Survey Shows That Surveyors, Others Need Education About Culture Change

Abstract

Senior contributing writer Joanne Kaldy is a freelance writer in Hagerstown, Md., and a communications consultant for AMDA and other organizations. WASHINGTON — A survey of nursing home leaders, surveyors, and others in long-term care suggests a need for additional communication and education between facilities and surveyors when it comes to culture change. At the recent national conference of the Pioneer Network, Peggy Williams, SW, MS, a former surveyor and now a project manager for CIBER Defense Technology Systems, presented results of a questionnaire that she had developed with input from a provider organization, a state survey agency, and two Quality Improvement Organization (QIO) project managers. She distributed the questionnaire to long-term care stakeholders in six states. The instrument had 16 questions divided into four sections. The first two sections sought to identify respondents’ involvement in culture change and what they understood about culture change principles and strategies. Sections three and four sought respondents’ perceptions of regulatory barriers to culture change and what actions they believe their survey agency should take to collaborate with change initiatives. A total of 291 respondents (an 18% response rate) included 186 providers (administrators or directors of nursing), 37 surveyors, and 68 stakeholders (ombudsmen, QIO personnel, social workers, provider associations, educators, and housekeeping supervisors). The respondents included two medical directors and one assistant director of nursing. Not surprisingly, providers indicated having the most involvement with culture change initiatives at the facility level. Nearly all (93%) said they had made changes at their facilities. A large majority (81%) had attended workshops on culture change, and 16% had sponsored a workshop on the topic. More than half (56%) had participated in a QIO learning session about culture change. In contrast, only 2% of surveyors and 23% of stakeholders had been active in facility-based culture change; 49% and 55%, respectively, had attended a workshop. Only 2% of surveyors had sponsored a workshop, while 15% of stakeholders claimed sponsorship. About one-third of surveyors (35%) have participated in a QIO learning session, while nearly one-fourth of stakeholders (23%) have attended such an event. Interestingly, many respondents in all three groups expressed familiarity with one or more culture change resources. Providers, surveyors, and stakeholders most frequently said they knew about state QIOs and the Eden Alternative. The questionnaire asked respondents to rate how much support they think various regulations provide for culture change in areas identified in the Resident Rights. The regulation rated lowest for supporting culture change was that for self-administration of drugs. While more than half of providers and nearly all surveyors said that the regs support efforts in most areas, only 45% of providers and 65% of surveyors said that the government rules support self-administration of medications; 39% of providers and 18% of surveyors said the regs actually hinder efforts toward culture change in this area. Asked about other regulations and whether they support or hinder culture change, 62% of providers, 77% of surveyors, and 75% of stakeholders said that resident assessment regs support change. Also, 68% of providers, 73% of surveyors, and 77% of stakeholders said that comprehensive care plans support culture change. Most providers (52%–67%) said that nursing, physician, dietary, and rehabilitation services support culture change. At the same time, nearly one-half (41%) of providers said that dietary services actually hinder culture change; and about one-fourth said that nursing services (25%), physician services (19%), and rehab services (26%) actually hinder change efforts. Similar numbers across the board (60% of providers, 68% of surveyors, and 76% of stakeholders) said they believe the medical director's role and responsibilities support change. No one called medical directors a hindrance. Respondents identified numerous barriers to culture change that they have experienced. These included resistance to dining innovations such as open, buffet, and/or family-style dining and potluck meals; resistance to bringing in personal furniture or refrigerators, to establishing neighborhood kitchens, and to individualized medication administration. Often, Ms. Williams noted, facilities hear that safety “trumps” residents’ rights and choices and that there are fire and safety restrictions on homelike environments. “Providers suggested that surveyors don't ask enough questions to understand what is really going on,” she said. They also are concerned that the survey process will punish them for isolated incidents, such as a mild burn suffered by a resident who wanted to have his morning coffee and newspaper in his room. “Providers sometimes feel that surveyors focus on paperwork, rather than outcomes,” Ms. Williams explained. The good news is that the results showed overwhelming willingness on the part of all parties to communicate about culture change. Surveyors especially expressed enthusiasm, nearly unanimously saying that they are open to discuss strategies, that they understand change, and that providers feel comfortable disputing deficiencies. About three-fourths of providers agreed that their survey agencies would be open to discussing culture change and that they would feel comfortable disputing a deficiency. However, only half said that surveyors demonstrate an understanding of culture change. “We have a way to go before we can say we have good, consistent communication about culture change among everyone involved,” said Ms. Williams. Questionnaire respondents identified several existing barriers to such communication. These include too much focus on the regulations, paper compliance, and perfection over resident outcomes; preconceived notions about culture change; “institutional” mind sets on the part of surveyors; and a tendency to view changes as “environmental” or as artifacts. All respondent groups agreed that it should be a priority to train surveyors about culture change principles and strategies and that opportunities for dialogue during surveys should be improved. However, there was some disagreement about other issues. For instance, over half (58%) of providers said that revising state regulations should be a priority, while only 21% of surveyors and 32% of stakeholders agreed with that statement. Elsewhere, nearly half (41%) of stakeholders—compared with only 16% of providers and 9% of surveyors—suggested using category 1 remedies. Large majorities of providers (80%) and stakeholders (81%) said that state survey agencies should provide culture change information to promote a greater understanding and application of best practices. This compares with only 50% of surveyors who supported such efforts. While the results of the questionnaire suggest progress has been made toward culture change, more needs to be done, said Ms. Williams: “I think understanding of culture change is still moving at a snail's pace. Some surveyors understand, embrace, and promote it, but these individuals are in the minority to date.” Facility leaders can take the lead, Cari Levy, MD, CMD, a medical director who has been involved in culture change initiatives in Colorado, said in an interview. “Offer to conduct quarterly seminars with surveyors at their meetings,” she suggested, adding, “Have them come up with questions, and provide a speaker who is a culture change leader and champion.” When survey time comes, Dr. Levy urged, medical directors should be on site—or at least be available via phone—to discuss any questions about aspects of resident care, including those related to culture change. It also is helpful to empower and encourage a facility's team leaders to “think like surveyors” when they are writing up documentation of culture change efforts, offered Ms. Williams. This includes noting why changes were made, what was discussed with the resident and his or her family and other decision makers, and what mechanisms were implemented to protect patient safety.