Kathy McCollett

Kathy is an Organizational Culture Change Specialist with PHI’s Training and Organizational Development team.

The Pioneer Network’s 10th National Conference “Meeting at the Crossroads” was convened in Indianapolis August 9-11, 2010. The Pioneer Network “advocates and facilitates deep system change and transformation in our culture of aging.” In record attendance, people from all over the country and around the world participated in the nearly one hundred sessions offered for those interested in advancing the culture change movement.

Bonnie Kantor, executive director of the Pioneer Network, presented valuable new tools and information that have been developed this year by the Pioneer Network–all of which are now available at pioneernetwork.net.

Carter Catlett Williams opened the conference. She acknowledged that we are at the crossroads of a nation, of an industry, and as individuals. The beauty of meeting at these crossroads, she said, is that it allows us to share information with each other about where we have been, what we have learned, our visions and our dreams, and where we are going.

Assistant Secretary for Aging Kathy Greenlee said that she “has a heart for people.” She believes that there is a great need for more home- and community-based services and sees culture change as a national priority. Acknowledging that the attendees at the conference are “revolutionizing aging,” she said, “I want to be a partner with you in every single way,” and, “I want this to be about ‘long term independence’ rather than ‘long-term care.’”

In recognition of her contribution to “deep system change,” Karen Schoeneman, the deputy director of the Division of Nursing Homes for CMS, was presented the 2010 Picker Institute Award for Excellence in the Advancement of Patient-Centered Care in the Long-Term Care Setting. She has worked tirelessly for many years toward deepening culture change values in the long-term care survey process.

Many of the presenters reflected the thought that changing the culture of aging is about developing and maintaining relationships. Dorothy Seman of the Alzheimer’s Family Care Center in Chicago said, “What we do isn’t rocket science, it’s much harder than that! We are about people and relationships. With each encounter, you either deepen or diminish the relationship.”

Relationship-centered care was also a theme in PHI’s presentations at the conference when addressing topics such as ‘The Role of the Nurse in a Person-Directed Culture,’ ‘Elder Perspectives & Residents Preferences,’ and ‘Transformative Training: Creating the Change You Wish to See in the World.’ PHI also took a special interest in building on the relationships that have been established in the State Culture Change Coalitions and moving this school of thought forward in as many states as possible. Two case studies demonstrating how PHI’s Coaching Approach℠ can transform organizations were presented by Tricia Cummings of The Edgewood Centre and Mavis Flowers from Beth Abraham Family of Health Services.

Whether in a learning session facilitated by an expert, in a restaurant or hallway conversation, attending a ‘sage conversation’ or a ‘think tank,’ and whether attendees were new to the field or veterans, all 1,150 people in attendance seemed to be intent on learning and sharing what was meaningful to them about changing the culture of aging. Meeting at the “Crossroads” afforded us all the opportunity to move forward with newly affirmed goals, traveling on a common road, yet taking our own path.

Four years ago, PHI’s National Director of Training and Organizational Development Susan Misiorski authored Getting Started, a handbook on implementing culture change, published by the Pioneer Network. The handbook has been a great success, but many Pioneers have asked for more direction regarding which changes to tackle when.

In response, Misiorski has teamed up with independent consultant and culture change expert Joanne Rader to author a new chapter titled, “Selecting and Prioritizing Changes.”

Both Misiorski and Rader have been supporting elder care and disability services providers to implement person-directed culture change for over 20 years. Below is an interview with them about the new chapter, which is available free at both the PHI and Pioneer Network websites.

What prompted you to write an additional chapter for the original Getting Started Handbook?

Rader: Providers were asking for this. We have seen excellent leaders struggle with issues that were a result of selecting the wrong project–for example projects that are too small, too big for the organization’s level of readiness, or have no clear impact on elder quality of life.

How does this chapter support better project selection?

Misiorski: The chapter introduces two tools, a gap analysis and a critical-thinking frame. These tools help to guide a change team through a thoughtful, data driven decision-making process that is inclusive of elder, family and staff voices. The chapter applies these two tools to multiple examples so readers can gain a deeper understanding of how they work.

How does a reader access the new chapter?

Rader: Readers can download the new chapter at www.PHInational.org/training (pdf); it will also be available soon at www.PioneerNetwork.net. We decided to offer this new chapter for free download to maximize dissemination and to ensure individuals who already purchased the full handbook could access the chapter at no additional cost.

What additional information is in the Getting Started Handbook and how do I get it?

Misiorski: The original handbook is available for $99.00 at the Pioneer Network’s bookstore. The handbook includes:

• A reproducible chapter explaining what culture change is. Share this with staff, elders and families.
• A process for developing and/or revising mission, vision, and values with high involvement of elders, families and staff.
• An organizational assessment ensuring measurements are built into the change process.
• Multiple staff inservice modules. There are 4 inservices included for each of the 13 Pioneer Network Values (pdf).

Individuals from 83 organizations have participated in the workshops

Pennsylvania has been the stage of an exciting training initiative to improve the quality of home- and community-based care. PHI is proud to have been able to participate in a pilot program that prepared in-house staff from local home care agencies, adult day service centers, personal care/assisted living residences, and disabilility service agencies to train direct-care workers in providing relationship-centered care in the state.

P. Afeefa Murray, Patricia Hillebrand, Maureen Sheahan and Maria Elena Del Valle—from PHI’s training and organizational development team—conducted “train-the-trainer” educator workshops, which explored adult learner-centered approaches to leading frontline staff through a competency-based entry-level curriculum for personal care workers developed by PHI for Pennsylvania’s Department of Labor & Industry.

Since April 2008, this PHI team trained 142 individuals from 83 organizations, as part of 11 educator workshops. Training the trainers builds capacity within participating organizations to implement and sustain the training themselves.

Relationship-Centered Caring in the Context of Adult Learner Centered Approaches

In teaching a relationship-centered approach to care, we recognize that by improving communication and problem-solving skills of caregivers, we can build healthier relationships among staff, and between staff and the individuals they assist. These skills build within the participants the competencies necessary to shift away from a task orientation (giving care to people) to a relationship centered orientation (engaging with people to offer care and support).

Using learning circles, small group exercises, role plays, and other interactive activities, the PHI trainers demonstrated methods to connect to a wide variety of learning styles. The trainers that attended the workshops stated they really appreciated the variety of adult learner centered methods they were exposed to.

As an owner from one home care agency recently told us, “Everyone I have talked to within my agency and others have walked away with many new skills and much needed education. This training has been a blessing to many and will be a blessing to many clients. It was extremely informative and [the impact] will last a long time.”

[Download the free, entry-level curriculum]

Falls are the leading cause of death by injury for older Americans. They threaten the lives, safety, and independence of older adults and have an enormous impact on the cost of health care. In 2005, the total direct cost of all fall injuries for people 65 and older exceeded $34 billion.

That’s why PHI and the National Council on Aging (NCOA) have launched a new partnership to provide — at no cost — a Fall Prevention Awareness curriculum for home health care workers.

Since its launch in mid-May, the curriculum has already been downloaded over a thousand times.

Uniquely Designed

Uniquely designed for adult learners, the Fall Prevention Awareness training curriculum is designed to help home health aides across the country reduce falls and minimize injury to their clients by increasing their awareness of the risk factors for common falls and enhancing their communication skills.

And while the curriculum is primarily geared towards training home health aides, some learning activities will work across settings, and other material can be adjusted for use in nursing homes.

Participants build on existing knowledge and skills by strengthening their “observe, record, report” skills and by developing communication skills that help them address with their clients how to reduce the risk of falling.

The downloadable course includes two three-hour sessions that employers can use to meet in-service requirements.

A Fruitful Collaboration

The curriculum was designed and written by PHI’s Curriculum and Workforce Development team. Peggy Powell, National Director of Workforce Development at PHI, said that collaboration with NCOA was “extremely valuable.” NCOA’s expertise, she explained, “was key in designing this important resource for aging consumers, workers and their families alike.”

The Fall Prevention Awareness curriculum was then piloted at Cooperative Home Care Associates (CHCA), where Home Health Aides provided feedback on the curriculum as it was developed.

“PHI is honored to partner with the NCOA to make this curriculum more widely available to the 3.2 million paid caregivers who serve and support older Americans,” said PHI President Steven Dawson.

“The incidence of falls can be reduced through lifestyle adjustments and intervention programs,” said NCOA President Jim Firman. “Working with PHI, we can greatly expand training options for the dedicated home health aides who provide so much of the day-to-day care to older Americans.”

Please let us know if you have any feedback on this product. Post your comments to the blog or send an email to jtabbutt@phinational.org.

Renya Larson

Renya is a specialist with PHI’s Training and Organizational Development team.

Strong communication and problem-solving skills are the bedrock of healthy relationships among staff and between staff and the individuals they assist.

What does it take for staff to adopt these skills? The first step is certainly training- but not just any training. Successful workplace training uses an adult learner-centered approach, emphasizing interactive training methods such as small group discussions, case scenarios, and role plays. These teaching methods create opportunities for staff to share their ideas and experiences with each other, and also to practice the new communication skills they are learning in a supportive environment. They also create a training environment that is conducive to learning (meaning fun, interesting, appropriately challenging, collaborative, supportive).

Sustained Behavioral Change

Yet even the best training is unlikely to lead most staff to sustained behavioral change. Ample research over many decades (beginning with the pioneering work of James Mosel in 1957) demonstrates that skill mastery also requires a workplace environment that encourages the use of new skills. Without this, the available literature indicates that the transfer of learning to job performance is generally significantly lower than desired (Tannenbaum and Yukl, 1992).

We believe that this is because behavioral change is a complex process, and one which continues long after the training ends and participants have returned to their day-to-day work. In order for staff to master new skills they have learned in training, our experience indicates that they will need:

• Modeling. Seeing the skills they have learned modeled by others provides evidence that “this stuff really works,” and can awaken the desire to change. Research also indicates that modeling by managers is perhaps the most important factor in determining the degree to which staff will adopt new behaviors that they learned in training. This is a primary reason why PHI’s suite of trainings and consultation services are geared to reach all levels within an organization—from frontline staff to senior managers and leaders.
• Practice. The training itself can provide some initial practice in a safe, low-risk environment. When staff begin to practice new skills in “real time” on the job, most will initially do so sporadically, and default to old behaviors when under pressure or in times of stress. At this stage, staff need an environment that encourages experimentation and tolerates imperfection.
• Feedback and support. The more that staff can talk about their successes and challenges in adopting new behaviors, the more confidence and competence they will gain. With ongoing feedback and support, ultimately the new behaviors can become the unconscious “default mode”—the stage of mastery.

PHI encourages the organizations that implement its training programs to invest significant time and effort in ensuring that the workplace environment is conducive to the desired behavioral change.

Partners in Care, one organization that has implemented the PHI Coaching Supervision℠ training, has subsequently developed robust support systems for trained supervisors. These supports are called “Boosters” (pdf) at Partners in Care. As a result, Partners in Care has ensured that coaching skills have indeed been practiced and increasingly mastered by supervisors throughout the organization.

Today, two and a half years after Partners in Care began participating in PHI trainings, President and CEO Marki Flannery sees the positive effects taking hold. She believes that the relationship-centered approach—and the specific communication and coaching skills that her staff has learned—have begun to shift the organization’s culture.

Staff, she notes, feel much more empowered. “If you walked in here now, you would see that they are respectful to each other. Lots of work is getting done without rush, noise, and anxiety,” Flannery says. “There’s a real difference in tone. Antagonistic interactions have become rare.”

Nursing and culture change leaders at PHI training

National leaders in gerontological nursing education and culture change participated in a two-day PHI Coaching Supervision^SM seminar in New York City in early June.

The long-term care nurse leaders convened to experience the PHI Coaching Approach^SM to Supervision firsthand and discuss its implications for successfully fulfilling the nurse’s role.

PHI has been documenting and field-testing its Coaching Approach to Supervision with long-term care providers for the past four years, with funding from The John A. Hartford Foundation and The Atlantic Philanthropies.

“It is a tribute to PHI and the work you have done that you were able to bring together such a distinguished group,” said Amy Berman, a program officer at The John A. Hartford Foundation who attended the program.

Spreading the PHI Supervision Approach

Sara Joffe, PHI organizational and executive coach and director of the Center for Coaching Supervision and Leadership, and Susan Misiorski, national director of PHI Training & Organizational Development Services, taught the seminar with PHI Certified Coaching Trainers Anna Ortigara of the Green House Project and the Pioneer Network and Joanne Rader of Rader Consulting and the Pioneer Network.

Rader has supported PHI by bringing the PHI Coaching Approach to Supervision (pdf) to colleges of nursing. Ortigara has partnered with PHI to bring the PHI Coaching Approach as applied to three key areas — supervision, leadership, and clinical partnership — to the Green House Project.

Every Organizational Level Would Benefit

“This coaching supervision class was remarkable,” Ortigara said. “These are the leaders who can bring coaching skills to undergraduate nursing students as well as long-term care provider sites. It can change the way nurses are engaged in empowering relationships with care teams.”

The seminar participants’ primary interest was in the application of coaching skills for nurses in the field.

“The nurse’s role as supervisor of nursing assistants is critical to the delivery of high quality care, yet nurses receive little formal training in this non-clinical aspect of their role,” said Assistant Professor Elena Siegel of the Betty Irene Moore School of Nursing at the University of California, Davis. “It’s wonderful to see how PHI’s Coaching Supervision program is supporting nurses’ development in this area.”

There was also a high level of interest and excitement in the relevance of this approach for culture change efforts in nursing homes.

“PHI has an exceptional approach to helping organizations on their culture change journey,” said Pioneer Network Executive Director Bonnie Kantor. She continued:

“One of the core values of culture change is that ‘relationship’ is the fundamental building block of a transformed culture. I think that the skills, attitude, and knowledge gained through the training could assist care providers at all levels of the organizations in creating the kind of caring, effective, and efficient culture that we all desire.”

The group of seasoned professionals also found the discussions, small group exercises, and skill practice sessions to be highly relevant to their own personal and professional lives.

The PHI Coaching Approach draws upon the skills of active listening, self-awareness, self- management, and clear communication without blame and judgment. When practicing these skills in the classroom setting and back on the job, participants learn a dramatically different way to support individuals and teams than that offered by traditional supervisory approaches.

– by Susan Misiorski, National Director of PHI Training & Organizational Development Services

Many eldercare facilities administer psychotropic drugs – drugs used to treat mental disorders and diseases such as schizophrenia – to residents with dementia in an attempt to control the behavioral symptoms of the disease. Unfortunately, these drugs are more heavily relied on than they should be in spite of documented evidence of adverse outcomes in combination with dementia.

In Dementia Beyond Drugs: Changing the Culture of Care, Dr. G. Allen Power, a board-certified internist, geriatrician, nursing home practitioner, and Eden Alternative Educator, challenges all care providers to undertake a true operational change that would make these medication practices nearly obsolete.

Download an interview with Dr. Power (pdf) to find out why dementia medication and culture change are inter-related and what we can do qualitatively transform the way that care is delivered.

Susan Misioriski

Susan is the National Director of PHI’s Training and Organizational Development team.

Choice. Self Determination. Control. These are words that hold great importance to all of us, and these words are no less significant for individuals living in residential care settings. Elders interviewed regarding what matters most to their quality of life clearly expressed the importance of these principles, naming them as one of four primary themes contributing to a meaningful living experience in the nursing home:

• Competent staff who meet their individual care needs
• Freedom to make personal choices
• Relationships in which each person is able to both give and receive
• Opportunities for meaningful activity

In this second of a four-part series on what matters most to elders living in nursing homes, we’ll focus on freedom to make personal choices. [Read PART 1]

The elders living at the Pleasant View Center in Concord, New Hampshire, offer an excellent example of voicing their individual and collective choices. I was invited to meet with members of Pleasant View’s culture change committee, which includes numerous residents who are very proud to call Pleasant View home. These individuals work together to suggest changes that affect their quality of life.

Committee member Shirley Frederick described just a few of the changes they have seen through to implementation:

• Hooks in the bathrooms to hang clothing/robes
• The purchase of softer towels
• Replacement of one-ply toilet paper with two-ply
• Family style dining where elders serve themselves from bowls and platters placed on their tables
• Memorial services honoring elders who have passed away

I was struck by the simplicity of most of these requests. I was also deeply impressed by the broad range and depth of decision-making elders are genuinely invited to exercise at Pleasant View. It is not often we see elders living in nursing homes have the opportunity to choose products as basic as toilet paper! These decisions are usually made by purchasing managers whose offices may be located far from the elders who are using the products.

According to Fredericks, administrator Mark Latham brought in multiple brands of toilet paper for the elders to “try and test.” Following this trial, they selected a brand of two-ply paper that they described as significantly better than the previous product throughout the home.

Other examples of choice, self-determination, and control that elders describe as important include such things as waking at the time of their choice rather than a time determined by “the assignment they are on,” when and how to bathe, who they would like as their caregiver(s), how they will spend their time, and when they would like to eat their meals.

The ability of staff to be able to honor these personal choices is largely dependent upon how well they know the person(s) they are supporting. Stable, consistent staff who have long-term relationships with the elders are in the best position to understand both the choices individuals make and the impact on the person’s quality of life.

Details

REGISTER NOW

Who: An invitation only event

When: Thursday, October 28, 2010. Breakfast will be offered from 9:00am to 10:00am. The conference program will be held from 10:00am to 4:00pm.

Where: Hamilton Park Hotel and Conference Center located in Florham Park, New Jersey. 20 min. from Newark airport and 5 min. from New Jersey Transit’s Convent Station.

Cost: With support from the John A. Hartford Foundation and The Atlantic Philanthropies, PHI is covering all costs associated with lodging, meals, and the conference. Participants are responsible for their own travel related costs.

In some cases organizations have expressed that they would like to cover their own costs in addition to travel. Please indicate on the registration form whether your organization will be covering your lodging, meals and conference costs.

We are pleased to invite you to PHI’s Center for Coaching Supervision and Leadership Closing Conference, to be held on Thursday, October 28, 2010.

Through this one day conference, you will have an opportunity to learn about the results of an exciting, four-year, $4.7 million initiative funded by The Atlantic Philanthropies and the John A. Hartford Foundation.

Background

Through CCSL, PHI has helped more than 1,000 nurses, administrators, and managers from 14 states to transform completely how they supervise their direct-care staff.

By replacing a more punitive, “traditional” model of supervision with Coaching Supervision – a practice designed to balance stronger communications, collaborative problem-solving, and accountability- participating employers have made substantial improvements to their organizational workplace cultures, to the quality of the jobs they offer, and to the quality of care they provide for elders and people with disabilities.

Over the past four years, PHI has field-tested our Coaching Supervision model, delivered field based education programs to more than 35 employer providers who have participated in the initiative at varying levels of engagement, and expanded our teaching tools and capacity. With the work of CCSL reaching far beyond supervision to addressing core organizational competencies related to leadership, communication, problem-solving and culture change, PHI broadened our work to develop a suite of services called the Coaching Approach. PHI has additionally introduced the Coaching Supervision training to select nursing schools at the baccalaureate, community college and associate degree levels and will continue to introduce these skills to nurses in academic or pre-employment settings.

We have documented our full Coaching Approach training curricula, and have developed a business investment calculator that estimates return on investment. Finally, we are conducting a rigorous evaluation of our work in nursing home and home health settings to position our practice for national impact. A few preliminary findings:

• Trained supervisors report practicing coaching in the workplace
• Job satisfaction has increased
• Nurses report re-allocation of time when, with coaching, problem-solving shifts to a more appropriate level
• Staff report increased capacity to solve problems
• Sites with robust implementation have experienced some decreases in turnover
• Coaching skills are being used to improve communication with elders and their families
• Nursing schools are interested in incorporating coaching supervision into their curricula.

We are excited to have this opportunity to share our findings and accomplishments in more depth.

Why Should I Attend?

Here are just a few reasons why you should consider attending:

1. Honor and celebrate accomplishments of CCSL participant organizations
2. Learn about the CCSL evaluation process and lessons learned
3. See how the coaching approach is helping employers to
   1. Improve supervision and communication within their organizations
   2. Improve direct-care jobs
   3. Improve the quality of services for elders and people with disabilities
4. Learn about the next steps for the coaching approach after CCSL

Questions

Please contact Makeeda Holley or Renya Larson with questions about the seminar. Contact Hamilton Park Conference Center with questions related to travel from the train station, Newark International Airport, or driving directions.

Makeeda Holley / mholley@phinational.org / 917-547-0368

Renya Larson / rlarson@phinational.org / 718-918-2068

Sara Joffe

As eldercare and disability services organizations move towards person-centered and person-directed care, frontline staff who provide care and supports, as well as supervisors and managers, are key to this transformation. But while we know that models of care need to change, we cannot assume that staff at any level will recognize the need for change or be enthusiastic about making the necessary adjustments.

For some, it is easy; for many, it is a struggle.

We all have some problems with change. Most of us have something that we feel the need to hold onto, that we just can’t change, or at least not yet. So, how do we change when we really need to, and how do we get people in our organizations to change when it is imperative that they do so?

A New Approach

A number of leading eldercare and disability services organizations are adopting a new approach to change. Using the PHI Coaching Approach℠, dozens of nursing homes, home care agencies, and continuing care retirement communities have witnessed significant changes in the ability of their staff–from executive leaders to frontline caregivers–to change. How do leaders using the PHI Coaching Approach do this?

Download this article (PDF) to read about why people are often resistant to change and how to utilize a new approach to understand and move through these challenges.