#10
PROJECT NAME: Improving After Hours Nutrition
Care
Institution: MD Anderson Cancer Center
Primary Author: Maureen Triller
Secondary Author:
Project Category: General Quality Improvement
Purpose/Aim:
Purpose: Late evening admissions, patient transfers, and modifications to patient nutrition orders can lead to
requests for patient nutrition support after the Room Service kitchen has closed. These requests were being
handled by the Off Shift Administrator (OSA). The OSA was handling between 70 and 90 requests for nutrition
care per month. This project was initiated to determine if there was justification for additional Clinical Nutrition
staff to provide after-hours nutrition care.
Aim: To reduce the number of nutrition care OSA service requests from an FY12 average of 80 per month
to fewer than 20 per month by August 31, 2013.
Tools and Measurement:
The source of the baseline data was the OSA data from January
2012-June 2012. The OSA kept a record of each nutrition request including date, time, type of nutrition
request (regular diet, liquid or nutritional supplement/formulary) patient unit, and time taken to handle the
request. This data was analyzed to determine the number and types of nutrition care requests. The team
looked at the time of the requests and unit from which the requests were being made. We also analyzed how
much time it was taking each evening to provide after-hours nutrition care. The data did not justify the addition
of Room Service staff, however, it did indicate that there were opportunities to modify our processes to
improve patient care and service delivery.
In order to understand the root causes and service variables associated with after- hours nutrition requests,
the team analyzed the data from a number of different perspectives. The team analyzed the number of calls
by time of day and type of request (regular diet, liquid diet, or formulary). The data indicated that the majority
of requests were received shortly after the room service kitchen had closed. However, the workload tapered
off sharply after that time.
The team also analyzed the requests by type and location to look for trends in service requests.
Further analysis of the data indicated that the daily workload associated with after-hours nutrition requests did
not justify the addition of staff.
Intervention and Improvement:
The team analyzed the after-hours requests for nutrition care by type: Regular Diet, Liquid Diet and Nutritional
Supplements (formulary) evaluated the root causes and proposed solutions for each.
Nutritional Supplements/Formulary
Current Process: Formulary is currently ordered by the Nursing staff via CARE. Room Service delivers
supplies to the nursing units from 7 AM to 9:30 PM. In mid-afternoon, Room Services Assistants contact the
inpatient units that have requested formulary that day to ensure that they have enough stock on hand to last
their existing patients through the night. Nursing contacts the OSA for assistance with after-hours requests for
formulary.
Proposed Improvement:
This process is working effectively. Room Service Assistants will continue to work with nursing staff to ensure
that they have enough formulary stock on hand to support existing patients.
Liquid Diet
Current Process: Nursing units order supplies such as cokes, teas and soups, etc., from Clinical Nutrition to
meet patient requests for beverages, crackers, soup during the night. Orders are delivered and stored in the
nursing area by Room Service staff. Maintaining this stock is the responsibility of the Nursing Unit. Nursing
contacts the OSA for assistance with after-hours liquid diet requests.
Proposed Improvement:
Clinical Nutrition will educate Nursing staff on the ordering process and work with them to determine and
maintain their supply needs, and identify areas where Nursing can conveniently store these items so that they
are readily available to meet patient requests.
Regular Diet
Current Process: Room Service ordering is available to patients between the hours of 6:30am and 9:30pm.
After 9:30pm, patient requests for a regular diet are received by the Off-Shift Administrator who has access to
the Room Service Nutrition Kitchens and creates a meal tray of a pre-made sandwich, chips and a drink for the
patient.
Proposed Improvement:
Clinical Nutrition will stage 1-2 sandwich meal trays on each inpatient unit so that the meals are conveniently
located for the Nursing staff and readily available to meet patient needs if requested.
Intervention Results:
The overall trend line declined significantly in February 2013 when the improved processes were implemented.
The 4-month trend supports that the new processes are becoming standard practice.
The initial improvements were implemented in February 2013. The level of improved performance has been
sustained through Q3FY13. We will continue to monitor this outcome monthly.
.
Revenue Enhancement /Cost Avoidance / Generalizability:
The value in this project was two-fold.
Cost Avoidance: The initial solution to the problem focused on adding Room Service staff to cover after
hours nutrition requests. Through collaboration and by streamlining processes, the cost of adding additional
room service staff to cover after hours nutrition requests would have been approximately $50,000 per year.
Improved Patient Satisfaction: Through a collaborative effort between Nursing, the Off-Shift Administrator
(OSA), and Clinical Nutrition we have improved our ability to respond to requests for after-hours nutrition care
quickly and efficiently.