National Certification Program for Retirement Housing Professionals

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

“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

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

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

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

Must Rising Acuity Levels Mean Lower Dining Quality ?
1993 MALNUTRITION THIS IS APPLICABLE TO ALL LEVELS OF CARE IL CHOICE ON SERVICES AL/SNF CHOICE ON ADL’S RAISE HANDS National Certification Program for Retirement Housing Professionals

Why Do 65% Of NH Residents Eat Less Than 75% Of Most Meals*?
Primary Factors That Contribute To Malnutrition In Nursing Homes 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 There are, essentially, three disruptive times throughout the course of the day in the provision of care for the residents. These disruptions are breakfast, lunch and dinner. We need to provide for the residents’ activities of daily living. 70-80% of the residents require some assistance in dining May be as minor as merely cueing the resident to the meal As significant as assistance in dining on a one-to-one basis. Consequently, Nursing staff and caregivers require more time to serve and care for the resident. The current structure creates a stressful and disorienting process for the residents. Nursing staff and caregivers are not able to provide the quality of attentive care desired or necessary because they are responding to the high acuity demands of the residents and assisting them with their ADL’s. With more residents requiring increased ADL supportive care, the caregivers do not have sufficient time to give to individual resident attention during the meal period. They need more support during the meal service. *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

Skilled Care Dining Today Restricted Service Times, Too Short For Quality & Assistance < 20 Minutes For Dining The Quality Gap Not designed to accommodate the longer times necessary Effective dining support for the residents Menu item integrity and presentation. Dining service staff focused tray delivery - not service to the residents. Tray delivery system has optimum service capacity of 45 mins./7-8 units Load cart 8 mins/1 units Transport 12 mins/2 units Waiting in DR 6 mins/1 Service 6 mins/ 1 units 2 – 3 units, mins to eat Residents requiring assistance with dining average mins./5-6 units 20 residents per floor; 50% require assistance 3 CNA’s to provide units of care ??? The window of service for a tray delivery system is very restrictive. Consequently, all dining service functions have to take place in a restrictive timeframe. Resident care of and participation in their other ADL’s is also restricted and dictated by these times for feeding the residents. National Certification Program for Retirement Housing Professionals

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 It is our agenda and objective to eliminate as many level three tasks as possible and to move as much of the allocated personnel and time resources from Dining Services to as close to a level impact in service as possible. This allocation of Dining Services staff to a closer contact with the residents provides a supportive and collaborative relationship with the care providers on the Health Care Center and Special Care. We are looking at creating service pantries for meal delivery in each service area. The service pantries would eliminate tray service. All menu items would be transported to the service pantries and held in appropriate temperature integrity in the service pantry. Dining Services would plate up menu items for service to the residents as needed. Staffing would be achieved by the redeployment of current position task assignments. National Certification Program for Retirement Housing Professionals

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 WHAT ARE WE ATTEMPTING TO CREATE WITH OUR DINING PROGRAMS National Certification Program for Retirement Housing Professionals

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? ENGAGEMENT National Certification Program for Retirement Housing Professionals

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. 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

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. MOTHER TURKEY NOT OUR PERCEPTIONS OR EXPECTATIONS – OUR FAMILY / RESIDENTS EXPECTATION ELIMINATE CHOICE/ENGAGEMENT BEST INTENTIONS LANCET National Certification Program for Retirement Housing Professionals

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: , 2002. [iii] Kane, R. “Long-Term Care and a Good Quality of Life” The Gerontologist 41: , 2001. National Certification Program for Retirement Housing Professionals

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 The current program options do not meet current residents’ needs for dining. At best they provide a feeding period for the residents. We need to create a more appropriate dining experience and option for the residents. We work throughout the continuum of creating an environment that enables the residents to establish their own Rhythms of Daily Living ©(RDL). Yet, the moment we move them into the Assisted Living, Healthcare and Alzheimer’s units, their RDL©’s are no longer valid because they do not fit into the structured regiment of those continuums. Current tray delivery systems are not designed to accommodate the longer times necessary for effective dining support for the residents and still maintain menu item integrity and presentation. Dining service staff is focusing their energies on the delivery of trays to the floors rather than service to the residents. National Certification Program for Retirement Housing Professionals

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 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 National Certification Program for Retirement Housing Professionals

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 self-determined choices are at the core of any good dining experience. BAD DINING EXPERIENCE GOOD DINING 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

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

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 PRIMARY SKILL/PERSONALITY SCIENCE ART National Certification Program for Retirement Housing Professionals

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

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

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

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

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

STAGES of RDL 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. SWIMMING POOL GET IN National Certification Program for Retirement Housing Professionals

Stages of RDL 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. National Certification Program for Retirement Housing Professionals

Stages of RDL 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. National Certification Program for Retirement Housing Professionals

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

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

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: Identify Service Initiatives Define Their Contribution To Strategic Objectives Define Appropriate Measurements Of Successful Experience Outcomes Identification Of Resource And Operational Intersects Identification Of Intersects And Roles Of Other Contributing Departments Structure Of The Process For Resource Allocation To Develop The Defined Initiative Sequencing Of The Tasks Implementation of The Initiative. WHAT ARE THE EXPERIENCES OR FEELING THAT YOUR CONSTITUENTS COME AWAY FROM YOUR COMMUNITY WITH? ARE YOUR RESOURCES ALIGNED TO CREATE A CONSISTENT AND COORDINATED EXPERIENCE IF YOU CANNOT DEFINE IT YOU CANNOT MEASURE/ALIGN / PLAN / PRESENT / EDUCATE / TRAIN / RESOURCE National Certification Program for Retirement Housing Professionals

Community Strategic Objectives
Community of Distinction Financial Enhancement Quality of Living / Quality of Work Operational Effectiveness ROLE OF COMMUNITY LEADERSHIP JACK KENNEDY National Certification Program for Retirement Housing Professionals

Program Intersects Grid
Strategic Objectives Community of Distinction Financial Enhancement Quality of Living Quality of Work Operational Effectiveness Step #1 Strategic Objective Benefit Step #2 Benefit Measure Measurement Tool Step #3 Administration Regulatory Operations Personnel PP&E Community Operational Resource Requirements Budget Impact $/FTE’s National Certification Program for Retirement Housing Professionals

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 Task Step #5 Task Implementation Procedure Policy Resource Requirement Inform/Train Measure National Certification Program for Retirement Housing Professionals

Project Management National Certification Program for Retirement Housing Professionals

Alignment The appropriate positioning of systems and resources to attain a defined goal, mission, outcome or culture National Certification Program for Retirement Housing Professionals

Fixed & Variable Navigation Points
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

POS Systems Horizon Software Micros National Certification Program for Retirement Housing Professionals

Additional Culture Change Organizations
Culture Change Now! The Eden Alternative The Pioneer Network Providence Mount Saint Vincent REMIND HOW AMNY HANDS WENT UP YOU HAVE THE ABILITY, RESPONSIBILITY, OPPORTUNITY TO CHANGE THIS SITUATION NO SINGLE WAY, THIS IS NOT THE SOLUTION, BUT IS A START GO HOME National Certification Program for Retirement Housing Professionals

Contact Information Dan Look 3605 Sandy Plains Road Suite Marietta, GA 30066 National Certification Program for Retirement Housing Professionals

"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

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

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