Community Hospital

Part I: Answer each question thoroughly, read over each problem, discuss the pros and cons of each option, and select the best option including your justification and your own opinion

CommunityHospital is a 200-bed care hospital located in a Midwestern city with a population of 300,000. The hospital was founded 25 years ago by a group of local residents. The hospital started as an 80-bed facility and has since grown to a 200-bed modern health care center. The founding physicians sold their interest in CommunityHospital to United Healthcare, Inc., 10 years later. Community Hospital was one of United's early acquisitions, and in the 15 years since its purchase, both Community and United Healthcare have exhibited healthy growth.

Although CommunityHospital has grown over the years, it has always had a reputation for providing warm and attentive care to patients. The staff has been proud of its reputation and seeks to give individual attention to patients. Approximately 400 people are employed to meet the staffing needs of the hospital. The largest percentage of hospital staff are employed in one of the many nursing service departments. The food and nutrition department and housekeeping department employ an equal number of employees to support the patient care services of other departments.

The individual departments are managed by a department head who reports to either the assistant administrator, director of nursing, or controller. Each department functions as a separate unit and department heads make many autonomous decisions regarding their operations. For successful operations, individual departments must work together and depend on each other in order to provide good patient care.An example of this interdependence is seen everyday in providing meals for the patients. The food and nutrition department prepares the food and patient trays, and the nursing unit is responsible for passing the trays to patients and returning them to the cart for delivery back to the food and nutrition department. The top priority of each hospital department should be to provide good patient care whether directly or indirectly. Communications between departments must be maintained in order to facilitate patient care.An organizational chart of the hospital is presented in Figure 1.

Competition

CommunityHospital is located in a very aggressive health care market. Its major competition is a CityHospital, which is a 500-bed medical center located in the downtown area. CityHospital is affiliated with the local medical school and offers some services unavailable at Community Hospital. CityHospital is also a public hospital versus Community's for-profit status.

CityHospital has a strong marketing emphasis, which includes advertising in print and television. It offers seminars for the public on current medical issues of interest to develop their patient base. To increase public awareness, Community Hospital has begun marketing efforts with billboards and print advertising.

CommunityHospital must not only compete for patients but also physicians.Almost all of the city's 250 physicians have privileges to admit patients at City Hospital. CommunityHospital has approximately 75 physicians who actively admit patients and use the hospital's services. Of the remaining 175 physicians, 100 use CommunityHospital occasionally, and the remaining 75 do not admit patients at all. Some of the reasons that physicians do not use Community Hospital are because it is located away from the traditional medical district and lacks some types of medical equipment and services.

To counteract these deficiencies, a new administrator was brought into CommunityHospital from United Healthcare. His primary goal was to develop stronger bonds between the physician and hospital. Several new pieces of medical equipment have been purchased to upgrade services.Construction has been completed on several medical office buildings in order to bring the physicians closer to Community Hospital. It should be noted that physicians often make the choice when deciding on the hospital for admission, especially when they limit their practice to one facility.Therefore, it is important for hospitals to develop strong and loyal ties with physicians to attract their business.

Trends in the Health Care Industry

The increasing cost of health care is causing tremendous changes for health care providers. New technology in medical equipment causes equipment to become obsolete and necessitates replacements with large capital outlays. The rising cost of health care has had a tremendous impact on insurance companies.With escalating costs, individuals are asked to pay a larger deductible and many employers are decreasing the benefits for which they are insuring employees.

Out-patient procedures are increasing to help decrease medical costs. This has hurt hospitals because occupancy rates are declining.In 1984, Medicare instituted a monumental change in the way that they reimburse hospitals for care given to their participants (those over 65). The new system, diagnostic-related groups (DRG) pays a fixed payment based on the average cost of caring for a patient with a particular diagnosis. Before DRG, hospitals were reimbursed for the charges made during the patient's length of stay in the hospital. With the inception of the DRG, shorter hospital stays have decreased patient occupancy rates. When patients must stay past the length of stay approved by Medicare, the hospital must absorb the costs not covered. Many private insurance firms are requiring that participants be approved for admission to the hospital in order to decrease unnecessary hospital stays in an effort to reduce costs.

Gone are the days when hospitals did not have to be concerned with their cost of operations.With declining patient census, hospitals are expanding into out-patient services to increase utilization of hospital services. Many hospitals have undergone reductions in staffing to decrease labor costs as occupancy rates have declined. Hospitals are coping with revenue changes and expanding into new areas to seek opportunities.

CommunityHospital has been affected only slightly by the declining occupancy rates. This can be attributed to the newly opened physicians' office building nearby and the healthy economy of the area. Other hospitals in United Healthcare have not been so fortunate, and many have had significant staffing reductions to counteract their decreased usage.

Food and Nutrition Services

The food and nutrition services department will be the focus of the study of the study of CommunityHospital. There are currently 30 FTEs (full-time equivalents employed in the department.The department has lost two FTEs by phasing out positions when employees resigned and by shifting some job responsibilities. Employees have also been cross-trained so that they are able to perform several jobs.This makes the employees more useful and this versatility eases scheduling. These efforts have been made in order to help control the labor costs of the department. Labor costs account for over 50 percent of the food and nutrition services department's costs and average $320,000 per year. Food costs run a close second with approximately $300,000 spent per year on food.The food and nutrition services department is considered a cost center in the hospital, although efforts are being made to increase revenue through the cafeteria and with nutrition services such as out-patient diet counseling.

The director of the food and nutrition services department is assisted by Laurie Maples, the clinical dietitian, and Brenda Smith, the food production supervisor. Laurie Maples has recently graduated from college and is a newly registered dietitian or R.D. Brenda Smith is a long-time employee of CommunityHospital. She has worked her way up from tray line aide to her current position as food production supervisor. Figure 2 presents the organization chart of the food and nutrition services department.

The department is responsible for meal preparation and service to patients and cafeteria patrons.Approximately 700 meals are served each day. The department is in operation from 5:30 a.m. to 7:30 p.m. daily. Three meals per day are served in the cafeteria and to patients.In addition, some catering is performed, ranging from breakfasts and luncheons to cookies and coffee for a meeting.

The department is split into two areas of responsibility: nutritional care of patients and food production. The clinical dietitian is responsible for the nutritional care of patients, which includes assessment of patients' nutritional needs, education of patients on modified diets, and monitoring food intake and tolerance. The clinical dietitian spends 80 percent of her time away from the department seeing patients on the various nursing units. The tray line coordinators oversee the preparation of patient trays, set up patient menus for meal service, answer phones, and note diet changes for the clinical dietitian. The tray line aide's job responsibilities include setting up the patient tray line for service of patient trays and stocking each station on the tray line. They assist the dishwashers when the patient trays are returned to the kitchen and put away clean dishes and silverware.The patient tray line can be thought of as a mini-assembly line, with six stations where particular food items are placed on the patient tray. It takes about 30 to 45 minutes to prepare the patient trays for one meal. The tray line is in operation three times per day every day of the week. When the patient food service is completed, food is put away to use for late patient trays, and the stations are restocked.

As food production supervisor, Brenda Smith is responsible for food purchasing and production, sanitation, and cafeteria operations. The storeroom manager is responsible for food purchasing and storage, with Brenda overseeing this area. Menus are the critical part of the operation because they define production needs.The director is responsible for writing the menus for the patients and cafeteria. The chef oversees the cooking efforts of the a.m. cook, who prepares breakfast for the cafeteria and patients and also assists the chef with lunch preparation. The p.m. cook prepares the supper meal for patients and the cafeteria, with assistance from the chef. The baker is responsible for preparing baked goods for cafeteria and patient meals.The salad maker has similar responsibilities with salad preparation in addition to the salad bar in the cafeteria.Three dishwashers are normally assigned each day. The first dishwasher comes in at 6:30 a.m. and is responsible for washing dishes.The second dishwasher comes in at 9:00 a.m. and is responsible for washing pots and pans. The third dishwasher comes to work at 1:00 and is responsible for dishwashing and special cleaning assignments in the afternoon.

The last area under Brenda Smith's supervision is the cafeteria. Two employees work in the cafeteriaan early aide is assigned to work breakfast and lunch, and a late cafeteria aide is assigned to work lunch and supper. Lunch meal service is the busiest meal in the cafeteria and requires two employees to serve the customers. Cafeteria aides are responsible for cleaning and restocking the cafeteria with food items and dishes between meals.

Lines of responsibility cross between patient nutrition care and food production. There are many areas of both the patients and cafeteria, but Laurie Maples is responsible for patient food service and Brenda Smith for cafeteria food service. This structure sometimes leads to confusion.

The top priority of the food and nutrition services department is preparing quality food.The needs of the patients rank above those of the cafeteria. The department has a reputation for preparing good food for the patients and cafeteria.Laurie Maples is responsible for ensuring that patients receive the correct food items served at the proper food temperature. This is especially important for patients who require modifications of their diet due to illness or disease. Forty percent of the patients in the hospital receive a modified diet. Many other patients need adjustments to the regular diet so that it is similar to what they are accustomed to eating.

Recently there have been a number of problems in the department. Janice Livingston has resigned as director. You have been hired as the new director and part of your responsibilities will be to address some of these problems.

Problem 1

The food and nutrition services department recently lost two employees. The positions vacated were evening cook and relief evening cook. A present employee was promoted to the evening cook position, and it is now necessary to hire a part-time relief evening cook. It would be desirable to hire someone who would have the capabilities to learn several jobs, including breakfast cook salad maker, cafeteria aide, and tray line aide in order to relieve employees on off days, vacations, and holidays.

The interviewing process has not been going well. There is only one qualified candidate for the relief job, Diane Baker. She has some previous cooking experience and she has the potential to learn the various jobs. The only drawback is that she is a close friend of Brenda Smith, the food production supervisor. Diane's husband is the brother of Brenda's boyfriend, and they often socialize together.However, this does not necessarily mean that there will be problems if she is hired, but the potential for favoritism and related inequity problems does exist.

At this point the job has been posted on the hospital bulletin boards; however, there has not been advertising of the position outside the hospital. The position needs to be filled as soon as possible. Based on this information several options for this staffing problem exist.

Problem 1 Options

Option 1

Hire Diane Baker in the position of relief evening cook.

Option 2

Hire the second choice from the application received. Although this person does not have the same experience as Diane Baker, it may prevent future problems with a supervisor and friend relationship.

Option 3

Advertise in the local newspaper and continue to interview other applicants.

Problem 2

Sarah Jones has worked as the evening cafeteria aide for the past six years. She is primarily responsible for serving the cafeteria customers during the evening meal and ringing up sales. She is expected to wait on patrons in a courteous manner.However, a problem has emerged in that she does not treat customers consistently and gives preferential treatment to her friends.

Recently, the hospital administrator overheard Sarah waiting on a visitor who made a special request to have his pie warmed in the microwave oven. Sarah informed the customer in the short tone of voice that this could not be done because she was too busy.

The administrator informed Mr. Beecher, the assistant administrator, of the conversation he had heard the previous evening and asked him to rectify the situation. Mr. Beecher informed Brenda Smith (her supervisor) of the incident but Brenda failed to discuss it with Sarah Jones. Brenda felt that it would be better to wait and cite this incident on Sarah's yearly performance evaluation, which is to be given in four months.

Four months later Sarah Jones received her performance evaluation and the incident discussed above was noted as a negative factor in her evaluation.Sarah indicated no recollection of treating any customer rudely and had difficulty believing the accusation.

You believe that incidents like this should be avoided in the future so a meeting is scheduled with Brenda Smith to advise her on procedures for handling several potential recommendations.

Problem 2 Options

Option 1

Tell Brenda Smith to inform employees of the problem in front of their coworkers. At this time explain the appropriate behavior. This method will utilize peer pressure to influence the employee.

Option 2

Tell Brenda Smith to send employees to you (the department director) when problems of this nature arises.

Option 3

Tell Brenda Smith to meet with employees privately when problems of this nature arise. She should be told to address the problem immediately and refer the person to you only when she is unable to resolve the problem

Problem 3

Diane Baker has been functioning effectively in the part-time relief position. Within two months, Diane has trained and learned five positions in the department. It often takes employees that length of time to master one or two positions.Employees come into a new job with a three-month probationary period in which their performance can be evaluated.If they are not performing as expected, they can be dismissed from work without going through the normal disciplinary process. Diane's performance has been quite good so her employment should continue.

The older employees still feel that Diane is receiving preferential treatment from Brenda Smith, food production supervisor. Some employees believe she works fewer weekends than they do as full-time employees.The full-time rotation allows each employee two three-day weekends off in a seven-week period. Part-time employees are not on any set rotation and work when needed.

The rumors and gossip persist even though Diane is performing her wok well. Given that this problem is adversely affecting the organizational climate and morale, you are considering the question of taking action to deal with the gossip and the problem of perceived inequity. There are several potential solutions to this problem.

Problem 3 Options

Option 1

Ignore the situation for the time being since it may resolve itself in time. Take action at a later date if the problem continues.

Option 2

Discuss the situation with Brenda Smith and ask her to avoid discussing personal issues with Dian at work.Furthermore, inform her that she must treat all employees equitably. A schedule of work should be posted for all employees in the work area.

Option 3

Ask Brenda Smith to assign Diane to more weekends to reduce the perceptions of inequity. Also, inform her that she must treat employees equitably.

Option 4

Schedule a department meeting and tell employees that you will not tolerate the spread of gossip.Tell them that if they have a problem it would be more appropriate if they would discuss it with you, the director.

Problem 4

Due to the loss of two positions and a slight increase in patient census, the evening employees are having difficulty completing their work without overtime. The evening shift personnel are responsible for preparing and serving the supper meal and subsequent clean up with only six employees.In this process, the patient trays are sent to each nursing unit in a separate food cart. Trays are delivered to patients by nursing personnel.Nursing personnel are then responsible for returning the empty trays to the food cart. Once all the patient trays are returned to the food cart, the food and nutrition department is responsible for their return to the kitchen.

Since the patient census has increased, the food and nutrition department has had difficulty obtaining the food carts in time. This lag has created overtime work for the dietetic services employees because they have been unable to complete their work in the usual time frame. The job of the clinical dietitian is to interact with nursing service to improve the timeliness in which the trays are returned to the cart by nursing personnel. You are currently considering what recommendation to make to your clinical dietitian.

Problem 4 Options

Option 1

Ask the clinical dietitian to request that the food and nutrition department dishwasher remove the food carts from the nursing units at a specified time regardless of whether the patient trays have been returned. Late trays can be returned later.

Option 2

Ask the clinical dietitian to go directly to the director of nursing and ask for a resolution of the problem.

Option 3

Ask the clinical dietitian to talk to the 3 - 11 p.m. charge nurse on each nursing unit and explain the problem. She should request their support and assistance in order to get the food carts returned to the kitchen in time.

Option 4

Explain to the clinical dietitian that it would be very difficult to correct the situation.Therefore, the department should continue to pay overtime.

Problem 5

The return of patient trays to the food carts has been occurring in a more timely manner. The evening shift food and nutrition services personnel have been able to complete their work without overtime most evening.However, there has been some difficulty getting the food cart back in time from the third-floor nursing unit.

The evening dishwasher informs you that he has seen some of the third-floor nursing personnel sitting in their break room when he goes to pick up the food cart. The evening tray line coordinator informs you that third floor's food cart has not been ready to return to the kitchen and that this has been continuing for two weeks after initial improvement was noted. The tray line coordinator says that they are having difficulty completing their work on time because they have to wait on the third-floor food cart.

Since the problem has not been resolved completely, you must now recommend a solution to the clinical dietitian. There are several possible options.

Option 1

Ask the clinical dietitian to talk to the 3 - 11 p.m. charge nurse again. She should explain the importance of getting the food carts back to the kitchen in a timely manner.

Option 2

Inform the third-floor head nurse of the situation and ask for her cooperation in improving the situation.

Option 3

Inform the director of nursing and ask her to assist in solving the problem on the third floor.

Option 4

Simultaneously implement all three of these ideas.

Problem 6

The clinical dietitian is responsible for supervising personnel who prepare the patient trays.This includes the tray line aides and tray line coordinators. Laurie Maples alternates working weekends with Brenda Smith. On weekends these two individuals assume total responsibility for running the food and nutrition services department. During the week the food and nutrition services department is split into two areas of responsibility: nutritional care of patients and food production.

Recently, a problem with the tray line aides has developed. A number of tray line aides have begun serving the afternoon snacks at an earlier time than is scheduled. In questioning one of the try lines aides regarding the change, you are told that Brenda Smith told them that it was all right with her if they adjusted the time on the last weekend when she was in charge. The tray line aides report to Laurie Maples. Their schedules and responsibilities are under her supervision.You are considering several potential options to this problem.

Option 1

Schedule a meeting and inform the tray line aides that if they want to make an adjustment in their work schedule they must check with you first.

Option 2

Allow employees to make changes with either Brenda Smith or Laurie Maples. However, request that one informs the other of any changes.

Option 3

Inform Brenda Smith that you would prefer that she check with Laurie Maples when any tray line aides wish to make adjustments in their work.

Problem 7

The food and nutrition department has hired employees through the local rehabilitation center over the years. These employees have completed a training program that includes learning how to operate an institutional dishwashing machine. The department presently employs one dishwasher/pot washer who is mentally challenged. John has worked for the hospital for five years ad has a flawless attendance record. In the past he performed his work in a satisfactory manner. He has always been willing to help out in unusual situations, and he works well by himself when staffing is decreased.

Recently, the other dishwashers have indicated that hey are having trouble getting along with John.They state that John is not working seriously and is leaving work for them to finish. The four other dishwashers have become friends and form a cohesive group. However, John is excluded from this group.

John likes attention, even if it is in the form of reprimands and punishment. Any negative feedback usually has a limited effect on John.His parents are very cooperative and want to be informed when John is having trouble performing his work as he should.

At this time the other dishwashers want you to do something to improve John's work performance. You must make a decision on how to handle this situation.

Problem 7 Options

Option 1

Inform John's parents of his decreasing work performance. Ask for their assistance in improving John's work as his capabilities allow.

Option 2

Change John's status from full-time to part-time dishwasher. Although money has little effect on John, this change and the resulting pressure from his parents may influence his behavior.

Option 3

Do nothing immediately.John has been a faithful employee for the past five years and has an excellent attendance record. Only intervene if the problem persists.

Option 4

Contact John's counselor from the rehabilitation center and ask him to talk with John about his work.

Problem 8

Almost a year has passed since Diane Baker was hired in a part-time relief position. Based on her financial needs associated with a recent divorce, she has requested a full-time position. There is not a full-time opening at present, but it may be in the department's interest to create one for Diane. Diane has performed various jobs in the last year and is an asset to the department due to her cross-training and excellent work performance.

The other employees are getting along well with Diane and the gossip had subsided until now.However, the rumors and gossip have started again as the employees wait to see what happens with Diane. Diane has let her coworkers know of her personal situation and need for full-time employment.

Within several weeks the hospital does approve a full-time position for Diane and you have decided to train her for a position as tray line coordinator. The gossip about Diane and her preferential treatment begins again.Older employees believe that their jobs would be in jeopardy if Diane decided she wanted their position.Although these fears are unfounded, the gossip persists. The employees still believe that Brenda Smith gives Diane special consideration. The situation reaches a point one day when Diane leaves mid-day in tears because she feels everyone is talking about her.Diane tells Brenda Smith that she is resigning from her position.

At this point you must decide what todo to resolve this problem. You are considering several potential solutions.

Problem 8 Options

Option 1

Accept Diane's resignation and begin interviewing to fill the position.

Option 2

Talk with Diane and ask her to come back to work. Tell her you believe the incident will be forgotten once she is put on the full-time rotation. Inform her that she is a valued employee and that you would like her to continue working in the department.

Option 3

Talk to Diane and ask her to come back to work after a month-long leave of absence. Tell her you believe the situation will improve while she is away for several weeks.