"Ask Pact" is our own question-and-answer column where people can ask their Culture Change questions and have them answered by our seasoned team of trainers and educators. You may find some topics here that are relevant to you - if not, feel free to Ask Pact!

Dear Ask Pact,

Our organization would like to re-evalute the way we do med pass to make it more resident-centered. Where do we start and what resources should we look into?

Thanks,

Judi

To answer this question we turn to Deb Heath, DON at Lenawee Medical Care Facility in Adrian, MI, who has reworked their med pass system.

Dear Judi,

We have used our QIO to assist in some of the best practice information. Your QIO should be able to help you get the information that is backed by research. We started by looking at Federal Regulations regarding medication pass. Nothing in this regulation says that med pass must be done a certain way. Then we looked at the state regs in Michigan and came to the same conclusion. In fact, we found that a new, more resident-centered way of doing med pass is in compliance with OBRA.

We started by looking at the midnight med pass to see if it was really necessary to wake people up in the middle of the night to do it. The idea of putting what was best for the residents above our own convenience really helped us to take the plunge into a new way of doing things. Then we looked at the morning medications and changed them to "upon rising" (though others have used a variety of terms, such as "a.m.").

Then we needed to look at how we would offer the QID and TID medications. With the help of our medical director and pharmacy, we changed a lot of our TID and QID to once or twice a day. This also assisted us in reducing the number of residents with nine or more medications. We have found by reducing the amount on medications, residents are healthier, we have less adverse reactions because of medications and med pass is not the focus of the whole day.

Once we decided we would use the system of "upon rising", "midday" and "prior to bed" we created time frames for each. "Upon rising" is from 6am to 10am. Our medical director decided that "midday" is five hours from "upon rising". "Prior to bed" is between 6pm and 10pm. Of course, this system offers more choice for the residents in how they structure their days and in general, medication pass is less stressful.

Good Luck,
Deb

For more information on changing med pass systems, as well as a feature on Lenawee's culture change journey and other fascinating and informative stories, be sure to check out Culture Change Now! Volume 4, currently available in our webstore.

Dear Ask Pact,

Our company has begun the culture change journey and as part of that process we are looking for someone to be a culture change point person for our 23 facilities. Do you have a sample job description and/or other suggestions to help us with this initial process?

Thanks,

Sharon B.

Dear Sharon,

For individual facilities, we actually do not recommend hiring someone for the sole purpose of leading this change in a facility. We find in a facility that the most effective way to guide the process is to have a Steering Team (made up of both formal and informal leaders) that establishes a very clear change plan, grows themselves as leaders and is committed to high involvement.

However, in a multi-facility organization, it could be very beneficial to have someone who serves as a facilitative educator and consultant. We would strongly suggest that you look for an individual with skills, or the capacity to grow skills, in very defined competencies. The following is a list of competencies that we feel are important, in order of priority:

Critical thinking skills really tie all the competencies together: the analysis that is needed in applying the theories of organization, change and education, and the interpersonal judgment that is required in all the competencies.

Organizational awareness, design and development requires strong analytical skills related to seeing the forest as well as the trees. The person can see complexities of cause and effect and interplay of systems. We call this a "systems thinker."

Facilitative skills help a person to understand group dynamics and can help create a healthy and safe environment where within which individuals can achieve their highest potential.

Knowledge of change theories. First, the candidate must hold a clear belief that individuals can change. He or she understands that change is both personally driven and is a product of environment. To bring about change, we have to create a safe, non-blaming environment where individuals can begin to see themselves as they are, and know that they can grow and change.

Educational skills. Candidates should have strong knowledge of adult education theories and be skillful at designing learning experiences for others. He or she sees that the goal of education efforts should be creating a learning climate and learning organization rather than "teaching" others.

Nursing home culture change knowledge. It would be helpful to have someone who is already knowledgeable about culture change in nursing homes and has perhaps had some experience in such settings.

General nursing home knowledge. There could be value in choosing someone who understands the nursing home world. Because of the complexities of the regulatory, reimbursement, HR and clinical systems that are so unique in nursing homes, it can be beneficial to have this knowledge coming in to this position.

Of course, Action Pact has many training and educational resources for someone in such a position.

Sincerely,
A. Pact

Dear Ask Pact,

Our organization is in the thick of planning for physical plant changes (new and remodel) to support person-directed care. While we have begun discussion of the mindset changes that need to occur, including learning circles, there are some concrete dollars and sense figures we're hoping you can provide:

1. Initial training costs in communication and problem solving
2. Rough Cross-Training Costs (a direct care worker trained as CNA/CMA, Activities, Culinary Arts)
3. Ideal FTEs for ongoing staff training and education annually for a staff of 260
4. Ideal training $$ for ongoing staff training and education annually for a staff of 260

Thanks!

- Kim

Dear Kim,

I'll assume that you are moving toward households, that is:

• A kitchen, dining, living room, outdoors, private home space and (typically) private rooms for 12 - 18 folks
• All staff and all functions assigned into and reporting through self-led teams in each household
• Department directors giving up departments and moving toward mentorships of their discipline (social work, etc.)
• Decentralizing dietary staff into the households with the exception of need to prepare main entree

$90,000 in external training and consulting on culture change. Action Pact typically provides 12 multi-day visits over the 12 - 24 months of household preparation for about that price, which includes all expenses and a wide array of materials for your facility and staff.

The equivalent of 1 CNA FTE wages for every 50 residents. This amount provides you with flexibility when scheduling training time and planning participation for frontline folks. The more available the leadership is to fill in, the less you will need to budget.

Purchase of training differs locally. Many states do offer programs that subsidize workforce training, in whole or in part. Some university and community college systems have grant dollars available as well. Taking some time to investigate these funding sources can really help reduce your initial cost investment.

You're on the right track with your list of training needed. It should include CNA training for anyone who will take it, as well as CDM training for one person per household. This is usually a 50-hour correspondence course with about 50 hours RD oversight. The course generally takes around nine months of part time study. Approximately 100 hours didactic plus a similar number of project hours that can be precepted by the RD in a group format.

We also recommend you add on some leadership training. Action Pact offers this via phone conference for direct care workers, or you might consider our Household Leadership curriculum. This is a program we offer on-site as a group training, but we also conduct an open registration session two to three times a year at our offices for those who only need to train one or two folks. You should have completed this step by around 3 months prior to your move-in date.

Each household should also have a certified Activities Director and Social Service Designee. At least one person per household in addition to the CDM should also undergo ServSafe® or other similar food-service training.

• Housekeeping training for the dietary staff;
• Dietary / kitchen safety training for all housekeeping staff (and at least an hour for all household staff);
• Activities training focused on basic relationships with the residents, engaging them in the daily life of the household, involving residents in activities around dining prep and clean up and salad, dessert and meal prep. You should offer some type of activities training to 100 percent of staff in the houses and outside of the houses (maintenance, office) so that everyone is comfortable interacting with residents.

And, finally, we recommend our signature PersonFirst™ training where we train a core team of 25+ trainers and community builders to be trainers within your organization on person-centered care and with special skills in establishing meaningful relationships with elders living with dementia. Please contact us for more details.

Sincerely,
A. Pact

Dear Ask Pact,

We are moving toward self-led teams and are currently operating in neighborhoods. Can you explain the Neighborhood Coordinator position, its duties and when in the transformation is a good time to implement it?

- Amanda

Dear Amanda,

With the neighborhood coordinator, you are just beginning to reframe the organization. You may have assigned a housekeeper consistently to each neighborhood, perhaps the same dietary person goes there each day, the activities person considers herself a member of the neighborhood and does at least some of the activities on the neighborhood. But you still have departments (SW department, activities department, housekeeping department, dietary department).

Hopefully you have regular meetings on the neighborhood and nursing staff is consistent. People may have named their neighborhood. You have a lot of fun as a neighborhood team. Residents are involved. You're beginning to do some dining things just for the neighborhood.

Almost all organizations combine a neighborhood coordinator with an existing position, just adding these additional responsibilities. We've seen it done many ways. Perhaps the coordinator is a CNA and takes on this role in addition to her regular CNA responsibilities. Perhaps you pay her a differential.

Some of her duties may be: assist or guide the self-scheduling (if you're doing that yet); be available to families on her shift; facilitate the team getting together for meetings (not necessarily leading the meetings - if you're using our Team Meeting Model that may be a rotating responsibility); and tune into the social mood of the neighborhood.

Some of the competencies you're looking for in this position are: Critical thinking skills including analysis (seeing the problems or issues in the neighborhood); judgment (saying and doing the appropriate and right thing); resident-centered or resident directed (seeking the resident's view in everything); interpersonal sensitivity (knowing how to say things in a way that they can be heard, and without hurting people's feelings); and active listening skills.

Keep us posted!

Sincerely,
A. Pact

Dear Ask Pact,

We are starting to cross-train staff with the goal of permanently assigned staff in each household. As we are trying to figure out how to staff the household teams, we'd like to know what the difference is between "versatile worker" and "universal worker"?

- Ben L.

Dear Ben,

That's a great question.

Often people use the words universal worker to describe a staff person who does more than one kind of work in an elder care environment. Traditionally in the world of business and manufacturing, a universal worker is someone who is typically trained in all jobs and may be called upon to do that job for the whole shift or for parts of a shift. In healthcare we have most often heard the term universal worker associated with cross-training of staff who have skills in all of the applicable disciplines (CNA, housekeeping, dietary, activities) and use them all during their shift caring for the resident. We see this more typically in assisted living rather than skilled nursing.

What Action Pact has found more helpful in the Advanced Neighborhood and Household Models is what we have defined as a versatile worker, something quite different in definition from a universal worker.

Action Pact, through our experiences with our clients, has found that in households all staff should be versatile. In other words, all staff should have some cross-training and be responsible to serve elders at least part of their day outside their primary area of expertise.

Example: A CNA may be cross-trained in dietary and housekeeping. Much of her day is providing the direct care typically done by a CNA. However, when Mrs. Smith says she is hungry for something warm, the CNA has the skills and knowledge to get Mrs. Smith a snack. It is an expected part of her job to go to the kitchen and warm up some chicken soup for Mrs. Smith even though it is not lunchtime. Mrs. Smith doesn't have to wait to have something warm to eat and the CNA doesn't have to find someone else to get food or tell Mrs. Smith that she can't have anything until later.

We call this the 80/20 rule. The CNA does CNA work 80 percent of the time and other cross functions 20 percent of the time.

A blended role is a new job that incorporates aspects of other roles into a newly defined role. For example, a homemaker performs a combination of dietary and housekeeping skills within the same shift. So, that role is 80 percent dietary job duties and housekeeping job duties. The other 20 percent would be versatile work that the person in this role is trained for.

Example: The homemaker (a position that is a blend of housekeeping and dietary) has her certification as a nursing assistant, and therefore is able to assist a resident to the toilet while she is cleaning her room.

Versatile workers are all cross-trained, but not always in the same functions.

Examples: A nurse may find the time early in the morning to help a resident with their breakfast. This provides an ideal time for her to assess the resident's progress, and yet gives her the opportunity to enjoy a cup of coffee with the resident while doing so.

A CNA may organize her work one afternoon, with the help of a homemaker, in such a way that she has 20 minutes to do a cooking activity with two residents.

A social worker, cross-trained in dining (feeding) assistance, makes time to assist at one mealtime every day.

A versatile worker will not be called off of their regular job in order to "cover" for another discipline if there is a call-in. A versatile worker will participate as part of the self-led team to decide what needs to be done and who will do it. An employee may choose, if cross-trained in a particular function, to fill a shift in a function other than their primary job.

Examples: A homemaker who chose to be cross-trained as a CNA called on her day off during a snowstorm to see if she could be of help.

A CNA, cross-trained in activities, asked to fill in an activities shift in the household on a particular day because she wanted to do a special activity that she had thought about.

Hope that helps!

Sincerely,

A. Pact

Dear Ask Pact,

I was wondering if you could provide me with a little more information on your Trainer Training: Champions for Care program. In particular, I am curious about the staff-led inservices that can be offered year-round. When the two-person training team is prepared to lead an in-service session, what is the recommended session size? Does the size of these in-house trainings vary greatly according to the comfort level of the training team? Will the Trainer Training: Champions for Care program offer guidelines for length of in-house trainings? If so, what are recommended lengths?

- Donna J.

Dear Donna,

The training curriculum that Action Pact provides encourages different lengths of training. So we show how the content can be used in short 20-30 minute trainings during a team meeting, in a 45-60 minute inservice, and even in a longer workshop.

We do recommend that the trainers work with small training groups, preferably under 15. The techniques that we focus on are small group techniques mainly because these are easy for naturally sensitive good listeners to become expert at. In other words, we suggest you discover the good role-models out there: those who have a natural sensitivity to the residents and their fellow workers. They make the best trainers in the model that we teach. We do not look for the speaker type: the person who may be very articulate and likes being in the spotlight, but rather for the great role model. This assures that the person's natural talents (of facilitation and awareness of others) is put to use. Training only a small group in each session will help if that person does not have the high energy of a skilled speaker. And, when these naturally sensitive good listeners are working with their small groups of 15, they are actually unconsciously demonstrating the skills as they teach them. That's a double-whammy!

However, if you're using a training topic for a large all-staff inservice, you would just use two teams (four trainers) with the most speaker-like person doing the basic presentation, and then breaking down with all four trainers doing facilitation in smaller groups. That works very well.

If you find 16 to 20 folks who take the training you will have eight to ten primary topics including: Learning Circles, The Team Meeting Model, Attributes of Leadership, Building Consensus, Observing Behavior, Listening Skills, Giving and Receiving Feedback and Team Evaluation & Skills. The Champions for Care workbook is available at our webstore. For even more topics for training, look at our trainer's guide for self-led teams, entitled "Living and Working in Harmony" (also sold as a part of the Household Matters Toolkit). That's a great year's worth of learning!

- A. Pact

Dear Ask Pact,

We are currently using a "shower stretcher" for bathing our bedridden folks. Do other facilities use these? Is there a better "culture change" way of bathing?

- Michelle B.

To answer your questions about bathing we turn to Joanne Rader and Ann Louise Barrick, editors of the book and DVD Bathing Without a Battle.

Dear Michelle,

Other places do use them but we have found them to be very rough and cold for those who are frail enough to need them. You can place a bath blanket on the contraption to try to make it less rough and drafty, but then it collects water, which can be messy and cold.

There is, of course, the topic of lifts to transfer the person to the stretcher. The use of lifts, in general, needs to be individualized like any other intervention. Some residents are fine in a lift, while others are terrified.

The training and comfort level of the nursing staff using the lift also contributes to the resident's experience. Many companies make specialized bathing equipment to make the bath more pleasurable for both the resident and the caregiver. The ARJO Company makes a variety of tubs and bathing equipment. They make lift bath trolleys that are essentially stretchers. The resident is transported on the gurney and then the gurney is lowered into the tub so the resident can soak. They also have shower chairs that adjust and are expensive but very comfortable.

However, we've found a bed bath or towel bath to be the preferred method of bathing for people who are frail, have difficulty with movement or are severely impaired either physically or cognitively. Towels are moistened with no-rinse soap and the resident is covered with this towel in their own bed. The caregiver then massages the resident, using the towel like a large wash cloth. Several wash cloths with no rinse soap are used for the face and areas that are heavily soiled. There are also inflatable hair-rinse basins for hair washing in bed. Both practices are detailed in Bathing Without a Battle.

Whatever method is used, it is important to ask for feedback from the resident, watch for cues of discomfort throughout the process, and concentrate on making it a pleasant experience.

- Joanne Rader and Ann Louise Barrick

Dear Ask Pact,

We are looking to have a designated dementia unit that incorporates person-centered care and would like to know if special care units will continue in the culture change movement or are we looking at the elimination of special care unit? Thanks!

- Aaron E.

We've passed this question along to Action Pact consultant Megan Hannan, who specializes in supporting those people who live with dementia and their caregivers. She has presented at the National Alzheimer's Association Conference, the World Congress on Alzheimer's, and the International Eden Alternative conference. These presentations centered on Community Learning Circles, an innovative means of bringing elders who live with dementia, their families and staff together for meaningful interaction.

Dear Aaron,

I am intrigued by your question. The most comprehensive research that I am aware of, done by he Alzheimer's Association several years ago, concluded that it did not matter if people living with dementia resided in a "special care unit" or not as long as the environment provided excellent (person-centered) care.

So then the issue becomes one of your organization, its market, the needs of the population you serve and your resources at hand. I am familiar with growing households and neighborhoods specifically designed for people with dementia. The traditional case for doing this is that "programming" can be tailored to the specific needs of the people living in that neighborhood.

However, if your organization is truly committed to the deep work of creating smaller groups of residents with a dedicated, cross-functional team who is responding to what the residents truly need both as individuals and as a community, then anyone living in that environment will thrive.

Unfortunately, we only have anecdotal outcomes on dementia-specific neighborhoods or households. Most of this evidence is, quite frankly, astounding. When people living with dementia live in a physical environment that has a kitchen, a living room and a dining room, somehow it feels more comfortable. When that environment is supported by staff who listen, watch and respond with support, any person in that environment feels more like "themselves." A specific example is of a lady who had been living in a nursing home for several years and required almost total assistance to eat her meals. She moved into a household about three months ago. Same staff, same residents, but the daily lifestyle is different. She arises when she feels like getting up, there is not a morning rush to confuse her and agitate her. And not only has she been totally independent in her eating, she is relishing her food, eating more and gaining some needed weight. The household team is astounded because it was not an expectation they had. They expected that people would feel better, more comfortable and more included. And that is so. But apparently, along with that is some renewed ability to take care of herself. After all, that is what we all want to do: care for ourselves.

Community circles, using the learning circle concept, are one of the most effective ways to help grow the community aspect of a group of residents by building relationships among residents, staff and families. The environment and organizational structure of a neighborhood or household is dependent on constant relationship building, the better the team knows each other the better the staff are at responding.

So to wrap up, you can see that any true neighborhood or household has the potential to serve people who live with dementia better than large groups with little identity or community. It sounds to me like you are going to create neighborhoods in your whole house, as it were. That is important - everyone deserves to be connected to a small group that benefits from individualized care.

The task you and your team have now is to envision your own future. Ask yourselves, "What makes sense for our home? Our community? Our organization?" You might start by reading In Pursuit of the Sunbeam as a leadership team to begin to shape your vision. I don't know what other resources you have already accessed and are using, but I will be glad to recommend more if you'd like.

You may also be interested in our PersonFirst™ process, which educates, empowers and facilitates an in-house team to teach person-centered care and work hard at growing that culture in your home. In fact, this curriculum and process focuses on people who live with dementia because they are most often left out of much of daily life. We use the knowledge and good skills for serving those living with dementia to apply to person-centered care for everyone.

Feel free to contact us directly with any other questions. Good luck in your endeavors!

- Megan Hannan

Dear Ask Pact,

I am an administrator at a 60-bed facility. We've been looking into implementing the Household Model and would like to know how staffing operates in that framework. There are concerns that it could be a logistical and financial mess. How can we make it work?

- Sharon B.

To answer this question we've turned to our good friend David Slack, Executive Vice President at Aging Research Institute. David, previously Senior Vice President at Lancaster Pollard & Co, an investment banking firm specializing in financing senior living and health care organizations, provides financial analysis and developmental consulting services as part of ARI's advisory services.

Dear Sharon,

Let me first assure you: The numbers can work, both staffing and financially.

And here's how:

1. The resulting staffing patterns end up with a little less middle-manager positions and a little more direct care staff.
2. The way that administration, dining services, nursing, activities and housekeeping departments operate will be affected the most.
3. Nothing will work right unless the CEO and all key managers buy in, get it and live it.
4. You should read "In Pursuit of the Sunbeam" by Steve Shields and LaVrene Norton to understand "culture change" concepts, resident-directed services, self-led teams, and the Household Model.
5. You can buy the "Household Model Toolkit" at www.agingri.org.
6. Action Pact can help assess the current organizational situation and set a plan for moving toward your future.
7. Steve Shields can help the CEO think through development issues and plans.
8. Going from say, a 60 person nursing facility in a traditional double-loaded corridor with mostly semi-private rooms to 3 households of 20 or 4 of 15 or 5 of 12 or 6 of 10 will probably add night time staff for property security and to meet State regs, so night shift duties usually need to change.
9. 3 households of 20 or 4 households of 15 is much more financially viable than 6 households of 10, we have found. Each organization has different factors that go into its decision about what is the right size for a household.
10. You won't save money on staffing a Household Model compared to a traditional nursing facility. Actually, you'll spend about the same amount. But in this new configuration, there will be a much better quality of life with higher resident and employee satisfaction.
11. All the basic nursing facility outcomes must still be met and done well - patient care, rehab, MDS, HR, food prep, all surveyed areas, etc.
12. It takes time to change from wherever you are now to a better way of working and living. You must be totally committed to making this work. It can't be delegated and it can't be part time.
13. It's not about staffing schedules, it's about doing the right thing for residents and staff and the future of your organization. Self-led teams work. Resident-directed services work. Organizations can thrive.
14. Leadership is critical. Backsliding will occur. Leaders must teach, stand firm and move the organization forward.
15. It isn't easy, but it works, and it is the right thing to do.
16. Read the book, decide to do it, then hire the most experienced advisors, consultants, architects, and financial feasibility/bankers you can find, who know what you're talking about and can help train you and your staff and advise you along the way.

Hope this helps!

- David

Dear Ask Pact,

We've heard about the "five meal plan" for enhanced dining and it sounds like a great service to offer our residents, but it also sounds like a logistical nightmare! How do you pull it off?

- Terry

Linda Bump, MPH, RD, LD, our dietary expert and author of the Action Pact workbook, Life Happens in the Kitchen, offers some thoughts on alternative dining options and implementation:

Dear Terry,

First of all, you are right - it is a great service to offer residents. But, in no way is it necessary that facilities in any stage of culture change implement the five-meal plan. It is simply one of many approaches that facilities should consider to achieve the goals of increasing resident choice, individualization and resident satisfaction with dining in long-term care. In fact, some facilities find that anything other than the three-meal plan does not fit their culture or residents' habits. This five-meal plan choice could be available to any facility, traditional to household, but to be successful, should be considered thoughtfully, and based on resident and family acceptance as determined through learning circles and other team approaches to care.

There are many variations of the five meal plan, but most include a continental breakfast, offered by nursing at the time of rising, a "big" breakfast brunch served from the main kitchen, an early afternoon healthy nourishment often served by activities, the traditional dinner/supper "main" meat and potato meal in the late afternoon from the main kitchen, and a substantial bed time snack often served by nursing as part of the evening routine. The same number of servings from food groups that are used in the traditional three meal/two snack meal plan are used in the five meal plan. This does not change the budget as the same food cost for the day is spread over five meals instead of three.

It's all about opportunity for resident choice and pleasant dining environment whether at three, four or five meals a day, depending upon the physical plant limitations, and the regulations of the state on alternative meal service. The Action Pact workbook Life Happens in the Kitchen offers additional approaches to resident centered dining at every stage of transformation, and might assist facilities in considering the implementation of resident-centered dining practices that are less stressful systemic changes than the five meal plan which, because it impacts on every system in the facility, requires a successful team approach to develop and implement successfully.

The high involvement approach to consideration of implementation is essential for its success, whether the facility is committed to culture change or has a more traditional approach to quality. In the absence of team, high involvement, commitment to resident centered care, and other features of deep commitment to culture change, the five meal plan may well offer no advantages in satisfaction over the traditional three meal plan, and in fact, may detract from success due to the complexity of the implementation process.

Other earlier efforts can be taken to increase choice including the addition of a continental breakfast, expanding the breakfast time and/or providing breakfast to order one day a week.

All hands on deck dining is a salient feature of many culture changed facilities, and the commitment to assist at meal times, especially with widespread cross training to the dining assistant role, is of significant assistance to achieve positive outcomes in resident-centered dining. Successful implementation of the five-meal plan is best supported by the active involvement of many departments, with dietary, activities, and nursing working together to most effectively serve each of the five meals. Each facility may find a different approach based on their traditional staffing pattern. But the reality is that traditional facilities have always been expected to serve bedtime snacks to many if not all of their residents, at the same staffing ratio they currently implement. So the five-meal plan may simply focus more attention on the traditional failed practice of the snack cart coming out from the kitchen at 6:30 or 7, sitting unserved to residents who are either already in bed or not hungry because they just finished eating.

The right meal plan for your organization is the meal plan most of your residents prefer. Brainstorming, trial and error, resident input and family involvement will help your team figure out what works best.

- Linda Bump

Dear Ask Pact,

We are in the process of Culture Transformation. The facility that I work at sent me and two other staff to Florida to attend a seminar. When we returned we were all excited and happy! Now that our staffing is down and we don't know when there will be new staff added, the morale in our facility is at the lowest that I have ever seen. I would like some ideas as to what can be done to make it a happier place to work again. Thank you for your time.

- Maurine

Dear Maurine,

Well, I'm guessing part of your morale problem is because people feel rushed to get everything done because there is not enough staff to cover. That can really stink. Low morale in any work place happens when people feel production and "efficiency" are valued more than the people themselves, both those providing service or product and those consuming. The answer then is putting the focus on people and relationships.

You're going to think we're crazy, but we'll suggest you spend more time with the residents. "What?!" you say, "We don't have time to do that." Well, the energy that sustains low morale is already costing you time. If you don't have the authority to authorize folks to spend more time with residents, take it to your Steering Team (if your transformation is that far along) or whoever does have the authority (this may be the person who sent you to the seminar in Florida). Try this. Each staff person takes 5-10 minutes a day to sit down, talk and get to know a resident. You can even structure it the way you do breaks - not that this should replace a break, but that times are staggered and time limits kept. After a week or two, get the staff together for a learning circle (click here for learning circle directions). Include residents too. Ask each staff member to introduce the elder they've been visiting with by telling the group what they've learned about the resident. You could even have the residents introduce the staff members they've been visiting with. Then keep it up. Make it part of the job. It may not have to be in such a formal matter, but make people spending time with each other a priority. Staff will be better able to serve residents because they will better understand them and their needs. And, residents will gain more confidence in the staff because they know and trust them. Remember, folks got into this line of work because they wanted to care for people, not because they wanted to check off tasks.

Here's a simple handout with a few ideas for connecting with residents. You may want to post it around to give folks some ideas or, you may want to ask people to add to the list.

The other thing would be to get residents and staff together to plan some change or event. Maybe adding some homey touches to the bathroom, throwing a holiday or "no reason at all" party or arranging to get residents together for coffee clutch or cards. Use a learning circle to get input from everyone and then figure out together how to make it work. This will keep the momentum of change moving and also integrate resident direction into daily life. All these things should help remind people why the work they do is important and that they are valued.

Sincerely,

A. Pact

Dear Ask Pact,

We'd like to make the physical environment of our facility more homelike. There is so much to do and so many options. Where do we start? How can we give residents a say in their surroundings? And how have other facilities addressed this issue?

- David

Dear David,

Each household or neighborhood should have a distinct character, perhaps in keeping with the name of the house or neighborhood or with an interior home style. We want to stay as far away from tract housing as possible, so design change as well as color change is important. Color alone is token and a very traditional institutional approach to individualization, so the more that the furnishings (both design and finishing) can reflect the character the better. So we have seen households that reflect an arts-and-crafts feel while others in the same building have a formal traditional or country style. The kitchen cabinetry, the archways in the common areas, the partial wall dividers, the book case units, the lighting fixtures, the artwork, the floor choices and colors, and the furnishings all reflect these differences. This can be done for very little cost differential because your purchases will still often be from the same vendors - but it will move your environment from feeling like institution to feeling like home. I could give you facilities to tour that only distinguished with color, and those that distinguished with style of interiors and furnishings. You would quickly see the dramatic difference this gives in the feel of the building. You would leave the tour insisting that the flooring, wall treatments, wood finishes, and furnishings in each household should be distinctive. Be attentive to this principle in the common areas of the households, but also to the greatest extent possible in the resident rooms.

Within a given house, the resident rooms generally will need to have the same furnishings in order to take advantage of bulk purchasing, but there should be at least two if not three choices for window treatments and choices in bed spreads. This requires purchase of a few extra of each design to have in reserve. Wall color in resident rooms is often an issue because painters take you to the cleaners for individual room choice, and besides, it is nearly impossible to know which resident will be in which room at the time the painters need to know the room color. So you can compromise with a neutral room color throughout the household, and then have repaint options for choice, or plan to offer borders for individualization of each resident room over the base color.

Other individualized touches can be created with swags. All windows could have a base curtain/drape that matches the walls, but swags could be available to change out the look and feel of a room. They could be different in color, fabric, plain or pattern, and even in style of draping on the rod. This, with bedspread choices can help a resident nicely "change out" a room. A shelf, window sills, or other places designed for resident display of belongings will do a lot to assist in individualization. One facility offered a choice of small round table or desk that greatly added to the private room in very different ways. And finally - in Minnesota you will see a number of facilities that offer a private "kitchen" in rooms with built in cabinetry and space for a small refrigerator, an additional tiny sink and a microwave (see Nielson Place in Bemidji, Lyngblomsten, Bigfork Valley).

The individual room appointments can also be different by having magazine racks, wastebaskets and other things that reflect home. Of course, you will encourage families to bring in belongings that create home including the residents' furniture. You could create a friendly brochure that helped families understand your principles and encouraged them to help the resident create home with some of their own belongings.

Sincerely,

A. Pact

Dear Ask Pact,

I have read a lot about Culture Change and have watched the pictures and stories on your website grow. I have been inspired to create a new life for our Elders, one that has the elders at the center of all daily decisions in their daily lives. We have great staff and a supportive management group, but unfortunately we don't currently have the funds to renovate into the household model. I have been told that the funds to renovate our building could be more than 2 years away. Do you have any suggestions for what we could do to our physical environment between now and then? We still have 'day rooms' and nurses' stations! Help!

We are ready to get started, but not sure how?

- Carolyn from Ohio

Carolyn, we have asked our friend Sarah MacKenzie from Australia to share her experience of how her organization was able to begin physical changes before having the money to fully renovate their home. Hopefully her stories from Down Under will help you to get started. Here is Sarah's response:

G'day Carolyn,

The question you pose is one that I struggled with a few years ago. I worked with Action Pact for several months back in 2001 learning about the Household Model and Culture Change. I was so inspired after visiting places like Meadowlark Hills in Kansas and Northern Pines in Minnesota that I knew I had to come back to OZ and implement the household model. It really was a journey in creating a new life for our elders, a place they could call home.

My organization in Australia has several long-term care homes and one of them was opening a new extension in 2002. This home (Ashley Terrace) was undergoing major change with a building extension, a home for a further 20 Elders and of course new staff and families joining the existing team. Ashley Terrace was in a time of change, so I decided to start our Culture Change movement there. I worked intensely with the elders, staff and families, as well as our Board of Directors and Managers to help them to understand how the household model works and talk about a new way of life for all. After many discussions, workshops, education, talking and listening, the team of elders, staff and families were in support of the idea. Even the Directors and Mangers were on board.

In 2002 when the Ashley Terrace extension opened, it was our first household of 20 Elders all living together with permanent staff team and high family involvement. We called this community Gumnut Grove and it is purpose built with a kitchen and dining room as well as a family room that opened to a backyard with a BBQ and outdoor setting, amongst a small garden.

The older part of Ashley Terrace was also renovated while we had the tradesmen (we call them "Tradies" for short in OZ) on site, which made it financially more affordable. The existing part of the home had new kitchen and dining rooms installed to make two other households, they were quickly named "Banksia Crescent" and "Waratah Way". In the first 12 months of Ashley Terrace trialing the household model, we witnessed amazing differences in elders, in staff and noticed more family and community involvement than ever before. It was working so well that even the company Directors could feel and smell the difference when popping in for a visit. One Elder commented, "This place feels bloody sensational", which translates to a very impressed Elder.

My organization was expanding and had new long-term care homes being built, and suddenly the architect was brought in to visit Ashley Terrace and requested to change his designs for all new developments to create small Households. This was great for all our projects going forward, however we still had another home called "Eden Terrace" that was not operating in this Culture Change model. Due to the cost of the Ashley Terrace extension and with new developments happening, we were told there were no available funds for renovation of Eden Terrace for at least 18 months.

Eden Terrace is just over a mile down the road from Ashley Terrace, so staff and some of the Elders had visited Ashley Terrace and observed the changes. We were being asked, "When is it Eden Terrace's turn to get households?" Faced with this challenge, we formed a team of people to work out what we could do that didn't cost. First and foremost we began with introducing permanently assigned staff teams. Instead of having staff rotate through different parts of the building, they were assigned to just one area. This was of course done in consultation with staff and Elders. Staff had a say in which elders they wanted to work with and elders had a say in to which staff they had a special bond with.

It is important to start to get the teams formed as a means to decisions being made by the elders or those closest to them. I encourage you to work at lot with the staff and elders to help them in the early days to have the confidence and support to make the decisions that were previously made by Management or Department heads. This a scary process to get used to for Staff and Elders and even more so for Managers and Department heads to learn to trust and empower, rather than do!

At this point in time, Eden Terrace still had a dining room for 60 elders and several very large lounge rooms. Staff and elders started to talk about moving furniture around to transform one dining room into small dining and small lounge room for 20 people, then to convert one of the large lounges into part dining as well. We did this for 3 areas of the facility. This was challenging for the kitchen staff (dietary) to now serve 3 areas instead of only one. We were able to find a small amount of money in the operating budget to purchase a food cart to transport the food and also, elders compromised and staggered their meal times to fit with the kitchen's capabilities. It is important to look at what space you have and what existing furniture you have - none of that costs.

After the dining was working reasonably well and teams were starting to display their own distinct personalities, we started to see photos of Elders appear on the walls. Staff had asked the elders in their area to donate a photo of themselves or their families to hang on the wall in the community. We wore the cost of the picture hook! A good majority of the elders were more than happy to bring a photo from their bedroom and share it with their Clayton (do you use that word in the US?) household team, and this provoked amazing storytelling and bonding between Elders. An elder sharing their life and personhood is all about the journey towards finding home and a connection with their environment and those around them.

[Ed. note: Clayton is an Australian term meaning 'pretend' or 'make-believe,' as in, "She has a Clayton boyfriend." In other words, while they weren't all the way there, staff were working together as a team, as if they had a physical household.]

Our Maintenance man had been busy at work performing minor changes to storage cupboards to convert them into mini-medication rooms for each area with room for their documentation folders. This meant that staff didn't have to travel far and didn't have to leave their Elders waiting. Think about that nurses' station! I bet there is space to be found there. I have seen nursing homes pull out the nurse station and convert to a private sitting area for elders. A small cupboard or a roll-top desk is enough space for your record keeping. And how private is a nurses' station for a verbal handover?

We found by this point households were forming without the walls. There were no Clayton teams, no Clayton companions. We had the real thing! What existed was actually home with loving little families and closed bonded teams. Culture Change had found legs and was starting to walk. In fact, we had so many Elders and Staff pestering the Chief Finance Officer for renovation funds, that Eden Terrace did get the funds after 18 months to build the walls and install the real kitchens and put front doors on the households. We had created a new culture and the final physical renovation to create the physical household was just a means to locking that culture in, adding the warmth and security to the family and team that lived inside that home.

Eden Terrace taught our organization about Culture Creation through Clayton Households and the spirit of believing in change and believing in people.

I really hope this helps you and your team on your journey. Good luck from OZ!

- Sarah MacKenzie

Dear Ask Pact,

The company I work for just sent us to a 3 day seminar on the Eden Alternative. We were all very excited and motivated. My question is this: the specific building I work in is a 50 bed facility where all our residents (Elders) have major behavioral issues. A lot of schizophrenia, bipolar disorders, etc. Do you have any specific idea on how to implement the different aspects we learned about? Most of what I have read is geared towards the geriatric resident. Many of our residents are very young. Thanks.

- Kim

Kim, we have asked our good friend Nancy Fox, Executive Director the Eden Alternative, to give your question her personal attention. She has kindly done so in great detail and has included two downloadable handouts for you to use. Here's Nancy's reply.

Dear Kim,

What an important question. If Eden were designed only to help old people or people without mental challenges, then I think it would be a failure. Our charge is to create a world that is better for everyone, not just the few.

In Eden language, we define an Elder as someone who by the virtue of their life experience is here to teach us how to be human. So an Elder is not defining a chronological age, it is defining a life experience. That life experience can include physical or mental challenges that place someone in a position of honor and respect in our society because they truly teach us everyday. They teach us those things that make us human. They teach us about patience and compassion and unconditional love, and forgiveness and humility. Caregivers understand that by giving care, they are also receiving something very valuable in return. That gift is the gift of our own humanity.

Bill and Jude Thomas know this lesson well. They have two special needs daughters who teach them every day. Hannah and Haleigh may be 9 and 11 years old, but they are truly Elders in our community.

As for Elders living with psychiatric illnesses, I can tell you from my own experience, that the lessons of Eden can help you create a life worth living for them, as well. I believe that many of the "behavior" problems we experience in caring for these special people are a result of our attempts at forcing them to conform to the scheduled routines and published policies of the institutional model. They are suffering from loneliness, helplessness, and boredom, and the lack of meaning in their lives. Eden teaches us that relationships matter - love matters! In the organization that I was privileged to be involved with in this Eden journey, we had 94% of our Elders living with dementia or psychiatric illnesses. By creating meaningful relationships and a world in which those Elders had autonomy over their daily lives, we were able to reduce "behavior problems" by 92%.

I would begin your journey by listening to the Elders and the hands-on caregivers. Engaging them in conversations (learning circles) about the things that they care about. Help the Elders become well-known by implementing permanent assignment of staff, so that the same people are caring for the same people every day. When we know the Elder well, we can begin to create a world in which he or she feels at home, and feels loved. Begin to grow your teams and listen to what they are telling you. What are the current institutional methods of operation that are getting in their way of creating a better world for the Elders? One of the best ways to warm the soil of your organization is to listen and involve others in creating a world in which they can be comfortable. When you do that, you will create a world that is better for all.

I would refer you to your Haleigh's Almanac that you received in Eden training. It is a vast resource for you to use in this journey. Look at two sections - The Farmer's Calendar - which is a personal pathway to Eden, and The Gardener's Companion - which is an organizational pathway to Eden. Those chapters are filled with tools that you can use to begin this journey. I am attaching two files from Haleigh's Almanac or you to use as you begin your journey. The first is Ten Ways to Create involvement. The other is a brief tool for creating a vision. You want to get as many people as possible involved in creating a new vision for your journey. I would also refer you to Carol Ende, our Eden Support person. Her email is cende@edenalt.com. If you will email Carol, she can put you in touch with other Eden Homes that have a large percentage of younger Elders and those who have a large percentage of Elders living with psychiatric illnesses. One of the great benefits of The Eden Alternative is that we have hundreds of organizations who are on this journey who are all willing to help each other. I would encourage you to talk with these other organizations to discover the things that have worked and not worked for them. This journey is not an easy one, but it is an important. Learn from each other. Be patient, Be creative. Be committed. I want to thank you for having the courage to make a better world, and for giving me this opportunity to answer your question.

- Nancy Fox, Executive Director, The Eden Alternative

Dear Ask Pact,

As the Business Manager, I am hoping that you can shed some light on the role of the "non-caregiver" in the culture change move. We who work in the office areas are not clear of what our role should be in the grand scheme of things, and it's never been clearly defined to us. Are there articles available or websites where we can get some information on this aspect of culture change? I'd appreciate any help you can give us.

- Sue Sawyer, Director of Administrative Services, Brethren Retirement Community

Dear Sue,

Great question! And one that could come up in every department in a facility - business office, housekeeping, laundry, maintenance and dietary - where people have not traditionally provided direct care to residents.

It's all about relationships. No matter what your primary role in the facility, work to establish relationships with residents and the staff in a household or neighborhood. This could be friend, neighbor, advocate, sponsor, pen pal, extended family, adopted grandparent.. as long as it is a consistent, caring dependable relationship. If you're in a neighborhood model, have each person in the facility be assigned to a neighborhood.

First let me describe what I mean by neighborhood. One vital component is to have decentralized dining or at least a clustering of dining experiences (continental breakfast, or snack bar) to whatever extent possible by your physical limitations in your hallway, wing or unit. It is also important to have staff who are permanently assigned to the neighborhood and do not rotate, except in emergencies. There should be an integrated team approach to care. And finally, the neighborhood should regularly involve residents and staff together in directing their neighborhood functions and activities.

So what do these folks from other departments do in the neighborhood? What is expected of them after they're assigned? I think that's different position by position - and perhaps facility by facility. But again, I can give you some suggestions by position.

Housekeepers: Each is assigned to a neighborhood and works only there with the exception that each might have some common area that they are also responsible for. A housekeeper can clean with the residents, reminiscing about the many hours they cleaned, the products they used, their special preferences for how to care for their special possessions. A resident could share the story behind Aunt Emily's vase or a favorite scent that reminds her of clean. The housekeeper then could clean the vase just the right way. (The housekeeper could ask family to bring in the favorite product, but remember, cleaning products need to be locked up.) In honoring their possessions and their preferences, you are honoring the person. As part of the staff team, housekeepers attend neighborhood team meetings.

Dietary: Dietary staff can become familiar with the residents' favorite foods and bring them a bigger portion or just the knowledge that supper tonight is their favorite and something to look forward to. There is opportunity to grow a special relationship just by bringing warm cookies out of the oven or knowing whether the resident likes white or dark meat without having to ask. Imagine the pride of the resident who teaches a dietary staff person how to make her famous homemade fudge, assists in the preparation and then shares the treat with members of her household or a neighbor. Dietary staff can grow in their relationship with the resident in their households by training to participate in the RAI process, particularly the care planning process, attending and sharing their relationships with the residents first hand. Dietary staff members should be assigned to a neighborhood. They deliver food to that neighborhood and help in the dining room if possible. They also do clean-up in that dining room. They attend neighborhood team meetings as the representative from dietary and serve the dietary department as a representative of that neighborhood.

Maintenance and Laundry: If there are enough laundry personnel, have each belong to a neighborhood. They can deliver to and collect from that neighborhood. They can get to know the residents there - solve their lost socks problems and learn how they like their clothes to be folded. If there is not enough staff in this area, consider having each neighborhood have a maintenance or laundry person assigned to them.

Business Office: Have each person belong to a neighborhood as an extended family member. They should try to make some of the meetings, especially when they're planning activities and special events. Encourage them to hang their coat in their neighborhood or household if it is reasonable. That way they stop and chat when they come in and say goodbye as they leave. The neighborhood might want to develop a buddy system so that non-caregivers assigned to the neighborhood can have a special relationship with someone. Definitely include them in all holidays and special events. It's important not to overwhelm them with expectations ("You have to answer call lights in our hall," for example), but let it be relationship based. We grow our expectations of ourselves as we begin to grow in our respect and love for each other. If business office folks are resistive, talk it through with them. What worries them? What intrigues them? Often they're afraid of the unknown. They think they won't measure up. They can't imagine building a relationship with someone who needs so much. Provide them with a little interpersonal training. Help them see that residents are people too. If a staff member is very frightened about building a relationship with someone who is seriously frail, assign that staff person to befriend someone who is able to give a little back. Let the business staff person ease into this new role, to grow in self-confidence.

Here is one HR staff member's story of the joy she found in her friendship with a resident (contributed by Vonda Hollingsworth of Pennybyrn at Maryfield in High Point, NC):

Today I had fried chicken and macaroni and cheese for lunch. It made me miss my friend Foby. She almost made it to her 99th birthday, missing it by only five days. You might think someone that old would be "slipping" a bit. Well, you might get into trouble thinking that way around Foby! She could recite all the books of the Bible at a speed that made me dizzy. Everyday she did the puzzle in the newspaper. Occasionally, she would get stumped, in which case I was usually of no help. If she couldn't figure it out neither could I. Sometimes I had to communicate by writing, since her hearing had mostly gone. However, she had taught elementary school in her past life and would chastise you for your poor handwriting or spelling without fail. Hers, of course, was elegant and flawless. If you were a republican, you had better learn to keep it to yourself - or else run fast. Everyday, she saved her boiled egg from breakfast to fuss at the kitchen staff for not knowing what SOFT BOLIED meant. Food was her favorite subject to fuss about, since obviously no one could cook in our kitchen. That is, except for Sundays when we had fried chicken and macaroni and cheese. For some reason, that day they would get it right. I would take her through the buffet where she would demand a big breast with no back meat and the corner from the macaroni pan (the cheese settled there) and we would enjoy lunch together.

When I held her hand in the hospital bed that last day, I thought how lucky I was to have known her. Five years ago, I would have never thought that I would so dearly love this woman her stuck out her tongue when you walked by and would never let anyone sit with her. Oh, what I would have lost out on. And maybe, just maybe, I gave a little back to her. We just might have missed that opportunity to love each other if it hadn't been for the strong pull of "Culture Change" in our home. See, I am not a direct caregiver, or even a housekeeper who gets to work and spend their days with the residents. I am just a Human Resource Director who has no reason to build relationship with residents. No reason except that it makes a difference in their life and in mine.

Oh, and Foby, I had the corner of the macaroni in your honor today.

Any staff member could get to know the resident's favorite powder or cologne or room freshener and be a secret pal providing it. You could also be a special link with resident family members, facilitating a special phone call to a family member each week just to report on the week. These could be business office things; just think how nice it might be to get an update on Grandma in with the bill. Make sure to consider confidentiality issues and get an OK from the resident.

Here's a list of 17 ways to engage elders. Use it to inspire and maybe even post it as a reminder.

Sincerely,

A. Pact

Dear Ask Pact,

I am a grad student studying activites and leisure in regards to the culture change movement. I would like to know how activities are successful in this model, and what are the challenges a community would face when planning, and implementing such. I am working on an education module to assist those in the culture change movement to use activity program to the benefit of all. I have looked around but there are not too many books on the subject of activities in a culture model, usually just the medical nursing home approach. Any suggestions would be greatly appreciated.

-Brandy M. from Kansas State

Dear Brandy:

There's not much written yet on activities and leisure in the new world we're all wanting to create. But one name does stand out: Carmen Bowman from Educatering in Colorado has written a couple of significant workbooks, Quality of Life and Lighting the Way, which are available in the Action Pact webstore.

We decided to contact our good friend Carmen and ask her to offer you some some sage words. Here's what she has to say:

Regarding activities and the exciting culture change movement, really what it is all about is getting back to what is normal. Person-centered care is what we all want, care that is centered around each of us, our lifelong routines, interests and preferences. Pioneers are realizing it is not normal to have group birthday parties for anyone who happens to have a birthday in the month, mass memorial services for anyone who happened to pass away since the last one or only structured activities planned by someone else. These are welcome and needed changes.

A sterile hospital-like environment is also not what people want. Thankfully, pioneers recognize this as well and as we create true home for people, even those needing nursing care, we find that persons with dementia no longer need to find home and families and visitors come more often and stay longer.

Person-centered care also includes that anyone can take care of me at anytime regardless of what I need. Thus there is a growing trend of the use of universal workers within the culture change movement. Unfortunately, many activity and recreation professionals (as well as every other kind of professional) fear this move to a cross trained workforce for fear of losing our identity and what we went to school to do! However, what has helped me is realizing that when we can each do anything a resident wants or needs, this is true customer service, what we're there for finally in its best form. Another way to view universal workers is that we are gaining more opportunity to offer residents activities via cross training and also the opportunity to teach others how to offer activities that are meaningful to residents. In addition, this model of care is becoming our future.

When we worry about "but that's not my job," we are simply perpetuating what is being called "disciplinary silos" or "department silos" that just add to the institutionalization of it all creating barriers toward providing residents with what they need and when they need it. Culture change is all about common sense. A home is where family members take turns taking care of the home and each other.

The universal worker concept works best when the entire home is undergoing changing from institutional to person centered care. Those pioneer homes who have really incorporated every aspect toward genuine person-centered care are succeeding with this much more than those who may only do parts of culture change. Case in point, in one home that decided to have CNAs also provide activities, that was the only change made - a new duty assigned to already burdened staff. When the activity/recreation director called me because activities were going undone I told her she would have to become the "activity ombudsman" advocating for the residents' desires and rights for activities. In this situation, you could try to make some demands up front regarding how activities will occur every day and get them in policy. But you see, this is a home that is not changing the entire culture, only adding burden to already burdened staff. LaVrene Norton of Action Pact teaches that culture change includes deciding to undergo personal transformation as well. This point of cross-training challenges us personally to make a commitment to change.

In a true neighborhood or household model, the original activity/recreation director now grows into a teacher and trainer of other staff in assessing, care planning and implementing activities that are resident-centered and resident-directed. An advantage to this cross-training is that no longer is the activity staff "assigned" to a unit, viewed as an outsider nor are activities viewed as something only the activity staff do and therefore only take place when activity staff are present.

Culture change is challenging us all to move away from only caring for "parts" of a person. I care for their activity interests and someone else cares for their dietary needs. We are all to be caring for the whole person this is where the institutional model fails us. When facility staff make this commitment, beautiful things happen from people living longer to increased census to more satisfied residents and staff. It really is a win-win when done thoroughly and in a way to affect the entire culture.

Feel free to copy this answer and download this questionnaire. Pass them around and encourage recreational therapy and activities folks to talk, argue and grow. This is an exciting time - a time in which we all can truly make a difference.

Sincerely,

Carmen Bowman

Dear Ask Pact:

Our staff keeps asking how they're going to make this culture change thing work with those who are bedridden, are severely contracted, or unresponsive. They can see how it's all meaningful for our active community members, but they focus their concern on the smaller number of people with this level of debilitation. Any thoughts on that?

I'm going to try to start up a focus group on this very thing, but I know they'll need something to jump start them. Any ideas?

- Mark

Dear Mark:

Mark, this is a question we hear all the time. It is interesting to me for a number of reasons.

First, though you have created 'home' and a sense of 'family', I assure you, that small group of staff will not be satisfied, will not sleep well at night, until they figure out the answer for the person(s) in their neighborhood that is lying in bed. The wonderful thing is that at that point there will be an entire team - caregivers, professionals, families - that will try to figure out the answer for the elder that needs special attention. And it will be far more effective than a care plan!

Person-centered care is extremely attentive to this situation. Think about it: who do we ignore in the traditional setting, who do we begin to think of as more of an object? The quiet, the non-responsive, the bed-ridden. And this philosophy says NO: 'I am a person, lying here, reach me, touch me, love me'. This is very powerful - you will see magic happen, and hear dramatic stories of a tear on the cheek, or a hand moving, a tight grip, a soft 'thank you'.

The story I tell to exemplify this, is of a group of elders on a small team with staff working to learn about daily pleasures. They divided up the elders in their neighborhood and began to interview them. One resident had been very eager to interview a non-responsive bed-ridden fellow. She said she had thought a lot about him, every time she passed his room, and wondered about his life. Other people were confused (how could she 'interview' him?) but were relieved that she had volunteered.

She went to see him and came away and told this story. She said that she told him what the team was doing. That they cared and wanted everybody to have a few minutes of pleasure every day - as they always had at home - that for some, that meant coffee in their pajamas, for others it might mean music in their room, or a chance to go outside every day. She told him that she was a resident, and that her daily pleasure has always been to talk to people and to connect with others. And so she had jumped at the chance to come and talk to him about his daily pleasure. He did not reply, but she sat with him. A little while later, she prepared to leave - his hand was just a few inches from her and as she started to stand, he reached over and put his index finger inside the cuff of her sweater, restraining her in the slightest manner. She turned to his face and tears were streaming down. She had found a new friend, someone she could be with every day for a few minutes, deepening her pleasures in daily life, and certainly his.

Please feel free to print this out and share it with staff. Encourage your staff to tell stories of miracles that they have already seen in their work lives. The stories are out there, even in the traditional world, of miracles of connection, relationship, and person-centered care for the severely disabled. Help your team discover them amongst themselves, and they will quickly realize their own power.

Perhaps hand this letter out before a learning circle, let people read it - then begin the circle with each person sharing a thought or feeling. When you open for discussion, ask who has experienced one of these miracles with the quiet elders who live in their beds and with minimal communication. Ask them to tell their story. After a few stories have been told, ask the group - who, of our residents, worries you the most? Then move to a discussion of what can we do to bring a few moments of pleasure each day to that elder.

Yours Truly,

A. Pact

Dear Ask Pact:

We're all very excited about beginning to implement Culture Change in our facility. I feel that with such an ambitious venture, our first steps should be squarely on the right path from the very start. I'm beginning to make plans for a retreat with our department managers that will help us consolidate our vision of culture change in our home.

Can you help me with some topic ideas, and/or exercises we can do to help us articulate and coalesce some of the many visions we have been discussing into a clear picture, that will have each of my managers moving forward in the same direction?

- An Administrator Committed to Culture Change

Dear Committed Administrator:

I'm including a complete plan for a leadership retreat that you can download and use, including the handouts that you will need. Please feel free to download them and use them as necessary.

Yours Truly,

A. Pact

Dear Ask Pact:

We're a great facility. We have good surveys, a solid administration (our Administrator has been here for 4 years, the DON for 15 years), and a lot of staff that have been with us for a long time. Our residents' families love us. We don't get many complaints from anyone!

But still, some of our residents aren't very happy. Most of them are, but we're beginning to feel like that's not enough.

To get to the point, many of us have been talking about this Culture Change thing. We've printed off pages from your website and talked about it at Department Head meetings and at In-services. Some of us have gone to some training sessions here in Illinois. A bunch of us heard Steve Shields talk.

We know this is what we want to do, but how do we get started?

- Friends from a Loving Facility

Dear Friends:

There are many ways to start. With a leadership retreat, or a facility-wide education process, or some wonderful event inviting families to come in and talk about possibilities. Gather up some volunteers from each of these efforts and go to work.

Below you will find the checklist we have developed that may be of some help to you. Good luck and let us know how we might be of further help.

Yours Truly,

A. Pact

Getting Started Checklist:

___ Read the article from Culture Change Now Volume 1, page 5, entitled: The Phases of Culture Change.

___ Form a Steering Team to decide what issues need to be tackled first. The best Steering Team will include both formal and informal leaders. Formal leaders are your department heads and others in leadership positions. Informal leaders are those who influence others, even though they may not be in positions of authority.

___ Create a Vision

___ Work to accomplish High Involvement (participation from residents, their families, and staff in all departments, shifts and positions).

___ Develop permanent Care Teams that can grow into Neighborhoods.

___ Engage staff, families and residents in helping to realize residents' Daily Pleasures.

___ Broaden the Leadership Team from Department Heads to include informal leadership (see above).

___ Use a Team Meeting Model to conduct all meetings.

___ Create Study Teams (that will have Steering Team representation) to study innovations in various areas (perhaps dining, creating home, bathing, person-centered rather than behaviorally managed dementia care, etc).

___ Encourage each team to look at what they can do in the short term and what they will need to move toward more slowly. For example, implement a Bathing Team that would review "Bathing Without a Battle" by Joanne Rader and determine how all staff would receive the relevant training. Then, establish a bath team in each neighborhood to begin to fix up each individual bath room.

___ Read Learning Circle article: Power of the Circle by LaVrene Norton and begin to use Learning Circles before and after in-services, as team-builders, as ways to change the climate in the early stages of culture change.

___ Carefully examine the Values of the Pioneer Network and the Principles of the Eden Alternative. Ask yourself how they are similar and how they are different. Where do they overlap? How do we articulate our own values and principles?

___ Pull out your policy and procedure manuals and look through them. Hold each policy up to the light of the principles and values, and write in the margin beside them which ideas they reflect. Perhaps they reflect a person centered culture of care, perhaps they don't. Do they reflect management caring for staff as management would have staff care for elders? If so, great! If not, what can be changed? Create Common Ground and High Involvement as you work through this exercise.