The How of Change describes the process B&F Consulting uses for moving from institutional to individualized care.
The world of long term care is entering a time of unprecedented change. On a scope and scale never seen before, nursing homes across the country have begun to embrace ideas and concepts that support transformation from institutional care to individualized care. Many are finding, however, that embracing ideas can be worlds apart from making real change. Homes that want to change often find their current culture is so deeply entrenched in providing good institutional care that they don’t know how to operationalize the system changes needed to provide high-quality individualized care.
We help organizations with the how-to, by providing a step-by-step approach to take on change. While there is no cookie-cutter approach to taking on distinct areas of change, there is a method for going through the process of change in a way that accelerates and sustains your changes. So whether you are opting to promote good sleep, prevent falls by promoting mobility, instituting Music & Memory, changing the way bathing is done, or the way meals are delivered, or even altering the way death and dying are honored, there is a framework that can be helpful when you move from your desire for change to putting these ideas into action.
Take on the area of change that is most meaningful in your home. This will be different for each home—and it may be a change in care practices, the environment, or even in workplace practices. By using a high involvement change process, you will not only succeed with the one change you’ve targeted, but you will also develop your capacity for the next change.
If you’d like to learn more, continue reading. Alternatively, you can click the buttons below to download a PDF version of The How of Change, or see an example of a case study where this was applied.
The How of Change will give you a way to begin thinking through and taking on the process.
Here are 10 steps for your team’s successful change:
Form a team of people involved who are charged with, and empowered, to make decisions. Before tackling the change, this group should take the time to get to know each other, and develop real relationships with each other. The change process takes honesty, focus, and requires us to learn to count on each other. This kind of change cannot happen in a top-down fashion, or by edict. It can happen only when the people involved decide that they really want something different to happen.
Personalize: Our ability to envision the possibilities for our change process starts with thinking about how we individually, as people, need our lives to be, and then to look at what happens in a nursing home. We need to recognize that our needs are the same as our residents’ needs. We are all human beings. A first step is to think about, and talk about, what our own needs are. For instance, if you were considering making changes to promote a good night’s sleep, start by thinking about what you would need for a good night’s sleep, and what happens for you when you don’t get quality sleep night after night. Have people talk in pairs about what they need for a good night’s sleep, and how lack of sleep affects them. It is important to take this step. This gives us a way to step back from current routines, and understand their impact on our residents. Much of the institutional routine that is currently in place in today’s nursing homes has happened over time, and because we have lost sight of how our routines affect our residents. Only when we start to see residents as real people with human needs can we take on this kind of transformational change.
Examine our current process. Step back, and objectively examine what exactly we are doing now. We will need to talk to those who are actually doing the work. To do this, we have to develop a way for committee members or staff to check in with all front line staff. We want to be sure to be able to identify what is working and what is not. What factors contribute to sleep interruption? What do we do to protect sleep? Ultimately, we want to keep what’s good, and what’s working, and figure out how to change what isn’t.
Make a target list of the current practices that aren’t working now. Make a list of everything you observe that you would ideally like to change, and sift through it. For instance, some people will want to get up early and others will want to sleep in. Residents’ sleeping and waking times will affect timing related to their care, meals, and other staff responsibilities. For each of these responsibilities, figure out, is it something that needs to be done when it is done, and if so, how can it be done in a way that is compatible with the needs and desires of the resident. Think about medications–can they be changed to be given at another time that will minimize sleep disruption? Can they be timed with an assist to the bathroom, or repositioning? What would we want for ourselves?
Take on the easier changes first. Prioritize it, by figuring out the easy things to change. Look for changes that don’t bump up against other areas. Most changes will have a ripple affect, but some changes will not bump up against many other areas. Take these changes on first. Think about what changes could be building blocks that, by making them, open up other opportunities. As you take on making changes, you will get better at it—you will be building your organizational capacity for change. Aim to start with changes that are low burden and high benefit. If you take on too big of a change all at once, it will be too hard, and may sink your efforts. Start with small changes that are easy to implement, and can have a big impact, so that staff experience the benefit without being overwhelmed. As you clear out the easier changes, the changes that you first saw as really hard to take on will be easier to identify, and you’ll know better what needs to happen next. You are, in essence, clearing out the old debris, so that you may move to the heart of things.
Pilot test with one resident, instead of trying to make changes for everyone. For example, work with one resident who is clearly distressed by a lack of sleep. See if you can learn from that person’s sleeping patters, and make adjustments to support their sleep. As staff see the benefits for this one person, they will have in mind other residents who may also benefit. If you make sweeping changes for all residents, staff may become overwhelmed and worried. When you pilot test on a small scale, you also make your mistakes on a small scale. Once you’ve learned what works for one person, you can apply the lessons more broadly onto the next, and can continue learning and adjusting. Pilot testing may require several instances before you can begin to find your footing, and feel confident enough in your system to bring it to the whole organization.
Be inclusive. As you decide on changes to make, you will need to think through exactly what needs to change, and who needs to be involved. Include all staff who will be involved in the change. Encourage honest dialogue. Rather than label questions as “resistance”, treat staff questions as important factors that will build success. These are real concerns that can form a to-do list of areas needing to be addressed. As you bring others in, create a climate where the truth can be heard, as Jim Collins wrote in Good to Great. Engage in passionate dialogue—encourage an open debate, not coercion. Do not forget to educate and inform family members. Involve residents and families whenever possible.
Make mid-course adjustments as each new experience creates knowledge, energy, and the ability to envision the possibilities for the next move forward. Think through each area for its clinical integrity, its psychosocial integrity, and its impact on your entire organization.
Measure, evaluate, and spread. Identify measures that are directly relevant and also be on the look-out for measures that you might not have anticipated. If you are individualizing mornings, good for better moods, fewer medications, fewer injuries, less stress. Monitor weight loss to make sure people are getting the nutrition they need. Be open to other affects, such as fewer falls, fewer pressure ulcers. Evaluate both resident and staff outcomes. When you know it’s working, spread it.
Finally, as you take on changes to your care practices, think like a surveyor. What are all of your regulatory and clinical responsibilities? How will they be affected by your changes? Update your policies and assessments to reflect your practices. Think through what surveyors will be looking for, and be sure to address all of these areas. If what you are doing is going to look different, make sure that you keep the survey agency in the loop as you make changes. Call the survey agency, and let them know what you are thinking, and ask if there is anything they would like you to keep in mind. When your survey starts, highlight the changes you are making, so that surveyors will know what they are seeing. Document in the medical record, care plan, and facility documents what are you doing, and why.
Press:
Brady, C., Frank, B., & Farrell, D. (2013, February). Relationships Matter. Provider Magazine. Retrieved from http://www.providermagazine.com/archives/2013_Archives/Pages/0213/Relationships-Matter.aspx
Brady, C., Frank, B., & Farrell, D. (2013, May). Relationships Matter…Part 2. Provider Magazine. Retrieved from http://www.providermagazine.com/archives/2013_Archives/Pages/0513/Relationships-Matter.aspx