Kansas State UniversityCenter on Aging Oct./Nov. 2006PEAK Project Newsletter Websites of Interest California Health Care Foundation Fast Facts for Administrators www.chcf.org/topics/view.cfm?itemid=120346 This site has links to three pdf documents titled Culture Change: The Business & Clinical Case; Culture Change: Foundational Principles for Nursing Homes; and Culture Change: Connecting the Dots U.S. Dept. Of Health & Human Services, Agency for Healthcare Research & Quality http://www.ahrq.gov/research/elderix.htm This is the section on elderly healthcare with links to evidence reports, workshop summaries, and an online newsletter Video Press, University of Maryland School of Medicine www.videopress.org A variety of videos related to caring for the elderly, end of life care, alzheimer's disease and more. MOVIE REVIEW Worlds Apart A Four-Part Series on Cross-Cultural Healthcare Filmed in patients' homes, neighborhoods and places of worship, as well as hospital wards and community clinics, this unique series follows patients and families from a variety of backgrounds as they face critical medical decisions. It is an invaluable tool for raising awareness about sociocultural barriers to patient-provider communication, and the way these barriers affect the healthcare of culturally and ethnically diverse patients. The ordinary acts we practice every day at home are of more importance to the soul than their simplicity might suggest. Thomas Moore The Journey Toward Culture Change Continues Advisory Group Resources The 2006/2007 quarterly newsletters will be featuring the 2006 PEAK award winners. In previous newsletters, we have been focusing on innovative designs and great achievements of nursing homes that have received an award for their successes in this area since 2002. This time, we shift our focus to the process of the implementation of various elements constituting culture change. We hope to help nursing home staff consider if some of these elements can be adopted in their homes, help them relate to other homes' ongoing struggle with changes, inspire them to continue their journey, and for others, encourage them to start the process of culture change. Bethany Home in Lindsborg Bethany Home is located in Lindsborg, also called Little Sweden, and the home exemplifies the Swedish culture with its focus on community and family. This focus is reflected in its mission statement: "Providing a Community of Christian Love and Concern." The home has been open since 1911, and its emphasis has always been on the provision of quality care and is viewed as the community's mission to its elders. To love what you do and feel that it matters --how could anything be more fun? Catherine GrahamDue to their mission, the administration and frontline staff have long recognized that the residents have individual preferences about when to start their days. When staff have followed these desires, they have observed that the residents' moods are better. The meal plan was changed to adapt to the residents' various schedules. If a resident prefers to sleep late, a mid-morning snack is offered with a beverage. Despite the obvious benefits for the residents, there is still resistance from some staff members. The shift from a "task-oriented" shift routine to a "resident-directed" paradigm is associated with a vision of chaos by some staff members. Expanded meal times not only created fear for some staff but also triggered resistance from some volunteers. When the morning volunteer, who was going from room to room with the Happy Cart, found out that some residents were not in their rooms because they wanted to eat later, she got very upset. She had to locate residents throughout the home instead of knowing who was at their room at a particular time. However, after only a week, she agreed that the new procedure was working fine for the residents. Flexible meal times allow staff to concentrate on the needs of fewer residents at a time and consequently provide them better assistance with eating. Residents who require minimal help can sit in a more intimate group. The new system resulted in more efficient use of staff time for the residents, positive resident outcomes, and continued respect in the long-term care industry. The administration has been working hard to make the change easier in the minds of the staff with continuing encouragement, role modeling and process re-evaluation. Through a resident enhancement committee the administration and direct care staff discuss changes in staffing, scheduling and assignment of resident care. This serves as the platform to identify concerns and work on solutions. The home's leaders' open door policy is another way to communicate difficulties and develop viable solutions. Before each change is implemented, it is evaluated from the perspective of the residents. A survey may solicit feedback about how a particular change works for residents and staff. As the process goes forward, the transition is also evaluated. The implemented changes are derived from resident direction, staff innovation and industry standards. The administration continues to provide various training opportunities in order to deliver the message to staff, especially to those who have a more difficult time switching to a resident-centered philosophy of care. They invite outside educators and review the positive aspects of culture change for residents and staff through power point presentations, memos and payroll insert messages. They also hold departmental or unit meetings and group in-services. Staff members even teach each other about residents' preferences. A preliminary practice of surveying staff has been introduced in order to determine their perception of the work environment, mission of the home, administration and management approach to staff and the residents' quality of life. The Bethany Home is in the process of acquiring land on which a new facility will be built. Understandably, the new home will be able to accommodate the residents' needs better, but the staff know that the residents' quality of life is not about a more beautiful home. It is about the residents' choices, the ability to follow their own routines, meet their goals, pursue simple pleasures and exercise their rights. Smaller groups of residents will give the staff the opportunity to strengthen meaningful interactions with the residents which is the hallmark of culture change. Bethany Home works very hard to continue to build and grow culture change in the old building, so when the time comes and the new home is ready, they will take the highest quality of life and care with them to the residents' new home. Hillsboro Community Medical Center A house that does not have one warm, comfy chair in it is soulless. May SartonThe journey toward a resident-centered home at Hillsboro Community Medical Center began about three years ago. The first step they took was purchasing a memory box for each resident. The boxes were placed outside every room. Residents and their families were encouraged to place objects in the boxes that represented the lives and personalities of the people living at the home. Talking about the things from the box was a very meaningful moment for the residents and staff. This moment clearly demonstrated the individuality of each resident, their preferences, interests, hobbies, and the traits that make each human being different from the others. The staff became motivated to turn a hospital model nursing home into a home for the residents and began to de-institutionalize the facility. Now when entering the facility, instead of seeing the customary nurses' station, you enter a living area with coffee tables, lamps, and sofas that residents find comfortable enough for a nap. The home's former Director of Nursing attended a workshop on culture change and brought the PEAK application to the facility. She was very enthusiastic about what she learned about a resident-centered philosophy. Soon after this training, the Hillsboro site was selected by Kansas Foundation for Medical Care as one of ten long-term care facilities to be in a pilot program for culture change implementation. This experience proved to be very valuable for the process. The pilot site teams met regularly, shared their successes and failures, and learned from each other. The Hillsboro staff that participated in these meetings shared information and materials with the rest of the staff members. The re-organization began by dividing the home into two units. The administration selected a team leader for each unit. A consistent team was assigned to the residents for each neighborhood. From the start, staff have been encouraged to submit their ideas, and many of them have been implemented. The biggest barrier identified by the management is the degree to which the medical model is ingrained in staff's mind-set. There has been resistance from some staff who have been working in this field for a long time. In the traditional model, the principal focus is on completing tasks. Culture change is about quality not quantity. Culture change may be seen by some staff members as a barrier to their efficiency, and their frustration may rise when all the tasks are not complete. With more and more benefits seen for the residents, there is a hope that these staff members will lose their skepticism and embrace the change. The residents have more choice about how to live their everyday lives and are happier. Some display more assertiveness and feel more comfortable asking staff for help. Staff spend additional time with the residents, and this results in building stronger relationships with each other. The direct care staff confirm that by knowing the residents' routine staff are more adept at ensuring that elders' choices are realized. The successful implementation of culture change in Hillsboro is largely due to monthly learning circles. All disciplines are pulled together: dietary, laundry, housekeepers, and nursing staff. All shifts have the same opportunity to learn about culture change philosophy. Staff members learn how to resolve conflicts with each other without necessarily involving the administration. The management recognizes that change is hard, and one change creates another so there is not much time to adjust to changes. Gayla Ratzlaff, the Director of Social Services, stated: "When you see people applying what you learned, even a small step, small growth, it is a huge success." She also stated that "The outcome is the value that as people who care for elderly we see them as a person who means something to their family and who are most powerful to make changes." The Hillsboro home started a journal titled "Reaching for the Stars" that portrays the culture change journey and its steps at their home. A reader can see the staff's pride in their accomplishments, the passion for improvement in quality of life and care for their residents, and the determined attitude to go on with the journey until reaching full success. The last page of the journal states: "Our venture into space has made us realize that there are not four separate galaxies, just one large one. As progress was made in one galaxy, it benefitted the other three. Progress should never cease, for there will always be other bright lights that are now beyond our vision. One day, residents of this facility will greet their visitors by saying, "Welcome to my home." Resources Advisory Group ResourcesFILM Almost Home: Changing Aging in America http://www.almosthomedoc.org/ BOOKS Mindfulness by Ellen J. Langer What's Worth Knowing? by Wendy Lustbader Household Matters: A Good Life Round the Clock, available from the Pioneer Network. Absolute Honesty: Building a Corporate Culture That Values Straight Talk and Rewards Integrity by Larry Johnson and Bob Phillips JOURNAL ARTICLE Nurse Aide Empowerment Strategies and Staff Stability: Effects on Nursing Home Resident. Barry et al. Gerontologist.2005; 45: 309-317. OTHER DOCUMENTS Daily Pleasures, available from Kim Milner, Kansas Foundation for Medical Care at http://www.kfmc.org/. Centers for Medicare and Medicaid Services Action Plan for Further Improvement of Nursing Home Quality www.cms.hhs.gov/SurveyCertificationGenInfo/downloads/2007ActionPlan.pdf A home is not where you live, but where they understand you. Christian Morgenstern