Lighting the Way to Culture Change

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Lighting the Way to Culture Change

• Presented by Renee Beniak, RN, LNHA, CPHQ
• Interim Executive Director, BEAM
• Sheila Atwood, RN, BSN, MSA,
• Assistant Administrator,
• Kalkaska Memorial Health Center

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Todays Objectives

• Describe the process of organizational culture
  development
• Compare the development of long term care
  organizations to hospital cultures
• Describe how long term care cultures are
  transforming and developing
• Identify how transformation and culture
  development can expand beyond long term care to
  acute care settings

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The Process of Organizational Culture Development
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Organizational CultureWhat Is It?

• Set of shared attitudes, values, goals, and
  practices that characterizes a company or
  corporation
• Combination of institutional history, leadership,
  budget reality, and staff experience
• Underlying sense of appropriate behavior and
  practice that prevails throughout the workplace

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Organizational CultureWhat Is It?

• Formally A pattern of basic assumptions
  invented, discovered, or developed by a group as
  it learns to cope with the problems, which have
  evolved over time and are handed down from one
  generation to the next. (Schein)
• Informally How we do things here
• What experienced staff know
• What new employees and clinicians learn
• What outsiders sense

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Organizational Culture

• A code of conduct, for example
• Org. Culture 1 Thats not my job, go away.
• Org. Culture 2 Sorry, thats not my job, go
  see someone else.
• Org. Culture 3 Let me see how I can help you.

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Clarifying Cultures

• Role/Task Driven Cultures
• Are highly formalized, bound with regulations and
  paperwork
• Authority and hierarchy dominate relations
• Innovative/Relationship Rich Cultures
• Preserve a strong sense of the basic mission of
  the organization
• Teamwork is the basis for work design

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Levels or Layers of Culture

• On the surface what is
• Seen
• Heard
• Felt
• Visible products such as
• Language used
• Technology (complicated therapy, acuity)
• Style of clothing, manners of dress, myths, and
  stories
• Easy to observe
• Hard to decipher

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Central Aspects of Culture

• Evaluative Element
• Involves social expectations and standards the
  values and beliefs that people hold central and
  that bind the organization
• Material Elements or Artifacts
• Signs and symbols that the organization is
  recognized by
• Events, behaviors and people that embody the
  culture

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Bonding Agent Social Interaction

• Social Interaction
• Medium or bonding agent of culture
• Web of communications that constitute an
  organization
• Shared language is especially important in
  expressing and signifying a distinctive culture

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Changing Organizational Culture

• Changing the corporate ethos
• Images and values
• New way of understanding organizational life
• Must be brought into the management, leadership,
  and personal transformation process

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Why Should We Change the Culture?

• The challenge
• If real change is to occur within organizations,
  as opposed to short-lived change, it has to
  happen at the cultural level.
• Organizational culture has many powerful
  attributes as a lever for change.
• The problem is how to get a hand on the lever.

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Keeping Patients Safe Transforming the Work
Environment (IOM 11/2003)
Sources of Threats to Patient Safety in Health
Care
Safety Defenses
Adopt evidence-based management and leadership
practices
Management
Maximize the capability of the workforce
Workforce
Work Processes
Design work and workspace to reduce error
Create and sustain a culture of safety
Organizational Culture
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Organizational Culture that Continuously
Strengthens Patient Safety

• Regularly reviews organizational success in
  achieving formally specified safety objectives
• Fosters a fair and just error-reporting,
  analysis, and feedback system
• Trains and rewards workers for safety

IOM Keeping Patients Safe 11/03
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Managing Culture Change

• The ability of organizations to be culturally
  innovative is related to leadership.
• Top management must be responsible for building
  strong cultures.
• Leaders construct the social realities of the
  organization.
• They shape the values and attend to the drama and
  vision of the organization.

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Challenges in Organizational Culture Development

• Culture spans the range of management thinking or
  styles.
• Organizational culture has been one of the most
  enduring buzz words of popular management.
• Culture of an organization, like the personality
  of a person, is difficult to change.

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The Development of Long Term Care Organizations
Compared to Hospitals
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Long Term Care FacilitiesHow Did They Develop?

• Early 1900s
• Federal assistance programs did not exist to help
  pay for the care of the elderly and disabled.
• Most states sent their impoverished citizens to
  "poor farms" or "almshouses"

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Long Term Care FacilitiesHow Did They Develop?

• 1930s
• The New Deal
• Promotes benefits based on need
• Social Security
• Universal
• Only tangentially needs-based

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Long Term Care FacilitiesHow Did They Develop?

• 1930s
• Social Security Act
• Matching grants to each state for Old Age
  Assistance (OAA) to retired workers
• Public institutions residents not eligible for
  the payments
• Private old-age homes created to enable
  collection of OAA payments

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Long Term Care FacilitiesHow Did They Develop?

• 1940s
• Hospitals seen as Houses of Hope
• Hospital Survey and Construction Act funds
  construction of state-of-the-art hospitals
• The Depression and World War II
• Limits those able to meet expectations
• Backlog in every community for modern facilities

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Long Term Care FacilitiesHow Did They Develop?

• 1950s
• Amendments to Social Security Act
• Licensed nursing homes
• Lifted ban on providing benefits to residents of
  public facilities
• Channeled federal moneys to health service
  providers

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Long Term Care FacilitiesHow Did They Develop?

• 1950s
• Federal law changes
• Construction grants for nursing homes in
  conjunction with a hospitals
• Worked to raise the quality of care
• Nursing homes modeled after hospitals
• Transformed nursing homes from being part of the
  welfare system

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Long Term Care FacilitiesThe Result

• After the development of long term care
  facilities, several legislative efforts have
  increased regulatory requirements.
• The result An institutional model with
• Low morale
• Little autonomy
• Emotional demands
• Inadequate orientation
• Lack of flexibility
• Increased stress

• Staff conflicts
• Inadequate leadership
• Task oriented care delivery systems

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The Transformation of Nursing Homes
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How Are Nursing Homes Changing?

• Recent culture development efforts focused on the
  challenges brought about by the institutional
  model
• Culture development philosophies
• Live Oak Regenerative Communities
• Eden Alternative
• Person Centered Care
• Etc.
• The story of Kalkaska Memorial Hospital Long Term
  Care Unit

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How Culture Development Efforts Can Impact
Hospital Acute Care Settings
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Creating a Culture of Patient Safety at Kalkaska
Memorial Health Center
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Kalkaska Memorial Health Center

• Munson Healthcare Affiliate
• Critical Access Hospital with 8 bed acute care
  and 8 bed ED (11,000 visit/year)
• Rural Health Clinic
• LTC 88 beds
• Majority of business is Outpatient (40,000/yr)

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Thoughts

• Safety must be a value not a priority.
• There is no Quality without Safety.
• Patient safety is an ethical imperative.
• The only thing you cant afford to do is nothing.

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KMHC Safety Journey

• Patient safety is part of our Strategic Plan and
  Strategic Imperatives.
• Leadership assigned/all managers part of team
• Develop goals and action steps with annual update
  using the Baldridge framework
• Develop KMHC goals based on National Patient
  Goals

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Culture Survey

• Conduct yearly surveys since 2003
• Administer to all departments
• Changed IHI survey questions to fit KMHC
• Share results with managers
• Managers share results with their staff
• Take action based on results

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Culture Survey Results

• Gradual improvement in scores
• Used 5 point Likert scale
• LTC Score
• 2003 3.68
• 2005 - 4.41
• More to it than
  just the score

• Acute/ED Score
• 2003 4.04
• 2005 4.45

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Culture Survey Strengths

• Strengths are
• Personnel in this area take responsibility for
  patient safety.
• I know the proper channels to direct questions
  regarding patient safety.
• I am encouraged by my colleagues to report any
  patient safety concerns I have.

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KMHC Safety Action Steps
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Medication Safety

• Removed unsafe meds
• Tall man letter labels for look-alike/sound-alik
  e meds
• Unacceptable/discouraged abbreviations
• Medication reconciliation

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Medication Safety Outcomes

• No adverse patient outcomes from a medication
  error
• No patient harm incidents from unacceptable/discou
  raged abbreviations
• Increase near miss reporting

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Leadership Walk Rounds

• All directors managers
• 7 teams round 5 times per year
• Have script and guidelines
• Base questions on Culture Survey results
• Share success stories in employee newsletter

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Safety Idea Fair

• Unique to KMHC
• Fun atmosphere to gather employee input
• Games/prizes/food
• Calculated by number of ideas, types of ideas and
  actions taken on ideas

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Idea Fair Examples

• Added more lift equipment, lower beds, fall alert
  equipment, IV poles
• Developed no-lift policy
• Education on lifting, teamwork
• New medication competency
• Cross trained staff
• Added more heated sidewalks

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Improve CommunicationAmong Caregivers

• SBAR for patient hand-offs
• Read back all telephone and verbal orders
• Process to report all critical values
• Shift to shift safety briefings

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MMC and KMHC

• We transfer the most patients of any hospital in
  Munson Healthcare
• Received GAE for QI of transfers
• Electronic Medical Record
• Attend IHI as a team

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Other Safety Actions

• Clinical alarms
• Two patient identifiers
• On-line incident reporting
• Increase near miss reporting
• MHC video / storytelling

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New Actions for 2006

• Root cause analysis within 72 hours of any event
  causing harm or potential harm
• Comply with the CDC on hand hygiene guidelines
• Fully operationalize medication reconciliation
• Reduce harm resulting from falls in LTC

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Challenges

• Many areas dont have adequate data to be
  meaningful
• Applying big hospital ideas to a small hospital
• Electronic Medical Records and EMAR in LTC

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Closing Thought

• KMHC may not perform many of the high risk
  procedures that lead to the big mistakes/negative
  outcomes, but one injury or death is too many if
  it is my mother.

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Thank You