Association of Jewish Aging Services by benbenzhou


									Culture Change:
 the Day to Day
            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
        Bronx – 816 Beds
        Westchester – 300 Beds
        Manhattan – 514 Beds
•   Specialty Care
       Hospice/End of Life
       Dementia Care
         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
• Jewish Home’s Palliative Care program specializes in pain management
  and compassionate services.
• Research in Alzheimer’s Disease, Parkinson’s Disease and
• Offers affordable, supportive housing for seniors: HUD 202, Moderate
  Income and Market Rate.
• Education & training of more than 350 medical students, fellows and
• We are not an "Eden" facility, though we incorporate EDEN principles
  and philosophy into our work, services and programs.
                                                       The Jewish Home & Hospital Lifecare System
                                                               2005 Persons Served - 8973
                                                            All Services by Program Grouping

                                                                          Transportation, 8%

                                                                                                                Long Term Care &
                                     Home Care
                                                                                                                 Subacute, 43%
                                    Services, 30%

                               Housing Programs,
                                      5%                                                       NORCs, 5%
                                                                  Day Programs*, 9%

                                                                 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.
 “We are passionate about the
         quality of aging.

The services we provide support
 health, individuality and dignity.

    Our mission is lifecare.”
     General “Staff Perception” of Nursing
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.

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.
•   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
•   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.”
       Why Bother Changing?
Rebuilding Nursing Homes
Past Trends:

Institutional Setting

Medical model of care

Current Trends:

Today’s Seniors desire:
        Choices and Options
        Homelike, residential designs
        Use of technology
        Senior housing, with different levels of independence and support

“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

                      Edgar Schein
                      Administrative Science
                      Quarterly June 1996
        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:
(1) elder-centered care,
(2) Greater involvement of family and friends,
(3) the empowerment of direct care staff to better meet the
    unique needs of our elders
(4) growth of organizational support for privacy, dignity,
    individuality, and creativity,
(5) advancement of technology, innovation, and research
    within the organization,
(6) improvements in fiscal integrity.

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.
      Improving Elders’ Quality of Life

Three Fundamental Principles of Care:
 We must recognize, appreciate, and promote each elder’s
  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”
     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
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:
         Empowering the Workforce
Comprehensive and strategic initiatives include:

      Identify and educate new leaders while nurturing current
      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
       Our Vision of 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.
                        Moving from Units to Communities:
                      A New Structure: What it might look like

                                                                              Dietician &
       Nurses                          Resident
                                           Friends                                RAUM
       & Students
                                                                          Social Work

                    Unit Manager                                     TR

                                     Housekeeping (Local)

Consultants- Care Support
Food Service
Information Systems
Materiel Management                  Administrator
Pharmacy                                  CEO                           Consultants- Support
PI                                  Board of Trustees                   SEIU/1199
Organizational Development                                              NYSNA
Public Affairs                                                          LABOR-Management
Compliance                                                              Project
Development                                                             Employment Training
HIM                                                                     & Job Security
Religious Life/Clergy                                                   Program

   Note: Community members are not all necessarily full- time staff members

When I am in the presence of a
person with whom I know I have a
relationship, I know that I am

   –Carter Williams
Give meaning to our lives, keep us
connected to the world and promote a
sense of well being
How do we promote relationships with:
   –The Outside Community
Building Relationships with Elders
Elders were traditionally known by their:
    –Illness, frailties & disabilities
    –Individual is “lost”
Culture Change supports knowing elders by
    –Family structure
    –Value system
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”
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:
   –Who is present
   –How is it framed
Building Relationships with Families
Inclusion in the Change Process:
    –Field visits
    –Planning sessions
    –Community meetings/community
    –Feedback process – surveys, family
      councils, open communications
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
Building Relationships with the Outside
Synagogues & Churches
 Culture Change at JHHLS
     Structures to Support Elder-Centered Care
1.   Organizational Structure
2.   Infrastructure
3.   Systems
4.   Quality Assurance Monitoring
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
Responsibility at the Community Level
Community Level Decision Making Includes:

     Daily Elder Care             Investigation & Resolution of
     Routines                   Complaints and
     Resident Care Plans        Incidents/Accidents
     Community-based              Community Meetings
     Activities                   Environment of the
     Community Décor            Community
     Staff Assignments on the     Hiring, Evaluating,
     Community – all            Disciplining of Community Staff
     disciplines                  Clinical Indicators/ Quality
     Appropriateness of         Measures of Residents
     Admission from another       Community-based
     Community                  Performance Improvement
     DOH Regulatory
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
Stable Senior Level Management
Low Levels of Turnover & Few Vacancies
 (during structural change)

 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

 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

 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
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
Opportunity to plan community events,
problem solve, work collaboratively
Encourages interaction & connection
resulting in new relationships
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
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
Community Meetings

 • Staff attendance and involvement
 • Group dynamics
 • Time
      Quick Wins: Building Support for Change
      One 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
Quick Wins Concept

Uniforms on the Communities:
    –Creating a community dress code
    –Fostered decision making
    –Increased team confidence in group
    –Engaged elders in the process
Creation of staff locker rooms:
    –Décor, type of lockers, ownership of
Purpose of The Culture Change Study
Time 1 (Sep 2003-March 2004) to
Time 2 (Jan-May 2005)

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

                                 Time 1                           Time 2                           Time 1 & 2

 Staff                           287                              280                              185
                                 (75% participation rate)         (73% participation rate)         (64% participation

 Residents                       199                              233                              108
                                 (54% participation rate)         (61% participation rate)         (54% participation rate)

 Family                          108                              122                              40
                                 (37% participation rate)         (34% participation rate)         (37% participation rate)

* Participation rate for Time 1 & 2 = Number of subjects who participated in both Time 1 &2/ Number of all subjects in Time 1
   Study Design
Longitudinal Study - 2 completed phases of data collection

Experimental and Control Study Units
                        Manhattan    Bronx          Sarah Neuman

       Culture Change   Sutro 1      Greenwall 9    North East 2
       Communities      Sutro 2      Greenwall 10   South West 2
       “Experimental”   Freidman 6

       Standard         Freidman 5   Salzman 3      North East 1
       Nursing Units    Frank 2      Salzman 4      South West 1
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
Culture Change Research Project:
Time 2 Data – Staff
Findings on the Culture Change
    –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
Culture Change Research Project:
Time 2 Data – Families
Findings on the Culture Change
    –Families indicate the JHHLS values
     have increased:
       »“resident focus”
       »“residents & families matter”
       »“staff matters”
    –Report an increase of joy displayed by
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.

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