Culture Change:

1
Culture Change Trends, Research and the Day
to Day
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The Jewish Home Hospital Lifecare System Who
are we?

• Founded in 1848 in Manhattan Private, not for
  profit healthcare system
• The 5th oldest system in the country and oldest,
  multi-site system in New York
• The largest Jewish multi-site system in the
  country
• Offers a continuum of services for a diverse
  group of elders and adults
• We have over 3,000 staff, both union and
  non-union, and serve more than 9,000 people
  throughout our system through inpatient, home,
  community and housing programs
• Long Term Care, Rehabilitation and Subacute Care
  in three skilled nursing campuses
• Dialysis
• Bronx 816 Beds
• Westchester 300 Beds
• Manhattan 514 Beds
• Specialty Care
• Dialysis
• Hospice/End of Life
• Dementia Care

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The Jewish Home Hospital Lifecare System What
do we do?

• Lifecare Services Division offering Adult Day
  Health Care (medical social models), Long Term
  Home Health Care, Home Health Aide Services,
  Transportation services and Health Care
  Management programs (Pre-Pace Program Lifecare
  Plus Program).
• Skilled nursing and medical care provided 24
  hours everyday by skilled physicians.
• Jewish Homes Palliative Care program specializes
  in pain management and compassionate services.
• Research in Alzheimers Disease, Parkinsons
  Disease and Pharmacology.
• Offers affordable, supportive housing for
  seniors HUD 202, Moderate Income and Market
  Rate.
• Education training of more than 350 medical
  students, fellows and students.
• We are not an "Eden" facility, though we
  incorporate EDEN principles and philosophy into
  our work, services and programs.

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Total Persons Served - 8973 Total Persons Served - 8973 Total Persons Served - 8973 Total Persons Served - 8973 Total Persons Served - 8973
Long Term Care Subacute 3827   Housing Programs 420
NORCs 470   Home Care Services 2730
Day Programs 808   Transportation 718
Data relating to the Manhattan Social Program
was not available at the time of this report. In
2004 we reported serving 9443.
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• We are passionate about the quality of aging.
• The services we provide support health,
  individuality and dignity.
• Our mission is lifecare.

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General Staff Perception of Nursing Homes

• They are institutions where
• Giving treatment equates to giving care
• Elders most important problems are disease,
  disability, and decline and we define them as
  such
• But, we need to remember that our elders are
  much more than just their diseases, disability
  and decline.

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INSTITUTION-CENTERED CULTURE

• The Old or Traditional Way
• Schedules and routines are designed by the
  institution staff and elders must comply.
• Work is task-oriented, and staff rotate
  assignments.
• Staff know how to perform tasks, which they can
  perform on any elder in the home.
• Decision-making is centralized.
• Structured activities are available when the
  institution schedules them.

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INSTITUTION-CENTERED CULTURE IN TRADITIONAL
NURSING HOMES

• Elders must eat at mealtimes set by the facility.
• Pre-served meals are delivered on trays.
• Snacks (nourishments) are offered at 10 am, 2 pm,
  and 8 pm.
• Baths or showers are given twice per week
  according to facility policy and assignment of
  CNAs.
• Elders are taken to the bathroom in prescheduled
  two-hour increments.
• Staff decide when elders get up and return to
  bed.
• Elders are passive recipients of services.
• Isolation, loneliness and boredom are common.
• Someone is always doing things to me, instead of
  looking at my needs and doing something with me.

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Why Bother Changing?

• Rebuilding Nursing Homes
• Past Trends
• Institutional Setting
• Medical model of care
• Current Trends
• Todays Seniors desire
• Choices and Options
• Homelike, residential designs
• Use of technology
• Senior housing, with different levels of
  independence and support

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CULTURE

• Culture can be described as the set of
  shared assumptions that a group holds and that
  determines how it perceives, thinks about and
  reacts to its various environments.

Edgar Schein Administrative Science Quarterly
June 1996
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JHHLS Culture Change Objectives

• In 2002, the early theory behind our culture
  change work was to track the pursuit of six
  objectives by JHHLS.
• These objectives were
• elder-centered care,
• Greater involvement of family and friends,
• the empowerment of direct care staff to better
  meet the unique needs of our elders
• growth of organizational support for privacy,
  dignity, individuality, and creativity,
• advancement of technology, innovation, and
  research within the organization,
• improvements in fiscal integrity.

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OUR VISION OF CULTURE CHANGE

• To create a culture of aging that is life
  affirming, satisfying, humane and meaningful.
• Culture change can transform a facility into a
  home, a patient into a person, and a
  schedule into a choice.
• The process and ongoing journey of culture
  change is a complex one involving a myriad of
  smaller changes, including structure, systems,
  roles and responsibilities, policies, procedures,
  programs all of which must support the
  development of new behaviors within the
  organization.

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Improving Elders Quality of Life

• Three Fundamental Principles of Care
• We must recognize, appreciate, and promote each
  elders capacity for continued growth.
• Our work must be defined by our elders needs and
  capacities, not by ours or our institutions.
• Treatment can be intermittent and brief, but
  care must be continuous and long lasting.
• Clearly staff play a critical role in all of
  these fundamental principles and they must feel
  empowered

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Workforce Challenges

• Nearly 900,000 new paraprofessional long-term
  care workers will be needed between 2002 and 2012
  
• Source US Bureau of Labor Statistics
• By 2020, a 24 nursing shortage in NY State is
  predicted
• Source Projected Supply, Demand, and Shortages
  of Registered Nurses, U.S. Dept. of Health
  Human Services, Health Resources Services
  Administration, July 2002
• Key Challenges include Staff
• recruitment
• training
• retention
• morale

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Empowering the Workforce

• Comprehensive and strategic initiatives include
• Identify and educate new leaders while nurturing
  current leaders
• Enhance Staff/Management and Labor relations
• Labor Management Problem Solving Structure
• Mentoring programs
• Encourage skill and knowledge development
• Improve staff satisfaction through empowerment,
  education and active participation
• Create a diverse and welcoming workplace
• Create opportunities for ownership,
  participation, and buy-in of all constituent
  groups.
• Ongoing staff training and education

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Our Vision of Tomorrow

• TOMORROW
• A series of communities, or self-contained
  neighborhoods, making APPROPRIATE DECISIONS
  within laws, regulations, and guidelines to meet
  the needs of staff, residents, families, and the
  community as a whole.
• Remember our change process includes changes in
  organizational structure, roles, and
  responsibilities, power and authority, budgeting,
  policies, procedures as well as programs
  services.

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Moving from Units to Communities A New
Structure What it might look like
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Relationships

• When I am in the presence of a person with whom
  I know I have a relationship, I know that I am
  living.
• Carter Williams

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Relationships

• Give meaning to our lives, keep us connected to
  the world and promote a sense of well being
• How do we promote relationships with
• Elders
• Families
• Staff
• The Outside Community

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Building Relationships with Elders

• Elders were traditionally known by their
• Illness, frailties disabilities
• Individual is lost
• Culture Change supports knowing elders by their
• History
• Family structure
• Value system
• Accomplishments

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Building Relationships with Elders

• We need to
• Learn all we can about each person
• Build on their strengths capabilities
• Affirm life at every opportunity
• Help people find ways to do for others so the
  person feels worthwhile
• From Sandy Meyers, Role of Social Workers in
  Old vs. New Culture in Nursing Homes

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Building Relationships with Families

• The Application Admissions Process Moving In
• LISTENING to families
• Understanding their experiences, their needs and
  forming a partnership
• The Care Plan meeting
• Scheduling
• Who is present
• How is it framed

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Building Relationships with Families

• Inclusion in the Change Process
• Field visits
• Planning sessions
• Community meetings/community events
• Feedback process surveys, family councils, open
  communications

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Building Relationships with Staff

• Recognition of their knowledge expertise
• Decisions at a local level
• Open communication
• Community meetings
• Town meetings
• Labor/Management Culture Change Committees
• All levels of staff working together
• Projects at each campus
• With common theme stabilize staffing
• Build relationships
• Value employees

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Building Relationships with the Outside Community

• Schools
• Synagogues Churches
• Programs
• Events
• Trips

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Culture Change at JHHLS

• Structures to Support Elder-Centered Care
• Organizational Structure
• Infrastructure
• Systems
• Quality Assurance Monitoring

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ORGANIZATIONAL STRUCTURE

• To Facilitate a Resident Centered, Family
  Involved and Staff Empowered Environment
• Decisions Regarding Care are Best Made by those
  Providing and Receiving Care
• Need a Decentralized Structure
• Decision Making Power at the Community Level
• Responsibility at the Community Level

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Community Level Decision Making Includes

• Daily Elder Care Routines
• Resident Care Plans
• Community-based Activities
• Community Décor
• Staff Assignments on the Community all
  disciplines
• Appropriateness of Admission from another
  Community
• DOH Regulatory Compliance

• Investigation Resolution of Complaints and
  Incidents/Accidents
• Community Meetings
• Environment of the Community
• Hiring, Evaluating, Disciplining of Community
  Staff
• Clinical Indicators/ Quality Measures of
  Residents
• Community-based Performance Improvement

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For a Community to Have Authority over these
Areas, the Structure Needs to Provide for

• Someone with Authority Responsibility for these
  areas at the Community Level
• Someone with the Knowledge and Skills
• Consultative Services Available as Needed
  Clinical, Human Resources, Administrative, etc.
• Budget for Activities, Supplies Capital
  Resources
• Stable Senior Level Management
• Low Levels of Turnover Few Vacancies
• (during structural change)

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INFRASTRUCTURE

• Decentralized Dining
• Allows elders to eat when they want
• Necessary to have steam tables, food pantries on
  the Communities
• Community Space
• Office space on the community for community staff
• Employee lounge
• Space on the community for Elders to participate
  in activities programs

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SYSTEMS

• Systems to Support the Areas of Community
  Decision Making Power, such as
• Accounting Systems which can Allocate Budgets
  Locally and not by Departments
• Payroll Systems which Allocate Staff by
  Communities and not by Departments

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QUALITY ASSURANCE MONITORING

• Monitoring Systems to Assure Quality Care
  Address Organization-wide Issues
• Monitoring Done at the Community Level
• JHH uses Consultants to Facilitate Problem
  Solving Locally to Oversee Overall Quality
• Nursing
• Dietary
• Recreation
• Social Services
• Medicine

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Community Meetings

• A meeting that everyone who lives, works,
  volunteers and visits the community is invited
  and encouraged to attend
• Opportunity to come together and talk about life
  on the community and in the greater neighborhood
• Opportunity to plan community events, problem
  solve, work collaboratively
• Encourages interaction connection resulting in
  new relationships

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Community Meetings

• The community drives the process
• Decide the day time
• Decide the focus and topic of discussion
• Meetings are posted in advance
• Elders are escorted to the meetings
• The meeting takes place as a large circle
• A facilitator begins the meeting

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Community Meetings

• The learning circle - lets everyone know they
  matter
• Introductions lead to more specific discussions
  on issues, special events, outings, celebrations
• A ritual ends each Meeting - this group has
  chosen poetry
• Some community meeting outcomes
• 4th of July BBQ, Retirement Party for a Community
  Staff Members, Birthday Parties, End of Summer
  Garden Celebrations, Trips

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Community Meetings

• Challenges
• Staff attendance and involvement
• Group dynamics
• Time

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Quick Wins Building Support for ChangeOne of
the important roles played by Community
Coordinators - Change Agents

• Any change process initiative needs to
  demonstrate some initial success-Quick Wins
• Short term wins must be part of the overall
  planned strategy and are created by deliberate
  action
• Creates broader base of other community members
  as change agents
• Quick Wins-Provide opportunities to celebrate and
  builds morale and motivation
• Importance of creating support
• Undermines cynics and self-serving resisters
• Clear visible wins and improvements makes it more
  difficult for those negative resisters to block
  future changes
• Builds momentum by
• Turns neutrals into visible supporters
• Gets fence sitters off the fence
• Turns the reluctant supporter into an active and
  willing participant
• Build teams on the local level
• Shows results
• Builds excitement
• Staff feel a sense of accomplishment pride
• Leaders gain trust credibility with staff,
  elders, and families
• Staff feel a sense of accomplishment pride
• Shows evidence of progress helps change
  continue

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Quick Wins Concept

• Uniforms on the Communities
• Creating a community dress code
• Fostered decision making
• Increased team confidence in group process
• Engaged elders in the process
• Creation of staff locker rooms
• Décor, type of lockers, ownership of lockers

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Purpose of The Culture Change StudyTime 1 (Sep
2003-March 2004) toTime 2 (Jan-May 2005)

To understand the phenomenon and effects of
culture change at the Jewish Home and Hospital
Lifecare System
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Goals of Presentation

• To examine the differences in staff satisfaction
  on culture change communities versus standard
  nursing units.
• To examine the relationship between staff
  satisfaction and resident outcomes

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Subjects
Participation rate for Time 1 2 Number of
subjects who participated in both Time 1 2/
Number of all subjects in Time 1
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Study Design
Longitudinal Study - 2 completed phases of data
collection
Experimental and Control Study Units
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Culture Change Research Project Time 2 Data
Elders

• Findings on the Culture Change Communities
• Elders feel they have more choice over their
  everyday activities
• When they wake up
• When they go to bed
• What they wear
• With whom they socialize
• Engage in more meaningful activities
• Treated as individuals
• Rate their health as better
• Say they are less sad
• Are rated by their primary CNAs as displaying
  fewer negative emotions

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Culture Change Research Project Time 2 Data
Staff

• Findings on the Culture Change Communities
• Staff rate residents and families matter as
  more evident
• Positive emotions, in particular love
  compassion, are displayed more frequently by
  staff
• Staff experience less burnout fear

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Culture Change Research Project Time 2 Data
Families

• Findings on the Culture Change Communities
• Families indicate the JHHLS values have
  increased
• resident focus
• residents families matter
• staff matters
• Report an increase of joy displayed by staff

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• Rudyard Kipling once said, It is better to
  travel than to arrive. When it comes to culture
  change, there is no ultimate peak on the
  mountain where you can stand and say, I did it!
  Because nobody can know what it is, or might
  have been. Corporate culture is not an artifact
  but a dimension. And culture change is both
  better understood and realized in the quest -- in
  the sifting through of its many variables, and in
  your determination to extract meaning from the
  process and the journey.