Sage D ie te t i c I n te rnsh ip Spr i ng 2014Process Improvement Pro j ec t f o r Food Se rv i ce ManagementIn te rn : J anna Ne i t ze lPrecepto r : J enn i f e r Phe lpsFac i l i t y: Bapt i s t Hea l th

THE IMPACT OF TRAY ACCURACY AND MEAL APPEARANCE ON

RESIDENT SATISFACTION AND FOOD WASTE

In residential, rehab, or long-term care facility, meals serve several vital functions, providing nourishment, aiding in the overall care plan of a patient, and helping to create a sense of home

Overall satisfaction relies heavily on meal satisfaction Many complex elements to meal satisfaction(2)

Patient’s rights Adequate nutrition through care provided (1)

Reliance on facility to meet needs Lack of control over meals (3)

INTRODUCTION

When patients cannot rely on the food service where they reside, it is an area of deep frustration and concern to not only the resident, but their family and the facility as a whole.

Residents select their meals, believing they will arrive with all items requested, in the proper consistency and within the diet type specified by medical professionals.

Residents expect meals to look attractive and taste desirable, so they are able to meet their nutritional needs.

INTRODUCTION

Missing tray items were common source of concern at the residential and rehabilitation facility used for the purpose of this project.

Patients complaints: Meals not as they expected and low meal satisfaction High rate of meal tray inaccuracy

The facility loses in two ways: food and staff labor costs increase, as the meal needs to be corrected, and resident/customer satisfaction decreases.

A facility must strive to maintain a level of satisfaction from their customer in order to function successfully as a business

INTRODUCTION

CURRENT MENU EXAMPLE

TRAY PRESENTATION: This process encompasses timeliness of tray delivery, temperature, tray accuracy, the appearance of foods, and the taste of foods.

Main goal: Increase resident satisfaction through monitoring the meal

tray processes in place, measure the critical areas of concern, and suggest and/or pilot changes that could improve meal satisfaction.

The outcome of this process improvement study could potentially decrease the workload of the kitchen/dietary staff , as less time will be spent reconciling unsatisfied residents, through meal tray correction, fulfi lling requests for additional foods to replace the original meal, etc.

OBJECT OF PI PROJECT

The initial stages of this study: Observation of the tray line, the system in place at this facility

through which breakfast, lunch, and dinner meal trays were assembled

To gain an understanding of the work load on dietary staff members, each tray line position was worked following the observation. Data was collected on days during which diff erent staff members worked diff erent positions, to gain a wide perspective when studying tray presentation.

Resident Meal Satisfaction SurveyingSurveying the cooksTray accuracy auditsMeal tray audits: specifi c diet and consistency, measuring

quality of meals and timeliness of tray passingPlate waste studies

METHODS: OVERVIEW

At the 225-bed facility, a total of 30 residents from all units combined were surveyed to obtain a wide mix of responses.

The surveying was conducted after diff erent meals, both meals known to be well-liked and some disliked by residents, to avoid bias, and at each of the meal times (breakfast, lunch and dinner).

METHODS: SURVEY

  Strongly disagree (1)

Disagree (2) Neutral (3) Agree (4) Strongly Agree (5)

a. Food is always the temperature to my liking

         

b. There is enough variety in the menu

         

c. The time it takes for my meal to arrive is appropriate

         

d. The food is presented attractively

         

e.Minimizing waste is important to me

         

f. I am always able to find something I like to eat

         

MEAL SATISFACTION SURVEY

1.What is your favorite item/meal on the current menu?2.What changes would you make to the current menu?3.Please respond to the following statements using the chart provided:

As soon as each full cart carrying meal trays to each unit was assembled and ready for delivery, trays were pulled from the cart and checked to see whether the meal ticket listing each item to be served matched the actual items on the tray.

In order for a tray to be completely accurate, each item had to be present, at the right consistency identifi ed on the ticket, and provided in the correct portion listed.

Additionally, many meal tickets made specifi c notes according to the patient’s needs/wants, such as “no straws” or “no green or black specs.”

A meal ticket would also list any adaptive eating equipment that the resident required.

All specifi cations that the meal ticket listed were to be refl ected in the meal provided in order for that meal tray to be 100% accurate.

METHODS: TRAY ACCURACY

A separate tray audit was conducted specifi cally designed to test temperature of food, appearance and taste of food, as well as timeliness of tray passing (the time it takes the meal to arrive to the resident).

A meal ticket was put into the GeriMenu ticket generator system with specifi cations for a made up resident.

This audit measured the temperature of food on tray line at the point of service, taking the temperature of foods in the steam table bins that were portioned onto plates in tray assembly. It took note of the time at which meals left the kitchen, the time at which meals arrived to the specifi ed unit, and the time of service, or when the resident would be served.

At the time of service, the meal tray was assessed for accuracy of the meal tray, presentation, temperature, and taste.

This audit was conducted seven times throughout each daily meal, breakfast, lunch, and dinner.

METHODS: MEAL TRAY AUDITS

Plate waste studies were conducted to measure the amount of waste over three meals assessing 130 meal trays from all units combined.

The audit used to measure plate waste categorized the trays into three groups based on three amounts of consumption.

When looking at the meal tray, the auditor circled the amount consumed; 25-50%, 50-75%, or 75-100%.

Plate waste studies were conducted three diff erent days, measuring intake following each of the meals off ered, breakfast, lunch, and dinner.

METHODS: PLATE WASTE MEASURES

All activities to be performed for the project and estimated time needed for completion: Observe tray line—3-4 days Observe end result of tray coming off tray line—3-4 days Work each tray line position and take note of needs for improvement in tray

line process as a whole—1-2 weeks Discuss finding with preceptor, cooks, and shift managers—3 days Question cooks on taste-testing food and meal satisfaction—1 day Develop resident meal satisfaction survey—3 days Conduct resident survey—2 weeks Conduct tray accuracy audits—2 weeks Conduct test tray audits

Create resident with specifi c diet and needs on meal ticket Audit tray for temperature, presentation, accuracy, timeliness, and taste—7 test

trays over 3-4 days Conduct plate waste studies—3days Analyze data—1 week Propose suggestions for improved process

Use hard cups in place of plastic and Styrofoam disposable cups Use highlighter to indicate missing item being fetched by “runner” position

Pilot suggested changes—1 week

STUDY PLAN

1) Favorite meal: 3 of 30 residents surveyed answered “spaghetti and meatballs.” All other answers varied with no trends identified.

2) What would they change: 12 residents responded they would not change anything about the current food service. 4 residents stated they would change the sandwiches typically served at dinner. 2 residents stated they would change the salads off ered and disliked the current salads served. 1 resident stated they would off er spaghetti and meatballs more frequently and 1 resident stated they would off er a greater variety of foods.

RESULTS: SURVEY

RESULTS: SURVEY

3) Results below: Strongly

Disagree Disagree Neutral Agree Strongly

Agree a. Food is always the temperature to my liking

10=33% 9=30% 3=10% 8=27% 0

b. There is enough variety in the menu

3=10% 7=23% 1=3% 19=63% 0

c. The time it takes for my meal to arrive is appropriate

6=20% 12=40% 3=10% 9=30% 0

d. The food is presented attractively

2=7% 4=13% 4=13% 20=67% 0

e. Minimizing waste is important to me

0 6=20% 2=7% 21=70% 1=3%

f. I am always able to find something I like to eat

2=7% 9=30% 1=3% 18=60% 0

Tray audits, conducted over 5 days, during each meal service to evaluate tray accuracy, revealed 370 out of 500 (74%) meal items were accurate on average.

The daily accuracy level ranged from 46% accuracy to 95% accuracy.

This wide range in the end product was primarily due to the range in skill level of the meal tray “checker” staff member on duty for that meal.

Some staff had more experience in this position than others and the data reflected this discrepancy.

RESULTS: TRAY ACCURACY

The 7 test trays analyzed for accuracy, presentation, temperature, timeliness and taste over 3 days during breakfast, lunch and dinner gave insight to the role of dietary staff in maintaining quality food service. Temperature: 5 out of 7 trays contained items that were above

or below proper temperature. Accuracy: 2 test trays were inaccurate when the meal tray items

were compared to the meal ticket, as there was a missing item on one occasion and a straw was present on the tray, though the ticket indicated “NO STRAW” (a common request for residents at the facility to ensure their safety).

Taste: adequate and presentation was acceptable on all 7 test trays audited.

Time: arrival of meal tray to the proposed resident varied based on the unit, which identified this as a critical control point which depends on nursing staff in order to maintain quality, as the temperature of the foods is greatly impacted.

RESULTS: TRAY AUDITS

Day 1 audits: Indicated half of the residents (63 out of 126 trays assessed

consumed 25-50% of their meal and the other half consumed 75-100% of their meal

Day 2 audits: 70 (58%) residents consumed >50% of their meal

Day 3 audits 75 (63%) residents consumed >50% of their meal.

As these studies were conducted after each of the three daily meals (breakfast, lunch, and dinner) and following meals that were both known to be liked and dislike, the results provide an accurate assessment of the average level of intake with the current menu in place at this facility.

RESULTS: PLATE WASTE

Highlighting missing items at the end of tray line “Loader” position Piloting this change

Catch the Wave Hydration Station education Prevention of dehydration

Identification of at-risk population Signs and symptoms Policy and procedure development Pre/Post questionnaire

IN-SERVICES

Need for policy and procedure of positions in tray line

Ownership of tray line position roles

Variance in accuracy due to which staff performed “checker” role

DISCUSSION AND RECOMMENDATIONS

Tray passing: Timeliness of meal delivery to the patient Auditing nursing staff role

Conducting resident meal satisfaction surveys after implementation of changes developed to improve the process of tray presentation Changes in effect that could be studied upon follow-up

surveying Making more of the food served from scratch and buying fresh

foods Serving fewer prepared and/or frozen items The menu is currently being updated to reflect the goals of the

new management company

Additionally, a larger sample size of residents surveyed would yield greater data for consideration.

AREAS FOR FURTHER STUDY

THEME MEAL

THEME MEAL

Tuesday March 4th Main entrée: jambalaya with okra and a wheat roll A traditional dish of rice, shrimp, chicken sausage, and ham with Creole seasoning and vegetables. A side of steamed okra and a wheat roll make this meal deliciously satisfying! Alternate: chicken gumbo A flavorful tomato-based stew made with chicken, sausage, rice, and veggies, including okra, carrots, and onions Dessert: King Cake Festive yellow cake with delicious sugar glazed topping in the traditional Mardi Gras colors of purple, green, and gold **A tasty celebration!**

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3. McKinnon, J. M. Hospital room service delivers comfort: Menu cater to needs, tastes of patients. Med Sci. Retrieved March 13, 2014 from http://www.toledoblade.com/Medical/2007/11/05/Hospital-room-service-delivers-comfort.html

4. Jackson, Rita. Nutrit ion and Food Services for Integrated Health Care. Maryland: Aspen Publishers, 1997.

5. Johns, N., Hartwell, H., and Morgan, M. Improving the provision of meals in hospital; the patient’s viewpoint. Appetite. 2009; 54:181-185.

6. Kim, K., Kim, M., Kyung, L. Assessment of foodservice quality and identifi cation of improvement strategies using hospital foodservice quality model. Nutr Res Pract. 2010; 4(2): 163-172.

REFERENCES