How to Grow a Quality End
of Life Organization.

"Our mission is to put life into days when days cannot be added to life," explains Dale Knee, president and CEO of Covenant Hospice in Pensacola, FL. Covenant served more than 5,500 patients and families last year in 35 counties. As co-founder with Studer Group of the Studer Covenant Alliance, Covenant also brings coaching expertise and leadership training to end of life organizations nationwide.

By any account, Covenant is living its mission. Family satisfaction is at the 99th percentile (compared to hospices nationwide in the NHPCO and Deyta databases). Length of stay has improved 20% to an ALOS of 70-plusdays; physician referrals areat a record high withfew seasonal dips; and average daily census has doubled to more than 1200 since 2002.

Leadership Training Is the Secret
Covenant credits its success in overall staff development and training to its OPTIMALSM program in which all staff are involved. For Covenant’s leaders, the leadership component of OPTIMALSM includes two days of focused training each quarter and then applying the skills learned on a daily basis to move organizational performance to the highest possible levels. "Just as we train our clinicians and accounting clerks on technical skills, we make the same investment in teaching leadership skills to leaders," explains Knee. "There is a direct correlation between skill development with lower turnover, better service to patients, higher and more consistent quality, stronger financials, and growth. We call it an evidence-based leadership model."

In fact, Covenant found that as it improved its service and quality—as well as its ability to promote its capabilities at all levels of the community—its reputation improved. Because a culture of excellence creates trust, an increasing number of physicians, nursing homes, and hospitals began to refer more patients.

Aligned Goals Grow Admissions
Covenant relies on an objective and measurable leader evaluation process to set clear expectations and accountability for leaders. All leader goals are aligned horizontally and vertically on key organizational goals under Covenant’s six Pillars: People, Service, Quality, Finance, Growth, and Community.

To meet its mission, one of Covenant’s goals is to ensure the greatest number of patients and families have access to end of life care when they need it. As a result, CEO Dale Knee set a growth goal to increase referrals and admissions. Success is measured by how much Covenant exceeds budgeted projections for growth. While senior leaders are all evaluated on this goal, the tactics they use to meet it vary.

For instance, VPs of operations are evaluated on how well they improve the quality of care, increase community recognition, and ask for patient referrals. The vice president of development works to increase media exposure and fund-raising. The branch managers are responsible for responding quickly to referrals and admissions. The result? Teamwork that is projected to result in a 20% increase in admissions for 2007.

Key Words Improve Physician Referrals
One focus of Covenant’s leadership training is building communication skills. Perhaps most importantly, the training leaders get is cascaded to all levels of the organization to hardwire a culture of excellence. For example, home health aides and other care team staff use key words to put families at ease by explaining their skills sets and introducing other team members.

In the community, leaders use key words with physicians to help them shift their paradigm about only considering end of life care in the last days or hours of life. Covenant staff visit physician offices and ask, "Do you currently have any patients that wouldn’t surprise you if they died in the next year?" If the answer is yes, Covenant asks the physician if he or she would like for them to do a hospice evaluation.

"Physicians are more comfortable if they can think in terms of a one year prognosis versus six months or less, which is the prognosis required to recieve Medicare reimbursement. It broadens the conversation and allows them to think about longevity and putting care into days," adds Knee. "In reality though, we find that 90% or greater of the patients we evaluate have a life expectancy of less than one year."

And yet, Covenant admits all patients that need its services regardless of ability to pay or Medicare eligibility. "We can’t allow our mission to be defined by Medicare reimbursement," he says. "We want to create a relationship of trust with physicians so that they act sooner rather than later for patients in making referrals. So sometimes we need to invest in working with one physician or patient by demonstrating our commitment to providing care to those who need it. More frequent referrals of other patients more than offset this cost."

Live Patient Surveys Boost Patient Satisfaction
In addition to retrospective patient-familycaregiver surveys conducted after the death of a patient, Covenant uses key words in live, concurrent patient surveys beginning upon admission. If a patient is able, Covenant asks the patient directly about the top three things they can do to put quality into the patient's life. Otherwise, the family is asked. "The care plan is designed not just by our own assessment of needs," notes Knee. "But it is also sensitized to the patient’s wishes based on how they define the quality of their life. On every patient interaction, we revisit questions so it becomes a process of concurrent questioning, frequently redefining the most important wishes of the patient." In this way, Covenant makes a difference real-time in the quality of patient care.

"Success all flows from a pervasive culture of excellence," Knee reflects. "Once employees understand why key behaviors are the right thing to do, they take a great deal of satisfaction in doing them. Eventually it becomes a part of the every day experience of everyone who works in the organization and will stand the test of time, regardless of who the actual leaders are."