• From my favorite blogger, Peter Bregman. The Martial Art of Difficult Conversations. While Peter is describing a personal difficult conversation, everything in this piece is applicable to the workplace. And since “difficult conversations” are the number one issue identified by every manager I coach and train – this is a must read!
• I admit, even I sometimes get stuck into thinking of teams as static beings. This great article talks about teams that come together ONCE, and must be effective, accurate, and functional immediately. Great lessons for how we look at similar teams in our own agencies, whether they be crisis teams, wraparound teams, or treatment teams. Teamwork in a Shock Trauma Unit: New Lessons in Leadership: Knowledge@Wharton
• I hear the question almost everywhere I go: “Should we offer an incentive program for that?” The questions are broader, and spelled out clearly and straightforwardly in this Forbes article: Incentives Vs. Recognition: How Do You Get Your Workers Engaged Again?
• The New York Times had a great, short little article entitled Workplace Gossip? Keep it to Yourself.
• And if you have more time, maybe a couple of hours, I highly recommend the little book: Leadership and Self Deception: Getting out of the Box by the Arbinger Institute. Despite its intimidating (to me) title, this is an easy to read book, with profound implications for how we lead, manage, and live our lives.

What have you read lately that is worth sharing?

He looked like he was imagining things when I responded with: “That’s great news!” “But, I don’t understand, how?”

This conversation happens regularly in organizations that are implementing new systems to get the results they want, whether those results be better retention, productivity, referrals, or documentation. The organization often starts with a training program to make sure that managers and supervisors all have the skills and knowledge needed to do the job and get the results. When that only gives them a fraction of the results that they were expecting, we begin to look at the systems and procedures that they have in place. If a system is missing, we add one. If there is a procedure that is adequate but not being implemented, we implement it. And then we look for changes in results again.

And it is at this point that we begin to hear the conversation about “new problems” cropping up. You can almost see the new confidence begin to drain out of the staff, the managers, and the entire organization.

So what gives?

I think of building new skill sets and systems as a layering process. This is true whether we are talking about an individual manager’s skills or the systems and processes that provide the organizational infrastructure. So the training provides one layer. Generally it adds the layer of awareness and knowledge. When we begin to add systems (procedures, processes, checklists), we are usually tackling the most conspicuous issue. As we get that system in place, and begin to see some results, we also get to look at what has been hiding behind the big issues. This provides the opportunity to gather more specific information that lets us improve our systems, approaches, and skills at a more specific level. We are making progress by turning up new “problems.”

Sometimes the tendency is to get discouraged when this happens. The biggest gift that a manager can give at this point is to help all concerned track the progress and maintain hope that progress is occurring. Using visual or chart graphics can help. Sometimes something as simple as a memory timeline – where we keep a list of what we were tacking at the beginning of each month – can help as all to see that we are moving in the right direction.

Leading After Layoffs: Best Practices for Re-Energizing Your Workforce. Wendy Mack and Deanna Banks have written this free e-book as “a gift for leaders who are looking for ways to re-energize and align their people in these tough economic times.“ The easy-to-read book is filled with practical tools and approaches. Three main areas focus on understanding and intervening in the layoff cycle, how managers can have a positive impact, and matching your actions to employee emotions. You can download it from the Management Resources page.

The Reflexive Generation: Young Professionals’ Perspective on Work, Career and Gender, from the London Business School. This study examined the needs of the upcoming generation of workers and explores how organizations can best use their strengths and manage them. Don’t let the word “study” be off-putting; this is easy to read, has clear practical recommendations, and clear graphics. You can download it from the Management Resources page.

Food Education for People with Serious Psychiatric Disabilities: An Evidence-Based Recovery Curriculum is new from the Center for Psychiatric Rehabilitation at Boston University. This will be incorporated into the Slayton Consulting Directory of Curricula for Rehabilitation Services – 2008 when it is updated. In the meantime, you can find the details about this new resource on the Service Delivery Resources page.

That’s why I love that the American Psychological Association (APA) has compiled a fact sheet and an entire website devoted to healthy workplace practices (http://www.phwa.org). They use hard data – including compelling financial data – to show how important this so-called soft stuff really is. Consider:

• APA’s 2008 Psychologically Healthy Workplace Award (PHWA) winners report an average turnover rate of 11% compared to 40% nationally, only 21% of their employees report chronic work stress compared to 34% nationally, and PHWA winners report an 82% employee satisfaction rate compared to 66% nationally. When you consider that turnover costs the average company between 12% and 40% of revenue, the reduction in turnover alone is stunning.
• Companies that invest more than average in employee training outperform the market by 45% and have returns that are 86% higher than those companies that spend less than average.
• In a study of 24 publicly traded companies, those with high morale outperformed similar companies in their same industries by almost 2.5 to 1, while the stock prices of companies with medium or low morale lagged behind their industry peers by more than 1.5 to 1.

(There’s more! Download the Fact Sheet.)

The PHWA results come primarily from for-profit companies. That makes sense – it is always easier to measure results in stock prices and profit statements. But if morale and organizational culture and other healthy workplace practices can make a difference in profits, then how much greater a difference can they make in the lives of our employees and the people we serve?

Just a little something to think about. Where can you start to make a difference in the health of your workplace?

Using this question with direct service staff can have equally powerful results. Let me give you an example.

In documentation training recently, I showed staff (case managers, rehabilitation staff, ACT team members, and clinicians) brief vignettes of real clients and then asked them to document what they saw. Before discussing their documentation, I asked them to respond to “What was that experience like for you? What did you observe about your experience of watching that client and then documenting what you saw?”

I was expecting short debriefings before we moved onto the main event – what they actually wrote. What happened instead became the main event.

Time after time, with six different groups of participants, the answers were personal and compelling:

• “I found myself wanting to describe his illness, and having a hard time seeing him.”
• “I kept bouncing between seeing this person and getting stuck in all the symptoms.”
• “It was hard for me to find words that weren’t straight out of a text book.”
• “The pull of judgment is so strong – it was really hard to just observe and describe.”
• “I could either be proud of what she was accomplishing or describe her mental illness – it was difficult to see both at the same time. Kind of like those optical illusions.”

Having an opportunity to identify their personal responses and experiences, made it easier for the participants to move to a more descriptive documentation approach. They could begin to separate out their own biases, set them aside, and simply report what was happening. Their resulting documentation became clearer, more individualized, and more strengths based.

In another exercise, I asked participants to watch a video vignette, then to document what they saw, starting with what was serving the client well. That simple lens – serving the client well – changed the entire focus of their observations to include the full range of the client’s experience. Instead of looking just for impairments and symptoms, the participants began to see strengths as well as struggles, and the person behind both.

Two questions, both offering immediate and substantial improvement in documentation. I suspect that they also will provide immediate and substantial differences in staff-client interactions.

What was your experience? What is serving this person well?

But what they really want, when we dig into a little bit, is to find somebody else to do some of the massive amounts of work they find on their plates. They want to dispose of tasks, rather than delegate them.

Disposing of tasks (or dumping and running) – has a wonderful short-term payoff, but almost always results in more work and pain in the end. And even if dumping-and-running worked, there just aren’t that many tasks we can run away from and still do our jobs. I know – I’ve been figuring out which tasks in my one-person business I can delegate or outsource. Running away is just not an option. If they are not done well enough, they land back on my lap.

Which brings me to another way to look at this topic. What if we think about delegating as partnering? In a partnership, we each clarify what our roles and contributions will be, and agree to work together, with this shared set of expectations, to accomplish a clear common goal. Lofty words. How might that look in practice?

Let’s say a clinical supervisor wants to delegate some documentation review to a senior clinician who is being groomed for promotion. In the world of partnerships, this might involve the following steps:

• A conversation about the goals of the task, and the goals of each participant. Included would be a shared assessment of the strengths of each relative to the task.
• A plan (yes, that four letter word!) to teach and transition some of the documentation review. This plan is likely to move from shared responsibility to increasingly independent responsibility.
• A measurement methodology, hopefully simple and effective, that tells both parties how close they are to achieving their individual and joint goals.

Clarity about what is being delegated is important in both the conversation and resulting “partnership contract.” Is it the doing of a task? Or are we delegating ownership of a set of responsibilities? If we are delegating a specific task, we are more likely to also specify the processes, tools, and timeframes for doing that task. That becomes part of the partnership agreement: “Here is the task and here is how it needs to be done.”

If on the other hand, we are delegating ownership of an outcome or responsibility, we need to be clear about what the outcome needs to be, including any timeframes, but the processes are in the domain of the delegatee.

“We need to have a process that results in at least monthly communication with the Department of Child Welfare about our shared clients. It needs to include problem resolution strategies and a way to quantifiably and qualitatively report on the results of our collaboration.”

The results and outcomes are agreed upon in the contract, but the “how” is left to the new owner.

It also helps to delegate the “whole” set of tasks when we want the delegatee to own the outcomes. If we split an accountability into too many small chunks, we may end up spending more time coordinating (and being perceived as micromanaging) than we have gained by delegating. We want to delegate the coordination of the tasks as well as the tasks.

The hardest part of delegating “ownership” is letting go of “how I would do it” and of the need for it to be “perfect.” Gaining some clarity between all parties as to the type of delegation (task/ownership) and viewing it as a partnership can help.

Let me back up.

Yesterday I was listening to Melanie Benson Strick describe the difference between Flurry Mode and Strategic Mode for Leaders. Flurry Mode occurs when we have massive projects, requiring tight coordination, project planning, multiple resources, and running on overwhelm for a defined time period to accomplish a specific goal. In our personal lives, this might be planning a wedding, a family reunion, or the 42-European-cities in two weeks vacation of your dreams.

At work, Flurry Mode might be a new computer system implementation, a major procurement (purchasing or bidding), the legislative session, or a new program initiation. In any of these cases, it is “all hands on deck” to accomplish the myriad tasks necessary to reach the goal on time and on target.

When we move into Strategic Mode, we rely on established systems, procedures, and processes to manage and monitor ongoing tasks. We then can shift more of our thinking and planning energy to leadership issues and questions. The scope of the question might be agency-wide, or focused on a work unit. So instead of “How do we get this done?” we move into “Should we get this done? Is there a better direction? Are we using our resources to their best advantage to meet out mission? How can we add value for our customers, our stakeholders, our staff?”

Strategic mode requires some mental and emotional space to step back, take a deep breath, and ponder. Not days or weeks, but some concentrated moments. In my experience, it is a rare person who can enter that strategic space when in the middle of a Flurry.

Back to my “AHA.” Middle Managers in our organizations may never experience any mode other than Flurry. They often describe their days as moving from crisis to crisis, meeting to meeting, task to task. It is not unusual for them to come to a training day with a stack of documentation (or policies or . . .) to review and approve before the end of the meeting. When presented with a question or issue that could benefit from Strategic Mode, they dive right back into Flurry Mode, ready to juggle all the pieces. Eventually, many get too tired of juggling and Flurries, and check out (mentally or physically).

So this particular Aha Moment has stimulated some questions.

• What benefit does it bring the organization, the middle manager, the customer/consumer for Middle Mangers to spend a majority of time in Flurry Mode? Does being in Flurry Mode 90-95% of the time get us closer to the goals and vision?
• If we really need Middle Managers to be in Flurry Mode most of the time, do we need to give them different project management tools, skills, and support systems?
• If we want Middle Managers to spend more time in Strategic Mode, do our organizations have the systems, policies and procedures to allow that? For example, do we have performance indicator dashboard for what they manage that help them stay in cruise control (strategic mode) more of the time?
• If we see Middle Management as part of a career path to senior management, then how do we find a way to help Middle Mangers become exposed to and develop the capacity to enter into Strategic Mode more of the time?

What are your questions, thoughts, reactions?

1.) Know what every person does. Sounds easy, but many jobs evolve over time, with staff taking on formal and informal assignments, duties and roles that may not be in the job description. If you’ve been coping with downsizing or turnover for a while, chances are that people have taken on duties that other people used to do. Take an inventory of what each person does now, and maybe even how they do it (especially if it is an occasional and unique task). Get the employee to help write this up. Don’t get too hung up on format until you’ve gotten the content. Then you can update policies, procedures and job descriptions if necessary. A good time to do this is at performance appraisal time. (I once had a boss evaluate my performance using a two year-old outdated job description. Updating the role descriptions for people before you write those performance appraisals is a good idea!)

2.) Have an Exit Plan. Most organizations have a clearly defined orientation plan – a way to bring new employees into the organization and their new jobs. But their exit plan rarely extends beyond turn-in-your-keys and name-badge territory. Come up with an exit plan that includes mandatory debriefing on current projects, contacts, caseloads, filing systems (paper and electronic), and other job duties. Develop a standardized set of questions and reports to communicate and handoff the information and tasks from these exit processes. And don’t forget to get their passwords and keys!

3.) Have systems and internal controls in place to keep required paperwork up-to-date. We all know the pain of having a clinician leave only to discover that their client records are incomplete. We lose vital clinical communication and the ability to collect revenue for the work that was done. But current paperwork is a must for other staff as well. Key committee minutes are required for accreditation processes. Contract compliance monitoring logs can hamstring future negotiations. Lack of supervisory documentation derails effective performance management. Develop simple internal controls to keep all paperwork current.

4.) Think about transition plans. Many organizations have a plan for what they will do if a key manager leaves. I suggest that you think about what your approach is when any staff member leaves, especially those where positions are hard to fill. Come up with some draft plans for what you will do beginning during the “notice” period to transition and cover responsibilities. Obviously, if considering a direct service provider, transitioning the clients on the caseload is of upmost importance. But think beyond direct service providers. What is your plan to communicate the vacancy or change in assignments internally and externally? For staff who represent the agency with external stakeholder groups, when and how are you going to tell the stakeholders? When will you assign an interim representative and introduce her to the external group? What about internal or external task groups or committees who need a certain number of hands to get their work done? If you’ve done step one, you can take that list to develop your transition list.

Please share any practical solutions you have found to ease the turnover blues!

“Conventional wisdom says ‘What gets measured gets managed.’ True, but still, you don’t make the pig any fatter by weighing it everyday. You must act.”

Lately I have been working with several clients who have access to very sophisticated data collecting and reporting systems. Their computers measure all kinds of clinical, scheduling, utilization, acuity, and other data, and can spit it all back out in four-color graphs and pages of detail. Such an improvement over the old days when we relied much more heavily on anecdotal data!

Yet in every instance, managers were reporting disappointment and frustration that things weren’t changing, improving. It is almost like we have some magical thinking that if we have the data, then everything will get better. Two different CEOs said to me in the same day: “But Lee Ann, they have the reports. They know that XYZ needs to change. What’s wrong with them?”

I think Marcus Buckingham adds the missing piece of bacon. (Couldn’t resist.) Measurement is only the first step. An important step, but not the outcome.

Once we provide managers, supervisors and direct staff with information, we may also need to help them learn how to use it. Here are six quick thoughts on what we might need to put in place to support thoughtful action:

1. How to focus on the most significant parts of the information. This might include discussions on what are significant variations, and when something may just be a blip. My financial friends call this the concept of materiality.
2. Once we decide what is important—both in a positive and negative direction—how do we know what to do? I am a strong believer in scripts and checklists, especially for new supervisors and managers. So the script/checklist might say something like: “Anytime the attendance in the program changes by 10% in either direction, do this.” The “do this” might just be calling their supervisor. Offering guidance on the parameters of when action is expected, and a simple action, can help shape an action response.
3. For more complex actions, script and practice. In one agency, new supervisors reported that they put off talking to their staff about notes being turned in late because they didn’t know what to say. A helpful response is to offer a scripted statement, and have the supervisor practice it before he or she needs to use it with an employee. For example: “Susie, you have 10 notes that are not turned in. I expect to see those notes by 4 pm tomorrow. Please drop by between 4 and 5 tomorrow to review those notes with me.” The structure of the script gives the new supervisor a starting place.
4. Make sure that reports have meaningful information, not just rows and columns of data. In most cases, staff, supervisors and managers will do better with a dashboard of key indicators (information), rather than a stack of details.
5. A corollary is making sure that the reports we get have data that is timely. The GPS in my car needs to know two pieces of information to help guide me to my destination: where am I right now, and where I am going? Knowing where I was last quarter may be valuable in lots of ways, but it does not promote action now.
6. For some reason, many of us tend to only act on what we see that we don’t like in reports. I encourage you to act on the things that are working as well. What is moving in the right direction, even if it is not at target yet? What is sustaining its quality? Make games of data reports by challenging staff to find as many things right as possible – things that they need to keep doing or do more of – within a data report.

What helps you move from weighing the pig to eating the bacon?

The one audit related to Target Case Management (TCM) is dated September 1, 2009, and concerns a review of Pennsylvania’s Medicaid payments for TCM. Like most federal audits, this one is clearly a retrospective, covering calendar years 2003 through 2005.

The results are still instructive and offer some practical guidance for all behavioral health programs billing Medicaid. I will first give you a summary of findings, and then offer my thoughts about what providers can learn from this.

The findings: The Pennsylvania audit looked at 375 claims from that three-year period. 36 claims (almost 10%) were deemed unallowable because the services were unsupported by case records or insufficiently documented. This resulted in a request for the state to refund $6 million plus for undocumented and unsupported claims, and to review other claims after the audit period to see if additional adjustments were needed.

My take: One of the most common documentation errors that I see in working with providers is that their notes fail to clearly describe an intervention that matches the service definition they are billing. This is true whether the service is a clinical one, like therapy, a rehabilitation service like PSR or Community Support, or case management. Staff understand the message that they are to write what they do – yet what they write and do are not always a billable service.

Practical solutions:

1. Develop a checklist with some key indicators describing interventions for each billable Medicaid service. Build these checklists from service definitions, provider manuals, any legislative or Rule language, and the approved Medicaid State Plan amendment (if applicable) for that service.
2. Use these checklists consistently across internal processes, including:
   1. Staff training
   2. QA and CQI audits
   3. Pre-billing monitoring of sufficiency of documentation
   4. Supervision
3. Note that most if not all the items on a checklist can be clearly described so that a trained administrative assistant can do the preliminary pre-billing reviews, referring questionable or inadequate notes back to a supervisor.
4. Track the data on clarity and accuracy of intervention statements in progress/case notes. Implement plans of correction, coaching, training, and intensified supervision whenever a work unit or individual service provider’s data falls below a critical standard or target.
5. Concurrent sampling of notes may well be adequate, especially once a benchmark of accuracy has been achieved by individuals/work units.
6. Note that these are concurrent, and preferably pre-billing reviews. They supplement the 90-180 day retrospective quality reviews that many organizations do.

For example, for case management, indicators on a checklist in one state might include:

• Actual face-to-face contact with client
• Service activity included one or more or the following:
  • Assessment of current service needs using approved state assessment tools and screening methods
  • Development of a service plan with client
  • Review of service plan and results of plan with client
  • Referral to a service provider as indicated to the service plan
  • Assisting client with linking and engaging with service provider as indicated on the service plan
  • Reviewing results with client of services provided by referrals, and need for any follow-up
• With the exception of the initial 30 days of service prior to the development of the service plan, interventions must be present on the active service plan to be considered billable.

Documentation, especially when it comes to covered Medicaid services, requires clear internal processes to sustain adequate description that the intervention provided was in fact, the one that was being purchased. My experience – and the recurring data from external and internal audits – is that continued vigilance is the best prevention.

What practical solutions have you found to inoculate your agency and your staff against these kinds of audit findings?