Bringing culture change into better focus: what are the real ingredients of culture change in nursing facilities?

Healthcare professionals who are working to provide and improve care and services for older adults living in nursing facilities are abuzz with talk of "culture change." While these stakeholders want change, no consensus has emerged on how to define and advance culture change in these facilities.

Even the best informed and most motivated providers may be confused about the scope and direction of culture change. Competing advocates seek to advance different values. A "culture of resident-directed care," for example, is the hallmark of the Pioneer Network. Those concerned with the prevention of skin disorders (particularly pressure ulcers) promote a "culture of movement." Others embrace a "culture of safety" that requires nursing facilities to exert even more control over the lives of their residents.

In late 2004, the Centers for Medicare & Medicaid Services (CMS) told Quality Improvement Organizations and State Survey Agencies that its culture change project involved encouraging 5% of facilities to operate without physical restraints. Subsequently, CMS altered its culture change parameters to include resident and staff satisfaction and reduced CNA turnover. The moving target keeps moving.

In April 2006, CMS released "Artifacts of Culture Change," a 70-page document that includes a scorecard covering 79 CMS-defined "artifacts." Labeled "Compliance and Culture Change in LTC," the scorecard is intended to help providers measure their success in implementing CMS's measurements defining culture change. However, the scorecard awards points for items without ever asking the residents and families if they want them, such as people baking in their living areas, aromatherapy, massages, pets living on the premises with residents, and residents doing laundry within the living areas.

If changing the culture of nursing facilities is the pathway to progress, what can providers, government, and quality advocates do to best ensure success? This article offers advice on dealing with diverse culture change agendas and suggests strategies that support genuinely lasting improvements in nursing home residents' quality of life.

Beginning Principles

Providers should balance competing cultures in a manner that is consistent with the residents' values. For those residents who value autonomy, a resident-directed care culture is ideal. However, not all residents place a high relative value on self-determination; some have a more passive nature. Others, especially those with serious illnesses, find comfort in knowing that trained, professional caregivers will offer structured, established daily routines.

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Occasionally, residents need to be sheltered from the consequences of their unhealthy choices and behaviors. Responsible resident-directed care is not without limits--limits including defined standards of care, compliance with government regulations, and practical constraints on the capacity of the particular facility to accommodate individual preferences. Providers should expect that surveyors will hold the facility accountable for poor outcomes that are the result of residents' self-directed choices.

Culture change means the transformation of the facility's fundamental values. As it happens, regulatory and reimbursement rule compliance have comprised the predominant culture of nursing facilities. For true culture change, the dominant culture should include a reliable process to define, measure, and deliver a high level of individual resident and family satisfaction.

Facilities that serve residents with different values will develop and sustain facility practices that embrace the respective values of their residents, while maximizing opportunities for individual resident preferences. This means that resident (and family) satisfaction should be measured on a macro and micro level. The satisfaction level of all residents should be determined through a periodic (at least semiannual), verified survey process. In addition, individual resident's satisfaction should be assessed as frequently as possible. Ideally, newly admitted residents should have a brief "values and satisfaction assessment" done daily for the first three days, then at the end of the first week, weekly for the next three weeks, and at least quarterly thereafter.

Results of individual and facility-wide satisfaction surveys should be analyzed by the Quality Improvement Committee and serve as a basis for timely adjustments in facility practices. Meanwhile, individual care plans should be adjusted, if necessary, to address each resident's quality-of-life preferences and priorities.

For this, nursing facilities need efficient, reliable tools that measure and analyze satisfaction. Perhaps firms that offer Minimum Data Set (MDS) software can add a section with questions aimed at revealing each resident's level of satisfaction and personal quality-of-life priorities. Early versions of the work-in-progress MDS 3.0 included a section to record quality-of-life information. (Interestingly, though, the current draft MDS 3.0 does not include what many may believe to be the single most important question: "Are you satisfied with the care and services at this facility? 'Yes' or 'No'").

Staff's Role

To sustain the new culture, facility staff need to fully understand that their primary role is to ensure delivery of the highest practical level of individual resident and family satisfaction. Job descriptions, competency, and performance evaluations should highlight this requirement. Individual and team salary increases and performance incentives should be similarly linked to frequent, objective measurements of "customer" satisfaction. For example, if residents and families are not satisfied with the quality of the laundry services, the responsible staff need to know that their periodic salary and benefit increases will be reduced or delayed until performance matches or exceeds customers' expectations.

It's worth noting that the consistent assignment of staff to the same area and residents allows the facility to better match customer satisfaction with staff performance.

Provider Support

Nursing facility providers cannot be the sole transformers of culture. Government and advocacy groups can do more to sup-port those providers who are eager to make real progress.

The federal government needs to modernize its impact on culture within facilities. The principles of culture change can be integrated, for example, into the guidelines that interpret government regulations. To do this, CMS could add a well-informed culture change expert to each panel selected to revise the guidelines. Also, the State Operations Manual, which instructs State Survey Agencies on how to conduct compliance surveys, can be updated to include strategies that support culture change. And providers who implement culture change can be rewarded through pay for performance.

The current culture of regulatory compliance through thorough documentation can be replaced with one that encourages streamlined, well-defined, simplified records that focus on each resident's quality-of-life preferences.

Surveyors, whose current role is restricted to finding fault, should be encouraged to help facilities advance strategies that will enhance resident-directed values and goals.

Meanwhile, because the long-term care profession needs to celebrate its success, quality advocates and others should report all positive quality measure and quality improvement data whenever possible. For example, they could highlight the percentage of residents at risk of falling who did not in fact suffer a fall with injury.

Lastly, everyone should stop calling modern nursing facilities "nursing homes." Old labels hinder the acceptance of new concepts. Let's call them "skilled living centers."

By working together, providers, government, and quality and culture change advocates can genuinely transform the culture of nursing facilities in ways that everyone understands, agrees on, and can implement successfully.

Daniel Moles, RN, BBA, MPS, LNHA, is Director of Quality Improvement and Clinical Services of the Health Care Association of New Jersey. For further information, phone [phone]. To send your comments to the author and editors, e-mail [e-mail].

Note: The opinions expressed are attributable only to the author. The Health Care Association of New Jersey has not adopted a policy position on culture change in nursing facilities.

by Daniel Moles, RN, BBA, MPS, LNHA