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What are the real ingredients of culture change in nursing facilities?

November 1, 2006
by Daniel Moles, RN, BBA, MPS, LNHA
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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 “Compli-ance 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.

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’”).