Lean Methodology: Reducing Residents' Breakfast Wait Times
Written by Bonita Matushewski and Dale Schattenkirk (Article previously published in Long Term Care magazine Winter 2012)
"Do angels work here?" an extremely frail resident asked upon admission to the Swift Current Care Center. Sadly, not an odd question for long term care.
The home had recently volunteered to be part of the Saskatchewan Ministry of Health Lean pilot project to improve resident care and outcomes in the province. The team identified several opportunities and ultimately settled in on refining the dining experience for the residents.
The team discussed the amount of time that was spent serving breakfast, and found that the gap between residents entering the dining room and actually receiving their breakfast was unacceptable. They established that it did not matter whether residents were in the main dining room or in the tray line. Food temperature was also questioned, since it was taking so long for meals to get out to the residents.
Like all the pilot projects, the Swift Current Care Center used Lean methodology and the 'Define, Measure, Analyze, Improve and Control' (DMAIC) structure. This structured approach ensured the team achieved their goal in a timely manner and created a sustainable, resident focused outcome.
The first step of the "define" stage was brainstorming all the potential issues within the dining process and creating an "opportunity statement" from those ideas. The statement the team arrived at was as follows: "The current meal process lacks communication, consistency and a clear procedure, which results in residents having to wait for the meals, which causes frustration for staff and clients".
The next step was to map the process. This visual allowed each person within the multidisciplinary team to understand how his or her work interacted with that of others. It also pinpointed any decisions that were made during the process and, most importantly, areas to measure for improvement. The baseline measurements were important, as the team needed to know at what level they were currently performing. When changes were made, improvements could then be quantified and validated as creating a better process for residents.
Measure and analyze
Over a two-week period, the team measured:
- the time it took to plate for assisted-eating residents and dining room tables;
- the time the residents entered the dining room;
- the time it took to serve meals in the dining room;
- the preparation time for both the dietary staff positions D4 and D8;
- the tray line set-up time and how long food sat before being distributed;
- the temperatures of last meal served on tray line and the last meal in the dining room;
- the number of times food needed to be boosted and how many times the product was
- incorrect or panned incorrectly or inappropriately;
- the time taken to search for and correct mistaken distribution of meals;
- the time to sort tickets; and
- the overall time for meal distribution.
The measurements revealed that residents sat for as long as 80 minutes before receiving breakfast.
This was not a reflection of the staff and their hard work, but rather of the system that was in place. As with most long term care homes residents could start arriving in the dining room relatively early, but breakfast service did not begin until a specified time, usually 8:30 am.
The other measure that was surprising to the team was the time that the tray-line food was picked up from the kitchen bore no relationship to its temperature when delivered to residents in their rooms.
Improve and control
Once the team had reviewed all of the measures they suggested serving residents as they arrived in the dining room. As with any shift in process thinking, this was met with skepticism and unease. The first step of the "improve" stage was to create an "aim statement" - in this case: "Increase the temperature of tray line by 15 degrees and decrease the time residents spend waiting by 50 per cent".
Secondly, the team brainstormed improvement ideas and decided which were valid. The team were happy with their ideas for change and arrived at the point of implementation. The tool they used for implementation was the PDSA (Plan, Do, Study, and Act) cycle. This tool affords opportunities to test the potential of long term changes in a process. A typical PDSA cycle lasts up to two weeks and engages the staff as they identify additional "tweaks" that can be made to the process.
The team completed the following activities over the PDSA cycle.
- Breakfast tables were not set up ahead of time.
- The tray line list that nurses needed to complete was removed.
- Breakfast was served to residents as soon as feasibly possible, instead of waiting until 8:30 am.
- Residents were served if they were in the dining room when the food was ready.
- A cut-off time for dining room residents was introduced. Residents who were not in the dining room by 8:45 am were served from the tray-line.
- The tray-line was set up after the main dining room was finished, at approximately 8:50am.
- Tables have been numbered
- Large magnetic sign has been made to help staff know where people sit
- Kardex going to be introduced in September to help with serving the lunch and supper serving times.
The team moved forward through the PDSA with great success and the feedback from the residents was very positive! Here's what residents said:
- "Now we don't have to wait anymore for our breakfast, we get it as soon as we come to the dining room."
- "It sure is nice to get hot fresh toast."
- "This is good, everything is hot and fresh."
- "Wow, that was quick, looks good."
- "I can still see the butter melting on my toast."
- One resident used to sit for over an hour continually asking when her breakfast would come and saying "I'm never coming to this restaurant again, the service is bad!" She is happy now and actually asks for seconds and thirds!
The team also added standard work procedures and a dining room chart that identified where each resident sat. This has been posted on the way into the dining room, so that anyone can assist residents to their assigned seats. For fun the team put colorful kites above each table with the table number on it. Although these are ultimately a tool to help staff do their jobs better, residents love the kites and show them with pride to their families and friends. The recreation staff plan to change the kites each season and to have special ones made for resident's birthdays.
Residents now receive their breakfast as soon as they enter the dining room. This has reduced the amount of time care aides spend in the dining room by 50 per cent and the time residents spend waiting by 70 per cent.
An additional unexpected improvement was, at first, deemed a concern. Registered staff were concerned that if residents were fed at random times it would be difficult and time consuming to track them down. One resident was of particular concern because of his diabetes and his need for insulin early in the morning. How would staff manage his blood sugar if they could not find him? But the unexpected happened: when the resident was able to eat his breakfast as soon as he wanted, he was able to control his blood sugar through his diet rather than through insulin. A very good and unexpected outcome!
The question was asked "Do angels work here?" Yes, yes they do, and they're enhancing their level of service every day!