Page 9 - One Nursing Home's Journey

“Everyone, not just leadership, but dietary, housekeeping, they’ve all grown,” says the Clinical Dietitian.
“I wouldn’t want to work anywhere else, says the LPN. I don’t think I could go back to that old model...the whole rou- tine of ya gotta get it done now!”
“Yup, we’re the facility of choice for people looking for jobs,” says the Administrator.
Meanwhile, Lenawee’s culture change journey to neighbor- hoods has arrived at households.
“We realized that calling ourselves neighborhoods wasn’t appropriate because we were farther along than that,” says Aube. (See boxed definitions.)
keepers knew only housekeepers,” says Heath. “Now they’ve built relationships with everybody in their household.”
While new challenges arise and old ones fall with each new phase of culture change, keeping staff on track and person-cen- tered requires constant maintenance.
More time should have been spent in the beginning to orient nurses to the new model, says Heath, “to help them consider the residents first...and understand how they fit into the whole scheme of things with a household coordinator and nurse leader.”
Early on, there was a presumption that nurse’s jobs would remain about the same as in the old medical model, but in fact their roles changed significantly in the households.
“We didn’t get them the tools or the time to talk about that, which has hurt us in the end, she says.
For instance, nurses have struggled in trying to establish a larger window of time for passing medications to make it more resident-focused. While homemakers and CNAs have learned to adjust their schedules to “resident time,” nurses still cling to med-pass timetables convenient for the system, says Heath.
And “call-ins” are still a problem, says Aube. Even though staff has options for requesting time off or trading shifts with other workers, some still wait until an hour or two beforehand to call in to say they aren’t coming to work.
“Which leaves me to believe staff doesn’t feel totally com- mitted to their co-workers,” she says.
Aube thinks the solution may lie in having households do their own scheduling, which could result in a heightened sense of teamwork.
“I think if we can get the households more committed to each other, people won’t be calling in as much,” she predicts. Despite the endless stream of new challenges, says Aube, “this is definitely the way to go, the right thing to do.”
“People call us all the time and say, ‘We know you are the best in the community and we want to come there.’ That is so rewarding!”
The Voice of Experience: ‘One Day at a Time’
So what advice do the Lenawee veterans of culture change have for their counterparts in other organizations contemplat- ing the journey?
Administrators must take responsibility for motivating oth- ers to make it happen, says Aube. “If they are not involved in pushing, it is not going anywhere.”
Directors of Nursing must have an open mind—“and I mean really open,” says Heath. “Question everything you do... try to figure out those things that really aren’t necessary that we’re doing just because we’ve always done them.”
Dietitians should visit as many other culture change facili- ties and networks as possible, says Hiltner. “Don’t spin your wheels trying to reinvent wheels that are already out there.”
Nurses must be patient, says Raymond. “Change is hard. It will get better for staff and residents in the long run. You just have to realize that everything’s changing.
CNAs and everyone should “bring up their concerns and questions... communication is number one,” says Meijer.
“Give it some time, settle down, and let things work out... it will turn out for the better,” says Rathbun.
“Don’t panic,” advises Garland. Just take it a day at a time.”
CCNOW!
Neighborhood Model—Breaks up traditional nursing units into smaller functional areas and introduces resident-centered dining.
Household Model—Consists of self-contained living areas with 25 or fewer residents who share their own full kitchen, living room and dining room. Staff operates in cross-functional, self-led work teams.
The households have become like mini-nursing homes as decision-making is decentralized and moved closer to the resi- dents. In recent months households have begun performing eval- uations that previously were the domain of top-down leadership.
High-temperature dishwashers—an essential physical component in the Household Model—have been installed. This enables dietary workers who once did food prep and tray lines in the central kitchen to now be permanently based in the households where they report to the Household Coordinator.
“The dishwashers have made a huge difference because now the dishes stay in the household, and that keeps the dietary people in the households,” says Aube. “Otherwise they’re run- ning back to the main kitchen half the day doing dishes.”
Most of them are cross-trained to do housekeeping and laundry and are called “homemakers.”
Though staffing is still a problem, the homemakers have made mealtime much less stressful for CNAs, says Rathbun.
Informal leaders are arising within the households among the ranks of nurses, CNAs and homemakers.
“We’ve given them parameters, but they’re the ones making the decisions and holding each other accountable,” says Heath.
And they are teaching each other, like the nurse in one household who taught an RSA how to read medication and administration records. The result: better monitoring of pain medicine intake.
“They have more information, and that helps build lead- ers,” says Heath.
We’re Not Done
“But we’re not done,” she adds.
Those in formal leadership roles continue to feel over- whelmed as households absorb more of the organization’s operational aspects. While decentralization improves the environment for residents and direct care staff, it creates more accountability for household coordinators and nurse leaders, says Aube. “They feel like their day never ends.”
As for the CNAs, they have largely resolved that issue. “It used to be the CNAs knew only other CNAs and house-
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