Practical StepsToward Culture Change

Originally Presented by Jayne Van BramerFormer Director, Office of Quality Management2011

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Note: This presentation has been slightly modified since its original use in 2011.

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No Matter What Kind of Program It Is…Agree to take this issue on as a priority…

Create a Team/Work Group to develop a Restraint/Seclusion Action Plan…

Formulate a plan to coincide with the six core evidence-based strategies…

Go to your staff and tell it on the mountain!Start by meeting with the director of your program or agency.Bring your enthusiasm, your passion. Decide to take this on.This is about nothing less than transformation.Create your team - look for stars among your staff.Develop your plan.Stay involved.

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Leadership Towards Organizational Change Use of Data to Inform Practice Workforce Development Use of Restraint and Seclusion Prevention Tools Full Inclusion of Consumers and Families Rigorous Debriefing

Six Core Evidence-Based Strategies

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Consider a revised mission statement.

Witnessing is huge. Brylin’s CEO, Eric Pleskow, conducts debriefings himself, and it’s a standing agenda item.

How will data be used to inform practices? Patterns and trends, which unit, what time of day, which individual, which staff… help direct intervention strategies.

Be transparent.

Celebrate success.

How will you incorporate the utilization of prevention?

How will leadership support this culture change?

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Tools - soothing plans, comfort room (manual posted on OMH website: “Guide to Creating a Comfort Room”)http://www.omh.ny.gov/omhweb/resources/publications/comfort_room/

Sensory items can be obtained in a dollar store.Snoezelen items can be expensive but worthwhile.Western NY Children’s PC has a wonderful therapy dog, Tommy.

Tools

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…It’s difficult to overcome “inertia” …You may have too much on your plate…Training staff on new practices requires time and expertise…Clinicians and staff may disagree with new approaches

“We’ve always done it this way.”“There’s no time for this!”

Barriers to Establishing Evidence-Based Practices (EBPs)

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Remember, this is the cornerstone of what we do. The foundation of any transformation effort.

Mentor and support through supervision, and remember the tipping point. It goes beyond classroom training.

You don’t have to convince everyone in your organization that this is the way to go. Once you get at least half of the staff on board, the naysayers tend to be silenced.

They either join the beehives, or shut up, or perhaps even leave – and that’s okay because this work is not for everyone.

Transformation

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Leadership is critical in the success of your project!!You are the leaders.Create a positive vision.

– Better outcomes for consumers– Latest and best evidence– “Let’s do it!” message

Communicate importance and commitmentEngage organizational leadership and Board

Become a Champion/Leader

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With knowledge comes responsibility, and you are now change agents.You are the future of this initiative. Create a positive vision.Stay on message.

Say it, say it again, and again and again, model it, show it, demonstrate it. Dream it.

Remember:• Strength-based, respectful interactions• Offer choices• Avoid coercion• What can I do to help the situation?• Nothing about us, without us

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John Kotter of Harvard Business School studied why transformation efforts fail, and suggested Eight Steps for “Leading Change”:

Eight Steps for Leading Change

1. Establishing a sense of urgency2. Forming a powerful guiding coalition3. Creating a vision4. Communicating the vision5. Empowering others to act on the vision6. Planning for and creating short-term wins7. Consolidating improvements and producing still more change8. Institutionalizing new approaches

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1. Urgency. The time is now. If you think something bad cannot happen in your organization, you are sadly mistaken. I was the Quality Director in a hospital where a 21-year-old man died in restraint. He had gotten out. There was literally a matter of life and death.

2. Be inclusive. Form a team or steering committee.3. Share your vision of coercion-free, strength-based services that promote recovery.4. Print it, post it, speak it, practice it. 5. Empower others to act and be flexible.6. Create short-term wins. For example, immediately reduce the maximum allowed restraint

or seclusion order duration to 1 hour for adults and 30 minutes for all youth - or even less.7. CQI (Plan, Do, Check, Act cycle): Test hypotheses, try things. Not everything will have the

desired outcome. It’s a series of experiments, of trial and error.8. Implement and institutionalize.

More about the Eight Steps for Leading Change

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Focus: Communicating the Vision–Simplicity

–Multiple forms–Repetition

–Leadership by example–Explanation of seeming inconsistencies

–Give and takeJohn P. Kotter, “Leading Change: Why Transformation Efforts Fail” Harvard Business School Press, 1995

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• Work as a Team rather than as individuals• Establish standing (regular) meetings and reporting mechanisms.• Make it a standing agenda item for meetings of Team and Executive

Leadership.• Develop a plan.• Identify barriers to implementation and address or mitigate problems.• Encourage thinking “outside the box”.• Have a kick-off date.

Project Team

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Share success stories.

Develop your plan, monitor implementation, and assess its impact. Use data.When you develop an action plan, include what, when, by whom.Think through what your barriers are, and how you can address them.“What can we do differently?” Break out of our comfort zone. Have a kick-off date? You need a drum roll. Community leaders, board, kids, parents, respect bracelets.

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Implementation of the plan is like Goldilocks - try to time it Just Right…– Not too fast: Don’t have a kickoff until ready to implement initial series of steps – Not too slow: Avoid long lags between implementation of steps

Start with Small Successes: For instance, if you’re still using 4-pt or 5-pt restraint, eliminate it!

Monitor process and outcome data Is the plan being carried out? Is the plan having the intended effects? Do you have a calming plan? Crisis prevention plans? Soothing plans? Are they being used? If no, drill down - ask why. (Not readily available, not feasible, wants to shoot hoops, don’t have any information on them, etc. …)

Review and respond to data

Project Team, continued

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• Assure review of data by leadership and team• Make processes and outcomes transparent• Educate and engage staff (clinical, medical and support staff) about the project• Share what worked and what did not

– Compare results across wards or units– Call your colleagues/network

Project Team, continued

We must turn data into information. Is that decrease last month cause to celebrate, or a random variation? Use control charts; collect data on staff surveys. Collect data from the individuals affected about what they find unhelpful. Do they like the comfort room? Could it be changed? Analyze content of debriefings. Do they result in changes to calming plans?

Post results and talk about them at staff meetings, TC meeting, Governing Body, Board of Directors. Post in the visitors’ room.Educate and engage staff. It takes a village. Share what worked and what did not. A little competition between units or agencies may work (like a bowling trophy).

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With both staff and individuals in care,As Management does unto Staff…

So shall Staff do unto Consumers

Give staff strength-based supervision.

Try the “three bucket” approach.When an individual is not doing something we asked them to do, or is doing something we don’t particularly like…

Can we 1. Let it go2. Negotiate it - offer choices, options3. Make it your line in the sand issue

Moving from Control to Collaboration

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Red rules can never be broken. Assaulting other recipients or staff, smoking on ward. Flowing blood from self-abuse.Green rules are flexible. Wake-up time, dinner time, group participation, showers…

Identify Red Rules and Green Rules

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The louder the ward is, the quieter you need to be.

• Promote calm, nurturing, healing environments – think about the messages of your signage

• Model caring, compassionate behavior• Demonstrate active listening• Interview and observe for triggers• Adjust environment to prevent triggers• Use a full range of prevention tools• Model, teach, model, teach - shape the behavior you want to see

Stress Primary Prevention

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I still hear “Medication Time!” yelled on wards.

Model caring, compassionate behavior for both direct care staff, and individuals in care. Adjust the environment to prevent triggers. Maybe stop using males for 1:1 observation. Cover fluorescent lights with fluffy cloud light covers. Use a microwave to offer a warm blanket.

Wards need to be peaceful places of sanctuary. Use all the tools and positively shape the behaviors you want to see.

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This work is not easy. Even our grant sites have not completely eliminated restraint and seclusion.

But we are learning more every day.Two steps forward, one step back is okay.

Don’t expect progress to be linear. It is a journey.

This will take persistence and sustained attention.Don’t get discouraged!

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“The measure of success is not whether or notyou have a tough problem to deal with,

but whether it is the same problem as last year.”

John Foster Dulles