Debbie Stadtler: Improving quality is always a goal in long term care. Hear more about the ins and outs of the continuous quality improvement journey in this episode of Perspectives in Long Term Care.
Hi, I'm Debbie Stadtler, editor-in-chief of Provider Magazine, the flagship publication of the American Health Care Association and the National Center for Assisted Living.
I'd like to welcome you to this episode of Perspectives in Long Term Care, a monthly podcast produced by AHCA and NCAL. Each month we'll talk with long term care and assisted living professionals about the opportunities and challenges impacting the long term and post-acute care profession.
My guest today is Renee Ridling, executive director of Gingerbread House, a nonprofit provider for high acuity, medically fragile, developmentally disabled individuals in Rolla, Missouri. Renee has served as a silver and gold level examiner for the AHCA and NCAL Quality Award program for eight years. She joined the quality award panel of judges in 2018 and continues to serve as a judge for the program.
She has also successfully led two skilled nursing facilities to two bronze and two silver quality awards, and in 2014, her facility became the first facility in Missouri to achieve the gold quality award. Welcome, Renee. Thanks for being with us.
Renee Ridling: Thank you for having me.
Debbie Stadtler: Those are some awesome accomplishments, and I want to talk much more about the Quality Award program.
But first, tell us about your career journey. How did you get into the field? What led you to choose this career?
Renee Ridling: I actually got into long term care by accident. I'd always wanted to work in health care, and I had a background in marketing. I interviewed for a position in marketing with a long term care facility and I fell in love with it.
And I worked at that time for Beverly Enterprises, a company that had over 200 facilities nationwide at that time. And I was asked if I would be interested in the AIT program and. It was intriguing, so I said yes, and the rest, as they say, is history. I obtained my license in late 1992, early 93, and I've been working in long term care consistently since then.
I just fell in love with everything about the people that we care for and the challenges that we face as an industry every day.
Debbie Stadtler: It's amazing, and as I talk to folks about their career and how they get started, it's so evident that there is a love and a passion for the industry and for the people that are in it.
So I can see that is reflected in your career as well. But let's talk about the quality improvement journey. You have a unique perspective because you've seen it from both sides, both as an applicant and recipient, but also as an examiner and a judge. So give us a quick overview of the program and your experience with it.
Renee Ridling: Well, I actually became an examiner after we received our bronze quality award in 2008 for my facility here in Missouri. And I wanted to learn more about the criteria, wanted to be able to help my organization to understand the process better and just to do a better job of learning and finding out what the quality improvement journey was all about.
So that's when I became an examiner. I've stayed an examiner because I found it to be helpful in learning about my organization, how continuous improvement can benefit all aspects of the organization, not just the leadership part of it, not my job, but quality improvement continuously. Looking at opportunities to get better can help everybody, my residents, my staff, and really just became a student of that criteria.
I really enjoyed the silver. And then I became a gold examiner. I've been a team lead at both levels. And then I was approached to be a judge, and that was a really interesting term. So it's been a really great opportunity for me not only to learn about myself, but to also learn about the organizations that I've had the opportunity to work with.
Debbie Stadtler: I love how you mentioned that becoming an examiner was a way for you to learn the knowledge for your facilities, firsthand knowledge of seeing what they're looking for. But that's a great point though that each level of the quality improvement journey and each level of the Quality Award program are looking for different things.
And so what advice would you give to those aiming for each of the three levels or applying for each of the three levels? What's the difference there?
Renee Ridling: I think beginning at the level we're really asking: What is your organization all about? Who are your customers? What are your key services? What challenges do you face?
What advantages do you have over your competition? Then you take that piece and you move it into silver, and then we start digging into those questions about, okay, we, we know who you are and we know what you do, so tell us now how you do it. I think that's probably the biggest jump from bronze to silver.
So those questions are how do you lead your organization? How do you make sure that you are focused on your customers. And then moving into the gold, that's a big trick. You go from the bronze, which is five pages, and then you go into silver, which is 26, and starting to be asked for some data, and then you open up the Baldrige framework for health care criteria and then you're asked to provide 55 pages of a response.
So you now have basic questions and you have overall questions just like you had in silver. But now you have those multiple levels that really dig in and help you to identify gaps within your organization and opportunities to get better. It's just, it's, wow, I've never thought about that for my organization, but now I am, and I think we need a process for that.
And so I think the biggest difference is just learning at each level what is expected, how to address what is expected of you, and then moving into gold. It's really challenging for your whole organization to become better, the results throughout your goal. But what's presented in category seven is really a visual representation. You're like, wow, we did that. We really are getting better at what we do. For me, the biggest thing is just that moving from face to face along that journey and seeing at each level how we can grow and get better.
Debbie Stadtler: I like how you described it, that each piece builds on the previous one, so you're not just thrown into the deep end on day one, where you start with the bronze and it's more introductory, basic questions, a shorter application, a good starting point. And then by the time you're ready for silver, you have more data, you have more information, more details, things of that sort, so you're building. And then by the time you're ready to stretch for that gold, then you really can put all of that on display and showcase your organization.
Renee Ridling: Yes, I think that's a good summary. It is just the only way we talk about the journey, and I know sometimes people look at us strangely, but the honest truth is that it really is a journey and really you're moving from step to step.
I think that's one of the great things about the AHCA/NCAL Quality Award program is that it is progressive. As a Baldrige recipient at the national program level for Baldrige, you start at the top. You start with that full criteria. You don't get that opportunity to start small and grow. And I think that the way AHCA in has developed this quality award program over the years has been really well thought out and just phenomenal in that it gives organizations an opportunity to move through those progressive levels and gain understanding throughout.
Debbie Stadtler: I always hear people describe it as a journey, and I think that's really the most accurate word there. From the examiner and the judge side. What are some common issues with applicants?
What are some sticking points that a lot of folks get caught up in?
Renee Ridling: I think probably the biggest thing that we see at the silver and the gold especially is we know what we do as organizations. If we ask someone a question, how do you do something? They can tell us what they do. They can tell us we do this, but the real question is how do you do it?
So the how question is really indicative of process steps. First we do this, then we do this, then we do this, and then we achieve an outcome. So all of those what things, those meetings that we have and that interaction that we have with one-on-one, with that resident or that family, all of those things that we do.
Those what things. Go into the how, but the steps have to be there. And the important part about those steps is that they need to be well ordered. They need to have a first, a second, a third, a fourth. They need to be repeatable, they need to be consistent so that you're doing things the same way all the time to produce consistent results.
Because that's really what we want, is we want those outcomes to be consistent and we want them to get better. And the way we get better is we have a process and that process helps us to get better. And then we look at the process and say, maybe if we tweak this, we could get even become even better. And I always tell people when I train other people like on the criteria and to try to differentiate between the what and the how. I said think of what do you need to make a peanut butter sandwich? I know that seems like a really silly example, but tell me what you need to do that. And they can list all of the things I said. Now tell when we do it, what do you do first?
What do you do next? And then your outcome hopefully is a sandwich that is edible. So I think what we want everyone to see, that's probably the sticking point, is the difference between what and how. I think we see that at Silver and Gold a lot. We see a lot of connected activities of what we do, but not necessarily how we do it.
And I think that's really critical for growing as an organization is having consistent processes that are well ordered, repeatable, systematic. They're effective in achieving the outcomes that you want at the end.
Debbie Stadtler: Yeah, it makes me think of showing your work on the math test that you took in school. Like it's not just about getting to the answer, it's about the process systems.
Really the mindset behind it. Because like you said, these processes, we want to repeat and get better at. This isn't just write it down and put in the application. This is like continuous evolution of quality, and we want to be able to take those processes and systems and grow from them. So I think that's a really great point between the what and the how.
What has surprised you or impressed you throughout your time as an examiner and judge? Are there any special moments that stand out to you in your memories?
Renee Ridling: I can honestly say that the one thing I miss being a judge is getting to do site visits. As an examiner, as a gold team leader and examiner, we get to go to locations, to facilities across the country who've earned that site visit because their application met the criteria level that we needed them to do, met the site visit characteristics, and getting to go to those facilities and see them in action. I think that was so amazing is I never went on a site visit that I didn't come home thinking: I learned something from that organization that I can apply to my organization, and that was always the so fun for me.
So now as a judge, I don't get to do that, but I love being a judge. So I live vicariously through my teams. When I go outside visits, I'm like, okay, what did you see today? Tell me what you saw today. Did they really do that? How did they do that? What did that look like? Because it's really fascinating to see how we all do the same job. We're all providers of long term care. We all are administrators or directors of nursing or whatever. Our role within the organization is, we all have the role and the basics of that role are the same, but every facility makes that happen differently. We do things that work for our organization and make it successful, and we can all learn from each other.
I love that we are now asking our applicants to tell us about how they share and use best practices. How do they identify those best practices? How do they make those refinements of those best practices? Because man, there's some brilliant people in our industry,
Debbie Stadtler: Yes.
Renee Ridling: And you can learn so much from other people and it was always fascinating to go on site visits.
So I love that. I miss that. But like I said, I get to live vicariously through the tease that I'm the lead judge for. So that's always nice. But I just think that's really great to see that everybody that I ever encountered in the facility was so engaged, so positive about what they do, and that just really means a lot.
Debbie Stadtler: I love that you emphasize how different each facility is and how they do things with their own flavor and their own process, but still aiming towards achieving the same goals. From a staff member perspective, we only get a little snippet of that when we see pictures and the winners and the recipients and things like that.
And we're always so impressed at the passion that everyone has throughout the organization. Everybody there is pulling in the same direction, and it's just so different for each one, but it's so exciting and fascinating, so I can completely see that the site visits would be super fun.
Speaking about individual differences, each facility being different. What kind of underlying principles or mindset shifts can folks use as they work through this process?
Renee Ridling: I think team engagement is critical. It's not a process that's just about the administrator or the person that's writing the application. The things that we're doing, those processes have to be deployed.
They have to be shared in a way that the team understands the role that they play. How that process is deployed to senior leaders is going to be significantly different than how it gets deployed to the people that are doing direct care or the dietary person. That's most giving person. But all of those people are critical to having a process well deployed.
I think the other thing that that sets applicants and recipients apart is that they use that criteria not as just something to get an award. Because if that's why we're doing it, that's probably not the best reason. We need to use that criteria as a management tool. We need to take each of those Baldrige core values that that AHCA/NCAL embraces in the quality award program, that leadership and strategy and customer focus, the knowledge management, and all of those key criteria processes, and use those as a tool.
In other words: use it to identify where you have process gaps within your organization. Use it to help you overcome those process gaps within your organization. If you step back and you're like, yeah, our strategic planning is maybe not where it needs to be. Get these things from our parent company, which a lot of organizations do, that's very common,
But how do we take those? Goals and objectives that our parent company says, okay, here it is for this year. How do we take those and internalize those, make those part of our strategy at the facility level so that we're getting the best outcomes for the people that we serve? It isn't just about corporate said, do it this way.
It has to be, well, corporate said do it this way, but you know what, we're already there on pressure ulcers and reducing pressure ulcers. So what do we do beyond that? How do we make that goal and move forward and continue to have success? I think just using that criteria, well, you don't have to do it all at once.
We always tell people I, when I look at an application, I look at leadership, which is category one. I look at category two, which is strategy, and I look in category six to see how we're doing with work process, and those are areas that we as long term care providers maybe are not the best at. So those would be the categories where I would say become students.
Learn what's expected at senior leadership, learn what strategy and strategy, development and implementation is about learn about work processes and support processes and the requirements for those things. Become a student of how to articulate that and deploy that back out to your workforce and to the people that make it happen.
Because I can sit at this desk all day long and I can write a beautiful application, but if my staff can't articulate and isn't really doing it, then it's just words on paper. It's really important that everybody becomes the ball. That team is engaged and the whole process, not just the person writing the application.
So that, I think is the biggest thing. Use the criteria as a management tool throughout the organization.
Debbie Stadtler: I think that makes so much sense. Like you said, someone in the corporate headquarters or senior leadership, they're going to see the strategy and the goals and digest and internalize them one way to be able to put those down through the organization so that really the folks that are in facilities or dining or, you know, interacting one-on-one with the residents every day, that they're also internalizing and getting those strategies and processes.
So important. And like you said, always keep learning. I just think that's so important as it's a continuous process. There are always things to do, tweaks to make all of that. So to continually be a student, I think is great advice. What closing thought would you get to everyone who wants to start or is in the quality improvement journey?
What's your closing idea?
Renee Ridling: If you haven't started, begin, begin this journey. It is awesomely beneficial. I would say if you've started, continue, don't get discouraged because sometimes you write that application, you get that feedback report and you're like, huh, didn't get it this time. Keep working. Use that feedback report.
Examiners spend hours as a team, as independent examiners. Writing feedback to help you understand what's missing, what are those gaps, and then use that criteria to address those gaps, those opportunities for improvement at every level of the criteria. It gives your organization an opportunity to get better, and I think if you're not there yet, get started.
And as you do, embrace that culture of becoming or continuing to be. An organization that is continuously improving. It is ongoing every single day. I've done this many years now, and frankly, I learn something new every single day. I never stop learning And every year I have been involved with the Quality Award program is always a learning experience.
I learn from my peers, I learn from my judges, peers, I learn from the examiners that we work with. It's fascinating to have so many people come together from so many different walks of life. One of the things that's always been fascinating to me is that not every examiner works in long-term care. I think that's something that many of our applicants don't realize is that they come from different industries, they come from different walks of life, different countries.
I have a team right now that has an examiner from England and one from Thailand, so they're all over the world, and the fact that these people are willing to give their time to help our industry continually improve is phenomenal.
Debbie Stadtler: It really is such a great feedback mechanism and one is so personalized to your facility, so it really is a great opportunity for that one-on-one advice.
Well, thank you so much for being with us today, Renee. This has been a great conversation.
Renee Ridling: Thank you for having me.
Debbie Stadtler: And visit ahca.org/qualityaward to learn more about the quality award program. And thanks to everyone for listening to this episode of Perspectives in Long Term Care. Join us each month as we discuss issues that impact the long term and post-acute care profession.
And be sure to subscribe to this podcast wherever you listen to your favorite podcasts. Take care.