Culture Change: Trends, Research and 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 campuses Dialysis Bronx – 816 Beds Westchester – 300 Beds Manhattan – 514 Beds • Specialty Care Dialysis 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 physicians. • Jewish Home’s Palliative Care program specializes in pain management and compassionate services. • Research in Alzheimer’s Disease, Parkinson’s 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. 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 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. 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. 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.” 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: “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 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. 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. 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 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 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 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. Moving from Units to Communities: A New Structure: What it might look like Community Coordinator Companions Pets Dietician & FSW Nurses Resident Families Friends RAUM Volunteers & Students Social Work C.N.A.’s Unit Manager TR Housekeeping (Local) Consultants- Care Support Food Service Consultants-Providers HR Physicians Finance Rehab Payroll Clinical Engineering 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 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 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 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 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: –Scheduling –Who is present –How is it framed Building Relationships with Families Inclusion in the Change Process: –Field visits –Planning sessions –Community meetings/community events –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 Community Schools Synagogues & Churches Programs Events Trips Culture Change at JHHLS Structures to Support Elder-Centered Care 1. Organizational Structure 2. Infrastructure 3. Systems 4. Quality Assurance Monitoring 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 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 Compliance 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) 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 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 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 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 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 Challenges • 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 process –Engaged elders in the process Creation of staff locker rooms: –Décor, type of lockers, ownership of lockers 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 Subjects Time 1 Time 2 Time 1 & 2 Staff 287 280 185 (75% participation rate) (73% participation rate) (64% participation rate)* 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) Members * 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 “Control” 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 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 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 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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