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.

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”. 

Managing 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.

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

We know we promised you a series on operational/organizational effectiveness, accuracy/consistency/efficiency (ACE), and going beyond compliance, but something happened this week that reminded us why doing these things is so important.  We will get back to our series with our next entry.

My brother’s wife is now somewhat frantically trying to arrange care for her Aunt K.  Aunt K lives in Indiana – my brother and sister-in-law just moved to Florida.  Aunt K has been in a rehabilitation facility, paying out of pocket because her Medicare Advantage plan said that she no longer qualified for therapy and the facility says they have to discharge her.  Aunt K has suffered some cognitive decline while in the facility and the rehab staff are referring her to assisted living, saying that Aunt K won’t be safe going home alone which is how she lived until her recent surgery.

My brother expressed to me “Our top priority is Aunt K’s safety. We want her to be 100% safe.”  I suggested that if she doesn’t want to be in a facility, perhaps they might want to listen to what she wanted and work to find a way to balance that with the safety considerations.  I was shocked when he said “that might be fine for now, but at what point, does what shewants just go out the window?”  Suddenly, Aunt K is no longer a grown woman, retired teacher, who just a few weeks ago was independent with a rich and active social life. So often in the midst of a crisis, the person ceases to be a person and becomes a problem or a situation that has to be handled. Now everybody just wants to “put” her somewhere where she will be safe, and they want it to happen quickly.

Aunt K has some money in the bank and income from a pension.  She owns her own home free and clear.  She’s not in immediate danger of requiring Medicaid assistance, so in theory at least, the state has no interest in Aunt K’s outcome. But is that really true?  Why should state systems care about people like Aunt K? Let’s break this down (in a somewhat oversimplified fashion):

• If my sister-in-law really wanted to ensure only that Aunt K was “100% safe” one option would be to admit her to a nursing facility as a private pay resident.While the appeal has been pending, she’s been paying $372/day.  Assuming no rate changes, $100,000 would buy her about 268 days, about nine months in the nursing facility.
• One can’t guarantee 100% safety in an assisted living community, but there is staff presence 24/7. If we assume the Genworth average cost of assisted living (~$3900/month), $100,000 would buy about 25 months of care.
• If Aunt K would prefer to stay at home and can do so in an acceptably safe fashion with a few hours a day of personal assistance and support from her active network of friends, that care would cost around $100/day and $100,000 dollars will last about a thousand days, or 3 years.

Medicaid is the largest payer of LTSS in the country, and LTSS is becoming a larger and larger portion of those expenditures as lifespans increase. It is in the state’s best interest to help people access good information about what’s available to them and how they can use their personal resources in the way that best balances what is important to them with what is important for them.  A person in this situation with $100,000 available to pay for care potentially delays running out of funds and becoming Medicaid eligible for up to a year.  Even better, that person and their circle of support retains the ability to manage their own affairs and make choices that are congruent with their goals and preferences.

Long term care is not easy for people to navigate and way too often, they are trying to do so while they are in a crisis.  Most people say that they would prefer to remain in their own home, but don’t always know what they need to do to identify and set up services they might need. When there is no access to unbiased, person-centered options counseling, the pathway to LTSS becomes rather narrow. For decades, that pathway led straight to nursing facilities. Now the path is shifting to assisted living. That sector is seeing burgeoning demand for their services, but it is unclear if that is reflective of overall demand or just that AL is the only pathway people think they have.  Assisted living operators work hard to make their services a very visible option to individuals and their families. If people had equal access to information about the range of service options available to them, they might make different choices,

No Wrong Door systems are intended to promote access to unbiased information and resources that people need to make their own best decisions regarding LTSS.  No Wrong Door systems require investment on the part of the state and federal governments, for technology, marketing and outreach, training, and funding high quality options counseling for people, regardless of payer.  To date, it’s been very difficult to quantify the benefits of this investment because it’s hard to measure.  People like Aunt K do not show up in a lot of the data decision makers use until they are eligible for Medicaid, although the consequences for Medicaid are great, if there is no No Wrong Door system of access to help people like Aunt K.

ACL recently funded ten states for the purpose of measuring the return on investment in the establishment of No Wrong Door systems.  This is an exciting opportunity for both ACL and states to start to learn what should be measured, what systems need to be in place to capture the data related to those measures, and to validate what types of processes or interventions are most likely to lead to desired outcomes, one of which is mostly certainly delaying the need to access publicly funded services.  It might be a little late for Aunt K, but for the millions coming behind her, it might be just in time.

“We help navigate change in HCBS/LTSS by adding subject matter knowledge and experience in operations and organizational design as well as capacity to organizations (agencies, states, companies) that are implementing new programs or updating business processes.”

This is the current version of our Sage Squirrel elevator speech. After we’ve said this, we try to share our mission which is to help our clients go “beyond compliance” by focusing on operational and organizational effectiveness, creating systems that are accurate, consistent and efficient (“ACE”) for payers, providers, and recipients.  These themes carry through the experiences Debbie and I have had across government, non-profit, and business environments. This is the second in a series of blogs we are doing to elaborate a bit on our elevator speech by sharing some experiences we have had or situations we have observed.

In January of 2005, I was working in the Indiana State Personnel Department.  The incoming governor came into office with a change-driven agenda and the desire to make government work like business.  I was in a terrific position to watch and participate in some key initiatives.  One of his goals was to transform how workers were appraised and how pay raises were distributed.

Up until that point, raises were across the board and there was little that people could do to move through their pay grades.  Performance appraisals were perfunctory at best and the process was largely perceived as an exercise in documentation.  I was tasked with updating the forms that were used.  This turned into a much larger project because performance management isn’t just about the form – it is about the definition and understanding of performance and how individual performance related to overall organizational performance and how that can drive continuous improvement.

This required culture change and some agencies were more successful than others in navigating that change.  The notion of “SMART” goals was foreign to large number of managers in state government at that time, including a lot of executives.  We conducted an extensive campaign of education and communication, starting in cabinet meetings and then meeting with all agency heads and division directors.  I was stunned at the numbers of agency leaders who said that the idea of performance was irrelevant to the work that they did.  They insisted that their roles were regulatory in nature, that they were not accountable for anything but compliance.

Why do businesses do business?  Because they can make a profit doing so.  When they are unable to make an adequate profit, they adjust – they cut costs or they increase prices, or they work to increase revenue through increased sales.  That profit motivation drives ongoing innovation and a constant quest for increased efficiency and continuous improvement that is a hallmark of operational effectiveness.

Why does government do government?  There’s no way that I can reduce that to an easy answer, but I can tell you for sure there is no profit motive in government.  Government does many things that the private sector would NOT do because there’s no profit in it.  Public safety and rural postal delivery come to mind as examples where the private sector might take a pass.  Child welfare might be another one. Government does these things because they have to be done.  Government, regardless of party, has a responsibility for ensuring the safety, liberty, and some measure of well-being of citizens. It’s part of the pact with citizens in exchange for the taxes we pay.

I don’t want to paint with too broad a brush here, but I think it’s fair to say that government does not always do things as efficiently as possible. I think it’s also fair to say that government is not always good at measuring the effectiveness of what they are doing and whether or not they are actually achieving stated policy outcomes. To me, that’s unfortunate because doing these things is also a big part of the pact with citizens. I think it’s fair to expect that the government should collect no more than what is actually needed in taxes and that they should do everything possible to make sure that those monies are spent effectively and efficiently.

There is a tremendous amount of subject matter knowledge in state governments – you need that subject matter knowledge in order to craft policy that supports the above outcomes.  There is also a tremendous sense of mission in most of the public servants that I have worked with.  Most are working in the public sector because they want to contribute to a greater good in some way.  What is in shorter supply in state governments are managers that have the skills to evaluate and facilitate ongoing and rigorous improvements in efficiency and effectiveness in the operations that support those policy outcomes. (the reasons for this are probably the subject of another blog!)

What you end up with are systems and processes that are built around compliance.  These are usually systems or processes that are built within programmatic or functional silos.  They are frequently not user-friendly for external users.  They almost never support person-centered practices, nor do they facilitate going beyond compliance in service to larger objectives.

Businesses also operate in a complex regulatory environment. Most successful businesses find ways to incorporate regulatory compliance into the success of their business mission.  A simple example –food-related illnesses are terrible for restaurants.  Conducting food safety checks is one way to ensure that their food does not cause a food-related illness.  Documenting those checks is a defense against claims of food-borne sickness. But the success of the business is still measured by its ability to survive and generate profit.

Compliance is a floor. In the LTSS world in particular, compliance alone is not enough to meet the challenges of growing demand, exploding expenditures, evolving regulatory requirements and changing consumer preferences. But sometimes organizations, particularly government agencies can get tunnel vision around compliance.  Human service agencies must address organizational fragmentation, funding siloes and ineffective business processes. It doesn’t matter if you get the policy right if operations and implementation are not effective. You have to go beyond compliance.

We have a couple articles on the topic of person centered planning that may be of interest.

Person Centered Counseling and No Wrong Door

Person Centered Planning and the Settings Rule

#BeyondCompliance, #LTSSTransformation, #OperationalEffectiveness, #SageSquirrel

Assisted living is often a critical component in LTSS options. Many states funded it through Medicaid. The CMS Final Rule on HCB Settings from 2014 and the more recent GAO report have put a spot light on assisted living. We will have more on this topic in coming weeks but this piece considers the need for appropriate health and safety monitoring while maintaining a home and community based setting.

Assisted Living

#BeyondCompliance, #LTSSTransformation, #OperationalEffectiveness, #SageSquirrel