Three successful hospice leaders share their strategies
Mission, vision, and leadership are common traits
Gretchen Brown, president of Hospice of the Bluegrass, can remember 1982 when her Lexington, KY-based hospice cared for only 17 patients per day. Today, it is the largest provider of care for the dying in the state, caring for 550 patients in 21 counties.
The Hospice of the Florida Suncoast in Largo, FL, also stands as an example of what many hospices aspire to become — a large provider of compassionate care for the terminally ill and a visible community partner.
In Buffalo, NY, the Center for Hospice and Palliative Care is the centerpiece of an end-of-life program that sets out to meet the needs of the terminally ill that fall outside the narrow box defined by federal and state regulations.
"The Medicare benefit was the best and worst thing that happened to hospice," says Don Schumacher, PsyD, president and CEO of the Center for Hospice and Palliative Care. "[Our idea is] not rocket science. It was our realization that the hospice benefit was wasn’t working that led us to find other ways to generate income."
Certainly, competition and market forces play a role in the degree of success a hospice can achieve. But leadership and vision are also important, successful administrators say. Without sound leadership, a hospice that enjoys market advantages, such as controlled competition, can languish in mediocrity — or worse. So, what do some hospice leaders have that others don’t?
According to three successful hospice administrators, guiding a hospice to success calls for the following:
• an unwavering commitment to the hospice mission;
• a vision for the future;
• an ability to rely on those around you to manage details.
Dedication to mission
It sounds like a simple covenant — remain true to the hospice mission. That is, provide uncompromised care to the patient and family. But it is not as easy as it sounds. Everyday challenges and the burden of regulatory requirements can subtly erode any hospice leader’s resolve.
"It’s difficult in this age of change," says Mary Labiak, president and CEO of The Hospice of the Florida Suncoast. "But you have to start with the patient and family and work outward. When you start saying, What does Medicare say?’ You start putting the cart before the horse."
The federal government’s recent attention to fraud and abuse in the hospice industry is one influence. With regulatory watchdogs focused on how hospices cultivate referrals, it’s understandable that hospice administrators are preoccupied with staying compliant. But in their zeal to implement polices to protect them against unwanted scrutiny, many hospice leaders raise unrealized barriers to care. Stricter admissions policies create the potential for patients who would benefit from hospice care to be turned away.
"Some people regard it differently than I do," says Brown. "I see some hospices that don’t have an open admissions policy. Convenience to staff seems to be more important. They don’t do weekend admissions. They discourage Friday admissions. Who do you want to serve?"
Even payer-driven initiatives such as the purchase or development of information systems can lead to distractions from the hospice mission. The tendency would be to implement a system that would meet Medicare needs, such as the ability to capture data for completing the year-end cost report.
"It would be easy to get seduced into building a system that meets regulations, but you have to ask yourself what will help staff at the bedside deliver better care," Labiak says.
The commitment to the hospice mission must permeate the entire organization. At The Hospice of the Bluegrass, Brown’s interpretation of her organization’s mission is prominent in writing and through practice. The mission is posted throughout the facilities, and management staff make sure they are conveying the same message to their charges.
"I make it their mission," Brown says. "No matter who you ask here, they will tell you that patient and family come first and staff come second, albeit a close second."
The attitude that governs a hospice’s approach to patient care must also permeate other aspects of operations, says Labiak. A commitment to the hospice mission should also govern how a hospice spends its money. "We have a stewardship responsibility," she says. "We have a responsibility to use the public’s money wisely."
To hear the three hospice leaders explain their approach, keeping the hospice mission in the forefront is a simple matter of caring well for patients, and taking all patients who are referred to their organizations’ care. Everything else seems to take care of itself.
Labiak also points out how easy it is for an organization to lose sight of its mission in the day-to-day grind of providing care. "We need to ask ourselves whether our gift to the world is providing bedside commodes or whether it is to change the culture of dying in our society."
Find a vision
A commitment to the hospice mission gives hospice administrators a strong base to plan for the future. Beyond that, unfortunately, most administrators allow their organizations to remain locked in the Medicare box. With government-sponsored health programs making up virtually every dollar hospices earn, it can be difficult to envision a world outside Medicare regulations.
"You have to be able to scan the horizon and see what’s coming," says Brown.
Managed care, the need to provide care more efficiently without compromising care, and finding ways to reach potential patients are all challenges that have to be addressed, Brown says.
"We’re innovators," she adds, applying her own experience as an example.
Looking back, her organization’s vision translated into taking on noncancer-diagnosis patients in the early years of hospice, the development of grief programs in the community, and collaborations with physicians, hospitals, and health plans.
Each innovation represented a changing need in their market, Brown says. She did not allow her hospice to stand aside amidst a trend that saw health care providers integrate: In the early 1990s, The Hospice of the Bluegrass became part of the Health Alliance of Cincinnati, inserting hospice care into the health system’s continuum of care.
When the hospice noticed a lack of grief programs in the communities it served, it developed bereavement programs. Most recently, the hospice established a grief program for children, recognizing that children deal with the loss of a loved one differently than adults.
For Schumacher and the Center for Hospice and Palliative Care, being a leader is about being able to look at end-of-life care from different angles and having courage to stand out. "Being a successful leader means not being afraid to take risks — and encouraging others to take risks. You need to have vision and be able to live three to five years out," says Schumacher.
Reaching out
According to Schumacher, it is obvious that relying almost entirely on Medicare under current rules is not a sound plan for the future. Instead, he says, the time has come for hospice leaders to redefine hospice care.
"It’s time for us to do the right thing," he says. "Because of the Medicare hospice benefit, we have become what hospices didn’t want to become. You need to recognize what works for your hospice and modify your organization to move forward."
The Hospice and Palliative Care Center has done this in a grand way. It has launched a $20 million capital campaign to create a 25-acre end-of-life care campus complete with physician offices, a senior living center, and a Program for All-Inclusive Care for the Elderly.
It would be easy to dismiss such a far-fetched concept. Medicare compliance implications, for example, would be reason enough to stop similar plans in their tracks. Will federal investigators see it as a scheme to direct patients to hospice?
Instead, the center and its leaders are focused on developing a lineup of services that would reach out not only to traditional hospice patients, but also to patients who are unlikely to ever become hospice patients.
To steer clear of compliance issues, the hospice has remained a separate business entity from the other programs that are also stand-alone corporations. Each provides the kind of care to people that hospices have been unable to reach because of rules such as the six-month terminal illness diagnosis, and the patient having to choose between curative care and hospice care. For example, programs now exist to provide palliative care to children with potentially fatal diseases. Rather than having to wait for the terminal diagnosis or force parents to choose between continuing curative efforts or hospice care, children and their families can receive important services such as palliative care and counseling.
Utilize your best resource
Creating innovative programs and transforming a hospice are tall orders — ones that cannot be impeded by the distractions of minutiae. All three hospice leaders say that their organizations’ successes are due in large part to those who carry out their marching orders.
"Talent lies with the staff," says Labiak. "Rely on those closest to the bedside. Don’t get in the way."
Allowing managers to carry out the daily tasks of monitoring staff and making decisions gives hospice leaders the opportunity to direct the future of their organizations. "I would not be allowed to do the kinds of strategic development that I have been able to do if I had to manage the details," says Schumacher.
"We believe we employ professionals," adds Brown. "We have a collaborative atmosphere here. We work on communication."
Collaboration at The Hospice of the Bluegrass includes group management meetings where managers discuss solutions to problems. Because managers are closer to patient care than Brown is, she places a premium on their advice.
"I almost never make a decision without talking to someone. It probably slows down the decision-making process, but it cuts down on the wrong decision."
It comes down to the simple premise that successful administrators are leaders, not managers. "I’m a much stronger leader than I am a manager," Labiak says. "I have the ability to take people out of their everyday life and have them focus on the big picture."
Determining the direction hospices will go at the beginning of a new millennium will depend largely on regulatory relief, but it is also driven by ideas hospices develop themselves. How some hospices respond to the needs of the dying can be the genus of future demonstration projects and perhaps lead to the needed regulatory changes, Schumacher says.
"Don’t be afraid to try something new," he says. "Don’t stay in the old hospice box."
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