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Rhythms of Daily Rhythms of Daily LivingLiving©
Liberating Care & Navigating Change
A Culture of Choice Dining as a Catalyst
Aligning Experiences – Expectations – Resources – Outcomes
October 20. 2005 Scripps/SAGE Conference 2
Session Objectives
Review Changing Factors of Environment & Constituencies
Review Demographics Define Assumptions Introduce Choice Dining Concept Discuss Culture of Service, Leadership, Choice Fixed & Variable Navigation Technology Applications
October 20. 2005 Scripps/SAGE Conference 3
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
October 20. 2005 Scripps/SAGE Conference 4
Must Rising Acuity Levels Mean Lower Dining Quality ?
©©
Independent Living Assisted Living Memory Enhanced Skilled Nursing
Nutrition Quality Food Quality Service Quality Life Quality
October 20. 2005 Scripps/SAGE Conference 5
Why Do 65% Of NH Residents Eat Less Than 75% Of Most Meals* ? Primary Factors That Contribute To Malnutrition In
Nursing Homes 1. An Inappropriate Dining Experience For The Resident.
2. Meal Delivery Methodology and Systems Not Conducive To Eating.
3. Good Nutrition is of no value if it is not consumed
*Excerpted 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
October 20. 2005 Scripps/SAGE Conference 6
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
October 20. 2005 Scripps/SAGE Conference 7
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
October 20. 2005 Scripps/SAGE Conference 8
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
October 20. 2005 Scripps/SAGE Conference 9
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?
October 20. 2005 Scripps/SAGE Conference 10
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.
October 20. 2005 Scripps/SAGE Conference 11
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.
October 20. 2005 Scripps/SAGE Conference 12
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.
October 20. 2005 Scripps/SAGE Conference 13
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
October 20. 2005 Scripps/SAGE Conference 14
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 Ten Communities That Have Implemented RDL
October 20. 2005 Scripps/SAGE Conference 15
STAGES of RDL1. Readiness GAP Analysis
Establish clear understanding among all constituents (residents, staff and administration) as to the program impact on 6 principle areas.
2. Culinary Capacity Establish a servery on the resident floor where all meals can be finished, plated and served.
3. Individualized Service Establish a service program without the tray system. Meals are plated in the servery when the
resident is in the dining room. Choice is based on pre-ordered menu items, however time of service is not flexible.
4. Point of Service Menu Choice Establish the opportunity for the resident to choose alternate items from a menu during meal
service. 5. 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.
6. 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.
October 20. 2005 Scripps/SAGE Conference 16
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
October 20. 2005 Scripps/SAGE Conference 17
Outcomes No complaints Socialization Weight stabilization Improved I/O’s Less plate waste Smiles Reduced staff turnover Improved skin integrity Reduced use of supplements Congenial and pleasant environment – warm & inviting
October 20. 2005 Scripps/SAGE Conference 18
Benefits Better interaction with staff & residents Freedom of choice Residents more social amongst themselves Better presentation Food is hot/cold Better texture POS selection for menu items Better I/o’s Resident choice of time to eat/when hungry
What Are Your Experiences?
October 20. 2005 Scripps/SAGE Conference 19
What Are Your Experiences?Obstacles
Structure of ordering Staff resistance to change Inadequate staffing Training of staff to new tasks Management of change (fair process) Need to educate the staff in the process of change Clear explanations of the reasons/outcomes of changes How changes will impact staff security and knowledge
of job tasks and resident served
October 20. 2005 Scripps/SAGE Conference 20
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
October 20. 2005 Scripps/SAGE Conference 21
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
October 20. 2005 Scripps/SAGE Conference 22
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.
October 20. 2005 Scripps/SAGE Conference 23
Culture of Servant Leadership“Servant leadership is a long-term, transformational
approach to life and work, in essence, a way of being—that has potential for creating positive change within our society. . .”
Ron Ortiz Dinkel
“Servant leaders put other people’s needs, aspirations and interests above their own.”Robert Greenleaf
October 20. 2005 Scripps/SAGE Conference 24
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.
October 20. 2005 Scripps/SAGE Conference 25
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
October 20. 2005 Scripps/SAGE Conference 26
SERVICE INITIATIVE 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 process from concept to implementation. The following are the task requirements for this process:
1) Identify Service Initiatives 2) Define Their Contribution To Strategic Objectives3) Define Appropriate Measurements Of Successful Experience Outcomes4) Identification Of Resource And Operational Intersects5) Identification Of Intersects And Roles Of Other Contributing Departments6) Structure Of The Process For Resource Allocation To Develop The Defined
Initiative7) Sequencing Of The Tasks8) Implementation of The Initiative.
October 20. 2005 Scripps/SAGE Conference 27
Community Strategic Objectives1) Community of Distinction
2) Financial Enhancement
3) Quality of Living / Quality of Work
4) Operational Effectiveness
October 20. 2005 Scripps/SAGE Conference 28
Program Intersects Grid
Strategic Objectives
Community of Distinction
Financial Enhancement
Quality of LivingQuality of Work
OperationalEffectiveness
Step #1Strategic Objective Benefit
Step #2Benefit Measure
Measurement Tool
Step #3 Administration Regulatory Operations Personnel PP&E Community
Operational Resource Requirements
Budget Impact $/FTE’s
October 20. 2005 Scripps/SAGE Conference 29
Program Intersects GridStrategic Objectives
Community of Distinction
Financial Enhancement
Quality of LivingQuality of Work
OperationalEffectiveness
Step #4Collaborating Departments
Nursing Resident Services
Therapies Pastoral Housekeeping Maintenance Activities
Task
Step #5Task Implementation
Nursing Resident Services
Therapies Pastoral Housekeeping Maintenance Activities
Procedure
Policy
Resource Requirement
Inform/Train
Measure
October 20. 2005 Scripps/SAGE Conference 30
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
October 20. 2005 Scripps/SAGE Conference 31
Alignment
The appropriate positioning of systems and resources to attain a defined goal, mission, outcome or culture
October 20. 2005 Scripps/SAGE Conference 32
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
October 20. 2005 Scripps/SAGE Conference 33
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
October 20. 2005 Scripps/SAGE Conference 34
POS Systems
Horizon Software http://www.horizon-boss.com/default.htm
Micros http://www.micros.com/
October 20. 2005 Scripps/SAGE Conference 35
Additional Culture Change Organizations Culture Change Now!
http://www.culturechangenow.com/index.html The Eden Alternative
http://www.edenalt.com/ The Pioneer Network
http://www.pioneernetwork.org/ Providence Mount Saint Vincent
http://www.providence.org/Long_Term_Care/Mount_St_Vincent/default.htm
October 20. 2005 Scripps/SAGE Conference 36
Contact Information
Dan Look 3605 Sandy Plains Road Suite 240-269 Marietta, GA 30066
[email protected] www.dm-resources.com 770-565-4006 Irene Dennis 989-275-8936