Five Stars and a Blog

So, how about the five-star nursing home rating system, huh? My first thought was that eating at a five-star restaurant doesn’t guaranty a good dining experience and that during one of my favorite dining experiences ever at a diner in New Orleans I saw one dead roach on the floor. I’m not saying that pest issues should be ignored or that a five-star rating doesn’t indicate some level of excellence, but that there are a lot of factors that effect a person’s experience that rating systems, such as the one recently released by Centers for Medicare and Medicaid Services, ignore.

I am, of course, not the only one who feels this way as the point is mentioned in the first few paragraphs of the many articles I have read on it. (Here’s one for example).

Interestingly, another sort of “quality indicator” recently showed up on the Web as well. The goal of Bob’s “Nursing Home Ninja Blog” is “to comment on conditions, care, and circumstances in Nursing Homes & Extended care facilities.” Bob is a resident in a long-term care facility and will be providing an “inside view” of the situation at his nursing home. Somewhere between these two new websites, and some personal investigation, perhaps people will find some aid in choosing a nursing home for themselves or a loved one. I think Bob will be able to bring up some good issues to think about and ask about that may not come to mind unless you’ve actually lived in a nursing home – some of those things that the five-star system doesn’t cover.

I encourage you to comment here on what you consider important indicators of quality of care so that with many view points we can all get a really good big picture of what quality life in a nursing home should be.

Power Struggle

I had an interesting dream last night - I was in a large group being taught different movements that were meant to represent animals. The teacher asked us to break up into groups of three and put several movements that we learned together to make a routine. So, I went off with the other two in my group, a woman and a man both in their 50s, and we got started. The woman said, “I thought we could start with the crab” and demonstrated. I said “Wow! I was thinking the same thing! But I was thinking we could modify the movement at the end so that we could more smoothly move on to the next movement” and there the woman cut me off and said. “No, I think we should do it my way” and I said “But you haven’t even heard or seen my suggestion.” “It doesn’t matter, “ she said, “I want to do it my way.” “Well, I could just as easily say ‘I want to do it my way’ that’s not a convincing reason.” (The man, bless his soul, was keeping out of it.) She then said people my age (30s) thought they could just come in and tell people who had been doing their jobs for years how things should be done and she wasn’t going for that. I pointed out that in fact, we usually did what the more senior people in the organization wanted to do often only because they were the more senior people. At this point, I think my mind figured out what was going on and I woke up, mad and frustrated. I mean, she didn’t even want to hear my idea.

There are two things you should know: 1) the dream took place in the gym of my grade school which is never a pleasant place for the subconscious to visit, making everything that happened feel a little more hostile and 2) I’m working on some stuff on steering teams. I think this dream was telling me that I have to make sure to pay proper attention to the power struggles that happen as an organization moves toward self-led teams.

Obviously there are power issues linked to position and that is technically changed as the organization is restructured. But just because positions change doesn’t mean behaviors or feelings change. We have some pretty well ingrained feelings about whose say has weight…As in my dream, age can be a factor. (Though in a nursing home, power can be denied to someone who is “too old” as well as “too young.”) Part of the age factor has to do with experience, but there is also experience in the particular organization – that is those who have worked there for years having more power than those who have only been there for a few months regardless of overall experience. While those with seniority may know the ins and outs of the organization well, a fresh perspective can be equally valuable.

And then there is the issue of personality types within subgroups. There are those like the woman in my dream and me who are comfortable taking the lead but there are also those like the man in my dream who wait to see which way the wind will blow, uncomfortable with the responsibility that comes with power.
These power struggles are part of our general culture, not just nursing home culture, making them a little harder to overcome because they are reinforced outside of work. Please share with us what you have done in your organizations to level the playing field. I’d really like to share the power of this blog platform.

Peace and Love, Imy

As Steve Shields said, “We lost Imy to the stars and the heavens.” Our dear friend and inspiration Imy Higbie passed away Friday, Nov 21 and I’m still trying to wrap my brain around the vast amount of love and wisdom she has passed on to so many of us. You may remember her from her presentation at the 2006 Pioneer conference or her contribution to In Pursuit of the Sunbeam wherein she shared the story of her own nursing home experience. Imy got her bachelor’s in journalism and went on to get her master’s in social work from Syracuse University. She later was a professor of social work at UW – Madison. An early and enthusiastic supporter of Barack Obama, Imy closely followed the 2008 campaign and election returns.

She was a champion of progress and kindness and human dignity and led by example. How could we not give our all for culture change after hearing or talking to Imy? Joe Angelelli has put together a beautiful tribute to her. It’s a wonderful opportunity to meditate on her smile and the determination in her face. Imy once ended an email to me with the following words: “In closing, let me say the word for today FORWARD!!!!!!! Peace and Love, Imy.” Indeed.

Collective Knowledge

Perhaps you’ve noticed that when you do an Internet search, especially if it is on a somewhat general topic, there’s a good chance the first site that comes up is Wikipedia. Go ahead – type in “nursing home.” Is it the best source for info? Maybe not, but they try hard to have the info well cited and I appreciate that. The other thing I appreciate is that it is a symbol of collective knowledge – something we work for in the process of culture change. But here’s the thing, take a look a the Wikipedia entry for “nursing home,” particularly the stuff under “trend” and “ resident-oriented care.” It just doesn’t seem quite right. (If for nothing else than they refer to residents as “patients.”) Is it just me? Let’s submit some new info. What’s it missing? What needs to be changed?

Get Out the Vote

I keep hearing things like “The most important election of our time,” “The worst financial crisis since 1929,” and “extraordinary times.” Things do feel pretty heavy these days, but I keep thinking that elders probably have a broader perspective on these claims. If you’re not doing learning circles or at least picking an elder’s brain about “these times” you could be missing out on information that could help you decide your vote or even bring you comfort about “getting through the tough times.”

And have you seen this news story about the 106-year old nun living in Rome who hasn’t voted since Eisenhower who jumped through all the necessary hoops to cast her vote this year? I guess that says something about this election.

I’m encouraging you to help elders who are interested cast their votes and even work with each other to vote early or arrange your schedule so that staff are able to make their voices heard as well. Culture change teaches us shared leadership, the power in taking part in framing the “way things are done” and the importance of being part of a community. Besides creating home for elders, I can’t think of a better way to do those things than voting.

Time to Reflect

I saw a quote in a recent Newsweek article* about election strategy that had me thinking about why it is so hard to change and learn new things. Here it is:

“When FDR was making radio addresses, ‘people had the time needed for reflection, to mix emotion with facts and reason,’ says [Antonio] Damasio. ‘But now, with 24-hour cable news and the Web, you have a climate in which you don’t have time to reflect. The amount and speed of information, combined with less time to analyze every new development, pushes us toward the emotion-based decision pathway.”

“…a climate in which you don’t have time to reflect…” Any of you familiar with that feeling? So, we cling to “the way we’ve always done things” because we know it is, if not the best way to do things, at least a safe bet. It’s worked this far, right? We put a wall up to protect ourselves and the institution because we don’t have time to look at alternatives and learn new things. We barely have time to get everybody to the dining room, for Pete’s sake.

But we must find time, or at least slow down a little, if we are ever to realize that there is a better way to care for our elders and to work together as a team. We need to value individuals and effectiveness as much as efficiency and task.

I have previously posted blogs and handouts on the spiral of learning and debriefing - practices that can help us process exactly what’s going on besides our gut reactions. In time, these pre- and post-action tools can become the new “way things are done.”

Anyone have any good ideas for carving out time for learning?

* “Heard Any Good Stories Lately?” By Sharon Begley, Newsweek, Sept. 22, 2008

Life on Campus

I haven’t been on my soapbox in a while, however, this time I’m on it so I can reach in and stir the pot. Basically, I’m looking for an answer to, “Why do you think that is? And why has nobody challenged it?” Here’s the issue at hand:

I’ve often thought life in a nursing home in many ways is like life in the college dorms and campus. They are environments constructed by an organization for people of a specific age group (generally) and a specific situation. Living in these environments, you have a roommate who you very likely did not know before you got there. There’s the dining room and cafeteria. And pretty much everything you need is right on campus: drug store, library, places for socializing and entertainment such as movie theater, coffee shop or recreation center, a place to worship, laundry, clinic, security, etc. The major stuff like taking care of the landscaping and green space, cleaning of common areas and general building maintenance are taken care of as well. (And talk about departmental silos- but that is getting off the point.) The idea is that the burden of the chores and errands of daily living are lessened so that focus, time and attention can be spent on other things. In college, it is studying, of course, and in a nursing home, it is the things that take a little more time and effort than they used to.

However, we know that for college students, time spared from daily tasks is also spent on those “new life experiences” and, well, having a good time! Why should it be different for those living in nursing homes? Of course, new experiences and having a good time means very different things to people in their twenties as opposed to folks in their eighties, but it seems so odd for me that in these very similar environments, one inspires activity and growth while the other centers on function (or dysfunction). I don’t think it is the age of the people living within. I think it is the expectations we all have about what is supposed to go on there. In fact, it seems the expectations should be reversed. College kids are going to grow and be active on their own, they don’t need a special environment for that. What they need to do at that stage in life, is learn to function in the “real world.” Whereas, elders are pros at functioning in the real world, but are not in a time of life we generally think of as full of activity and growth like our twenties.

What do you think? How can we change the expectations of what living in a nursing home should be to match the richness of the college experience?