ABOUT THIS MODULE Included here you will find 7 pages of a 21 page educational module which is intended for use by nursing homes who wish to promote more social, nontraditional models of long-term care. The intent of the PEAKED project is to assist organizations in implementing progressive, innovative approaches to care that should make a significant difference in the quality of care and the quality of life for those living and working in long-term care environments. To receive the module in its entirety, please send an email to gerontology@ksu.edu with the following required information: # Name of Individual and title # Name of Organization/Facility # Complete mailing address including zip code # Telephone number # Email address A CD (or email attachment when possible) will be sent with the module along with forms to complete which will enable our project to track the number of people and hours spent reviewing/implementing these ideas. CD's will be sent free of charge to any nursing home in Kansas, and will be sent to those outside Kansas for a fee of $24.00 to cover costs of materials, postage and handling. For further information on the PEAK-ED project please email gerontology@ksu.edu. Pioneering Change Measuring Change Education Module to Promote Excellent Alternatives in Kansas Nursing Homes Table of Contents Measuring Change Education Module Course Objectives 2 Introduction: Why is Measurement Important? 3 Outcome Measures 4 Resources for Measuring Change 5 Start at the End 6 Definitions 6 Example 6 Case Study 7 Questions for Reflection 7 Activity 7 Writing Goals and Objectives 8 Measuring Outcomes in a Managed Evolution 8 Timing for Measurements 16 Case Study 16 Questions for Reflection 16 Now that You Have the Measurements, What Should You Do with Them? . . . . . . . . 17 Module Objectives: 1. To understand process and outcome measures. 2. To be able to apply appropriate outcome and process measures for culture change projects. 3. To understand the importance of and the utility of measurement for the advancement of quality of life issues. Introduction/ Why is measurement important? For culture change to advance it will need support from legislative and regulatory factions. That support, perhaps in the form of incentives and flexible regulations, is more likely to occur if culture change factors can be established as having provided cost savings as well as improvements in the quality of life. Support from boards or owners may also hinge upon providing a cost savings. Because of this there is a direct need for clear outcomes linked to culture change philosophies. Nursing homes are no strangers to data collection. The following page shows a list of the primary sources of data currently being collected in long-term care facilities at this time. Despite this emphasis on outcome measures, know-how or the time to translate this information into statements about what is and what is not being affected by cultural changes is sometimes lacking. When asked about the effects of these changes, replies usually tend toward the anecdotal---single incidents of resident improvement or satisfaction, or statements like "we don't have any slumpers any more." Qualitative analysis is important but may not be enough to influence owners, boards and legislators to support culture change. Influencing funders and regulators is not the only reason to evaluate the work you do. Measurement is critical for finding out what works and what doesn't work. Corporate businesses don't rely on intuition or moral values to provide the basis for change processes. They depend on critical analysis of the outcomes related to the change process. One intent of the OBRA legislation was to try to get long-term care providers to think in the same general terms. Carter McNamara (1998) states "Too often, service providers rely on their own instincts and passions to conclude what their customers or clients really need and whether the products or services are providing what is needed. Over time, these organizations find themselves in a lot of guessing about what would be a good product or service, and trial and error about how new products or services could be delivered."(www.mapnp.org/library/evaluatn/fnl_eval.htm, p.3) Measurement can also provide information about how to improve delivery mechanisms in such a way that they provide optimal results without additional increases in expenditures. Evaluations can identify strategy strengths and weaknesses and be used to bring additional improvements. There is also a chance that you might not be doing what you think you are doing. Culture is made up of several levels, some that are easy to understand and some that are not. On the surface, the culture change may be going well while problems lie hidden beneath the surface. Evaluation will help to determine if the intended goals are being met. Perhaps the primary reason for doing measurement is to encourage organization members to excel. Outcome Measures Clinical Outcomes weight loss/gain pressure sores infection control medication laxatives supplements activities Resident Satisfaction quality of care quality of life: dignity safety/security relationships staff activities privacy HR indicators staffing open FTEs turnover retention education satisfaction absenteeism sick leave/no-shows workers' compensation Reg. Compliance survey deficiencies OSHA complaints OHFC complaints JCAHO surveys life safety codes Safety/risk manage. safety committee incident reports Financial indicators census department budget Thoughts about Measuring Change excerpted from Leadership Books A number of popular leadership books have included information about measuring change and why it is important. In his book, Teaching the Elephant to Dance: The Manager's Guide to Empowering Change, James Belasco has this to say about measurement: Measure it or forget it!...What gets measured gets empowered and produced. So measure the behavior you expect. In bowling you roll the ball down the alley and count the number of pins still standing (hopefully none!) to see whether you met the standard (Belasco, 1990, p. 158). Belasco elaborates on this point in Flight of the Buffalo: Soaring to Excellence, Learning to Let Employees Lead. To stress the importance of measurement for the ability of organization members to excel he returns to the bowling example. "How many would keep bowling if you hung a sheet over the pins so they couldn't see how they did on every roll?" Belasco asserts that this is the way it is in most companies, that staff members do not know how the things they do affect the organization. Any information they do receive is typically dated or unrelated to things that they did. People want so much to measure their performance that they will develop their own methods if not given instruction in how to do it. The rest of the chapter describes Belasco's philosophy of guiding organization members to perform better through performance measurement. His belief is that people don't perform better because they are happier, they are happier because they perform better, so constant and current feedback is important. Kenneth Blanchard and Robert Lorber in Putting the One Minute Manager to Work: How to Turn the 3 Secrets into Skills, describe what they call the PRICE system. The components are: P=Pinpoint: Determine the performance are of interest; R=Record: Measure current performance level on a graph; I=Involve: Agree on performance goals and strategies for coaching and evaluation; C=Coach: Observe performance and manage consequences; E=Evaluate: Track performance progress and determine future strategies. Start at the End The current culture change movement has created a ground swell of organizations jumping on board. Some put a great deal of effort into planning the end result of the change in their community while others adopt pieces of culture change simply because they have heard it was working for someone else and perhaps also because of the fear that if they did not institute culture change, the baby boom generation would pass them by and select another option. In other words, some facilities are selecting the intervention without clearly defining what they are wanting to affect. Culture change is more likely to succeed if organizations plan for it by working backwards. What is the end goal? If the end goal is quality of life for the residents, then there may be a long list of interventions or strategies that could be implemented toward that goal. Many of these interventions have been suggested by the Pioneer Network objectives. You can revisit that list on page30 of the culture change module. Quality of life for staff and residents alike may be the umbrella goal that embraces many smaller goals. End goals of stable workforce, stable census, zero deficiencies, and many others are more specific than quality of life and it is possible to be more specific with selecting the processes that will lead to these end results. For example, it is not likely that buffet dining will have a direct effect on an end goal of zero deficiencies but perhaps a continuous learning environment with mentoring and improved orientation processes would. Definitions: It is important here to define the difference between measuring the end results or outcomes, and measuring the process that leads to the outcomes. Outcomes evaluation means a measurement that will look at impacts/benefits/changes in the residents and/or staff as a result of your strategy's efforts. Process evaluation means examining the factors that tell you how well things are going before you get to the actual result. Example: A simple example demonstrating these two types of measurement might have to do with baking cookies. The result or outcome, might be how many good cookies vs. how many burnt cookies in a batch. The process data that you collect might be the temperature you set the oven, the type of baking sheet used, the accuracy of the oven thermostat, and so on. Both types of information are important. Case Study: A university professor was explaining to a group of nursing home administrators and staff members the expected benefits from culture change. She listed reduction in medication use, reduced staff turnover, improvements in resident engagement as well as quality of life. However, she also acknowledged the possible expenditures necessary to support and maintain organizational change. During the question/answer period one administrator stated that he would not be committing to culture change unless someone could prove what the effect would be to his financial picture. Questions for reflection: List the outcomes from the case study. What processes could be examined that would lead to the outcomes listed? Develop a logical plan to persuade the cost-conscious administrator to give culture change a try. Activity: Put an X before the items that you believe to be outcomes and a check before those that are process goals. ___ Reducing incidence of incontinence ___ Prompted toileting every two hours ___ Behavior-based interviewing ___ Mentoring for new staff members ___ Reduced staff turnover ___ Increased resident satisfaction ___ Implement a new dining policy Answers can be found on the next page. Answers from previous page: outcome (X), process (check), process (check), process (check), outcome (X), outcome (X), process (check).