liberating care & navigating change a culture of choice: dining as a catalyst aligning...
TRANSCRIPT
Liberating Care & Navigating Change
A Culture of Choice: Dining as a Catalyst
Aligning Experiences – Expectations – Resources – Outcomes
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Session Objectives
Review Changing Factors of Environment & Constituencies Demographics
Define Service Model Introduce Choice Dining Concept Discuss Culture of Service, Leadership, Choice Discussion of Process
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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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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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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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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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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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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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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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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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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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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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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
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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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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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Service Impact of Choice
Open Service and Schedule Food Integrity & Safety Service Flexibility Decentralized Tasks to Allow for Staff Presence Resident Centered Schedule/Flex Staff Seamless Environment Throughout Continuum Transparent Use by Constituencies
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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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Leadership Impact of Choice
Aligning Current Culture with New Expectations Servant Leadership Understand Nuances of Current & Evolving
Cultures Identify Conflict Points and Educate to Alleviate Create Environment for “All Boats Rise”
Experience Leadership for Culture Transformation - #1
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STRATEGIC OBJECTIVES – TACTICAL IMPLEMENTATION PROJECT MAPPINGAs 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.
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Map Process #1, 2 ,3
Strategic Objectives
Community of Distinction
Financial Enhancement
Quality of LivingQuality of Work
OperationalEffectiveness
Map#1Strategic Objective Benefit
Map #2Benefit Measure
Measurement Tool
Map #3 Administration Regulatory Operations Personnel PP&E Community
Operational Resource Requirements
Budget Impact $/FTE’s
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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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Design Impact of Choice
Temperature Management & Integrity Ware washing Light production capacity Resident visual & sensory engagement Possible multiple tasks – activities & cooking
classes Dining area incorporated into the resident space
usage flow
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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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POS Systems
Horizon Software http://www.horizon-boss.com/default.htm
Micros http://www.micros.com/
Advanced Answers on Demand www.advanced-answers.com
Positouch
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Contact
Dan Look – 770-565-4006Dining Management Resources, Inc.
3605 Sandy plains Road
Suite 240-269
Marietta, GA [email protected]
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"For every complex, difficult problem,There is a simple solution.And, it is probably wrong!"
H.L. Mencken