What is Culture
Change??
Culture Change is described as a transformation of nursing homes from the
traditional model to a new way of caring; one in which the elder is the
decision-maker. Caregivers are empowered to be responsive to the elder and each
other. An atmosphere of home prevails. The
Pioneer Network defines culture
change as "The transformation of traditional institutions and practices
into communities in which each person's capacities and individuality are
affirmed and developed". This transformation is an ongoing, never ending
journey. As culture change continues to spread throughout the country, nursing
homes that do not put their customer first will be a relic of the past.
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What Does Culture Change Look Like?
The best way to see culture change is by the smiles and deep satisfaction
you see in residents and staff every day. There is no prescribed
"cookie-cutter" approach to culture change. The simplest way to begin
is by asking some tough questions that include:
-
What do our residents want?
-
What does our staff want?
By continually asking these questions and acting upon the answers that are
achievable, culture change begins to happen. There are four pillars widely
accepted by the long-term care community that were coined by the Pioneer
Network. They include:
-
Resident Centeredness
-
Staff Centeredness
-
Environment
-
Community Involvement
-
Leadership
Resident Centeredness
focuses on the staff “knowing” the resident, their preferences and daily
pleasures. Basically, knowing their “story”. The community collects information
regarding a resident and then uses that data to assist the resident to
participate to their functional level in those activities. The care plan
reflects the residents specific needs, desires etc and can be written in the
“I” person.
Staff Centeredness
focuses on the concepts of Universal Workers, each household is autonomous and
staff self schedule for the resident needs based on parameters set by
administration. A program that has gained national attention regarding
decreasing turnover is LEAP (Learn, Empower, Achieve and Produce).
Web site:
www.matherlifeways.com/re_leap.asp
Transformation Newsletter, May 2007
had a good description of how Learning Circles work. Action Pact also has
information regarding Learning Circles.
Web site:
www.actionpact.com/
Environment flows from a
“Home” model of care. The environment looks and feels like home. This includes:
private rooms, shared rooms if acceptable to the residents, separate dining and
living areas and outside spaces. Minimal noise levels via the use of wireless
care giver notification of needs. Nursing space is decentralized along with
medication management. Average household census is 10-20 residents.
Ideas Institute has publications
on the impact of Color, what does your building say, the nursing home of the
future: are you ready? . They all can be found at:
www.ideasinstitute.org
Community involvement
includes the community coming into the facility to provide programs but also
the residents going out into the community on a routine basis whether it is for
a meal, shopping, fishing or going to a casino.
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Stages of Transformation
L. Norton notes in “A Tale of
Transformation” that there are 4 distinct stages to culture change an
organization including:
-
Institutional Stage-traditional NH-department silo’s
-
Transformational Stage-staff
grow personally and professionally. Resident’s begin to make choices
-
Neighborhood Stage-facility is
broken into smaller, more manageable work and living areas. Staff work in
the same neighborhood. Staff and resident work as a team to increase
resident choices.
-
Household Stage-Self contained
living unit. Major physical renovation which includes kitchens, dining and
living areas. Self lead teams focus on resident directed care. Authority
and accountability is through the households rather than departments.
Web site:
www.culturechangenow.com
A Tale of Transformation.
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Leadership and Culture Change
Action Pack, Inc. has developed
a Self Assessment and Teaching Guide for the Leadership team to utilize to
begin the journey through the process. You can access their tools at:
www.culturechangenow.com
Kansas Foundation for Medical
Care has developed a comprehensive notebook with educational materials and
video’s of a multiple day presentation by Nancy Fox. It is “Person Directed
Care Leadership Series: 2006 Education Video Series and Facilitator Guide. You
should contact them at 1-800-432-0770 for information regarding the manual. Web
site:
www.kfmc.org/nursinghomes
Steve Shields, CEO at
Meadowlark Hills and Laverne
Norton from
Action Pact, Inc. have
developed an in-depth toolkit to assist
nursing homes with the culture change process. The toolkit includes:
-
“In Pursuit of the Sunbeam”
which focuses on the leadership aspects of changing an institution to
Home.
-
“Creating Home”
is a
set of policies and procedures for household life
-
“Midday” Living and
Working in Harmony is an Integrated human resources systems that reflects
the values of the new model
-
“Evensong” Reflecting
on Quality: is a system of team-based, continuous quality improvement.
The toolkit can be purchased
through
www.Kahsa.org or
785-233-7443.
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Models of Culture Change
Culture Change does not fit in a box and will look and feel different in
each nursing home. Several models have become popular and bear mention:
A
Non profit’s experience
Al Stubbenfield, in 1995,
took a poor performing medical center and over the course of years turned its
culture upside down to create an environment that has been routinely ranked as
one of Fortune magazine’s Best Companies to work for in America and have spent
multiples years in the top one percent in patient satisfaction based on survey
results from the largest hospital patient data based in the world. In 2004, the
company was awarded the Malcolm Baldridge National Quality Award. The
turnaround of this organization focuses on the following key concepts:
1)
Create and maintain a great culture-mission, balanced approach of
operational excellence, engaging your work force
2)
Select and retain great employees-maximizing loyalty, celebrating
successes through reward and recognition
3)
Commit to service excellence-service teams, scripting for superior
service, rounding and service recovery techniques
4)
Continuously develop great leaders-ongoing leadership training
5)
Hardwire success through systems of accountability-culture holds people
accountable
Baptist health care has a web site
and leadership training open to the public. Also, note Al’s book listed in the
management reference list. (www.ebaptisthealthcare.org)
The Planetree
Model was developed in 1978 by Angelica Thieriot, taking its name form the
sycamore, or plane tree, under which Hippocrates taught his students, the
organization dedicated itself to radically changing the way health care was
delivered. Under this model, everything in the hospital setting was evaluated
for the perspective of the patient. Every element of the organization’s culture
was assessed, based on whether it enhanced or detracted from personalizing,
demystifying and humanizing the patient experience. A premium was placed on
making information available to health care consumers, enabling them to be
informed partner in their care. This model, until recently, has been used
mostly in hospitals. In the past 5 years, a small number of long term care
communities have adapted the key elements in their day to day operations and
community mission. The nine elements of the Planetree Patient Centered Care
Model are as follows:
1)
The importance of human interactions - affects on health and healing,
satisfaction via personalized care,
·
Presence,
·
Patient advocacy,
·
Caregiver needs,
·
Staff satisfaction,
·
Appreciation,
·
Participation, and
·
Recognition
2)
Informing and empowering diverse populations-consumer health libraries
and patient education
3)
Healing partnerships-inclusion of family and friends-unrestricted
visitation, collaborative care conferences, sharing of
·
Clinical guidelines with families,
·
Family spaces, and
·
Pet visitation
4)
Nutrition: nurturing aspects of food-personalized service, unit pantries
and unit kitchens,
5)
Spirituality: Inner resources for healing-assessment, counseling,
meditation, prayer, visualization, ritual
6)
Human touch: communicating caring through massage-adult, child, infant,
employee
7)
Healing arts: nutrition for the soul-nature: waterscapes, landscapes,
flowers and gardens, figurative and music
8)
Integrating complementary and alternative practices into conventional
care
9)
Healing environments: Architecture and design conducive to
health-natural light, way finding, access to nature and the outside,
·
Small nurses station around a cluster of 4-6 rooms,
·
Comfort zones,
·
Patients encouraged to read their own charts and ask questions.,
·
Engage the senses, and
·
Decrease noise, lighting and color
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What Makes Culture Change a Best
Practice?
The simple fact that the locus of control is returned to the nursing home
resident makes it a good candidate for the title of best practice. Allowing the
resident to have more control over their daily routines and care naturally
improves their quality of life. Along with improved resident/consumer
satisfaction, culture change allows front-line staff an opportunity to make
decisions that best affect the resident. This improves morale and puts them in
the driver's seat of their jobs. A job becomes a vocation as the culture change
journey progresses because the individual has the opportunity to be heard and
make decisions that were traditionally made for them.
NEW! PEAK (Promoting Excellent Alternatives in Kansas Nursing Homes),
a Kansas Organization, has developed numerous resources for the development,
implementation and evaluation of culture changes concepts and principles. If
your facility is in Kansas, the modules are Free. Topics include: pioneering
change, strengthening staff educations, Activities, dining and returning
control to the residents, to name a few.
www.ksu.edu/peak.
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Dining: How food is prepared and
served is a major focus
Options include: open dining, continental breakfasts, buffet dining, menu
order dining, family style service, partial preparations in the household, all
food preparations in the household, infection control issues and food preparation
issues for caregivers and residents.
Action Pact has numerous “Ask Pact” questions and answers regarding the
dining process.
www.culturechangenow.com/askpact.html
also on their blog
Ideas Institute has information regarding meal times. “The Secret to Happier
Meal Times”,
www.ideasinstitute.org/
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Artifact Tool: Measurement of
Progress in Culture Change
Carmen Bowman , a state surveyor and now a consultant and Karen Schoeneman
with CMS. Have developed a comprehensive tool to assist a community with
measuring their progress in the culture change process. The tool is divided
into the following areas: Care Practice, Environmental, Family and Community,
Leadership, Workplace Practice and Outcomes. An added plus to the tool is that
for each item listed there are source areas for each of the items for back up
references for that issue. To access the Artifacts tool:
www.culturechangenow.comm
Other Surveys Include:
Culture Change Indicators Survey: guide to Assessing Progress on the Culture
Change Journey. Institute for Caregiver Education, PA,
www.caregivereducation.org
Kansas Culture Change Organizational Self Assessment. Kansas Foundation for
Medical Care, KS.
www.kfmc.org
Homelessness
J. Carboni, in 1990 wrote a eye opening article entitled “Homelessness Among
the Institutionalized Elderly”. It
became a well sited reason to change how we do business in LTC facilities that
lead long term care leaders to transform their institutions. She describes a
home-homelessness continuum with the focus on control, lived space, identity,
privacy, power and autonomy, connectedness and safety moving from home to
homelessness. See resources below.
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Culture Change Resources:
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Additional Resources:
- B. Baker. Old Age in a New Age.
Vanderbilt University Press, VA, 2007
- N. Fox. The Journey of a Lifetime.
Nancy Fox, 2007.
- C. Bowman. Development of the Artifacts
of Culture Change Tool, CMS, 2006.
- L. Grant et al. A Stage Model of Culture
Change in Nursing Facilities. Paper presented at the 56th
Annual Meeting of GSA, 2003, CA.
- KFMC. Kansas Culture Change Organizational
Self Assessment. Topeka, KS, 2005.
- The Continuum of Direction. The Pioneer
Exchange. Topics: dining, staffing etc, www.pioneernetwork.net
- D. Garvin et al. Change Through Persuasion. Harvard
Business Review. February, 2005, p 104-112.
- J. Carboni. Homelessness Among the
Institutionalized Elderly Journal of Gerontological Nursing (16:7),
1990, 32-37.
- C. Bowman. Living Life to the Fullest.
Action Pact, Inc. Milwaukee, WI, 2005.
- L. Bump. Life Happens in the Kitchen.
Action Pact, Inc, Milwaukee, WI, 2005.
- Culture Change Now! Magazine. Action Pact,
Inc.
- W. Thomas. What Are Old People For?
VanderWyk And Burnham, Acton, MA, 2004.
- M. Rantz et al. Person Centered Care.
ANA, Washington, DC, 2003.
- J. Kotter. The Heart of Change.
Harvard Business School Press, MA, 2002.
- G. Kleiner. Where River Turns to Sky.
Avon books, Harper Collins Press, 1996.
- T. Gass. Nobody’s Home.. Cornell
University Press, NY, 2004.
- C. Bowman. Quality of Life. Action
Pact, Inc, Milwaukee, WI, 2004.
- L. Norton. The Power of Circles. Social
Work in LTC. (2:3-4), 2003, 285-292.
- C. Williams. Relationship: The Heart of
Life and LTC. Pioneer Network, NY, 2001.
- W. Lusbader. The Pioneer Challenge: A
Radical Change in the Culture of Nursing Homes. Pioneer Network, NY,
2000.
- L. Norton. Champions for Care. Action
Pact, Inc, Milwaukee, WI, 2002.
- R. Fagan et al. Meeting of Pioneers in
Nursing Home Culture Change, NY, 1997.
- R. Connors et al. The OZ Principle.
Penguin Group, NY, 2004.
- R. Connors et al. Journey to the Emerald
City. Prentice Hall Press, NY, 1999.
- B. Barkan. The Way of the Champion.
Pioneer Network, NY, 2002.
- Lusbader et al. Getting Started in
Culture Change. Pioneer Network, 2004.
- J. Rader. Bathing without a Battle,
video, NC, 2003.
- R. Putman et al. Better Together.
Simon and Schuster, NY, 2003.
- C. Krugh et al. Changing the Culture of
Care Planning: a person directed approach, Action Pact, WI, 2006.
- S Shields et al. In Pursuit of the
Sunbeam. Action Pact, WI, 2006.
- S. Shields et al. Household Matters: A
Good Life Around the Clock, Action Pact, WI, 2006.
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Videos
-
Becoming Who We Are. Action Pact, Inc, Milwaukee, WI ( skills for
building community with elders with dementia)
www.culturechangenow.com/
-
Heart Work. Direct Care Clearing House, NY. (Life as an NA)
www.directcareclearinghouse.org
-
A Way Back Home. Action Pact, Inc, Milwaukee, WI 2004.
www.culturechangenow.com/
-
Almost Home, shown on PBS, Independent Lens, Fall 2006.
www.371productions.com
-
Brave New Home,
www.channel9store.com
(item #424010)
-
Chances Are, Action Pact, 2007.
NEW!
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Video Resources - Kansas Foundation for Medical Care (1-800-432-0770) www.kfmc.org/nursinghomes
·
Person-Directed Care
Leadership Series
·
Celebrate What's
Right With the World (email
mkamprath@ksqio.sdps.org to
check-out copy)
·
Stand Up and Tell
Them (email mkamprath@ksqio.sdps.org to check-out copy))
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