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Promising Practices in Dining

Transforming the Institutional Dining Experience

Click on each of the links below to learn more about transforming the institutional nursing home dining experience

FROM INSTITUTION TO COMMUNITY

TRANSFORMATION PATHWAY - CONDUCT THE ORGANIZATIONAL ASSESSMENT    

TRANSFORMATION PATHWAY - ESTABLISH THE CULTURE CHANGE LEADERSHIP DINING TEAM

TRANSFORMATION PATHWAY - IMPROVING QUALITY IN DINING AND CHOICE

TRANSFORMATION PATHWAY - FOCUS ON THE SIMPLICITY OF WHAT RESIDENTS WANT

TRANSFORMATION PATHWAY - PUT THE "I" INTO INDIVIDUALIZING THE DINING EXPERIENCE

TRANSFORMATION PATHWAY - CREATE THE LOOK AND FEEL OF HOME

TRANSFORMATION PATHWAY - CREATE STAFF CONSISTENCY: EDUCATE AND CROSS-TRAIN STAFF IN THE DINING EXPERIENCE


TRANSFORMATION PATHWAY - QUALITY ASSESSMENT AND ASSURANCE PROCESS: DOCUMENTING THE DINING EXPERIENCE PROCESS

TRANSFORMATION PATHWAY - CREATE PERSON-CENTERED DINING EDUCATION AND COMPETENCY STANDARDS



From Institution to Community
Dining plays a large role in resident quality of life and the culture change movement.  With the release of the June 12, 2009 CMS Interpretive Guidelines revisions, nursing home providers are beginning to re-assess the methods by which they accommodate resident dining in a more person-centered fashion.  In the first segment of our Promising Practices in Dining Series we begin by Examining the Institutional Nursing Home Dining Experience.  We explore key components of nursing home operations and dining and the common institutional practices that CMS expects providers to change. CMS expects nursing homes to raise the standard for accommodating resident choices over his or her activities,  health care,  and schedules according to his or her needs and preferences in the release of CMS Interpretive Guidelines Revisions F - 242 (Self-Determination and Participation).  



In addition to residents maintaining control over meal choices and schedules the entire dining experience is expected to be dignified.  Some nursing homes have struggled with consistently providing a dignified dining experience.  Providers may recognize that parts of the revised Interpretive Guidelines include basic dignity practices. For example, staff are expected to use dignified language with residents such as replacing "feeders" with "residents who require assistance with meals."  Other parts of the Interpretive Guidelines can be viewed as part of a transformation process that may take time. In several instances, CMS recognizes that implementing some of the Interpretive Guidelines may constitute financial hardship and may take time, and in many cases a home can find ways to accommodate the revisions by re-allocating resources. 

Ironically, at the same time that a number of the Interpretive Guidelines have been revised to allow for greater resident freedom, other Federal Regulations and Interpretive Guidelines continue to emphasize stringent infection control and food handling requirements, food temperature and Hazard Analysis and Critical Control Points (HACCP), nutritional and sanitation regulations.  Recent developments in both the nursing home industry and the regulatory community are setting the stage for innovation to overcome barriers to achieve a more dignified dining experience. 

In an effort to remove barriers to innovation and address both provider and regulator concerns, CMS and Pioneer Network recently collaborated on Creating Home in the Nursing Home II: A National Symposium on Culture Change and the Food and Dining Requirements.  The on line Symposium includes a downloadable background paper and a series of webinars, including papers authored by webinar presenters that can also be downloaded.  An in-person invitational stakeholder's workshop was also convened by CMS and Pioneer Network on May 14, 2010 to review the presenters' recommendations and add recommendations that will be used to further understanding of the food and dining side of the culture change movement and to identify solutions to furthering innovation in nursing homes.

While some perceived and actual barriers exist, creating a more person-centered meal and dining experience, and expanding resident choice over meals and meal times are consistent with the requirements intended in OBRA '87.  Many nursing homes are already making great strides towards improving the resident's dining experience.  Central to the beginning of transformation is the theme of conducting a deep facility operations assessment (labor and supply management). This simply means that a team should review the budgeted dollars allocated for performance improvement tasks associated with assessing, reporting, improving the dining experience. Of similar importance is the job functions related to labor. As the assessment process moves along, the home may determine that job descriptions may shift. Included in the assessment is also resident satisfaction. If residents are unhappy with meals and dining or if the home has food and dining related deficiencies, the outcomes will continue to be negative. Measuring and monitoring resident satisfaction as part of the QA program would go a long way towards knowing how well you comply with the released June 12, 2009 CMS Interpretive Guidelines and Dining.

  • Many of the changes in the release of the Interpretive Guidelines, while new, are not new concepts or practices. Many are intended in OBRA '87.
  • Conduct an Organizational Assessment with key stakeholders (residents, board members, staff) should be conducted, assessing compliance with the Interpretive Guidelines.  Conduct a mock survey to identify where you are in terms of a snapshot of compliance. 
  • Identify the budgeted dollars to perform any tasks associated with making dining changes and look for ways to re-allocate labor or supply dollars.
  • Assess job descriptions as they may change over time, as you build a better dining program.
  • Review Quality Assessment and Assurance and Quality Committee process and determine how the measuring and monitoring of progress will occur.

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TRANSFORMATION PATHWAY
Conduct the Organizational Assessment
Each facility will benefit from conducting a full operational assessment of the nursing home dining experience in order to determine the most cost effective and operationally efficient pathway towards improvement.   Each home can identify and create an action plan to modify dining practices in small ways and in areas that eventually may even involve capital equipment and purchasing. The key is to begin the assessment process as some of the core compliance components do not have negotiable time frames, while CMS does recognize that changes which may constitute financial hardship may take more time. 

From the outset, it is important to start small, and begin with education on the dining     requirements along with establishing goals for how the home will begin to conduct a facility assessment.  Start by setting clear expectations with key stakeholders (ownership, board members) residents, and staff, that the culture change journey is a process that takes commitment and time.  In some cases 90-day action plans might be appropriate, particularly for a "special focus facility" with a long history of consistent violations in basic dignity and dining practices. For homes seeking to move from "good to great", the longer journey may take several years depending upon the degree of hardship to a home (capital purchases in physical plant re-design) or in labor reorganization (a more integrated, less hierarchical structure, with high levels of cross-trained staff).

Each home will need to define a balance between innovation and resident freedom and resident safety and nursing home liability.  For example, a home might review some of following risk areas: Nutrition and Hydration, Accidents and Supervision, sanitation, advance directives, end of life care, all in relation to food and dining change and resident risks. In each it would be advisable to have the attending physicians, medical director and clinical staff discuss relevant risks in accommodating resident choices in food and dining, particularly as it may relate to policies and procedures and in resident specific risk matters. As with all regulations, there is a balance that the home always must identify, and for each home and resident this will be unique. Since most of the June 12, 2009 CMS Interpretive Guidelines revisions, are currently enforceable at team approach to change is critical.


  • Create Strategic Plan with milestones for outcome measurement
  • Identify per patient day cost for supplies and labor and determine where re-allocation can occur
  • Identify per patient day cost related to dining and performance improvement
  • Review liability and risk management practices pertaining to resident food and dining related resident safety risks

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TRANSFORMATION PATHWAY
Establish the Culture Change Leadership Team
In order to transform the dining experience, each home should consider a variety of systemic and interdisciplinary practices.  The best place to start is with the formation of a culture change leadership dining team. This team may be called a culture change leadership team, a dining transformation team, or simply be a sub-set of an existing Quality Assessment and Assurance Committee, but it all boils down to some fundamental basics.  First, the key to success in the formation of the team and achieving valuable and sustainable outcomes is in making sure that staff at every level of facility 'hierarchy',  residents of varied cognitive and functional levels and/or their representatives, and decision-making leadership are all involved in the assessment process and re-design of dining.  The early and continual input of residents and their legal representatives, family members, is critical as the ultimate success of the dining experience will be measured in large part by the satisfaction levels of these key stakeholders.  Similarly, staff must be the drivers of change and be empowered to have input into the change process so that the change is not viewed as just another marketing plan or scheme; rather staff need to see how the changes will benefit the residents and the staff and they will then hold on to the reins of change.  If the home is accustomed to 'top-down' decision making with little or no involvement from staff, the required changes will likely not sustain as some of the more involved dining changes pertain to staff behaviors that could never be maintained all the time in an autocratic management model.

Perhaps the best place to start in creating the Culture Change Leadership Team is to identify those staff who make who can and do make decisions about food and dining.  Each home has a different leadership structure but typically each has operational functions of food purchasing, food handling, food service, nutrition and dining, which all fall into various disciplines in the home.  A home might consider having the Quality Assessment and Assurance Team lead this process.  One home, for example, might determine that the initial Culture Change Leadership Dining Team would consist of the QA Director, The Staff Educator, Human Resources, Diet Aide, Cook, Nursing Aide, Nursing Supervisor.  Beyond some of the more obvious staff, it is essential to consider all layers of staff, direct and non-direct care givers, as each plays a role in assessing the resident, providing for the resident, or monitoring the care of the resident.  Those who are the closest to the point of service should consistently be included in decision making.  This ensures a better chance of establishing buy-in from the staff, residents and those who are accustomed to conducting business a certain way, and in a framework that seemed acceptable for years.

In addition to identifying key culture change leadership team members from the staff pool, concurrently the home should identify the key stakeholders, consumers (residents, families, visitors).  Perhaps the first Assessment Team meeting will include a comprehensive review of the current dining experience. Begin by determining some of the aspects of dining and quality of life.



QUALITY IN DINING

  • Establish an inter-disciplinary dining leadership team (include all hierarchal levels and key stakeholders)
  • Review the regulations, the findings from mock survey and determine key compliance components and document which items are already in place and which items will require action plan

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TRANSFORMATION PATHWAY
Improving Quality in Dining and Choice
What are the important traits that anyone can associate with as important to having a positive experience in dining?  For each person it may be slightly different, but a good place to begin the assessment process is to discuss the June 12, 2009 CMS Interpretive Guidelines and itemize Establish questions surrounding the regulations and then begin to discuss what the current dining what they really mean, as wells as to discuss some of the key components of great dining.   



QUALITY ASSESSMENT AND ASSURANCE
  • Establish an inter-disciplinary dining leadership team (include all hierarchal levels)
  • Review the regulations and determine key compliance components and document which items are already in place and which items will require action plans
  • Set measurable milestones and document progress via Quality Assurance Committee

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TRANSFORMATION PATHWAY
Focus on the Simplicity of What Residents Want

The following is an excerpt from Linda Bump's "The Deep Seated Issue of Choice" from the 2010 Creating Home in the Nursing Home II: A National Online Symposium on Culture Change and the Food and Dining Requirements. 


Resident satisfaction is the true measurement of dining and quality of life and the residents should be central to the process of improvement.  Residents can be included in reviewing the meal delivery process, menus, identifying resident preferences and in working directly with the staff. The process of resident involvement can be formally acknowledged by taking minutes and by including the actions and follow-up of meetings in Quality Assessment and Assurance documentation.


  • Conduct resident satisfaction surveys  (e.g., Dining Resources, CMS QIS Survey Forms and CMS Traditional Survey Forms
  • Review findings from surveys, reports that pertain to resident oriented food and dining outcomes. (e.g., Quality Assurance, recent regulatory surveys, recent MDS census and condition reports) and identify where action plan is required.
  • Document progress in the minutes from Quality Assessment team or a dietary culture change leadership team
  • Meet with residents, loved ones and staff to identify strengths and weaknesses in the food and dining experience

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TRANSFORMATION PATHWAY
Put the "I" into Individualizing the Dining Experience


The following is an excerpt from Linda Bump's paper "The Deep Seated Issue of Choice" from the 2010 Creating Home in the Nursing Home II: A National Online Symposium on Culture Change and the Food and Dining Requirements. Click here to download the paper and view the webinar.

"Simply speaking, it is all about choice. It is as simple as asking, "What does the resident want? How did they do it at home? How can we do it here?" Asking those three simple questions, pushing away "the way things are done," connecting with the resident and his or her preferences and letting choice rule, you realize the "the way things are done" is certainly not the way you would have done them in your house, and you are on your way to individualized resident directed care. Favorite foods, comfort foods, foods prepared from residents' favorite recipes, foods they chose to eat in their own home, foods that make them look forward to the day…foods that are good for them, from a therapeutic perspective, or foods that they have enjoyed for their whole life even though they may not be the best choice from a medical perspective…for most elders, these foods will not come wrapped in individual snack packs, but rather from real kitchens, from caring staff. But for some, a candy bar and soda, or chocolate chip cookie and milk may be the "supplement of choice." Knowing what specific foods tempt specific residents can make the difference between weight loss and gain and between supplement and food first. Knowing the residents, their choices, their preferences and their daily pleasures in dining leads to optimal intake and optimal quality of life in dining". (BUMP)

The key to successful identification of resident preferences is ultimately in the resident participation in the care planning process and the accuracy of documentation of resident wishes and needs.  A wonderful opportunity to assess the true satisfaction of resident likes, dislikes, and clinical nutritional goals, occurs during the care planning process.  This process should take beyond just the MDS cycle. The goals should be geared towards improving the ability of residents to expand food choices. The presumption is that residents will be able to enjoy meals that they like as well as to eat at a time that resident prefers. The Interpretive Guidance is intended to help accommodate resident food choices and their lifestyles it is still imperative that the MDS and resident clinical concerns are documented and that staff understand the resident goals, the change in process lies in identifying ways to give residents more control over their dining experience.  This means that staff must consistently understand and care about the choices residents make. 

Each home will need to determine the amount of risk associated with modifying policies and procedures and practices; however, by reviewing the risks with informed team members, the home can properly prepare for the future. . In some cases resident refrigerators may be a simple addition to accommodate personalize choice, and will have to be balanced with food and safety requirements. In other cases, residents may begin to select more items from a menu that has been discussed with resident council members.

One of the best ways to increase resident satisfaction in choices over meals and meal times is by asking each resident what he or she desires.  In order to truly individualize the resident's care, residents should be able to state their desires.  Once the resident's desires are know, the staff must be fully aware of the preferences and be able to accommodate them.  This will be a much easier task if staff are consistently assigned to residents in order that they will become innately familiar with resident needs rather that constantly having to reference a care plan.  Identifying resident desires and accurately document them is only the first part of carrying out the resident's desires.  Staff must be able to help deliver on the promise to give residents maximum flexibility in meals and meal times.

For those residents who cannot express themselves, significant time should be taken with family members, significant others, and by observing resident intake and habits, to help make the best informed choices as possible.  These residents are always at-risk for a loss of dignity in the dining experience and should not be isolated from the deep assessment process that takes place with vocal residents or forums such as resident council.  Staff need to be trained in identifying resident preferences and outcomes for residents who lack communication ability and/or whose needs are not easily identified.  The power of observation, resident history and continual monitoring of resident care is essential for these groups who always experience changes in process without the benefit of easily expressed self-determination.

Person directed care ensures a holistic approach, one that effectively utilizes the interdisciplinary team and incorporates resident choice as well as information from the clinical assessment.  In fact resident choice is not just a part of person directed care, it should drive it.  While these choices may sometimes conflict with recommendations of the clinical team, the label of being "non compliant" should be avoided.  Usually, a careful discussion of risks and benefits with the resident and/or their family/POA will allow for resolution of this conflict and help to create an agreed upon plan of care that can then be monitored for desired outcomes and recommendations


  • Use Minimum Data Set (MDS) and Resident Assessment Instruments to identify resident condition and trends in relation to dining program
  • Review staff education program and determine if staff require any additional training related to dining changes
  • Meet with resident council and family council, resident advocacy groups, and inform the of the changes that the home is undergoing
  • Establish a method for identifying the needs of those residents who cannot adequately express themselves in order to find out what their nutritional needs and dining desires may be and how to best accommodate them.
  • Establish a risk process so that safety issues can be addressed quickly and as a team.

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TRANSFORMATION PATHWAY
Create the Look and Feel of Home

The process of shifting from an institutional dining model is typically a gradual one for those homes who have not yet begun to expand resident choice beyond one alternate served on a main menu and who have rigidly set meal times. In the beginning there are simple steps that a home can take to become more of a "home".  It is helpful to define what makes a home feel like a home. Let the residents and staff assist with this effort.  The answers are not so far from what we all want in a dining and meal experience.  At the core of the shift is the sense of developing a community that treasures the meal experience rather than focuses on it as a facility task.

Some homes call this 'fine dining' or 'enhanced' dining and these programs may include the use of fine china, pre-set tables, and combine a buffet style, restaurant style experience. Some offer pre-meal breads and salads, while others have expanded choices by using desert carts at all meals, and involving residents in the menu planning and food ordering. Many already serve meals without the use of meal trays for the most part, and have long since discontinued or never used clothing protectors. Many homes are at least attempting to create a more dignified dining room, using table cloths and some combination of fine or faux china as well as avoiding the use of trays at least at the point of placing the meal before the resident. Some homes use cloth napkins like those in a restaurant, or paper napkins and some residents may wish to have a terrycloth type clothing protector.

The key to enhancement is to identify what you wish to enhance. Not every home will need to make every change. This is a continual improvement process that starts where you are. Look at your practices in relation to the June 12, 2009 CMS Interpretive Guidelines Revisions

"Transformational design can be as simple as - we brought our toasters to the table.
We actually physically set the toasters in the middle of the dining room. When the
core team met, they said, "We always cook it in the kitchen, stack it up, bring it out
and by the time it gets to the dining room it's cold and hard. And that's just the way
We've always done it. Now a resident asks for a piece of toast, we put the bread in,
butter it and we give it to them right there. Now, it was just an experiment and the
whole building was talking about it for days afterwards, over toast. It was probably
the very best thing we did, to start with that because everybody got excited about all
the other things we could do." (Nourish the Body and Soul DVD, 2008) Quoted Bowman, 2010 p. 10
Click here to learn more about the Stage Model of Culture Change
Creating Home in the Nursing Home II: A National Symposium on Culture Change and the Food and Dining Requirements

The following is an excerpt from Carmen Bowman's paper, "The Food and Dining Side of the Culture Change Movement: Identifying Barriers and Potential Solutions to furthering innovation in Nursing Homes." from the 2010 Creating Home in the Nursing Home II: A National Online Symposium on Culture Change and the Food and Dining Requirements.

CAN YOU IMAGINE STAFF EATING WITH RESIDENTS?

Dining Together Equalizes Everyone "The extra socialization and encouragement, plus ready offers to get an alternate or to pour an extra cup of coffee makes all the difference between institutional food service and enhancing the residents dining experience" (Bump, 2004-2005). An example of "socialization in action" comes to mind. Beth Irtz, then the administrator of Clear Creek Care Center in Colorado and now Quality of Life Lead for Sava Senior Care Colorado region and President of the Colorado Culture Change Coalition, implemented a Wednesday Buffet where staff were invited to eat (free of charge) with residents. The buzz of conversation was almost deafening and thrilling to see and hear. When people dine together, they are just people, no longer separated as "residents and staff." All people eat. Dining together serves as a well known experience that "equalizes everyone" a practice which serves to soften the "us-versus-them" atmosphere that may occur in institutional living (Krugh and Bowman, 2009).


  • Create a checklist of all the elements of dining that the environment must accommodate and routinely assess and monitor compliance.
  • Determine how you assess resident input and satisfaction as well as how you identify resident preferences and honor them.
  • Find out what residents and staff think of food and food and dining.
  • Seek to establish degrees and milestones for improvement, tackling the basic dignity factors first.
  • Identify a core group of residents and staff and do a trial in dining and test various process before expanding to entire resident and staff base.

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TRANSFORMATION PATHWAY
Create Staff Consistency: Educate and Cross-Train Staff in the Dining Experience

In an more institutional nursing home environment staff perform duties within a rigid segregations of duties (typically distributed between nursing and dietary staff); however as the dining experience allows for residents to have expanded choices of meals and meal times, the traditional job description likely begins to change.  Traditional job descriptions for both nursing and dietary staff, for example, may include substantial dining related tasks.  The nursing staff tend to be required to serve and monitor meals, and to participate in the dining process from beginning to end.  Other than preparing the meal and, in most cases, cleaning up after it, the institutional model maintains this segmentation.

Some homes have already identified the benefit in having all staff participate in meals during meal times.  Though different nursing home cultures call their employed staff by different names, the key point is that their job duties tie to a culture and to performance and outcomes. Some include the requirement that department heads and other key leadership participate in what is commonly referred to as "meal monitoring."  As "institutional" as this phrase may see, it served many purposes for a complex meal delivery process to be accommodated in accordance with existing laws.

The theories behind more integrated and cross-trained staff all point towards better interdisciplinary cooperation as a result of shared experience, better operational efficiencies (as staff can all resolve more time oriented tasks in real-time, and a more expanded choice over meals and meal times.  While there may be cost associated with process change some early studies point to overall costs savings in many measurable areas including staff retention, reduced meal waste, supplement costs, increased resident and representative satisfaction.

Nursing homes that are in the process of changing their meal delivery process will quickly identify, during the assessment phase, that one of the central themes in providing more person-centered care in dining is in the consistency of staff assignments (see consistent assignments) and in the involvement of many departments, a higher level of cross training in dining assistant roles (see paid feeding assistants). and a different approach to the staffing and roles within the home. Initially, some steps that a home might take include some of the following:



Click here to read more about the benefits of cross training staff

Staff Availability and Accountability - It is essential that staff are fully engaged in making the dining process a successful one. The shift away from highly structured meals and meal times emphasizes the need for all staff to participate at meal times. Some homes already commit to meal time monitoring programs but a true blending of roles means that the process is a permanent one and many departments are expected to assist (Workforce Toolkit)

Consistent Assignments - Consistent assignments are the key to consistent meal delivery along with all service delivery. While it is challenging to maintain the same staff and consistently assign them to the same residents, consistent assignments should be a constant effort. Quality of care depends upon the degree of staff knowledge of residents over time.

Cross-Trained Staff - Silos of staff are likely counter productive to any long term success with person-centered care and dining. As resident individual needs become more personalized, operational efficiency, cost-control, and resident satisfaction can best be accommodated by many people understanding and providing for resident needs.

Decentralized Eating - As meals become more personalized, the point-of-service expands. The central kitchen slowly becomes less of the 'command center' and meal service moves closer to the resident. In some cases this may look more like a restaurant operation or small pods of service in various dining areas, or steam tables brought up on to nursing units and served ready-to-eat.

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TRANSFORMATION PATHWAY
Quality Assessment and Assurance Process:
Documenting the Dining Experience Process
  • Most recent Federal or State Surveys- What is your survey history in any of the F – Tags associated with Dining?    
  • Quality Assurance Data- What information can you identify from your current and past year of QA Data that relates to food and dining?  Does your home seem to have problems with food temperatures, issues with therapeutic diet compliance, care planning, dining satisfaction, clinical issues? 
  • Identify resident needs based upon census and condition- Use MDS and Census and Condition reports to assess aspects of population needs on a long-term and short-term basis? What is the cognitive and functional status of residents in relation to dining and nutrition?    
  • Review Resident and Family Council and Satisfaction Surveys pertain to the food and dining experience.
  • Use results of mock survey or other food and dining feedback to determine baseline action plan and create a measurable and actionable compliance plan.   
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TRANSFORMATION PATHWAY
Create Person-Centered Dining Education and Competency Standards

In many respects the education and competency standards pertaining to food and dining are the most important as staff need to understand the standards they are expected to reach as well as how to reach these standards. As staff truly gain a working understanding of the critical importance to providing a dignified dining experience, and they desire to create it, the process will perhaps even been seen as team bonding, and end up improving morale and food service efficiencies and have the tools to create that experience, then the long term success of the program is easier to achieve.

For many homes job descriptions currently exist for numerous departments who all participate in the food and dining experience. For example the laundry staff job descriptions may tie in to the cleaning of clothing protectors, and a cook and diet aide job description may contain numerous food and cleaning standards, and the nursing staff job descriptions may all contain various components of monitoring, serving or helping with meals. As staff education and competency is established in dining, some homes may find a need to alter job descriptions.  Additionally some providers may determine benefit in cross-training and integrating staff.  A lot of homes already have adapted a meal program which includes the requirement that many staff from all disciplines, including leadership, participate in serving and creating a dignified and enjoyable meal experience for residents.

However each home chooses to approach compliance with the June 12, 2009 CMS Interpretive Guidelines revisions, Surveyors will likely be using expanded Surveyor Protocols. Staff must be able to demonstrate how they understand resident needs and accommodate resident choices in a dignified fashion. Orientation programs and continually can likely be modified to accommodate any new staff training that is not already in place. 


  • Assess how the home is currently serving meals and staff assignments during meals
  • Review orientation and training programs related to dining standards
  • Review job descriptions of staff and determine how performance standards might change or how job duties might be blended, resources re-allocated
  • Consider beginning the process of introducing all staff to the dining experience (department leadership, other members of the staff beyond nursing and dietary departments

Beyond the initial transformational dining steps, some homes are in a more advanced stage of development.

In Part III Series, "DINING NIRVANA" we explore some dining models that show promising practices
Click here to download the paper and view the webinar.

From the Stage Model, Stage IV is the Household Model, and also includes the Green Houses®, small houses, and the Scandinavian Service Houses. Home has been established Again, living in houses with self-contained fully functioning kitchens, cross-trained staff reporting into the house and not to departments. Elders run their lives, get up when they want, eat what and when they want, choose snacks, have friends over for dinner or coffee, and plan their lives (Nourish the Body and Soul, 2008). In some households there is a new Staff role, homemaker, responsible for cooking meals and other homemaking duties. Many households designate a food budget for the household for true resident choice. On a weekly basis, residents make their grocery list. They decide what kind of ice cream they would like or cereal - Captain Crunch anyone? (Bowman 2010)

 Click here to learn more about the Stage Model of Culture Change

In A Stage Model of Culture Change in Nursing Facilities, Leslie Grant and LaVrene Norton introduce a conceptual model of the culture change process in which they use an expertise elicitation method. They note, "Just as people progress through distinct stages of human development, going from infancy to childhood to adolescence to adulthood to old age, nursing facilities undergoing culture change progress through distinct stages of organization change and development." They define four stages of culture change – institutional model, transformational model (awareness and knowledge begins to spread, consistent staffing may be initiated and minimalist changes to the physical environment occur), neighborhood model (traditional nursing units are broken into smaller functional areas and resident centered dining is introduced without full kitchens), and household model (self-contained living areas with 25 or fewer residents who have their own full kitchen, living and dining room; staff work in cross-functional self-led teams and traditional departments are eliminated). (Grant and Norton, 2003) (BOWMAN)

In the CMS Individualized Care Video series, (Part III, 2007), a CMS Central Office dietitian from the Division of Nursing Homes, Alisa Overgaard, made the following profound statements:
"Liberalized diets should be the norm, restricted diets should be the exception"; "No research shows restricted diets have any benefit"; "Some homes have made liberalized diet the standard with monitoring of edema, high blood pressure, blood sugars and then make changes as necessary"; "Research shows that quality of life may be enhanced by a liberalized diet"; "Facilities should review existing diets to minimize unnecessary restrictions"; "There is broad consensus that dietary restrictions, the so‐called therapeutic diets such as low fat, sodium restricted and modified textured diets are only sometimes helpful and may actually inhibit adequate nutrition especially in undernourished or at risk individuals"; "Generally weight stabilization and adequate nutrition are promoted by serving residents regular or minimally restricted diets."


Would You Like to Share Your Promising Practices in Dining and Learn From Others
We encourage providers to share their practices, operational tools and resources, including vendors that have products and services that have helped homes to meet regulatory expectations at the lowest possible cost that you have implemented to enhance the dining experience.

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