Leadership is more than giving orders

Nursing Homes, April, 2004 by Paul R. Willging

Last month ("'Culture' Is More Than Just Beethoven," March 2004, p. 18), I wrote about the essential characteristics of the culture that propels a successful long-term care community and how to go about developing and sustaining it. This month, I discuss how staff (and, through staff, a community's residents) can best be induced to buy into the community's prevailing culture. How can staff be made to feel a part of that culture, ifnot, in fact, responsible for it? How do they become an essential part of the team creating that culture? And, finally, who makes it happen?

The need for real teamwork in long-term care stems from a number offactors. Perhaps the most important is the very nature of the customer to whom we're providing services. The typical resident in a seniors housing and care community can present with any number of disparate issues; handling those issues in uncoordinated fashion risks engaging in poor communication and inadequate care. Social concerns must be handled, medical services need to be delivered, and psychological concerns must be integrated into the comprehensive service package--not to mention dining, transportation, family involvement, etc., etc. The successful community will make sure that all a resident's issues are dealt with both collaboratively and holistically, and services are delivered in an inter- and multidisciplinary fashion.

This is where teams and team leaders come in. Addressing customer satisfaction with empowered staff teams is a hallmark of quality management. Equally, it reflects that companies have embraced culture change as a critical force driving quality, and by inference value, as perceived by the customer.

Different companies approach teambuilding for quality improvement from different perspectives. Some replicate the quality improvement team from the existing management team. The advantage to this is a reduction in meeting frequency and a decreased imposition on staff time. The disadvantage is that it won't--and can't--bring employees who would not normally participate in management team meetings into the loop. Those left out are typically frontline staff, who can be the most valuable resource in constructing quality improvement strategies.

While a combination approach can work (i.e., management team meetings supplemented by teams at other organizational levels), care must be taken that we don't create the impression of a two-tiered system, where the "lower-level" teams are looked upon as mere window dressing, leaving all major deliberations in the capable hands of senior management. The purpose of the quality improvement team is twofold: the obvious initial goal of improved outcomes and customer satisfaction and development of a process that, when conducted correctly, will itself improve corporate culture.

Remember the value formula--what customers value in a culture rests on the twin concepts of quality and price. Improving quality helps improve perceived value--that is, the customer will notice and evaluate improved knowledge, skills, and attitude displayed by staff. Any process that by its very existence noticeably improves staff attitude will contribute as much to perceived value as the more tangible benefits of the caregiving process itself.

So, where do we start? We begin with leadership. For teams to function effectively, leadership is essential. Egalitarian societies are wonderful conceptually, their only drawback being that they don't work very well in practice. Accepting the reality of leadership and designating a team leader does not violate the concept of an empowered staff' any more than a quarterback's play calling violates the concept of a football "team." The key to team success is how well the leader fulfills his or her responsibilities.

Team leadership comes in many flavors. It can be self-centered or it can be inclusive. The team can be directed or it can be motivated. It can mandate activities and processes or it can entail the techniques of team problem solving with one-on-one coaching, as needed. It is clear which side of this ledger promotes true culture change.

One of the most effective (and enjoyable) methods for a leader to create a quality management culture within the team is to start with the development of vision and mission statements. Absent consensus on who the customers are and what their needs might be, the team is unlikely to achieve its goals. One approach would be to distribute a simple matrix among team members and ask them to describe at least three customers and what their expectations might be. This can bring real focus to one of the basic tenets of quality management, i.e., a company has multiple customers, both internal and external. whose needs, at least initially, might appear to be at cross-purposes with one another, and difficult decisions must be made.

For example, are the needs of government (one of a nursing home's most important customers) antithetical to the needs of the resident? To be more specific, is the government's penchant for standardized approaches to care at variance with residents' desires for independence and autonomy? Reconciling such conflicts is a real test for any management team. This is where team leadership, coaching, and problem solving become critical.