An Interview with Steve Shields
"It began to dawn on me piece by piece that this whole way that we 'care' for elders should make all of us feel sick."
Shortly after moving into newly constructed facilities, Steve Shields spoke in depth and about the long and continuing journey through culture change at Meadowlark Hills. His excitement and enthusiasm are evident in the series of video frames above, as well as in the answers to some challenging questions.
An Interview with Steve Shields
How did you get involved in the culture change movement? What made it happen for you?
It all started slowly for me because I had no frame of reference. I was new to the industry, and I had made it a point the first month not to do anything except meet every person I possibly could. So I was assimilating it, but I remember the moment that I realized this place was dying and nobody knew it. The average age of our independent residents was 91. I remember thinking, Oh my God, we have all of these people who are getting ready to go into the last stage of their life and all we have is a 60-bed health care unit run in a very clinically solid, yet very old-fashioned way, and there are no support systems. We had no home health, no in-home services except housekeeping, no special diets. I knew we had limited time, plus a market that was begging for a new product that we weren't delivering, but still we were viewed as the best. We had a very solid reputation because we were started by the community 15 years earlier and the standards that were set were solid and had endured.
Changing direction is always a big risk in an organization. If you were on top already, why shake things up?
I felt an urgency to do something to make sure we maintained not only our market position, but that we put the programming in place to responsibly deal with all of these folks who were going to [need additional care]. So, that got me thinking, where are they going to go? What's going to happen? So we put in two home health agencies, one Medicare and one private duty. It was a finger in the dike. We had to do a pretty radical financial turn-around because we had very little cash and were losing money. All the cards were stacked against us. I share that because there are all sorts of reasons we can find to not change.
No matter how bad it is, it's always easier to let it be than to change?
Exactly. But I think more than anything, knowing that these people were going to need [more services] is why I started looking ahead and thinking, what about Gwen, Mrs. Smith and Ruth? What's going to happen to them? It got very personal for me.
My mother was in our health care facility with advanced Alzheimer's and I knew what the rest of her life looked like, but my father lived in one of our apartments, and I thought, what's ahead for Dad? I had bonded with [Meadowlark Hills] and all the people, and suddenly it wasn't just about Mom and Dad. It was about hundreds of others just like them, and that was pretty overwhelming to think about. It felt like this enormous obligation that I personally had that no one [else] seemed to understand. Maybe it was because I was so new to this and everyone else had already found this truth and dealt with it. For me it was new and staggering.
How did this revelation affect you and your work?
I began to look at everything differently. I would go down to the health care center, which was poorly lit. The floors were linoleum, very shiny, you know the stuff. It was clean, we never had odors. We clinically were viewed as the best in the state. We went an entire decade without any citations or survey deficiencies. But I would go down there and [become] physically uncomfortable. I really struggled with what was going on. I wondered, am I in the wrong business? I wasn't able to identify what was bothering me.
It began to dawn on me piece by piece that this whole way that we "care" for elders should make all of us feel sick. I tried to dissect what was bothering me one bit at a time. The call lights and buzzers offended me because it was a barrage of noise of people expressing need. What a strange way to transmit that you have a need. It goes through this system that screams, I have to go to the bathroom, or I need somebody to say a kind word. Those things started bothering me. And all the while those flashers or beepers are going off because they're required by regulation. Then comes the cart with all the big plastic trays, bouncing, clattering. It offended me that these trays would sit in front of people and the bibs would go on - the titanic nurses' station, the regimentation of bathing. That's probably the worst, really.
The strict schedule of bathing?
The scheduling is bad enough. Imagine you want to take a bath, and you have to ask, and then someone tells you, "No, sorry, it's Wednesday, you can't have a bath until tomorrow." But even worse is how they give baths in the first place. They pick people up hydraulically on these lifts, five feet in the air, then mechanically move them over and drop them in the water. Can you really feel like a human being in that situation?
And that's just the beginning. What time people get up in the morning, the kind of food they have for breakfast, the whole process of getting them up. We were dividing the responsibility of getting people up between third and first shift so that it would be an equitable load on our staff. The sad thing is, I didn't even think about it. It took several years to occur to me that it was a blatant disregard for the person. Half of them were up by the third shift, which precedes breakfast by two and a half hours.
Think about that. You're sleeping, and people start getting you up. You actually have no purpose for getting up, and you don't really want to. But they get you up and you can't completely dress yourself, so here you've got people jerking your clothes on in a hurry because they've got all these other people to get up. Once they get you dressed, you sit until it's time for breakfast. That's two hours away, so what do you do [until then]? And if a person is problematic during that [time], you wheel [them] up to the nurses' station where you've got that offensive nursing home staple - everyone clustered around the nurses' station.
These processes and ideas had been in place so long, people didn't even think about them, didn't question them. It was just the way things were.
So we began to have conversations as a leadership team. It was hard at first, because we had such a high-functioning team who were viewed as so successful and were proud of what they'd done. This was viewed as one of the premier facilities in the state for many years. I didn't want to take anything away from anybody, but I couldn't put their feelings over what we were doing to these people.
I began to ask questions. That's how I started getting ideas across. How do we do this or that? I don't think it was in a way that offended people. In fact, once it became permissible for us to start saying we want to change, then everybody began to ask questions. We got to this point of radically changing our culture and our plans through subtraction. We started looking at what had to go. Those were our first big strides in the right direction. We've got to get rid of the call lights, we said, all those lights and beepers and buzzers are no good. We need to change the way people bathe, it needs to be luxurious, relaxing, like you're in a spa.
I look back on that and think just how bizarre that is, that we're so out of whack that just imagining someone having a regular old bath would be something big and wonderful. So as we began to do that, the passion began to grow. We were so uneducated that we've literally done this out of blind passion, and we've made so many mistakes it's hard for us to feel victorious at times. It hasn't been easy, and it hasn't always been fun.
But you are doing it, and that's the important thing. We touched on how difficult it is to change, and it's always more difficult for some than for others. How did you get everyone involved and committed to this huge undertaking?
The key to moving any organization is to involve all the stakeholders. Now that I look back, if I really thought through just how large of a task it was going to be, it would have been too daunting. But there was this thing in my stomach that had to be satisfied, so I didn't think about that. I just knew I had to move forward, so I began posing the problem to everyone, starting with the leadership team. Momentum began gathering. There was consensus that we had to do something. Now that we were talking, we were obligated to do something.
When I was hired, the board knew we had to expand. So, I was getting pressure from the board about what we were going to do, so that dovetailed nicely. The board was fully behind doing something, so we gave it our vision of culture change. We didn't really know what culture change was and didn't have the neighborhood concept solidified. We weren't that smart yet. Now I'm glad we weren't because it began to emerge through the bringing in of stakeholders. Because it happened organically, we didn't have to make any concessions. We didn't have to compromise our vision to fit into another, more established, vision.
While that meant we made more mistakes in the long run, it also meant it was easier to get everyone involved, because we didn't have to develop people to fit the vision, we got to develop the vision to fit the people.
So it wasn't just your vision, or management's vision, it was everyone's vision?
It's kind of funny and scary at the same time. For the longest time everyone called it Steve's vision. They thought I had this vision, and beyond that they thought I knew what I was doing as a leader. That was the scary part, because I didn't. I just knew that I had to pull everyone in, one by one, group by group, and that we would get there. But I didn't ever really say that, I just pulled them in piece by piece. We talked with independent residents about their needs and what they thought their needs would be in the future. And that articulated the assisted living addition.
We talked with people in the community about their anticipated needs. We had focus groups from all over town of different age groups, whether family members or prospective customers. As we began to move into the design phase, our vision still wasn't fully articulated. That's when the real momentum began, because we began to bring in all the different staff and resident groups and talk about specific characteristics.
For example, we gathered a group of aides together when we talked about designing the bathroom, and that has been a large payoff. The kitchen employees designed the kitchen. We brought residents into the process of deciding what their living spaces would be like. So that generated a sense of involvement. We knew we wanted country kitchens for people to gather and we knew we didn't want nursing stations. And we knew that we wanted living accommodations that afforded people a lot more privacy.
So you had the various parts of the building designed by the people who had the biggest stake in them?
Yes, and it was such a strange feeling, like we had just stumbled upon this idea, this undeniable truth, that was so obvious that nobody had ever seen it before. Or at least, if they did, they didn't tell us about it. (Laughs)
But in fact, other people had discovered it too...
Of course. But it wasn't until we had engaged LaVrene Norton that we found out. She knew of other places and encouraged me to go visit some of them. So we went to Minnesota and Saskatoon in Canada, and that was such a breath of fresh air. It was such a strange feeling when you think you're starting this brand new thing, and then you find other places that are thinking and doing the same things. It validated for me that it could be done. Although we'd go to these places, and they weren't exactly what we wanted. They were all great, and we took away something valuable from each, but we didn't find anything that totally satisfied us.
Then we visited this place way up in northern Minnesota. We flew into Minneapolis, caught a puddle jumper to Grand Rapids, rented a car and drove up a winding road through a wilderness of pine trees into this tiny town of Bigfork. We pulled up to this hospital. I had brought our DON and the DON from another facility we were merging with, and here we are in the middle of nowhere looking at this plain, small hospital building that looked like it was built in 1962. And I thought, "She sent us all the way up here, thinking it was going to be this pinnacle moment."
I was silently working LaVrene over. Then they welcomed us with such hospitality, and took us to one of the households. They opened the door and I can't describe to you the emotion I felt. They had achieved most of the architectural things that had been floating around in my head. I've only had that feeling twice in my life, but I walked in there and felt it and saw it and recognized it. It was a place I had already seen in my mind. That really revved me up.
So you had found what you were looking for.
Well, not that we were going to go back and do exactly what they did. But it crystallized all these things in my mind. Both DONs got jazzed about it. Linda Frey is a tremendously talented DON who is largely responsible for our strong clinical history and continues to be a central part of where we're going, she's getting it - we intellectually discussed it and she understood it. The other DON, Roger, is a phenomenally gifted leader from the facility we were merging with. His reaction was very different - he was silent. I respect Roger a tremendous amount, so I gave him the distance he needed to process. I've learned throughout the years now that you honor that because he's very thoughtful. So we didn't talk about it with him through the whole trip. But Linda and I were just going and going. Then, we were on a plane for home and I thought, ok, the time is right. So I asked him, "What do you think, Roger?" He was silent for a moment and then he said, "I don't know what I've been doing all these years." I thought, yes, that's just the question he needs to be asking. He's on board. Linda was on board in her way, he was on board in his way.
We came back and - I'm surprised that I still have my job (laughs). We came back and I was so jazzed up. Now I knew I had 'gotten it'. We were doing everything wrong in terms of design. I went back to the board and said we've got to stop. We've got to redesign and reconfigure how we're doing all this.
How far along were you in the design process at this point?
We had the complete design done and we scrapped it. I am very financially driven in terms of making sure what we do is responsible. I was sure that we could pull it off financially, but we had to raise more money. I told the board we're way off base and we've got to do this again.
If I were on the board of directors and this person was leading me down this trail that involved millions and he says we've got to go back and spend more, I don't know how I'd have reacted. But the board understood what I was conveying and they thought it was the right thing to do. Bless them. So we went out and raised some more money and started over.
That was a real lesson for me because I guarantee that if you start on this journey, you're going to stub your toe so many times. If you know you're wrong, stop, regroup and don't lose heart. We'd already borrowed money and were already out on a limb. It would have been almost smarter in the moment if we had said it's too late, we can't spend any more. But we didn't lose energy on that.
We went back to Bigfork, and we took the architect with us this time. I think Bigfork was getting so sick of us by that time, because I was sending folks, especially the nay-sayers, up there on busses. That was the turning point when people were starting to not think of it as 'Steve's vision'. That was a relief to me, because all I really did was go out to get the resources, sell people on [the idea] and try to bring people together to achieve that. It was when everyone came in to it that the trip began.
You've already talked about some pretty radical differences in your design process. Tell us about these changes you had to make.
After I talked to the board, I went to the independent residents, because we have a town hall meeting once a month. It was very moving for me, because I was making eye contact with them. I began to describe the vision. Now we have flashing lights, bells, long hallways, scheduled meals and fixed menus. Your life is taken away simply because you have a physical need for care. Then I described what it would be like. I've never just gone about business here. This is a home that belongs to all of the people here, and I felt that we needed to seek their permission. So I began to describe it. What if you lived in a smaller house of 10 or 15 folks, and people didn't just walk through, they rang a doorbell, and you had private space and you got to choose what time you wake up and what you want to eat for breakfast.
I watched them, and they were looking incredulous, but mostly I remember the emotion in the room. It was heavy. I remember after the meeting a woman came up to me. She had a walker, and she looked me right in the eye and said "Please do it before I need it." And she began to cry, and said, "I'm afraid."
Now that tells me people in the community live in fear of the culture we have created [in nursing homes] all these years. When you go to the people who are going to be customers and you get that response, you know you're right, so it gives you more energy and commitment. For me it was a race against time because I wanted to make sure Norma got to go to the new place, and God, let us get it done before Gwen or my Dad needs it. So everyone went up [to Bigfork] including the architect. I purposely sent up the nay-sayers and they came back, some pretty enthused and some begrudgingly admitting that there was potential. No one said this is a bad idea. They were impressed to have talked to the [Bigfork] staff. They said, we can talk to the administrator all day and he's going to blow smoke at us. I want to talk to the real people. And they did, and were powerfully moved by that.
So they got to see not just what it was going to be like for the home, or for the administrator, or even for the residents, they got to see what it was going to be like for them.
Yes. Yes. And they liked it.
So now you've got your ideal design, your staff believes in this idea, and all your residents are behind you, are you done?
We thought we were done, but we weren't. We had never done this before, of course, and so we were just at a loss of what to do next. We could have built the new facility and started implementing our vision, but we knew we were missing something, we just didn't know what. So we brought LaVrene back, and she helped us realize some things.
It's funny, I've been this far in my career, and I've led people for so long, 25 years, and I never figured this out. I was frustrated, thinking why doesn't everyone get this? Why can't they naturally feel it, know it and be done with it?
LaVrene told me, "Steve, you have to give them the skills, this isn't going to come automatically."
And that's what the last two years have been, just intense, continuous, infusion of skills through learning circles, written word and whatever methods we can use to convey them.
Conflict resolution skills, critical thinking, judgment, hospitality and person centered care - it's endless. It's got to become a part of who you are if you go on a culture change journey.
One of the fundamental truths about culture change is, it's about personal conversion at all levels of the organization, and that has to be sustained and nourished. You have to continue expanding people's horizons, thoughts and realms and how we relate to each other. So that's what we've done for a couple of years now. We still need outside facilitation, and we probably always will, but it will be a diminishing need because we're trying to grow that wisdom internally. The really exciting thing is that now people are teaching each other.
We're infants, babes, but the wisdom is starting to flower. People are starting to have ideas that they're presenting in a group setting and making things happen through the skills we're offering in learning circles. That's where the facilitator first defines it, and then poses scenarios for people to wrestle with. A rule of the learning circle is that everyone has the opportunity to participate. It spawns thinking about what's happening in the life we're leading here. It won't be a quick fix. It takes several years, and if you can't come to terms with that, then you're not going to go on a deep, sustaining culture change journey.
How do you celebrate, how do you reward people for a job well done when it's never done?
There are always things you can celebrate. No, you can never say, okay, we're finally done with culture change, good job everyone. But there are milestones that can be finished and celebrated.
Let me give an example. Once we had defined what the houses were, it was so exciting. I could tell that the architect "got it". We'd taken an old T-shaped nursing home, gutted it and made houses out of it. The nurses' station was gone. One day seven years ago, the DON, Linda Frey, and I made rounds. I remember looking at this huge nurses station and I said, "You know Linda, someday that thing has to go." I watched her kind of go, oh, right, don't even think about it. But she didn't say it. Instead, she said, "Well, yeah, that might be something we consider." I said, "When we do, you and I are going to break open some champagne, and drink it."
That was the last time we talked about it. So, when we started construction and began ravaging the T-shape, everything went out the door. The nurses' station was cut up, so I looked for Linda, because I had a bottle of champagne. It was seven years later. I finally found her in a meeting, and I said, "I need you for a minute."
I asked her if she remembered what we said we were going to do when the nurses' station was gone. She looked at me blankly, and I pulled out this champagne. I couldn't get the cork out. So we asked this big 6'5", 300 lb construction guy and he couldn't get it out either. So he got some pliers, and finally, after 10 minutes, POP! We drank the whole bottle then went about our business, and very well, I might add. That was definitely a celebration moment.
So you look for reasons to celebrate. Just because you're not DONE with it all doesn't mean you can't relax for a minute and pat yourselves on the back before you go back to work.
Take us through the deconstruction and reconstruction of your nursing home.
As construction began to materialize, people were sneaking peeks. When it finally was completed, you couldn't recognize it. I'm so excited about the T-shaped conversion because it's duplicable. There are T-shapes all over the country, so others can look at ours and do this. When you walk in, there's no nurses' station. There are three outside front doors that have architectural features. One is Georgian, one Farmstead - they're distinct front doors. They have potted plants next to them, and there are doorbells with a completely different signal.
The day we opened one of the family members said, "How do I get in to see my mother?" I told she had to go to the door and ring the doorbell. We take away so much from elders when they come to these environments, I told her, and we're trying to give them back everything that was taken away, like not having people just walk into your house. She said, "You mean I'm going to have to ring the doorbell to see my own mother?" She was a little incensed about it.
"I don't know, you're going to have to ask your mother," I told her.
That told me that we've institutionalized not only our elders, but also our whole society about how we interact with them. The point is, if her mother lived anywhere else on the planet, there would be no confusion. Depending on your relationship with your mother, you might knock, say "Mom", and go in, or knock and wait for her to answer, but there would be no confusion about how to see your mother. So, that's what we've created. When we bring people into long term care facilities, we change the dynamic of how you go see your mother. You immediately act differently with your mother. Your relationship changes because the environment drives it that way.
The beauty of this is that a daughter doesn't come and ask me if she has to ring the doorbell. That's up to their mother, because it's her mother's house.
You do everything just the way you'd do it if it was your own home.
That's what I thought at first. But everyone does it differently at home. I was taught when someone comes to your house you open the door and are very hospitable. But not everyone is taught that, so we learned we have to teach skills on hospitality and the proper etiquette of receiving people.
Now, when you go into one of our houses it's not like walking into a traditional nursing home. You don't feel like you're in an institution. There's a living room, a dining room, a kitchen, bedrooms, and bathrooms just like at home. The environment sends a message of home, but what really makes you feel at home is how you're received. When you go in there's music playing, cookies baking, popcorn popping and people socializing.
I had a real nice experience just yesterday. I window-peeked and saw Mrs. Jones and her daughter playing dominos. Mrs. Jones has lived with us for seven or eight years. She's pretty special to me and she was my mother's roommate. There is a lot of love in that family but the relationship between the mother and daughter had come to feel more formal or obligatory because the mother lived in a semi-private room. The daughter would come, get her mother, go for a drive, bring her back and drop her off. That is what their relationship had evolved to. So it was neat to see the dynamic of the visits change. They were experiencing life in the households together.
I happened to see her daughter as she was leaving, and I said to her, "You know, I have to tell you that I was watching you through the window, and it was nice to see. She replied, "Yeah, and it felt good too." You could see it had meaning for her. The environment in typical long-term care facilities is not conducive to that.
You mentioned that your own parents lived in your nursing home. Could you talk a little about how these changes have affected them?
My father has been a resident here for six years and until Christmas of last year lived in an independent apartment. He's had Parkinson's for 17 years, and has managed very well. But by Christmastime, his struggle to remain independent was over. He's in one of our households now. That was a silent victory for me, though it was difficult for me to see him lose his independence. Dad is a painfully shy man, thoughtful and very intuitive about his surroundings. He is an observer.
When he was a caretaker for my mother for 15 years, he kind of withdrew within himself. When mother died last year he withdrew even further in his grief. But now he's moved into Lyle House, and he's flowered. He's reaching out to people, greeting them and he's referring to this as his house. About three weeks after he'd moved in, he was talking about Michelle. He said, "You know, she really likes me, and so does Lillian. I used to think that they were nice to me because you were the top guy, but I think they really like me here, and I really like them."
And that was really good - his whole terminology is starting to change, and he's seeking people out. He never did that even as a young man. I'm seeing a man in his last years, even as he's losing the ability to walk, self-actualizing in ways that he didn't as a young man.
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