A storm-inspired makeover: how a snowstorm forced a nursing home's complete culture change.

It was late November some years ago, and the Chicago area was experiencing an early snowfall that continued from one day into the next--16 inches in 24 hours. It was a nightmare commuting anywhere, including to the Fox Valley Nursing Center in Elgin, IL.

I received a call that morning from the facility's new assistant director of nursing (ADON) saying that the staff was not showing up on schedule. The director of nursing was a no-show as well, and the ADON wanted to know what to do. I told her to list the critical tasks by resident and assign the list to a specific person. Then staff members should work in teams to deliver food, medications, and clothing.

When I arrived, there was a different feel and atmosphere to the facility. There was activity, but it was focused on the residents, not on other tasks. There were no meetings, no breaks, no complaints, and no time for wasting time. The ADON and a charge nurse were in charge, but they were not chasing staff members trying to get them to show up. Instead, they were directing the teams to certain problems, such as laundry, transporting residents to meals, and calling families to assure them that all was well with their loved ones.

The staff enjoys a challenge

A notable, positive result of the storm was staff attitude, which I observed was the best it had ever been. Staff members were on a mission: There was no turnover, no calling in sick, no insubordination, no name-calling, and no excuses--just good, efficient performance and the satisfaction of getting the job done right.

Seventy-two hours later, the same staff members were still on watch, working and sleeping in shifts. No one was allowed to push him- or herself beyond the ordinary, but everyone tended to the residents. We accomplished more in that three-day period with half a staff than at any other time with our flail staff.

That's when I and the other members of the management team decided to never go back to the former organizational structure and workflow. The new facility would be without autocratic, departmental, territorial limitations. We had found a new way of functioning--better than ever before.

The new system paid off. Staff were:

* Accountable--they had to sign off upon completion of each task

* More efficient--each task had an estimated time it should take

* More productive--each task helped them reach an outcome goal

* More satisfied with their work they felt they were actually spending time with residents and improving their lives

A sea change

From my perspective as the administrator, we had redefined the service model for a nursing home. We named our new way of doing things The Caregiver System. It starts with the assessment of each resident's condition and results in a care plan of standardized programs. (See "Functional management at a glance" on p. 30 for a detailed explanation of the system.)

We assign these programs to specialists who are specifically trained to solve or alleviate a resident's particular problems. This gives the team leaders something to measure: accountability, performance, and effectiveness. It also leads to a much more efficiently run facility because the work is better organized and focused on outcomes.

Staff morale

Under The Caregiver System, problem-solving staff members were organized into teams with specialty programs at their fingerfips designed to respond to the assessment. We set up a library of blueprints or templates for each available program and standardized as much of the process as possible, which built consistency and allowed the staff to complete each program.

Immediately, staff morale rose, absenteeism subsided, and turnover decreased significantly. Why? Because the staff had the feeling of actually making a positive difference in each resident's condition.

We thought that we could perhaps get a reputation in the community of being problem solvers, which would lead to more referrals--and this did, in fact, happen: During the preteam days, occupancy declined to 169 in our 207-bed facility. After the institution of teams, the occupancy rose to an average of 199.

The Medicare census was four residents when we converted to specialty units; 13 months later, it was 34. The specialty units were distinct areas on the first and second floors. We had 36 Medicare beds, 100 chronic-care beds, 50 dementia/confused/Alzheimer's beds, and 21 respiratory/pulmonary care beds.

A true turnaround

Before the snowstorm, Fox Valley was decertified, disorganized, and operating on a conditional license. The conditional license was due to a resident drowning in the whirlpool when a therapist walked away from the tub. We were being pressured by the state to shut down or turn the facility back over to the original owners.

Within three months of the conversion to our new structure, our license and certification were reinstated. The facility was also rated as one of the best in that region, getting five out of six stars in a quality rating--along with a deficiency-flee survey.

After the snowstorm and due to an enhanced Medicare program and better services to the Medicaid program, the Facility had record months of profits and cash flow. The increase in census was a major factor in our profitability, because the excess capacity costs were eliminated.

Costly turnover and call-ins were gone, and the risk of injury to staff and residents diminished. What had been a group of 12 middle managers running departmental teams was now three case managers running case management teams. This new approach also eliminated $200,000 per year in middle management costs.

We now had hospitality aides supporting the case management teams with room care, restaurant services, clothing care, and basic entertainment. The unit care certified nursing assistants served the dependent residents, the restorative nursing aides provided the restorative programs, the rehab aides assisted with the rehab cases, and the therapists and nurses specialized in certain diseases and nursing diagnoses.

In addition, this was all accomplished in a blueprinted and programmatic format created by our computerized library of care. This library was set up to standardize the response to the assessment-triggered programs based on each resident's problems.

When I tell the snowstorm story, the reaction is, "You can do it on adrenaline, but that will wear off, and you will slide back into the abyss." This certainly was not my experience. The staff informed me that they knew how to provide this level of care all along, but no one would let them do it. I believed them, and they were the ones who made it work.

Got a good story to tell?

CLTC's "first Person" covers from an on-the-ground perspective the people, places, and events that shape our difficult and often-fascinating industry. Do you have a good story like this one to share, or know someone who does? Send along your idea or submission to [e-mail]. Maybe it will be in a future issue of the magazine!

Jerry L. Rhoads, CPA, FACHCA, LNHA, is the CEO of Caregiver Management Systems, Inc., and has had over 30 years experience in Medicare/Medicaid reimbursement and 20 years experience in operations of nursing homes, assisted living centers, and home care. His company specializes in capturing the Medicare entitlement for qualified beneficiaries, and he has published two books and more than 100 articles on reimbursement and management systems. Contact him at [e-mail].

Functional management at a glance

Under our new organizational structure, which I call
"functional management," a problem-solver manned every
priority function in the facility as follows:

Problem             Team member function

Lost, stolen,       A clothing aide keeps track of the
or misplaced        clothing as it moves between the
clothing            resident, the laundry, and the family

Nursing             Each shift has its own treatment nurse
treatments

Odors               A room care aide takes responsibility for
                    each room, saving certified nursing assistants'
                    time so they can serve the residents

Residents losing    Restaurant waiters are assigned to serve specific
weight because      tables so residents get what they want and receive
they are            assistance if necessary
not eating meals

Exercising and      Restorative aides exercise and stimulate the
strengthening       residents during two shifts per day
residents

Showers             Shower and skin care aides manage
                    baths and showers daily

Resident privacy    An ambassadors' club listens to residents' desires
and independence    and helps devise a method for carving out and
                    integrating privacy times; these times are
                    interspersed with dressing and eating time for
                    organized functions such as meals, activities,
                    and social events

Interaction of      Psychosocial clubs are organized around medical
dementia            diagnoses that allow for the interaction of the
residents with      functional residents with the lower-functioning
other, more         residents
functional
residents to
improve
cognition

Pain                A pain manager uses a pain program to take
management          responsibility for treating pain within
                    a resident caseload

Respiratory         Each resident with respiratory issues is assigned
disease             to a respiratory program with a respiratory
management          manager who has the responsibility of treating
                    this condition as part of his or her caseload

--Jerry L. Rhoads, CPA, FACHCA