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Integrating Services for Older People:
A resource book for managers

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Contents menu:
Foreword. 1Integrated care: concepts and background. 2Integrated organisational structures. 3Involvement, empowerment and advocacy. 4Needs assessment. 5Care pathways. 6Case management. 7Integrated teams. 8Workforce. 9Cultural change. Definitions. Objectives and intended outcomes. Models and approaches. Systems and instruments. The implementation process. Staff. Monitoring and evaluation. Barriers. Supports. Key points. References and further reading. 10Leadership. 11Strategic planning. 12Information management. 13Quality management. The contributors. CARMEN participants.

Chapter 9: Cultural change

Mia Defever

When two or more organisations, professions or teams from different backgrounds come together to provide needs-driven integrated care for older people, they have to work together in ways that are unfamiliar to them. If they come from different sectors, or if they have different histories or traditions, this is even more the case.

These innovative ways of collaborating, between systems and across organisations, can bring about an added value that equals more than the sum of the efforts of all organisations. To realise this surplus value, the parties involved have to cope with and overcome their multitude of differences in mutual perceptions, status, work styles, organisational affiliations, employment regimes and salaries, or in frames of reference. So in integrated care, the organisations and workers alike need to share each other’s value patterns in order to provide a coherent care package.

This chapter outlines the issues and recommendations that managers need to consider when cultural change is introduced as a management instrument for developing needs-driven integrated care for older people.

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Definitions

The term ‘culture’ refers to the value patterns of a society, a system or organisation, and to the attitudes of people and workers. ‘Cultural change’ is an intended process that supports the strategies of change in organisations. Cultural change may follow as a result of collaboration and innovation. In this chapter, cultural change is considered as a mechanism to support the development towards needs-driven integrated care for older people.

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Objectives and intended outcomes

Cultural change in integrated care is designed to bring about:

• a fundamental shift in the paradigms about care for older people among the people and organisations involved in the integrated care process – including staff, older people as clients, and their carers
• a perception among older people, their carers and staff in daily interactions of shifts towards person-centredness as a result of cultural change efforts
• a tangible reorientation in beliefs and attitudes towards the core values of integrated care
• a shared purpose and vision that puts older people at the centre
• deeply rooted and sustainable change, internalised by the different partners, operational at every level and in all parts of the system
• understanding, respect and sensitivity to cultural differences and mutual roles, for the work of each other between the different persons and agencies involved
• sustainable change, with the aspiration of reaching a cumulative and non-reversible change in attitudes, values and beliefs.

Sustainable cultural change Page 145

Since so many health and social service processes depend on the actions of people, sustainability comes down to winning the hearts and minds of all those involved. Cultural change becomes sustainable when new ways of working and improved outcomes become the norm, so that it becomes clear that the organisation has really evolved and is definitely not going back.

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Models and approaches

Various models can be applied to guide the process of cultural change. Some, such as ‘triple-loop learning’, are more general and refer to organisational processes, fitting into what we can call the ‘learning approach’. Others, such as ‘client responsibility’, refer specifically to the core values of integrated care. They fit into what could be called the ‘client-comes-first approach’. These models are not mutually exclusive. For example, triple-loop learning is an approach to guiding cultural change throughout an organisation, while client-centredness introduces the values of integrated care.

These two models – the learning approach and the client-comes-first approach – are discussed in full below. We then look at a number of other instruments that are helpful in implementing the cultural change process.

The learning approach

Managers who want to support and initiate cultural change in their organisation need to understand the strategy of a learning organisation and to consider learning as a core activity. In that respect, this activity goes beyond superficial learning – a barrier to sustainable change. Learning organisations consider their environments to be a rich source of opportunities. They are familiar with the perceptions of the different stakeholders, and are focused on a deep understanding of their clients’ needs (Davies and Nutley 2000).

Becoming a learning organisation is not always easy. Learning organisations need to learn how to learn. This is expressed by the concept of triple-loop learning, which makes a distinction between three levels of learning:

• Single-loop learning involves detecting and correcting errors with a simple feedback mechanism, such as an audit that compares practice with standards.
• Double-loop learning is a more sophisticated level of learning that affects the organisation’s processes by questioning its objectives and the course of change. This level can lead to a redefinition of the organisation’s goals and policies and even to structural changes.
• Triple-loop learning, also known as ‘learning about learning’, is usually an underdeveloped aspect of learning. Here, organisations learn about the contexts of their learning and develop the capacity to identify when and how they learn and when and how they do not, and to adapt accordingly. Successful learning organisations build on their experience of learning to develop and test new learning strategies (Argyris and Schön 1996).

The process outlined in the practice example above shows that the organisation understood the lessons from their learning in former phases. What started as a reorganisation of service (single) developed to including the perspectives of the client or customer (double). They finally understood (triple, or ‘learning from learning’) that a real reform could only take place beyond the traditional pathways by involving partners and collaboration from other sectors.

The client-comes-first approach

Client-comes-first models emphasise core values of integrated care. These include the patient-centred model and the client-responsibility model:

• The patient-centred model is a framework based on the beliefs and expectations of a patient. Health workers need to be able to identify the patient as a person, the relationship that exists between themselves and the person, and the expectations that each has about that relationship. To be operational in practice, person-centredness requires the values of the patient and care providers to be explicitly identified, alongside those values prevalent in the care environment (McCormack 2003).
• The client-responsibility model incorporates creatively engaging the client, assessing family needs, setting mutual goals, following the goal achievement process, and setting aftercare objectives. It includes issues such as confidentiality, shared medical decision-making and respect for patient autonomy. This model emphasises decision-making, taking into consideration the patient’s goals and preferences for their care so that the patient and their non-paid carers negotiate the process of care decision-making taking into account the patient’s values and perspectives (Pantilat et al 1999).

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The implementation process Page 147

Cultural change can either occur as a result of careful planning, or it can emerge through programmes of integrated care, or through collaborative behaviour among services and institutions. In the first scenario, a planned cultural change programme in initiated by the managers, while in the latter, a reorientation in beliefs and attitudes and an understanding and respect for mutual roles comes about as a result of integrated care activities.

Implementing cultural change for integrated care based on the needs of older persons is a step-by-step process. Looking for an unambiguous set of common values would be an over-simplification – on the contrary, it is an evolution towards a deeply rooted change in vision and attitudes of workers on collaboration and integration of care. This process includes the following:

• team building and team development
• transparent, mutually agreed management lines, with the support of contractual clauses and codes of conduct
• staff appraisal systems linked to reform objectives, such as salaries and promotion rewarding front-line workers
• developing sustainability criteria
• external facilitation (especially in the starting phase)
• external monitoring by regulatory bodies and insurers
• developing joint protocols
• working together and systematic reflection.

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Systems and instruments

This section provides three examples of instruments that can be helpful in implementing cultural change:

• vignettes, including older people’s stories
• mentoring or leadership
• models that guide people through the process of change. Page 148

These three instruments are detailed below:

• Vignettes, including older people’s stories – These can be used by managers as illustrative models to help survey the organisation and root out the obstacles to change. Vignettes are hypothetical or real-life stories that trigger the response to a set of questions, which in turn offer the possibility to evaluate systems, conditions, situations or changes. Vignettes can be particularly usefully applied when an explicit conceptual framework or methodology is lacking (Liaw et al 2003), and can be very useful for discussing professional values and organisational norms.
• Mentoring and leadership – Because managers sometimes overlook the need for leadership skills, it may be necessary to engage external mentors to teach them specific leadership skills, such as improved communication. Managers can sharpen their leadership skills by
  • distinguishing between leadership and management
  • adopting a new mentoring model management style
  • evaluating the usefulness of new management techniques
  • understanding the connection between technology and leadership
  • looking for the solution beyond the problem, which means being seen and heard by other agencies and organisations (Kowalski and Campbell 2000).
• Models that guide people through the process of change – for example, the ‘what’s in it for me?’ model. A ‘what’s in it for me?’ analysis is a useful way to consider the different needs and attitudes of each of the key stakeholders in the change initiative (whether individuals or groups). The analysis should be carried out right at the beginning of the improvement initiative, before people have taken up ‘positions’, and can be revisited as often as required.

Table 5: What’s in it for me?

Key people/group	What's in it for me?		What could the partners and stakeholders do to support or prevent the improvement initiative?	What can/should the manager do to reduce non-compliant activities and encourage and support compliant ones?
	Impact	Risk
A	B	C	D	E

Adapted from NHS Modernisation Agency 2003a

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Staff

The involvement of all staff is a major prerequisite for developing cultural change towards integrated care for older people. Special efforts will be needed in the first place to increase the awareness and sensitivity of the staff to the values and ideas of integrated care. The ‘internalisation’ by staff members of values and beliefs is critical. This means that the ideas of integrated care emerge among staff as obvious, and are perceived as being their personal values and belief.

It is important to take the following elements into consideration:

• an emphasis on innovation
• team development
• representation of all groups involved
• a bottom-up approach
• attention to the roles of volunteers and NGOs
• training of professionals
• empowering frontline staff
• special attention to middle-level management.

These factors are considered in detail below:

• Emphasis on innovation – Learning organisations are constantly searching for new ways of delivering services, so innovation and change are highly valued. A prerequisite for progress includes a tolerance for learning from failure, which in turn requires a culture that accepts the positive spin-offs from errors, rather than seeking to blame and scapegoat. This does not, however, imply a tolerance of routinely poor or mediocre performance from which no lessons are learned. Page 150
• Team development – As a team leader, the manager can convey the mission of integrated care in terms that are understandable and applicable to each organisation since, eventually, effective cultural change depends on its acceptance by all members of the integrated care team. The emphasis on team delivery of care reinforces the need for team learning. In this respect, team leaders and managers have to act as major change agents, and to operate as a living example.
• Representation of all groups involved – All stakeholders should be represented in steering committees, and in developing the integrated care team.
• A bottom-up approach – This approach must take into consideration the perceptions and attitudes of the client or family, and of ground workers involved in implementing the programme. Managers need to be aware of the danger of using cultural change as a top-down control mechanism to extend control and power (Mahony 2000).
• Attention to the role of volunteers and NGOs – This will involve identifying volunteers and being aware of their values and objectives. Managers must be conscious of the importance of the input of volunteers, and of the relevance of their beliefs (Rayner and Marshall 2003).
• Training of professionals – This activity deserves major attention, since training curricula of health professionals often do not include sharing information beyond their professional field. Special training efforts of the medical group are needed to convey the integrated care culture.
• Empowering frontline staff – Managers must be able to trust that subordinates will use wisely the time, space, and resources given to them through empowerment programmes, and will not indulge in opportunistic behaviour. Without trust, learning is a faltering process.
• Special attention to middle-level management – Accrediting middle-level managers in the integrated care team to re-affirm their commitment is important. Examples of accreditation might include formal appointments, command over budgets, and delegation of power and authority.

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Monitoring and evaluation

A follow-up process, using validated instruments, is not helpful in this area because there are no instruments designed specifically to measure cultural change. Changes in attitudes, values and beliefs towards a deeply rooted common vision develop and evolve alongside the development, growth and implementation of integrated activities, so it is not possible to measure the ‘processes’ of the changes – only their outcomes.

This means that the evaluating process requires qualitative instruments, such as:

• qualitative views of service users and staff (how they perceive the collaboration in the integrated care team)
• a definition of the mission of integrated care, by each team member in his or her own terms
• viewing complaints by team members, older persons and their non-professional carers as indicators of reluctance to change, or wrong direction of the integrated care programme
• an evaluation, by a simple survey method, of client and staff satisfaction
• a formal evaluation meeting among staff members, offering each member the opportunity to voice the positive elements and those that need improvement
• a permanent alertness in the manager to the comments and recommendations voiced by the team members during informal gatherings and while working on the floor Page 151
• an attention to rumours spreading among outsiders about the integrated care developments.

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Barriers

A number of obstacles need to be overcome before cultural change can take place:

• short termism (‘target culture’) – the attitude that integrated programmes are less important because the results are not noticeable in the short term
• intolerance of ambiguity – the goals and objectives of integrated care programmes are less clear and tangible in comparison with clinical care programmes, leading to intolerance for a certain level of vagueness
• inflexible funding – funding is mostly allocated by type of service or system, rather than for innovative programmes. Traditional or vested interest groups perceive adequate funding for programmes through different segments as ‘waste’ or ‘overlap’. At times, limited resources are used as an excuse for inappropriate funding
• professional cultures – despite cultural pluralism, the values of the dominant groups tend to prevail, with dominance by the traditional powerful groups based on their professional status or on their positions in the hierarchy and by dominance of the medical profession
• the prevailing cultural climate – a poor understanding of the aims and instruments necessary to achieve integration with the prevailing belief that one’s own system and the traditional mechanisms are superior Page 152
• resistance to change – a reluctance to engage in unfamiliar structures and pathways and in programmes that may disrupt the daily activities. The fear of one’s vested interests, such as power and income, being challenged
• the mismatch between macro- and micro-levels – especially between the developments in society at macro level and the aspirations of the client or family at micro level to be entitled to services. Due to the shrinking social safety-net in European welfare states, a considerable group of older people and/or their families are not covered for care spending, and are unable to make payments themselves. Integrated care team members need to become acquainted with the shifts in values, structures and beliefs around ageing and care provision in the society at large
• the focus in funding on high-tech, acute care provision – this often means neglecting long-term care. Lip service is paid to the aims of integrated care for older persons, but attention and resources are devoted to glamorous medical technology. This means promoting care for frail older persons while embracing a high profit acute care industry.

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Supports

Several factors are helpful in the development towards changing the vision and attitudes of team members of integrated care programmes. They include:

• a clear demonstration of commitment by key managers, as opinion leaders – especially in the phase of development (Gaunt 2000)
• a culture that encourages risk taking and gives scope for learning from mistakes
• availability of information that is appropriate and acceptable, about the aims and instruments of the integrated care project
• financial incentives for innovation and risk taking – incentives for individuals to give of their best and develop their competencies, and for groups to take risks. It is important to support the idea that risk-taking activities will be appreciated and valued, and in particular, to provide confidence that if someone makes a mistake, they will be supported and not rebuked
• the policy climate – consistent and clear policies that reflect the ideas and objectives of the integrated care approach (on national, regional and local levels as well as on the systems level) are a major prerogative. The integrated care ideology behind the regulatory framework should be visible
• national awards – as mechanisms of external pressure to praise efforts, promote their example, and provide continuity. Awards can be a major vehicle to keep successful programmes going, especially in periods of shifting national health care priorities.

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References and further reading

Argyris C, Schön DA (1996). Organizational Learning II. Reading, MA: Addison-Wesley.

Armstrong A, Foley P (2003). ‘Foundations for a learning organisation: organisation learning mechanisms’. The Learning Organization, vol 10:2, pp 74–82. Also available at: www.emeraldinsight.com.

Bell CR, Dirksmeyer LJ (2003). ‘Juggling corporate cultural change’. Journal of Nurses Staff Development, vol 19:2, pp 88–91.

Cragg DK, Campbell SM, Roland MO (2002). ‘Out of hours primary care centres: characteristics of those attending and declining to attend’. British Journal of General Practice, vol 52:481, pp 641–45.

Davies HTO, Nutley SM (2000). ‘Developing learning organisations in the new NHS’. British Medical Journal, vol 320, pp 998–1001.

Drinkwater C (2003). Personal communication, meeting between European Union and CARMEN members, Barcelona.

Gaunt N (2000). ‘Practical approaches to creating a security culture’. International Journal of Medical Informatics, vol 60:1, pp 151–57.

Kowalski RB, Campbell MW (2000). ‘Leadership skills help financial managers achieve career success’. Healthcare Financial Management, vol 54:4, pp 50–52.

Liaw ST, Sulaiman N, Pearce C, Sims J, Hill K, Grain H, Tse J, Ng CK (2003). ‘Falls prevention within the Australian General Practice Data Model: methodology, information model and terminology issues’. Journal of the American Medical Informatics Association, vol 4, pp 207–14.

Mahony K (2000). ‘Faith in the “cultural fix”: limits to a planned cultural change programme in a rural health service’. Australian Health Review, vol 23:4, pp 187–96.

Marshall M, Sheaff R, Rogers A, Campbell S, Halliwell S, Pickard S, Sibbald B, Roland M (2002). ‘A qualitative study of the cultural changes in primary care organisations needed to implement clinical governance’. British Journal of General Practice, vol 52:481, pp 641–45.

McCormack B (2003). ‘A conceptual framework for person-centred practice with older people’. International Journal of Nursing Practice, vol 9:3, pp 202–09.

Mintzberg H, Ahlstrand B, Lampel J (1998). The Strategy Safari. New York: Free Press.

New B, Neuberger J (2002). Hidden Assets. Values and decision-making in the NHS. London: King’s Fund.

NHS Modernisation Agency (2003a). Managing the Human Dimensions of Change. London: NHS. Also available at: www.modern.nhs.uk.

NHS Modernisation Agency (2003b). Spread and Sustainability. London: NHS. Also available at: www.modern.nhs.uk.

Øvretveit J, Mathias P, Thompson T (1997). Interprofessional Working for Health and Social Care. London: Macmillan.

Pantilat SZ, Alpers A, Wachter R (1999). ‘A new doctor in the house. Ethical issues in hospitalist systems’. Journal of the American Medical Association, vol 282, pp 171–74.

Rayner H, Marshall, J (2003). ‘Training volunteers as conversation partners for people with aphasia’. International Journal of Language and Communication Disorders, vol 38:2, pp 149–64.

Robinson L, Drinkwater CK (2000). ‘Care of the frail elderly in the community: a critical incident study’. Primary Health Care Research and Development, vol 1, pp 163–77.

Sapountzi-Krepia D, Antonakis N, Sgantzos M, Lionis C (2003). ‘Seeking the attitudes and perceptions of the Greek primary-care professionals on voluntary work in caring for people with HIV/AIDS’. Nursing Management, vol 11:4, pp 258–65.

van Harten WH, Casparie TF, Fisscher OA (2002). ‘The evaluation of the introduction of a quality management system: a process-oriented case study in a large rehabilitation hospital’. Health Policy, vol 60:1, pp 17–37.

Wilson J (1997). Integrated Care Management. The path to success? Oxford: Butterworth-Heinemann. Page 154

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