At a glance…

Isabella Geriatric Center, New York, has found that by stating its values, involving everyone in the process, and tackling issues that are important to residents and staff, the “small town feel” is flourishing.

Amid the hustle and bustle of New York City, a small town is thriving. Not Greenwich Village or Soho, but Isabella Geriatric Center. It is a place where many staff have worked 10, 15, or even 25 years; where they regularly recruit their friends and families because it is such a great place to work. It’s a place where staff willingly spend extra time volunteering, and where relatives of residents come to work.

Isabella has the culture of a small town, where people know and care about each other deeply. As this 700-resident nursing home embraces culture change and explores major environmental changes, it is committed to keeping its small-town culture-a culture based first and foremost on relationships.

Previous articles in this series, (Long-Term Living, September 2008, p. 56 and DESIGN, March 2009, p. 17), described the initial efforts at culture change that started in 1993 and evolved into Isabella’s Home Again program. Recipients of a $50,000 grant from the The Hulda B. and Maurice L. Rothschild Foundation, Isabella is planning significant changes to its built environment to support its goal of becoming more resident-centered. The master planning for major changes to the campus is well under way, but staff didn’t want to wait for the new building to begin to improve their existing environment.

Improving the community

This article describes just a few of the activities Isabella is undertaking to improve its environment-and they are changes that virtually any community can implement, because they are, with few exceptions, low-cost or free. As described in the article in the DESIGN 2009 issue, Isabella has developed a number of inter-departmental workgroups of staff and residents who are focusing on their environmental values. Instead of directing their attention to environment as “artifact” (meaning the size and layout of spaces, surface materials, colors), they are focused on environment-in-use (i.e., how flow-through and use of spaces is managed). The success of three such groups is highlighted here as examples. The campus is comprised of two multistory buildings (17 and 13 stories), so there is a great deal of vertical transportation-of staff, of supplies and food, and of residents and visitors moving throughout the buildings over the course of the day. It is not surprising that they regularly experienced “elevator gridlock”-times when the demand for elevators far exceeded capacity. A Coordination of Elevator Services workgroup started by tracking elevator use over multiple days-members of the workgroup would just ride up and down and monitor the traffic, as well as gather daily schedules of all departments. It quickly became clear that there were some time-sensitive traffic patterns-such as before and after meals. If resident activities that involved residents moving from one floor to another were not scheduled to coincide with the times dietary needed to move food through the building, there would be fewer backups. Discussions were held about building-wide scheduling of activities, events, and necessary support activities (dietary, environmental services). The workgroup confirmed that residents always have first priority on elevator use, but that through better communication, overlap and gridlock could be avoided or at least minimized. The workgroup’s overall goal was to create better awareness among staff, and especially those staff who have flexibility in when they use the elevators. The workgroup created a gridlock alert system, letting staff know when heavier-than-usual elevator use will occur so they can plan accordingly. In addition, they created a permanent Coordination Committee to coordinate elevator use to maximize availability of the elevators for the residents (see sidebar).

Coordination of services

Another workgroup also looked at coordination of services, in this case between life in the community and the scheduling of thorough room cleaning by environmental services. Eventually, they piloted an intervention where each resident has a sign posted on the door that indicates when the room will next receive a thorough cleaning. Now nursing staff know which days they don’t need to make the beds, because environmental services will be coming shortly to clean the room-including the beds. Residents are not only offering to be out of the room when it is being cleaned, some are even tidying up before environmental services comes! Some households have asked for notices to be posted the day before, while others want it two days in advance to better coordinate activities.

There are two noise workgroups, one for mechanical noise and one for person-generated noise. The mechanical noise group was particularly concerned about noise levels on the ventilator unit, where each resident might have, at the bedside, a compressor, nebulizer, suction, and concentrator. Together these can generate well over 80 dB of noise, which may be punctuated by bed or chair alarms, the pill crusher on the med cart, the call system, or the narcotic box, each of which might generate noise in the range of 90 dB. This is clearly above OSHA-approved noise-level standards. Interventions thus far: Bed and chair alarms were eliminated (with an accompanying reduction in falls by 24%), a quieter pill crusher was identified, specialized mattresses were found that do not use an audio signal when adjustments are made, and the workgroup is looking into other interventions such as quieter ice machines and higher quality acoustical ceiling tile. They have also provided wireless headphones to residents for listening to TV or radio that do a better job of blocking out general noise levels.

‘Clear but vague’

These are but a few of the changes that Isabella is making. Like many communities that seek to embrace culture change, the charge is “clear but vague”; clear in terms of the mandate to provide a nurturing and loving community that meets every member’s needs, but vague in explicit activities that should be undertaken to move forward. Isabella has found that by stating its values, involving everyone in the process, and tackling issues that are important to residents and staff, their “small town community” is flourishing.

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