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In It Together

Our first book, Meeting the Leadership Challenge in Long-Term Care: What
You Do Matters, focuses on achieving staff stability through leadership
practices that break the “vicious cycle of instability.” We shared David
Farrell’s personal account of turning around a troubled inner-city nurs-
ing home and drew on Barbara Frank’s and Cathie Brady’s experiences
working with challenged nursing homes. We detailed leadership prac-
tices that reduce stress, build a stable staff, and create a “positive chain
of leadership.” We ended the book with strategies that build on the
momentum of achieving stability to engage staff in working together to
make improvements.
This book picks up where the first book left off by focusing on
leadership practices that bring everyone together to work in common
cause for continuous improvement. In performance-based healthcare,
it is essential for long-term care leaders to have the systems, staff, and
processes in place to provide the right care for every resident, every day.
In developing our first book, we knew that it all starts with staff—
people matter most. So we provided in-depth information about how
to take time to hire the right people, provide them a warm welcome so
they stay, and transform staff absenteeism to staff attendance. Staff sta-
bility is the prerequisite for improving performance. Every leader who
has spent the day washing windows, making beds, and running to the
kitchen for substitute resident meals knows that when you are down
staff because you have unscheduled absences and vacancies, you have
to focus on getting through the day. Thinking about improvement

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initiatives is a luxury. And yet, in the performance-based world, work-

ing on improvement initiatives is a necessity. In fact, if you work on
improvements in a way that brings staff together, you have a win-win,
because you not only address your improvement need, but you also fos-
ter a work environment where people are in it together.
People work both for a paycheck and for affiliation; people stay at
jobs where they feel they make a difference. This is especially true of
people who choose to work in long-term care. Think about your own
situation. There are many easier ways to make a living, but few are as
rewarding as long-term care. It makes your day when you feel you made
residents more comfortable, eased their pain, and brought them a smile.
The same is true for your staff. People who work in nursing homes en-
dure a lot of stress because they care about their residents, and they care
about their co-workers. When they know that their organization cares
about them, they stay, and they contribute to the best of their abilities.
In working with homes facing significant challenges, we have
come to a deeper understanding regarding the interconnectedness of
the best practices that we highlighted in the first book. And while we
didn’t use the term bundles at the time, we noticed that certain best
practices (e.g., taking time to hire right) didn’t have the same impact
on outcomes unless other best practices were also in place (e.g., having
a good welcome and good teamwork among new co-workers). As our
work continued, David focused on finding a more effective sequence
of changes to reach a tipping point faster, and Barbara and Cathie
started to group best practices together as they led quality improve-
ment collaboratives.
As we focused on the sequence of changes and the grouping of
best practices, we got better at helping nursing homes turn around more
quickly from challenging circumstances. And we saw that the way to
overcome the vicious cycle of instability was to create a work environ-
ment where staff and management are in it together. In his book Good
to Great, Jim Collins describes the flywheel effect, whereby each best
practice implemented serves as another push on the giant flywheel, until
eventually all of the pushes have a cumulative effect, and the flywheel
starts turning on its own. In our experiences, by bringing people together
to make positive changes, the cumulative effect served both to stabilize
staffing and as a springboard into continuous quality improvement.
As our first book was going to print, we were all headed back into
challenging undertakings. David took on management of another trou-
bled inner-city nursing home and again documented his experience.
A Note to our Readers  xxxvii

Barbara and Cathie worked to help stabilize staff and activate quality
improvement at 17 critical access and special focus facilities in four
states through an Advancing Excellence project led by Carol Benner
and funded by Mary Jane Koren at The Commonwealth Foundation.
This provided all of us with new opportunities to apply our methods,
and then understand and refine them.
In this book, David describes how he quickened his process of
improvement and made sure each step he took strengthened relation-
ships. He also describes having greater self-awareness about his own
impact in fostering good working relationships. He recounts the im-
pact of each change and the cumulative, mutually reinforcing effect
of the bundle of changes being implemented. As he led the critical
access nursing home that was on the verge of closing, he documented
each step along the way, noting how the changes built on each other
and how, taken collectively, the changes reached the tipping point. As
he stepped back at the end to reflect, he realized he had never before
invested so much time on communication. In this home, he had con-
tinually told staff what was going on, and he had given them avenues
to join in with their ideas and efforts. As a result, he created a sense of
community in the workplace. Everyone was in it together.
Similarly, Cathie and Barbara further refined their methods for
building communication and teamwork as they worked with the lead-
ership teams from struggling homes. The leaders started rounding and
huddling, positively checking in on people, and using an “all hands
on deck” approach to help out at the busiest times. All three practices
gave leaders a finger on the pulse as they worked as part of the team.
The practices gave them a different way to build relationships.
Leaders engaged staff in tackling absenteeism. They sought staff’s
ideas and involved them in rolling out those ideas. The ideas worked.
People started coming to work at their scheduled times. Immediately,
staff felt the relief of full attendance at work, having enough people to
do the job. Within a few months, these critical access nursing homes
were able to tackle areas of clinical improvement.

Attain or maintain the highest practicable physical, mental, and

psychosocial well-being of each resident.
—omnibus Budget Reconciliation Act of 1987

All three of us saw the impact of bringing people into the com-
mon cause of improving care for residents. We used the momentum
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of achieving staff stability to engage staff in quality improvement and

individualized care, which is at the heart of the Nursing Home Reform
Law of 1987. The law’s focus on individualized care drew on work by
practitioners who then helped establish the Pioneer Network to pro-
mote adoption of person-centered care. Through a series of issuances
over the decades since the law was passed, the Centers for Medicare
& Medicaid Services (CMS) was becoming increasingly more explicit
in requiring person-centered care. One example was a new version of
the resident assessment tool, the Minimum Data Set (MDS 3.0). It
required resident interviews to determine their customary routines and
preferences. Once nursing homes ask residents about their routines
and preferences, they have to, as the surveyor guidelines spell out, pro-
actively assist residents to maintain their routines. This refinement of the
MDS, along with other issuances by CMS, drove nursing homes to
individualize care and linked person-centered care to quality improve-
ment. We realized that to individualize care, nursing homes need a way
for staff to work consistently with the same residents to know their
routines and preferences. And these staff need easy ways to communi-
cate residents’ needs and routines to those in charge of all of the ser-
vices residents need—meals, medications, activities, and so forth. As
you’ll see in reading through his account of his experience working to
turn around a nursing home’s dire situation in 2011, David responded
by immediately starting huddles in addition to his routine of rounding
every day. The huddles gave the staff ways to check in with each other,
and for David to check in with them. Barbara and Cathie worked with
homes to create a similar communication pipeline for knowing and
honoring residents’ routines.
We knew that achieving the highest practicable well-being starts with
stability at the point of care. Our experiences working with the most
challenging nursing homes strengthened our conviction that staff’s
solid stable relationships with each other and with individual residents
established the foundation for quality. We had advocated for consistent
assignment throughout our entire careers. We realized at this point that
we were no longer just encouraging nursing homes to adopt consistent
assignment. We now knew it to be the foundational practice neces-
sary to provide high-quality individualized care. We also identified the
bundle of best practices needed to support consistent assignment.
It became clear that when consistent assignment is put in play
along with all of the supports needed for it to succeed, the approach
does succeed. The crux of the matter is using what consistently assigned
A Note to our Readers  xxxix

staff know. When the organization depends on and regularly benefits

from the deep knowledge a consistently assigned certified nursing
assistant (CNA) has about a resident, then the organization will do
everything to preserve that most essential relationship. The way to tap
into that deep knowledge is through regular, timely communication—
huddles—to engage staff who know that particular resident best in de-
termining the most effective course of action. While everyone wants
good teamwork and communication, the staff needs venues for that
teamwork and communication to happen—regular ways to come to-
gether to share information about what they know about the residents
and to plan together for what is needed.
This is the core concept of relational coordination, Jody Hoffer
Gittell’s theory for high performance in healthcare: frequent, timely,
problem-solving communication among staff closest to the residents is
the key to good outcomes. No wonder our work aligned. Gittell’s first
work in healthcare was as part of a team with our friend and colleague
Susan Eaton. Eaton’s research study “What a difference management
makes!” was foundational to our field and also aligned with our work.
Eaton found a bundle of management practices that contributed to
staff stability. She asserted that if you want staff to stay, you have to
value your staff and design work systems that reflect their value. She
identified consistent assignments as a key system, since relationships
are key to quality. Consistent assignments build deep, caring staff rela-
tionships with residents and solid teams with each other. We partnered
with Gittell and Eaton in “Better Jobs Better Care,” a Robert Wood
Johnson Foundation study that Gittell completed after Eaton’s death.
Their study documented how nursing homes had better outcomes
for residents and staff when they had effective everyday systems for
staff to share what they knew and to problem solve together. Huddles
were the complementary practice that made consistent assignment
more effective.
We had long been adherents of huddles. David practiced “patient
safety huddles” where he brought a whiteboard to the staff and asked for
a root-cause analysis about unnecessary rehospitalizations on the unit.
Barbara and Cathie had seen the effectiveness of huddles at a nursing
home in Maine where administrator Connie McDonald used huddles
at the start and end of each shift, as well as at mid-shift, so that staff had
timely ways to check in. Consistently assigned CNAs led the huddle,
taking charge of the reporting on and problem-solving for the well-
being of each of their residents. We saw how the CNAs were turned
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to for what they knew about each resident; their timely and accurate
information was the building block for meeting each resident’s highest
practicable well-being. This bundle of communication practices would
be necessary for the MDS 3.0 to go from asking about residents’ pref-
erences to honoring them. These systems together—consistent assign-
ment, huddles, quality improvement closest to the resident, and CNA
involvement in care planning—gave nursing homes an infrastructure:
a communication pipeline linking staff closest to the resident with all
other staff whose work shaped how well residents’ individualized needs
were met.
In healthcare, you cannot do it alone. High-quality, individual-
ized care requires teamwork. If a resident wants to sleep in and have a
later breakfast, this has to be coordinated among nursing, housekeep-
ing, food services, and other staff. Barbara and Cathie trialed a bundle
of high-involvement approaches to individualizing care through learn-
ing collaboratives in South Bend, Indiana, with the Community Foun-
dation of St. Joseph’s County, and in New York City in partnership
with 1199SEIU Continuing Care Leadership Coalition led by Janice
Dabney and Jay Sackman. In both groups, teams came together to trial
a bundle of best practices that engaged staff in individualizing care.
Several of the participating homes involved CNAs right away in learn-
ing about residents’ customary routines, and they developed systems
to share the information with the rest of the care team. In many par-
ticipating homes, satisfaction scores went up, complaints went down,
and fewer new residents returned to the hospital. Homes in the pilots
in South Bend and New York City saw benefits for residents as the
homes nimbly met their needs. The homes also saw benefits for staff,
who felt their value as they contributed to individualizing care. They
recognized the value of a bundle of practices to solidify relationships
with residents so their nursing homes could deliver individualized care.

We’re always there for them. But now they can count on it.
—Liz Bomkamp, Assistant Administrator at Holy Cross Village, South Bend, indiana

The Holy Cross Village leadership team decided to take their

morning stand-up meeting out to the staff. They called it Everyone
Stands Up Together, and twice a week they huddled in the morning
with staff on each unit. Everyone was there who could address an issue
immediately. When staff talked about a new resident who was tall and
A Note to our Readers  xli

didn’t fit in his bed, the administrator and director of maintenance

could immediately change out the bed. When the dietician wanted
to review residents with undesired weight loss, she could use the hud-
dles to ask staff what they noticed, and together they could create a
game plan.
The Indiana stakeholder organizations, coordinated by Qual-
ity Improvement Organization staff Kathy Hybarger and Connie
Steigmeyer, partnered to support these sessions. When they then
brought the learning collaborative to Indianapolis, they invited this
home’s administrator to share Everyone Stands Up Together. An in-
state corporation with several homes participating in the Indianapo-
lis collaborative made it a company-wide practice for management to
huddle with the staff in the morning. They called it the Gemba Walk,
after the Japanese performance improvement term, meaning “going to
the real place.” One home added a whiteboard so that the whole team
could keep a “watch list” of people who were of concern. They started
with a whiteboard in the conference room. Then they put one in a pri-
vate area by each nursing station. Another home built its quality im-
provement system on these daily huddles with staff, because everyone
was present for all of the conversations needed. Administrators talked
about how the morning’s huddling process saved them time because
they caught problems early. They used the huddles as follow-ups to
confirm that new interventions had been implemented and were work-
ing. Directors of nursing talked about how the huddles took them half
the time to get twice as much done. They were “able to validate” that
a plan of care was working and “not just something we dreamed up in
the conference room.”
This process of management huddles with staff created timely, ac-
curate, problem-solving communication that allowed the organization
to respond quickly and effectively at the earliest stages of a problem.
It engineered teamwork into daily practice by having everyone start
the day together, on the same page, sharing what information needed
to be shared so that everyone could go about the day contributing to a
common purpose. Staff could count on leaders being there. This is very
different from an “open door policy” for staff to come in to voice con-
cerns, which in reality rarely works, because it requires staff to leave
their post to see the administrator. This only happens when things
have gotten so bad that staff are compelled to take this kind of ac-
tion. By then, a small issue has become a big problem. When everyone
stands up together via the regular huddles, staff know that the leaders
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will come to them. Staff can tell leaders what they need them to know
so that problems can be fixed at the earliest stages. The process opens
up the lines of communication and makes everyone a part of what is
going on. It improves morale, cohesiveness, and performance.
At the same time, David was committing himself to consistent
leadership practices that fostered communication and relationships
with staff—through rounding, community meetings, and notes to staff.
He focused on building staff’s relationships with each other and on
hiring people for their relational skills. David put in work structures
to support relationships, like a schedule that was predictable and that
the staff could count on. Staff knew David was counting on them, and
knew they could count on him. He paid attention to relational coordi-
nation, and the whole team reaped the benefits.

I always thought you could start anywhere. Now I realize you have to start
with consistent assignment and huddles as a package. And then you can
go anywhere, because with this system in place, you can do anything.
—Joan devine, Pioneer Network Learning Collaborative Local Convenor

The Pioneer Network realized that MDS 3.0’s focus on resident in-
terviews about customary routines provided an opportunity to advance
its call for culture change to individualized care. Through funding from
the Retirement Research Foundation, the Pioneer Network convened
a learning collaborative to test our bundle of communication practices
to engage staff in individualizing care. Homes were asked to achieve a
quality goal by implementing a bundle of four key practices:
• Consistent assignment
• Shift huddles
• Quality improvement closest to the resident
• Involving consistently assigned CNAs in care plan meetings
In a virtual collaborative coordinated by Cathy Lieblich, Barbara and
Cathie worked with four nursing home corporations and five culture
change coalitions that led 49 nursing homes through a one-year pro-
cess. Homes first put in place or strengthened their consistent assign-
ments and huddles, and then used those systems to tackle a care area
needing improvement. The homes ranged from 1 to 5 stars. As they
strengthened their consistent assignments and huddles, their clinical
A Note to our Readers  xliii

and human resource outcomes improved. Homes reduced hospitaliza-

tions, lowered their fall rate while eliminating the use of alarms, and
eliminated off-label antipsychotics at a faster rate than homes in the
rest of the country.
Researchers Amy Elliot and Sonya Barsness evaluated the process
for the Pioneer Network and documented the impact of the bundle
of best practices on the ability of homes to deliver high-quality, indi-
vidualized care. Homes reported a faster rate of change with a higher
success rate, as well as the additional benefit of staff becoming more
critical thinkers and working better together. Lynda Crandall, Pioneer
Network’s interim Executive Director, also served as guide to the pilot
homes in Oregon. An administrator at one of her pilot homes reported
that in all the years of working on performance improvement, this had
been the quickest and most effective process, because the home had
put the communication infrastructure in place, using the whole bundle
of practices.
Pioneer decided to dig deeper to learn about the pilot homes’
experience. In a second year of evaluation that was funded by the
Retirement Research Foundation to harvest the knowledge gained,
researchers Elliot and Barsness mapped the communication process
with and without the bundle of all four practices in place. The results
demonstrated the impact on quality of care and on nursing home time
and resources. Pilot homes that used the whole bundle of practices
reported quicker and more effective improvement. Putting the bundle
in place allowed homes to take on any area of clinical improvement
and succeed. These systems allowed for direct communication from
the staff, who knew residents well, to the clinical team so that together
they could determine and implement an effective course of action.

The River Moved

Many forces are now driving nursing homes toward quality improve-
ment and individualized care, including the introduction of Quality
Assurance and Performance Improvement (QAPI), new long-term
care facility Requirements of Participation (ROP), the Partnership to
Improve Dementia Care and eliminate off-label use of antipsychotic
medications, and performance-based reimbursement with penalties
for avoidable hospitalizations and other adverse events. All of these
point in the same direction—know the resident well, catch residents’
problems early, and intervene individually and effectively. All of these
xliv  A Note to our Readers

initiatives and requirements make an infrastructure for communication

Don Berwick, M.D., one of the chief architects of this change
while serving as administrator for CMS, tells the story of a bridge
built in Honduras in the 1930s, an engineering feat in its time. The
bridge was so solid that it withstood a hurricane 60 years later that
devastated the entire area. He then shows a recent picture with the
bridge. While it still stands, it is of no use. It spans dry land, because
the river has moved. The old bridge no longer served its purpose. Like
the river, he says, our healthcare system has changed course. The old
model of payment based on volume is going away. The new model
pays for value. Berwick says we need a new bridge to serve twenty-
first century healthcare—a nimble, collaborative environment where
all providers of care communicate and coordinate on behalf of their
mutual patient.
While Berwick headed CMS, the agency established the Nursing
Home Convergence Group to coordinate this transformational effort.
The group included leads from divisions responsible for reimbursement,
survey, rule making, innovation, research, and quality improvement.
They asked us to share our experiences improving performance in
troubled homes. They wanted us to focus on how to stop the yo-yo
effect that typically occurs after serious action is taken against a low-
performing home: the home comes back into compliance for resurvey,
but does not stay in compliance. Their improvement rarely holds. We
explained that unsustainable add-ons achieve temporary improvement
only for as long as the add-ons are in place. We described how corpo-
rate experts rush in and swamp a building with new policies and proce-
dures and forms and audits. Everything is in a whirlwind until after the
home passes survey. When corporate staff leave, everything goes back
to normal, only now, there are more forms and processes to follow. The
corporate staff didn’t get to the systems and communication issues that
prevented staff from following the previous forms and processes in the
first place. Nothing changes in the way people work together, so in the
long run improvements are not sustained.
We shared our way of using a bundle of best practices to con-
nect people, so that they work together to improve care. New forms
never make up for poor communication among staff. Systems for con-
tinuous communication and collaborative problem solving sustain im-
provement. They are the communication infrastructure for staff, who
know their residents well, to identify the earliest warning signs that
A Note to our Readers  xlv

something is amiss and to work together to address any problem expe-

ditiously and effectively.

The Infrastructure for Improvement

David used the bundle of communication practices to implement
inTerACT® (Interventions to Reduce Acute Care Transfers), a qual-
ity improvement system developed by Dr. Joseph Ouslander to prevent
unnecessary rehospitalizations. It focuses the organization on the early
identification, assessment, and documentation of and communication
about changes in a resident’s status. One component of INTERACT
that depends on these communication practices is Stop and Watch, a
tool for CNAs to identify early warning signs of an underlying condition
needing treatment. As David discovered, the barriers to implementation
of Stop and Watch had to do with ways that CNAs and nurses worked
together and communicated with each other and the rest of the depart-
ments. He noted that for Stop and Watch to be effective and catch
symptoms early, the bundle of best practices had to serve as the infra-
structure. CNAs and nurses had to be consistently assigned so they knew
the residents well. Teams had to huddle to share what was happening.
His leaders needed to round to find out what staff needed to tell them.
Barbara and Cathie also worked with homes through projects to
reduce hospitalizations using the communication bundle tied together
with the staff stability bundle. As homes worked to reduce hospitaliza-
tions, they were faced with staff instability driven by the tight labor
market. Homes that succeeded in reducing hospitalizations first put
practices in place to achieve staff stability and then relied on what staff
knew, through regular communication. Here, again, was the critical
connection between staff stability and clinical improvement.
Cathie and Barbara also learned from collaboration with
Louisiana’s Partnership to Improve Dementia Care, in a project led
by Barbara Anthony, RN, LNC, Project Coordinator for LEADER
(Louisiana’s Culture Change Coalition). Together, we worked to help
five homes that were among the highest users of off-label antipsy-
chotic medications in the state. By implementing the bundle of high-
involvement change practices, the homes were able to learn what was
triggering residents’ distress and to adjust their care to ease that dis-
tress. They then saw that the medications weren’t needed.
David also applied the bundle of communication practices to re-
ducing antipsychotic medications. He provided consultation to special
xlvi  A Note to our Readers

focus facilities that were serving residents with both physical health
issues as well as serious mental health issues. In these nursing homes,
he was struck by the sense of resignation among both the leadership
and the staff regarding their ability to make a difference. Resident-on-
resident assaults as well as falls and weight loss among residents were
seen as inevitable in the population the facilities served. When he first
started working with these homes, he found that, for them, the root
causes were always related to a resident’s diagnosis rather than to a
systems issue. As a result, they never took on the heavy lift of building
the organizational infrastructure designed to prevent the root causes of
problems. When two residents got into a fight waiting in line to take
care of banking needs, the staff identified their diagnosis of schizophre-
nia as the cause and medication as the solution. Instead, David guided
them to look at the conditions that caused the fight—a tense, crowded
line on a hot patio right before lunch. To prevent the next fight, they
needed to address the banking hours, the line, the timing, and the lo-
cation. To take all of that on and create the organizational capacity to
prevent the next fight on banking day, they needed high engagement
from staff in the process to figure out with them what changes needed
to be made. But they had not built a foundation for engagement, and
so instead they floundered and blamed the residents involved. David
helped them build that foundation by implementing the bundle of best
practices for better staff communication and problem solving. David
discovered the power of implementing all of the practices together and
watched how well they work as a bundle of changes. The communica-
tion systems he used created the conditions for staff to prevent such
incidents from recurring.

Doing Better Together

Lynn Snow and Christine (Tine) Hartmann received a grant from the
Veterans Administration’s Office of Cultural Transformation to apply
and document our high-involvement change method at the Tuscaloosa
VA Medical Center. Working with Chuck Gils, Associate Chief Nurse,
and with nurse managers in their Community Living Center, Barbara
and Cathie met with staff to hear what was working well and what
needed improvement. They focused in on an area for staff to work
on together that would benefit veterans and reduce staff stress. Each
neighborhood identified its stressors. Through short huddles, just-in-
time teaching, and rounding, leaders invited staff to identify what
A Note to our Readers  xlvii

made it stressful, contribute their ideas to do something different, trial

these interventions, and share successes. A year later, all staff surveys
showed improved morale and better teamwork. Through their research
role, Lynn and Tine helped us delineate the steps in the process. They
found the short huddles and regular problem-solving communication
to be the breakthrough process, the key to success. The bundle pro-
vided the infrastructure, and, because staff had regular, timely ways to
share and receive accurate information and problem solve together,
their performance, and their morale, improved.

We’re All Works in Progress

In their book The Leadership Challenge, James Kouzes and Barry Posner
assert that leadership is a discernible set of skills and practices that
can be learned and improved with practice. So we were thrilled to be
invited to serve as faculty for the Nursing Home Leaders Academy of
Excellence, a partnership of the California Association of Health Fa-
cilities and the American Health Care Association created by Jocelyn
Montgomery. Jocelyn recognized that most leadership programs focus
on the topic of the day or the next challenge on the horizon. She asked
that we, instead, build an enduring leadership academy curriculum
around the bundle of leadership skills and practices that could be ap-
plied to whatever was the topic of the day. The curriculum teaches
leaders how to use the bundle of interventions to generate staff en-
gagement by involving staff, both in the day-to-day as well as in im-
provement initiatives. Participants reported the power of the energy
unleashed when they invited staff to join in improving performance.
Staff had information the leaders would not otherwise have known,
about what was occurring, why, and what could be done about it. Fur-
thermore, once staff realized that their input was sincerely sought and
consistently used, they willingly joined teams to work to achieve their
aims. Mary Jane Carothers brought this concept to her Iowa Health
Care Association members, and they, too, discovered that the bundle
of practices for high engagement was key to their success.

The key to winning is not putting the five best players on the court at the
same time. The key to winning is putting the five players on the court
who play together best.
—Red Auerbach, Boston Celtics coach
xlviii  A Note to our Readers

Coach Auerbach’s formula for success was to look for people who
played well together. Our formula for success is to create the working
conditions that make working well together the norm. When we do,
people perform at the top of their abilities. We’ve seen this in play.
After Hurricane Katrina, when nursing home staff talked about what
got them through it, they pointed to teamwork, everyone in it together,
titles thrown out the window—we were side by side helping each other survive.
This book draws on all of these many experiences and shares sto-
ries of incredible leadership. It describes how bundles of practices make
a difference, and how putting all of the practices in play makes the
most difference. We’ve learned so much since our first book, and we
want to share what we have learned with you because we know how
much you want to do right by your residents, your staff, and your orga-
nization. This book is our thank you to all you of who put your hearts
and souls on the line every day in your jobs caring for nursing home
residents. We deeply appreciate how hard you work, how much is on
your shoulders, and how committed you are to getting it right for every
resident, every day.

What you do really does matter. Nursing homes have to get care right
for each resident every day. Your organization’s performance—and
survival—depend on your ability to do so. When you create the systems
for your staff to work well together, they will. When they work well to-
gether, your performance improves, and you provide consistently good
care. Continuously improving your organization’s performance so you
provide consistently good care requires a bundle of leadership practices
that engage your staff in Doing Better Together. These mutually rein-
forcing practices, taken as a whole, develop your people, strengthen
your systems, and use a high-involvement change process. Care for
your staff and they will care for your residents. Involve staff in shaping
improvements, and your residents and your organization will thrive.
This book provides a roadmap for Doing Better Together. The
book’s three interwoven sections, when applied cohesively, provide a
way to lead that creates the conditions for staff to perform at their best:

Part I—People: Bundle of Leadership Practices for Bringing Out the

Best in People

Part II—Systems: Bundle of Leadership Practices for Systems to Maxi-

mize Teamwork

Part III—Processes: Bundle of Leadership Practices for High-Involvement

Processes to Do Better Together
This book draws on the concept of bundles to help leaders more reliably
deliver the care that allows each of their residents to achieve their high-
est practicable well-being. The Institute for Healthcare Improvement
(IHI) developed the concept of bundles. They define a bundle as “a
structured way of improving the processes of care and patient outcomes;
a small, straightforward set of evidence-based practices—generally
l  introduction

three to five—that, when performed collectively and reliably, have been

proven to improve patient outcomes.” IHI stresses that the power of a
bundle comes from the consistency of execution of all of its elements.
In this book, we apply the bundle concept to highlight the
necessity of implementing key organizational changes together. Through
direct experience, we have learned about the complex organizational
dynamics that play out in nursing homes and the mutually reinforc-
ing aspects of changes when they are implemented together. Nursing
homes are fragile ecosystems that are highly responsive to the power of
the bundles of changes highlighted in the book’s three sections.
The specific best practices in the bundles are not new; they are
well-established best practices in our field. However, they are often
not executed together, as a package. Each bundle comprises a set of
practices that are all necessary and that mutually reinforce each other.
They are all coherent parts of a way of doing things. The synergy of
these practices working together makes their total impact, when taken
together, far greater than the sum of their parts. A leader who executes
only four out of five of the best practices within a bundle would not
achieve as good results as another leader who implemented all five. In
this book, we describe how a leader can use these bundles to create the
organizational conditions to deliver the best care.
At the core of these bundles is a system for communication among
staff working most directly with residents, and between those staff
and the rest of your organization. The communication system powers
high performance, as Jody Hoffer Gittell describes in her foreword on
relational coordination. Amy Elliot describes in “X Marks the Spot”
how the relational coordination practices work better when employed
together, and work best when implemented with the bundles of sys-
tems and high-involvement leadership.
“My job is to create the right conditions so that the staff perform at
their very best,” David writes of his epiphany moment in his personal
account, “Shock and Awe,” which opens this book. David describes
his journey to high performance at a struggling nursing home. He ac-
knowledges his initial extreme discouragement at the depth of neglect
he encountered. It seems that previous leaders sent a clear signal that
“no one cares and no one is watching.” From graffiti to rodents to illegi-
ble forms to inconsistent schedules, the home was in complete disarray.
Swiftly and steadily he brings staff together. He tells staff their survival
depends on their joining together to turn around their performance across a
broad base of measures—human resource, clinical, and financial. Through
introduction  li

community meetings, notes to staff, quick huddles, and regular rounding,

he engages with staff every step of the way, as they pull together and make
gains. David shares every change they made together to turn around their
performance and how each change built on and reinforced the others. He
also illustrates the interconnectedness of each change and which bundles
of best practices come first. David ends his personal account with his reflec-
tions on his experience and what he learned about leadership and about
the importance of stepping up his systematic communication efforts.
Building on David’s account, the book has three sections—
People, Systems, and Process. The bundles of practices in each section
are mutually reinforcing. People perform better when they have sys-
tems for regular communication and teamwork and high involvement
in change processes. These systems work better when organizations
have staff stability and when leaders continuously invest in their staff’s
development. And, since these systems are mutually reinforcing and
interdependent, organizations that involve staff, keep staff. When staff
perform better, your organization performs better.
Part I, People, opens with Chapter 1, “High-Performance Leader-
ship,” which makes the business case that these leadership practices are
needed as nursing home regulatory and payment systems increasingly
require high-quality outcomes. How do leaders trigger staff to perform
at the top of their licenses and abilities? What bundles of practices
create the right conditions for staff to step up? The chapter draws on
research and practice to describe why and how high-performing lead-
ers maintain a consistent presence and foster relationships among staff
to motivate everyone to join together. It describes the steps to move
from Eaton’s vicious cycle of instability to a positive cycle of continuous
improvement, by fostering relational coordination among staff. The
chapter explains how to use rounding, huddles, notes, and community
meetings to keep staff informed and build positive working relation-
ships among staff. Whether you are starting from a challenging place or
already well on your way to high performance, this bundle of practices
will help your team move your organization continuously forward.
Chapter 2, “Staff Stability: Why and How,” details a bundle of
proven best practices that can be used to create a stable workplace.
Your ability to improve your organization’s performance depends
on staff stability and staff stability hinges on staff engagement. The
practices in this bundle work well to attract, engage, and keep high-
performing staff, especially in times of low unemployment when the
labor market is highly competitive. The chapter’s first section discusses
lii  introduction

the steps to break the vicious cycle of instability and provides examples
from troubled nursing homes that used staff engagement to set them-
selves on a positive path. The second section describes how to recruit
and hire great staff and how help them succeed in your workplace. In
our first book, Meeting the Leadership Challenge in Long-Term Care, we
provide detailed information on how to (1) take the time to hire right,
(2) ensure a good welcome, and (3) move from absenteeism to atten-
dance. In Chapter 2 for this book, we add new information on how to
attract and keep “Triple Crown winners,” those who have the friendli-
ness, skills, and dependability to add value to your team. We describe
how to build a team composed of full-time staff who deeply know the
residents and each other. The bundle of best practices described here
has far less impact when only one or two of the practices are adopted.
The efficacy of the bundle lies in implementing all of the best practices
together. The last section in Chapter 2 explains the socioeconomic and
organizational factors that affect the way staff relate to each other and
what you can do to build good working relationships. It draws from two
sources, a study of Kansas nursing homes and the work of an organiza-
tion called aha! Process and their book, Bridges Out of Poverty. Both
describe the impact of a lifetime of extreme poverty on people in the
workplace. aha! Process explains the gap between workplace assump-
tions of middle class stability and the reality for staff living in severe
economic vulnerability. The Kansas study identified how the ways in
which staff related to each other were affected by differences between
those experiencing extreme economic disadvantage and those with
more secure economic circumstances. The Kansas researchers observed
ways that organizational practices reinforced this gap, and how the gap
strained interpersonal relationships between CNAs and nurses. Chap-
ter 2 offers specific ways to overcome these challenges so that everyone
knows how their contribution matters. It describes how to provide the
regular presence that builds trust with staff and values what they know
about the residents. Staff stability requires use of a bundle of human re-
source practices that builds staff connection to each other and creates
a mutual commitment between staff and you as their leaders.
Chapter 3, “High-Involvement Leadership: Why and How,” ex-
plains that “when you involve staff, they will be engaged.” Staff have what
Susan Eaton called an intrinsic motivation to provide good care. They
chose caregiving work because they want to care for others. They want
to make a difference. They come to work ready to engage. When leaders
provide staff with information, develop their skills, seek their insights,
introduction  liii

and empower them to act, staff own the quality of their care. Under
these conditions, the staff step up quickly and effectively to address res-
idents’ needs and eagerly join efforts to improve. Effective leaders are
people developers. This chapter describes how to maximize staff’s en-
gagement through a bundle of leadership practices that develop staff’s
critical thinking skills and trigger and support staff to work collabora-
tively to meet residents’ needs. The chapter provides tips for creating a
true team by using the bundle of leadership practices that bring staff to-
gether to focus on shared goals, shared knowledge, and mutual respect.
Part II, Systems, provides leaders with an organizational road-
map for the bundle of changes to tap into staff’s intrinsic motivation
to provide good care. Your systems create your outcomes. Part II builds
on this key principle from W. Edward Deming, a key figure in quality
improvement. Deming’s principles focus on using systems to engage
staff who are closest to the customer and as such have the most timely,
accurate information about what is working and how to improve upon
what isn’t. Deming recognized that we can improve our organizational
systems only by improving the relationships among staff involved in
those systems. Jody Hoffer Gittell took this concept a step further in
developing the theory of relational coordination based on her research
findings that when healthcare leaders systematically support staff to
have frequent, timely ways to share their knowledge and problem solve
together, outcomes are better for residents, staff, and organizations.
Our policies and procedures assume high staff engagement and
that everyone is working well together. But, in truth, every leader has to
work for high staff engagement every day. This is easier said than done;
although your staff hungers to contribute, daily practices can uninten-
tionally work against the practice of high staff involvement. Part II
describes a bundle of key organizational systems that engineer team-
work into daily practice. These systems start with stability at the point
of care and then provide a means for consistent staff to communicate
their timely information to shape quality care planning. Clearly, having
staff’s timely, accurate information and involvement in problem solving
is essential for good outcomes. This bundle of practices for relational
coordination is more effective as a whole, and most effective when the
bundle of people practices described in Part I is also deployed. When
staff are continually supported to perform at their best, they can take
the greatest advantage of the systems for communication and teamwork.
The Pioneer Network facilitated a learning collaborative in which
49 nursing homes improved staff engagement by using the systems bundle
liv  introduction

of best practices. As Amy Elliot describes in “X Marks the Spot,” homes

that implemented the whole bundle of practices had the greatest positive
effect. Part II draws significantly on the lessons learned from the Pioneer
Network homes and provides leaders with an organizational roadmap for
the bundle of changes designed to tap into staff’s intrinsic motivation to
provide good care and contribute to organizational goals.
Chapter 4, “Relationships Closest to the Resident Matter Most,”
describes how to create stable, cohesive relationships between staff and
residents as well as among staff. The first part of the chapter describes
how to implement consistent assignment, which is no longer optional;
it is now a necessity for good outcomes. When staff care for the same
residents every day, they come to care about the residents. “What better
way for giving good care than caring about the people you care for,” said Con-
nie McDonald when she was administrator at Glenridge Living Com-
munities in Augusta, Maine. Clinical quality care and resident quality
of life is driven by the staff knowing residents so well that they recog-
nize the early warning signs that something is amiss with a resident,
and they know just what is needed to address it. Having the same co-
workers working together creates the conditions for teamwork. When
people work well together, residents and the organization feel the ben-
efits. Remember that the bundles of practices are mutually reinforcing.
Consistent assignment also helps to stabilize the workplace by creating
a predictable schedule and daily work routines that staff can count on,
and the teamwork that makes for a good workplace. Consistent assign-
ment as a lone best practice, however, is not very effective unless it is
supported by the best practice of huddles, which use what staff know and
promote teamwork through everyday sharing of information and prob-
lem solving. When organizations use huddles to tap into staff’s deep
knowledge of residents, consistent assignment thrives because staff’s
knowledge of residents is valued and supported. When organizations do
not have a way to value what staff know, consistent assignment is not
as effective because the benefits of consistent assignment are not tapped
into. The second part of Chapter 4 describes how to use huddles to sup-
port staff working consistently together. Holding daily huddles on each
shift engineers teamwork and communication into daily practice. The
chapter explains the importance of making these huddles two-way, and
how to use good facilitation to support staff in using the time together
effectively. Elliot’s communication map is used to depict the benefits of
this information flow from staff closest to the residents to the rest of the
care team, as covered in Chapters 5 and 6.
introduction  lv

Chapter 5, “Quality Improvement Closest to the Resident,” describes

ways to use rounds and huddles to involve staff in ongoing quality over-
sight and in Quality Assurance & Performance Improvement (QAPI)
efforts. Creating a pipeline for daily communication between staff closest
to the residents and the rest of your organization provides the infrastruc-
ture to make quick adjustments to meet residents’ needs. Your ability to
prevent avoidable adverse events, such as hospitalizations, depends on
how quickly staff recognize the need for intervention and how quickly
and effectively your organization responds to that need. Through just-in-
time teaching, the bundles of people development and high-involvement
change come together in quality improvement closest to the resident.
Chapter 6, “Care Planning for the Highest Practicable Well-Being,”
challenges organizations to reinvigorate the care plan meeting so that it
steers you to deliver person-centered, preventive care. It provides his-
torical background on the aims of care planning and how effective care
planning is now essential in meeting performance-based goals in reim-
bursement and regulation. So many care plan meetings are rote check-
offs with computer-generated copycat care plans. To be person-centered
and preventive, care plan meetings need to pair staff’s deep knowledge
of residents with the clinical expertise of the whole team. Chapter 6 also
explains how to involve consistently assigned certified nursing assistants
(CNAs) in care plan meetings. Doing so brings these meetings to life and
gives families and residents the comfort that comes from hearing from
staff who know the resident intimately. Their knowledge is forged by the
other best practices—consistent assignment and huddles—contained
within the systems bundle. When CNAs regularly huddle together to
share and problem solve, they become attuned to what information the
rest of the care team needs to know, and can contribute more effectively
in care plan meetings. Pioneer Network homes found that they often
made adjustments to the care plan right after a huddle because CNAs’
observations and adjustments to care were so on point. Again, the bun-
dle of systems practices work best when implemented together. Without
each element, the others are less effective. Implementing and sustaining
this bundle of best practices is complex and requires daily focus and effort
on the part of leaders. But the benefits are clear. When you involve staff,
they will perform at the top of their abilities and your organization will
thrive. When everyone works well together, everyone feels the differ-
ence. Residents and families feel it, and their appreciation for staff fulfills
and fuels your staff. It is clear that when everyone works together, staff
look forward to coming to work and arrive ready to do their best. This
lvi  introduction

bundle of systems practices for staff engagement will transform staff’s per-
ception from “what you do matters” to “what we do matters.”
The chapters in Part III, Processes, detail a high-involvement
change process that continually grows your organization’s capacity to
improve. Chapter 7, “Doing Better Together,” describes the elements
that constitute the change process, and how Doing Better Together
changes how change happens. Doing Better Together uses people de-
velopment and communication systems to invite staff into continual
problem solving and improvement. The day-to-day problem solving can
then be tapped into for continuous improvement efforts. Doing Better
Together starts improvement efforts by asking staff closest to the resi-
dent about their experiences in relation to the area needing attention.
Leaders find out what’s working and what’s in the way. They find a small
low-burden, high-benefit place to start to trial a new approach. Staff use
trial and error and check in frequently to share observations and make
adjustments. Leaders round to check in on how changes are going and
what staff need from them. As staff have each success, they expand to
another resident, another situation, another innovation. This iterative
process continually grows staff’s skills and the organization’s systems, so
that staff are able to take on increasingly complex changes.
Chapter 8, “A Doing Better Together Story: Finger Foods,” provides
a story of the change process in action. It illustrates how this method of
implementing bundles of best practices was put into action and describes
how the bundles accelerate sustained improvement. The story describes
an organization’s efforts to reduce the use of antipsychotic medications.
First, leaders engaged staff in identifying the causes of residents’ distress.
Staff described challenges at mealtime. Together, they trialed interven-
tions as they changed mealtimes at their home. Staff became more in-
novative in looking for individualized solutions at mealtimes for residents
with dementia. As the team changed the meal experience, they hud-
dled to adapt in real time. The leadership team supported staff to make
changes. The team expanded their innovations, making changes in night-
time and morning care that reduced residents’ distress and helped staff
reduce the medications given to residents. In Doing Better Together, staff
continually learn from what works and then build on that knowledge.
Staff’s ability to succeed depends on the concurrent bundles for people
development (Part I) and communication systems (Part II). In Chapter
8, the bundles of changes for Doing Better Together are mutually rein-
forcing, and each adopted practice supports the next. Using a high staff
involvement approach to organizational change engages everyone. It’s a
introduction  lvii

win-win: it improves the area being focused on; it improves staff team-
work; and the process values staff. When staff know how valued they
are, their morale and performance improve in the process. Staff who are
valued contribute eagerly. Staff stay, because they know they matter.

Downloadable Resources:
Four How-Tos and a Self-Assessment
The downloadable resources for this book apply high-involvement
approaches through how-to guides for successful change:
• Three Steps to Transforming the Medication Pass: Individualizing
Care and Managing Workflow
• Rethinking the Use of Position-Change Alarms
• Eliminating Off-Label Use of Antipsychotics: A 10-Step Guide
for Nursing Homes
• MUSIC & MEMORYsm: Implementation Steps to Maximize
Benefits: A Nursing Home Leader’s Guide
The downloadable resources also include a self-assessment of your
organization’s communication infrastructure.
These are all high-benefit, win-win changes, because they help
residents and staff. Changing your med pass will free up your nurses to
spend more time as leaders. Rethinking alarms and eliminating off-label
antipsychotics by knowing residents and individualizing care will help
you prevent deconditioning and improve resident physical and psycho-
social well-being. Implementing MUSIC & MEMORYsm will bring you
joy! Each of these changes is an opportunity for high involvement that
has lasting benefits for staff stability, engagement, and performance.

The bundles of best practices we describe in this book don’t take more time;
they actually save time. When leaders conscientiously use their time dif-
ferently, getting out of their office, asking staff what they think, delivering
on what staff need, leaders become “preventionists.” With these practices,
leaders invite the whole team to be part of preventing problems or catching
them early enough to address them while they are still manageable. In the
end, doing so saves time and improves care outcomes. It brings everyone
together in common cause. Doing Better Together is a win for everyone.

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