THE IMPACT OF TRAY ACCURACY AND MEAL APPEARANCE ON RESIDENT SATISFACTION AND FOOD WASTE

1. THE IMPACT OF TRAY ACCURACY AND MEAL APPEARANCE ON RESIDENT SATISFACTION AND FOOD WASTE Sage Dietetic Internship Spring 2014 Process Improvement Project for Food Service Management Intern: Janna Neitzel Preceptor: Jennifer Phelps Facility: Baptist Health

2. introduction • 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)

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.

4. 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

5. Current menu example

6. Object of pi project • 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, fulfilling requests for additional foods to replace the original meal, etc.

7. Methods: overview • 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 different staff members worked different positions, to gain a wide perspective when studying tray presentation. • Resident Meal Satisfaction Surveying • Surveying the cooks • Tray accuracy audits • Meal tray audits: specific diet and consistency, measuring quality of meals and timeliness of tray passing • Plate waste studies

8. Methods: survey • 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 different 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).

9. Meal satisfaction survey • What is your favorite item/meal on the current menu? • What changes would you make to the current menu? • Please respond to the following statements using the chart provided:

10. Methods: tray accuracy • 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 identified on the ticket, and provided in the correct portion listed. • Additionally, many meal tickets made specific 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 specifications that the meal ticket listed were to be reflected in the meal provided in order for that meal tray to be 100% accurate.

11. Methods: meal tray audits • A separate tray audit was conducted specifically 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 specifications 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 specified 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.

12. Methods: plate waste measures • 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 different days, measuring intake following each of the meals offered, breakfast, lunch, and dinner.

13. Study plan • 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 specific 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

14. Results: survey • 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 offered and disliked the current salads served. 1 resident stated they would offer spaghetti and meatballs more frequently and 1 resident stated they would offer a greater variety of foods.

15. Results: survey

16. Results: tray accuracy • 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.

17. Results: tray audits • 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.

18. Results: plate waste • 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.

19. In-services • 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

20. Discussion and recommendations • 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

21. Areas for further study • 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.

22. Theme meal

23. Theme meal

24. references • Beck, A. M., Balknas, U. N., Furst, P., Hasunen, K., Jones, L., Keller, U., et al. Food and nutritional care in hospitals: How to prevent undernutrition report and guidelines from the Council of Europe. ClinNutr. 2001; 20(5): 455-460. • Sheehan-Smith, L. Job satisfaction of hotel-style room service employees. J Food Mgmt Ed. 2006; 2:1-14 • 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 • Jackson, Rita. Nutrition and Food Services for Integrated Health Care. Maryland: Aspen Publishers, 1997. • Johns, N., Hartwell, H., and Morgan, M. Improving the provision of meals in hospital; the patient’s viewpoint. Appetite. 2009; 54:181-185. • Kim, K., Kim, M., Kyung, L. Assessment of foodservice quality and identification of improvement strategies using hospital foodservice quality model. Nutr Res Pract. 2010; 4(2): 163-172.