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Best Practices
Meeting the AHCA/NCAL Challenge in the Dining Room

Setting higher standards at mealtimes will help your senior living community reach these goals faster 
by Cindy Heilman, MS, DTR

Last October I presented "How to Meet the Demanding Dining Needs of Boomers" at the AHCA/NCAL 63rd Annual Conference in Tampa. Of course The Quality Initiative was on everyone's mind throughout the conference and I immediately started considering how Higher Standards, LLC could help senior living communities meet these ambitious, but important, goals through Kind Dining® Training.

As you know, The Quality Initiative sets specific, measurable goals for continuous improvement in quality of care in skilled nursing centers and assisted living communities. AHCA/NCAL members are encouraged to reach defined, concrete goals over the next three years, in four core areas.

Successful leaders agree the place to start a quality shift is in the dining room. In In Pursuit of the Sunbeam, LaVerne Norton and Steve Shields observe, "We often start [system change] in dietary because it allows for incremental shifts in resident service that often lead to highly visible and positive results and creates those 'a-ha' moments that energize teams and the process of change." Industry expert Vivian Tellis-Nayak, Phd, says in Hospitality for Boomers, "Higher satisfaction with the dining experience wins over residents and family members. They in turn are more likely to recommend a community." Instruction in service basics, geared toward strengthening knowledge, confidence and communication skills, can quickly and fundamentally impact the collective psyche of the entire community.

Mealtime offers an opportunity not just to serve, but to connect. When a server takes the time and knows how to skillfully communicate, personal connections are made and satisfaction soars for both residents and staff. Offering superb service at mealtime can quickly move the organization forward to meet the requirements for more person-centered care. The lessons learned in the dining room can then be applied in housekeeping, reception, nursing, and all areas of the community.

1. Safely Reduce Hospital Readmissions
According to AHCA/NCAL, improving communication between care providers and residents, consistent staffing, and engaging providers at all points throughout the spectrum of care are three ways to meet the goal of safely reducing hospital readmissions. These elements of high quality care create an environment where staff are familiar with "what is usual" for each resident. When something changes, staff is more able to spot the problem early, before hospitalization is required.

Because improving communications between all stakeholders is a core component of Kind Dining® Training, communities who have implemented the curriculum have found AHCA/NCAL is on target with this recommendation. Kathy O'Hara, a Registered Dietitian at Villa Crest Nursing Retirement Center in Manchester, New Hampshire recently shared, "We've always had low rates of significant weight loss, but [since implementing Kind Dining®] we have no unexpected weight losses." She observes, "Staff has gotten to know residents much better and have even learned peoples' dining preferences, departments are cooperating like never before, and we are all focusing on meeting the residents' needs."

2. Improve Staff Stability
The Quality Initiative recognizes "empowering staff at all levels to participate in problem solving and quality improvement ensures solutions are based in first-hand knowledge of the systems and challenges that impact day to day care. There is significant research showing that satisfied and happy staff contributes to greater quality of life of the residents in our communities and provide greater quality of care."

Higher Standards, LLC has found well-trained, respected workers who feel satisfaction and a sense of ownership in their job remain engaged. Employees who truly enjoy their job, feel valued, and feel connected to the entire organization are more loyal, stay longer, and help recruit other high-quality workers. Kind Dining® Instructors regularly report employees like the positive feedback they receive when they start using their new skills. As staff continues to polish their skills, a positive loop develops resulting in greater satisfaction among residents and staff alike.

3. Increase Customer Satisfaction
As AHCA/NCAL points out, "Just like any other business, skilled nursing care centers and assisted living communities must ensure that the customer is king. Research shows that facilities with the highest rates of satisfaction perform better in other organizational indicators including staff stability, staff retention, survey results, census and cash flow."

Because mealtimes are so important to residents, if they enjoy eating in your community, they are more satisfied overall with living there. Conversely, the less they enjoy eating in your community, the less satisfied they are overall. Research shows this holds true for all levels of senior housing: skilled nursing, assisted living, and independent living. 

When describing what leads to mealtime satisfaction, residents see three things as important:
  • Server courtesy and attitude during service
  • The social skills of their servers
  • Service techniques
No one is born with this knowledge. Therefore, staff training is crucial to transforming your community's dining experience. However, time and again, Kind Dining® Training has proven these key skills and attitudes can be taught and inspired at every level of staffing. From nurses deciding to pour coffee to new trainees encouraging their teammates to excel, our experience shows small steps in dining service make a big difference community-wide.

4. Safely Reduce the Off-Label Use of Antipsychotics
As AHCA/NCAL points out, how care is delivered to residents with dementia can reduce the need for behavior modification through drugs. Consistency in staffing, schedules, and processes combined with a resident-centered, positive atmosphere, can help prevent the frustrations that lead to challenging resident behaviors and give staff non-pharmacologic approaches for addressing residents' behavioral expressions when they do occur.

Since providing a great dining experience strongly enhances the health and well-being of residents, and because mealtimes are so important to residents, the benefits gained in the dining room—better nutrition, social connections, and activity—have a tendency to carry on throughout the day. Done right, dining "sets the stage" for an optimal resident experience.

Now is the Time
Meeting The Quality Initiative goals isn't just about learning to set down plates politely, but research and experience show customer service is one of the most important tools available to meet the health and quality of life goals communities hold dear. Setting higher standards in the dining room is also one of the best ways to improve your community's reputation, marketability, and profitability. Forward-thinking senior care organizations are making profound changes in their dining rooms to meet The Quality Initiative goals, new nursing home survey processes, industry-mandated initiatives, and their own internal missions. As the long-term care profession moves increasingly toward person-centered care, the time is right for providers to advocate for best practices in serving meals that enhance the experience of residents and the entire organization.

Download The Quality Initiative one sheet for skilled nursing here.
Download The Quality Initiative one sheet for assisted living here.

Success Story

Setting a Higher Standard in Bethesda's Dining Rooms

Muriel Van Oordt demonstrates how initiating higher standards starts with hands-on research

"My goal was to move beyond the traditional nursing home model of meal service, which is targeted as simply nourishing the body, to set the stage for a dining experience that also nourishes the souls of those who are served and those providing the service," said Muriel Van Oordt, Vice President and Senior Administrator at Bethesda Dilworth in St. Louis, Missouri.

Muriel decided to enhance Bethesda's dining experience while a fellow of the 2011 LeadingAge Leadership Academy. After 30 years in healthcare and a long history with Bethesda, Muriel had some insights into how to tackle the dining project. She started with hands-on research to determine her project's focus. She dined at each Bethesda facility to assess service, food, and table settings. She also visited with management, staff members, and residents to learn what mattered most from each perspective.

"I found out that some of the things [residents] missed the most were candlelight dinners and being able to eat outside," Muriel said. "From that point, we decided to use hospitality as our model."

Muriel assembled a team comprised of herself and Bethesda long-term care dining directors Shelly Carley, RD, LD, Mary Knowles, CDM, and Amy Van Oordt, RD, LD, (Muriel's daughter), plus other key staff, to develop a plan that would improve the entire dining experience. The team decided to focus on three areas: hospitality training, employee appearance, and table setting. Then, they researched hospitality training options. Kind Dining®, a program developed by Cindy Heilman, MS, DTR, was chosen for staff training.

"One of the things Cindy observed was high levels of anxiety among seniors when they moved into a new community and were seated with people they didn't know." Muriel said. "The interdisciplinary program she created recognizes the importance of a meal and how we can all make it an enjoyable, relaxing experience for our seniors."

According to Amy Van Oordt, RD, LD, and Director of Dining Services at Bethesda Meadow, Kind Dining® Training has been very well received:

"The employees almost always come into the class with doubts that they should be there, especially those employees from departments other than Dining Services. Once the class gets started they all really seem to enjoy the class and usually all are participating. We have received very positive feedback from every person who attends the class. There are always a few staff members who stop and thank us for teaching the class and express how much they learned. We will continue promoting positive customer service through implementation of Kind Dining®."

Meanwhile, the core team worked to update uniforms and upgrade place settings.

"When you're coming back from being at a hospital, small touches, like crisp ironed linens and fresh flowers, are aspects of the dining experience our patients really seem to appreciate," Muriel said.

The ultimate goal for the Bethesda team, Muriel explained, is to "improve the dining experience across Bethesda's long-term care communities, and for changes to continue to evolve."

Their successes thus far are an example of why raising service standards in senior living begins with careful assessment. When leaders like Muriel are prepared to act and take an honest look at current procedures, the steps required to increase resident satisfaction and quality of life become clear.

Do you aspire to build a stronger organization that exceeds resident expectations? Follow Muriel's lead: share a meal with residents at your senior living community today.

Smart Visual Aids

Ever found yourself working with a resident who wants to see something, but forgot her reading glasses? Or realized you might need reading glasses as you squinted at tiny type? Next time, whip out your smart phone and magnify digitally. With the iCanSee app for iPhone or Your Magnifier for Android, you can magnify on the fly. They even have built-in lights!

Quick Empathy Tune Up

Sometimes it’s hard to avoid feelings of frustration while serving others, especially when we feel rushed or under pressure. These frustrations can prevent us from exercising our empathy and providing genuine hospitality to residents.

Next time this happens to you, take a slow, deep breath and check in with your heart. Ask yourself, “Am I providing kind, caring service?” None of us want to be uncaring. Taking a moment to be grateful for the opportunity before you to be more kind. Recite a favorite quote or the Golden Rule: Do unto others as you would have them do unto you. It will help melt your irritability and reconnect you to your empathy so you can provide your best service.

You can even use this technique before you start your shift or return from break to set yourself up for serving success. 

Grow Your Own Centerpiece

Watch Spring Bloom at the Table: Just when it seems winter will never end, crocus pushes itself out of the icy ground and through the snow to reassure us Spring is on its way. Watch the seasons change in your dining room by growing crocus centerpieces. Generally, to grow crocus indoors you need to start in the Fall. However, if you purchase pre-chilled bulbs you can start your plantings now and have blooms within a few weeks.

Have residents help assemble your living centerpieces by planting the bulbs in attractive pots. Once the bulbs are fully chilled, move the pots into the dining room so the entire community can watch them emerge and bloom. If your dining room is light-challenged in some areas, rotate the pots so they all get some time in sunny spots.

Use your homegrown centerpieces as conversations starters all season.

Skip the resolutions; plan a garden instead!

The seed catalogs are starting to arrive! It’s the time of year when gardeners begin to dream of sinking their fingers back into the dirt. Many are already plotting how they could get a couple more feet of space this year to try some exotic variety they have seen advertised. Now is the time to start planning a kitchen garden for your senior living community.

If this is your first year, consider starting small. An herb patch is fairly easy and doesn't take much space, but yields big benefits. Fresh herbs enliven any meal and offer a variety of health benefits.

For best results, and to build community, encourage your resident gardeners and dining management to collaborate. Ask the Activities staff to help coordinate their efforts, recruit newcomers, and invite family members to help out. You might even have gardeners on your staff who would enjoy contributing plant starts or participating in other ways. Making the garden a team effort will help build relationships and motivate people to cross out of their normal departmental orbits.

Gardens are a wonderful source of healthful activity and tasty produce. Get inspired and get growing for a bountiful year!

If I can be of service as you make plans for the coming year, please call me or e-mail any time.

Kind Regards,

Cindy Heilman, MS, DTR

Higher Standards, LLC

2012 Friendsview Garden Gallery

Friendsview Retirement Community in Newberg, Oregon has a fabulous kitchen garden. Check out their abundant harvest last year!
Click on each picture to see it larger.

Have a colorful snapshot of your community garden? Share it with us on our Facebook page.

Hospitality for Boomers

Order today and save 10%!

Hospitality for Boomers: How to attract residents, retain staff, and maximize profitability by Cindy Heilman, MS, DTR, is available now. This quick read shares a unique service perspective and is full of hospitality tips.

Order copies for your staff today and save 10% off regular pricing, now just $17.95 + S&H. (Call for volume discount pricing.)

Association of Nutrition & Foodservice Professionals

ANFP Pride in Food Service Week
Feb. 4 - 8

Celebrate creatively; then tell ANFP your story. You could win free registration to ANFP's First National Leadership Conference (NLC)! In the meantime, print the 2013 Pride in Foodservice Week mini poster to hang throughout your department and facility.

While you are at the ANFP site, check out the January 2013 edition of Nutrition & Foodservice Edge. My article, "Boomer Pleasing Foods You Should Include on Your Menus" starts on page 29. 

Prepare for National Nutrition Month®—March 

Once again the Academy of Nutrition and Dietetics is sponsoring a month-long campaign of nutrition education and information. Visit for free resources, handouts and tip sheets to download and print. (Non-members are welcome.) 

Maplewood Staff Ties One On

Employee initiative boosts dining standards one apron at a time at New Hampshire senior living community
by Kathryn Kindopp, B.Sc.P.T., NHA, Administrator, Kind Dining® Instructor, Maplewood Nursing Home

Years ago when we first started serving on the resident units, we encouraged staff to wear aprons. It didn't catch on and it stopped.

Several weeks ago, our Staff Development Coordinator Assistant, Ada, had an idea. She grabbed an apron, just to see the reaction. Residents told her she "looked like someone from Kind Dining®." That blew her away. But even better than the positive reactions of the residents were the positive reactions from staff, who wanted to wear one too.

So, we bought some new aprons, worked out a simple system with laundry, and Ada wore an apron again a few days later. We also talked about it at our Monday training.

Last evening, the staff who had just been trained took the aprons, wore them, and encouraged the other staff to wear them as well. Residents immediate reactions were positive and some staff asked if it would be ok if they got their own aprons, such as themed ones for special occasions. I've told Ada that I don't want to put any rules on this at this point. I want staff to "run with it" and let's see where this goes.

I love what is happening because it was not a "policy" or "procedure" from management, but an individual idea that is catching on like wildfire. 

I keep giving my staff "homework" assignments and I love watching what they are coming up with on their own. Some are taking empowerment all the way, and others see this and follow suit. Best of all - I did not direct them to do anything specifically, nor am I telling them what to do. I just plant ideas, encourage, facilitate and support.

It's just small steps but it's giving staff ownership.
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