​When the 2009 American Health Care Association/National Center for Assisted Living Quality Award recipients were announced this summer, many facilities celebrated a milestone in their efforts to maximize quality of care for their residents and quality of life for residents and staff. While all were pleased to receive this award—whether they were honored for reaching Step I, Step II, or Step III—few were surprised.

As Shelly Fink, executive recruiter at Altercare of Ohio, notes, “Our organization has many wonderful characteristics that have led us to this success. We are committed to learning and skills development. We have a strong rewards program, an emphasis on recruiting and retention, corporate leadership with a strong vision and mission, and demonstrated support for innovation. We worked hard for this achievement, and we’re very proud, but we weren’t surprised. Quality care is who we are every day.”

Step III: Making It Look Easy

Facilities reaching Step III made it look easy, partly because quality and excellence already were so engrained in their cultures. As Lee Larson, administrator at St. Gertrude’s Health & Rehabilitation Center in Shakopee, Minn., says, “We’re part of an organization that’s never satisfied with standing still. Striving for quality—using pillars of strategic planning that include financials, care, services, and people—is part of who we are and what we do every day. We need to continually make this a better place for residents to receive care and for staff to work. Going through the step processes embedded this even more.”
Jane Goebels, nurse administrator at St. Gertrude’s, says, “Ever since we’ve been in existence, it has been a requirement for us to have a quality assurance program, then quality measurement, then quality improvement. We have had strategic planning for at least 10 years.” She adds, “We have had expectations by our leadership group that we would be an education organization. And our leadership has been critical to our success by putting processes in place and enabling them to be implemented easily and affordably.”
This commitment to quality and change just seemed to grow as Larson and his team moved through the steps. As Goebels says, “Step II made us look at our strategic planning efforts—including a SWOT [Strengths, Weaknesses, Opportunities, and Threats] analysis—and made us realize that we needed quality improvement as part of our strategic planning. Now, with Step III, this has become the driving force of our strategic planning. It involves all areas and all staff at the facility,” she says.
Anna Bojarczuk-Foy, administrator at ElderWood Health Care at Wedgewood in Amherst, N.Y., says “Our owner has always had a vision of challenging staff toward a pursuit of excellence. As a facility, we decided to undertake this journey—although we didn’t look all the way to Step III when we started.”

Seeing The Big Picture

Step III award winners credit the application process with helping them to see the big picture of how far they have come. For example, at one time in the past, St. Gertrude’s noticed that its family satisfaction scores had declined.
“We instituted a partnership with a family initiative that took place at family council meetings. We met with family members individually and talked about our desire to partner with them using a quality management process to identify areas where we weren’t meeting their needs,” says Goebels. The facility implemented consistent assignments/staffing, addressed dining room issues, started a family newsletter, redesigned bathrooms to be less institutional and more spa-like, and extended more flexibility in dining, bathing, and rising and retiring to bed times.
“As a result, we really have forged a positive relationship with families, and the improvements we instituted led to improvements in scores—in the top quartile nationally—and better communication between families and staff,” she says. “When we won this award, families were excited for us but not surprised. And we realized how far we’d come in forging this positive relationship.”
“Going through Step III made us realize the importance of communication. Sometimes we forget that,” says Mark Cairns, administrator and chief executive officer (CEO), Madonna Living Community in Rochester, Minn.
“When we wrote the application, it came back to us the importance of communicating back to staff the role they play in ways we haven’t done before. We actually brought together focus groups to find out what staff expect from communication. We found that staff wanted more postings of minutes and sharing of what goes on in management teams,” he says, adding, “We are now trying to provide as much information in as many different ways as possible.”
Cairns notes that they also discovered the alphabet soup of abbreviations and acronyms they used—such as the MDS (minimum data set) and MARs (medication administration records)—were confusing for some. “We developed a glossary of terms for board members and others to help them understand what these things mean and to make sure everyone has the same understanding of different terms,” he says.

The Challenges Of Climbing To Step III

Getting to Step III wasn’t easy, the award winners admit. “You really have to have systems in place to get here. You need processes to measure, analyze, and decide what you will do with this information,” says Goebels. “Along with that, you have to roll that information into strategic planning and leadership. Then you have to walk people through the processes and make your organization a learning body,” she says.
“We really looked at how our processes and our QI system worked, and we developed our game plan,” Bojarczuk-Foy says. “By doing Step III, we actually communicated this plan at every level. It became part of staff orientation, the lingo used at every meeting, and every system we employ. It is a verbal reminder that we all have to be on the same page with our goals, actions, approaches, and how we will monitor and measure outcomes and implement change.”
A key part of this game plan is the Wedgewood System Wheel, which substitutes for the facility’s organizational chart, “the spokes of which are the concepts that we are constantly reaching for—education, clinical outcomes, communication, technology, and so on. This is not just something on paper; it’s what we do and who we are,” Bojarczuk-Foy says.
Wedgewood uses an acronym for it game plan that everyone can understand—“g” is for goals, “a” is for approach, “m” is for monitoring, and “e” is for evaluation. “We use this for everything from how we wash the dishes to what we do to make sure we don’t develop any in-house pressure ulcers. We talk about everything we have to do from a communications, clinical, and education perspective. As a result of all of this, we have formed a nice, close-knit team,” says Bojarczuk-Foy.

Lessons Learned

Even though the Step III application process was rigorous and designed to document what facilities have accomplished and learned already, Larson says they learned much as they pursued the award. “It forces you to quantify and sharpen your quality measures and track outcomes over time,” he says.
“Having a strong emphasis on statistical significance and seeing it all laid out over a period of years gives you a chance to see the big picture and how your facility has really performed over time.”
Criteria, patterned after the Malcolm Baldrige national quality awards, “set up a benchmarking system that relies on outcome measures at various points,” Bojarczuk-Foy says. “We learned that you have to systematically measure your progress at various points and levels to make sure you are going in the directions you want and that you can react quickly when there is a problem or need for change. That was huge for us.”
Not surprisingly, Step III award winners have high standards for themselves. They always are looking for ways to do better and be better. However, winning the award gave them an opportunity to step back and appreciate what they have accomplished.
“We were amazed when we looked at what we had gone through,” says Goebels. “When you pursue quality on a daily basis, you tend to focus on what you still need to accomplish. When we saw our achievements in writing, they were pretty big.”
“When you step back, you’re able to see the progress of going from Step I to Step III. It’s like going from grade school to high school to college,” says Bojarczuk-Foy. “I actually believe there should be a fourth step—not an award, just a step that facilities can strive for that promotes ongoing growth.” Bojarczuk-Foy and her team also learned the importance of ongoing communication and ensuring that everyone is on the same page and has the same understanding of goals.
The award’s impact on morale can’t be underestimated, Larson says. “It helps staff feel more strongly that this is a place that they feel proud of and where they want to work.” The good feelings also have extended to the community—including family members and other stakeholders. As Larson says, “We’ve gotten a lot of positive feedback. It raises the perception in the community of what senior care is all about and expectations about what it can do.”
“One of my goals for this was to be able to show what staff is really doing and what they are accomplishing through their dedication and loyalty,” says Cairns. “This was a chance for us to tell our staff what they are doing right and talk about how wonderful our staff is.”
Cairns was eager to share the good news about the award with everyone. “We announced it to staff as soon as we got the news that we won. We also announced it to nearly 600 people at our family picnic. We ran a full-page ad in the local newspaper with everyone’s name in a list, and we purchased special t-shirts for everyone,” says Cairns. “When people ask, they’ll be able to say that it’s the highest award you can receive.”

Step II: Success Stories Abound

All Step II recipients said they look forward to pursuing Step III, and they encourage facilities that haven’t started this journey to set their eyes on Step I.

Applying for the Step II award gave facilities an opportunity to reflect on their quality successes. Their stories suggest the power of a commitment to quality and the consistent use of processes to solve problems.

Hartford Health Care

Les Hogan, administrator, Hartford Health Care in Hartford, Ala., says, “We discovered that there wasn’t a diagnosis to support the use of antipsychotics in all of our patients. We identified ways we could decrease the use of these meds. We reviewed each chart, making sure there was a diagnosis and a need for the antipsychotic.
“We not only improved quality of care but also improved financial quality by saving money spent on those drugs; we also reduced the time nurses had to spend on medication administration.”
Once Hogan’s team identified the problem, they were able to move through the process easily. They focused on one hall per month and completed the process in a six-month period. The result was a reduction in antipsychotic use from 33 percent to 6 percent.
Teamwork and communication made this process successful, according to Hogan.
“The medical director was very supportive and worked with nurses to determine when meds could be discontinued or doses reduced,” he says. “If patients were cognitive enough, we talked to them about it; if not, we spoke with the family. As we slowly titrated the meds down, we constantly monitored patients—including their behaviors—to make sure there were no adverse reactions.”

Maryhill Manor

At her facility, Maryhill Manor in Niagara, Wis., Jana Clement, administrator, president, and CEO, and her team focused on making meals more homelike for residents.
“We wanted to work toward something that would let our residents feel empowered. We started with enhanced meals and kept a list of goals. The change didn’t happen all at once. Several action teams each took a section of the process and worked at developing something to make it feasible.
“At the same time, we developed interest sheets on which residents could write something they wanted. From there, we developed the dining program,” she says.
 The facility started a five-meal plan, but it was discontinued because the residents didn’t want it. They also didn’t want buffet style dining; they wanted to be served restaurant style. “We moved from neighborhood to neighborhood with natural risings. Residents now can choose from a menu, and we can create special foods as they desire. The residents love it, and it’s been a wonderful growth experience for staff,” says Clement.

Golden LivingCenter

Amy Wall, executive director, Golden LivingCenter, Decatur, Ga., and her team started their enhanced dining program by “getting rid of all the plastic because you don’t eat off plastic at home. Instead, we use china and silverware, and we have tablecloths and centerpieces. We start the meal with a beverage cart, and we initiated a dessert cart. We also have a soup course that enables us to get a few more calories in the residents.”
Residents are brought in early enough to socialize before meals if they so desire. They can choose between the featured menu item, an alternative, or other options such as a salad, burger, or grilled cheese sandwich.
In dining areas, dietary aides run the show, and certified nurse assistants help.
“Everyone loves it,” says Wall. “It helps maintain weights, it has decreased waste in the kitchen, and residents like that they feel as if they are dining in a restaurant.”

Golden LivingCenter—St. James

In preparing her facility’s Step II application, Renee Riding, executive director, Golden LivingCenter—St. James in St. James, Mo., at first had trouble answering a question about how her facility promoted diversity. But as she pondered this, she realized that her team actually had made a huge step forward in this area. “It hit me that for us diversity means looking at the available staff pool. We had looked at recruitment and retention and why we lose people,” she says.
Riding and her team discovered that many in their potential workforce were single moms who had trouble feeding their families and getting to work. “It occurred to us that these people often don’t have the resources to pull themselves out of the hole. So we created the ‘helping hand pantry,’ stocked with staple food items, gas cards, and other things our workers need. When someone needs help, they come to the pantry. It’s based on the honor system, and people are supposed to pay back what they used when they get their paycheck,” says Riding.
“We’ve been doing this for about two years with very positive results. We have much less turnover, and people can focus more on their work and worry less about feeding their families or having gas to get to work,” she says.

Oak Hill Nursing and Rehabilitation Center

Improving quality in the risk assessment area was an important goal for Scott Sanborn, executive director, and his team at Oak Hill Nursing and Rehabilitation Center (Kindred Healthcare) in Pawtucket, R.I.
“We established a multi-pronged process that works for us,” he says. The facility has daily clinical meetings that involve licensed nurses, plus activities, rehab, and other staff. Then they have a once-weekly at-risk meeting where they discuss all patients who have risk factors in any area.
“We develop action plans right there on the spot—whether that means a new order from the attending physician, a change in diet, or other intervention. Everything is documented at the meeting, and everyone is there to hear the plan and discuss their role in it. It puts everyone on the same page and enables us to be proactive; and everything happens in real time,” Sanborn says.
As a result, the facility has seen steady improvements in quality indicator numbers for pain control, wound care, and other areas. “We’ve set targets, met them, set new ones, and met those,” he says.

Spa Creek Center

A few years ago, Administrator Margaret McGovern and her team at Spa Creek Center (Genesis HealthCare) in Annapolis, Md., realized that their admissions were down, so they initiated a customer service focus. “We made sure our department heads and nursing managers were informed and educated. We hired a company that conducts staff satisfaction surveys, and we conducted an annual resident satisfaction survey. We trend and monitor this data regularly,” she says.
In addition to initiatives such as enhanced dining programs, spa-like bathrooms, and a beauty salon for residents, McGovern’s team also has done much to improve staff satisfaction. “We have an employee relations committee that organizes employee activities every month. We celebrate birthdays and have special meals for staff. We have an employee recognition dinner and awards ceremony. We recognize retention,” she says.
The result? According to McGovern, “Our last survey showed that 100 percent of patients would refer a friend or family member to the facility; the number for staff was 92 percent,” she says.

Lessons Learned

As with the Step III award recipients, Step II winners learned much from going through the application process. As Hogan notes, “It taught me just how intertwined every aspect of the facility is with every other one. For example, what the bookkeeper does affects nurses. If the patient isn’t admitted correctly and the payer source isn’t identified, it affects nurses ordering the meds. This helped me understand the need for consistent education and training to keep everyone on the same page.”
Wall says, “When you piece all of the information and data together and look at results over a year, it’s interesting to see how people in the facility have maintained benchmarks set by the corporation. When you start showing things like your turnover are under benchmark year after year, it’s easier to show how your quality measures have improved.”
Sometimes facilities learned about areas where quality could be improved. According to Anthony Hanson, administrator, Prince of Peace Care Center (Benedictine Health System) in Ellendale, N.D., “We came up with some glaring information that told us things we thought we were doing right could be done better. We learned that if one process doesn’t work, you try another to get the results you want.”
Riding says, “We realized that we don’t always tell our story as well as we could sometimes. It made us focus more on how we communicate with residents and families, as well as staff.”

Culture Change, Step II Go Hand In Hand

Most Step II recipients say they understood the value of quality improvement and culture change before they even thought about the award. Hogan says, “Our team knows their ideas will be respected and that they can come to management with their ideas. We’ve long believed in bringing everyone together to accomplish quality care and that everyone on the team is important and has a key role."
“You need to have undergone culture change before you can move through the quality steps. If you don’t have a culture that values staff, you will encounter resistance when you try to evaluate your process,” says Roy David, administrator, Van Dyk Manor of Ridgewood in Ridgewood, N.J. “You couldn’t go through this process without knowing you have the full backing of your people and without having strong processes in place,” he says. At the same time, “moving through the steps validates the change itself and helps you solidify your culture change activities. The award is the icing on the cake,” he says.
Celebrations for reaching Step II were common and festive. Clement says, “We’re a small facility, and we celebrate our lives together. We made announcements on the loudspeaker, put an article in our newsletter, celebrated with a party, and passed out key chains.

“We took photos when we made Step I, and the pride on everyone’s faces is amazing,” she says. “Winning these awards reminds us all of how much we impact residents and each other.”
Wall says, “I think my staff heard me yell when I got the news that we’d won [Step II]. Staff were extremely proud, and while residents were happy, they weren’t surprised. They already were living the improvements.”
Like many quality award recipients, Riding uses the reward in staff recruiting efforts. She says, “We put it in the ads. We let people know that this is an award-winning facility with high standards. We tell applicants that they may make more money at another facility, but working here will give them an opportunity to participate in a facility that has quality systems in place. They will learn to do things the right way and with integrity.”

Looking Up And Ahead

Whether a facility has reached Step II or III, its progress has made leadership and staff look up and gaze to the future. “Sometimes, we have our heads down, so focused on what we need to do that we forget to look up and see where we are and how far we’ve come,” says Cairns. “This award has made us lift our heads high and take pride in ourselves and our industry.”
Hanson adds, “We’ve dedicated ourselves to this journey and are looking ahead to Step III. It will be one gigantic standard setter, and we welcome the opportunity to go there.”
Joanne Kaldy is a freelance writer and communications consultant based in Harrisburg, Pa.