Evaluation of culture change practices and its impact on quality of care outcomes in nursing homes around the Bluegrass

1. Evaluation of culture change practices and its impact on quality of care outcomes in nursing homes around the Bluegrass Region Doris M. Castellanos-Cruz Martin School of Public Policy Masters in Health Administration Capstone Project April 16, 2008

2. Outline • Introduction -Bluegrass Region -Skilled Care -Culture Change • Purpose • Methods • Findings • Recommendations

3. Bluegrass Region

4. Skilled Care Skilled nursing or rehabilitation staff manage, observe and evaluate care. Staff consists of: -Registered nurse -Licensed & vocational nurses (CNA) -Physical and occupational therapists -Social worker -Pharmacists

5. Skilled nursing experience • Follow fixed schedules -Bathing -Eating -Resting -Recreation • Share a bedroom and bath with someone they have never met

6. Culture Change • Create an organizational structure that reflects resident’s dignity, independence and rights • Reduce institutional feel Goals: • Improve resident satisfaction and quality of life • Improve resident’s function and health status • Improve staff efficiency and productivity

7. Quality Quality of careQuality of life -Infection rates -Resident satisfaction -Number of medications -Individualized activity plans -Medication errors -Staff satisfaction -Acquired pressure sores -Staff turnover -Physical restrains -Staff absenteeism

8. Culture Change quality of life = quality of care employee satisfaction = quality of care

9. Purpose Evaluate culture change practices among nursing homes in the Bluegrass Region and find out if facilities that have adapted culture change attributes are more likely to achieve better quality of care outcomes than facilities that do not

10. Methods • Sample -Nursing home facilities (n=33) • Data Collection -NHOA care complaints 10/2006-9/2007 -CMS health deficiencies 10/2006-12/2007 -Type of ownership -Initiative participation -Interviews

11. Methods Data Analysis MAU model • Assess and evaluate degree of culture change practice • Grant’s Four Stages of Culture Change • Organizational areas -Decision-making -Staff roles -Physical environment -Leadership -Organizational design

12. MAU Model results

13. Data Analysis Correlation Analysis • Check for multicollinearity Correlation Analysis results

14. Data Analysis Regression Analysis • Measure the relationship between culture change practices and number of complaints, deficiencies, type of ownership and initiative participation • All regressions were based on a 95% confidence level

15. Regressions Degree of culture change=f{deficiencies, complaints} • Negative statistical significant relationship between Degree of culture change practice and number of deficiencies • No statistical significant relationship between Degree of culture change practice and number of complaints reported Regression Statistics Results

16. Regressions Any culture change=f{ownership, initiative participation} • Both independent variables had a statistical significant relationship with culture change practice -Ownership: (-) significant -Initiative participation: (+) positive significant Regression Statistics Results

17. Regressions Degree of culture change=f{deficiencies, complaints, ownership, initiative participation} • Number of deficiencies: (-) significant • Initiative participation: (+) significant • Complaints: no statistical significant relationship • Type of ownership: no statistical significant relationship Regression Statistics Results

18. Data limitations • Small sample size -Only 33 skilled nursing facilities • Data variation -CMS and NHOA reports

19. Findings • Association between increase in culture change practices and decrease in number of deficiencies • For-profit facilities tend to be more hesitant to change • Culture change practices increase for facilities that participate in initiative program

20. Recommendations • Become involve in quality programs -Advancing Excellence in America’s Nursing Home coalition • Begin the implementation process of culture change -Obtain commitment and continuity of corporate leadership • Strategic planning committee -Guide the process - Prevent to loose focus - Optimize the use of human and financial resource

21. Recommendations Resident-directed care and activities • Expand choices • Provide time options for bathing • Assist residents in determining their own schedules, activities and care plans • Communicate the vision, principles, and values of resident-centered care to all staff

22. Recommendations Home environment • Design residents rooms for privacy, personalization, and individual needs or preferences • Introduce plants, pets, children, or familiar artifacts from the resident’s past • Change the environment as much as possible from institution to home • Implement neighborhood or household designs

23. Recommendations Relationship with staff family, resident and community • Commit to consistent staff assignment • Promote a sense of community • Involve family members in decision making • Provide intergenerational activities • Honor death and dying with dignity

24. Recommendations Staff empowerment • Involve multidisciplinary staff in care planning and care conferences • Enable staff to self-schedule • Implement cross-training across departments and staff roles • Promote staff development and autonomous decision • Develop self-directed work teams

25. Recommendations Collaborative management or sharedleadership • Implement practices to improve staff satisfaction through enhance work environments • Improve core leadership competencies and expand participation on leadership teams • Promote open communication through consensus • Decentralizing decision making about hiring and promotion • Encouraging multidisciplinary teamwork and problem solving

26. Recommendations Measurement based quality improvement processes • Adopt principles of evidence-based management • Evaluate based on key measurements like clinical, workforce, customer satisfaction, quality of life, and other outcomes

27. Relevant Courses • Organizational Change and Strategic Planning (HA 602) • Qualitative Methods of Research (HA 621) • Public Program Evaluation (PA) 622) • Decision Analysis and Decision Support Systems (HA 623)

28. Acknowledgements Committee Chair: Dr. Philip Berger Committee member: Dr. Sarah Wackerbarth Reader: Dr. Jeff Talbert Outside practitioner: Kathy Gannoe, MPA Executive Director Nursing Home Ombudsman Agency of the Bluegrass, Inc. Martin School PhD student: Gabriel Serna

29. Questions?