A Visionary Path to Culture Change

Texas Coalition for Culture ChangeSan Marcos, Texas September 23, 2011

Pearl Merritt, EdD., MSN, MS, RN Regional Dean Texas Tech Health Sciences

andDebby Burgett, LNFA

Member of Pivot Senior Living Experts

The Beginning of a Journey

"Vision without execution is hallucination.” — Thomas Edison

OBJECTIVES

• Analyze contributions of small houses for elders• Propose innovative strategies for ADL’s by

CNA’s• Critique the role of the nurse in small houses• Questions and Answers

Small House Design

• What is the definition of a small house?• Do you already have an existing campus

infrastructure?• Will the design meet with regulatory guidelines? • Is the design financially viable?

Traditional Home Repositioning

Assisted Living

Mall

House A

House BHouse CHouse D

MyHouseNursing

Houses E/F

IL

Support

Assisted Living

Mall

House A

House BHouse CHouse D

MyHouseNursing

Houses E/F

IL

Support

Outcomes• Opens doors for increased opportunities

– Better clinical outcomes– Lower staff turnover– Increased staff satisfaction– Increased campus census– Increased elder and family satisfaction– Better survey results

• Changes negative image of long-term care• Creates a brand strength for your organization• Increase revenue if proves to be a good financial

model

Cultivating Relationships

• Buy-in from federal and state surveyors• Educate and keep surveyors informed of your adopted

philosophy and practices• Design approval is required from the State of Texas. • Connect with TAHSA, TXCCC, SAGE, Pioneer Network

CMS offered its contribution to the movement by stating, “It is our goal to have State agencies assist innovative providers in determining how changes they wish to make to improve the lives of their residents can be compliant with the Federal regulations that protect all residents.”

Financial Viability

• Market study• Financial pro-forma• Secure financing and fundraising• Operating and Projected budget• Timeline for completion of project

Care Givers in a Small House Home

The Direct Care Staff: Flexible, Talented, Multi-Taskers,

Selflessness, Adaptable, Generous, Courageous, Trustful

Activities, Celebrations and

Meaningful

Engagement

Care Givers and

Companions

Self-Led Team• Team scheduling• “Keepers” of the daily rhythm of the house• Work as a team with nurses, therapists and any

clinical support member• Coordinate meals to include planning with

elders, ordering, receiving and cooking of food. • Responsible for maintaining the house in a

clean, neat and orderly. • They report to a coach, guide or mentor. • They are highly skilled with culinary talent, safe

cooking practices, and CPR.

Time, Training and MethodTIME• Direct Care Staff, prior to opening, 2-4 weeks • Leadership, prior to opening, 4-12 weeks

TRAINING• Culinary Skills• Food Safety • CPR• Conflict Resolution• Communication• Elder Centered Care• Support –VS-Accountability• Developing Self-Led Teams• Team Scheduling• Ageism• Regulatory Support/Survey Readiness

Time, Training and Method

METHOD• Classroom Instruction

– Role Playing– Lecture– Videos– Brainstorming– Active Participation– Power Points/handouts– Problem Solving Scenarios– Involvement from All

Leadership Development

• Begins as soon as possible

• Key stakeholders– SWOT– PDSA – Realign vision and mission statements– Strategic planning– Readiness Assessment

Nursing in a Traditional Home

• Steep bureaucracy• Nurses control all unit activity• Nurses are the “boss” of the nurse aides• Nurses are responsible for nurse aides

scheduling and finding replacements• Departmental • Regimental• Nurses station is the center of most units• Institutional feel• Nursing Charts and paperwork intensive

“Giving nursing staff a voice in the organization’s decision making related to care practices and work process changes will influence staff retention—an integral part of maintaining quality care.”

– Barbara Bowers, PhD, RN, FAAN

Associate Dean for Research

Helen Denne Schulte Professor of Nursing

University of Wisconsin-Madison

Nursing in a Small House • Bureaucracy is flattened• Daily rhythm of the home is in the control of the elders• Nurses are not responsible for CNA scheduling or finding

replacements• Nurses and Nurse aides work as a team; they are often

described in a small house as educators.• The functions of the nurses station are provided, but the

“look” is different• Home environment; the institutional look and feel is

removed• Nurses truly are nurses and not supervisors

Nursing Stations

Technology

Institutional Features are

Removed

On- Site Training

Conclusion• Research validates small house outcomes of improved quality of care and improved quality of life.

• CNA’s through education and training maintain the home with the elders at the center of all decision making.

• The role of a nurse in a small house home is crucial in maintaining quality of care.

• The small house design can be financially viable.

• State and Federal agencies are supportive of the small house model and culture change.