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Culture Change in For-Profit Nursing Homes

Slowly, "culture change" is gaining a foothold in the nursing home industry. The perception of nursing facilities as grim, regimented institutions is gradually giving way to more welcoming images—of communities where residents feel at home and have a say in running their lives and where the "frontline" workers who know residents best are empowered to provide better care. So far, culture change has been largely confined to the not-for-profit sector. Leslie Grant, Ph.D., director of the Center for Aging Services Management at the University of Minnesota, has been evaluating the culture change initiative at one of the few large, national, for-profit chains undergoing the transformation—Beverly Enterprises (now Golden Gate National Senior Care). Dr. Grant talked to us about the challenges companies like Beverly face, and why culture change entails more than just a physical makeover.

Talk of culture change often focuses on physical modifications—redesigning the nursing home to make it look less like a hospital and more like a home. But much of your work focuses on system changes. What are the organizational changes needed to establish resident-centered care?
Leslie Grant: A lot of people focus on the physical environment, but that's just one out of five core organizational systems that are transformed. First, there's decision-making. In the traditional model, you have people—administrators, department heads, supervisors—making decisions top-down. In a culture change organization, there are processes—like learning circles—to enable frontline workers and residents, as well as family members, to have a greater voice in decision-making.

Another organizational attribute is staff roles. In the typical nursing home facility, people work in departments with specific job descriptions. In culture change organizations, roles begin to get less differentiated. A nurse could do some light housekeeping and might be engaged in activities or help with food preparation. Next is organizational design. A typical nursing home has a hierarchical model. In a culture change organization, the organization is broken up into autonomous, neighborhood or household teams, with a much more direct chain of command from frontline workers to top management.

And what about those at the top?
Grant: Leadership is also affected. The interesting thing about leadership is that it's both an impediment to and driver of culture change. Good leadership helps the process go smoother, but with bad leadership, it becomes very difficult to implement. In a culture change model, responsibility for leading the organization becomes embedded throughout. It's like a cut of steak: in a traditional organization, the leadership is a glob of fat on the side; in a culture change organization, that fat is marbled throughout.

In a recent study, you found that families' satisfaction with care provided has a positive effect on nursing home workers' job satisfaction. How are the two related?
Grant: We did two surveys of family satisfaction and employee satisfaction, collecting data from 315 facilities in Georgia. When I looked at the relationship, I found an incredibly powerful correlation—between factors like quality of work environment, quality of management, quality of supervision, and family satisfaction. If you want happy, satisfied employees, you need happy family members. If you want happy family members, you need employees who are satisfied. It's a pretty amazing correlation.

Why should it matter that staff are happy?
Grant: I think that when staff are not happy, families can sense it. And when you have an unhappy group of employees, it has an impact on they way they interact with the residents and family members and it undermines satisfaction. Ultimately, satisfaction is important because it's related to a lot of other performance metrics, like turnover. It's related to state survey compliance, better clinical outcomes, and financial factors, like occupancy.

You have been evaluating culture change at Beverly Enterprises—one of the nation's largest for-profit nursing home chains. What have you learned so far?
Grant: Over the past three and half years, Beverly has piloted a resident-centered care model in a small number of facilities and then expanded it to a larger number, with the goal of ultimately changing all their facilities nationally. What Beverly has learned is that you have to be selective in terms of which facilities to invest in, because some will have a lower probability of being successful—those without stable leadership or those with poor state survey compliance records. In such cases, the energy gets consumed trying to bring the sites back into compliance.

What kind of unique challenges for implementing culture change does a for-profit environment present?
Grant: Historically, large publicly traded chains have made investments with the goal of achieving results based on quarterly performance. For Beverly to make these investments, knowing that culture change won't make an immediate return on investments is a huge gamble on the part of their board. But in the long term, not making them could put them at a competitive disadvantage. Another challenge is that multi-facility chains tend to have policies and procedures that make their structure very hierarchical. For Beverly to be successful, corporate policies have to change to enable facilities to be autonomous.

Is there a viable 'business case' for culture change?
Grant: There are a number of forces converging that make it clear that the current way of doing business in nursing homes is not sustainable. In recent years, [the Centers for Medicare and Medicaid Services] has expanded the definition of quality measures and quality indicators. In addition, we have to understand what customers really want. When residents and family members are asked about quality of care, they don't talk about regulatory survey deficiencies. They talk about the relationships they have with staff, the quality of nursing care, whether aides treat residents with respect. We're beginning to pay much more attention to the voice of the customer—residents, family members, and staff. As baby boomers begin to approach retirement, their expectations are different. Facilities that are able to transform successfully will have a huge competitive advantage, compared with those stuck in the old model.

November 2005

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