Transcript National Certification Program for Retirement Housing

National Certification Program for Retirement Housing Professionals
CORE COURSE III
Managing the Financial and Physical Environments
Lesson
Dining Management and Philosophy of Service in Long-Term
Care
Date:
November 6, 2005
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
National Certification Program for Retirement Housing Professionals
Slide 2
“We did the best we could, with what we
knew,
And when we knew better, we did better. “
Maya Angelou
National Certification Program for Retirement Housing Professionals
Slide 3
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.
National Certification Program for Retirement Housing Professionals
Slide 4
•
•
•
•
•
•
•
•
•
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
National Certification Program for Retirement Housing Professionals
Slide 5
Assumptions
• Envision the Future, Honor the Tradition
• Imposition of Dining
• Until the Experience Dining is Resident
Centered, a New Culture will not Take Deep
Root
• What is Current Does Not Work As Well As It
Can & Should
National Certification Program for Retirement Housing Professionals
Slide 6
Must Rising Acuity Levels Mean
Lower Dining Quality ?
©
Independent Living
Nutrition Quality
Assisted Living
Food Quality
Memory Enhanced
Service Quality
Skilled Nursing
Life Quality
National Certification Program for Retirement Housing Professionals
Slide 7
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
National Certification Program for Retirement Housing Professionals
Slide 8
Skilled Care Dining Today
Restricted Service Times, Too Short For Quality & Assistance
Loading Time
Transport Time
Waiting Time
< 20 Minutes
For Dining
Service Time
The Quality Gap
Dining Time
Extra Assistance
Food Quality Zone
Temp. Integrity
0
10
20
30
40
50
60
Minutes
National Certification Program for Retirement Housing Professionals
Slide 9
Bridging The Quality Gap
Serve 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
National Certification Program for Retirement Housing Professionals
Slide 10
What Are Factors of a Quality Dining
Experience?
 Individual Service Honoring Personal Eating Habits Generational Expectations
 Choice
 Where & When You Eat
 Residents Eat When Hungry
 Defined And Met Expectation = Reputation & Consistency
 Presentation Of Meal, Taste & Pace “Do Not Rush Me”
 Neighbors Atmosphere, Aroma, Friendliness, Relationships
National Certification Program for Retirement Housing Professionals
Slide 11
How Do You Individualize Care?
 What Are Strategic Objectives?
 Must Contribute
 What Is The Vision for Community Dining
Experience?
 Choice
 What Is History of “Transformation” Projects?
 What Were Expectations
 How Defined and Structured
 How was it trained & accepted?
 What Are Constituency Most Important Experiences?
National Certification Program for Retirement Housing Professionals
Slide 12
Rhythms of Daily Living
The 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.
National Certification Program for Retirement Housing Professionals
Slide 13
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.
National Certification Program for Retirement Housing Professionals
Slide 14
Quality of Living Considerations
A 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.
National Certification Program for Retirement Housing Professionals
Slide 15
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
National Certification Program for Retirement Housing Professionals
Slide 16
RDL Is Real
Reported Results From Ten Communities That
Have Implemented RDL
• 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
• $0.25 – $0.32 Reduction In Food Cost Per Meal From Less
waste.
• 85% Decrease In Use of Supplements
• Higher Job Satisfaction
• Improved Hydration
• Outcomes Exceed Regulatory Requirements
National Certification Program for Retirement Housing Professionals
Slide 17
The ROI Of A Dining Experience
Building “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 selfdetermined 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
National Certification Program for Retirement Housing Professionals
Slide 18
Comparison of Culture
Pioneer 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
National Certification Program for Retirement Housing Professionals
Slide 19
Culture
CULTURE OF CURE
CULTURE OF CARE
HIERARCHIAL
SERVANT
OUTCOME
RSIDENT
QUALITY OF CURE
QUALITY OF LIFE
STRUCTURED
SPONTANEOUS
WORKMANSHIP
CERTAINTY
RISK
MEASURE
OBJECTIVE
SUBJECTIVE
REGULATION
PROCESS
ENVIRONMENT
PRIMARY SKILL/PERSONALITY
SCIENCE
ART
LEADERSHIP
ENVIRONMENT
FOCUS
PROCESS
National Certification Program for Retirement Housing Professionals
Slide 20
A Culture of Caring vs. a Culture of
Curing
There 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.
National Certification Program for Retirement Housing Professionals
Slide 21
Workmanship of Risk
vs. 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?"
National Certification Program for Retirement Housing Professionals
Slide 22
Workmanship of Risk & Workmanship of Certainty
Cultural & 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.
National Certification Program for Retirement Housing Professionals
Slide 23
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
National Certification Program for Retirement Housing Professionals
Slide 24
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.
National Certification Program for Retirement Housing Professionals
Slide 25
STAGES of RDL
1. 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.
National Certification Program for Retirement Housing Professionals
Slide 26
Stages of RDL
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.
National Certification Program for Retirement Housing Professionals
Slide 27
Stages of RDL
5.
Schedule Choice I[1]
– Establish the opportunity for residents who are selfsufficient 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.
National Certification Program for Retirement Housing Professionals
Slide 28
Assessment Points for RDL
Implementation
Stages 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
National Certification Program for Retirement Housing Professionals
Slide 29
Obstacles
 Structure of resident 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
National Certification Program for Retirement Housing Professionals
Slide 30
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 Objectives
3) Define Appropriate Measurements Of Successful Experience Outcomes
4) Identification Of Resource And Operational Intersects
5) Identification Of Intersects And Roles Of Other Contributing Departments
6) Structure Of The Process For Resource Allocation To Develop The Defined
Initiative
7) Sequencing Of The Tasks
8) Implementation of The Initiative.
National Certification Program for Retirement Housing Professionals
Slide 31
Community Strategic Objectives
1)
2)
3)
4)
Community of Distinction
Financial Enhancement
Quality of Living / Quality of Work
Operational Effectiveness
National Certification Program for Retirement Housing Professionals
Slide 32
Program Intersects Grid
Strategic
Objectives
Community of
Distinction
Financial
Enhancement
Quality of
Living
Quality of Work
Operational
Effectiveness
Administration
Regulatory
Operations
Personnel
Step #1
Strategic
Objective Benefit
Step #2
Benefit Measure
Measurement
Tool
Step #3
PP&E
Communit
y
Operational
Resource
Requirements
Budget Impact
$/FTE’s
National Certification Program for Retirement Housing Professionals
Slide 33
Program Intersects Grid
Strategic
Objectives
Community of
Distinction
Financial
Enhancement
Quality of Living
Quality of Work
Operational
Effectiveness
Step #4
Collaborating
Departments
Nursing
Resident
Services
Therapies
Pastoral
Housekeeping
Maintenance
Activities
Nursing
Resident
Services
Therapies
Pastoral
Housekeeping
Maintenance
Activities
Task
Step #5
Task
Implementation
Procedure
Policy
Resource
Requirement
Inform/Train
Measure
National Certification Program for Retirement Housing Professionals
Slide 34
Project Management
National Certification Program for Retirement Housing Professionals
Slide 35
Alignment
• The appropriate positioning of
systems and resources to attain a
defined goal, mission, outcome or
culture
National Certification Program for Retirement Housing Professionals
Slide 36
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
National Certification Program for Retirement Housing Professionals
Slide 37
POS Systems
• Horizon Software
– http://www.horizon-boss.com/default.htm
• Micros
– http://www.micros.com/
National Certification Program for Retirement Housing Professionals
Slide 38
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/de
fault.htm
National Certification Program for Retirement Housing Professionals
Slide 39
Contact Information
• Dan Look
– 3605 Sandy Plains Road
– Suite 240-269
– Marietta, GA 30066
• [email protected]
• www.dm-resources.com
• 770-565-4006
National Certification Program for Retirement Housing Professionals
Slide 40
"For every complex, difficult problem,
There is a simple solution.
And, it is probably wrong!"
H.L. Mencken
“An unreasonable man tries to change
the world’s thinking to fit his own.
The reasonable man adjusts his thinking
to fit the world.
Therefore, all progress relies on the
unreasonable man.”
National Certification Program for Retirement Housing Professionals
Slide 41
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
National Certification Program for Retirement Housing Professionals
Slide 42