Despite the study by the General Accounting Office identifying abuses in California nursing homes and media reports of statements of abuse provided to the Senate Special Committee on Aging (Thompson, 1998), most nursing homes are not guilty of such abuses. They should not be subjected to the same punitive measures suitable for those who are guilty. Moreover, many nursing homes in the United States have achieved the status of deficiency-free, which is a cause for celebration in these facilities.
Deficiency-free is admirable, but this minimum level of quality, as defined by federal and state inspectors of these facilities, can become the maximum level of quality. Where is the incentive to strive for excellence? Furthermore, the deficiency-free organization is beset by problems that prevent it from having the consistency necessary to achieve a high level of quality and excellence. The purpose of this article is to persuade all relevant constituencies to address the problem of nursing home quality and to work collaboratively to develop a set of shared values and strategies to achieve excellence. Deficiency-free is not an adequate performance goal. It should not be the acceptable definition of high quality and excellence.
A LOOK AT CURRENT REALITIES
The problems needing solutions in deficiency-free long-term care facilities are many, including staff turnover rates greater than 50%, absenteeism, call-ins (notification of absence with little notice), thefts, false workers' compensation claims, low morale, and low job satisfaction. Unlike private industry, where the injury and illness rate among employees has been stable or has declined since 1980, the rates for hospitals and nursing homes have increased by 52% and 62%, respectively (National Research Council, 1996). On-the-job injuries are on the rise and are especially troublesome for understaffed nurse assistants who are called on to do heavy lifting. In addition, injuries resulting from violence directed toward health care workers appear to be increasing. Incident rates and days of lost rime have continued to increase since the early 1980s. In 1994, there were 16.8 injuries per 100 workers, making the nursing home industry more dangerous than mining, construction, electrical work, and automobile repair (King, 1995).
Annual turnover among nursing home administrators may be 40% or higher (Singh & Schwab, 1998). Staff turnover in nursing homes is exceptionally high when compared to rates in other types of organizations; studies have found that employee turnover in nursing homes can reach as high as 400% and often exceeds 75% (Halbur, 1983; Harrington, 1991). High turnover rates can lead to problems in maintaining quality of care, and contribute to the high cost of personnel training - dollars that could be spent on enhancing quality of life for the residents and staff. Aides frequently leave within months of being hired. Social workers can play a crucial role in empowering residents by increasing their autonomy, but they do not have much influence until they have tenure in a facility (Poweil & Kruzich, 1995). In view of these statistics, nursing home organizations need to make an effort to develop a culture of excellence. You cannot cultivate excellence without first defining it. Grunig (1992) suggests the following definition:
Excellent organizations empower people by giving employees autonomy and allowing them to make strategic decisions. They also pay attention to die persona] growth and quality of work life of employees. They emphasize the interdependence rather than independence of employees. They abo emphasize integration rather than segmentation and strike a balance between teamwork and individual effort (p. 223).
How should this journey toward excellence begin? It is not the imposition of new controls and punitive measures that will motivate facilities to go beyond deficiency-free. The 1987 Omnibus Budget Reconciliation Act (OBRA) legislation, which mandated government to be the driving force for change in nursing homes, has often led to a self-protective, paper-centered, culture with a focus on what is wrong instead of rewarding and sharing what is right (Barkan, 1995). There is little or no emphasis on collaboration between surveyors and nursing home personnel to share best practices and solve problems. In fact, such collaboration has been attacked because it is believed that it fosters "cronyism," a close relationship between state overseers and nursing home operators, leading to neglect, abuse, malnutrition of residents and suspicious deaths (Thompson, 1998).
Neither a sense of pride nor competition seems to be enough of a motivator to encourage quality and excellence. For most facilities, a culture change must precede this transformation to excellence because it requires an organization with innovative leadership, considerable sharing of information, building a team, soliciting suggestions from them, being politically sensitive, and sharing rewards and recognition willingly (Kanter, 1997). From the perspective of the stakeholders, administrators and owners are not providing that kind of leadership. To remain competitive and responsive to the stakeholders, the traditional command and control structure may not be capable of adapting quickly enough to changes in the entire aging field.
THE USE OF FOCUS GROUPS
Six years ago, stakeholders in eight nursing homes in western New York participated in a series of focus groups on the subject of quality and excellence. Separate focus groups occurred first with administrators; then with directors of nursing; followed by certified nursing assistants (CNAs), social workers, family members, and residents in each of the eight facilities. Although there are many other staff positions critical to achieving a high quality nursing home, these employees were chosen because they are in key positions to have an influence on this issue of quality and excellence.
The discussion points in the focus groups centered on each group's definition of quality, the identification of barriers to quality, the strengths and weaknesses of the current system, opportunities for change, and the threats that change presents. The nursing homes were selected to represent small, medium, and large facilities; for-profit and not-for-profit facilities; and rural, urban, and suburban locations. Finally, a similar focus group session was held with the 15 New York State surveyors who evaluate these facilities. All of the sessions were audiotaped (Deutschman, 2000).
THE DEFINITION OF QUALITY
The first question posed for discussion with each of the focus groups was their definition of quality. The main points, gaining agreement from participants at that specific session, are summarized for the following groups:
* Directors of nursing.
* Certified nursing assistants.
* Social workers.
* Family members.
Administrators began their discussion of the definition of quality with "whatever the state director of longterm care says it is." Administrators emphasized the basics of deficiency-free survey; happy, clean, dry, and fed residents; and motivated employees. They acknowledged that quality may be a subjective idea defined by family, tied to the minimum data set, and different for each resident.
Directors of Nursing
Directors of nursing tended to view quality as a philosophy depending on the "owner's agenda." Quality, for them, meant meeting an ideal facility's standards with input from residents, family, and staff. They warned that minimum standards can become maximum standards, especially because of the low status of long-term care and the lack of educator involvement to enhance quality through research and training. They called for improvement in morale, camaraderie, and personalized care to accompany the initiatives of OBRA.
Certified Nursing Assistants
For the CNAs, quality meant total dedication of each department and good communication among departments; inclusion of aides in patient care meetings; giving them training in each department; allowing them to speak with the doctor, family, dietitian, and physical therapist; and providing them with good CNA role models. They wanted their knowledge to be taken seriously. Quality should include, in the care plan, the extras they provide to residents to det them know they matter," and what they do to meet the social, physical, and mental needs of residents while maintaining their dignity.
Social workers defined quality in terms of excellence, advocacy for the resident, and consistency of care in a homelike environment. They emphasized dignity, respect, and autonomy for the resident. They stressed that caring for the whole person and knowing the individual needs of each resident were necessary to give residents a feeling of trust. They believed staff members needed to separate problem behaviors from the individual, and everyone needed to recognize the resident as a customer. Warm, caring, friendly staff should work with family participation to create a large extended family atmosphere.
Family members defined quality in terms of staff attitudes and good interstaff communication, "right down to the janitors. " Family members expected a well-trained staff to provide genuine caring, a broad range of activities, medication, and nutrition. They expected special training to be provided for special needs, especially for understanding differences in personality, information processing, and memory and cognitive deficits of residents.
Surveyors defined quality as resident satisfaction, recognizing that this may be different for each resident if each is to live to full potential with respect and dignity. They listed comfort, nutrition, and human contact acceptable to the individual resident, but quality meant moving a step beyond basic needs to anticipating resident needs and wants by providing the personal attention that creates quality.
Note the similarities and differences in perspectives. The recurring theme implies personalized care as characterized by a social model, but it is not a clearly stated priority. The social model emphasizes individualized quality of Ufe for each resident rather than a package of services. On this issue, for example, surveyors and CNAs are quite compatible in their view that quality and excellence involve providing "the extras beyond basic needs," but aides do not have the power to set these core values for the facility.
The administrator and director of nursing, who do have that legitimate power, may have other priorities. Traditionally, the medical model, on which most nursing homes are based, is a highly fragmented organization. The high degree of specialization is compounded by differences in personal reactions. Many of these professionals are pre-certif ied with training in their own disciplines and a strong identification with their profession. Administrators generally do not know much about medicine or the medical problem-solving model. There may be minimum understanding of each other's issues and lack of a common language (Gauthier, 1995).
Every organization must assume full responsibility for its impact on employees, the environment, customers, and whomever and whatever it touches (Drucker, 1 998). Customers can be defined in many different ways but certainly the residents are the prime customers of nursing homes. Separate focus groups occurred with a total of 44 residents at eight different facilities. For efficiency, their definitions of quality were consolidated and duplicate responses are eliminated in this summary. Full summaries are available by contacting the author (contact information is listed on page 36).
OBSTACLES TO QUALITY*
Residents were usually chosen by the social worker. It is presumed that those chosen were higher functioning because most exhibited little or no symptoms of dementia during the sessions. Only two or three openly displayed some confusion. Some of the residents, who were especially articulate and responsive at the focus group, when observed sitting in the public spaces after the session could easily be misjudged as confused and withdrawn because they did not openly display evidence of their capability. They may be far more capable, in some respects, than generally perceived by busy, understaffed nursing home personnel.
For residents, aides were considered paramount - especially those who helped with tasks residents could not perform, but who did not control their every move. They wanted considerate, experienced, caring staff with good attitudes who "make you feel as though you're not a forgotten person." They appreciated the "nice things done for the unlovable person." They wanted aides who enjoyed their work and those who did not assume all residents were confused. They wanted the nursing home to "separate the screamers from the rest of us."
OPPORTUNITIES FOR CHANGE IN QUALITY
They acknowledged that residents need to gain inner peace and acceptance of their condition before gaining satisfaction with quality of life. "Sometimes you can't communicate your needs. Treatment comes very slowly and reluctantly," said one resident. They expected a good activity program; a congenial bedroom partner; respect for privacy; and enough staff on each shift to provide compassion, patience, caring, understanding, warmth, sympathy, sensitivity, and a smiling face.
Do these perspectives demonstrate the compatibility necessary for developing a set of core values, principles, and practices? According to Drucker (1998):
Because the modern organization is composed of specialists, each with his or her own narrow area of expertise, its mission must be crystal clear. The organization must be single-minded, or its members will become confused. They will follow their own specialty rather than apply it to the common task. They will define "results" in terms of their own specialty and impose its values on the organization. Only a focused and common mission will hold the organization together and enable it to produce (p. 121).
BARRIERS TO QUALITY AND OPPORTUNmES FOR CHANGE
At the beginning of each session, before any discussion occurred in the focus group, an open-ended survey form was distributed asking each participant to identify the barriers to quality. Each participant could list as many barriers or obstacles to quality as space and time permitted. Note that the session with the residents did not include the form but the question was discussed in their focus groups. All responses were listed and a content analysis was conducted to identify recurring themes and categories. See Figure 1 for a graph and list of obstacles to quality as identified by participants.
At the end of each session, after 2 hours of discussion had occurred, another survey was distributed asking each participant to list opportunities for change to achieve improved quality. Again, content analysis was conducted to develop the categories of recurring items and the most frequently mentioned opportunities. See Figure 2 for a graph and list of opportunities for change as identified by participants.
The number of participants in each focus group varied (i.e., 7 directors of nursing, 8 administrators, 8 social workers, 15 CNAs, 15 surveyors, 13 family members). It is important to remember that each participant could list as many barriers and opportunities as space on the form and time permitted, and resident responses are not represented on either of these lists. The distribution of these responses according to position in the organization produced the following pie charts for each barrier to quality (see Figures 3 to 5 for breakdown of most frequently mentioned barriers).
"Inconsistent staffing and shortages" was a barrier widely acknowledged by participants in all groups. In comparison, administrators never mentioned "need for individualized care," yet surveyors established this as a high priority. "Lack of staff cooperation, attitude problems, and prejudgment of residents by staff" was a major concern for CNAs, as compared to other participants and other issues.
Among the opportunities for change, "training/orientation/education" and "quality staff" were relatively high priorities for all, and "improve communication" was more important for CNAs. The administrators never mentioned an "interdisciplinary team," but the CNAs viewed this as an important need and opportunity for change. The surveyors placed a high value on "more personal care and choices - understanding individual needs of residents," yet no administrator or director of nursing listed anything in this category. It was surprising that there were only two CNA recommendations in this category. It was understood why family members considered "improve communication with family" as a high priority, but it was not clear why administrators and directors of nursing did not list this at all.
Despite the fact that nursing aides receive low wages (the average yearly earnings can be as low as $10,000) and 28.5% have no health insurance (Crown, Ahlburg, & MacAdam, 1995), note that wages and benefits were not mentioned often as high priorities either as barriers or opportunities for change.
Individuals often become fixed in their own perception of reality. Relationships can improve when members of an organization listen to feedback about how others perceive a situation. Learning can occur as an autonomous, uncontrollable function that happens consciously or unconsciously in an organization.
Huffman and Withers (1995) suggest that listening to lunchroom conversations can telJ more about the real lessons learned in an organization than what is heard at formal meetings. "The way we do things around here" is often used as a simple definition of the culture of an organization. Communication is the binding factor maintaining this culture. It is through stories and anecdotes that staff members learn what is valued.
For most corporate structures, survival, competition, and shortterm thinking (represented by the first rung of Maslow's hierarchy of needs) govern behaviors. There should be no expectation that addressing higher needs will be an effective motivator if basic survival needs are not met. However, despite their low salaries and lack of career ladder, in a 1 996 study, aide turnover was shown to be significantly reduced by involvement in interdisciplinary care plan meetings. It is worth noting that aide involvement in assessments, aide training and workload, case mix severity, payer source mix, and facility size were not significantly related to aide turnover in that study (Banaszak-Holl & Hiñes, 1996).
Organizations striving for excellence must clearly communicate their mission, vision, goals and objectives to their members. A variety of different styles can be tolerated in an organization as long as individuals are anchored in the same values (Kouzes & Posner, 1993). These shared values can be inculcated into the diverse population of employees. Organizations that excel in the future will need to know how to gain commitment from all workers at all levels (Rolls, 1995). Organizational commitment has been shown to buffer the relationship between stress and job displeasure. Organizations may benefit from creating situations that enhance commitment (Begley & Czajka, 1993).
BUILD ON STRENGTHS IN THE EXISTING SYSTEM
Every organization, regardless of its problems, has had some initiatives toward innovation and excellence. Administrators identified the following strengths in the current delivery of long-term care:
* Educated demanding residents.
* Rehabilitation programs.
* Special care units.
* Proprietary and not-for-profit sectors joining forces.
* Top-down sharing of information.
* Improvements in bottom-up communication.
* Customer service orientation.
Directors of nursing added reputation and long-term employees as strengths. They believe upper management seems to care more, teams are growing, and more residents are exercising their rights and choices. The aides measured positive value in increased segregation of residents according to mental status and rehabilitation potential, and fewer staff from agencies. Social workers found strengths in the CNA developing care plans, and in the concept of sharing the function of manager.
Families appreciated support groups and the steps toward adapting to the individual functional needs of both resident and family. Many residents said they could not address strengths of the current delivery system because they had insufficient knowledge of other facilities for comparison. They focused on activities, security and safety, the care, the atmosphere, friends, and the "extras." Surveyors believed strength existed in their own dedication, improved interdisciplinary communication, more educated staff, more inservicing, an evolving recognition of quality of life, and improved networking among facilities to help them use their creativity.
Enhancing these strengths and reducing or eliminating known weaknesses is one way to start building quality and excellence. The most frequently mentioned barriers and opportunities were identified in the focus groups. Although each facility has a different culture, it is unlikely that these issues are unique to these eight facilities.
SEARCH FOR BREAKTHROUGH PROJECTS
The encouragement of incremental experimentation throughout an organization produces options, opportunities, and learning. This process builds confidence, reduces risk, and provides alternatives and best practices for internal benchmarking (Kanter, 1997). One facility in the Midwest introduced a luxury "spa" bathing area. Another introduced 12hour activity programming, 7 days per week. Restaurant-style dining and a cooking club held several times a week made a difference in another facility.
Because finding and keeping good staff is one of the biggest challenges, some facilities build flexibility among staff by including secretaries, housekeepers, medical records personnel, and others when sharing the responsibilities of delivering food, helping with feeding, and developing relationships with residents. Such a "helping-hand program" has resulted in excellent interaction and relationship building in some facilities. The creation of households and neighborhoods with smaller numbers of residents may require significant environmental restructuring but a pilot project may yield the commitment, energy, and enthusiasm to give life to the mission of treating loneliness and boredom, which are the real problems for this population.
Have staff members ever thought to call a family member with good news about a resident and celebrate the happy times? Family should be partners and advocates in the development and changes in care planning but they need education to understand how they can be integrated into the process. In-house day care programs could provide the individualized care everyone considers a high priority.
Where to begin to strive for excellence and quality will vary widely depending on the issues, resources, and commitment of leadership. Surveyors could be valuable resources for sharing best practices. States should act more quickly to close down poor quality homes and facilitate the exchange of information to foster excellence, especially among those facilities that are deficiency-free.
Experimentation can occur anywhere in the organization. A good leader will walk around, observe, listen, ask questions, identify and negotiate conflicting interpretations, and enable breakthrough projects. The difference between success and failure in a business can be traced directly to how well the organization unleashes the great energies and talents of its workers, who must first share the core values and then gain the support to demonstrate them throughout the organization. Leaders need to look for those defining moments for inspired action and personal growth.
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