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Modeling and Measuring Nursing Home Reform: The Culture Change Staging Tool

The Culture Change Staging Tool is a Web-based tool that enables nursing home administrators to assess their progress in transforming resident care. After leading administrators through a series of detailed questions about decision-making processes, staff roles, the physical environment, organizational design, and leadership practices at their facilities, the tool generates a management report that can be used to highlight successes and pinpoint areas in need of development. Researchers can also use the tool to compare culture change programs across the nation. The tool can be freely accessed at the My InnerView Web site.

Organization: University of Minnesota and My InnerView, a nursing home quality improvement and management consultancy

Target Populations: Nursing home administrators, directors of nursing and other nursing home staff, long-term care researchers

The Issue: In nursing homes, it's as important to provide a good place to live as it is to offer good care. A grassroots movement that began in 1997 among nursing home providers, long-term care professionals and researchers, often termed "culture change," proposes a radical departure from the traditional nursing home model. It aims to improve the lives of the 1.5 million people living in nursing homes, as well as those who work there. Proponents of culture change believe long-term care residents can and should direct their own lives and recommend replacing hospital-like units with households of small groups of residents and permanently assigned staff. In addition, they seek to improve training of nursing home staff, giving them a voice in how their job is performed and valuing their contribution to the organization.

A variety of culture change models such as Wellspring, Service House, and the Eden Alternative have demonstrated the viability and benefits of resident-directed care. Yet, there is no common definition of the culture change process; research suggests that organizations attain different types and degrees of change, depending on their leadership and organizational resources.

It has become clear that achieving "culture change" requires a significant commitment on the part of the nursing home. While some reforms emphasize the appearance and comfort of residents' living environments, others focus on deeper organizational processes, including how decisions are made and whether residents exercise control over their daily lives.

The Intervention: A new Culture Change Staging Tool presents a conceptual model of the culture change process, which was created by eliciting expert advice and pilot testing in more than 30 nursing homes across the country. According to this consensus model, culture change can be broken down into four basic stages:

  • Stage I: The institutional model is a traditional medical model organized around a nursing unit without permanent staff assignment. The organizational structure is hierarchical, moving from administrators down to department heads, supervisors, and frontline staff.
  • Stage II: The transformational model is the initial period of culture change implementation, during which awareness and knowledge spreads among direct care workers and the leadership team. Many organizations at this stage make permanent staff assignment to units. Often, "symbolic" changes are introduced into the physical environment (e.g., new furnishings, artwork, animals, or plants).
  • Stage III: The neighborhood model breaks up traditional nursing units into smaller functional areas and introduces resident-centered dining. The role of a "neighborhood coordinator" is typically formalized at this stage and neighborhoods are given unique names.
  • Stage IV: The household model consists of self-contained living areas with 25 or fewer residents who have their own full kitchen, living room, and dining room. Staff members work in cross-functional, self-led work teams. The hierarchical organizational structure is "flattened" through the elimination of traditional departments.The Culture Change Staging Tool asks users a series of questions about 12 culture change domains. Because the tool explains terms and reform processes, it does not require users to have any prior experience with culture change. The questions encompass decision-making processes, staff roles, the physical environment, organizational design, and leadership practices. Using a decision tree, the tool then classifies nursing home facilities into one of 12 steps along the culture change path.

The tool then generates a management report identifying areas of progress and areas in need of further development. Such tools help nursing home administrators gauge what stage they are in, whether they are making progress, and what they need to do to keep their organizations moving forward. In addition, the tool enables researchers to measure progress in transforming nursing home systems and identify best practices from across the nation.

For Further Information:

July 2009

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