Self-Managed Work Teams

The ultimate mission of the Leonard Florence Center for Living (LFCL) is to allow residents to live life to the fullest. Ten homes in Chelsea, Massachusetts, with not more than 10 residents in each home, comprise this first urban GREEN HOUSE® skilled nursing facility.

One of the principal tenets of the GREEN HOUSE Project is that staff operate under what are called “Self-Managed Work Teams” (SMWTs). Leadership at the LFCL are quick to point out that, since their home opened only seven months ago, they are far from finished with their journey toward SMWTs. However, they are pleased with their progress to date, particularly in the three residences that were first to open, the two specialty units, and one eldercare unit.

Responsibilities of SMWTs

Each home of 10 residents within the LFCL has its own SMWT, which brings together a core group of five to six Shahbazim (the Green House term for the direct-care workers who provide a wide range of assistance, including personal care; activities; meal planning, preparation, and service; and laundry care for residents in each home), with others who fill in as needed across the three shifts. The Shahbazim report to the LFCL guide (the term used for the home’s administrator) Betsy Mullen, rather than the Director of Nursing, as is common in traditional nursing homes.

The primary responsibilities of the Shahbazim SMWT are:

• Self-scheduling and determining the rhythm of the day with the resident;
• Ordering food & supplies for the home;
• Sending representatives to care planning meetings; and
• Designating a team coordinator who looks at systems and processes in the home, finds ways to solve problems with the input of other Shahbazim, and coordinates team meetings.

Training

According to the Green House guide book, key to the success of the Green House model is a 120-hour training program to prepare Shahbazim, nurses, and other clinical support team members to work in the Green House model. The training provides staff with the skills and knowledge to support residents’ self-direction and daily life, to respond appropriately to emergencies, and to handle other responsibilities through their self-managed work teams. Everyone that works at LFCL must take this comprehensive Green House core education training.

The training reviews the Green House philosophy, roles and responsibilities of different staff, and focuses heavily on developing core skills in communication, problem solving, and teamwork. These skills are key to Shahbazim making the transition to an environment in which residents are in charge. “Residents Rule” is the LFCL Green House motto—a very different philosophy from a traditional nursing home.

To develop the skill-based training, the national GREEN HOUSE Project turned to PHI, which adapted the PHI Coaching Approach℠ to meet the specific needs of staff working in self-managed teams. In addition, senior leadership take a PHI-developed course called The Coaching Approach to Leading Change, and the Guide attends a PHI Coaching Supervision℠ training specifically adapted to build skills to support the Shahbazim self-managed work teams.

According to Mullen, the training has been well received, especially by Shahbazim who report that they are using the communication skills not just at work, but also at home and in the community.

Implementation

According to Mullen and Director of Nursing Janet Geiger, the SMWTs are still a work in progress — but the teams are strengthening their skills and becoming more independent. The first element of SMWTs that Shahbazim have taken on is learning how to communicate and problem-solve with their team in the house, across shifts, and with the residents and their families. Establishing the necessary level of open communication takes time.

Another aspect of establishing well-functioning SMWTs is having Shahbazim learn to respond to residents’ wishes themselves, rather than immediately calling on a nurse. Mullen and Geiger emphasize how important it is to let workers have the time they need to develop these skills in the workplace, and how essential is it to the success of SMWTs. According to Mullen, “there are many small steps along the way to becoming a self-managed work team,” but, she adds, “they are already doing a lot!”

Other tasks the Shahbazim have taken on include negotiating for scheduling changes or days off on their own. According to Mullen, while leadership still create the master staff schedule, in a traditional nursing home, schedule changes would still go through the director of nursing. She adds, “Now they work it out on their own. I only hear about it if there’s a problem with a shift that they can’t cover.” The other principal assignment the Shahbazim have taken on is their resident assignments. According to Mullen, the residents at the LFCL determine when and how their care happens; the Shahbazim are responsible, at the end of the day, for making sure that this care happens.

Janet Geiger gave an example of what this self-managed approach to care looks like: a resident had an 8 am doctor’s appointment that he was nervous about being on time for. The resident told his Shahbaz that he wanted to have his shower at 5 am followed shortly thereafter by his breakfast in order to be ready in plenty of time for the appointment. The resident was dressed and ready for the appointment an hour and a half before it was time to go, but this is how he wanted it. According to Geiger, “This was a wonderful opportunity for the resident to direct his own ship.” The caregiver was able to fulfill the resident’s wishes because Shahbazim are empowered to accommodate the rhythm of the household.

Geiger told another story that illustrated the impact of SMWTs. She had the opportunity to take the time one day to prepare an egg salad sandwich for a resident who really wanted one. She said that while this might sound trivial, it was very satisfying for her to have this level of interaction with the resident and to meet this resident’s desire. She believes that with SMWTs, clinical staff have more opportunities to step in to do resident care.

During the day, two Shahbazim work with the 10 residents in the home. Because they work together to develop the plan for care that meets the residents’ wishes, they know the residents well. They are therefore more comfortable than direct-care workers in traditional settings talking to families and answering questions from family members. For example, Shahbazim talk to family members easily about residents’ eating habits, sleep patterns, and their activities. Typically, families might go to nurses with these questions, but in this setting, the nurse might not even know. Family members at the LFCL also talk directly to the Shahbazim about plans for a resident’s birthday party, or work directly with the residents to plan the event.

Outcomes

Mullen and Geiger commented that the SMWT model has given Shahbazim a “can do” attitude about their work. Both acknowledged that it can be hard to give up the authority that traditionally comes with their positions, but that they have seen the Shahbazim come up with creative solutions to difficult problems, without their help. According to Geiger, “After all, they all lead complex lives, and run homes and have families of their own — why wouldn’t they be able to do this at work?”

The leadership team feels that SMWTs enhance Shahbazim self-esteem and self-worth since they are empowered through SMWTs. Staff seem happy to be at work, and call outs are infrequent. Shahbazim comment on how the residents tell them that they miss them while they are on vacation, and they know how important they are in the residents’ lives.

Wes Wells, who has been a guide at Baptist Retirement Community, a Green House in San Angelo, Texas, for three of the five years it has been operating, provided additional insights into success of SMWTs: “Self-managed work teams give Shahbazim the training, trust, and respect to allow them to partner with elders to create a home. This takes a lot of trust, and is dependent on developing relationships over time, but the benefits for the home are significant.

“For example, turnover for the Green Houses is now around 8 percent per year, which I attribute in large part to self-managed work teams and improving job satisfaction.

“Another benefit is the flexibility these teams give to the workers—about half of our Shahbazim are currently enrolled in college. Because of SMWTs, if they need more flexibility in their schedule, such as coming in an hour late on a given day, they can ask a team member to cover for them, and they can take care of the schedule change themselves. It’s very rare for us to have a situation at the Green Houses where we have no one to work a given shift. They really cover for each other.”

Lessons Learned

According to Mullen and Geiger, it would be difficult to overestimate the amount of time it takes for staff at all levels, used to working in traditional nursing home environments, to implement the changes needed for SMWTs to take hold.

In addition to good communication, SMWTs require a tremendous amount of trust, particularly from clinical staff who are accustomed to having more direct control over all aspects of the care provided by frontline staff. According to Mullen, Shahbazim learn over a period of time what they can and cannot do. She added that if someone in her role is going to be successful with SMWTs, “they cannot be overly controlling. They have to learn to share responsibility” and to move away from the more hierarchical traditional medical model.

Mullen added that lots of patience is needed on behalf of leadership in order to implement SMWTs. “The process takes lots of time, effort, and energy, but in the end, it’s worth it.” Frontline caregivers, if they worked in non-Green House homes, might be used to being told what to do, and not used to being asked what they think. This transition can be hard for them too, although in the end, Mullen feels they appreciate being empowered.

Geiger emphasized that the process is particularly hard on licensed staff because they have to learn to step back and watch, which they are not used to doing in traditional homes. She said that “everyone has had to grow in many ways and no one draws lines about the hierarchy except in cases of a medical emergency.”

Finally, Mullen says that the shift to SMWTs can be hard, but it’s wonderful to see how creative their staff is; she adds that she is extremely proud of her staff. She is also proud of how well the Green House model, and SMWTs, serve the Leonard Florence Center for Living’s residents. “The doctor and the nurse are behind the scenes in the Green House model. We operate actual homes for people with complex medical needs. The Shahbazim are, in every way, at the center of that home.”

Sponsoring Organization: The Leonard Florence Center for Living is America’s first GREEN HOUSE® community to provide skilled nursing care in an urban setting. It is a part of the Chelsea Jewish Foundation of Chelsea, Massachusetts.

Setting: Composed of ten homes, each containing ten private bedrooms and baths, the Leonard Florence Center for Living serves a total of 100 residents within a six-story condominium-style complex situated on the Dr. Miriam and Sheldon G. Adelson Campus on Admiral’s Hill in Chelsea, Massachusetts. Residents at LFCL include elders, individuals requiring short-term rehabilitation, as well as individuals living with disabling medical conditions such as ALS and multiple sclerosis.

Start Date: The Leonard Florence Center for Living opened its first home in February 2010. The complex will consist of 10 homes when it is completed in October 2010.

Costs & Funding: The cost of implementing the Green House model is potentially more expensive than in a traditional nursing home, since a significant investment is made in staff training at the outset; however, senior management believes these costs are recouped over time by lower turnover rates among all staff. Leadership from Green Houses that have been in operation for longer than LFCL have reported that operational costs are less over time, because large departments, such as dietary, do not exist in Green Houses, so operational costs are lower.

Additional Resources:

• “Guide Book for Transforming Long-Term Care.” (pdf) GREEN HOUSE Project, April 2010

Contact Information:

Betsy Mullen, Guide
165 Captain’s Row
Chelsea, MA 02150
(617) 887-0001 | website