Lincoln SquareDelta Valley Convalescent Home in Stockton, Calif., was not exactly known for the high quality of its care. A few years ago, in fact, it racked up more than 600 points in its annual survey. Employees at the hospital across the street remarked that when walking past the convalescent home on warm days, when its windows were open, the stench of urine was overwhelming even from the sidewalk. Within the local medical community, Delta Valley was referred to as “Death Valley.” 

But then in 2009, Delta Valley was sold. The new owners contracted with a consulting firm that had stated its goal was to help all of its client facilities achieve a five-star rating from the Centers for Medicare & Medicaid Services (CMS).

The owners embarked on a multimillion dollar remodel, instituted a radical change in culture that empowered employees to improve the lives of those they care for, and incorporated technology to enable easy tracking of quality indicators. The owners also increased the number of caregivers per patient and rebranded the facility Lincoln Square Post-Acute Care. 

Last year, Lincoln Square was ranked the No. 1 provider of post-acute services in its county, based on hospital discharge data. Its surveys had improved so much that it received a five-star rating on the CMS Nursing Home Compare website. And its 2013 annual survey turned up not a single deficiency. Not one.
Last September, after that survey was complete, 50 or more Lincoln Square employees gathered to hear from the surveyors how they’d fared, says Ben Pyper, Lincoln Square’s administrator.

“Our state surveyors—because they knew how bad Delta Valley had been—the two surveyors couldn’t even get out the words ‘zero deficiencies’ without crying,” he says. They weren’t alone. “Half of our staff was crying,” he says. “It was a tremendously emotional experience.”

How They Did It

The 68-bed facility’s new owners focused a lot of attention on staff, says Pyper.

Although the change in the facility's culture resulted in the departure of some of the employees who had worked there when it was named Delta Valley, many more remained and embraced the changes, Pyper says.

“There were people here craving a better experience for their patients, and they’re still here now,” says Pyper, saying these individuals were at all levels and included dietary personnel, certified nurse assistants (CNAs), nurses, and Activities Director Michelle Adams and Social Services Director Lorena Mora.

“They’ll tell you they were just craving a change like this. They were doing everything they could to give the best care, but because of limitations of ownership and management” weren’t able to do as much as they would have liked, he says.

In addition, the overall number of staff was increased. “A lot of good care is just giving patients the [amount of] time they need for good care,” Pyper says. “Our philosophy is to give outstanding patient care, and everything else will fall in line behind that. We staffed up and hired great nurses that we had to recruit from other facilities, hospitals, and right out of school,” and then they provided a lot of training, he says.

Involving All Staff In Quality Assurance

Beyond that, most components of providing care and services seem to be looped through a pervasive quality assurance (QA) process.

“Having a solid QA process allows us to make changes quickly and effectively and follow up on them,” says Pyper. “That’s how you develop a culture where people actually care about who their patients are and who they’re working with. Say I’m a CNA and I noticed that the macaroni salad we’re serving, nobody’s eating that. So I’m going to make a suggestion to my supervisor” that a different salad be served, Pyper says.

“We take that suggestion to our QA meeting, and we actually make a change; we replace the macaroni salad with a nice broccoli salad. So that CNA feels empowered and thinks, ‘I made a difference in my patient’s life.’” So having a QA process where suggestions turn into change results in staff who personally feel invested in the process, Pyper says.
Lincoln Square

Aggressive Feedback Solicitation, Technology Support

But perhaps the most important group whose feedback is solicited weekly is made up of residents and their families. It’s called the Guardian Angel Program.

Pyper and his team found that paper customer service surveys given to families or residents don’t generate enough of a response to be optimally useful.

Instead, Pyper and all of the department heads at Lincoln Square interview residents every Tuesday and call a family member of each resident every Friday (or else catch them while they’re at the facility for an in-person interview).

The interviews are conducted using a set of questions developed in the QA meeting, which are designed to elicit any concern, no matter how small, the individual may have had over the past week.

The information gathered through the interviews is brought back to the monthly QA meeting, where changes are proposed and considered and, if appropriate, their implementation is designed.

“I can’t think of a better QA process than that—straight from the front lines we hear about food, care, lighting, or whatever feedback they may have,” says Pyper. “It’s working well. For us, it’s wonderful. If you don’t know what your customer is thinking, then you’re at a disadvantage. You have to know what they’re thinking, wanting, and expecting for their loved one’s care, and we have to try to meet that—especially if you want to be the best in the county.”

Lincoln Square also put technology to work in its QA efforts, using a tool called SNF QAPI. Staff throughout the facility put data into the system, and it automates everything from reminders to perform specific tasks to tracking and measuring the results of a clinical program more closely.

“We’re able to all get on it and check in and measure data,” says Pyper, “and that really helps, because it’s so complex trying to turn around the culture and go from terrible care to great care.”

The Essential Role Of North American Health Care

Pyper gives a lot of the credit for the facility’s phenomenal success to North American Health Care (NAHC).

The relationship between NAHC and its 35 “client facilities,” of which Lincoln Square is one, is complicated. While the client facilities are all standalone entities, they benefit from many NAHC services, which range from managing payroll to providing consultant services on everything from physical plant maintenance to clinical care. Individual client facilities (including Lincoln Square) may even have a board of directors composed of the same individuals that are on the NAHC board. In fact, some of the owners of Lincoln Square also have ownership interests in NAHC.

In 2008, NAHC announced a new goal: helping all of its client facilities achieve five-star ratings on Nursing Home Compare.Lincoln Square

It was a lofty goal, but it only took NAHC five years to do it. Last year, every single one of NAHC’s 35 client facilities received the coveted five-star rating.

“I think we would not be able to [achieve a five-star rating] without them,” says Pyper. “I know that for a fact. NAHC has given me as the administrator what it takes to take care of my patients. I need people who are experts on medical records and best practices, and they’re always there to support us with that. We always have best practices at our fingertips.”

One of the NAHC services that directly impacts a facility’s rating on Nursing Home Compare is the mock surveys conducted a couple times a year at each facility. The mock surveys occur without notice so the facility’s actual practices can be examined.

NAHC sends teams composed of former state surveyors to inspect the facilities from top to bottom, exactly as the state surveyors do. Any issues noted by the mock surveyors are pointed out to the facility, which then must develop and submit a written plan on how it will correct the issue. How well the plan worked is checked during a second survey.

The process is highly beneficial, says Pyper. “It calms our nerves” about the real state survey, he says. “Our staff know the regulations better because we’re having to address them. The same team spends a day or two with our nursing team, following the nurses around the building, coaching them and giving them constructive criticism.”

Pyper says the process is invaluable. “People like to learn and be challenged,” he says. “It’s when you get bored that you get complacent and don’t care anymore about what you’re doing.”

Kathleen Lourde is a freelance writer based in Dacoma, Okla.