Systems Change: Use of an Artifacts of Culture Change Tool to Drive Resident-Centered Care in VA Community Living Centers (formerly known as VA Nursing Homes)

BACKGROUND: Veterans Affairs (VA) Secretary Shinseki set three fundamental attributes to guide VA HealthCare: people-centric, results-driven, and forward-looking. Embodying that mission, VA Geriatrics and Extended Care (GEC) Community Living Centers (CLC) Program aims to make the 132 VA CLCs truly a home for residents admitted for short stay, skilled nursing, rehabilitation, hospice, and long stay care. VA CLCs serve four generations of veterans, each with specific challenges in creating a home that reflects their age group, cultural and personal needs. METHOD: The VA promotes rapid-cycle change by annual program-specific Performance Monitors (PM). In 2008, the GEC selected the “Artifacts of Culture Change Tool” (ACCT) to transform the CLCs. The ACCT, from the Centers for Medicare and Medicaid Services (CMS), is a 360-point survey with six scales measuring aspects of patient-centered care. The core categories include Care and Workplace Practices, Environment, inclusion of family and community, and role of leadership. CLCs score themselves in January, identify improvement needs, act and reassess every six months thereafter. OUTCOMES: In 2008, average ACCT score improvement was 32%. This metric catalyzed innovative programs: resident pets, garden therapy, dance parties, community collaborations, innovations in dining, private space for spousal visits, removal of nurse stations, homey living spaces, and consistent staffing assignments. CONCLUSIONS: Most nursing homes measure culture change by proxy variables, resident and staff satisfaction, to evaluate success. VA selected the ACCT because it directly measures the physical and administrative structures that affect the resident. Rapid-cycle re-evaluation of concrete changes achieved tremendous innovation in one year.