The quarterly report summarizes the activities of the Food and Nutrition Services department from October to December 2015. Key points include: regulatory compliance was maintained; a new hospital building and kitchen were approved; costs were reduced through decreased overtime and increased productivity; staff training and recognition continued; food safety and quality improved; and healthy options in the cafeteria increased sales.

1. QUARTERLY
REPORT
FY 2015
This report is from the Director & Assistant Director, Food and Nutrition
October – December 2015.
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
Environment of Care – Cafeteria _____________________________________________________________________ 8
Contact Information ___________________________________________________________________________________ 9

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
• Department of Public Health Environmental Health Inspection at BHC Nov 2/15 no findings. (SS)
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, Competency checklists 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.
Updated foodservice,
submitted for review
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.
Compliant since July 2015
Disaster Plans CDPH AFL – Dec 14/2014, Detailed written plans to meet all emergencies and disasters.
Meals for All™ available for patients, Menu updated for Staff, and Visitors
compliant
Nutrition Adequacy Ensure the nutritional needs of the patient are met on regular and modified diets. Incorporated Blossom Foods™
nutritional information into
pureed menu nutritional
analysis
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 90-100% compliant
Wt compliance increased
from 87 % to 95%
Pantry Updated Nourishment centers to provide individual PC, 6 month expiry April and September

5. BLDG 25
Page 3
BLDG 25
REGULATORY APPROVAL
 City and County of San Francisco Department of Public Health Environmental Health inspection completed Building
Permit approved for the Kitchen (Sep 2015)
 California CDPH consultancy review of Food and Nutrition Services (Nov 12, 2015)
 FDI consultancy review of Food and Nutrition Services (Dec 9 2015)
NOURISHMENT CENTER STANDARDS
 Reviewed specifications for Nourishment Centers refrigerator, ice machine, microwave and freezer (Nov, 2015)
TRAINING
Corilee Watters, PhD RD Asst. Director with Super-users Heather Waldorf, RD and Elaine Tang, MS, RD
SF City Fire Inspection Dec 22/15

6. FINANCIAL STEWARDSHIP
Page 4
Financial Stewardship
1.1 Reducing Over-time
Overtime pay @ 1.5 has been by 41% reduction in 6 months -- From an average of 220 hours per pay period
in FY ’14-’15 (Jan-July2015) to 131 hours (July – Nov) per pay period in FY ’15-16 a savings of ~$4303 pp
1.2 Security of Food and Supplies
 Video cameras installed throughout Food production /Storage and Cafeteria area (SS)
1.3 Reducing Waste in Food Purchasing and Supplies
 Increase use of re-useable containers vs disposables for patient foodservice, utilizing compostable cutlery Dec
2015
1.4 Increasing revenue from Novation Provider agreement
July to September 2015 77% compliance with Novation purchasing from U.S. Foods
1.5 Increasing Productivity
 Tracking Daily Productivity of Clinical Dietitians and DTRs (CW)
Increased Productivity by 13% from average of 6 pts seen/day (May, June 2015) to 6.8 pts/day (Dec 2015)
 Clinical Dietitians have provided nutrition care for ~7,484 patients this year which is ~47% of admitted
inpatients congruent with the proportion on therapeutic and texture modified diets , and have completed over
777 clinical chart audits to monitor regulatory compliance with nutrition care. (CW)
 Submitted IT request for Diet Order interface to reduce staff time entering diet orders and paper waste (CW)
paper waste generated each month resulting from no Diet Order Interface
1.6 Malnutrition Coding
1326 of 16, 765 inpatients admitted from 10/1/2014 until 9/30/2015 had a MCC or CC relating to malnutrition.
A prevalence rate of 8% is comparable to that reported by West Virginia University Medical Center a trauma
center, but below ~10% reported by New York Presbyterian Hospital. Malnutrition coding significantly impacts
reimbursement rates which reflects the increased length of stay and healthcare resource utilization. (CW)

7. DEVELOPING PEOPLE
Page 5
Developing People
1.1 Monthly Clinical Nutrition Rounds
Nutrition co-chaired SFGH Medical Grand Rounds on Oct 13, 2015 (CW)
Drs. Critchfield, Watters and Stollman Medical Grand Rounds
Dr. Stollman presented on Medical Management of C. Diff.
1.2 Audit Education competency relating to Weekly Foodservice Topics (CW)
*based on observation, verbal explanation or demonstration with individual employees (Oct 2015)
1.3 Staff Recognition
1.4
Healthcare Foodservice Workers week October
- Foodservice staff newsletter highlighting staff roles and
accomplishments (CW)
- Daily events for staff including pumpkin decorations, ice cream
social, pizza, and employee photo board (CW,SS)
Thanksgiving meal for Foodservice Staff (SS)
70
75
80
85
90
95
100
FSW 2604
(n=20/60)
Sr FSW 2606
(n=4/6)
Cook 2654
(n=5/11)
Audit Education Competency
Assessment*

8. SAFETY
Page 6
Safety
1.1 Patient Food Safety
New Test Tray Evaluation form developed Oct 22/15 (RC) which indicated that the New Follett Trayline Refrigerators
for milk, salads and soups introduced Nov 12/15 improved temperature.
1.2 Patient Nutrition Safety
Christine Struble, RD, CNSC led an update of Pediatric TPN order form
2. Staff Safety
Injury Reporting Binder and Log developed April 2015 (CW), Number of days injury free tracked daily on Huddles
70%
75%
80%
85%
90%
95%
100%
Test Tray Temperature Compliance
Oct Nov

9. QUALITY AND CARE EXPERIENCE
Page 7
Quality and Care Experience
2.1 Tracking HCAHPS monthly scores and comments
Response to survey question “During this hospital stay, how often did the staff who brought you your food treat you with
courtesy and respect“ reached national average score results.
2.2 Patient satisfaction rounding with written meal survey cards and interviews (RC, CW)
2.3 Improving Food Quality
Replacing disposable salad containers with reusable Dinex containers on patient trays (Oct RC, CW

10. ENVIRONMENT OF CARE
Page 8
Environment of Care
SELLING HEALTHY FOOD
Beginning in October, freshly prepared entrée salads were established in the cafeteria on a daily basis. Sales data indicated
that entrée salads increased the overall number and amount of transactions, shifted customers away from meat entrees,
grill and outsourced packaged Grab N’Go.
Donna Harrison
Serving Taco Salad
Starting in December, freshly prepared in house Grab N’ Go items are made including fresh fruit, fresh vegetables,
yogurt and banana pudding parfait, cheese, crackers and grapes. (CW)
Sept, Non
Salad Days
Sept, Salad
Days
October November
Veg Entrée 5.30% 3.79% 3.88% 3.79%
Meat Entrée 8.50% 8.06% 6.85% 7.23%
Salad 9.24% 9.74% 8.82%
Grab n Go Items 18.60% 15.50% 15.35% 10.76%
Grill 6.90% 4.80% 3.75% 5.04%
0.00%
2.00%
4.00%
6.00%
8.00%
10.00%
12.00%
14.00%
16.00%
18.00%
20.00%
Percent Daily Average Cafeteria Sales

11. CONTACT INFORMATION
Page 9
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