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BY: WENDY BODWELL, RN, MBA; SARA DENT; TRACIE GRANT; MILT HAMMERLY, MD; and JEANIE MAMULA

Ms. Bodwell is executive director, The Villas at Sunny Acres, Thornton, CO, and chief nursing officer, Centura Senior Services, Denver. Ms. Dent is administrator, The Villas at Sunny Acres. Ms. Grant is manager, human resources; Dr. Hammerly is vice president, medical operations and integrative health; and Ms. Mamula is director, clinical quality improvement, Catholic Health Initiatives, Denver.

Imagine that you just moved into a beautiful new home. You have arrived ahead of the movers and are anxious to get your furniture in place and meet your neighbors.

Now imagine that someone walks in your front door, welcomes you briefly, and hands you a list of house rules. Rule 1 is "Send most of your belongings back, as they won't fit in this new house." Rule 2: "Meals are served at set times, with no exceptions, and you should line up at the dining room door early to get a good table." Rule 3: "Bathing is done on a schedule, but not in your own bathroom. Someone will come to your room to wheel you down the hall to the public bathroom." Rule 4 . . .

But wait a minute! Is this a bad dream?

Unfortunately, this is how older people are often treated when they enter a long-term care facility. Fortunately, there is a growing movement towards change. The Centers for Medicare & Medicaid Services (CMS) is behind the change concept.

In 2004 CMS chartered a collaborative, led by Quality Partners of Rhode Island (QPRI), called Improving Nursing Home Culture through Workforce Retention. The collaborative involved seven corporate partners representing 86 long-term care centers. Using the work of Susan Eaton, Jim Collins, J. M. Kouzes, and B. Z. Posner,¹ along with a number of national experts(including QPRI's David Farrell and Anna Ortigara, the founder of Learn, Empower, Achieve, Produce, a workforce development program*), QPRI developed, first, a set of "discovery activities" to help long-term care facilities take a fresh look at themselves, and, second, a set of "change ideas" to use as a road map for improving quality. The goal was a culture in which, first, residents and their care is the focus of all decisions, and, second, respect for employees guides organizational policies.

*For more information about LEAP, go to www.matherlifeways.com.

Paul McGann, MD, technical director for CMS's Office of Clinical Standards and Quality, challenged the collaborative to imagine a world in which, by the year 2008:

All nursing homes participating in CMS and other quality initiatives have restraint rates under two percent and less than four percent pressure ulcers. No chronic care or post-acute residents ever experience untreated pain. The average tenure of a nursing home administrator is 10 years and directors of nurses typically stay 15 years. There is a waiting list for nursing assistants, who report very high satisfaction with their jobs, and only 20 percent annual turnover, mostly attributable to promotion and advancement in their careers. Acute hospitals acknowledge that the big improvements they are making in the care of Medicare beneficiaries started when nursing homes showed that it was, in fact, possible. Nursing home employees are sought out by all sectors of health care as quality improvement consultants and the U.S. nursing home profession is widely respected by Congress and in other countries. Schoolchildren around the country regularly visit nursing homes to learn the value of and respect for a life well lived.²

Centura Becomes a Pilot Group
Catholic Health Initiatives (CHI), Denver, was ready to accept McGann's challenge. CHI selected Centura Health, Englewood, CO, the state's largest health care system, to be a pilot group. Karen Hoskins, CEO of Centura's long-term care division (which is called Senior Services), said, "I truly believed the collaborative's ideas would help increase our employee satisfaction, and happy employees equal happy residents. In follow-up surveys, we had a tremendous jump in overall satisfaction and employee engagement."

Centura's leaders formed a team to assess the system's eight long-term care facilities. The team was led by three of this article's co-authors: Tracie Grant; Milt Hammerly, MD; and Jeanie Mamula, each of whom represented a different part of CHI. The team's 30 members also included administrators, directors of nursing (DONs), and certified nursing assistants (CNAs). All had worked in long-term care for years, were committed to seniors, and believed that they provided the best care possible. Accepting the idea that change could improve such care was a challenge to them.

Janice Fisher, DON, Progressive Care Center, Canon City, CO, said, "When I initially was introduced to the idea of culture change in long-term care facilities, I was a bit resistant. How insulting that someone would suggest that our wonderful facility was far from being the next best thing to home. However, after reflecting about our residents and employees, I admitted that the Progressive Care Center is good, but there are many ways in which we can be better and possibly be the best of the best."

Team members were given eight homework assignments that specifically explored Centura's long-term care. They were to assess the eight facilities':

• Cycles and causes of turnover
• Cycles of understaffing
• Costs of recruitment and retention
• Financial incentives for retention
• Leadership practices
• Employee motivation
• Management practices*
• Employee frustrations

*Although there is some overlapping, "leadership practices" at Centura typically have to do with the organization's vision, overall direction, and general tone, whereas "management practices" involve hiring, firing, and supervision.

To conduct such assessments, QPRI's design team had developed what it calls the "way of inquiry." About this, Marguerite McLaughlin, lead project manager of the CMS collaborative's pilot study, said:

Variations in size of nursing homes, number of residents, architecture, longevity of staff, staff ratios, finances, support, leadership, and geography meant that a manual or recipe book to effect change would never do. Nor would a top-down directive within a facility allow for the subtle, yet necessary foundational and systems changes to take place. The "way of inquiry" allows organizations to discover and work through change by way of a process of self-guided exploration. The "way of inquiry" describes a process whereby people begin to notice what isn't working in their current system (irritants) and awaken to the possibility of change. This gives them the impetus to explore and envision new possibilities, and the openness to choose to do something different.³

Centura's team used the QPRI "way of inquiry" in order to look at the facilities through residents' and employees' eyes. They asked such questions as: What do the bath and shower rooms look like? Are the residents' rooms really like home? If residents are withdrawn, is it because of frailty or dementia or how they are treated? What happens when a resident gets sick? What happens when residents die? How do we handle their passing, involve employees and allow them to grieve?

What about employee lounges? Do employees want to take breaks there? Are break rooms conducive to employee refreshment and revitalization? What problems do employees face in their personal lives that might cause them to call in sick or be late for work? What can we do to help solve such problems? Are there leadership issues that might cause employees to leave the organization? Do our hiring practices increase or even cause rapid turnover? Do we orient employees adequately?

The questions kept multiplying in team members' minds. At times, they seemed overwhelming. However, during the course of the year — from September 2004 through August 2005 — every question was asked and answered, often more than once or twice.

Because Centura's long-term care centers are located in different parts of the state, team members held only four face-to-face meetings during the year, but they did have monthly teleconferences. Each meeting was part education and part sharing.

The team asked each care facility to answer the eight homework-assignment questions over the course of the year. Each facility started with a different question, so that within the first month all eight questions were answered at least once.

At each meeting, the team discussed the results of the homework done so far — including the insights gained and the changes made. Team members benefited from the fact that they had worked together for many years and thus had no trouble sharing what they learned. Although they recognized that what worked at one facility might not work at another, they continually challenged each other to try things that proved successful somewhere else.

Employee-Related Change Ideas
Concerning long-term care employees, the CMS collaborative proposed a number of ideas that have since been implemented at Centura facilities.

Hire for "Fit" and Skills
Staffing shortages can cause long-term care facilities to hire quickly, only to find that new employees may not have the best skills or temperaments to work with senior citizens. After considering this fact, the staff at one Centura facility requested that they be allowed to work shorthanded rather than hire too quickly. Although skills and experience are important, the facility's leaders agreed that finding personalities that fit the organization is key. This facility revised its interview process in ways that provide a very complete picture of applicants and their values.

Revamp the Orientation Process
Interviews with new employees uncovered frustration in the early days on the job. Some newly graduated CNAs reported that they did not feel welcomed by more experienced CNAs. The team studied turnover rates and timing, discovering that nearly 50 percent of CNA turnover occurred within the first three to six months on the job.

Centura facilities made a number of changes, including giving new CNAs more complete tours of the facility, introducing new employees to other staff members on their first day, revising formal orientations, and pairing new employees with experienced employees who serve as mentors. One facility developed a frequently-asked-questions sheet for new employees. The same facility also reviewed its schedules for orientations and in-service programs, changing their times to meet employees' — rather than the administrators' — needs; for example orientations were scheduled for evenings, as well as during work hours, to make it easier for employees to attend.

"Primary (Consistent) Staffing"
Evidence shows that "primary staffing" — setting schedules that allow employees to be assigned to particular units, so that they work with the same residents — results in higher satisfaction for both residents and employees.⁴ With such staffing, residents and employees get to know each other better, and employees become more committed to "their" residents. However, such scheduling is difficult for facilities that are short-staffed. And some employees resist the idea because they fear they will get "stuck" with residents whose care is challenging. Some Centura facilities have implemented the "primary staffing" idea, but they have not yet had enough time to draw conclusions about its effectiveness.

Push Decision Making Out to Hands-On Caregivers
Part of the team's homework involved interviewing CNAs to promote understanding of the issues they face. A recurrent theme in these interviews was that although CNAs love seniors and feel good about taking care of them, they become frustrated when short staffing requires them to spend less time with residents and hurry through tasks. CNAs also believe that nurses don't respect or listen to them. The CMS collaborative recommends that facilities form CNA-led care teams empowered to solve interpersonal and interdepartmental problems as they arise, rather than awaiting a nurse's decision. Centura facilities have formed such teams, and they are functioning well at present. CNAs are also more involved in care planning.

Enhance the Environment for Employees
Centura administrators were asked to examine employee break rooms to judge how conducive such rooms were to relaxation and refreshment. Administrators also asked employees what could be done to improve their break rooms. Employees suggested a variety of inexpensive ideas, all of which went a long way toward improved morale. Some facilities painted their break rooms or made other simple improvements. Some purchased more comfortable chairs. One facility set aside a "Reflection Room," where employees can go to spend quiet time. This facility also created a "Soul Space" bulletin board, on which employees post the family pictures and other mementos that people in other fields put on their desks and hang on their office walls.

Improve Employee Recognition
Centura's team developed many ideas in this area, including giving employees small gifts on their birthdays, holding frequent anniversary celebrations instead of a single annual celebration, giving special recognition to newly certified CNAs, and giving employees awards for perfect attendance.

Some facilities sponsor a game for employees called "Safety Bingo." Played with traditional bingo cards, the game allows employees to cover one space for each day they all go without an injury. When the entire card is covered, the employees win (prizes include dinners, movie tickets, and small cash awards). If an injury occurs, the game ends and another starts at the beginning of the next month. Safety Bingo has proven to be very popular.

Resident-Related Change Ideas
The CMS collaborative maintained that long-term care centers should put residents at the center of all operations. The Centura team accordingly tried to consider everything from the residents' perspective. If a program or action failed to meet residents' needs or wishes, it was a candidate for change. The Centura team also made a distinction between "resident-focused care" and "resident-centered care." In "resident-focused care," decisions, policies, and processes are made for the residents; whereas, in "resident-centered care," residents are involved in the decision-making process. To the extent possible, the team wanted residents to be involved in the decision-making process.

The team viewed a video, created by Anna Louise Barrick, PhD, Joanne Rader, RN, and Philip Sloane, MD, at the University of North Carolina at Chapel Hill, called Bathing without a Battle.⁵ The video shows how frightening a bath or shower can be for someone who suffers from dementia, and offers simple alternative approaches that help alleviate such fears. When team members took these ideas back to their facilities, they inspired lively, thoughtful discussions among employees and an increased willingness to move away from institutional models, not only for bathing, but for other practices as well. The following are some of the ideas that sprang from these discussions.

Remodel or "Refresh" Bath and Shower Rooms Team members toured their own facilities and were often surprised at the state of the bath and shower rooms. They found, for example, that shower rooms sometimes doubled as equipment storage areas; the rooms themselves were frequently cold and sterile.

The changes made included removing everything from the shower rooms that didn't belong there, freshening the rooms up with new paint, and adding "homey" touches. Some facilities have created spa-like atmospheres, with plush bath towels. Centura facilities have also relaxed previously rigid policies concerning the number of showers or baths allowed per week, thereby beginning to accommodate the bathing regimens that residents followed in their own homes. This doesn't mean that the facilities have relaxed requirements for good hygiene. They do, however, recognize that good hygiene can be accomplished in more than one way. This change enables Centura to use the "resident-centered care" approach and involve residents in deciding when they want to bathe while still meeting the standard of care.

"Open Dining" (Continuous Meals)
When team members observed meal times in their facilities, they noted a lot of "hurry-up and wait" during all three daily meals. Employees would hurry to get residents up, dressed, and to the dining room — where they would then wait for their meals, often lined up in the hall outside the dining area.

Some Centura facilities are now trying the idea of "open dining." Meals are served for longer periods of time, and (in keeping with a commitment to "resident-centered care") residents are allowed to choose when to have breakfast, lunch, and dinner. These facilities also have a wider range of entrées for each meal, plus some items that are available all the time.

Because open dining is one of the more recent changes, Centura does not yet have results to report. However, other long-term care facilities report increased resident satisfaction with the open-dining system. More important, several facilities report improvement in residents with unhealthy weight losses. When residents eat when and what they want, they tend to eat more and begin to replace lost weight. Dietary departments also report decreases in wasted food. Some facilities also report decreases in resident agitation when they are allowed to get up when they want, rather than on a schedule.

Happier Workers, Healthier Residents
Overall employee satisfaction at Centura's Senior Services facilities has improved. At first, employee turnover at some facilities increased, due in part to an effort to ensure the right "fit." But turnover has now stabilized, and the system's leaders expect it to decrease in the next few months.

Meanwhile, employee involvement in decision making has increased, and employees seem to be having more fun on the job. Best of all, residents seem happier.

On August 2, 2005, the Centura team held its last face-to-face meeting, celebrating the work accomplished with a "commencement" ceremony. The ceremony was intended to remind everyone that the year's work was only a beginning and that culture change is an ongoing process. The leaders of each Centura facility have committed themselves to address any operation or process that is not resident-centered and to do whatever is necessary to promote employee teamwork that supports residents.

CHI is a strong advocate of person-centered care as the underlying framework for all clinical endeavors. At Centura, one hospital and one long-term care facility have been assigned to develop "scorecards" that will help the system assess the depth and impact of its person-centered care movement.

NOTES

1. S. C. Eaton, "Beyond 'Unloving Care': Linking Human Resource Management and Patient Care Quality in Nursing Homes," International Journal of Human Resource Management, vol. 11, no. 3, June 1, 2000, pp. 591-616; J. Collins, Good to Great: Why Some Companies Make the Leap and Others Don't, HarperCollins, New York City, 2001; and J. M. Kouzes and B. Z. Posner, The Leadership Challenge, Jossey-Bass, San Francisco, 2002.
2. Paul McGann, address to the Outcomes Congress, Providence, RI, October 4, 2005, delivered via PowerPoint slide.
3. Marguerite McLaughlin, personal communication, October 28, 2005.
4. Eaton; Centers for Medicare & Medicaid Services, "What a Difference Management Makes! Nursing Staff Turnover Variation within a Single Labor Market," in Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes, Phase II Final Report, December 2001, available at www.cms.hhs.gov/medicaid/reports/rp1201-5.pdf. Eaton was also the principal author of this study.
5. Anna Louise Barrick, Joanne Rader, and Philip Sloane, Bathing without a Battle (videotape), Cecil G. Sheps Center, University of North Carolina at Chapel Hill; and the Oregon Health and Science University; in conjunction with the University of Aging, University of North Carolina at Chapel Hill; and EO Studios, 2003. For more information, access www.ohsu.edu/son/alumni/e-notes-ay04.html.

THE PILOT GROUP PARTICIPANTS

The Centura facilities participating in the pilot group were:

Centura Senior Life Center, Denver

The Gardens at St. Elizabeth, Denver

Medalion Retirement Community, Colorado Springs, CO

Namaste Alzheimer Center, Colorado Springs

Porter Place Retirement Residence, Denver

Progressive Care Center, Canon City, CO

Villa Pueblo Senior Living Community, Pueblo, CO

The Villas at Sunny Acres, Westminster, CO

THE VILLAS AT SUNNY ACRES EXPERIENCE

Although all of Centura's long-term care centers participated in its culture change effort, a single facility, The Villas at Sunny Acres, Thornton, CO, were chosen to present results at the CMS collaborative's Outcomes Congress, in Providence, RI, in October 2005.

The facility's presenters were Wendy Bodwell, RN, MBA, executive director, The Villas at Sunny Acres, and chief nursing officer, Centura Senior Services; and Sara Dent, the facility's administrator. They described some of the changes at the facility. The center's leaders have, for example:

• Changed the locations of certain activities, thereby reducing noise levels in the halls (employees believe this led to a calmer atmosphere).
• Hired an afternoon receptionist to take phone calls previously answered by nurses and CNAs.
• Identified, counseled, and in some cases disciplined a small number of CNAs who had patterns of calling in sick. Leaders also established a formal policy that will hold all employees accountable to the same standard.
• Changed employees' work schedules, moving from the traditional system to "consistent" scheduling.
• Hired two PRN CNAs to help cover peak times (4 pm to 8 pm).
• Introduced the use of audio taped reports, instead of face-to-face reports, at shift changes and made these tapes available to CNAs.
• Expanded the facility's successful training program.
• Followed employees' suggestions to improve break rooms.
• Improved supervision of the employee orientation process.
• Implemented continuous meals and open dining.
• Employee satisfaction improved dramatically, ranking second among Centura facilities. Employees are now much more focused on residents. As a result, clinical measures such as pressure ulcers, pain, and weight loss have improved.

CATHOLIC HEALTH INITIATIVES AND CENTURA HEALTH

Catholic Health Initiatives (CHI) is a national not-for-profit health corporation based in Denver. It comprises 68 hospitals; 44 long-term care, assisted-living, independent-living, and residential facilities; and five community-based health organizations located in 19 states. CHI has approximately 65,000 employees and annual total revenues of $7 billion. It is the second largest Catholic health system in the United States.

Centura Health is cosponsored by CHI and the Adventist Health System, Winter Park, FL. Centura is Colorado's largest health care provider, comprising 12 hospitals, eight senior-living residences, medical clinics, the Flight for Life Colorado air-ambulance service, and home care and hospice services. A not-for-profit, faith-based organization, Centura provides care and comfort to more than 500,000 every year and is Colorado's fourth largest private employer, with more than 12,000 associates. For more information about Centura Health, visit www.centura.org.

Copyright © 2006 by the Catholic Health Association of the United States
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