A collaborative approach to facility reorganization: sophisticated business concepts and no-nonsense application of them are upgrading this once-troubled facility. (A 2002 Optima Award Entry).

The early "seeds" of our program--A Collaborative Approach to Facility Reorganization--began at the end of 2000 and continued throughout 2001, starting in earnest during the second quarter of 2001. While the efforts remain ongoing, we can quantify the gains made since that time. In a nutshell, this program is about leading a lasting organizational change within a nursing facility organization by tapping into the heart and soul of its workforce through a process of inclusion and collaboration.

The Problem

One of the largest nursing facilities in Ohio, Lake Park Nursing Facility is a 250-bed nursing home attached to an acute-care community hospital located in a metropolitan area. The facility and hospital are both part of the larger, not-for-profit ProMedica Health System.

Once considered a premier nursing home, Lake Park had slipped in recent years. By the end of 2000, the building truly was heading for dire straits because of its declining performance and reputation. In August 2000, the facility had received its second annual survey in a row with double G-level deficiencies, thus losing its nurse aide training program and placing future Medicare admissions at risk. Census was also becoming a problem as referrals waned. Staffing dwindled as morale dropped. In December of that year, the building administrator announced her resignation, effective in January 2001.

In the same fourth quarter of 2000, Lake Park's parent company brought in a new vice-president of Senior Services, who began holding meetings with various departments within the building--in particular, meeting with the management team, the clinical team, and the Employee Solutions Council. In the course of those meetings, coupled with addressing the performance issues described above, it was determined that a comprehensive reorganization was necessary.

Planning

The meetings with the facility's three teams-management, clinical, and the Employee Solutions Council--had centered on gathering information and opening lines of communication. Time was spent with all three groups to gain insights into what each individual team saw as the problem areas and its assessment of what was needed to fix those problems. Some of the common complaints included:

* A glaring lack of trust

* Lack of clear communications 

* Breakdown in the "basics" of resident care

* Misalignment of direct care staffing

* A large amount of management overhead

* Low employee morale

* Numerous individual department challenges and missed opportunities

As the groups identified problem areas, they also exhibited a high level of commitment and dedication to improvement, as well as a growing willingness to tackle the issues in specific detail.

Planning for the reorganization effort took place during the first quarter of 2001 and rather than focusing on specific steps of realignment or reorganization, it focused on designing a process for developing a game plan. At the heart of the process had to be several key factors:

* Rebuilding trust

* Fostering employee buy-in

* Establishing an environment of collaboration

* Undertaking the steps needed for a turnaround

* Using education and learning at the appropriate times along the journey

The process used a hybrid of business ideas, theories, and concepts from business texts. It also was very simple: Get the right players around the table, guide them in the direction you want to go, empower them to develop their own set of goals for the facility, assist in implementation of these goals by clearing obstacles-and, for senior management, stay out of the way. We took the following steps:

Step A: Gather ideas from stakeholders and create a common vision. In March 2001 the three teams met. All team members completed several readings in business texts related to five basic ideas that would serve as a foundation for the efforts (Table 1). Ideas about the problem areas and potential solutions were shared based on the previous months of input, with action prioritized using a multivote procedure (i.e., each team member had several votes and was instructed to prioritize action items; this brought the list down to a more manageable number). Likewise, a shared vision was created at this session--a vision statement that would become a rallying cry for future efforts.

Step B: Establish a clear picture of where we are heading and develop goals goals to direct us there. At this point a smaller, multifunctional, multilevel Core Planning Team was appointed that included membership from all three groups. This team was asked to accomplish the following:

* write "desired outcome" statements for each of the key areas (Table 2);

* divide into-subgroups to work on SMART (specific, measurable, agreed to, realistic, and time-phased) goals for each of the areas; and

* propose a sequence for accomplishing the goals using an interrelationship digraph (Table 3). A "digraph" arranges goals in a circle and sends arrows out from each goal to the goal(s) it should precede; the goal with the highest number of "out" arrows is top priority, and on down.

Step C: Let the employee-based group accept the ownership of the goals. When finished with the above, the Core Planning Team presented its set of the Top 10 goals to the company president for approval.

Step D: Implement the goals. The management team met weekly with the vice-president to discuss ongoing implementation.

Step E: Report back on progress. Periodic meetings were held with all three teams to keep the stakeholders apprised of progress.

Step F: Celebrate successes. Effort was invested in celebrating success and milestones attained.

Step G: Undertake an annual review and re-establish goals. After one year the Core Planning Team process was repeated, starting with a recap of progress toward the original set of goals. This step was repeated most recently at Lake Park in May 2003.

The vice-president selected this overall process for a range of reasons. First and foremost, it was very important to begin restoring trust among all levels of the organization. A collaborative approach to reorganization demonstrated a level of trust, belief, and commitment to the employees--and it recognized that the employees best know and understand the facility. Care had to be taken to establish an environment where blame and finger-pointing were not allowed. In all meetings, the emphasis was placed on identifying problems and discussing solutions.

By assembling a Core Planning Team to undertake the bulk of the planning work, ownership for the resulting goals clearly was placed with the employees. Given the tasks that needed to be accomplished, a high level of employee involvement and ownership was critical to success.

Implementation

Selection of the right administrative team was very important--even before the process formally began. Shortly after the original administrator's departure in January 2001, the DON also resigned. In recognition of the care issues that were prevalent, the vice-president made a decision to restructure with a nurse executive and a DON, in addition to a new administrator. By March, the administrative team had been identified; the three individuals (the new nursing home administrator, nurse executive, and DON) brought a variety of experiences and tenure to the team.

The vision statement adopted for the facility came from the administrator's introductory comments to the management team: "A building where I would be comfortable placing my own mom (Table 1). This statement was discussed in depth within the various teams, highlighting the dimensions of care, environment, and service that each individual would expect if his/her mother were a resident. As the three teams met in March, and later during Core Planning Team deliberations, a sense of energy could be felt. Employees were participating and watching very closely to see if they truly would be empowered. Trust started building ever so slowly.

On April 17, 2001, the Core Planning Team delivered its presentation to the company president. The meeting began with a quote from Dorothy in The Wizard of Oz: "Toto, I've got a feeling we're not in Kansas anymore." In the 60 minutes that followed, each of the subgroups presented its goals and, as the meeting continued, it became obvious that Lake Park would not be the same place anymore. At the conclusion, the president expressed her sincere amazement at the work and plan of attack. She told the team of her initial hesitation in agreeing to such a planning process, but confirmed her belief in the resulting product. As an initial "quick win," she approved the immediate start of the proposed employee newsletter.

Members of the Employee Solutions Council partnered with members of the management team to hold round-the-clock sessions to share the new set of goals. The two biggest items, in terms of potential impact, were the proposed realignment of the entire direct care staff to better meet resident needs and stepping up accountability for all staff. The administrative team, with the addition of the human resources (HR) director and HR representative, worked to create a master schedule for the realignment. Meanwhile, the vice-president and president went to work inside the parent corporation to clear the way for the massive staffing move. A communication plan regarding this was drafted and implemented.

In early May 2001, the master schedule was given to the nursing and nurse aide staff. The emphasis of the new schedule was aligning staff with the resident census instead of staffing simply by floor. Everyone was given the opportunity to bid on a job from the master schedule, based on seniority, and the guidelines for bidding on new jobs were distributed and explained. Following the bidding process, all unfavorably impacted employees were invited to a meeting with the vice-president and administrator--and the administrator sat for hours working Out individual problems and details. The new schedule took effect in June, with surprisingly little backlash.

Also in May, the state surveyors showed up for the annual survey. The building obviously was caught in the midst of transition and, unfortunately, ended up receiving yet another set of double G-level deficiencies--for the third year in a row. Although disappointing, this event underscored the need for change. The administrative team also was put on notice that the state probably would be paying closer attention to the facility in the coming months--and, indeed, the state did pay multiple unannounced visits to the facility throughout the balance of the year.

Throughout the summer months, emphasis was placed on holding all employees accountable--starting with attendance. Likewise, the nurse executive and DON stepped up efforts to enforce care standards. A "zero tolerance" stance was adopted for substandard performance. By the beginning of the fourth quarter, the number of terminations in the building was in the upper 100s, and exceeded 200 by the end of the year. Although some might consider this stance a bit tough, good employees made it known that they were pleased to see management enforcing policies and holding employees accountable for their performance.

The turnover also wasn't limited to the employee ranks--management and supervisory personnel were given the chance to opt out as accountability was stepped up. Those who either wanted to return to nonsupervisory work or opt out of the organization altogether were replaced with individuals who could share in the vision and philosophy of management for Lake Park. Time was spent with the management team discussing the concepts from the book First, Break All the Rules: What the World's Greatest Managers Do Differently by Marcus Buckingham and Curt Coffman (Simon & Schuster, 1999). One of the authors' key points is the need to understand the reasons employees leave an organization, with the focus turning out to be on employees' relationships with their direct supervisors. Recognizing that many frontline supervisors are promoted-based on their technical skills and that, therefore, they need a different set of human relations and leadership skills to be successful, a monthly supervisor/manager forum was created, in conjunction with Lake Park's "sister" facilities, to provide an opportunity for networking and leadership development.

As we entered the fall of 2001, staffing levels again were a growing concern, partly because of our zero-tolerance stance. In October, planning was undertaken for an unprecedented recruitment effort--one that would couple multimedia advertising with open houses and a commitment to expedite the hiring process and develop a retention strategy (Table 4). "Destination: Excellence" was the campaign's theme. Not only did it result in bringing in more than 250 candidates, in highlighting the changes taking place at Lake Park the campaign heightened employee morale.

Evaluation

The results of the process to date have been outstanding in terms of quality of care, resident satisfaction, employee morale improvement, and building a better reputation.

One of the greatest areas of improvement has been in pressure ulcers--a good indicator of the level of attention and care being provided by the direct care staff (and the area in which the facility had received G-level tags in the past). Internally, Lake Park monitors data on the percentage of residents with "in-house acquired" pressure ulcers. This would include any sore (stage I through IV) that is acquired in the facility, as well as any externally acquired pressure ulcer that increases in severity after admission. At the beginning of 2001, Lake Park's internal pressure ulcer measure was running at well above 10%. Through 2002, the facility has consistently kept that rate at 3% or lower, and was still seeing rates below 3% as of spring 2003.

Equally impressive has been the increase in a range of resident satisfaction measures, as measured monthly based on customer satisfaction surveys mailed upon discharge (and administered periodically to residents). The greatest increase has been in the average score for the overall experience at the facility, having improved 27% from the first quarter of 2001 to the first quarter of 2003 and sustaining at a level of 3 on a 4-point scale.

In terms of employee morale, Lake Park, unfortunately, did not conduct a baseline survey at the onset of the process. However, Lake Park's parent corporation did have a consulting firm conduct an assessment of employee relations at the facility throughout 2000 and 2001 as part of a separate initiative. As the initial meetings with the three teams had indicated, the consultants saw multiple morale issues prior to the reorganization effort--at one point characterizing the building as a "war zone." When Lake Park completed an employee opinion survey after the reorganization, positive key findings emerged (Table 5.)

Lastly, the improvement in care and morale has assisted in improving the building's reputation, as evidenced by a growing census. In the summer months of 2001, the average daily census in the building dropped to the 180 range. Through the first quarter of 2002, the average daily census had exceeded 210, with some days in the 220s. Today there are times when it exceeds 240--and the building has added a dementia unit and an innovative end-of-life unit (called Comfort Care).

In April 2002, the Core PlanningTeam was reassembled to review the original set of Top 10 goals and begin to work on another set. Interestingly, in an industry experiencing high employee turnover, almost all 18 members of the Core Planning Team were still part of the staff. Some had taken on new roles and some had moved from frontline positions to join the supervisory/management team. The concept of collaboration was working--obviously the members of the team believed that they were integral parts of the organization and felt a certain degree of ownership.

The Core Planning Team found that all 10 original goals had been achieved. And, from all indicators, the collaborative approach to facility reorganization was working. In 2001 the overall focus had been "putting out fires." In 2002 the focus was more on fine-tuning ongoing improvements, building on the gains that were made, and addressing some of the support areas outside of direct care.

At the 2003 convening of the group (this May), there was celebration of another long list of goals achieved, and an emphasis was placed on further team development and on looking out to the long-range future for the building--in fact, 10 years ahead. There is still room for improvement, as Lake Park continues its quest toward a destination of excellence. But, as the measurements have demonstrated, significant progress has been made.

Table 1

Five Ideas on Which the Process Was Built.

1. Our "northbound train" statement. This is the vision statement for the building. The idea of the northbound train comes from the book The Northbound Train: Finding the Purpose, Setting the Direction, Shaping the Destiny of Your Organization by Karl Albrecht (AMACOM, 1994). It is, according to Albrecht, the "fundamental driving idea of the business, before which all resistance crumbles." Lake Park adopted the statement, "A building where I would be comfortabte placing my own mom."

2. Servant leadership. This is the point of view that anyone in a leadership role, whether it involves formal authority or not, must lead by enabling others, not by trying to drive them.

3. Building an organization around a team of servant leaders. We examined the five principles of ethical management from the book The Power of Ethical Management by Norman Vincent Peale and Kenneth Blanchard (William Morrow, 1988). Those principles are purpose, pride, patience, persistence, and perspective. Lake Park also adopted a management philosophy that included the following characteristics: team-based; employee-friendly; customer-focused; committed to empowerment, accountability, and open communications; uncluttered; innovative; excellence-driven; valuing compassion dignity, and fairness; and respectful.

4. Collaboration. Borrowing from the book Transforming the Way We Work: The Power of the Collaborative Workplace by Edward M. Marshall (AMACOM, 1995), the key assumptions are: (1) we get work done through people, (2) a successful business values its people, (3) successful change is owned by the workforce, (4) a shared perception of reality is essential, (5) an organizational culture has bottom-line value, and (6) integrity begins at the top.

5. Addressing culture. Again, from Marshall, who says, "The workplace culture is perhaps the least understood but most powerful force for organizational transformation in any enterprise." We determined that the "culture first" mindset means that decisions are driven by principles and core values. This approach places focus on the long term (vs short term), is collaborative (vs top-down), and assumes the workforce is fully responsible (vs not responsible).

We put all five ideas together in a purpose statement for Lake Park's management team: "As servant leaders, we will lead a change process at Lake Park Nursing Facility that will harness the values of collaboration to the power of the workplace culture to produce long-lasting change and breakthrough results--ultimately creating 'a building where I would be comfortable placing my own mom.'"

Table 2

Outcome Statements for the Top Five Issue Areas, as Written by the Core Planning Team.

A. Team Approach. "A clean work environment that is positive, pleasant, welcoming, supportive, trustworthy, and respecting--as evidenced by happy, calm, and content residents; low employee turnover rates; better customer satisfaction rates; and a sense of employee ownership."

B. Big Picture. "A continuing business that is well maintained, patient-centered, friendly, and well known for positive outcomes--as evidenced by familiar faces (residents and employees), profitability, good state surveys, good reputation in the community, and a waiting list for patients and employees."

C. Communication. "Workplace communication that is free-flowing, open, honest, as forthcoming as possible, informed, current, readily available, consistent, and clear--as evidenced by a learning environment, no repercussions, teamwork, common focus, positive responses, better patient outcomes, and a safer environment."

D. Staffing. "Staffing that is adequate to meet patient needs, consistent, willing and able, engaged, empowered, and included--as evidenced by good patient care/outcomes, low/no agency usage, low employment turnover, increased nurse aide test-passing rate, decreased absenteeism, and more retirement parties."

E. Education. "An educated workforce that is well-oriented, functional, up-to-date, adaptive, flexible, and cross-trained--as evidenced by competence, ability to respond to needs/questions, consistency of care, innovation, confidence, positive attitudes, and an increased number of training classes and in-services."

Table 3

Summary of Top 10 Goals in Sequenced Order, as Determined by the Core Planning Team.

1. Nursing staff realignment. Undertake a house-wide realignment of all direct care staff.

2. Redefine nursing supervision role. Review structure and increase accountability.

3. Nurse aide flow sheet. Develop a flow sheet to better communicate tasks.

4. Regular unit meetings. Schedule regularly and provide for two-way communication.

5. Pep rally for Lake Park. Build morale and pride in the facility.

6. Mock surveys. Conduct internal mock state surveys to increase readiness.

7. More relevant orientation program. Tailored to the facility.

8. Orientation checklist. For supervisory and management new hires, to ensure rientation.

9. More relevant in-service program. Undertake a survey to improve topics.

10. Lake Park Nursing Facility employee newsletter. To facilitate better communication.

TabLe 4. OutLine of Recruitment Campaign's Key Components.

1. Used a campaign of newspaper, radio, and direct-mail advertising that featured employee "testimonials." Highlighted the work environment and Lake Park's ongoing journey to create a building where the destination is excellence--excellence in care, excellence in employees, excellence in work environment, etc.

2. Commitment to returning all inquiry calls within 2 hours. Interviews and offers to viable candidates within 48 hours of initial contact.

3. Scheduling (and advertising) two open houses, with commitment to interview all candidates within 30 minutes of arrival at the open house.

4. Implementing a "Buddy Program" to assist in retaining new hires, whereby new hires were assigned a "buddy" from existing employees. Staff "buddies" had to apply for the role, and were paid a small stipend at the onset of accepting a buddy and, again, 90 days later, provided the buddy completed the probationary period. (This did not replace orientation efforts.)

5. Offering an internal referral bonus for employees who referred new hires, with the amount varying based on the position of the new hire.

Table 5

Key Findings From an Employee Opinion Survey After the Reorganization.

Question                         % Strongly Agree
                                     or Agree

1. I enjoy coming to work most          77
   days.
2. I feel my job is important.          94
3. Employees of all disciplies          64
   work together to meet
   resident needs
4. Employees treat each other           84
   with respect
5. My direct supervisor treats          84
   me with respect
6. I would recommend Facility           69
   X as a potential employer to
   family or friend.
7. Employees welcome new                71
   employees and offer
   assistance to them.

Gary M. Cates is senior vice-president of Operations for ProMedica Continuing Care Services Corporation. Lake Park Nursing Facility, Sylvania, Ohio, is a member of the ProMedica Health System, based in Toledo, Ohio, and is one of 10 Senior Services Division facilities. For more information, phone [phone] or e-mail [e-mail]. Additional facility contacts at [phone] include Mark Mullahy, administrator; Sandy Gang, DON; or Arnie Richason, director of human resources. For more information on the OPTIMA Award, visit www.nursinghomesmagazine.com. To comment on this article, please send e-mail to [e-mail].