Rhythms of Daily Living Rhythms of Daily Living © Liberating Care & Navigating Change A Culture of Choice Dining as a Catalyst Aligning Experiences – Expectations

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


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


Must Rising Acuity Levels Mean Lower Dining Quality ?

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Independent Living Assisted Living Memory Enhanced Skilled Nursing

Nutrition Quality Food Quality Service Quality Life Quality


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


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


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


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


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?


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.


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.


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.


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


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


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.


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


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


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?


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


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


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


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.


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


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.


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


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.


Community Strategic Objectives1) Community of Distinction

2) Financial Enhancement

3) Quality of Living / Quality of Work

4) Operational Effectiveness


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


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


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


Alignment

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


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


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


POS Systems

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

Micros http://www.micros.com/


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


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


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

H.L. Mencken