Ana Urrutia is transforming the current socio-sanitary care system in Spain. Starting by removing restraints, a standard practice with outraging figures in the world, her movement has evolved towards a radical transformation of the current care model based on medical aspects and risk control, leading to dignified and humanized approach to elder’s care. Ana’s strategy focuses on changing the way care institutions work, by completely remodeling their work culture and placing the attention on the needs of the person, rather than the institution.
The New Idea
Ana is implementing a successful and proven Person-Centered Care model that entails a profound change in the work culture of social and healthcare institutions, and is spreading it through a system of indicators that measure the positive impact in the patient’s quality of life, both physically and psychologically, being the key indicator the number of physical and chemical restrains removed.
Geriatrics and most care services in Spain and other countries have traditionally worked only around medical aspects. This approach that focuses on medication and risk control ignores basic aspects such as freedom and dignity, having dramatic consequences on patients both in physical and mental terms.
Starting from a personal commitment (from very young) with elderly, and moved by an ethical drive of eliminating fastenings in her own residence, Ana quickly arrived to the need of a systemic change in the sector. Her vision is that quality care and patient centered care should be given and could be given to all elders and patients in socio-sanitary, socio-care, socio and sanitary centers in Spain and beyond and she therefore defined and implemented an evolutionary care model based on 4 principles:
Eliminating excessive medication and above all physical and chemical restrains
Creating a certification process to promote a behavioral change in institutions and as a sign of change
Lobbying public administrations to demand quality care by law
Developing a replicable model through a partners’ network
Ana is instituting a new framework in the socio-sanitary sector, focusing on staff and management training and follow-up, as well as establishing measurable quality of life indicators, certified by her foundation, Cuidados Dignos (Dignified Care).
Changing working culture of socio care institutions implies changes on management models, architectural adaptations, in some cases small investments in technological innovation and, above all, a change in the roles and responsibilities of the staff. The professionals, independently of their position, cooperate as a team to find solutions to day to day challenges,, and undertake new roles and responsibilities in their routines. These changes allow the institution and its professionals to adapt to the needs and desires of the patients, and not the other way around.
By placing not only the patient at the core of the care system, but also prioritizing the wellbeing and participation of staff and team members, Ana is achieving a transformation that positively influences the work environment, helping reduce worker burnout, humanize the relationship with the patient’s family, and improve the physical and mental health of people in residential homes, hospitals or day care centers.
Ana is creating a competitive sector that recognizes that better care for elders, based on their needs, personalities and above all based on their dignity, is necessary.
Pulling from her experience in this field, Ana is piloting this new system in geriatrics, with the intention of expanding to other areas of care for dependent people.
In our society, there is a significant lack of awareness, sensitivity and appreciation of the elderly community, and more broadly of dependent persons (people with physical or mental illnesses, people with disabilities etc.) who require care and accompaniment. Generally, they are referred to in negative terms, often focusing on the expenditure they generate through pensions and healthcare, thus encouraging a generalized attitude of slackness and negligence, or even abuse.
The social apathy around this issue does not stimulate a social demand for change in the current socio-sanitary system, nor does it push for a model centered on the rights and dignity of the person. It only generates more inattention in institutions and public administrations, and a lack of motivation to transform the system.
In this sector, as in many others, there is a resistance to change from within institutions, staff and professionals, and society in general. It is perceived that any transformation could result in added risk, extra workload and more importantly, a need for empathy and commitment for which not everyone is prepared.
Furthermore, the training professionals receive is mainly focused on the technical and healthcare aspects, rather than emotional and social ones, converting them in mere implementers of procedures that seek cost and time efficiency.
The “social” element in socio-sanitary care has been lost, prioritizing clinical or health approaches over person-centered ones. The care provided to dependent persons is generally defined by the needs of the organizations and institutions, rather than the patients themselves. This leads to the establishment of unnecessary rigid norms that go from small but important issues such as sleeping schedules or family visits, into more serious ones such as the systematic use of physical and chemical restraints.
Restraints are an indicator of the “mechanization” of care procedures. Studies show some alarming statistics in this respect: While in the UK and Germany the percentage of elderly persons with restraints is of 4% and 5% respectively, in Spain – although there is a lack of official data – it is estimated that the rate reaches around 40%. Moreover, when treating people with dementia or mental illnesses, the percentage can reach up to 60-80% of patients restrained 24 hours a day, every day. These figures are similar in other southern European countries and Latin America.
The use of restraints is a practice derived from psychiatric care, with the well-intentioned objective of avoiding the patients from falling or hurting themselves or others. Although they are not considered a malpractice per se, physically or chemically restraining a person is a threat to his/her dignity and can cause severe physical and psychological consequences, without mentioning the financial costs that these damages can entail (extra treatment or medical attention).
There are existing initiatives within the socio-sanitary sector that seek to improve the quality of care, but these rarely address a systemic change from within the institutions, and concentrate on one-off campaigns with little or no follow-up that are difficult to measure.
With falling birth rates and an increasingly aging population, strain on Europe’s resources to maintain the older generation is increasing. In Spain, 18% of the population is 65 years old or older, while over 1.2 million people are officially dependent. Other European countries face an even more challenging situation in terms of aged populations such as Germany (20.8%) or Italy (21.4%).
The certifications and/or quality evaluation methods that do exist in this sector, such as ISO or EFQM, required in many cases by public administration and demanded by society, focus solely on assessing the procedures and management, excluding essential elements such as the impact of these procedures on the quality of life of the persons involved.
Ana Urrutia is changing the framework of aging and dependence by radically transforming the institutions responsible for the care of dependent persons through a process that involves training, assessment and certification.
Ana reaches out to institutions and organizations through the implementation of Libera-Care, a flexible approach to gradual elimination of physical and chemical restraints that is eventually established as a certifiable norm. The certificate, recognized by a wide community of national and international professionals and validated by the National Accreditation Entity (ENAC, in Spanish), is not an end in itself, but part of the transformation process, which requires changes in the cultural and physical environment of each institution.
The implementation of Libera-Care is a four-year process divided into three phases: in Phase I, the organization is trained and sensitized on the non-use of restraints and the implementation of other practices, based on the needs, preferences and well-being of the patient. Phase II focuses on the cultural transformation of the organization, and in Phase III, once the institution is ready, alternatives to physical and chemical restraints are generated. The final stamp is the certificate, revised and renewed every five years. The structural changes in staff roles, teamwork, decision-making processes, management models and the overall work culture of the organization are the elements of Ana’s strategy that ensure a systemic change within the sector.
Through the Cuidados Dignos Foundation, Ana and her team offer training and support in the implementation of the Libera-Care methodology. Moreover, the training material, as well as the indicators used to assess the certification, is publically available, allowing any institution across the country to implement the process on its own and independently apply for the certificate. Both the training service and the certification also function as a business model (institutions pay to receive the training and/or be certified) to ensure the foundation’s sustainability. Since 2006, more than 120 centers of all types and sizes are applying the Libera-Care model.
Ana’s vision is that these indicators are expected and required not only by society but by the public administrations, whot via their own institutions or as funders of private ones are in a strong position to change the way care institutions work.
Libera-Care measures its impact in terms of quality of life, evaluating results not only on the physical wellbeing of the patients but including factors such as the number and severity of falls (drastically reduced since the implementation of the methodology), the use of chemical restraints and other drugs, or behavioral improvement. Other relevant outcomes include increase in the patients’ families’ satisfaction, improvement in the organization’s image and perception, and greater staff satisfaction and motivation.
The Libera-Care certificate is a tool used to leverage the power of social demand and awareness, generating a multi-stakeholder movement in which organizations, professionals, public administration and society (family members, patients etc.) take part in the transformation.
Ana’s process of organizational transformation aims to generate a widespread demand for change in the sector, going beyond a change in public and private residential homes, extending to homecare, hospitals and other institutions. She does this by acting as an ambassador for the Libera-Care model, raising awareness in strategic channels (medical networks, media, conferences) and lobbying to key partners in the private and public sector.
Influenced by the strong affection for her grandfather, Ana studied to become a geriatrician. In the absence of geriatrics in the public sector in her region, and given her natural instinct to take care of elderly people, she quit her job and, with the support of family and selected partners, set up her own center for elderly care.
Ana’s personal and professional track naturally evolved towards the creation of Libera-Care. One of the tipping points in her career occurred when a colleague – also family member of one of the patients in her residence – criticized the use of restraints in her center. Faced with mixed emotions of irritation for being criticized, but also frustration for not finding a better solution – “this is how it’s always been done” – Ana’s professional mindset was transformed.
Unable to ignore this revelation, Ana researched and enquired, and eventually tested and developed alternatives to physical and chemical restraints in her own center. Having witnessed the incredible results, and after waiting in vain for the public administration to reply to her proposal to extend the newfound model to other organizations, she decided to lead the process on her own.
As a result she founded the Cuidados Dignos Foundation with the objective of expanding her model. At first, with scarce resources, she attended and accompanied each organization one by one, identifying the early adopters, both in private enterprises and the public administration, most likely to undertake the necessary steps. Today, Ana’s teams work on training and certification, while she focuses on lobbying and raising awareness on the urgent need for a paradigm shift nationwide and across other sectors.