Culture Change : The Importance of Leaders

1. Culture Change:The Importance of Leaders AAHSA Annual Meeting November 7, 2005 Mary Tellis-Nayak, RN, MSN, MPH

2. 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

3. 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?

4. Quality: Its Meaning

5. Nation-wide study Number 241 272 108 124 32 2,058 66 26 States 26 26 5 5 5 36 20 5 Residents…………………….…… Families…………………………… Administrators…………….……… DONs……………………………… ADONs………………………….… CNAs…………………………….… Medical Directors………………… Others…………………………...… 2,927 36

6. The voice of experience Years worked in nursing homes Average Cumulative Administrators….… DONs……………...… ADONs…………..….. CNAs………………… Medical Directors… 15.9 1,767 12.2 1,523 9.9 317 9.02 16,650 13.2 871 Total years of NH experience 21,078

7. 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 HCFA: checklist 1. Choice in daily routine 2. Resident well-groomed & drs 3. Facility looks-smells clean 4. Staff-resd interact warmly 5. Choice in food 6. Religious & sp. needs met Critical QIs 1. Pressure sores 2. Dehydration 3. Weight loss 4. Fecal impaction 5. Restraints Add your own

8. Most important feature of good NH: The frontline view

9. First most important feature of good NH: Residents-Families Quality of life Res: 74% Family: 84% Quality of Care

10. First most important feature of good NH: DONs, NHAs, M-Ds Quality of life DONs: 95% NHAs: 95% M-Dirs: 88% Quality of Care

11. 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

12. Quality: The residents’ point of view (1985 NCCNHR study) Question:“What does high quality care mean to you?” • Residents answer:“Good staff”! • “Good staff” = • “they want to help” • “they are kind, nice, good to me” • “there are enough of them” • “they are polite, courteous, respectful, treat me with dignity” • “they are friendly, cheerful, pleasant, jolly” • “they are patient, they have time for me” • “they are patient, listen, take complaints seriously” • “they relate well, positively” • “they are well-trained, qualified, skilled, knowledgeable” #3 = Adequate staff #9 = Competent staff

13. Is there a disconnect between what residents, families, and staff believe are the elements of quality and what we actually provide?

14. Leaders and Managers

15. Administrator and DON: the architects of excellence A nursing home excels or fails with its managers “80% of all quality problems are the fault of managers.” --Deming

16. Manager versus Leader Manager 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

17. Administrators and DON’s are the KEY to Quality Quality of care: QI Index Survey results Family satisfaction Staff satisfaction Staff turnover Administrator turnover Census Liability Finances Other The NHA-DON turnover is by far the best predictor of a quality collapse. Every quality-related outcome turns direction and heads south

18. Creating a Quality Workplace

19. A Leader’s Mission Old culture New culture • Quality of life • Devoted care-givers • Innovation, best practices • Resident-directed care • Quality of care • Competent, trained staff • Policies-procedures, protocols • Professional control

20. A Leader’s Challenge • Quality of life • Devoted care-givers • Innovation, best practices • Resident-directed care • Quality of care • Competent, trained staff • Policies-procedures, protocols • Professional control

21. Lofty goal, loooooong journey Where do we start? ? Goal Starting point

22. Lofty goal, loooooong journey Person-centered care-giving STAFF ! ? Person-centered workplace Quality of Life for resident Quality of Work for care-giver Care-giver: first customer Resident: primary customer

23. The nursing home: CNAs Residents • 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 where 2 worlds meet ? How do the DON and Admin. generate quality of life?

24. The cradle of quality = Resident CNA interaction 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

25. Quality of Life Is best assessed by the customer: Resident, Family, Staff Quality of Care Is best judged by Experts in the field Quality of Care Vs Quality of Life Satisfaction surveys capture customer’s expectations & satisfaction QIs wereinvented by experts. They measure success in care-giving. Heavy resources are spent on refining QIs Few resources are spent on advancing satisfaction surveys

26. Quality of Life flows from a new culture of care-giving. • Quality of Care • is the result of • adequate knowledge, competence & skills • proper procedures & protocols • It can be attained in the traditional cultural setting Quality of Life adds TLC to Quality of Care Quality of Life adds TLC to Quality of Care Where high QoL flourishes, good QoC is assured. But good QoC is no guarantee a high QoL. Where high QoL flourishes, good QoC is assured. But good QoC does not guarantee a high QoL.

27. It’s all about…..Relationships

28. 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

29. 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

30. Elements of Culture Change

31. 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

32. Think about the average nursing home in VA– what comes to your mind? • Dining • Bathing • End of Life

33. Think about the most IDEAL home you can imagine – what comes to your mind? • Dining • Bathing • End of Life

34. How would you change these if you could? • Dining • Bathing • End of Life

35. Waking Shift Dietary Lts Out 14 Hr Wake up HR Bathing Transport Snacks B ofc Days only Communication PT/OT Choice Trnspt Shower Food CofC Trays Dietary Link 3 Link 3 Needs Link 4 Link 4 Link 3 Breakfast: a jigsaw-network of different processes Breakfast – Residents can wake up!

36. Attitudes Budget History MedM Supp HR People Regs Instit Snacks BusOf Staff Habits 14 Hr. PPD Trnspt PT/OT Dietary Link 1 Link 4 Link 4 Link 3 Link 3 Link 2 Link 4 Link 4 Link 3 Breakfast: a jigsaw-network of persons, habits, attitudes Breakfast

37. Why is breakfast settings difficult? How long will it take? Why is breakfast setting difficult? How long will it take? Breakfast setting 2 Breakfast setting 1 It involves a culture change You don’t merely rearrange breakfast furniture You change the character of a facility

38. 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 “Excellent” “Cheerful” “Caring” “Friendly” “Mediocre” “Depressing” “Cold” “Disorganized” Aggressive romantic moody

39. 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

40. 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

41. 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

42. 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

43. 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 Traditional vs Person-Centered Care

44. 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

45. 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

46. Why are we considering this change?

47. We KNOW there is a better way to care for our elders…. And to ignore that moral imperative is wrong!

48. Requirements for CC • Personal change • Organizational Systems change • External changes

49. 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?”

50. 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!’”