This past Friday I attended the 2014 Katz Policy Lecture at the Benjamin Rose Institute. Peter Kemper, PhD, Professor Emeritus of Health Policy, Administration and Demography from Pennsylvania State University gave the lecture on Expanding Culture Change to All Nursing Homes: Challenges and Policy Approaches.
Professor Kemper acknowledged early on what is often the opening salvo of critics of culture change – that defining exactly what it is can be a formidable challenge. In fact, as he noted, it may be preferable to think of culture change as a movement instead of a model. This perception would be consistent with the concept of continuous quality improvement where it is recognized that while operational perfection is inherently unachievable, evidence shows its pursuit drives measurably better outcomes.
Cutting through the theory and research, at its core culture change is the ability to create an organizational environment in which individuals are empowered, trusted and valued: and this must be true for both patients and the workforce caring for them. What does this look like? Well, in listening to the lecture I found that we need look no further than the five elements of Quality Assessment Performance Improvement (QAPI).
Element 1: Design and Scope: Culture change can only take place if there is a shared commitment to be cognizant and aware of how each individual’s role and responsibilities support achievement of the organization’s future state vision. To accomplish this there must be an understanding and pragmatic recognition that the approach needs to be comprehensive, inclusive and constantly evolving.
Element 2: Governance and Leadership: It is the organizational leadership’s primary responsibility to create the environment by owning (without controlling) the design and scope process, while the role of governance is to ensure sustainability and accountability of that environment once created.
Element 3: Feedback, Data Systems & Monitoring: The old adage of you can’t manage what you can’t measure, however incomplete in its ability to capture the full essence of organizational behavior, nonetheless is the primary means of incenting desired behavior while discouraging unwanted behavior (i.e., accountability). This must be a fundamental element of culture change, particularly from the standpoint of sustainability.
Element 4: Performance Improvement Projects: The key concepts attributable to culture change here are prioritization and ability to impact. The important nuance that many PA/LTC organizations have difficulty understanding is that PIPs don’t have to be directed retrospectively. They can (and should) be borne out of a comprehensive design and scope process (i.e., Element 1). This is a key element of intersection between culture change and QAPI programming that must be embraced and understood.
Element 5: Systematic Analysis and Systemic Action: Socrates noted that, “the unexamined life is not worth living.” I contend that an organization committed to culture change will continuously assess and examine whether and how well it is able to achieve its vision while fulfilling its mission and always reflecting its core values. This brings us full circle to the concept of continuous quality improvement noted at the beginning of this post.
As Professor Kemper also noted during his lecture, there is nothing necessarily innovative or revolutionary about culture change in PA/LTC. My observation is that it is really a matter of borrowing – or adopting – proven best practices of organizational behavior from other industries and research that dates back to the early 1900s. But going from theory and research to realized benefit takes the type of leadership that isn’t as easy to import. That’s where a lot more work needs to be done before either culture change or QAPI can achieve meaningful and lasting improvement in patient outcomes and life enrichment of the individuals served.
Picture Credit: Provider Magazine