First of a four-part series Creating Home and Building Community II: The Urban Experience
To demonstrate the feasibility of creating an urban high-rise culture change program, and to encourage the elder care community to consider this option, a national foundation provided a funding opportunity through a program titled: Creating Home & Building Community II: The Urban Experience. (Creating Home & Building Community I was awarded to the Garfield Community Hospital District in Pomeroy, Washington, which was pioneering a number of new management processes in long-term care.)
Approaches to the delivery of long-term care are changing dramatically. Virtually every aspect of the setting, from staffing models and staff training, to organizational structure, to the physical design is under scrutiny and being re-engineered.
Increasingly, elders live with a small number of other residents in settings that resemble a house more than a hospital. Staff consistently care for the same residents, supporting relationship-based care. The focus is shifting from the provision of good healthcare to an approach that attends to the psychosocial, emotional, and spiritual well-being of each individual, thereby ensuring they are achieving the highest practicable quality of life.
To illustrate and better understand ways in which this systemic change can be planned and managed, with particular focus on an urban setting, this is the first in a series of four articles following Isabella Geriatric Center, a large urban high-rise nursing home, as it continues its “journey of deep change” toward become more resident-centered. It is already engendering ideas that might apply to many nursing facilities seeking change, urban or otherwise.
“Deep change” targets more than care practices and belief systems. It changes management philosophy, organizational structure, job descriptions, and performance evaluations, as well as program philosophy, resident involvement in decision making, use of technology, board-CEO relationship, vision and values statements, and, of course, the built environment.
“Deep change differs from incremental change in that it requires new ways of thinking and behaving. It is change that is major in scope, discontinuous with the past, and generally irreversible.”
1 Deep change does not happen quickly and requires a commitment to the process for each and every function of the organization. The authors will observe and describe this process of transition at Isabella Geriatric Center over the next two years for the readers of
Culture change defined
Culture change is the general term for a movement that is broadly described as an effort to move away from traditional, institutionally structured care settings toward an approach that respects the needs and desires of the people who inhabit them. A number of terms describe this new philosophy, including resident-centered, resident-directed, self-directed, homelike, individualized care, and others. This diversity reflects not only philosophical differences about how the care setting should be structured, but different approaches that homes are using to achieve their goals or realize their visions. While there is no one “right way” to accomplish this, a common unifying theme is the creation of “home.”
Most of the current models involve creating households, or even separate houses, for small groups of residents, with consistent staffing and greater resident involvement in the important decisions that affect their lives. Many of such models described in the literature or in conference presentations require substantial property for their construction, as they are either low-rise or ranch-style in design.
This “freestanding single-story household” model may not be financially viable, or even appropriate, for an urban setting. A typical residence in a major metropolitan area would be encompassed in a high-rise structure. Yet, the underlying principles of increasing resident autonomy and decision-making and providing relationship-based care in a setting that reflects a familiar home are certainly as important for residents in urban locations as they are in suburban or rural communities.
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 that was engaged in the process of becoming more resident-centered. As part of the process, the home needed to be planning significant changes to its built environment. The Hulda B. and Maurice L. Rothschild Foundation is a private philanthropy based in Chicago, and was created in 1980 under the will of Hulda Bloom Rothschild, who lived to the age of 102 and was always concerned with the needs of elders in the community. The Foundation 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. It is the only national philanthropy in the United States exclusively focused on changing the culture of long-term care.
The purpose of the grant was to provide support for planning the restructuring of the environment, but not for actual construction costs. The grant program was open to nonprofit nursing homes in urban areas (including those within multilevel or multisite care organizations) committed to comprehensively restructuring their care policies, practices, and setting toward more resident-centered models. Applicant homes had to be within the city limits of one of the largest 50 cities in the United States by population. It was expected that applicants would have begun the restructuring process and would have already achieved some steps toward change. The purpose of the grant was to provide support for that restructuring and design process. Thus, projects that had already completed the design phase and were entering construction were not eligible.
The staff at IDEAS Institute coordinated the grant application and selection process for the Foundation. A jury panel of seven experts in the field of long-term care chose a small group of applicant finalists. Representatives of the Foundation and IDEAS Institute then visited all finalists and chose Isabella Geriatric Center as the grant awardee.
Isabella Geriatric Center
Isabella is a 705-bed skilled nursing facility located in two high-rise buildings in northern Manhattan. Since its beginning in 1875, Isabella, a nonprofit, nonsectarian organization, has been a pioneer in the care of the elderly of New York. Isabella has grown from a traditional nursing home into a progressive provider of state-of-the-art care for all, both on its own campus and in the community at large. In 1993, the convener of the Pioneer Network, Carter Catlett Williams, visited Isabella and introduced some alternatives to the traditional institutional models of care.
Isabella has been on the journey ever since, through a culture change program they call Home Again. It features many of the person-centered elements so familiar to others on the journey: community directors and workgroup leaders appointed and trained; newly created neighborhoods; country kitchens constructed, with residents helping out in the kitchen; interdisciplinary culture change workgroups created to focus on the dining experience; performance improvement as it relates to the built environment; and rapid-cycle decision making to focus on person-centered projects. Isabella is a friendly and nurturing community that encourages, values, and facilitates individuality, personal choice, and self-determination. Residents, families, staff, volunteers, board members, and guests all create an environment that rises above preconceived notions of traditional long-term care. Through the collaborative efforts of all involved, Isabella is becoming a place of freedom, dignity, and alternatives that nourish body, mind, and soul.
Although Isabella has been engaged for many years in a variety of culture change efforts, its work during the past three years has focused on specific structural changes that they believe will support and sustain a much strengthened participatory approach to problem solving and creating care/quality of life improvements. Isabella has found support through the work of the Quality Care Committee (QCC), a large-scale culture change initiative jointly led by 1199 SEIU, the healthcare workers’ union in New York, and the Continuing Care Leadership Coalition, which represents the not-for-profit nursing homes in the region. The QCC has, through a series of conferences and pilot projects in several homes, including Isabella, helped create not only a deeper understanding of person-centered models, but an environment in which management and frontline workers feel comfortable working together to find new approaches to care. It represents a national model of how organized labor and management can work constructively and collaboratively to improve elder caregiving.
As part of this restructuring, Isabella decided to appoint six Community Directors. Each Community Director works with three neighborhoods (a neighborhood being 30 to 45 residents living together on a floor), with the expectation that this decentralized approach to oversight will significantly enhance the integration of disciplines and departments, support and enhance the role of direct-care staff, and bring decision making much closer to the residents who live there.
In addition, over the past year and a half Isabella has been steadily reorganizing its Performance Improvement Program. They created a Person-Centered Care Committee (PCCC) whose members include representatives from different disciplines, different levels in the hierarchy, and different shifts. They then provided training to members of the PCCC on setting up successful committees aimed at clarity of purpose, collaborative problem solving, maintaining focus, effective communication with the stakeholders, leadership, and partnership strengths and challenges.
During 2007, the PCCC concentrated on the implementation of a major change in the provision of dining services, recognizing that any such change would have wide impact and would engage to varying degrees virtually everyone at Isabella. After a trial change with one neighborhood, which consisted of moving from a system where food is plated in the main facility kitchen and an assembled tray is brought to the units and served, requests for additional food or the alternate is phoned to the main kitchen, with a subsequent wait. In the new system, bulk food, including the alternate, is brought to the unit at the beginning of the meal. Implementation of the new system was brought to all neighborhoods in June 2007.
From the very beginning, it was understood that implementation of the new system was not by itself the solution to improved dining at Isabella; rather, it was a necessary step in making further improvements possible. Thus, once the new system was implemented, the PCCC “chartered” an Isabella Dining Values Workgroup. The purpose of this group was to establish person-centered goals for dining at Isabella, which would then aid Isabella in identifying the gaps between the goals and current practice.
The goals are to make dining a positive experience for the residents and those who serve by presenting variety and choice reflecting the stated preference of the residents; improving communication by incorporating resident and staff feedback into processes; and encouraging flexibility on the part of staff and residents to allow for occasional disappointments.
The secondary purpose of the workgroup was to model Isabella’s new, inclusionary approach to Performance Improvement (PI). Managers, direct-care staff, residents, and a family member comprised this workgroup. The process they used was to combine training in PI and communication skills with activities designed to achieve the objectives of the workgroup. Between meetings, workgroup members interviewed other residents, family members, and staff members to gain their perspectives on dining at Isabella, both current and ideal. As a result of the issues that emerged as part of establishing “Isabella’s Dining Values,” projects related to methods for keeping food hot when it is brought to residents in their rooms, increasing opportunities for more ethnic (especially Latin) food, and improving the taste and interest of pureed foods are under way. Forty percent of Isabella’s residents are Hispanic, 34% are African American and 16% are white—and, since only 7% of the residents are admitted for short stay, accommodating the residents’ ethnic food preferences is important.
The Isabella staff fully recognizes that progress in general is made typically in small steps, each of which has to be examined for its contribution to resident choice and empowerment. For instance, when the Foundation and the IDEAS Institute conducted a site visit, they were told about a new food service system that had recently been implemented at Isabella. Food was brought up to a kitchen adjacent to each dining room, so that residents can easily choose an alternate to the main menu, and specify how much food they would like. However, the concept that residents should be able to select food at the point of dining was one with which some staff were not yet comfortable. When the Isabella’s management was questioned about the new serving procedure, they generally replied that they served food to the residents based on the menu card with each resident’s (prior stated) preferences and special diet restrictions, rather than allowing the residents to make a choice at the point of dining.
Isabella has recognized the need to enhance the understanding and engagement of their mid-level managers and supervisors in this new, more inclusionary process of problem-solving. Isabella has provided training to introduce these managers to the reorganized PI approach, as well as to skills that would help them as they worked with their own staff on implementing the dining program and other initiatives (e.g., active listening and working with resistance). While some of these staff will clearly play a more active role than others in initiating/facilitating change, Isabella wanted everyone to be more comfortable and better able to support each other, not just those staff who may be participating in workgroups.
All the training mentioned was planned and conducted in collaboration with the Paraprofessional Healthcare Institute (PHI). PHI works to improve the lives of people who need home or residential care by improving the lives of workers who provide that care. PHI’s premise is that creating quality jobs for direct-care workers is essential to providing high-quality, cost-effective care. In future articles, the authors will discuss this training in more detail.
Now Isabella is embarking on the development of a Master Plan for the physical space of its campus. The architectural firm Perkins Eastman has been asked to develop recommendations. Once Perkins Eastman has completed its work, Isabella will then be faced with making decisions about next steps. Because of the integral role of the built environment in supporting culture change, it seemed appropriate to the PCCC to involve itself in consideration of physical environment changes at Isabella consistent with the person-centered approach. Therefore, an “Environmental Values Workgroup” was “chartered.”
The process for this workgroup has been virtually identical to the one used by the dining values workgroup. Members included managers and direct-care staff, family members, and a resident. The group brainstormed together and, between sessions, conducted interviews and learning circles with other staff members, departments, residents, and family members. The Environmental Values it established include the need for a physical environment that emphasizes resident comfort as critical to quality of care and quality of life, a physical environment that is welcoming and conducive to positive interactions among residents, visitors, and staff, and recognition that relationships are at the heart of appealing environments.
This information was shared with Perkins Eastman for consideration to include in the inquiry phase of their work, when they conducted interviews with staff, residents, and families. The premise behind this development of environmental values for Isabella is that the process will identify both issues that need significant further exploration and some that can be addressed now (in either case, from a person-centered perspective). Some issues may be addressed on an organization-wide basis (i.e., communication systems), while others may vary from neighborhood to neighborhood.
In completing its training for mid-level managers, Isabella realized that what is needed now is training and support specifically for staff who will lead and facilitate the various Performance Improvement Workgroups. One of the challenges of Isabella’s Performance Improvement Workgroup model is bringing staff (from different departments and different levels of the hierarchy), residents, and family members together to model a more inclusive approach to problem solving. For this effort to succeed requires having facilitators who are skilled in group processes and in applying the tools and techniques that can assist the group to better understand and address the problems they are confronting. Facilitators will be responsible for organizing, convening, and supporting the efforts of the workgroups. The six Community Directors and six others (natural leaders culled from different departments, different positions) who Isabella identified as facilitators have already received an initial two days of training from PHI, and will receive mentoring and support over the next several months, as well as two more days of training in the fall. The goal is for these 12 leaders to fully integrate the concepts of inclusion, measurement, integration of quality of care and quality of life, along with the steps in the PDSA Performance Improvement Methodology (Plan, Do, Study, Act), which will always include the perspectives of relevant staff, residents, and their families.
Using the newly adopted “Isabella Environmental Values” as a basis for discussion, six projects were selected during the training for attention over the coming months. A workgroup will be formed for each of these projects, with two facilitators assigned to work together for each group. By having two facilitators work on each of the six projects, they will all have the opportunity to integrate their learning with specific projects and, in doing so, involve more staff, residents, and family members in this inclusive model of problem solving.
Project areas that will be addressed by the workgroups include mechanical noise throughout the facility (overhead paging, nurse call systems, ice machines in the dining rooms, etc.); noise caused by people (staff entering and leaving the neighborhoods at shift change, some visitors, etc.); improved access to the elevators through more effective scheduling; and coordination of support services with life on the neighborhoods (waxing of floors, maintenance of equipment on the neighborhoods, etc.).
In addition, because the dining environment inevitably has an impact on the dining experience, we want to be sure that environmental factors in the dining process don’t get short shrift because of the focus on food and the food service that has been the priority so far. Two workgroups will therefore concentrate on (1) how the dining room is organized from an environmental perspective (furniture, layout, plants, etc.), i.e., the “ambiance,” and (2) how the food is presented (food combinations, colors, textures, plating, bread baskets, etc.).
These are not the only environmental concerns that Isabella needs to address in the years ahead; rather, they are priority areas, based on several factors, including which is of greatest or most urgent need of resolution for staff and residents, and the potential for developing recommendations for the Master Planning process.
Isabella is also planning to develop a “Values and Projects” kiosk—a place with a computer and Internet access, and where a collection of written materials will be available. This will be a common information resource where workgroup progress can be shared, and individual residents, staff members, and family members can find links to Web sites and other design information. It will also be open to residents in the community around Isabella.
As Isabella moves ahead on its culture change journey, its goals will be always twofold: (1) to create and sustain a care environment that promotes and supports resident-directed care, resident preference, and resident comfort, combined with clinical excellence, and (2) to achieve a culture of dialogue that enhances communication and builds relationships between and among residents, staff, family members, and visitors, as well as effective (and inclusive) problem solving throughout the organization.
Regardless of whether you call it culture change, restructuring, re-engineering, resident-directed care, or resident-centered care, this movement is all about changing the way long-term care homes operate. The goal is to focus on the positive aspects of personhood and recognize residual strengths and abilities to engage in meaningful relationships and activities that have purpose. The Isabella Geriatric Center experience represents a unique effort to bring culture change to a large-scale urban high-rise nursing home. Please join us in future articles over the next several months as we describe Isabella’s progress, setbacks, and lessons learned during this important undertaking.
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