Construct solid business practices that support your purpose.

A well-run nursing home excels as a business yet feels like home. It seeks ways to effectively manage the bottom line with integrity and with the resident as the focus. It runs efficient operations; invests in equipment and supplies to provide the highest quality care; and ensures that its physical and outdoor environments are comfortable and inviting. Site visit teams observed that the facilities in this study paid close attention to these foundational practices. Change concepts identified for this strategy are:

• Seek strategic and creative approaches to expand your resource base to meet your mission and serve your residents.

• Maximize your efficiency.

• Ensure you are making the most of your physical assets.

Following is a narrative description of what the site visit teams observed with respect to this strategy, including specific examples of the strategy in action.

To expand resource bases, staff members at the homes were encouraged and empowered to help identify opportunities for additional revenue, consistent with their organizations’ values and mission. Staff regularly reviewed the needs of the resident community to determine whether opportunities to address potential service gaps exist.

Grants and research opportunities were explored, fundraising was conducted and partnerships were developed to assist with fundraising, for example with community members and family members. Communicating specific needs that fundraising could support and making events fun are helpful ways, commonly used by these homes, to make the case and generate enthusiasm and support from staff and potential donors.

Referral programs, involving staff, community members and various provider settings (including hospitals, hospice agencies, assisted living communities and home health agencies) were used to attract residents. The nursing homes routinely used resident satisfaction surveys and

resident community meetings to hear directly from residents about what they liked and didn’t like. Leaders consistently followed up on issues and concerns, and as a result would have helpful data to share with prospective residents and the community.

To maximize efficiency, the nursing homes made investments in items and services to reduce costs over time, for example more efficient heating/cooling, lighting, solar panels, water-saving plumbing fixtures and equipment, recycling, and medical waste disposal. They had audits done by utility providers to look for cost savings and rebate opportunities. They closely monitored scheduling and hours worked to avoid overtime and use of agency staff. Prior to implementing any cost saving ideas, they assessed how the change would affect staff and residents; they thought about unintended consequences. They negotiated prices for products and services, buying in bulk as appropriate or taking advantage of group consortia volume discounts. They focused on accurate and ethical financial management and accounting practices by analyzing receivables balances and ensuring accurate billing and documentation.

These homes made the most of their physical assets; they created meaningful spaces, such as gardens and kitchens, which residents and families actually use in their daily lives. They critically analyzed noise and lighting to promote resident comfort and safety. They sought feedback from residents, families, and staff on the physical environment and explored

opportunities for improvement. They invested in building upgrades to keep the physical plant modern and efficient. They had processes and audits in place to ensure the buildings were clean and well maintained, expecting all staff to report any maintenance issues immediately. Scheduled rounding occurred to check that all areas were clean and to assess whether needed equipment was available, current, and in good working order. They did not skimp on supplies, wanting to ensure that staff and residents had supplies available when and where they were needed.

Change concepts and action items associated with this strategy assume a creative,

entrepreneurial orientation in successful leaders, a set of personal characteristics these leaders bring to the job. In addition, it is clear that other actors – especially the board of directors and the larger system or corporation of which the home is a part – play an important role in creating a culture that supports leaders in their entrepreneurial pursuits. For example, at Mercy Care Center, the board actively encourages innovation. When someone brings a new idea to the board, they discuss it and then, if it appears to have potential, create a team (of staff or staff plus board members) to go out and explore it, even if that means taking the team on the road. This process has led to Mercy Care’s adoption of culture change, consistent assignment, and an electronic health record system.

At Jewish HealthCare Center, the board expects the staff to be on the cutting edge with respect to technology and actively supports innovation. Their support is evident in the way technology is incorporated into the life of the community.

Several years ago, Foulkeways at Gwynedd was in the process of shaping their vision for what kind of community they wanted to be and what they wanted the care they offer to look like. The board and staff worked together to hold focus groups within the community, and traveled

nationally to inform their learning.

When a cell phone company wishing to expand its service area approached Mercy Care Center, the senior leadership team explored the opportunity and took action, allowing the company to lease their building’s roof to install a new cell tower. This alternative revenue stream seemed unconventional, but it was an opportunity to give back to the local community and this is consistent with the facility’s values and mission, so the team decided to move ahead.

When Franciscan Convalescent Hospital identified that their residents were frequently being hospitalized for respiratory issues, they decided to make respiratory therapy services available on-site. While there are costs associated with having the specialized respiratory care staff, equipment and procedures available in the facility, those costs have been offset by revenues the facility receives for days that patients and residents spend at Franciscan rather than in the hospital. The financial impact of adding respiratory care services has been positive, but the real benefit has been to the patients in post-acute care and the residents in long term care that have

avoided a potentially stressful hospital readmission because they could receive needed care at Franciscan instead of having to be transferred to the hospital.

Franciscan’s focus on efficiency is also evident in their Minimum Data Set (MDS) processes. “We consistently do double checks on our MDS assessments, charting, and care planning, looking for consistency, accuracy, and completeness. We review any discrepancies and follow through on updates. This is to ensure that all resident needs are identified and addressed. All disciplines review the documentation. Every department is involved and is in close

communication with the MDS coordinator.” MDS Case Manager, Franciscan

Foulkeways at Gwynedd pays great attention to its physical assets. They have a long history of involving residents and families in building and grounds design and renovation, gathering information on their needs and expectations and focusing on creating a resident centered environment. They create comfortable, inviting, and accessible spaces for individuals, and for gathering small and large groups together across the different settings in the CCRC. They invest in their buildings, keeping them modern and efficient. They understand the value of green space and create gardens and landscapes for residents and staff to enjoy. All resident rooms have a window that is low to the floor with a large windowsill so that even when a resident is in a chair they can see the outdoors. They have a number of committees for residents to participate in, including a gardening committee and an art committee.

Foulkeways also ensures that staff and residents have adequate supplies that are conveniently located, including supplies and chemicals for standard infection control processes. For

example, the organization has a supply of "red buckets" that any staff member can easily find and use to clean up spills. The bucket contains all the supplies and chemicals needed to safely and thoroughly clean blood, for example, but staff are not limited to using these just for blood spills. Foulkeways has decentralized a number of services, including housekeeping, to provide for supplies and decision making where the work is actually occurring.

Bethany Health Care Center has worked to implement various “green” initiatives to save water, gas, and waste costs. The organization carefully weighs the costs and benefits of each

potential green initiative. They’ve tackled and seen a quick return on investment on numerous projects, such as energy-efficient light bulbs and electrical ballasts, rain sensors on outdoor sprinkler systems, HVAC, and faucet aerators. In 2009, Bethany installed a cogeneration system which enables the capture of heat produced by the generator, which can then be used to heat water for use throughout the buildings. The system paid for itself in two years, with subsequent significant annual savings in energy expenses. The cogeneration system produces 60 percent of Bethany’s electricity, heats the buildings during winter and keeps hot water flowing in the summer.

Related evidence supporting the importance of constructing solid business practices that support your purpose includes Weech-Maldonado, Neff and Mor, “The relationship between quality of care and financial performance in nursing homes” [Journal of Health Care Finance, 2003 Spring, 29(3), 48-60].