Transcript Culture Change – What, Why and How?

Culture Change:
The Importance of Leaders
AAHSA Annual Meeting
November 7, 2005
Mary Tellis-Nayak, RN, MSN, MPH
Presentation Outline
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Quality – what is most important
Quality of life for residents=Quality of work
life for caregivers
Leaders and Managers
Leadership: essential to create a quality
work environment
The Leaders challenge in changing the
culture
Presentation Outline
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The importance of a Quality Workplace
The Elements of culture change
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What does it mean
What do we need to do to:
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Create a quality of life for our residents?
Create a quality of work place for our
staff?
Quality: Its Meaning
Nation-wide study
Number
States
Residents…………………….……
241
26
Families……………………………
272
26
Administrators…………….………
108
5
DONs………………………………
124
5
ADONs………………………….…
32
5
CNAs…………………………….…
2,058
36
Medical Directors…………………
66
20
Others…………………………...…
26
5
2,927
36
The voice of experience
Years worked in nursing homes
Average
Cumulative
Administrators….…
15.9
1,767
DONs……………...…
12.2
1,523
ADONs…………..…..
9.9
317
CNAs…………………
9.02
Medical Directors…
13.2
Total years of NH experience
16,650
871
21,078
Central research question
What is the character of a good nursing home?
• “Choose the one most important feature”
• List of 11+ items: mingled, positively stated
HCFA: checklist
Critical QIs
1. Choice in daily routine
2. Resident well-groomed & drs
3. Facility looks-smells clean
4. Staff-resd interact warmly
5. Choice in food
6. Religious & sp. needs met
1. Pressure sores
2. Dehydration
3. Weight loss
4. Fecal impaction
5. Restraints
Add your own
Most important feature of good NH: The frontline view
Staff interaction
Clean premises
Choice-daily routine
Choice-food
Resident groomed
P-sores
Resident
Family
Don
Adminstrator
Rlgs-sprtl needs
Mdirector
Dehydration
Restraints
Wt loss
F-impaction
0%
10%
20%
30%
40%
50%
60%
70%
80%
First most important feature of good NH: Residents-Families
Staff interaction
Clean premises
Choice-daily routine
Quality of life
Res: 74%
Family: 84%
Choice-food
Resident groomed
P-sores
Rlgs-sprtl needs
Quality of Care
Dehydration
Restraints
Resident
Wt loss
Family
F-impaction
0%
5%
10%
15%
20%
25%
30%
35%
40%
First most important feature of good NH: DONs, NHAs, M-Ds
Staff interaction
Clean premises
Quality of life
Choice-daily routine
Choice: Food
DONs: 95%
NHAs: 95%
M-Dirs: 88%
Resident groomed
P-sores
Rlgs-sprtl needs
Quality of Care
Dehydration
Restraints
Don
Wt loss
Adminstrator
Mdirector
F-impaction
0%
10%
20%
30%
40%
50%
60%
70%
80%
Quality: The residents’ point of view
1985 NCCNHR study
Question to residents:
“ What does high quality care mean to you?”
Answers found in open group discussions
• 457 residents speak up
• 105 nursing homes
• 15 cities
Quality: The residents’ point of view (1985 NCCNHR study)
Question: “What does high quality care mean to you?”
Residents answer: “Good
“Good staff” =
#3 = Adequate
staff
1. “they want to help”
staff”!
#9 = Competent
staff
2. “they are kind, nice, good to me”
3. “there are enough of them”
4. “they are polite, courteous, respectful, treat me with dignity”
5. “they are friendly, cheerful, pleasant, jolly”
6. “they are patient, they have time for me”
7. “they are patient, listen, take complaints seriously”
8. “they relate well, positively”
9. “they are well-trained, qualified, skilled, knowledgeable”
Is there a disconnect between
what residents, families, and staff
believe are the elements of
quality and what we actually
provide?
Leaders and Managers
Administrator and DON:
the architects of excellence
A nursing home
excels or fails
with its managers
“80% of all quality problems
are the fault of managers.”
--Deming
Manager versus Leader
Manager
Leader
• Is like a conductor: keeps
everyone on the same
page
• Is like a composer:
marches to a different
drummer
• Avoids disharmony: follows
rules and regulation
• Is inspired by a vision and
a dream
• Ensures adequate
resources
• Innovates, inspires,
empowers
• Goal: avoid deficiencies
achieve compliance and
family satisfaction
• Goal: reach for excellence
and family recommendation
Administrators and DON’s are the KEY to Quality
Quality of care: QI Index
Survey results
The NHA-DON turnover is by
far the best predictor of a
quality collapse.
Family satisfaction
Staff satisfaction
Staff turnover
Administrator turnover
Every quality-related outcome
turns direction and heads south
Census
Liability
Finances
Other
Creating a Quality Workplace
A Leader’s Mission
Old culture
New culture
• Quality of care
• Quality of life
• Competent, trained
staff
• Devoted caregivers
• Policiesprocedures,
protocols
• Innovation, best
practices
• Professional control
• Resident-directed
care
A Leader’s Challenge
• Quality of care
• Quality of life
• Competent, trained
staff
• Devoted caregivers
• Policiesprocedures,
protocols
• Innovation, best
practices
• Professional control
• Resident-directed
care
Lofty goal, loooooong journey
Where do we start?
Starting point
Goal
Lofty goal, loooooong journey
STAFF !
Person-centered
workplace
Quality of Work
for care-giver
Care-giver: first
customer
Personcentered
care-giving
Quality of Life
for resident
Resident: primary
customer
The nursing home:
CNAs
Residents
where 2 worlds
meet
• lowest status age group
• weakest social class
• loss of health, roles, home
• lowest social status job
• dependent, frail
• powerless to change
?
• least paid, least autonomy
• powerless to change
How do the DON and Admin. generate quality of life?
The cradle of quality
=
Resident
CNA
interaction
Resident’s world = The CNA CNAs significant world =
•
•
•
90% of personal care
6 times as an RN
5 times as an LPN
Q of life = CNAs
relationship
The Nursing Home
50% of waking hours
• 90% economic support
• significant social bonding
• self image, self respect
•
Q of life = n-h relationships
Quality of Care Vs Quality of Life
Quality of Care
Quality of Life
Is best judged by
Is best assessed by the
customer:
Experts in the field
Resident, Family, Staff
QIs were invented by
experts. They measure
success in care-giving.
Satisfaction surveys capture
customer’s expectations &
satisfaction
Heavy resources are spent
on refining QIs
Few resources are spent on
advancing satisfaction surveys
Quality of Life adds TLC to Quality of Care
Quality of Life
flows from a new culture of caregiving.
Quality of Care
is the result of
• adequate knowledge, competence & skills
• proper procedures & protocols
It can be attained in the traditional
cultural setting
Where high QoL flourishes, good QoC is assured.
But
But
good
good
QoC
QoC
does
is no
not
guarantee
guarantee
a high
a high
QoL.
QoL.
It’s all about…..
Relationships
It’s all about relationships!
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No man can stay alive when nobody is waiting for
him. Everyone who returns from a long and
difficult trip is looking for someone waiting for
him….Everyone wants to tell his story and share his
moments of pain and exhilaration with….someone
waiting for him to come back….A man can keep his
sanity and stay alive as long as there is at least one
person who is waiting for him”.
Henri Nouwen
The Wounded Healer
I hope for the day when everyone
who lives in any long-term care
situation knows there is someone
waiting for him or her each morning
after the journey of sleep one takes
each night.
And I yearn for the day when each
staff person, most especially CNA’s,
know that there are people who are
waiting for a morning greeting,
interested in learning how the CNA
fared in the hours they were apart.
Carter Williams
Elements of Culture Change
CULTURE
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The uniqueness of an organization or
an institution
Its “personality”
The way an organization/institution
does things
The values, the lifestyle, the goals
which are peculiar to an organization or
an institution
Think about the average nursing
home in VA– what comes to your
mind?
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Dining
Bathing
End of Life
Think about the most IDEAL home
you can imagine – what comes to
your mind?
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Dining
Bathing
End of Life
How would you change these
if you could?
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Dining
Bathing
End of Life
Breakfast: a jigsaw-network of different processes
Breakfast – Residents can wake up!
Waking
Shift
Dietary
Lts
Out
HR
Bathing
Wak
e up
Transport
14 Hr
Snacks
B ofc
Communication
Trnspt
Days
only
CofC
Food
Dietary
Sho
wer
Needs
Link 3
Link 3
Link 4
PT/OT
Choice
Link 3
Link 4
Trays
Breakfast: a jigsaw-network of persons, habits, attitudes
Breakfast
Attitudes
Budget
History
MedM
HR
People
Instit
Regs
Supp
Snacks
BusOf
Staff
Habits
14 Hr.
PPD
Trnspt
PT/OT
Link 4
Link 3
Link 4
Link 1
Dietary
Link 2
Link 3
Link 3
Link 4
Link 4
Why
Why isis breakfast
breakfast settings
setting difficult?
difficult? How
How long
long will
will itit take?
take?
Breakfast setting 1
Breakfast setting 2
It involves a culture change
You don’t merely rearrange breakfast furniture
You change the character of a facility
The culture of a facility is like an individual’s personality
Your personality makes you unique
Its culture makes a NH unique
Personality is a sum total of your
Culture is a sum total of its
• character and status
• history and traditions
• values and beliefs
• organization and systems
• likes and dislikes
• commitment to quality
• style and disposition
• rules and relationships
Aggressive
romantic
moody
“Mediocre”
“Excellent”
“Depressing”
“Cheerful”
“Cold”
“Caring”
“Disorganized”
“Friendly”
Culture change is a process, its goal is a
person-centered quality home
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Culture change aims at a change in goals
A change from the traditional emphasis on
quality of care to a new focus on quality of life
The goal of QoC can be attained in the traditional
institutional culture of a facility
To attain and sustain QoL we need a cultural shift
Culture change is like personality change
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It will be slow and will take time
It will face obstacles and resistance
It will require resources & concerted effort
It could be joyous or painful
It will need planning and re-training
It will succeed if there is a strong and caring
leader who hand-holds and shows the way
Culture change is like personality change
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It will mean a new focus and new priorities
It will call for commitment and sacrifice
It will change schedules and assignments
It will ask for change in attitudes and
relationships
It will assign a different set of responsibilities and
different kinds of accountability
Components of a facility
involved in Culture Change
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Elders have a choice in their daily
schedule
The design is moving toward a
neighborhood or community
environment
Empowered staff – more delegated
authority
Home style or buffet dining
Traditional vs Person-Centered Care
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Treatment based on medical
diagnosis
Schedules established for
convenience of the staff
Work is task-oriented –
easily transferred from
person to person
Decision making is
centralized
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Care based on individual’s
needs
Schedules established
around resident need
Work is relationship
centered and staff have
consistent assignments
Decisions made by
residents and those closest
to them
Traditional vs Person-Centered Care
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Facility belongs to the staff
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Structured activities
revolve around the
activities coordinator
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Isolation and loneliness
are common
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Facility is the resident’s
home and staff work in
their home
Spontaneous activities
happen around the
clock
Residents and staff
share a feeling of
community and
belonging
Reinvent NOT Reform
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Transform facilities into places where
people want to live
Into places where people want to
work
NOT places there they are
institutionalized
Why are we considering this change?
We KNOW there is a better
way to care for our elders….
And to ignore that moral
imperative is wrong!
Requirements for CC
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Personal change
Organizational Systems change
External changes
Personal Change
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Cultural change begins with every
caregiver facing their own beliefs about
how care is given.
Have you had your “aha” moment?
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“…an instance of clarity and awareness
that awaken one to the fact that the
traditional nursing home…and overall
experience of aging….is largely
unacceptable?”
An “aha” moment!
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“I visited a resident living in a nursing
home and pulled the curtain around the
bed so we could have some privacy.
The resident looked at me and said, ‘I
never thought I would end up living my
life in a tent!’”
An “aha” moment
An elder in a nursing home said with
tears streaming down his cheeks:
“I am not a baby. I am 85 years old, I
was married for 54 years, and I want to
be treated like a man! Don’t tell me
what to do, don’t tell me how to run my
life. I am a grown man”.
From Darwin
It is not the strongest of the species that
survives, nor the most intelligent; it is
the one that is most adaptable to
change.
The personal journey
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This is NOT something you can be told to
do…
It requires adopting new values and beliefs
about aging…and the ways in which
individuals are cared for
Everyone must internalize the values
underlying culture change and examine how
these values affect them personally and
professionally
Organizational Systems
Change
Fixing nursing homes involves more than
just stopgap funding or looser laws. It
consists of producing a profound shift in
the way nursing homes look and
operate, as well as in the way staff
members think and feel.
Shaping the culture through
its values and traditions
If the organizational culture is to change,
the LEADER needs to design a work
environment that clearly communicates the
new expectations to the employees and the
residents.
External System Changes
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Researchers will have data to support QofLife and
QofCare outcomes in person-centered care
environments
Regulations will not be seen as an impediment to
person-centered care
Resident satisfaction will be accepted as an outcome
measure of quality
Corporations will support culture change initiatives in
their homes
Families will seek out homes which provide personcentered care
What are some of the
characteristics
of the homes which have
achieved changing their
culture?
Outcomes after 2 years
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Fewer antipsychotic and anti-anxiety medications
Decline in sleeping medications
Decline in hospitalizations
Food costs declined
Nutritional supplements declined
Weight loss declined
Decline in cost for disposable incontinence supplies
Increase in the involvement of the low-functioning
residents
Higher staff retention (waiting list for CNA’s)
Positive financial results
Case Study (1)
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Residents on one floor in a nursing
home:
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Rearranged their furniture
Selected a movie night
Took care of a household plant
Case Study (1)
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Residents on the control floor were told:
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Staff are responsible for your welfare
The movie night was chosen for them
Staff members watered their plants
Case Study (1)
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Results
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Residents given responsibility were
reported to be happier and more active at
the end of the study
30% died on the control floor
15% died on the study floor
Conclusion
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People who have more control over their
lives are more mindful, alive and engaged.
We did the best we could,
with what we knew,
And when we knew better,
we did better.
Maya Angelou
Case Study (2)
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This study examines job stress among
CNA’s working in empowered and nonempowered environments to determine
which stressors were associated with
the two types of environments.
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Valerie Gruss – Doctoral Student, Rush
Case Study (2)
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Two units in the same facility were utilized
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Unit A was a unit which was undergoing “culture
change”
Unit B was a traditional unit
Both were dementia units with like residents
Questionnaires were distributed to staff to
determine their major sources of stress
Case Study (2)
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Empowered Unit employee stressors
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Falls and accidents of residents
Stubborn and uncooperative residents
Terminally ill or dying residents
Depressed residents
Death and emotional stress
Case Study (2)
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Traditional Unit employee stressors
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Low wages/salary compensation
Abusive residents
Heavy workload and difficult tasks
Disagreements with co-workers
Lack of staff manpower
Case Study (2)
Job stressors differed between the two different
units of CNA’s – in fact, the two groups of
CNA’s did not share any of the same “Top
Five” stressors.
1.
CNA’s working in a non-empowered
environment experience job stressors
related to negative CAN job characteristics
2.
CNA’s working in an empowered
environment have redirected their focus and
are concerned with stressor related to
resident issues.
Iowa Study
Survey question:
Does a home that is engaging in a culture
change initiative operate differently
from a home that is not? According to
the administrator’s who completed this
survey, the answer is YES in six key
areas.
Key areas
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Residents dine family-style and/or buffet
All employees respond to call lights
Culture change committee established
Staff is supported in developing new models
of leadership
Staff is empowered to make decisions
Required training in responding to residents
with sensitivity and flexibility
Catalysts for Culture Change
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Elder choice and growth
Organizational systems changes
Staff Empowerment
Physical Environment
Elder Choice and Growth
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Choice in daily routines
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Decisions which impact the home
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Participate in day-to-day activities
Inclusion on organizational committees
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Residents “wake up” on their own – no lights out!
Menu planning
Involvement in the community and its activities
Personalized rooms
Lifelong learning opportunities
Organizational systems changes
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Care plans written in 1st person
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Reflect all domains: medical, social,
emotional and spiritual
Honor life passages
Spontaneous activities
Institutional language eliminated
Elders goals are THEIR goals and based
on functional outcomes - QofLife
Organizational systems changes
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Age and gender appropriate activities
Individualized schedules for toileting,
bathing and eating
The elder is put before the task
P&P reflect the change of culture
Staff Empowerment
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CNA’s participate in care plans
Consistent staff assignments
Interdisciplinary neighborhood teams
Career ladders
Solid orientation and ongoing education
program
Staff self schedules
Formal and informal recognition
Staff Empowerment
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Staff recommendations are heard,
listened to and implemented where
appropriate
All staff answer call lights
Performance evaluations reflect the
vision of CC
Cross functional and self led teams
Environment
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Discontinuation of the “tray system” for
serving meals
Family or buffet style dining
Pets and plants and children
Deinstitutionalized nurse’s station
Comfortable surrounding
Environment
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Shower rooms converted into Bathing
Spas
Linen is colored and patterned
Art is reflective of residents’ culture and
tastes
Welcoming and accessible outdoor
space
Access to the community
References
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Getting Started: A Pioneering Approach to
Culture Change in Long-Term Care
Organizations; The Pioneer Network, 2004.
www.pioneernetwork.net
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Culture Change in Long-Term Care; Weiner
and Ronch, 2002. www.HaworthPress.com
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Person Center Care: A Model for Nursing
Homes; Rantz and Flesner, 2004.
www.nursingworld.org
Risk vs Choice
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By removing risk we also rob residents
of choice.
Residents robbed of choice become
bystanders who watch others do things
for them.
As humans, we have a right to risk pain
to ourselves. If we take that away, we
are infantilizing people. Dr. Langer
“The survey process is experienced as
such a threat by many nursing homes
that they devote considerable energy to
eliminating as much risk as possible.
Often this translates into depriving
residents of choice and spontaneity for
the sake of ‘safety’”.
Freeman
Contact Information
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Mary Tellis-Nayak, MSN, MPH
Business Development Executive
CARF-CCAC
1730 Rhode Island Avenue, NW, Suite 209
Washington, DC 20036
202-587-5001 x5002
[email protected]
www.carf.org