Everyone has a voice in environmental upgrades

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.

Staff of various disciplines meet with residents and families

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.”

Performance improvement

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.

Ultimately, they came up with “Isabella's Environmental Values,” which were subsequently formally adopted by Isabella's PI Committee. Along with the values, the workgroup made a number of recommendations for specific practices that would need to be addressed if these goals are to be realized. Several of these, such as noise reduction, are the basis for the environmentally focused workgroups that are now underway.

Interestingly, even in a workgroup focusing on environmental issues, there was unanimous agreement that relationships are at the heart of both quality care and quality of life for residents at Isabella, and should form the basis for environmental goals. To support this basic principle or vision, workgroup members agreed that the built environment at Isabella should promote an atmosphere of comfort, clinical competence, and quality of life for residents; be welcoming and appealing to family members and visitors; and be respectful, pleasant, and supportive of staff.

Specific recommendations the workgroup made to accompany these values include:

  • Residents and their families should be encouraged and assisted in integrating personal items into their rooms.

  • Isabella should facilitate personalization of resident rooms by offering residents choice of comforters, artwork, plants, room color, room identifiers, etc.

  • Residents should have the choice of a private or shared room.

  • Noise should be minimized throughout the home, and especially in resident rooms and on the neighborhoods.

  • Equipment should be as inconspicuous as possible.

  • Maintenance schedules (cleaning, routine repairs, etc.) should be coordinated with neighborhoods with an eye towards reducing the intrusions or disruptions experienced by residents, visitors, and staff.

  • The perspectives of residents, visitors, and differing departments and positions should be included in the decision-making process regarding changes in the built environment.

Over time, Isabella expects to address all of these issues and more. However, too many projects at one time can dilute their effectiveness. For this reason, the decision was made to begin with six workgroups that would focus on some core environmental issues. A further consideration was that for any workgroup to progress effectively, it was important that there be at least one facilitator assigned to the group, someone skilled and experienced in supporting group members to achieve their improvement goals. Isabella decided that before the workgroups could begin, a new cadre of staff should be trained as facilitators, with additional training in performance improvement as well.

Twelve staff members were identified as good candidates. This group includes Isabella's six community directors, as well as six other staff: a nursing assistant, a recreation therapist, a beautician, a housekeeping supervisor, a unit coordinator (also a nursing assistant), and a housekeeper (all of whom are known to be facility leaders in person-centered care). Each of the six workgroups is led by two co-facilitators. Each facilitator, or community director, is responsible for one neighborhood. Isabella is organized into neighborhoods, each consisting of three communities. The communities vary in size from approximately 20 to 40 elders.

A resident's room integrates the use of personal items

Training workgroup facilitators

In most nursing home environments, managers spend a great deal of time in meetings. The experience is often less than satisfying, with the oft-heard complaints, “nothing was accomplished” or “only a few people spoke” or “everything takes so long.” At Isabella, organizational leaders recognized early in the culture change process that succeeding at solving problems in a new, inclusive way would require improved communication skills and training in collaborative problem solving.

Isabella has been working for the past two years to prepare organizational leaders, managers, and workgroups to do effective, interdisciplinary, and cross-hierarchy problem solving through training provided by PHI (formerly the Paraprofessional Healthcare Institute), a national nonprofit group working to improve the lives of people who need home or residential care by improving the lives of the workers who provide that care. Their goal is to ensure caring, stable relationships between consumers and workers, so that both groups may live with dignity, respect, and independence.

The Rothschild Foundation grant made it possible for the 12 facilitators to participate in several days of training throughout 2008. Facilitators were selected by Isabella with the support of PHI, and the group participated in two days of training provided by PHI's Sara Joffe and Shakira Abdul Ali prior to forming their workgroups. The initial session helped frame the role of a facilitator and strengthened participants' skills in managing a high-involvement group process. At this stage the focus was on developing a structure and process for the workgroups so that the voices, interests, and concerns of multiple stakeholders could be heard. The new facilitators developed their two-person teams, identified the issues their workgroup would be addressing, and had an opportunity to practice their facilitation skills.

Article coauthor Jennifer Brush had the pleasure of attending the second set of training sessions conducted by PHI's Joffe. When she first walked into the room, there were two groups of people sitting at separate tables. Everyone was intently focused on 22 cards that were spread out on the tables. Each card had a clue printed on it. The facilitators were solving a murder mystery by working together, creating time lines, categorizing clues, and using a number of other techniques that came naturally as they progressed through the exercise.

What stood out most about the group's interaction was that no one person was left out of the group or unable to give his or her opinion. No one person took over as “head” of the group for the entire exercise. Each member made room for everyone else to provide input-it was turn-taking and recognition of others' contributions at its best. After the mystery was solved, each person spent a few minutes talking to the group about their personal style of work and leadership. Jennifer thought to herself, “If this is how people are acting during the icebreaker, this is going to be a great day!”

After the icebreaker, the facilitators took turns reviewing their workgroup progress and concerns with the larger group. The workgroups had just been identified and had recruited new members, and had one or two initial meetings to articulate the purpose of each workgroup and recognize the key stakeholders. The rest of the day focused on strengthening participants' shared leadership and facilitation skills so that the workgroups could be successful.

The group participated in informal lecture and role-playing that helped them practice managing group dynamics, including power dynamics, conflict differences, and working through resistance. Joffe provided many examples to empower the group to address core concerns, maintain focus of the discussion, and to include multiple perspectives in all stages of the problem-solving process.

All facilitators were open to learning more and engaging others in this effective manner of problem solving. Staff enjoyed the training and clearly benefited from it. One facilitator commented, “It has helped me learn about myself and be a better leader.” Others members appreciated being recognized as contributors to Isabella, stating for example, “I have realized that I am not just a CNA; I am part of a big picture” and “I have grown a lot [from this training]. Most of my life I haven't had a voice. I have learned through this that I have a voice and my ideas are important.” Yet others expressed pride in where they work. One facilitator, a nursing assistant, said “I feel good to say to someone new, ‘Welcome, welcome to Isabella, your new family!’”

The enthusiasm of the facilitators is spreading. As Karen, a community director at Isabella stated, “Culture change is spreading-we have created a new environment.” There is a new awareness of “voice.” Clearly the facilitators felt personally empowered through the training; they have also been able to apply what they have learned to creating and leading workgroups to address core environmental concerns at Isabella, engaging a broad range of stakeholders in the process.

Mechanical Noise Workgroup in action

The work of the Mechanical Noise Workgroup (see “Environmental Workgroup in Action,” p. 19) illustrates how the workgroups are operating. This group consists of a resident, a family member, a finance coordinator, a wound care specialist, a recreation worker, a beautician, a nursing assistant, and a community director. Its first goal was to identify all the sources of mechanical noise at Isabella. Each workgroup member had an assignment to sit at a different neighborhood and take note of the different “mechanical noises” there. Each team member identified different sources of noise that appeared to have an impact on residents' ability to communicate with each other, to sleep, and to maintain general peace of mind. The team also reviewed facility complaint logs to ascertain any possibly noise-related complaints, and they interviewed social workers, nurses, and rehab staff who were in a position to have received such complaints from residents or families.

Based on the information collected, the workgroup identified the following sources of noise:

  • oxygen concentrator

  • call bell system

  • chair/bed alarms

  • specialty mattress

  • pharmaceutical box alarms

The workgroup measured each of these sources of noise to determine the decibel level, and then went on to research each item to determine if there is similar equipment that produces less noise. During the course of the research, they discovered that Johns Hopkins Hospital and Health System had made many changes to their physical plant to decrease noise levels1; for example, use of specialized tiles to better absorb noise. The workgroup is planning to make a site visit to the hospital to learn more about the noise reduction measures Johns Hopkins has undertaken.

In the meantime, the workgroup has taken the following steps to address the identified issues:

  • Discussions with the Director of Facilities Management about identifying ways of decreasing the current “volume” for the call bell system, with possible differentiation based on the time of day.

  • Isabella's wound care specialist has identified a nonpowered specialty mattress with no source of noise. As mattresses are being replaced, new “beepless” mattresses are being purchased.

  • A team member working in Finance researched and identified an oxygen concentrator that makes less noise than the one currently in use; the current concentrator noise level is above 60 decibels. The possibility of a trial use of the new equipment is being evaluated.

This and other workgroups will continue to meet and work on identifying effective strategies for specific environmental improvements at Isabella. The goal of each group is to identify some improvements that can be accomplished now, and others that should be included for consideration as Isabella plans for future renovations.

In conclusion, one of the facilitators summarized Isabella's progress towards resident-directed care very eloquently: “If I were old, I would like to come to a place like this. I think all of us would be very lucky to live in a home where the caregivers are working so very hard to make it the best place it can be.”

In our next article, we plan to discuss the specific environmental changes made by Isabella Geriatric Center as a result of the Environmental Workgroups. D

Jennifer A. Brush, MA, CCC/CLP, is Executive Director, IDEAS Institute, Kirtland, Ohio; Debora Allen, RNC/ANP, MPA, is a Community Director at Isabella Geriatric Center, New York, New York; Sara Joffe, MEd, is National Director of Training and Organizational Development, PHI, Bronx, New York; Mark J. Kator is CEO/President, Hope Miller, RN, is Vice President of Care Services, and Ann Wyatt is a Board Member, Isabella Geriatric Center, with its main campus located in northern Manhattan, phone (212) 342-9200, e-mail info@isabella.org.

For more information about the program, call the IDEAS Institute at (440) 256-1883 or visit https://www.ideasinstitute.org. For more information about PHI, e-mail info@PHINational.org. To send your comments to the author and editors, e-mail brush09d@iadvanceseniorcare.com.


  1. Busch-Vishniak IJ, West JE, Barnhill C, et al. Noise Levels in Johns Hopkins Hospital 2005; 118 (6): 3629-45.


Environmental Workgroup in Action

The six workgroups established to address environmental issues, along with examples of problems they would be reviewing, were:

  1. Mechanical noise

    • call bells

    • overhead paging

    • ice machines

    • television noise

  2. People-generated noise

    • noise when staff congregate together

    • noise at shift change, etc.

  3. Elevators

    • improved coordination of elevator use to reduce waiting

  4. Planning together (neighborhoods and support services):

    • maintenance schedules

    • availability and storage of supplies

    • use of communication systems

  5. Appearance of meals

    • more appealing pureed food

  6. Ambience in dining room

    • attractive décor at the table setting

Progress depends on the facilitators. “The facilitator's job is to support everyone to do their best thinking,” according to PHI, which was involved in this training. To do this, the facilitator encourages full participation, promotes mutual understanding, and cultivates shared responsibility. By supporting everyone in doing their best thinking, a facilitator enables group members to search for inclusive solutions and build sustainable agreements.


Foundation Support

The Hulda B. and Maurice L. Rothschild Foundation sponsored a $50,000 grant opportunity to assist a not-for-profit, urban long-term care home engaged in becoming more resident centered. As part of the process, the home needed to be planning significant changes to its built environment. The foundation, a private philanthropy based in Chicago, has a primary interest in improving the quality of life for elders and a firm commitment to expanding knowledge about the therapeutic potential of the physical environment. The purpose of the grant was to provide support for planning the restructuring of the environment, but not for actual construction costs. The staff at IDEAS Institute coordinated the selection process for the Foundation, and the jury panel of seven experts chose Isabella Geriatric Center as the grant awardee.

Design Environments for Aging 2009 2009 March;():17-20

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