Developing and Implementing an Interdisciplinary Feeding Training Program Within a Large Institution: The Manager's Planning Responsibility

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Sherrill K. Harnish, OTRh Debra K. Schmidt, OTlUL

SUMMARY. Planning is a daily part of every manager's job. Occupational therapy managers are frequently involved in the planning process and its component functions of designing, making decisions, delegating, controlling and evaluating. A11 of these management skills were called upon when a small occupational therapy department was assigned the program planning responsibility for developing a comprehensive feeding training program for a large institut~on. OVERVIEW Prior to May, 1985, feeding training at Mexia State School (MSS) was sporadic and'loosely defined. Charged with the care and training of 1100 mentally retarded residents, Mexia State School offered extensive academic and functional training in a broad range of vocational and self-care areas, but not in feeding skills. Development and implementation of formal training programs for clients were left up to the individual prerogative of direct care staff in the -

Sherrill K. Harnish received her master's degree from Texas Women's University. She is Director of Habilitation Programs at Mexia State School, Mexia, TX. Debra K. Schmidt is Senior Occupational Therapist at the same facility. This article appears jointly in The Occupational Therap Manager's Survival Handbook (The Haworth Press, Inc., 1988) and in Occupational Therapy in Health Care. Volume 5, Number 1 (1988). O 1988 by The Haworth Press, Inc.

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The Occupational Therapy Manager's Swvival Handbook

six residential units on campus. The effectiveness of existing social and family style dining programs was reduced by inconsistency in unit implementation, by the absence of uniform selection criteria, and by limited client involvement particularly for the 220 clients on the multi-handicapped unit who received only minimal training. Many clients, formerly independent in eating skills, had lost the ability to feed themselves and were now completely dependent upon staff assistance. Across the campus, staff had come to regard mealtime merely as a service to be provided, rather than as an extension of training programs. Improper feeding techniques were prevalent and rigid adherence to schedules made mealtimes impossibly rushed and hazardous. Adaptive feeding equipment prescribed by occupational therapy was frequently lost, damaged, not used, or used with the wrong clients. All these problems were noted in an on-site inspection by the Texas State Surveyors of Intermediate Care Facilities for the Mentally Retarded (ICFIMR). As a result, major deficiencies were cited in the facility's active training programs for lack of feeding training and inconsistencies in use of adaptive equipment. Unsatisfactory progress in correction of these deficiencies would have resulted in decertification and loss of funding. The plan of correction submitted by the school's chief administrator to the ICFMR surveyors proposed that occupational therapy would assume supervision of the mealtime eating skills training program. Subsequently, a program planning operation was launched in which all aspects of the planning process were to be addressed including: needs assessment, solution proposals, resource acquisition, implementing plans and on-going evaluation. PARTICIPANTS The Occupational Therapy Clinical Supervisor assumed responsibility for direction and supervision of four occupational therapists and five occupational therapy aides. She was given the overall responsibility of planning a course of action that would remediate the deficiency and result in implementation of a unified eating training program across campus. Although direct lines of supervision were not established outside the occupational therapy department, the additional authority assigned to her enabled her to call on other areas

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Shenill K Harnish and Debm K Schmidt


and disciplines for cooperation and input in adhering to the plan of correction. Qualifications of the Senior Occupational Therapist included eight years clinical experience in training the severely handicapped mentally retarded adult. Although she had no direct supervisory responsibilities over others than occupational therapy staff, her depth of experience and knowledge made her the prime resource for difficult diagnostic evaluations and oral-motor problems across campus. She assisted training staff in assessment techniques and treatment and was primarily responsible for designing an inservice training module to be presented to staff from other training departments and to residential direct care personnel. In addition, two entry-level occupational therapists were involved during the client assessment and implementation stages of the project. Both had been employed less than six months prior to the project and tended to have a short ranged, action oriented, often rigid or simplistic concept of the project. They functioned best when given specific technical duties centering around client evaluation and presentation of prepared modules for staff training. An administrative liaison was temporally "assigned" t o the Occupational Therapy Department to assist in implementing and monitoring a unified feeding program across campus. As a former unit director and department head, his 16 years of experience in education and management activities encompassed residential as well as training perspectives. Although he had no direct authority as a supervisor over unit or department staff, he and the clinical supervisor shared ultimate administrative responsibility for effective planning and successful implementation of the Plan of Correction. His functions on each core team included trouble-shooting and resolving problems during the early stages of implementation. Con? Teams

Each of the six residential. units established a Feeding Core Team with membership varying according to the needs of the unit's clientele. Key personnel included:

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1. the adminktrative liaison who served as a member of each of the six Core Teams. Duties included monitoring both problems and progress among and between the different teams in order to bring unity to the campus wide program 2. a self-managementtraining (SMT) supervisor who specialized in providing training in self-help skills and routine ADL 3. a unit training superviror who s u p e ~ i s e dthe unit's direct care staff involvement in client training activities 4. the unit activity coordinator who planned and monitored activities on the dormitories to supplement and assure carryover of departmental training 5 . an occupational therapist andlor speech pathologist 6 . a food service employee 7 . a regktered nurse 8. the unit director or the assktant unit director who held administrative responsibility for all programs on the unit. Each Core Team could enlist other disciplines or departments as needed; psychologist, social workers and dieticians were frequently involved. The diversity among team members included not only educational and employment backgrounds, but also scope of responsibility and authority, temperament, motivation, decision making abilities and value systems. The combined effects of these differences resulted in distinct "personalities" among the Core Teams which often dictated how effectively they functioned and the type of programs ultimately implemented on the separate units. With six separate, yet similar Core Teams, over 50 different unit staff and 13 different department staff members were involved in the ultimate plan to establish six sub-sets of a cohesive, unified campus-wide feeding training program, each sub-set functioning autonomously on the unit, yet in concert with the related feeding programs on the other units. THE ORGANIZATION

With a population of approximately 1100 clients, Mexia State School is Texas' largest state funded residential facility for the mentally retarded. Although all ages and levels of clients are served, the

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S h e d 1 K HantiFh and Debm K. Schmidt


client population has become increasingly composed of older and more physically handicapped individuals in the lower ranges of cognitive function. More than half the population have IQ's below 20. Approximately 86% are between the ages of 18 to 64 years old, with an overall range from 6 to 96 years. Nearly 55% have some degree of motor dysfunction. Facility services fall into three general categories. Residential Services Division includes direct care and administrative staff who provide 24-hour residential care and supervision on the 38 dormitories within six separate units. Education and Tmining Division includes specialized instructors and program monitors who supply the major portion of the required 6 hours of active treatment per resident per day. Habilitation Programs Department is one of seven training departments comprising Education and Training, which also includes the Self-Management Training Department. Occupational Therapy, and Speech Therapy are subdepartments of Habilitation Programs. At the time of this project, the occupational therapy supervisor also served as acting director of Habilitation Programs. The third division, Client Support Services, encompasses all other departments and services without direct client contact who are required to keep this multi-dimensional residential community operational. CHRONOWGY OF EVENTS Month




Action Taken

On-site ICFIMR inspection results in major deficiencies for lack of feeding training program and appropriate use of adaptive feeding equipment. Plan of Correction developed by Director of Education . and Training designating occupational therapy as the service responsible for planning, implementing and monitoring a program to correct the deficiency. Occupational therapy develops a sequential developmental program in five levels, including entrance and exit criteria for client participation, and screening checklists for assessment at all levels.

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The Occuptwnal Therapy Manager's Survival Handbook

Occupational therapy begins systematic screening of 1100 clients across campus, identifying those in need of training, adaptive equipment or therapy. Entire Self-Management Training Department staff of 45 trainers receives training from occupational therapy on oral-motor development and normal sequential acquisition of feeding skills in preparation for training clients. Core Teams are developed on five units and 50 unit staff receive the same inservice training as SMT. Using the results of initial screening and number of potential clients identified in need of services, the Occupational Therapy Clinical Supervisor initiates negotiations with the Director of Education and Training for additional staff to assist at meals. Occupational Therapy begins a series of inservice training sessions for Residential Services staff to assure carry over training from SMT to weekend and evenings. Of 1650 Residential Services staff, over 1000 received training through occupational therapy during this period. Client training begins on the 3 units where previous programs had existed. Occupational therapy's initiates use of their training module with new hired employees as pan of established, routine, on-going orientation. Occupational therapists and speech pathologists attend a regional 3-day continuing education workshop on dysphagia and together develop a specialized, detailed evaluation tool for use with multi-handicapped clients. Client training is imolemented on 2 more units. Occupational theGpy/spkech team begin evaluations of multi-handicapped clients and Core Team is developed on this unit ticarry out the program. Education and Training Division supplies 154 department training staff to assist Residential Services staff with feeding training at the noon meal. These employees receive training from occupational therapy before beginning rotating shifts in the dining rooms.

Shenill K Harnish and Debra K Schmidt




Training is implemented on the multi-handicapped unit. All new admissions to MSS receive screenine and/or evaluation by occupational therapylspeech tear;; to establish the initial program for SMT and the unit staff to cany out. Individual Core Teams assume responsibility for wntinuing evaluation and monitoring of the established feeding training programs for their units. Consultation and further inservice training provided on an "asneeded" basis by occupational therapy.

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CONTEXT For occupational therapy, the task of planning and developing a feeding training program that could be effectively and consistently implemented by staff from other departments was overwhelming. Further, any program designed must be sufficiently flexible to meet the diverse training needs of the school's large population. Even if such a program wuld be designed, how could a handful of occupational therapists, who had bulging caseloads already, hope to direct such an undertaking? Although the residential units and training departments worked together for the clients' overall program, a long standing territorial attitude between professional and direct care staff often prevented one from offering or following suggestions from the other. In this case, the units perceived feeding as being within their jurisdiction since meals occurred on the units and outside of regular training classes. Even within the Educational and Training Division, the training departments tended to see clients as "yours" and "mine" rather than "ours." Implementing any program would entail a great deal of cross-disciplinary interaction and cooperation. The seriousness of the deficiency and the firm stand by those in administration supporting implementation of a campuswide program helped pave the way for occupational therapy staff to work in both residential and training areas outside their usual clinical realm at MSS. Although occupational therapy regularly prescribed adaptive feeding equipment and treated clients with oral development problems and feeding deficits due to physical handicaps, the department had not been directly or actively involved in

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The Occypationnl T h e w Manager's Swvival Handbook

any form of mealtime training. Having knowledge and skill in task analysis, a holistic perspective of clients' needs, and with no strong ties to either the units or other training areas, occupational therapy seemed a likely catalyst for planning such a facility-wide endeavor. To accomplish this task, occupational therapy staff would be required to assess needs and if indicated, place clients in oral development or eating training programs at mealtimes. Occupational therapy would need to establish a written policy to guide acquisition, distribution and inventory of adaptive feeding equipment and ensure that prescribed items were available and being used appropriately. Four full-time and one part-time occupational therapists could never hope to provide direct services to nearly 1100 clients. However, a close scrutiny of roles, functions and staffing patterns of all the training departments and units revealed that many tasks could be delegated to nontherapy personnel and support staff. Only those services that were the unique domain of occupational therapy would be provided directly by that staff. Occupational therapy's roles as consultant and client advocate were felt to be most suitable for assuring program continuity and effective integration of training between the disciplines and direct care staff involved daily in feeding. In addition, any new training program for clients would also include a similar training program for staff. The administration at MSS viewed seriously the surveyor's recommendations that the job of staff professionals was two-fold: both to train clients and to train staff in how to train clients. Developing a comprehensive feeding program and enrolling clients was not enough; staff would have to be trained and monitored as well, to ensure that there was carrythrough among both current employees and those newly hired. Subsequently, occupational therapy assumed an additional role as teacher.

RISKS AND CONSTRAlNTS The sole risk and primary concern identified by occupational therapy was the potential detriment to current caseloads when feeding program responsibilities suddenly increased. Approached with the problem, those in administration approved compensatory overtime for OTRs who worked 45-55 hour weeks for several months at

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Shenil1 K Harnish and Debra K Schmidr


the program's inception. In addition, individual occupational therapy treatments for certain clients were combined with existing groups. Several small treatment groups were merged, thus freeing additional staff for conducting feeding evaluations and participating in Core Team Meetings. Once implemented, the project was plagued by constraints including: (1)a short timetable in which to show improvement; (2) a vast number of clients to be assessed and started in programs; (3) a large number of personnel to be trained; (4) a limited number of residential staff available for mealtime duties; and (5) budgetary restrictions that prevented hiring persons part-time to do feeding or offering paid overtime for those employees who were willing to give up their own meal breaks to feed clients. Because the feeding program was created to correct an ICF/MR deficiency that could affect facility reimbursement, a large number of clients had to be evaluated and enrolled in programs within a short time. As over 900 clients were evaluated during the first three months of the project, evaluations were necessarily brief. As a result, these one-time observations were not always valid. Personnel in both the units and occupational therapy would have preferred a more in depth evaluation based on multiple observations. The individual therapists varied in the amount of information they obtained from direct care staff to augment their own assessment impressions. Further, the therapists' own interpretations of their consultant role on the Core Teams also influenced the interactions and decision-making processes among Core Team Members.

CHOICES I . How could one effectively plan and organize such a complex project?

Implementing a campus-wide feeding program involved a great deal of planning and organizing. The Plan of Correction outlined would eventually become a large-scale, multi-faceted project. Planning methods were needed to take into account a variety of variables and constraints: coordinating a set of diverse, on-going activities in several units at once, estimating time lines for completion of aspects of the project and the project as a whole, coordinating deci-


i%e Occupatwml &mpy Mamger's Survival Handbook

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sion-making and anticipating future events. A tool for quantitative planning and decision making was needed. Various program planning techniques were considered, including decision grids, pay-off tables, decision trees and management by objective (MBO). The Program Evaluation and Review Technique (PERT) was the method of choice for focusing attention on planning and tracking decision-making as well as monitoring the effectiveness of the individual Core Teams within the context of the overall program. 11. On what design should the feeding training program be based? Although several pre-designed commercially available feeding programs suitable for the mentally retarded were considered, all focused on the development or refinement of general skills. None of these were geared toward lower functioning clients, nor was any applicable to a large institutional setting. After extensive study and planning, the decision was made to develop an in-house program specifically designed to meet the needs of MSS clients. Occupational therapy staff designed a sequential, developmental program proceeding from absence of oral-motor skills to basic skill acquisition to family-style dining behaviors. Ultimately, five levels of function were outlined with criteria for entrance and exit from each level. 111. How could such a large number of clients forprogramming be efficiently assessed? The large number of clients to be evaluated and the relatively small number of occupational therapists available to do the assessments dictated that a brief, simple tool be used to screen each client. Several options were considered: Should clients merely be screened or was a thorough evaluation needed? Did each client need to be assessed by an occupational therapist? Could other personnel share assessment responsibilities? Could feeding training needs be effectively translated to unit staff and, in turn, direct care staff be relied on to spot and report problems to occupational therapy? Did the multi-handicapped population require a more comprehensive assessment than clients who could feel themselves? Should detailed follow-up evaluations be done on those who demonstrated special problems on a screening? Should clients currently involved in unit feeding programs be re-evaluated by occupational therapy or ex-

Sherrill K Hamish and Debm K Schmidt


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cluded from the new campus-wide program? Should assessments proceed simultaneously on all units or be concentrated on one unit at a time? The final choice was that, based on the five levels of feeding function previously established, occupational therapy staff would screen each client for behaviors at the first three levels of function. Unit staff would be trained to spot potential problems that needed a therapist's immediate attention, and would screen clients at the two higher, more independent levels of feeding function.

IV. %%at was the most appropriate on-going role for occupatioml them^? Those clients who needed to learn feeding skills in the absence of physical or oral handicaps did not require the services of an occupational therapist. Under other circumstances occupational therapy might have opted to deliver such training, however, the large number of clients identified as needing training and the short time alloted to establish and implement a program precluded this. There would be an on-going need for individual client re-assessment and treatment by occupational therapy after the program implementation. In addition, a return to routine clinical caseloads would be necessary. As a result, occupational therapy staff chose to concentrate their roles to client evaluation, staff training and consultation.

V .How could other depament and unit staffbe utilized in training and canyover of occupational t h e r k recommendations? Appointing one overall planning committee was not feasible. The units differed greatly in terms of clientele, physical layout of the dining areas, staffing patterns and in their previous or current experience in feeding programs. Separate committees for each unit were briefly considered, however, prior experience showed that appointed committees were often good at making recommendations, but poor at taking action or responsibility. Each unit needed to assume responsibility for planning and implementing a program to meet its own unique needs, yet conform to an overall, unified approach to feeding training across campus. To meet this complex requirement, the occupational therapy supervisor proposed a Unit Core Team concept around which the final overall project was designed and implemented.

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The Occupationnl Therapy Manager's Swvival Handbook

VI. How should the actual training program be implemented? Once clients were assessed and training needs identified by occupational therapy, how would their recommendations be carried out? Following the original premise that client training also involved staff training, a two-part approach was designed to include not only programming for identified clients, but also training for staff who would carry out the work with the clients. Although occupational therapy has assumed responsibility for and completed the majority of training recommendations, were they the best candidates for training staff? One option was to initially train only the members of the Core Teams and then allow them to assume responsibility for training additional staff on their respective units. But what about the other training departments who would be involved? Should they be trained by occupational therapy, by SMT, or be temporarily assigned to a unit to be trained in the new program plans? Client training posed even greater concerns. Staff availability was insufficient on both the units and in the departments to individually train each client identified as having deficient eating skills. How could client training needs be prioritized? Was a formal training plan truly indicated for each identified client, or could feeding skills be refined simply by changing staff expectations of eating behaviors? Ultimately, specific, formally documented training objectives were implemented on 185 clients while approximately 260 others received specific, yet informal prompting to refine emerging or existing skills. VII. Once implemented, how could the program effectively be monitored and maintained?

The occupational therapy staff initially invested a great deal of time and effort in project planning, client assessment, developing client training programs and training staff to carry out these activities. Once a program was implemented on a unit, occupational therapy staff preferred to assume a less prominent role in on-going management of the new program and began to re-focus attention on their clinical caseloads. Without some type of periodic program review and remediation of problems, it was feared that the newlyfounded programs would falter or fade away. Thus, as the units Core Teams assumed increasing responsibility and accountability for their individual programs, they also took charge of monitoring

S h e d l K Harnish and Debra K. Schmidt


themselves. Using a Monitor's Checklist developed by the occupational therapy supervisor and senior therapist, Core Team members made regular visits to dining areas to troubleshoot and resolve feeding training problems without direct involvement of the occupational therapy staff. OUTCOMES

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I. Program Planning

Program Evaluation and Review Technique (PERT) is a procedural tool and planning method used for large scale, complex, onetime projects requiring advanced planning, scheduling and controlling a number of diverse activities. Intended to be used with interrelated, but independent activities that must occur in a specific sequence, PERT involves sequencing a set of events, estimating time needed for their completion, identifying those events that would delay the entire project if not completed on time or in sequence, and assisting in decision-making regarding use of manpower, time, equipment, and other resources. Development of a campus-wide feeding training program met all the traditional criteria for use of PERT: the project was multi-dimensional in nature, component activities were interrelated, yet independent of each other, starting and ending points were definitive and activities were parallel. A composite PERT chart detailing each unit's plans and target dates was maintained by the occupational therapy supervisor and routinely reviewed with the occupational therapy staff in order to coordinate overall progress on the Plan of Correction. 11. Program Design

The occupational therapy staff felt that every client who did not possess basic feeding skills should receive some sort of training. Considerations included the extent of training actually needed and determining what skills were required for self-feeding. A significant amount of time was initially invested in reviewing research in occupational therapy and mental retardation fields, previewing programs from other institutions, and synthesizing this information

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The Occupatio~lTherapy Manager's Swvival Handbwk

into a composite program designed to meet Mexia State School's needs. Occupational therapy staff felt this was a necessary step in order to achieve a strong program base in which virtually all possible client variations were considered and consistency of evaluation was more readily achieved. Occupational therapy designed a sequential skills development program that encompassed five levels of feeding skill: Level I, Oral Facifitation, addressed the needs of clients with severe oral-motor problems and abnormal reflexes; Level 11, Oral Development, identified those clients whose oralmotor skills were immature but not abnormal; Level 111, Feeding Ski&, was designed to address basic acquisition of self-feeding skills, including finger feeding, utensil use and drinking. Undesirable feeding behaviors such as a rapid rate of eating, inadequate chewing, or posture were addressed at this level. Level IV, Social Eating SkilLF, refined table manners; Level V, Famity Style Dining, addressed the client's ability to set a table, pass serving bowls, serve himself appropriately, use condiments and eat in public. Ill. Client Assessment

The large number of clients to be evaluated and the need to show "substantial improvement" in correcting the survey deficiency before the survey team's expected return in 90 days dictated that a simple screening tool be used to assess each client on campus. The senior occupational therapist developed screening checklists for all five levels; occupational therapy staff conducted screening at Levels I, 11 and 111, and unit staff assessed Levels IV and V. Those exhibiting problems in any one of several identified areas would receive a more detailed assessment after the majority of clients needing services had begun programming. Unit staff were instructed in spotting potential problems or deficits that should be brought to the OTR's attention if noted before extensive evaluation could be done. A separate, more extensive evaluation was developed for clients on the unit for the multi-handicao~ed.Each of these clients was evaluated by an occupational thera&/speech pathologist team with special training in swallowing disorders. This evaluation addressed oral structure< detailed lip and tongue movements and chewing

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S h e d l K Harnish and Debra K Schmidt


patterns, abnormal orofacial reflexes, breathing patterns, voice quality, diet texture, amount of food consumed during meals, adaptive equipment needs, and positioning needs. Other considerations pertinent to determining feeding training needs, such as weight loss, vomiting, oral stasis, mucus production or excessive time needed for feeding, were also noted. The client's potential for self-feeding training was evaluated by assessing upper extremity range of motion, coordination and strength, grasp, hand-to-mouth patterns, awareness of and interest in eating, and responsiveness to prompts for self-feeding. Only the multi-handicapped clients received this detailed evaluation since the screening tool would not glean enough information on which to base recommendations. Evaluation of this unit was deferred until the end of the project when time lines were more relaxed and concentration on monitoring the program and training clients had shifted to the Core Teams.

N.Occupational Therapy's Role Ultimate responsibility for all facility training programs rested jointly on the Director of Residential Services, who managed the unit staff, and the Director of Education and Training, who managed the training department staff. By confining the role of occupational therapy to client evaluation, staff training and consultation, professionals from other departments, disciplines, and units could assume direct responsibility as appropriate, for providing and monitoring a feeding training program on their respective units. Occupational therapy staff provided only those services in the unique domain of occupational therapy and which could not be delegated to other staff. The impact of occupational therapy was further enhanced by assigning an OTR to each Core Team and by planning and coordinating all staff training through the occupational therapy department.

V. Interdisciplinary Unit Core Teams As these could be designed to incorporate those persons in positions of power and authority on the units, along with those who were likely to be affected by changes involving the unit, the Core Teams were conceived as a variation of the interdisciplinary treat-

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The Occupatwnal Therapy Ma~ger'sSuwival Handbook

ment teams with which each unit was already familiar. Those Core Team members who were regular members of the interdisciplinary treatment teams, such as the nurse, activity coordinator, SMT supervisor and dietician, were experienced in structured program planning, problem solving and compromise. Newer Core Team members, such as food service workers and direct care staff, quickly adapted to being part of a dynamic team effort. No one person would be solely accountable, though each team member would have assigned tasks. The team could share ultimate responsibility for the continuity and quality of their established feeding program. Further, planning and decision making could be made at the lowest possible level, nearest the point of action and the time action was to occur. The Core Team concept promoted individual accountability by delegating project objectives and authority to those actually involved with implementation. Additionally, the use of Core Teams reduced procrastination and prevented passive team members from delaying, avoiding or shifting decision making, since corrective action could be initiated by the individual Core Teams. The administrative liaison attended all Core Team meetings in order to coordinate their activities with the objectives of the overall campus program and to relay common concerns and solutions between the Core Teams. Although he had authority to call on additional departments and resources as indicated, and reported directly to the Director of Education and Training, the final authority for goal achievement rested with the individual Core Teams. One year following project implementation, five of the six units involved reported positive feelings and attitudes about the Core Team system. Significant improvement was noted in cooperation between staff in food service and the direct care staff on the units, resulting in a more relaxed, quieter dining atmosphere for the clients. These five units perceived their Core Teams and feeding programs as their personal responsibility rather than as occupational therapy's. The assigned administrative liaison was able to assume a less prominent role as unit team members assumed leadership. The vitality of individual teams even survived the inevitable turnover of staff as the teams were developing a transdisciplinary interest in the

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SherrilI K Hamirh and Debm K Schmidt


feeding process. Occupational therapy staff, having evaluated all clients and trained all staff, could assume the role solely of feeding consultant, confident that appropriate referrals would be made as needed by other members of the Core Teams. Occupational therapists andspeech pathologists could thus work even more closely on oral development, positioning and self-feeding for the physically handicapped clients. On one unit, the Core Team failed to coalesce. Team members seemed to feel that the team was not "their own," and subsequently took little initiative to cultivate the feeding program on their unit. Core Team members appeared to perceive the team as "belonging to" either the administrative liaison or the occupational therapist. Team members deferred all decisions to the unit director, who lypia l l y did not attend meetings, therefore, little could be accomplished. Team members described this Core Team as a "waste of time" with the same problems being brought up repeatedly with no solutions or follow-up. It was found that the success of each unit's Core Team was directly proportional to the degree of support and involvement of the unit director or his assistant. Each of the five successful teams pointed to the presence of the unit director and other unit administrative staff in the dining rooms and at the Core Team meetings as a key factor. In contrast, the unit director and unit administrative personnel were usually absent from the meetings on the sixth unit with the weak, ineffective team. The ideal composition of a Core Team included both the hands-on people who knew the clients and provided daily training or service, and administrative staff with the final authority to effect immediate change. Failure to include both types of members limited the team's effectiveness.

W.Program Implementation Staff Training

With only a handful of staff available in the dining rooms during mealtimes and a large number of clients identified as needing training, it was apparent that assistance would be required to carry out a program of this magnitude. Trainers, technicians, secretaries and aides from the various training departments were enlisted to assist with client feeding from 12:OO p.m. to 1:00 p.m., taking their own

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The O c c u p a t w ~ Therapy l M a ~ g e r ' sSurvival Handbook

lunch breaks afterwards from 1:00 p.m. to 2:00 p.m. Over 150 employees f ~ o mEducation, Recreation, Occupational Therapy, Physical Therapy, Speech Therapy, Audiology, Chaplaincy, SelfManagement Training and Vocational Programs were required to participate in the feeding program. The resulting increase of available staff allowed development of a rotating schedule in which each employee was assigned to feed only one day per week. These employees assisted with serving the food and informal training of clients, thus freeing the units' direct care staff for formal training. Since most of these employees were generally unfamiliar with how to teach feeding skills, a series of inservice sessions was conducted by occupational therapy for all direct care and departmental training staff, that outlined the scope of the planned program, provided information about the use of adaptive feeding equipment and stressed the importance of independent feeding as the most basic of all developmental self-help skills. Strategies were developed on how to teach basic feeding skills and were posted on the walls of each dining room for quick reference by the trainers. Employees to be involved in training multi-handicapped clients needed more extensive instruction. The Occupational Therapy Department had previously developed a self-paced workbook on how to feed the multiply handicapped; this was used as the basis for the new training sessions. Information included how to normalize muscle tone, deal with abnormal reflexes, understand the swallowing mechanism, how to position for eating as well as specific techniques for eliciting desired oral skills during feeding. A laminated card was attached to the wheelchairs of clients requiring special feeding techniques. This card described specific techniques needed and included a photograph of the proper mealtime position indicated. All new MSS employees received six hours of training in handling, positioning, and feeding multi-handicapped clients. This was followed by a practicum in which each one fed physically handicapped clients under the supervision of a Core Team member. In this way, the problem of maintaining standards for feeding, in spite of personnel turnover, was addressed. Because the number of direct care staff could not be increased and because the use of trained

S h e d l K Hamish and Debm K Schmidt


department "feeding aides" to assist or support direct care staff worked so well, this aspect of the program was designed to continue indefinitely. Indeed, weekly feeding responsibilities were ultimately incorporated into all residential unit staff and training department employee job descriptions.

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Client Training Feeding training took one of two forms: (a) formal, goal-directed training activities or (b) the use of informal prompts while the client fed himself. Based on recommendations of the occupational therapy staff, the SMT supervisors developed written teaching strategies to guide direct care staff who carried out and documented formal training. Program activities focused on acquisition of basic skills such as grasp of the spoon, coordinated hand-to-mouth patterns, using a fork, cutting with a knife and eating at an appropriate pace without gulping foods. Direct care staff kept data on a client's daily performance and SMT trainers summarized this in monthly progress notes. Although direct care staff were under the daily supervision of the unit training supervisor, their performance during mealtime training times was monitored by the SMT supewisor. Informal training was directed toward general refinement of basic eating skills or development of prerequisite skills, with no documentation required. Although all staff were trained to recognize the need for and offer appropriate prompts for improving skills, this duty fell mainly on the training department feeding aides. Clients with extensive oral-motor problems received direct therapy from an occupational therapist or speech pathologist. Such therapy was performed apart from meals so that therapists could be available for evaluation and consultation during meals. Therapists might occasionally feed a meal to a client as part of an evaluation or consultation process, but were never assigned to feed on a routine basis. Since it was the responsibility of the direct care staff to feed the clients on evening and weekends, it was felt that the client's needs could be better served by having occupational therapy consult with the direct care staff on specific techniques, rather than replace them in feeding difficult clients. On the unit housing multi-handicapped clients, where previously

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The Occupational Therapy Manager's Survival Handbwk

virtually no training in basic feeding skills had been offered, the Core Team chose to offer one-to-one training at all meals to twelve clients at a time. Giving consistent, concentrated training to a few clients was expected to produce more independent feeders more quickly than would a diffuse approach to many clients. The clients chosen for this one-to-one approach had an awareness of and motivation toward food along with emerging hand-to-mouth patterns. By investing staff time initially in intensive training of clients with emerging skills, it was felt that these clients would soon become functionally independent in feeding, thus freeing the staff to work with more difficult clients. Overall, as staff expectations for independent feeding behaviors rose, the number of clients receiving formal training was gradually reduced as clients progressed out of formal training programs and performance levels were maintained with occasional informal prompts.

MI. Program Monitoring Core Team members were expected to monitor meals on a rotating basis, using a checklist jointly developed by the occupational therapy supervisor and the administrative liaison. This checklist wvered sanitary procedures, feeding techniques, staff-client interaction, training techniques and environmental considerations in the dining areas. These checklists were reviewed and discussed at weekly meetings, and strategies for dealing with identified problems devised. For example: The dietician observes a client spitting out pineapple chunks and asks occupational therapy to review the client's diet texture and oral structures. Follow-up by the therapist assigned to that Core Team and discussion with the other occupational therapists reveals a more global problem with fresh pineapple-other units report choking incidents and excessive waste as clients with chewing problems are skipping pineapple altogether or spitting it out partially chewed. The food sewice manager is wnsulted and the final decision, which affects all units, is to crush fresh pineapple for all diet textures. Core Team meetings increased members' awareness of the approaches of various disciplines and departments; in many cases, Core Team professionals on duty in the dining room wuld identify

Occup Ther Health Downloaded from by McMaster University on 12/03/14 For personal use only.

Sherrill K Harnish and Debra K Schmidt


and solve problems pertaining to another service area, even though each discipline, department, and area had its own clearly defined function. Initially, weekly meetings revealed major problems with the feeding experience. In time, however, programs on most units operated so smoothly that the Core Teams needed to meet only every other week, as monitors identified fewer, less generalized problems and were able to deal with relatively minor individual discrepancies as they arose. Monitoring of adaptive feeding equipment was delegated to an occupational therapy aide who kept inventories of equipment and verified that the equipment given to clients corresponded to rewmmendations on the occupational therapy evaluation. Additionally, adaptive feeding equipment needs were listed on each client's diet card to guide any staff involved with their use. The equipment inventory was computerized and updated quarterly; copies were also forwarded to food service staff in the individual dining rooms and to the dormitories, where the inventory was verified against supplies on hand.

With a comprehensive feeding training program now implemented on all six residential units and transdisciplinary Core Teams functioning as monitors and program planners, occupational therapy staff were able to return to their regular therapy caseloads, confining their involvement with the Core Teams to consultation .and client re-assessment. What had begun as a program planning responsibility within a small occupational therapy department evolved into an interdisciplinary team effort that eventually involved more than 175 training department staff, over 1000 residential direct care aides and 445 clients. Only by utilizing sound management strategies for planning and organizing could such a major project have been designed and implemented, and ultimately judged a success. At re-survey the institution passed with flying colors! Note: Interested readers may request copies of various forms used in screening and as checklists. Send a self-addressed stamped envelope to the senior author at the school address.


The Occupational Thempy Manager's Survival Handbook

Occup Ther Health Downloaded from by McMaster University on 12/03/14 For personal use only.

QUESTIONS FOR READERS 1. How might the program design and final implementation either remain the same or be modified for use in a smaller, more homogeneous population? 2. In the absence of a timeline, what other options could have been considered in the areas of client assessment? In occupational therapy's role? 3. By assuming sole responsibility for staff training, what kind of impact did an occupational therapy "point of view" have on the final program? 4. If the Education and Training Division had not agreed to provide training department staff to assist in the dining rooms at the noon meal, how else might the need for more hands-on assistance have been met? 5. Without a central authority figure on the Core Teams, how could motivation and investment in the finished program be sustained? 6. What part of occupational therapy's role could have been delegated to other personnel?

REFERENCES American Occupational Therapy Association: Manual on Administmtwn. Rockville, Maryland, 1978 D ~ c k e r ,PF: An lntroductoty View of Management. New York. New York, Harper and Row, 1977 Hampton, DR. Summer, CE, Webber, M:Organizational Behavior and the Pmcrice of Management. Glenview. Illinois, Scott, Foresman and Company, 1982 .. .-

Longest, BB, Jr.: Management Practices for the Health Professional. Reston. Prentice-Hall, 1980 Magnussen, KO: Organizational Design, Development, and Behavior. Glenview, Illinois, Scott, Foresman and Company, 1977 Schaeffer, Kris, Editor: Organizational Development: Strategies for the Future. American Society for Training and Development, Madison, Wisconsin, 1981 West. JD and L e y , FK, A Management Guide to PERTICPM. Englewood Cliffs, New Jersey. Prentice-Hall, 1969

Developing and implementing an interdisciplinary feeding training program within a large institution.

Planning is a daily part of every manager's job. Occupational therapy managers are frequently involved in the planning process and its component funct...
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