culture change in ltc...cultural change cultural change ––––why now? generation youngest...

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Culture Change in LTC Culture Change in LTC Culture Change in LTC Culture Change in LTC Culture Change in LTC Culture Change in LTC Culture Change in LTC Culture Change in LTC

Jessica Shyu, M.S., R.D.

Corporate Director of Nutrition & Wellness

Morrison Senior Living

Culture Change?Culture Change?Culture Change?Culture Change?Culture Change?Culture Change?Culture Change?Culture Change?

National Movement for the Transformation

of Older Adult Services to create a

culture of aging that is life-affirming,

satisfying, humane, and meaningful


TransformationFrom Medical Model or Institutional Model –- Overemphasis on safety, uniformity, and medical issues

To Home Model To Home Model ––- Focus on person-centered care, supporting elder’s life, dignity,

rights, and freedom

PhilosophyCreating a HOMEHOME-like environmentEmpowering People with CHOICECHOICE

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HOMEHOMEHOMEHOMEHOMEHOMEHOMEHOMEIs Where The Heart IsIs Where The Heart Is

I long, as does every human being, to be at

home wherever I find myself.

Maya Angelou

Culture ChangeCulture ChangeCulture ChangeCulture ChangeCulture ChangeCulture ChangeCulture ChangeCulture Change

Goals:Goals:• Support personal satisfaction in lives

• Create individualized living spaces

• Empower staff as advocates of residents

• Respect lifestyles, preferences, needs

• Provide opportunity for growth, contribution

• Connect to community

Culture ChangeCulture ChangeCulture ChangeCulture ChangeCulture ChangeCulture ChangeCulture ChangeCulture Change

Based on person-directed values & practices

Pioneer Network www.pioneernetwork.net

CMS Regulations Changes

Is a PROCESS, not a project or a program

Fundamental to this transformation is a focus on the importance of the relationships between residents and direct care staff.

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Continuum of Person Directedness Continuum of Person Directedness Continuum of Person Directedness Continuum of Person Directedness Continuum of Person Directedness Continuum of Person Directedness Continuum of Person Directedness Continuum of Person Directedness

Provider Provider DirectedDirected

Management makes decisions with little conscious consideration of the impact on residents and staff.

Residents are expected to follow existing routines.

Staff Staff CenteredCentered

Staff consult residents while making the decisions.

Residentsmay have some choices within existing routines and options.

Person Person CenteredCentered

Resident preferences or past patterns form basis of decision making.

Staff begin to organize routines to accommodate resident preferences.

Person Person DirectedDirected

Residentsmake decisions every day about their individual routines.

Staff organize their hours and assignments to meet resident preferences.

Core PersonCore PersonCore PersonCore PersonCore PersonCore PersonCore PersonCore Person--------directed Values directed Values directed Values directed Values directed Values directed Values directed Values directed Values

Choices Dignity RespectSelf-

determination

Purposeful living

Mission of Pioneer NetworkMission of Pioneer NetworkMission of Pioneer NetworkMission of Pioneer NetworkMission of Pioneer NetworkMission of Pioneer NetworkMission of Pioneer NetworkMission of Pioneer Network

Guided by 13 Values and Principles:Guided by 13 Values and Principles:

• Know each person

• Each person can and does make a difference

• Relationship is the fundamental building block of a transformed culture

• Respond to spirit, as well as mind and body

• Risk taking is a normal part of life

• Put person before task

• All elders are entitled to self-determination wherever they live

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Mission of Pioneer NetworkMission of Pioneer NetworkMission of Pioneer NetworkMission of Pioneer NetworkMission of Pioneer NetworkMission of Pioneer NetworkMission of Pioneer NetworkMission of Pioneer Network

Guided by 13 Values and Principles:Guided by 13 Values and Principles: continue …

• Community is the antidote to institutionalization

• Do onto others as they want done onto them

• Promote the growth and development of all

• Shape and use the potential of the environment in all its aspects:

physical, organizational, psycho/social/spiritual

• Practice self-examination, searching for new creativity and

opportunities for doing better

• Recognize that culture change and transformation are not destinations

but a journeyjourney, always a work in progress


Three Basic Questions:Three Basic Questions:

�What does the resident want?

� How did the resident do this at home?

� How should we do it here?

~ Bump’s Law ~

Excellence in Individualization in DiningExcellence in Individualization in DiningExcellence in Individualization in DiningExcellence in Individualization in DiningExcellence in Individualization in DiningExcellence in Individualization in DiningExcellence in Individualization in DiningExcellence in Individualization in Dining

• Choice - true choice, not “token” choice

• Accessibility - 24/7 & refrigerator rights

• Individualization - favorites/preferences

• Liberalized Diets - evidence-based practice

• Food First - foods before supplements

• Quality Service - relationship building

• Responsiveness - meet resident’s needs

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4 Stages of Culture Change4 Stages of Culture Change4 Stages of Culture Change4 Stages of Culture Change4 Stages of Culture Change4 Stages of Culture Change4 Stages of Culture Change4 Stages of Culture Change

Stage 1 Stage 1 –– The Institutional Model The Institutional Model

Traditional Long Term Care environment

• Traditional and medical in orientation

• Organized around traditional nursing unit

• No consistent assignment

• Top-down organizational structure that lends itself to

disempowerment in residents and direct care staff

• Large central dining, scheduled meal times, tray service


Stage 2 Stage 2 –– The Transformational ModelThe Transformational Model

Culture Change Emerges

• Leadership and direct care staff become more aware and

knowledgeable of culture change

• Consistent assignment is implemented

• Learning circles develop amongst staff and residents

• Low-cost changes in décor to a more home-like environment

• Tray service but taking foods off the tray

• Have variety of ways to increase choice at mealtimes


Stage 3 Stage 3 –– The Neighborhood ModelThe Neighborhood Model

Transition to smaller “neighborhoods”

• Traditional nursing unit broken into smaller neighborhoods

• Multi-disciplines working as one team

• Dining area decentralized and residents in smaller dining room on

their neighborhoods

• Residents could sleep and eat when they want

• Neighborhood identity emerges in both name and actions

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Stage 4 Stage 4 –– The Household ModelThe Household Model

Home established again!

• Elders run and plan their lives

• Self-directed teams in the households

• Staff is cross-trained for multiple tasks and reports into a self-led

household team, not to a department

• living in houses with self-contained fully functioning kitchens

Transformation of Dining ProgramTransformation of Dining ProgramTransformation of Dining ProgramTransformation of Dining ProgramTransformation of Dining ProgramTransformation of Dining ProgramTransformation of Dining ProgramTransformation of Dining Program

Institutional Model -----> Home Model

• Tray service without table setting

• Non-select menu

• Fixed meal times

• Seating chart

• Large dining hall with no

decoration

• Use of clothing protector

• Labeled nourishment/snacks

• Tasks before person

Restaurant style service with

table setting

Tableside menu selection

Open dining hours

Seating by choice

Decentralized small dining

rooms with pleasant decoration

Use of cloth napkin

Snack stations

Put person before tasks

Cultural Change Cultural Change Cultural Change Cultural Change Cultural Change Cultural Change Cultural Change Cultural Change –––––––– Why NOW?Why NOW?Why NOW?Why NOW?Why NOW?Why NOW?Why NOW?Why NOW?

•Demographics

•Regulations

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Generation Youngest Oldest

GI 84 106

Silent 66 83

Boomer 48 65

DemographicsDemographics

Silents Want …..Silents Want …..Silents Want …..Silents Want …..Silents Want …..Silents Want …..Silents Want …..Silents Want …..

Autonomy, choice, control, individuality and continuity of a

meaningful personal life over safety!

Home-like setting

Make decision used to making

Consistent caregiver that knows me – PCC!

Give care where they live, not live where care is the focus

….. Living is the focus, not just care

Cultural Change Cultural Change Cultural Change Cultural Change Cultural Change Cultural Change Cultural Change Cultural Change –––––––– Why NOW?Why NOW?Why NOW?Why NOW?Why NOW?Why NOW?Why NOW?Why NOW?Regulations

• CMS = Culture Change Partner▫ Starting from 1987 OBRA

▫ started culture change training at 2002

▫ Major regulations change in 2009

▫ Developing person-centered nurse aide training modules

• CMS –no barriers from certification▫ States “its vision for LTC is that the system will be person-centered; the system will be organized around the needs of the individual rather than around the settings where care is delivered.”

▫ State Surveyors???

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Food & Dining Clinical Standards Task Force

• Consisted of symposium experts, CMS, FDA, CDC, and national standard setting groups

• Food and dining are an integral part of individualized care and self-directed living

• GOAL STATEMENT – Establish nationally agreed upon new standards of practice supporting individualized care and self-directed living versus traditional diagnosis-focused treatment.

New Dining Practice StandardsNew Dining Practice StandardsNew Dining Practice StandardsNew Dining Practice StandardsNew Dining Practice StandardsNew Dining Practice StandardsNew Dining Practice StandardsNew Dining Practice Standards

12 National Professional Organizations agree to the New Standards

• Individualized Nutrition Approaches/Diet Liberalization

• Individualized Diabetic/Calorie Controlled Diet

• Individualized Low Sodium Diet

• Individualized Cardiac Diet

• Individualized Altered Consistency Diet

• Individualized Tube Feeding

• Individualized Real Food First

• Individualized Honoring Choices

• Shifting Traditional Professional Control to Individualized Support of Self Directed Living

• New Negative Outcome


Format:Basis in Current Thinking and Research� AMDA – American Medical Director Association

� ADA – American Dietetic Association

� CMS – Centers for Medicare & Medicaid Services

Current Thinking

Relevant Research Trends

Recommended Course of Practice

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Focus Points of Diet Liberalization

• Liberalized diets should be the norm, restricted diets should be the

exception.

• Diet is to be determined with the person and in accordance with his/her

informed choices, goals, and preferences, rather than exclusively by

diagnosis.

• When a person makes “risky” decisions, the plan of care will be

adjusted to honor informed choice and provide supports available to

mitigate the risks.

• All Decisions default to the person!


Focus Points of Honoring Choices:

• “Choice” defines quality of life.

• For Dining, true choice is exemplified in point-of-service choice.

• Risk and benefits are being discussed with residents at the same time when asking for choices and preferences.

• “Red Flag” – trayline or set/limited meal times.

• “Red Flag” – documentation of resident being “non-compliant”.

• Resident dining profiles should be limited to adapted equipment, allergies, consistency modification and unique dietary needs.

Person Centered Care Person Centered Care Person Centered Care Person Centered Care Person Centered Care Person Centered Care Person Centered Care Person Centered Care -------- Take Away PointsTake Away PointsTake Away PointsTake Away PointsTake Away PointsTake Away PointsTake Away PointsTake Away Points

Resident centered with choices

Homelike atmosphere with freedom

Close relationships with consistent care givers

Staff empowerment with self-directed care team

Collaborative decision-making among management, staff and residents

Quality Improvement Process – ongoing!

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Culture Change Culture Change Culture Change Culture Change Culture Change Culture Change Culture Change Culture Change –––––––– ResultsResultsResultsResultsResultsResultsResultsResults

• High Staff Retention

• Higher Occupancy (competitive advantage)

• Lower Operational Costs

• Lower Absenteeism

• Better Outcomes

• Calmer Residents

• High Resident Satisfaction

How to Get Started?How to Get Started?How to Get Started?How to Get Started?How to Get Started?How to Get Started?How to Get Started?How to Get Started?

• Educate Self & Staff - Articles, Internet, Tours

• What Are Our Options? - All Communities are Unique

• Tour Communities That Have Implemented

• Start the Journey!

Four Buckets of TransformationFour Buckets of TransformationFour Buckets of TransformationFour Buckets of TransformationFour Buckets of TransformationFour Buckets of TransformationFour Buckets of TransformationFour Buckets of Transformation

PCCPersonal

Organizational Leadership

Physical

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Six Phases of Culture ChangeSix Phases of Culture ChangeSix Phases of Culture ChangeSix Phases of Culture ChangeSix Phases of Culture ChangeSix Phases of Culture ChangeSix Phases of Culture ChangeSix Phases of Culture Change

I. The Study Circle - High involvement to assess needs

II. The Design Team – Determine the changes

III. Skills Assessment & Development – ensuring everyone has the

necessary skills and attitudes

IV. Team Development - Self-directed work teams

V. Implementation – Crossing the line together

VI. Evaluation - Comparing CQI indicators

Health PromotionHealth Promotion

Institutional CareInstitutional CareIndividualized Individualized

CareCare

Risk PreventionRisk Prevention

Old PracticeOld Practice

New New

PracticePractice

Action

Action

Action

Action

Points to think about …….Points to think about …….Points to think about …….Points to think about …….Points to think about …….Points to think about …….Points to think about …….Points to think about …….

• Regulations – need to be expert on interpretations

• Complete involvement with all disciplines – not just dining or marketing alone

• Resident’s choices vs. medical

• We are their voices – for residents with declined cognitive ability

• Nutrition – help residents maintaining their highest possible functional/mental capability

• It is their HOME! – residents need to be involved

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Action Plan Action Plan Action Plan Action Plan Action Plan Action Plan Action Plan Action Plan

Which Stage is your community at?• Stage 1 – Traditional Long-Term Care Facility

• Stage 2 – Culture Change Emerges

• Stage 3 – Transition to smaller “neighborhoods”

• Stage 4 – Final Stage – Household Model

What can you do to help your community moving

forward with culture change?

Dining in the Health Suites at Clermont Park

Resident-Centered Dining Model

Christian Living Communities & Morrison

Nursing and Dining PartnershipNursing and Dining PartnershipNursing and Dining PartnershipNursing and Dining Partnership• Management team collaboration

• Resident Service Associates received Caregiver training

• Nursing and Dining team members meet weekly

• Eden Alternative training for all team members

• Manager Hosts at each meal

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Country Kitchen SetCountry Kitchen SetCountry Kitchen SetCountry Kitchen Set----upupupup• Completely self sufficient

▫ Little to no dish transport

▫ Daily stocking of kitchen

from main kitchen

▫ Cook/prep to order menu items

▫ Main menu items prepped

in main kitchen & severed to order

▫ Snack items always available

Table SettingTable SettingTable SettingTable Setting▫ Linen

▫ China and glassware

▫ Consider rolled silverware-sanitation

▫ Table menus

▫ Meal tickets- order taking, intake documentation

Restaurant Style ServiceRestaurant Style ServiceRestaurant Style ServiceRestaurant Style Service� Open dining 2 hours per meal

� Open seating

� Resident is seated, menu presented

� Offer beverage/s

� Order taken

� Serve soup, salad or an alternate

� Clear first course document on meal ticket

� Present Entrée

� Clear second course, document

� Offer dessert refresh coffee

� Area is cleared and meal tickets are collected and used to chart

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TrainingTrainingTrainingTraining

• Safety and Sanitation training program

• Nursing staff trained on use of kitchen equipment and safe serve practices

• Dining staff carefully selected to own the area and work autonomously

• Morrison’s Caregiver Training utilized

• Dining Staff trained to calculate intake and document on meal tickets as well as nursing staff

A Great Dining Experience for Residents!

� Increased satisfaction first and foremost▫ Hot food hot, cold food cold, freshly prepared

▫ Preferred dining

▫ Family satisfaction and peace of mind

� Decreased transport traffic in common areas▫ Reduction of noise and institutional model, keeping the homelike feel through out community

� Increased intake▫ Appetite stimulation

▫ Aroma of cooking

� Person centered approach▫ Promoting choice

▫ Reduced usage of clothing protectors

People judge their experiences by the way they are

treated as a person, not by the way they are treated for

their disease.

~Fred Lee … If Disney Ran Your Hospital

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culture change in ltc...cultural change cultural change ––––why now? generation youngest...

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