Home Health Culture: The Quality Capability Model – Home Health

1. Home Health Culture:The Quality Capability Model – Home Health Collaborative Teleconference Call Tuesday, February 7, 2006 David Boan, PhD Delmarva Foundation Easton, Maryland

2. Objectives • Describe how organizational culture relates to home health agency OBQI activities. • Identify concepts that are useful in improving the organizational culture.

3. A Metaphor for Culture – Healthcare as Walking in the Woods • Caring for the trees is what you do in the woods – the clinical process • The path through the woods is culture • Caring for trees is a different process than maintaining the path • Quality culture supports and facilitates delivering care • Ad hoc culture makes people find their own way through the woods.

4. Culture as Infrastructure • There is a relationship between infrastructure, clinical quality outcomes, and work environment factors such as staff satisfaction and turnover. • This structural view is the basis of the Magnet Hospital program • Also applies to Home Health (see Flynn & Detrick, 2003, Home Care Nurses Descriptions of Important Agency Attributes, Journal of Nursing Scholarship, 35:4)

5. Focus on Structure Alone Not Enough • Changing the infrastructure does not necessarily lead to improvement. • For example – TQM is an infrastructure change that gets mixed success. • Quality Capability Model describes infrastructure change as a developmental process • Developmental means the sequence matters. Earlier stages are the foundation for later stages.

6. Why Structure Matters • A process that cannot be repeated cannot be improved. Further, data is meaningless. • Repeatability is not regimentation. It is the discipline to follow a preferred practice so talent is not expended in reinvention or managing crises. • Consistency is a requirement for organizational learning and for sustained performance.

7. Strengths of the Quality Capability Model (QCM) • Common sense approach • Describes a developmental path for attaining high performance • Specific interventions related to each developmental phase • Unique among quality models • Cannot skip phases, each step depends on full development at prior stage • QCM predicted performance on ACM in hospitals (anecdotal)

8. Quality Capability Model Stages • Initial / Ad hoc - The organization has undefined processes and controls. Quality depends on individual effort. • Repeatable - The organization has standardized methods facilitating repeatable processes. • Defined - The organization’s managers monitor and improve it’s processes. • Managed - The organization possesses advanced controls, metrics and feedback. • Optimizing - The organization uses metrics for optimization purposes.

9. Application of QCM • Provide staff with orientation on developing an infrastructure • Strong emphasis on management practices and alignment of infrastructure • Cannot overstate importance of an organizing model to guide development • Beware of tendency to overestimate capability. Having capable staff is not the same as having a capable infrastructure

10. QCM and OBQI • QCM emphasizes having a model that is replicable, managed from data, and continuously improved. • OBQI has similar features • Teaches consistent application of a data based model • Suggests, but not explicit about, organizational processes related to the model • To the extent that OBQI builds an infrastructure it is already a culture change model • Not explicit about culture • Future papers will clarify cultural aspects of OBQI

11. Examples of Structure From OBQI Manual • Recognize what is going well and document your approach. • It is a very good idea to build this in as a regular part of evaluating every meeting, especially when there is conflict, or energy is lagging. • Learn from your mistakes. Discuss why the problem happened, how to avoid it in the future and what you learned. Stay objective; do not place blame. • Your documentation will be useful for other team activities in the future.

12. The Domains of Home Health Culture

13. Used Expert Panel to Identify Key Areas of Home Health Infrastructure • The areas are similar to most healthcare settings, but specifics different • Infrastructure in Home Health is different • Models for other settings of limited value for that reason. Need a home health specific model • Asked experts what needs to improve to support consistent high quality

14. Developed HHA Culture Survey • Reduced QCM to four stages for simplicity • Identified key strategies for each of the eight domains • Result is a 4 by 8 culture model for development of high performance

15. Quality Model (OBQI) Which of the following best describes how your agency approaches quality improvement and safety: • Ad hoc • Integrated QI Model • Integrated QI Model and data • Model and data used to manage and optimize performance

16. 2. Teamwork (complete) Which statement best describes your agency’s approach to helping people (staff, management and consumers) work together to deliver care: • Ad hoc • Integrated QI Model • Integrated QI Model and data • Model and data used to manage and optimize performance

17. 3. Communication (expected in 2006) Which of the following best describes how well people communicate, including how open and direct people are as they work together. Consider how direct they are about resolving differences and how well they manage disagreements:

18. 4. Care Coordination (expected in 2006) Which of the following best describes how care is integrated across disciplines, roles, or settings:

19. 5. Leadership (expected in 2006) Which description best reflects the overall commitment to safety and quality shown by leadership at your agency:

20. 6. Patient Centered Care (expected in 2006) Which of the following best describes the role of the patient in care delivery at your agency:

21. 7. Organizational Learning(to be developed) Which of the following best describes how the agency learns from experience and how it passes on important knowledge and staff expertise:

22. 8. Information Management(to be developed) Which of the following best describes your agency’s approach to making sure patient care information gets where it is needed, that quality, confidentiality and integrity of information are maintained, and staff and patients are informed in a timely manner:

23. Providing More Guidance: Culture Improvement Strategies that Cut Across Stages • Build a foundation for the domain (basic models and processes) • Motivate staff (incentives, rewards, etc) • Shape the workforce (develop staff skills and capacity) • Develop organizational capability (management, innovation, learning, etc)

24. The Intervention Process:Suggested Approach for Using the Assessment and Intervention Model

25. The Process • Survey • Staff Discussion and Analysis • Select Domain for Improvement • Select Target Process • Define Intervention • Reward and Recognition • Measurement and Feedback

26. Key Points • Emphasis is on staff discussion to translate abstract assessment into agency processes • Discussion key part of the culture making process • Do not let management dominate the process • Managers overestimate performance • Distribution of manager role also a culture issue

27. Survey Example

28. Example (cont) • HHA elects to target the patient centered care domain based on staff discussion • Staff report no consistent understanding of roles, expectations, or methods for Pt centered care. Current approach is ad hoc. • HHA sets goal to develop comprehensive model that is endorsed by majority of staff • Measure for improvement is staff report that there is a consistent care framework that is being used to guide development of services.

29. A Word About the Change Packages • A teamwork package was completed 10/05. • Communication, Care Coordination and Leadership packages are nearing completion and expected this Spring • OBQI is a package, needs clarification of culture intervention • Each package is a set of strategies and tasks with resources using the QCM developmental method.

30. Discussion, Comments, Questions?