"Expect the Best!"

By / Posted on January 15th, 2015

My work often brings to mind my good friend and mentor, Nancy Fox. Nancy is Chief Life Enhancement Officer for Vivage in Colorado, was the first Executive Director of The Eden Alternative™, and has many years’ experience as an administrator and an educator. The lessons she has taught me pop into my head on many occasions.

In 2007, Nancy wrote a book called Journey of a Lifetime: Leadership Pathways to Culture Change in Long-Term Care (available at www.edenalt.org or online booksellers). The book lists ten important principles for enlightened leadership, illustrated by stories of good and not-so-good experiences she has had, and lessons learned. One of these is called “Expect the Best,” a principle that is ignored with alarming regularity in long-term care, on both the provider and the regulator sides.

Here is an example of each:

First, a recent McKnight’s article described a study in the upcoming issue of Geriatric Nursing that can only be described as what my friend Jane Verity would call “a blinding flash of the obvious.” This study of nursing homes in the US and Germany showed that CNAs had a much better work experience if they were notified of the deaths of their elders before discovering it for themselves (such as walking into a room to provide care and finding an empty bed). The study recommended “more mindful” approaches to such transitions for those who have formed close, caring relationships.

Wow. What’s sad about this study—even the need to conduct such a study!—is that it reveals how often we give lip service to honoring our hands-on care partners, but choose actions that say the opposite. Then we are quick to blame those same people for lack of a “work ethic.”

Look at your employee handbook and ask yourself, does this document expect the best of our employees? Does it treat them as responsible adults or as children (or worse yet, as potential criminals)? Then look at the actions and interactions of leaders and managers throughout the day. Are our care partners included in decision-making discussions? Do we ever ask for their opinions or advice?

Expecting the best creates two complementary results—it improves people’s abilities and their accountability. Nancy frequently says that “empowerment is not something you try; it is something you do.” When we approach those who support our elders with an expectation that they are capable of great wisdom and growth, we create an environment where growth can occur and wisdom will blossom. And by treating people as equals, we create an environment where people care about each other and about the consequences of their actions, and accountability thrives.

Such discussions raise the inevitable objection that there are people who will take advantage of your good intentions and try to game the system. Welcome to the planet Earth. The problem not that such people exist; the problem is that we write our policies and choose our actions based on the worst person we can imagine and punish everyone else with our low expectations, rather than addressing (or removing) the individual in question. Nancy would likely say, “Expect the best, (and individually address the worst).”

The second example was raised by Karen Schoeneman, formerly of CMS, in a recent culture change discussion that highlights this issue on the regulatory side. She was upset to hear that surveyors in her home state were not permitting elders to have refrigerators in their rooms because of the concern that a resident with diabetes could potentially enter the room and take something that would not be good for his/her diet.

There is so much wrong with that citation that I could devote an entire post to it. But let’s stick with “Expect the Best,” as it applies to surveyors. The fundamental flaw in our regulatory system, I believe, is that surveyors inhabit a primary identity as enforcers, rather than educators. Therefore, they come into the nursing home expecting the worst and constantly imagining “What could possibly go wrong?”

(Of course, Nancy added her two cents to the discussion thread as only she can do, suggesting that perhaps “surveyors shouldn’t be allowed to drive, because they might hit a diabetic.” If it’s possible to laugh and cry at the same time, that’s what I did when I read her comment.)

Incidentally—to be fair to surveyors—many of them work in states where they are required to be enforcers only, because the rules say that they cannot advise providers, only tell them if what they are doing is “in compliance” or not. Apparently the concern is that surveyors might lose their objectivity if they try to mentor the homes. And apparently the rule makers have never heard of school teachers, who mentor their students every day and still give them quarterly grades. If the regulatory bosses don’t expect the best of their surveyors, then a trickle-down effect at survey time is entirely predictable.

These are two examples of why I sometimes despair that our current system of elder care will never truly create well-being for anyone. There is far too much talk about “culture change” and too little evidence of it. Nancy Fox is one person who has always walked the talk. We would all do well to read, or re-read, Nancy’s book.