Foodservice Manual for Health Care Institutions

By Ruby Parker Puckett

The thoroughly revised and updated fourth edition of Foodservice Manual for Health Care Institutions offers a review of the management and operation of health care foodservice departments. This edition of the book—which has become the standard in the field of institutional and health care foodservice—contains the most current data on the successful management of daily operations and includes information on a wide range of topics such as leadership, quality control, human resource management, product selection and purchasing, environmental issues, and financial management.

This new edition also contains information on the practical operation of the foodservice department that has been greatly expanded and updated to help institutions better meet the needs of the customer and comply with the regulatory agencies'standards.

TOPICS COVERED INCLUDE:

• Leadership and Management Skills
• Marketing and Revenue-Generating Services
• Quality Management and Improvement
• Planning and Decision Making
• Organization and Time Management
• Team Building
• Effective Communication
• Human Resource Management
• Management Information Systems
• Financial Management
• Environmental Issues and Sustainability
• Microbial, Chemical, and Physical Hazards
• HACCP, Food Regulations, Environmental Sanitation, and Pest Control
• Safety, Security, and Emergency Preparedness
• Menu Planning
• Product Selection
• Purchasing
• Receiving, Storage, and Inventory Control
• Food Production
• Food Distribution and Service
• Facility Design
• Equipment Selection and Maintenance

Learning objectives, summary, key terms, and discussion questions included in each chapter help reinforce important topics and concepts. Forms, charts, checklists, formulas, policies, techniques, and references provide invaluable resources for operating in the ever-changing and challenging environment of the food-service industry.

Companion Web site:
www.josseybass.com/go/puckett4e

Additional resources:
www.josseybasspublichealth.com

• Language: English
• Publisher: Wiley
• Release date: Nov 13, 2012
• ISBN: 9781118234112

Book preview

TABLES, FIGURES, AND EXHIBITS

TABLES

FIGURES

EXHIBITS

FOREWORD

IT IS AN immeasurable honor to write this foreword for Ruby P. Puckett. I have known Ruby for more than 30 years and observed her as she became an icon in the health care foodservice industry.

As a former food and nutrition service director, I looked to Ruby as a leader in health care foodservice who was willing to share her vast knowledge with her peers. I have had the opportunity to serve on professional boards and committees with Ruby where her contributions were invaluable to the success of the outcomes to further the profession of dietetics.

After retiring as director of food and nutrition services at the University of Florida Shands Hospital, Ruby became a sought-after consultant. I have had the privilege of working with her on multiple projects. The most notable assignment was at UCLA Medical Center where her professional advice for performance measures and peer comparisons resulted in improving the department from the lowest percentile to the top percentile in cost containment and patient satisfaction. Her guidance contributed to reducing operational costs by $11 million and increasing revenues by 48 percent. She assisted in enabling the clinical team to become one of the finest in the nation.

Her commitment to continuing education has been instrumental in developing competent leaders in the field of health care foodservice management. Her former students have become leaders in the management and clinical areas. She has tackled the most difficult and intractable problems and has written or spoken about them to train current and future leaders.

Based on the numerous books, pamphlets, CDs, DVDs, online material and eLearning modules, it is imperative that readers know the author(s) to evaluate accurately the credibility of the provided information. Ruby has been a prolific writer so when people are seeking knowledge, they can be assured that her information is accurate and the most current available to the reader.

Professionals in foodservice management and health care facilities who are looking for management ideas, plans, policies, forms, charts, equipment recommendations, and the latest information on a wide range of managerial and operational ideas will find this book beneficial as they increase their knowledge. This book is a practical guide for the total operation of a foodservice department. The book is written in a manner that will benefit students in the dietary manager’s training program, college students, plus the seasoned foodservice manager.

This revised book is well organized, with stand-alone chapters for quick references. Each chapter includes an introduction, a summary, and a list of key terms. With the numerous charts, figures, and tables, the text can be considered a how-to book that allows readers to use the information to improve their operations.

Readers can be assured that this book is one of the most thorough reference books for foodservice management and includes references from authors who practice in areas besides foodservice management. Detailed information is presented on such topics as hazard analysis critical control point (HACCP), Occupational Safety and Health Administration (OSHA) regulations, disaster or emergency planning, newest concepts in marketing, continu­ous quality control, fire safety, equipment selection, presentation methods for menu service, layout and design, and an improved chapter on clinical nutrition management. Because communications and human resource issues involve most of a manager’s time, these chapters have been updated to present the latest information available. A chapter devoted to information management and chapters on product selection and purchasing have been revised and contain new material. This book is a management and operational handbook.

Ruby writes in a style that is descriptive but not diffuse; that is, thorough but not rambling. This book will be a valuable addition to a foodservice operation’s library.

Ruby is the owner of Foodservice Management Consultants and is the program director for the Dietary Manager Training Program through Professional Learning at the University of Florida. Ruby has had a variety of experience in foodservice—she has been the only dietitian in a small charity hospital, director of foodservice in private and university hospitals, a consultant, educator, and author. She has written 13 books, six chapters in other books, published more than 450 articles in peer-reviewed journals and trade/association magazines, and given more than 425 speeches—some on an international level. She presents workshops on HACCP, food safety, and emergency preparedness.

Ruby developed the award-winning Correspondence Course for Dietary Managers Training. Since the inception of the course Ruby has served as the program director for more than 40,000 students who have enrolled. She received the (IFMA) International Foodservice Manufacturers Association) Silver Plate for Health Care Operations. She has been awarded the ADA Excellence Award in Management, the ADA Medallion, and the highest honor given annually to a dietitian—the Marjorie Hulsizer Copher Award. Other awards include the Distinguished Service Award from the Dietary Manager Association and the Foodservice Consultants Society International Robert Pacifico award for her many years of service, not only to the foodservice industry, but also to other organizations, communities, and churches. The Management in Food and Nutrition Systems Dietetic Practice Group of the American Dietetic Association honored Ruby with the Ruby P. Puckett Leadership award, establishing the Ruby P. Puckett scholarship for a Nutrition and Foodservice Professional. In addition, Ruby was honored twice by ASHFSA with the Jim Rose Publication Award. Some of her writings have been translated into Spanish, Chinese, and Japanese. In April 2012, she was only the third woman to be inducted into the Council of Fellows of the Foodservice Consulting Society International. She was the first woman to be inducted into the 1905 University of Florida Athenaeum Society.

In closing, Ruby has been a mentor to me in my career as well as a close personal friend. She continues to graciously mentor many aspiring leaders, most likely contributing to others more than any single person in the foodservice. My life has been enriched by my close association with Ruby P. Puckett and by watching her inspire others to achieve their potential.

L. Charnette Norton, MS, RD, FADA, FFCSI, FHCFA

President, The Norton Group, Inc.

PREFACE

THE COMMERCIAL AND noncommercial foodservice environment continues to change, offering challenges for leadership/management skills, food and nutrition knowledge, fiscal accountability, and human resource practices. Internal and external environments require continuous learning, adapting, and assurance to the stakeholders and the public, in general, that the people who are rendering the services are com­petent to perform their duties. The United States is currently experiencing the worst economic crisis since the great depression of the 1930s. The unemployment rate has reached a new high, millions are without jobs, and the mortgage crisis has left many families homeless, and the political, social, and technological changes continue to have long-term effects. Health care organizations are dealing with shortages of qualified staff and reduced funds at a time when supply, labor, and operating costs continue to increase.

The passage of President Obama’s health care plan, which was to provide health care insurance for millions of uninsured people, has divided the nation, due to the cost not only to employers but also to employees, and due to the question of which treatments are or are not covered. As the new Congress is being seated, there is much discussion for possible changes or repeal of the Bill. Accreditation agencies are placing more emphasis on quality, safety of the customer and the staff, and customer satisfaction. Federal regulations for health care organizations have resulted in increased regu­lations (especially paperwork and reporting) that organizations must follow. There is a shift in the delivery of health care from inpatient to outpatient, in many cases to specialty centers such as orthopedics. These changes and events continue to place an additional burden on the organization and staff for leadership and fiscal responsibility.

Today individuals seeking a career in commercial and noncommercial (health care) foodservice management are experiencing challenges and opportunities that have never before been present. These individuals must possess leadership, managerial, and technological skills. Customers are demanding that their needs, wants, and perceptions be met, which brings new opportunities and challenges to enhance the abilities and skills of the workforce. There are many new changes that must be addressed, which include the emphasis on wellness and prevention, programs to reduce obesity in all ages, reimbursement for medical nutrition therapy, exercise programs for the aging population, and methods to provide care due to the increase in diabetes and heart disease. The shift to the protection of the environment, sustainability, use of farm-grown organic foods, equip­ment technology, meal delivery systems, and (for the first time in history) four generations of employees working side-by-side in the organization will give the manager the opportunity to use advanced practice standards. The manager must be able to adapt, improve existing skills, and think outside of the box to survive in this atmosphere. These changes will affect all systems and subsystems in food and nutrition service. Managers and employees will be challenged to be more efficient and effective in the delivery of service.

Because of these ongoing and continuous changes, I have been challenged to upgrade this fourth edition of this book. As you read the book, you will find many new ideas and upgraded information.

A note: There must be a degree of acceptance and understanding of diversity among employees and customers and family and friends. People differ by race, ethnicity, social status, education, and ances­try and in their hopes and desires for the future. The following philosophy of life was written by Larry Willard Puckett, retired counselor and administrator, and has hung as a plaque in our home for 40 years.

I Offer My Hand

If you can accept it

without regards to its

color, without asking what

political philosophy it defends,

what religious doctrine it

embraces, or what labor

it undertakes, then you

and I have taken the

first step toward mutual

understanding—toward

the ultimate dream—

universal peace.

Larry Willard Puckett© 2012. Used by permission.

Ruby P. Puckett

Gainesville, Florida

ACKNOWLEDGMENTS

THE FOLLOWING INDIVIDUALS provided valuable assistance in obtaining resources, or providing technical assistance (or both): Laurel P. Brown, marketing and program coordinator, TREEO, University of Florida, for formatting a number of figures and charts; Keith R. Brown, safety and health consultant, University of South Florida Consultation Program, Tampa, Florida, for providing the latest information on OSHA and answering a number of questions on safety, especially during an emergency; and L. Charnette Norton, MS, RD, president of the Norton Group, for support, for the Foreword to this book, information on room service, and suggestions on other topics. A special thanks goes out to students, preceptors, dietitians, and instructors for your evaluations and helpful comments. Many of them are included in this fourth edition. Some of the latest equipment trends were provided by Robert Giele, Hobart Consultation Services. Data and lean cell system illustrations in Chapter 21 were provided by Roger Skillman and the Burlodge USA Co. I thank Beth Lorenzini, editor of FCSI’s The Americas Quarterly, for ideas and encouragement. Mitch Mallard, computer assistant tech, was available at all hours when I called for help (Someone bugged my computer!). Mitch retrieved and saved an entire chapter and hours of additional processing. Thanks to CBORD for the computer printouts in Chapter 11. A special thanks also to Larry W. Puckett for permission to reprint the philosophy statement, I Offer You My Hand, in the Preface. Thank you all.

The definitions of organization culture in Chapter 6 were reprinted from Robbins and DeCenzo’s Fundamentals of Management (2001), by permission of Pearson Education. Some of the data in Chapter 11 of the 2004 edition of this manual was an update of the 1988 edition (edited by myself and Bonnie Miller, and published by the American Hospital Association). This material has been further updated for Chapter 12 in this edition.

Thanks to all of the employees, students, and colleagues who have kept me on my toes. It has been my pleasure to teach, mentor, and work with you as I strive to promote the importance of food and nutrition systems management.

I would also like to thank reviewers Carlton Green and Sharon Sweeting for their thoughtful and valuable feedback on the draft manuscript.

I am especially grateful to be able to work with such a talented group of people at Jossey-Bass/Wiley, especially my editor, Andy Pasternack, and associate editor, Seth Schwartz. Thanks for the journey.

Ruby P. Puckett

THE AUTHOR

RUBY PARKER PUCKETT retired from Shands Hospital at the University of Florida after serving 27 years as the director of food and nutrition services, while working with dietetic interns and teaching food systems management to undergraduates on the University’s main campus. In 1994 she opened her own foodservice management consulting company. Since 1972 she has been the program director of the twice award-winning University of Florida’s Professional Education, Dietary Manager Training Program, which she developed and has revised 12 times. To date approximately 40,000 students have enrolled.

Ruby is the prolific author of 13 books (four with coauthors) and has contributed six chapters to other textbooks. Her publications include 460 articles, many of them peer reviewed. She has given more than 425 presentations to professional, educational, civic, and religious organizations. She has held elected offices as well as appointments to numerous committees and has held task force responsibilities in local, state, and national professional organizations in addition to appointed and elected positions in educational, charitable, government, and financial organizations.

In 2003 Ruby was honored with the Marjorie Hulizer Copher Award, the highest honor annually bestowed on a dietitian by the Academy of Nutrition and Dietetics (AND; formerly the American Dietetic Association [ADA]). That organization has also honored Ruby with their Excellence in Management Practice and Medallion awards for contributions to the profession.

Ruby’s other awards and honors include the Jim Rose Publication Award (twice); International Food Manufacturers Association Silver Plate Award in Healthcare Foodservice; the Ivy Award of Restaurateurs of Distinction; and the Distinguished Pacesetter award from the Roundtable of Woman in Foodservice. Auburn University’s College of Human Science has presented Ruby with three awards, including Alumni of the Year. In 2005 she was the first woman inducted into the University of Florida Athenaeum Society since its founding in 1905 and in that same year the University initiated the Ruby P. Puckett Leadership Award enabling a Certified Dietary Manager to attend the Association of Nutrition and Foodservice Professionals (ANFP; formerly Dietary Manager Association [DMA]) multiday leadership conference.

In 2006 the DMA presented Ruby its highest award, the Distinguished Service award for outstanding service to DMA. In 2010 the Foodservice Consultant Society International recognized Ruby with the Robert Pacifico annual award, Doing Well by Doing Good, for dedication to her profession, the community, and to religious organizations. Also in that year the Ruby P. Puckett Legacy Leadership Award for energizing leaders was established by the Management in Food and Nutrition Dietetic Practice Group of the ADA.

Most recently, in April 2012 Ruby was inducted into the Council of Fellows of the Foodservice Consultant Society Inter­national (FCSI).

In addition, Ruby has traveled worldwide with three branches of the U.S. military (Navy, Marines, and Air Force) as an evaluator of military foodservice for the Ney-Hill and Hennessey Award.

Ruby is listed numerous times in the Marquis Directory of Who’s Who in America.

I lovingly dedicate this book to my family,

my husband, Larry Willard Puckett; our daughters,

Laurel P. (Keith R.) Brown and Hollie P. (Reed) Walker;

our six grandchildren and four great-grandchildren;

and to all the foodservice employees

who daily strive to meet the wants and needs

of the millions of people they serve.

INTRODUCTION

THIS FOURTH EDITION of Foodservice Management for Health Care Institutions is written to meet the changing needs and to explore trends and demands of today’s foodservice managers by providing the latest information on systems management and operations. This edition continues to provide information on all aspects of foodservice operations, by dividing the book into areas of operation. As appropriate, quality, ethics, regulations, and customers are incorporated in many of the chapters. Each chapter for this edition contains:

Major learning outcomes

Introduction to chapter

Chapter information

Chapter summary

Key words

Discussion points

The purpose of this edition is to assist students, and new or seasoned managers, to use the latest information, charts, forms, formulas, policies, techniques, and references for operating in the ever-changing and challenging environment of foodservice. Whether for managers or students preparing for careers in foodservice management, this book will contribute to an understanding of foodservice operations.

The book contains 22 chapters divided into major parts, management, and operations of a health care foodservice. There are numerous charts, forms, and exhibits, tables, and formulas to assist in the understanding of the concepts presented. An appendix provides a glossary of culinary terms. The chapter on nutrition and medical nutrition therapy has been deleted from this edition. Customer service, quality improvement, and change may be found throughout the text.

Chapter 1 is among the most important chapters in the book. It is an introductory chapter which provides an overview of the entire book and identifies issues relevant to the ongoing changing environment. The fourth edition has been enlarged to include a brief history of foodservice, professional membership, ethics and social responsibilities, challenges related to the workforce, diversity, and regulations. Foodservice departments can be one of the most stressful environments for employees; suggestions on dealing with stress have been included. A comparison of the advantages and disadvantages of contract management versus self-operated departments is noted. Political ramifications and regulatory regulations are discussed. The material in this book is written for the health care foodservice operation; however, the information is applicable to other foodservice operations such as schools, universities, and correctional facilities. Much of the information is also applicable to commercial operation.

Part One (Chapters 2 through 11) provides information on management and leadership, motivation, participative management, marketing, empowerment of employees, quality management planning, organization and time management, decision making, com­munications, human resources, information systems, and financial controls. Materials on how the foodservice image affects the department are added.

Chapter 3 deals with marketing, market segmentations, advertising, promotions, merchandising, with examples on how to promote the department and increase revenue, especially through catering. Methods used for merchandising and packaging of products can increase sales.

Chapter 4 discusses continuous quality improvement (CQI), quality assurance (QA), and total quality management (TQM). The use of team management to improved quality is discussed. Regulatory agencies such as The Joint Commission, (TJC), Center for Medical Services (CMS), and their standards are described. Involving and empowering teams to participate in quality assurance is described. Various tools used in TQM are outlined and examples of each tool are included. Quality is also discussed throughout the book.

Information on planning and decision making includes new materials found in Chapter 5. Various types of plans used by managers are identified. Missions, values, and methods used in strategic planning (SWOT), goals, objectives, and plans are carefully detailed. Examples of policies and procedures and a revised business plan are included. Decision-making and problem-solving procedures are outlined.

For foodservice managers to be more efficient and effective they must be able to organize their work, the work of others in the department, and to use good time management. They will need to build teams to accomplish the work and provide an organizational structure that is appropriate to their department. Job descriptions, job analysis, productivity, scheduling, and work schedules are all a part of the manager’s responsibility. Information on how to accomplish these duties is described in Chapter 6.

Foodservice managers must communicate every day using written, verbal, body language, and listening skills. Chapter 7 deals with all types of communications (such as the sender and receiver), all types of barriers that hinder effective communications, con­ducting meetings, and the use of various agendas. Listening is an important function of communicating, and a discussion is included on how to listen. Foodservice managers frequently give presentations, so new materials to help the managers to be successful presenters are added. There will always be a grapevine in departments: tips on how to use this method of communicating are included.

Chapter 8 from previous editions has been split to make two separate chapters: Chapter 8, Human Resources: Laws for Employment and the Employment Process, and Chapter 9, Human Resource Management: Other Needed Skills. Foodservice managers spend more than 60 percent of their time on human resource issues. In Chapter 8, the discussion centers on federal laws and surveying agencies’ standards. The remaining portion of the chapter deals with the employment process, orientation, and in-service requirements. Chapter 9 describes the evaluation of performance of employees, the right to unionize, corrective action, coaching, mentoring, the employee assistance program (EAP), and the need for an employee handbook. Turnover and absenteeism cost the department additional money. Formulas to calculate these rates and the use of the information help to achieve a more efficient department are included. Employee recognition programs are suggested.

In Chapter 10, the use of management information in foodservice operations is explored. New printouts of the use of information in foodservice have been added, as well as a warning of the consequences of inappropriate use of electronic mail and web surfing using the organization’s time and computers that may lead to termination.

Chapter 11 on financial management includes new information on controlling a foodservice department’s finances. Controls need to be in place to control all expenses—food, labor, supplies, and so forth. Budget procedures are used as a tool for management control and management. Various reports for food, labor, and so forth must be maintained through journaling. This chapter contains many examples of charts and forms used to control financial management. Cash handling has been elaborated.

Part Two includes Chapters 12 through 22. These chapters give the readers a road map of how to operate a foodservice operation using the system approach. Chapter 12 deals with environmental issues such as waste control, sustainability, and the 4Rs—reuse, recycle, reduce, and rethink—for the protection of the environment. This chapter is so important that plans need to be made to strive for zero waste. Because of ongoing conflicts and concerns in areas of the world where most fossil fuel is produced, this chapter offers recommendations and suggestions for energy conservation. Clean air legislation and water conservation round out the concern for protection of the environment.

Chapter 13 and Chapter 14 make up what was Chapter 13 in the third edition of this text. Chapter 13 deals with microbial, physical, and chemical hazards, the need to use the appropriate temperature measuring devises to ensure the safety of food. The chapter was rearranged to include information that deals with emerging pathogens, food-borne illness, their causes, cost, and number of illnesses and deaths each year.

Chapter 14 thoroughly discusses the Hazard Analysis Critical Control Point Principles (HACCP), health inspection to include a form of what sanitarians are checking, cleaning, and sanitizing, pest control, and suggestions for self-evaluation of the conditions and practice completed by the foodservice management and employees.

Chapter 15 explains safety and security to include the cost and the events that cause most problems. The Occupational Safety and Health Administration (OSHA) revisions are included in material safety data sheets, and methods to use in providing orientation and training employees on safety in the workplace to include the use of personal protective equipment (PPE). This chapter has addi­tional information available on disaster-emergency preparedness. The author has included a new form to assess the department readiness in case of a disaster. With everyday concerns about terrorism—nuclear, biological, and chemical threats—the author has included what they are and what to do in case of an attack. The different types of fire extinguishers and their use are described and instruction is given on what to do in case of a fire as well as other safety and security measures.

Chapters 16 to 22 detail how to operate a foodservice operation. Chapter 16 has been revised to provide more information on the menu planning process; it emphasizes the menu as the key to the entire operation. Various menu options are outlined. Room service as the latest innovation for foodservice to the customer is discussed.

Chapter 17 and Chapter 18 explain product selection and purchasing; new material has been added to include several new forms. Specifications for all food, supplies, and small equipment are provided including exotic fruits and vegetables. Organic, irradiated, genetically modified, cloned foods, and game meats are discussed as these foods are available on the market. The types of food in categories (meat: pork, beef, lamb, and so forth) contain examples of specifications. Ethics in purchasing is discussed.

Chapter 19 is a discussion on receiving and storage and inventory control. Receiving techniques are reviewed to ensure that what is ordered is what is received. Storage method and temperature control measures are needed to provide safe food to the customer. A number of inventory control tools are available to account for the inventory. Once food and supplies are received and stored an accounting and payment system needs to be in place.

Chapter 20 is on methods of food production to conserve nutrients. Using ingredient control rooms allows less skilled personnel, rather than cooks, to do the prepreparation. As a further benefit of using ingredient control rooms, the products are always consistent. Recipes are the heart of food production and a method to decrease or increase the servings of various items is essential; this chapter explains how to do this. All of the methods used to produce food are explained. A culinary glossary is at the end of the chapter.

Chapter 21 is on distribution and service and includes the four basic systems of distribution to patients. Improved tray lines and tray assembly are discussed to include drawings to depict this system. Room service is discussed as an alternative to other distribution systems. There are many delivery systems for distributing food to nonpatients including the new concept of food truck food. Customer satisfaction allows the foodservice direction to benchmark with peer groups. A number of quality standards are available to be used to determine if standards are being met.

Chapter 22, the final chapter, gives information on the use of a team approach in planning a renovation or a new building project. When individual team members carry out their roles, the system works. Using an industrial engineering approach (Gantt and PERT methods) keeps the project on time and usually on budget. Equipment selection must be carefully evaluated and justified. Records for preventive maintenance schedules, cleaning proce­dures, and repairs and replacement must be kept. In designing a new area, avoiding cross-contamination and cross-traffic is vital.

This book may be read chapter to chapter when used in an academic setting. Because each chapter introduces a specific topic, the book may be used in a skip-around fashion. If specific information is needed, choose that chapter. If necessary, check out the back-of-book references for additional information on the subject.

CHAPTER 1

FOODSERVICE INDUSTRY: Managing for Change

LEARNING OBJECTIVES

Develop methods, procedures to identify a diverse and generational workforce.

Learn who the customers are and how to meet their needs and wants.

Accept ethical challenges and social responsibilities for all areas of foodservice operation.

Define and apply changes, trends, and regulatory standards.

Identify and utilize technology as a tool for effective and efficient operation of a foodservice operation.

Discuss political issues affecting foodservice operations.

Analyze changes in demographics—aging of the population, role of women and culture and how it is affecting services.

HEALTH CARE IS being met with increased public awareness associated with the cost of, and equal access to, high-quality care and the passage of a national health care bill that is causing much discussion with the possibility of deletion of parts of the bill or completely discarding the entire bill. If the bill is discarded, a new bill may be introduced in Congress at a later date. The percentage of the national budget spent on health care is still rising at an alarming rate and will require persistent emphasis on cost-effective management. Past cost-control efforts include rightsizing the workforce by staff reductions, flattening management levels, using multidepartment management, heightening productivity, outsourcing various activities such as environment and grounds­keeping, and participating in purchasing groups. Changes occurring within health care are affected by the economy and by business and industry trends. In addition to their effect on health care costs, these trends will affect methods of operation, especially as those methods relate to quality, customer satisfaction, and management style.

Health care of the future will experience increases in patient age and acuity level and a continued population shift from inpatients to outpatients. Responses to these changes have caused hospitals to add extended-care services such as rehabilitation units, skilled-nursing units, and behavioral health centers to increase inpatient census. Hospital-owned home care services now extend services for patients after discharge while they increase revenues. Once the primary health care facility, hospitals now face competition from a growing number of alternative health care facilities. These competitors include nursing homes, adult day-care centers, retirement centers with acute care facilities, freestanding outpatient clinics, and independent home care agencies.

There is continuing concern about the millions of people who do not have any form of health insurance or access to health care, as well as for the millions of others who have severely restricted or inadequate protection. The health care field still faces other concerns. President Obama’s health care plan will impact the delivery of care as more people may be covered by insurance. It is imperative that all health care employees gain knowledge on how the plan works and its effect on the foodservice operation. This knowledge includes the obesity crisis of all ages, but especially children, autism, cancer, heart disease, diabetes, Alzheimer’s disease, the increased number of people with tuberculosis (TB), the increased prevalence of child and adult drug abuse, the aging of the population, diabetes, few medically trained personnel in geriatric medicine, and the emotional stress of daily living and working that takes its toll on health care providers.

These external factors affect the internal operation of health care organizations. Many of these organizations are faced with shorter lengths of stay, reduced census, increased use of the emergency room (ER) as the primary care physician, influx of immigrants, fewer payers, shortage of qualified personnel, increased paperwork and verification of services, and competition for customers. They are also faced with meeting the increasing cost of providing quality service while still meeting the needs, wants, and perceptions of the customers. As a result, many health care organizations are engaged in cost-effective programs that downsize the number of personnel, implement cross-functional training for the realignment of job duties, and combine elementary functions that may not meet the mission of the organization (therefore reducing expense cost). This includes more outpatient procedures, less invasive procedures, and the increased use of technology. The aging of the population and the increased number of sophisticated older adults in residential health care services are additional causes for concern. The implemen­tation of continuous quality improvement processes or improved organizational performance as required by TJC is also tied in with cost-effectiveness.

This chapter is important because it gives an overview of foodservice in health care today and in a number of instances projects problems that will need attention in the future. Read it carefully.

ISSUES: CHANGE

Changes are occurring almost minute by minute all across the world. Changes must happen for society to progress. Not all changes are due to the discoveries of scientists and advanced technology; some are due to the economic climate of the time, the desire for social equality, wars, and catastrophic disasters. Change is the result of substitutions, disruptions, competition, or new developments; it is a difference in the way that things are done.

A change in health care organizations may be seen in the way that care has shifted from a hospital base to outpatient departments, home health care providers, and other outreach centers. As these changes in organization take place, specialists who deliver care in hospitals are refocusing the way they deliver this care. Many physicians are being trained to perform cross-functional job duties. Cross-functional training is the integration and progressive sequence of learning experience whereby employees are provided with the knowledge and skills needed to perform more than one function.

Socioeconomic changes are taking place on a worldwide basis. The former Eastern Bloc nations are still seeking not only independence but also improved financial and technical assistance from the more prosperous nations. War in Iraq, Pakistan, and Afghanistan has cost many billions of dollars and the deaths of many U.S. soldiers and civilians. Problems still exist in other parts of the world, and changes are occurring now in the former Eastern Bloc. Wars and rumors of wars that use technological advances in weaponry are present. Daily across the world, thousands of people die of malnutrition, natural disasters, emerging pathogens, and major diseases and wars. Transportation and communications are almost instantaneous. When an event happens on the opposite side of the world, we are able to see and hear about it as it is happening. The length of time it takes to transport goods and people to a different location has been reduced from weeks to days (even hours). It has become impossible for any nation to remain isolated. Every developed country has experienced numerous problems: rapidly rising health care costs, increased and fluctuating gas prices, depressed or failing economy, high unemployment, sluggish home sales, increased workplace violence, homelessness and hungry people, especially children.

In the twenty-first century, health care providers face the following factors:

Consumer movements (protection of patient rights, informed consent, reporting, privacy)

Managed care (prepaid health care, reshaped health care)

Increased use of ambulatory centers (may be stand-alone centers)

Integration of health care organizations, departments within the organizations

Health maintenance organizations (HMOs)

The aging of the population

A prospective payment system based on classification of patients’ diagnoses and the use of resources

Quality of care (the longer patients stay in the hospital, the higher the risk for serious slip-ups, rising 6 percent for each extra day in the hospital)

Worker’s compensation laws

Financial woes (decreased profit margins)

Competition, mergers, and consolidations (especially of management teams)

Social litigation that includes:

Sexual equality

Maternity leave

Length of workweek

Flexible scheduling

Cultural diversity, generational difference in the workforce.

Increased technology

Ethics

Economic downturn, high unemployment, and increase in number of people receiving workmen’s compensation

Public health: Approximately 1.3 million women and 835,000 men are physically assaulted by an intimate partner annually in the United States; many of the assaults include rape, physical injury such as gunshot and knife wounds, which result in an emergency room visit or admission to a health care facility as a result of the attack. Violence against ER nurses and other health care providers by patients and family members is on the increase.

Other Changes in Delivery of Care

Other changes in the delivery of care have been labeled clinical pathways, empowering, restructuring, cross-functional training, decen­tralization, care paths, interdisciplinary team approach, and integrated systems approach. Regardless of the labels placed on these changes, all of these approaches have some of the following commonality:

Flattening of organizational structure, from the familiar pyramid-shape organization with six or more levels of management to a structure with just three or four levels may be necessary

Redesigning of technological content and services to prevent hawking of employee personnel records and patients medical records

Improvement of the admission and discharge procedures

Training people to do more than one function, foodservice managers may be responsible for multioperations or departments

Reducing the lengths of stay (quality may not be better despite shorter stay)

Maintaining a stable, fiscally viable organization

Building high-performance teams that empower personnel to do their jobs and take necessary risks

Implementing standards and rewards to give control of care back to patients

Benchmarking internally and with competitors

Lacking qualified health care employees in some areas of the United States, especially family physicians

Changing surveyors regulations

Many of these changes will also dovetail with the imple­mentation of TJC’s and other regulatory agencies’ mandated improvement of organizational performance. Some of the changes need to be defined:

Empowering personnel. Giving authority and responsibility to personnel to define problems and identify solutions that may involve resource allocation or interdepartmental coordination; giving employees the power to set their own work schedules, rotate jobs, and have a larger measure of control over the job—a greater sense of responsibility and authority. W. Edward Deming, who is credited with bringing quality control to Japan in the 1950s, is generally regarded as the intellectual father of total quality management. His concept of total quality is based on the 14-point system. These points were such that, when implemented, they improved quality, provided on-the-job training, broke down barriers between departments, and focused on zero defects.

Empowerment provides employees with the tools, authority, and information to do their jobs with greater autonomy. It also broadens the knowledge base, causing a shift in power; encourages creative open communications; and provides for access to data, the ability to cut through corporate bureaucracy and to communicate with shareholders, and the ability to implement solutions.

Clinical pathways. This is a method or approach to improve care of patients from preadmission through inpatient stay and after discharge, with delineation of nutrition service for each practitioner involved. Information is provided among other providers such as physicians, home health care providers, and long-term care agencies. It is a multilevel, multidiscipline, multidimensional, long-term approach to care that flattens the organization, eliminates redundancy of bureaucratic functions, redesigns work, allows for creativity, allows empowerment of personnel, and gives employees the ability to take the initiative and, if needed, take risks. The facility environment must be one of support for change.

Interdisciplinary health care providers. These providers have been cross-functionally trained. They are personnel who have been educated or trained to provide more than one function or job duty, often in more than one discipline. They are multiskilled, competent, and cross-trained. The day of the generalist has come, as has the preventive approach to health care. Health care institutions are focusing on the interdependence of the various functions that must be completed to meet their organizational goals. Cross-functional training will also result in broadbanding (that is, combining multiclassifications of jobs under one occupational category). These changes will alter the roles of nutritional care providers. The director will assume more of the responsibilities of middle managers. Employees will play an increased and more visible role in the organization. Clinical registered dietitians will be involved in more nontraditional health care jobs, including entrepreneurial activities and consultation with pharmaceutical companies and home health care agencies as nutrition support directors, educators of the public, and major players in the critical pathway of care to patients. In-service teams can work together to cut costs and increase quality.

POLITICAL ISSUES

The future direction of health care will be influenced by political and governmental intervention as a direct result of increased public awareness and demands. Regulation of the health care industry is likely to continue, even intensify, as access to care becomes a concern of politicians and consumers alike (see the Obama health care plan). Health care foodservice departments will feel the effects of the political environment as it shapes and regulates the way service is delivered. In addition to regulation, managers will see the effects of more emphasis on environmental safety, the protection of the environment and sustainability, while they struggle to provide accurate nutrition information to consumers.

Regulation and Legislation

The nature of this text precludes a comprehensive discussion of legislation as it pertains to health care nutrition and foodservice delivery. Even so, legislative effects and subsequent regulations must be taken into account when foodservice directors plan the direc­tion of their departments. This section briefly reviews various governmental and private sector regulations that affect foodservice delivery. In addition to those covered, the 12-week family leave legislation (Family and Medical Leave Act of 1993) should be scrutinized closely to determine what, if any, modifications are required in work methods and staffing patterns (discussed in full in Chapter 9). Another concern is the return of military personnel and the lack of medical care and job opportunities.

Most of the surveying agencies (TJC, Centers for Medical Services [CMS], Occupational Safety and Health Administration [OSHA], and Omnibus Budget Reconciliation Act [OBRA]), as well as local and state public health agencies, have updated and made changes in the surveying system.

Medicare and Medicaid

The regulations that currently have the greatest effect on health care are those dictated by Medicare and Medicaid, the largest managed-care providers in the United States. Reimbursement rates for services have been set by Medicare and embraced by other managed care systems. Although most foodservice managers recognize their responsibility to provide a high-quality and safe food delivery sys­tem, Medicare regulations continue to ensure these entitlements for consumers. The Obama health care plan has made a number of changes in the Medicare and Medicaid regulations that need to be noted. These plans may not affect the nutrition services offered, those services for which a fee is charged, and the quality of care delivered through meal service. Emphasis is on adherence to medically approved diets, written prescriptions, and the service of wholesome food. Medicaid coverage continues to be an ongoing problem, with various bills awaiting action in both the House and the Senate. In 2007 21.9 percent of all federal movement expenditures were spent on Medicare and Medicaid. In 2008 Medicare provided coverage to 44.8 million Americans over the age of 65 and by 2030 is expected to cover 78 million as the baby boomers retire. Federal Medicare expenditures went up steadily in the past three years. In 2006 the expenditure was $378.6 billion and in 2008 $432.6 billion, and Medicaid spending grew to $203 billion in 2008, reaching $216 billion for the federal government cost, plus more than $100 billion or more paid by states. Medicaid is the largest and fastest growing part of state budgets, comprising 20 percent of all state expenditures. The number is expected to grow as the population ages, the need for long-term care increases, and older people enter nursing homes. Medicaid is the largest purchaser of nursing home services and maternity care in the nation. Much of the anticipated increase in spending will go to purchasing prescription drugs. On March 20, 2010, the Congressional Budget Office estimated that the new health care bill will cost $940 billion over the next 10 years; however, the actual amount is estimated to be several trillion dollars. Two major changes in the Medicare bill are the reduction in physician payments and the reduction in the cost of drugs after a specific amount has been spent. (It is important to keep informed on the cost, as it will affect you personally as well as the foodservice operation.)

Omnibus Budget Reconciliation Act of 1987

Foodservice departments that serve hospital extended-care units and long-term care facilities also must comply with the Medicare and Medicaid Requirements for Long-Term Care Facilities. These requi­rements, finalized in September 1992, implemented the nursing home reform amendments enacted by the Social Security Act by Omnibus Budget Reconciliation Act (OBRA) of 1990, as published by the Health Care Financing Administration. It is estimated that nearly 50 percent of the OBRA regulations relate directly or indirectly to nutrition and foodservice departments. The OBRA standards pertain to dignity and independence in dining, initial and annual nutrition assessments, nutrition care plans, and participation of a dietitian in family conferences. Anticipate additional changes in this act.

The Joint Commission

Medicare and Medicaid regulations are government-imposed, but some facilities choose to further their compliance efforts by following standards set by independent organizations. The Joint Commission (www.jcaho.org) is one such organization. Standards set by TJC are similar to those set by Medicare; however, TJC surveys tend to place more emphasis on the systems, processes, and pro­cedures that influence quality of patient care and outcomes. More recently, publications by TJC report that future emphasis will be on the education and training of patients and their families; orientation, training, and education of staff; leadership roles of directors; work place violence, and approaches and methods of quality im­provement. They also have announced increased standards for safety, infection control, pain management, and emergency readiness. They will no longer announce the date or time of the surveys. Because TJC guidelines are updated and published annually, they must be reviewed annually to ensure compliance.

Americans with Disabilities Act

In addition to significantly influencing operations, legislation continues to dictate employment practices. As the labor force shrinks and alternative labor sources are explored, Americans with dis­abilities are one solution to some of the problems associated with inadequate staffing. Furthermore, ensuring equal employment opportunities for this segment of the population is mandated by federal law. In 1990, President George H. W. Bush signed the Americans with Disabilities Act, which prohibits employment discrimination against the disabled. The act mandates that employers with 25 or more employees are prohibited from discriminating against qualified individuals with disabilities with regard to applications, hiring, discharge, compensation, advancement, training, or other terms, conditions, or privileges of employment. The act affects both the selection of employees and the service of meals to consumers. Reasonable accommodations have to be made for both groups. Further explanation of the Americans with Disabilities Act is found in Chapter 8.

Health Care Affordability

Given the alarming rate of increases in health care costs and in an aging population, alternative health care options will be necessary. In 2008 U.S. health care costs were about $7,681 per resident and accounted for 6.2 percent of the nation’s Gross Domestic Product (GDP); this is among the highest in industrial countries. The new health care law, the Patient Protection and Affordable Care Act, and the amendment reconciliation bill, requires all U.S. residents to have insurance or pay a tax penalty. The Obama health care plan will provide coverage for most uninsured workers. This is extremely important and directors and managers must keep up to date on these changes.

Extended-Care Facilities

The concept of seamless delivery of care is demonstrated by hospital-based, long-term-care beds, with patients being moved to skilled-nursing beds or rehabilitation units designed to assist them in becoming self-sufficient. Moving from the higher-cost acute care setting benefits patients, hospitals, and payers. Meals and menus continue to increase in complexity (such as the introduction of the spoken menu, room service, and gourmet menus) and diversity to meet the needs of inpatients in skilled-nursing and rehabilitation units. Although hospitals continue to convert unused beds to long-term care beds, most growth in long-term care is occurring in outside facilities. The elderly population, aged 85 years and older, will be about 17.6 million in 2050, with about 66 percent of this number being women. Assisted living continues to increase as more facilities become available. Extended-care facilities are becoming more innovative in meeting their patients’ mealtime needs. Many such facilities now provide selective menus; others have experimented with wait service and restaurant-style menus (that is, a number of selections per category per meal). Providing meals that meet the required nutrition modifications for elderly patients is becoming easier with the use of general diets that are lower in fat, sodium, and sugar; the liberalization of other diets; and the increased number of products on the market that meet texture adjustment needs.

Extended care facilities include:

Skilled nursing care

Residential care

Adult day care

Elder care

Rehabilitation care

Personal/boarding care

Congregate/semi-independent living

Independent living

Life care

Home care service

Patients’ lengths of stay vary from one institution to another and from one geographical region to another. The length of stay for hospitals (excluding psychiatric and rehabilitation facilities) in 1996 was 6.9 days; by 1998 it had decreased to 5.9 and has stayed in this range, with the exception of patients with acute problems such as heart disease and cancer and has continued to have slow decline since this date. In 1998 the mean occupancy rate had dropped to 69 percent. The length of stay and occupancy rate are projected to decline over the next decade. Most beds will be occupied by seriously ill patients.

The average length of stay is affected by the high acuity level of patients. The high acuity level of a patient determines the need for extended care after discharge. Home care is one type of extended care that can positively influence the cost of health care, allowing for shorter hospital stays while ensuring that a patient is cared for in a familiar setting. Furthermore, readmissions have been shown to decrease as a result of team-managed home care. Advances in technology allow more services to be performed in the home, including infusion therapy (such as total parenteral nutrition). Home care offers bigger challenges for home delivery of meals, as does the continuing decline in funding for meal programs for the elderly.

Ambulatory Care

Ambulatory care is expected to show significant growth throughout the next decade. The number of outpatient procedures continues to increase, resulting in a net increase in adjusted admissions. Surgical procedures in ambulatory care settings continue to increase nationwide. Technological advancements and reimbursement trends continue to support the shift from inpatient services to outpatient services. Emergency department visits increased due to a larger number of individuals without health insurance and the enforcement of the federal Emergency Medical Treatment and Labor Act. Outpatient visits will continue to increase by a rate of 15.7 percent per year.

Even though hospital foodservice departments continue to encounter declines in the number of meal demands for inpatients, the number of meals prepared for nonpatients is likely to increase. For example, as outpatient procedures increase, foodservice departments will serve more visitors and family members who accompany patients as well as employees associated with ambulatory care.

Case Management and Patient-Focused Care

The goals of case management and patient focused (or patient centered) care are to improve patient care and satisfaction, decrease the cost of delivery, and improve access to health care. Patient-centered care is a more advanced extension of case management, but both are designed to use critical pathways or standardized care paths that specify a road map for the care team and are specific to individual diagnoses. The standards of care or critical paths, developed with input from all team members, are based on the best-demonstrated practice within the facility. Comparing the standards and paths with those at other organizations can help further quality improvement efforts. The patient-focused care model uses a case manager or coordinator who is assigned to a patient on admission and is responsible for monitoring the patient’s progress throughout the hospital stay.

Patient-centered care eliminates traditional departmental lines, opting instead for health care teams that focus on patients with related conditions. To realize this type of care, a change in employee attitudes and structural changes to patient care units are necessary. Changes in these units will affect the nutrition and foodservice department as well as clinical caregivers. In models across the nation, foodservice workers are cross-trained to deliver meals and assist patients with their other needs. Some models assimilate jobs previously done by foodservice staff, housekeeping staff, and nurses’ aides into new positions, such as the multiskilled patient care employee.

Accountability and Ethics

Government intervention and regulation have placed new emphasis on institutional accountability as it relates to physician recruiting. Once able to recruit physicians with income guarantees and low-interest loans, hospitals now must use their physician workforce plans and development plans to access and document their requirements for additional physicians. Demand cannot be based on the institution’s need alone but must be supported by hard