PatientPatient Room Service Room Service at St. Joseph Memorial Hospitalat St. Joseph Memorial Hospital

St. Joseph Memorial Hospital

�Part of the 3-hospital Southern Illinois Healthcare System

�25 bed critical access hospital

Press Ganey Scores

�From 04/01/07 to 09/30/08 mean scores ranged from 82.0 to 85.1

�This fluctuation in mean scores resulted in a percentile range of 48 to 78 in the Press Ganey small hospital data base

Things We Tried

�Verbal menus�Menu rewrites (multiple times)�Tray passing�Stocking and rotation of floor

stock

Room Service Decision

�Started planning in October 2007

�Gathered a team of employees from the Food Services Department, Nursing and some Ancillary Departments

�Used “Design for Six Sigma” methodology to chart our course

Six Sigma History

�Six Sigma training throughout Southern Illinois Healthcare began in 2004.

�GE Healthcare was utilized as our training vendor.

Six Sigma

�A measure of quality that equates to 3.4 defects per million opportunities

�Design for Six Sigma is a way of translating customer needs and expectations for a product or service into a design that will meet those requirements using a variety of tools and data

�A great method for mobilizing commitment from staff by creating a shared need

So How Did We Get Started?

It was important to formulate a plan for meeting our patient and staff needs.

We scheduled a structured meeting with representatives from Food Services and Nursing to kick off the planning. During this meeting we started creating a shared need for Room Service.

Voice of the Customer and CTQ’s (critical to quality)

Customer Needs Mapping

Customer Sample CommentsKey Output Characteristics

Important to Customer (CTQ's)

Patient “Need wider variety of foods on menu, and a menu given to patient upon entering room.”

Variety

Patient “The food could be better tasting. Very bland and I didn’t have a diet to follow.”

Flavor, seasoning

Patient “Food was good but the green beans was stringy.”

Texture

Patient “Eggs cold.” Temperature

Patient “Did not have a lot of choices on the menu that I liked. Any meat I got was tough.”

Variety, texture

In Scope:

Med/Surg unit, SCU/PCU unit, Food Services, job descriptions/tasks, LEAN process, Food Service Department Organization, purchase of new equipment

Out of Scope:

No additional FTEs

Business Case:

Improving meal satisfaction for St. Joseph Memorial Hospital inpatients demonstrates our dedication to the SIH values of quality, compassion, collaboration and stewardship. By adding variety and choice to our menu selections, and improving meal quality, we will increase our Press Ganey patient satisfaction scores.

Problem Statement:

Over a period of 2 years, quarterly patient meal satisfaction scores have fluctuated from the 48th percentile to the 78th percentile in the Press Ganey small hospital data base.

Goal Statement:Improve Press Ganey patient satisfaction mean scores by 5% over a period of 3 quarters beginning 4th quarter 2008: mean score improvement to 87.86 by July 2009 with no losses over the 9 month period.

Start / Stop Points for Project:

Start Point: Physician’s diet order for patient.

Stop Point: Successful delivery of room service tray

Develop Team Charter 10/07

Action Plan from Patient Room Service Structured Meeting

WhatAction/Commitment

Who: When:

Develop Menus Beth, Cathy, Stephanie, Jackie

No Timeframe

Develop Communication Plan for Patients

Rhonda, Cathy, Sandy Jo, Vicki, Debbie

No Timeframe

Develop Communication Plan for Staff

Debbi, Jo, Sandy, Nadia, Vicki

No Timeframe

Develop Process for Room Service

- Ordering/Communica-tion

- Screening/Eval for Room Service Appropriateness

- Delivery process- Lean for kitchen

Cathy, Judy and others as needed

No Timeframe

Stakeholder Analysis Tool

�Assessed where key players were in their willingness to assist with this change.

�Helped us to determine how to focus our efforts with staff members for optimal outcomes.

Stakeholder Analysis

Name/TitleStrongly Against

Moderately Against

Neutral Moderately Supportive

Strongly Supportive

Nurse Manager –Med Surg

X

Ward Clerk X-Today X- They need to be here for program to be successful

RN-SCU X- Today X-They need to be here for program to be successful

RN-Med Surg X-Today X- They need to be here for program to be successful

Dietary Lead X-Borderline

Food Handler II X-Borderline

Assistant Dietary X-Borderline

Aides CNA X

Dietician X

Physician X-Today X-They need to be here for program to be successful

Quality Functional Deployment (QFD)

� In the design process, QFD helps to translate customer needs and expectations into the finished product.

�Our project had 2 customers:�Patients�Staff

�By combining QFD from both groups we built a 2nd QFD “house” and were able to address the needs of patients and staff when designing our program.

QFD #1

�Patient requirements (Y)

�Taste�Timely �Temperature�Texture

QFD #1

�Staff requirements (Y)

�Limited and manageable program�Menus need to reflect simple and

fast preparation�Standard recipes�Scripting

Combined QFD Houses

�Look at requirements for both patients and staff

�Compare these requirements with steps in the process

QFD #2�Combined expectations (Y)�In order to meet patient and staff

expectations, we must build our program to reflect�Timely service�Courteous service�Standard recipes with pictures�Scripting�Adequate training and updated job

descriptions

QFD #2Combined Requirements (X)

The most important steps in the design process are:

�Menu development�Patient explanation of Room Service�Patient orders meal�Meal is prepared�Meal is delivered

Room Service Timeline10-07 11-07 12-07 01-08 02-08 03-08 04-08 05-08 06-08 07-08

Project Kick off

DevelopPatient survey

QFD house 1 patients

SurveysDone

DevelopPatient Screen

PatientMenuDev Done

New Equip-ment Ordered

PresentTo MedicalStaff

PrintMenus In house

BeginTrial Runs

QFD house 1Staff

QFDHouse 2Done

Dev Patient Diet Order

BeginDev ofCommPlan

RecipesDevelopDone

Dev RecipesCon’t

DevSubstitu-tionList

SeniorRenewal menus

Pugh matrix

Begin Dev. Ofmenu

Site VisitsDone

BeginDev of Job Descrip-tions

DevOf TrainingProgram

DevPatient Data Base

StaffTraining

Fishbone FMEAWith group?

BeginRecipeDev

ScriptsDevelop

CommPlanInitiated

Work areaRedesign

Done GroupDevProcessMap

DevService Hours

Policy Updates

Call centerSet-up

1 Menu

2Comm

3Process

LEANConsult

Pictures of menu items

Room Service Survey

� What is your favorite breakfast food?� What is your favorite main course?� What is your favorite vegetable?� What is your favorite fruit?� What is your favorite dessert?� What is your favorite beverage?� What is your favorite snack?� Once you have placed your meal order, how long should

it take to receive it?� What other suggestions/ideas do you have that could

help make this program successfully?

Menu Development

�Patient survey results�Staff preferences-what do we do well?�What can we prepare and deliver within 30

minutes?�Garnishing very important�Recipes tested�Pictures attached to recipes to assist with

consistency of presentation

Recipe ExampleRECIPE: Spinach & Cranberry SaladDIET: All

INGREDIENTS Side Entree

Fresh spinach, bite-size 1 ½ oz. 3 ½ oz.

Red onion, thinly slice ¼ oz. ½ oz.

Feta cheese crumbles ½ oz. 1 oz.

Mandarin oranges, drained 1/8 c. ¼ c.

Dried cranberries ¼ oz. ½ oz.

Recipe ExampleRECIPE: Sun-Dried Tomato Chicken PORTION SIZE: 5 oz. DIETS: All PORTION TOOL: Scale KCAL: 275GM FAT: 15

INGREDIENTS1 5

10

6 oz. Boneless, skinless chicken breast

1 5 10

Sun-Dried Tomato vinaigrette

¼ cup 1 ¼ cup 2 ½ cups

Garnish: parsley/kale & tomato

Education for Nursing Staff� INFORMATION FOR NURSES REGARDING ROOM SERVICE� Room service overview:

� Patient satisfaction initiative� Name of program: “Meals Your Way”� Patient is admitted and screened� Diet order is entered� Food Services brings a menu to the patient and explains the program� Patients call the room service number to order between 0630 and 1830 each

day � Any item on the menu can be ordered at any time (breakfast for dinner, etc.).

� Standard Operating Procedure: attached� Patient screen: See next slide� Communication is very important:

� timely entry of NPO orders� timely entry of status changes/rescreens (becomes eligible or ineligible for

room service)� timely entry of isolation status

� Meds� diabetics will receive meals at scheduled times so you will know when a tray is

coming� patients needing meds with meals should easily be accommodated since

these need to be given 30 minutes before to 30 minutes after the meal

Room Service Ordering Screen

� Is the patient alert and able to converse? Y____ N____� Can the patient read and understand the menu? Y____ N____� Is the patient able to order and use the telephone? Y____ N____

� If patient is diabetic, what are the home meal times?� B______ L______ D______

� Diet as ordered: ______________________________________________

� Styrofoam needed? Y____ N____

� Calories: ___________ Fluid Restriction? Y____ N____ � cc per day: _______

Standard Operating Procedures (SOP)Standard Operating Procedure Room Service Operation

� Patient arrives to the nursing unit.� Patient is screened (order) using the Room Service Screen Form (will place in

admission packet)� Rescreen as needed.

� If diabetic patient is identified, please follow the procedure below, if not, move to bullet # 4.� Obtain the normal eating time for the patient at home (try to accommodate the

patient times)� Place times on the screen (using breakfast, lunch, and dinner)� Adjust the accu-checks and/or medication times according to the meal delivery

times� Notify pharmacy of profile changes if needed (nurse needs to do this).

� Ward clerk/ Nurse given screen and entered as Meditech OE.� Food Services processes order.� Food Services visits patient, issues menu and explains Room Service process, etc

(education is done).� Patient places order.� Food Services prepares tray and updates data base.� Food Services delivers tray to the patient.� Tray is picked up by Food Services and intake is documented on I & O sheet posted

by Nursing staff.

SOPs Continued

Standard Operating Procedure for Room Service Calls

� Answer telephone before third ring.� “Meals Your Way Room Service. This is ________. How may I help you?”� Ask for name and room number. � Check Kardex for diet order and special notes/restrictions.� Take order making sure all items ordered fit within diet parameters. Also, be sure

to ask about condiments, drinks, etc. appropriate to the meal.� If diabetic, check carbs ordered. If too many, ask what they would like the most. If

too few, suggest other options to get them to their correct carb. level.� Read the order back to the patient. “Is there anything else I can get for you?”� “Thank you for calling Room Service. Your meal will be delivered in 30 minutes.”� Prepare and deliver tray.� Record time of delivery on data board.� Deliver tray to patient checking name and birth date every time.� Set the tray up. “Is there anything else I can do for you?”� Pick-up tray 30 to 45 minutes after delivery. Record Intake.

SOPs ContinuedSOP for Patient Visitation

� Diet order is received and recorded on data base.� Menu is selected to match patient diet and patient is visited.� Knock on door.� “Good day, I am ________ from the Food Service Dept. Is now a good time to talk to you about our

“Meals Your Way” Room Service program?� We hope that by ordering your own meals from our restaurant-style menu, at the times you choose

that we can provide a meal service that suits your needs. � Let me point out some things about the menu:

� The phone number, 55EAT or 55328 is printed on the front of the menu and at the top on the inside� Our hours of service are 6:30 a.m. until 6:30 p.m.� You may order your meals at any time as long as you are not on a diabetic diet� If you are on a diabetic diet, we will take your menu each day after breakfast for lunch, dinner and

breakfast the next day. We will do this in order to provide consistent carbohydrates to you throughout the day and to adjust your insulin accordingly.

� The special menus have information specific to your diet. This information is listed here (show them).� The phone is located here and this is the way to use it (show them).� Do you have any questions? Please do not hesitate to call us if you have any concerns. Our

number is 55EAT.� We’re very proud that every meal will be cooked to order and our plan is to serve your meal to you

within 30 minutes of receiving your order. However, since this is a brand new program, we hope that you will be patient with us if we encounter a few snags in the beginning.

� We will be checking back with you to be sure that you are completely satisfied with your meals and to see how we can better serve you. We hope to provide the best meals and service to make your stay more pleasant.

� If you would like a copy of our menu, please ask your food server. We will be happy to provide you with a take-home copy.

� Is there anything else I can do for you before I go?”

Patients Ineligible for Room Service

�Room Service Host visits daily to assist with menu selection.

�Meet with family members to assist with menu selection, if possible.

�Status can change either way (from room service able to unable and back)

Job Responsibilities

�Each position was reviewed with consideration given to each of the jobs in the department.

�Roles were reassigned as needed with creation of new job descriptions

�Training was provided

Job Responsibilities

�Kitchen opening/closing�Patient data�Patient food preparation�Vending�Doctor’s lounge�Dish/pot washing�Tray delivery/pick-up�Patient Interaction�Telephone

responsibilities

�Senior Renewal�Feedings�Catering prep/delivery�Stocking�Cafeteria

pre/service/cleaning�Salad bar�Trash/laundry�Kitchen Cleaning�Miscellaneous

Issues addressed included:

Data Base

�Developed for quick review of patient meals status

�Made sense because of our small bed size (licensed for 25 inpatient but total of 40 beds) (OR recovery/observation/etc.)

� If patient misses one meal, we call the patient to encourage them to eat.

� If patient misses two meals, we call nursing to notify them.

Lean Principles Applied

Follow Up for the Program

� Food Services staff complete 3 surveys each day using the following key phrases:

� “This is _______from the Food Service Department, is now a good time to talk to you about your meal service?

� If “no”, ask if you may call back later.� If “yes”, ask the questions below� “Was your hot food hot and your cold food cold?� Record concerns and offer to send something else.� How would you rate your food?: Very Good, Good, or

Poor?

Follow Up ContinuedBased on the answer

Very GoodThank you, we take pride in what we do. You may be receiving a survey in the mail, please take a moment to let us know any comments you may have.

GoodWhat can we do to make it very good?

PoorI’m sorry, is there anything I can get for you right now? How can I make it better?

And finally“Thank you for assisting us in improving our meal service. Please

do not hesitate to call if we can do anything for you.”

Comments from our Patients

Current Concerns

�Low sodium diets�No additional staff added�Getting eligibility screens completed�Constant reminders needed regarding

importance of consistency of meals and service

Questions?