Dining Culture Change: Communication

Change is not easy for anyone! That is one of the reasons that communication is so important. Good communication can help ease many fears.

Before implementing a change, it is important to discuss it with everyone that will be affected. This includes the residents, families, and employees. It also includes others that may be affected. For example, changing meal times may affect therapy and even the beautician.

Before discussing it with everyone, have a detailed plan in place. The more thoroughly the new system is thought out, the better. It will need to be changed as you go, of course, but the better the planning, the smoother it will go.

Before creating a plan, communicate with everyone the goal—increasing resident directed care and increasing choice for the resident. And then get people’s ideas and suggestions on how to make it work. The more people are involved in planning a change, the more they will support it and the more successful the plan will be.

Continue to communicate during implementation. Ask everyone for their recommendations on how to improve the situation. (If you just ask how things are going, you may get mostly complaints. If you ask for their suggestions, you are making them part of the solution.) If a change is made, communicate it to everyone. (Be hesitant about making changes too quickly, however. It takes time for a change to occur and a new system to operate smoothly.)

Continue to communicate the successes throughout the process. And once the new system is in place, communicate regularly on the status.

Dining Culture Change: Meal Selection Options

Menu selection in long-term care has an interesting history. The progression follows.

• No select. You got what was served! (Sounds like prison, doesn’t it?)
  
• Pre-select. Your likes and dislikes were obtained in advance. If a dislike was on the menu, a substitution was automatically served. (Let’s hope it was something you did like!)
  
• Select menus. You got to circle what you wanted to eat. The problem was, it may have been for a week or more in the future! This is fine if the choice is liver and chicken and you hate liver. But what if it is roast beef and chicken, you really like both, but you don’t know what you will feel like eating in a week?
  
• Selection at the time of service. Just like a restaurant! You are told the selections for the meal and you get to choose what you feel like eating at the moment!

Which type of selection would you prefer? Which type do you think your residents would prefer?

The closer to meal service the selection is made, the better for the residents. In part, this is because many of our residents forget what they have chosen or change their minds. This type of selection requires accurate production and serving records so that forecasting can be as accurate as possible the next time, but it is possible.

If selection at the time of service is not possible, the next best thing is the meal before. Selecting at breakfast for the rest of the day is another option. This is easier for forecasting and production, but it is not as good of a service for the residents.

There are various ways to offer selection. One is restaurant-style. The residents are seated. The menu selections are offered verbally or a menu is placed on the table. The wait person takes the order. This may be verbally or the residents may have selected on the menus at the tables. The wait person goes to the server and communicates the request. The server portions the items and the wait person takes it the resident.

Another good method for meal selection is buffets. Residents can see and smell the food and decide what they want to eat. Generally with buffets, nursing staff assist the residents through the buffet line and carry the plate to the table for them. Dining services staff portion the plate. With this method, residents can also choose the amount they want, which can decrease waste while increasing consumption.

Other methods to offer choice include beverage carts, salad and/or soup carts, and dessert carts. And there are many variations possible on the basic ideas presented.

Dining Culture Change: Dining Times Options

Offering choices is a good way to enhance culture change. At home, we have choices on what to eat and when. We also have choices on when to get up in the morning. (Well, most of us at least have choices on weekends!) When we retire, however, our options will open up greatly. And the same choices we will have then are what we should be offering our residents now.

Some facilities have implemented the 5-Meal a Day Program. This is also called Everyday is a Holiday and Resident Choice Meal Plan. In essence, it allows residents to rise when they want. The meal pattern follows. Times are approximate and depend upon the facility.
7:00 – 9:30 a.m., optional continental breakfast served on the units
10:30 – 11:30 a.m., brunch served in the dining room(s)
1:30 – 2:00 p.m., heavy snack served on the units
4:00 – 5:00 p.m., dinner served in the dining rooms(s)
7:00 – 7:30 p.m., night cap snack (mini-meal) served on the units

With this system, there really are two large meals (brunch and dinner) and two heavy snacks. The continental breakfast is optional for those residents who like to rise early and have something light to hold them over until brunch.

Facilities that have had success with this plan report a quieter morning environment, a more even workload for staff, more variety with meals, positive clinical outcomes, and positive financial outcomes. In some facilities, this works great and residents and employees really enjoy it.

It has not worked in other facilities, however. From my experience it seems that a major stumbling block is the concept that a continental breakfast is light. It means a slice of toast and a glass of juice or a muffin and coffee. Oftentimes too much is offered and residents choose several or all of the options: cereal, toast, fruit, juice, coffee, etc. In reality, they have had a full breakfast. When it is time for brunch, residents do not want breakfast items—they already had breakfast in their minds. They want lunch.

The concept that a continental breakfast is light and optional also appears to be difficult for the employees as well. This may be why residents have difficulty with it. Residents will always take cues from staff. (This goes back to why behaviors and attitudes of staff are so important to culture change!)

In many facilities, this program has evolved into open meal times. Rather than breakfast being served at 7:00, breakfast is available from 7:00 to 9:30 (for example). This allows those residents who want to sleep in to do so. Or, a hot breakfast is available from 7:00 to 8:00 and a continental breakfast is available from 8:00 to 10:00 (again, the times are just examples). This allows the resident to choose which is more important to him or her—a hot breakfast or sleeping later.

It also avoids citations for F368 which states that no more than 14 hours may elapse between the evening meal and breakfast the next day, unless there is a substantial evening snack, then 16 hours may elapse. For example, if dinner is served at 5:00 p.m., and breakfast is offered and available at 7:00 a.m., then F368 is being met. It is resident choice if the resident wishes to eat at 7:00.

In addition to offering open dining times for breakfast, it is possible to do this for lunch and dinner as well. This is very similar to what retirement centers do routinely. Residents can eat anytime during the posted dining room hours. This requires very careful planning of employee schedules and very close cooperation between dining and nursing services, but it does happen!

Dining Culture Change: Homelike Environment

There is a great deal of emphasis placed on a “homelike” environment in long-term care. This is a great concept. But what does it mean?

CMS defines “homelike” under the guidance to surveyors for F252. It discusses making the facility less institutional and allowing the residents to use personal belongings. A goal is to recognize the resident as an individual and provide an opportunity for self-expression.

This can happen easily in the residents’ rooms. But what about the common areas? What does “homelike” mean in the dining rooms, lounge areas, and other areas where many residents gather?

Well, it depends. Remember the adage, “There is no reality, only perception.” This is true. Everyone’s perception becomes his or her reality. And so “homelike” will have a different definition for you, your employees, and your residents based upon what “home” is like for each individual.

“Homelike” could be everyone sitting down to eat together or it could be everyone grabbing something to eat as time permits. It could mean a clean, uncluttered environment or it could mean messy. It could mean discussing the day or it could mean all attention on the TV. It varies with each family!

Because of this, it is not possible to simply tell employees “make the dining room homelike.” Everyone will have a slightly different idea of what that means, and maybe none of the ideas match what any of the residents think.

The point is that you have to define what “homelike” means in your facility and educate employees accordingly. Set standards on the level of cleanliness, food quality and appearance, dining room appearance, courtesy, service, etc. and educate, educate, educate!

Dining Culture Change: Balancing Resident Choice and Facility Operations

We also have to balance the choices we offer with our operational capabilities. This includes physical plant, equipment, staff, and budgets. Most facilities cannot offer steak, lobster, and champagne every night no matter how much the residents might want it. But maybe it can happen for special occasions.

Most facilities are not set up to be short-order restaurants, either. That is understood. Resident choice is about giving the residents the opportunity to make reasonable choices, not offering them every choice in the world.

In determining what choices to offer, it is important to understand what the residents want. Ask them! Listen to them! And talk to all the residents, not just resident council or resident food committee. Although what the committee members say is supposed to be reflective of what the majority of residents want, often it is just the individual members’ opinions. So get as much information as you can.

An easy way to increase choices for each meal without substantially increasing production is to have 3-5 easily prepared items always available in addition to the 1-2 menu items. Easy items include cold sandwiches, soups that can be heated in the microwave oven, cottage cheese and fruit, and pre-portioned entrees that can be removed from the freezer and heated. These pre-portioned items can be convenience items or items that the cooks prepare, portion, and freeze. Accurate production records will determine how often these items need to be made.

More options for choice will be discussed later. For now, remember that it is acceptable to set reasonable limits.

Dining Culture Change: Balancing Resident Choice with Resident Care

Although residents have a choice not to follow their diet or not to eat, that does not absolve us from our legal and moral responsibilities to do everything possible to assist the resident in maintaining or improving his/her health.

It is not enough to simply offer choices, we must offer good choices, and help the residents to choose wisely. To put it another way, do not offer bad choices; do not offer items that a resident cannot have on his/her diet.

Have you even been in a restaurant, decided what you wanted to eat, only to be told by the server that it was not available and you could not have it? How did it make you feel? How do you think a resident feels if you offer her something and when she states she would like it, you tell her she cannot have it?

For example, if you have a written selective menu, only include on the menu the items that the resident can have on his/her diet. Yes, this means a different menu for each diet (therapeutic and texture modified) that you offer. Yes, this is a great deal of work if you do not have a computerized menu system that will print them automatically. But it will increase customer satisfaction.

If you have a spoken selective menu, only offer the items the resident can have. Yes, this means work through either educating staff or different menus, or both, but it will increase customer satisfaction because it will decrease the conflict that arises when a resident is told they should not eat something.

Sometimes residents will see what other residents are eating and want it. That is when we are really between the rock of resident rights and the hard place of regulatory compliance! And there is no one best way to handle it. It depends upon the situation and the resident.

If the resident routinely does not want to follow the diet, or does not want to eat, we assess to determine why, we develop plans to address the situation, we implement the plans, we evaluate to see if they were successful, and we develop and implement new plans as necessary. We involve the resident, we involve the physician and the other members of the care team, we involve the family as appropriate, and we educate, educate, educate. And we document everything we do, because if it is not documented, it did not happen.

There is no doubt that it can be a tough balancing act, but we have to follow regulations as well as honor resident rights.

Dining Culture Change: Culture Change in Long-term Care

In the past, nursing homes have had a facility-directed culture. Management decided what was to happen and when. It was important that schedules were followed. This was good from an efficiency standpoint, but not so good if you, as a resident, did not like the schedule imposed upon you. Or you did not like to eat what was served to you.

Residents were not necessarily viewed as individual people. Often they were viewed just as people to do things to, like feed, bath, clothe. Sometimes, too, because they needed care, they were treated as infants or children. Staff knew best what the resident needed!

Later, many facilities started a resident-centered culture. Events in the facility were to center around the resident. Some good came of this. The environment become more attractive, meal service more pleasant, menu selection made more options available. But resident-centered care does not go quite far enough.

Resident-directed care is the goal for long-term care to create a real culture change. With resident-directed care, each resident has the right to direct his or her own life within the facility. This means that each resident has the right to choose when to get up, when to go to bed, when to eat, what to eat, whether or not to follow physician’s orders, etc.

Think of the huge shift in attitude that this requires in staff! The goal now is not to take care of residents, but to help them take care of themselves. The type and amount of care varies with each individual resident. And it is the resident directing what assistance he/she wants. It is no longer acceptable to treat residents as children. It is necessary to view them and treat them as equal adults.

A good place to start with this level of culture change is with behaviors. Terminology is one behavior. Instead of calling someone a “feeder,” indicate that this is someone who needs to be fed. Instead of calling someone a “pureed,” indicate that this is someone who requires a pureed diet. Rather than “bringing” residents to the dining room, “escort” them to the dining room. This helps staff to view residents as individual people with their own needs, thoughts, and feelings.

Other behaviors include simple courtesy. Call the resident by name, make eye contact, engage him or her in conversation, and talk with him or her rather than with co-workers. Treat each resident with respect and dignity.

Depending upon your employees, you may have to define what treating someone with respect and dignity means. Remember, they come from their own home culture. In their home, it might be normal to yell or shout at other family members.

Open meal times, buffets, selective menus, dessert and salad carts, resident-selected menus are all great ways to offer residents more choice. But new systems like these alone will not change the dining culture. How the employees of a facility, especially management, views and treats the residents is what will create the greatest culture change.

And even the golden rule does not go far enough. It is not about how you want to be treated, but how each individual resident wants to be treated.

Dining Culture Change: Organizational Culture

An organization’s culture is composed of the values, beliefs, and attitudes of the individuals involved. This leads to behaviors of the individuals and of the group. Culture in a particular organization can be difficult to define, but it can often be “felt.”

Have your ever walked into an office, store, care facility, or other organization and felt good, relaxed, comfortable, or experience other positive feelings? Has the opposite ever happened? You walk in somewhere and immediately feel stressed, anxious, worried, or other negative feelings? Of course, some of those feelings relate to what is happening with you at that particular time. But these feelings can also be reflective of the culture of the organization.

It is easy to see why culture change is difficult. It can be hard to define what the current culture is, never mind change it!

The good news is that culture is evidenced by behaviors. And behaviors are learned. Behaviors that receive positive results are repeated. Behaviors that are ignored or achieve negative results are changed. Attitudes, beliefs, and even values can also be changed.

Culture change in long-term care really started with OBRA-87. This created federal regulations to improve the quality of care and quality of life for residents in long-term care. Change is still happening!

Today, many facilities are trying to implement culture change in various ways—increasing choice in menu components and dining times, increasing choice in when to wake and when to go to bed. These are all good changes, but what are the underlying values, beliefs, and attitudes that need to change to really make culture change successful?

That is the topic for the next blog!