Medical Director Colleen Riley on Independence, Wellness and Choice at Laguna Honda

Laguna Honda Medical Director Dr. Colleen Riley

Laguna Honda Medical Director Dr. Colleen Riley spoke about the hospital’s experience with culture change at the Environments for Aging Conference  sponsored by the Vendome Group in Atlanta last month.

Her talk, “Independence, Wellness and Choice at Laguna Honda,” touched on some key markers in our organization’s journey so far from institution to community, or as nursing home reform advocates sometimes put it, from institutional care to individual care.

This summary of her remarks contains four parts:

(1) Defining Laguna Honda,

(2) The Therapeutic Value of the Built Environment,

(3) The Culture Change Project, and

(4) The Move.

Defining Laguna Honda

Dr. Riley provided context by presenting demographics of Laguna Honda’s community of care.  The average age of residents is 68, with a range at the present from 22 to 105.  Applicants must be 17 to qualify for service.We have an extraordinarily ethnically diverse population, as the breakdown below demonstrates.

25% African American

25% Chinese

13% Hispanic

39% Non-Hispanic White

13% Other Asian

2% Filipino

2% Other

Residents are about evenly divided between male and female , with 52.4% mean and 47.6% women.

Principal diagnoses of residents are four: (1) neurological disorders, (2) progressive chronic illness, (3) HIV/AIDS, and (4) traumatic injury

We provide a range of specialized programs.

• Rehabilitation – both acute and skilled nursing
• Enhanced Support – for residents with chronic/complex medical problems who require extensive assistance with activities of daily living
• Memory Care – for residents who have Alzheimer’s or other forms of dementia
• Positive Care – for residents with HIV/AIDS
• Monolingual Care – to enable residents who speak Spanish and Chinese to receive care in their native tongue
• Hospice and Palliative Care
• Acute Medical Care – We provide acute services to our resident population.  We have no emergency services.
• Outpatient Clinics – One of the services that sets us apart is the range of outpatient clinical services we provide to residents, including specialists in neurology, oncology, surgery, optometry, dentistry, and podiatry.

The Therapeutic Value of the Built Environment

The new Laguna Honda was conceived by the award-winning health care design team at Anshen+Allen, now Stantec Architecture, using the principles of evidence-based design.  They created a facility uniquely suited to maximize community integration, resident choice and independence, and the healing effects of the natural environment on Laguna Honda’s 62-acre campus.

Residents at the new Laguna Honda have choices about how they can spend their day.  They can visit with friends in the living room of their household.  They can join the organized activities in the Great Room of their neighborhood.  They can visit the Esplanade, the town center, where people may be gathering in the art studio, the community theatre, the general store, the barber shop, or the beauty salon.

They can get some fresh air in the Clarendon Valley, Laguna Honda’s backyard.  The Valley was formerly the site of the hospital’s maintenance services, and is now restored to its natural state. It is home to a petting zoo, an orchard, and wheelchair-accessible planting beds.  Residents may also want to retire to their room for a bit of privacy, or catch San Francisco’s Muni Metro subway across the street for a ride downtown.

Laguna Honda is the first hospital in California to be certified by the Leadership in Energy and Environmental Design program (LEED) of the U.S. Green Building Council, the leading national organization for designating sustainable buildings.  The hospital was awarded a LEED silver certification in June 2010, as construction of the new buildings drew to a close.

Our LEED certification recognizes innovative steps in a number of designated categories: sustainable sites, water efficiency, energy and atmosphere, materials and resources, indoor environmental quality, and design process.  For details about our sustainable buildings, visit http://lagunahonda.org/newConstruction/greenFuture.asp.

The objective behind the creation of Laguna Honda’s healing environment is to help residents achieve their highest quality of life through professional, compassionate relationships and flexible individualized care.  Our ultimate goal is to help each resident reach the highest level of independent functioning so he or she can move to a lower level of care or to independent living elsewhere in the San Francisco community.

The Culture Change Project

Organizational culture change at Laguna Honda is a joint project of the San Francisco Department of Public Health and the city Controller’s Office.  Two nursing home reform organizations, B&F Consulting and Lumetra Healthcare Solutions, have spearheaded the project.

The culture change work has focused on achieving shifts of perspective among staff members through small tests of change, manageable projects that allow the hospital to implement its new paradigm toward resident-directed care in a deliberate and effective way.

The major advances toward resident-centered care over the past year of the project have been several.

Consistent Assignment.  In order to facilitate relationship-building, which leads to improved quality of care, the hospital assigns the same caregivers to the same residents on a consistent basis.  In doing so, it is following the predominant recommendation in the healthcare literature for implementing individualized care.

Dream Teams.  We take a systems theory approach to services, leaving behind the old management silos by integrating the branches of the organization for one purpose: quality improvement.  In practical terms, inter-departmental integration has meant that in each of our thirteen 60-person nursing programs, or neighborhoods, there is coordination among clinical staff, housekeeping staff and maintenance staff.

Our executive director, Mivic Hirose, coined the term “dream team” for each of the neighborhood staffing cohorts.  The new approach allows us to respond to resident needs more quickly as they arise on the neighborhood, and to develop collaboration among staff members with diverse skill sets.

Individualized Schedules.  We have introduced individualized schedules for dining, medication and sleeping so that the desires of the residents, rather than the efficiencies of the hospital, take precedence in the routines of daily life.

Community Meetings.  On each of our thirteen neighborhoods, the dream team, led by its activity therapist, convenes monthly community meetings where residents and hospital staff meet to discuss issues of community life on the neighborhood.

Community meetings are attended by hospital administrators known as “executive partners.”  Each member of the hospital’s executive committee serves as a liaison to one or more resident neighborhood to help cut through red tape that can get in the way of response to resident needs.

The Move

Our move on December 7 and 8, 2010 was the biggest U.S. hospital move that any of us are aware of.  We accomplished the monumental task of moving approximately 750 residents on schedule over a two-day period with no adverse outcomes.

Our guiding principles were two: resident safety and preservation of dignity and respect for residents.

The move required intricate planning and months of practice.  It was coordinated, as most hospital moves are, pursuant to the Hospital Incident Command System (HICS).  Five workgroups were responsible for defined operational areas:

(1) Master planning,

(2) Patient care,

(3) Staff orientation and training,

(4) Furniture and equipment fit-up, and

(5) Support services.

We followed a carefully determined patient aggregation and bed allocation plan (PABA) based on residents preferences and clinical needs.

The key milestone on the way to move day was certification by the Office of Statewide Hospital Planning and Development (OSHPD) that the three new buildings were ready for occupancy.  Other major projects leading to the move were:

• The installation of furniture and equipment, including testing of the systems in the technologically sophisticated environment,
• Staff assignments, including a house-wide bidding for assignments by approximately 1200 employees, one of the largest labor biddings of which we are aware,
• Training on the workflows and operational systems of the new environment, and
• Licensing of the new buildings by the California Department of Public Health.

To prepare residents, staff and family members, we launched a number of projects.

We were unable to take residents on tours of the new buildings until they were licensed by the state close to move day.  We instead presented the new environment to residents by publishing a booklet with color photos and making available a computerized virtual tour of the buildings.  We also produced five versions of a handout containing frequently asked questions and answers.  We updated it periodically as new questions were asked and new information became available.

Our extremely active and creative residents’ council was a useful forum for questions and answers, as were eight workshops held over 12 months by our clinical nurse specialists and activity therapists.  Staff members set up a mock resident room to help people get a sense of where they would be living and plan how to pack and move into the new rooms.

Forums for family members provided the opportunity for an introduction to the move process.  We encourage family and friends to participate in the move, and established specific roles so that family members could fit constructively into the intricate operation on move day.

Staff training took the form of a train-the-trainers process.  We identified a group of 160 new building “super-users” who were the first to learn the ins and outs of the buildings.  The super-users group, which contained representatives from every hospital department, served as trainers for their colleagues.  In addition, we employed a national best practice called Day in the Life training, which simulated a typical resident’s day, including built-in problem scenarios so that staff members would have practice managing most eventualities before the move.

After residents were in their new homes, we instituted a check-in process to catch evolving problems and respond to them as rapidly as possible.  We conducted follow-up surveys with each resident able to participate at 10 days, 30 days and 90 days.

The 10-day survey produced favorable results with 60% of the 476 respondents reporting they were “fully satisfied” with the new environment.  For the other 40%, we identified specific complaints and addressed them on an individual basis.

Laguna Honda Residents' Council President Elizabeth Cutler at opening ceremonies for the new hospital with former San Francisco mayor Gavin Newsom (l) and Congresswoman Jackie Speier (r).

We will discuss our survey outcomes in another entry on the blog.

In her presentation to the conference, Dr. Riley gave the last word to Elizabeth Cutler, president of the Laguna Honda Residents’ Council, who spoke these words at our ribbon cutting ceremony in June 2010.

“We come from all walks of life. Difficult circumstances, sometimes crushingly difficult, have bought us here.  Despite all the differences, we need the healing that Laguna Honda is famous for.  It is exciting to have a brand new building.  It is even more exciting to receive a new model of care; care that is resident-centered, care that honors each person as an individual instead of a body in a bed, care that involves talking to us, and, more important, listening to us, hearing our voices.”