A nontraditional team approach fostered by strong leaders was the common link between two facilities’ extraordinary success in managing pain.

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an Juan Nursing Home knew all about the practical side of caring for residents with pain. As in other facilities, when residents complained of having pain, staff conducted an assessment and administered pain medication as appropriate. It was not until one of their own nurses, a veteran of 18 years, was admitted that they were forced to face the reality that any of them could become a resident.
       “We always thought that we knew about pain, that we knew about cancer. She helped us to realize that this could be any of us,” says Dalia Aguayo, Director of Nursing (DON). “When things like this happen, you think about pain management and quality of life that much more.”
       The administrative care team at San Juan is driven by its belief in the importance of emphasizing the emotional support that residents need as much as clinical support. Located in southern Texas in the city of San Juan, the 122-bed facility could be called by many measures “nontraditional.” It has implemented a pain management support group and healing teams, sent a certified nursing assistant (CNA) and someone in its medical records department to become registered massage therapists, and developed annual staff retreats for all staff. Even though it is nontraditional compared to the number of nursing homes that operate with a medical model, the way San Juan approaches pain management is a reflection of the culture and faith of the people in southern Texas. It is an approach that has worked well for the facility, which has some of the best pain management rates in Texas. In the fourth quarter of the calendar year 2005, San Juan’s pain management rate was 1.4%.
       More than 500 miles to the north, Denton Rehabilitation and Nursing Center (Denton, Tex) is led by 2 take-charge leaders, Bob Foster, administrator, and Robert Norris, DON, who constantly challenge the mantra, “We’ve always done it that way.”
       “It’s our management philosophy that if an issue arises, you get up immediately and resolve it. It doesn’t matter if it is a laundry issue, a facilities issue, or a pain issue,” says Foster. The staff members have always wanted to do the right thing, but they did not have the right tools and were not empowered to make changes until Foster became the administrator.
       Foster, Norris, and their staff work tirelessly to address issues immediately. Take restraints, for example. In 3 days, the facility’s restraint rate went from 6% to zero. It is now a restraint-free facility. Staff at the 196-bed facility took the same lightning-fast approach with pain management. Once they identified that their pain management rate was not where they wanted it to be, they sprung into action. Like San Juan, they now have one of the best pain management rates in Texas and have maintained it 15 months.
       When 2 facilities approach pain management in such drastically different ways, it begs the question: What is the magic bullet that makes them so successful? In this case, strong leadership gives both facilities their edge. While leadership at San Juan challenge staff to do more to make the residents comfortable in their own home, Denton’s leaders identify an area that needs improvement and swiftly execute change. Their differing styles demonstrate that improvement is not necessarily about what you do to improve but how you do it.
       The leaders of both facilities constantly embrace change and follow through to make sure the adjustments are not just temporary. Since both are stand-alone facilities, the leaders must also do extra work to give staff the resources and support they need. Finally, the leaders recognize that having the right staff on board is vital for any change to succeed.

Commit to Change

       The Denton facility began to take pain management more seriously when it came to the realization that pain is not a normal part of the aging process, says Norris. Working in collaboration with TMF Health Quality Institute, the Medicare Quality Improvement Organization (QIO) for Texas, Foster and Norris realized that they could do something more to manage pain and, in turn, set higher standards for themselves and their staff.
       “It wasn’t a choice for staff whether or not they wanted to improve pain management for the residents. Bob wanted to raise the bar, and all of our staff are committed to that vision,” says Norris. “We found that when we brought pain to the forefront and took the time to talk to the resident and actually listen to them, it was amazing what we found.”
       The leadership at San Juan was open to other possibilities to manage pain after working with TMF on a statewide nursing home quality improvement (QI) collaborative project. During collaborative learning sessions with other facilities, San Juan learned about alternative methods, such as prayer and healing touch, to control pain, says administrator Olga Navarro.
Many of its residents were already taking pain medications either as needed or routinely, says Navarro, but facility staff felt the need to do something more effective. Navarro approached Josefina Suarez, San Juan’s pastoral director, to see how residents might respond to an alternative approach in addition to their clinical regimen.
       “We started out by doing a healing session support group. Once we saw how quickly the residents responded to it, we thought, ‘We have to keep doing this,’” says Suarez. “It’s not just good for the residents, but it’s also good for us. It’s so relaxing that it is very effective for our spirits as well.” Overall, resident complaints of pain have decreased, says Aguayo. She has also noticed that the residents are more alert and smiling, especially during the healing sessions.
       “They want to participate more and feel like they are doing better.”

Care Planning and Assessments

       Though the Denton facility made a commitment to change, Foster and Norris knew that getting staff to follow through would be the tough part of the equation. They addressed this challenge in several ways. Looking at their processes, they developed incident reports that included pain. Residents who scored “1” or more on the assessment were given pain medication.
       “Our weapon as managers is consistency,” says Norris. When something is off-track, they know right away by looking at the assessments and getting feedback from others, including staff, residents, and families.
       “Pain management is not rocket science. We have to admit when we make mistakes and then fix them right away,” says Norris. Working to quickly correct problems, any problem, on the spot is integral to winning the trust of the residents and families.

Building on Small Tests of Change

       San Juan, inspired by its first attempt with a support group, used the initial success as a springboard for other solutions. The first support group evolved into a weekly meeting of residents and now focuses on aromatherapy, light massage, breathing exercises, silent meditation, music, and prayer. The group also incorporates hands-on exercises using herbs and oils. For example, many of the group members grew up using an herb similar to peppermint, called Yerba Buena, to comfort them. Smelling the herb now reminds many of their youth and brings back comforting memories, says Suarez. At the sessions, the pastoral director passes the different herbs to every resident and says, “Tell me the story of what you remember about this herb. Talk about what you used to do with this herb.”
       “We talk about the emotional and the physical pain,” adds Suarez. “It is something that the residents look forward to every Monday.” So much so, she said, that San Juan is now considering having 2 groups—one for those who are experiencing pain and one for those who are feeling better from the first group.
       “One of our greatest successes is that residents in the support group are now doing breathing exercises and meditation in their own rooms to help alleviate their pain,” says Aguayo. “It’s important for them to be able to do it themselves. They tell me they feel [rejuvenated].”

Staff Empowerment and Education

       One of the critical steps the Denton facility took to improve its pain management rate was to give CNAs and nursing staff an outlet for communication if they saw something that needed to be addressed, says Foster. For Cynthia Canada, a licensed vocational nurse (LVN) who started working for the Denton facility in 2002, this communication is critical and flows both ways.
       “Teamwork is vital to what we do here, so open communication with our supervisors is very important,” says Canada. “Robert will come to me with a problem, and we’ll work to fix it right away.” Christine Montoya, a CNA at Denton, is responsible for activities of daily living (ADL) interventions, so she is constantly looking for residents who might be frowning, bracing, or moaning.
       One of the biggest improvements that Montoya has noted is that she sees more of the residents moving around and fewer staying in bed. “Robert and Bob give us a voice in making change,” she says. “Of all of the places I have worked, this has been the most team-oriented.”
       The Denton facility also focuses on learning opportunities for staff. Every quarter, it sets aside 3–4 hours of class time where they address policies and procedures. The staff members also do walking rounds daily. The rounds include administrative staff who know nothing or very little about nursing care. Like a resident or family member, these staff members do not necessarily know what to look for or why something is a certain way. Their observations provide an outsider’s perspective that clinical staff don’t necessarily have, says Foster. “We want the staff to take pride in where they work, like Robert and I do.”

Getting Staff Involved

       Staff involvement is another one of the keys to San Juan’s success. For the past year, it has implemented 5 interdisciplinary pastoral care teams, called healing teams, throughout the facility. Each employee has a small assignment each day to see how a resident is doing, says Suarez. The healing teams are an extension of the rest of the nursing homes because they are interdisciplinary and able to work quickly and effectively to resolve issues for residents or just to do special things for residents.
       Each healing team consists of employees from the different departments, including dietary, housekeeping, laundry, activities, CNAs, nurses, department head staff, and administration. Even the administrator and the DON are members of a healing team. Members of each team select a name for their team. Healing teams meet monthly to report on the activity of residents assigned to them. Each healing team is responsible for resolving any concern that the resident might have.
       “The staff might visit for a few minutes, see if they need anything fixed, or tidy up their room for them. If a resident needs something, they work with the other teams, like housekeeping and dietary, to help them. They also talk about personal things, like if someone’s family is coming for a visit,” says Suarez. Some teams create door decorations for holidays while others take residents out for their birthdays to the cafeteria across the street. They also check closets to make sure everything is clean. Some teams will donate clothing or enlist community support for those whose families cannot afford to provide for their needs.
       Each healing team is responsible for 10–12 residents. The team’s responsibility is to do whatever needs to be done for the resident that does not occur within normal routine care. In addition, the teams go on retreats throughout the year to recharge their own batteries and learn to grow as a team. “This helps to show that everyone is very valuable in this process,” says Suarez.
       One of the newer things that San Juan tried was to have several staff members become registered massage therapists. Navarro approached Reyes Rostro, a staff member in the medical records department, about becoming a massage therapist because she saw a need for that skill for the residents. Shortly thereafter, Ofelia Carrizales, a CNA at San Juan, joined him. “After Reyes started going to classes, we saw the additional need to expand this program, and Ofelia was interested in the same sort of work,” says Navarro. San Juan pays for the school and works around schedules so that staff members can have these additional educational opportunities.

Seeking External Support and Resources

       As part of a greater mission to provide quality improvement assistance to Medicare facilities, the Centers for Medicare & Medicaid Services (CMS) contracts with organizations like TMF to work with long-term care facilities in their respective states. Both Denton and San Juan worked with TMF to improve their pain management rates and care planning.
       “TMF brought things to our attention and changed our focus,” says Foster. “We are a stand-alone facility and don’t have the opportunity to share with sister facilities. Access to this kind of outside resource helpful for us.”
       In addition to learning about other trends in the industry at TMF’s collaborative sessions, San Juan worked with TMF’s QI consultants to provide continuing education (CE) pain management in-service sessions. They also seek out external resources from state agencies and pharmacists.

Enlist the Right Team Members

       When Foster arrived in 2000, he could have changed everything about the facility. But he is proud of the fact that the same nursing leadership that was there when he first started, with the exception of the DON, has remained.
       “Our success didn’t happen overnight. It took us a while to build this team,” says Foster. Adds Norris, “Imagine what it would be like to live in a nursing home where you had every confidence in the staff that they would immediately correct a problem that needed to be fixed.”
       Plans are under way to open a new facility in Plano, Texas. Both Foster and Norris intend to move to the new facility. “We will have had an administrator and a DON in training for a year so that when we leave, the success in this building will continue,” says Foster.
       The Denton facility’s leaders place a strong emphasis on having pride in where you work and wanting to tell people in the community about your job. “We are trying to change long-term care, but the only way to do that is by raising the bar,” says Norris.
       Adds Navarro, “Someone may ask us, ‘Why are you doing so many different things? Why are you trying to make it better?’ I tell them that when the staff work well together and feel supported in their work, the residents are happier and healthier.”
       It is clear that employees are satisfied at both facilities. TMF staff recently conducted a staff satisfaction survey of more than 160 facilities in Texas. While the average staff satisfaction rate was only 63% or all of the facilities, both San Juan and Denton scored significantly higher.
       Foster and Navarro have honed in on 2 areas that help them to excel—leadership and data. Drawing on their personal strengths as leaders and the strengths of the leaders around them, the administrators use data to make improvements and to try something new. “We really believe that this is not work. That it’s not a job. It’s a mission. You need to love what you do,” says Suarez. “We love what we do, and with the support of each other, that really helps.”

       Authors’ disclaimer: This material was prepared by TMF Health Quality Institute, the Medicare Quality Improvement Organization (QIO) for Texas, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the US Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy (8SOW-TX-NHQI-06-26).