resident choice resident choice culture & environment aligning expectations – resources –...

Resident ChoiceResident ChoiceCulture & Environment

Aligning Expectations – Resources – Outcomes

April 28, 2004 IAHSA - a clebrration of age 2

The Customer Value Of Positive ExperienceA Memorable Feeling Created By You As A Result Of Us

Relative Customer Value

EXPERIENCE

SERVICE

GOOD

RAW MATERIAL

Source OfCustomer Loyalty

Created WithinThe Customer

Created ByA Provider


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.


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.


Rhythms of Daily LivingRhythms 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.


Rhythms of Daily LivingRhythms 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.


Comparison of CulturePioneer 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


Alignment

1. The appropriate positioning of systems and resources to attain a defined goal, mission, outcome or culture


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 RunwayAltitude Too High Aligned

Air Speed

Cross Winds

Altitude

Wind Speed

Pitch


The Main Thing For Senior Care

Choice


PLAN & DEVELOP

Organize

Alter

Codify

Train

Improve

Choice Dining AlignmentProcess Overview

Plan

Evaluate

Define

Assess

Implement


Plan Transition Process and Commit ResourcesWrite 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 AlignmentPlan and Develop

Plan

Evaluate “Readiness” With Leadership, Managers & Residents/FamiliesDefine Outcomes Baseline and Expectations

Evaluate

Define Define Service Functions and Outcomes For Each ExperienceIdentify Beneficiaries/Benefits and Diagram Service Functions


Choice Dining AlignmentEvaluate1. Complete High-Level Operations Assessment2. Executive Leadership (Executive and Board)

1. Clarify Strategic Objectives2. Identify Target Alignment Measures

1. Satisfaction (QOL/QOW), Efficiency and Clinical2. 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


Choice Dining AlignmentOrganize

1. Select Experience Alignment Team Members1. Culinary/Production, Environmental, Clinical, Service,

Employment, Others1. Draw Upon Multi-level, Multi-Departmental Participants

2. Schedule and Conduct Team Leader Orientation Workshops

3. Develop Team Presentations With Alignment Team Leaders


Choice Dining AlignmentDefine1. Complete Site Visit (Optional) 2. Complete Alignment Team Orientation Workshops3. Complete Affinity Group Exercise With Each Alignment

Team1. Identify Group Beneficiaries2. Identify Benefits By Beneficiary

4. Define Functional Work Flows1. Identify Functions To Serve Beneficiaries2. Complete Functional Work Flow Diagram


Choice Dining AlignmentPlan1. 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


Program Intersects Grid

PROJECT COMMUNITY OF DISTINCTION

FINANCIAL ENHANCEMENT

QUALITY OF LIVING

QUALITY OF WORK

OPERATIONAL EFFECITVENESS

HEALTH CARE CENTER

3 & 4 Modification RDL

Creates a signature service for the Memory Support neighborhood

Reduce costs with the implementation of RDL

Improved resident QoL and improved staff working environment

Operational benefits of RDL

RDL Dining Creates a signature model of resident service for the HCC

Reduce costs with the implementation of RDL

Improved resident QoL and improved staff working environment

Operational benefits of RDL

MDR Service Modifications Compliment service model of RDL, grille options and service venues

Increased accessibility to dining program increasing revenue options

Increased selection and choice improving QoL

Increased productivity while increasing services reducing neighborhood service requirements.

MOW Capacity Increase Increase presentation of McLean Brand into the community

Increased revenues and improved efficiencies of the existing resources

Improve QoL for MOW clients Increased operational effectiveness for facilities


Project Management

ID Task Name

12 Review Horizon Proposal

13 Approve and Accept

14

15

16 Organize

17 Presentations of service concept and education

18

19 Define

20 Review community operational expectations & outcomes

21 Identify and assign measurements

22

23 Plan

24 Coordinate Plan for Installation

25 Develop Plan for Coordinated Training

S M T W T F S S M T W T F S S M T W T F S S M T W TApr 25, '04 May 2, '04 May 9, '04 May 16, '04


Choice Dining AlignmentCodify1. 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 QualATIsm 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


Alter

Alter Procedures, Training, Tasking, ResourcesConfirm and Eliminate Practice Conflicts

Train

Improve

Choice Dining AlignmentImplement

Learn Improved ProceduresDemonstrate Understanding

Measure Satisfaction and Efficiency ResultsEvaluate/Report Result Scores

Assess

Identify Opportunities For Improvement Assess Practices To Find Procedures Not Practiced


Choice Dining AlignmentAssess1. 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


Choice Dining Alignment Alter1. 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


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


Choice Dining Alignment Improve1. 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


Choice Dining Alignment Continuous QualATIsm Alignment

Improve

Train

Alter

Assess

EffectivePractices


A Culture of Caring vs. a Culture of CuringThere 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.


Workmanship of Riskvs. 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?"


Workmanship of Risk & Workmanship of CertaintyCultural & 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.


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.


“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.


Quality of Living ConsiderationsA 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]

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.

2. [ii] Chou, S., Boldy, D., and Lee, A. “Resident Satisfaction and Its Components in Residential Aged Care.” The Gerontologist 42:188-198, 2002.

3. [iii] Kane, R. “Long-Term Care and a Good Quality of Life” The Gerontologist 41:293-304, 2001.


Additional Culture Change Organizations1. Culture Change Now!

http://www.culturechangenow.com/index.html

2. The Eden Alternative

http://www.edenalt.com/

3. The Pioneer Network http://www.pioneernetwork.org/

4. Providence Mount Saint Vincent http://www.providence.org/Long_Term_Care/Mount_St_Vincent/default.htm

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