“Evidence that person-centered care is making a difference.”
So wrote Gavin Kerr, Inglis CEO, in an email he forwarded to his executive team last July. In the original message, a physical therapist praises long-term care staff at Inglis House in Philadelphia for the remarkable progress made by a resident with severe physical disabilities.
“They (staff) did the impossible,” the therapist wrote. One resident “told me she got out of bed and ate in the solarium yesterday. This is something that has not been done as far as I know, ever. She is now agreeing to get out of bed three times a week to eat lunch in the solarium… We talked; ‘New room, new life,’ she said.”
The new neighborhood solariums at Inglis House, home to 252 persons living with quadriplegia or paraplegia, are magnets for even the most reclusive residents, offering homey, spacious, brightly-lit surroundings and panoramic views of the outdoors. Here, breakfast is made to order, and if you don’t like what’s on the menu for lunch and dinner, you can choose from a variety of food alternatives that a friendly homemaker or other staff member will prepare for you on the spot, at any time of the day or night.
“Grilled cheese, tuna melts, burgers, I mean, I like to cook,” says Karen Yeagins, a former food service worker turned homemaker. With her urging, residents are becoming more assertive in asking – and receiving – their hearts’ desires. Like the resident who recently had a birthday: “I asked her what she wanted; she said steak. I told my manager and he made it happen,” says Yeagins.
Connected on either side to hallways with resident rooms, solariums are situated at the U-shaped corner of the building. Windows comprise half the wall space, allowing for abundant natural light. They are furnished with cabinets and refrigerators for storing residents’ favorite foods, and Volrath induction cooktops that enable any food preparation possible in a skillet. Lunch and dinner still arrive from the main kitchen, but warming trays in the solariums keep the food hot.
“Food selections, plating and delivery to the residents is all solarium-based,” says Harold Strawbridge, Vice President of Innovation and Continuous Improvement.
It’s a far cry from the hospital-like environment Inglis House left behind when they embarked on a culture change journey to person-centered care and the Neighborhood Model six years ago. Cluttered hallways, centralized nursing stations, noisy paging and call bells, bathing and dining schedules that residents described as “dehumanizing,” limited food choices often arriving cold from the centralized kitchen, and top-down decision making – all drove Inglis management and board members to conclude they would not want to live there, Kerr told Action Pact in a 2011 interview.
Now, the old nursing units have been renovated into six neighborhoods, each with 38-50 residents served by permanently-assigned staff. Huge nursing stations are gone, their space converted to residential areas, and formerly tiled hallways jammed with medical equipment are now tidy with devices stowed in closets. Hallways have attractive new wood floor coverings and walls are lined with “memory boxes” that tell the stories of residents living there.
When choosing the new cabinets, paint colors, appliances, dining assistance chairs, dish colors and more, decisions were left to residents and staff at every opportunity. “We had neighborhood meetings where staff and residents across all shifts weighed in on what they liked,” says Strawbridge. “It was the first real opportunity for people to be listened to and begin building critical thinking and intellectual muscle. While such decisions may sound trivial, they are a starting point for greater self-determination.”
As resident input grows, neighborhoods are taking on their own unique personalities. Residents in one neighborhood, for example, are night owls while those in another go to bed in the late afternoon. These differences affect dining habits, and staff must accommodate them accordingly. As a result, “we’re seeing discussions move away from institutional uniformity,” says Strawbridge.
New Culture Takes Root
“Person-centered care is me being management and a resident sees me walking by and says, ‘Hey, could you set up my tray?’ And I say, ‘Sure not a problem,’ and I do it instead of saying, ‘Let me go see who your care nurse is and I’ll tell them to come back here and do it.’ And suppose they don’t come back even though I asked them? One of the benefits of person-centered care is that you take time out and address or acknowledge that person at that time from the heart. It doesn’t take much to set up a tray. And it can set the mood for the rest of someone’s day.”
–Cecelia Watts, Neighborhood Clinical Leader
Though impressive, the physical changes at Inglis House are mere window dressing compared to the new culture taking root, says Strawbridge.
“Our organizational structure and culture was primarily top-down “command and control”. Residents were institutionalized in their view of things, as were staff from the standpoint of ‘What do you want me to do next?’” Strategy was set by clinical leaders and the Director of Nursing, he says.
Now, the organization is flat. Neighborhoods determine their own care strategies that focus equally on quality of life and clinical care.
Management and leadership within each neighborhood are shared by a life leader and clinical leader permanently stationed there. Clinical leaders are drawn from nurse manager positions; life leaders from social work, therapeutic education, recreation, and adaptive technology backgrounds. Both positions are modeled on that of a co-executive director.
Life leaders report to the organization’s senior administrator; clinical leaders to the chief nursing officer – both stationed outside of the neighborhood in House Services. The new chart eliminates an entire layer of management comprised of community clinical leaders to whom nursing managers in the old “units” used to report.
Neighborhoods are the center of the new organizational chart. Along with a life and clinical leader, they are permanently staffed by LPNs, CNAs, homemakers, dietitians, social service and engineering workers, and volunteers. Outside supporting services and upper management are like concentric circles around the neighborhoods, their focus drawn toward the center of the chart comprised of residents and family members (see chart).
Having life and clinical leadership in the neighborhoods allows staff to have their issues addressed locally rather than going outside through a chain of command. And, there is someone working full-time to improve daily life for residents and their caregivers.
It also enhances quality of care, says Cecelia Watts, Clinical Leader, by enabling her to visit each of her 38 residents in their rooms every day. Just acknowledging individual residents for a few minutes reassures and helps them feel more secure, she says. And, she is better able to notice changes in their health. Meanwhile, she’s learning each resident’s likes and dislikes, “and that’s fun.”
Challenges to Change
“Days when I go home feeling satisfied are when I feel like I’m making change the way I hadn’t been able to before. The hard days are that much harder too, because there’s a lot going on, there’s a lot of moving parts.
– Michael Kelly, Neighborhood Life Leader
Inglis House’s challenges to change are unique compared to most long-term care organizations because of its residents’ severe disabilities, often caused by multiple sclerosis, cerebral palsy, or spinal cord injuries.
Early on, some Inglis staff members visited other homes operating in the Neighborhood Model. Though inspired by what they saw, “a lot didn’t apply here,” says Michael Kelly, Life Leader. Inglis’ residents require more hands-on care, and resources are shared and spread thin because of their complexities, he says.
Some have a tough time adjusting to or even noticing the benefits of change because they are focused on their own debilitating diseases. “Some folks with a disease process like MS have a hard transition moving into a home,” says Kelly.
Adding to the complications of creating a home for Inglis residents is that they are generally younger than residents in most nursing homes. Some come and go and have livelihoods despite being wheelchair bound, says Watts.
Skepticism and resistance by some staff members has slowed the pace of change. “Some people still don’t understand the simple idea of what person-centered care is,” says Kelly. “They’ve worked here for decades and learned to keep in their lane. Even the idea that we can change shower schedules is new to them.”
Not everyone understands the work team concept, causing a heavier workload to fall on the shoulders of those who do. “We’re between having high performing teams doing things on their own, and needing to define every detail of the day to ensure tasks gets done,” says Kelly. When he feels forced to assign tasks to guarantee their completion, some accuse him of micromanaging.
Though she doesn’t mind, Yeagins often carries a heavier workload because residents are unaccustomed to asking just any neighborhood staff member for assistance. Rather than disturb an unoccupied CNA, they instead turn to her for help.
Some staff and residents seek to bypass their local leaders by taking their issues to a higher authority outside the neighborhood, says Strawbridge. But now, senior management sends them back to their neighborhood to resolve the matters. Thus, decisions are increasingly being made in the neighborhoods – an important step toward self-directed teams, he says.
Building Support for Change
“I’ve developed friendships with them, so they look at me as an important part of their family and I treat them as such. I don’t treat them like people with disabilities. If I know a certain resident likes to open up his own can of soda, I’m not trying to say, ‘l’ll get that for you,’ because I know he’s an independent guy.”
–Karen Yeagins, Homemaker
Community learning circles with staff and residents are helping break down resistance, says Kelly. Participants freely voice their opinions or, if they prefer anonymity, they write down their issue and put it in a communication box to be drawn and hashed out at the meeting. “Sometimes there isn’t an issue to discuss, but it’s just the idea of getting everybody together regularly,” he says.
Meetings are made as fun as possible with themes like “meet and greet” and “chat and chew,” says Watts. To get the conversation rolling, questions are sometimes taped to a ball and tossed around the room. The person catching the ball answers the question facing them.
“They come with the expectation of learning something or hearing the latest update. Some topics are not so fun and pleasing, but they have to be addressed. It’s all in the process of growing,” she says.
Her adjustment to change is helped tremendously by the “open door policy” of her neighborhood peers that allows her to go to them for advice and assistance, says Watts. “It promotes family-ness, neighborhood-ness, and camaraderie to keep us grounded … it is challenging because everybody doesn’t have the big, marvelous, perky day every day, but at the same time we’re forming relationships so that we can talk to one another.”
Perhaps most importantly in the change process is to be a good listener, says Watts. Listen to everyone without assuming that they don’t know, “and if you’re a real good listener, then we can agree to disagree and things do happen.”
Building Local Leadership
“When I see the change in leaders, I know the change is going to multiply in the people those leaders serve.”
–Harold Strawbridge, Vice President of Innovation and Continuous Improvement
Initially, staff across the entire organization took Action Pact’s PersonFirst® training. Of special urgency now is to prepare six teams of neighborhood life and clinical leaders for their new responsibilities. “We are basically running a management training program,” says Strawbridge.
“Crash courses” on topics requested by the life leaders are provided at half-day retreats by Strawbridge and directors of Human Resources and Organizational Development. Recent topics include issuing disciplines, facilitation, and team performance. Participants were taught how to build teams and diagnose elements of unresolved issues, goals, and individual performance.
“I was already kind of good at conflict resolution, dealing with difficult people and telling them to stay calm, but now I have to be good at it,” says Kelly, a former volunteer coordinator. As life leader, he’s learning to pick his battles: “I’m figuring out when is the right time to address an issue and not think everything is ‘right now.’ I think I’ve grown a lot in that.”
Clinical and Life Leaders Find Balance
“I think the biggest thing is being kind to one another. Person-centered care is respect. It’s heart. It’s caring. It’s sharing.”
Kelly is learning a lot from his neighborhood leadership partner Cecelia Watts, a former clinical educator for nurse students at Widener University. He now understands, for instance, that clinical needs sometimes must trump his priorities for the neighborhood: “Sometimes the learning circle must wait,” he says.
“We balance each other,” says Watts. “The only downside is we don’t have enough time together.” She appreciates the fresh perspectives Kelly brings to the issues at hand. “He and I will sit down, work it out, and brainstorm.”
Such collaboration is especially important in coordinating neighborhood events that have both a clinical and non-clinical side to them. Like picking a movie, which might be considered a non-clinical event. “But if we’re going to be eating there, there is a clinical factor because we want to make sure somebody is on hand to ensure aspiration precautions,” she adds.
Engaged Board Vital to Transition Amid Medicare/Medicaid Cuts
Inglis’ culture change success to this point would not be possible without an engaged board of directors, which includes several wheelchair-bound members, says Strawbridge. Members were impressed from the onset by Action Pact’s PersonFirst® training. “Their perspective is that we should do this because it’s the right thing to do,” he adds.
That attitude has enabled Inglis to keep a steady course toward a culture of person-centered care despite concurrent but unrelated cuts in Medicare and Medicaid reimbursements.
How is that possible?
Partly because Inglis development staff found underwriters to cover half the construction and renovation costs of the neighborhoods, says Strawbridge. Also, much of the expense of transitioning to person-centered care is absorbed by existing training programs. “So much of culture change is how we treat one another,” he says.
There also is a monetary benefit in growing leaders among rank and file staff. “The vast majority are working here and doing this very difficult physical and emotional work because they have a vocational calling to it … studies show that if you engage your employees you’ll get a productivity gain that is upwards of 10 percent,” he says.
“So if we ask employees, ‘how do you want to fix that? How do you want to improve that? Here are our constraints. Here are our tools. What is our approach?’ there is gold in that engagement,” he concludes.
So what, exactly, do LIFE LEADERS and CLINICAL LEADERS do?
LIFE LEADERS, in their own words…
- We round with staff
- We cohost regular neighborhood meetings
- We help residents’ preferences to be honored
- We keep family members updated
- We help create a culture of socialization
- We act as Person-Centered Care role models
- We advocate for residents and staff
- We create a Life Calendar for neighborhood activities with TR/TE
Improve Neighborhood Operations
- We work to ensure a positive dining experience for all
- We work with clinical staff and Neighborhood Coordinators to bring new systems to the neighborhood
- We educate ourselves about Inglis policies
Support Staff Productivity
- We recognize excellent work
- We partner with the Clinical Leader to track neighborhood staff lateness & absences
Bring the Team Together!
- We document event attendance, incidents and family calls
- We help implement and track behavior plans
- We participate in resident Plan of Care meetings
- We partner with all departments to meet
CLINICAL LEADERS …
Promote a culture of Person-Centered Care
- Encourage staff and residents to have mutual respect by listening and seeking to understand
- Provide a confidential ear for staff, family and resident concerns
- Through regular neighborhood meetings
- By rounding with staff
- By participating in interdisciplinary meetings and relaying important communications to staff and residents
Promote Optimal Health and Wellbeing
- Ensure availability of adequate supplies
- Coordinate clinical operations (i.e., follow up appointments and medications)
- Act as liaison between resident and physician
- Place orders and consults
- Monitor routine yearly appointments
- Follow up with lab results/reporting to responsible MD
- Collaborate with other disciplines (RD, PT, OT, SLP, adaptive, restorative, etc.)
- Provide input into behavior management plans and med adjustments
- Teach staff and coordinators about disease processes and best practices
Promote Effective Daily Neighborhood Operations
- Act as staff role models
- Collaborate with Neighborhood Life Leaders
- Oversee resident and staff safety; promote safety rounding
- CNA assignments and oversee resident care
- Track staff behaviors and performance
If you’d like to know more about Inglis, go to their website: http://www.inglis.org