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Transcript of Liberating Care in a Culture of Choice: Navigating Change Dining as Catalyst Aligning Experiences...
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.
September 15, 2004 AOPHA Annual Conference - The Power to Change Our World
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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
September 15, 2004 AOPHA Annual Conference - The Power to Change Our World
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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
September 15, 2004 AOPHA Annual Conference - The Power to Change Our World
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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?
September 15, 2004 AOPHA Annual Conference - The Power to Change Our World
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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.
September 15, 2004 AOPHA Annual Conference - The Power to Change Our World
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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
September 15, 2004 AOPHA Annual Conference - The Power to Change Our World
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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.
September 15, 2004 AOPHA Annual Conference - The Power to Change Our World
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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
September 15, 2004 AOPHA Annual Conference - The Power to Change Our World
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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.
September 15, 2004 AOPHA Annual Conference - The Power to Change Our World
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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.
September 15, 2004 AOPHA Annual Conference - The Power to Change Our World
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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.
September 15, 2004 AOPHA Annual Conference - The Power to Change Our World
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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
September 15, 2004 AOPHA Annual Conference - The Power to Change Our World
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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
September 15, 2004 AOPHA Annual Conference - The Power to Change Our World
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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.
September 15, 2004 AOPHA Annual Conference - The Power to Change Our World
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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?"
September 15, 2004 AOPHA Annual Conference - The Power to Change Our World
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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.
September 15, 2004 AOPHA Annual Conference - The Power to Change Our World
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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.
September 15, 2004 AOPHA Annual Conference - The Power to Change Our World
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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
September 15, 2004 AOPHA Annual Conference - The Power to Change Our World
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Assisted Living
Flexible Service Options Traditional Dining Take Out Multiple Service Venues
September 15, 2004 AOPHA Annual Conference - The Power to Change Our World
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Skilled Nursing
RDL Dining Flexible Schedule Increased Menu Options with New Cooking
Applications “country kitchen”
September 15, 2004 AOPHA Annual Conference - The Power to Change Our World
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Staff
Selection Fresh Quality - not a “Leftover” Dumping Station Home Replacement Meals
September 15, 2004 AOPHA Annual Conference - The Power to Change Our World
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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
September 15, 2004 AOPHA Annual Conference - The Power to Change Our World
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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
September 15, 2004 AOPHA Annual Conference - The Power to Change Our World
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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
September 15, 2004 AOPHA Annual Conference - The Power to Change Our World
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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
September 15, 2004 AOPHA Annual Conference - The Power to Change Our World
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Alignment
The appropriate positioning of systems and resources to attain a defined goal, mission, outcome or culture
September 15, 2004 AOPHA Annual Conference - The Power to Change Our World
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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
September 15, 2004 AOPHA Annual Conference - The Power to Change Our World
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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.
September 15, 2004 AOPHA Annual Conference - The Power to Change Our World
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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
September 15, 2004 AOPHA Annual Conference - The Power to Change Our World
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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
September 15, 2004 AOPHA Annual Conference - The Power to Change Our World
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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
September 15, 2004 AOPHA Annual Conference - The Power to Change Our World
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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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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
September 15, 2004 AOPHA Annual Conference - The Power to Change Our World
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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.
September 15, 2004 AOPHA Annual Conference - The Power to Change Our World
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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
September 15, 2004 AOPHA Annual Conference - The Power to Change Our World
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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
September 15, 2004 AOPHA Annual Conference - The Power to Change Our World
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PLAN & DEVELOP
Organize
Alter
Codify
TrainImprove
Choice AlignmentProcess Overview
Plan
Evaluate
Define
Assess
Implement
September 15, 2004 AOPHA Annual Conference - The Power to Change Our World
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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
September 15, 2004 AOPHA Annual Conference - The Power to Change Our World
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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
September 15, 2004 AOPHA Annual Conference - The Power to Change Our World
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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
September 15, 2004 AOPHA Annual Conference - The Power to Change Our World
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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
September 15, 2004 AOPHA Annual Conference - The Power to Change Our World
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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]