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15.11.2015
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. At least half the tortoises and turtles, a third of the amphibians, a quarter of the mammals, and an eighth of the birds on this planet face a risk of extinction in the near future. This from a review of the book The Sixth Extinction: An Unnatural History by Elizabeth Kolbert.
It’s not just climate change that accounts for the increased rate of species extinction. The general tendency of our species—a tendency that seems to be intensifying all the time—is to decrease biological diversity on this planet.
I don’t expect she will forgive me, but it might be useful for her to get a glimpse into the mindset, if only for the purposes of comprehension.
Given the stressful nature of Wakefield’s situation – some accuse him of a moral crime, others feel he should be prosecuted – it’s both eerie and fascinating to watch him defend himself. But what motivates certain scientists to relentlessly cast doubt on peer-reviewed scientific evidence that’s inconveniently contrary to financial interests?
The author, Bradford Plumer, points out that most climate-change induced migration will happen within developing countries – country folks from villages will move to urban centers.
So when Grantham tells investors the equivalent of “you better believe climate change is for real,” this gives me hope.
Unfortunately for investors, Grantham thinks it’s too soon to profit from attempts to stave off global warming. The gush of filth is a reminder that we have surrendered our independence to a technology we cannot master. Although this has no bearing on the ideas expressed, this exchange on Father’s Day is especially poignant in view of Tony Judt’s illness. More people are injured in crosswalks than when jaywalking because they assume they’re safe. It’s a good thing they pointed out that at least some of these dynamics are speculative, since there’s not much evidence lately that astrology affects the weather. Meanwhile, BBC Earth News reports that polar bears will experience a dramatic “tipping point” due to climate change and suffer a sudden decline in population.


Based on what is known of polar bear physiology, behaviour and ecology, [research] predicts pregnancy rates will fall and fewer bears will survive fasting during longer ice-free seasons. As the lead signer points out, since it’s unusual to get 255 scientists to agree on anything, the endorsement of this statement by so many scientists is important and significant. We are deeply disturbed by the recent escalation of political assaults on scientists in general and on climate scientists in particular. Many recent assaults on climate science and, more disturbingly, on climate scientists by climate change deniers, are typically driven by special interests or dogma, not by an honest effort to provide an alternative theory that credibly satisfies the evidence.
We also call for an end to McCarthy- like threats of criminal prosecution against our colleagues based on innuendo and guilt by association, the harassment of scientists by politicians seeking distractions to avoid taking action, and the outright lies being spread about them. Steven Pearlstein, writing in the Washington Post, points out that the passage of health care reform may have convinced Democrats that the perfect really isn’t the enemy of the good (a Voltaire phrase now associated with Ted Kennedy).
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. What’s worse, these numbers apply only to the small fraction of known species whose conservation status has actually been assessed. We do so by destroying habitats, overconsuming natural resources, and spreading invasive species, willingly or not. She imagines how, in the year 2050, she would explain to a hypothetical granddaughter why previous generations failed to act. Deer also made the case that Wakefield’s motive was financial gain: Wakefield was employed by a lawyer who planned a highly lucrative lawsuit against vaccine manufacturers and investors were promised millions. They argue that the health care industry will perform at its best when government involvement is reduced to zero. Great Britain went to war with China over trade policy (the Opium Wars), and the US has a long history of using tariffs to protect its industries.
They oppose the regulation of smoking or pollution because they benefit from the financial contributions of those industries. The migration that will follow climate change is certainly an issue that should be kept in the public’s awareness. A powerful symbol of what to expect is the fence along the 2,500 mile border between India and Bangladesh. The asset management fund GMO, where he’s Chairman of the Board (the ‘G’ stands for Grantham), was responsible for $107 billion at the end 2009.
In fact, we are in the worst possible position: we are old enough to understand better than you what has to be done, but far too young to do it. The easy answer is, there’s a financial incentive for going forward, and a financial disincentive for holding back.
For one thing, humans have a propensity to alter our behavior in ways that negate attempts at risk management …. The resolution cited a number of significant, interrelated dynamics affecting “world weather,” including “climatological, meteorological, astrological, thermological, cosmological, and ecological” factors. There’s a lot we can learn about temperature distribution from infrared images of the earth, but the term thermology is reserved for the medical diagnostic technique that analyzes infrared images of the human body. As these ice-free seasons lengthen, fewer bears are expected to have enough fat and protein stores to survive the fast. It’s titled “Climate Change and the Integrity of Science,” and it’s not simply about climate change.
Society has two choices: we can ignore the science and hide our heads in the sand and hope we are lucky, or we can act in the public interest to reduce the threat of global climate change quickly and substantively.


Republicans may be ready to acknowledge that if they attempt to kill another piece of important and historic legislation simply to be ornery, they will miss out on significant concessions they could have won.
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. Her teachers will already have explained that what was happening to the weather, in 2014, was an inconvenient truth, financially, politically—but that’s perfectly obvious, even now.
In that interview, Wakefield claims his accuser committing a fraud by selectively omitting data.
He has a reputation for predicting market bubbles, valuing history, and giving advice that’s worth listening to. As we collectively watch oil rise from a gash in the ocean’s floor, it seems appropriate again. In the bigger picture, big oil has no long-term future: sooner or later the contemptible little sheikdoms that have arisen upon a pool of liquid greed will sink back into the desert. Program managers are rewarded for meeting budget and schedule milestones and obtaining results.
So safety sometimes gets short shrift against more tangible commercial gains and public image. Doctors worry that if a genetic test tells you you’re not at risk for a disease, you might indulge in unhealthy behavior. It argues that politically motivated attacks on climate change threaten the very integrity of science. There is always some uncertainty associated with scientific conclusions; science never absolutely proves anything. 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. We like to imagine that cultural diversity is an adequate substitute for biological diversity—for ourselves, if not for other species. A global movement of the people might have forced it onto the political agenda, no matter the cost. The tragedy is not so much the literal mutilation of the earth as it is the ratcheting up of our collective disillusion with politicians and corporate executives, whose financial interests take precedence over the common good.
Likewise, when there’s a safety or back-up system in place, people are often willing to push further into riskier territory (like drilling five miles beneath the ocean). When someone says that society should wait until scientists are absolutely certain before taking any action, it is the same as saying society should never take action. 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. But beyond these people, infidelity is being parcelled up as safe and predictable, for those who presumably did their best to steer clear of it, until (for whatever unforeseen reason) they couldn’t resist it. And we often misconstrue luck (at having nothing go wrong) for proof that an activity actually contains an acceptable risk — a belief that gets stronger the longer we go without an accident. For a problem as potentially catastrophic as climate change, taking no action poses a dangerous risk for our planet. So I might say to her, look: the thing you have to appreciate is that we’d just been through a century of relativism and deconstruction, in which we were informed that most of our fondest-held principles were either uncertain or simple wishful thinking, and in many areas of our lives we had already been asked to accept that nothing is essential and everything changes—and this had taken the fight out of us somewhat. Like hipsterism, the promise of administered infidelity is to have one’s cake and eat it, to experience the rush of living on the margins without any of the risks that once went with that.
What’s more, risk taking is tangibly encouraged and rewarded in American culture and business. Just look at the bonuses given out on Wall Street, and the way we idolize entrepreneurs and the risk-taking entrepreneurial spirit.
Findings From The Commonwealth Fund 2007 National Survey of Nursing Homes, The Commonwealth Fund, May 2008.



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