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Providence Mount St. Vincent

Challenges and Lessons Learned

  • Change doesn't happen overnight and leadership must stay the course. It's not a magical practice. It's consistency. For example, adopting language like "home" and "neighborhood" takes time but is important to transform action. Ultimately, complex interactions build the relationships and those take time to develop and understand. According to Charlene Boyd, "There were more stops and starts than we expected. You test something, try, learn….You do what's needed to change the foundation of the work, but it takes longer than you think." 
  • Sustainability requires constant innovation. This means that The Mount spends time and resources maintaining the resident-directed focus. Thus, The Mount is constantly re-investing back into the organization (making it difficult to track all of the positive quality and financial outcomes). 
  • Relationships and engagement are tangible and observable outcomes for staff and residents at The Mount but difficult to measure. "Having good relationships in life is one of the greatest challenges for all of us – this is an extension of that."- Mount staff member. 
  • Jobs change when an organization transforms to a resident-directed focus. Tasks formerly done by administrative and licensed nursing staff are now shared by the team including resident assistants. Switching to a resident-directed focus also requires ingenuity and innovation by staff to organize work around residents' schedules. For example, interaction and activities need to be available for residents that stay up later (as opposed to staff having all residents in bed by 7:00). "The difficulty is accepting that you are not the one directing care and the schedule anymore." – Mount staff member. 
  • The New Generalist Versus The Former Expert – The creation of inter-disciplinary teams may be an adjustment for certain staff that want to slip back into role segregation. According to the case study, it can be especially difficult for clinical staff that are educated and often have experience in an acute care setting. For example, even though some resident's have chronic conditions, they wouldn't typically take their own pulse hourly in their home. The Mount attempts to acclimate clinical staff to this type of logic. 
  • Flexibility Versus Rigidity – Standardization of certain elements of quality of care (e.g. pain management) can be complex given that each nursing neighborhood is unique. This requires clinical leadership to be involved and aware of the dynamics of each neighborhood culture. Although the expectation of certain standardization in processes that equate to positive quality outcomes is more rigid, the respect and understanding of each neighborhood's dynamics requires a level of flexibility. 
  • Even though physical transformations are complete, resident-directed care won't work without the underlying systems. For example, renovations at The Mount occurred floor by floor. It became clear in the early days that some of the spaces were not being used how they were intended and were still staff driven. By the final phase on the 5th floor, the leadership team and architect were able to address these problems for a smoother transition. 
  • Attributes of The Mount that may have eased the transformation – The Mount is a part of a larger organizational structure (Providence Health & Services) which could lead to some economies of scale and scope in areas such as administration. Through Providence, The Mount is also able to offer employees extended benefits including sick, annual, and bereavement leave; life medical, and vision insurance; disability, and tuition reimbursement. These are attractive benefits to employees (although they still do not account for turnover improvements post-culture change that are significantly below national standards).

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