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30.11.2013
The Nursing Home Reform Act, passed in 1987, established quality standards for nursing homes nationwide, emphasized the importance of quality of life, and preserved residents' rights.
In the culture change model, which has gained momentum over the past decade, seniors enjoy much of the privacy and choice they would experience if they were still living in their own homes. The Commonwealth Fund 2007 National Survey of Nursing Homes In the past decade, there has been growing awareness of culture change among professionals and providers in the field, but the extent to which nursing homes across the country have adopted a resident-centered culture is still unknown.
The questionnaire was administered to directors of nursing who were asked about three domains of culture change: resident care, staff culture and working environment, and physical environment.
Although survey results are mixed regarding the degree to which nursing homes report they have adopted resident-centered practices, findings indicate a hopeful picture about the potential for deep, systemic change within the industry. Furthermore, the survey shows that in facilities that incorporate some aspects of culture change, the more culture change initiatives that are under way, the greater the benefits in terms of staff retention, higher occupancy rates, better competitive position, and improved operational costs. Using self-reported data from directors of nursing, we categorized nursing homes that participated in the survey as culture change adopters, culture change strivers, or traditional nursing homes (Figure ES-1). In general, nursing homes have been most successful at increasing residents' involvement in decision-making, and there is some evidence that management is accommodating collaborative and decentralized decision-making to empower direct-care workers. Culture change adopters are more likely than traditional facilities to implement resident-centered care approaches. Fifty-eight percent of culture change adopters allow residents to determine their own schedules, compared with only 22 percent of traditional nursing homes (Figure ES-2). Nearly two-thirds (64%) of culture change adopters implement bathing practices that are more resident-centered, while only 37 percent of traditional nursing homes do so. Seven of 10 culture change adopters report that residents are involved in decisions about their facility, but only one-quarter of traditional nursing homes (27%) involve residents in such decisions.
Overall, just over half of nursing homes (53%) provide staff with leadership training opportunities but only 15 percent indicate that they currently enable direct care workers to create self-managed work teams and only 14 percent currently cross-train staff to play several functional roles (for example, housekeeping, nursing, food service, and activities) to serve a variety of resident needs. Among culture change adopters, one third (32%) support self-managed work teams yet far fewer traditional homes do so.
Fifty-nine percent of culture change adopters include direct care workers and residents on the senior management team, compared with only 24 percent of traditional nursing homes. Culture change adopters are more likely than traditional homes to consistently assign the same aides to residents (86% vs.
On average, nursing homes report that only 8 percent of residents currently reside in neighborhoods and only 1 percent live in households. Only 16 percent of culture change adopters report they are currently breaking down large units into smaller operational units and only 7 percent have eliminated large nursing stations, which are often given prominent placement in the center of the unit in institutional-style nursing homes.
While more nursing homes are making the dining experience resident-centered, progress in this area is still slow. Nearly half (46%) of culture change adopters report they have changed how meals are served. The more culture change principles are embraced, the greater the increase in staff retention and occupancy rates and the greater the decrease in operational costs. Among facilities that are engaged in some aspect of culture change, 78 percent currently implementing seven or more culture change initiatives report that culture change has improved their competitive advantage in their market area. Another 60 percent of nursing homes that are currently implementing at least seven or more culture change initiatives report improved occupancy rates, while only 44 percent with three or fewer culture change initiatives under way reportthis improvement. Half of nursing homes that are most engaged in culture change report that staff absenteeism decreased; in contrast, only one-third of nursing homes with three or fewer culture change initiatives under way report this improvement in staff absenteeism. The Commonwealth Fund 2007 National Survey of Nursing Homes finds that while many nursing homes are aware of the "culture change" movement, progress has been slow in transforming long-term care facilities from institutions to homes. The mission of The Commonwealth Fund is to promote a high-performing health care system that achieves better access, improved quality, and greater efficiency, particularly for society's most vulnerable, including low-income people, the uninsured, minority Americans, young children, and elderly adults.
A basic definition of organizational culture is the collective way we do things around here. An organization espouses that a€?people are our most important asseta€? as part of its new philosophy. While I agree that culture change is more important than a business strategy, I also believe that culture change must be a business strategy.
In my view, it needs to be the driving force for any and all business strategies, specifically for social business initiatives.
I would also argue that most of the other reasons suggested above all revolve around the cultural norms, behaviors and values that live behind the firewall. Executives defined social engagement today as online listening (28%), blogging (24%) and building relationships with online influencers (21%).  But the top performers have a different view – they will be more focused on ideas and action in the next two years. I’ve gotten into many a tangled argument as people say that you never know who knows who in the online world, so engaging with everyone is great. Great post, love your content you really make sure that you have relevant post and the graphic presentation are very good! Joey, I would argue that yes you may have a hiring problem, but possibly and most likely you have a leadership problem. I’m a large advocate for a change in management mindset leading companies towards being social businesses, so I thoroughly agree. By what happened at GM, do you mean what happened with Chrysler regarding the motor city profanity Tweet? Once consensus has been established about the business situation (easier said than done sometimes), there are models and steps for how to go about change management. Creating a vision to help direct the change effort, and developing clear strategies for achieving that vision, are central to successful change.


This means you are obligated to remove obstacles to change for those people who are working with you on the team and at different levels in the organization. This increased credibility must be utilized to change systems, structures, and policies that don’t fit the vision.
The connections between the new behaviors and organizational success must be articulated, and these changes must be institutionalized.
In fact, one of the most challenging things I have found is to note ad hominem attacks and try to progress beyond them. I recommend a data-driven approach, in general, where people are educated in their data and the data are not personally assignable.
This focus on data makes for a situation which is not often encountered in Medicine; yet, when we do attain it, it is truly magical. I really enjoy helping groups in healthcare see that not all changes or improvements need come by confrontation or finger pointing. Functional systems based on data which run smoothly often alleviate the need for frustration, conflict, and other issues.
Last, please remember: even if you know the steps, practice them, and work to create positive business situations these change situations are challenging and high risk. However, despite enactment of this law, serious concerns remain about the quality of care provided to residents in the nation's 16,000 nursing homes. Residents' needs and preferences come first; facilities operations' are shaped by this awareness. In 2007, The Commonwealth Fund conducted a nationally representative survey of nursing homes to learn more about the penetration of the culture change movement at the national level and measure the extent to which nursing homes are adopting culture change principles and practicing resident-centered care. Specifically, the survey examines whether nursing homes have adopted practices that make care more resident-directed, that engender a work environment that fosters staff autonomy and decentralized decision-making, and that alter the physical environment to make their facilities look and function like a home, rather than a hospital. Four or five years ago, few nursing homes were familiar with the term "culture change." Today it is recognized by and familiar to almost all providers. As the awareness of these and other competitive and operational advantages becomes more widely known, it is likely that many more nursing homes will begin to shift toward making the changes in human resource management, the physical environment, and care delivery that are the hallmarks of resident-centered care.
Only 5 percent of nursing homes report that the definition of culture change or resident-directed care "completely" describes their home.
The 25 percent of nursing homes in this category indicate that the definition of culture change describes their nursing home "in a few respects" or "not at all" but leadership is "extremely" or "very" committed to adopting culture change. The remaining 43 percent of facilities that fall into this group say that the definition of culture change describes their nursing home "not at all" or only "in a few respects" and the leadership is only "somewhat," "not very," or "not at all" committed to the adoption of culture change (Figure ES-1). However, very little organizational redesign has penetrated the field and very few homes have changed their physical environment to support culture change. The survey finds that there is wide variation among nursing homes in terms of the choices and autonomy given to residents and in providing environments that are resident-centered (Figure ES-2). Overall, a minority of nursing homes have undergone organizational changes, such as supporting a team approach for workers or cross-training staff, which makes the organization less hierarchical and empowers direct care nursing home staff.
Very few nursing homes have renovated their traditional nursing units into "neighborhoods"—smaller functional areas that can include common community and dining areas—or "households," which are small home settings with a full kitchen, dining room and living areas for 25 or fewer residents and their dedicated staff. As nursing homes become more engaged in culture change and adopt more of its associated practices, staff retention, market competitiveness, occupancy rates, and operational costs also improve (Figure ES-3). In contrast, only 54 percent of nursing homes that are implementing three or fewer culture change initiatives report such an improvement. Nursing homes that are considered strivers—that is, they are not yet culture change adopters, but have leaders who are committed to culture change and resident-directed care—are similar to the culture change adopters in their ability to provide resident-directed care.
But with the examples and best practices gleaned from the culture change movement, nursing homes can begin to make the necessary changes to improve the quality of life for their residents and staff. Not sure who coined the term but I first heard it from Sandy Carter, VP of Social Business from IBM last year. When something needs fixed, changed or persuaded, many times it helps to start at the foundation of the business – organizational behavior (culture).
Two-thirds of the organizations  achieving the highest returns reported that their C-suites are active advocates– that is, they commit to social engagement as a strategy and they reallocate resources to make it happen.
Big-return companies crowdsource new products (57%), or let customers participate in developing ideas — they are predicting a significant portion of new products will be derived from social engagement insights. Companies can no longer afford to think of their organization as distinct from the environment in which it dwells.
One one hand, we are all influencers, meaning we are influencing our micro-communities’ purchase decisions (and non purchase decisions) everyday via organic conversations. I also think that with the correct mindset in management and hiring practices upfront, that systems and written, trained and understood guidelines can be an effective way to get everyone communicating and on the same page. This can be a short timeline until a quality review or some event that is important to the organization.
This is key to give the team something to work towards and to give the team something to achieve. Again, if there is no administrative support from you from your colleagues in administration, or if you don’t communicate the vision, then people are unlikely to understand and accept the roadmap for the future. In short, this goes back to the classic idea that you must make it easier to act in the way that change effort requires people to act.
Your hiring, promotion, and development of employees must be such that those who can implement the vision are brought along.
There must be a means to ensure succession in leadership roles so that these changes become commonplace and are reinforced.


In fact, the lean six sigma statistical process control pathway satisfies each of these steps in a positive way that allows us to avoid taking issues with each other or personal attacks. Fortunately I have not been in this situation often, but let me say this can be a real challenge especially in a failed change effort or in difficult organizations…and, of course, despite our best efforts most change efforts fail.
This prevents finger pointing and allows us to make data driven decisions which are reproducible, transparent, and may be followed over time to gauge improvement. Sometimes I see my colleagues in Medicine reinventing tools that have names and are well utilized in other fields.
Often, in different service lines in Medicine, it is too often the case that staff attribute issues to personal defects rather than system defects.
To improve the quality of care and the quality of life for nursing home residents, a growing movement, known as "culture change," is working to deinstitutionalize long-term care and radically transform the nursing home environment. To this end, nursing home residents are given greater control over their daily lives—for instance, in terms of meal times or bed times, and frontline workers—the nursing aides responsible for day-to-day care—are given greater autonomy to care for residents. A representative sample of 1,435 nursing homes was surveyed between February and June 2007.
If the first step to change is awareness of a problem and the availability of an alternative, then the field of nursing home care is indeed poised for transformation.
An additional 25 percent indicate that their nursing home "for the most part" fits the description of a culture change. About 30 to 40 percent of all nursing homes report they are currently implementing some principle of culture change that fosters resident-directed care, including allowing residents to determine their own daily schedules, practicing resident-centered bathing techniques, or by actively involving residents in nursing home decisions.
But, direct care workers are more likely to have leadership opportunities and be authorized to make decisions about delivering resident care in nursing facilities that self-identify as culture change adopters. Even culture change adopters have difficulty altering their physical environments to make facilities more home-like.
They also demonstrate that they are moving toward being the type of facility that empowers workers, provides direct-care workers with leadership opportunities, encourages decentralized decision-making, and allows staff to make decisions about resident care. John Kotter, previously a Harvard Business School Professor, developed these 8 steps in part to help articulate why change efforts fail and to better improve our numbers with respect to successful change efforts.
Articulating this change as a vision is key and this must be represented by both how you act and what you say. That is, you remove barriers to people acting in the way they need to act for the change to occur. Whatever the short terms wins are, these must be visible and these must be followed through with people receiving recognition and reward in a way that gets noticed. It is useful at this point to demonstrate that the new way is superior to the old with data. Incidentally, one of the things I have noticed in change efforts is that what are called ad hominem attacks may abound. If you can get the culture to respond to data rather than personal attacks, the team can improve over time in a meaningful way. Some of these are utilized in the lean six sigma toolset, which is mostly a pre-established pathway to use these advanced statistical process controls for quality improvement and culture change.
In addition, the physical and organizational structure of facilities is made less institutional. A total of 31 percent of surveyed nursing homes are considered culture change adopters (numbers do not add because of rounding). Indeed, culture change strivers reported significantly more positive responses on all measures related to improving staff working environments, compared with traditional nursing homes. Technology is imperative and will help facilitate collaboration; but it’s behavior change that is the foundation for adoption.
Being sure that people around you understand the importance of the event and feel the urgency without being overly anxious is key. If you find yourself where there are clear issues and yet you do not have administrative support (or are not able to enlist it) it is likely you have a nonstarter for change management. This is supported by the quality control literature and I have often noticed that poor systems may set up physicians and healthcare providers for confrontation amongst themselves.
We always enjoy hearing and learning about change management across different organizations.
Large, hospital-like units with long, wide corridors are transformed into smaller facilities where small groups of residents are cared for by a consistent team. These findings reiterate the importance of a committed leadership for encouraging culture change.
That is, they erect barriers to acting in the current mode to create enough friction that people must favor the newer, easier pathway to which barriers have been removed.
Of course you should have a framework and some basic rules of engagement, but these should not be the focus. It can be even harder when a change agent has clinical decision making, technical prowess, or other professional, patient care skills questioned as part of an ad hominem attack.
Findings From The Commonwealth Fund 2007 National Survey of Nursing Homes, The Commonwealth Fund, May 2008. Stay calm, and think of how good it will look when the situation is successful, or, failing that, leave if the situation becomes threatening either personally or professionally.



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