'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 quality--including the actions that produced it--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.

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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). Value--at least the customer's perception of value--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 profitability--some would say its very existence--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 experience--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 center--personnel. This is short sighted. In a service industry it is only through staff (and staff culture) that one can enhance quality and, in so doing, create value.

So, although cost containment must be addressed, it must be informed. Otherwise, it will work at cross-purposes with the goal of revenue growth by reducing the customer's perception of value. Reducing turnover, while much more difficult to accomplish, is informed cost containment. It, too, requires the appropriate backdrop of community culture to succeed.

In creating value, some factors have a tangible impact, while others are less likely to make an appreciable difference. Government, for much of seniors housing and care, actually falls into the former category. Particularly for nursing facilities, government can be an aggravating, frustrating factor.

Some companies, large and small, simply have not allowed government to have an impact on their culture. Indeed, there are many examples of companies and communities that, after installing quality management programs (thereby underscoring the importance of culture), have found government's impact to be less intrusive. If nothing else, a noticeably more satisfied staff--and a resulting improvement in resident attitudes--could not go unnoticed by the survey team.

To reiterate: Quality creates value, and we know what affects the customer's perception of quality. It is the knowledge evidenced by staff, the skills they display, and the attitude reflected in their activities. The first two characteristics are more easily defined and measured than the latter. Core competencies should be written for each job in the facility. Both parties to the employment agreement must understand the knowledge and skills required for the position being filled. The effective manager has either hired for those core competencies or will provide the requisite training to achieve them.

Attitude is less tangible. Like good art, you often recognize it only when you see it. Your attitude is a critical component of your perspective. If you think your work is important, the pleasure you take in it is likely to show. Although attitude may be difficult to define, perspective is not. For example, people with a genuine love for the elderly are more likely to become long-term employees than those who see them as just a cantankerous group of demanding customers.

A background that includes volunteer work in a senior center, elective course work in gerontology, or leisure activities with grandparents might all be signals of an abiding interest in working with the elderly. And if the personality traits exhibited by a potential employee are more extroverted than introverted, it might be a better sign of the "right attitude" for work in a seniors housing and care community. Pre-existing skills and knowledge need not be a sine qua non for employment, although they may be an important litmus test for perspective. Here is where effective training comes in. You can train for competencies once you've hired for attitude.

Ben Pearce has suggested that "behavior is manageable; personality is not". (1) Buckingham and Coffman insist throughout their seminal text that personality (referred to as "talent") can only be hired, never created. (2) If you make a mistake in hiring for "talent" (what they call a "casting error"), don't assume you can change the employee's behavior to rectify that mistake.

It stands to reason, therefore, that the development of a community culture begins and ends with its leadership, particularly its CEO. If talent can't be trained, it is equally unlikely that it can be "reborn." More than one CEO suffering under the delusion that seniors housing and care is just another form of real estate can be found among those leading today's bankrupt companies. Successful companies are a function of culture. Culture is based on belief systems. Seldom do we see an individual develop a whole new belief system simply because the old one was found wanting.

Although you can't train for culture, you can nourish it. Effective training can build on attitude as it helps develop core competencies. Dining room waitstaff may want to make the experience pleasurable for the resident. Training can help them pull it off. That, in turn, will structure the actions undertaken by the employee in a way appropriate to the functions involved. The end result will be an employee that displays all three of the attributes needed to improve quality and, consequently, enhance value: knowledge, skills, and attitude.

Maintaining attitude and, consequently, maintaining culture require constant attention to the concept of staff involvement and empowerment. You can direct within a rigid hierarchical structure using "carrots and sticks" for motivation, or you can lead, based on a common vision, while sharing responsibility for success with an empowered staff. The latter requires the implementation of a concept not that common in many communities--staff understanding of (and involvement in) as many community and/or corporate processes as feasible. Staff may have been committed when they came on board, but that commitment can easily disappear if their experiences are not what they had expected.

Staff suggestions for improving resident satisfaction, if never discussed by management (much less accepted), can only have a chilling effect on staff attitude (culture). Let's cycle back to the example we used to begin this column: Your residents are not satisfied with their dining experience and you need to know why. Is it how the food is prepared? How it is presented? When it is served? Waitstaff are in a better position to answer those questions than management. Ignore their input at your own peril.

This is where the establishment of community teams becomes critical. I'll talk about that next month.

To comment on Dr. Willging's views, as expressed here, e-mail [e-mail].

References

1. Pearce BW. Senior Living Communities: Operations Management and Marketing for Assisted Living, Congregate, and Continuing Care Retirement Communities. Baltimore: Johns Hopkins University Press, 1998.

2. Buckingham M. Coffman C. First, Break All the Rules: What the World's Greatest Managers Do Differently. New York: Simon & Shuster, 1999.