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Paul Willging Says...

March 1, 2004
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Culture Is More Than Just Beethoven

'Culture' is more than just Beethoven
The success of a seniors housing and care community is as much a function of the community's culture as of its business plan. Although both are critical, even the best business plan cannot overcome a culture that satisfies neither customers nor staff.

And just what is culture? Well, we might refer to it as that set of values in a senior care community that determines staff behavior. It can also be characterized as the community's "attitude." The successful community requires a working environment in which (1) the values and belief systems (i.e., culture, attitude) are customer-oriented, and (2) the human capital responsible for the community's success buys into those systems. Put differently, the culture needs to be resident-centered and staff-empowered.

In this issue, I will discuss the characteristics of "culture" in the successful long-term care community, and how to develop and sustain them. Next month, I will look at the role that staff (as a team) plays in applying that culture to caring for the community's residents.

Let's start with the basics: Quality is the product by which any seniors housing community is judged. And we know, of course, that customers measure a community's quality by perceived outcomes. To really understand quality, it is useful to go back to the actions that generated the outcomes. This is particularly true when the customer's satisfaction with the product (i.e., the customer's perception of quality) is in question. Once you know, for example, that your residents are not satisfied with their dining experience, it is imperative to find out why. Ultimately, the reasons for poor qualityí¬including the actions that produced ití¬can be traced to the attitudes (culture) displayed by the staff: Attitude (belief systems) inevitably tempers actions, and actions determine quality. The entire chain needs to be analyzed and understood if quality is to be assured.

But even if the specific actions producing poor outcomes are not immediately understood, there is no question that customer satisfaction depends on staff attitude. Absent a satisfied customer, profitability will suffer.

This has not always been the case in all sectors of seniors housing and care. As I've alluded to in previous columns, until the 1990s nursing homes operated in an economic environment in which the absence of alternative sources of facility-based care allowed operators to focus less on the customer (and customer satisfaction) than on the payer (in this case, state Medicaid programs). Valueí¬at least the customer's perception of valueí¬took a backseat to satisfying the regulators.

Nursing homes no longer have the luxury of omitting customer satisfaction as a key quality indicator. And that reality has, in turn, forced greater attention on the issue of acceptable outcomes. The industry's profitabilityí¬some would say its very existenceí¬requires that attention and energy be devoted to improving facility outcomes or, at a minimum, to improving the public's satisfaction with those outcomes.

Back to our dining experienceí¬a service that is often a primary object of customer scrutiny and a leading cause of customer dissatisfaction. In how many nursing facilities do clinical, regulatory, and financial considerations determine the nature of the dining experience? While these are admittedly critical, should not the primary focus be on providing residents with a rewarding social experience? That is, after all, the residents' focus. Quality improvement, therefore, becomes a key ingredient in managing a successful seniors housing and care community, and culture creates quality.

I started writing this column immediately after concluding a call with my sister-in-law, who was looking for the right assisted living community for her mother. Price was important to her, but not as important as value. In her mind value was a reflection of how well the community was going to take care of her mother. What was the community's culture, its attitude? What belief systems would propel community staff as they cared for Mom? Would their primary focus be on her needs, her requirements, her desires? Or would staff operate "by the book," looking at Mom as just one more of their many "charges"?

This lesson is not universally understood in long-term care settings. Value is what attracts the customer. Value, therefore, is what stimulates revenue growth. The community that cannot create value in the minds of its customers cannot succeed in a competitive environment, no matter how low its price points. My sister-in-law finally opted for a community that was more expensive than its closest competitor. She chose what was, for her at least, the more "valuable" service, not the least expensive.

A major mistake communities make when revenue growth lags is to focus exclusively on the cost of service. In a highly competitive market, too many communities attempt to entice the customer with a marketing strategy based primarily on price. But price, absent quality, will not enhance value.

Indeed, uninformed cost containment focuses initially on the community's largest cost centerí¬personnel. This is shortsighted. In a service industry it is only through staff (and staff culture) that one can enhance quality and, in so doing, create value.