Tales from the Trail

Culture Change -- Begin with a Vision

by Jocelyn Montgomery
CAHF Director of Clinical Services

The hardest part of a journey is often the first step. That is why when one of our CAHF members told us that she was currently involved in the ground floor implementation of culture change at one of her buildings, she got our attention.

What we wanted to know from Mary Anne Branch, vice president of clinical services at Foresight Management Services, was how her team was approaching this important project and what first steps they had identified for action.

Based in San Ramon, with a Web site at www.foresightms.com, Foresight Management Services owns and/or manages 10 skilled-nursing facilities in the Bay area. Staff there have been working with Lumetra, the California Quality Improvement Organization, in its quality initiative program for several years and now have decided to take their quality improvement activities to a new level by perfecting a model for culture change at one of their buildings.

Eventually, they hope to replicate this model at all 10 of their facilities – but first things first and one building at a time.

The first thing they needed, according to Branch, was a vision.

In search of a vision, a core group of staff known as the “Home Team” researched different models of culture change and decided to design a model that was unique to Foresight. They named their project "Just Like Home."

Because remodeling of the physical plant is not something that is feasible right now, they began by asking themselves: "What do we want it to look like, and what can we do within the current environment to make a real difference in the way we deliver services?"

Their answer became their vision – namely to provide services in a manner that increases residents’ freedom of choice and empowers resident decision-making.

They envision an environment that is comfortable, stimulating, secure and non-institutional. They picture a schedule that allows for flexibility and spontaneity. They aspire to provide an atmosphere that honors elders, values their input, promotes their growth through wellness opportunities and addresses their social needs through relationships and purposeful activity.

The "Home Team" has designed the implementation of this culture change in a way that provides for maximum stakeholder input through a series of focus groups. The project is broken up into five stages:

• Stage 1 – Identify vision, values, and stakeholders. (This is their current stage).
• Stage 2 – Involve stakeholders, plan for the present and future, design survey questions for focus groups.
• Stage 3 – Conduct focus groups among their staff, with their residents and families and community stakeholders. Analyze the focus group data and use it to refine the vision and build the work plan.
• Stage 4 – Put together work teams based on focus group data.
• Stage 5 – Develop the model; identify the building to pilot it in. Begin!

Branch hopes to be in Stage 3 in three months time, and to be ready to implement the pilot around the first of the year. She agreed to share the trials, tribulations, and successes of the "Just Like Home" project from time to time with the CAHF News readers, so we can learn from their efforts and support their hard work.

Stayed tuned to Real Change for more on "Just Like Home."

Bringing Back the Family Table

by Jocelyn Montgomery
CAHF Director of Clinical Services

"Food is our common ground, a universal experience." – James Beard (1903-1985)

Idylwood Care Center, a skilled-nursing facility licensed for 180 beds in Sunnyvale, serves a challenging population.

Many of the residents face the special challenges associated with mental illness and dementia in addition to their medical problems.

But Administrator Franco Diamond and the staff at Idylwood say that they have found a powerful way to build human connection and improve the quality of life for the people in their care – and it all started with soup.

Diamond admits that he is a “foody” and says he brings his love of good food to his job. That may be why he started a contest to find the “soup of the day” for the facility’s menu.

He invited staff to make their favorite soup recipe and bring it in to work. The residents were the judges – they voted for their favorite, and the winning soup became "soup of the day" on the regular menu.

This simple idea was wildly successful and was really the beginning of a movement toward building an integrated activity program around growing, cooking and enjoying food.

Today, the activity areas at Idylwood have been converted to include cooking and dining areas where residents participate in the preparation and enjoyment of their favorite foods.

Staff and residents teach cooking classes to each other, and these classes reflect their unique ethnic histories. An Idylwood cookbook captures the residents’ favorite family recipes along with stories from their lives.

The grounds of the facility are being converted to organic gardens. Every day fresh veggies and flowers find their way into the facility – and residents find their way out to the gardens.

Trained chefs often offer guest instruction in food and nutrition at Idylwood, and Diamond has even hired one as his head cook.

He says the positive effects of this focus on good, fresh foods can be measured in the improved health and well-being of the residents. Weights have normalized, negative behaviors have decreased, and there is a sense of the celebration of life that permeates the place for residents, families and staff.

Diamond has big plans for the future. He subscribes to the "slow food" philosophy, an international movement whose mission is to raise public awareness of the importance of the high-quality food that is produced in an environmentally sustainable and socially just manner.

He wants to expand the gardens on the grounds and move toward purchasing locally grown produce whenever possible. He visualizes an "Idylwood farmers′ market" in the near future and has two staff members and two residents who have completed an organic gardening course.

Diamond is also working with the local school district to set up inter-generational classes at Idylwood for middle-school students to take classes in gardening and cooking along with the residents.

Everyone participates in the culinary celebration at Idylwood. Diamond says even the most fragile residents join them at the family table – and, at the very least, the aroma therapy of baking bread fills them with memories of warm kitchens and loving hands.

Life is good at the family table.

A Tale of Transformation

by Jocelyn Montgomery
CAHF Director of Clinical Services

Where does real change start? According to J.K. Shea, it starts with the question; "What do I want my life to be like if I need to live in a nursing home?"

An important question – so important to CAHF member Kennon S. Shea and Associates in El Cajon that they brought staff representatives together from all eight of their facilities to spend a day talking about it. Every care discipline was represented, from administrator to dietary.

Leading the discussion was LaVrene Norton, a national expert on the movement to transform nursing facilities from institutions to households where self-led care teams focus on resident-centered care.

LaVrene shared the history of care models that started in the last century with poorhouses and rest homes and led to the medical model that we know today.

She also talked about her vision of the four stages of culture change in long-term care, namely:

• Stage 1 – Institutional: Departmental structure, medical model.
• Stage 2 – Transformational: Move toward resident-centered care, choices in bathing and dining.
• Stage 3 – Neighborhoods: Small functional units, consistent staff assignments, resident and staff teams.
• Stage 4 – Households: Self-contained living units, with authority and accountability through the household instead of departments.

This culture-change model is described in a workbook and DVD titled A Tale of Transformation by Action Pact Inc. These materials, as well as many others, including free downloads, are available at the Action Pact Web site at ] www.culturechangenow.com.

The time with LaVrene flew by in exercises, self assessment and honest communication. There were laughter and tears – and a good hard look by the Shea staff at where they are now on the culture-change continuum and where they want to go.

Before the end of the day, it became obvious to this writer that process of culture change is very challenging, but this organization already has the most critical elements for success: Leadership, honest communication and a commitment to doing the right thing.

"Is there anything more we can do for you?"
Part 1 of a two-part visit to Ararat Nursing Home

by Jocelyn Montgomery
CAHF Director of Clinical Services

Care conference meetings are a crowded affair at CAHF member Ararat Nursing Home in Mission Hills. Every Tuesday and Wednesday morning, the Resident Centered Care Team meets in a room decorated like a cozy parlor with colorful teacups on the shelf. Around the big table, key team members meet to review care and discuss the status of their residents. Each of the 196 elders living at Ararat is reviewed in this manner every three months.

Present at every care conference are the primary CNA, RNA and charge nurse for the resident, the resident-care planner, MDS coordinator, social-services and activities coordinators, the manager of dietary services, the director of clinical services, Executive Director Margo Babikian and, of course, the resident. Families are always invited to care conference as well, and often they attend.

Consistent assignments are in place at Ararat, so the charge nurse and CNA who attend will change depending on which resident is being discussed. The charge nurse generally starts things off with a brief summary of the resident’s general health status, pain management and medication regimen. Often there are questions from Margo about potential drug side effects, the rationale for a certain medication or the status of a dose reduction. The CNA reports on activities of daily living and the resident’s general mood. The RNA talks about the efforts the resident is making in therapeutic dining, strengthening exercises, or ambulation. Nearly all the residents are on an RNA program at Ararat, and no one is restrained.

Dietary services reviews the resident’s food preferences, intake and weight status. Liberalized diets and accommodation of cultural preferences are the norm here, and most residents have stable weights. Food is available whenever they want it, even in the middle of the night.

Social services and the activities coordinators present on the resident’s psychosocial status and quality of life. They discuss the resident’s participation in and response to the specific care programs she or he is involved in, such as pain management, doll therapy, college courses or “forgiveness factor,” a process where staff help them to work on letting go of resentment and anger.

At this point Margo may read from the resident’s chart about his or her hopes and dreams. Every resident is asked about this upon admission, and the Ararat team works hard to help them fulfill these wishes. Quality indicators and the care plan are reviewed. The staff, resident and family confer on the resident’s progress towards measurable goals, and the whole team has input into revisions to the plan of care if it is indicated.

At the close of the review, Margo touches the resident’s shoulder or hand in loving reassurance. She looks them in the eyes and asks them and their family member, if present: “Are you satisfied with your care here?” It is an earnest question, and the entire team waits attentively for an answer. The answer is usually an expression of intense gratitude to the team for the excellent, loving care that they give every day, day after day, year after year.

Ararat is known for its excellent, person-directed care. The facility has 100-percent occupancy and a waiting list. Three of its last four surveys have been deficiency-free. But what is important to this dedicated team is the answer of happy satisfaction that they get from their residents when they ask: "Is there anything more that we can do for you?"

Excellence in workforce practices
Part 2 of a two-part visit to Ararat Nursing Home

by Jocelyn Montgomery
CAHF Director of Clinical Services

Research shows that staff satisfaction in nursing facilities is tied to better occupancy rates, better surveys and lower turnover. It also makes for happier residents. At CAHF member Ararat Nursing Home in Mission Hills, the turnover rate for direct-care staff stays between zero percent and 4.6 percent per quarter. Their employee satisfaction rate is over 95-percent satisfied, and on a recent survey of Ararat staff, 100 percent of them agreed with the statement: “I love my workplace and am very proud to be a part of it.” Is it a coincidence that their most recent “Family Satisfaction” rate was 98.8 percent? I don’t think it is. Here are some of the workforce practices that are in place at Ararat Nursing Home – judge for yourself.

Teamwork

All the direct-care staff at Ararat are assigned to a “Resident Centered Care Team” with a group of consistently assigned residents as their responsibility. Their roles on this team are well defined, and they are treated as professional partners by their other team members. Their input is solicited, acknowledged and taken into serious account, and those who are closest to the residents – the CNAs and LVNs – have the greatest decision-making authority when it comes to their care environment and their residents. The members of each care team do their own schedule and cover for each other when unexpected changes come up.

Visibly valued

All the staff at Ararat are recognized for a job well done. When families answer positively about the care their loved one received from an individual or a team, the executive director and CEO write a letter of thanks to those staff involved and post it in the communication book for all to see. When staff are observed doing something right, they are praised at stand-up meetings and sometimes rewarded with a "pin of excellence."

Happy staff = happy residents

There is a "Wall of Fame" where employees of the month are immortalized. RNAs who meet specific resident goals in the therapeutic dining programs are honored by having one of the beautiful "view" windows named after them. When managers do their monthly status reports, they are asked the question: "Did you positively acknowledge any employee this month? If so tell me [the executive director] who so I can recognize them too." Staff birthdays, kids getting their driver licenses or graduating high school, births, weddings, new cars – all are the subject of acknowledgment and joy at Ararat Nursing Home.

Environment of support

Staff can’t go or come back without being noticed. If they are off ill, they are warmly welcomed back at the daily meeting. If they have a sick family member or a personal loss, they are given cards of condolence and offers of help from their team. When they lose a resident, they are encouraged to share their grief and are given an opportunity to attend the funeral if they want to. There are no "bosses" at Ararat Nursing Home – there are mentors, coaches and role models.

Unleashing potential

Professional growth and career ladders exist for all staff at Ararat, and most of them have taken advantage of the opportunities. There are laundry workers who train to become CNAs. There are multiple levels of promotion for CNAs (which at Ararat Nursing Home stands for "Champions of Noble Advocacy"), all of which come with a pay increase. There are scholarship programs for CNAs to become LVNs and LVNs to become RNs. There are professional enrichment activities on-going such as the required reading of articles, opportunities to attend conferences and in-services, topics assigned for staff to research and write about or present to their peers.

Building on intrinsic motivation

The staff are caregivers because that is what they want to do. Caregiver input is solicited, acknowledged and taken into serious account. Ararat leaders recognize this sense of calling in the people who work there and build on it by helping them to feel the awesome responsibility and immense reward that comes from providing excellent care. Sensitivity training is done with all care staff. This might involve putting a staff member in a bed with the side rails up and not answering the call light for a while. It might involve having to write an essay about what your life will be like when you are 84.

It definitely will include adopting a resident. Every staff person at Ararat Nursing Home – whether in the laundry, kitchen or executive office – adopts a resident. Their assignment is to spend time getting to know that individual and then to tell her or his story. This can be done through a book, an album, a poem or a picture framed on the wall, but it must reflect the life of the resident before coming to Ararat Nursing Home. These residents’ stories fill a room, and they are beautiful testimonies to the respect and honor that are given to every person at Ararat – even visitors like me. Ararat Nursing Home is a healthy, nurturing, joyful place to live, work and visit. People who come to work there stay because of job satisfaction, not wages and benefits. They stay because the values of Ararat Nursing Home match their values and because Ararat gives them what they need to do the job they love to do: Providing excellent, loving care to the elders who live there.

Note: The research referred to in the first paragraph of this article is Tellis-Nayak, V., "Customer Satisfaction in Long Term Care," American Health Care Association, 2003.