Tag Archives: Shahbazim

More on the Green House Model of Long Term Care

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Minstrel 

In a series of posts in 2015, CNA Edge offered a caregiver’s perspective of the Green House Project, an innovative alternative model for Long Term Care. In today’s post, caregiver and guest contributor Minstrel gives her take on the Green House Project after a visit to one of the homes.

Yang has written previously on the Green House Project.  Recently I also visited a Green House Project complex.  Today these embody the most promising ways of caring for those needing long-term skilled nursing care.  It’s a tremendous care model.  I do have several reservations.

First, this model depends on having a majority of residents with substantial nest eggs.  (At one home in New Jersey, I’m told this is about $350,000.)

Second, while Green House homes do pay their Shahbazim more than what they were previously earning, they are still not earning a living wage, and some work a second job to supplement income.  One of the Green House Project’s three philosophical underpinnings is staff empowerment.  Doesn’t staff empowerment need to include their economic empowerment?  I asked this question at a GHP seminar but didn’t get a satisfactory response.

Third, as aging impacts physical and mental health, some elders will develop dementia and some will need two-person assists for transfers. We may find that even a two-to ten ratio won’t sustain the quality of care as care needs increase.  The current staffing ratios, which seem ideal, may not be adequate.  Down the line there is likely to be a need for more staff at greater cost to the home; or, if staff isn’t increased to meet the greater needs, a diminution in care.

It’s hard to imagine how this model could be affordable on a large scale — and Dr. Bill’s vision is enormous — without a changed allocation of national resources.  In 2014 the US GDP was over $17 trillion. Green House nursing homes are an economic possibility, just not a political possibility yet.  Thus the current model of LTC homes seems likely to survive.  But the culture of care — for residents of LTC homes and also for their caregivers — must and can be improved radically.  This belief is at the heart of CNA Edge’s mission.

Staff Empowerment and Caregiver Relationships in the Green House Model

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Yang

I think one of the things that make the Green House Model viable from a caregiver’s perspective is that it incorporates many of the positive things that direct care workers in traditional institutional settings already do – or would like to do – and then formalizes and enhances them in a supportive environment. For example, that “deep knowing” of elders so vital to the Green House Model also exists in traditional settings. However, in places where caregiver workloads are too heavy, that level of awareness can’t happen consistently – even with the best of efforts – and some residents are going to fall through the cracks.

This is also applies to how workers relate to one another. Anyone who has been in the business for any length of time will tell you that friction among direct care staff is a staple of the institutional work environment. At its worst, it is exhibited in things like petty rivalries, cliquish behavior and bullying. Some of this behavior borders on the juvenile and the atmosphere on a nursing home unit can sometimes feel more like a middle school cafeteria than a home for the elderly. A quick check of the CNA Facebook pages will confirm this. Frustrated managers will often respond by saying something along the lines of “Why can’t you just act like adults – aren’t we all here for the residents?” apparently oblivious to the fact that having to remind workers of something so patently obvious is an indication that the problems go deeper and require a better solution than simply telling people to “grow up.”

On the other hand, it’s not unusual for direct care workers to create strong and positive relationships with one another and cooperate in ways that benefit their residents. Even in the worst work environments, caregivers often form very close bonds that resemble family ties and can even last a lifetime. Sometimes these are bonds are formed because of poor work environments, as a matter of mutual self-preservation. These relationships develop spontaneously, more a result of the nature of the work and the individual personalities of caregivers than from any systematic institutional initiative. And the value of these relationships often go unrecognized. Indeed, according to the conventional wisdom of many managers and caregivers “We are here to take care of the residents, not to make friends.” As if creating heathy personal connections with your coworkers is somehow inconsistent with good care.

By empowering staff, the Green House Model depends upon self-managed teams of workers to deal with the day to day issues of the home. In this model, strong interpersonal relationships among caregivers is a critical element. As part of their extended training, shahbazim receive instruction in interpersonal skills. This provides them with the tools that enable them to defuse personality clashes and focus their energies on resolving common problems. In the process, the natural bond that forms between caregivers is nurtured and can grow into a strong and effective professional relationship.

Furthermore, prior to the opening of a Green House Home, direct care staff go through a team building process that enable workers to develop positive relationships. In this way, caregivers become familiar with one another, learn to trust each other and a cooperative foundation is established even before the real work begins. As new workers are hired, they are brought into an environment that is open and supportive. The self-managed team has the supportive aspects of a clique, but without the exclusion. In a Green House Home, everyone belongs to the clique.

The shahbazim I talked to characterized their work relationships as “like a family.” I have no doubt that this is precisely what the creators of the model intended.

Staff Empowerment and Problem Solving

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Yang

In this post I will address how the Green House Project’s core value of staff empowerment creates a work environment that better utilizes the ability and motivation of direct care staff to solve problems. Please bear with me as I take a bit of an indirect route…

One of my favorite games in elementary school was “Telephone.” In Telephone, one person whispers a message to another, which is passed through a line of people until the last player announces the message to the entire group. The original message is inevitably changed in some significant way, often absurdly. There were those of us who took advantage of the anonymity and helped the process along by purposely changing keys words. Thus “Miss Austin says that London Bridges will be falling down at 2 p.m. next Tuesday” became “Miss Austin says her big britches will be falling down with b.m. today” much to the delight of her entire 4th grade class. But the lesson remained the same.

The object of the lesson was to teach us the impact of gossip and rumors. You simply shouldn’t believe something just because someone says it (an idea that seems to have lost ground with the advent and popularity of social media). And perhaps it was also meant to teach us the value of clear and precise communication.

I remember actually playing a version of Telephone during an inservice training class. Again, the focus was on gossip and rumors, but also to demonstrate the importance of written communication and to help explain why health care in general seems obsessed with documentation. Of course, this part of the lesson didn’t say much about the fact that written communication can distort the truth as well, indeed more powerfully and often more by design than by misunderstanding. We were left to surmise that part of it ourselves.

There is something else that happens to both verbal and written communication as it is passed down the line. Not only can the literal meaning be altered, the significance of the message can change. In other words, the message is often most important to the person who initiated it and it can lose a measure of importance with every link in the communication chain it passes through.

I experienced this both as caregiver, and later as a storekeeper responsible for keeping a 730 bed facility and its 300 busy nurses supplied and happy. As a caregiver, I learned that it was often quicker and more efficient to bypass the official line of communication – that is, through my supervisor – and go straight to the person who could help me solve the problem. Plugged toilet in Room 237? I knew the extension of the maintenance person responsible for plumbing issues and I knew he would come up to the unit ASAP if I asked because we had a good working relationship and he knew I wouldn’t expect him to drop what he was doing unless it was really important. And it was really important, because Mr. Verlander absolutely refused to use any toilet except the one in his room and would rather risk defecating in his pants then sit on an unfamiliar commode. And the clock was ticking.

Normally, I would inform my supervisor of the problem who would then instruct the unit secretary to create a work order that would be sent to a maintenance supervisor who then delivered the work order to the plumber’s desk. While the literal meaning of the problem – a plugged toilet – doesn’t change, with each step the immediacy and significance of the problem fades and thus the motivation to address it promptly diminishes as well. While no one wished for Mr. Verlander to crap his pants and understood it as – in the parlance of moderately over-educated professionals – a “negative outcome,” it had the greatest meaning first to Mr. Verlander and then to me. My supervisor, the unit secretary and the maintenance supervisor may or may not have been present and able to respond quickly – they weren’t always where I wanted them to be. And besides, they all had their own problems that no doubt had higher priority to them.

As a storekeeper, I got to experience being at the other end of the service chain. Every day I would get requests for nursing supplies from caregivers who chose to contact me directly rather than go through their supervisors. While I completely understood their reason for doing so, it did create a few problems for me, like the phone constantly ringing and a bit of flak from the people in my own department who insisted that I was subverting the requisition process by responding to requests from “just caregivers.”

But I knew something about these workers. That is, the ones who pestered me the most were also the best caregivers. I knew this because I had worked on the nursing units with them, some for several years. I was well aware of the kind work they did, how they treated the residents and how important they were to their residents. They were willing to do whatever they needed to do to get the job done, even if it meant breaking some rules and going outside the facility’s official procedures. Bad caregivers tend to hide behind the rules and use them as an excuse not to act.

I should also note that while I knew these caregivers well and trusted their judgement, they also knew me well and thus felt comfortable coming directly to me. In a sense, this relationship empowered them, albeit unofficially.

Recently, I sat down with a small group of shahbazim from a local Green House Project home. When one of them used an example of dealing with a broken bed to illustrate how problem solving differs in a Green House verses a traditional institutional setting, I knew exactly what she was talking about. No one could understand better than her the particular difficulties the broken bed created for one of her elders and thus she was the one most motivated to get the problem resolved as quickly as possible. Not having to go through any chain of command or requisition process, she made the appropriate call herself and was able to state the urgency of the situation directly to the individual that could help her solve the problem. In one person, she represented the authority, the responsibility and the motivation to resolve the problem in a way that benefited the elder most. And make no mistake, such problems are routine in a long-term care setting.

Given the appropriate tools and support, no one is more capable of creating a “positive outcome” for a resident than a motivated caregiver.

A Culture of Empowerment

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Yang

In my last post, I listed the structural elements that enable the Green House Project’s core value of empowered staff to become a reality. In this post, I will begin to tackle the less easily defined dynamics of empowerment.

Whenever we talk about staff empowerment, we need to keep in mind the reason behind it. While the title “shahbaz” denotes respect for the caregiver, it is actually the elders that are being empowered. The Green House model simply recognizes that in order for elders to be empowered, those closest to them and know them best must have the means to facilitate that empowerment.

Obviously, caregivers in traditional institutional settings play a critical role in how a resident experiences life in in long-term care. Both the nature of the work and the manner in which caregivers engage residents guarantee that central role. For many long-term care residents, the quality of their relationships with their caregivers determines the quality of their lives.

However, when it comes to actual power – the ability to make day to day decisions that most directly impact residents and the accountability for those decisions – the traditional model provides the caregiver with a distorted version of power, created more by default than by design. While caregivers report to a unit supervisor, much of their daily routine is conducted without the direct involvement of that supervisor. The nature of the long-term care business demands that a manager’s time and attention be occupied by matters not directly related to the details of daily care. Simply put, a supervisor has limited awareness of what goes on down the halls and in the rooms.

In this vacuum, individual caregivers are compelled to make decisions regarding the use of limited resources – time, especially. How they prioritize these choices is often influenced by an informal, but powerful subculture in which the caregivers with the strongest personalities sent the standards. Sometimes, this actually works well and supervisors even learn to rely on these caregivers to help manage the unit. But all too often, it leads to mistrust and petty bickering among caregivers. The relationship between caregivers and managers is commonly characterized by conflict over authority, self-promotion, stonewalling and manipulation. Good work is not rewarded and poor work is left uncorrected. This is not the kind of “power” that contributes to a meaningful life for residents on a consistent basis.

By providing the Shahbazim with real decision making power, the Green House Model formalizes and expands the caregiver subculture. In doing so, it changes the dynamics of the relationship both among caregivers themselves and between caregivers and the individual charged with holding them accountable, the Guide. Leaders will still emerge within the group, but everyone is expected to grow into leadership roles. Along with the guide and clinical staff, the strongest and most experienced shahbazim are charged with coaching newer staff members into those roles.

Furthermore, the Shahbazim are held accountable in a way that caregivers in a traditional setting are not. While caregivers are always responsible for their individual actions, the ultimate responsibility for what happens on an institutional unit falls on the licensed supervisor. In the Green House Model, the caregivers assume that responsibility. The team is self-managed and while there can be a degree of flexibility in some matters, they have a vested interest in following their own rules and developing a cooperative work environment.

While the Guide expects and encourages the Shahbazim to make decisions, he or she is much more aware and involved with the day to day details of the home than a traditional manager. Not only does this allow the Guide to be effective in the coaching and support roles, it leaves less room for the kind of finger pointing and lack of transparency so prevalent in traditional settings. Issues are more likely to be dealt with directly and in the open. Again, this is aided by the small size of the home compared to large institutional nursing units.

In my next post, I would like to talk about how an empowered staff’s approach to problem solving differs from the approach taken in a traditional institutional setting.

A Flattened Hierarchy

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Yang

Continuing my exploration of the Green House Project, I will now turn to the second core value of the model, “Empowered Staff.” Empowered staff refers primarily to the workers who provide direct care.

The Green House term for a caregiver is “Shahbaz” (plural: Shahbazim). Shahbaz means “royal falcon” in Persian and is meant to convey a person worthy of respect, someone who is valued. The title is representative of the Green House Model’s investment in and support of the workers closest to the Elders.

The Shahbazim perform the same basic personal care duties as CNAs in a traditional long-term care setting, but along with the new title they are given a significantly expanded role which makes them responsible for the day to day management of the home. They make decisions that would normally be made by supervisors or mid-level managers. These include decisions involving scheduling, food preparation, laundry, housekeeping and care planning. They rotate the leadership roles – typically each quarter – so that each shahbaz takes a turn coordinating each of these functions.

This organizational structure is often characterized as a “flattened hierarchy.”  However, while the homes are operated by self-managed work teams, the Shahbazim do not work unsupported. They report to a “Guide,” an experienced LTC professional with extensive training in coaching skills. The Guide is responsible for providing the team with support, accountability and the resources necessary for the Shahbazim to succeed.

While it would be easy for a caregiver to simply regard the Guide as just another kind of supervisor, the core value of Empowered Staff requires the Guide to leave the day to day problem solving in the hands of the Shahbazim. A Shahbaz must be willing to receive coaching and grow into these new roles. In this sense, empowerment is not simply a matter of delegating responsibility, but it is a process that depends on the personal and professional growth and development of individual caregivers.

How and why this organizational structure works from a caregiver’s perspective will be the subject of upcoming posts.