1. Liberating Care in a Culture of Choice: Navigating Change Dining as Catalyst Aligning Experiences – Expectations – Resources – Outcomes

2. September 15, 2004 AOPHA Annual Conference - The Power to Change Our World 2 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.

3. September 15, 2004 AOPHA Annual Conference - The Power to Change Our World 3 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

4. September 15, 2004 AOPHA Annual Conference - The Power to Change Our World 4 The Customer Value Of Positive Experience A Memorable Feeling Created By You Relative Customer Value EXPERIENCE SERVICE GOOD RAW MATERIAL Source Of Customer Loyalty Created Within The Customer Created By A Provider

5. September 15, 2004 AOPHA Annual Conference - The Power to Change Our World 5 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?

6. September 15, 2004 AOPHA Annual Conference - The Power to Change Our World 6 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.

7. September 15, 2004 AOPHA Annual Conference - The Power to Change Our World 7 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 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

8. September 15, 2004 AOPHA Annual Conference - The Power to Change Our World 8 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.

9. September 15, 2004 AOPHA Annual Conference - The Power to Change Our World 9 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

10. September 15, 2004 AOPHA Annual Conference - The Power to Change Our World 10 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][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. [i]  [ii] Chou, S., Boldy, D., and Lee, A. “Resident Satisfaction and Its Components in Residential Aged Care.” The Gerontologist 42:188-198, 2002. [ii]  [iii] Kane, R. “Long-Term Care and a Good Quality of Life” The Gerontologist 41:293-304, 2001. [iii]

11. September 15, 2004 AOPHA Annual Conference - The Power to Change Our World 11 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.

12. September 15, 2004 AOPHA Annual Conference - The Power to Change Our World 12 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][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. [1]

13. September 15, 2004 AOPHA Annual Conference - The Power to Change Our World 13 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

14. September 15, 2004 AOPHA Annual Conference - The Power to Change Our World 14 Culture CULTURE OF CURECULTURE OF CARE LEADERSHIPHIERARCHIALSERVANT ENVIRONMENTOUTCOMERSIDENT FOCUSQUALITY OF CUREQUALITY OF LIFE PROCESSSTRUCTUREDSPONTANEOUS WORKMANSHIPCERTAINTYRISK MEASUREOBJECTIVESUBJECTIVE REGULATIONPROCESSENVIRONMENT PRIMARY SKILL/PERSONALITYSCIENCEART

15. September 15, 2004 AOPHA Annual Conference - The Power to Change Our World 15 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.

16. September 15, 2004 AOPHA Annual Conference - The Power to Change Our World 16 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?"

17. September 15, 2004 AOPHA Annual Conference - The Power to Change Our World 17 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.

18. September 15, 2004 AOPHA Annual Conference - The Power to Change Our World 18 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.

19. September 15, 2004 AOPHA Annual Conference - The Power to Change Our World 19 Independent Living Residents  Resident Choice Dining  Flexible Service Options  Café/deli  Traditional Dining  Take Out  “Mise en place” Dining  Multiple Service Venues  Wellness

20. September 15, 2004 AOPHA Annual Conference - The Power to Change Our World 20 Assisted Living  Flexible Service Options  Traditional Dining  Take Out  Multiple Service Venues

21. September 15, 2004 AOPHA Annual Conference - The Power to Change Our World 21 Skilled Nursing  RDL Dining  Flexible Schedule  Increased Menu Options with New Cooking Applications  “country kitchen”

22. September 15, 2004 AOPHA Annual Conference - The Power to Change Our World 22 Staff  Selection  Fresh Quality - not a “Leftover” Dumping Station  Home Replacement Meals

23. September 15, 2004 AOPHA Annual Conference - The Power to Change Our World 23 Must Rising Acuity Levels Mean Lower Dining Quality ? ©

24. September 15, 2004 AOPHA Annual Conference - The Power to Change Our World 24 Skilled Care Dining Today Restricted Service Times, Too Short For Quality & Assistance < 20 Minutes For Dining The Quality Gap

25. September 15, 2004 AOPHA Annual Conference - The Power to Change Our World 25 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

26. September 15, 2004 AOPHA Annual Conference - The Power to Change Our World 26  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 Real Reported Results From Communities That Have Implemented RDL

27. September 15, 2004 AOPHA Annual Conference - The Power to Change Our World 27 Alignment The appropriate positioning of systems and resources to attain a defined goal, mission, outcome or culture

28. September 15, 2004 AOPHA Annual Conference - The Power to Change Our World 28 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 Runway Altitude Too High Aligned Air Speed Cross Winds Altitude Wind Speed Pitch

29. September 15, 2004 AOPHA Annual Conference - The Power to Change Our World 29 The Main Thing Choice

30. September 15, 2004 AOPHA Annual Conference - The Power to Change Our World 30 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.

31. September 15, 2004 AOPHA Annual Conference - The Power to Change Our World 31 Map Process Steps #1, 2,3 Strategic Objectives Community of Distinction Financial Enhancement Quality of Living Quality of Work Operational Effectiveness Map#1 Strategic Objective Benefit - Maintain market position – choice - Breakeven in program Diverse dining experience Predictable program More active dining experience Generate additional volume Greater efficiency Map #2 Benefit Measure Sales & marketing Operating reports Response surveys Diverse menu Staff turnover Quality of wellness Productivity factors Food cost Measurement Tool Sales reports P&L Meal counts Resident wellness Turnover reports Guests & family meals Cost & management reports Map #3AdministrationRegulatoryOperationsPersonnelPP&ECommunity Operational Resource Requirements POS Board support Departmental support NA Menu development Service model Training Recruitment for positions Kitchen design Education collaboration Budget Impact $/FTE’s

32. September 15, 2004 AOPHA Annual Conference - The Power to Change Our World 32 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

33. September 15, 2004 AOPHA Annual Conference - The Power to Change Our World 33 Map Process Steps #4, 5 Map #4 Collaborating Departments Resident Services FinancePastoralHousekeepingMaintenanceActivities Task Map #5 Task Implementation NursingResident Services TherapiesPastoralHousekeepingMaintenanceActivities Procedure Policy Resource Requirement Inform/Train Measure

34. September 15, 2004 AOPHA Annual Conference - The Power to Change Our World 34 Project Management

35. September 15, 2004 AOPHA Annual Conference - The Power to Change Our World 35 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

36. September 15, 2004 AOPHA Annual Conference - The Power to Change Our World 36 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.

37. September 15, 2004 AOPHA Annual Conference - The Power to Change Our World 37 Design Impact of Choice  Aligning Current Culture with New Expectations  Look for Operational Solutions 1 st  Understand Nuances of Current & Evolving Cultures  Identify Conflict Points and Educate to Alleviate  Create Environment for “All Boats Rise” Experience  Leadership for Culture Transformation

38. September 15, 2004 AOPHA Annual Conference - The Power to Change Our World 38 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

39. September 15, 2004 AOPHA Annual Conference - The Power to Change Our World 39 PLAN & DEVELOP Organize Alter Codify Train Improve Choice Alignment Process Overview Plan Evaluate Define Assess Implement

40. September 15, 2004 AOPHA Annual Conference - The Power to Change Our World 40 Continually Test For Outcome And Process Alignment Make Sure That Procedures Are Practiced, Understood and Working Procedures AssessTrainAssure Assess Current Practices Assure Expected Outcomes Train Improved Procedures (Test Understanding Of What and Why) Develop Improved Procedures, Revise Tools and Protocols

41. September 15, 2004 AOPHA Annual Conference - The Power to Change Our World 41 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

42. September 15, 2004 AOPHA Annual Conference - The Power to Change Our World 42 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

43. September 15, 2004 AOPHA Annual Conference - The Power to Change Our World 43 Project Management

44. September 15, 2004 AOPHA Annual Conference - The Power to Change Our World 44 POS Systems  Horizon Software  http://www.horizon-boss.com/default.htm http://www.horizon-boss.com/default.htm  Micros  http://www.micros.com/ http://www.micros.com/

45. September 15, 2004 AOPHA Annual Conference - The Power to Change Our World 45 Satisfaction & Leadership Effectiveness Survey

46. September 15, 2004 AOPHA Annual Conference - The Power to Change Our World 46 Operational & Compliance Gap Analysis

47. September 15, 2004 AOPHA Annual Conference - The Power to Change Our World 47 "For every complex, difficult problem, There is a simple solution. And, it is probably wrong!" H.L. Mencken

48. September 15, 2004 AOPHA Annual Conference - The Power to Change Our World 48 Additional Culture Change Organizations  Culture Change Now! http://www.culturechangenow.com/index.html http://www.culturechangenow.com/index.html  The Pioneer Network http://www.pioneernetwork.org/ http://www.pioneernetwork.org/  Dining Management Resources, Inc.  770-855-3135  www.dm-resources.com www.dm-resources.com  dcl@dm-resources.com