QUARTERLY REPORT FY 2015 This report is from the Director and Assistant Director, Food and Nutrition Services date of hire March 2015 – September 2015.

SAN FRANCISCO GENERAL HOSPITAL

FOOD AND NUTRITION SERVICES

TABLE OF CONTENTS

Contents

Overview _________________________________________________________________________________________________ 1

Regulatory Compliance ________________________________________________________________________________ 2

BLDG 25 __________________________________________________________________________________________________ 3

Financial Stewardship _________________________________________________________________________________ 4

Developing People______________________________________________________________________________________ 5

Safety _____________________________________________________________________________________________________ 6

Quality and Care Experience__________________________________________________________________________ 7

Contact Information __________________________________________________________________________________ 10

OVERVIEW

Page 1

Overview

REGULATORY COMPLIANCE

SFGH FNS works actively to be regulatory compliant with Title 22, CMS (2014), Title 9 for BHC , Title 15 for Jail Services and CDPH – All Facilities Letters.

BLDG 25

San Francisco General Hospital Medical Center (SFGH) is developing a 284 bed new acute care hospital and

Trauma Center tower (Building 25) within the current medical center including a fully functional kitchen to

support patient services.

FINANCIAL STEWARDSHIP

FNS is working to reduce labor and supply costs by increasing productivity, reducing OT, and by practicing good business and foodservice management practices for security of food and supplies.

DEVELOPING PEOPLE

FNS works to develop staff, improve staff satisfaction and develop staff as problem solvers.

SAFETY

FNS takes safety of our patients and staff very seriously and daily monitors all aspects.

QUALITY

FNS is working to improve the quality of both the food and service provided to patients and customers.

CARE EXPERIENCE

FNS is committed to improving the patient care experience in both hospital in-patient dining as well as cafeteria services.

Sylvia Shih, Director, Food and Nutrition Services

Corilee Watters, Assistant Director, Food and Nutrition Services

Steve Koneffklatt, Assistant Administrator

REGULATORY COMPLIANCE

Page 2

Regulatory Compliance

SURVEY PARTICIPATION

• CDPH - Emergency Medical Treatment and Labor Act (EMTALA) April 14, 2015 – developed and distributed a FAQ on Foodservice (What Food, right to diet order refusal, How food preferences are met, How is satisfaction ensured) to SFGH Medical and Nursing staff; no FNS findings. (CW)

• Title 9 - BHC 3rd Floor (MHRC) June 1, 2015 - provided BHC menus, snack list, meal delivery schedule, reviewed disaster menu and supplies, nutrition staff (RD and Nutrition Assistant) and services (screening, assessment parameters and frequency of follow-up in both policy and charts), no FNS findings. (CW)

• CMS Patient Rights & Nursing Services – July 1, 2015 – Upon request provided chart review summary of a patient to Quality Management, no FNS findings. (CW)

• Title 15 – Adult Jail Health Services – July 20, 2015 - reviewed frequency of meal service, menu and diet servings per food groups, diet manual, no FNS findings. (CW)

REGULATORY REQUIREMENTS

CRITERIA REGULATORY DESCRIPTION STATUS

Organizational Chart

The responsibility and the accountability of the dietetic service to the medical staff and administration shall be defined. Director of Food and Dietetic Service must be qualified and have responsibility and authority for the direction of the food and dietary service. Registered dietitian shall be employed on a full-time basis, supervise nutritional aspects of patient care.

Compliant.

Competency Ensure competency of Nutrition Services staff upon hire, and quarterly and annual review, Weekly Foodservice Education in services developed.

Annual reviews ~90% complete

Policies and Procedures

Policies and procedures shall be developed and maintained in consultation with representatives of the medical staff, nursing staff and administration to govern the provision of dietetic services. Policies shall be approved by the medical staff, administration and governing body. Procedures shall be approved by the medical staff and administration.

QAPI for revision underway

Diet Manual A current diet manual approved by the dietitian and the medical staff shall be used as the basis for diet orders and for planning modified diets.

Complete, on website, FAQ sent to RN and MD

staff 7/17/15

Disaster Manual

CDPH AFL – Dec 14/2014, Detailed written plans to meet all emergencies and disasters.

Meals for All™ available for patients.

Nutrition Adequacy

Ensure the nutritional needs of the patient are met on regular and modified diets.

Met with female patients, with male patients: RDs providing increased

calories.

Ethnic, Cultural,

Food Preferences Patient menus adequately meets the ethnic, cultural and religious needs of the populations that are served.

25% of menus Hispanic/Asian

Nutrition Care Screen, Timely, MD Acknowledgement, Accurate Weight, Ins & Outs 93-98% compliant

Pantry Updated Nourishment centers to provide individual PC, 6 month expiry April and September

BLDG 25

Page 3

BLDG 25

REGULATORY APPROVAL Updated 2010 FNS Operations Plan (CW) Presented to CDPH June 29/15, Receiving, Storage, Cook Chill Production in Bldg 5, and Diet Office,

Storage, Cold trayline and retherm Bldg 25 which was approved (CW) CDPH indicated they want to review 2 days of regular perishable patient food supplies in Bldg 25,

7 days Emergency Menu & Supplies for Staff and Visitors in Bldg 5, and Nursing policy and procedures to follow Guidelines for Infant Formula /Breastmilk Preparation and Handling.

Senior Environmental Health Inspector inspection scheduled 9/21/15 (SS, CW)

TRAINING Equipment Review with Vendors – August 2015

Manuals obtained for all Foodservice Equipment – September 2015 (CW)

FAQs (How to use, How to Clean, Safety Issues) for each piece of Equipment are being drafted (CW)

Vendors for Train the Trainer session (Managers, Supervisors, employee leads from Production, Warewashing, Patient Service) To be scheduled

SERVICE LEVEL AGREEMENTS WITH EACH NURSING UNIT

Nourishment Centers Refrigerator/ Freezer: request for combined refrigerators/ freezer was denied

(Aug 2015), however separate freezer units approved 1-2 nourishment centers/ floor (Sept 2015) CW

Met with ED, ICU and Maternity/ Peds, updated list of Nourishment Center/ Pantry locations CW Unit based review using Cart/ Receptable equipment with EVS, Confidential Bins, Infection Control,

Nursing etc) to determine location of food y transport carts: to be scheduled. CW

IT Testing has been done in CBORD to see how patients can be transferred from Bldg 5 to Bldg 25. Information provided to Cerner consultant about RD LCR_NVision consults to print on 2D3 printer (Blg 5) with Diet Office moving to Blg 25. CW

FINANCIAL STEWARDSHIP

Page 4

Financial Stewardship

1.1 Reducing Over-time

Systematically tracking absenteeism (FMLA, sick, Worker’s Comp) to reduce the need for OT – April – present (SS)

Foodservice Workers (2604) hired on a Part-time basis to provide schedule coverage (SS)

1.2 Security of Food and Supplies Memorandum to all staff about steps taken to secure food and supplies for patients and

customers (locked storage, cameras, security patrol) – Sept 2015 (SS, CW)

1.3 Reducing Waste in Food Purchasing and Supplies

CBORD FSS functionality to generate Purchase Orders for US Foods, Beta test stage (SK) Increase use of reusuable containers vs disposables for patient foodservice

1.4 Increasing revenue from Novation Provider agreement Moving from Sodexo purchasing to City and County Purchasing utilizing Novation

agreements March 2015 (SK) Ushering CBORD through contracts with DPH Longitano to have DPH wide agreement

for both hospital. Now patient food service (CBORD) and retail food service Micros cash registers (changed to Odyssey) are under the Novation umbrella. Sept 2015 (SK)

Reviewing US Products Order list to increase compliance : 2-3% rebate of total purchases to be seen in 3rd QTR (SK)

1.5 Increasing Productivity

Tracking Daily Productivity of Clinical Dietitians and DTRs (CW) Increased Productivity by 7% from average of 6 pts seen/day (May, June 2015) to 6.4 pts/day (Aug 2015)

Dietitians doing Electronic Charting started April 2015 (CW) MD (Chief GI) attending Nutrition Support rounds – started August 2015, but plan to change to surgeon to improve efficiency of dietitian communication regarding nutrition support (parenteral/ enteral nutrition) (CW)

Kelly Toth MPH, RD, CNSC Critical Care Dietitian

DEVELOPING PEOPLE

Page 5

Developing People

1.1 Daily Huddles conducted about Operations and Outcomes (SS)

1.2 Daily Education relating to Weekly Foodservice Topics Inservice Schedule, Topics and Training developed (CW)

1.3 Monthly Clinical Nutrition Rounds (CW)

Nutrition co-chairing SFGH Medical Grand Rounds on Oct 13, 2015 (CW)

1.4 Monthly Staff meetings (SS, CW)

1.5 Staff Recognition Daily at Staff Huddles Monthly at Staff Meeting with Gift card given Bi-annual Staff Newsletter highlighting staff roles and accomplishments (CW)

1.6 Staff Satisfaction Survey

1.7 Lean Thinking Training

A3 Training – May 2015 Value Stream Mapping – May 2015 (include 18 people from across SFGH and FNS) Lean Principles presentation – May 2015

Kaizen Promotion Office (KPO) Specialist, with Anthony Anies, Supervisor, Value Stream Mapping

SAFETY

Page 6

Safety

1.1 Food Safety Installation of New Food Production Equipment (repainting the ceiling, ensuring the

installation of new capital equipment in the form new ovens, grills, charbroilers, steam jacketed kettles, and slow roast ovens) June 2015

Convection Dinex retherm carts (March 2015) replaced Conduction Ala-Carte (Jan- Feb 2015) improved temperatures as below

DINEX THERMAL AIRE-II CART

1.1 Patient Safety

Diet Orders audited weekly indicating 95% compliance with CBORD Diet order & LCR_NVision Nursing Orientation seminar July 2015 (CW)

1.2 Staff Safety

Injury Reporting Binder and Log developed April 2015 (CW), Number of days injury free tracked daily on Huddles

QUALITY AND CARE EXPERIENCE

Page 7

Quality and Care Experience

1.3 Tracking HCAHPS monthly scores and comments

Host David Satram

1.4 Patient rounding in-person – May – present

1.5 Improving Food Quality Serving salads in covered containers (May, CW) Addressing current menu production quality areas (eg. Beef and Broccoli stirfry) July (RC) Replacing packaged buns with freshly baked dinner rolls. (Sept RC) Replacing disposable salad containers with reusable Dinex containers (Sept RC, CW)

Fresh baked rolls for Patient Foodservice

QUALITY AND CARE EXPERIENCE

Page 8

1.6 Patient Satisfaction Meal Cards – September – present

1.7 Improving Service Quality - Care Experience Training AIDET: June 2015 monthly meeting, (CW) AIDET: ID reminder cards (CW) AIDET evaluation – July 2015 (CW) C-I-CARE: ID reminder cards developed, training planned (CW)

QUALITY AND CARE EXPERIENCE

Page 9

Healthy Beverage Initiative In alignment with SFGH’s strategic plan to enhance wellness, the Healthy Beverage Initiative formalized our commitment towards creating a healthy environment that promotes healthy lifestyles for patients, staff, visitors and the community at large. To this extent, SFGH effective June 12, 2015 no longer offers any sugar sweetened beverages (SSBs).

Analysis of sales data relating to beverages indicates that there has been no reduction in % of sales for beverages, and overall has been an increase in % of cold beverages reflecting increased products available.

Cafeteria Cold Beverage Sales

Creating a Positive Cafe Dining Experience at SFGH FNS was successful recipient of $71 K Hearts Grant to improve Dining Experience at SFGH (SS)

The goal of this project is improvement in service excellence, enhancing wellness and health of staff and patients, to meet the Hospital Accreditation Standards relating to Environment of Care and Infection Control, and to improve the food environment to promote wellness.

Sylvia Shih at Hearts Grants Award event

CONTACT INFORMATION

Page 10

Contact Information

SYLVIA SHIH, CDM DIRECTOR

CORLEE WATTERS, PHD,RD ASST. DIRECTOR

STEVE KONEFFKLATT, MBA ASST. ADMINISTRATOR

Tel :206-6288

Sylvia.Shih@sfdph.org

Tel :206-4539

Corilee.Watters@sfdph.org

Tel 206-6286

Steve. Koneffklatt@sfdph.org