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BEST PRACTICES: Providence Mount St. Vincent

ABSTRACT: In transforming its traditional model of long-term care to a resident-directed model that strives to maintain the independence, privacy, and dignity of residents in a home-like atmosphere, Providence Mount St. Vincent has changed the way direct-care work is carried out. The workers in closest contact with residents have been given more autonomy and are encouraged to grow professionally, in part to empower them to foster resident choices in daily routines and, in part, to make their jobs more attractive and improve retention. (December 2009)

Practice

Outcomes

Lessons

Background

Resident-Centered Care

The strength of relationships between residents and staff is what separates Providence Mount St. Vincent — better known as simply “The Mount” to its residents and employees — from most other long-term care facilities, said Thomas Mitchell, administrator of The Mount. Since 1990, The Mount has emphasized a variety of resident-friendly practices, ranging from consistent Resident Assistant (RA) assignment to person-directed care, as part of its broader culture change endeavor.

Today, The Mount houses more than 400 residents, grouped into “neighborhood” communities of 20 to 24 that are managed by a neighborhood coordinator and staffed by a consistent team of nurses, RAs (trained as certified nursing assistants, or CNAs), recreational therapists, spiritual care and social workers, food and nutrition workers, and housekeepers. Its innovative practices have made The Mount one of the most desirable long-term facilities in the U.S. — for residents and direct-care workers alike.

If she wants to eat a peanut butter and jelly sandwich before bedtime, she can do that too.

Consistent Assignment: At The Mount, RAs are consistently assigned to work with the same residents, day in and day out. Such consistency fosters the growth of caring relationships, and sometimes, genuine friendships. Mitchell said that RAs get to know residents so well that they can detect when the slightest thing seems wrong and alert the proper Mount employee, whether it’s a licensed nurse, a doctor, a social worker, a nutritionist, or a spiritual health advisor. “They see these people every day and know them as individuals,” Mitchell continued. “I think [consistent assignment] improves not only the relationship but the care that [residents] receive.”

Individualized Caregiving: Consistent assignment is just one way that The Mount makes life easier for its residents. Another way is its focus on allowing residents to do what they want, when they want. If a resident wants to wake up at noon, she is free to do so. If she wants to eat a peanut butter and jelly sandwich before bedtime, she can do that too. Indeed, The Mount frequently adapts its own institutional policies to meet the residents’ requests. Mitchell said that The Mount’s food policies and laundry schedules have recently undergone complete overhauls to more closely correspond to the needs of the residents.

Supportive Work Environment

The Mount’s culture change efforts have resulted in a more empowered and autonomous staff. Here are some of the ways The Mount has supported its RAs:

Worker Supports: The Mount runs several worker-support programs, including an on-site English as a Second Language classes, a substantial subsidy for employees using the on-site day care center, and “Emily’s Cupboard,” an internal food bank that stores staples such as bread and canned goods for workers who need food support. In October 2009, The Mount received the Washington State Psychologically Healthy Workplace award from the Washington State Psychological Association for its worker-support efforts.

“The locus of control is really close to the staff”

Charlene Boyd, Administrator

In-house training: The Mount provides its CNA training for RAs. Trainees are educated about the philosophy of resident-directed care, relationship building, and communications skills in addition to the standard certification requirements. RAs are also encouraged to enroll in outside classes on a variety of topics. Beth, an RA who has been with The Mount for more than 30 years, has taken courses on everything from using Microsoft Excel to working with Alzheimer’s patients. The Mount covers tuition and transportation costs, and employees are paid for the time they spend attending classes.

Worker Participation in Decision Making: Prior to culture change, The Mount was managed as a standard, top-down, hierarchical organization. In recent years, however, that top-down leadership has slowly filtered down to RAs and other non-management staff members. Today, said Charlene Boyd, a former administrator who helped introduce culture change to The Mount in the early 1990s, RAs enjoy greater autonomy and a larger role in decision making. “The locus of control is really close to the staff,” she said.

Outcomes

Relationship-Centered Care: When The Mount committed to a model of culture change in 1990, RAs initially expressed reluctance that a resident-centered model of care could work. Today, however, culture change has taken hold so totally that RAs cannot imagine any better way of providing care. Resident-centered care and consistent assignments make their jobs more interesting, Mitchell said. “They see [residents] as individuals.…[T]hey really get to know them and understand their likes and preferences.” In 2009, 93.8% of The Mount’s residents rated the facility either “good” or “excellent” in a satisfaction survey.

In 2008, more than 50 of The Mount’s RAs had at least five years of service.

Low Turnover: Perhaps because their jobs are more personally rewarding, most RAs remain at The Mount for many years. Administrators recognize the five-year anniversaries of resident assistants, and in 2008, more than 50 of The Mount’s RAs had at least five years of service, with several having remained on board for more than 30 years. The average tenure of an RA at The Mount is nearly eight years. In an industry in which annual turnover at most facilities ranges from 70 to 100 percent, The Mount turns over just 15 to 18 percent of its workforce each year. (Before initiating culture change, The Mount had turnover rates as high as 56% annually.) It is estimated that The Mount’s low turnover rate saved the organization $2 million from 2000-08.

Sense of “Family”: In a recent staff satisfaction survey highlighted by the Pioneer Network, 95% of Mount staff compared their work environment to a “family,” a “team,” a “home,” or a similar word implying a strong sense of community and closeness. Beth said that The Mount’s management does all the “little things” that make workers feel special, from birthday celebrations to sending flowers when they experience a death in their family.

Lessons Learned

Leadership at The Mount believes that systemic change cannot occur without commitment from the top, development of a positive climate for change, and a leadership that stays as close as possible to the people who make changes happen on the floor. This is achieved through decentralized management and an emphasis on teamwork and job role flexibility. In addition, every worker must be empowered to make decisions about the work he or she does as part of a self-directed team.

Culture change must occur either totally or not at all

Of course, culture change is easier said than done, and some aspects have not gone according to plan at The Mount. One of the most important lessons The Mount’s administrators learned came when they tried to alter the way dining services were structured. They made a critical mistake, Boyd said, by introducing the changes to just one of The Mount’s neighborhoods. “We thought we could make changes in isolate,” Boyd said, but “you have to deal with the foundation if you want change to stick.” Culture change must occur either totally or not at all.

The Mount found that it took seven years of continuous change and adjustment to achieve a stable, effective balance between the environmental, programming, and financial aspects of the culture change process. But Mitchell and Boyd are not ready to claim victory in their march toward culture change. Culture change “is a journey, not a destination,” Boyd said. “You never really get to the end.”

Sponsoring Organization: Providence Health System, a not-for-profit health care system operated by the Sisters of Providence, based in Seattle, WA.

Best Practice: Providence Mount St. Vincent’s resident-centered approach to care allows its direct-care staff to act with greater autonomy, leading to more natural interactions with residents, higher job satisfaction, and lower turnover.

Setting: Providence Mount St. Vincent is a senior living facility in Seattle, WA, with 215 skilled nursing beds, 112 studio and one-bedroom apartments with assisted living services, and a 20-bed medical rehabilitation unit. The five-story, 300,000 square foot facility also includes a 50-client adult day center, an adult family home, and a child care center serving 125 children.

Start Date: Strategic planning for the resident-directed model of care began in 1989. The change process has continued ever since, and has included a $9 million renovation of the physical facility, making it more home-like.

Costs & Funding: The transformation process has been budget-neutral. A skilled nursing room, in 2010, costs $107,675 annually for a shared room, and $114,975 for a private room. Assisted living apartments, meanwhile, range from $42,450 to $78,900 in annual rent.

Additional Resources:

Baker, Beth. “Home, Sweet Nursing Home (pdf).” Ms. Spring 2007.
Boyd, Charlene. “The Providence Mount St. Vincent Experience.” Journal of Social Work in Long-Term Care. 2002.
Boyd, Charlene. “Residents First.” Health Progress. September 1994.
Boyd, Charlene, and Bruce Johansen. “A Cultural Shift (pdf).” Health Progress. January/February 2008.
Elliot, Amy. “Providence Mount St. Vincent — A Case for Sustainability (pdf).” Pioneer Network Case Studies.