What is Culture and Why Change?

1. What is Culture and Why Change? Tiffany Langham, RN, BSN 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 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

2. Disclosure to Participants Conflict of Interest: • A conflict of interest occurs when an individual has an opportunity to affect or impact educational contact with which he or she may have commercial interest or financial relationship. All planning committee members and presenters are required to disclose any potential or actual conflicts of interest with any commercial entity that may have an interest in the activity’s educational content. • The planners and presenters of this CNE activity do not have any relevant financial relationships to disclose. Non-Endorsement of Products: • TMF does not endorse any product, service, or company displayed at or referred to at this educational event. Off-Label Product Use: • This educational activity does not include any information about off-label use of a product.

3. Refreshments Compliments of: • Nexion • Texas Healthcare Association • Inspirations Outpatient Counseling Tyler • Atria Copeland Assisted Living & Retirement

4. Criteria for Successful Completion To receive credit for this program, participants must: • Sign in • Attend the entire activity • Complete the on-line evaluation form • Once successful completion is verified, a Certificate of Successful Completion will be awarded

5. CEU Instructions • Written CEU Instructions will be given to participants at the end of the event. • At that time, the CEU authorization code will also be announced. • Please make sure you get this information if you wish to be awarded CEU credit.

6. 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.

7. 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?

8. Daily Pleasures What are some of yours?Images: bottle of coke, woman taking a bath, cup of coffee, figure is of candy, is of ice cream

9. 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?

10. Morning Routine

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

12. 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! journey to transform traditional institutions into places where people are proud to live and work. Where the person can say, “this is home”. So, “Where do you begin?”Figure is a cartoon man looking at a paper that says "Person centered care" and looking at a street sign that has 2 arrows that point in different directions. The first arrow says "Culture Change" and the other arrow says "Person Directed"

13. 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

14. 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 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. JOURNEY

15. Image Slide 1 Figure is of 3 circles intertwined with a heart in the middle. Each circle is labeled. the first circle is "Environment" the second circle says "Care Practice" and the last says "Workplace Practice"

16. 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

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

18. Person Directed Care ModelFigure is of one large circle, one medium circle and one smaller circle. Inside the smallest circle there are 3 more circles that are intertwined with a heart in the middle of them. The 3 circles in the middle are labeled "Environment", "care Practice" and " Workplace Practice": The largest outer circle is labeled "Government and Regulations" and "Financial Resources". The middle circle is labeled "Family" and "Community". the smallest circle is labeled "Leadership"

19. Old Culture vs. New Culture 1. Institutional-driven systems vs. individual-driven systems Solution: Create systems within which individual preference is honored and defended

20. 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

21. 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

22. 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.

23. 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.

24. 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.

25. Care vs. Treatment

26. 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.

27. 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.

28. 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.

29. 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.

30. Person Directed Care ModelFigure is of one large circle, one medium circle and one smaller circle. Inside the smallest circle there are 3 more circles that are intertwined with a heart in the middle of them. The 3 circles in the middle are labeled "Environment", "care Practice" and " Workplace Practice": The largest outer circle is labeled "Government and Regulations" and "Financial Resources". The middle circle is labeled "Family" and "Community". the smallest circle is labeled "Leadership"

31. 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?

32. Goal: Move InwardFigure is 3 hearts intertwined with 3 arrows point inwards toward a heart in the middle

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

34. 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

35. 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

36. Image Slide 2Figure is a flow chart called "Way of Inquiry": Phase 1: Irritant- an annoyance based on a belief, behavior or practice that becomes a tolerated part of the culture.: Phase 2: Catalyst- an external influence suggesting news of a difference that change is possible and necessary: Phase 3: Awakening- A heightened sense of awareness creating a tipping point in one's personal sense of understanding and responsibility in changing the belief, behavior or practice.: Hope verses Despair: Hope-Gives rise to growth, action, and our greatest humanity: Despair- Produces resignation and surrender: Hope has a arrow that points to phase 4: Phase 4 Action Step- Now ready to create action: Despair points to Immobilization- Continue the current process.

37. 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? Consider the daily pleasures • What are some of the common irritants?

38. CEU Instructions • Written CEU Instructions will be given to participants at the end of the event. • At that time, the CEU authorization code will also be announced. • Please make sure you get this information if you wish to be awarded CEU credit.

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