By Eleanor Alvarez

The recent excitement about culture change programs in long term care facilities demonstrates our decades-old desire to focus on the basics of caring for each resident’s most important needs – and not necessarily the physical ones. First and foremost, we all want to be valued, respected and cared for as unique individuals. Culture change advocates believe that quality of life is just as important as the quality of care.

Communities that have embarked on changing their culture seek to de-institutionalize the typical skilled nursing facility. Some organizations are choosing to physically overhaul their facilities to reflect a community rather than a clinical focus. But the change to better serve residents is much more than a physical overhaul. Culture change is about attitude and relationships -- our attitudes toward aging and our relationships among residents, among staff, and between the two. Small adjustments can make all the difference in the lives of residents and the satisfaction of employees.

We as providers started this shift in 1987 with Omnibus Budget Reconciliation Act (OBRA) regulations. Long-term care facilities prepared for a new survey process that was “outcome driven” with an ultimate goal of resident-centered care that adapted to people and their personalities and histories, not just their physical needs. But our efforts to offer residents more choices, more independence and a stronger sense of dignity plateaued: We had made significant improvements in restraint reduction, incontinence, nutrition and skin care programs. We started looking at ways to individualize care with flexible meal and bathing times. But a new system of fines and citations put focus on compliance obligations rather than on continuing to find new ways to adapt to residents, and we are only now truly shifting the long-stagnant paradigm that too often treated residents as cases instead of people.

The most obvious outward changes are coming now in Green House and Main Street concepts – sometimes complete campus overhauls that offer rooms in communal ranch-style homes or pedestrian shopping areas with beauty parlors and dining services. Good Samaritan Home in Evansville, Ind. will recreate Main Street Evansville, circa 1940, to offer a familiar and comfortable environment for its independent, assisted living and skilled nursing residents. Marymount Health Care Systems in Ohio added an ice cream bar when it expanded its nursing and dementia care services.

Homes for the aging can and should be homes in the cozy and comfortable connotation of the word, and there is plenty of room for small changes to make big differences. It’s not for nothing that nursing homes have high turnover among staff; historically, they have not been happy places (the terms “institution” and “bureaucracy” come to mind). Successful organizations have established work teams based on the universal worker concept. Care is delivered according to the residents’ preferences and wishes, not based on the staff’s routine. They have softened the environment by creating neighborhoods and adding some of the familiar touches of home, such as pets and plants. Central bathing areas become spas, and family-style dining offers many choices to meet individual preferences. Activities are provided spontaneously by numerous staff members and are resident directed. The environment is lively and energized, designed to care for the human spirit as well as residents’ clinical needs.

The results have been remarkable and measurable. Communities that have successfully changed their value systems through culture change have reported reduced staff turnover and absenteeism, increased employee satisfaction, increased occupancy levels, and improved resident and family satisfaction. Staff feel more empowered to make decisions in a team-oriented, less bureaucratic environment. Clinical measurements have also shown a positive trend in facilities that have successfully changed their cultures. Many of the key clinical quality indicators such as falls, weight changes, behaviors and skin condition also have improved, proving that attitude adjustments can have even more profound effects on clinical outcomes than clinical regulations.

Inspiring stories from across the country have been told in numerous publications. Even if your organization cannot renovate its facility, you can implement changes that will loosen routines and give residents more choices in their care.

• Consider selective menus and individualized wake-up and bathing times.
• Brainstorm ways for various departments to coordinate their services, such as activities and therapy.
• Introduce pets, plants and intergenerational programs.
• Search continuously for creative ideas to break down rigid processes and offer opportunities for independence and choice. 

As communities seek to improve and enhance their operations, culture change emerges as a wonderful way to provide exceptional services to our residents. Staff, residents, families and other stakeholders quickly embrace the initiatives and are enthusiastic about the changes. By redefining how care and services are provided, a skilled nursing facility can quickly become the community of choice in its market.

Eleanor Alvarez is the president of LeaderStat, an Ohio-based consulting group that  provides comprehensive assessments, market studies, financial improvement strategies and new product design and implementation programs for senior communities nationwide. She has more than 25 years of management experience in the long-term care field, including opening and running senior living communities.

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