Nursing excellence: the Aristocrat Berea.

Meet the managers of the first long-term care facility to win a prestigious nursing award

It is deeply satisfying to be judged as excellent by your peers.

It is even better when you're the first. That rare experience was enjoyed recently by the Aristocrat Berea Skilled Nursing and Rehabilitation Facility, a 250-bed facility in Berea, Ohio, that provides an array of skilled, post-acute and dementia-related services. It was one of the first five long-term care facilities surveyed by the American Nurses Credentialing Center, a subsidiary of the American Nursing Association that has been providing Magnet Recognition for Excellence in Nursing Services awards to acute care facilities since 1994. This year represented ANCC's first venture into the long-term care field, and Aristocrat Berea was the facility it liked best. More specifically, it was the facility that best implemented the ANA's Scope and Standards for Nurse Administrators, as determined through a two- to three-day site visit by ANCC officials.

"Even though they had only offered this opportunity to hospitals," says Josephine DeLuca, RN, C, CRRN, director of nursing services, "when I saw the application, I thought, 'We do these things.' The documentation to prove it took up three 4-inch binders."

"Typically," adds administrator Dan Zawadzki, LNHA, LSW, "ANCC placed heavy emphasis on nursing credentials in making these awards. In this case, even though our nursing administrators are RNs who are certified in gerontology and rehabilitation, the ANCC surveyors focused more on the program itself."

Just what was it about the program that gained ANCC's approbation?

"It was the entire package," says DeLuca. "We do a lot of education, both of residents and of staff. Resident education begins from the day of admission, and it is all focused on reducing length-of-stay. The topic might be diabetes or nutrition self-management, and whatever is done - formal teaching in a group, talking at bedside - is documented. And the education follows a decision-tree, depending on how the resident is taught and how he or she responds."

"Staff education has a career path orientation," adds Zawadzki. "We have close relationships with nursing schools, and right now we have three LPNs studying to become RNs and five nursing assistants studying to become LPNs. This has helped a great deal with staff retention."

Long-term care residents and their families are provided with their own educational sessions on such topics as advanced directives, Medicare rules, low-salt diets and the like, notes Assistant DON Judy Wilkinson, RN, C, CRRN.

"A lot of nursing homes provide the education we do," says DeLuca, "but the difference is that we follow a documented decision-tree for every resident."

Another attraction, notes Zawadzki, was a continuous quality improvement (CQI) process that the facility has spent several years fine-tuning. "We started with a 10-step process, then brought it down to a six-step process for identifying and implementing improvements. But the process was taking too long, and everyone was giving up hope on ever achieving any changes. So now we brought it down to a three-step process - data collection and goal setting; planning; and evaluation - and we time-limited each of the steps and added formal evaluation. We have a team, for example, that's been working on creating a ventilator unit for children for the past two-and-a-half months. We pay team members for putting in the extra hours. We've had to upgrade nurses' pediatrics training, redecorate the room for kids, update the kids' immunizations, and come up with a way of measuring patients' and families' satisfaction."

What, I wondered, does a facility that strives so hard for excellence think about the major challenges that confront all long-term care facilities these days, for example:

OBRA surveys (and comparing them with Joint Commission on Accreditation of Healthcare Organizations [JCAHO] surveys): "I think everyone would agree," says Zawadzki, "that although the JCAHO surveys are a lot of work to prepare for, they really are a good process because they focus on measuring outcomes rather than on enforcing compliance with standards."

"During our JCAHO survey, we felt light bulbs going on; it was really an educational process," adds DeLuca, noting that "ANCC has a similar philosophy. I wonder if ANCC and JCAHO worked together to develop a survey program, HCFA might consider it for deemed status."

Problems adapting a long-term care facility to post-acute care: "When we started with rehab seven years ago," says Zawadzki, "we thought we were doing pretty well, but the hospitals continued to think of us as a nursing home rather than as a rehab center. We realized that, for starters, we had to move these patients to a more distinct patient care area, with staff and equipment that was oriented to giving very specific types of medical care.

"Shifting patients and residents to specific areas of the facility shook things up for a while, but we tried to work on this by reorienting the staff. We started by hiring a rehab coordinator, because I didn't think I could do the job justice, and we hired a professional."

"We also offered certified rehab nursing (CRRN) training for nurses who were interested," says DeLuca, "and readjusted staff hours so that some on the rehab unit had 12-hour shifts to allow for consistency."

"It's interesting that our staff tends to gravitate to specific areas," notes Zawadzki. "Some prefer rehab, others the dementia unit, and some may move from there eventually to the long-term care unit, where people are able to communicate a little better. We try to allow for flexibility, but find that staff will stay in one particular unit for years, because it's work they enjoy."

"The ability to move to an area of interest is one of the advantages of having such size and diversity in a facility," says Assistant DON Judy Wilkinson. "Another is that we encourage staff to 'take ownership' of their jobs, so it is not only the Aristocrat Berea unit, but my unit."

Readiness for the Medicare Prospective Payment System (PPS): "We're ready," says Josephine DeLuca. "We started a year-and-a-half ago tracking materials management and treatment costs. We can do preadmission costing in our heads by now, because we've been doing it for so long. We are looking at a computer system, though, that can run graphics showing the cost picture and allowing some new ideas for cost reduction and cost-effective treatment scheduling."

"Right now," says Zawadzki, "complex medical seems to be the way to go. Rehab looks good, but we're concerned about the $1,500 cap, which we hope the next Congress will do away with. In general, PPS is now moving back to a more cost-effective setting in facilities like ours, so this has been a positive development."

Long-term care financing: "The key," says Zawadzki, "is to try to have as good a payment mix as possible, so that you're not that affected by changes in any one area. We're at about 68% Medicaid. We've seen very little private long-term care insurance, but managed care is starting to grow."

Adapting to managed care: "It's a challenge," says DeLuca, "because we're working with a lot of insurers, and they're all asking for different things - daily reports, weekly reports, working with specific vendors. You have mail order pharmacies that know nothing about OBRA requirements; they'll want to give you 200 codeine tablets when all you want is a 30-day supply. So there's a lot of education that has to go on here."

"We have also had to learn how to negotiate capitated rates for services such as pharmacy, X-ray and IV therapies," says Zawadzki. "This has led to a new relationship with several of our vendors. The bottom line is that, if we're going to survive all this, we have to be partners. I have found the vendors to be very educated and realistic about this. They know that if, somewhere along the line, they make a serious error in calculations, we're not going to hold that one instance against them and perhaps cause their demise. On the other hand, they know that if they don't come in with a realistic price, we have a lot of incentive to look elsewhere."

One leaves the Aristocrat Berea with the impression that this is one long-term care organization that has successfully branched out in several directions - just as the survival manual of the '90s says you're supposed to. The foundation for success is provided by a highly professional approach to staff, as evidenced by the ANCC award. Clearly, management has committed itself to providing staff with education, encouragement and career paths for advancement. And it is doing so with heart.

"Dan Zawadzki just loves coming to work every day," says Josephine DeLuca. "And so do I."

Richard L. Peck is editor of Nursing Homes/Long Term Care Management. For more information on the Aristocrat Berea, phone [phone]. For more Information on the ANCC, contact Fay S. Gold [phone].