1. Resident Choice Resident Choice Culture & Environment Aligning Expectations – Resources – Outcomes

2. April 28, 2004 IAHSA - a clebrration of age 2 The Customer Value Of Positive Experience A Memorable Feeling Created By You As A Result Of Us Relative Customer Value EXPERIENCE SERVICE GOOD RAW MATERIAL Source Of Customer Loyalty Created Within The Customer Created By A Provider

3. April 28, 2004 IAHSA - a clebrration of age 3 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.

4. April 28, 2004 IAHSA - a clebrration of age 4 Operational Culture Rhythms of Daily Living is an operational culture that aligns resources and expectations of service experiences. RDL works in collaboration with initiatives of environmental culture change advocated by other organizations. The core service model for liberating residents and staff from an institutional paradigm is dining service. Dining is a catalyst and enabler to initiate change across coordinated services.

5. April 28, 2004 IAHSA - a clebrration of age 5 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.

6. April 28, 2004 IAHSA - a clebrration of age 6 Rhythms of Daily Living 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.

7. April 28, 2004 IAHSA - a clebrration of age 7 Comparison of Culture Pioneer Network Institution-Directed Culture 1.Staff provide standard “treatments” based on clinical 2.Institutional defined schedule and routines – resident comply 3.Work is task oriented and staff rotates assignments – interchangeable residents 4.Centralized decision making 5.Hospital environment 6.Structured activities 7.There is a sense of isolation and loneliness Choice – Directed Culture 1. Staff enters into a care giving relationship based upon individualized care & resident desire 2. Residents and staff design the schedules 3. Care is relationship-centered, consistent assignments 4. Frontline decision making 5. Environment reflects the comforts of home 6. Spontaneous activities 7. Sense of community and belonging

8. April 28, 2004 IAHSA - a clebrration of age 8 Alignment 1.The appropriate positioning of systems and resources to attain a defined goal, mission, outcome or culture

9. April 28, 2004 IAHSA - a clebrration of age 9 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

10. April 28, 2004 IAHSA - a clebrration of age 10 The Main Thing For Senior Care Choice

11. April 28, 2004 IAHSA - a clebrration of age 11 PLAN & DEVELOP Organize Alter Codify Train Improve Choice Dining Alignment Process Overview Plan Evaluate Define Assess Implement

12. April 28, 2004 IAHSA - a clebrration of age 12 Plan Transition Process and Commit Resources Write Program Transition Budget and Operating Narrative Organize Codify Organize For Culture Change Establish “Experience” Alignment Teams To Define/Implement Transition Codify Policies/Procedures and Training By Function Write & Task Procedures/Training Using RDL© Base Choice Dining Alignment Plan and Develop Plan Evaluate “Readiness” With Leadership, Managers & Residents/Families Define Outcomes Baseline and Expectations Evaluate Define Define Service Functions and Outcomes For Each Experience Identify Beneficiaries/Benefits and Diagram Service Functions

13. April 28, 2004 IAHSA - a clebrration of age 13 Choice Dining Alignment Evaluate 1.Complete High-Level Operations Assessment 2.Executive Leadership (Executive and Board) 1.Clarify Strategic Objectives 2.Identify Target Alignment Measures 1.Satisfaction (QOL/QOW), Efficiency and Clinical 2.Compare Against Available Historical Data Validate Cross-Functional Organizing Model (Experience, Function, Procedure) Determine Cultural, Operating and Financial Readiness 3.Operating Leadership (Department Managers) Validate Outcome Targets Review Lessons Learned From Prior/Ongoing Change Processes Configure Experience Alignment Team Approach Identify Knowledge Worker Involvement Process 4.Resident Briefing Resident Council - Validate Objectives, Delights & Updating Process Community Newsletter – Publish Objectives and Updates

14. April 28, 2004 IAHSA - a clebrration of age 14 Choice Dining Alignment Organize 1.Select Experience Alignment Team Members 1.Culinary/Production, Environmental, Clinical, Service, Employment, Others 1.Draw Upon Multi-level, Multi-Departmental Participants 2.Schedule and Conduct Team Leader Orientation Workshops 3.Develop Team Presentations With Alignment Team Leaders

15. April 28, 2004 IAHSA - a clebrration of age 15 Choice Dining Alignment Define 1.Complete Site Visit (Optional) 2.Complete Alignment Team Orientation Workshops 3.Complete Affinity Group Exercise With Each Alignment Team 1.Identify Group Beneficiaries 2.Identify Benefits By Beneficiary 4.Define Functional Work Flows 1.Identify Functions To Serve Beneficiaries 2.Complete Functional Work Flow Diagram

16. April 28, 2004 IAHSA - a clebrration of age 16 Choice Dining Alignment Plan 1.Draft Program Operational Requirements Document 1.Write Summary Brand, Service Expectations 2.Complete Project Timeline Milestones and Budget 1.Identify Launch Site 2.Establish Target Levels of Choice 3.Key Resources In Place 4.Initiate Launch Site 5.Complete Proof-Of-Concept 6.Full Program Roll-Out By Stage 2.Complete Executive Presentations For Alignment Team Leaders

17. April 28, 2004 IAHSA - a clebrration of age 17 Program Intersects Grid

18. April 28, 2004 IAHSA - a clebrration of age 18 Project Management

19. April 28, 2004 IAHSA - a clebrration of age 19 Choice Dining Alignment Codify 1.Write Outline Of Service Policies Required For Launch Site (Word Document) Define Experience Groups Define Service Functions (Name Only) Finalize Outcomes and Satisfaction Statements For Each Service 2.Establish QualATI sm Collaboration Site For Client Facility Publish Experience - Service Function Groups Load Appropriate RDL© Service Policy/Procedures and Training Content Train Team Writers On Publishing With 3.Edit/Create Procedures Assign Position Responsibility 4.Secure Regulatory, Safety and HR Review 5.Develop Training 1.Write/Edit Training 2.Comprehension Questions 3.Publish Multimedia Training

20. April 28, 2004 IAHSA - a clebrration of age 20 Alter Alter Procedures, Training, Tasking, Resources Confirm and Eliminate Practice Conflicts Train Improve Choice Dining Alignment Implement Learn Improved Procedures Demonstrate Understanding Measure Satisfaction and Efficiency Results Evaluate/Report Result Scores Assess Identify Opportunities For Improvement Assess Practices To Find Procedures Not Practiced

21. April 28, 2004 IAHSA - a clebrration of age 21 Choice Dining Alignment Assess 1.Assess Practice Compliance Complete Self-Assessment By Alignment Teams 2.Reward Compliance Scores Above 80% 3.Investigate Corrective Opportunities (Compliance Scores Below 80%) Validate Practices Not Practiced

22. April 28, 2004 IAHSA - a clebrration of age 22 Choice Dining Alignment Alter 1.Improve Resources To Facilitate Procedure Practice Property, Plant & Equipment Systems Food, Supplies 2.Improve Procedures Eliminate/Revise Ineffective Procedures Change Training/Improve Understanding Change Responsibility Tasking

23. April 28, 2004 IAHSA - a clebrration of age 23 Choice Dining Alignment Train 1.Train The Trainer 2.Complete Interactive Training Sessions 3.Complete Self-Study Courses 4.Assure Comprehension Self-Testing Proctored Testing

24. April 28, 2004 IAHSA - a clebrration of age 24 Choice Dining Alignment Improve 1.Complete Launch Site Satisfaction Survey Residents Family Staff 2.Analyze Findings Identify Benchmark Results Identify Improvement Opportunities 3.Report Findings Resident/Family Staff 4.Identify Opportunities For Improvement Resources Measures Procedures Understanding

25. April 28, 2004 IAHSA - a clebrration of age 25 Choice Dining Alignment Continuous QualATI sm Alignment Effective Practices AssessAlterTrain Improve

26. April 28, 2004 IAHSA - a clebrration of age 26 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.

27. April 28, 2004 IAHSA - a clebrration of age 27 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?"

28. April 28, 2004 IAHSA - a clebrration of age 28 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.

29. April 28, 2004 IAHSA - a clebrration of age 29 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.

30. April 28, 2004 IAHSA - a clebrration of age 30 “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.

31. April 28, 2004 IAHSA - a clebrration of age 31 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] 1.[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] 2.[ii] Chou, S., Boldy, D., and Lee, A. “Resident Satisfaction and Its Components in Residential Aged Care.” The Gerontologist 42:188-198, 2002.[ii] 3.[iii] Kane, R. “Long-Term Care and a Good Quality of Life” The Gerontologist 41:293-304, 2001.[iii]

32. April 28, 2004 IAHSA - a clebrration of age 32 Additional Culture Change Organizations 1.Culture Change Now! http://www.culturechangenow.com/index.html http://www.culturechangenow.com/index.html 2.The Eden Alternative http://www.edenalt.com/ 3.The Pioneer Network http://www.pioneernetwork.org/ http://www.pioneernetwork.org/ 4.Providence Mount Saint Vincent http://www.providence.org/Long_Term_Care/Mount_St_Vincent/default.htm