Category Archive

Nursing homes made the front page of today’s Wall Street Journal, but the story wasn’t a scathing expose or a blurb on a new regulation. Rather, this article took an honest look at the possibilities, as well as the challenges, that face nursing homes as they strive to put the “home” in nursing home.

The story’s protagonist was a man named Bill Thomas.  Thomas is a 48-year old physician who is known for developing the Green House  care model.  Unlike other nursing homes, elders in Green Houses live among 10 to 12 of their peers in small, homelike accommodations.  The first Green House was built seven year ago in Tupelo, Miss. Today, there are currently 41 houses in 10 states.

Thanks to the Robert Wood Johnson Foundation, that number may soon be going up. The Foundation recently pledged $15 million dollars over five years to NCB Capital Impact, a not-for-profit organization that is offering technical assistance help to any party interested in operating a Green House.

Money aside, building a Green House isn’t without its challenges. Take regulatory issues.  Nursing homes are some of the most highly-regulated institutions around. There are “life safety” rules intended to keep residents safe, “physical plant” standards that deal with building codes along with health-care rules, food preparation guidelines and general quality of life standards.  Some nursing-home executives argue such rules can make it difficult, if not impossible, to establish a Green House’s homelike environment.

Plus, the concept often faces resistance from nursing home administrators and staff who’ve grown accustomed to the traditional model. I saw this resistance first hand during a screening of Almost Home, a documentary about culture change. In it, a head nurse complained that these kinds of models make it “so much harder” to do everyday tasks like distribute medications or serve meals.

So what is AAHSA’s take? We support the organizations that are  implementing Green House model, but we don’t think there’s a “one size” fits all approach to transforming America’s nursing homes. Eliminating designated meal times, having consistent staffing and making minor modifications to a home’s physical structure can all promote better nursing home care. In fact, our web site features whole section devoted to tips and tools that can help our members offer nursing home residents the services they need in a place they can truly call home.

It’s no secret that adopting culture change principles in a nursing home is the right thing to do. But a new report from the Commonwealth Fund finds that it may be better for business too.

Take staff retention.  Researchers found that 59% of nursing homes who implemented seven or more culture change intiatives, like letting residents determine their daily schedule or asking nursing assistants to participate in care planning, had improved their staff retention rate since they implemented these initiatives.

That’s not all. Occupancy rates went up and operating costs fell as nursing homes adopted more programs that empowered direct care staff and focused on residents’ needs and preferences.

That’s not to say these programs aren’t costly. 31% of nursing homes surveyed reported that cost was the biggest barrier to implmenting more culture change programs in their facility. This survey, however, begs the question: does embracing culture change give nursing homes a better “bang for their buck?”

Lutheran Services for the Aging  (LSA) does. In fact, they made the pages of the Salisbury Post because of their efforts to keep the landscape around their new facilities intact.

“It would have been easy and less costly just to level everything to build our parking lot, but we really wanted to be good stewards of the land and preserve the natural surroundings,” Keesha Smith, LSA’s director of special projects, said in the article.

Smith’s words say it all. Our not-for-profit members have an obligation to be effective stewards of all resources, including natural ones.

How can your organization start “going green?” The “Environmental Stewardship” section of the AAHSA Quality First Web site features a variety of tips and tools you can use to get started.

Bill Thomas offers a new perspective on aging and how we define it in our society.

I’ve been watching with interest TIAA-CREF’s new advertising campaign, the powerof.org.  TIAA-CREF is leveraging its status as a not-for-profit provider of financial services to draw a distinction for customers.  Their point is that because they are a .org, people should trust their motives and mission.  I think this is an excellent model for aging services providers to embrace.  Over the last couple of months, I have asked several AAHSA members how they use their not-for-profit status in their marketing, and the answer often comes back that they just haven’t figured out how to do so.  Some who have done market research find that potential residents and clients like the values that being not-for-profit convey, like being focused on people over profits, dedicated to staff, and stable for the long-term.  Do you accentuate your not-for-profit status in your marketing materials?  If so, I’d love to hear about it.  I’m leading a session at our Annual Meeting on this topic and would be delighted to feature your efforts.

 Check out TIAA-CREF’s Web site at www.powerof.org. 

Congratulations to Morningside Ministries of San Antonio, for some wonderful media coverage in the San Antonio Express-News about their advances in design for the aging.  Though senior-friendly design and home-like environments are old news to most people working in aging services, we have a ways to go before the media and the public understand  that living in a senior housing community doesn’t mean living in a hospital. Every story like this one helps break down old stereotypes  of what growing old means for where you live and how you think. We like to see all the coverage like this that’s out there.

What are you doing to tell your story through the media?

AAHSA’s vision for long-term care is a “healthy, affordable and ethical” system of aging services. Today, those three criteria are far from reality. Few would argue that health care in general, and aging services in particular, reflects well-defined, healthy outcomes. Nor do I know any expert who says what we have today is affordable. Many countries spend far less and have better outcomes. Public outcries related to health care scandals have questioned health care’s ethical underpinnings. And now, Congress and the IRS have their sights focused on not-for-profit ethical behavior and accountability.

Recently, I met with a leading consumer advocate about the state of nursing home care in general and the future of aging services in particular. I asked her what AAHSA’s and the nonprofit role should be in getting beyond where we are today. She said she believes our responsibility is two-fold: continue to create a vision of what the continuum can be for older people in our society and create trust in our work. A provocative perspective succinctly stated.

I submit for your consideration that the vision so badly needed in our field and the trust so hard to earn begins and ends with ethics.

Oh, I’m sure most of us could say with confidence that we are corporately ethical. Our intentions have been noble and honorable for generations. But without a disciplined process of ethical reflection as organized as our processes for financial analysis, it is easy to drift ethically. Ethical lapses lead to crises of trust reflected in headlines that are etched in the public’s mind for decades.

What do ethical lapses look like and how do moral imperatives manifest themselves in difficult times? Let’s use a couple of human resources (HR) examples from real situations. I use human resources because AAHSA’s Ethics Commission, under the leadership of Audrey Weiner from the Jewish Home and Hospital Life Care System in New York, will soon publish a Quality First white paper entitled Our Moral Imperative: Creating an Ethical Workplace. It has guidelines for human resources ethics. It should become part of your corporate ethics tool kit and library, along with corporate compliance, codes of ethical conduct and social accountability material - examples of which AAHSA has available for our members.

In fact, AAHSA’s annual meeting in Orlando this fall is themed “Living Your Story” with daily themes of “A Life of Conscience,” “A Life of Community,” “A Life of Integrity” and “A Life of Legacy” - driven by the AAHSA Ethics Commission’s work.

Back to the human resources lapses and imperatives. Years ago, I visited a colleague’s facility to share solutions to common problems. My organization faced a much higher food service cost per meal than others I compared with. The colleague’s facility had a particularly low-cost program, with labor costs less than half of my facility’s costs. I asked the food service director his secret. He smiled and replied, “It’s simple. Our community has lots of immigrants who need work, so I don’t have to pay more than minimum and I don’t have to offer vacation and other benefits. And if they don’t like it, I can replace them immediately.” Stunning! I wonder: was that an HR policy sanctioned by the board? Did the board even know? Was this an ethical lapse under the board’s radar or corporate intent?

Contrast that with the ethical imperative loudly stated in the actions of Boston member Mary Immaculate Health Care, whose CEO is Barbara Grant. Mary Immaculate experienced a river flood that could have been an even worse disaster. Fire and rescue, local hospitals and nursing homes all responded nobly and quickly, resulting in no injury, no loss of life as the facility succumbed to the river. Perhaps most inspiring was the employee response. Employees on site stayed, others came in to help. All followed their residents to various facilities that took them in. Immediately post evacuation, with a now uncertain future for the facility, the board of Mary Immaculate reassured the staff that no employee would miss a paycheck! A moral imperative, from their perspective.

Our ethical imperative is the leadership dynamic of transformation needed in long-term care. Recently retired CEO Dick Lamden from Wexner Heritage Village in Ohio testified at a state legislative hearing in which conflict about a public policy objective was apparent. Dick’s recommendation to this committee contrasted significantly with the profit sector’s recommendation. After discussion, a prominent elected official stated that he trusted Dick’s recommendation because of Wexner’s history of quality and doing the right things for the right reasons. Unanimous approval.

The Kendal organization in Pennsylvania calls it “One Common Interest” on the cover of its 2006 annual report, which quotes John Woodman, who, in 1763, said:

“Here we face the prospect of one common interest from which our own is inseparable, that to turn all the treasures we possess into the channel of universal love becomes the business of our lives…”

Yes, we have an ethical imperative. It begins with corporate leadership, including the board. It should pervade all aspects of our work. It should encompass all groups of people with whom we have relationships. It is the key to transformational leadership to change a broken system of inadequate quality, despite the resources thrown at it and the competition for them. Ethical thinking is the foundation for change. And it needs to happen every day, in every community.

Larry

William L. Minnix, Jr., D.Min.
AAHSA President and CEO

P.S. Be sure to watch for the September/October issue of AAHSA’s FutureAge magazine, where you’ll find articles that profile members who take ethics and quality to heart, examine the characteristics of a just society, look at what determines an ethical corporate culture and more.

We had better know how to connect with consumers. Our scenario planning document, “The Long and Winding Road,” shows that consumer behavior is one of the two biggest uncertainties for the next decade. (The other is talent availability, which will be addressed in another letter.) What will consumers need? Want? Expect? Will the people be available to provide the services the market needs?

I’d like to comment on consumer connections in two dimensions: the science and the art of understanding and responding to basic human needs in our work. I’ll spend more time on the art because there is an abundance of resources on the science.

Of course, market studies are now an essential part of strategic planning and day-to-day management of current and future service. Regular, daily consumer feedback and response are rapidly becoming the norm, and the ability to analyze that information to generate effective and satisfying consumer service may be the most important management work we can do. There are numerous tools and business friends that can help with the most important driver of our work: understanding perceptions of the people we serve and those who serve them. The science of marketing is complex, but we must master it.

While the razzle-dazzle of marketing science is increasingly critical in our increasingly sophisticated work, I hope we can remember the fundamentals of the art because the fundamentals continue throughout our ongoing service relationship with the people who call on us to help them. This hit home to me recently through a colleague with a mother in crisis. Demented, frail, combative, falling apart, this elder went through a saga that began in an assisted living facility and continued through hospitals, nursing homes, a mental health unit, a rehab facility and a home health agency. My friend and her sister went with her. You know from your own experience that this typical family predicament is difficult in the best of conditions.

As my friend reflected on the situation, she said, “Maybe I’m expecting too much…” I picked up on that statement, perhaps thinking she and her sister were unrealistic—wanting cure where there could be none, wanting an idealistic relationship with their mother that will never exist again, wanting restoration to health where irreversible damage has taken its toll. So I asked her, “What did you expect?” She had no trouble in responding — these are mostly her words—so listen carefully—it is the market speaking through this daughter, who is YOUR colleague—and they apply regardless of the types of service you offer.

1. I expected my mother to be offered a good quality of life for the condition she was in. I expected that she not be avoided because she is unpleasant.
2. I expected her to be clean, well-fed, have interaction and receive the attention the facilities said she would be given and that we paid for.
3. I expected her to be treated with dignity even if she is beyond understanding her condition.
4. I expected staff to let me and my sister take the time to tell them what a wonderful person my mother used to be because all they see now is a crotchety, difficult demented woman.
5. I expected them to believe us when my sister and I said something was wrong.
6. I expected the long-term care facility to know my mother’s medical problems well enough to know that there was a developing crisis.
7. I expected the hospitals where she was transferred to diagnose and fix what they could—not discharge her with an infection she didn’t enter with.
8. I expected my mother to be released from the hospital when her medical problems were resolved, not when she ran out of coverage.
9. I expected professional guidance from professional staff, with a doctor who takes leadership responsibility for coordinating medical care and nurse leaders who would advise me and my sister on what we should do.
10. I expected nursing staff to recognize that cleaning my mother or giving her a treatment and putting her back into a soiled bed isn’t good. Simply saying another department didn’t do its job is not acceptable.
11. I expected on-site advocates—not 1-800 numbers.
12. I expected someone to empathize with me when I sobbed about my mother’s obvious state of affairs—not ask me what’s wrong.
13. I expected to be able to trust the people and institutions to provide good professional care and support my sister and me through all of this.

Too much to expect? Maybe all of our marketing, hospitality, sales and consumer relations programs should begin and end with asking people like my colleague and her sister what they expect throughout the service delivery process… Is that too much?

The great organizations stay closely connected to expectations and needs of the people we serve—connected most closely and intimately in the midst of crisis, not just through the perspective and distance of sophisticated science, though both are essential. No, that’s not too much to expect of us, is it?

Larry

William L. Minnix, Jr., D.Min.
AAHSA
President and CEO

In 1973, my mentor and boss, the late Scott Houston, sent me to visit the late Dr. Herb Shore of University of North Texas long-term care leadership fame. Truth be known, Dr. Shore probably has more disciples in long-term care administration than anyone.

My objective in the visit with Dr. Shore was a report on “philosophies of administration” as part of my own administrative internship experience. As we began a tour of Golden Acres, where Dr. Shore served as CEO, I asked him to define his fundamental philosophy. “Very simple,” he said. “If I take care of the staff, they’ll take care of the residents.”

An enduring truth! Now, 34 years later, AAHSA’s Institute for the Future of Aging Services just completed a multi-year grant called Better Jobs Better Care (BJBC) funded by the Robert Wood Johnson Foundation and The Atlantic Philanthropies. Our March/April issue of futureAge summarizes the experience of the multiple BJBC sites and projects throughout the country. I urge each of you read that issue cover-to-cover and make a human resources plan based on it.

I was also struck by a speech I read from an event at Phoebe Ministries in Allentown, Pa. Though the President and CEO, Rev. Rodney Wells, is an eloquent clergyman, the speech actually came from Louise Santee, a certified nursing assistant (CNA) at Phoebe. Ms. Santee delivered the speech at a celebration of Phoebe’s success with Better Jobs Better Care.

In that speech, she said: “A CNA must have love in her heart for the residents, because it is more than just a job. When you leave work, you think about it all the way home, and then some. If, after you have done your care, the resident is smiling or has a twinkle in the eye, that is all the thanks you need. ” She says BJBC helped her “make things better” by “working together as a team,” which she says is “the Phoebe way.”

So, here’s what we can learn from Dr. Shore, Better Jobs Better Care and Louise Santee:

1. Nurture the love in your heart.
2. Conduct employee satisfaction surveys, act on the findings and measure employee recruitment and retention.
3. Discuss what respect means to everyone in the workplace.
4. Offer competitive wages, family-friendly benefits and career ladders and lattices.
5. Teach and mentor people on leadership.
6. Create a multi-cultural sharing program.
7. Create an ongoing team-building program and teach continuous quality improvement-TOGETHER-at all levels!
8. Invite policy leaders into your setting and let them hear from employees about the importance of the role of the care and service professions.
9. Have fun, celebrate events and share sorrows.
10. Oh, yeah… remember to nurture the love in your heart — because it’s not just a job.

All these have stood the test of time. If we take care of employees, they’ll take care of the people we serve. Or, better jobs generate better care. It’s the right thing to do. And remember what Louise Santee says about the unique rewards of a great day’s work. Bigger hearts, better jobs, better care!

LarryWilliam L. Minnix, Jr., D.Min.
AAHSA President and CEO

Learn more about Better Jobs Better Care.

Feb. 6, 2007

We’ve been emphasizing the need to “tell your story.” The story of aging services is not an easy one to tell. Why? The reasons are many. The frailties and indignities associated with age-related conditions are often hard to face. None of us likes to think of our parents growing old, and our culture pays a fortune to makes ourselves think, look, feel and act younger. Good care is inadequately funded, yet the public thinks that government pays for everything, so people face sticker shock when they need help. Our work forces everyone to face their own mortality.

Yes, it’s a hard story to tell, but we must find authentic ways to tell it. That’s why we introduced the “Tell Your Story” theme at our Annual Meeting & Exposition in San Francisco, and we have a follow up theme of “Live Your Story” at our fall meeting in Orlando. We’ve also started a story bank where you can share the great stories you live every day.

We often let others tell our story. On one extreme, slick commercials tell a glossy tale with graying actors who wear adult diapers while they play golf or kiss each other while you guess which one wears dentures.

On the other extreme, negative stories abound in the popular media. Recently, an issue of AARP The Magazine included a story that reflected the sad experiences of a self-defined younger disabled man who had a short stay in nursing home after surgery. He was surrounded by other residents of a more traditional nursing home population and became familiar with all the sounds, smells and personalities associated with frailty in a care setting.

His complaints focused on problems inherent in institutional care — boredom, loss of control, lack of meaningful activities and relationships, a sterile, hospital-like environment and staff with various levels of concern. All of these are the dynamics you deal with every day. They are especially difficult for people like this man, a successful writer with his mental faculties intact, who died at 68 from cancer — not dementia. A truly dismal experience for him, and he had no real alternative. We can all sympathize and empathize with him and others like him that we’ve known in our work.

I remember Gerald, a resident at Wesley Woods when I was there. A near quadriplegic at 30-something due to an auto accident, Gerald lived in our nursing home. He died a couple of years ago. On good days, Gerald appreciated staff, was an active on the resident council, could go on outings in the van and dealt with the sights and sounds of people three times his age with good humor. On tough days, he fought bladder infections, endured impactions and complained anonymously to the state, which sent a survey team to investigate. He tried to leave the nursing home a couple of times for more independent settings, but he was vulnerable to critical clinical problems that other settings were ill-equipped to handle. Our nursing home was home. Staff was family. We all fought the complaints and conditions together. We loved Gerald — and he loved us — in spite of the inherent problems of living together. Wesley Woods was home for Gerald. An imperfect home, but home. This is not a pretty story, a perfect story nor an easy story to tell. But it is real, it is loving and it is essential for the Geralds of the world. You have your Geralds too. Neither glossy nor despairing, but an authentic story of hope and care.

But people like Gerald are not the only story. Areti Staudohar from Riverside Senior Living in Kanakee, Ill. , writes of the birthday party for a wheelchair bound, 104-year-old Lois and her two friends with Alzheimer’s. Areti had rented a red Ford Mustang convertible while her car was in the shop and used it to take Lois and her friends out for a spin. Each resident told stories of their adventurous younger years. Jack, a resident who retired at age 88, told how he became a successful business man in the community after entering it on the road on which they were driving. “Punch it,” Jack yelled, urging Areti to drive faster. She’ll never forget the smile on his face as she did.

“I am sharing this story to help us all remember how much we touch people’s lives everyday,” Areti writes. “In our own way, each of us makes a huge impact on the patients and residents we serve, and they in turn give us back their own priceless gifts.” Neither glossy nor despairing, but authentic.

Or, there’s the story from Penacook Place, in Haverhill, Mass., of an older women with multiple problems, referred by a hospital, demanding daughter in tow. The mother died within a couple of months and the daughter told staff her mother’s last year had been a tough one, but her last days at Penacook Place the best ones of the year. Not high gloss, not despairing, but authentic and reassuring.

For the many people we serve, the story is one of new-found quality of life in spite of disease or other difficulties, finding the shreds of meaning that are still available to the mind and heart. For others, it is helping them make the best of stressful and difficult circumstances in coping with a loved one.

Charles Dickens’ great novel, A Tale of Two Cities, brilliantly describes the same city from two starkly different sets of experiences, making one city seem like two. You and I have the challenge of telling the tale of two cities in the work we do. And we can’t let just one set of experiences — as real as they are — be told. We must continue to make the experience as meaningful as we possibly can for all the residents of “our cities.” So the tale gets better in the telling as we address quality of care and quality of life for an aging population who would rather think they will be perpetually youthful and will never need our services.

And when it works, the tale and the telling can be magical for those we serve and for ourselves. Take this story from Mary Ann Johnson of Lutheran Services for the Aging in Salisbury, N.C. She wrote us about Tim Setzer, a 45-year-old father of three who came to the Lutheran Home after blowing out both knees at a softball game:

Though he had only seen it from his car, Setzer had admired the Hickory campus every time he traveled down Springs Road.

Now, after a 27-day stay there, he admires the inside too.

“I can’t tell you how good people were to me,” he said. “My housekeeper, John, the activity directors, aides, everyone. The place is absolutely spotless and everyone was so kind and helped me so much.”

Strolling the halls (yes, strolling on two good knees) during a recent visit, Setzer couldn’t find enough adjectives to describe the respect he has for the staff and his therapists. “They worked me hard and they pushed me, but they never hurt me,” he said.

Setzer also grew quite fond of the residents, especially a group of men who frequently gathered outdoors on the patio or in the courtyard. They were fascinated by my legs,” he said. ” They’d point and say, “Look there, that boy’s gone and broke both his legs.”

Many of those same residents stopped by his room each day to offer words of encouragement. Setzer credits that encouragement for his recovery. “Seeing their age and how much pain some of them were in, that took all the self-pity right out of me.”

It also changed his outlook on nursing homes. “I still have half a life to go, but if I didn’t, I’d be here. In fact, I’d like to come back here now and then just to rest. I know I’d find nothing but kindness.”

Tim’s visit dispelled all the negative stereotypes he had about nursing homes; and he had plenty. He had a huge extended family and dozens of friends that visited him and came to feel positive and comfortable in the nursing home. His 92-year-old grandmother even enjoyed visiting him. The moral? “We’re not just for old folks anymore” or “Don’t believe everything you read” or perhaps, “Seeing is believing.”

Like a Dickens novel, we have a classic human story to tell. It is a tale of two cities. We must tell both. It is incumbent upon us to improve the conditions associated with the tragic tales and illuminate the tales of hope. Gerald’s life was a tale of two cities. Authentic, tragic, hopeful. You live these stories every day. Tell them!

LarryWilliam L. Minnix, Jr., D.Min.
AAHSA President and CEO

Share your story with us.

Nov. 14, 2006

As you know, I had the distinct honor of interviewing Walter Cronkite at our Annual Meeting & Exposition. A wonderful man. He made me feel like we’ve been friends for years. I marveled at his deep, soothing voice, compelling eyes and authoritative eyebrows. And what a chuckle. It is how I might imagine God would chuckle.

Who is this man Walter Cronkite and how did he earn the “most trusted man in America” designation for more than two generations? The ingredients are no doubt journalistic talents, an engaging personality, the right mix of humility and self confidence, a strong work ethic, a lucky break here and there, integrity and a certain wisdom that comes from experience and mystical realms.

You and I know people — residents, clients, relatives, friends old and young — who were born wise. I call it the “Wisdom of the Ages.” Yes, Walter Cronkite possesses the Wisdom of the Ages. He could have been a commentator in the era of Socrates, or during the Renaissance, an advisor to Washington or Lincoln.

People with Wisdom of the Ages help us find meaning in life, rediscover or clarify enduring values and put things in perspective. They redefine paradigms we live in. They ground us in truth and reality, yet compel us to grow beyond where we are. Some of those “Wisdom of the Ages” people live and work in our facilities, though they aren’t famous like Walter Cronkite.

For me, Walter Cronkite helped redefine the aging paradigm. I asked him two questions outside the bounds of what is traditionally asked of him.

• Does he think of himself as retired?
• Does he think of himself as old?

His responses: No, he doesn’t even use the “R” word. He complained that he isn’t busy enough. He wishes CBS would use him for political commentary but he stays engaged in the media through other outlets. He thinks of himself as a journalist, and he voluntarily commented on the Iraq war, as he once did on the Vietnam War.

Fully immersed in the issues of today — and tomorrow. Not just yesterday. Though his hearing is impaired and his gait more cautious, he is clearly a man living to the fullest. No retirement, only adjustments to how he’s engaged.

His response to thinking of himself as “old” at 90? “It depends on what I’m trying to do at the time,” he chuckled.

His messages to me are that retirement is becoming an antiquated term and chronology is irrelevant. To be replaced by vitality of spirit, ability to stay engaged and refocus of interests.

We should consider a replacement term for “retirement.” Instead, let’s say we will all enter the “Walterian” era of life, where engagement is adjusted for time, interests and capabilities — God willing.

The Old Testament story of Abraham and Sarah are part of the Wisdom of the Ages reflected through Walter Cronkite. God asked Abraham and Sarah (I’m taking liberties with the original text) if they’d be willing to be the father and mother of many nations at an advanced age. Sarah laughed and said they were too old. God responded that he didn’t ask them how old they were, he asked them if they’d do something really important. Put that way, they agreed. As I recall, the “retirement” word isn’t used in the scriptures.

AAHSA’s recent scenario planning study about the future envisions that people like Walter Cronkite are the new archetypes of aging role models. Personally, I hope I live long enough so that when someone asks me how old I am, I can respond, “I am not only old enough for the AARP discount, but I am in the Walterian era of life…I forget exactly how many years that is. Why? Is age important? Do you have something important for me to do?”

“And that’s the way it is,” to quote Walter Cronkite.

Walter Cronkite’s job at 90 is to be the distributor of Wisdom for the Ages. That’s a really good job for any of us in that era of life… Ask some of your residents and clients to share the Wisdom of the Ages with you. You might be surprised how it changes your perspective.

LarryWilliam L. Minnix, Jr., D.Min.
President and CEO

AAHSA
2519 Connecticut Ave NW
Washington DC 20008

Oct. 5, 2006

Last Friday, we participated in an unprecedented quality summit. The purposes of the summit were to draw a baseline on where quality stands in nursing homes, model a new relationship paradigm with stakeholders — some with whom providers have had adversarial relationships — and to take an experimental step in the Quality First journey. The experiment is a campaign called “Advancing Excellence in America’s Nursing Homes” and its mission to improve quality of life for nursing home residents and staff. It is a focused, voluntary, two-year initiative. To clarify up front, this campaign does not replace Quality First. If successful, the campaign and the processes used to advance it will enhance Quality First.

So this is a report on where quality stands today and how we plan to move forward.

Context and History

Four years ago, we, the American Health Care Association (AHCA) and the Alliance for Quality Nursing Home Care publicly committed to Quality First, a national quality improvement plan to demonstrate excellence and earn public trust. While Quality First covers the total aging services continuum, it was widely recognized that the nursing home sector had been embattled for years and we found ourselves in a “crime and punishment” approach to public oversight. After pointed feedback from policy and consumer leaders, we reasoned that the only way out of this awful dilemma was to take responsibility for quality based on continuous quality improvement (CQI) principles. Quality First was born.

While our members have traditionally delivered quality, good works were overshadowed by isolated bad incidents and bad care or deceptive business practices by a few. Yet, it was evident that quality is achievable, measurable and worthy of public good will. And it is my experience there’s more good care available than we’ve been given credit for. Quality First would enable good providers to shine and the chronically incompetent and ill-motivated to be run out of business. Quality First was designed to build on other quality initiatives like Pioneer Network, Eden and Wellspring, and to complement the Centers for Medicare and Medicaid Services’ (CMS) Nursing Home Quality Initiative of 2001.

In the ensuing four years, we’ve had the opportunity to discuss Quality First with numerous groups — including the Founders of the new campaign. These interactions have led me to six major conclusions about quality:

1. Quality is getting better, though more must be done. Quality measures and process improvements are in their infancy for many of us.
2. Workforce is the key to quality and we must address caregiver needs.
3. We need to understand consumer perceptions and enlist consumer groups to help us fulfill Quality First.
4. We have more collective knowledge than we are effectively using.
5. Many key policy makers don’t really understand the complex issues we face and, therefore, are not making the most constructive policy decisions.
6. All interested parties: consumers, government, providers, professionals and business, must work together better if quality nursing home care is to become the automatic public expectation it should be.

A Definition of Quality

To pursue nursing home quality, we must define it. The Founders of the new campaign drafted the following definition:

We’ll see how well this definition wears over time.

Where Quality Stands

Here are the summary bottom lines from various sources, much of which was expressed at the quality summit.

1. Improvement in nursing homes is evident in several CMS quality measures. Use of restraints and pain management are two examples. No progress is evident in pressure ulcers for a variety of reasons. Refinement of measures will be an ongoing concern.
2. Culture change initiatives are proving successful in improving staff retention, with correlations to quality and cost-effectiveness. While studies are relatively small in scale, it is abundantly clear that respect and effective human resource management can make a major dent in the 70 percent average turnover rate nationally for certified nursing assistants (CNAs). One study reports a rate of 10 percent staff turnover based on culture change. We know that staff turnover rates will never be zero and shouldn’t be because a certain amount of turnover is healthy. But a national average of 70 percent is too high, and culture change helps bring that number down.
3. No one really knows in a collective and disciplined way, how residents and families evaluate the services we offer. Our recent AAHSA Member Value Survey found that two-thirds of our members perform resident satisfaction surveys, but little is known about how those results get reported and used to improve quality. There is no national profile for resident satisfaction. Approximately one-third of our members conduct employee satisfaction surveys, but again, little is known about what changes these surveys generate.
4. The momentum behind Quality First is growing. Two-thirds of AAHSA members have signed the Quality First Covenant. In AAHSA’s recent member survey, approximately half of our members report they are using Quality First to help them improve. Interestingly, approximately one-fourth of those who have not signed the covenant say they, nevertheless, are using Quality First to improve. We have strong anecdotal information about how Quality First is helping to transform organizations. Our Web site is full of Quality First member success stories.
5. National leaders who spoke at last week’s summit are recognizing that quality care is a national responsibility, and that the financing of it needs to be revamped. While no one promised more money, there is general acknowledgment that quality should be defined and paid for adequately, with financial incentives for good care. Emerging themes at the meeting were changes that allow people to stay at home longer, redirection of dollars to follow clients and the potential for technology to improve care and cost.
6. Sen. Charles Grassley (R-Iowa) addressed the summit. He is a skeptic about voluntary self-responsibility initiatives, and stressed his support for strong survey and certification oversight. He reported that there are several hundred chronically bad providers who should be shut down but are not. Sen. Grassley, and those groups who reinforce his view, are our acid test critics. While we disagree with his conclusions about the effectiveness of voluntary initiatives, we have much work to do to prove him wrong. And we agree that the bad apples should be discarded. The issue becomes how to support CMS and the state agencies in accomplishing that objective.

What Should We Do Next?

1. Full steam ahead with Quality First! I believe we are close to the tipping point in its effectiveness. The Quality First Elements need to be embedded in every member’s culture. There is plenty of evidence that this is occurring. Quality First is taking root.
2. Implement consumer and staff satisfaction surveys, use the results for improvement and report findings through annual reports and newsletters.
3. Embrace culture transformation. It is our salvation.
4. If you are a nursing home, sign up for the “Advancing Excellence” campaign. This is a way to show that voluntary efforts can be successful. Your participation will give us reliable, collective national data on improvement.
5. Learn to tell our story better locally and nationally.

At the close of the “Advacing Excellence” summit, I asked one of the dozen or so nursing home residents in attendance how he would “bottom line” the day. He replied, “It looks like if residents and staff are given the respect they deserve, and the people that run these places will train people well and have better communication, we shouldn’t have too many problems.”

Yes, let’s ask the consumer what he or she thinks. It could be enlightening and helpful on this next phase of the Quality First journey. And let’s see what this campaign can teach us about quality improvement, working more collaboratively with other groups and the effects we can have on policy makers. We have a big opportunity and responsibility to lead permanent transformational change. Yes, we are close to a tipping point!

Larry

William L. Minnix, Jr., D.Min.
President and CEO

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