Episode 51: Employee Turnover: Focus on What's in Your Control with Jill and John Jacobson

And John Jacobson took a path less traveled to the world of talent acquisition and human resources in ABA. He has a bachelor's in chemistry and a master's in Human Resource Management, and he split his career between manufacturing and healthcare. And there are many more commonalities listener than you might think. We're gonna get to those in a little bit. John's been involved with ABA since 2014 and the two of them, John and Jill, are the partners and founders of J2Jacobson Consulting.

John and Jill, welcome to the Pod.

What'd you learn from that experience?

Without integrity, without accountability, to your own actions, your behaviors, you're gonna struggle, right? You're gonna second guess yourself. Not really sure where that moral compass is gonna be, or where it's going to lead. But, living by that mantra of just do the right. has provided me just of that sense of peace, whether it's personally or professionally in my career. I will say, it doesn't mean that you're always rewarded for that or commended for that. that can get a little sticky.

But surrounding yourself with people that, exemplify true integrity, creates a really good positive ecosystem, right? Just whether it's in your personal life or whether it's in your professional life. I think my most recent experiences, chief Growth officer and compliance officer just solidified it, solidified for me. just do the right thing.

I think secondly to that, and more specific just to the world of ABA, it's been reinforced for me and had to relearn this I think in my hospice career, which was very long. and Disney Institute helped me with this, that the, client and the family unit experience is just as equally important as the team member experience. And, I think especially as we've been going through, the great resignation, quiet, quitting, those types of things, that it's really important.

and so that was, a little bit renewed for me over these last couple of years. I think that the size of the provider, the national footprint, those kinds of things, probably my greatest takeaway there is that it's all about relationships. If you want that culture of compliance, that culture of, that support strategically growing the business, you have to have relationships, not just at the executive level, but throughout the organization.

And that helps you to build those relationships with funders as well. educating the team about, scrutiny and those kinds of things that you see rising in the world of compliance and regulatory. It just helps people to, navigate, the importance of those relationships within an organization. It's the people, it's the process. It's the passion that makes this work.

I'm a nurse, I'm not A BCBA, so they're not gonna take any action against me as an owner or an operator or chief compliance officer. So you are right, it's not a poster on the wall. It's not this plan that I put in a binder somewhere or, have online, in our intranet.. it's about building that culture and knowing that if I come forward and I disclose something or I think that maybe something doesn't feel right and I talk with my supervisor that I'm not gonna be penalized for that.

And we talk about ethics so much in this industry, more than any other place I've ever been in healthcare. And it's not that physicians don't have ethics. It's not that everybody else doesn't have ethics in the world of healthcare, but John will call it situational ethics. We talk about it a lot, but I don't think that, we have it quite figured out everywhere, still in the world of ABA about how to build that culture. and you're absolutely right, it comes down to that relationship.

But you mentioned qapi and I'm gonna drop a link in the show notes cuz this is an example of analogs we can look to in other parts of healthcare that will at some point apply to ABA Because our field though our science is old, our field is still in its infancy. and I think that's a really good sort of compliance lens, for thinking about, building and your organizational dna. So John, I want to turn to you. And by the way, John, you and I just got to meet this past summer.

We had a conversation and you know what my first thought was? I was like, where has Jill been hiding you all this time? Are you kidding me? It was like this phenomenal conversation and I keep thinking if I were to have to ask who is my favorite Jacobson? That's that's not fair cuz it's like asking who's your favorite kid and you can't say that, but you are both my favorite Jacobson.

Like what insights did you glean from that, that ABA providers can take on to improve it?

it's absolutely critical. but We can't overlook these other things we as people don't come with these management skills. Sometimes we can't manage ourselves, let alone manage other people. So to think that just because I wanna put a manager title on you, you have those skills, is a wrong way to think. And then, we exacerbate that as employers because we're not good at hiring people. So we have a management position open and we hire somebody, but we don't know what to look for.

We don't know how to hire, so then we make it even a little bit worse in that, or we don't make it a whole lot better I think that the insight is that managers and management is taken for granted. It's that it needs to be done, but everybody can just do that. I think when I taught for that one year, somebody said, you can just muddle through.

there's a lot of muddling going on out there and we need to do more to do that, but we expect these people are ready to roll when we hire a new BCBA that just showed up on LinkedIn with that photo with their certificate. That's the best thing in the world that they've reached that achievement. But for us to think that they are ready to do all of the things that we then expect of them is a little bit shortsighted.

And I think the other thing that has taken place over time is that there has been this, Reduction in the willingness to train by organizations. And so much of that comes in margin and all of things. Not just in aba, but in everything. And so one of the first things to go always is that on the job training, and we think, we hired you, you have these characteristics and you have this certification, you have these different things. You can do the job yes.

But you don't have all of the skills that are going to go into that. And ABA is no different than other things, but maybe it's even more complex. Because to me, when I look at different things, if you hire a nurse first into nursing, usually they're coming into a position that is a little bit lower down on the scale than a clinical director or a manager of a unit or something. But they are doing the tasks using the skills that they were trained for.

In ABA, you come in as a BCBA and you are expected to manage right away. You're not just doing the things that they taught you, but you have case management. You have family management, you've got the tech management, all of those things. And then you throw on top of that, there's just all kinds of different facets there. There's logistics, there's productivity, there's communication technology, there's the financial part.

There's technology, performance management, even labor relations because nobody can work without having labor relation issues about whether it's, I was late because I had so-and-so problem, or somebody got in my way or whatever. Those things come up every single day, multiple times. And so we don't do a good job with that. And so I think in that we have to, as individuals understand that we have to be open to the concept that our education is not finished when we come out.

And I think we always talk about this lifelong learning, but this is a little bit different in that these are just skills. maybe we didn't want to do those skills or to have those skills. Maybe that's what drove us into our profession. I went into math and science because I wasn't so adept, I didn't think at English or some of those kind of things.

So you go into the things that you're better at, but that doesn't mean you don't have to use them, whether it's writing or speaking, different kind of communication tools. You have to be able to have those skills. So we have to be open to that but then as providers, as owners, as operators, we have to be part of that as well.

We have to be able to say, we're committed to bringing someone in that has the right characteristics, has those leadership qualities, has the aptitude to take these things on. But we have to be part of that training. We have to give them those skills and we have to somehow fit it in there amidst all the budget items and everything else, and thinking about not just lost revenue and things like that, but we have to give them those skills to perform.

And I think that's really critical in, in ABA, we have to focus both on leadership and on management. They're separate, but they're both quite important.

But I'm curious, John, are there, analogs in, in other parts of healthcare or other organizations or just best practices around this idea you describe of, hey, this is on us. We have to give supervisors those skills to perform. what are some best practices around training for managerial skill sets?

But then even with that, they had very well established preceptor programs so that they worked with someone who was already in that. So I think that's one really good parallel to look at, and that's a, an industry, Jill, you can probably add to that. Yeah. And it's funny when I talk about preceptors or mentorship or academies that, that I've been a part of or led in my past life, and I mentioned that in the world of ABA, look, there's a lot of good intention.

but it has to be a commitment because I can decide that I'm gonna hire X amount of BCBAs and I'm not going to give them a caseload. I am going to spend the first X amount of weeks or a month or whatever it is. Doing what John is talking about, right? Really preparing them, leading them, building on the skills that they just didn't get in their education and they have no real work experience yet.

But what happens, We have turnover, we have pressures to admit cuz we all wanna provide access to services. And what happens is that somebody comes in and instead of a new caseload that you're going to bill for them. they're acquiring someone else's caseload because they're no longer going to be with us. the commitment and the dollars, it's not just time, it's also the dollars to putting in true preceptor programs.

I'm not talking about someone where you say, God, John, I think you do a really good job out in the field, so I'm just gonna have you go with this person because you don't know whether or not they're following policies, procedures, whether what they know and what they don't know.

And and I have a lot of stories about that, the best preceptor program that I built out in hospice took a full year to build it out with a lot of really good expertise around the table with board support behind it for those finances. can you scale that? I think so. I'm not gonna spend a year when I'm a smaller organization, with, 10 million, and revenue. But I probably have greater influence and control over certain individuals that are those BCBAs that could put into that role.

It's a commitment

And if you're home based services, they're gonna be out there on their own in a couple of weeks. And to make sure that you're equipping, folks with the right, like you say, supervision and so forth. Take someone that, you have the confidence that they have that competence to do so and what I call meaningful supervision, right? So that they're constantly training in education.

I can't tell you how many supervisory visits I did in my nursing career on the home health and hospice side and yet I would always walk away with a page of notes of, Hey, let's talk this through. To help them be more efficient, effective, do better, whether it was communication skills or technical skills. I've done round tables around this where I've had really good people who have done a great job and great documentation around supervision and I say, how did we get here?

And it's always comes down to, I had a great supervisor when I was an RBT and those were their takeaways. And so that's great, until you have the BCBA who didn't have a great super or only had exposure to one supervisor in all of their thousands of hours.

Yeah, I think it's such a relevant discussion today because again, supervision, from my understanding, when I hear it in ABA sometimes becomes so task like that, they're looking at that my requirement is X percent of supervision, meaning I check these things that I did. but what we need is we need more than supervision. Maybe it needs a different word to describe it because again, it's not just being there to say, yes, we did these things, but it's to give them feedback.

To give them development. Exactly. Continued development so that they are learning from what they're doing, what they're seeing with the clients, and that not just saying, I met my 5% or my 10% of a payer requires that, or whatever, but am I getting something that is more feedback related and is helping me develop and become a better clinician? It's not just checking that I've got the right amount of minutes, but am I getting something valuable to make What I do more valuable to the client

The biggest pushback that I hear when I talk to organizations or when I'm on, different provider calls, it's oh, we're not getting paid by the insurance company to do supervision. let me ask, are you getting paid to be compliant? No, but are you compliant? Yes, cuz it's the right freaking thing to do. So that is not an excuse in my book for not providing that highest quality supervision. And that's not just like, okay in the first few weeks or month or months to do it.

That has to be an ongoing process of learning and, sometimes failing at certain things and getting great feedback from their supervisor. That's how we, anyone who's been exposed to great supervisors and has developed those skillsets, that's how they learn.

It's something that is expected because you can't do your job without it people. And I just thought that was a great example of, yeah, you're not just gonna go in there without markers and do radiation, so same thing here folks. We don't get paid for everything in healthcare. That's a whole nother podcast and argument and some payers do better than others, but you still have to do your job.

And that's the clients and their families. We talk about when we get so swamped by all the financial concerns over it, everything from loss of revenue, cost of hiring, it goes on and on. But it's those clients that can't make progress if, first of all, they don't have service. And if all of a sudden they get a tech or a BCBA that is different oftentimes that's a setback. And so that is, a huge thing for the families and the clients.

But it's also a huge thing for the payers and everyone else in terms of the overall cost of things. So we need to make sure that when we talk about turnover, we keep focused on that, that is still the guiding principle is what happens when you have turnover, what happens with the outcomes. so that's the first thing that, that they need to keep in mind. And again, I think most people are, but you get so swamped, I gotta make payroll, I gotta do everything else.

I'm really worried about these things. So it's hard. then I think the other thing is you have to look at turnover and you have to expect, there's always going to be turnover that happens. And that's good in some ways cuz turnover is created by career advancement. Who doesn't want that for their team members to have career advancements? So if that means there's not something within the organization, then somebody leaves.

That's a great thing we are selfish if we think that's not a good thing, but it does create hardship, no doubt about that. There are relocations there are other family commitments that go with that, and there are babies in the ABA there's a lot of babies and that is the greatest possible way to have turnover. but it's real. so my point. we can't always be overly focused on those things that are outside of our control and that are good things to, to be happening.

We've got a plan for it, certainly, but I think we need to focus more on the areas that can be controlled in turnover, and those come down to relationships. The relationships you have with your team. the structural opportunities that you have built into your organization and you need to have them. that's important. You can't just hire people in and expect they're gonna wanna do the same job for the next 20 or 30 years and not have different, reasons to advance. We all do that.

That's why most people own their business is because they wanted to advance and they wanted to make those decisions. So we have to make sure that those structural opportunities are there. We have to keep in mind the survival aspects. And with inflation that rears its ugly head, now more than ever, we have to understand that compensation and benefits things are things that you have to plan for. And so that has to be there.

I think the key in some of the studies that we've done is that there has to be a continuous dialogue. You have to have a communication structure that is well distributed. It can't be one way. So many organizations, the communication goes down hill, and we have to do work to make it go the other direction. And that means you have to get out there and you have to talk and you have to listen. That's probably more important than anything is you have to listen.

I, there're not many employees out there that say, I don't want say anything. I don't want to chime in. I don't want to affect the good of what we're doing at this company. People wanna be involved. That's why they, that's why people go into ABA. They wanna help these kids. They want to help these families. So we as providers have to find ways to make that happen. And that means we have to listen. we always talk about recruitment and retention. I think it should be retention and recruitment.

We have to talk always about how am I keeping someone, I was telling Jill earlier, I hate to bring in athletic analogies, but I was listening on the radio and someone was asking a coach, what does this new transfer portal and college athletics mean to you? Has it made your job harder? And he said, no, not really, because my attitude has always been I need to recruit all of my athletes every day. Not before they come in, but every day.

And we as providers, whether it's an ABA or anything else, we have to recruit our people every day. We have to listen to them. We have to find ways to get it to be an enjoyable atmosphere. it's not always work and always fun, but you gotta, there has to be something to drive some enjoyment there. And then you gotta look at the, the promises we make. Everyone talks about value or values propositions. that's very important in your recruiting, in your marketing, but it has to be more than that.

Just like these other things we talked about. It can't just be a, something on the shelf or a program that we put out. We've gotta test those propositions. Are they working? Are we doing what we say? do we make good on our promise? Because people will hold you to that and they will turn over if you don't.

just have an org chart that everyone can see that labels their supervisor and then set up the structures of being great about checking in formally At some frequency. quiet quitting is like one of these things that has come out of the Great resignation or that is much newer, and I think I was reading that best antidote to that is just a 30 minute weekly conversation between supervisors,

that's on you as a supervisor to create that environment, not just expect that it will happen. And then as people do come to you with challenges, make sure you're communicating upward what you're hearing from your team, and vice versa, that you're being great communicator downward. And I think that's an easily forgotten in the midst of how busy we are.

It's an easily forgotten thing to do about creating that culture of psychological safety, great communication, farming for dissent, and then being a great two eight communicator.

There were really high emotion. That had to be dealt with. and so what I didn't know at the time was that would prepare me a little bit to be some more flexible, a little bit more fluid, from my ABA experience. To your point, integration is absolutely the lifeline to success. somebody is putting out a whole lot of money. to acquire a provider. And it doesn't matter what metrics that you use for M and A to, to describe those accomplishments. the clinical and sometimes the operational models.

There's just, more adaptability in people, understanding that, yes, I'm gonna have to shift a little bit in my thinking and in my processes compared to culture, and cultural integration. And I think that, there's a couple things, right? It's, it doesn't take very long, in M and A to know, look, somebody might not be a cultural fit, just like they may not be a clinical operational fit. And so why would you do that acquisition? It takes a lot longer through the diligence process.

And I have second guessed myself over and over a lot of times, three months in going, was I right? can we integrate? And, what I love about M and A and. not everybody sees this, but I see M and A as taking two of the best in putting those together. And that's not just operational in business foundation in clinical operations and best practices, but also culturally. And so I see that as taking the best of the best and making something even greater.

the integration challenges that I've seen in the world of ABA, they have to do with the lifecycle of where we're at in ABA, the fragmentation, the maturity of where we're at in this industry. the people that are drawn to ABA, like John was saying, they're very mission focused, they're very passionate about what they do and that creates sometimes this perception that they're losing control, when they are partnering or joining up with another operation.

when really, again, we're just asking that we shift maybe that thought process or, how we think about culture and operations. so there tends to be this level of resistance, I think that you're referring to. and it's about change, right? It's about, the fact that they have poured their heart and soul into this, that they've built, this brand that they've built, operations around it, and the thought that it could be improved upon, is not the first thing that's foremost on their minds.

I think that, Frankly, not everyone approaches M and A in the same way as well. I think that, it's not just those who are being acquired who have to shift their thought process as well. Sometimes the acquiree, Could learn a lot from the provider that they're acquiring and also have to shift a little bit in their playbook and in their operation. And again, take the best of the best and make it even greater. I think that where I have seen some more success.

And just, less resistance, I'll say, is when it's not pure play ABA, and they also have maybe some speech and some OT, maybe some PT. they've got some other services, that are involved. And those folks they've already jumped in feet first. they understand how to work together and they lean in and. they know that they can benefit from the other disciplines in the other sectors, and those tend to be, a little bit easier to integrate.

And as leaders, I think it's important for us to remember that if we're, whether it's going through, an acquisition, or whatever we are experiencing change wise, our teams, our supervisees are experiencing that at an exponential level. And that can be really easy to forget if we are only concentrating on, oh, how am I gonna manage through this change,

And again, we're getting stronger as a unit rather than, individuals and so as the industry as well. but it's, it is tricky, that transition and that, change is hard.

And the one thing that they kept for Continental, that you can see to this day is they kept the logo on the back of the plane. And I think change the colors a little bit to be united colors, but with the idea, hey, maybe like teams will then, like they still have ownership, Oh my gosh. I was just like, I get the intention behind that.

How do we keep that spirit alive of pride around our brand and what we've built and what we've did, but we've done, but just throwing it on the back of a rudder, I dunno. John, you spent, some of your early career in manufacturing and you've pointed out to me before, like healthcare and manufacturing, though they might seem like two disciplines that world apart, each is rooted in process and people and the analysis therefore of the interaction between those two.

And as an example, productivity is something really important in healthcare services and certainly in ABA it's really important in manufacturing. and you had designed this finance 101 training you do with your frontline manager. what pain points did you experience that indicated the importance of this finance 101 training? What was the impact and how can that apply to the ABA field?

So every single employee that entered in their initial orientation, they received a day's worth of finance 101 in window hardware in this instance. And so the thought was, if you want ownership of the product and the process and that you have to give people the tools to do that. And at home we say, if you've got your checkbook and if it doesn't have any money in it, you can't write a check with the same kind of concept. We want people to understand how what they do impacts the overall.

And so in manufacturing, it's a little bit different, and I'll get to ABA here in a second, but in manufacturing so many times it's repetitive processes. People are assigned one spot, maybe they're standing on a line, they're doing the same thing over and over again.

So they may be handling the same looking parts or the same boxes or whatever, and it's easy to forget and to discount the value of the pieces that you have in your hands and the effect of what you do, whether you decide to take a break and your process stops, or whether you allow parts to go through that aren't good and they get caught later in manufacturing. The other thing is that it's, each process is dependent on the one before them.

All these downstream processes are dependent on you and most of the processes run continuously. It's not like you do one batch necessarilly but lines are running continuously. So if an individual on a manufacturing line doesn't do their job, it's gonna affect somebody down the line. And the inventory is all just in time because you're trying to keep costs down in that. So becomes something that you have to get people, these tools to understand how they fit into the whole process.

And so by teaching them that, maybe this part is only 3 cents, but you handle 10,000 of 'em in a day that's a lot. If you make a mistake or something that could affect all of them. And then you affect everything down the line too. If the next group doesn't have parts, they, they can't do their work. so in ABA, it's also, you've gotta have this transparency and you've gotta add some of these trainings.

So if ABA is able to give some of these financial understanding and some of these different tools to their team members being transparent. it helps them to understand their role and their impact that they have all the way through. And, it's important. we, Jill talked about it before. 90% of the revenues coming from that one position for the most part. But there's really just two positions, BCBA in that techs that are driving revenue.

There's a lot of other people in the organization that have to be there, whether it's HR or it's billing or it's, there's, you can name all kinds of 'em. There's more indirect people than direct. But you have to understand how those people are paid. They're not paid by making visits and being paid for it. They're being paid out of that same reimbursement that you're getting from the payer.

And I don't think people always understand that when they get that logic and they understand it, it helps them piece together a little bit more about how things function. I've heard comments where people say, I know we're getting $75. from a payer, why am I only getting 30 of that or whatever, I should be paid more. Perhaps you should, but you need to also understand all of the other elements. So I think that there's a great opportunity for ABA to add additional training.

It's the same thing as I talked about before, the management skills, but we need to give some finance 101 to all team members to be able to appreciate how those things work. We always talk about consumers, an educated consumer as a better consumer, same kind of thing as a professional, a more educated, skilled professional is likely gonna be a better one and produce better for the team and to have a better impact

but if you understood the whole financial component and framework of it, maybe you would be more willing to, you wanna help the parent and the child out most importantly, but you gotta keep your doors open.

It's engaging people in the dialogue not to be afraid of those things. stand on the shoulders of the people in the past, but be creative and figure out new ways to face the opportunities that are here today and in the future.