Jumpstart Your Culture Change Journey with the Dallas – Fort Worth Coalition

What is Culture and Why Change? Melody Malone, PT Quality Improvement Consultant TMF Health Quality Institute This material was prepared by TMF Health Quality Institute, the Medicare Quality Improvement Organization for Texas, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 8SOW-TX-NHQI-07-57

Disclosures TMF Health Quality Institute has no relevant financial relationships to disclose TMF Health Quality Institute does not accept commercial support from other organizations or companies for the development of Continuing Medical Education activities

Objectives At the completion of this conference the participant will be able to: Define culture change in long-term care. Describe the process for culture change in long-term care. Implement team building strategies that will assist in implementing a QI process to test changes that would improve the work environment and culture of the nursing home.

Daily Pleasures What are those items, habits or events that on a daily basis provide you with comfort, joy, a sense of identity, security or delight?

Daily Pleasures What are some of yours?

Daily Pleasures How would you feel if you could no longer experience that daily pleasure? Do you think our residents are missing any of their daily pleasures?

Morning Routine

Underlying Question How do we organize our systems around the people who live & work in nursing homes to bring quality of life?

The Culture Change Journey The mere words can cause confusion. What culture are we trying to change? Why should I? I like my culture! What does it have to do with me? I don’t have time to change my culture!

What is Culture Change? Culture change in long-term care is an ongoing transformation in the physical, organizational and psycho-social-spiritual environments that is based on person-centered values. Culture change restores control to elders and those who work closest with them. Pioneer Network

The Culture Change Journey Person Directed Care Resident choice directs lifestyle, care, systems, daily routine. Staff choice influences the way the home is run. Institutional Care Task oriented Schedule driven Medical model driven Person Centered Care Resident choice in planning care. Shows movement in culture change journey. The culture in LTC is changing from an institutional model to an environment so that those who live and work in the nursing home are empowered to make the decisions that affect their living and working lives. JOURNEY

According to a national study . . . 70% of seriously ill older adults are unwilling to go into a long-term care facility. 30% state that they would rather die than go into one. Elders with Illness, April, 2000

So…. 100% of the people in YOUR nursing home DON’T want to be there!

Person Directed Care Model

Old Culture vs. New Culture 1. Institutional-driven systems vs Old Culture vs. New Culture 1. Institutional-driven systems vs. individual-driven systems Solution: Create systems within which individual preference is honored and defended (Person adapts to institution vs. Institution adapts to person) Considerations include: Waking and sleeping Meals Food preference Daily Routine Bathing frequency, time and method ADL’s Activities

Old Culture vs. New Culture 2 Old Culture vs. New Culture 2. Perception of nursing homes as a place to die or “last stop” vs. nursing homes that nurture an individual’s ability to thrive, flourish & grow Solution: Establish an environment where all are given the opportunity and provided the resources to thrive, flourish & grow Create community by shared joyful events. Create rituals and celebrations that acknowledge life Celebrate lives of those who live and work there Activities that support life and growth Day-to-day life provides opportunity for meaning and purpose, diversity and spontaneity Residents have the opportunity to give, teach, offer and share Staff are given the opportunity to learn, grow new skills

Old Culture vs. New Culture 3. Iatrogenic helplessness vs Old Culture vs. New Culture 3. Iatrogenic helplessness vs. individual accepts appropriate degree of risk, challenge and choice Solution: Promote the abilities and optimal level of function for all people Resident empowered to live life and make choice to the optimal level of their ability Resident council

Old Culture vs. New Culture 4. Medical model focus vs Old Culture vs. New Culture 4. Medical model focus vs. focus on an integrated, holistic model Solution: Support and integrate quality of life with quality of care by focusing on the Holistic Model -spirit, mind and body. Consideration of the whole person-spiritual, mental and physical well-being in all decisions throughout all disciplines

Old Culture vs. New Culture 5. Quality Assurance vs Old Culture vs. New Culture 5. Quality Assurance vs. Quality Improvement Solution: Provide an organizational understanding that quality is a continuous process that is driven by consumer needs & desires; therefore expands beyond regulatory practices and assurances through education, modeled behavior and satisfaction. Makes data driven decisions and seeks areas for improvement based on evidence Commitment to quality improvement Seeks innovative and creative opportunities and strategies for improving care

Old Culture vs. New Culture 6. Exclusive, impersonal work practice vs Old Culture vs. New Culture 6. Exclusive, impersonal work practice vs. inclusive, relationship-based practice Solution: Hold as paramount an environment where relationships are placed at the forefront of all practice.

Care vs. Treatment

Old Culture vs. New Culture 7. Authoritarian change process vs Old Culture vs. New Culture 7. Authoritarian change process vs. empowered, informed integrated change process Solution: Seek to create opportunities where individuals are given the opportunity to better the home and their lives by offering their voice to make empowered decisions, take greater responsibility and provide their thoughts & ideas. Learning circles Family, Resident Councils Resident hiring councils

Old Culture vs. New Culture 8. Segregated departments vs Old Culture vs. New Culture 8. Segregated departments vs. integrated work teams that influence care Solution: Formulate integrated teams that will guide the organization into the best possible care, work and environmental practice. Consistent Assignment>neighborhoods

Old Culture vs. New Culture 9 Old Culture vs. New Culture 9. Isolated, change resistant organization vs. open, sharing/learning community Solution: Resolve to be a community open and available to education, change and the sharing of best practices.

Old Culture vs. New Culture 10. Hospital environment vs. home Solution: Commit to de-institutionalize, wherever possible, providing personal living accommodations, a sense of peace, safety and community, for all.

Person Directed Care Model

Rule of Thumb Ask Yourself/Team Does this system (or the change we are considering) allow for greater power or input to be exercised by the resident or those closest to them? Will this system (or the change we are considering) heighten the quality of life, experience or lifestyle of the resident and staff?

Goal: Move Inward

What are your five favorite activities, pleasures, things? Please write one per piece of paper…

Deep Culture Change Ability to assimilate the domains more and more deeply into the lives of residents Ability to provide broader and greater opportunity for the people who live and work in nursing homes to have power over their lives and lifestyles Put into the hands of each individual the opportunities needed to live their best life

Beware! The trappings and superficial displays of culture change: Having mailboxes and front doors yet no one knocks or takes seriously the privacy it is meant to offer Fin, fur and feathers Food line buffet Memory boxes Brag board

Consider the daily pleasures What are some of the common irritants? What creative changes could be made to this sensitive process that would put as much power and input as possible into the hands of the resident & those who care for them?

Let’s play a game!

How are facility routines contributing to the decline in Mr How are facility routines contributing to the decline in Mr. McNally’s condition? What clues do you have about Mr. McNally’s strengths and interests? How can these strengths and interests be used as starting points to a person-directed approach that reverses the decline? What changes in Mr. McNally’s routine would need to be put in place? What changes in the home’s routine would need to happen so that Mr. McNally’s personal routine could be restored? What additional information is needed? Who else would need to be involved in the discussion?

Challenge! Live like a resident for 24 hours: Get admitted (with a diagnosis) Eat some meals Take a bath Spend the night…