1. 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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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)

11. 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

12. 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