[NOTE: I'm bumping this post back up to the top to give more visibility to the excellent comments and to encourage folks to keep contributing.]
I didn't have time during the actual Institute to do a lot of "live blogging" (a combination of the hotel not having WiFi access in the meeting rooms, me doing a lot of videotaping of the sessions, and me being on the phone/computer working on the Katrina relief efforts).
But I chose to post the clip below of Sue Misiorski setting up the "
Pilot vs.
Whole Organization" debate in the
Getting Started pathway because the discussion is worth exploring at length.
From my understanding of Sue & Joanne Rader's teaching, it seems the risk of doing a pilot in one area of the organization relates to the fact that it must be a
shift in values that drives changes away from "old culture" norms (e.g., non-consistent assignment) and artifacts (e.g,. tray dining service).
Pilots run the risk of being
just programmatic change -- i.e., only trying to change the norms and artifacts. So starting with a pilot
can be a recipe for failure because it's usually not accompanied by a fundamental shift in values (among other reasons).
That point from the
Getting Started pathway got me thinking about a discussion I had with David Farrell of
Quality Partners of Rhode Island before his talk on the 2nd day of the Institute. He shared a report on staff retention and described reading it as an "aha" moment -- something he couldn't put down once he started reading. David is one of the clearest thinkers on these matters, so I got a copy for myself and started reading...
The report,
Identifying Behavior Change Intervention Points to Improve Staff Retention in Nursing Homes* (by Mary-Lescoe Long and Michael Long) is a research study of 6 nursing homes in Kansas that had experimented with one or several job satisfaction programs, but the facilities had been
unable to substantively reduce turnover rates or sustain enthusiasm for the initiatives.
The 6 homes had "excellent state inspection records and community reputations as high quality facilities." In short, they were the kind of places that provided good quality health care but they lacked that
something that made them places where one would want to live and work. They were good organizations, but they weren't great organizations. They were not engaged in culture change.
So what did the researchers conclude caused the failure of behavior change interventions in these settings? The authors observed how the direct care workers had a host of
predisposing circumstances which set up a "cycle of powerlessness and unfamiliarity with the skills and rewards associated with performance and achievement in the work place."
They observed how the rewards that are part of conventional personal development programs (internal reward systems like job redesign emphasizing genuine two way communication and shared decision making between supervisors and direct care workers) were not consistent with the
predisposing values, beliefs, and expectations of the direct care workers in their study.
Such predisposing circumstances include
reduced social status (minority status, students and other young people),
reduced social support (female, single parent heads of households), and
less human capital (limited opportunities for education, income, employment). Direct care workers have other predisposing circumstances such as limited training for the job they are required to master.
The above predisposing factors mean it's critical that internal reward systems
originate with the workers and not be some new "policy" or norm that is imposed by the organization on the worker.
"Much of the practitioner-directed management literature presents job satisfaction programs in terms of changes that begin at the level of organization policy rather than in the minds of administration and current or newly recruited employees. This view directs attention away from barriers to implementation which exists at the employee-job interface and the employee-employee interface. These are the interfaces where the human condition meets the organizational condition. They serve as flash points for the generation of perceptions and behaviors which can render internal reward systems ineffective. Understanding what barriers nursing homes face at these vital flash points, and why these barriers exist, is the key to designing internal reward systems that are robust in the current nursing home environment.
I read this as meaning that
deep culture change requires attention to the
life circumstances of the direct care workers -- either intervening explicitly via life skills mentoring to address some of the predisposing circumstances, and/or doing so indirectly by introducing culture change principles with a greater degree of socio-cultural competency than we have to date.
Is there a certain "universal instinct" concerning the care of elders that can be tapped for transformational change? How can we
reach direct care workers who find themselves in challenging predisposing circumstances, but do so
where they are (i.e., seeing the change through their eyes, as opposed to directing the process from above with no attention to the real-life circumstances of the workers)?
To me, the report makes the argument for whole organization change as opposed to pilots because it's awfully difficult -- if not impossible -- to pilot such a fundamental
value questioning process.
But it does raise a question in my mind about how well the whole "Good to Great" concept applies to long-term care. Is there something fundamentally different about the care of elders that makes the A&P vs. Kroger grocery store example not fit here? I'll explore that question in another post.
*The report is available for purchase ($15) at the Kansas Association of Homes and Services for the Aging (KAHSA)
website.
