As the Society for the Advancement of Gerontological Environments (SAGE) approaches its 20-year anniversary, David Green, founding member, reflects on the significant changes in long-term environments and offers a call to action for those designing environments for the senior market. [Editor’s note: David Green died March 3, 2014, six months after this interview was published. You can read our tribute to him here: “Senior Care Community Loses A Visionary.”)
Environments for Aging: How has your work in long-term care changed over the past 20 years?
David Green: For much of my professional life, I have strived to define what the attributes of the “perfect” nursing home would be. The development of my understanding of perfection related to long-term care environments for elders began during the two years of my graduate studies for an M.S. in Studies in Aging, which I received in 1970. This is when I was exposed to the research done in the 1960s showing that persons with dementia behaved more normally when living in small groups. This research was the foundation for our development of the household/neighborhood model of long-term skilled nursing care beginning in 1987, when I was CEO of Evergreen Retirement Community in Oshkosh, Wis.
By 1994, when SAGE was founded, Evergreen had already tested the household model in a year-long pilot project and recognized that a new management philosophy would be required. In 1990 we determined that Continuous Quality Improvement (CQI), which is a team-based approach to management, was the right philosophy, and so began the total transformation of the organization. (CQI is the precursor of the Lean management philosophy for maximizing the value of services and facilities provided.) I believe that Evergreen was the first skilled nursing facility in the U.S. to adopt CQI as the management philosophy.
To implement CQI required training all Evergreen staff members in how to be effective team members. This training, which took over two years, proved to be very important in the transformation of the organization to be resident- and relationship-centered. We also learned that effective teams require trained facilitators. In 1996-97, prior to opening a 36-resident household/neighborhood, Evergreen had more than 50 teams of various types in operation.
During the pilot project, we learned that when staff work in separated households, personal communication devices are essential. This led us to become the first skilled nursing facility in the U.S. where all the direct care staff carried radios (later we learned that in-house cellular phones were more effective).
One major driver of my learning in recent years has come through assisting the governing boards of about 15 organizations with the adoption of Values Driven Governance (VDG). VDG is a significantly enhanced version of Policy Governance (created by John Carver about 40 years ago) that I developed beginning in 2000. Good governance is essential for sustainable “culture change” in long-term care settings.
A second driver for my new learning has been my membership on the Health Guidelines Revision Committee of the Facilities Guidelines Institute, which every four years publishes national model regulations for all types of healthcare facilities, including long-term care. One major area of learning for me has been regarding the design and use of mechanical lifts for movement of residents. For me, an important new insight is that as much attention needs to be given to maintaining and improving resident mobility as to staff safety when selecting and using this equipment.
A third driver has been my involvement since 2009 as director of conceptual planning and development for China Senior Care Inc., a small organization that’s developing skilled nursing facilities in China. We will be opening our first facility, which is based on the household/neighborhood model, in mid 2014. It will have eight households of eight residents each in a five-story building near Hangzhou.
Key areas of new learning from my experience with China Senior Care have been (1) understanding the difference between the “medical model” and the “life model” of programming, (2) recognizing the importance of transitions between daily life “events” to the quality of life of the residents, (3) realizing that the social model adult day service program offers the best approach for programming in long-term care, and (4) seeing how beneficial technology can be to maintaining relationships between residents and their families and friends.
What do you see as the biggest challenges facing the development of long-term care environments over the next 20 years?
Providers, designers, and regulators need to make some significant changes in how they approach the environmental design process. To have great long-term care environments, providers need to do comprehensive pre-architectural programming so they can clearly define for the designers and the regulators what the environment is supposed to do. The designers need to know all the users, all the activities in which the users will engage, the desired experiences of the users in each activity, and the functional requirements to provide those experiences. The designers also need to know the core values of the provider, which should guide the design decisions. If the regulators also have this information, it may help them interpret the applications of the regulations. Convincing providers of the importance of pre-architectural programming is and will continue to be difficult, since it takes time and effort.
The challenge for the designers is to know how to use the pre-architectural programming to the greatest advantage through the application of their design skills. The challenge for the regulators is to support in any way possible the provision of the desired experiences for the users.
What accomplishments are you most proud of when you consider your contribution to the field of long-term care? What would you like to be your legacy?
I am grateful to have been in the leadership position at Evergreen where we had the time, support, and resources required to create the first household/neighborhood model for skilled nursing care. In retirement, I am very grateful to see that model introduced in China with the opportunity to more fully develop it.
I am grateful to have been given the opportunity to develop Values Driven Governance as a result of a governance crisis at Evergreen, and now to be able prepare others to carry on the facilitation role with the governing boards of other organizations, including long-term care.
As my legacy, I would like both of these accomplishments to live on beyond my lifetime.
DAVID GREEN’S CAREER CHRONOLOGY:
- B.S. degrees in architectural engineering/business: 1962
- Engineer: 4 years
- Moved to long-term care field: 1966
- Received M.S. degree in Studies in Aging: 1970
- CEO, Evergreen Retirement Community, Oshkosh, Wis.: 1976-2005
- Founder of SAGE: 1994
- Founder of Wellspring: 1997
- Initial member of Pioneer Network: 1997
- Award of Honor recipient, AAHSA: 2005
- Honorary doctorate, UW Oshkosh: 2006
- Health Guidelines Revision Committee: 2006-present
- Director of Conceptual Planning and Development, China Senior Care Inc.: 2009-present
- Long-Term Living’s 10 Most Influential People: 2011
