BUILDING CULTURE CHANGE ON A QUALITY SYSTEMS FOUNDATION.

BUILDING CULTURE CHANGE ON A QUALITY SYSTEMS FOUNDATION

BUILDING CULTURE CHANGE ON A QUALITY SYSTEMS FOUNDATION

Elliott Nursing & Rehab CenterElliott Nursing & Rehab Center

We are a Diversicare / Advocat Facility The facility is a 75 bed facility located in

rural Northeastern Kentucky We are dually certified in Medicare &

Medicaid

We are a Diversicare / Advocat Facility The facility is a 75 bed facility located in

rural Northeastern Kentucky We are dually certified in Medicare &

Medicaid

The Beginnings of Person Centered Care

The Beginnings of Person Centered Care

We have been on a journey toward Person Centered Care since 2005

Started with permanent staff assignments, creation of neighborhoods, some increase in choice and staff education about encouraging resident choice and increasing dignity

We have been on a journey toward Person Centered Care since 2005

Started with permanent staff assignments, creation of neighborhoods, some increase in choice and staff education about encouraging resident choice and increasing dignity

Continued with added food choices with meals and improving the dining experience

More effort to request resident feedback and act on their suggestions

Continued with added food choices with meals and improving the dining experience

More effort to request resident feedback and act on their suggestions

Education & DiscussionEducation & Discussion

Educated administration and entire staff by watching videos and reading books about other homes who had initiated Person Centered Care programs

Held group meetings with all levels of staff about what programs could be implemented in our facility

Educated administration and entire staff by watching videos and reading books about other homes who had initiated Person Centered Care programs

Held group meetings with all levels of staff about what programs could be implemented in our facility

Set GoalsSet Goals

Create more flexible schedules and less regimented routines

Decrease the institutional aspects of our facility Add choice and variety Increase resident involvement in everyday

decision making for self Maintain or improve quality of nursing care and

key outcomes

Create more flexible schedules and less regimented routines

Decrease the institutional aspects of our facility Add choice and variety Increase resident involvement in everyday

decision making for self Maintain or improve quality of nursing care and

key outcomes

Identify Staff Related ChallengesIdentify Staff Related Challenges

Staff feel that a large population of residents cannot make decisions for self

Fear of change Staff question if the quality of care can be

maintained with a less structured regimen

Staff feel that a large population of residents cannot make decisions for self

Fear of change Staff question if the quality of care can be

maintained with a less structured regimen

Review Quality Measures and Quality Indicators to Identify Trends

& Challenges

Review Quality Measures and Quality Indicators to Identify Trends

& Challenges Large population of Diabetic Patients Patients at risk for skin breakdown Many polypharmacy residents Many patients who exhibit behaviors and

receive antipsychotics or behavior modification meds

Large population at risk for falls

Large population of Diabetic Patients Patients at risk for skin breakdown Many polypharmacy residents Many patients who exhibit behaviors and

receive antipsychotics or behavior modification meds

Large population at risk for falls

Identify Proposed Person Centered Care Programs Identify Proposed Person Centered Care Programs

Sweet Dreams Rise & Shine Anytime 5 Meal or Peak Dining Home-Like Medication Regimen

Sweet Dreams Rise & Shine Anytime 5 Meal or Peak Dining Home-Like Medication Regimen

Sweet DreamsSweet Dreams

Goal is to increase quality of life for all residents by providing a more home-like atmosphere. Also, to decrease behaviors and related medications by modifying our schedules to allow for meaningful sleep time for patients

Goal is to increase quality of life for all residents by providing a more home-like atmosphere. Also, to decrease behaviors and related medications by modifying our schedules to allow for meaningful sleep time for patients

Sweet DreamsSweet Dreams

Quiet hours implemented from 9p.m. to 9a.m.

Only essential care is performed at night

Lights in hallways turned to lowest setting

Staff to use quiet voice

Quiet hours implemented from 9p.m. to 9a.m.

Only essential care is performed at night

Lights in hallways turned to lowest setting

Staff to use quiet voice

No overhead lights in resident rooms unless absolutely necessary

Overnight briefs Implemented

Elimination of unnecessary turning and repositioning at night

No overhead lights in resident rooms unless absolutely necessary

Overnight briefs Implemented

Elimination of unnecessary turning and repositioning at night

Residents are evaluated for use of overnight briefs

Residents are evaluated for use of overnight briefs

Review Skin Assessments Bed Mobility SRNA/Nursing Report Empower SRNA’s to make immediate status

changes Daily, weekly, and quarterly review ongoing

Review Skin Assessments Bed Mobility SRNA/Nursing Report Empower SRNA’s to make immediate status

changes Daily, weekly, and quarterly review ongoing

Rise & Shine AnytimeRise & Shine Anytime

Goal is to allow residents to sleep undisturbed until they awaken naturally unless medically contraindicated.

Goal is to allow residents to sleep undisturbed until they awaken naturally unless medically contraindicated.

Rise & Shine AnytimeRise & Shine Anytime

Identified preferences of all residents regarding sleep with interview and observation

All facility schedules reevaluated and updated to accommodate resident preferences

Identified preferences of all residents regarding sleep with interview and observation

All facility schedules reevaluated and updated to accommodate resident preferences

Quiet hour until 9 a.m. Lights stay low and

voices quiet until 9a.m.

All daily routines reevaluated and updated

Update preferences and adjust ongoing

Quiet hour until 9 a.m. Lights stay low and

voices quiet until 9a.m.

All daily routines reevaluated and updated

Update preferences and adjust ongoing

Outcomes for Sweet Dreams And Rise & Shine Anytime ProgramsOutcomes for Sweet Dreams And Rise & Shine Anytime Programs Fewer combative residents LTCQ data revealed behavioral symptoms

improved from “Needs improvement” to “Exceptional”

Depression decreased from 23% in Sept 2007 to 7% in March 2008. (Programs were implemented Sept 20th, 2007)

Fewer combative residents LTCQ data revealed behavioral symptoms

improved from “Needs improvement” to “Exceptional”

Depression decreased from 23% in Sept 2007 to 7% in March 2008. (Programs were implemented Sept 20th, 2007)

Outcomes ContinuedOutcomes Continued

Identified a decrease in episodes of shear No negative outcomes from use of

overnight briefs

Identified a decrease in episodes of shear No negative outcomes from use of

overnight briefs

5 Meal or “Peak Meal” Dining5 Meal or “Peak Meal” Dining

Goal is to allow residents more food choices and greater flexibility regarding meal times to accommodate overall preferences. Program is also intended to address the needs of the diabetic population through appropriate monitoring.

Goal is to allow residents more food choices and greater flexibility regarding meal times to accommodate overall preferences. Program is also intended to address the needs of the diabetic population through appropriate monitoring.


Continental Breakfast Brunch Siesta Fiesta Dinner Night Cap Snack

Continental Breakfast Brunch Siesta Fiesta Dinner Night Cap Snack


Housekeeping and activities staff assist SRNA’s in passing trays

All staff assist with meals on their neighborhoods Meals in dining room as served buffet style with

two meals and added choices. SRNA’s take orders from each table to create a

dining out feel and encourage choice

Housekeeping and activities staff assist SRNA’s in passing trays

All staff assist with meals on their neighborhoods Meals in dining room as served buffet style with

two meals and added choices. SRNA’s take orders from each table to create a

dining out feel and encourage choice


Therapeutic diets are limited to lower concentrated sweets and mechanically altered diets

Choices are honored regardless of diet Diabetic patients are monitored as needed

and A1C levels for all diabetics are tracked and trended.

Therapeutic diets are limited to lower concentrated sweets and mechanically altered diets

Choices are honored regardless of diet Diabetic patients are monitored as needed

and A1C levels for all diabetics are tracked and trended.

Outcomes of “Peak Meal” DiningOutcomes of “Peak Meal” Dining

No weight loss in observation period that were not expected outcomes of disease process

Improvement in A1C levels in 11 of 15 diabetic residents

Weight Gain was a negative result in two alert and oriented residents. Their preferences are honored but risks and benefits explained

Some desirable weight gains in patients who were difficult to encourage to eat or ate very small portions

No weight loss in observation period that were not expected outcomes of disease process

Improvement in A1C levels in 11 of 15 diabetic residents

Weight Gain was a negative result in two alert and oriented residents. Their preferences are honored but risks and benefits explained

Some desirable weight gains in patients who were difficult to encourage to eat or ate very small portions

Home-Like Medication RegimenHome-Like Medication Regimen

Goal is to develop an individualized medication program for each resident while also accommodating daily routines and preferences as much as possible.

Goal is to develop an individualized medication program for each resident while also accommodating daily routines and preferences as much as possible.


Meet with Medical Director & Pharmacist to develop a plan of implementation.

Interview residents to determine current preferences of sleeping, waking, activities,etc.

Review each resident’s MAR to determine if frequencies can be reduced or unnecessary meds eliminated.

Meet with Medical Director & Pharmacist to develop a plan of implementation.

Interview residents to determine current preferences of sleeping, waking, activities,etc.

Review each resident’s MAR to determine if frequencies can be reduced or unnecessary meds eliminated.


All Q day administered once a day as indicated

All BID meds are administered upon rising & at bedtime

All TID meds are administered upon rising, afternoon, and bedtime.

All QID meds are administered upon rising, early afternoon, late afternoon, and bedtime.

All Q day administered once a day as indicated

All BID meds are administered upon rising & at bedtime

All TID meds are administered upon rising, afternoon, and bedtime.

All QID meds are administered upon rising, early afternoon, late afternoon, and bedtime.

Home-Like Medication Regimen Outcomes

Home-Like Medication Regimen Outcomes

No survey deficiencies for med pass Does away with the traditional 2 hour med

pass time frame. Allows flexible resident schedules Reduced overall number of pills passed

No survey deficiencies for med pass Does away with the traditional 2 hour med

pass time frame. Allows flexible resident schedules Reduced overall number of pills passed

Ongoing MonitoringOngoing Monitoring

Continue to utilize methods of monitoring and screening patients for participation in all programs and update as needed based on resident need and assessment.

Track and trend customer satisfaction results, QM’s, QI’s, and other quality information and address negative outcomes or trends

Continue to ask residents and staff about changing needs and preferences

Continue to utilize methods of monitoring and screening patients for participation in all programs and update as needed based on resident need and assessment.

Track and trend customer satisfaction results, QM’s, QI’s, and other quality information and address negative outcomes or trends

Continue to ask residents and staff about changing needs and preferences

Contact InformationContact Information

Benita Adkins, Administrator

Nancy Lowe, Dietary Manager

Michelle Adkins, LPN

Elliott Nursing & Rehab Center

P.O. Box 694

Sandy Hook, KY 41171

Phone: 606-738-9400

Email: [email protected]

Benita Adkins, Administrator

Nancy Lowe, Dietary Manager

Michelle Adkins, LPN

Elliott Nursing & Rehab Center

P.O. Box 694

Sandy Hook, KY 41171

Phone: 606-738-9400

Email: [email protected]

BUILDING CULTURE CHANGE ON A QUALITY SYSTEMS FOUNDATION.

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