(Not) the Same Old Story

By: Chuck SalterWed Dec 19, 2007 at 12:32 AM

Eden Alternative is a change-minded organization determined to save a critically ill patient: long-term care for the elderly. The nursing-home industry should be about living, argues founder Bill Thomas, not about dying. Here's his prescription -- and lessons for changing any industry.

That's the case in the Toomsboro Nursing Center, a 62-bed facility in rural Georgia. Since adopting the Eden model, the staff has become more responsive and more unified, and the care has become more compassionate and individualized, says Jane Lough, an administrator at the center. Instead of giving orders, Lough tells the certified nurse assistants, "You know this resident. Tell me what you think she needs." By working in teams -- the Conquerers, Earth Angels, Outrageous Girlfriends, and Untouchables -- employees began seeing beyond their roles as cook, laundry aide, nurse, and housekeeper. They realized that every staff member provides care in one way or another. As the stickers that they wear declare, "I'm a world-maker." "That's one of Dr. Thomas's terms," says Lough. "In a nursing home, very little of the outside world comes in, except for the staff. They are the residents' world, and they have the opportunity to make it a special place."

Eden does not reverse the aging process, of course, but studies, including one done by the Texas Long Term Care Institute in San Marcos, Texas, indicate that the residents' overall health does improve: They had fewer infections and required less medication. Meanwhile, the staff absenteeism went down and retention went up -- a significant improvement in an industry that is notorious for high turnover.

"Relationships are the foundation of good health care," Thomas says. "This is nothing new. But it's not something that the industry has made a priority." In fact, some institutions actively discourage relationships between staff and residents. "When I started out, I was told, 'You don't share yourself with residents, because it hurts too much when they die,' " says Lough. "That's definitely not the attitude here."

Voices in the Garden (Part II) Kathleen Perra, director of nursing, St. Luke's Home, New Hartford, New York: "Every day last summer, we had school-age day care here. There were kids screaming down the hall, cats jumping on tables. It was bedlam, but it was great. You want those unpredictable things happening for the residents. Of course, health-care workers favor predictability. We work around schedules. I'd say the biggest change with the Eden program is for the staff."

Method: Warmth, Suction, Frost

Nursing homes that are designed like gardens provide an apt metaphor for Bill Thomas's program, because, like a garden, Eden Alternative doesn't occur naturally. It requires preparation, hard work, and continuous scrutiny as it evolves. Otherwise, if the changes are taken for granted or neglected, Eden eventually shrivels up and dies.

Since founding their organization, Bill and Jude Thomas have become change experts out of necessity. Merely tweaking facilities wasn't effective. Creating an Eden involves a complete transformation. "Some homes think that Eden and the operation of the facility are two separate things," he says. "But Eden is all over. It affects everything you do."

The duration and success of the change process depends on what Bill Thomas calls the "warmth" of the organization. A warm culture is open to change, because employees have trust and generosity for one another, whereas a cold culture is characterized by pessimism and cynicism. After conducting a survey to determine an organization's temperature, the Thomases or one of 5,000 Eden associates nationwide begin "warming the soil." In some cases, managers hold a potluck dinner at someone's house, where they can't discuss work. Employees also perform good deeds, or mitzvahs, for their colleagues and the residents without expecting anything in return. "You open people's minds by opening their hearts," Thomas says.

Before virtually every step -- before adding pets, before switching to self-scheduling -- the staff votes. If the outcome isn't unanimous, the group continues the education process. "You can't force change on anybody," says Thomas. "Consensus is the only way. You have to get the entire staff to see the advantages for themselves and become excited about what you're going to do. We call it creating 'suction.' "

Thomas also expects setbacks, or "frost," as he puts it. It's a natural part of change. "I tell the leaders to expect that what they're changing will be smashed to bits, and when that happens, they have to be ready to pick up the pieces and move forward," says Thomas. "People are going to get scared. They're going to make mistakes." Every year, about 5% of Eden homes drop the program. But Thomas doesn't give up hope for them. He prefers to think that they're experiencing a long frost.

Voices in the Garden (Part III) Ron Rothstein, president and COO, Levindale Hebrew Geriatric Center and Hospital, Baltimore, Maryland: "You don't cure the three plagues overnight. Some of our residents have been here a while, and they've become depressed. It takes time to bring out the best in them. I'm a type A personality -- a 'gotta get it done today' type. But culture change is slow. And subtle. You don't necessarily see the relationships between people every day."