Transcript Culture Change in Multi-Facility Systems

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Time Line Overview
• 2002 - RCCI facilities selected 10 facilities/4 states
• 2005 - RCCI facilities expanded to 24/7 states
• 2006 - Company-wide education on the principles of
Culture change
• 2006 - Life’s Simple Pleasures introduced throughout
company
• 2007 - Artifacts of Culture Change incorporated – 100
point scale
• 2009 - 3 year plan developed “Cultivating
Community”
• 2010 - Cultivating Community 5 Domains Introduced
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FOUR STAGES OF CARE
• 1.
Institutional Model – traditional - It is organized around a
functional area known as a nursing unit (with a nurses’ station with
medication and chart storage, and clean and dirty utility areas).
• 2.
Transformational Model – start of looking at more resident
centered - This is the initial stage when culture change begins to
show itself in terms of key culture change attributes.
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FOUR STAGES OF CARE
• 3. Neighborhood Model - This model represents one way of
breaking up the typical nursing unit with 25 to 35 resident rooms,
into smaller functional units (called neighborhoods). However, these
neighborhoods are not self-contained as is the case with the
household model. They share core services (e.g., dining, laundry,
activities, and bathing) with other neighborhoods.
• 4. Household Model – final stage - This is the final stage in the
culture change process. To achieve this stage, renovations to the
physical environment are usually necessary. Since most units in the
typical nursing home have been designed to support an operational
model that was taken from acute care hospitals, most lack the
architectural and interior design amenities needed to support a
household mode
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Resident driven systems - Resident or Elder makes decisions about:
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Waking and sleeping
Meals
Food preference
Daily Routine
Bathing frequency, time and method
ADL’s
Activities
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Create community by shared joyful events
Letters of thanks in prominent places.
Note accomplishments-large or small
Celebrate lives of those who live and work there
Activities that support life and growth
Day-to-day life provides opportunity for meaning and purpose, diversity
and spontaneity
Residents have the opportunity to give, teach, offer and share
Death and Dying rituals
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Resident empowered to live life and make choices to the optimal level of
their ability
Resident council
Consideration of the whole person’s spiritual, mental and physical
wellbeing in all decisions
Makes data driven decisions and seeks areas for improvement based on
evidence
Commitment to quality improvement - seeks innovative and creative
opportunities and strategies for improving care
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STAFFING
Make priority the creation of meaningful and lasting relationships (staff,
residents, family)
Allow consistent staff assignments
Administration is visible and knows people
Invests in staff through time, education, commitment to personal issues
Focus on soft skills –communication, mediation
change processes
Promote an environment where individuals are empowered to make
decisions
Establish self-managed work teams
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ESTABLISH SELF-MANAGED WORK TEAMS
Support a setting where the opportunity to better the facility and
individual’s lives are what’s most important
Create opportunities for individuals to lead and take greater responsibility
Learning circles - everyone speaks, and every one listens
Task force
Change Agent teams
Integrated Care Team: Nursing
Assistants generate the basis of care plan and function as equals on the
care plan team
Inclusive decision making process (staff, residents, family)
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ENVIRONMENT
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Resolve to establish a sanctuary and shelter that provides a sense of
community, safety and peace, free of unwanted intrusions
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Support individualized personal environments
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Organize a design which allows for accessibility
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Diminished barriers
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Provide for nature and natural settings as much as possible
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De-institutionalize common room such as bathrooms
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Enhance lighting
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ENVIRONMENT (cont)
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Decrease random alarms, alerts and pages which startle
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Demonstrate affection, validation and support
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Encourage artifacts, personal items that reflect individuality & autonomy
(refrigerator); comfort and peace
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Provide a place for reflection and solitude that allows individuals to set clear
boundaries and control them
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Shift towards neighborhoods, communities
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Resident a key part of teams
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SIX STANDARDS AS KEY ELEMENTS OF RESIDENT CENTERED CARE
TRAINING: All facility staff must demonstrate an understanding of the principles of
Resident Centered Care by participating routinely in the neighborhood, honoring
resident choice, and performing some tasks outside their typical duties.
• a. 90% of all Associates have completed the 8-hour Person-First training. If not, is
there a plan in place to provide the training within a 12-18 month period following the
completion of Level Two of the RCC Implementation? Are there records to indicate
that the plan is being worked according to the schedule? If so, this criteria is
considered met.
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b. 90% of all staff has viewed “Bathing without a Battle”. In-service logs are available
to demonstrate compliance.
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c. Orientation with all new hires includes training on Learning Circles, Daily
Pleasures, Person-First, Bathing Without a Battle video, and neighborhood
participation expectations.
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d. In-service records of all trainings conducted by Change Agents or designated
others are maintained and available for review by FPA reviewers.
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SYSTEMIC PROCESSES: In order to maintain the integrity of the
principles of Resident Centered Care, specific systems will be in place to
ensure high involvement, continuity of care, and maximum autonomy for
residents and associates.
a. The Steering Committee (consisting of original change agents,
neighborhood coordinators and others chosen for this committee) meets
regularly (at least every other week) to review neighborhood input,
determine the need for training, and resolve other issues as they arise.
b. Learning Circles are held at all Neighborhood and facility meetings.
c. Permanent nursing staff is assigned to each neighborhood and
assigned associates are working in their own neighborhood 90% of the
time.
d. Neighborhood teams have been assigned so that each neighborhood
includes a multi-disciplinary group of associates.
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SYSTEMIC PROCESSES: (cont)
e. Attendance logs indicate that 95% of all associates attend at least one
neighborhood meeting or function monthly.
f. The Team Leadership model is utilized for all meetings so that
responsibilities are rotated, minutes are kept and action plans are created
and completed.
g. A Person-Centered Care plan has been written for every resident that
identifies some of the resident’s Daily Pleasures as well as the approaches
staff will use to accommodate them.
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NEIGHBORHOOD ENVIRONMENT: Residents will have the opportunity to
live, socialize, and engage in meaningful leisure activities in the more
intimate setting of the neighborhood.
a. The facility is configured into distinct neighborhoods identifiable by
theme décor and signage.
b. Neighborhood associates provide programming in his/her
neighborhood. Neighborhood activity calendar should indicate that at least
75% of the multi-disciplinary neighborhood members are delivering
programs within the neighborhood at least monthly.
c. Each resident’s bedroom is personalized according to his/her taste and
interests. Whenever possible, efforts are made to accommodate a
resident’s own furniture and personal items.
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NEIGHBORHOOD ENVIRONMENT: Residents will have the opportunity to
live, socialize, and engage in meaningful leisure activities in the more
intimate setting of the neighborhood.
d. Each neighborhood has its own dining space, as well as a kitchenette
or pantry available to residents and their families.
e. Residents are allowed to help themselves to snacks from the pantry at
any time with staff assistance as needed.
f. Each neighborhood has its own leisure living space where small groups
may gather. The décor of the leisure space is consistent with the
neighborhood theme.
g. The neighborhood leisure spaces contain items and supplies for small
group and individual leisure activities.
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DINING: residents will enjoy greater flexibility and choice in their dining
experience compared to the traditional SNF meal delivery system.
a. All meals are served in the neighborhood according to the style
selected by the residents (either Family Style dining, the 5 Meal Plan,
steam table buffet or Russian style service).
b. Residents are allowed to retain their private snack foods in the
neighborhood kitchenettes or pantry according to regulations and facility
policy.
c. Neighborhood associates and residents assure that kitchenettes are
clean, refrigerators are maintained at proper temperatures and all food is
stored and marked according to regulation.
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RESIDENT CHOICE: Residents enjoy autonomy in daily decision making
and choice in lifestyle pursuits.
a. Residents exercise choice in deciding what time to awake in the
morning and go to bed at night.
b. Residents’ choice of time and method of bathing are honored.
c. Residents’ food choices are honored.
d. Residents are assisted to engage in leisure activities of choice in the
neighborhood or in large group settings.
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RESIDENT AND STAFF SATISFACTION: Residents and staff feel positive
about the environment and about their opportunities to make decisions in
the neighborhoods.
a. Interviews with residents indicate they are highly satisfied with their
level of autonomy and daily decision-making opportunities.
b. Interviews with staff indicate they feel increased job satisfaction by
having more decision-making responsibility and direct interaction with
residents.
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Quality of Life
Living Life to the Fullest
Culture Change
Golden Clinical Services
Ed McMahon, Ph.D.
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• Home:
A strong, intimate, fluid relationship
between the individual and their
environment
Judy Carboni
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Home
 Identity
 Connectedness
 Lived
Space
 Privacy
 Power/Autonomy
 Safety
Predictability
 Journeying
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Homelessness:
The predominate state that
occurs when an individual’s
relationship with the
environment has been
severely damaged
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Homelessness
 Non-Personhood
 Disconnectedness
 Meaningless Space
 Without boundaries
 Powerless/Dependence
 Insecurity/Uncertainty
 Placelessness
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Home – Homelessness Continuum
Relationship of Person to Environment
HOMELESSNESS
Severely
damaged
Damaged
Weakened,
impaired
Mary Tess Crotty
HOME
Strong,
intimate,
fluid
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Health
Promotion
Institutional
Care
Old
Practice
New
Practice
Individualized
Care
Risk
Prevention
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Life’s Simple
Pleasures
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PURPOSE
• Provide a means to enhance the
residents’ quality of life
• Increase customer service outcomes
• Adhere to F-248 guidelines
• Move living centers toward a culture of
person-centered care, in line with the
culture change movement
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Definition
• A “simple pleasure” is anything defined by
the resident or RP as something that
enhances quality of life or brings joy to the
resident
• Examples: “Hot coffee when I wake up,”
“a beer or glass of wine before dinner,” “a
walk outside,” “hot dogs for lunch,” “clam
chowder on Fridays,” “breakfast at 10:00
AM,” “ice cream each afternoon,” etc.
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Responsibility
• IDT identifies the simple pleasure
while completing the initial
assessments
• All current residents should have their
“simple pleasure” identified by 4/30.
• Oversight of process to be
determined by ED
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The How of Change
 Personalize
the situation: How would you
need it to be if you lived or worked here?
 Compare what you would need to what is
currently happening
 Bring people together to figure out how
to make changes.
 Pilot changes
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Steps Toward Culture Change
Living Center Name: _____________________________________ Date: _________________
Facility number: ___________ Division number: ___________ District number: ____________
Current number of residents:__________
Life’s Simple Pleasures
1. ALL residents in Living Center have an identified
“simple pleasure” that is delivered regularly:

A simple pleasure is defined as anything that
enhances the quality of life, brings joy or
pleasure to the resident
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The simple pleasure is identified by the
resident or RP
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The Interdisciplinary team determines where it
will be care planned i.e., activities, dining
services, social services, nursing, etc.
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The simple pleasure is incorporated in the plan
of care as an intervention or distinct entry
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Examples are: “hot coffee when I wake up,” “a
walk outside,” “hot dogs for lunch,” “bath in the
evening,” “a glass of beer or wine before
dinner,” “continental breakfast at 10:00 AM,”
etc.
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Oversight of the process and delivery of
“simple pleasures” is determined by ED
_______ Met (5 points)
_______ Not Met (0 points)
Life’s Simple Pleasure Subtotal: Out of a total of 5 points, you scored ______
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Care Practice Artifacts
2. Percentage of residents who are offered any of the
following
styles of dining:

restaurant style where staff take resident orders;

buffet style where residents help themselves or tell
staff
what they want;
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family style where food is served in bowls on
dining tables where residents help themselves or
staff assist them:
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open dining where meal is available for at least 2
hour time period and residents can come when they
choose; and

24 hour dining where residents can order food from
the kitchen 24 hours a day.
_____ 100 – 81 % (5 points)
_____ 80 – 61% (4 points)
_____ 60 – 41% (3 points)
_____ 40 – 21% (2 points)
_____ 20 – 1% (1 point)
_____ 0 (0 points)
3. Snacks/drinks available at all times to all residents
at no additional cost, i.e., in a stocked pantry,
refrigerator or snack bar.
_____ All residents (5 points)
_____ Some (3 points)
_____ None (0 points)
4. Baked goods are baked on resident living areas.
_____ All days of the week (5 points)
_____ 2-5 days/week (3 points)
_____ < 2 days/week (0 points)
5. Home celebrates residents’ individual birthdays
rather than, or in addition to, celebrating
resident birthdays in a group each month.
_____Yes (5 points)
_____ No (0 points)
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6. Home offers aromatherapy to residents by staff or
volunteers.
_____Yes (5 points)
_____ No (0 points)
7. Home offers massage to residents by staff or
volunteers.
_____Yes (5 points)
_____ No (0 points)
8. Home has dog(s) and/or cat(s).
_____ At least one dog or one cat
lives on premises (5 points)
_____ The only animals in the
building are when staff bring
them during work hours (3
points) _____ The only animals
in the building are those
brought in for special activities
or by families (1 point) _____
None (0 points)
9. Home permits residents to bring own dog and/or
cat to live with them in the home.
_____Yes (5 points)
_____ No (0 points)
10. Waking times/bedtimes chosen by residents.
_____ All residents (5 points)
_____ Some (3 points)
_____ None (0 points)
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11. Bathing without a Battle techniques are used with
residents.
_____ All (5 points)
_____ Some (3 points)
_____ None (0 points)
12. Residents can get a bath/shower as often as they
would like.
_____Yes (5 points)
_____ No (0 points)
13. Home arranges for someone to be with a dying
resident at all times (unless they prefer to be
alone) - family, friends, volunteers or staff.
_____Yes (5 points)
_____ No (0 points)
14. Memorials/remembrances are held for individual
residents upon death.
_____Yes (5 points)
_____ No (0 points)
15. “I” format care plans, in the voice of the resident
and in the first person, are used.
_____ All care plans (5 points)
_____ Some (3 points)
_____ None (0 points)
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Leadership Artifacts
16. CNAs attend resident care conferences.
_____ All care conferences (5
points)
_____ Some (3 points)
_____ None (0 points)
17. Residents or family members serve on home
quality assessment and assurance (QAA)
(QI, CQI, QA) committee.
_____Yes (5 points)
_____ No (0 points)
18. Residents have an assigned staff member
who serves as a “buddy,” case coordinator,
Guardian Angel, etc. to check with the
resident regularly and follow up on any
concerns. This is in addition to any
assigned social service staff.
19. Learning Circles or equivalent are used
regularly in staff and resident meetings in
order to give each person the opportunity
to share their opinion/ideas.
_____ All new residents (5 points)
_____ Some (3 points)
_____ None (0 points)
20. Community Meetings are held on a regular
basis bringing staff, residents and families
together as a community.
_____Yes (5 points)
_____ No (0 points)
_____Yes (5 points)
_____ No (0 points)
Leadership Artifacts Subtotal: Out of a total 25 points, you scored ______.
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Cultivating Community
• VISION – A Community of
Individuals living together in an
environment that honors and
supports the uniqueness of every
person
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Mission
• Facilitate autonomy to create a
personally satisfying
experience for every individual
who is a part of our
community.
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Cultivating Community Model Development
• This model was developed based on knowledge
gained from our Resident-Centered Care pilots,
the PEAK program in Kansas as adopted by our
LivingCenters, the artifacts of culture change as
promulgated by CMS, the principles and values
of the Pioneer Network, and the work of a
dedicated Golden Living Culture Change
Steering Committee.
Cultivating Community
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Domain I – Individual Empowerment
Domain II – Community Involvement
Domain III – Staff Empowerment
Domain IV – Home Environment
Domain V – The Dining Experience