Transcript Rhythms of Daily Living

Rhythms of Daily Living
©
Liberating Care & Navigating Change
A Culture of Choice
Dining as a Catalyst
Aligning Experiences – Expectations – Resources – Outcomes
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
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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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Must Rising Acuity Levels Mean Lower
Dining Quality ?
©
Independent Living
Nutrition Quality
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Assisted Living
Food Quality
Memory Enhanced
Service Quality
Scripps/SAGE Conference
Skilled Nursing
Life Quality
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Why Do 65% Of NH Residents Eat
Less Than 75% Of Most Meals* ?
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Primary Factors That Contribute To Malnutrition
In Nursing Homes
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An Inappropriate Dining Experience For The
Resident.
Meal Delivery Methodology and Systems Not
Conducive To Eating.
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
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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
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40
50
60
Minutes
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Bridging The Quality Gap
Serve The Resident, Not The System
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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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What are the Attributes of a Quality Dining Experience?
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Quality of menu item presentation
Appetizing
Taste
Variety
Atmosphere, environment
Pleasant service
Choice
Consistency
China/glassware
Timely
Appropriate temperature & consistency
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How Do You Individualize Care?
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What Are Strategic Objectives?
 Current Strengths
 Opportunities Identified For Improvement
What Is The Vision for Community Dining Experience?
 Choice
 Menu, Time and Venue?
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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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.
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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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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]
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[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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Balancing the Natural Rhythms of Resident
Living and Care Work
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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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RDL Is Real
Reported Results From Ten Communities That Have
Implemented RDL
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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
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STAGES of RDL
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Readiness GAP Analysis
Establish clear understanding among all constituents (residents, staff and administration) as to the
program impact on 6 principle areas.
Culinary Capacity
Establish a servery on the resident floor where all meals can be finished, plated and served.
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.
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.
Venue Choice (If Appropriate)
Establish the opportunity for residents to choose alternate places to dine.
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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
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Outcomes
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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
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What Are Your Experiences?
Benefits
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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
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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
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Comparison of Culture
Pioneer Network
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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
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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
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
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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.
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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
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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.
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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
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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.
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Community Strategic Objectives
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Community of Distinction
Financial Enhancement
Quality of Living / Quality of Work
Operational Effectiveness
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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
Community
Operational
Resource
Requirements
Budget Impact
$/FTE’s
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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
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Project Management
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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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Fixed & Variable
Navigation Points
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Fixed
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Budget & Cost Management System
Schedule – Timeline – Scope of Work
Process Map
Variable
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POS
Resident Preference/Therapeutic Data
Production Systems
Satisfaction & Leadership Effectiveness Survey
Project Manager
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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
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POS Systems
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Horizon Software
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http://www.horizon-boss.com/default.htm
Micros
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http://www.micros.com/
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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
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http://www.providence.org/Long_Term_Care/Mount_St_Vincent/default.ht
m
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Contact Information

Dan Look
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3605 Sandy Plains Road
Suite 240-269
Marietta, GA 30066
[email protected]
 www.dm-resources.com
 770-565-4006
 Irene Dennis 989-275-8936

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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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