Culture Change and Medical Directors: Let

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Culture Change and Medical Directors Lets
add medical directors to the culture change
movement!Cari Levy, MD, CMD
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Core Concepts

• 1.Medical directors are an important component of
  culture change implementation.
• 2.Medical directors must be aware of culture
  change values and principles to support the
  culture change mission.
• 3.Medical directors can be important agents of
  change in long-term care facilities as
  transformations of practice occur.

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Presentation Objectives

• Participants will understand the role of medical
  directors in the culture change transformation.
• Participants will understand the values and
  principles of culture change relative to medical
  direction.
• Participants will develop strategies to
  incorporate culture change principles into
  quality assurance meetings.

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Presentation Objectives (cont.)

• 4. Participants will learn how medical directors
  can advocate for culture change during state
  survey.
• 5. Participants will be able to provide examples
  of best practices by medical directors advocating
  for culture change transformation.

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A Self Assessment

• In the past month.
• When did you feel most understood?
• When did you feel most spiritual?
• Did you take a risk?
• Were you put before a task?
• When did you feel part of a community?
• When did you feel most healthy?
• What did you do that was spontaneous?

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A Preamble..

• Once upon a time following a rousing
  presentation at a national conference on culture
  change..

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A Few Disclaimers and Assumptions.
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Assumptions

• You know more about culture change than your
  medical director
• You have much to teach your medical director
• Your medical director wants to learn
• Your medical director will be resistant to change
• All things are possible!

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Diagnosing Your Medical Director

• When you say culture change your medical
  director is likely to respond
• I noticed the new fountain in the meditation room
  while doing yoga this morning great addition!
• Well never pass our survey messing around with
  that stuff.
• Culture what?

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Diagnosing Your Medical Director

• If your medical director responded
• I noticed the new fountain in the meditation room
  while doing yoga this morning great addition!
• Congratulations! You have a Culture Change
  Acceptor!

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Diagnosing Your Medical Director

• If your medical director responded
• B) Well never pass our survey messing around
  with that stuff.
• You have a Culture Change Basher - weve got some
  work to do.

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Diagnosing Your Medical Director

• If your medical director responded
• C) Culture what?
• Youve go a medical director who is Culture
  Change Clueless we also have some work to do.

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What type of medical director do you have?

• Type A Culture change Acceptor
• Type B Culture change Basher
• Type C Culture change Clueless

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How Can We Move Your Medical Director to the Next
Level?

• Type A Culture change Acceptor into Advocate
• Type B Culture change Basher into Believer
• Type C Culture change Clueless into Cognizant

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What Your Medical Director Needs to Know

• How often are you dominated by medical care? Not
  often we hope. This is not normal existence.
• Medical care should not dominate care.
• Care is for the whole person.
• Culture change principles include

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Culture Change Values and Principles

• Know each person
• Each person can and does make a difference
• Relationship is the fundamental building block of
  a transformed culture
• Respond to spirit, as well as mind and body
• Risk taking is a normal part of life
• Put person before task
• All are entitled to self-determination wherever
  they live
• Community is the antidote to institutionalization
  
• Do unto others as you would have them do unto you
  
• Promote the growth and development of all
• Shape and use the potential of the environment
  in all its aspects physical, organizational,
  psycho/social/spiritual
• Practice self-examination, searching for new
  creativity and opportunities for doing better
• Recognize that culture change and transformation
  are not destinations but a journey, always a work
  in progress

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Practical Tips for Moving Your Medical Director
to the Next Level

• Educate rather than Alienate
• Educate in small doses
• Call it something other than education
• Celebrate successes and their connection to
  innovation
• Integrate medical director education about
  culture change into the fabric of conversation

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An Exercise

• Do a culture change dipstick each month during
  quality assurance meetings.
• Where on the dipstick is your facility?
• ______________________X_____________
• Institution
  Home

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An Exercise (cont.)

• Where on the dipstick is your medical director?
• ________X___________________________
• Institution
  Home

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Know Each Person

• Take pictures and place them in the chart with a
  core description of the individual in addition
  to the usual medical description of the
  individual.

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Know Each Person

• Start with first person care plans and expose the
  medical director to this approach
• Functional Decline Care Plan
• I am a proud grandmother and take great
  pleasure in being a part of the life of my
  grandchild, David. Im eager to attend his Bar
  Mitzvah in December. Im going to participate in
  daily activities that will allow me to fully
  enjoy this event. These include 1) morning
  exercises 5x/week, 2) laughter club on Tuesday,
  3) move the wheelchair out of my room so I use
  the walker instead, 4) take my medications as
  prescribed.

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Respond to Spirit

• Communicate your efforts to nurture mind, body
  and spirit
• Describe ongoing programming
• Invite the activities director to psychotropic
  and quality assurance meetings
• Describe observed changes with innovative
  programming
• Report on new programs

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Risk Taking is a Part of Life

• Remind your medical director that residents have
  the right to make what they may consider poor
  choices
• Diets could include
• Regular
• Regular no added sweets
• Regular no added sodium

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Person Before Task

• This means you - Yes, you doctor!
• We need to expect more from physician visits
• Staff observations are essential
• Unilateral decisions by MD, PA or NP are NOT
  acceptable
• Rushed rounds are not ok
• Visits in the public areas NOT OK!
• Physicians need to sit down is there a place to
  sit? If not, consider this.

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The Everywhere Chair!
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Community is the Antidote to Institutionalization

• Add consistency of staff as an outcome measures
• The worst call, I dont know Mr. Smith. This is
  my first night with him Im an agency nurse.
• Where do you feel part of a community?
• Neighborhood
• Religious community
• Softball team
• Parent-Teacher Organization
• Your facility?
• What makes it feel like a community?

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Community is the Antidote to Institutionalization

• Relationships
• Shared experience
• Other..
• Take every opportunity to share the
  characteristics of the community and invite your
  medical director join, support, advocate for
  community enhancement

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Healthy Human Habitat

• When do you feel healthy?
• Do you leave work with a spring in your step? If
  not, why not?
• What would it take to have your medical director
  leave with a spring in his/her step?

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Spontaneity

• What was exciting, what was spontaneous?
• Feel compelled to share during quality assurance
  meetings
• Feel compelled to share in the hallway

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Dr. Type C says

• Evie brings in her dogs I think were really
  quite progressive.

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Your Response..

• Culture change embodies a culture of aging
  that is life-affirming, satisfying, humane and
  meaningful. Culture change helps us recognize our
  need to create ways of living and working
  together different from the traditional models
  where individuals live in open, diverse, caring
  communities.
• Its not about the cats and dogs!

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Dr. Type B says

• Ive heard the phrase culture change for years
  but not much seems to change. What does it really
  mean anyway?

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Your response..

• The movement toward a new culture of aging is
  a vital source of hope for millions of Americans
  trapped in the old system. The practice of
  person-directed care offers a relationship-based,
  values-driven alternative to the out of sight,
  out of mind institutional model that has plagued
  the system for decades. The movement is about
  promoting household living environments where
  individuals and direct care workers are able to
  express choice in meaningful ways.

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Your response continues..

• Individuals living in long-term care
  environments are growing, learning human beings
  with potential, and whose life continues to have
  promise for and connection to the future. They
  pursue happiness, joy and pleasure. They deserve
  respect and honor. Their work is to synthesize
  wisdom from long life experience and formulate
  this into a legacy for future generations."

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Talking Points

• In 2002, the Center for Medicaid and Medicare
  Services (CMS) hosted a 2½ hour session about the
  Pioneer Network broadcast via satellite and
  available now on CD
• In 2003 nine states established active culture
  change coalitions Colorado, Florida, Illinois,
  Michigan, New Jersey, North Carolina,
  Pennsylvania, South Carolina and Washington
  state.
• Reduces turnover from gt100 to 9-26

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Talking Points (cont.)

• Multi-facility organizations have committed their
  homes to culture change, Apple Health Care,
  Pinion Management, AGE Institute Holdings, Inc.
  and The Evangelical Lutheran Good Samaritan
  Society.
• Research looking at culture change outcomes, is
  being conducted
• Providers are reporting improved  retention of
  direct care workers and are reporting positive
  outcomes in resident quality of care and quality
  of life (decreased psychoactive meds, depression,
  specialized diets and mortality).

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If It Seems Risky.

• Call health department
• Call the ombudsman
• Read the regulations and adapt the regulations
  are designed to PROMOTE culture change
  innovations!
• Be there during state survey
• Ask for time to discuss at Colorado Medical
  Directors Association Meeting

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A Medical Director Assessment

• In the past month.
• Did your medical director make you feel
  understood?
• Was your medical director aware of spiritual
  support/resources provided in your facility?
• Was your medical director aware that risks were
  taken?
• Did you medical director observe staff putting
  person before task?
• Did your medical director feel part of your
  community?
• Did your medical director walk out of your
  facility with a spring in his/her step?
• Was your medical director aware of any
  spontaneous activities in the facility?

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Culture Change Values and Principles

• Know each person
• Each person can and does make a difference
• Relationship is the fundamental building block
  of a transformed culture
• Respond to spirit, as well as mind and body
• Risk taking is a normal part of life
• Put person before task
• All are entitled to self-determination wherever
  they live
• Community is the antidote to institutionalizatio
  n
• Do unto others as you would have them do unto
  you
• Promote the growth and development of all
• Shape and use the potential of the environment
  in all its aspects
• physical, organizational,
  psycho/social/spiritual
• 12. Practice self-examination, searching for new
  creativity and
• opportunities for doing better
• 13. Recognize that culture change and
  transformation are not d
• destinations but a journey, always a work
  in progress

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How Can We Move Your Medical Director to the Next
Level?

• Type A Culture change Acceptor into Advocate
• Type B Culture change Basher into Believer
• Type C Culture change Clueless into Cognizant

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Best Practices
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Your Medical Director Action Items

• Immediate
• 3-month
• 6-month
• 1 year

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Presentation Objectives Revisited

• Participants will understand the role of medical
  directors in the culture change transformation.
• Participants will understand the values and
  principles of culture change relative to medical
  direction.
• Participants will develop strategies to
  incorporate culture change principles into
  quality assurance meetings.

45
Presentation Objectives (cont.)

• 4. Participants will learn how medical directors
  can advocate for culture change during state
  survey.
• 5. Participants will be able to provide examples
  of best practices by medical directors advocating
  for culture change transformation.

46
Core Concepts Revisited

• 1.Medical directors are an important component of
  culture change implementation.
• 2.Medical directors must be aware of culture
  change values and principles to support the
  culture change mission.
• 3.Medical directors can be important agents of
  change in long-term care facilities as
  transformations of practice occur.

47
Questions??