Back to Culture Change Fundamentals

A Free Starter Toolkit for Engaging Staff in Individualizing Care

This Toolkit is a product of Pioneer Network’s National Learning Collaborative on Using the MDS as an Engine for High Quality Individualized Care, made possible with the support of The Retirement Research Foundation. The Collaborative incubated B&F Consulting’s method for engaging staff in individualizing care to improve outcomes for residents. The method first puts in place four foundational organizational practices – consistent assignment, huddles, involving CNAs in care planning, and Quality Improvement (QI) closest to the resident. These practices create a forum for regular communication, critical thinking, and problem solving among and with staff closest to the residents.

Forty-nine nursing homes incubated these practices through fifteen month learning collaboratives convened and facilitated by five Culture Change Coalitions and four nursing home corporations. The incubating homes strengthened these practices by applying them to high priority clinical areas, and found that with huddles and consistent assignment they were able to improve outcomes by adapting to residents’ customary routines. As they saw the benefits in clinical outcomes and honed their foundational practices, the incubators were able to build on small scale adjustments to expand their flexibility in dining, morning routines, and night time care. The homes found that the practices together – engaging staff in individualizing care – accelerated improvement in clinical, human resource, and organizational outcomes.

Four Foundational Practices

B&F’s method puts four organizational practices in place as the foundation for deep change: (1) consistent assignment; (2) huddles; (3) involving CNAs in care planning; and (4) QI closest to the resident. Making change successfully requires frequent, timely, accurate information sharing and problem solving among staff. With these four foundational practices in place other changes have the support they need to succeed.

These four practices, used together, are foundational because they encourage and provide a forum for learning and sharing deep knowledge of residents. They serve both as communication vehicles and relationship building tools. These practices support staff in developing deep relationships with residents and with each other, within and across shifts and departments, and they put in place systems that support good communication. Solid communication does not happen routinely if there are not systems in place; resulting communication gaps impede progress. Regular communication, through these practices, accelerates successful continuous improvement.

Incubator nursing homes put these foundational pieces in place in daily practices. B&F’s model for adoption and spread is an applied method. To strengthen implementation of these organizational practices, their use was applied to specific clinical challenges that were priorities to the homes. By using the organizational practices to improve clinical outcomes, the homes saw the value of the practices and worked to strengthen them. Once these foundational practices were in place other changes were adopted fairly smoothly because staff had developed effective relationships through the communications systems in place and could talk through what needed to happen to make changes work well.

The incubator homes all began their implementation by taking the quick organizational self-assessment (see Appendix A) of their degree of adoption of these practices, and then determining in which areas they needed to concentrate their efforts. While many had some semblance of each of these practices already in place, all found that the practices could be strengthened. They also quickly learned that the four foundational practices are interrelated, and mutually reinforcing.

With consistent assignment, staff are able to be dedicated to the residents they serve and know them well. As they know residents, huddles allow staff to do on-the-spot problem solving to catch problems and opportunities early and intervene effectively to prevent declines and promote well-being. When CNAs know residents well, they can contribute pivotal information to the care planning process and are in the prime situation to conduct as needed QI. The management teams of these incubator homes supported staff closest to the resident in making the necessary adjustments for residents’ highest practicable well-being.

As staff in the incubator homes knew residents more deeply, they were able to make individual adjustments in care delivery to align with residents’ customary routines. The huddles among staff closest to the residents evolved into forums for sharing observations and problem solving – essentially on-the-spot assessment and care planning. Incubator homes used staff’s knowledge of residents in QI huddles to find individualized care solutions to address clinical issues. Through QI huddles and CNA involvement in care planning, staff from all departments worked together to follow residents’ rhythms of life in waking, sleeping, eating, bathing, and daily activity.

The improvements the incubator homes saw include: increased mobility for residents; fewer falls; reduced use of bed and chair alarms and antipsychotic medications; stronger relationships between staff and residents, and among staff within and across shifts and departments, as well as between management and staff; and most importantly, improved quality of life for those in their care.

Webinar Series

In addition to attending five collaborative learning sessions, teams from incubator homes watched 12 webinars covering the topics as they were implementing them. The webinar series starts with the foundational practices, then applies them to clinical areas, and by operationalizing customary routines. Each webinar was accompanied by a facilitator guide with starter exercises to begin the conversation about why and how to make a change.

Each webinar featured nursing home staff sharing in practical terms how they are implementing practices and what the benefits are. The team from Glenridge Living Community in Augusta, Maine, whose integrated use of these four foundational practices was the basis for Pioneer Network’s collaborative, participated in a number of the webinars. Webinar 12 features incubator homes describing their experience and sharing their how-to’s, based on their experience in the collaborative.

The webinars are available for a fee for five on-demand viewings of each webinar. To purchase viewings of one or more of the webinars, go to Pioneer Network Store for the full set of webinars on DVD.

Maximizing MDS, QIS, and QAPI

Pioneer Network launched this collaborative to maximize important opportunities presented by federal initiatives to promote individualized care. Two decades after OBRA 87 established the requirement that each home’s care and services support the “highest practicable physical, mental, and psychosocial well-being of each resident,” several recent CMS initiatives support implementation of the individualized care needed to meet this standard of practice.

MDS 3.0 requires nursing homes to interview residents about their customary routines

QIS quality of life survey protocols guide surveyors to ask residents if they are satisfied with the way their customary routines are being followed, and to determine that staff caring for residents know and honor their routines

The CMS Partnership to Improve Dementia Care identifies adherence to resident’s customary routines as a primary intervention to prevent residents’ distress and the ensuing use of antipsychotic medications

Quality Assurance & Performance Improvement (QAPI) guidelines stress the importance of a culture of resident centered care in which residents’ quality of life and preferences are utilized in improving performance and outcomes

As federal requirements place increasing emphasis on individualized care, this toolkit provides a way for nursing homes to activate staff engagement in transforming from institutional to individualized care by engaging staff in the day to day work of assessing, care planning, and performance improvement to promote residents’ highest practicable well-being.

Pioneer Network’s National Learning Collaborative was designed to demonstrate how to maximize the MDS assessment and care planning process by transforming it from a burdensome paperwork exercise done in the conference room or a corner office into a living process conducted just in time by the staff closest to the resident. Now, because of their involvement in the Collaborative, in the incubator homes, assessment and care planning is indeed an active, useful process in which all staff contribute to residents’ well-being. Similarly, incubator homes are using their experiences to recalibrate their quality improvement activities to re-center the locus of activity to the staff closest to the residents. By engaging staff in the daily practice of thinking about their residents, and individualizing care to prevent declines and promote good outcomes, homes have transformed the practice of assessment, care planning, and quality improvement into an engine for high performance.

Toolkit Content

This toolkit is designed to activate quality improvement through individualized care by helping homes put in place the four foundational systems and then use those systems in high priority areas. It draws from the material developed for the five learning sessions and 12 webinars to help the incubator homes activate their process. It incorporates their advice and experience as they learned how-to implement, and strengthen, and apply these practices.

This is a “starter toolkit” with how-to information for initiating and strengthening these practices. To support implementation, each topic area in the Toolkit includes a tip sheet, an exercise to generate conversation among staff, and a video or audio clip to support that conversation. The exercises are designed to give people a personal experience and to open conversation on the topic. The media clips and tip sheets provide how-to information from practitioners.

The toolkit has three sections reflecting the three steps used by the incubator homes. All of the resources listed below can be found in the resource library, Getting Started Toolkits section.

Step 1

Introduction to Four Organizational Practices

Step 2

Clinical Practices Introduction

Step Three

Individualizing Care Practices

Organizational Assessment Tool

There is a Quick Organizational Self-Assessment to discuss with your team where you are in your implementation of the practices used by the incubator homes, and to identify what you want to work on as you get started.

This toolkit is a resource for nursing homes seeking to take full advantage of the resident assessment and care planning process in combination with their emerging Quality Assurance & Performance Improvement (QAPI) activities. QAPI emphasizes high involvement from staff closest to the issue being addressed, and stresses the importance of using individualized care as a means to better outcomes. The four organizational practices incubated in this collaborative are foundational to any nursing home’s effort to engage staff in individualizing care for performance improvement.

The How of Change

For effective implementation of new practices, people need to know why the change is called for and how it will work. They also need to trust that they will be actively involved in working through implementation issues.

The exercises in this toolkit are designed to be conversation starters for each of the topics. Most of the exercises build on staff’s intrinsic motivation to care for residents by giving participants a personal experience on the topic being taught so they then have a personal understanding to draw from. The exercises serve as a reminder that our residents are not that different from us, only older and more vulnerable. When we understand on a personal level about how we would act or react in situations, we understand in a different way what residents experience and need.

Allow time for discussion and ask probing questions to get everyone thinking about the topic. Pay attention to quieter participants and elicit responses from them. It may be tempting to brush off the staff member who is openly skeptical, but putting into play major changes requires that everyone be supportive and that everyone’s concerns be taken seriously. Get to the root of the concern that is underneath the skepticism. Addressing it upfront will likely prevent it from causing difficulties later if unaddressed.

Pilot test first so that you can work through the early implementation issues on a small scale. Trying to make changes across the whole organization can be overwhelming. You will get traction by phasing in the changes across the organization, building on the positive pilot experiences and having staff involved in the pilot explain the benefits and the how-to to their peers. In choosing where to pilot, determine the area where you will have the most success, based on staff who you know will be open to trying something new and are your strongest team members. Pilots are learning laboratories – be sure to set up times for people to talk through what’s going well and what still needs to be worked on. Measure results and keep tweaking so that new systems work well for residents, staff, and your organization.

It Takes a Team

Quality of care and quality of life, the result, is a function of the quality of your processes and systems. The better people work together, the better they can care for residents. Putting in place systems that secure and draw on staff’s knowledge of residents creates the capacity for teamwork to provide high quality individualized care from Day One.

Thanks to our team:

The Pioneer Network team: Project Director: Cathy Lieblich, Researcher: Amy Elliot, Lynda Crandall, Interim Director, and Faculty: Barbara Frank and Cathie Brady, B&F Consulting.

Our team thanks:

the team at Glenridge Living Community in Augusta, Maine for sharing their practices
the 49 nursing homes who successfully and passionately incubated the practices
the project’s national advisory board (listed below)
the National Learning Collaborative conveners (listed below)
Toolkit reviewers: Sue Crane, Joan Devine, Anna Ortigara, and Linda Sadden

National Learning Collaborative National Advisory Board:

Chair: Mary Jane Koren, The Commonwealth Fund
Doug Pace and Carol Scott, Advancing Excellence LTC Collaborative
Sarah Burger, Coalition of Geriatric Nursing Organizations
Sherrie Dorenberger, National Association of Directors of Nursing Administration in Long-term Care (NADONA/LTC)
David Farrell, The Green House® Project and QAPI Technical Expert Panel Member
David Gifford, American Health Care Association, Co-Chair Advancing Excellence Board and QAPI Technical Expert Panel Member
Marianna Grachek, American College of Health Care Administrators
Christa Hojlo, US Department of Veterans Affairs
Ruta Kadonoff, American Health Care Association
Becky Kurtz (ex officio), Administration for Community Living, US Department of Health and Human Services
Beverley Laubert, National Association of State Long-term Care Ombudsman Programs
Michele Laughman, Division of Nursing Homes, Centers for Medicare & Medicaid Services
Christine Mueller, University of Minnesota, Pioneer Network Board of Directors, and QAPI Technical Expert Panel Member
Cheryl Phillips, LeadingAge, Co-Chair Advancing Excellence Board, and QAPI Technical Expert Panel Member
Marilyn Reierson, Stratis Health and QAPI Resource Group
Carol Siem, American Association of Nurse Assessment Coordination
Karyn Leible, American Medical Directors Association

National Learning Collaborative conveners:

Sue Crane, Florida Pioneer Network
Joan Devine, Missouri Coalition Celebrating Care Continuum Change (MC5)
Darlene Cray, New Hampshire Culture Change Coalition
Lynda Crandall, M.O.V.E (Making Oregon Vital for Elders)
Peggy Williams, South Dakota Culture Change Coalition
Peggy Brenner and Vicki Dedrick, ACTS Retirement-Life Communities
Mary Tess Crotty and Francine Fineman, Genesis HealthCare
Angie McAllister and Ellie Curry, Signature HealthCare
Julie Ballard, Health Systems, Inc.

Thank you to the following collaboratives for piloting B&F’s method during its formation so that it could be incubated in the National Learning Collaborative:

Culture Change in Long Term Care: A Case Study of Glenridge Living Community in Augusta, ME
Improving the Nursing Home Culture, a 21-state QIO pilot project by Healthcentric Advisors (formerly Quality Partners of Rhode Island)
Relational Coordination research project for Better Jobs Better Care by Susan Eaton, Christine Bishop, and Jodi Gittell, MA
New Orleans Nursing Home Staffing Initiative, LA
Critical Access Nursing Home Initiative in four states through the Advancing Excellence LTC Collaborative
Making MDS the Engine for High Quality Individualized Care with the Quality Care Community, NY
Indiana Leadership Collaboratives in South Bend and Indianapolis