As long term and post-acute care organizations desire to make the shift
toward person-directed care, the neighborhood model is a likely first
step of the journey. Neighborhoods are a smaller unit of the larger
skilled nursing center that is made up of elders, stakeholders, and
family members who live, work, and visit in that area.
This parallels the outside community, in which people live and work
in smaller, more compact areas that make up a larger network.
In 2011, leaders at Signature HealthCARE, a long term and
post-acute care (LT/PAC) organization with 117 locations across the
country, made the decision to start a transformation process that would
eventually lead it to the development of this model of care. Leaders
created clear goals to destroy institutional silos, transform the entire
organizational design, and build systems that breed accountability and
transparency.
Signature’s leaders realized that a new approach focused on
developing leadership, agile teams, communication, education, quality
improvement, and measuring progress would be the keys to overcoming
obstacles in the path before them. Prepared for the challenge, they
began to devise a strategy that they hoped would drive them toward
person-directed care.
Getting The Basics Right
The key tenets of a successful transformation to the neighborhood
model included creating smaller areas for elders to live in, high team
engagement through a team leadership model, ensuring decisions are made
closest to the elder, and an atmosphere of home, among many more.
In traditional skilled nursing centers, decisions are made for
everyone by the management team. In a team leadership model, decisions
are made closest to the people they affect. This means that the people
who work on the neighborhood as nurses or nurse assistants are empowered
to make choices that impact their lives. This creates engagement among
all staff as well as improves customer service through faster response times and stronger relationships.
In this model of care, the elder truly becomes the center of attention. In other words, everything that
happens within the community involves the elders and coincides with their choices, desires, and goals.
Many leaders are interested in beginning a person-directed care
journey but often give up because the work it takes to achieve those
goals can be overwhelming in the whirlwind of LT/PAC. That is one reason
it is so important to develop leaders who can carry the mission and
vision forward. They can stay the course to realize the person-directed
care goal amid changing dynamics.
Investing in Leaders
In order to realize a team leadership model, Signature created its
Pinnacle program. This is a career ladder program geared toward
certified nurse assistants (CNAs). Through this program, CNAs are
rewarded for learning new skills, achieving new certifications, and
assuming informal leadership roles.
For example, Pinnacle graduates will have led team huddles,
neighborhood meetings, and performance improvement projects on their
neighborhoods.
Signature also invested in a variety of educational experiences,
including an administrator in training program, as well as a customized
school for administrators, directors of nursing, and other key leaders
for leadership development. The organization also recognizes leaders who
display exemplary work each calendar year by naming them Champions.
Champions give back by becoming mentors to new leaders, serving on
agile teams, or helping with special project development areas. The
emphasis on leadership development creates a culture with a focus on
service, innovation, and continual self-improvement. As a result, many
Signature leaders are also CNAs and participate in the organization’s
days of activating its “service program,” in which corporate and
regional leaders volunteer in various roles that impact elders’ daily
lives.
This might mean that some work shifts as nurse assistants, some may
use their passion for decorating, gardening, or other hobbies to spend
time with elders, while others may volunteer for special service
projects such as remodeling an area in the nursing center to make it
more appealing.
The Agile Team
The organization realized early on that many LT/PAC leaders fail to
align with each other or create sustainable partnerships to impact
overall culture. To address this issue internally, Signature launched an
agile team framework to engage employees of all levels in key
decision-making projects.
Agile teams, a term coined in the technology industry, are
cross-functional teams dedicated to specific projects to innovate within
the organization at a faster pace. The use of agile teams has helped
Signature break down departmental and corporate silos by bringing
together individuals with varying skills and knowledge bases.
Within the organization, agile teams have been responsible for
things such as clinical innovations, program development, and problem
solving. For example, the implementation of team huddles and the
organizational design of the neighborhood model were created by agile
teams.
Hardwiring Communication
For the shift to the neighborhood model to truly take place, a
defined process for communication must be in place within the
neighborhood itself. Signature leaders recognized that in many
instances, department leadership teams were receiving the bulk of the
education, yet direct caregivers still were not being given all the
tools needed to make execution of the neighborhood model a reality. It
was evident that the traditional ways of educating team members through
all staff mandatory inservices in existing educational systems were
lacking luster and appeal and could even be considered outdated in the
fast-paced world of health care.
It was time to create something new, something that would appeal to a new generation of employees. It
became clear that the team huddle would be the vehicle in which communication practices would be born.
An agile team quickly went to work to develop a team huddle process
that engaged employees at all levels. The team huddle engages everyone
in the nursing center because it is attended by people at all levels of
care. This means that department leadership teams go out to the
neighborhood unit to be part of the daily communication process. Nurse
assistants are also trained and encouraged to lead the team huddles,
which further empowers them to become leaders on the neighborhood.
Huddles Embed Care
Team huddles were standardized with a five-minute micro learning
sequence that embeds person-directed care learning principles into the
daily routines of the organization. The learning sequence includes a
descriptive method of breaking down the education piece into what, why,
how, who, and a key take-away. Some of the topics covered include
person-directed care, person-directed dementia care, and leadership
techniques.
For example, when learning about recognizing unmet needs in people
living with dementia, the learner would discover what an unmet need is,
as well as how to identify and meet that need. The learner would also
have a quick overview of why people living with dementia communicate in
various ways, such as they might be hungry, need to use the restroom, or
simply feel uncomfortable with something. The key take-away would be a
one-sentence overview of the lesson. The education topic repeats for
seven days in each huddle so that everyone has time to reflect.
The team huddle also serves as a communication tool on the
neighborhood to communicate important changes and news. The micro
learning offered in the team huddle is also discussed during daily
leadership meetings. Additionally, the education ties back to the
organization’s Sacred Six Values: compassion, integrity, teamwork,
respect, positivity, and patience.
The team huddle quickly became one of Signature’s company standards
for communication and team engagement. The impact of the team huddle is
felt through the fostered teamwork and faster problem solving by the
neighborhood team to impact the lives of elders and their families
daily.
Keeping Quality Improvement Fresh
With the team huddle in place, the organization wanted to continue
to highlight process improvement and quality control on the
neighborhoods themselves. The next logical step was to teach CNAs to use
root-cause analysis and tracking to help solve key problems. The tool
in which they do this is known as a Quality Service Expansion Team
(QUEST) board.
The QUEST board is a daily project management tool in which CNAs
track outcomes related to specific measures for their communities. For
example, CNAs tracked falls in some locations and were able to identify
causes and prevent falls overall. The QUEST board engages all care staff
in a visual reminder of measures being tracked as well as overall
process improvement methodology.
With so many programs in place, Signature needed a way to track and
measure implementation of the neighborhood model. To support this idea,
the leadership team created a visual scorecard called The
Transformation Tree.
A Transformation Tree was hung in each community, which was given
the opportunity to earn a total of 53 leaves. Each of those leaves
represents key steps and goals that are important to the community’s
elders and stakeholders and also provide momentum toward the
organization’s vision for person-directed culture development.
For example, communities could earn leaves for eliminating overhead
paging, adding pets to the community, and making environmental
improvements such as adding a chapel or general store to meet elders’
needs.
Integrating person-directed care methodology throughout an
organization can be done. However, it requires foundational efforts to
be made before any lasting change can take place. Those foundational
efforts warm up the environment and inspire confidence in local leaders
for deeper systems change. While a vision to change is beautiful, it
requires persistence and strategic planning to become reality.