Embracing Comprehensive Culture Change

The culture change initiative at Bigfork Valley Communities embraces the Eden Alternative and other initiatives that are intended to provide elders with more control over their everyday lives.

Between 1997 and 2000, by renovating its buildings and reorganizing the way care is delivered, Bigfork created three distinct communities of residents:

• Spruce Lodge, a community of 16 residents who are able to provide some of their own care.
• Balsam Lane, a community of 16 residents with cognitive challenges.
• Cedar Grow, a community of 8 residents who require extensive care.

Changes in management structures and staff practices were designed to break down departmental silos, improve communication, and support the entire staff with training opportunities. This change process incorporated several key innovations that directly affected direct-care workers.

Blended Workforce

At Bigfork Valley Communities, all frontline staff, including housekeeping and dietary staff, receive training as certified nursing assistants (CNAs). The result has been a “blended” approach to delivering services to residents. The direct-support staff (CNAs) now spend approximately 20 percent of their time cleaning rooms and preparing meals, and employees who previously had only provided housekeeping and meal preparation services now spend approximately 20 percent of their time providing direct support services.

“While challenging to implement at first,” said Annette Buckingham, the Director of Nursing at Bigfork, “the overall result has been positive for both workers and residents.”

Other than reducing the sense of “division” in the workforce, frontline staff report enhanced job satisfaction because the work environment is more varied and less monotonous. The frontline staff also express appreciation for the different kind of conversations — and other social interactions — that are possible when work responsibilities are more varied.

“Overall, our blended frontline workforce has increased the job’s emotional rewards for everyone,” said Buckingham. “It has also made the entire staff more flexible when, on occasion, there is a staffing shortage. We have more people available to fill-in in a crunch and get through the day.”

Team Decision-Making

Each community (Spruce Lodge, Balsam Lane, and Cedar Grove) holds a weekly decision-making meeting, which is attended by frontline staff (who are paid for their time). Meetings are coordinated and facilitated by the Community Coordinator, and management staff is also present to hear concerns and respond to questions.

At these meetings the staff discusses and makes decisions about a range of issues involving the week ahead — such as the food to be served, emerging dietary issues involving particular residents, upcoming activities, scheduling, and any other staffing and/or assignment issues that may arise. Staff also have the opportunity to bring challenging situations and other general (or personal) concerns to the group, and receive support and advice from peers.

Career Ladders

All frontline staff who are not certified nursing assistants (CNAs) when they are hired (including housekeeping and dietary staff) receive CNA training and certification during their initial year of employment. This training is provided in-house, and upon completion these individuals are listed on the Minnesota Nursing Assistant Registry.

Additionally, CNAs participate in a mandatory cross-training program that enables all frontline staff to perform a more comprehensive range of services. This program is divided into three modules or segments — Dietary, Housekeeping, and Activities — and is generally completed within the first year of employment.

Frontline staff who wish to advance their career even further have the opportunity to take the following trainings:

• Medication Aide. A certification program authorized under Minnesota’s Nurse Practice Act that permits a CNA to dispense medication.
• Advanced CNA. A certification program that equips CNAs with the skills that they need to provide a wider range of restorative care (physical therapy) services.
• Health Services Specialists. A college-level pilot program, initiated in 2010, that builds a strong basis for becoming what is known in Bigfork as a universal worker — one who is cross-trained in several departments and can therefore accept a wide variety of assignments within the facility.

Bigfork also provides scholarship support to frontline staff interested in completing LPN or RN programs.

“There is nothing more important than training and education,” said Buckingham. “Particularly when a facility is engaged in culture change, ongoing staff training and career support is key to maintaining momentum.”

Leadership Opportunities

In each of the “communities” (Spruce Lodge, Balsam Lake, and Cedar Grove) one of the frontline workers serves as “Lead Care Assistant.” This person —elected by her peers and approved by management — serves as a liaison to the community’s management team (Director of Activities, Director of Nursing, Social Worker, etc.), and ensures that the opinions and needs of frontline staff are represented during management team discussions.

Bigfork management also considers its training and educational support programs a leadership opportunity for all frontline staff. Management makes a point of identifying promising CNAs and actively encouraging them to participate in the educational opportunities available to them.

Wage Enhancement

The entry-level wage for all non-CNA frontline staff — direct-support, housekeeping, and dietary — is between $9.00 and $10.00 per hour, depending upon qualifications and experience. As of 2010, new employees who are already CNAs start at $10.99 per hour.

Wage enhancements available to all workers with CNA credentials are as follows:

• For each area of cross training completed (mandatory): + 10 cents per hour
• Completion of “Medication Aide” certification: + 30 cents per hour
• Completion of “Advanced CNA” training: + 15 cents per hour
• “Lead Care Assistant”: + $1.00 per hour

The management team at Bigfork Valley Communities strongly believes that its frontline CNAs must be financially motivated to become fully engaged in its mandatory training programs, as well as become attracted to ongoing educational opportunities.

“It is very important to encourage the development of this workforce with ongoing training and educational opportunities,” said Director of Nursing Annette Buckingham. “But we must also reward each person’s individual efforts and educational accomplishments with better wages.”

Outcomes

While a formal and comprehensive evaluation of the Bigfork Valley Communities culture change initiative has not been performed since 2000, there were significant improvements in staff turnover and the quality of care reported after the first three years:

Staff turnover. Before starting this culture change initiative in 1997, turnover averaged 85 percent for frontline staff. In just two years, frontline staff turnover was reduced to 20 percent (in 1999) and 13 percent (in 2000). From 2001 to 2009, frontline staff turnover has not been formally tracked, though management reported frontline staff turnover to be relatively low. Formal tracking of staff turnover re-commenced in 2010.

Infection rates. Over a three-year period (1997-2000), the level of client infections (per month) fell from 22 percent to 12 percent.

Weight loss. Over a three-year period (1997-2000), precipitous weight loss among residents declined by 69 percent. This improvement over such a short time period was attributed to the cross-functional training provided to all CNAs, and the improved communication between frontline staff and management through weekly team “decision-making” meetings.

Resident, family, and staff satisfaction. Bigfork received the “Minnesota Health and Housing Alliance “Excellence in Service Award” in 2002.

Lessons Learned

The management team at Bigfork Valley Communities believes that the biggest challenge at the onset of their culture change initiative was about engaging the frontline staff about its importance.

“Our frontline staff didn’t ‘get it’ at first,” said Annette Buckingham. “I don’t know how many times I heard, ‘We’re already an excellent facility, why do we need to change?’ But once we began our training programs, and the staff experienced the positive reaction of our residents, it began to make sense to everyone.”

Buckingham also communicated the importance of top management vision in keeping a culture change initiative “real and vibrant” over time, and also the importance of having a strong, stable, and committed managerial staff and board that are on the same page about what long-term care — and culture change — is all about.

“At Bigfork we had an unfortunate turnover in leadership for several years,” Buckingham said. “This set us back a bit, but we’re back on track now, and on the right path.”

“Culture change initiatives always transform the rubric about what ‘quality care’ is all about,” Buckingham continued. “Anyone embarking on a culture change journey must be able to welcome a bit of conflict into the organization, be able to talk about it, and include others in the process that leads to resolution. Culture change is dynamic at its core and involves ongoing challenges. But isn’t that what life is all about?”

Sponsoring Organization: Bigfork Valley is a diversified health care campus, which offers medical services and a variety of senior living options on the same site.

Setting: Bigfork Valley Communities provides a continuum of care — homecare services to help seniors remain in their own home, adult day stay for seniors to socialize with others and for caregiver respite, 30 units of independent and assisted living apartments along the river, and a 40-resident rehabilitation and long-term care facility. In 2010, Bigfork Valley Communities employed 35 direct-care workers in the nursing care facility, which is the focus of this best practice profile.

Best Practice: Introducing and maintaining a comprehensive “person-centered” model of care in the nursing care facility, where each elder receiving services is central, and staff are trained and supported in providing person-centered care.

Start Date: Bigfork Valley began its culture change initiative in 1997, after an extensive, three-year planning process.

Costs & Funding: Physical renovation of the nursing care facility (at a cost of $300,000) was made possible through the facility’s capital fund. Workforce development initiatives have been almost completely budget-neutral, and made possible by cost savings realized through program implementation and the resulting increased cooperation between management and staff that reduced costs.

Contact Information:

Sally P. Sedgwick, Manager, Public Relations
258 Pine Tree Drive
Bigfork, Minnesota 56628
218-743-4249 | ssedgwick@bigforkvalley.org

Annette Buckingham, Director of Nursing
258 Pine Tree Drive
Bigfork, Minnesota 56628
218-743-4119 | abuckingham@bigforkvalley.org