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Culture Change:
The Importance of Leaders
AAHSA Annual MeetingNovember 7, 2005
Mary Tellis-Nayak, RN, MSN, MPH
Presentation Outline 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
The importance of a Quality Workplace
The Elements of culture change What does it mean
What do we need to do to: Create a quality of life for our residents? Create a quality of work place for our
staff?
Quality: Its Meaning
Residents…………………….……
DONs………………………………
ADONs………………………….…
CNAs…………………………….…
Medical Directors…………………
Others…………………………...…
Administrators…………….………
States
26
26
5
5
5
36
20
5
Number
241
272
108
124
32
2,058
66
26
2,927 36
Families……………………………
Nation-wide study
Administrators….…
DONs……………...…
ADONs…………..…..
CNAs…………………
Medical Directors…
The voice of experience
Years worked in nursing homesAverage Cumulative
Total years of NH experience 21,078
15.9 1,767
12.2 1,523
9.9 317
9.02 16,650
13.2 871
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
Critical QIs
1. Pressure sores2. Dehydration3. Weight loss4. Fecal impaction5. Restraints
HCFA: checklist
1. Choice in daily routine2. Resident well-groomed & drs3. Facility looks-smells clean4. Staff-resd interact warmly5. Choice in food6. Religious & sp. needs met
Add your own
0% 10% 20% 30% 40% 50% 60% 70% 80%
F-impaction
Wt loss
Restraints
Dehydration
Rlgs-sprtl needs
P-sores
Resident groomed
Choice-food
Choice-daily routine
Clean premises
Staff interaction
Resident Family
Don Adminstrator
Mdirector
Most important feature of good NH: The frontline view
0% 5% 10% 15% 20% 25% 30% 35% 40%
F-impaction
Wt loss
Restraints
Dehydration
Rlgs-sprtl needs
P-sores
Resident groomed
Choice-food
Choice-daily routine
Clean premises
Staff interaction
Resident Family
First most important feature of good NH: Residents-Families
Quality of lifeRes: 74%
Family: 84%
Quality of Care
0% 10% 20% 30% 40% 50% 60% 70% 80%
F-impaction
Wt loss
Restraints
Dehydration
Rlgs-sprtl needs
P-sores
Resident groomed
Choice: Food
Choice-daily routine
Clean premises
Staff interaction
Don Adminstrator Mdirector
First most important feature of good NH: DONs, NHAs, M-Ds
Quality of life
DONs: 95%NHAs: 95%M-Dirs: 88%
Quality of Care
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 staff”! “Good staff” =
1. “they want to help”
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”
#3 = Adequate staff
#9 = Competent staff
Is there a disconnect between what residents, families, and staff believe are the elements of quality and what we actually provide?
Leaders and Managers
A nursing home
excels or fails with its managers
“80% of all quality problems
are the fault of managers.”
--Deming
Administrator and DON:
the architects of excellence
Manager versus Leader
• Is like a conductor: keeps everyone on the same page
• Avoids disharmony: follows rules and regulation
• Ensures adequate resources
• Goal: avoid deficiencies achieve compliance and family satisfaction
• Is like a composer: marches to a different drummer
• Is inspired by a vision and a dream
• Innovates, inspires, empowers
• Goal: reach for excellence and family recommendation
Manager Leader
Quality of care: QI Index
Survey results
Family satisfaction
Staff satisfaction
Staff turnover
Administrator turnover
Census
Liability
Finances
Other
Administrators and DON’s are the KEY to Quality
The NHA-DON turnover is by far the best predictor of a quality collapse.
Every quality-related outcome turns direction and heads south
Creating a Quality Workplace
A Leader’s Mission
• Quality of care
• Competent, trained staff
• Policies-procedures, protocols
• Professional control
• Quality of life
• Devoted care-givers
• Innovation, best practices
• Resident-directed care
Old culture New culture
A Leader’s Challenge
• Quality of care
• Competent, trained staff
• Policies-procedures, protocols
• Professional control
• Quality of life
• Devoted care-givers
• Innovation, best practices
• Resident-directed care
Lofty goal, loooooong journey
Where do we start?
GoalStarting point
Lofty goal, loooooong journey
Person-centered
care-giving
STAFF !
Person-centered workplace
Quality of Life for resident
Quality of Work for care-giver
Resident: primary customer
Care-giver: first customer
The nursing home:
• lowest status age group
• loss of health, roles, home
• dependent, frail
• powerless to change
• weakest social class
• lowest social status job
• least paid, least autonomy
• powerless to change?How do the DON and Admin. generate quality of life?
where 2 worlds meet
CNAsResidents
The cradle of quality
=
Resident’s world = The
CNA • 90% of personal care• 6 times as an RN• 5 times as an LPN
Q of life = CNAs relationship
CNAs significant world =
The Nursing Home • 50% of waking hours • 90% economic support• significant social bonding• self image, self respect
Q of life = n-h relationships
Resident CNA
interaction
Quality of Life
Is best assessed by the customer:
Resident, Family, Staff
Quality of Care Vs Quality of Life
Quality of Care
Is best judged by
Experts in the field
Satisfaction surveys capture customer’s expectations & satisfaction
QIs were invented by experts. They measure success in care-giving.
Heavy resources are spent on refining QIs
Few resources are spent on advancing satisfaction surveys
Quality of Life flows from a new culture of care-
giving.
Quality of Life adds TLC to Quality of Care
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 good QoC is no guarantee a high QoL.
Quality of Life adds TLC to Quality of Care
Where high QoL flourishes, good QoC is assured.
But good QoC does not guarantee a high QoL.
It’s all about….. Relationships
It’s all about relationships!
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 NouwenThe 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 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?
Dining Bathing End of Life
Think about the most IDEAL home you can imagine – what comes to your mind?
Dining Bathing End of Life
How would you change these if you could?
Dining Bathing End of Life
Breakfast – Residents can wake up!
Shift
Waking
Dietary
Bathing Transport
Communication
HR
B ofc
Trnspt
Dietary
Days only
Shower
Link 3
Link 4
14 Hr
Snacks
Choice
Trays
PT/OT
Food
Link 3
Link 4
Wake up
Lts Out
Needs
Link 3
CofC
Breakfast: a jigsaw-network of different processes
History
Attitudes
Budget
People Regs
Habits
HR
BusOf
Trnspt
Link 4
Staff
PT/OT
Link 3
Link 4
Supp
SnacksPPD
Link 4
14 Hr.
Dietary
Link 3
Link 4
Instit
MedM
Link 2
Link 3
Link 1
Breakfast: a jigsaw-network of persons, habits, attitudes
Breakfast
Breakfast setting 1 Breakfast setting 2
Why is breakfast settings difficult? How long will it take?
Why is breakfast setting difficult? How long will it take?
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
Personality is a sum total of your
• character and status
• values and beliefs
• likes and dislikes
• style and disposition
Its culture makes a NH unique
Culture is a sum total of its
• history and traditions
• organization and systems
• commitment to quality
• rules and relationships
Aggressive romantic moody
“Excellent”
“Cheerful”
“Caring”
“Friendly”
“Mediocre”
“Depressing”
“Cold”
“Disorganized”
Culture change is a process, its goal is a person-centered quality home
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
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
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 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
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
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
Facility belongs to the staff
Structured activities revolve around the activities coordinator
Isolation and loneliness are common
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
Traditional vs Person-Centered Care
Reinvent NOT Reform
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
Personal change Organizational Systems change External changes
Personal Change Cultural change begins with every
caregiver facing their own beliefs about how care is given.
Have you had your “aha” moment? “…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!
“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 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 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 person-centered care
What are some of the characteristics of the homes which have achieved changing their culture?
Outcomes after 2 years 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)
Residents on one floor in a nursing home: Rearranged their furniture Selected a movie night Took care of a household plant
Case Study (1)
Residents on the control floor were told: Staff are responsible for your welfare The movie night was chosen for them Staff members watered their plants
Case Study (1) Results
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 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)
This study examines job stress among CNA’s working in empowered and non-empowered environments to determine which stressors were associated with the two types of environments. Valerie Gruss – Doctoral Student,
Rush
Case Study (2)
Two units in the same facility were utilized 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)
Empowered Unit employee stressors Falls and accidents of residents Stubborn and uncooperative residents Terminally ill or dying residents Depressed residents Death and emotional stress
Case Study (2)
Traditional Unit employee stressors 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 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
Elder choice and growth Organizational systems changes Staff Empowerment Physical Environment
Elder Choice and Growth Choice in daily routines
Residents “wake up” on their own – no lights out! Decisions which impact the home
Participate in day-to-day activities Inclusion on organizational committees
Menu planning Involvement in the community and its
activities Personalized rooms Lifelong learning opportunities
Organizational systems changes
Care plans written in 1st person 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
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 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
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
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 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 Getting Started: A Pioneering Approach to
Culture Change in Long-Term Care Organizations; The Pioneer Network, 2004. www.pioneernetwork.net
Culture Change in Long-Term Care; Weiner and Ronch, 2002. www.HaworthPress.com
Person Center Care: A Model for Nursing Homes; Rantz and Flesner, 2004. www.nursingworld.org
Risk vs Choice 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 Mary Tellis-Nayak, MSN, MPH Business Development Executive CARF-CCAC 1730 Rhode Island Avenue, NW, Suite 209 Washington, DC 20036 202-587-5001 x5002 mtn@carf.org www.carf.org
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