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CHAPTER 11
FUTURE PULL Understanding the Culture in Culture Change by LaVrene Norton
THIS IS NOT ABOUT QUALITY IMPROVEMENT BUT ABOUT PROFOUND, DRAMATIC CHANGE
The changes needed to sustain progress in long- term care must be deep, from small and specific to grand and broad sweeping, and they must all some- how interplay and complement each other.
All parts of a long-term care organization are inter- related and should be seen as a whole. Change in one area affects all others, so all areas must be addressed in order to bring about profound change. If you push here, there will be reaction over there. For example, changes in when, how, and what is eaten for break- fast also will affect dietary, nursing, and clinical care, housekeeping, laundry, pharmacy, and the timing of doctor’s visits, accounting, purchasing—all functions across the organization.
So you cannot merely convert your building into households and then have staff do things the same way they have always done them. Instead, you must rede- sign the organization and make it responsive to your new vision and philosophy. The articulated and func- tional must be in sync, the gap between myth and real- ity closed.
Quinn (2004) relates the story of sailors caught at sea in a mighty storm. The anchored ship was about to be torn apart as the waves crashed wildly upon it. The sailors realized their only hope of surviving was to cut free the anchor, normally a source of stability, to keep the ship from being swamped and thus enable it to ride out the storm unfettered on top of the tumultuous waves.
Organizations and individuals, he adds, also devel- op anchors in the form of belief systems around their identities and ideas on how best to cope with adversity. But in a changing world with gathering storms, these usual sources of stability might need to be cut free so that we can move forward “into real-time learning” (Quinn, 2004).
The change must be on both an individual and an organizational level. The reason why change initiatives fail, says Senge, “cannot be remedied by more expert advice, better consultants or more committed manag- ers. The sources lie in our most basic ways of thinking. If these do not change, any new ‘input’ will end up producing the same fundamentally unproductive types of actions” (Senge et al., 1999, p. 6).
The change process must be maintained and sus- tained because there is always danger of sliding back into the old way of doing things. One strategy for keep- ing the change initiative on track is to use what we call “Bump’s Law,” named after our colleague Linda Bump, who arguably is the mother of the Household Model. When tempted to revert to assembly-line efficiencies, ask these questions inherent in Bump’s Law:

his or her previous home?

THE BEAUTY OF DEEP CHANGE IN LONG-TERM CARE COMPARED WITH OTHER INDUSTRIES
A compelling purpose energizes life. It is the force that activates our “wave of becomingness.” It brings forth happiness and joy. (Land & Jarman, 1992, p. 177)
No matter the industry in which we labor, deep culture change is exciting and humanizing. Pride in workmanship and constant quality improvement ini- tiatives have been a part of American manufacturing of products from automobiles to baseball bats to soup since the 1970s. Culture change success in companies such as Ford, Chrysler, Shell, AT&T, Hannover In- surance, and Harley-Davidson are examined by Peter Senge in The Fifth Discipline: The Art and Practice of the Learning Organization (1990) and The Dance of Change (1999).
But as satisfying as transformation is in widget pro- duction, it is even more so in long-term care because our work is particularly mission based. We believe April Turner’s sentiments voiced during an interview with Action Pact in November 2009 are broadly shared among long-term caregivers:
“This is a great opportunity to make a huge differ- ence in someone’s life—that’s one of the reasons I de- cided to become a CNA,” she says. But it was only after hearing about the transition to the Household Model at a local nursing home that she was enticed from her job at a truck dealership to begin a new career. Her
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