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