Conversations with Leaders in the Field of Patient-Centered Care:
Barbara Frank, M.P.A.
One of the ways Picker Institute supports patient-centered care is by recognizing significant contributions to achieving patient-centered care nationwide. “Conversations with Leaders in the Field of Patient-Centered Care” is a regular feature that highlights these contributions
This Conversation is with Barbara Frank, M.P.A., the co-founder, with Cathie Brady, of B&F Consulting, whose mission is to help nursing homes to be better places to live and work. They often serve as faculty for learning collaboratives to improve staff stability, care outcomes, quality of life and overall organizational performance. Presently B&F Consulting is leading a multi-state Pioneer Network National Learning Collaborative in “Using the MDS as the Engine for High-Quality Individualized Care” in collaboration with 1,000 nursing homes.
In 2011, B&F Consulting worked with special-focus and critical-access nursing homes in four states through an Advancing Excellence initiative that led to improvements in staff stability and care outcomes. As faculty to the Quality Partners of Rhode Island (now Healthcentric Advisors) “Improving the Nursing Home Culture” pilot in 2005, they helped 254 nursing homes improve staff, resident and organizational outcomes, and co-produced Quality Partners’ Staff Stability Toolkit and the four-part CMS Web series “From Institutional to Individualized Care.”
Barbara led a team in the New Orleans Nursing Home Staffing Project that helped nursing homes recover from the aftermath of Hurricane Katrina, and co-produced a film with Louisiana Public Broadcasting, “The Big Uneasy: Katrina’s Unsung Heroes.” She co-authored Meeting the Leadership Challenge in Long-Term Care: What You Do Matters (Health Professions Press, 2011) with David Farrell and Cathie Brady, and Nursing Homes: Getting Good Care There (Impact Publisher, 1996) with Sarah Burger, Virginia Fraser and Sara Hunt.
Earlier in her career, Barbara worked for 16 years at the National Citizens’ Coalition for Nursing Home Reform in Washington, D.C., where she directed the landmark 1985 study “A Consumer Perspective on Quality Care: The Residents’ Point of View” and helped establish the national network of state and local ombudsman programs. She facilitated the Campaign for Quality Care through which providers, consumers, practitioners and regulators developed consensus on what became the OBRA 1987 legislation that refocused nursing home regulations on individualized care. Barbara facilitated the first Pioneer Network gathering in 1997, and in 2005 she facilitated the St. Louis Accord, a national gathering of providers, consumers, regulators and quality-improvement organizations that came together to improve clinical outcomes through staff stability and culture change.
Barbara serves on the board of the Pioneer Network and has an M.P.A. from the Kennedy School of Government.
You have a very long record of achievements in the field of long-term care and its need for patient-centered care, starting with your work with NCCNHR. What piqued your interest in this field?
The summer after my first year of college, I got a job as a home chore aide in Washington Heights in Manhattan. I lived in New Jersey, so it was an hour-and-forty-five-minute commute each way on buses and subways. And I loved it. I felt heart connections with so many of the people I helped out each day. I took them to clinic appointments, grocery shopping and Mass. I cleaned their houses, and all the while we’d visit. I learned a lot about the challenges and choices of aging, and I found role models and harbingers. My boss was Ann Wyatt, who became my mentor and friend. When I finished school, she introduced me to her friend Elma Holder, with whom she had just founded a national consumer advocacy group. Everything Elma talked about made so much sense to me, and for 16 years I had the amazing experience of getting to work side-by-side with her. She and Ann have nurtured me personally and professionally ever since.
You were very involved in the effort to bring about OBRA ’87 [ the Omnibus Budget Reconciliation Act of 1987 that set new standards for care in nursing homes], which many people regard as the first important breakthrough in changing the culture of nursing homes. How well has that legislation served the people for whom it was enacted? What is the need for an update?
I live by OBRA’s words that each home provides the care and services to “attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.” That sets such a clear vision: No resident declines unless it’s a natural progression of the person’s condition or disease. We’ve come such a long way that it’s hard to remember the days when restraints were the norm. And we have a long way to go. I see such promise in the progression that is underway. It’s more than two decades since OBRA initiated a new wave of progress, and there’s so much moving it along: the Pioneer Network, culture change coalitions and all the organizations that take specific approaches to transformational change; the QIO network and the Advancing Excellence LANEs; and government action through MDS 3.0, QIS and QAPI. We have a growing understanding of the “how to” as we have more and more adoption of individualized care and staff engagement, and I think in the coming generation we will see the tipping point of the transformation of the norms of care in our field.
You were also involved in the formation of the Pioneer Network, which was truly a groundbreaking development. As a board member, do you feel Pioneer is living up to the expectations of its founders? What do you see as its role in the continuing culture change movement?
Our founders were very wise. They planned to hand over what they started to others who would make it their own, knowing that the best ways to move forward evolve. One of the most thrilling aspects for me about being on the inside of the Pioneer Network is to see how much they live in practice the values they support. People really talk things through, and everyone’s contribution counts. I think that’s a key to the Pioneer Network’s role—to foster continual growth and innovative development. We’re involved now in facilitating a national learning collaborative on using MDS 3.0 as the engine for high-quality individualized care. Assessment and care planning are supposed to be agile, just-in-time, inclusive processes, but instead they’ve been burdensome rote exercises in documentation. We’re helping homes make the care planning process come alive among the staff closest to the resident so there’s a give and take among the care team and with the resident. That’s how you individualize care.
Why is long-term care such a hard sell? It is almost literally the only health development everyone has potentially in common, and yet it doesn’t yet appear to have the star power of cancer or AIDS or the disease of the month. Is this massive denial, aided and abetted by our preoccupation—often to the absurd—with youth?
People fear living in an environment where they can no longer be themselves. The loss of personhood that comes with living in a place where you aren’t at home compounds the horrors of the diseases you mention. In 1985, NCCNHR asked people living in nursing homes all across the country what were the most important factors for quality care. The universal response was “kind, caring staff who know me as an individual and help me continue to live out my days being myself.” That still holds true today. That’s what’s so important about the drive for individualized care through which nursing homes help people live according to their lifelong customs and routines. For all of us, our patterns of daily life and relationship are the foundation for our well-being.
How much of your work is directly with elders? Do they have places in all the organizations you’ve been a part of? Are they advocates for themselves? Of course, we will all be old some day, so perhaps age is irrelevant here.
At B&F Consulting, Cathie Brady and I work directly in nursing homes and then also with networks of stakeholders. Elma Holder’s words echo in my mind every day as I work—to keep the resident’s needs, perspective and experience at the center of my thinking. We generally work with staff and management to support their ability to help residents have the best possible experience. We help staff work better together, and as their ties strengthen, they are better able to support residents. We often use “discovery assignments” in which we encourage staff to ask residents about their experience, or to have the experience themselves, such as wearing an alarm, sitting in a shower chair, lying in a resident’s bed to feel, see, smell, hear. The more we can help management and staff personalize the experience, the better they know how to care for residents.
“The Big Uneasy” was very moving. It is always a wonder to see the heights to which people can rise under pressure. How have you disseminated the DVD? It deserves a huge audience.
Nursing home staff really were the unsung heroes of Hurricane Katrina. They were first responders to the nursing home residents they safely sheltered for days, weeks and months as the entire area collapsed. We had an amazing group—Cathie Brady, Dr. Susan Wehry and colleagues on the ground in New Orleans—that teamed up to provide support as nursing home staff worked to recover. Hearing what they faced, and how they faced it, we were just in awe of their full-hearted courage and compassion. In our last year working with them, as life started to regain some stability, we felt a need to make sure others knew the truth about what they had done, because so many people have the wrong idea of what actually happened. We filmed interviews with staff from six of the homes. It was hard for them to relive it, but they were determined to do so because they believed that by sharing their experience they could help others who might someday face similar circumstances.
We’ve shown it as part of disaster preparedness training with Jocelyn Montgomery from the California Association of Health Facilities, and people have found it to be a perfect primer for emergency readiness, because people speak concretely from real experience.
Linda Sadden, the State Ombudsman oversaw our work, and Louisiana Public Broadcasting produced the film, which was funded using civil monetary penalty funds. The ombudsman’s office sent copies to every state survey agency, ombudsman, QIO and provider association, and sends out bulk orders at cost. You can also order a single copy from the Pioneer Network (www.pioneernetwork.net/Store/BigUneasy/).
What do you see as the most formidable obstacles to reforming nursing homes? How can they be overcome?
Corporations have a huge influence on health care now, and they need to take a page from the “stop doing” list David Farrell included in our book, Meeting the Leadership Challenge in Long-Term Care. We’ve worked with some outstanding corporations who understand that to do well as companies, they need to do right by their staff and residents. But too many corporations have gotten too far away from the basics of good business. They focus on today’s census and profit rather than on how to invest in the people and systems needed to provide good service.
Corporations need to foster innovation and understand that caring about and listening to their staff is the best way to assure good care for residents as well as good performance for their organizations. I’ve seen some amazing examples of high-performing corporations, and very capable, caring administrators and directors of nursing whose good management and people development have been the bedrock of good care.
The best management practices are bottom up—and yet too many corporations don’t listen to and don’t support their administrators and DoNs. Too often these on-site leaders are micro-managed with questions like “Why did you spend so much on broccoli crowns?” or directed to take actions that break trust with staff, such as staffing to census. We’ve watched time and again as good administrators have had to leave because they were not well enough supported by their regional directors and corporate bosses, or because they faced situations that required them to act against their conscience. The turnover of good top leadership shatters an organization.
We have a strong body of evidence about effective leadership and human resource practices. If corporations would adopt these practices, we would be well on our way to good care for all.
Many of your accomplishments have been the result of collaboration. Can you tell us a little about those experiences?
I believe very strongly in the power of collaboration. When people with different points of view get together, they often find they have far more in common than they originally thought. That’s been powerful in building a national movement, it’s powerful in a learning process and it’s been a powerful force in my life.