Foodservice Departments Research Articles

Are New Meal Distribution Systems Worth the Effort for Improving Patient Satisfaction with Foodservice?

The health care industry has been slow to adopt the philosophy of focusing on patients as customers (1,2). However, competition for health care consumer dollars is forcing health care managers and the industry to recognize and redefine the patient as customer (3). Patient satisfaction is an important component in the assessment of the quality of medical care received (4–6), and patients usually communicate their concerns, needs, and perceptions of the medical care they receive through hospital questionnaires. These questionnaires include a few questions, at most, concerning foodservices (7). Hospital foodservice directors find it difficult to improve their foodservice operations without knowing the expectations of patients regarding good foodservice (7). In an effort to improve patient satisfaction with meal service, hospital foodservice departments are developing and implementing programs and services designed to enhance the meal experience (8). One area being explored is the role meal distribution systems play in patient satisfaction.

Factors Other than Environmental Issues Influence Resource Allocation Decisions of School Foodservice Directors

Objective To identify resource allocation decisions and policies and procedures used by school foodservice directors that were based on the concepts of pollution prevention, product stewardship, and sustainable development. Design A questionnaire about operational characteristics (including equipment and production systems, menu selection and service style) and environmental issues was mailed to school foodservice directors. Subjects/setting Subjects were school foodservice directors in major cities who were members of the American School Food Service Association. Of the 389 questionnaires mailed, 168 (45.5%) were returned and used for data analysis. Statistical analysis performed Descriptive statistics, analysis of variance, and correlation were used to analyze data. Results Cost factors were rated more important ( P≤.05) than environmental factors when operational decisions were made. Labor was ranked as the most important future issue by 45.0% of respondents, but it was not the most important factor when current operational decisions were made. Less than 20.0% of the respondents indicated that their districts had specific water (3.3%), energy (14.2%), or solid waste management policies (16.0%). However, 62.6% of respondents stated that their district had a recycling program. Applications/conclusions With the exception of recycling programs, school foodservice departments have not adopted a framework of pollution prevention, product stewardship, and sustainable development practices. Recycling and energy conservation programs and use of locally grown food products would minimize the environmental impact of school foodservice operations while reducing operational costs. J Am Diet Assoc. 1999;99:944–949,

To the Editors

To the Editors

Quality Ratings of a Hospital Foodservice Department by Inpatients and Postdischarge Patients

Objectives To examine quality of food and nutrition services using the ratings of inpatients and patients who had been discharged (postdischarge patients). Design Questionnaires were used to collect perceptions of inpatients and postdischarge patients on the quality of food and nutrition services. A 5-point scale allowed subjects to rate quality from very poor to very good. Subjects Questionnaires were completed by 252 inpatients and 437 postdischarge patients of a midwestern teaching hospital. Statistical analysis Analysis of variance was used to assess differences in quality ratings on the basis of demographic variables. Stepwise regression was used to determine variables that best predicted overall satisfaction. Paired t tests were conducted to compare matched inpatient and postdischarge ratings. Results Ratings of food and nutrition services indicated that patients were satisfied; few differences were found in ratings on the basis of patient demographics. Food quality was the best predictor of overall satisfaction for both inpatients and postdischarge patients. As patient expectations were increasingly met or exceeded, patient ratings of quality increased. The majority of patients in the matched sample gave the same ratings on the inpatient and postdischarge questionnaires. Applications Foodservice managers who desire to improve patient satisfaction should focus attention on meeting or exceeding patient expectations for food quality. J Am Diet Assoc. 1998;98:1303–1307.

Implementation of an In-Room Patient Menu to Improve Customer Satisfaction.

Utilizing customer feed back as the basis, the need was identified to provide the patient with a permanent in-room menu. This concept not only provides the “WOW” that all food service departments are striving for, but additionally it provides the customer with the perception that they are staying at a luxurious hotel. The content of the menu includes; the scope of patient support services (food service, environmental service, laundry, patient service associate, plant operations and maintenance, safety, security and the service center), the cafeteria hours, patient lunch and dinner daily features, alternative choices, a brief description of diets and the hospital mission and values statement. The in-room menu is utilized in tandem with the spoken menu concept. This collaborative process not only provides the patients with individualized conversation prior to each meal, but a menu which provides both themselves and family members a vehicle to utilize when making meal time selections. The purpose of the menu came from the customer feed back of “never received a menu” as well as from family members who want to assist their loved ones with making meal-time choices. This menu also allows a basic understanding about special diet restrictions that are prescribed. Most importantly this makes the patient feel as through they can take an active part in their care, during their stay. Individuals, whether patients or not, feel they understand food, and like both choices and control over what they receive, regardless if they are at a health care institution or the most luxurious hotel. This in-room menu is a concept that was able to exceed our customers needs and expectations during their stay.

Innovation in Meal Service System Increases Patient Satisfaction

Research has demonstrated “quality of service” and “courtesy of server” have the greatest influence on impacting the patients’ overall satisfaction with food service. However, with declining healthcare dollars, the staffing of labor necessary to provide the level of service desired by patients is not feasible. In fact, most hospital food service departments have had to reduce staffing in recent years. ARAMARK Healthcare Support Services approached this challenge by redesigning the traditional food service system to create an innovative service system that would potentially increase overall satisfaction while maintaining or reducing department operating costs. With the SelectServicesm system, the traditional trayline system is streamlined and patients verbally select their entrée and beverage at the point of service with not written menus to distribute, retrieve and modify. The base menu has been engineered to meet the needs of the majority of patients with a limited number of entrée choices. Those patients on highly restrictive or transitional diets receive a pre-selected entrée with their choice of beverage. In August 1996, the University of California San Diego Medical Center met their challenge with a reduction of $300,000, including reduction of 9 FTE's, by implementing SelectServicesm. Their overall patient satisfaction has increased in the very good and excellent ranges by 20%. Since that time Desert Hospital, Palm Springs, California; Marietta Memorial Hospital, Marietta, Ohio; and Fallston General Hospital, Fallston, Maryland have implemented the SelectServicesm system and shown an increase in their patient satisfaction by 19%, 17% and 6% respectively. SelectServicesm is planned for implementation in select hospitals throughout the country.

Current and Future Practices in Hospital Foodservice

The purpose of this study was to identify current and future operational practices in hospital foodservice, establish the probability that current practice will change, and determine whether differences exist based on profit status and size of hospital. Data were collected from 214 foodservice directors (43% response). Results suggested that foodservice departments of the future will serve fewer inpatients with less staff, have smaller expense budgets while expecting to generate more revenue. Expected operational changes included increases in: services provided for a fee, spoken menu or computerized menus, nonselective or restaurant style menus, self-operated food and coffee kiosks, branded products, home meal replacement programs, on-site catering, debit cards, and management responsibilities. Directors are trying a variety of strategies to deal with the changing environment; Chi-square analysis results suggest that current practices and expected future practice do not often differ based on hospital profit status and size.

Status of Hospital Foodservice Training Programs and Turnover Rates

Hospital foodservice departments have experienced higher than desirable turnover rates for at least twenty years. This study was designed to determine if the turnover rates were related to, or effected by, status of training programs. A randomized sample of 400 hospitals was chosen from a national listing to be surveyed for this information. The 28-item double pilot-tested survey was addressed to foodservice directors for completion and return. The survey asked questions regarding: presence of a training program, budget for training, qualifications of trainer/educators, components of the training programs, department demographics and turnover rates. By studying possible reasons for higher turnover rates and possible relationships to certain variables, foodservice administrators can propose departmental programs that may actually reduce future operating costs by reducing the high cost of turnover. Our results indicated no significant difference between groups in which training was provided, number of hours spent training, inclusion of performance appraisals, or budget for training. However, a significant difference in turnover was seen between groups of departments that had been under the same structure for 18 years or greater. Those departments whose management structure had remained unchanged for more than 18 years, had higher turnover rates.

Comparison of patients' meal intake estimates: The eye is bigger than the plate

Objective: To compare the dietitians' calorie count and the nurses' subjective evaluation with the patient's calculated food intake using the calorie analysis provided by the Food Service Department or computer software, and to determine the correlation of the nurses' subjective evaluation versus the dietitians' calorie count. Design: Dietitians use the Diabetic Exchange List to perform calorie counts of patients dietary intake. Physicians have come to rely on calorie count reports or nurses' reports to make decisions concerning nutritional support. A nurse's report of a patient's meal intake is visual assessment of the meal trays. The dietitians' calorie counts provide an objective assessment. The dietitians' calorie counts and nurses' subjective evaluations are compared with the calorie analysis using a prospective pilot study design. Patients: Patients with chronic or acute renal failure admitted to the Nephrology service and whose physician ordered calorie counts were studied. Main Outcome Measure: Percentage estimates of meal intakes by the dietitians' calorie counts and the nurses' subjective evaluations are compared with the calorie analysis. Results: Sixty-three meal menus were collected on 9 different patients. The diets were either standard regular or renal pattern restriction. Fifty-five percent of the dietitians' calorie counts were within 10% of calorie analysis; 18% were underestimated and 27% were overestimated. Forty-eight percent of the nurses' visual assessment of meal trays were within 10% of calorie analysis; 6% were underestimated and 46% were overestimated. Both the dietitians' and the nurses' methods of evaluating a patient's dietary intake are inaccurate. Conclusion: The findings of this pilot study indicate that renal patients' calorie intake is often overestimated or underestimated. Renal patients who could be actually consuming significantly fewer calories than suspected may become nutritionally compromised.

Characteristics of a Hospital Based Adult Transitional Care Unit and It's Impact on Nutrition Services

LEARNING OUTCOME: To provide data on a new Adult Transitional Care Unit that receives its population from an attached, affiliated tertiary/quartenary care facility, and to evaluate it's impact on nutrition services. A growing number of Acute Transitional Care Units (ATCU) have been established throughout the country in both hospital and long term care settings. For the hospital based ATCU's, these units often present a challenge for the nutrition services department primarily due to new rules and regulations enforced by the Omnibus Budget Reconciliation Act (OBRA), increased patient turnover, new documentation requirements, and aggressive rehabilitation goals. Our objective was to review data on the newly established 20 bed ATCU in our tertiary/quartenary care facility, and evaluate it's impact on nutrition services, including the functions of the Registered Dietitian (RD) and the Food Service Department (FSD). Data from the past 5 months was reviewed using the Monthly Census Statistical Review Report, and the Monthly Productivity Report with the goal to evaluate the daily average census, percent occupancy rate, length of stay, referrals, and diet orders. In light of the data obtained, the role of the RD would be required to 1) provide timely assessments, and frequent follow-up documentation 2) establish a broad knowledge of various disease states with emphasis on the geriatric population 3) consult with acute care RD's regarding previously established goals and treatment plans to provide a continuum of care 4) become proficient in nutrition support to deal with complex medical/surgical patients, and 5) become efficient in completing interdisciplinary care plans. The changes for the FSD would include 1) preparation of more specialized foods to cater to the special needs of the ATCU patient 2) development of a 3-week cycle menu to meet OBRA guidelines to ensure variety on the standard hospital menus 3) initiation of a snack program to provide patients with a choice of a substantial evening snack and 4) development of a texturized meal program to improve on presentation, taste, and quality of meals.

Implementing Cost Effective Measures in Food Service Departments of Adult Correctional Institutions

LEARNING OUTCOME: To define two procedures that can be employed to reduce costs in food service departments of adult correctional institutions. The number of convicted adult offenders is on the rise. Rigorous standards must be met when providing adequate facilities to house, feed, and clothe these individuals. This places a tremendous financial burden on state governments (and essentially taxpayers). It is crucial that cost effective measures be employed at all times to help ease the burden. The Ohio Department of Rehabilitation and Correction implemented two programs that directly affect food and food production costs in its twenty-nine adult correctional institutions. The first program mandated that at all lunch and dinner meals, a complete-protein vegan entree must be offered as an alternative to the entree containing animal products (usually meat). This saves the department money because the vegan entrees are usually less expensive than the animal-product entrees. An added benefit is that this allows inmates a higher quality of life by allowing them to choose whether or not they will eat the entree that contains animal-products. This is especially important to those who wish not to consume animal products because of religious beliefs. The second program initiated was a Quality Assurance Committee that focuses on: cost, quality, production, communication, training, and security issues. This committee researches, reviews, analyzes, and makes proposals for changes that will not only save the department money, but also provide higher standards of quality in food production. By implementing these programs, the department has become more cost effective while enjoying the additional benefit of offering a higher quality of life to the inmates. Other state adult correctional food service departments implementing these programs may see similar results.

Re-Engineering Process in a Community Hospital: The Transition to Patient-Focused Care

LEARNING OBJECTIVE: Provide an overview of the inpatient care re-engineering process and role of the Food and Nutrition Service in a community hospital setting. Shortly after the merger of two community hospitals, a re-engineering project was undertaken to examine the delivery of inpatient care. A interdisciplinary team was given the goals to: 1.) establishing standardized systems at both facilitates; 2.) improve patient care; 3.) improve work efficiency; 4) limit the number of health care provider contacts for each patient; and 5.) reduce cost of care. Data developed for the team by the Food and Nutrition Service included: 1.) work flows and task analysis for all service staff; and 2.) food and non-food supplies used by the units. The team developed a model of patient -focused care utilizing a multi-skilled service worker. Responsibilities of the new position, titled Service Associate, included tasks previously assigned to Food and Nutrition Service, Environmental Services and Transport Department. Service Associates, now deployed to specific nursing units under the supervision of nurse managers, perform the following food service functions: 1.) patient tray delivery and pick-up; 2.) assisting patients with menu selection; 3.) delivery of patient nourishments; 4.) documentation of intake; and 5.) ordering of food and non-food supplies. As part of the implementation process, the Food and Nutrition Service was responsible for: 1.) development of job descriptions, including competency assessment; 2.) recruitment and selection of internal and external candidates; and 3.) training and education of personnel selected for the role. The development of quality monitors to be used in the evaluation of the patient care model include satisfaction and quality indicators related to Food and Nutrition Services at both sites.

Inpatient and Post-Discharge Quality Ratings of a Hospital Foodservice Department

LEARNING OUTCOME: To examine quality ratings of food and nutrition services given during and after a hospital stay. This study assessed quality ratings of a food and nutrition department using inpatient questionnaires, post-discharge questionnaires, and telephone interviews. Data were collected from 252 inpatients, and 437 patients post-discharge; 48 patients completed both. Patients rated the quality of 12 aspects of food and nutrition services using a five-point scale ranging from very poor to very good. Results suggested those who completed questionnaires as inpatients were different demographically than those completing post-discharge questionnaires. Quality ratings generally were good to very good. Interpersonal aspects of providing food and nutrition services tended to receive higher quality ratings than technical aspects. Regression analysis results indicated food quality was the strongest predictor of overall satisfaction with the food. As patients’ expectations of food quality and staff courtesy were met at higher levels, associated quality variables received higher ratings.

An Investigation of Hazard Analysis Critical Control Point Programs (HACCP) in Hospital Foodservice Facilities: A Nationwide Survey

LEARNING OUTCOME: To identify the status and trends of implementation of HACCP programs in hospital foodservice facilities. Little information is available regarding trends of HACCP implementation in hospital foodservice settings. The objective of this research was to identify the status of implementation of HACCP programs in hospital foodservice facilities nationwide. A questionnaire was developed to achieve research objectives and sent to a random sample of 500 foodservice directors/managers in the American Society of Hospital Foodservice Administrators 1996-1997 Membership Directory. A total of 177 (28%) facilities responded. The majority of respondents were from acute care facilities (69%) with <250 beds (34%) that utilized a cook/serve method of operation (58%). Major findings include that 76 facilities (43%) reported having HACCP programs already in place, 67 (38%) reported planning to implement HACCP programs within the next year, and 12 facilities (7%) will implement HACCP programs once it has become mandatory. Only 16 facilities (9%) reported no current HACCP implementation plans. Utilization of HACCP programs in hot/cold holding subsystems was reported by 106 (60%) of the foodservice directors responding. Other subsystems utilized by at least 50% of the facilities currently following HACCP guidelines included distribution, service, preparation and production, assembly and portioning, thawing, receiving, dry storage, and cold storage. Most facilities (60%) utilized a departmental team for HACCP implementation, however only 5 facilities (6%) reported the need for additional FTE's and 16 facilities (9%) reported budget increases for HACCP implementation and utilization. In conclusion, the majority of hospital foodservice departments have implemented or plan to implement HACCP programs in the near future. Since trends for HACCP utilization are consistent throughout the population surveyed, foodservice directors must acquire the knowledge to effectively utilize this emerging food safety assurance program.

Computer Use and Needs in Foodservice Departments of Small and Medium-Size Hospitals in Texas

LEARNING OUTCOME: Identify computer software use and needs of small to medium-size foodservice departments of hospitals in Texas.The purpose of this study was to identify computer software use and needs of foodservice departments in small to medium-size hospitals in Texas. A questionnaire was developed focusing on current computer use and reasons for not using computer software. Respondents were asked to indicate relative importance of 17 management and clinical software applications. Two hundred hospitals ranging in size from 120 to 199 beds were randomly selected for a mail survey. Forty-two questionnaires were returned for a 21% return rate. Word processing and spreadsheets were the most frequently used computer applications. The top five foodservice management applications and numbers of users were ordering (21), inventory (17), food costing (14), recipe scaling (11) and production scheduling (8). The top five clinical applications and numbers of users were patient status (20), nutrient analysis (20), nutritional assessment (14), nourishment labels (12) and weight tracking (6). On a 5-point scale ranging from 1.0 (not useful) to 5.0 (very important), respondents ranked the following software as most important: nutrient analysis (3.90+0.94); patient status (3.81+0.98); inventory management (3.60+0.82); menu and recipe costing (3.56+0.97); and ordering (3.53+1.01). Foodservice departments not using software cited lack of funds and employees’ lack of computer skills as principal reasons. This may indicate an opportunity for dietitians to assist foodservice administrators in justifying expenditures for computer software and hardware and in training employees on basic computer skills.

Comparisons of Patients’, Employees’, and Food Service Directors’ Satisfaction With Meal and Service Quality Using Four Types of Meal Distribution Systems

LEARNING OUTCOME: To examine the impact of four different hospital meal distribution systems on patient satisfaction with food and service quality.Hospital food service departments are developing and implementing programs and services designed to enhance patient meal experiences. In an effort to improve patient satisfaction with meal service, one area being explored is types of meal distribution systems. The purpose of this study was to determine if there are differences in patients’, employees’, and food service directors’ level of satisfaction with food and service quality in hospitals using: (1) Traditional food service distribution, (2) Traditional nursing service distribution, (3) Non-traditional food service distribution “hostess program”, or (4) Non-traditional nursing service distribution “patient-focus care”. Nineteen hospitals participated in the study. Questionnaires developed by Gregoire (1994) to determine the participant's level of agreement with various food and service quality items being provided in their hospitals was completed by 395 patients and 161 employees who distribute the meal trays. The 19 food service directors completed a questionnaire that was developed to obtain their level of satisfaction with their system. Patients in hospitals where the traditional food service distribution system is used rated me quality of food significantly higher than patients in hospitals where the traditional nursing distribution system is used. Whereas, patients in hospitals using either of the other two systems showed no significant difference in their rating of the food quality. There were no significant differences in patients’ rating of service quality items among the four meal distribution systems. There were no significant differences in employees’ ratings of food and service quality items among the four meal distribution systems. Food service directors utilizing traditional nursing service for meal distribution evaluated their systems significantly lower man food service directors who used other systems for meal distribution. Much energy and time goes into developing and implementing programs to improve patient services. This study suggests mat changing meal distribution systems may not enhance meal experiences as perceived by patients.

An Investigation of Hazard Analysis Critical Control Point Programs (Haccp) in Hospital Foodservice Facilities in the Dallas/Fort Worth Area

LEARNING OUTCOME: To identify the status and trends of implementation of HACCP programs in hospital foodservice facilities.Little is known regarding trends of implementation and use of HACCP programs in hospital foodservice settings. The overall objective of this research was to identify the status of implementation of HACCP programs in the Dallas/Fort Worth area. A questionnaire was developed to achieve research objectives and sent to all 84 foodservice directors/managers in the Dallas/Fort Worth Hospital Council 1995-1996 Membership Directory. The instrument included questions for facilities with or without HACCP programs. A total of 39 (46%) facilities responded. The majority of respondents were from acute care facilities (72%) with < 250 beds (69%) that utilized a cook/serve method of operation (79%). Major findings include that 14 facilities (36%) reported having HACCP programs already in place, 13 (34%) reported planning to implement HACCP programs within the next year, and six facilities (15%) will implement HACCP programs once it has become mandatory. Only five facilities (13%) reported no current HACCP implementation plans. All facilities with HACCP programs in place reported utilizing HACCP in hot/cold holding subsystems. Other subsystems utilized by at least 75% of the facilities currently following HACCP guidelines included distribution, service, preparation and production, assembly and portioning, thawing, receiving, dry storage, and cold storage. Most facilities (58%) utilized a departmental team for HACCP implementation and use, however no facility reported the need for additional FTE's or budget increases for HACCP implementation and utilization. In conclusion, the vast majority of hospital foodservice departments have implemented or plan to implement HACCP programs in the near future. Since trends for HACCP utilization are consistent throughout the population surveyed, foodservice directors must acquire the knowledge to effectively utilize this emerging food safety assurance program

Quality of patient meal service in hospitals: Delivery of meals by dietary employees vs delivery by nursing employees

Objective To compare patient assessment of meal-service quality and employee-service orientation in hospitals where dietary employees deliver meals trays and in hospitals where nursing employees deliver meal trays. Design Survey. Setting General, medical-surgical (not Veterans Administration) hospitals of 300 to 500 beds with a self-operated foodservice department and a centralized, conventional food production system. Subjects 552 patients and 192 employees in nine hospitals geographically dispersed in the midwestern and eastern United States. Dietary employees delivered meal trays in five of the hospitals and nursing employees delivered trays in four. Main outcome measures On a five-point scale, patients indicated level of agreement with 16 statements about hospital meal service. Employees who delivered meal trays rated their agreement with 20 service orientation statements on a five-point scale. Statistical analysis Factor analysis with varimax rotation, χ 2 analysis, and analysis of variance. Results Patient assessment of the quality of meal service was multidimensional. Patients gave more positive ratings to characteristics of the personnel delivering the tray than to the quality of the food. Patients in hospitals where dietary employees delivered meal trays rated the quality of food significantly higher ( P < .01) than did patientsin hospitals where nursing employees delivered trays. Service orientation of the personnel delivering the trays was also multidimensional. Dietary and nursing employees did not differ in their personal motivation toward providing service; however, dietary employees rated the organizational support for providing service significantly higher ( P < .001) than did nursing employees. Nursing employees were significantly more positive ( P < .05) than dietary employees about their interactions with patients. Conclusions Patient perceptions of service quality differed in hospitals where dietary employees delivered meal trays and in those where nursing personnel delivered trays. Dietary and nursing employees differed in some aspects of their service orientation.

Operational characteristics of hospital foodservice departments with conventional, cook-chill, and cook-freeze systems

Operational characteristics of hospital foodservice departments with conventional, cook-chill, and cook-freeze systems

Food and the quality of life of patients with cancer

A six month pilot study was conducted to determine if food impacted upon the patient's quality of life during the hospital stay. Seven, long-term patients with cancer were given the choice of ordering meals from outside restaurants, in addition to the hospital menu. The majority (6 of 7) stated that their food consumption increased and a few (3 of 7) maintained their weight during chemotherapy or radiation. Also, the hospital stay was viewed as more pleasant (7 of 7) and of an increased quality (7 of 7). This study provides distinct implications for the role of dietitian and the food service department in providing desired meals to increase the quality of life of patients.