“We Used To Be A Nursing Home…”
"Culture change is not an event or a program. There is no one blueprint to follow."
In addition to the objective articles on Meadowlark Hills in our current edition, we felt that it would be valuable to have an insider's account of their changes and successes. Roger Beins, a DON for the organization before, during and after their move to the household model of care, graciously consented to help us out. Read on for his insights into the culture change process.
"We Used To Be A Nursing Home..."
This article was contributed by Roger Beins, a DON at Meadowlark Hills before, during and after their conversion to the household model of care.
One day a couple of months ago, I was assisting with a group touring Meadowlark Hills' recently renovated healthcare households. One of the people in the group remarked, "you can kind of tell this used to be a nursing home". Used to be. It was at that moment I was struck by how far we have come in our journey to ensure a life worth living to the elders we serve. Not that we aren't proud of the care we had given prior to our change in philosophy. We were always doing the best we knew how. But now, we know a better way. We want to share what we've learned, and continue to learn, with others so that elders everywhere might have choices in how they live their lives.
Culture Change is a real buzzword these days in long-term care and elsewhere. But what does culture change really mean? Is it a program you purchase and then say, "we're a culture change facility"? Does it require you to start over and build a new facility from scratch? Culture change is not an event or a program. There is no one blueprint to follow. Everyone has to choose their own path. Only one thing is certain: It is never finished. Every time you achieve what you thought was the summit, you see another mountain on the horizon. You can always do better. There is no perfection, only the continual struggle to achieve excellence.
Culture change began at Meadowlark Hills long before ground was broken on the expansion and renovation project in June 1999. Our culture change began with the vision of Steve Shields, the Executive Director. Steve deserves much of the credit for warming the soil, planting the seeds of change, and preparing his staff for the challenges ahead. But it didn't stop there. It couldn't stop there. Executive leadership cannot dictate culture change. True culture change can only happen when everyone in leadership is willing to take the plunge. Without the support of department heads and directors, culture change will not take root.
Consultants with expertise in strategic planning, team building, and visioning were contracted. Days and weeks and months were invested in the leadership to help bring them to a place where they could see the future with a shared vision. Front-line staff were introduced to the concepts of self-directed work teams, resident-directed care, flattened hierarchy, and the Eden Alternative 18 months before the actual move into the finished facilities.
Joint "learning circles" were held with staff from both Wharton Manor and Meadowlark Hills to introduce them to each other and help them see that they shared the same values of providing quality care to their elders, and to help allay fears of the unknown. Former competitors became co-workers.
Resident and family meetings were organized to educate them and answer questions related to the changes that were happening. Resident and staff household selections were developed based on current relationships and resident preferences, while at the same time valuing the diversity of the new relationships that were possible.
We contracted with Vital Research Incorporated to conduct a REAL (Resident Experience and Asssessment of Life) survey, which is essentially a resident satisfaction survey that addresses multiple aspects of the elders' lives, ranging from autonomy and choice to food quality and safety and security. Surveys were conducted in September of 2000, before the movement to the household model and again in November of 2001, approximately eight months into the model.
And this was just the beginning.
Inside The Households
The most obvious change at Meadowlark Hills the casual observer will notice is the physical environment. While the environment is not the most important factor in culture change, it is an important component in promoting community between residents, their families, and staff.
Residents of Meadowlark Hills live in one of six unique households, ranging in size from thirteen to twenty-five persons. In Collin's Landing, the two houses are specifically designed for people who live with Alzheimer's Disease or other forms of dementia. Every household is fully certified for Medicare so a resident returning home from the hospital can receive skilled services in their own household and not have to be placed in a "skilled unit".
The nurse call system operates with remote pagers carried by direct-care staff so there is no audible call bell in the houses. This helps lend an air of tranquility that is lacking in most nursing homes. You won't find a nurses' station at Meadowlark Hills. The majority of computers and monitoring devices are kept in a den outside of the households. Each house does have a computer workstation in a roll-top desk or an armoire for the various disciplines to utilize during the course of their day.
Resident medications are located in a locked cabinet in each person's room. There is no med cart lumbering down the hallways or sitting in the middle of the dining room. Although many residents prefer to take their medications at mealtime, it is not a required part of the routine. Residents may take their medications in the privacy of their rooms and medication schedules are made flexible, with resident convenience in mind.
Residents make most choices about their daily routines. These choices range from when to get up, what to wear, what activities they want to be involved in, to how aggressively they want to manage their health conditions. Decisions concerning residents are given a litmus test before implementation. What does the resident want? How would we do it at home? How can we do it here?
Nowhere is choice more evident than at the breakfast table. Breakfast is cooked to order in each household every morning. Residents awaken to the smells of fresh brewed coffee and frying bacon. Most mornings there is a "special", but it is always optional. Breakfast is served as early as 5:30am for the early riser in Honstead House who likes Cap'n Crunch and coffee until the last person is served around 11:30am. Meadowlark Hills was recently recognized as a 2001 recipient of the Kansas Consulting Dietitians Association's 5-Star Gracious Dining Award for our progress in this area.
Our lunch and dinner menus have been recently modified to provide an alternative selection to every entree. If neither option is to a resident's liking, the staff will make them something that is. The beauty of having a kitchen within each household is that alternative food is accessible to residents 24 hours a day. There are many snacks or easily prepared foods that anyone can make for the night owl or the person with distinct food preferences, and refrigerator raiding is encouraged.
Resident learning circles are utilized in each house to promote communication between residents, to discuss household concerns, to encourage dialogue between residents and staff, and to plan events or activities within the house or out in the community.
Last month, 45 residents and staff decided to attend the Shrine Circus and took along a sack lunch to eat while they were there. Lyle House packed up one Saturday and took everyone to a staff member's farm for a picnic. They were joined by many off duty staff as well as resident families. I wonder what people thought when they went by the house only to find that nobody was home? This type of activity isn't possible in a larger setting, but when there are 13 residents living in the house, the possibilities seem endless.
Many houses choose to celebrate holidays or special events with meals cooked in the house, using resident recipes and with participatory labor as well. A couple of ladies in Ptacek House are probably sorry they volunteered to make potato salad for the first potluck their house had. They've been asked to make it at every celebration since!
Staffing Under The New Model
Staffing and household leadership is another significant aspect of culture change at Meadowlark Hills. Each household has a dedicated staff who work almost exclusively in a single house. Some staff, out of necessity, split their time between two sister houses. This dedicated workforce concept fosters and develops relationships between residents, staff, and resident families. Staff develop a sense of pride and ownership in their house as much as the residents do. The annualized turnover percentage for 2001 was 43%. This was in a merger year and the organization was undergoing tremendous change. We anticipate less turnover this year, particularly if relocation and involuntary dismissals are factored out.
Aside from the nursing staff, each house has its own homemaker staff, life enhancement staff and a full-time social worker that splits her time between sister households. Cross training is encouraged so that everyone has the ability and opportunity to directly care for the elders in the houses in a diverse and meaningful way. It is not uncommon for an LPN to prepare an evening snack, or for CNAs to be actively involved in a group or individual activity. Some of the life enhancement staff and homemakers are certified as CNAs or CMAs, so if the need arises they can help out with direct care.
The object of bringing ancillary staff and services into a household position is that it allows more staff to be more closely in tune with resident needs. It also brings decision making closer to the people that are affected. If all meals were prepared in the main kitchen and served on trays, would the cook know the likes and dislikes of the 105 residents she cooked for? Not likely. But when there is a dedicated homemaker in each smaller household, what you get are staff who are intimately acquainted with the people they serve.
Each household has a leadership team made up of staff within their house. This team is accountable for all outcomes within their house. Each team is made up of at least 5 staff members and includes the designated team leader, the household RN, the life-enhancement person, the social worker, at least one person from second shift and at least one CNA or homemaker, although most houses have at least two CNAs since most team leaders carry that credential.
The Leadership teams are supported by a mentor group comprised of the Director of Nursing, Social Work mentor, Chief Operating Officer and two household mentors. This group is charged with helping to grow the teams by teaching them conflict resolution skills, delegation, team decision making, education and coaching skills, and other leadership competencies. They are further charged with bringing outside resources to the teams so the household staff can focus on resident needs.
In March, we were in a predicament as to how we could accommodate several independent living residents who were to be discharged from the hospital and needed temporary health care. They were men and the only openings at the time were for women. After much discussion among the mentor group, it was decided the best thing would be to request a certain resident be moved from one house to another. We assumed this would not impact her much since she is essentially non-communicative.
When we advised the household that this lady would be transferring out of their house, the team refused to allow it to happen. They cited many small, but significant improvements in the resident's condition over the past couple of months. She was no longer withdrawing when care was given; she was beginning to track people with her eyes as they cared for her. The staff had initiated a sensory-stimulation program with her that CNAs were helping with on a daily basis. They had developed a relationship with someone incapable of giving anything in return.
When we heard of the wonderful, personal enhancements in the quality of this woman's life, there was no way we could proceed with our original plans. You never know so much that you can't learn more. And I'll never forget the lesson this group of dedicated caregivers taught me.
The Hard Numbers
Aside from the many personal stories of residents and staff who have benefited from our transforming culture, there is some hard evidence that culture change is producing better outcomes than the traditional model.
We have made every attempt to ensure that the quality outcomes that have been Meadowlark's tradition stand firm as we change our systems to reflect a resident-directed philosophy. We are in the process of restructuring our Quality Assurance program to develop household-level accountability for outcomes. Registered Nurses at the household level are to be involved in data collection and interpretation in their own houses, as well as in the problem-solving arena. A QI process, including clinical rounds and quality of life rounds is in the developmental stages. Housekeeping and dietary rounds are already in place and are conducted by the Head Housekeeper and a Certified Dietary Manager to ensure sanitation and food service standards are not compromised as more staff become cross-trained.
According to State Quality Indicator reports, unexpected weight loss at Meadowlark Hills has dropped significantly, from the 91st percentile statewide for the first quarter of 2001 to the 35th percentile for the first quarter of 2002. Similarly, restraint usage has dropped from the 56th percentile to the 35th over the same time period.
It just makes sense that if you provide people what they want to eat when they want to eat it, in a pleasant home environment, there will be less weight loss. Similarly, where there is community, and with multiple disciplines involved in monitoring the environment and encouraging spontaneous life-enhancing activities, there is less need to restrict a person's movement.
The REAL data collected is also encouraging us to believe we are making progress every day. As of November 2001, 91% of our interviewed residents said they would recommend Meadowlark Hills to a friend as opposed to 78% in September 2000. Overall satisfacion went from 81% in 2000 to 91% in 2001.
Even with the numerous changes that have taken place over the last few years, and those that soon will, we know we are a long way from many of our goals. We are proud, however, that we continue to make steady progress in our journey. And yes, we used to be a nursing home.
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or Steve Shields