Kansas Masonic Home:

PWB’s

by Dr. Tony Lybarger

Introduction:

• I created this Power Point Presentation for managers and supervisors in health care facilities. The content is based on my education, training and experience as a manager in health and human service agencies.

• During our session you will learn the characteristics of a Culture of Execution and how to create that work Culture at the Kansas Masonic Home (KMH).

• Identify Preferred Work Behaviors (PWBs), rate employee performance on PWBs, create a POC for deficient performance and use the Lybarger Matrix Management to represent shift/department performance.

What is the Value of Leadership Without Execution?

• Leadership without execution is incomplete and ineffective. That means (to me) that no matter how great you are at leading employees, if you are not getting things done effectively and efficiently --- who cares!

• The test of your leadership/supervisory ability is knowing what work needs to be done, what skills are required to get that work done, knowing which employee can best do that work and getting employees to do that work correctly 90% of the time promptly with little or no supervision.

Hardwiring ExcellenceQuint Studer:

• Quint Studer is a hospital administrator turned author and consultant to health care organizations across the country.

• He has learned how to increase patient satisfaction through increased employee satisfaction.

• He believes that once systems and processes are in place to sustain service and operational excellence, an organization is no longer dependent on a particular leader for continued success.

• The work behaviors that create service and operational excellence are hardwired (automatic) into the culture of the organization.

Baptist Health Care:

• Al Stubblefield (CEO) said they were desperate

• They decided to build a service culture that would be hard to duplicate or compete with

• The tipping point was when they realized the key to increased patient satisfaction was increased employee satisfaction

Execution (the discipline of getting things done) by Larry Bossidy:

• Larry Bosssidy worked at General Electric for 27 years as a soul mate to the greatest CEO in American industry --- Jack Welch.

• The organizational success at GE (the 2007 Most Admired Company) is based on a Culture of Execution.

• That management philosophy is transportable to your long-term care facility.

• The three most important concepts in this style of management are differentiation, accountability & robust dialogue.

How Was the Work Culture at the KMH Created?

• An organization's culture is the sum of its shared values, beliefs and norms of behavior.

• Another way to describe “culture” is what you as a Department Manager expect from yourself, other leaders and employees.

• Culture can also be defined as the unwritten rules you live by at work.

• An organization's culture defines what gets appreciated, respected and rewarded.

Macro or MicroThat is The Question:

• You have two management styles to choose from related to problem solving and getting things done.

• You can be a Macro Manager who gets things done through the culture by making one decision that solves 100 problems.

• You can be a Micro Manager who gets things done by making 100 decisions that solves one problem.

• What is your choice?• Once you’ve made that decision, you can move on to the

three most important questions supervisors must answer [1] What to Change, [2] What to Change to & [3] How to Create that Change.

Macro Management Concepts (1)

• There are two types of organizational change (symbolic & systemic). Symbolic comes first followed by systemic.

• Right-to-Left Management: Select an organizational destination and operationally strengthen all activities, programs and people that increase the probability of arriving at that destination and discard all others.

• Hire slow and fire fast. Recruit, select and retain the 90/90 employee. The 90/90 employee does 90% of her work correctly 90% of the time with little or no supervision.

Macro Management Concepts (2)

• Have the least number of employees possible and pay them as much as possible.

• If a job requires 10 employees assign 9.• Pursue vocational equity --- employees love to see people get what

they deserve.• Identify the macro success for your Unit/Shift and based on that

success select five – eight Preferred Work Behaviors (PWB’s).• Lybarger 70 – 15 – 15 Rule --- 70% of the people working in your

organization are vocationally normal (remove demotivating factors and they will give you a days work for a days pay), 15% of the people are genetically happy (they will help you no matter what you do) and 15% of the people are genetically angry. They will be pissed-off no matter what you do. Don’t waste your energy on them.

Macro Management Concepts (3)

• The rate of organizational change increases when specific people are held accountable for specific tasks at specific times.

• The rate of changes is even more rapid when positive and negative consequences are applied consistently contingent on performance.

• A person can only be a victim so long, then they become a participant.

• Every adult is responsible for his/her own behavior.

Macro Management Concepts (4)

• Fix the cause not the symptom (turnover, absenteeism, low moral, low productivity and/or too many errors).

• Your Department is not a Rehab Unit for Negative People!

• You cannot manage effectively from a position of weakness --- confront what or who you fear most.

• The Messiah is not coming for Supervisors.• Learn how to talk like a “Behaviorist” (weird).

Macro Management Concepts (5)

• Commit to 3 – to – 1 relationships.• Create a consequence rich work

environment.• Management is a contact sport!

How Can KMH Become a Better Place to Work & Live ?

• Get the right people on the bus in the right seat and get the wrong people off the bus.

• Recruit, select, train & retain the 90/90 employee.• Good hiring looses value without good firing.• Hardwire excellence by creating a Culture of Execution.• Differentiate significantly between productive and non-

productive employees with compensation & rewards.• Create a consequence rich work environment. Manage

the culture (macro management) not the people (micro management) Pay less attention to motivation & more attention to demotivation.

Execution:The Art of Getting Things Done

• Execution has to be embedded in the reward systems and in the norms of behavior that everyone practices.

• Leaders who execute look for deviations from desired managerial tolerances---the gap between preferred and non-preferred behaviors.

• Execution has to be a part of the organization’s culture driving the behaviors of all leaders and employees at all levels.

• We don’t think ourselves into a new way of acting, we act ourselves into a new way of thinking.

Create a Culture of Execution:

• An culture of Execution is put in place by leaders who exhibit the following behaviors:

• [1] Promoting and rewarding people who get things done.

• [2] Assign and monitoring the performance of tasks.

• [3] Leading and coaching through honest communication and feedback =‘s Robust Dialogue.

How Do You Change the Culture?

• You change people’s behavior so that they produce results.

• [1] Tell people what results you expect.• [2] Discuss how to get those results• [3] Reward people for getting those results• [4] For those people coming up short,

provide coaching, withdraw rewards, move them to another job or fire them.

“First Who”Easy to Say --- Hard to Do!

• This management philosophy requires that your organization differentiate between productive and non-productive employees.

• That you hire slow and fire fast (probationary period is a great time to loose low potential employees)

• That productive employees receive rewards that are significantly different from non-productive employees

Rigorous Not Ruthless:

• The only way to deliver to the people who are achieving is to not burden them with the people who are not achieving.

Accountability Talk!

• In a Culture of Execution people talk to each differently. Every conversation is a performance evaluation. Employees hold each other accountable!

• You cannot have an execution culture without Robust Dialogue --- that brings reality to the surface through openness, candor and informality.

• Harmony --- sought by leaders who wish to offend no one --- can be the enemy of truth

• Don’t fight your way up the “Pecking Order.”• BS walks & behavior talks!

Are You Paying People to Help You Fail?

• When in doubt about a job applicant --- keep looking.

• When you know you need to make a people change, act.

• The moment you feel the need to tightly manage someone, you’ve made a hiring mistake (hire slow & fire fast).

Can Employees Change their Behavior? YES!

• People don’t think themselves into a new way of acting they act themselves into a new way of thinking!

• Identify PWB’s --- then reward employees who exhibit those PWB’s correctly/consistently and coach, transfer or fire those that don’t.

• The foundation for changing behavior is linking rewards to performance and making that linkage transparent.

• If you, the leaders, reward and promote people that Execute, the culture will change to match their behavior.

How Do I Motivate Employees I Supervise?

• You don’t!• GTG companies paid little attention to motivating employees. Under

the right conditions, the challenge of motivating employees melts away.

• When employees (85%) see PWB’s being rewarded significantly, they will, without being told to do so, exhibit those same behaviors.

• Recruit, Reward & Retain the 90/90 employee and the need for supervision and/or motivation will evaporate. (almost)

• Spotlight the “high performance” employee• The only way to deliver to the people that are achieving is to

not burden them with the people who are not.

Remove Demotivating Factors From the Work Environment:

• Create a Stop Doing List! • The fastest way to make a profit is to stop doing

things that don’t make a profit.• Four times a year ask employees to identify irrelevant

and non-productive work. Then stop doing that work! • Initiate a monthly “What We Do Worst” meeting. • Remove “CRAP” from the work environment! • If the job requires 10 employees --- assign 9. Too many

employees is an organizational disaster looking for a place to happen!

You Are Now Entering a PWB Zone:

• The preceding information describes management issues and strategies that strengthen the use of PWBs to maximize employee performance. You are now entering the PWB Zone. During our session we will create a Matrix and PWBs specific to your area of responsibility at the Kansas Masonic Home.

Preferred Work Behaviors:

• There are two types of employee work behaviors in healthcare organizations:

• Employee work behaviors that increase the probability of achieving the Departmental or Medical Center’s most important success --- Preferred Work Behaviors.

• Employee Work Behaviors that decrease the probability of achieving the Departmental or Medical Center’s most important success --- Non-Preferred Work Behaviors.

What You Must Be Able to Do:• First, you must be able to identify the most important organizational

success (problem to be solved) for your area of administrative responsibility.

• Second, you must be able to identify five Preferred Work Behaviors (PWB’s) that if exhibited correctly and consistently by employees increases the probability of achieving that organizational success.

• Third, know how to use a rating scale of 1 – 5 to quantify individual employee behavior using the Lybarger Matrix Analysis Process.

• Four, be able to use the Matrix to identify employee behaviors to be rewarded (4 & 5) and employee behaviors that require correction or elimination (1 – 3).

• Five, use the Matrix over time to determine if employee work performance is improving, staying at the same level or getting worse.

The Evolution of PWB’s:• From 1987 to 1994 I was the Director of a 500 bed public

residential facility for the mentally retarded with an operating budget of $35 million and 1500 employees.

• During my tenure we moved from 42% compliance (1987) with external federal regulations to 100% compliance (1994).

• As a part of that management matriculation I discovered [1] Right –to-Left Management, [2] the importance of choosing the organization’s Macro Success, [3] identification of PWB’s in alignment with that Macro Success, [4] the Lybarger Decision Making Matrix and [5] how to use the Matrix as a guide for exerting control over employee work behavior.

• From 1994 to 2003 I was the Administrator of a Critical Access Hospital and used the Lybarger Decision Making Matrix in several Departments including Accounts Receivable.

• For that same period of time I had administrative responsibility for a 50 bed long term care center where we used the Matrix related to reducing the number of deficiencies on surveys.

Compliance from 1987 – 1994:Percent of Compliance

40%

50%

60%

70%

80%

90%

100%

87 88 89 90 91 92 93 94

Fiscal Year

Per

cen

t o

f C

om

plia

nce

Lybarger Decision Making Matrix:

Question Unit A Unit B Unit C Unit D Unit E Unit F WSHCompliance

Level3. Rotation 95 98 77 75 92 95 89 904. Schedule 100 100 100 100 90 93 97 755. Materials 85 100 82 83 54 76 80 906. Staff EXP 100 100 100 98 100 100 99 1007. Professional 60 59 33 33 54 55 49 50*8. SIB/PA 100 100 100 100 100 100 100 909. Intervention 100 100 100 100 100 100 100 10010.Dignity 100 100 100 100 100 100 100 9011. Privacy 95 100 100 95 97 100 98 90

Unit A 334 YES answers out of 360 possible YES answers = 93%Unit B 351 YES answers out of 369 possible YES answers = 95%Unit C 309 YES answers out of 351 possible YES answers = 88%Unit D 313 YES answers out of 360 possible YES answers = 87%Unit E 307 YES answers out of 351 possible YES answers = 87%Unit F 344 YES answers out of 378 possible YES answers = 91%

WSH TOTAL1958 Yes answers out of 2169 possible YES answers = overall 90%* Percentage changed 10/1/93

OBSERVATION PERCENTAGESMay 23, 1994

Baptist Health Care:Preferred Work Behaviors

• Baptist Health Care developed what they refer to as “Baptist Behaviors.” These behaviors represent my PWB’s. They also created ten Standards of Performance that are observable, measurable and reportable.

• To select PWB’s Baptist Health Care employees identified recurring interactions between customers and employees and established expectations for specific employee behaviors in those situations. Their goal was to outline a set of acceptable (preferred) behaviors that would become the standard for all workers.

• Driving out variance in employee behavior is in the best interest of your organization.

Standard of Performance:Attitude

• Promptly welcome your customers in a friendly manner, smiling warmly and introducing your self. Do not allow anyone to feel ignored.

• Meet the customer’s need or gladly take him or her to someone who will.

• Thank our customers for choosing our hospital.

Standard of Performance:Appearance

• Dress in a manner that is professional. tasteful and discreet.

• Always wear your identification badge properly.

• When you see litter, pick it up and dispose of it properly.

• Return all equipment to its proper place.

Standard of Performance:Communication

• Use “please,” and “thank you,” “sir,” and “ma’am” in all conversations when appropriate.

• All employees must know how to operate the telephones in their areas. When transferring a call, first provide the caller with the correct number in case the call is disconnected.

• Use easily understood and appropriate language when giving patients information about their health status.

• Never discuss information about patients or hospital business in public areas.

Standard of Performance:Call Lights

• All hospital employees are responsible for answering patients’ call lights.

• At the nursing station, call lights will be acknowledged by the fifth ring.

• Check on patients one hour before shift change to minimize patients request during shift change reports.

Standard of Performance:Commitment to Coworkers

• Treat one another as professionals deserving courtesy, honesty and respect.

• Welcome newcomers.• Show consideration. Be sensitive to a

fellow employee’s inconvenience by avoiding last-minute requests.

• Never chastise or embarrass fellow employees in the presence of others.

Standard of Performance:Customer Waiting

• Provide a comfortable atmosphere for waiting customers.

• The acceptable waiting time for a scheduled appointment is ten minutes; for unscheduled appointments it is one hour. Apologize if there is a delay and always thank customers for waiting.

• Update family members periodically --- at least hourly --- while a customer is undergoing a procedure.

Standard of Performance:Elevator Etiquette

• Use the elevator as an opportunity to make a favorable impression. Smile and speak to fellow passengers.

• When transporting patients in wheelchairs, always face them toward the door and exit with care. When transporting a patient in a bed or stretcher, politely ask others to wait for another elevator.

Standard of Performance:Privacy

• Use discretion in telephone conversations with customers.

• Close curtains or doors during examinations, procedures or when otherwise needed.

• Provide the proper gown size for customers and provide a robe or second gown when a patient is walking or in a wheelchair.

Standards of Performance:Safety Awareness

• Report all accidents and incidents promptly and completely.

• Protect your back when lifting, pushing, pulling or carrying. Get help when necessary.

• Use protective clothing and equipment when appropriate and be prepared for emergencies.

Standards of Performance:Sense of Ownership

• Keep your work area and surrounding environment clean and safe.

• Look beyond your assigned tasks. When it is appropriate for you to perform a service, do so.

• Do not say, “It’s not my job.” If you are unable to meet a request, be responsible for finding someone who can.

• Complete tasks. If interrupted, return to the job as soon as possible. If you are unable to finish a task, find someone who can.

This is our Destination:

Goal PWB

1.2.3.4.5.

1. 2. 3. 4. 5.Employee Name

Matrix

Matrix Management Question #1:

• Can you identify the most important problem (I understand you have several problems needing resolution) needing to be solved on the shift/unit of KMH under your administrative control?

• One way to get at this Macro Problem is to list five problems you are facing. Then prioritize that list. For this activity, problem #1 is the place to start.

• Today we are talking about Charge Nurse related behavior management issues. However, for other Departments the Macro Problem (Goal) could be food temperature, sanitation, infection control, work order completion, failure to check references or physicians signing charts.

• The Goal must be written in a way that is time specific and measurable.

Writing the Goal:

Goal

Ten or Less New Decubitis Ulcers in the Next 30

Days

Matrix Management Question #2:

• Can you identify five work behaviors (PWB’s) that if exhibited correctly and consistently by employees increases the probability of solving your Macro Problem. For this activity, solving your Macro Problem is achieving your Macro Goal?

• I have chosen the following PWB’s: [1] employee can describe each resident’s Treatment Plan (MDS) related to skin care, [2] answers resident’s call light before the fifth ring 90% of the time, [3] provides skin care in compliance with Treatment Plan 90% of the time, [4] turns resident as scheduled 90% of the time and [5] ensures that protective devices are in place 90% of the time.

Five PWB’s:

Goal Preferred Work

Behaviors1.2.3.4.5.

Knowledge

Call light response

Provides skin care

Turns resident

Protective devices

Ten or Less New Decubitis Ulcers in the Next 30

Days

Matrix Management Question #3:

• Can you create the Lybarger Decision Making Matrix and rate each employee’s job performance on a scale of 1 – 5 for each PWB? (1 = low & 5 = high)

• This step in the Macro Problem resolution process will illuminate employee performance on each PWB. This quantification allows you, as the manager, to know which employee is performing at or above standard and which employee is below standard.

• My position is until you know what Success Behaviors (PWB’s) are for the employees you supervise you don’t know which behaviors to strengthen or which behaviors need to be eliminated. If you don’t have that information, you are managing generically not prescriptively!

• Finally, if you don’t know what Success Behaviors are, how can employees know?

Completed Matrix #1:

Employee Name 1. 2. 3. 4. 5.

Bill 3 4 3 5 3Robert 1 5 3 4 4

Jane 3 1 5 1 3Susan 4 1 1 3 5Mike 5 2 3 2 4Sarah 4 3 2 5 3

Matrix Management Question #4:

• Can you analyze the Lybarger Decision Making Matrix and design a reward system for employees exhibiting above standard job performance (4 – 5) and/or create a Plan-of-Correction for each employee exhibiting below standard job performance (1 – 3) which would include [1] coaching, [2] training or [3] progressive disciplinary action?

Creating A Culture of Accountability:

• There are two types of Organizational Behavior Modification --- Individual and Environmental.

• Individual Behavior Modification (EBM) involves changing employee behavior one employee at a time by manipulating behavioral consequences.

• Environmental Behavior Modification involves changing the behavior of all employees concurrently through the Culture. EBM, in my opinion, is the most effective and efficient process for increasing the rate of exhibition of PWB’s.

• For this Training Activity, I am using EBM with the understanding that the probability of achieving success in the Nursing Department, related to skin care, would be increased if the entire KMH operated with a Culture of Accountability.

• A Culture of Accountability is a consequence rich work environment where employees exhibiting preferred work behaviors experience rewards significantly different from employees exhibiting non-preferred behaviors.

Rewarding Success Behaviors:Sarah

• The initial Matrix shows Sarah to be proficient in knowledge about the treatment plan (skin care) (4) and that she turns residents as scheduled (5).

• You want Sarah to continue performing at that level. To increase the probability of that occurring you should connect preferred performance with rewards meaningful to her.

• Rewards might be a gift certificate, time off, theatre tickets, free lunch, thank you or public appreciation by posting her success scores on PWB’s.

Plan-Of- Correction:Sarah

• The initial Matrix shows Sarah needing improvement in call light response, providing skin care & making sure that protective devices are in place. Your strategy for improving her performance might include:

• Call Lights – Arrange for Sarah to talk to Robert (his score was 5) about the significance of answering call lights promptly. Also, schedule a conference with Sarah and the Charge Nurse. The focus of this conversation is to make sure Sarah understands the significance of answering call lights promptly.

• Skin Care – You might talk with Sarah about skin care techniques and how they prevent skin breakdown. You want to make sure she understands the process.

• Protective Devices – Set up a training session to make sure she understands the role of each protective device in skin care and breakdown prevention. You might ask Susan (her score was 5) to shadow Sarah for part of a shift to make sure she is competent in applying the concepts discussed during training.

Matrix Management Question #5:

• Can you lead the employees in your area of administrative responsibility through the weekly Lybarger Decision Making Matrix analysis process and make the necessary modifications to rewards or Plans-of-Correction as required to solve the Macro Problem and achieve the Macro Goal?

Week 3 Week 2Week 1

1. 2. 3. 4. 5.Employee

Name

Bill

Robert

Jane

Susan

Mike

Sarah

3 3 3

3

3

3 3

3

3

3

1

1

1 1

1

2 2

2

4

4

4

4

44

5

5

5

5

5

5

1. 2. 3. 4. 5.Employee

Name

Bill

Robert

Jane

Susan

Mike

Sarah

4 3 4

4

3

4 4

2

2

3

3

2

2 2

3

2 2

4

4

4

4

4

44

5

5

5

5

5

5

Employee Name

Bill

Robert

Jane

Susan

Mike

Sarah

1. 2. 3. 4. 5.

5 4 5

4

4

4 4

1

4

4

4

3

4 4

4

2 4

4

4

5

4

4

44

5

5

5

5

5

5

Weekly Matrix Analysis:

Management is a Redundant Process:

• As you can see Nursing Department employees have increased their proficiency on most PWB’s. Bill, Robert and Susan are at 4 and 5 on all Pwb’s. Congratulations! Jane has a score of 4 or 5 for all PWB’s except Call Light Response where her score has increased from 1 – 3. Mike’s scores 4 or 5 on all PWB’s except Call Light Response where he has a score of 2 on each Matrix. Sarah scores 4 or 5 on all PWB’s except Protective Devices where her score has decreased from 3 to 1.

Plan-of-Correction:Call Light Response

• Jane – Based on her improvement on 4 of 5 PWB’s I believe Jane can learn new skills and put them in place. I suggest a meeting where you ask her if she knows what is required to score 4 or 5 and then ask her why she hasn’t. I believe you will learn from that conversation what is blocking her progress. You might consider having a staff trainer shadow her for part of a shift and use the interaction as a Coaching opportunity. Create a five day POC based upon your observations.

Plan-of-Correction:Call Light Response

• Mike – Mike has scored 2 on each Matrix. You must determine if he has the knowledge required to perform at the 4 or 5 level, if he wants to perform at the 4 or 5 level or if there is another issue inside or outside the Department. I suggest [1] ask him if he knows what skills are required to score 4 or 5, [2] have Robert shadow Mike for part of a shift to gain another opinion about Mike’s skill level and [3] create a five day POC based on those observations.

Plan-of-Correction:Protective Devices

• Sarah – Her performance on all PWB’s except Protective Devices is at the 4 or 5 level. This suggests that she can learn how to exhibit individual PWB’s successfully. However, her performance on Protective Devices has decreased from 3 – 1. Based on your conversation with her you determine that she does not have the capacity or motivation to learn the skills required to score 4 or 5 on all PWB’s. You need to talk to HR about a transfer or start Progressive Disciplinary Action.

Departmental Motivation:• You could post the Matrix in a public place for all employees to see.

Some of you will have concerns about embarrassing employees with below standard performance on PWB’s. Your decision has to do with differentiation and transparency.

• You could post the Matrix inside the Department where it could be seen by all employees. Your decision has to do with differentiation and transparency.

• Create a weekly Departmental Reward where, based on number of employees scoring 4 and 5 on PWB’s, lunch is provided by the CFO for all employees.

• You could post the Matrix inside and outside the Department. For employees outside the Nursing Department this would offer an opportunity to describe the importance of skin care for the people living at KMH.

Culture of Accountability:• You don’t need a lot of complex theory or employee surveys to

create a Culture of Accountability. You need to change people’s behavior so that they produce results. First you tell people clearly what results you’re looking for. Then you discuss how to get those results, as a key element of the Coaching process. Then you reward people for producing the results. If they come up short, you provide additional Coaching, withdraw rewards, give them another job or let them go.

• The only way to deliver to the people who are achieving is to not burden them with the people who are not achieving.

• Organizations win when managers make a clear and meaningful distinction between productive and non-productive employees by cultivating the strong and culling the weak.

• Employees don’t think themselves into a new way of acting, they act themselves into a new way of thinking.

Increase in Decubitis Ulcers:

40

45

50

55

60

65

70

75

80

Week 1 Week 2 Week 3 Week 4 Week 5 Week 6

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Questions?

• I would like to respond to any questions or comments you have.

• You may contact me at tlybarge@yahoo.com or 316-630-9320.

• Thank you!• Dr. Tony Lybarger