Effective quality management begins with the investment of time and energy of CEOs, board members, and other senior management However, solutions to adaptive challenges can be found beyond the confines of the executive offices in the collective intelligence of employees at all levels. Individuals in an organization have special access to information from their own vantage point (Heifetz & Laurie, 1998). Excellence cannot be achieved without a strategy and commitment to finding better ways to address new priorities. Otherwise, there are too many distractions that can divert attention from the good intentions.
Values are an organization's guiding principles, helping define their beliefs. Shared values are the foundation to building productive working relationships - they provide a starting place for discussion when there are increasingly diverse perspectives and they facilitate progress toward consensus because they provide a common core of understanding (Kouzes & Posner, 1993).
The purpose of this article is to provide insights from two specific interventions. Both were developed to assist facilities to harness the talents of their employees, while adapting to change and building a culture dedicated to excellence and quality. The first was the videotaping of a search for excellence. The second was a unique theatrical performance of communication behaviors found in the nursing home setting.
SEARCH FOR ROLE MODELS OF EXCELLENCE
A search for excellence becomes more of a search for the attributes of excellence that can be isolated from studying good organizations (Grunig, 1992). In one recent attempt to find exemplary nursing facilities in New York State, those that go beyond deficiencyfree, state surveyors were asked to identify a facility that is known to be successfully striving for excellence. Their response was that they were not in the business of ranking facilities as "good, better, best." The director of long-term care for the Western New York area reluctantly provided the name of a facility in Buffalo, even if her surveyors were unwilling to do so.
The administrator of that facility granted permission to videotape interviews with key members of his organization. Two additional sets of videotaped interviews with key stakeholders were conducted in Troy, New York and in Clifton Park, New York, following contact with the director of long-term care in the eastern part of the state. Those who were interviewed shared their perceptions about what makes them a high quality organization and culture. In addition to the administrator, director of nursing, one or two certified nursing assistants (CNAs), a family member, and a resident in each facility, other stakeholders such as the medical director, the certified therapeutic recreation specialist, a social worker, and a charge nurse were interviewed.
The objective was to determine what motivates some nursing homes to strive for excellence and quality beyond deficiency-free status while others are satisfied with minimum compliance. In an effort to determine attributes of excellence, the following general interview questions were asked:
* Why do you think this nursing home is considered excellent by those who evaluate these facilities?
* How does it maintain such high quality?
* What or who is the motivator?
* How have state budget cuts affected the high standards?
* What is it about this nursing home that makes you especially proud?
* Do the people who work here have a clear, shared vision of the objectives of this nursing home?
* How do you know that this vision is shared?
These were starting points for discussion and those interviewed spoke quite freely citing examples, anecdotes, and stories that represented the shared values of the culture.
THE ATTRIBUTES OF EXCELLENCE AND A QUALITY CULTURE
Culture and quality of life are not the same. Quality of life is an end point, while culture is the means to achieve that end. Culture refers to context; quality of life refers to aspects of life meaningful to an individual (Fagan, Williams, & Burger, 1997). All three of the videotaped organizations may be considered examples of high performance workplaces with a quality culture. Unfortunately, culture cannot always be reduced to a single set of indicators because these indicators are meaningful only in the context of the environment and the individual. The additional problem a quality culture faces is not only to acquire new concepts and skills, but also to unlearn ideas that are no longer serving the organization well (Schein, 1996).
There was evidence that these three organizations generally adapt well to change by encouraging innovation and continuous improvement. Clear communication of their model of care is evident in the sense of family and community mentioned by many of those interviewed. Other common qualities follow:
* They find the time and resources to perform what they value as important, despite the paperwork.
* They encourage creativity and risk-taking.
* They believe in participation rather than control.
* They acknowledge that recruitment and selection of staff members who share the same values is critical because they do not just share a written philosophy, they try to live it in their daily decision-making.
* They do not appear to just "pay lip service" to culture change while still perpetuating the medical model.
In these organizations, there appeared to be little or no gap between what their leaders say and do. Their leaders take an active role in demonstrating that all jobs are equally important, even though different. For example, one of the administrators could be seen wiping urine off the floor - an important display of this philosophy and the values of this culture. All three administrators and directors of nursing are visible, accessible, and involved with residents on units.
Information sharing, involvement, and participation are priorities. For example, when state budget cuts were anticipated, the problem was discussed with teams to determine options and all agreed that reduction of standards would not occur. Instead they looked for innovative ways to overcome the impact of cutbacks. These facilities appear to be customerdriven, searching for better ways to meet the evolving needs of residents, taking pride in their accomplishments and physical environment. All three demonstrate bottom-line differences in lower turnover, absenteeism, and call-ins than the norm for the industry. This is a good example of "winwin*' strategies where both the resident and the service provider benefit from the culture change.
AN INTERVENTION TO SENSITIZE AND IMPROVE RELATIONSHIPS
Many staff members enter a nursing facility, pre-certified to perform their jobs with greater loyalty to their professional discipline than to the organization that employs them. Their approach to problem-solving and decision-making is usually based on the training in their discipline. The hierarchical structure of the traditional medical model of the nursing home perpetuates an adherence to this status and control. This culture, consisting of interdependent staff members, often finds them incompatible, resulting in frequent conflict and dissatisfaction followed by absenteeism and turnover. How can organization members be sensitized to the importance of communication and shared values?
With the assistance of a small grant, the producer/director of Theater for Change (a professional theater group located in Buffalo, New York) was contacted to develop scenarios that demonstrate typical behaviors in a nursing home setting. They have performed for many different organizations on such issues as diversity, sexual harassment, and domestic violence, but had never worked with specific nursing home issues.
A script for two scenarios was prepared in collaboration with the producer/director, who reviewed this author's audiotapes of a series of focus groups with stakeholders from eight facilities, as well as the videotaped interviews of key members of three faculties. Performances of the scenarios were planned for presentation at an all-day workshop. The objective was to determine the effectiveness of this intervention intended to sensitize staff members concerning their own effective and ineffective communication behaviors.
Letters of invitation were sent to all the nursing homes in Erie County (in western New York), asking each administrator to attend a full-day workshop accompanied by the director of nursing, a CNA, and three other staff members in key positions in the organization. Seven nursing homes participated - three for-profit homes and four not-for-profit homes. Each facility was asked to provide data on turnover, absenteeism, call-ins, and workers' compensation claims.
The workshop occurred at Buffalo State College on May 22, 1997. The morning session was devoted to presentation of two scenarios, each approximately 15 minutes long. The first performance was a patient care conference, which was a typical staff meeting to discuss the status of residents. The second scenario presented interaction between a resident, her daughter, and a CNA. After professional actors from the local theater company performed each scenario, the actors remained in their roles while the audience asked them questions about their behaviors. This is a powerful interactive process resulting in a discussion of values, attitudes, and communication. Overall, the morning session was very lively, with considerable interaction with the audience.
Although the role-playing technique has been used effectively in many nursing homes as part of in-service training, the difference here is that the actors develop credible characters with both positive and negative traits. They engender both empathy and anger, but the strength is in the audience identification with the characters. Typical role-playing contrasts more polarized appropriate and inappropriate behaviors and does not develop a whole credible person.
The patient care conference was selected for the scenario because it offers an opportunity to witness behaviors and relationships among a diverse group of staff members. Prior focus groups had demonstrated differences in perspectives and the need for training to share values and to solve problems collaboratively.
The second scenario was aimed at sensitizing staff members to the emotional pressures present in famiîy relationships. The resident's daughter faces many of the criticisms and bitterness of a beleaguered former caregiver. The CNA demonstrates the compassion, patience, and understanding of a minority staff member facing prejudice from a resident of a different race and socioeconomic group. It was expected that the halfday session would simply sensitize the audience members to their own behaviors and foster an understanding of the behavior of others. Ideally, the performance would be supported by subsequent sessions at each facility, addressing the specific issues identified by their staff members.
The afternoon session included the viewing of two of the videotapes of excellent facilities. This program was intended to provide insights for best practices that any facility could implement. It was an opportunity for the participants to link the individual behaviors demonstrated in the scenarios with the group and the organizational behaviors required in a high performance facility. Adaptive change is distressing for those experiencing it. They need to adopt new roles, new relationships, new values, new behaviors, and new approaches to work. Many are ambivalent about the efforts and sacrifices they must make.
For example, to adapt to change, there must be collaboration and flexibility. To encourage creativity and risk-taking, there is a need for mutual respect. Although change usually begins with leadership, communication and interpersonal behaviors make it work. Participation must replace control. A portion of the afternoon session was set aside to allow the team from each facility to meet, share learning experiences, and begin to develop an action plan to address their own spécifie issues. Participants were given a notebook in which to identify their own productive and counterproductive communication work behaviors during the next 2 weeks.
The program was successful. This was especially evident in the response to the performances by the actors. All but two evaluations rated that program as "excellent." The remaining two said it was "very good." Comments included the following:
* "It was very helpful seeing how others view a situation as well as how the resident feels."
* "The role-playing was excellent. It assisted me in seeing some of my own professional faults. I will think more about my overall performance.
FOLLOW-UP SURVEY: 1 YEAR LATER
* "It put a great perspective on the resident who is the reason for our employment."
* "Food for thought. Very realistic and informative discussion."
* "The scenarios really hit home and were a very real portrayal of nursing home life."
* "It was excellent - an accurate portrayal of a nursing home happening."
The videotapes of facilities striving for excellence were rated "very good" or "good" by 84% of the audience. This was the first showing for each of these interventions. Some participants noted that they were already doing some of the activities shown in the videotapes. Some found that change may not be as difficult as they presumed, while others were not as optimistic.
There was some resentment about designating one or two facilities to represent excellence. Participants also questioned the wisdom of having die state director of long-term care or surveyors make the selection of excellent facilities because nursing home staff members view surveyors as adversaries rather than partners in a quest for excellence.
Follow-up visits to each facility, by this author, were scheduled 4 to 6 weeks after the workshop. Predictably, very few used the notebook (in which they were to monitor their own communication behaviors) for more than a few days. However, some facilities implemented an action plan following the program. One facility set up a team meeting every other week to address the relevant issues their six participants identified at the workshop. Membership on this team began to rotate as they continued to address new communication problems. Three of the facilities subsequently applied for grants to integrate the theatrical performance with ongoing in-service role-playing sessions in their organization. This process was intended to reinforce the sharing of the core values they identified to support their mission and vision statements.
A follow-up survey was sent 1 year later to each of the participants. In addition, each administrator was asked for updated data on turnover, absenteeism, call-ins, and worker compensation claims. There were no significant differences within facilities 1 year later on any of these variables. Without follow-up reinforcement, none were expected. Some of the participants had changed jobs since the previous year. Of the 39 participants to whom the surveys were mailed, only 14 responded, representing too small a sample to make any generalizations about the program and its impact. However, participants were asked to evaluate the program and its influence on themselves and their facility (on a scale of 1 to 5), and these survey results reinforced the value of the theatrical performances and the videotapes (Table on page 40).
Open-ended responses included the following:
* "Because we become so busy, sometimes the way we treat and speak to others has a negative effect. We all need reminders that we are dealing with real people, with real feelings."
* "I feel the Theater for Change and the videotapes were a very effective means to enlightenment and change. It gave us a chance to see ourselves from a different perspective."
* "When people actually sit and watch actors play out a scene, they see in the situation the effect it is having on each of us. They learn the effect communication (verbal and body language) has on the situation and how it relates to themselves. Each person may see himself in the scene and mistakes that are made. They then will try their best to correct them."
* "My staff and I met to review what we had experienced. There was a sense that using Theater for Change was a legitimate approach in orientating employees. We applied for a grant to explore the effectiveness of this approach."
* "We formed a team of all levels of staff to attempt to increase morale. That team has basically dissolved. It was very difficult to get various staff involved in the team. The same people participated who always participate. I feel our administrator needs to be more visible both to staff and residents. Unfortunately, many of the residents don't even know that we have an administrator."
* "I feel that not enough staff members attended to have a large impact on what we do and how we see ourselves. We did feel stimulated after attending and those who did attend came up with some creative ideas for quality improvement, but unfortunately they were never followed through."
* "Each facility strives for perfection. I think seeing employees on the video who were terminated from our facility made me realize nobody's perfect."
Theater for Change was an effective and entertaining intervention. Without reinforcement, its impact may be short-lived, even though five of the seven facilities reported meeting formally to implement changes in procedures as a follow-up to the program. A facility may have the best intentions for creative change, but other more demanding priorities prevail. Little change is expected unless there is effective leadership to reset priorities.
One such example occurred at one of the participating nursing homes. The home was part of a chain of proprietary nursing homes that became self-insured in 1994. Ownership and administration made safety a high priority. They hired a full-time employee for claims management. She developed a whole new set of procedures to address the problem and has had dramatic results. The home reduced workers* compensation claims from 2,000 in 1993 to 245 in 1996. Commitment to building communication skills and cultivating shared values may have the potential for equally dramatic results in curbing absenteeism and turnover.
DISCUSSION OF CURRENT CULTURAL CHANGE MODELS
A comparative analysis of longterm care programs in the United States found that in all but two states, expenditures for nursing home care far exceeds those for home- and community-based care programs (from 2 to 21 times as much) even though many of the home- and community-based programs are cost-effective (Kane, Kane, & Ladd, 1998). Nationally, only 16% of state long-term expenditures are for home- and community-based care and the remaining 84% is consumed by nursing homes, representing little change from 1990 when it was 85.3% (Polivka, 1999).
The environment of long-term care facilities has been characterized as dehumanizing, creating increased dependence and powerlessness because of the dominance of the medical model in the design, organization, and ambiance (Gamroth, Semradek, & Tomquist, 1995). Any significant change in the direction of individualized care for residents will require training, better understanding of residents, and collaboration with the larger system. If the medical model is to be replaced by a social model, what form should it take? WuI it resemble home, or an upscale resort, or another version of a senior center? Which model will successfully reflect an organization's values?
If self-directed teams are a goal, there must be a clear vision and commitment to a single new model. An organization needs to effectively use all the verbal and nonverbal communication resources, including voice mail, e-mail, fax, a newsletter, and personal contact to share timely information with all the stakeholders. This becomes their organization. It will not happen quickly. Trust and commitment are earned incrementally, over rime, while capturing the results of culture change.
A number of nursing home organizations throughout the country are progressing slowly through culture change. They recognized that the medical model is appropriate for a short-term residence, but not for permanent housing. Lacking the stimulation and variety of a community, boredom, loneliness, and helplessness prevailed.
Currently, front-line staff have been empowered and management is slowly relinquishing control. Some facilities have introduced birds, animals, and children nearby as a source of stimulation to reduce the impact of the institutional setting. In several facilities, instead of the coordination and control of a director of nursing, a nurse manager is the head of the team on all three shifts in the unit. The nurse manager and staff select their own staff for their unit. The culture is family-centered with individualized care and a permanent assigned caregiver for each resident. These changes are not an easy transition for many staff members. Organizations seem to need multiple strategies to empower staff.
Another facility went through major reconstruction and used this opportunity to introduce a major commitment to culture change. Departments were flattened and decision-making was decentralized. Every unit has a team to serve its 20 residents. All rooms became private rooms in an environment intended to be similar to home where residents will continue to do all they did in the community. This aging-in-place model eliminated a need for shift supervisors. A care coordinator supervises the teams on all shifts in the unit. In the past, many aides had "pet" residents. Currendy, an entire team can take credit and satisfaction in the achievements of a resident.
The director of nursing no longer exerts as much control and the care coordinator need not be a nurse. They are finding that it is often difficult for nurses to step back and let others solve problems. Trust must be a part of the process because no one person is overseeing the work of the team. This requires training and careful recruitment of new personnel. Shared vision includes shared accountability.
Communication is still chaotic, but calm is expected to set in after 1 year of adjustment. Transformation means a new way of thinking. Appropriate staff are cross-trained to perform the job of others. The consensus is that nurses are not the most important staff, but neither are the aides. Self-directed teams schedule, set vacations, set priorities, control work hours, and take on other responsibilities that were previously hierarchically structured.
There is no one formula for culture change. A joint steering committee of staff members can develop plans that will build trust, address each other as equals, and drive out fear as they move the process of change. Training and sharing information help staff recognize this is a process, not an event. New wellscreened team members need training to integrate them into the culture. It is important to identify the knowledge and expertise of team members to maximize their energies and talents. Recruitment and retention of those who share the values of this culture are of paramount importance. It is worth the time and effort to secure commitment to these values.
One example of this effort is a facility in Pennsylvania that, at its worst, had two thirds of its staff turnover in a year. The national average was 82% in 1995, an increase from 71.5% the year before. They were able to reduce their turnover rate to 27% by examining the hiring records and finding that workers with certain personality traits and attitudes were less likely to leave. They looked for compassion and communication skills, perceptions of older adults, ability to cope with death and dying, and ability to handle the unpleasant tasks of resident hygiene and bathroom visits. Current staff members determined and voted on best fit of candidates (Montague, 1997).
Although training and evaluation are an important component of retention and commitment to values in any organization, training and evaluation of nursing home employees may be quite different from other employment. A nurse in a nursing home needs to be evaluated not only on clinical skills, but on communication skills, attitude, and leadership (Meyer, 1995). Then training and employee development programs can be targeted to specific areas for corrective action.
What is taught in training and what occurs on the job should correspond, or role conflict occurs increasing the likelihood of turnover (Steifen, Nystrom, & O'Connor, 1996). Although occasional exit of poor performers and fresh ideas of new recruits can be beneficial, inability to retain experienced personnel can result in replacement costs as high as $7,000 per employee (Proenca & Shewchuk, 1997). Furthermore, fostering employee commitment also has a mediating effect on family members' satisfaction with service quality (Steifen, Nystrom, & O'Connor, 19%).
Each organization must be sensitized to its own problems. Attitudes cannot be changed by rules. Staff members need to be involved with listing all the strengths and weaknesses and how to change the negatives to positives in their own facilities. This requires a continuous learning process.
The learning organization usually needs to restructure to improve its operation to reduce the hierarchy. If au employees understand the reasons for change and have participated in the change process, they are more likely to have learned organizational values such as trust, commitment, honesty, and integrity by inculcating these values and teaching them to others.
Every employee is a partner in building a good reputation for the organization. One person can make a difference in creating, protecting, and building an organization's good name (Young, 1996). Staff members need to have a collaborative relationship with those who survey them, those who use their services, and those who compete with them. That does not mean "cronyism" (a dishonest, close relationship), but an honest, sharing relationship that fosters problemsolving and sharing of best practices.
Leaders of the future must be more flexible with a broader variety of experiences. Their ceremonial responsibilities as the head of the organization become a critical and necessary function (Steere, 1996). Ceremonies, rites, and rituals bind the members to the organization. The values and culture work well because leaders exhibit these values in their interactive communication behaviors. The trend toward increasingly empowered organizations addresses the need to move decisionmaking to lower levels, leaving the leadership role to one of clearly articulating and demonstrating a sense of purpose and direction dedicated to excellence and quality.
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FOLLOW-UP SURVEY: 1 YEAR LATER