Team-Tested Practices

After Northern California began a regional push in 2009 to improve the identification and diagnosis of malnourished patients, the Roseville Medical Center sought to put the plan to action.

The clinical nutrition team was partifcularly concerned because diet plays a key role in the body’s recovery.

This can be especially true for the elderly and patients with diabetes —two groups at the highest risk for malnutrition. Mary Hart, director of clinical nutrition for Roseville and Sacramento medical centers, says a lack of proper proteins and vitamins affects their ability to recover and heal.

And short hospital stays can be particularly challenging because most patients don’t stay in the hospital very long.

After sifting through the electronic charts of all admitted patients, the dietitians must spot patients “at risk” for malnourishment and reach them in time for a full evaluation and treatment—all before the patient is discharged.

While physicians are the only ones who can make an official diagnosis, they rely on clinical dietitians to assess the patient and alert the physician.

“We keep track of the number of patients who have met the criteria for clinical malnutrition, communicate that to the physician and follow up to see if (the patient) has actually been diagnosed,” Hart says.

The dietitians at Rockville put their assessments and recommendations into a patient’s electronic chart, but everyone did so a little differently.

So they standardized their process and language, which included bolding notes to doctors and speaking directly to them about potentially malnourished patients. Those simple steps made it easier for physicians to know what to look for, and diagnose accordingly.

“It helps because we can see them sooner and start nutritional management sooner and figure out how to refer them to outpatient care after they are discharged,” says labor co-lead and registered dietitian, SEIU UHW, Jennifer Amirali.

The team also piloted a KP HealthConnect tool that made it easier and quicker for clinical dietitians to identify at-risk patients. It pulls data from electronic medical records, and color-codes assessments, recommendations and final diagnoses between dietitians and physicians.

“There was more recognition (among physicians) of what a dietitian does other than just ‘serve food,’” Amirali says.

Hart agreed.

“(Physicians and administration) now see the important role of dietitians in the care team and what we can contribute to the organization and the health of the patient.”

For more about this team's work to share with your team and spark performance improvement ideas, download a poster or powerpoint.

Employees calling in sick was having a negative impact at the radiology lab.

Those serving the South San Francisco Medical Center and Daly City Medical Office Building had to work harder to fill in gaps.

Morale was sinking. And tired employees were vulnerable to getting sick, creating a downward attendance spiral.

Recognizing a crisis, the UBT issued an anonymous attendance survey and found there was widespread confusion about sick leave.

Wanting to encourage teamwork in improving attendance and to boost department morale, team members agreed to create department-wide goals, a department-wide educational effort, and a group celebration.

But the true aim was clear—help all staff members make their goals and encourage them to attend the party. They also wanted employees to have a clear understanding of expectations.

In setting the new targets in the attendance guidelines, the team defined clear goals. By announcing the guidelines at a staff party, it also set an upbeat tone, says labor co-lead Donna Haynes.

The new targets included:

• no more than one tardy per two-week pay period (a tardy is three minutes past start time)
• no more than two sick leave absences per quarter; and
• no more than two 'danglers' (forgetting to clock in or out) per pay periods.

Supervisors met with each employee to review his or her attendance trends and to discuss concerns or needs. The staff found the meetings supportive.

"They asked, 'What can we do to help?’ They were trying to encourage you," says labor co-lead and lead mammography technologist, SEIU UHW, Adie Hoppis.

Employees who met the guidelines were invited to a quarterly lunch—complete with white tablecloths, silverware, wine glasses (for nonalcoholic beverages), music and catered food. Managers served the staff members.

"We're there to celebrate the staff," says Tracey Fung, service unit manager. "They were really floored. There had never been anything like this before in the department."

Hoppis says the lunches are a powerful positive reinforcement.

"They’re really nice. You’re treated special.”

With more employees at work, patient waiting time has decreased.

"Employees are happier, and patients are, too," Hoppis says.

When the Anaheim Medical Center Admitting department unit-based team set out to increase its collection of inpatient hospital copayments, it had several hurdles to overcome.

Some staff members had to get comfortable with asking for money from patients. Others had to learn how to calculate copayments. They also needed to notify Admitting of a patient’s pending discharge so copayments could be collected at the point of service.

And since the team goal of collecting copayments didn’t always dovetail nicely with individualized goals, that put some staff members at odds.

“We had created this unhealthy competition,” admitting supervisor/manager and union co-lead David Jarvis says.

They also had the problem of convincing staff members in other departments that collecting copayments from hospitalized patients was not a bad thing.

"They used to think of me as Public Enemy No. 1," says Patti Hinds, a financial counselor and member of SEIU UHW.

To educate and motivate staff members about the importance of collecting copayments, the unit-based team held a kickoff meeting in January 2010.

Staff members who were good at collecting and calculating copayments were deemed “master users” and received training so they could help their peers learn to correctly calculate amounts due. They also got pointers on speaking with patients about the money they owed.

"We wrote scripts, we role-played and, as people did it more, they became more comfortable with asking for money and with knowing when it is appropriate to do so," admitting clerk, SEIU UHW Patricia Hartwig says.

The team also had to teach staff members in other departments about the benefits of copayment collection.

"We showed them the bottom-line connection between revenue collection and their paychecks," Hartwig says.

Better working relationships developed between admitting department staff and the nursing units, prompting nurses to contact admitting staff more consistently before patients are discharged.

"They came to realize we’re not the 'bad guys,' " says financial counselor Marcela Perez, an SEIU-UHW member.

The Pediatric Neurosurgery team in Oakland couldn’t figure out why their staff courtesy scores were low.

They had a new office building and felt providing exceptional care was part of the routine.

Then union co-lead Tanya Johnson noticed there was very little for the department’s young patients and their families to do in the waiting room.

“Kids would be running up and down the hallway,” says Johnson, who is a medical assistant and SEIU UHW member. “Parents would be chasing after them and not being able to focus. It was crazy.”

The department of Pediatric Neurosurgery cares for children with a full spectrum of disorders, including tumors of the brain, spinal cord and peripheral nervous system.

“These kids are the sickest of the sick,” says service manager Jim Mitchell, RN PNP. “They have serious, serious conditions. Anything we can do to make their visit a little brighter, we do.”

So the team decided to create a child-friendly environment, and went to senior leadership for funding.

The improvements included a large, colorful playhouse, a treasure chest, books and toys in each of the patient rooms—as well as a custom-built train set.

“Everyone on the team had input as to how the clinic would be set up and where the items would be placed,” union co-lead and receptionist Leap Bun says of the improvements that cost about $18,000.

To ensure infection control, the toys are wiped down on a regular basis by Environmental Services employees.

And the atmosphere does a lot to ease tension for their medically fragile patients and their families. 

“The children are less threatened and want to come here to play,” Mitchell says. “It seems like every day we have parents on a regular basis having to coax their children to leave the clinic.”

In three quarters, department scores for staff courtesy increased from 69.6 percent to 90.3 percent.

“In addition to our MPS scores we can measure the change in the faces of the children we interact with,” Mitchell says.

For other teams interested in this type of project, they suggest field trip to other facilities doing the same work. The Oakland team visited Sacramento and Roseville to refine their workflow processes.

And the team also found that families with children choose to wait in the clinic, even if their appointment is elsewhere or they’re picking up a prescription from the nearby pharmacy.

"They tell us it’s a nice place to relax and to calm their kids down while waiting,” Bun says.