Liberating Care in a Culture of Choice: Navigating Change Dining as Catalyst Aligning Experiences – Expectations – Resources – Outcomes

Liberating Care in a Culture of

Choice: Navigating Change

Dining as Catalyst

Aligning Experiences – Expectations – Resources – Outcomes

September 15, 2004 AOPHA Annual Conference - The Power to Change Our World

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Need for Change?! Do you think so?Insanity – to continue to do the same things and

expect different outcomes

It is increasingly clear that we need to change the environment, practices and culture of caring for and with residents. What we have been doing is not as effective as necessary or possible.


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Changing Demographics More Couples More Choice & Selection More Control More Flexibility Experience Consumers More Knowledgeable of CCRC Living Healthier – Wellness Important Seamless Experience Broader Constituencies


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The Customer Value Of Positive ExperienceA Memorable Feeling Created By You

Relative Customer Value

EXPERIENCE

SERVICE

GOOD

RAW MATERIAL

Source OfCustomer Loyalty

Created WithinThe Customer

Created ByA Provider


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How Do You Individualize Care?1. What Are Strategic Objectives?

Current Strengths Opportunities Identified For Improvement

2. What Is The Vision for Community Dining Experience? Choice

Menu, Time and Venue?

3. What Is History of “Transformation” Projects? What Were Expectations How Defined and Structured How was it trained & accepted?

What Are The Most Important Experiences? Resident Experiences Staff Experience Family & Other Stakeholders?


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Choice Is The Way We Live

“Some facilities studied, usually the lower turn-over ones, were in the process of thinking about how to increase individualized care. For example, the researcher asked, what are you doing if anything about resident choice. ‘We are looking at it. Ideally, we want them to eat when they want. We encourage them to tell us what care they want, a shower or bath, or to get up when they want.”

Page 5-49 Appropriate of Minimum Nurse Staffing Ratios in Nursing Homes, Phase II Final Report prepared by Abt Associates for the Centers for Medicare and Medicaid Services, December 2001.


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The ROI Of A Dining ExperienceBuilding “Experience Equity”

Dining establishes the daily quality of life for all members of a senior living community. The culture defined by the dining experience resonates with and dictates that of the entire community. The dignity and joy of making self-determined choices are at the core of any good dining experience.

BAD DINING

EXPERIENCE

GOOD DINING

EXPERIENCE

High Staff Turn-Over/Contract Labor = High Costs & Poor Morale/Service

High Staff Retention = Lower Labor Costs

High Food Waste/Use of Supplements = High Food Cost

Low Food Waste/Elimination of Supplements = Lower Food Costs

Low Appetite/Unanticipated Weight Loss = High Care Costs

Healthy Appetite = Lower Care Costs

Poor Image = Higher Marketing Costs and Lower Income

Great Dining Program = Lower Conversion Costs & Higher Occupancy


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Attributes of Community Dining Program The dining service program will provide a variety of dining venues,

services and menu selection for all community constituencies. The dining service program will expand and enhance its offerings

while remaining consistent with established traditions, ministry and mission.

The program must accommodate current constituency expectations and traditions while providing for anticipated expanding community requirements.

The program will identify skill sets required for service delivery to initiate transition training and identify appropriate personnel.

The dining experience will be developed with consideration to: a seamless service regardless of level of care, a singular community service, measurable key success indicators, fully leveraged efficiencies, creation of a signature service brand for community.


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What are the Attributes of a Quality Dining Experience? Quality of menu item presentation Appetizing Taste Variety Atmosphere, environment Pleasant service Choice Consistency China/glassware Timely Appropriate temperature & consistency


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Quality of Living ConsiderationsA large proportion of nursing home residents are malnourished

and up to half are substandard in body weight, leading to serious consequences including infections, hip fractures, and even death. The environment in which residents eat and the degree to which residents may choose when and what to eat can affect residents’ health (malnutrition and dehydration) and quality of life (perceived safety, enjoyment, social relationships, individuality, autonomy, choice). [i],[ii],[iii]

[i] Burger, S.G., Kayser-Jones, J., and Bell, J. P. “Malnutrition and Dehydration in Nursing Homes: Key Issues in Prevention and Treatment.” National Coalition for Nursing Home Reform. June 2000.

[ii] Chou, S., Boldy, D., and Lee, A. “Resident Satisfaction and Its Components in Residential Aged Care.” The Gerontologist 42:188-198, 2002.

[iii] Kane, R. “Long-Term Care and a Good Quality of Life” The Gerontologist 41:293-304, 2001.


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Rhythms of Daily LivingRhythms of Daily LivingThe core of RDL is the opportunity to exercise choice –

residents’ for how they choose to live their day and staff choice for care delivery. This creates a collaborative coalition of residents and caregivers working together in a living environment. RDL facilitates the delivery of care, the experience of living and the dignity of self-determination.

RDL is a management principle that aligns the natural rhythms of residents and the support they need. The organizing principle of RDL is that people should be able to make meaningful choices in their daily lives – on their own or with assistance. RDL relies on caregivers to help define and achieve outcomes that balance individual choice and system efficiency.


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STAGES of RDL Readiness GAP Analysis

Establish clear understanding among all constituents of program impact on 6 principle areas. Culinary Capacity

Establish a servery on the resident floor Individualized Service

Establish a service program without the tray system. Meals are plated when the resident is ready. Choice is based on pre-ordered menu items, however time of service is not flexible.

Point of Service Menu Choice Establish the opportunity for the resident to choose alternate items from a menu during meal service.

Schedule Choice I[1] Establish the opportunity for residents who are self-sufficient and independent to dine at a time of their

choosing, within established service times. Schedule Choice II

Establish the opportunity for residents who require assistance with dining but are able to determine when they would like to dine to do so within established service times.

7. Venue Choice (If Appropriate) Establish the opportunity for residents to choose alternate places to dine.

[1] Schedule choice is the last and most difficult stage to implement because it affects the scheduling of all resident activities from bathing to medication and activities.


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Comparison of CulturePioneer Network

Institution-Directed Culture Staff provide standard

“treatments” based on clinical Institutional defined schedule and

routines – resident comply Work is task oriented and staff

rotates assignments – interchangeable residents

Centralized decision making Hospital environment Structured activities There is a sense of isolation and

loneliness

Choice – Directed Culture Staff enters into a care giving

relationship based upon individualized care & resident desire

Residents and staff design the schedules

Care is relationship-centered, consistent assignments

Frontline decision making Environment reflects the comforts

of home Spontaneous activities Sense of community and

belonging


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Culture

CULTURE OF CURE CULTURE OF CARE

LEADERSHIP HIERARCHIAL SERVANT

ENVIRONMENT OUTCOME RSIDENT

FOCUS QUALITY OF CURE QUALITY OF LIFE

PROCESS STRUCTURED SPONTANEOUS

WORKMANSHIP CERTAINTY RISK

MEASURE OBJECTIVE SUBJECTIVE

REGULATION PROCESS ENVIRONMENT

PRIMARY SKILL/PERSONALITY SCIENCE ART


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A Culture of Caring vs. a Culture of CuringThere is a significant difference between these two

cultures. A culture of curing, the medical model, requires workmanship of certainty – specific, objective, regimented procedures to achieve a specific outcome. A culture of caring, the LTC model, requires workmanship of risk – the collaborative relationship to create a quality of living experience that is subjective and defined by the resident and care provider at the moment of service.


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Workmanship of Riskvs. Workmanship of Certainty

The distinction between workmanship of risk and workmanship of certainty turns on the question "Is the result predetermined and unalterable once production begins?"


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Workmanship of Risk & Workmanship of CertaintyCultural & Leadership Attributes

Workmanship of certainty requires a traditional hierarchical leadership style. Workmanship of risk is best developed with a servant leadership model of direction. Leadership defines, through collaborative development, the expectations. The role of servant leadership is to then provide the community direction and then assure that staff have the necessary resources and environment for achieving the experiential outcomes.


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Servant Leadership

“I don’t necessarily have to like my players and associates, but as the leader I must love them. Love is loyalty, love is teamwork, love respects the dignity of the individual. This is the strength of any organization.”

Vince Lombardi

It is the value and contribution of each individual, staff and resident, that creates a culture based upon the dignity of self-determination and choice.


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Independent Living Residents Resident Choice Dining Flexible Service Options

Café/deli Traditional Dining Take Out “Mise en place” Dining

Multiple Service Venues Wellness


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Assisted Living

Flexible Service Options Traditional Dining Take Out Multiple Service Venues


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Skilled Nursing

RDL Dining Flexible Schedule Increased Menu Options with New Cooking

Applications “country kitchen”


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Staff

Selection Fresh Quality - not a “Leftover” Dumping Station Home Replacement Meals


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Must Rising Acuity Levels Mean Lower Dining Quality ?

©©

Independent Living Assisted Living Memory Enhanced Skilled Nursing

Nutrition Quality Food Quality Service Quality Life Quality


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Skilled Care Dining TodayRestricted Service Times, Too Short For Quality & Assistance

< 20 MinutesFor Dining

0 10 20 30 40 50 60

Minutes

Loading Time

Transport Time

Waiting Time

Service Time

Dining Time

Extra Assistance

Food Quality Zone

Temp. Integrity

The Quality Gap


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Bridging The Quality GapServe The Resident, Not The System

The System – Individual Preparation, Bulk Service Prepare Individual Menu Items For Storage Place On A Tray For Transport To Feeding Area Transport and Leave In Cart Distribute and Unwrap At Scheduled Meal Time

The Alternative – Bulk Preparation, Individual Service Prepare Menu Items In Bulk Transport To Dining Room Servery Plate Individually and Serve Upon Request


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40% of Residents Gain Weight In The First Few Program Months

50% Reduction In The Number Of Residents Losing Weight. Consistent Improvement In Resident Satisfaction $0.18 – $0.21 Reduction In Food Cost Per Meal From Less

waste. 85% Decrease In Use of Supplements Higher Job Satisfaction Improved Hydration Outcomes Exceed Regulatory Requirements

RDL Is RealReported Results From Communities That Have Implemented RDL


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Alignment

The appropriate positioning of systems and resources to attain a defined goal, mission, outcome or culture


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When Landing A Plane, What Is The Main Thing? 1

1. Concepts and Diagrams From The Power of Alignment - How Great Companies Stay Centered and Accomplish Extraordinary Things By G. Labovitz/V. Rosansky

Left Of RunwayAltitude Too High Aligned

Air Speed

Cross Winds

Altitude

Wind Speed

Pitch


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The Main Thing

Choice


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STRATEGIC OBJECTIVES – TACTICAL IMPLEMENTATION PROJECT MAPPING

As dining options and program enhancements are discussed, specific initiatives are defined and envisioned by department management and staff. These new “dining experiences" require a specific definition process from concept to strategic alignment to tactical implementation.

Executive and Board leadership must clearly identify specific strategic organizational considerations. Leadership must clearly define their expectation and measurement of a successful contribution to the community strategic vision. This must take place prior to the initiation of Step 1.


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Map Process Steps #1, 2 ,3

Strategic Objectives

Community of Distinction

Financial Enhancement

Quality of LivingQuality of Work

OperationalEffectiveness

Map#1Strategic Objective Benefit

-Maintain market position – choice-

Breakeven in program Diverse dining experiencePredictable programMore active dining experience

Generate additional volumeGreater efficiency

Map #2Benefit Measure

Sales & marketing Operating reports Response surveysDiverse menuStaff turnoverQuality of wellness

Productivity factorsFood cost

Measurement Tool Sales reports P&L Meal countsResident wellnessTurnover reportsGuests & family meals

Cost & management reports

Map #3 Administration Regulatory Operations Personnel PP&E Community

Operational Resource Requirements

POSBoard supportDepartmental support

NA Menu developmentService model

TrainingRecruitment for positions

Kitchen design

Educationcollaboration

Budget Impact $/FTE’s


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Assessment Points for RDL ImplementationStages are defined against the requirements of: Administration: fiscal, management and leadership

considerations Regulatory: compliance criteria (grouped by clinical and

operational considerations) Systems: software programs, forms, policy & procedures,

protocols Personnel: staffing requirements, training, HR. The impact

on each care disciplines is identified by department PP&E: Property, Plant & Equipment necessary to perform

the tasks and functions Community: Communications, Resident & Family

education; community collaboration


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Map Process Steps #4, 5

Map #4CollaboratingDepartments

Resident Services

Finance Pastoral Housekeeping Maintenance Activities

Task

Map #5TaskImplementation

Nursing ResidentServices

Therapies Pastoral Housekeeping Maintenance Activities

Procedure

Policy

ResourceRequirement

Inform/Train

Measure


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Project Management

ID Task Name

12 Review Horizon Proposal

13 Approve and Accept

14

15

16 Organize

17 Presentations of service concept and education

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19 Define

20 Review community operational expectations & outcomes

21 Identify and assign measurements

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23 Plan

24 Coordinate Plan for Installation

25 Develop Plan for Coordinated Training

S M T W T F S S M T W T F S S M T W T F S S M T W TApr 25, '04 May 2, '04 May 9, '04 May 16, '04


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Service Impact of Choice

Open Service and Schedule Food Integrity & Safety Service Flexibility Decentralized Tasks to Allow for Staff Presence Resident Centered Schedule Seamless Environment Through Continuum Transparent Use by Constituencies


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Points of Utilization The full utilization of the kitchen capacity often

can be expanded by staffing evening shifts. The points of operational separation are: Receiving Storage Preparation Production Service Sanitation

The first three functions are not time sensitive.


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Design Impact of Choice

Aligning Current Culture with New Expectations Look for Operational Solutions 1st

Understand Nuances of Current & Evolving Cultures Identify Conflict Points and Educate to Alleviate Create Environment for “All Boats Rise” Experience Leadership for Culture Transformation


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Balancing the Natural Rhythms of Resident Living and Care Work A “More Normal” Pattern of Living and Work

Residents Eat What And When They Want Over A Longer Meal Service Pre-Meal Medications, Bathing and Other Activities Are Less Pressured Staff Provides Assistance As Required

24 Minutes Is Average Optimal Feeding Assistance Time With A Range From 5 To 70 Minutes Depending On ADL Status*

48% Of Nursing Home Population Require Some Degree of Assistance* A Dining Experience, Not A Feeding Period

Shift Dining Service Focus From Trays To Residents and Quality Collaborative Service Support Aroma Therapy Course Presentation Minimal Distraction Environment

*Excerpts From Ch 14 Of Report To Congress “Appropriateness of Minimum Staffing Ratios In Nursing Homes” Authored By J. F. Schnelle et al, Borun Center For Gerontological Research


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PLAN & DEVELOP

Organize

Alter

Codify

TrainImprove

Choice AlignmentProcess Overview

Plan

Evaluate

Define

Assess

Implement


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Continually Test For Outcome And Process AlignmentMake Sure That Procedures Are Practiced, Understood and Working

Procedures

Assure Train

Assess

AssessCurrent Practices

AssureExpected

Outcomes Train Improved Procedures

(Test Understanding Of What and Why)

Develop Improved

Procedures, Revise Tools and Protocols


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Fixed & Variable Navigation Points Fixed

Budget & Cost Management System Schedule – Timeline – Scope of Work Process Map

Variable POS Resident Preference/Therapeutic Data Production Systems Satisfaction & Leadership Effectiveness Survey Project Manager


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Technology Applications

Excel Budget & Cost Management Worksheets Microsoft Project Manager Visio Flow Management Software POS Resident Data Management Satisfaction Survey Documents Leadership Effectiveness Survey Documents Operational & Compliance Gap Analysis


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Project Management

ID Task Name

12 Review Horizon Proposal

13 Approve and Accept

14

15

16 Organize

17 Presentations of service concept and education

18

19 Define

20 Review community operational expectations & outcomes

21 Identify and assign measurements

22

23 Plan

24 Coordinate Plan for Installation

25 Develop Plan for Coordinated Training

S M T W T F S S M T W T F S S M T W T F S S M T W TApr 25, '04 May 2, '04 May 9, '04 May 16, '04


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POS Systems

Horizon Software http://www.horizon-boss.com/default.htm

Micros http://www.micros.com/


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Satisfaction & Leadership Effectiveness Survey


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Operational & Compliance Gap Analysis


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"For every complex, difficult problem,There is a simple solution.And, it is probably wrong!"

H.L. Mencken


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Additional Culture Change Organizations Culture Change Now!

http://www.culturechangenow.com/index.html The Pioneer Network

http://www.pioneernetwork.org/ Dining Management Resources, Inc.

770-855-3135 www.dm-resources.com [email protected]