Q1 2020 Leadership Letter - Mike Counter

March 31, 2020

Mike Counter

President of North Country Home Health and Hospice

Mike Counter is President of North Country Home Health and Hospice, a healthcare provider based our of Littleton New Hampshire. During Mike's tenure at North Country, the agency has seen strong financial growth, improvements in star ratings, as well as increased satisfaction among the team that provides care to the New Hampshire community.

Mike was previously the CFO for VNA of Vermont and New Hampshire where he was able to help drive significant financial improvements. He started his career in manufacturing which led him to learn and implement Lean Six Sigma practices and other efficiency driven methodologies into the healthcare space. Mike is a graduate of University of Massachusetts, Amherst - receiving his Master of Business Administration.

Mike & Matt in Whitefield, NH - Nov 2019

Matt: Mike, to give our readers some context, it would be great to learn more about your background and your journey into home care. Can you describe your background and the story about how you came to be the CEO of North Country Home Health and Hospice?

Mike:  Starting at the beginning, I worked my way through college and only went to school full time for a short period. Most of the time I was working during the day and going to school at night. I did this all the way through the MBA program at the University of Massachusetts at Amherst. Shortly after, I started moving into management in the areas of finance, accounting, cost accounting, within manufacturing enterprises. This is along the time when Toyota was coming into the US market and the Toyota Production System was getting introduced. Any manufacturing enterprise that was out there was starting to learn about Lean Six Sigma and lean manufacturing practices. The reason I mentioned that, is the knowledge I gained studying these concepts in business school and my experience with it in manufacturing had a big impact on my view as I transitioned into healthcare. One of my earliest positions was in northern Vermont at an automotive parts factory where they were heavily leveraging Lean Six Sigma, driving out waste at every turn. It was in a rural area, but not too far from Dartmouth Medical Center, which is a tertiary Medical Center, the biggest in New Hampshire and Vermont. I always felt that the growing industry was healthcare and it very hard to get into unless you had experience in it.

The factory that I was working for moved to North Carolina to try to achieve efficiencies. During that time, I made an effort to get into Dartmouth Hitchcock Medical Center where an opportunity presented itself in affiliation with a home health and hospice agency. With my finance background, experience in lean principles, and by putting the right things on my cover letter, I had a lot of the things they were looking for so they were willing to give me a shot. I went in as a Financial Controller and learned home health and hospice. Within a few years I was Chief Financial Officer. A few more years after that, the phone rang and asked if I'd like to be President of an agency. It was an external consulting firm we used in the past and they thought I was perfect for the job. There was a big health system that was just taking over home health and they wanted to combine two small agencies that were struggling and had a lot of challenges. So with a little bit of luck, that was the essence of my journey.

M:  Do you have any examples on how your background in lean manufacturing principles has impacted your journey to North Country and some of the improvements you’ve been making there?

Mike:  When I went into healthcare as financial controller of the VNA where I worked, I was just amazed at the amount of waste and inefficiency that was going on. At that time healthcare seemed to be just introducing these concepts of Lean Six Sigma. Medicare was beginning to get the drift, and you would hear things like value based purchasing is coming from Medicare and they're going to pay more to people that provide value and less to the people that don't. These various concepts that were really in place since the 80s within manufacturing were now creeping into payers like Medicare. So I was well poised to help address that within the agency I worked for and I was astounded at the lack of data that was being gathered on the operational side. By gathering all this data and implementing changes, we were able to save our agency a lot of money.

In regards to North Country, one area we looked at was leveraging the technology we have 100%. So what we found is that, our EMR could do 20 things, though five things are being used and side systems were being created when they weren’t necessary. We started focusing on using the technology that we had, whether it be accounting software or EMR software. Generally through attrition we wouldn't backfill the jobs so we would use the technology more effectively while lowering overhead.  Which is always something that any healthcare agency has to watch out for. For example if you're using a communication tool like Tallio to measure your communication and engagement across your agency, or you're using your EMR to do scheduling versus on a piece of paper. Ensuring our team knew how to use the technologies we had in place has helped in our performance. Also focusing on productivity across our staff was critical. We found that the productivity was really nowhere near where it needed to be. And so we started asking the Five Whys. We were able to get down to the root cause of some things and made some very simple corrections and saw productivity improve.

M:  The Five Whys is a great method to uncover a challenge or an area for improvement. What did you uncover that appeared to be impacting productivity?

Mike: I think the number one reason for lack of productivity was lack of management. The clinical management wasn’t watching productivity at the level we needed to be at. There were a lot of organizational development issues around being, for example being ‘too busy’. So we looked at schedules, travel time/distance from where folks lived. So we set up geographic teams to keep people in the city and the towns where they lived. Thereby reducing mileage and mileage reimbursement and increasing visits per day. This coordination by management and the scheduling area was one of the top things that we changed. We also realigned compensation because there was a lot of time spent on documentation and that was not aligned when folks are hourly. We went to a salary plus productivity bonus structure. So we realigned compensation with the company goals, which were five visits per day. 

Working with clinical management to focus on scheduling, keeping people in a tight geographic team, and aligning the compensation for nurses and therapists with the company goals, we were able to increase visits, which were basically increased admissions without hiring any more nurses and therapists. It resulted in being able to grow the top line without adding staff.

M:   Do you have any books that have influenced you on your leadership style or approach to leadership?

Mike: I would say the single most important book I've read is “Straight From The Gut” by Jack Welch. A lot of the concepts in there we don’t necessarily use, but a lot of the general common sense things he outlined really grabbed me. One of the main concepts that he drove into General Electric during his leadership was differentiation. It’s about differentiation of products and differentiation of people. Since we're a people business, one of the things that we brought here was that not everybody's the same. His philosophy is one that is viewed as controversial, especially with HR people. But what we did at North Country - is we looked at each clinician by their quality scorecard and their productivity scorecard and we differentiated them. I would say the difference between Jack Welch's philosophy is that we weren't trying to drive out lower performers, but help educate those people and help them grow to a higher level of performance. The approach of differentiating our staff has really helped us increase our overall team performance by providing a more individualized employment experience.

Also Ken Blanchard’s theory of Situational Leadership is another concept we’ve incorporated. This concept of Situational Leadership, outlines that not everybody should be managed the same. There are some people who learn via different methods and at different rates. There are people that need coaching and support at a very high level when they come on board. So we work towards measuring their progress and then flipping that over to supportive roll down the road when they can manage themselves. It encompasses the idea of differentiating our people but it's differentiating your management style to better compliment different people styles.

M:  With that being said - How do you go about executing the concept of differentiation among staff versus having a standard boilerplate approach to management?

Mike: We have an executive leadership team which is a very small group of people where we discuss our approaches and concepts of management. Around budget time, we go through the staff and discuss rewards for certain people for doing exceptional work. We also have to identify the folks that are not doing exceptional work and develop the message to bring their awareness to it. Then we have a management team level, where our executives generally have one, two, or three managers under them and they’ll discuss these items with their managers. The managers then take that message out to the staff. We do this both on a team level as well as an individual. For example, we're doing that now with a team, where we’re saying - “Here’s where you are and here’s where you need to be, as a team.” Then our managers dive into individuals within the team to discuss where they're at. At every stage of this, we reinforce that whole focus is on education, support, and driving for a win-win and a successful outcome with the staff that we have.

I want to underscore one thing though, and that is that you have to have and use data. We use SHP which provides a lot of quality and productivity data. So if you are a nurse, we would sit down and you'd have a scorecard. We’d cover the number of admissions you did in the last six months, your quality scores, your productivity, your case wait, and review how it’s compared with everybody else in the company, everybody else in New Hampshire, and everybody else in the United States. We review this information quarterly with individual clinicians and it’s indispensable. By using data for performance management, we’re able to say this isn't about a gut feel or I don’t like you because you don't wear the right clothes. But it’s about the data and using it to show folks how to succeed in their role. Only a handful of people self-select and say this isn't for them, but most people just get better.

M:  Do you have a favorite failure or an apparent failure, that later led to a success that you were able to learn from?

Mike:  I actually have a recent example. Last year our health system did a Press Ganey survey and our agency had some of the lowest satisfaction scores across the system. Awareness about this failure provided us the information needed to take action to make improvements. So fast forward to today, we did very well in the second Press Ganey survey. The reason being is that we saw these low scores and a lot of them were around communications. Since I got here we have been doing two annual meetings, a company newsletter, a PDF, among other communications. But perception is reality and we thought we were doing all this great stuff, yet in looking at what the Press Ganey results and we had very low results. We were essentially out of touch. I think a lot of it was not asking the right questions. On a financial basis and a quality basis we were improving and we assumed that the staff were all psyched up about that, but that didn’t seem to be the case. So being more in touch with the field staff is something that I need to continue to always work on as a leader. 

With that being said, communication, I believe is really hard. You can see it in the HCAHPS, survey. One of the lowest scores we receive is on communications. As a leader, a nurse, or anyone interacting with people, you can think you're doing the right thing and communicating properly but you might not be, and feedback is critical for improving it. We believe we can always do better with communications. I think we have made great strides with that and in fact, Tallio has been a very good product to improve this for us. We wanted to do something different and we felt that a two way communication channel where we could collect real time feedback and communicate improvements would add value. And we were right with that as our satisfaction and performance have been significantly improving because of it.

M:  Aside from the tools you may be using, are there any additional initiatives or processes you’re doing to help support your staff since you’ve seen such a good improvement among their satisfaction?

Mike:  In this industry, I believe that at times, field staff feel alone. No matter how much we try to support them, they're out there, day in and day out in their cars, alone. So we’re constantly looking for ways to stay in touch with them. We have to be cognisant because we have to balance a couple of things. One of which is productivity. We don’t want to impact productivity by pulling people out of the field. Remember there's a lot of them that want to make their bonus so pulling them out for meetings isn’t always the answer. We focus on balancing productivity with face to face communications and with quality of life, which we take very seriously.

We've invested in some video conferencing equipment here which allows staff to conference call in via video on their phone, instead of having to spend time driving in. They’re also able to speak with their manager via our video conferencing system as well. We’ve improved some of our supplies drop site locations to reduce drive time and accessibility for our staff. We’ve invested in one more support person in the office here to help handle things like ordering supplies, triage, little problems like calling doctors offices, whereas the nurses used to have to do that. So we’re continually looking for ways to ease the burden of clinical staff.

One thing that I didn't do as much last year is travel around to the locations where people work. This is an area I’m going to improve as we have little drop sites that are close by and I’m going to check in and be there to just say “Hey, here’s how we’re doing as an agency. How are you doing? What’s going on in your world? How can we do better and support you better?” Also by simply saying - “Look how good our business is doing and this is because of what you’re doing out here and we're very grateful to you.” I like to touch base with people every two months in one way, shape, or form. Sometimes with the day to day communications staff can still be frustrated if things change and they’re not aware of it. So we’re continually improving how we do things. Most importantly though, we want to be in communication with our team letting them know we care about them.

M:  Taking it up a step from field staff and looking at your Clinical Managers, how does your team empower and support them specifically?

Mike:  Clinical support managers are absolutely critical functions because not only are they interacting with staff, they're interacting with referral sources and solving problems for them, but they’re also interacting with patients and their families. So they're basically daytime triage and handling all kinds of issues in support of ultimately the highest quality care a patient can get. It’s a big responsibility keeping the work life balance for a nurse as high as possible and keeping our referral sources happy. At North Country we have three Clinical Managers who are all RNs. Our senior managers are the ones who oversee our Clinical Managers. Those Clinical Managers are coached to be looking out, daily and about a week or so in advance and planning for our staff. Helping them adjust from daily firefighting and scrambling was a big concept of mine that I wanted our team to work on. It’s difficult sometimes but I think we're really getting there and the staff are feeling better because of it.

In terms of supporting them, a lot of it has to do with the tools and technology to do their job effectively. We give a lot of training on the EMR system, or other software that they use. Each person has a different function they focus on, whether it is home health or hospice, but they work very closely as a tight knit team and support each other immensely. Hiring and selection for the right skills from the beginning is imperative as they have to come in with very good clinical skills, good organizational skills, and thick skin. Once they’re on board we watch out for self care. I emphasize a high priority to our senior people to watch their clinical management team make sure they don't burn out. I think that might be a little unique to some organizations, but it's an investment.

M:  What's an example of some of the things you might do for supporting people from a self care perspective?

Mike: One of the things we’ll advise is to take some time off or take the afternoon off if we think we're seeing some stress. We typically monitor that very carefully. We’re discussing a comfort room here in the office where you can go in and just sit down in a nice easy chair and chill out. This is an area that we’re focusing on significantly to better support all staff from management down to field staff and are fairly early on in the process. But again, the underlying concept is investing in the people that are here. Good people don't grow on trees. So we want to invest in them and I think that it's working and I believe that most of the people here know that we care about them.

M:  How do you socialize the importance of supporting self care to the rest of your management team so your message is cohesive?

We ensure it’s a constant part of our conversations at the management level. We discuss the importance of taking time off on a regular basis. One of the nice parts of healthcare which I never saw in the manufacturing industry is that most healthcare organizations start you off with four weeks of vacation. Whereas you might get two weeks after working at a manufacturing facility after five years. But in healthcare you can sometimes get pushed which makes using your time off very difficult. So, we make sure people use their time. Then having constant check ins among our staff, while using data, enables us to address concerns and issues with the team before larger issues arise. If we see results slipping, attitudes changing, we jump all over it right away. For example, we recently had an RN that indicated that they might be leaving shortly, so we sat down with them to see what was happening. We said that we wanted to make this a successful job for them, what can we do? So we made some changes based on their feedback and they’re back enjoying their job and contributing well to our team and patient care. The key is quickly addressing challenges straight on with individuals.

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