Facility turnarounds are a managerial specialty.  Effective turnaround executives must be subject-matter experts in licensing interpretation, regulatory compliance, profit and loss analysis, interdepartmental platform integration, risk management, and liability exposure reduction.  And, they must thrive under pressure.

Providers managing long term and post-acute care (LT/PAC) centers that consistently perform poorly often create a revolving door for executive directors (EDs) and administrators who are not equipped to handle the operational challenge.  Effective turnaround executives rapidly analyze, synthesize, and summarize deficient operational practices into performance improvement training modules. Training in these areas is essential to producing effective outcomes.

Empowering Staff

The lingering effect of a failing operation is staff who feel devalued and demoralized. The signature of an effective turnaround specialist is someone who enters the turnaround assignment poised to reassure, motivate, and empower staff to appreciate that their very own expertise and effort are critical to the mission of caring for America’s frail elderly.

Staff must be immersed in a transformational message, motivating them to become subject matter experts within their own facility, while learning the importance of cross-departmental collaboration as they move forward to improve all aspects of facility operations.

The Turnaround Process

A comprehensive turnaround has three dynamic processes:  

1. Focus review: Intense dissection and analysis of existing operational deficits. Study the problem or deficient practice until the root cause is discovered. Stay focused.

2. Fast track: Assign resource allocation of staff and man-hours until the problem is corrected. No delays. No deliberate passivity allowed. Stay on track.

3. Survey prime: Many problems are fixed initially, and then ignored until they are problematic again. Once corrected, whether it is one problem or many, establish a comprehensive compliance audit with sufficient frequency to prevent regression. Stay primed.

Turnarounds often reveal liability exposure in every department. Neglect of licensing requirements and regulatory compliance must be evaluated first. Consider a scenario where a facility is under heavy scrutiny by local regulatory agencies for repeat substandard performance. The facility recently received a survey report detailing widespread, regulatory violations; corporate officers finally decide to bring in a valid turnaround specialist.

On day one, the turnaround ED immediately analyzes the survey report. The ED highlights precise text outlining deficiencies and enters side notes with instructional guidelines to correct each deficiency.

A department head meeting is convened, and survey copies are distributed for group discussion and review of side notes. The intent of this initial meeting is to dissect the survey findings and teach staff how to efficiently identify the root cause and then proceed to corrective actions.

Face-to-face meetings are quickly scheduled with all staff mentioned in the survey, to either confirm or dispute the alleged deficiency. Staff responsible for deficiencies will receive refresher training relating to company policy and state/federal guidelines pertaining to the specific deficiency. Signed copies of in-service training will be kept as proof-of-practice. 

Correcting Deficiencies

Department heads will also be taught to analyze and correct each deficiency. Below is a list of actions to take using the focus review, fast track, and survey prime methodology.

1. Corrective action: Investigate to confirm or dispute deficiency (surveyors make mistakes, too). If verified, identify time, date, and staff who conducted corrective action at time of discovery.  If still deficient, correct immediately. When investigative evidence contradicts the survey finding, provide supporting documentation to the ED for the informal dispute resolution.

2. Procedure for identifying other residents potentially affected: There’s always a potential that any deficiency may have negatively affected other residents. Therefore, develop a process to identify if other residents were affected by cited deficiency and take corrective action immediately.

3. Procedure to prevent recurrence and monitoring: Develop ongoing process to prevent operational regression and recurrence of deficiencies by creating a quality assurance monitoring audit to maintain compliance.

Below is an example of these actions put into practice.

Consider a deficiency where the surveyor observed a resident slide off his wheelchair to the floor. The surveyor examined the chair and noticed a wheel-lock broken. The surveyor reported the incident to the charge nurse and staff immediately responded. The corrective action and written response for the plan of correction is:

1. Corrective action: Please note that on (date) the director of nursing examined the resident and found no visible injuries. The resident also reported to the nurse the absence of pain or discomfort. X-Ray conducted with negative results. Immediately following surveyor’s report of the incident, the director of plant operations replaced the disabled wheelchair and verified both wheel-locks functioned properly on the new wheelchair. Additionally, under the direction of the director of plant operations, on or before (date), all staff will receive in-service training pertaining to the safe operation of durable medical equipment with a focus on wheelchairs and how to identify safety concerns.  

2. Procedure for identifying other residents potentially affected: On (date) the director of plant operations conducted a physical inspection of all facility wheelchairs to rule out safety concerns and verify proper working order. A comprehensive inspection of each wheelchair revealed no further deficiencies.  

3. Procedure to prevent recurrence and monitoring: Under the direction of the director of plant operations, or designated representative, a weekly inspection of all wheelchairs will be conducted to verify proper working order. Deficiencies will be corrected on the spot. The results of these unannounced inspections will be documented and presented to the quality assurance and performance improvement (QAPI) committee meeting for review and further corrective action.

The first week of the three-month interim turnaround assignment will be dedicated to resolving survey deficiencies and preparing documentation for the plan of correction. The remaining 11 weeks will consist of systematically correcting performance deficits in each department with a focus review, fast track, and survey prime.

Customer Service Front and Center

Essential in all turnarounds is a reorientation of the staff to customer service. Therefore, the interim ED will introduce a staff training module that focuses on person-centered care. Staff will learn that a resident’s desires, values, lifestyle, and expressed preferences are important in the daily care of each person. The training will also reinforce the importance of caring for residents in a manner that preserves their dignity and is compassionate and respectful. Reorienting the staff to provide care with a person-center focus will enhance customer service throughout all departments.

The significant reality about using a turnaround process with a focus review, fast track, and survey prime is that staff learn a simple operational application that improves their performance and produces positive outcomes. When staff are exposed to effective mentors, with efficient methods, they themselves become better mentors. In business, hope is not a plan, but once a turnaround specialist leaves an assignment, they can only hope the corporate office hires a new ED who adds value to all the platform improvements already in place. If not, at least the staff have been trained to do a turnaround.

Jaime Todd is a health care reorganization/turnaround executive specializing in acute care, behavioral and mental health, primary care, and long term care. He is a widely published author of leadership, licensing/regulatory compliance, risk management, and health care operational management articles. He can be reached at jtandarlene@outlook.com.