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CW 100: Jane Rhode

Resident experience and the programming processes! Jane Rhode of JSR Associates discusses the resident and user experience and the operational flow processes that impact those experiences.

Welcome to Bridge the Gap Contributor Wednesday, I’m Jane Rohde, JSR Associates and nonprofit Live Together. Thank you for coming today and listening. I thought today we could talk a little bit about home and what does home mean? So this kind of came about as a result of working with a client and talking with them about language and what their understanding was of certain terminology. My background comes from working both on the facility and what we would call more of an institutional setting and trying to get to a more residential care setting. That was where we looked at doing intergenerational living, different kinds of training for staff evaluating different means and methods to make it better for residents and for staff and for the resulting outcomes. As we talk through that, I recently was talking to a potential new client and we had a conversation about different things that we needed to evaluate during the programming stage.


So what does programming mean? It really depends on who you’re talking to. Right? We could be talking about activity programming or financial programming or how the physical environment is designed as a program. The type of program we’re using in this context is the idea of talking about operations and talking about, what are the ebbs and flows? But one thing that I left out of the dialogue that was really key and important is this opportunity to talk about out what is the user experience? So what are our resident desired outcomes? What is the resident experience? What is the family experience and what is the operational flow processes that impact those? So the key thing to start with is really evaluating when you’re looking at whether it’s renovation or new construction is really crystal clear, being crystal clear on what do we want to include as the resident experience, and also the staff experience, because it’s critical to those outcomes overall.


So in evaluating that, we started a conversation about talking about food delivery, and clean and soiled, and all the different types of operational flows that happen. And although we’re talking about residential assisted living in this case, it came across as a little institutional. And I thought, so how do we look at those languages in the context of looking at their desired resident outcome? So when we do focus groups, we evaluate each component, each part, understanding how all of those flows that are really critical. And we do that more when we think about facility-based or commercial architecture design. We don’t talk as much about that in the residential feel of it all. So I had this thought that after talking with this potential client, working up some information for them and explaining how the process works, that we need to shift our nomenclature slightly.


So if we’re gonna talk about person centered care, which we’ve talked about on other Contributor Wednesdays, we also wanna talk about it from the perspective of, what do you need to know to make sure that something really is resident-centered? Or really is focusing on the resident desired outcomes. I also find that family members find that to be much different than what a resident may like. When we do focus groups, I like to talk first with residents. Residents, particularly that have some dementia are always interesting because they really tell you exactly what they think in a certain context. But when I talked to one gentleman, he was talking about the dining experience and how it was too far away. They only gave him an hour to do the ordering, waiting for his food to come, trying to get any conversation or visiting in, and then to actually eat his meal, get up from his table and leave the space. An hour is not enough time.


So as we talked about that, we talked about the distances and the need for distances to be shorter. And then in talking to staff on the same premise, same idea, talking about delivery of care. One staff member told me, “I walk seven miles a day and that’s without giving any care.” So when we talk about residential styling or residential assisted living, or the household or small house or whatever the nomenclature may be, we’re talking about smaller environments that are either subsets of a larger environment or smaller environments that are separate from one another, which would be more like a small house or an individual home. When we start talking about those different flows and processes, that’s how we determine what’s important and what’s impacting people and making it hard for them either to do their job, or it’s making it really hard for them to have a nice life, an experiential life.


The family members were next in this particular group and we were talking to them and the, I said, “well, what would you like to see for your, for your family member?” And it was all about glossy floors and big chandeliers and all these different, big, big entities and things that they wanted in terms of big design and sort of the shiny penny of it all. So they got done. And I said, “would you like to know what your dad thinks?” And they were surprised. And they’re like, “of course, what, what does my dad think?” And I said, “your dad really would like to have a longer period of time to be able to eat his dinner in a more, more time effective way and allowing him not to feel rushed or hurried.” Because if you think about it, food is one of the main parts of the day for any resident, no matter what the meal is.


So allowing them to have time to do that and time to think through it, time to be able to evaluate what their meal choices are, seeing what their meal choices are, talking to their friends about, “oh, what are you going to have?” Just like you would, if you were going to have a date out, or you were going to have a dinner out or people at your home. And so they were surprised at that, that that was really more of the concern than it being really shiny and new and luxurious. The other thing that we found is that acoustics are a huge issue. So if you can’t hear and you have trouble seeing, and you have trouble ambulating, you’re not really impacting the comforts of those. Or if you’re cold, we call those the four comforts of light mobility, thermal and acoustic comfort. And larger spaces don’t necessarily provide any of those.


So when you start looking at scaling things down to a more manageable environment, you also can improve the quality of life potentially for both the staff and the residents. So the residential experience is to have a lovely dinner and whatever that looks like for that person is individual to them. So when we talk about other things that are more operationally focused, like, how your food is delivered, for example. In a home setting, or in a household setting, do you have that delivered to the front door? Not typically, right? At home, you wouldn’t do it that way. So what’s the side door configuration look like? What is the separation of clean and soil? Even though those are seem like institutional comments, they’re very, very important because if we don’t look at those, then we’re not providing as safe of an environment as possible while still creating a homelike experience.


So it’s, it’s a balance. And understanding things like trash removal, how are you gonna do your laundry? How is the laundry gonna be done? When is it gonna be done? What are the different chemicals that are gonna be used for…. if we want to use green purchasing programs, all of those different combinations of conversations of operational procedures. And we find, plus the design is going to give you a much, much better outcome. So when we think through all of the different flows of what happens in care and service and amenity, I always come back to, “can you ask somebody a question,” and we often forget to ask the resident the prime question. The other thing with staff is trying to evaluate things from an interdisciplinary perspective, but then coming together and talking through it, talking through what made that experience more lovely and having different kinds of choices.

It was a story a long time ago that was told to me, it was in a learning circle. And they had a woman resident who was very unhappy. And to the point of being unhappy, she would not strike out physically, but strike out verbally and clearly was not happy. Finally, someone just asked, “what’s the matter? What bothers you?” And it was, “I don’t like peas. They serve peas at every meal and I just hate peas. And no one hears me.” So being heard is so important. So if we’re looking at the experience and yes, some of those things are more clinical, but if you look at them overall in the context of the resident experience and what would be good for the resident, different decisions could be made both design wise as well as operational wise. So as we look at our different policies and procedures and putting them together, kind of a tendency of, I don’t wanna say rubber stamping, but sometimes it does feel that way.


So if we really look closely at our operation policies and procedures, we have to have them, how are we training on them? Are we training on them in a context that evaluates what’s going on with each person? Are we looking at that in terms of we have a health and wellness management policy? What’s the impact for the resident? What’s the impact on the staff? Does it provide an area of respite for the staff when they’re working with a very vulnerable population and the additional stress to it? I saw an article this week that talked about, are we just burning our long term care staff to the point we of burnout, where they’re just not going to ever recover. Are we ever gonna recover from this from a staffing perspective? If we’re gonna do that, we have to change. We have to change in terms of how we address people, what our expectations are, how people are trained and how we evaluate what’s important to the resident and what’s needed by the staff. 


We’ve talked in some of our other presentations, a lot about what the staff member needs. We also need to look at how we evaluate their lifestyles and what their needs are. And those are questions too. Those are additional focus groups. We have found out amazing information when working with focus group folks, and we find frontline staff, you cannot combine them with administrative staff. If the administrative staff walks in during a focus group, no one will speak. But if we give them the anonymity of being able to talk to a third party, we have found that they will open up into the memory care, she was really having trouble, being able to settle in. And it just was foreign to her and uncomfortable for her. She couldn’t understand why she was there with folks that were a much higher level of need than she was that they seemed like very sick people and she was not.


And the woman who was asking the question from the frontline staff side wanted to know why they had changed the products without asking her, because she could not keep this particular residence shirts, bright and white. And so when we talk about person-centered care, we’ve told this story many times where this is someone who really cares about this resident and sees her struggling and knows that there are problems for her, yet the administration side did not see it that way or even notice. So we think through too, about what are the importance of talking regularly to frontline staff, but also having them sharing decisions that are made. So if this woman, I said, “what would you need to make this better?” She said, “I want the products back that we had before this decision was made without my input.”


And so by providing that input in providing that information, she could feel like she could give the resident a better experience for someone who was struggling, who was recently moved into memory care. So when we focus groups, we find that there are all kinds of opportunities and learning from frontline staff. They’re the folks who are there all the time. And that’s one of the things we find with communication systems. Most of the senior living settings we’ve been in rather large or small, they’re still communication systems issues because it’s not consistent. And that is something, if you can correct that, can help with staff, interaction, staff interdependency in a good way, and the evaluation and the time to be able to talk to people and understand what is going on, or if something happens and you have full communication by your staff and you don’t have someone getting up from the reception desk to go find someone or paging, overhead paging.


We don’t use overhead paging in our homes. You know, we may call up the stairs when it’s time for dinner, but we don’t necessarily have a paging system. And so this opportunity to make things create and feel more like home and address that experience is important, utilizing both the information filters of how do people come together and where? So if we think about things from an organizational perspective, how do we look at bringing people together organizationally? So what I mean by that, is what brings people together? We know food does, right? So what are the points of interaction? So why would a cafe that’s close to the front of the building and closer to the front door, be more widely used than say another type of dining venue? That’s kind of buried into a community. That’s because that’s where the interactions are.


That’s where the people are. So we, in addition to looking at operational flows and understanding the, and how they influence, whether no matter how small and residential a community may be in terms of one home, or if it’s multiple homes, or if it’s households within a larger community. However, that is put together, we find that the connections are incredibly important to understand where the interaction points? You’re looking at operational flow, your desired outcomes for both resident and staff, but then you’re also looking at what brings people together and where, and why? So if there is a certain reason why people gather and that could be, we know performances, for example, give us destination spaces. So that’s why someone goes there. But what if it is the interaction of daily life? Something that’s more normalized. People coming and going, people saying hello, people of different ages. Animals, and pets, different things that allow for interaction on both an individual level, as well as on a more group or social level.


So when we start looking at those types of things, as an overlay, when you’re looking at designing and programming a space, you can work and achieve a much higher opportunity or higher, maybe higher isn’t the right word, but a more open and observant and being observant to understand the opportunities that can occur. And when is a room more than a room? When it’s activated and what creates that activation? And sometimes that activation will change and over time it definitely changes. So if you have a resident population that’s living there and there’s an evaluation of what they like and what they do not like, that is really important to do periodically. People’s taste change, people’s activity level change, their opportunities to being able to do things and, and still being capable. So understanding if someone loves to paint and draw, but they may need to change the medium slightly so that they can address perhaps an arthritis or other impairment.


So being able to understand what’s most important, and as an environment gets smaller, or their world gets smaller, what does that mean? So what do they wanna hang onto? Kind of brings us back to Being Mortal, the book that Atul Gawande wrote, because it really talks to what are those different interactions and what is most important? So whether you’re planning a day to day, or you’re planning for a large change in life that has occurred and how do you work through that? Or if you’re really planning for the end time. All of those thoughts and processes to think through those in the beginning of a project in the programming process, and then being able to illustrate those in a larger process of being able to look at the design and how the design works, and then coupling that with the beauty of what the operational processes of those are. 


So it seems simple. When we first start talking with people, they’re sort of like, “well, what’s the design process?” And trying to understand the design process, particularly those who are smaller operators, but I also think everyone, no matter what scale you are, is to talk through the operational piece. Talk to your residents in finding out what the desired outcomes are for them, understanding your staff issues, addressing the staff issues that you can. And if you can’t find other ways to address them. That’s how we’re gonna rebuild our staffing models. And that’s how we’re going to rebuild being able to care for elders. There’s so much work we need to do. I know that we can do it if we do it together. And with that, I would like to close out and thank you for listening to this week’s Bridge the Gap Contributor Wednesday, please connect with me at

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CW 100: Jane Rhode