During the normal stress of being admitted to the hospital, it's not always clear to patients and their families who does what.

And if a nurse or clerk can’t answer a question on admissions, the patient can get frustrated.

So it was in the admitting department at Fremont Medical Center in Northern California, where patients gave low satisfaction scores regarding the process.

“Many different staff use the word ‘admitting,’ so we needed to make sure we stood out, and that patients knew when their admission officially began and ended,” says labor co-lead and admitting representative Joanna Nelson.

Team members thought one of their biggest challenges was making sure patients knew when they were dealing with admitting staff versus other employees.

They first tried using scripted language, the “Right Words at Right Time” (RWRT) approach to let patients know when the actual admission process had started and the representative’s role.

When that failed, the UBT added another level of patient service and rounding, which included a small gift and card.

The gifts were mostly Kaiser Permanente brand items including cups, tablets, aprons, vases or plants. Admitting representatives also gave personal cards to each patient.

“We came up with an extra-special plan for our new admissions. Once the patient was admitted, the Admitting rep went back up to the room—either later that same day or the next day—and gave our patients a welcome gift,” shop steward and OPEIU Local 29 member Nelson says, describing the gesture as a “thank you for choosing our hospital.”

And it worked.

In four quarters, polite and professional customer service scores improved 21 points, and efficient and easy customer service scores picked up three points.

The team also helped by letting patients know how all the pieces fit together.

“Personalize your admitting process,” says Fonda Faye Carlisle, manager, Admitting and Patient Financial Services. “Since the admitting department is not the only voice that says, ‘I will be admitting you,’ admitting needs to personalize so the patient can differentiate between them and others, such as nursing.”

There were team benefits, as well, beyond the scores. Department morale and attendance also increased.

“Our satisfaction is seeing our patients happy and watching our scores improve,” Nelson says.

An accurate list of a patient’s prescriptions is critical to maintaining continuity of care.

It also helps to decrease medication errors, and one of the Joint Commission’s national patient safety goals requires medication reconciliation at hospitals and clinics.

So, in order to protect patient safety, it's crucial caregivers compare the medications a patient is taking (and should be taking) with newly ordered medications.

The Infectious Disease/Oncology team at Cumberland Medical Office Building in Atlanta had a high percentage of patient records in KP HealthConnect that listed duplicate medications.

To improve medication reconciliation, the team did a manual cleanup of patient charts over a period of several weeks. Then it instituted a new process for checking medication. They had the licensed practical nurses (LPNs) and medical assistants (MAs) call patients and ask them to bring their bottles of medication to their office visit.

During the initial workup, the MAs and LPNs reviewed patient medications, and checked off in the members’ charts which medications the patients were and were not taking.

The providers then confirmed medications once again with the member and removed all possible duplicate oncology meds from the patient’s record.

In collaboration with the clinical pharmacist, the MAs printed out a snapshot of the patient’s medications and gave it to the nurse practitioner for review and removal of any expired medication.

As they found success, the team included more medications in the process.

For instance, the team members reviewed patient records for infusion medications and one-time-only meds a patient might need to take before a procedure. Infectious disease pharmacists also began removing duplicate medications for their overlapping oncology patients.

Team members reviewed statistics for duplicate medications from KP’s National Reporting Portal, analyzed the data at huddles and posted it in the department.

They also monitored whether providers increased the number of times they had to reorder medications (which would indicate they were too aggressive in deleting prescriptions). As it turned out, the reorder rate was unaffected by the project.

The percentage of duplicate medications fell to 15 percent, far exceeding the team’s goal. And by avoiding hospital admissions due to inadequate medication reconciliation, the team saved $90,000 in three months.

It also created better communication with patients.

“Knowledge is power,” says Gwendolyn Brown, the team’s management co-lead. “It helped patients and their families ask more questions.”

And a full team effort helped the project succeed, as they moved from Level 2 to 4 in Path to Performance.

“It is tiring and frustrating when you are the only person doing the work,” says Brown. “Here, everyone is involved.”

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.