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What is culture change?

An interview with John George, Nursing Home Administrator at Saint John’s

How did you first come across culture change and why did it sound appealing?
I first started to hear about culture change when we received grant money from the Retirement Research Foundation. A lot of us didn’t even know what we were talking about. It wasn’t until the Pioneer Network conference in Chicago a few years ago that I had an ah-ha moment and realized what we were truly talking about. It was thrilling and scary all in the same breath. We had no idea how we were going to do this, or what we were going to do, or how we’d even convey what we’re envisioning to others to get them excited about it. But I knew that if I never wanted to end up in a nursing home the way they look today, I was personally going to have to do what I could do to change the way that care is delivered, in 99.9% of nursing homes across the country.

What steps did you take to start the process?
When we came back from The Pioneer conference, to really get the process started we held small sessions with groups of 10-15 people and really posed the question “If you were in an accident today, and you did not recover from that accident, and you had to spend the rest of your life in a nursing home, what would you most miss?” Then we listed all the things that people miss, all the things that get taken away from you when you move into a nursing home. You lose your privacy, you lose when you eat, what you eat, when you bathe, the things you wear, the things that are important to you, creating your day. We’ve just described institutional living like prisons, dormitories, hospitals, nursing homes. Then we said, “In almost every one of these scenarios you’re going to leave. You’re going to get better and leave a hospital, you’re going to graduate from college and move out of a dormitory, unless you’ve done some heinous crime you’re going to get out of prison and go back to society. But a nursing home, in many situations, is a life long sentence. Then we asked them, “How many of you want to spend the last years of your life in a nursing home?” Out of about 130 people, only six said that they wanted to but only because they didn’t want to be a burden on their families. And we said, “We give some of the best care in the state of Wisconsin, and if none of us ever want to be here then we owe it to ourselves to change what is currently going on.” That lesson was really what planted the seed in many employees heads about what change could look like or just the idea that we needed to do something different because none of us wanted to end up in the current system. What was really startling is that some of the employees were already well into their 60s, and they looked around like “oh my God this could be me someday.” And I was thinking, some of these residents aren’t any older than some of our employees. There’s no one in this building who ever said, I want to get old and live in a nursing home. No one ever plans it. It could be each and every one of us at some point in our lives.

How was the transition into culture change?
Too much planning went into thinking about how employees would react to situations versus letting employees decide situations. We spent too long behind the scenes talking about the “what ifs” and “how are we were going to do this” before getting out to the floor.” Once we did, it became really clear that employees had the answers. We had been spending all of this time behind the scenes trying to solve what they were going to figure out in a matter of days. I brought laundry to the floor and said, we need to talk about the challenges of this. Within 48 hours staff had figured it out, had it in place, had it up and running smoothly. If we had all sat in a classroom to try and figure it out the process would have taken weeks or months. We just over thought every detail. That was our fear of the unknown that we had to battle. We really didn’t have a whole lot of models to draw from and say “ok, let’s contact this other facility and see how they did it.” It became a huge struggle. Another struggle was getting upper-level management to really have true “buy-in” to what culture change is. They’re onboard today, but for some of them it was really difficult for them to comprehend what we were even talking about because so much of it was intangible. It’s kind of like faith; you either have it or you don’t. Nobody has a blue print called “here’s what culture change is.” You’re creating it as you go and it’s hard for people to see and to understand.

What challenges do you continue to struggle with?
We still struggle with working through the “med pass” to the point where it really is person first; where we truly don’t have a medication cart, where we know the resident’s timing and we can distribute meds in their rooms while they’re getting ready versus in the dining room. That’s the most difficult piece because it really would require time studies. I would say that we’re really only 50% of the way there. That has been ongoing and the longest struggle.

We also struggle with sustaining it. Once you’ve done culture change, how do you sustain it, and what does deeper change look like? We’ve let people sleep in, and pick their own food during meals, and have voice and all of those things, but what’s next? Two and half years into this, you take a breather and say, ok, how do we keep this going? It’s so easy to slide back into what fits our routines better than the residents. So, what would be next? What would we envision as the next layer or re-empowering the employee and re-instilling choice and giving residents a voice? So the hardest struggle at this point is sustaining it.

Why do you personally think culture change is important?
People with dementia are not given enough credit for who they are. They are labeled and dumped into a category. We think they are not able to make any decisions in their lives, and so they need to have their care delivered. This is simply not true. None of us want to be ruled and regulated and have our spirit taken from our bodies. There’s a better way to deliver care that’s not all measured on medical outcomes. There’s a whole element of quality of life that is hard to measure, and people haven’t spent a lot of time understanding that, yes, you can take care of the physical needs of someone incredibly and still have them be a shell of a body because you don’t know who they were, or you don’t engage them. They aren’t feeling part of a community or a family, there’s nothing in their environment that resembles home, there’s nothing that’s familiar to them. You’ve really in essence stripped them of who they are completely because you’ve created this sterile environment. This escalates the dementia process; it rips the souls from their lives and it shortens them because they give up the will to live.

What have you done in your own job to be a 'culturally changed' professional?
Early on, there was a core group of administrators who had to work as the team leaders, which we traditionally wouldn’t do. I worked as a pseudo team leader until one evolved. Culture change gets into who you are. When someone asks you questions about culture change, before you know it you’ve gone on for twenty minutes. We feel passionately about why this is the right thing to do. We want people to see that if they don’t ever want it to be them then we need to do something differently. People I’ve talked to about culture change don’t, well this makes sense, why isn’t everybody doing it? A few people who have been in the industry a long time have been really opposed to it. They don’t think it makes money, they don’t think it would work in a different environment. It’s very hard to envision their facility doing it based on St. John’s. One of the downfalls is that we have a nice facility, we have a nice clientele and other facilities say, well this would never work in a facility that was primarily Title 19, or this would never work because we are a Union facility. They like to find reasons why it can happen at St. John’s. The reality is, we didn’t use very many financial resources to make culture change happen. In fact, most of that went into training and development, and by blending job duties we easily recouped all of that money. And so it actually hasn’t cost us anything. We’ve actually saved in food cost and reducing personnel based on job efficiency.

When you walk down the halls, what differences do you see in the facility?
I see it most when I go to other facilities. I am so in this environment all the time and I begin to think that this is how it is everywhere. When I enter other facilities, I am struck with how different it is and how I immediately want to get up and say, why are you doing this? What is the purpose of people being corralled to a breakfast table at eight o’clock in the morning while everyone gets the same food, no one is talking to each other, and the C.N.As are in these ugly colored uniforms not addressing residents? That’s when I realize the differences most, because it strikes me how far we’ve come, and how far other organizations need to go.

John George is the Nursing Home Administrator at Saint John's on the Lake, an elder care facility dedicated to turning its hospital-like environment into a true home. George is one of the culture change leaders at Saint John's and been involved with the Pioneer Network for four years. He started with the facility in 1993 after earning his degree in Health Information Administration from the University of Wisconsin-Milwaukee. George has held a variety of positions at Saint John's over twelve years.

culture change?

Why culture change?

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Essay by Susan Misiorski

Essay by Linda Bump

»Interview with John George


Additional resources

Pioneer Network, a culture change organization

Action Pact, a culture change organization

The Foundations of Culture Change: Underlying Principles

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