Changing an organization's culture from a medical model to a resident-centered model is a continuous process that takes time and does not happen overnight. Think of it as a journey, rather than a destination. It is a movement that encourages homes to examine their values, structures, and practices to transform a medical or institutional approach to care delivery into one that is resident-directed. As a staff member at Isabella Geriatric Center (New York City) describes it, “It has been a good journey for me. I am not at the end of it yet, but I am glad I am on it.”
Isabella Geriatric Center is a 705-bed skilled nursing facility located in two high-rise buildings in northern Manhattan. Isabella was first introduced to the readers of Long-Term Living this past September in the first article of this series (“Creating Home and Building a Community II: The Urban Experience,” Long-Term Living, September 2008, p. 56). Recipients of a $50,000 grant from The Hulda B. and Maurice L. Rothschild Foundation, Isabella is planning significant changes to its built environment in order to support its goal of becoming more resident centered. (The purpose of the grant was to provide support for planning the restructuring of the built environment, but not for actual construction costs.)
Isabella's urban environment presents particular challenges to its becoming more person-centered-challenges that are both physical and organizational. Dealing with elevators, noise, or individualizing anything becomes that much more formidable in two high-rise buildings located on a busy street in a densely populated area of New York. What the culture change movement has helped long-term care providers understand, however, is that one of the keys to individualized care, and to an atmosphere promoting a supportive living and working environment, is a decentralized approach to addressing the myriad decisions and challenges involved.
Like other homes engaged in culture change, Isabella has created a neighborhood structure to support this decentralized approach. Over the past few years, Isabella has also been reorganizing its performance improvement program, sometimes referred to as quality improvement, to better link quality of care with quality of life, with the ultimate aim of meeting resident-centered goals and objectives for all the care and services that Isabella provides. Performance improvement is essentially a problem-solving methodology that focuses on identifying, analyzing, and improving existing ways of working within the organization.
Everyone is involved
One of the most important components of this approach is involving the people who are closest to the issue-residents, families, nursing assistants, other direct care staff, as well as supervisors, managers, and department heads-in finding new solutions. In such a large facility, the traditional hierarchical structure can get in the way of effective problem solving because of the tendency for departments to try and address issues and problems on their own or at meetings with other managers.
The reality is that virtually everything that happens in a long-term care home involves many departments, and most of the work is performed by direct care staff. Those who are closest to an issue always provide an additional, unique perspective, which is why Isabella is now beginning to place so much emphasis on cross-disciplinary, cross-hierarchy teams and resident and family participation. This decentralized way of working also brings fresh energy and excitement to the change process.
Finally, performance improvement is already a regulatory requirement, and Isabella's decision to use it as a way of linking quality of care with quality of life, in a way that is so inclusive of all stakeholders, is completely consistent with federal and state mandates, as expressed by the Centers for Medicare & Medicaid Services (CMS): “The principles behind culture change echo OBRA principles of knowing and respecting each nursing home resident and providing individualized care that best enhances each resident's quality of life.”
With the support of the Rothschild Foundation (see “Foundation Support,” p. 20), Isabella is now expanding its performance improvement program to address areas of concern in its environment. “It takes courage to challenge the status quo,” says Ramon Rios, facilitator at Isabella, and the staff is doing just that, in an effective, thoughtful manner through the establishment of performance improvement (PI) workgroups that give everyone a voice in improving the environment. “Everyone” includes residents, family members, and staff members from different departments, shifts, and levels of the hierarchy.
To begin the process, Isabella's overall PI Committee established a workgroup (made up of direct care staff, managers, family members, and a resident) to articulate a guiding principle or vision, a set of environmental values, and specific examples of how to operationalize these values. The workgroup met several times last winter, brainstorming ideas and talking with other staff, residents, and family members in between sessions. These between-session conversations were intended to involve an even greater number of individuals and departments in considering how Isabella's built environment could be improved.