Artifacts of Culture Change Intro for Nursing Homes

Artifacts of Culture Change Self-Assessment for Nursing Homes

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Protocol for Completion

It is recommended that the home use a forum such as a task force/committee/team to complete the ACC to gain the insights of residents, families, and team members. The team should consist of the administrator, director of nursing, and representatives from each department or team in the organization. In order to have complete representation of the home, it is important that there be representatives from all levels of the organization and different shifts. It is recommended to include direct care team members, family members and residents. All those involved in the discussion should have a copy of the ACC.

In order for a home to make any changes described in the ACC, it is crucial for a high-level manager to lead these culture change efforts in order to provide support and necessary resources. To check progress in making changes over time, the home may want to review the ACC periodically, perhaps every six months or yearly. This becomes a way to assess progress, celebrate successes and revise goals and action plans, as necessary.

In addition to the team completing the ACC together, some other options that homes have used for completing the ACC are: 1) a group of team members completes, a resident group completes, and then conclusions are made together; 2) one cross-section team completes, another cross-section team completes, and then conclusions are made together; 3) individuals complete the ACC and then a discussion is convened of the whole team. The ACC is designed to be completed for an entire home, rather than sections of a home, special neighborhoods, or a single household.

Certain items have information regarding CMS regulations and guidelines for nursing homes. The purpose is to refer to information at the CMS tag referenced. Completing an ACC item as Fully Implemented does not necessarily indicate compliance with all elements of a CMS regulation.

To assess a home’s progress in implementing the ACC, each practice should be marked in the appropriate implementation status: FULLY IMPLEMENTED, PARTIALLY IMPLEMENTED, or NOT A CURRENT PRACTICE. Examples of Fully and Partially Implemented are noted below:

FULLY IMPLEMENTED Examples

  • All team members are aware of the practice and use it in their work.
  • A policy is in place that explains the practice.
  • All residents are aware of the practice and experience its occurrence regularly.

PARTIALLY IMPLEMENTED Examples

  • The home is working on implementing the practice, but it is not fully implemented yet.
  • Only certain sections of the home have the practice implemented.
  • Policies have been written but not fully implemented yet.

If the team is questioning whether a practice is “fully” or “partially” implemented, a good best practice is to ask, “Can we do better?” If yes, the practice is likely partially implemented.

After consensus is reached on all items, the checkmarks in each column are added up and placed in the totaling grid at the end of the ACC. Then, a percentage number is calculated for each column based on the guidance in the grid. (Refer to the example of a completed grid at the end of the ACC). This implementation percentage is intended to help homes set goals as well as to assess progress over time.

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