managers fly that plane and bring it in for the landing successfully.

Good managers hold the tough conversations and they keep things moving forward. They make decisions about who stays and who goes. I think this is one of the reasons that managers get the bad rap and are perceived as autocrats who like to boss people around. That’s unfortunate – while those managers do exist, good managers are working to do the right things for the right reasons, and they do these things as positively as they can. While nobody likes to have those conversations, sometimes they have to happen.

Some of the best managers don’t see themselves as leaders because they don’t need to be out in front of things. They frequently don’t work front and center where their efforts are seen by all. It can be easy to overlook people who are or can be good managers because we are all too busy trying to identify the leaders.  

The lure of leadership is strong – the gentleman who wrote that post is right about that. But leadership without management is a bit of an empty shell. In a room full of leaders nothing is going to get done until or unless one of them has the management chops to make it happen.

Sharing a new In a Nutshell on Employee Turnover.

Employee Turnover

#BeyondCompliance, #LTSSTransformation, #OperationalEffectiveness, #SageSquirrel

Robert Kennedy is quoted once as saying, “Some men see things as they are, and ask “why?”.  I see things as they could be, and ask “why not”? The people who seek to bridge the gap between how things are and how they could be are change agents . You might call them disrupters, transformers, modernizers, or innovators. The term may be somewhat passé, but I still call them change agents. Some are appointed to the role; some have it thrust upon them accidentally; some just assume the role naturally but change efforts of all types need one or more of these folks.

I haven’t thought about this much recently, but I was speaking with somebody just the other day about organizational change and realized that I have been on the front lines of at least four – and probably more – major organizational change initiatives. I never really set out to be a change agent, but I’ve certainly had some experience with it, and I think it comes from seeing what could be and always asking “why not?”.  

I used to tell my teams when I was a restaurant and retail manager that I wanted the store to run so well that the company could film a commercial there – they knew exactly what that meant. Sometimes there were days when that vision felt unachievable, but I just kept telling them to focus on what they coulddo that day and asked them to just make one thing better than how they found it every day, no matter how small. Over the course of two years, we went from being a “D” grade store to being a frequent “A” grade store. 

There are some common principles across other transformative changes that I have been part of – sometimes as the one bringing the change, sometimes as one who has embraced a change that was thrust upon me. There’s no one best way to be a change agent, but there are some behaviors that are common to successful agents of change.

  • Change agents either bring or embrace a clear vision – what does the future look like and why does it need to look like that? They are able to define what’s different in that vision from current conditions.
  • They communicate about change frequently and in a multitude of ways – everyone in the organization has to understand where they are going and why. Transparency is a key attribute.
  • Change agents create or embrace the plan that will take them from where they are now to where they want to be. That plan will have short term and long term elements and will change along the way – everything does! Change agents are flexible and able to adjust to changing conditions or new learning, keeping the vision and mission as lodestars to stay on track.
  • Change agents understand that change can happen in big leaps or in tiny day-to-day bits, but it has to keep moving toward the new vision, even in the face of what might appear to be insurmountable obstacles. Some things may take months or even years to implement fully, but change agents keep the ball moving forward.
  • Some elements may seem to be out of control (especially if you’ve ever worked with a  legislature!) Effective change agents bring a solutions-orientation to their work – keeping the vision in mind and always seeking ways to keep moving forward, regardless of obstacles, even in baby steps. They’re the ones always asking “why” or “why not”? every time they hit a barrier.

Organizations can create change without doing these things, but the long term sustainability and success of that effort may be undermined. In fact, I would posit that the frequent changes of leadership and the very long timelines associated with policy changes in the public sector are among the reasons that the public sector is perceived as so resistant to change. There’s inertia there that can take a very concerted effort to overcome. Change agents in government run the risk of being viewed as rebels, if not outright troublemakers, but government may need them more than any other type of organization.

We do most of our work in the area of publicly-funded long term services and supports, currently facing enormous disruptive pressure. Growing demand, exploding expenditures, workforce challenges, evolving consumer expectations, and regulatory requirements are all creating an environment where change is the norm and it may no longer be tenable to just tweak systems around the edges to achieve desired outcomes. Disruptive change willhappen, but it will only be transformative and positive with intentional effort to make it so. Change agents, or whatever you want to call them, build the bridges that can successfully carry organizations over the chasm between “as is” and “to be”. 

making it workManaging change can sometimes put you in a precarious position. Change is not only expected but necessary in many situations. Learn how to not only manage change but create it when needed — be a change agent!

In our latest In A Nutshell, we share Nine Tips for Bringing About Positive Change.

Change Management

A friend of mine just recently helped her mother-in-law, whom I’ll call “Bea”, move into an assisted living memory care community. My friend was instructed that they were not “allowed” to visit Bea for at least two weeks because she needed to adjust to living there. They didn’t know anything about Bea – just that she was a person with dementia moving into a new environment, so they applied a general rule. While I think I understand why they are doing this, it seems that it is potentially not kind and it certainly isn’t person-centered. Hold that thought and I’ll come back to it.  

Debbie and I have been looking at a lot of things workforce-related lately. There’s a lot of discussion about current and future direct care workforce challenges. Turnover is very high and the ratio of workers to persons who need care is only going to continue to get more challenging. One strategy employers may use to help address workforce challenges is to better “engage” workers in their day-to-day jobs (see “In a Nutshell – Workforce Engagement”). Engaged workers are less likely to leave and more likely to contribute to the overall well-being of their clients and their employer. There’s no downside there. Creating an engaged workforce can involve significant culture change on the part of the company, but the investment may be worth the effort. In culture change efforts, it is important to be aware of “parallel process.”

There is a lot of very scientific literature on parallel process in psychology and social service work and that’s what many people think of when they hear the term. There is also organizational parallel process which is about the interplay between and among clients, staff, and the organization itself. Within this interplay, patterns of behavior and dynamics among and between staff are replicated in how staff behave and relate to clients. When two or more systems have significant relationships with each other, they begin to develop similar attitudes, thoughts and behaviors (paraphrasing Dr. Sandra Bloom).

In my very non-scientific take, parallel process is the organizational alignment of values and behavior across all systems in order to achieve maximum business outcomes. In health and human services those outcomes include clinical and quality of life as well as revenue and expenditure outcomes. Basically, you can’t ask or expect your direct care workforce to provide respectful, person-centered care if they aren’t having a respectful, person-centered work experience. This is what I mean when I use the term parallel process. Leaders and managers must model the same behaviors with their workforce that they expect the workforce to demonstrate to the clients. It does require an investment in the workforce that goes beyond wages and benefits.

Let’s go back to the facility I describe above. There was nothing “wrong” with the facility mentioned above and what they told my friend about visiting her mother-in-law – just like there’s nothing “wrong” with managers and supervisors who manage in “because I said so (even if I say it nicely)” fashion. Neither action breaks any rules. But quality is about more than compliance alone. 

What if there was engaged and empowered staff available, who were free to meet with my friend and Bea, who were able to ask questions, review records, and then work with the two of them on a visiting schedule that supported a positive transition? Is there any reason that the aide who was going to work with Bea the most couldn’t be part of that process and couldn’t be engaged with my friend and her husband to get Bea settled in? If it was determined that a no-visitation period was necessary, couldn’t those staff people be proactive in communicating with family members about how Bea was adjusting, instead of making my friend call each day and hear only that “she’s doing fine”.  

What would it take on the part of leadership and management in that building to have staff who want to take a person centered approach to care? Many people would say that it takes training and I would agree that training is part of the process because the skills may not come naturally. Does it need to be baked into performance expectations? Yes, it does – but howthat gets done is a key part of how successful an organization may be in engaging their workforce. 

Some organizations put a lot of words around their expectations and claim that this is what they do – including the assisted living facility described above. They have value statements and mission statements that say all the right things about putting people first and respect and service. These are just words if they don’t align to the experience of the staff. Richard Branson says, “Clients do not come first. Employees come first. If you take care of your employees, they will take care of the clients.” This investment can pay off financially with reduced expenditures associated with employee turnover and workers comp claims. It also can pay off with increased quality of life for clients and residents. That, despite all laws of geometry, is parallel process come full circle.

Sharing a new In a Nutshell on Employee Engagement.  This really goes along with our latest blog on the shortage of direct care workers. Be sure to check that out as well.


Employee Engagement

#BeyondCompliance, #LTSSTransformation, #OperationalEffectiveness, #SageSquirrel

Planted outside a nursing facility not far from my neighborhood is a sign that reads “Now Hiring:  RN’s, LPN’s, and CNA’s”. Right around the corner from that nursing home are two buildings with home health and personal care agencies. They also had “Now Hiring” signs out front. Other nursing facilities and agencies in my town are advertising for help – signs, newspapers, online, billboards. All of these Now Hiring signs are adding up to the appearance that this town is in critical need of long term caregivers. And this town isn’t the only one.  

The problems may only get worse. An astonishing new report from PHI, the Paraprofessional Healthcare Institute, states that between 2016 and 2026, the U.S will need to fill 7.8 million direct care jobs, and that by 2026, the direct care workforce will be larger than any other single occupation. (This doesn’t count nurses.) Direct care workers are the home health aides, certified nurse aides, personal care aides who provide the majority of the hands-on assistance with activities of daily living for persons who have disabilities associated with aging, or other conditions.  

The factors driving this explosive job growth include the increasing use of home and community based services versus nursing facility care, increasing life expectancy, and the aging of the baby boomer generation. There’s no surprise here – it’s been talked about for years.

What is different in this figure is the use of newly available occupational separation data from the Bureau of Labor Statistics that allows PHI to project the number of people who are leaving the direct care workforce. Of the 7.8 million job openings, 6.4 million are the result of people either leaving the workforce entirely (3.6 million) or leave direct care for other industries (2.8 million).  Rising demand only accounts for 1.4 million new positions. These numbers don’t account for people who move from employer to employer within direct care. 

This is a challenge that is calling out for both macro-level and micro-level solutions. I could go on and on about the macro level solutions required at the state and federal levels, but for now let me stay at the micro level. What can HCBS providers do, if anything, to attract people to and keep people in direct care?  

A few years ago, I was the Director of Human Resources for a company that owned and operated long term care facilities, both nursing and assisted living, around the state.  Even then, recruiting and retaining direct care staff was a significant challenge. Unfortunately, there was a sense that high turnover and recruiting challenges are just the cost of doing business. It’s true – turnover and running short-handed are costly. Using available data I calculated that the cost of each separation and new hire cost the company, on average, about $2700. This didn’t even take into consideration the costs that are more difficult to quantify, but there is evidence that high levels of turnover are also associated with higher workers’ compensation costs and reduced outcomes for individuals served.  

Of course, pay is one of the factors that leads to high turnover and difficulty in recruiting. Pay is closely tied to levels of reimbursement which may be out of the hands of many providers, particularly in the HCBS world with Medicaid’s prominent role. But pay is only one of many factors that employees value in their jobs. The opportunity to develop meaningful relationships with the individuals they care for and supervisors, and the ability to contribute to the quality of life for people who depend upon them are also highly valued by direct care workers. I have heard numerous stories of people who left direct care for what they thought would be easier, comparably paid work in retail or other areas, and then came back to direct care because they missed “their” residents or clients. 

There’s an opportunity here for employers to differentiate themselves by investing in management practices that promote that different value proposition, and this investment may make good business sense. These practices could include training managers how to coach and empower direct care workers to participate as full members of the care team, investing in training or education to increase skills or develop career paths for direct care workers. They can be as simple as scheduling and pay practices that incentivize desired behaviors and outcomes. Employers can more effectively recruit and select for the “soft” skills that are central to good caregivers:  compassion and empathy, alongside dependability, reliability, and trainability, and that may contribute to longer service as an employee. These are not necessarily expensive investments to make, dollar-wise, but they can pay off in a more loyal, engaged workforce that is committed to the well-being of the people that they are serving.  

Many employers say how much they value their workers but are not always aware of the extent to which their practices don’t reflect that value.  They aren’t doing anything wrong – but they may be missing an opportunity to stand out in this highly competitive labor market.  Sage Squirrel would love to connect with HCBS providers (personal care agencies, home health agencies, and assisted living communities) who are interested in how they might do this. 

#BeyondCompliance, #LTSSTransformation, #OperationalEffectiveness, #SageSquirrel

Casey Stengel said, “Getting good players is easy. Getting ‘em to play together is the hard part”. In January of 2014, there were good, hardworking, and very well-intentioned people in the DA, but I wouldn’t necessarily call them a team, or even a collection of teams. As I transitioned in, I reviewed the organizational chart and met with everybody there, both individually and as teams, sometimes more formally, and sometimes with pizza just to get acquainted. I learned a lot in those conversations, both about the individual people and the organization itself. 

By February of 2018, the Division of Aging was functioning as a much more cohesive unit, with a shared sense of purpose and clear line of sight to organizational objectives, and capable of achieving high performance levels in service to those objectives. I’d love to reflect a bit on how we got there. I think it demonstrates the themes of operational/organizational effectiveness and accuracy/consistency/ efficiency (ACE) we talk about as Sage Squirrel.

There was a clear delineation between people who worked on HCBS and people who worked on things related to nursing facilities (Money Follows the Person was considered a nursing facility program!). Half the DA staff were identified as the “Assistant Director of …”. When asked what work they performed, almost all of these Assistant Directors said: “My job is special projects.” (I even think Debbie’s title at the time was Assistant Director of Special Projects!) There were professional staff stacked on top of each other in narrow reporting columns that were up to five people deep – and yes, individuals in those columns were all Assistant Directors of something. Most of the reporting columns and work groups had little connection to, or little knowledge of, work that was done in other parts of the agency. That was a LOT of fragmentation and organizational silos – within a division that consisted of only 35 people!  

The Indiana DA is one of the smallest state units on aging in the country and is responsible for a great deal relative to its size, compared to other states. In the face of growing waiver utilization and the demographics of the aging baby boomers, we knew the Division would need to increase capacity. A typical response to that need is simply to hire more workers, but that is not always the best or most feasible solution, especially in state government where you are faced with budget limitations, hiring freezes, and cumbersome hiring processes and limited recruiting support. We did not want to request additional funds for additional staff until we were confident that we had maximized the capability and capacity of the existing staff structure, so that’s where we focused.  

To make the most of the resources we had available, we focused on:

  • Automating business processes wherever possible;
  • Creating efficient, effective, valued added processes; 
  • Ensuring there were well defined expectations – and accountability for meeting those; and 
  • Getting the right people in the right roles. 

Some specific steps that we took included:

  • Establishing the concept of “ACE” – accuracy, consistency, and efficiency – and making that our guiding principle in the review of business processes and measuring performance.  
  • Improving software, tweaking business process, retraining internal staff, empowering staff, and retraining of case managers in the field, made a great difference in how we handled waiver care plan reviews and approvals. In three years, that team was handling almost 100% more participants, while staffing was only increased by half an FTE.  
  • Creating flexible teams that could be deployed as needs and priorities waxed and waned through cross-training. This had the added benefit of creating job enrichment for people who may have been a little stale, bolstering learning and engagement.
  • Updating job descriptions and ensuring that each job description emphasized the role and level of responsibility for a position, rather than the specific tasks or duties.  
  • Identifying core competencies for each job and featuring those prominently in the recruiting and hiring process. Assessment of candidates was oriented around those competencies rather than specific previous experience or knowledge. We found the best candidates regardless of location and leveraged technology to allow them to work remotely.
  • Standardizing comprehensive onboarding for new hires. 
  • Ultimately restructuring the entire organizational chart and creating a much flatter and networked organizational structure with no one more than three levels from the Director.

An aphorism that has stuck with me from almost the beginning of my work in HR is that “culture eats strategy for lunch”. I don’t believe that it is possible to achieve strategic objectives without paying very close attention to organizational culture, and organizational culture is notoriously difficult to change. The strategies we used at the DA were effective because we didn’t neglect organizational culture. While there are models of culture change, I believe we achieved a large measure of by being very pragmatic about where we wanted to go and what it was going to take to get there, and then being very transparent about sharing all of this with the team. And then putting those things on repeat… and repeat… and repeat…  until they finally started to be absorbed and integrated.  

This was not a linear or chronological process – in fact, it was quite iterative as we learned and evolved and built on what we were learning and as changes occurred. Some of that flexibility was part of the point; too many people were wedded to always doing what they had always done. While stability and consistency have their place in any well-run organization, rigidity has no place in today’s world. We wanted to foster a culture of ongoing learning and continuous improvement rather than rigid compliance. We not only allowed people to ask “why?” we encouraged it, even expected it. 

To achieve transparency, we held weekly “stand-up” meetings which all staff were encouraged to participate in, used Yammer to promote informal intra-departmental communications, and held quarterly staff meetings with expanded in-depth subject presentations, and an annual retreat. We consulted with the team on updating job descriptions and the organizational chart, and the team drafted the division’s mission statement during one of our holiday retreats. Most importantly we were accessible and open and encouraged questions and dialogue at all levels.

We didn’t label it this way, but person centeredness was always central to our thoughts and actions. It started with our concern that consumers needed to be at the center of the programs and services they utilized. We knew programs and services could not be person centered if we didn’t start with our own team and embrace a person centered culture. It was a work in progress to be sure; we were all learning fast – with credit to our Case Management Director, Amy Rapp, for continually pushing person centered concepts into how we interacted with one another in the division. 

It was all about aligning our organizational structure, culture, and business operations to the larger outcomes we wanted to see in the programs we administered. Organizational alignment is about getting everyone to play together to achieve shared goals and objectives. That’s what we mean when we talk about aligning operations and policy objectives.

#BeyondCompliance, #LTSSTransformation, #OperationalEffectiveness, #SageSquirrel