Culture Change in Action: Coaching Comes to Partners in Care
By Ellen Murphy
This excerpt from a workshop brochure caught the eye of Marki Flannery, president of the home care agency Partners in Care, when, in 2006, she was considering whether to sign up the agency for training in the PHI Coaching Approach to supervision. An affiliate of Visiting Nurse Service of New York, Partners in Care employs over 7,400 home care workers. The agency, which has been in operation since 1983, provides services to over 20,000 clients a year throughout New York City.
The statistic about supervisors was depressing, but it rang true to Flannery. Having worked at Partners in Care for over 25 years, beginning in frontline care, she knew that disciplinary issues involving aides drained an inordinate amount of her supervisors’ time and energy. Each supervisor carried a heavy caseload—about 90–100 cases. Given these stressful circumstances, many supervisors didn’t last long in the job. “They were frustrated,” says Flannery, and she didn’t blame them.
Another pressing issue was turnover among aides. Many of those who left complained that they did not feel respected. As president, Flannery knew that something had to change. She wanted to put Partners in Care on a better track—one that would lead to better retention of office and field staff. She also wanted to find ways to help aides feel more respected and valued in her organization.
The Foundation of Culture Change
The PHI Coaching Approach, she realized, could be the foundation of the culture change she envisioned for the agency. “Culture change means changes in behavior, in practice, in interactions all down the line. It’s about improving relationships,” Flannery says.
PHI Coaching Approach training programs teach staff throughout an organization the specific skills they need for more effective communication and relationship-building. When supervisors learn these skills, they are better able to support workers while also holding them accountable.
It’s About Relationships
Positive relationships, Flannery explains, are key to improved retention as well as to customer satisfaction. Aides who feel respected, known, and cared about are much more likely to remain on the job. Supervisors could provide that support, if they were not constantly addressing disciplinary issues.
For Flannery, these workplace realities meant that improving relationships between supervisors and aides had to be a priority.
She also knew from experience that clients of home health agencies typically value the relationship with their aides more than any other aspect of their care. They want aides they can talk to easily, who will listen and understand, and whose company they can enjoy. They want to look forward to seeing their aides. Clients who don’t have good relationships with their aides are far more likely to break their connection to Partners and look elsewhere for care.
Improved retention and customer satisfaction make for a better, healthier business. Both depend on improving relationships throughout the organization—exactly the focus of the skills-based training offered by PHI.
Training Timeline
In 2006, Flannery, along with three other top executives at Partners in Care, attended the PHI Executive Leadership Seminar. Their experience persuaded them to take the next big steps.
In 2007 five Partners in Care managers attended a nine-day “Train-the-Trainer” program run by the PHI Center for Coaching Supervision and Leadership (CCSL). These managers returned to Partners in Care as trainers in PHI Coaching Supervision, ready to teach the communication and problem-solving skills they learned to supervisors throughout the organization.
During 2007 and 2008, these managers-turned-trainers taught all 85 supervisors at the agency to use coaching skills—with each other, with aides, clients and family members, and with executive leadership. After that, all other office staff at the agency received the same training.
Most recently, in 2009, Partners in Care embarked on the mammoth project of training its 7,400 direct-care workers in the same core communication skills.
Outcomes: Stronger Relationships and Improved Retention
Today, two and a half years after Partners in Care began participating in PHI trainings, Flannery sees the positive effects taking hold. She believes that the relationship-centered approach—and the specific communication and coaching skills that her staff has learned—have begun to shift the organization’s culture.
Staff, she notes, feel much more empowered. “If you walked in here now, you would see that they are respectful to each other. Lots of work is getting done without rush, noise, and anxiety,” Flannery says. “There’s a real difference in tone. Antagonistic interactions have become rare.”
In addition, Flannery notices people giving each other more positive feedback and having more constructive conversations. Staff are teaching and learning from each other, supporting each other in doing the best they can at their jobs. They share a greater sense of being “in it together,” and enjoy each other’s successes in using the new skills.
“We’re retaining people by improving relationships,” Flannery says. “Ultimately, the coaching approach results in improvements for me and my staff that just wouldn’t happen otherwise—improvements that are occurring because we invested in this.”
Outcomes: Better Communication with Aides and Clients
Nancy Ramirez, one of the supervisors who was trained in PHI Coaching Supervision, agrees. She says that implementing the coaching skills she and other supervisors learned has lessened her stress and made her job more enjoyable. Relationships with aides have become less adversarial.
“They see me more like a friend,” she says. Aides know she wants and expects them to succeed. Aides also feel more able to approach her with a problem, because they know that she is able to listen and offer constructive feedback rather than a punitive response.
Ramirez has found that the coaching skills she has learned have helped her save time, as well as aggravation. For example, in the past, aides “used to call about some problem and talk around and around in circles,” she says. “Now I know how to help them focus by asking the right questions.” Knowing how to ask the right questions, and how to listen more carefully, has saved time and helped eliminate confusion—benefits that are passed on to everyone, including clients.
Ramirez observes that the coaching skills have helped improve relationships across the board at Partners in Care. One of the core coaching skills is pull-back—meaning “pull back from your initial, highly charged emotional response to a situation.” In training, participants are taught specific skills to help calm and compose themselves before responding in a difficult interaction.
According to Ramirez, “A lot more pull-back is happening now with supervisors, managers and aides” at the agency. She sees this skill used in action every day as office staff handle phone calls from aides, clients, and family members who are upset.
The office staff is ready. They have the flash cards—received during their training—taped up right in front of them.
“Pull Back,” says one, and right underneath, “Take a Breather.” Another simply says: “Say, ‘Excuse me, hold on please.’”
Staff also signal to others throughout the day—for example, stage-whispering to a co-worker on a difficult call: “Pull back!” “Put them on hold!” Or, “Ask them a question!”
Outcomes: Improved Problem Solving
As direct-care workers join the ranks of those at Partners in Care who are trained in the communication and problem-solving skills embodied by the PHI Coaching Approach, the positive changes are reaching even farther.
“Since home health aide training began in July [2009], we are seeing the effect,” says Maria Guzman, manager of the Partners in Care Bronx unit and also one of the in-house trainers who was trained.
“Now the aides are on the same page as the supervisors, and they are able to relate better,” Guzman says. “We’re getting good feedback from the aides—they’re using the skills to listen to their clients and to focus on what the real issue is. They’re really listening and asking the right questions.”
Aides are finding the communication and problem-solving training inspiring and useful. “They’re all thankful that they had the training,” says Guzman.
At monthly booster sessions—or when Guzman is just walking down the hall at the agency—aides run up to her, eager to tell how they have implemented their training on the job. “Maria! I used the skill! I used the skill!” they say.
Guzman is thrilled. There’s no better satisfaction for a teacher than a student who has put her learning to use and been changed by it.
Using Coaching Skills with Clients: A Case Study
Nancy Ramirez offered an excellent example of how using the coaching skills helped her resolve a problem case that had been a thorn in her side—and a big drain on her time and energy—for over a year.
Background
The client, whom we’ll call Mrs. Young, had been sent several different aides, one after the other. At first Mrs. Young always said she liked the new aide, but after three or four months she would call Partners to complain.
“This aide doesn’t do anything,” she’d say in a loud, angry voice. “She’s not right for the job.”
Each time, she demanded a new aide, and a new aide would be sent. But after another three or four months, the same scenario invariably occurred.
Intervention
With some trepidation, Ramirez—along with a VNSNY nurse—went to see Mrs. Young. While Ramirez was used to Mrs. Young’s voice on the phone—and was well-prepared to “pull back”—she wasn’t prepared for what happened next.
After knocking on the door, she was surprised to be greeted by a small, stooped, white-haired, fragile-looking, and very elderly woman. “Mrs. Young?” asked Ramirez doubtfully.
Mrs. Young then opened her mouth, and—in her incongruously booming voice—invited her visitors in. She then proceeded to regale Ramirez with a list of her numerous medical ailments and complaints.
Mrs. Young’s current aide was already there, and in an exchange of glances with the aide, Ramirez understood that this was Mrs. Young’s routine.
Using Coaching Skills
Over the next hour, Mrs. Young, very loudly recounted the story of her ailments several times. It was a daunting experience, and required all of Ramirez’s pull-back skills. But as a result of her coaching training, Ramirez was able to see that Mrs. Young was lonely and just didn’t know a better way to communicate.
Drawing on the active listening and paraphrasing skills learned in her coaching training, Ramirez just sat and listened to Mrs. Young., giving her full attention. The complaining soon stopped.
During the visit, another piece of the puzzle emerged when Mrs. Young’s adult son came home, said hello, and went off to his room. The training that PHI provides includes the importance of reading body language—as well as verbal cues.
Ramirez noticed at once that Mrs. Young went stiff and quiet when her son entered the room. Mrs. Young seemed scared of her son.
Ramirez later confirmed this suspicion with the aide, who explained that Mrs. Young was terrified of her son’s temper. Once her son came home, she became silent and required complete silence of the aide as well. She sometimes asked her aide to just sit and do nothing. Later, however, Mrs. Young would call the agency to complain that the aide was not helpful.
The Benefits
In one brief home visit, Ramirez used virtually all of the skills she had learned in the coaching training to gain a much fuller understanding of the situation — both from Mrs. Young’s and the aide’s point of view.
Her own view of Mrs. Young had also shifted radically—from a “problem client” to a “client with a problem that we can help her resolve.”
With this understanding, Ramirez was finally in a position to give Mrs. Young the help she needed. She worked with others at Partners in Care to come up with a long-term solution for Mrs. Young’s care, and arranged for a social worker to intervene with Mrs. Young’s son.
The Time, Work, and Money Is Worth It!
Culture change, whether in the home care setting or in a nursing facility, is really about making the kind of shift in thinking illustrated so clearly by Ramirez’s interaction with Mrs. Young. But often, as much as staff believe in culture change, they don’t have the skills they need to align their interactions with clients, family members, or staff with those beliefs.
Ramirez’s coaching skills allowed her to place her assumptions about this client’s behavior to the side, and to listen and observe attentively, thereby establishing a relationship with Mrs. Young. When she saw the situation from Mrs. Young’s perspective, Ramirez could then work with her to find a solution. In the end, Mrs. Young’s quality of life improved, and Partners benefited from having a more content client who no longer cycled through so many aides.
“The coaching approach applies similar skills throughout all facets of an organization. These skills can be applied to client and family interactions, to supervising and supporting direct-care staff, to mentoring new staff, and to strengthening teams throughout eldercare organizations,” says Maria Elena del Valle, PHI New York training manager, who has worked closely with Partners in Care.
“There is no question that adopting the PHI Coaching Approach at a large, urban organization like Partners in Care requires a significant investment of time, work, and money. Everyone, at every level of the agency, has had to put in extra time in training and booster sessions. But it is clear that the investment has paid off in stronger relationships among staff and between staff and clients.”
Marki Flannery believes the work has been well worth it.
“As a leader, it’s very fulfilling to see this transformation,” Flannery says. “Direct-care staff are being valued and respected as never before. This differentiates us from our competitors and makes us a better organization.”
