The How of Change

The How of Change describes the process B&F Consulting uses for moving from institutional to individualized care.

Get a printer-friendly copy at TheHowofChangeweb.doc To see how it works in one home’s experience, go to Culture Change in Long-Term Care: A Case Study.

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 deep transformative change.

Many nursing homes have expressed a desire for a formula—a step –by-step approach to taking on change.  While there is no cookie cutter approach to taking on distinct areas of change, there is a formula for going through the process of change.  So whether you are opting to change the way bathing is done, or the way meals are delivered or even 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. 

The How of Change will give you a way to begin thinking through and taking on the process.  There are essentially eight steps involved in this process and they involve a group thinking through all of them.  The group can be a group that has agreed to be a part of a culture change initiative, your department heads, your quality improvement group, or any group who is charged with and empowered to make decisions.  Before tackling taking on change, this group should take the time to get to know each other and develop real relationships with each other.  The change process is one that 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 be happening. 

1.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. So a first step is to think about and talk about what our own needs are.  So for instance, if you were considering changing your morning routine, and ensuring that residents who like to get up late will be able to, and still get breakfast, a place to start is to think about your own morning routine.  We all have a morning routine, so in a meeting have everyone first write down their own routine, and then talk about how much of their routine they would be able to keep in place if they were to move in to your nursing home.  It is important to take this step.  Much of what is currently in place in today’s nursing homes has happened over time and because we have allowed nursing home residents to become other. Only when we start to see residents as real people with real needs can we take on this kind of transformational change.  

2.We then need to step back and objectively examine our current process. What exactly are we 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.  Ultimately we want to keep what’s good, what’s working.

3.List out all of the things that feel like they would not work for you or from others in your group.  For instance, going back to the change of morning routine, 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 morning medications- can they be changed to be given at another time for the resident who likes to get up later?  What would we want for ourselves? 

4.Make a list of all that you see that you would want to change and sift through it. 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. 

5.Take on the easier changes first. This will build your staff’s capacity to change. As you clear out the easier changes, the changes that you at 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 can move to the heart of things.

6.As you decide on changes to make, you will need to think through what exactly needs to change and who needs to be involved.  And then include them.  Encourage honest dialogue—treat what you might have thought of as resistance instead as important questions that need answers in order to be successful. 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. 

7.Make mid-course adjustments as each new experiences 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. 

8. 8.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
   

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10.     Finally, as you take on changes to your care practices, think like a surveyor.  What are all 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 really different, make sure that you keep the survey agency in the loop as you make the changes.