NOTES FROM THE GEMBA – This French company provides support to the severely disabled, and is currently using lean thinking to limit employee turnover and recruit faster.

Words: Catherine Chabiron, lean coach and member of Institut Lean France

Working in home care may be rewarding, in that it contributes to the well-being of sick or disabled people, but it is certainly stressful. This is what I quickly find out, as I walk around the small open-space office of Aloïs with the company’s CEO and founder Arnaud Barde. It is stressful because, first of all, you need to find customers, but also because you need to attract and retain employees for jobs that typically require empathy, professionalism and continuity of service.

Arnaud made the bold move towards home services a few years ago, when he left the restaurant business to start a company that would help severely disabled and elderly people in their own home, seven days a week and often 24 hours a day. The job entails human presence and assistance – for example in taking the patient for a stroll, to the movies, or listening to music, painting, or reading with them – as well as tasks like moving the patient from the bed to an armchair and to the toilet and back, cleaning, dressing, shopping, feeding, ironing and assisting nursing care.

Arnaud founded Aloïs at the end of 2014 (he named it after Aloïs Alzheimer) and launched a lean management strategy for the company in April 2016 after attending a Lean Summit in France. Four years after the founding, Aloïs employs 130 people (of which 80 FTEs) and takes care of 50 customers, most of whom require a minimum of five hours of home assistance each week.

As I walk through the doors on a recent visit, Arnaud greets me with a smile and, to break the ice, I cheerfully ask, “How is the business doing?” Arnaud‘s answer is a bit hesitant. I immediately assume his problem is with customers or sales, and ask him if that is indeed the case. “Oh no,” he says. “That is not our problem. We retain all our customers, and at the moment we have a growth rate of about 20%. Our turnover has grown eightfold since our first full year of operation.”

“What is your problem, then?” I ask, slightly surprised by what I had just heard.

“Our problem this year is that we have to can’t keep up with the requests for help we receive, because we can’t recruit fast enough.”

The hourly price of home care is set by the Departmental Council Healthcare Board (the payer), not by Aloïs. Needless to say, selling a service to disabled people, who have no income other than government support, at a premium is not an option. This constraint, combined with the fact that the job typically doesn’t require a high level of training and education, results in employees being paid rather low wages. At the same time, this is a demanding job. Add to the mix a recent upturn in employment offer in France and the traditionally high turnover of employees in home care services, and you will easily see why Aloïs is struggling: despite some improvement over time, employees leave regularly and recruitment remains difficult. This, in turn, puts a lot of pressure on remaining staff.

The story of these improvements and difficulties can be read on a very extensive system of visual management boards that the company deploys. Key indicators show customer satisfaction rates, the number of new patients joining, the number of those Aloïs no longer serves (most unfortunately due to their passing), continuity of service (the worst month this year in Aloïs was 99,6%), customer claims, employee turnover and recruitments, hours “sold”, and so on. And that’s before we even get to problem solving and task tracking sheets.

The company’s management team is small, and often out in the field supporting employees in their tasks or training them. However, they try to collaborate by participating in a weekly discussion on problems and a “daily checkpoint”, together with Arnaud.

It is great to see the strategic double challenge defined by Arnaud at the beginning of my visit underlying all the data displayed on the walls, which is centered around two main questions:

• How do we attract and retain customers?
• How do we attract and retain employees, so that they can better serve our customers?

OUT TO MEET THE CUSTOMERS

Word of mouth plays a huge role in this business, and providing a good service and finding a clear differentiator can quickly attract new patients. Arnaud has a very clear idea of what sets Aloïs apart from the 220 or so competitors operating in the area: even though the company started with the idea of providing home care to seniors, it quickly veered towards severely disabled individuals needing high levels of care. According to Arnaud, this is a niche in which Aloïs can offer top-level service that other, more generalist competitors can’t provide. Aloïs also offers a nursing service for tracheotomized patients, for which 50 members of staff have been trained. (A capability rarely available to their competitors, certainly in such numbers.)

But there is more. Taking inspiration from the lean idea of going to see, Arnaud has begun to schedule two-hour gemba sessions with every single Aloïs patient in their own home once a quarter. Upon mentioning this, Arnaud pulls a bundle of one-sheet reports from his drawer to show me how these gemba visits happen. During each visit, the patient and her family are very thoroughly listened to, both when they share positive feedback and when they raise a problem, lodge a complaint or suggest an improvement.

“Sometimes, I am also allowed to observe operations like lifting the patient from the bed or dressing them, but people are often unwilling to share this kind of intimacy with someone they don’t know well, which is understandable. When this happens, however, it is the best opportunity I get to detect the pains and constraints we create for them,” he tells me. This, at least in my experience, is unheard of in the world of home care – and probably in most businesses.

This attention to detail is further pursued with employees taking turns in caring for patients, as work standards (how to move a patient, for example) are defined, discussed, improved and logged for each patient. The idea is to offer a perfect service, approved by the patient, but also to enable an efficient induction should a new caregiver step in. Some of the work standards we check on my visit state the “why”, but Arnaud tells me they all should. He is right. In my experience, the why on work standards is very important: when I coach problem solving, I see numerous cases where the problem is actually lost know-how. Complex tasks spelled out on a work standard will progressively be bypassed because nobody remembers why you need them, and this invariably results in increased failures and wastes. Some people in the company knew how to do it at some point, and why it was necessary, but as the job was handed over to others and no one worked on the design to eliminate those awkward tasks, the message was forgotten.

On the topic of hand-overs, Arnaud asked his teams to develop a very thorough training protocol for the onboarding of an employee to a new patient, where the group leader will supervise all the tasks and gestures required for that patient, before leaving the employee on her own. One of the scores provided by the patient is about how serene and trustful they feel with the Aloïs employee. Arnaud remembers a quarterly visit during which he saw the patient, a severely disabled man in his thirties, fall asleep with the caregiver’s hand resting on his head. “What’s more serene than that?” he remembers thinking.

Care is important for the well-being of patients, but so are the stimuli coming from social life. This is an important extra offered by Aloïs, which, beyond home activities, arranges a quarterly event for all patients and their caregivers, with activities ranging from theater to karaoke, a wine tour of Bordeaux to chocolate making.

In mid-2017, Arnaud was advised to check whether this ambitious service approach would not severely impact his margin. But he sees things the other way around: his hunch is that he should work on the quality of service first and the rest will follow. He was right: at the end of the year, profitability was double the expected level. As mentioned before, this strategy of differentiation pays off, and growth is certainly not an issue for Aloïs!

BOOST TRUST, INCREASE RETENTION

At this point of my visit, Arnaud and I walk to another set of visual management boards, where we engage in a long conversation over the problem of attracting and retaining talent.

Recruitment has been a headache recently, for a variety of reasons. New hires are needed both to grow (it may take up to six caregivers taking turns to assist a patient day and night, not to mention backups) and to replace those who leave.

As we talk, I draft on a piece of paper the causal model of the hassle:

But recruiting is not so easy: between the upturn in the French employment market and the fact that Aloïs is not well known yet, the company cannot rely on a database of potential candidates.

In this scenario, you have two options (none of them ideal): either growth stops or Aloïs staff will find themselves struggling with continuity of service for 24/7 patients – not to mention stand-by services on others – with the risk of straining scarce resources and generating even more turnover or absenteeism.

Arnaud confirms the three steps he has taken with his teams to try and address the issue: “We brainstormed how we could build a solid database of potential prospects for recruitment, in addition to the very strong partnership we have develop with the local unemployment agency [which includes a 10-week course, mostly taking place at the gemba]. And we defined a takt time to complete the tasks to build it. We now track our achievements against the takt time.” Seeing an office task work at takt time, with weekly discussions on what is late and why, is a rare opportunity that I gladly jump at.

“Secondly,” continues Arnaud, “we have tried to speed up our recruitment process. September saw a relief after two or three strained months.”

Lastly, and this is the most interesting part, Arnaud and his teams have attempted to address the root causes of the problem (employee turnover and absenteeism). Backache is a serious concern there and stems from the fact that patients are sometimes reluctant to use a complicated and rather humiliating piece of equipment for lifting patients. They are simply unaware of the strain this puts on the caregivers. Arnaud is contemplating an investment in ergoskeletons, similar to exoskeletons but lighter and great to transfer the strength of the legs into the upper body. Another issue that creates absenteeism is recurrent illnesses, such as gastroenteritis: the caregivers cannot come close to patients suffering from this condition, so it is important for Aloïs to find ways to avoid contagion.

Another key point is convincing caregivers to accept being on call. They find it stressful and poorly paid. More generally, as we discuss with Arnaud, the problem is that the 120 or so caregivers at Aloïs are only supervised by six group leaders – in other words, 20 persons for one group leader. Taking into account the quarterly visits to patients, the recruitment and induction of new caregivers, this leaves little time for kaizen, improving standards, daily checkpoints and occasional last-minute replacements. Arnaud is thinking of developing a team of experts to take over on-call requests and start using them with new patients (while new recruits would be assigned to existing patients, where the operating standards are well known and agreed on). Could those experts take over a role of team leaders, supporting teams on the gemba smaller than the current ones? The scheme would offer increased career opportunities for caregivers, thus making a job in home care more attractive.

As we end the tour, Arnaud and I discuss at length what is being done to develop the competence of caregivers. This is another way to address turnover: as caregivers are given more autonomy in carrying out their tasks, and the freedom to improve their standards, their interest for the job will increase. Arnaud gives me two examples: “We ask caregivers – and not group leaders – to define the monthly operating schedule of tasks together with the patient. Also, when we establish the planning for the upcoming month, we take into account their own constraints to adjust the timetable – be it a dentist appointment or two days off to attend a wedding. They feel their needs are taken into consideration now.”

Working in home care is stressful, because of the seriousness of the patients’ conditions, but it pursues a great mission, in that it represents an alternative to a hospital or a nursing home. When I ask Arnaud what made him decide to leave the restaurant business to work in this sector, he takes time to think and then says” “I wanted something with purpose. Something meaningful. It was important for me.”

_{THE AUTHOR}