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Defining culture change begins with defining culture. Culture is how different aspects of human conduct—roles, norms, values, customs, likes, dislikes, symbols, language, priorities and more— dovetail and turn a group of disparate individuals into a community with a distinct identity.

To transform a culture is a momentous undertaking; the word "change" almost doesn‘t suffice. We change our clothes, change our minds, have a change of heart―all fleeting, often
insignificant adjustments. Culture change is anything but fleeting and insignificant. It is deep, systemic and enduring. Since the fairly generic term has been adopted for the very specific purpose of representing a transformation of long-term care culture, the implications are even more profound. Now, we are talking about the lives and experiences of society‘s most vulnerable citizens and those who have dedicated their professional lives to working with them.

There are numerous variations on the definition of culture change. Fundamentally, though, it is a quality improvement approach for shifting from an institutional model characterized by topdown power structures and a medical orientation to a person-centered one distinguishable by smaller self-contained living areas, the blurring of staff roles and a flattened organizational structure in which those who work closest to residents are empowered with decision making authority. The changes that take root to reflect these values are attitudinal, operational and environmental, and they occur at an individual and organizational level. Common elements of culture change include resident-direction in care and daily activities, a home atmosphere; close relationships between residents, family members and staff; staff empowerment; collaborative decision-making; and quality improvement processes.3

With the aim of defining culture change by classifying long-term care communities intently focused on it, a number of efforts have been made in recent years to create a more concrete framework for evaluating communities‘ progress in their change journeys. The Culture Change Staging Model identifies four stages: the institutional model, transformational model, neighborhood model and household model, with the most advanced stage being defined more specifically by:

  • Resident-directed decision-making
  • Universal workers who function in multiple roles
  • Self-contained living areas with 24 or fewer residents
  • Decentralized core services
  • Decentralized, autonomous and multidisciplinary teams
  • Leadership practices supportive of change and process management4

A subsequent study classified 16 practices commonly associated with culture change based on their level of complexity and correlated the adoption of the more complex practices with homes self-characterized as "complete" culture change adopters. These practices include:

  • Including direct care workers and residents as a regular part of the senior management
  • Involving residents in decision-making, including creating calendars for social events,
    activities and outings
  • Creating self-managed work teams, and
  • Involving residents in decisions about who provides their hands-on care5

Though the term culture change has tended to be associated with nursing homes, more recently the definition has broadened to include the full continuum of long-term care; in other words, "the place wherever one lives." Ultimately, at the core of any definition of culture change are the same attributes: choice, dignity, self-direction, relationships and an emphasis on possibilities versus limitations.

Transforming Philosophy into Tangible Change

This definition of culture change represents a colossal shift for a field whose institutionalorientation
has long prioritized efficiency, productivity and profits, resulting in a focus on quality of care over quality of life, decisions being made for residents rather than with them, and in a general reputation as places people go to die rather than places people go to live out a rich and full chapter of their lives.

This highly institutionalized model that has guided long-term care organizations for decades has
bred dependence, indignity and relinquishment of much that is inspiring, enjoyable and stimulating in life. How could we possibly expect people to want to make such places home? For that matter, how can we expect to attract and retain staff with the skills and character to be effective caregivers in settings where rules and rigidity can quickly burnout even the most devoted employees?

When it comes to culture change in long-term care settings, the prevailing wisdom from a philosophical standpoint is that, of course, it is the right thing to do. Where the breakdown occurs is in efforts to actualize these concepts in day-to-day operations, given the mighty pressures applied by state and federal regulations, narrow operating margins and a pervasive attitude within the field that is both change and risk averse.

A growing number of organizations are breaking the mold that for far too long has sustained an unacceptable status quo for long-term care. These pioneering organizations represent the full continuum of long-term care―skilled nursing, independent and assisted living, sub-acute and short-term rehabilitation. They are forprofit and not-for-profit, religiously-affiliated and not, with diverse payer mixes. In the day-to-day ways that each is building community, cultivating relationships, engaging all stakeholders in decision-making and personalizing support and services for those who live there, these communities are modeling what is possible. The emergence of data correlating these efforts with lower staff turnover, improved clinical outcomes, higher occupancy rates, and improved resident, family and staff satisfaction is steadily converting culture change from a moral imperative to a financial one.The business case
for culture change is explored more fully by clicking here

Nonetheless, the question lingers for many communities of how to translate philosophical alignment with the values of culture change into tangible and sustainable transformation.


The genesis of the Long-Term Care Improvement Guide was the release in 2008 of the Patient-Centered Care Improvement Guide (www.patientcenteredcare. org), anunprecedented compendium of practical strategies for transforming patient-centeredness from a nebulous concept into a concrete one. Developed by Planetree and Picker Institute, the Patient-Centered Care Improvement Guide has been downloaded more than 57,000 times. Strategies highlighted have been realized in acute care hospitals, ambulatory centers, physician practices, and even long-term care settings.

While many of the patient-centered practices and resources featured in the Patient-Centered Care Improvement Guide are certainly pertinent to longterm care providers, the focus of the Guide was definitively on acute care hospitals. This companion Long-Term Care Improvement Guide explores the experiences of residents, their families and their caregivers in greater depth. Here we explore approaches for meeting needs in a setting where expectations, preferences and priorities differ from those of hospital patients and staff. However, just as a number of long-term care communities turned to the Patient-Centered Care Improvement Guide as a resource for their culture change journeys, acute care providers are encouraged to look to the innovations that have burgeoned in long-term care to further advance hospital efforts to support patient autonomy, dignity, and privacy, preserve patients‘ personal routines and promote healing in a supportive and comfortable environment.

About the Long-Term Care Improvement Guide

The Long-Term Care Improvement Guide has been developed as a response to this ongoing challenge. A compendium of more than 250 specific changes a longterm care community can make to move toward a more resident-directed, relationship-centered approach, the Guide‘s focus is on the practical more so than the philosophical. These are not "pie in the sky" ideas; every process and practice spotlighted in these pages has been implemented in a real setting. They are presented here as tools for you to use in your organization‘s ongoing improvement efforts.

What the Guide is not is a step by step recipe for culture change. Such a "recipe" is inconceivable because there truly is no one size fits all approach. While some concepts are fundamental, how those concepts manifest within an organization requires the influence of the staff who work there, the residents who live there, the board members who govern, the volunteers who provide support and others.

Nor is the Guide a checklist of strategies for an organization to work its way through, one at a time, section by section. In fact, on its own, such an inventory of practices can, at best, result only in superficial and short-lived change. While some would argue even short lived improvements are beneficial, there is an important counterpoint to raise. A sporadic, bits and pieces approach to change may actually do more harm than good by raising and then dashing expectations and undermining stakeholders invested in creating a different kind of experience. Ultimately, a poorly thought out approach will fail not only in the short term, but may stymie future efforts by fueling attitudes of skepticism and disengagement.

The seeds for deep, systemic change are not isolated interventions, but rather a comprehensive approach for nurturing a collective vision, engaging stakeholders, breaking down barriers to challenge even the most steadfastly held conventions; and expanding the accepted definition of leadership and community. For this reason, the process for how opportunities are identified; how goals are set, implemented and sustained; how all members of the organization contribute to problem-solving; and how success is measured is the crux of the matter. In the absence of such processes, the strategies highlighted in these pages will be without the essential roots that transform discrete practices into an all-embracing culture. A framework for these processes is the focus of the Building Community section (click here)

Strategies that Transcend Specific Models and Span Settings

Through her research, Dr. Robyn I. Stone has concluded that "ogranizations interested in radically transforming their care, work and residential environments should begin with a living template that has successfully implemented and sustained one or more dimensions of culture change" 6 A number of models provide such a "living template" to guide long-term care communities in this process of improvement, among them Green House®, Eden Alternative®, Wellspring and Planetree. While each has distinct elements, what they have in common is far more profound than what sets them apart. With this Guide, we look beyond any specific model, letting the voices of residents, staff and thought leaders in the field guide us to approaches that address universal desires for living and working in long-term care settings. With a goal of creating a resource that is broadly applicable, the intent is that regardless of what model is
guiding your organization‘s efforts, this Guide will support you in putting in place the necessary groundwork and building on progress to date.

Nor is the Guide specific to the nursing home setting, often thought of as the focus of culture change efforts. The concepts of resident-centeredness span the full continuum of care, which is all the more relevant as an emphasis on aging in place intensifies. Elders‘ desires to age in place compel us to consider how best to support resident independence, dignity and choice in a way that optimally meets their evolving needs and preferences—regardless of the setting they‘re in or the degree of support and level of care they are receiving. Accordingly, the Long-Term Care Improvement Guide features innovations from nursing homes, assisted living and short-term rehabilitation settings. In the spirit of being guided by individual needs versus a specific setting, these innovations are co-mingled throughout these pages, and the majority of them are portable across environments. Users of the Guide are encouraged to think beyond the perceived
limitations to change efforts for specific populations or settings (e.g. the shorter length of stay for short-term rehab patients or the challenges of providing resident-directed care for individuals with cognitive functional loss), to instead focus on the possibilities and to learn from innovations from across the continuum.

Listening to the Voices of the Community
The Resident Perspective It has been established that the content of this Guide was driven not by a specific model for change, nor by a specific setting. Rather, the foundation for this work―and truly for any endeavor toward organizational transformation―is the voices of those who live and work in long-term care communities. The first step in developing the Long-Term Care Improvement Guide was an analysis of qualitative data collected through focus groups with long- and shortterm residents in settings across the long-term care continuum. A team from Brown University‘s Center for Gerontology and Health Care Research analyzed transcripts from 39 focus groups facilitated by Planetree in 19 Planetree-affiliated long-term care communities. Collectively, the focus groups captured the voices of 340 residents from skilled nursing homes, assisted living communities and short-term rehabilitation centers. Out of this analysis emerged core thematic areas about the resident perspective on living in these settings, as well as challenges or barriers that have hindered their preferences from being met. These themes have framed every aspect of the development of this Guide. In each section, residents‘ perspectives—in their own words— will underscore their priorities, a demonstrated connection back to why each of the strategies
included here is important.

The Community Perspective

This focus group work was also the basis for a series of site visits to numerous culturally transforming long-term care communities. On these site visits, we were able to thoroughly explore how the resident priorities that emerged from the focus group analysis have been addressed in meaningful and effective ways in the field. Leadership, staff and residents graciously welcomed us to their settings, and candidly shared with us both their triumphs and struggles in shifting attitudes and operations. Sites visited represented a variety of settings implementing different culture change models in regions across the country.

The Staff Perspective

The experiences of those who live and work in these settings are intricately interwoven, and
there is no greater influence on the life of a long-term care community than the relationships
between residents and staff. Findings from a subsequent analysis of staff focus groups have also
been incorporated into the Guide to showcase the all-important staff perspective.

The Leadership Perspective

Change efforts relocate the locus of decision-making power to residents and to those closest to residents (family members and staff who work most directly with them.) This is not to minimize, however, the role of leadership. Leaders both galvanize the organization around a shared philosophical vision and also must ensure on a practical level that operational priorities, expectations and policies are consistent with that vision. Given this, the leadership perspective was an essential component to the development of this Guide.

In February 2010, guided by the resident and staff focus group findings, Planetree and Picker Institute convened a Long-Term Care Leadership Roundtable to engage leaders in the culture change movement in a dialogue about their experiences, barriers to advancement and next steps. Participants included leaders from such esteemed models as Eden Alternative, Green House, Wellspring and Planetree, as well as long-term care administrators, nurses, gerontologists, researchers, funders and representatives from trade associations. This dialogue significantly influenced this Guide, particularly in underscoring the importance of connecting practices to process and outcomes. A list of participants is included as Appendix A. Another important outcome from the meeting was the recommendation to more deeply examine the perspectives of long-term care executives to explore how the definition of quality and incentives can be realigned to drive more widespread adoption of culture change principles. A series of interviews with 15 senior executives provided fascinating insight into these questions. The findings from those interviews are captured in Section I, Making the Case for Change (Click here)

The Importance of Language

It is fitting that this section includes definitions and a discussion of language. Language is an important, but often overlooked, component of change. Examples abound of ways that language can either reinforce change efforts or, more commonly, undermine them. 7It is virtually impossible for concepts of personalization and relationship-building to take root in an organization where a resident requiring assistance at mealtime is referred to as a "feeder." Authenticity is immediately lost when the act of walking is referred to as "ambulation," and spontaneity suffers when the only space for an impromptu get-together is the"multi-purpose room." Purposeful lives unfold in communities, not in "facilities," which is why throughout this Guide, unless explicitly clarified as referring to the external community, the term community
alludes to the collective population of a long-term care organization.

The widely-used language of long-term care continues to reflect an institutional orientation, and part of any change effort must be thoughtful consideration of the words and expressions we use to describe the work we do, and the people and spaces that make up our communities. For instance, the term "resident" emphasizes the special relationships between person and place and person and community that the term "patient" fails to evoke. But those in short-term rehab anticipating a return home may not identify as being a resident; for them "patient" may be more appropriate. Throughout this Guide, special effort has been made to use language that is consistent with the values of deep and sustainable change.

A discussion of terminology goes beyond the mixed messages sent when there is a disconnect between language and values. Change can also be stalled when the language used to describe thed vision fails to strike a chord. Throughout this Guide, we refer to "culture change." It is important to acknowledge, though, that this terminology may not resonate for all readers. Some organizations may eschew culture change as an industry buzz word that lacks broad appeal and understanding; others take offense that the terminology implies there is something wrong with their culture that needs to be fixed. Some recognize in the core aims of culture change what is commonly referred to as continuous quality improvement. Others, though, argue that it is a transformation process, one of growing and becoming something new and different, not just
improving what exists. Most important is that each community finds the language that works best for them and not let the lack of consensus on what to call "it"delay change efforts.

Similarly, approaches are commonly characterized as "person-centered," "resident-directed," "resident-centered" and "relationship-centered." Despite the differences in terms used, all have as common threads the core values of meaningful change identified at the start of this section. In the absence of a singular, all-encompassing and widely accepted term, for the purposes of this Guide the term resident-centered will be used most prevalently.

The First Step: Harnessing the Power of Community

We hope this Guide will be a useful resource in helping you to frame your organization-specific approach for transforming attitudes, operational priorities and the environment to best meet the needs of those in your long-term care community. Specific ways to put it to use include providing sections for staff to read and discuss. A candid dialogue about the similarities and differences between your organization and those profiled in these pages may yield some interesting ideas for improvement. Invite residents, family members and volunteers into these discussions as well. Post the priorities that emerge from the self-assessment for all to comment on and offer suggestions for how they may be addressed.

The most powerful resources available for those on a journey of organizational transformation are not guides, Web sites or lecture series; they are the individuals who make up the heart and soul of a community. Involving residents, families, administrators, direct care workers, staff, volunteers, medical staff, the governing board, and other partners in defining a vision and establishing goals exponentially expands the potential for profound and sustainable change.