How to Change the Operating Culture Within a Long Term Care Facility

by Jennifer Helfrich-Will

You have just accepted a new administrator position. The interim administrator and quick tour of the facility gave you the impression this was a self-managing facility. Welcome aboard and here are your keys. After several days of work you are informed the home has had eight administrators in six years. Previous annual survey results show multiple level G survey citations resulting in the home's inability to conduct certified nursing assistant classes. You notice a lot of restraints throughout the facility and many high-risk residents have wounds. Meal atmosphere, cleanliness of residents and high numbers of bedfast residents catch your eye. Nurses pass medication while eating candy and drinking colas. Employees don't make eye contact or smile at visitors, the facility occupancy is at 40% and the employees say, "it's always been like this". Just as you are attempting to grab your briefcase and run, the state department of health knocks on your door to investigate a complaint. After the investigation is complete you are told the complaint is substantiated, a fine will be assessed and this is only your third day on the job!

Previous attempts to change the nursing home's reputation are noted. Most recently, a past regional director believed remodeling one unit of the facility would change the community perceptions of the home. The home spent money painting, wallpapering and bought new bedspreads without any positive results. Another administrator believed an Alzheimer's unit would do the trick, but the administrator left before the idea was put into effect. What are you going to do?

By examining your organization strategically you may find the answer. Strategic management is based on developing facility goals that ultimately reflect how the mission statement is operationalized. You may begin by completing an external analysis of the facility's operating environment by identifying markets not being served, untapped labor pools and community influences. How do these areas directly impact your nursing homes operations. Maybe your nursing home is one of seventeen homes operating in the same country. How can you separate your home from the competition, when you are all selling the same service. Every nursing home states they provide the best care, but how does one show the word best as a tangible product? An internal facility analysis will bring the operating organizations strengths and weaknesses from within into focus. Upon completion of an internal analysis one might find positive facility traits such as longevity employees, facility layout strengths and weaknesses and quality of care being provided.

Facilities need to be completely honest when looking at internal operations. You must develop strategic alternatives and realistically look at the organization's ability to attain proposed goals, and then make a sound strategic choice.

Based on the negative operating information which was provided about the current nursing home it would be counter-productive to add new services at the current time. If one is not successful at providing their current services why would anyone attempt to provide a division of the same service yet requiring more specialization? The competence you display in providing your current service will have a much greater positive impact on future more diversified operations.

Consider the facility's ability to meet nursing home regulations, increasing competition and reimbursement "cut-backs". The nursing home environment, as we know it, is constantly evolving. The role of the nursing home in the healthcare continuum is being redefined. Nursing home operators are not only being asked to meet the needs of "inside customers" such as residents, employees and contractors but, "outside customers" as well consisting of families, regulatory agencies and payer sources. Nursing home administrators are challenged to develop a strategy to transform their facility into one that will be a leader of providing services in the current century.

Nursing home owners base facility success on statistical reports, survey results and high reimbursement rates while consumers of nursing home services base their perception of a "good" nursing home on less tangible criteria. The public's opinion of nursing homes is laden with feelings and emotions. Intangible qualities are very hard to market to the "outside" customers. Quality care will not be publicly perceived in a facility's tri-fold glossy brochure. In order to change public perception and beef up operational practices, a nursing home administrator must first change the culture within the nursing home itself. And teamwork is not simply had by having your employees wear facility t-shirts with the word teamwork on the back.

There is a difference between implementation and actual facility adoption of this idea. Start the ball rolling by challenging those located within the facility itself to believe in the concept of it becoming the best nursing home. A facility's pride will build internally and eventually spill outwards into the community. Many homes fall short of these operational expectations because they failed to ensure their employees fully actualized the idea of being a success first.

Now you are ready to begin actual strategy implementation in order to solve facility specific problems such declining census, staffing issues and regulatory non-compliance. This Total Quality Management (TQM) approach can make a huge impact by creating a new operating culture in which staff is trained to "get it right the first time." The nature of managerial work has gone away from a model of controlling employees. Accepting this new management role requires re accumulation to the idea of empowerment and leadership? Linking employee roles and facilitating interactions across departmental lines will ensure mangers help employees deal with daily problems resulting from interactions with other departments. Understanding that every department within the nursing home is important and plays a vital role in the overall performance rating of the facility is crucial. The president of the United States as a panel of expert advisors which he frequently calls upon for input into his operational decisions. Challenge your management team to rise to this active role within your facility.

The general public and state inspectors independently rate each department within the nursing home. Their perceptions of a department can be similar or very different. Certainly their perceptions may be developed on very different expectations, and each can affect the facility's reputation.

Twenty-first century managers are asked to create a work environment that supports innovation and creativity in order to meet customer demands and to prevent problems instead of simply treating them. A total quality manager invites employee's opinions on career development and promotions instead of solely relying on a manager's instinct. Managers should focus on facility processes, customer services and relish the opportunity for both public and peer feedback. Our staff and customer's perception of our nursing home becomes reality. Embrace the opportunity to explore and understand someone else's perception of your nursing home operation. If their perception doesn't agree with the facility culture you are working to instill, find out why. Anyone can be a autocratic manager, but without challenging ideas and asking "why not" your company will not grow and flourish. Ideas are conceived from individual people not organizations.

So, what do you think happened at the nursing home mentioned in the beginning of this article? Did the latest administrator succumb under enormous pressure only to be labeled as the 9th administrator to run the facility in the past six years? After studying the internal and external facility analysis the administrator realized her home had an advantage over her competitors: its dedicated workforce. In fact, the majority of her employees had worked at the nursing home for over 4 years some as long at 10 years. The administrator decided that with this intense employee commitment she could use this as a springboard to develop a new culture of believing they are the best, to promote new ideas and operational practices. The facility staff had already committed to making the facility a success but the constant turnover of administrators impeded their progress.

Seventeen months later the administrator finished the facility's second deficiency free annual survey, the home no longer utilized any physical restraints and had not had a complaint survey in over 7 months. Census had soared, certified nursing assistant classes were restored and an actual waiting list was developed for individuals who were interested in working at the nursing home. Staff made eye contact while speaking with visitors but best of all everyone associated with the nursing home believed that they worked at the best nursing home! The administrator gave all the credit to her employees because she knew the truth, success was only achieved because the employees were committed and then given the challenge to succeed. Today the facility attempts to "do the job right the first time, but still realizing that nursing home operations will always be a work in progress."

Why can't all nursing homes be like the one mentioned in our article? They can be it just takes an administrator's ability to maximize on operational strengths and challenge the weaknesses. Begin today by implementing innovative management strategies and take the time to really examine your facilities strategic operations. These exercises can be the springboard towards changing your facilities internal and external culture.

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About the Author

Jennifer Helfrich-Will, HFA, MSM is President of National Continuing Education Providers which is located in Evansville, Indiana. She has a total of over 10 years healthcare operational and management experience in a wide variety of settings including; long-term care, pharmacy, hospital, private practices, home health, Medicare certified out patient clinics and contract services.

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