April is an entrepreneur and executive with a 20+ year track record as founder of Encompass, her second successful home health venture. She has led Encompass’ expansion from a single start-up location to an industry leader with a national presence. She was the recipient of Ernst & Young’s prestigious 2006 Entrepreneur of the Year award based on her creative and innovative approach to home health care and has led the company’s long standing culture which has led to recognition on a national level as a best place to work.
Below is the transcript of an interview between April and Matt Challberg with Tallio.
Is there any book on leadership, or in general a favorite of yours, that you would recommend to other aspiring leaders?
April: One book that has been transformative for us as a business is The Four Disciplines of Execution (4Dx). It comes out of the Covey Institute and has some of the same principles of The Seven Habits of Highly Effective People but I really liked the simplicity of it. 4Dx outlines that in order to achieve a strategic vision, you have to consistently follow four disciplines. The first is that you've got to set a meaningful goal, one that people will really want to achieve. It can’t just be “I want to make more money” or “grow more revenue”, it's got to really be a purposeful goal. Two, once you have the right goal, you have to put in place what the book refers to as “lead measures.” Lead measures are a set of predictable and influenceable behaviors. You need to be willing to manage these behaviors consistently, routinely, at the right cadence, with the right intensity, frequency, and so forth. Then the third discipline is - you’ve got to keep score. You need to monitor both daily behaviors and the results that are being created from them. Fourth, you have to have an accountability structure to hold one another accountable. We've really found over the years that when we take pretty much any challenge we're facing in our business, and really thoughtfully put those four disciplines in play, that we can overcome just about any challenge. It's probably one of the more foundational principles of how we operate and address challenges within our business.
Matt: Of the four disciplines, I found lead measures to be especially interesting as it relates to home care. It's such a powerful concept because so many times we're looking at metrics that are reactionary, especially when looking at the Center for Medicare and Medicare Services data. It's hard to make strategic decisions based on information that has been measured months prior instead of measuring the behaviors and actions that will produce the intended results.
A: That’s really the magic of it, you've got to really understand what is a lead measure versus an outcome. It’s important to get people to focus on the behavior that will drive the outcome and how you create a way to measure it. Which leads me to another book recommendation - Excellence Wins by Horst Schulze, the Co-Founder of The Ritz Carlton Hotel Company. I think so much of what we do in a home care business is service oriented, and that there's much we can learn from the hospitality industry. Unfortunately, healthcare has never really thought about themselves much in the realm of customer service. We’ve never gone to a doctor's office or hospital and really felt like you received a premium customer service. So it's an industry that really hasn't embraced the importance of customer service yet. But I believe, particularly in the highly competitive home care space where there's 12,000 places you could go and if you're operating in a non-Certificate of Need market where there are hundreds of providers you could choose from, the customer service has to be a huge part of it. I enjoyed this book, Excellence Wins because it really gets down to some of those tactical things that you have to do every day if you really want to create a culture where patients feel like you gave them that Ritz Carlton kind of experience when you walked in their door.
M: I love the hospitality analogy because it’s important to think not only about patients and their experience, but the experience caregivers and staff receive from their employer. Creating a hospitality experience for employees as they’re introduced to your company or home care in general is important in order to keep turnover low and potentially more importantly, keep caregivers in the industry.
A: I couldn't agree more that it starts at home within our organizations. The number one job of management, where we can make the biggest difference, is to really take care of our people. To make them feel that our mission of ‘a better way to care’ is all about the way we care for them [our employees], and then empower them through the right tools, training, resources, acknowledgement, and appreciation to take that mission to the streets. Once they’ve received that experience with us, we can say that's the kind of experience we expect you to take out to the homes of our patients. We found that as simple as that philosophy is, if we will keep our focus as a management team solely on how do we take better care of my people, then by very nature, they'll go take better care of our patients. That's who they [caregivers] are, and that's why they got into the caregiving business in the first place. They wanted to take good care of patients but sometimes organizations don’t enable them to do that because they make their work experience negative. If we can make that employee experience positive, we believe they will then take their natural propensity to be caregivers, and deliver a positive experience to our patients. When the patients receive that level of care, they're going to tell somebody. In particular, they're going to tell their physician that they had a great experience with Encompass. That’s going to embolden that physician to use us, become more loyal to us, and see us as a differentiated provider in the marketplace which will help us grow. Then our growth will create financial success, and our financial success lets us reinvest in our culture and our people. It’s a circular process but it really all starts with thinking about, how do I take better care of my people, and everything else seems to take care of itself.
How did you cultivate a culture of caring and keep this an area of focus within your company as you grew from a small provider into one of the largest in the country?
A: Of all the things we've done in our 20 years, the hardest thing we've done, and the thing I'm most proud of, is that we have really created a homogeneous culture at scale. We have 286 offices in 32 states. For us, it's really been about creating one educational vehicle to be super intentional about culture. When we bring a new leader or employee onto our team, we immerse them in our culture from the very beginning. We have a training center here in Dallas where we bring all new full time hires in for a three day course. It's has a little bit of technical content, but it's mostly organized around our philosophy of delivering a better way to care. It also covers what you should expect of us as an employer, and what we expect of you, as a caregiver to our patients. The objective is cultural indoctrination. So we're going to give you the tools, we're going to do the training, we're giving the empowerment, but then we're going to hold you accountable and will not stand for anything less than that. It really builds up within our team and our leaders across the country, who have the tools to do their jobs and who are really hired for attitude. Yes, they've got to have basic requisite skills and experiences as clinicians, but at the end of the day, there are lots of people with skills, requisite criteria, and qualifications. What we're really looking for is the people who have the attitude to lead in our better way to care philosophy. So we hire for it, we train for it, we audit for it, we hold accountability to it, we stand for nothing less than it. As a result, we start to see this culture throughout the organization. In addition to our auditors, I spend about 60 days a year traveling to our branch locations to do a couple of things. I do a presentation and a town hall type Q&A with all of the team members in each of those branches. Part of this is to communicate to the team, but it's also to observe. When I walk in the door, you can feel if you've got that culture that really represents our better way to care mission. You can feel it in how the employees interact with one another, you can feel it in how they interact with a supervisor, you can feel it in the way that room looks in the level of commitment to orderliness and efficiency, and then you can feel it when it's not there. When I don't feel it, we’re doing something about that and putting an action plan in place by the time I’m heading to my car.
I personally still spend a huge chunk of my work year being present in the field. That really provides that twofold observation ability, but also allows for our employees all across the country, to not just work for Encompass but feel like they work for April. They know who I am. They know where my heart is. They know what my passion is, they know what I want for them. They know what I want for our patients. So that creates a level of commitment, loyalty and standard that frankly, has people self select out if it’s not a fit for them. For those people who were willing to say, “Hey, this is exactly the kind of place I want to be where I can feel valued and important, where I can make a difference and where I know I'm empowered to do what's right for patients”, those people gravitate to us. As a result, our retention rates outpace the market. So the best place to work awards and other recognition, really come as the result of a ton of hard work that starts with who did we hire in the first place. Not only is that true of our leadership, but it's really true of every team member. When people aren’t aligned with our mission, we just don't let those people stay. If you’re a great home health aide, but you treat your peers terribly and communicated ineffectively, you can't stay any more so than if you're a branch director. If we misfired and hired the wrong person, their peers will help force that decision to say - “Hey, you can't be on my team.” It's not all top down, it's oftentimes bottom up. As soon as you start weeding those bad apples out and refusing to let them come into the organization, then you elevate the performance of all your team members. One of the things I hear most frequently from our clinicians, is, “You know, I'm a better nurse/clinician/caregiver here than I've been anywhere in my professional career because my peers call me to that. My organization gives me the tools I need to be that. I'm actually a better professional because this organization empowers me to do that.” When you can create that kind of environment where I can take people who have innate skills, talents, and abilities and make them the best of themselves, that's really where the magic starts to happen. That's where culture starts to build. One of the things I'll say about culture, though, is that I'm a big believer that culture follows process. You can be as nice and kind to people as you want to be, but if it is chaos in the way things function and operate it won't last and people will eventually burn out. But if you can create an environment where everybody understands what their role is, what their function is, and where everyone is held accountable then that creates a fertile soil for culture to grow. Culture can then take root in that soil and really become an exponential value add on top of it. You've got to have that process in place. As I think about the nationwide scale and what we've been able to do, I think that formation of processes and efficiencies and operating models has been as important as anything we've done, because it's what creates the fertile soil for us to grow.
What was your original vision for Encompass and how did that evolve over time?
A: The reality is that I stumbled into home care. I didn't know anything about the industry. Honestly, when I bought that first business 60 days into my healthcare experience, I did so thinking that this will be a reasonably easy way to make a living. I really thought I'd be a stay at home mom and maybe this would be more of a side gig. Then when I arrived here and became really engaged in healthcare, what I found was passion. I found that the work we could do for patients and families that were in extreme need was so rewarding. Then, as I began to experience what our care in the home looked like by riding with our clinicians, I realized that clinicians were some of the most poorly treated people in health care. They really hadn't been valued or appreciated or invested in by the healthcare community. To the contrary, they were very much treated like a commodity and used up until there was nothing left for them to give. That seemed like a losing strategy. So I became equally passionate about not only what we could do for patients, but how we could create an environment where we could support caregivers in such a way where they could truly live out this passion for caregiving in the long haul. We were going to have to create an environment that would allow us to fill our people back up with energy and spirit. Part of that was creating the right kind of vacation policies, creating the right compensation structures, and developing the right tools for them to actually do their job all while providing the right kind of training so that they felt empowered to do what they needed to do. Finally and probably most importantly, just saying - “Thank You. I noticed, I appreciate you, you went the extra mile, and I see it and I see the impact that it's making. I just want you to know, we appreciate it.” It is the simple things. Yet it was so countercultural to what they've experienced in the healthcare world. There’s a reason they say that they’re better nurses here than anywhere else in their career. It is because we pour into them and keep them supported. Whether it's teaching, training, tools, acknowledgement, appreciation, recognition or benefits that we’re providing them, it’s our goal to show them that this can be a place where you can stay for the long term.
As I began to experience this, that's when I thought about the concept of doing this in other markets. We felt that every patient deserves this ‘better way to care’ experience and every employee in healthcare deserves this ‘better way to care’ employment experience. That really became the catalyst of our mission. People ask me frequently - How big do you want to be? My answer for 20 years, it's always been the same: I want to be as big as we can be and still be “a better way to care”. I only want to do this in a way that's meaningful and impactful, that makes people feel like they're a better version of themselves because of the organization we've surrounded them with. That's why we're always trying to create that environment which allows us to be a better way to care, and not just a bigger way to care. Thankfully, because of that, we've been able to actually realize the bigger portion, not because it was our focus, but because it was in fact a natural byproduct.
Can you tell me a little bit about your leadership team or advisory dynamics as Encompass grew to one of the largest providers in the country?
A: For us, even more so than external advisors, it was really about finding the right leadership team members. I was fortunate that our Chief Operation Officer, our first leading operational support person came along nine months after we started the company and has been here ever since. Our Chief Financial Officer has been here for 14 years. Our Chief Strategy Officer for 15 years. As a result our leadership team has been incredibly stable, incredibly like-minded, and equally committed to serving our team members around us while trying to avoid the bureaucracy that can sometimes come as being part of a large company. So we’re constantly thinking about how do you keep that [bureaucracy] out. How do we leverage the good things about being large and eliminate the bad things about being large. For us, it’s about our leadership team creating the homogeneous view of what are we trying to accomplish and then challenging one another, but in a way that’s always respectful. We may have vigorous debate about something inside the boardroom but when we walk out of the door, we're all on one page. We’ve been very fortunate to have the right people who are commonly committed to a mission. I can't say enough about how being mission driven has been part of our success as leaders and an organization. It’s the rudder that keeps us going in the right direction.
We always challenge ourselves about decision making to ensure we can stand up in front of our employees and say that this is the policy we made, this is why we made it, and this is why it's a better way to care for you. If we can't do that, then we're not making that decision and we need to solve that problem another way. We obviously have to meet regulations, we have to be profitable, we have to create growth engines. So how can I say this decision balances all that we have to be responsible for and, and still explain myself to employees every Monday why we’re making this decision. If we can't explain ourselves in a way that we're proud of and that embodies our ‘better way to care’ philosophy for our employees, and ultimately our patients, then we're not making that decision. As a management team, having that common definitional approach to decision making has helped us be better, challenge one another, and create the right kind of environment.
M: From conversations I’ve had, that’s a significant challenge that most other leaders of agencies identify with. The idea of how to create an environment that provides clarity of the decisions that are being made, why those decisions are being made, and what it means to the individuals who are on the front lines providing the care.
A: It's really comes back to knowing the end game. If you don't find that rudder, if you don't find that guiding principle that says, “This is who we are, this is why we exist, this is what we're trying to do”, then I contend that you will be constantly blown by the winds of regulatory change, by reimbursement change, by market dynamics and any number of things if you don’t have clarity of why you're doing what you're doing. Another phrase that I like to use regularly is that if you if you believe enough in why you will figure out how. When we come across a challenging decision, where we’re struggling to see how we are going to come through this, it always comes back to our management team saying that we don’t have a choice to prevail because the reality is the patients we serve and the impact that we make is too important. Our why is so big that we cannot let this hurdle, this challenge, or this barrier stop us from realizing that why. So let's just go figure out how we overcome this challenge. To know your why and believing in it so wholeheartedly that you just won't let anything take you off course from achieving it is why we’ve accomplished what we have so far.
M: This was extremely enlightening and thank you for sharing your vision and passion for Encompass and home care. I’m looking forward to seeing how your insights will steer the industry in the future.
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