Pioneering change in Kansas: the PEAK project: Kansas offers its nursing homes the tools needed to embrace culture change.

Sharon didn't know where to turn. She desperately wanted to make a new life for herself. For the past four years she has worked as an aide at Windsor Place, a nursing home in Coffeyville, Kansas. Her attendance record is exemplary and she works hard to give residents the quality of life she feels they deserve. While her work life grows more rewarding, past decisions interfere with improving her home life. She was living in a rented apartment but had found a nice little "fixer-upper" house she dreamed of buying. Unfortunately, everywhere she turned, Sharon's credit history blocked her way.

One day, after yet another loan refusal, Sharon was expressing her frustration to the human resources director at the home. Because Windsor Place had helped staff members in the past with personal challenges, including loans and advances, Sharon decided to ask for assistance. To her amazement, she was told that because of her commitment to the nursing home and its residents over the years, the organization would be happy to demonstrate its commitment to her. Leadership co-signed her loan. Two months and one very happy employee later, Sharon moved into her new home.

The philosophy at Windsor Place is: "As the staff is treated, so shall the residents be treated." When the administration shows that it values its employees as individuals, then these same employees--from aides and housekeepers to nurses and dietary staff--will pass this caring on to the residents. This is just one reason Windsor Place is a repeat winner of the PEAK (Promoting Excellent Alternatives in Kansas) nursing homes award.

The PEAK Project

In 2002, Kansas Department on Aging Secretary Connie Hubbell's interest in improving nursing home care converged with the national culture change movement to dramatically accelerate change in the Kansas long-term care environment. To encourage culture change, Hubbell's staff designed PEAK as a recognition and education program to advance new care practices in the state. Nursing homes applied for recognition of their efforts to implement the Pioneer Network's core objectives of returning the locus of control to the residents; enhancing frontline staff's capacity to be responsive; promoting home; and community involvement. Seven sites were visited and selected to receive statewide recognition. Monetary awards, raised through suppliers, were distributed and used to celebrate the progress that had been achieved with staff members.

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The PEAK recognition process continues to evolve as organizers learn more about the principles of culture change and the different ways change can be creatively implemented. In 2003, PEAK applicants faced more rigorous screening, but could compete in a category of their choosing rather than having to demonstrate change in all of the core objectives. Ten sites earned recognition, with Windsor Place qualifying in all four core objective areas and the only participant to repeat its achievement. As a result of Windsor Place's first award, empowered staff were in a position to proactively use their skills to seek input from residents and their families so that resident-focused care could continue to develop. Recognizing that winning in only one area might not necessarily change a nursing home's culture, the advisory group for the recognition process has stipulated that those competing for the award this year must be working in both resident control and staff empowerment, in addition to other areas of excellence.

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While examples of culture change are essential to disseminate new ideas, providing information about the process of change is also critical. The Galichia Center on Aging at Kansas State University (KSU) was awarded a contract to develop educational materials and resources on culture change targeted toward nursing home personnel.* The initial PEAK-ED project was Pioneering Change, a 112-page booklet that highlights culture-change principles, illustrated with examples from PEAK award winners and other exemplars of culture change in Kansas. The booklet was organized around Pioneer Network objectives and includes research to support changes, possible expected outcomes, and a wealth of resources. It was distributed to all nursing homes in Kansas and is also available online at www.ksu.edu/peak.

The second phase of the project was to provide in-depth educational materials focused on teaching culture change concepts. The first two modules developed focus on Culture Change Basics and Measuring Change. Each module lists suggested projects that might help fulfill a step toward culture change. The modules provide activities for personal reflection and for group practice. Most of the activities begin with a case study. For example, after learning about goal setting in the Culture Change module, a list of goals compiled at a real-life in-service was given. Two of the goals were to help others when needed and to have positive attitudes and improve communications with other shifts. Staff were asked to mark a target posted on a bulletin board whenever these goals were achieved. If a goal remained unmet, staff members were asked how the goals could be rewritten so they would know when they hit the target. The resulting group activity is to take each of the goals from the staff-meeting case study and state them as measurable objectives.

Each module lists suggested projects that might help fulfill a step toward culture change. Suggested projects from the Culture Change Basics module include a staff "visioning" process, strategic planning, identifying resident desires, improving orientation, and rewriting employee and resident materials. The Measuring Change module helps nursing home administrators understand how to use the data that they are currently collecting to evaluate the changes they have made.

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These modules are being field tested at eight nursing home sites. Each site completes a basic assessment, chooses and completes a project, evaluates its outcomes, and then provides feedback to the Galichia Center on Aging on the usefulness of the materials. The center's staff provide technical support, work with leadership teams, conduct in-service training, and provide PowerPoint presentations for organization use. A team of experts, KSU faculty members from a variety of disciplines, is available for consultation.

Additional information and resources are provided on the project Web site. One of the site's features is a research-to-practice page that shares with administration how to apply information practically from a variety of journal articles that are posted monthly. For example, an article titled "Residents Who Cannot Communicate" highlights acceptable strategies for measuring quality of life in residents who cannot communicate because of cognitive or physical problems. Another article describes the significant weight gain experienced by residents with Alzheimer's when aquariums were placed in the dining area.

The PEAK-ED project is guided by a diverse advisory group, including volunteer providers, the Department on Aging, the Department of Health and Environment, for-profit and not-for-profit nursing home associations, nursing home advocacy groups, and quality assurance groups. The 20-person panel meets quarterly to review the latest information regarding culture change and to share viewpoints and philosophies. These meetings feature a guest expert, such as a faculty member, who makes a presentation and leads a follow-up discussion. These presentations are open to all interested professionals and not just the advisory group.

From this experience, Galichia Center on Aging staff have learned that nursing homes approach change in three ways: evolution, revolution, or managed evolution. Evolution is the change that occurs from new regulations or staff attrition--usually slight changes that make little difference in the lives of the residents. Few nursing homes are using the revolutionary approach because it requires massive changes in organization, physical environment, and philosophy. Revolution also can be very expensive and disruptive. In addition, determining which outcomes are related to which type of change is difficult.

Most Kansas nursing homes are achieving culture change through a managed evolution. The most successful organizations are very intentionally approaching the culture change process. They involve all staff members in creating a vision, and then they prepare a stepwise plan to reach targeted goals. Center staff have found that measuring change is simplified when incremental changes are made. Another positive aspect of making change in steps is that it gives the staff the opportunity to see the success of smaller changes and makes them more likely to accept the larger ones.

The Windsor Place Experience

The best illustration of the success of managed evolution in Kansas is Windsor Place, which first began its culture change journey in the early 1990s. Unlike other organizations that tend to focus on developing resident-centered approaches or changing the physical environment, Windsor Place puts its emphasis on caring for staff and promoting leadership training at all levels of the organization. As staff have become more empowered, change has escalated because more members of the organization are equipped to contribute to the vision. In another example of how successful role modeling can be, the empowerment felt by the staff is now being passed on to the residents and their family members. Staff surveyed residents and family to find out what changes they desired. As a result, Windsor Place now has spa bathing, buffet dining, a renovated beauty shop, weekly parish masses, a daily live radio show, and consistently

staffed neighborhoods.

Windsor Place has carefully documented the outcomes of these incremental changes. Perhaps most gratifying has been a reduction in employee turnover every year, from 97% in 1995 to 29% in 2003. A 75% employee retention rate translates to improved resident care. Survey teams consistently recognize Windsor Place for delivering high-quality care.

The change to buffet dining was made while maintaining previous food costs but resulted in an 81% decrease in supplement costs, a 350% increase in employee meals, a 311% increase in guest meals, and increased resident satisfaction. No unexplained significant resident weight losses have occurred in more than two years.

The shower spas were collaboratively designed and decorated by staff and residents. The updated rooms have resulted in enthusiastic bathing staff who see more residents bathing more frequently with fewer shower refusals. Residents' dignity has been enhanced as staff look for ways to reduce the trauma some residents have felt with the bathing experience.

To return to Sharon's story, Sharon got her new home and the residents she cares for continue to get the benefit of a loving and compassionate caregiver who, because the organization helped her solve one of her problems, was able to devote loving attention to her work. This is a true culture change philosophy that Windsor Place has found works. Over the years they've given more than $700,000 dollars in loans and advances with all but $5000 returned in full.

New ideas are disseminated when innovators share their successes. In Kansas, this sharing has been promoted through the PEAK program, a program that can easily be duplicated in other states. The dual process of education and recognition has helped Kansas to be a front-runner in the culture change movement.

Acknowledgment 

Special thanks to Monte Coffman, CEO of Windsor Place; Lyn Norris-Baker, PhD, Linda Gray, and Pam Evans from the Galichia Center on Aging, for their data collection and editorial comments.

* The project is supported by the Kansas Department on Aging and the Kansas Department of Social and Rehabilitation Services through a Title XIX contract and through matching funds provided by Kansas State University. Additional matching funds are provided through the Kansas Association of Homes and Services for the Aging, the Kansas Health Care Association, and the personal time volunteered by the long-term care professionals on the advisory group.

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BY GAYLE APPEL DOLL, PHD

Gayle Appel Doll, PhD, is Project Coordinator of the PEAK-ED project. For further information, phone [phone] or e-mail [e-mail]. To comment on this article, please send e-mail to [e-mail]. For reprints in quantities of 100 or more, call [phone].