Willow Bend: A Transformation Story

1. Willow Bend: A Transformation Story DFW Coalition on Culture Change November 6th, 8th, & 14th

2. Culture – How To Change? Culture is the patterns of behavior & thought that groups of people learn, create, and share. It includes beliefs, rules of behavior, language, rituals, politics, economic systems, and symbols. culmination of Experiences  create or reinforce Beliefs  reinforce / drive Actions  produce Results As Culture spins, it creates an inertial energy that produces Results (whether we like them or not) Changing the spin & the inertia begins with EXPERIENCESFigure: Culture, Results, Experiences, Beliefs, Actions & Behaviors

3. Org Structure Influences Experiences Corp or Regional Decision Making – Top Down (P&Ps, Contracts, etc.) Facility Feeds the Bureaucracy Facility Staff Feel Subjected to Corporate Whims – Out of Control Facility is just another place to work Local Decision Making – Staff Empowerment Entrepreneurial Nature – Meet Needs of Market Intelligent Risk Taking – Capital Investment Model Common Org Functions – Outsourced to “Service Center” Staff Feel More Invested in OutcomesFigure: Corporate Leadership, Regional Leadership, Facility Leadership, Facility Staff Figure: Facility Leadership & Staff, Service Center

4. Facility Structure Influences Experience Why are nursing homes built the way they are? • To maximize efficiency in the operation … such as: • Shower rooms – why put a shower in each room when we can just go to the car wash? • Long hallways / corridors – as long as we don’t exceed the regulation for distance – we’re good! • Central kitchen & dining – mass production & economies of scale • Central Nurse Station – optimize staff & visibility of residents • To comply with LTC regulations Why such a focus on maximizing efficiency? • The Medicaid $ only goes so far – cram & jam, heads in beds is the only way to adequately cover fixed costs & make a marginal $ - hard to do in TX What type of experiences do these “Structures” facilitate? • Staff are departmentalized (“that’s not my job …”) • Loss of dignity & independence • Is there any dignity in a shower room? • We plug the elderly into these operational machines – they comply with our structure

5. Change @ Willow Bend • Employee Culture • Accountability & Ownership • Incentive & Recognition • Customer Second – success stories • Renovation & Operations • Demolition • New Facility

6. Renovation & Operations Focus on investing capital where we get maximum change / impact on the resident & staff EXPERIENCE • Meals • Staff involvement in cooking & eating w/ residents • Maximize resident choices in “how” (when & where) and “what” they eat • Bathing • GET RID OF THOSE SHOWER ROOMS!!! Building showers into existing bathrooms – resident dignity issue • Convert shower room into a spa / massage area – focus on relaxation, wellness, and the power of human touch • Activities • Good-bye Nurse Stations – knocking down barriers • The Great Outdoors – building landscaping options that maximize residents’ abilities to be outside the facility

7. Demolition – A Cleansing Experience Demolition • tore down 15,000+ sq. ft. in May – June • opens up room for 3 new buildings … approx. 25,000 ft2 • black mold growing in resident rooms • feral cats and opossum families living in building attics pictures of destroyed house

8. New Facility New Construction • May – June demolished 15,000 + sq. ft of existing facility • Focus on Private rooms, common kitchen & dining • New, state-of-the-art therapy center • Form to drive Function (Experiences) – chapel, store & post office, movie theater, etc. • Goal is to create OPTIONS for Staff & Resident EXPERIENCES Plan of new facility and image of new facility

9. Barriers to Change The discussions about “culture change” rarely, if ever, acknowledge the massive operational upheaval required in order to achieve the desired changes. Changes in a regulated operation bring significant risk – in this case borne primarily by the provider Case Study #1 • Farmer Jones admits as a LTC resident at Willow Bend. His initial assessment reveals a lifelong love of farming & horticulture. He desires to spend as much time outside gardening as possible. Farmer Jones wants to use Miracle Gro as a supplement for his vegetable patch, and the facility professionals determine that he is able to do so safely. A state surveyor visits the facility and sees Farmer Jones handling Miracle Gro – what happens? Case Study #2 • Susie Malibu is a LTC resident who loves to play board games. Parchisi is her favorite. At home, she used to play board games while sitting on the floor, and insists that the staff play on the floor with her. A state surveyor visits the facility and sees the resident sitting on the floor – what happens?

10. Barriers to Change (cont.) Case Study #3 • James Brown is admitted as a short-term rehab resident, dx of broken hip. He rolls up to the snack bar and asks to make his own PB&J sandwich – just like he does at home every afternoon. He is completely A&O, and not on any medications which impair his coordination. The caregiver gets out the PB&J, some bread, and a butter knife. Mr. Brown starts to make his own sandwich. A state surveyor walks in the door and observes Mr. Brown holding a butter knife, and handling jars of peanut butter & jelly – what happens? Case Study #4 • As part of a strategy to incorporate caregivers more fully into the lives of residents, facility staff are participating in cooking & preparing meals for residents. Two CNAs finish morning incontinent care on their residents, wash their hands and disinfect, then head to the dining room to make a la carte waffles & omelets. A state surveyor who watched incontinent care earlier now observes the CNAs cooking resident meals – what happens?

11. Are We Really Ready for This? • Government will always lag innovation1 • This has been proven in case study after case study (examples cited at end) • CMS reimbursement models are not robust enough at this time to differentiate and reward innovators, above and beyond the average • Regulatory Readiness • Regulations and regulators are accountable for a significant portion of provider cultures2 • Individuals w/in the regulatory process must be willing to “bend” – everyone needs to take ownership for changing the paradigm • I think the answer is “sort of” • Regulatory leadership in the DFW market is as open as I’ve met • As a facility of “one” – we are 100% committed to “flooring it” • As a company we embrace an entrepreneurial approach and business model that facilitates the innovation

12. Sources Cited • http://books.nap.edu/openbook.php?record_id=11652&page=15 • http://www.nursinghomesmagazine.com/Past_Issues.htm?ID=5723 … c.f. section on Provider Support