1. Culture Change in Multi- Facility Systems Mary Tess Crotty, MA Genesis HealthCare Ed McMahon, Ph.D. Golden Living

2. What do Culture Change and Quality Have in Common? In small groups, introduce yourselves, and identify one or two things Culture Change Quality ?

3. CFMC, the Medicare Quality Improvement Organization for Colorado, under contract with CMS Culture Change Concepts

4. Baldrige Concepts Resident Focus – Engagement How do you identify and innovate healthcare service (and other) offerings to meet the requirements and exceed the expectations of your residents and their families? How do you create an organizational culture that ensures a consistently positive resident and family experience? Voice of the Resident How do you listen to residents and their families to obtain actionable information and to obtain feedback on your healthcare (and other) services? How do you determine resident and family satisfaction and how do you use this information to improve your organization? Workforce Focus – Engagement How do you foster an organizational culture that is characterized by open communication, high-performance work and an engaged workforce? How does your workforce performance management system reinforce a resident focus?

5. Culture Change & Baldrige Criteria Focus on the resident Employee engagement Strategic planning Process Improvement It’s all about culture!

6. Organizational Definitions of Culture Change GHC – since 2004: A great place to be – to visit, live and work Person-centered care Practices organized by People, Care and Environment Golden Living – since 2002: Living Life to the Fullest Resident-directed care Practices organized by Resident-Driven Systems, Creating Community, Staffing, Self-Managed Work Teams, Environment

7. Right-Sizing Your Approaches Genesis HealthCare Approximately 220 nursing homes and assisted living centers, in 13 eastern seaboard states operates in three geographical areas – 5-7 operations groups within geographical area Collaborative Learning model – primarily by Area; monthly Conference Call companywide

8. Right-Sizing Your Approaches Golden Living Approximately 360, 22 states, 4 Divisions Started with pilots and structured training Integrated into companywide Performance Management System

9. Genesis Story Collaborative Improvement Model PCC materials developed by QIOs Learning Sessions: area level Center team conferences, on-site learning sessions Skill Development: Coaching Supervision (now The Partner Approach), Respectful Workplace Training, Neighborhood Training Leadership Development

10. Genesis HealthCare The culture change story

11. Collaborative Improvement Model Common goals and definitions Learning sessions Conference calls during “Collaborative work” periods Final Congress

12. CMS/QIOs Collaborative Pain Collaborative (Multi) Workforce Retention (Multi) Continued same format with Person- Centered Care (Culture Change)

13. Integrated into Quality Dept. Common goals and definitions: Culture Change Self-Assessments Learning sessions Range from 350+ - with direct care teams Small pilots and on-site visits Conference calls during “work” periods Monthly Conference Calls (35-80 Centers) Final Congress Goals integrated into Customer Satisfaction, Employee Satisfaction/Retention, and Census

14. Culture Change Assessment Areas People 1. Consistent Assignment 2. Respectful Workplace/ Coaching Approach 3. Learning Circles 4. Orientation 5. Language Environment 12. Neighborhood Concept 13. Noise reduction 14. Safety and Independence Care 6. Medication Reduction 7. Bathing 8. Night-time Routines 9. Alarm reduction 10. Dining Choices 11. “Get to Know Me”-I Centered Care Plans

15. Self-Assessment Example: People 1. Consistent Assignments 1.1 Consistent Nurse Assistant assignments are in place for … M-F day shifts on (All/Most/Some/None) of the units. M-F evening shifts on (All/Most/Some/None) of the units. S-S shifts on (All/Most/Some/None) of the units. 1.2 The Center has a float/back-up system to provide consistent replacements. (Yes/No) 1.3 A team composed primarily of nurse assistants meets to discuss and oversee assignments… ( Weekly/Monthly/Quarterly/Never) 1.4Over the course of a month, a resident receives personal care from (No more than 10 NAs/Between 10 and 20 NAs/Over 20 NAs/Have no way of knowing) 1.5. Other Notes:

16. Culture Change Conferences Sample Themes… Individualizing Daily Routines Leading for Change Patient Safety through Person-Centered Care Creating Neighborhoods The Spirit of Neighborhoods

17. Continuum of Customer Orientation Staff Directed Staff Centered Person Centered Person Directed S taff make most of the decisions with little conscious consideration of the impact on residents. S taff consult residents or put themselves in residents’ place while making the decisions. R esident preferences or past patterns form basis of decision making about some routines. R esidents make decisions every day about their individual routines. When not capable of articulating needs, staff honor observed preferences and lifelong habits. R esidents accommodate staff preferences; are expected to follow existing routines. R esidents accommodate staff much of the time— but have some choices within existing routines and options. S taff begin to organize their routines in order to accommodate resident preferences— articulated or observed. S taff organize their hours, patterns and assignments to meet resident preferences. LowHigh Developed by Mary Tess Crotty, Genesis HealthCare Corp, based on the model by Susan Misiorski and Joanne Rader, distributed at the Pioneer Institutes, 2005.

18. Continuum of Worker Orientation Institutionally Directed Institutionally Centered Person Centered Person Directed S upervisors make most of the decisions with little conscious consideration of the impact on staff. S upervisors consult staff or put themselves in staff’s place while making the decisions. W orkers’ make some decisions about how to arrange their routines to meet resident needs. W orkers make decisions among themselves every day about how to arrange their routines to meet resident needs. W orkers accommodate supervisor preferences; are expected to follow existing routines. W orkers accommodate supervisors much of the time—but have some choices within existing routines and options. S upervisors guide staff to organize their routines in order to accommodate residents. S upervisors oversee staff systems (hours, patterns, assignments) that workers create to meet resident preferences. LowHigh

19. Conference Call Topics I-Centered Care Plans Noise Reduction Bathing Options Dining Approaches Strengths-Based Approaches Re-engineering the Med Pass Self-Scheduling Personal Alarm Reduction Neighborhood Development

20. Skill Development Used PHI (Sue Misiorski and colleagues), developed Train the Trainer model Coaching Supervision (now The Partner Approach) – 2 day program for Department Heads and Nurses Respectful Workplace Training Neighborhood Training Pilots (Resident-Staff Learning Circles, “Approach Coaches” for behavior challenges

21. Leadership Development Rotating through Culture Change intensives by Operational Area – every other month, Administrators and DNSs attend an “onsite learning session” – within the company. Integrating into our long-term care strategy for customer experience

23. Northeast Area 3 Yr Results Coaching Supervision training >1,800 completed 2-day training Family Satisfaction 1% increase to 90% would recommend Employee Satisfaction 9% increase to 70% would recommend Occupancy.6% decrease to 91.7%

24. Learning Cultivate early adopters then recognize and reward them Integrate into your discipline support Bring leadership teams on-site to see and ask about change processes Choose your framework – everyone needs to change – that takes time Give concepts time to take root in your organization’s language Be ready to adapt and connect culture change to organization’s priorities.

25. Golden Living The Culture Change Story