Paul Willging Says…


It’s time to get systematic

You’ve put together your budget and, on paper at least, you’re running a profitable community. Now it’s time to manage your finances and maintain control over what’s actually happening in the community. That requires systems-systems that will help you understand what’s going on, systems that will enhance community productivity, systems that will bring the latest in technology to your management environment.

Sounds good, doesn’t it? But what does it all mean? Let’s explore both the benefits and the challenges of ensuring that your community can take advantage of the best of what is available in information and management technology. Maintaining your competitive edge is critical to the success of your community. Important as it is at any point in the history of senior housing and care, it becomes even more so in a saturated market.

Being competitive requires much more than setting the right price. Price is important, but reducing price without enhancing productivity is likely, in the long run, to make you less, rather than more, competitive. Competition is, after all, based on value, and price is only one component of value, the other being quality. Consequently, your prices can be reduced without adversely impacting value only by increasing productivity. This is where technology comes into play.

Technology is more than equipment, machinery, and devices. It is just as much skills, expertise, and knowledge. While the former set cannot be overlooked, the latter-certainly in long-term care-are more likely to make the more appreciable difference over time. And, indeed, the former are only tools for the latter. One of the most critical tools, for example, is data. And in today’s increasingly complex senior housing and care environment, data certainly need to be automated. But it is the application of data, not their generation, that will spell the difference in terms of community productivity.

The ability to gain easy access to information and to communicate that information to all involved stakeholders is indispensable to the provision of high-quality service. Data need to be accurate, timely, and readily communicated. But the machinery is less important to that process than the techniques for its dissemination and use.

There are any number of systems for improving productivity. The traditional view has focused on the department level, where the most basic tasks are performed. In this approach, responsibility for results rests primarily with supervisors and department heads. At that level, techniques to promote efficiency have been applied to controlling resources, monitoring output, changing work processes, and enhancing worker and group competencies and motivation.

While such processes bring benefits, there are also natural limits in terms of their ultimate value, at least in our profession. Senior care is, essentially, a task-oriented service based on a one-to-one relationship with the client. And while all of the above techniques can be beneficial, there comes a point where the number of minutes to perform a basic task cannot be further pared. Dressing Emma will take 15 minutes, regardless of technology.

That said, the number of programs has multiplied, and proposed organizational structures for enhancing productivity have become increasingly sophisticated and technically advanced. Planning and control processes now cut across all departments. Production technologies are now applied to the entire facility as a self-contained and complex system consisting in many interrelated subsystems. In this approach, managers are aided by functional specialists in areas such as human resources, information technology, and materials management.

The management gurus certainly emphasize the value of the company-wide system, as opposed to a piecemeal departmental approach. But, admittedly, the installation of system-wide techniques is also more challenging (and, the broader the application, the more critical the community’s culture becomes in supporting this). Today, productivity enhancement is as dependent on “leadership” as it is on “administration.” Which leads to a discussion of an entirely new approach to the application of technology, one less oriented toward production and more focused on direction. The installation and cultivation of strategic planning and quality improvement systems provide perhaps the best examples of a “management” as distinct from a “production” strategy.

Given the natural limits on task fulfillment in the senior care setting, a production strategy alone will be insufficient to enhance value in either the short or the long term. Capital and human resources are no longer as predictable as they once were. Competition and regulation are more intense. As a result, external forces (including economic and marketplace turbulence) create threatening conditions that require an organization to try to control its environment as much as its production.

Here there is less emphasis on control and more on strategic planning and quality improvement, as the volatility and complexity of the environment makes more traditional methods of control problematic. Here adaptation to a changing marketplace is the ultimate measure of productivity. Here responsibility shifts away from the department level to the most senior levels of management, including owners and boards of directors.

But, again, the technology most critical to either a production or a management strategy is data. In either situation, a good management information system in long-term care will rest on the realization that there are three types of data critical to effective operations in the facility: service, finance, and administration. Not only are all three critical, they actually feed and build upon one another.

The services you provide are at the core of your management information system, for they will determine to a considerable extent your costs and, ultimately, your financial success. They are a product, of course, of your staff and the administrative systems you have installed to manage the staff. All three information sets can only be as effective as their linkages, one with the other. Good software vendors in the industry offer applications that tie all three together.

In implementing information technology (IT), though, managers are often prone to four major mistakes:

1. They abdicate their responsibilities for IT altogether. Technical details can (and should) be delegated to subordinate staff. But the need for and applications of IT are too important for managers not to focus on.
2. They exhibit too much of a “silo” mentality. Applications are often built around individual concerns in the arenas of finance, service, or administration and, in a relatively short time, these “islands of information” can no longer communicate with each other. The end result is a staff with a lot of data, but not very much information.
3. They fail to look at technology from the perspective of its appropriate “fit” within an entire process. This failure assumes that technology for the sake of technology is the ultimate goal. In reality, the technology is beneficial only if it makes an entire process more efficient (or efficiently substitutes for an entire process). Providing staff with laptop computers, for example, won’t improve the process if the computer notes still need to be manually transcribed to resident records.
4. They think of IT as “just computers.” IT is actually the entire panoply of technologies required for the collection, analysis, and reporting of information. That can include such rudimentary tools as fax machines, telephones, and the Internet. Implementing new technology can be challenging and goes far beyond computers. The process is seldom simple and rarely accomplished without challenges along the way.

I have written in previous columns about the critical need for integrating systems. It is not uncommon to have multiple systems in one facility, and it is just as common that these systems do not share data easily. Many applications grew to meet the needs of a particular department without considering the need to share that information with other departments or external parties.

One problem underlying this is the proliferation of different standards, thus creating the “Tower of Babel” phenomenon. Say what you will about the federal government’s intrusion into community operations, the advantage to nursing homes is that the Minimum Data Set (MDS) established standards for recording information. Compare that with the rest of healthcare, which has been struggling with the bare essentials of the electronic medical record for eons.

The introduction of IT in a community should be accompanied by a comprehensive review of work processes within the facility to ensure that new systems are making those processes more, not less, efficient. It is common for providers to continue with old processes, even when the introduction of new technology makes them superfluous.

Finally, the introduction of new technology requires behavioral change along with the installation of new machines and processes. How many of us can recount tales of CEOs who have their secretaries print e-mail messages so they can conduct “business as usual”? Installing new IT will move smoothly or will be fraught with difficulty, depending upon a number of variables:

1.A lack of adequate training and education of staff has been identified as a major obstacle to the successful deployment of IT in many organizations.
2.Appropriate managerial, structural, and operational changes, as well as changes in work processes and policies that could improve the application of IT, are often ignored.
3.Whether standards have been created and adherence to them required sufficiently to help staff use information technology effectively.
4.Whether it is recognized that technology lessens the dependence on the more traditional and rigid hierarchical organizational structure. Maintaining this structure can lessen the benefits of the new technology.
5.The symbolism of IT’s organizational placement. Putting it in the finance department, for example, sends a clear message as to its primary function.
6.Installing new IT also requires the development of new policies in the community, ranging from job descriptions and training to information access, e-mail use, system security, and virus protection.

Only the largest corporations enjoy the luxury (and suffer the risks) of developing their own IT systems. Most communities and small corporations will purchase systems off the shelf or customized. When purchasing the system from a vendor, all of the considerations enumerated above apply. Be wary of any vendor who cannot deal with them, particularly the requirement that the system integrate financial, services, and administrative data.

If this is your first venture into the complex world of IT, it may be advisable to retain the services of a consultant who can help you navigate what can often be choppy waters.

Under any circumstances, remember that the first step is to remember who is “number one.” The system should be designed to meet your needs, not those of the vendor. And understanding and being able to specify your needs are critical to the successful implementation of new IT in your community.

Finally, a little about benchmarking. In an increasingly difficult and competitive marketplace, it is imperative not only that you manage your own community well, but that you are able to assess how well you stack up against the competition, both regionally and nationally. Benchmarking is a relatively new discipline in senior housing and care. It involves comparative analysis of critical industry operating factors, financial ratios, and overall best practices. The benchmarking discipline can provide early warning signals and identify potential problems, while determining how you rank with industry peers.

Benchmarking also depends on data, but now data about your peers in addition to yourself. And data, for much of senior housing and care, can be problematic. In nursing facilities, with the availability of public data as varied as cost reports and clinical information through the OSCAR (Online Survey, Certification, and Reporting) system and the MDS, this is less of a problem. In congregate care and assisted living, the generation of comprehensive industry-wide data is still in a very rudimentary stage.

Internal benchmarking involves the comparison of similar functions within departments or, if relevant, various communities within the same corporation. It can be as simple as the time allotted to cleaning a unit or as sophisticated as admissions per numbers of leads across a corporation’s many communities.

Benchmarking the competition takes the process one step further and compares your operations against those of facilities attempting to penetrate the same market. This approach will likely require not just the analysis of comparable data sets and the competition’s marketing materials, but some “mystery shopping,” as well.

Regional and national benchmarking is particularly useful from the perspective of quality management. While, as I say, data can be a problem for much of senior housing and care, some are available through private database companies, which compile information on industry trends, statistics, market factors, financial ratios, pro forma profiles, best practice policies, and staffing patterns. Of course, much relevant information is more readily available for nursing facilities through federal and state databases.

Functional benchmarking compares not similar facilities, but similar activities. While relevance is always a consideration, service industries perform similar functions, and best practices in one can be informative for others, e.g., the timeliness of responses to inquiries, the speed of service in serving meals, etc.

In benchmarking, as well as internal operations, the availability of data is important. But the application of data is even more critical. Again, back to my basic premise: Technology is more than machines. It is critically dependent on the industry- and facility-based knowledge essential for its application and use. Forget that and new technology will lessen, not enhance, your productivity.

To send your comments to Dr. Willging and the editors, e-mail To order reprints in quantities of 100 or more, call (866) 377-6454.
Paul R. Willging, PhD, was involved in long-term care policy development at the highest levels for more than 20 years. For 16 years as president/CEO of the American Health Care Association, Dr. Willging went on to cofound the successful Johns Hopkins Seniors Housing and Care postgraduate program (cosponsored by the National Investment Center for the Seniors Housing & Care Industries), and later served as president/CEO of the Assisted Living Federation of America. He has enjoyed an equally long-lived reputation for offering outspoken, often provocative views on long-term care.

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