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CW Ep. 18: Innovations in Senior Care with Charles Turner

Charles Turner, founder and CEO of Kare, discusses how planned continuation bias applies to senior housing. We’re talking about the unconscious cognitive bias to continue with your original plan in spite of changing conditions.

Rebecca: Hi, this is Rebecca Turner. Charles’ wife. If you’re expecting to hear Charles, don’t worry, he will come on in a second. But when he was recording this, I happened to eavesdrop on what he was saying, and I felt in the interest of everything good and right that I better set the record record straight. Before this podcast was released, I got with the good people at Bridge the Gap to allow me to insert commentary here and there when I felt you, the listener, were not getting the full story in the next few minutes, Charles is going to tell you a story about a family vacation that occurred about a decade ago. Know that everything he is saying is his view of events. And that as wonderful as my husband is he can be quite stubborn. And with that here’s Charles.


Charles: Family dynamics are interesting. Sometimes we create such solid plans for our lives that we don’t realize the effect it is going to have on the rest of our family. One of the most frustrating family memories occurred about 10 years ago. Our children were little, just a few years old, and we were going to take a long anticipated trip to the beach. We knew under normal circumstances with the kids, the trip should take about 11 hours from our house in Texas to the white sand beaches of the Florida panhandle. It’s a trip we’ve taken dozens of times before. We knew every exit, every pothole and every fast food restaurant along Interstate 10. We also knew where traffic would back up and where we would need to schedule meal and bathroom breaks.


Rebecca: Okay. So far everything Charles has said up to this point is true.


Charles: It just so happened that about a week prior to this trip, my wife all elected to have LASIK surgery to improve her eyesight about a week before this trip, assuming she would be fully recovered by the time we were to take our journey.


Rebecca: Okay, here’s where the story starts to fall off the rails. I didn’t elect to have LASIK surgery, as he said, my doctor said that if I didn’t have it, I would be blind in a couple of years.


Charles: Unfortunately, the doctor wanted to schedule what I felt was an unnecessary followup appointment for the morning we were supposed to leave to go to the beach. My wife, not wanting to question the doctor, agreed to this plan, knowing that it would jeopardize the timeline of our family vacation, the rest of the family was upset that the plan of going to rye appointment would increase the likelihood that our drive would take even longer, even as we would hit certain traffic points at the worst times of day.


Rebecca: Right. Where to begin. There are so many things wrong with this. One, if I didn’t have the appointment, I could have suffered irreversible damage to my eyes. Two, the doctor bent over backwards to open his office on a Saturday morning, just so I could make our vacation. Three, the rest of the family was not upset that our drive was going to take longer. Our kids were five and three at the time, they had no clue what was going on.


Charles: As expected, the day of our trip arrived, taking my wife to her doctor’s appointment, put us three hours late into partying Houston, meaning that, of course we got stuck an hour long, a traffic on the Baton Rouge Bridge over the Mississippi river. And of course I had to be the bad guy to yell at our kids to eat their Chick-fil-A nuggets in 15 minutes so we could get back on the road and not lose time.


Rebecca: He made a complete fool of himself in the Hammond, Louisiana Chick-fil-A.


Charles: And of course her delay meant that I would not get off at the Springs exit in Florida because as we all know how bad the traffic you can get there, no, I had no choice but to take a gamble and get off on a muddy back road in the middle of a rainstorm where we literally almost slid off the side of the road in the middle of the woods. Obviously, we were not going to make it to the beach on time as we had all planned to do.


Rebecca: Okay. Literally no one asked him to do this. He was a man possessed. We couldn’t stop him. I was texting my family constantly in case we got stuck and they had to call the national guard. When we arrived, we had so much red mud caked in our exhaust pipe.


Charles: And finally, after we did arrive, tired, hungry with a car covered in mud. The stress of the situation made me physically sick for the next two days.


Rebecca: Okay. A really key piece of information he left out here. Remember the Chick-fil-A part of the story? What Charles neglected to mention is that in his arbitrary haste to get me in the kids out of that restaurant, he ate way too quickly and somehow managed to eat a large chunk of a plastic mustard packet. I still to this day, have no idea how he did that, but it was the mustard packet that made him sick. I’ll spare you the details, but it was not pretty.


Charles: And why did this have to happen? Because God forbid, we deviate from my wife’s doctor’s plan of having her follow up eye appointment to this day. I’m still mad about that trip. And it did not need to be this way.


Rebecca: No, no. It did not.


Charles: Welcome to Bridge the Gap Contributor Wednesday. My name is Charles Turner. This is a podcast on innovation and senior care. We like to explore the things that keep ourselves and our organization stuck in the past, especially in a time when we need innovation more than ever. I am the CEO of Kare. Again, that is Kare with a K. We’d like to think of ourselves as the future of frontline staffing. Think of us as an Uber like platform that gives you access to thousands of nurses and caregivers at a price that is a fraction of the cost of a staffing agency or paying your own own employees overtime. Feel free to look us up. Do again, that’s Kare with a K. The story you just heard is an example of something called the planned continuation bias, which is defined as the unconscious cognitive bias to continue with your original plan in spite of changing conditions.


This is a term that came out of the aviation industry that described pilots’ tendencies to irrationally stick to their flight plan and the face of increasing elements of danger. If you go back to my first episode, we talked about the concept of the granny shot, how we as individuals won’t do what is in our best interest, because we worry about ridicule, the loss of respect, and possibly damaging our careers. Even though the evidence may overwhelmingly dictate, we should change our actions anyway. So if the granny shot talks about how we as individuals limit ourselves from changing, think of the plan continuation bias as how we, as organizations limit ourselves from change. It’s like this podcast I’m trying to record right now. My inertia, my plan, is telling me to continue recording, even though I am pretty sure someone is right outside my door, eavesdropping on me while watching Netflix. My plan continuation bias says that I should just plow through, try to finish recording, even though I know the best course of action is to pause and solve the problem right front. Just hold on. What’s going on? My recording. 


Rebecca: Oh, no, no, I’m just, I’m just folding laundry and you know, watching a little Gilmore Girls. Okay.


Charles: I’m trying to finish this recording. It’s just a few more minutes.


Rebecca:Oh, sorry.


Charles: Alright. Where was I? Okay. Sara, when you get this, can you just make sure you edit out this part? Where was I and blah, blah, blah, blah. Okay. I know the best course of action is to pause and solve the problem right in front of me, assuming I can get this thing recorded in time. This podcast will be released in late September, which means that October is coming. And those of us in the senior care world know what October means.


It means budget season.


So for those of you who are unfamiliar, here’s how budget season works. The company, CFO and his team build these elaborate spreadsheets that sort of work. And they set arbitrary monthly financial goals for each part of the organization. Then solicit feedback from each part of the organization about how they want to tweak their budget. Then the CFO takes all that input and throws it in the garbage. And then 10 weeks later, the budget is presented, all with the blessing of the CEO and the end. At the end of the day, they will build a model that forecast 3% revenue growth with only 2% expense growth and all the meetings and spreadsheet, exercise and planning cost and staffing matrixs, will lead to that one. Undeniable fact, your revenue must grow at 3% while your expenses can only grow at 2%. I know this because I have been a CFO and a CEO of several organizations. Of course, this year, we’re going into budget season and the largest black Swan event our industry has ever faced. So I guarantee you that the second you release your budgets, assuming your CFO actually gets them done on time. Your actual budget variances will be so far off that the budget itself will cease to be useful.


As I have pivoted from building assisted living and memory care buildings to building software and apps that improve our industry, I have become increasingly familiar. What is called agile development methodology. If you listen to one of my earlier podcasts, I talked about how before I ever got into real estate and the senior care world, I worked at several large software companies having nothing to do with this space at all. But back in the 1990s and early 2000, the leading methodology was what is referred to as waterfall methodology.


And it’s essence. It is a method analogy of doing what doing a lot of planning and testing and analysis before any software has ever built to de-risked your development process, to ensure that there are fewer bugs that you have captured everyone’s requirements. And at each stage of the methodology, there must be an approval step before the next phase can begin. This is a great methodology when taking large problems that need a complex solution and a complete solution once it is released. And it’s also a similar process to how we build our budgets in our industry, but this methodology has its flaws. The process itself can get bogged down and bloated requirements. And by the time the product or in this case, the budget is released, reality has now shifted from the goals that the plan was created to begin with.


This is why agile methodology is now used instead of creating a grand plan. Agile is very incremental in its approach. For example, at Kare my company, we have a new software release about every two weeks under the more traditional approach we would release about every six months. But with agile, we try to simply identify and attack the next problem, fix it, see how it goes in the wild, then fix it a little more and more each time. While there is risk that each little release may be a dud, our risk is that it has just a little release and it’s a highly incremental, innovative approach. And when a black Swan event comes along, like say a pandemic, we can quickly pivot and build in functionality that helps solve that problem too. So how can this be applied to planning and our space? Well, how about this:


How about, instead of trying to solve every organizational problem, using financial goals, instead, identify those things that you want to improve so that by improving that you will improve your financial performance. So let me give you an example. My guess is if you are in the senior care world, your budget process looks something like this. “We expect to have so many residents each month, and therefore we need to build staffing ratios that support those residents each month. And our staff shifts are 6:00 AM to 2:00 PM, 2:00 PM to 10:00 PM and 10:00 PM to 6:00 AM. Given our number of residents. We need to have X number of caregivers on the floor during each shift.”


Now you ask your marketing department what they want, and they say, we want to advertise that we provide person-centered care. But if your shifts are 6:00 AM to 2:00 PM, 2:00 PM to 10:00 PM and 10:00 PM to 6:00 AM, is that really person centered care? Or is that staff centered care or budget centered care?


What if you got away from the concept of fixed shift times altogether, instead of an anesthetic just brought in staff when residents wanted to be cared for, instead of caring for residents, when the staff were on site? Maybe experiment with staggering, your shift start times to match resident habits, maybe even throw in some part time shifts during peak times using a variable staffing platform, like ours, so that you can improve resident satisfaction and improve financial performance. Maybe your marketing department for once can honestly say that you provide person centered care.


My point is this: experiment with it, take two weeks to a month to see how it goes, learn and tweak it, then learn and tweak again, use the tools you already have. EHR nurse call systems, dining platforms, and payroll systems to identify the patterns and trends and try to influence those trends.


So I know what you’re probably thinking, Charles, this puts stress and strain in our leaders and staff, and they already have to manage all the stuff. We can’t have all this constant change. This is going to be a problem. Of course, it means it’s going to be a problem, but do you know anyone else who manages and operates senior care communities that are just not under a tremendous amount of stress and strain already? The idea is that if you have your teams focuse on constant improvement, they will actually build better processes in the long run that will reduce that stress and strain. Stop with this planned continuation bias, try to be more agile. If you feel your people can’t handle the stress of innovation, maybe get new people. For example, a couple of years ago, Patrick, a business partner of mine was working with one of the most respected companies in our space. Subjectively speaking, this is definitely a top five brand in terms of reputation and high end quality. He was working with them to help them realize how they can measure and improve their operational performance using a middleware platform we had developed called Veritas Solutions. Fairly quickly, Patrick was getting resistance from this organization’s leadership and a conversation with the founder and CEO. The CEO lamented St. Patrick, my company was built by caregivers. And now the company is run by caregivers. Of course, the CEO was not diminishing the value of caregivers, rather his frustration stemmed from the fact that he had no one in his company that had experience outside of the care industry, they simply didn’t know any better. And they assume that certain things we’ve always done. For example, say, fix the shift times were gospel and no longer needed to be questioned. We talked about this at length in my last podcast so I don’t need to belabor the point.


What the CEO wanted without actually saying it was, he wanted to transform his company from a company of caregivers, to a company that resembles leading manufacturing, logistics companies, which I know sounds weird, but think about it. Why do we love Amazon? I know there are those who hate Amazon, but come on, you get your phone, you order say underwear and it arrives at your doorstep the next day. And it is generally less expensive than traditional retail. What’s not to love really? Do you think that Amazon was designed by Jeff Bizos? He says in one master spreadsheet and then built without any improvements? Of course not. I guarantee you that there are thousands of people right now who are looking at how they shave a penny off a stick of deodorant, how they speed up the average delivery time by five minutes and how quickly they can pull an item off a shelf, get it in a box and attach a shipping label to it. 


They have thousands and thousands of employees who do this every day. Why? Because like them or not, Amazon is fanatical fanatical about customer service and improving customers deliveries. Now, without a doubt, Amazon is a massive company with a lot of resources, far bigger than any company in our space, but there are tens of thousands of companies who manufacture and distribute goods all over the world. Each of them in some way, employ a bunch of people who constantly seek out ways to improve processes in order to improve revenue, decrease costs and improve customer satisfaction. I know, I was one of them. My first job out of college was working for a large industrial supply company. My job was to figure out how we could improve shipping times from Georgia to Texas by 12 hours. 


Rebecca: Sidebar. This story is true, but get him to tell you about the time he sent an entire 18 wheeler full of packages to Jackson hole Wyoming, instead of Jackson, Mississippi.


Charles: Now think about some of the largest companies in our space. How many employees do they have that focus entirely on similar process improvement? Oh, I’ll let you figure that one out on your own, but to improve, we have to get away from this plan, continuation bias. We have to be more agile. We have to find ways to be incrementally more innovative. 24 hours after I released my last podcast, I read a study that came out of Rice University and studying the innovation trends of 271 manufacturing companies. It found that in companies with low turnover and high employee morale, innovation did increase, but only on the margins. What was fascinating was that in companies where there was true transformative innovation, those companies tend to have a bit higher turnover. I don’t think that is any different than what that CEO said. When he said that his company was built by caregivers and now run by caregivers.


This Rice University study did insist that employee morale was a good thing. Would that too much employee morale causes companies to look inward focusing only what is known. A certain level of organizational discomfort may actually be a good thing. This probably speaks as well to my theory from my last podcast, that we may place too much emphasis on culture for its own sake and not for the sake of our residents, families, employees, and overall improvement. We may worry too much about being nice. So let me wrap up this edition of Contributor Wednesday, by drawing a parallel between my wife’s stubborn behavior during our vacation and a movie I recently watched with my family.


Rebecca: Okay, at this point is Charles the only one who does not see his own hypocrisy or have I just become the mayor of crazy town?


Charles: If you have not already done. So I highly recommend watching the movie, the Boy who Harnessed the wind is a true story of a young African boy named William and the poor country of Malawi who teaches himself electronics despite the fact his family has no money for school. In this story, a severe drought of family famine, decimates, the country’s corn crop William’s families face three, they’ve faced one of three choices, either leave their community and search for working foods somewhere far away with no hope of success. Try to grow crops in the dry dirt we’re starved to death. Their only real option, William’s father determined was to try to grow crops in the severe drought with no hope of rain during a time of year, when crops were not supposed to grow. William’s father decided the only solution like so many of us was just to try to simply work harder than anybody else and refuse to listen to his son.


When his son came up with an ingenious solution to build a windmill pump using the families only asset the family bicycle, which had to be destroyed in order to make the pump work. As the story goes, William’s father plants corn, and of course it doesn’t grow, but still he still refuses to listen to his son. We have to work harder while he was father and says finally faced with no other choice and no crop Willem’s father relents and gives William the bicycle, which has subsequently destroyed and used to build a motor for a waterwell. But in true Hollywood style, the pump works drawing near unlimited supply of water from the ground to irrigate crops and save the village. So what is the lesson to be learned here? William’s father clearly suffered from planed continuation bias in spite of the overwhelming odds that his plan had little chance of success and the downside of risking his one remaining asset, the bicycle, there was a plan of low upside high downside.


William’s plan also had a downside losing the bicycle, but the upside, if it worked and of course it did, it was massive. So could we stop building budgets with 3% revenue growth and 2% expense growth? Can we try a different approach? Don’t boil the ocean, identify one or two things you’re going to fix and work 100% toward fixing that it will succeed or it will fail, but then you will know, and then you will go into the next problem and the next problem and the next, and for once let’s throw out our 2021 budgets, just throw them in the trash. Let’s look at this pandemic as our drought. It could be the greatest opportunity we’ve ever received. Thanks for listening to this week’s BTG Contributor Wednesday, I’m Charles Turner. I’d love to hear your thoughts. So please connect with at


Rebecca: Okay. Just so you know, Charles insisted on finishing this recording, even though there is a tropical storm about to hit us and we have done nothing to prepare the house. Now it’s raining pretty hard. So there’s that.


CW Ep. 18: Innovations in Senior Care with Charles Turner