Food Service Manual for Health Care Institutions Third Edition

Food Service Manual for Health Care Institutions Third Edition
Food Service
for Health Care Institutions
Third Edition
Ruby P. Puckett
Foreword by Carlton Green
Health Forum, Inc.
An American Hospital Association Company
Food Service
for Health Care Institutions
Third Edition
Food Service
for Health Care Institutions
Third Edition
Ruby P. Puckett
Foreword by Carlton Green
Health Forum, Inc.
An American Hospital Association Company
Copyright © 2004 by the American Hospital Association. All rights reserved.
This publication is designed to provide accurate and authoritative information in regard
to the subject matter covered. It is sold with the understanding that the publisher is not
engaged in rendering professional services. If professional advice or other expert assistance
is required, the services of a competent professional person should be sought.
The views expressed in this book are strictly those of the author and do not represent the
official positions of the American Hospital Association.
is a service mark of the American Hospital Association used under license
by AHA Press.
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Library of Congress Cataloging-in-Publication Data
Puckett, Ruby P.
Food service manual for health care institutions / Ruby P. Puckett ;
foreword by Carlton Green.— 3rd ed.
p. ; cm.
Rev. ed. of: Food service manual for health care institutions / Brenda A.
Byers, Carol W. Shanklin, and Linda C. Hoover. 1994 ed. 1994.
Includes bibliographical references and index.
ISBN 0-7879-6468-9 (alk. paper)
1. Health facilities—Food service—Handbooks, manuals, etc. 2.
Hospitals—Food service—Handbooks, manuals, etc.
[DNLM: 1. Food Service, Hospital. WX 168 P977f 2004] I. Byers, Brenda
A. Food service manual for health. care institutions. II. Title.
RA975.5.D5P83 2004
Printed in the United States of America
PB Printing
10 9 8 7 6 5 4 3 2 1
Figures, Tables, and Exhibits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix
Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvii
Preface. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xix
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxi
About the Author . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxii
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxiii
Part One.
Part Two.
Food Service Industry: An Overview . . . . . . . . . . . . . . 1
Management of the Food Service Department
2. Leadership: Managing for Change . . . . . . . . . . . . . . . 27
3. Marketing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
4. Quality Management. . . . . . . . . . . . . . . . . . . . . . . . . 69
5. Planning and Decision Making . . . . . . . . . . . . . . . . 101
6. Organization and Time Management . . . . . . . . . . . . 131
7. Communication . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
8. Human Resource Management . . . . . . . . . . . . . . . . 197
9. Clinical Nutrition Care Management . . . . . . . . . . . . 249
10. Management Information Systems . . . . . . . . . . . . . . 277
Appendix 10.1. Glossary of Computer Terms
for Food Service Operators . . . . . . . . . . . . . . . . . . . 301
11. Control Function and Financial Management . . . . . . 305
Operation of the Food Service Department
12. Environmental Issues and Waste Management . . . . . 345
13. Food Safety, Sanitation, and Hazard Analysis
Critical Control Points. . . . . . . . . . . . . . . . . . . . . . . 371
14. Safety, Security, and Emergency Preparedness . . . . . . 433
15. Menu Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . 471
Appendix 19.1.
Product Selection. . . . . . . . . . . . . . . . . . .
Purchasing . . . . . . . . . . . . . . . . . . . . . . .
Receiving, Storage, and Inventory Control
Food Production . . . . . . . . . . . . . . . . . . .
A Culinary Glossary . . . . . . . . . . . . . . . .
Distribution and Service . . . . . . . . . . . . .
Facility Design and Equipment Selection .
. . . . . . . 509
. . . . . . . 559
. . . . . . . 589
. . . . . . . 609
. . . . . . . 665
. . . . . . . 669
. . . . . . . 691
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 735
Figures, Tables, and Exhibits
Levels of Hospital Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34
Maslow’s Hierarchy of Needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .41
Production and Consumption of Goods Versus Services . . . . . . . . . . . . . . .53
Determining the Market Cycle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .56
Health Care Food Service Marketing Mix . . . . . . . . . . . . . . . . . . . . . . . . .56
A Gift Certificate Used in a Promotion . . . . . . . . . . . . . . . . . . . . . . . . . . .58
A Menu Used for a Special Event or Theme Day Promotion . . . . . . . . . . .58
A Reduced-Price Coupon Used in a Promotion . . . . . . . . . . . . . . . . . . . . .59
Another Example of a Reduced-Price Coupon Used in a Promotion . . . . . .59
Sample Action Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .65
Shewhart’s PDCA Cycle for Process Improvement . . . . . . . . . . . . . . . . . . .70
Deming’s PDCA Cycle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .71
CQI Flowchart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .83
Flowchart for Patient Late Tray Process . . . . . . . . . . . . . . . . . . . . . . . . . .91
Pareto Chart of Problems Associated with Patient Late Trays . . . . . . . . . . .92
Cause-and-Effect Diagram for Patients Not Receiving Late Trays . . . . . . . .93
Figures, Tables, and Exhibits
Run Chart for Late Trays Longer Than 15 Minutes . . . . . . . . . . . . . . . . . .93
Control Chart of Tray-Line Start Times . . . . . . . . . . . . . . . . . . . . . . . . . . .94
Top-Down Flowchart of the Major Steps in a Business Planning Process . . .114
Food Service Department SWOT Analysis
Sample Business Plan Outline for the Food Service Department . . . . . . . .117
Steps in the Development of Departmental Objectives . . . . . . . . . . . . . . .119
Functional Organization of a Food Service Department . . . . . . . . . . . . . .133
Making Coleslaw Using a Systems Approach . . . . . . . . . . . . . . . . . . . . . .140
Organization of a Food Service Department with a
Food Service Director in a Large Hospital . . . . . . . . . . . . . . . . . . . . . . . .142
Organization of a Small Institution’s Top-Level Management . . . . . . . . . .143
One Management Level in a Small Food Service Department . . . . . . . . . .143
Two Management Levels in a Large Food Service Department . . . . . . . . .143
Matrix Structure for a Health Care Institution Showing
Project Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .144
Nutrition and Food Services Process Structure . . . . . . . . . . . . . . . . . . . . .144
Organization of a Food Service Department with a Dietary Consultant
in a Small Hospital or Extended-Care Facility . . . . . . . . . . . . . . . . . . . . .145
Example of a Daily Schedule Pattern . . . . . . . . . . . . . . . . . . . . . . . . . . . .165
Example of a Shift Schedule . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .166
Example of a Work Schedule for an Individual Employee . . . . . . . . . . . .167
Example of a Manager’s Daily Planner . . . . . . . . . . . . . . . . . . . . . . . . . .169
Example of a Food Service Director’s Weekly Planner . . . . . . . . . . . . . . .171
Communication Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .176
An Operational Agenda . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .182
A Consent Agenda . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .183
Sample Business Letter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .188
Sample Memorandum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .188
Sample Justification Statement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .190
The Employment Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .206
Example of a Task Analysis for a Food Service Department
Training Session . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .222
. . . . . . . . . . . . . . . . . . . . . . .115
Figures, Tables, and Exhibits
Excerpt from a Performance Evaluation Form for a Food
Service Employee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .227
Progressive Corrective Action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .235
Clinical Nutrition Staff for a Major Medical Center . . . . . . . . . . . . . . . .254
Organizational Chart—for a Medium-Sized Facility . . . . . . . . . . . . . . . . .255
Proportion of Registered Dietitian’s Time Spent on Various Tasks . . . . . .258
Initial Screening and Data Collection for Medical Nutrition Therapy
Consultation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .262
R.D. Consultation for Medical Nutrition Therapy Intervention . . . . . . . .264
Goal of Nutrition Screening: Identify High-Risk Patients Who May Be
Prone to Poor Nutritional Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .265
Four Elements of an MIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .279
Sample Purchase Order . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .289
Inventory Template . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .290
Receipts Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .292
Beef Barley Soup, Scratch
Menu Cost Report
Production Work Sheets Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .295
Financial Management Systems Model for Health Care Food Service
Operations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .307
Development of a Budget for Financial Management . . . . . . . . . . . . . . . .312
Excerpt from Annual Food Service Department Operating Budget . . . . . .322
Food Purchases Register
Labor Cost Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .334
Integrated Solid Waste Management System . . . . . . . . . . . . . . . . . . . . . .347
Economics of Recycling: A Work Sheet
Energy Management Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .359
Food Service Energy Management Survey . . . . . . . . . . . . . . . . . . . . . . . .360
Route of Food Contamination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .374
Effect of Temperature on Bacterial Growth in Food . . . . . . . . . . . . . . . . .376
Water Activity (Aw) or Moisture of Various Foods . . . . . . . . . . . . . . . . .377
Components of Food Hazard Analysis . . . . . . . . . . . . . . . . . . . . . . . . . .403
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .293
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .294
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .331
. . . . . . . . . . . . . . . . . . . . . . . . .351
Figures, Tables, and Exhibits
Decision Tree for Critical Control Points (CCPs) . . . . . . . . . . . . . . . . . . .404
HACCPs for Cook-and-Chill Procedures . . . . . . . . . . . . . . . . . . . . . . . . .406
HACCPs for Cook-and-Serve Procedures . . . . . . . . . . . . . . . . . . . . . . . .407
Flowchart for Critical Control Points . . . . . . . . . . . . . . . . . . . . . . . . . . .408
HACCP Cooling Plan Documentation . . . . . . . . . . . . . . . . . . . . . . . . . .411
HACCP Action Plan for Implementation . . . . . . . . . . . . . . . . . . . . . . . . .412
Schedule for Cleaning of Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . .423
Food Service Safety Checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .434
Basic Safety Tips for the Kitchen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .435
Universal Precautions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .448
Biohazard Symbol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .449
Safe Lifting Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .450
Know Your Fire Extinguishers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .454
Types of Fire Extinguishers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .455
Food Guide Pyramid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .475
Pediatric Menu for Normal Diets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .493
Menu Repeat Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .494
Sample Gourmet Dinner Menu
Restaurant-Style Health Care Menu for Normal Diets
Procurement System Flowchart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .510
Procurement Subsystem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .511
International Irradiation Logo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .512
Standard Label Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .513
Grade Stamps and Inspection Marks Used for
Meat, Poultry, Eggs, and Seafood . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .515
Food Distribution System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .565
Procurement Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .568
Receiving System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .591
Comparison of Par Stock and Mini-Max Inventory Systems . . . . . . . . . . .605
Accounting Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .606
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .495
. . . . . . . . . . . . . .500
Figures, Tables, and Exhibits
Flow of Products in Food Service Production System . . . . . . . . . . . . . . . .610
A Standardized Recipe Format . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .621
Product Evaluation Check Sheet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .624
Production System Based on Ingredient Control . . . . . . . . . . . . . . . . . . . .625
Food Production Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .628
Typical Tray Makeup Lines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .673
Flow of Planning Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .694
Flow of Work and Materials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .697
Cafeteria Service Line Configurations . . . . . . . . . . . . . . . . . . . . . . . . . . .700
Types of Power . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36
Cultural Traits Shared by CQI Organizations . . . . . . . . . . . . . . . . . . . . . .76
Meeting Room Setup . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .184
Nutrition Management Team . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .254
Cost Calculation for the Services of a Registered Dietitian
Physical Signs Indicative of Malnutrition
. . . . . . . . . . .259
. . . . . . . . . . . . . . . . . . . . . . . .267
Sample Monthly Operating Statement
. . . . . . . . . . . . . . . . . . . . . . . . . .323
Sample Monthly Operating Statement and Revised Budget . . . . . . . . . . .326
Method for Calculating Revised Operating Expenses
Percentage Volume of Materials Disposed of by Two
Noncommercial Food Service Operations . . . . . . . . . . . . . . . . . . . . . . . .347
Energy Conservation Practices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .365
Estimates of Leading Causes of Food-Borne Illness . . . . . . . . . . . . . . . . .372
Bacterial Growth Needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .375
Nonbacterial Illnesses of Infrequent or Rare Occurrence . . . . . . . . . . . . .391
Sick Employees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .393
Internal Cooking Temperatures of Food . . . . . . . . . . . . . . . . . . . . . . . . .397
HACCP Recipe Flowchart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .399
Hazardous Practices Observed in Food Service Operations . . . . . . . . . . .401
. . . . . . . . . . . . . . .328
Figures, Tables, and Exhibits
Some Common Kitchen Pests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .428
Serving Sizes for Use with the Food Guide Pyramid
Menu-Planning Suggestions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .484
Common Processed Meats . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .520
Official USDA Size Categories for Shell Eggs
Manufacturing and Inspection Specifications for Selected
Egg Products . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .529
Common Cheeses
Apple Varieties
Recommended Storage Temperatures and Times
Advantages and Disadvantages of Food Production Systems . . . . . . . . . .611
Approximate Yield from Scoops and Ladles . . . . . . . . . . . . . . . . . . . . . .619
Weights and Measurements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .626
Pan Size Yield . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .628
Cooking Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .629
Smoke Points of Various Fats . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .633
Recommended Cooking Methods for Fish
Conversion Factors for Substituting Egg Products . . . . . . . . . . . . . . . . . .643
Alternative Systems for Food Service to Patients . . . . . . . . . . . . . . . . . . .670
Permissible Noise Exposure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .704
Effective Lighting Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .705
. . . . . . . . . . . . . . . .476
. . . . . . . . . . . . . . . . . . . . .527
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .535
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .540
. . . . . . . . . . . . . . . . . .595
. . . . . . . . . . . . . . . . . . . . . . .639
Team Documentation Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .81
Inspection Criteria for Food Production and Service . . . . . . . . . . . . . . . . .85
Policy and Procedure Format for the Food Service Department . . . . . . . .109
Sample Policy and Procedure for the Food Service Department’s
Policies and Procedures Manual . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .110
Sample Gantt Chart for Planning a Catered Dinner . . . . . . . . . . . . . . . . .118
Planning Grid Format for Short-Term or Project Planning . . . . . . . . . . . .118
Job Questionnaire
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154
Figures, Tables, and Exhibits
Sample Job Description and Job Specification . . . . . . . . . . . . . . . . . . . . .156
Sample Productivity Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .163
Sample of an Employee’s In-Service Record . . . . . . . . . . . . . . . . . . . . . . .225
In-Service Record for Human Resource Management . . . . . . . . . . . . . . . .226
Example of a Coaching Action Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . .231
Corrective Action Record . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .236
Record of Employee Counseling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .238
Resignation Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .240
Food and Nutrition Screening Form . . . . . . . . . . . . . . . . . . . . . . . . . . . .266
Counseling, Education, and Discharge Planning . . . . . . . . . . . . . . . . . . .270
Nutrition Care Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .272
Cashier’s Report
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .317
Format for Monthly Profit-and-Loss Statement . . . . . . . . . . . . . . . . . . . .318
Food Transfers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .320
Daily Meal Census
Daily Food Costs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .333
Example of a Monthly Performance Report Form . . . . . . . . . . . . . . . . . .336
Recycling Materials Flow Plan Work Sheet . . . . . . . . . . . . . . . . . . . . . . .350
Selection of Waste Materials Storage Containers: A Work Sheet . . . . . . . .352
Selection of Waste Materials Transportation Options:
A Work Sheet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .353
Selection of Waste Baler or Crusher Options: A Work Sheet . . . . . . . . . . .354
Material Safety Data Sheet (Excerpt) . . . . . . . . . . . . . . . . . . . . . . . . . . . .357
Energy Equipment Survey Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .363
Food-Borne Illness Record of Complainant
HACCP Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .410
Material Safety Data Sheet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .440
Employee Chemical Information Request Form
Change in Product or Material Safety Data Sheet . . . . . . . . . . . . . . . . . .444
Hazard Communication Monitoring Checklist . . . . . . . . . . . . . . . . . . . .445
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .330
. . . . . . . . . . . . . . . . . . . . . .389
. . . . . . . . . . . . . . . . . . .443
Figures, Tables, and Exhibits
New Employee Orientation Checklist for Hazard Communication
(OSHA) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .447
Example of a Safety Checklist
Customer Survey Form for a New Menu Item
Survey of Suggestions and Comments from Customers . . . . . . . . . . . . . .505
A Purchase Requisition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .571
A Purchase Order Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .572
Sample Score Sheet for Can-Cutting . . . . . . . . . . . . . . . . . . . . . . . . . . . .574
A Bid Request . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .580
A Quotation Sheet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .582
Meat or Storage Tags . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .591
Invoice Stamp . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .592
Merchandise Receipt . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .593
Daily Receiving Record . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .594
Stores Requisition Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .599
A Physical Inventory Record . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .602
Leftover Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .618
Daily Production Sheet
Recipe Evaluation Sheet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .624
Patient Satisfaction Questionnaire
Sensory Assessment for Test Tray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .687
Plate-Waste or Food-Return Record . . . . . . . . . . . . . . . . . . . . . . . . . . . .687
Equipment Record Card
Equipment Cleaning Record
Equipment Management Inventory
Preventive Maintenance Schedule . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .732
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .452
. . . . . . . . . . . . . . . . . . . .504
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .619
. . . . . . . . . . . . . . . . . . . . . . . . . . . . .686
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .730
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .730
. . . . . . . . . . . . . . . . . . . . . . . . . . . .731
t is truly an honor for me to write this foreword for Ruby P. Puckett. I have known Ruby for
approximately ten years, and she is a legend in our industry.
As director of Food and Nutrition Services for the University of California, Los Angeles,
Medical Center, I am always looking for good resource materials that will help me and my
staff to be more productive, more efficient, and improve the quality of our service to meet the
demands of our customers, patients, and nonpatients. Ruby was a consultant for UCLA’s Food
and Nutrition Services, and through her professional advice on our performance measures and
our peer comparisons, the department improved from being at the bottom to going to the top.
Her advice contributed to reducing operational costs by $11 million and to increasing revenue
by 48 percent. Along with this wonderful change, she helped us to reorganize and focus our
clinical team to become one of the finest in the nation. Her commitment to continuing education has been helpful in training and developing competent leaders in the field of health care
food service management.
Ruby has tackled some of the most difficult and intractable problems and has written
about them to educate managers. With hundreds of books, pamphlets, CDs, DVDs, and the
like available, I have found the most efficient way to evaluate materials is first to know the
author(s). Ruby is a prolific author, having written many books and developed the two-time
award-winning Correspondence Course for Dietary Manager Training. Since the inception of
this course, Ruby has served as the program director for the more than 31,000 students who
have enrolled.
People in food service management and health care facilities who are looking for management ideas, plans, policies, forms, charts, and the latest information on a wide range of
managerial and operational ideas will find this book helpful in increasing their knowledge.
This book is a practical guide for the total operation of a food service department. It was written to assist students in dietary manager training programs as well as college students and new
and seasoned managers.
This book is well organized, with stand-alone chapters for quick references. Each chapter
includes an introduction, a summary, and a list of references as well as some Web sites. With
all the charts, figures, and tables, this text can be considered a “how-to-do” book that will
allow readers to use the information to improve their operation.
This is one of the most thorough reference books on food service management and
includes references from authors who practice in areas besides food service management. It
presents detailed information 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, presentation
methods for menu service, and an improved chapter on clinical nutrition management. Because
communications and human resource issues involve most of a manager’s time, these two chapters have been updated to present the latest information available. A chapter is 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 food service operation’s library.
At present Ruby is the president and owner of Foodservice Management Consultants and
program director and author of the Dietary Manager Training Programs. She presents workshops on HACCP, food safety, and emergency preparedness and is definitely a standard for our
industry. She received the (IFMA [International Foodservice Manufacturers Association]) Silver
Plate for Health Care Operations and has been honored three times by the American Dietetic
Association (ADA), having received the highest honor given annually to a dietitian—the
Marjorie Hulsizer Copher Award. She is involved in not only ADA but also the American
Society of Food Service Administrators, Food Service Consultants Society International, and
many, many others. She has given presentations in thirty-five states, some states multiple times,
and is active in community affairs. Ruby has been publishing articles in magazines and journals since 1963, far too many to list.
I close by saying that Ruby is an inspiration and role model to many in the industry. I am
pleased to acknowledge that following her example has contributed to my own professional
growth, including being honored in 2001 with the Silver Plate in Health Care. Ruby has contributed more than any other single person that I have ever had the pleasure of meeting or
Los Angeles
Carlton Green, Ph.D.
he health care environment continues to change, offering challenges for leadership and management in all areas of the organization, especially in food service management. Internal and
external environments require continuous learning, planning, and assurance to the public that the
staffs rendering the services are competent to perform their duties. The United States is currently
experiencing economic, political, social, and technological changes that will have long-reaching
effects. Health care organizations are faced with staff shortages and reduced finances at a time
when operating costs, including the cost of care for customers who have little or no health care
insurance, are increasing. Accreditation agencies are placing more focus on quality and customer
satisfaction. Recent federal legislation for health care organizations has resulted in increased regulations that managers and organizations must follow. Health care has shifted from predominantly inpatient to outpatient, which has had an influence not only on care but also on staffing.
All of these events are placing an additional burden on organizations and staff.
Individuals seeking a career in health care food service management today are experiencing increasing challenges and opportunities. Effective management and leadership skills in this
changing environment are paramount. The ever-changing demographics are affecting both the
demands of customers and the needs and abilities of the workforce. Increased emphasis on
health and wellness and the increased role of health care professionals to help curb the trend
toward obesity in the United States are providing additional opportunities for education in
medical nutrition therapy and reimbursement for service. These changes will affect meal planning, production, and service. Advances in technology continue to influence the life
expectancy of the population and the costs and methods of delivering health care and food
service. Managers are being challenged to effectively use technological advances.
As a result of the challenges food service directors will continue to face in the coming
decades, I thought it was important to revise and upgrade the 1994 issue of this text, especially
in the areas of food safety, hazard analysis critical control point (HACCP) regulations, safety
procedures regarding fire safety, emergency and disaster preparedness, marketing, and quality
Gainesville, Florida
September, 2004
Ruby Puckett
This book is dedicated to the most important people in my life: my husband Larry W. Puckett,
daughters Laurel P. Brown and Hollie P. Walker, and my mother Ethel Parker Tuggle, who
passed away December 2, 2003.
he following individuals provided valuable assistance in obtaining resources or provided
technical assistance (or both): Joyce Adams, word processing; Marcia Walker Hurst, Ph.D.,
computer consultation; Keith R. Brown, help with Occupational Safety and Health Administration regulations and safety practices in the workplace; Ellyn Luros Elson, R.D., CEO, and
Ani Baltayan, M.S., R.D., Documentation Manager, Computrion, computer printouts; and
L. Charnette Norton, M.S., R.D., information on hazard analysis critical control points and other
food safety issues.
The definitions of organizational culture in Chapter 6 were reprinted from Robbins and
DeCenzo’s Fundamentals of Management (2001) by permission of Pearson Education, Inc.
Some of the data in Chapter 11 is an update of the 1988 edition of this manual, edited by me
and B. Miller and published by the American Hospital Association, Chicago.
I thank Shands Hospital at the University of Florida, Shands Healthcare System, and the
Division of Continuing Education, University of Florida in Gainesville, for my many experiences as a food service director and educator. Thanks also go to all my former managers,
supervisors, employees, and students who I have had the pleasure to teach, mentor, and work
with for their patience and sense of humor while we tried new methods and proved that there
was a more efficient, effective way to do almost everything.
I also gratefully acknowledge the Jossey-Bass’s Public Health Team staff, particularly
Seth Schwartz, Gigi Mark, Jessica Egbert, Janice Andersen, and Andy Pasternack.
About the Author
uby P. Puckett, M.A., R.D., F.C.S.I., retired from Shands Hospital at the University of Florida
in Gainesville after serving as director of Food and Nutrition Services for twenty-seven years
and started her own food service management consulting company. Since 1972 she has been the
program director for the Dietary Managers Training Program in which more than 32,000 students
have been enrolled. She is a prolific author, having published ten books, four with coauthors, and
contributed five chapters to textbooks. She has published 350 articles, many peer reviewed, and
given more than 400 talks on food and nutrition topics to professional, educational, civic, and religious organizations. She has held offices in local, state, and national food and nutrition organizations and has served on the boards of editorial, charitable, and financial organizations.
In 2003 Puckett was honored with the Marjorie Hulsizer Copher Award, the highest
honor annually bestowed on a dietitian by the American Dietetic Association (ADA). Other
awards she has received are the International Food Manufacturers Association Silver Plate
Award for Health Care; the Ivy Award of Restaurateurs of Distinction; the Distinguished Pace
Setter Award from the Round Table of Women in Food Service; the ADA Award for Excellence
in Management; the ADA Medallion; and Alumni of the Year Award from College of Human
Science, Auburn University, Auburn, Alabama—to name a few. She has traveled worldwide
with three branches of the U.S. military (Marines, Air Force, and Navy) as an evaluator of military food service for the Ney-Hill and Hennessey Award. She is listed in numerous directories
of Who’s Who.
his edition of Food Service Management for Health Care Institutions was written to meet the
needs and demands of today’s health care food service directors by providing the latest information on food service management and operations. Although this edition continues to provide
information for successful management of daily operations, it adds greater emphasis on leadership, quality control, human resource management, communications, and financial or control
management. The section on the practical operation of a food service department has been greatly
revised and enlarged to meet many of the regulatory agencies’ standards and to meet the needs of
My purpose in revising this book is to design a textbook that has practical up-to-date
information to assist students—whether enrolled in college or in a dietary manager training
program—and new or seasoned directors or managers employed in health care food service.
Whether students are preparing for careers in food service management or clinical management, this book will contribute to an understanding of food service operations. Directors or
managers in health care operations will find the information and suggested forms, formulas,
policies, techniques, and references valuable in managing in a difficult environment.
This book is divided into two major categories, the management of a health care food
service and the operation of a health care food service. Each chapter contains its own introduction, summary, list of references, and in some instances, Web site addresses. In addition,
where appropriate, various figures, charts, exhibits, and tables have been provided to assist
users in managing a food service operation. Two appendixes provide glossaries of computer
terms and of culinary terms. There is also an index.
Chapter 1, an introductory chapter, provides an overview of the entire book and identifies issues relevant to health care reform with emphasis on the rapidly changing environment
of health care food service. This edition has also been enlarged to include a brief history of
food service, professional ethics and social responsibilities, professional membership, and the
benefits of professional food service organizations. Because food service departments can be
one of the most stressful environments for workers, suggestions on dealing with stress have
been included. The advantages and disadvantages of contract management companies operating a food service versus self-operation have been identified. Readers can be assured that materials contained in this book can be appropriately applied to all health care food service
Part One (chapters 2 through 11) provides information on “how-to management,” participative leadership, managing change, the responsibilities of a manager, and types of power that
a food service director would use. Material on how the food service image affects the department has been added.
Marketing is examined in Chapter 3, with new material on advertising and promotion and
with examples on how to promote the food service operation. Chapter 4 discusses continuous
quality improvement, quality assurance, and total quality management. Suggestions on how to
use team management to improve quality have been included. Benchmarking as a quality tool is
discussed. Regulatory agencies and their quality standards are described. Not only is detailed
information on quality provided in Chapter 4 but quality is also highlighted throughout the text.
Chapter 5, on planning and decision making, has been expanded to include information
on the mission, values, and strategic planning for a department. Methods to develop policies
and procedures are included. The existing business plan was expanded to include an executive
summary. Methods for decision making and problem solving are detailed.
For food service managers to be more effective, they must know how to communicate and
to use time wisely. The chapter on communications (Chapter 7) was expanded to include a discussion on the “sender and the receiver,” cultural barriers to communication, and examples of
different agendas that can be used for conducting meetings. Additional materials were included
on listening, verbal communications, and etiquette for using e-mail. New updated material was
added on cross-functional training, various types of teams and their roles, and the introduction
of systems management in a food service operation. A discussion of organizational culture and
its characteristics has been added.
Because human resources consume much of food service directors’ time, in Chapter 8 I discuss federal laws and accrediting agencies’ standards that relate to human resources. I also
describe how to hire, orient, train, and evaluate the performance of personnel, the right to
unionize, and disciplinary action. As a result of the public’s demand that food service staff be
competent to perform their task, methods for developing competence-based job descriptions
have been included.
Chapter 9 may be short, but it is one of the most important chapters in this book. It
includes new information on charting, governmental and other regulatory agencies’ standards,
and various new forms that can be used to assess customers and to develop care plans.
In Chapter 10 I explore the use of management information in a food service operation. A
glossary of commonly used words in this technological field has been appended, and various
information forms are included.
Chapter 11 on financial management has been revised to include new information on
controlling a food service department’s finances. Budgets as tools for financial management are
discussed in detail, including steps used in budget preparation. Many words that relate to
financial operations have been defined, and a number of new charts and forms are included.
Part Two of the text includes chapters 12 through 21. These chapters give readers a road
map of how to operate a food service operation using a systems approach. Chapter 12 deals
with environmental issues such as waste control, and suggestions are included for how food
service directors can protect the environment by reducing the amount of refuse that is placed
in landfills. This is important enough that a plan to recycle and reuse should be included in the
organization’s policy and procedures manual. Because of the ongoing conflicts and concerns in
areas of the world where most fossil fuel is produced, I offer in this chapter recommendations
and suggestions on energy conservation.
Chapter 13 is the longest chapter in the book. It has been revised to include more information on microbiological hazards and emerging pathogens, food-borne illnesses and their
causes, and sanitation and cleaning of equipment. Hazard analysis critical control point principles and how to handle a crisis are thoroughly discussed. Information from the Food and
Drug Administration Food Code has been added, as have methods on how to deal with pests.
Chapter 14 explains safety, security, the latest guidelines from the Occupational Safety and
Health Administration, material safety data sheets, and methods to use in providing orientation and training to employees on safety in the workplace. This chapter has additional information on how to maintain a safe and ergonomic work area and the latest information
available on disaster–emergency preparedness, including data on nuclear, biological, and chemical bioterrorism. A suggested plan for disaster–emergency preparedness is included to assist
food service directors in developing an individualized plan for a food service operation. The
different types of fire extinguishers and their use are described and instructions given on what
to do in case of a fire. Other security measures are also included.
Chapters 15 through 20 detail how to operate a food service operation. Chapter 15 discusses the menu as the key to the entire operation. New methods of presenting customer menus
are included, such as the spoken menu and bedside ordering.
In Chapters 16 and 17 on product selection and purchasing, new material has been added
to include specifications on a variety of foods that are now used in a food service operation.
Descriptions of methods of purchasing have been revised. Information on irradiation, genetically modified foods, and organic foods has been added. Discussions on receiving, storage, and
inventory have been revised to include more safety measures in these areas.
Chapters 19 and 20 provide information on how to produce food to meet the nutritional
needs of customers, including the use of an ingredient control room, standardizing recipes,
maintaining proper temperature control, and various cooking methods. The four basic systems
of the distribution of meals are outlined.
Chapter 21, the final chapter, gives readers information on the important factors that
need to be considered in laying out a food service operation for efficiency and avoiding crosscontamination. Equipment selection, both large and small, is discussed.
This book may be read chapter to chapter when used in an academic setting. Because each
chapter introduces a specific topic, the book may also be read in a skip-around fashion.
Chapter 1
Food Service Industry:
An Overview
Health care is being met with increased public awareness associated with the cost of, and equal
access to, high-quality care. 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, 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 cost, these trends will
affect methods of operation, especially as those methods relate to quality, customer satisfaction,
and management style.
Hospitals 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 faces still other concerns. These include the growing number of persons affected with the human immunodeficiency virus (HIV), the increased
number of people with tuberculosis (TB), the increased prevalence of child and spousal and drug
abuse, the aging of the population, 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, 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
Food Service Manual for Health Care Institutions
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 the Joint Commission on the Accreditation of Healthcare Organizations
(JCAHO) is also tied in with cost-effectiveness.
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 and the desire for social equality.
Change is the result of substitutions, disruptions, competition, or new developments; it is a difference in the way that things are done.
One 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 crossfunctional 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 Berlin Wall fell fifteen
years ago. The eastern communist nations are still seeking not only independence but improved
financial and technical assistance from the more prosperous nations. The war in Iraq has cost
many billions of dollars and the deaths of many U.S. soldiers and civilians. Problems still exist
in Bosnia and Afghanistan, and changes are occurring now in the former Eastern Bloc such as
the Russian-Chechnyan war. Wars and rumors of wars that use technological advances in
weaponry are ever present. Daily across the world, thousands of people die of malnutrition,
natural disasters, and emerging pathogens. 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 twin problems: rapidly rising health care costs and a sluggish or failing economy.
Since the twenty-first century began, health care providers have been facing the following
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)
Food Service Industry: An Overview
• Social litigation that includes
Sexual equality
Maternity leave
Length of workweek
Flexible scheduling
Cultural diversity
Increased technology
Public health (domestic violence each year results in about 21,000 hospital admissions,
99,800 inpatient days, 28,700 emergency department visits, 39,000 physician visits, and
about 212,000 new cases of breast cancer)
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-shaped organization
with six or more levels of management to a structure with just three or four levels may
not be necessary
• Redesigning of technological content and services
• Improvement of the admission and discharge procedures
• Training people to do more than one function
• Reducing the lengths of 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
Many of these changes will also dovetail with the implementation of the JCAHO’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 standards, 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
Food Service Manual for Health Care Institutions
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 who have been cross-functionally trained. These
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 cost 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. Health care food service 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 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 food service delivery. Even so, legislative effects and subsequent regulations must be taken into account when food service directors plan the direction of their
departments. This section briefly reviews various governmental and private sector regulations
that affect food service delivery. In addition to those covered, the twelve-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 8).
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
food service managers recognize their responsibility to provide a high-quality and safe food delivery system, Medicare regulations continue to ensure these entitlements for consumers. Medicare
regulations 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. By
2012 Medicare spending will exceed $425 billion, with 69.3 million beneficiaries. Part A spending
Food Service Industry: An Overview
will grow 86 percent, reaching $267 billion, and Medicare spending will grow nearly 110 percent,
reaching $216 billion. Medicare budgets will increase more than 44 percent. Medicaid is the largest
and fastest growing part of the 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.
Omnibus Budget Reconciliation Act of 1987
Food service 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, implement the nursing home reform amendments
enacted by the Omnibus Budget Reconciliation Act (OBRA) of 1987, 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 food service 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. Discussions of how to maintain compliance with these regulations are covered in chapters 9 and 20.
Joint Commission on Accreditation of Healthcare Organizations
Medicare and Medicaid regulations are government imposed, but some facilities choose to further their compliance efforts by following standards set by independent organizations. The
JCAHO ( is one such organization. Standards set by the JCAHO are similar to those set by Medicare; however, JCAHO surveys tend to place more emphasis on the systems, processes, and procedures that influence quality of patient care and outcomes. More
recently, publications by the JCAHO 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; 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 JCAHO 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
mandated 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 chapters 8 and 20.
Health Care Affordability
Given the alarming rate of increase in health care costs and in an aging population, alternative
health care options will be necessary. It is estimated that by 2011 the total national health expenditures will be $2,815,813 and will account for 17 percent of the gross domestic product. By 2009
the percentage of uninsured workers will be between 22 and 30 percent or about 60 million workers by 2011. The American Hospital Association (AHA) has called for hospital leaders to become
Food Service Manual for Health Care Institutions
active in reforming the health care delivery system. Specifically, the AHA has developed a model
that calls for health care organizations to integrate care and collaborate to form networks at the
community level. Community networking would prevent the duplication of services and thereby
lower cost. Through assessment of community needs and consolidation of services, access to care
also can be expanded to the uninsured. More health care institutions will move toward a seamless delivery of service and evolve into acute care facilities, with extended-care, home care, and
ambulatory care facilities becoming majority caregivers.
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” and the computer-ordered menu) 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.
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 days and has continued to 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 food service 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, food service departments will serve
Food Service Industry: An Overview
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 food service department as well as clinical caregivers.
In models across the nation, food service workers are cross-trained to deliver meals and assist
patients with their other needs. Some models assimilate jobs previously done by food service
staff, housekeeping staff, and nurses’ aides into new positions, such as the multiskilled patient
care employee.
Access to Service and Care
In addition to health care affordability, health care access has become a national priority in public calls for health care reform. The number of underinsured or uninsured persons will continue
to rise as unemployment increases. Indigent care will continue to be a major issue as society’s
demographics change and the number of individuals living at or below the poverty level rises.
Access to care will be coupled with equal quality for all, meaning that a uniform standard of
care will continue to be a regulatory focus. The question confronting health care reform advocates is: Will universal access apply to only basic services or to all services? Some health care
institutions have begun to meet the needs of indigent persons through mobile clinics designed to
deliver basic health services. Caring for these individuals will likely require participation from
nutrition and food service personnel through the provision of either meals or clinical services such
as nutritional assessment and counseling.
Access to care is connected to questions on ethical decision making. Because today’s health
care system is ill equipped to provide equal care to the entire population, reforms must address
what services should be universally accessible versus those limited to individuals capable of paying. This question, raised by the state government in Oregon, has been met with mixed reviews.
Whereas the general population may recognize the restrictions of providing complete care for
all, the context changes when the choice must be made for an individual or for loved ones.
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 requirement for additional physicians.
Demand cannot be based on the institution’s need alone but must be supported by hard evidence of community need. In addition to recruitment accountability, hospitals are confronted
with questions related to joint ventures between physicians and hospitals. Usually these joint
ventures have been entered into for freestanding laboratories and diagnostic centers. A federal
Food Service Manual for Health Care Institutions
ban now prohibits physicians from referring patients to joint venture facilities where referral is
a condition of investment.
Ethics play a role for nutrition and food service managers in their decisions regarding meal
delivery and clinical care. For example, purchasers of food and supplies must avoid suppliers
whose offer of favors or gifts would place them in a compromising purchasing position. Further
discussion on ethics related to food procurement is presented in Chapter 17. As part of the health
care team, registered dietitians must give input regarding the delivery of nutrition hydration services to terminally ill patients. Some ethical issues dealing with nutrition management are addressed
by state-specific advance directives signed when patients are admitted to a facility. These advance
directives, which reflect a patient’s wishes, help physicians and other caregivers in their decisions
about the course of treatment.
Environmental Trends
Despite inroads on the amount of waste sent to landfills, more effort is needed. In 1990, the
Environmental Protection Agency reported that the amount of waste being sent to landfills had
decreased to 67 percent, down from 80 percent in 1988. Even so, Americans continue to generate more waste than ever before. Each individual generates about five tons of waste per year.
If this rate of growth continues, many landfills will be closed and there will be a demand for
new ones or for shipping the waste to offshore locations. Health care and food service, both
separately and together, have been targets in the environmental controversy. The waste from
food service operations is composed of 60 percent to 70 percent of solid waste that includes
food, paper, and plastic supplies such as napkins and single-use plastic items. The remaining 30
percent to 40 percent is from food production and preparation. Waste management efforts in
all areas of health care should consider three agendas: reducing the quantity of waste, reusing
as many materials or items as possible, and recycling used materials. The increase in environmental regulation and public concern is forcing health care institutions to take innovative
measures in handling medical waste, which includes many hazardous products as well as infectious waste that usually is incinerated.
Many food service opportunities exist to decrease waste and to implement recycling systems. For example, using individual coffee mugs and soft drink cups and eliminating or limiting disposable tableware can reduce waste. Recycling office paper, glass, steel and aluminum
cans, and corrugated paper is another waste-reduction effort.
Many health care organizations have found a way to simultaneously decrease landfill use and
help those less fortunate. For example, programs designed to feed the hungry are operated in
many metropolitan areas. Food products prepared by health care food service departments are
picked up by volunteers and distributed to organizations that distribute the food to homeless or
low-income individuals. These programs have an added advantage in that the food service manager can measure and monitor food waste so as to improve preparation forecasts. An in-depth
look at the environment and the responsibility of health care food service managers is presented
in Chapter 12.
Food Labeling and Nutrition Claims
In 1992, the Food and Drug Administration (FDA) announced food-labeling regulations in conjunction with the Nutrition Labeling and Education Act of 1990. Both the number of foods covered and the amount of information required on labels have increased. The purpose of this
legislation and ensuing regulation is to provide consumers with more reliable and informative
material. Since May 1994, all processed foods regulated by the FDA must be appropriately
labeled, and labels must include standardized serving sizes, grams of saturated fat, and fiber content. The percentage of daily values provides the percentage of fat, saturated fat, cholesterol,
sodium, carbohydrate, and fiber contributed by a single serving, based on a 2,000-calorie daily
diet. The new guidelines allow seven nutrient or disease-specific relationship claims and provide
Food Service Industry: An Overview
more detailed ingredient listings. Labels that use free, lean, lite, or extra lean must meet the
established standards for these product descriptions.
An exemption to providing nutrition labels has been made for food served for immediate
consumption, unless health claims are made. This exemption applies to restaurants and health
care food service facilities. However, if health claims are made, these facilities have to meet the
specific guidelines for the nutrient, and the claims must be verified by a minimum of three
chemical analyses. For example, a claim that a product is low in cholesterol requires that the
product have three verification analyses that prove it is at least 30 percent lower than the original product.
Foods that are organically grown and irradiated foods must be labeled as such. Companies
that wish to include genetically enhanced ingredients in their food products may label genetically enhanced ingredients and ingredients enhanced using biotechnology.
Workforce Issues
Globalization, deregulation, and technology are changing the nature of jobs and work. Today
over two-thirds of the U.S. workforce is employed in producing services, not products. Of 21
million new jobs added through the 1990s, many will become part-time, and virtually all will
be in service industries such as food service, retailing, consulting, teaching, and legal work.
The civilian workforce is expected to grow by 17 million people by 2010, reaching about
158 million. The demand for institutional food service jobs such as chefs, cooks, and dietitians
is expected to be the highest. Because of the increased number of dual-income families and
women, who make up 48 percent of the workforce, and because of the aging of baby boomers,
the demand for service workers has grown. Food service managers in health care will have to
compete with other service industries for the dwindling labor resources. A reduction in skilled
workers coupled with an increased need for food service workers will require higher pay scales,
which will negatively affect budget and cost-control efforts.
Not only has the labor market diminished, the demographics have changed: The workforce
of the next decade will be older, more culturally diverse, and include more women, people with
disabilities, and those with sexual or affectional orientation. These trends will continue, especially with the increasing diversity of the population. The decrease in the number of teenaged
workers and the increase in the number of workers older than 50 changes the face of the average employee. Baby boomers will still be in the workforce before becoming eligible for
Medicare. As a result, the largest pool of workers will also be the older labor force, with the
number of workers aged 55 to 65 increasing to about 8.5 million. According to the Bureau of
Labor Statistics (BLS;, the median age of the labor force will continue
to rise, even though the rate of growth in the youth labor force (16 to 24 years old) is expected
to be larger than the growth rate for the overall labor force. The growth rate for the female
labor force is expected to slow, but it will grow more rapidly than the male labor force. By
2010, the workforce will comprise 52 percent men and 48 percent women. As mentioned earlier, the full effects of the Americans with Disabilities Act have yet to be felt but are expected
to be tied closely with the aging of the population, escalation of the acquired immunodeficiency
syndrome (AIDS) epidemic, and job shortage. The decreasing literacy rate among the nation’s
workers continues to be an area of focus. A shrinking labor pool necessitates identifying
employees as customers and focusing on their needs. Specifics on managing, recruiting, and
retaining tomorrow’s workforce are outlined in chapters 2 and 8.
Cultural Diversity of the Workforce
Cultural diversity in the nation is reflected by the growing number of minority workers.This
trend will continue because racial and ethnic groups compose about 25 percent of the U.S. population. By 2010 more than half of the population will be of Hispanic origin, and it is expected
that by the end of the decade, Hispanics will represent 11.1 percent of the labor pool.
Food Service Manual for Health Care Institutions
Cultural diversity of the workforce is experienced to some degree by managers nationwide
but varies regionally. For instance, the African American population is centered primarily in the
South and Southeast, whereas Hispanics are located in the Southwest, West, Florida, and the
Chicago metropolitan area. Native Americans are concentrated in Alaska, the Southwest, and
the Plains states, but Asian Americans most likely live in the West, with concentrations in
Hawaii, California, and Washington.
Along with gains in cultural diversity comes the necessity for managers to recognize opportunities to draw on differences that enhance quality and service. In addition, these differences
must be understood to provide compatible leadership that can create career ladders and encourage minorities in entry-level health care positions to access the system for further development.
Health care nutrition and food service departments represent entry points where training becomes
more of a priority. Employee socialization and retention are specific concerns for food service
The number of younger women (ages 25 to 29) entering the workforce continues to increase
but at a substantially lower rate than before 1985. A slower economy and an escalation in the
number of births for this age group are cited by the BLS as a reason for the slowdown.
Incentives—benefits, flexible schedules, job sharing, maternity leave, and child care centers—
will need to be provided for them to return to work.
Age of the Workforce
Working teenagers (16 to 19 years old), a traditional food service complement, have declined
in number due to the low birthrate. Despite the swell in this age group to a projected 8.8 million in 2005, their number in the labor pool will still be 1.2 million below the 1979 level.
The average age of the workforce today is 40 years. Workers aged 50 years and older are
expected to remain the dominant age group during the remainder of the next decade. The aging
of the workforce has been attributed to maturing of the baby boomers, lower birthrates, and
increased life expectancy. The shrinking pool of available workers and the growing number of
older workers has necessitated their selection as alternative labor. Today’s older worker is
healthier and can work longer than the same-age worker of a few decades ago.
Having knowledge of the average worker’s age and the diversity of the labor force helps
food service managers make the changes needed to attract and retain employees. The value system of most of the workforce will be based on worker individuality, maximum amount and
control of free time away from work, and participation in deciding how work is accomplished.
These values will require nutrition and food service managers to be flexible with schedules,
including total hours worked, workdays, and responsibilities.
Infectious Disease in the Workplace
Closely tied to the Americans with Disabilities Act is the treatment of employees with AIDS in
the workplace. In terms of knives and other tools and equipment that could cause cuts, certain
risks are involved with kitchen employees who are HIV positive. Closely tied to AIDS—and
perhaps more important to food service managers—is the near-epidemic number of cases of TB
currently identified. Because TB is an airborne infection that is highly contagious, food service
managers have to diligently ensure annual employee physical examinations.
Literacy and the Workforce
About 2.5 million or more Americans who are illiterate are expected to enter the workforce each
year; many will be attracted to the service industry, specifically food service. Of about 69 percent
of Americans who finish high school, only two-thirds will have adequate skills for employment.
With the predictions of future labor shortages, quality of education and on-the-job training are
Food Service Industry: An Overview
increasingly important employment considerations. On-the-job training, once limited to specific
job skills, has to go a step further to provide basic reading and writing skills. Partnerships between
educational institutions and health care organizations are in demand to improve the knowledge
base of the fewer number of entry-level employees available for food service work. Some organizations now include basic literacy courses as part of the health care employee-training program
intended to provide service areas with needed staff.
Employee as Customer
The leaders of today and tomorrow have to consider employees not only as a resource but also
as a valuable asset to be empowered, trained, and properly motivated. Although expert predictions that the demands of tomorrow’s workforce will be linked to autonomy, more time off, and
their being included in decisions affecting their work may hold some truth, differing employee
value systems must be considered as a factor in this scenario. Value systems vary from one individual to another based on age, culture, and past experiences.
Viewing the employee as a customer can be effectively demonstrated through scheduling.
Flexible scheduling based on the desires and needs of the workforce is not necessarily new.
However, not all food service managers have felt the need to be accommodating. Part-time and
occasional staff can be used to provide adequate coverage while maintaining flexible scheduling for staff. Occasional staff may consist of full-time parents who wish to earn extra income,
older workers who wish to remain active without jeopardizing their retirement income, or disabled workers who may be unable to work full-time hours. Over the past few years, 32-hour
schedules have become commonplace in many health care institutions, allowing full-time benefits with an extra day off for personal activities. Food service managers might learn by observing schedule patterns from other health care departments. Over a number of years, a shortage
of professionals has created the demand for flexible, imaginative scheduling to provide adequate coverage, and no method of coverage should be dismissed without being given adequate
If not settled by government within the next few years, medical coverage in this country
will remain a primary concern not only for low-income workers but for all workers. Benefits
are not limited to health insurance and may even include paid time off, freedom to design work
areas, on-site child care, elder care, maternity leave, and time off to care for an ailing family
member, to name a few.
Compensation continues to be a priority concern for health care food service employees,
traditionally among the lowest-paid positions. Compensation is a focus for employees deciding
which jobs to pursue. Specifically, cooks and chefs can expect income gains due to higher
demand for their technical expertise.
Customer-Oriented Focus
The views and demands of customers affect their choices and have a tremendous influence on
the health care delivery system. To determine customer wants and needs, customers must first
be identified. Seven customer groups can be identified: patients, family and visitors, physicians,
employees, volunteers, vendors, and payers. Of these, in the immediate future seniors, their
children—the baby boomers—and women will influence the purchase of health care services.
The customer concept is relatively new to health care providers and may be somewhat disconcerting because it depicts the delivery of health care as a business, an outlook that many of
today’s health care leaders believe necessary for survival.
The trend of identifying and meeting customer needs will likely intensify. Added services
intended to increase satisfaction eventually become expected, so that further service-expansion
attempts must be made continually to ensure customer satisfaction. This phenomenon encourages
the philosophies of continuous quality improvement and total quality management, discussed in
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Chapter 4. Frontline employees will become more important in providing customer satisfaction
because they are the ones who represent the organization or department. Customers and their
wants will be identified through market research and its application, discussed in Chapter 3.
Value in the Quality-Cost Equation
To provide value, quality must be delivered while keeping cost under control. Customers’ demands
for quality from their perspective have provided the stimulus for customer satisfaction programs
in health care. These programs span the continuum from simple customer service guidelines to
detailed continuous quality improvement programs. All have the essential objective of improving
quality and customer satisfaction in an effort to improve outcomes and increase use. Whereas customer satisfaction programs emphasize service delivery, continuous quality improvement programs
provide a mechanism for in-depth enhancement of systems, processes, and methods of delivery.
Nutrition and food service departments have many opportunities to provide full quality
and satisfaction to customers. Three distinct opportunities related to the food service component are the product, the service or delivery of the product, and the nutritional value of the
product. In addition to these food service opportunities, many more exist in the delivery of clinical nutrition care. Each of these opportunities for quality enhancement must be evaluated in
the customer service or quality improvement process selected.
Programs and services have continued to evolve, with the purpose of generating revenue for
nutrition and food service departments, but they are now developed with a dual focus on customer satisfaction. Approaches to patient meal service include menu enhancement, nontraditional
offerings such as room service, and home meal delivery after discharge. Cafeterias continue to be
the primary type of service in health care facilities, although many have added restaurants, 24hour coffee shops, and cooperative vending. Some hospitals, finding it necessary to reduce costs,
no longer offer 24-hour or weekend services. Many have installed vending operations that may
be managed by hiring an outside contractor, by leasing machines and managing the operations in
house (cooperative vending), or by purchasing machines for independent operation. “Branding”
is another concept adopted by some health care food service departments to improve satisfaction
for a variety of customer groups, either by including products in the existing service areas or with
fast-food franchises opening on site. Branding is defined as the use of a nationally known labeled
product for sale in the current food service area or the inclusion of an entire operation (for example, a McDonald’s in a hospital lobby). More detailed discussion of quality and customer satisfaction is found in Chapter 4, and branding information is presented in Chapter 20.
Nutrition Awareness
Today’s consumers have an increased awareness of nutrition and the effect diet can have on their
health. Nutrition information collected through research efforts is no longer the exclusive domain
of professionals who pass this information on to their patients. Consumers are bombarded at
every turn with reports on the latest nutrition research through television, newspapers, magazines,
and numerous books and pamphlets. Although intended to educate consumers, this information
is often conflicting and not easily interpreted for application to daily dietary intake. Because
informed consumers are not always wiser consumers, attempts must be made to meet their perceived needs if customer satisfaction is the goal.
Heightened nutrition awareness is closely linked with an increased emphasis on fitness.
Yesterday’s fitness fad is today’s lifestyle for many consumers of health care and nutrition and
food service. Even so, people continue to indulge their appetites, especially when dining out.
The number one health problem is now obesity. Portions in fast-food outlets, restaurants, and
other food service operations continue to be “supersize,” adding additional unneeded calories.
Increased nutrition awareness and health education will prove beneficial for patients who
desire to participate actively in their care. This trend may be one answer to lowering the cost
of delivering health care while improving customer satisfaction. In contrast, the large number
Food Service Industry: An Overview
of less knowledgeable persons living at or below the poverty level will be further disadvantaged
by the continued economic dual tiering of society and the growth of a minority immigrant population. The upward trend of poverty will negatively affect the number of individuals at nutritional risk in communities and further validate the role of nutrition awareness.
Demographic Changes
Three primary demographic changes will affect the delivery of nutrition and food services in
health care: an aging population, more women as decision makers, and cultural diversity. By
2010 the median age will be 37.4 years, and by far the largest age group will be younger than
19 years. Their health care needs will continue to center on preventive medicine, fitness, nutrition, and well-child checkups. In addition, this age group will become the primary caregivers
for the majority segment—the elderly. (The elderly are sometimes classified as either “young
elderly,” ages 65 to 74, or “older elderly,” ages 75 and older.) Those from age 60 to 80 and
older will be the largest segment of the population.
An Aging Population
The aging of the population, or the graying of America, is reflected in an increased acuity level of
patients, an increased number of patients at nutritional risk, and more older patients requiring
health care than at any other time in history. The fastest-growing population segment includes
those older than 50, who represent 30 percent of the population. By 2010, the U.S. Census Bureau
projects that 21 million Americans will be between the ages of 65 and 74, a 15 percent increase
over 1989 ( This shift is fostering extensive growth in extended-care facilities, including nursing homes, adult day care centers, and retirement centers. In addition to the
increased growth in these freestanding facilities, a larger number of hospitals include skilled-nursing units and rehabilitation units. In addition to caring for the elderly once they become ill, health
care organizations are proactively designing preventive care programs to evaluate the health needs
of older persons and provide appropriate education. Evaluation includes individualized screens
for nutritional risk and guidelines for improving nutrition status related to illness prevention and
Women as Primary Decision Makers
Women are the primary decision makers in health care delivery choices and want more involvement in matters dealing with their health and that of their families. Centers and specific departments that consider their unique needs continue to influence the delivery of care. Interest in
women’s health concerns also is evidenced by increased research in this area. As the average life
expectancy continues to increase, women are facing more responsibility in caring for parents
and other extended family members as well as their immediate families. This fact, together with
the expanding number of women entering the workforce, will further emphasize customer satisfaction from the perspective of women. As health care decision makers, women influence the
balance between high-touch and high-tech aspects of care.
In addition to those nutrition and food service demands already mentioned—affordability,
continuity of care, equal access, and so forth—the growing number of working women expect
convenience. Food choices for this group are influenced by the makeup of the family unit, and
many experts in nutrition and food service predict that children will become the new “gatekeepers” of the food supply. Convenient, well–prepared, nutritious food becomes a key element
in this scenario as the demands of female consumers provide opportunities for health care food
service managers. For example, the cafeteria can be extended to offer take-out services, bakery
products, and prepackaged kids’ meals.
Cultural Diversity in Menus
The effects of cultural diversity on food service are prominently reflected in menus enhanced
with ethnic dishes. Some operators call for a return to more basic, home-style “American” food
Food Service Manual for Health Care Institutions
choices, but the question arises as to what that means. For example, one of the most popular
foods in America is pizza, followed closely by Mexican and Asian food selections. These
cuisines have become American menu staples. In planning menus, food service managers
should consider the population to be served. Demographics vary by region in age and cultural
diversity and should be evaluated before making menu selections. Although menus may return
to basics in the coming decade and reflect lighter fare, the signature items of various cultures
will find a place. Application of this and other information pertinent to menu planning is found
in Chapter 15.
Technology Trends
The past several decades have been marked by a pronounced growth in technology. The area
that underwent the most rapid growth was information services. In general, health care has been
slow to implement computerization, especially in food service. Many hospitals today, however,
have chief information officers who coordinate computer systems planning and implementation.
In addition to information technology, medical technology has significantly changed the delivery of health care. Both diagnostic advances and treatment technology have improved patient
outcomes while placing extreme financial burdens on health care organizations. Because of
heavy diagnostic and clinical advances, many nutrition and food service departments have been
left out of the capital expenditure cycle or have spent more time justifying equipment needs.
However, this does not mean that significant advances have not been made in food service technology that are important to the delivery of cost-effective, high-quality food service.
Information Systems
Information systems will continue to dominate the technological front in the coming decades.
Information systems in health care organizations over the past decade have been primarily in
the areas of financial, accounting, and human resource management. This emphasis will continue and become more refined in assisting management with making budget-related decisions
and with reporting specific information for the new requirements established by Medicare and
Current emphasis is on the design and implementation of a universal electronic data interchange system for processing health care claims. This system necessitates the development of a
common language for hospitals, the federal government, and insurers, along with standardization of core financial information. Most hospital billing departments do not find it easy to
accommodate a common language or method because of the lack of integration of computer
systems and the large volume of services billed. This type of common claims processing will
make it increasingly necessary for hospitals to improve their current computer systems.
Medical professionals are including clinical information systems in their office practices.
Much of this technology provides for more accurate diagnosis, improved customer care, and
improved patient medical records. As the technology becomes more commonplace, future professionals will have greater access and comfort levels. Clinical information systems tie diagnostic testing results directly to nurses’ station or physicians’ offices, a linkage that allows
quick review and action on test results and facilitates improved patient care. Bedside charting,
a term used more and more frequently in discussions of patient care, and the computerized
medical record improve information flow, thereby assisting with reimbursement.
Information systems also are important in the food service department, where management control systems are numerous and their applications vary considerably. Systems may
include software packages designed to manage information for clinical management and meal
service; menu planning; forecasting and purchasing; inventory management; food safety; payroll; financial management; and in skilled-nursing facilities, material data sheets. Many vendors
or distributors offer food service operators a direct computer link to warehouses for the purpose of placing orders and accessing information regarding purchase history. Food service
Food Service Industry: An Overview
inventory systems range from department-specific personal computers and software to mainframe systems designed for the organization. Information is entered into inventory either manually or through the use of a scanner.
Still other software programs include nutrition analysis and additional clinical applications. As it becomes increasingly important to evaluate past and current information to make
the best decisions for tomorrow, advanced information systems will become more significant.
The use of computer systems may not decrease staff needs, but in today’s environment they are
necessary to manage the increasing amount of information needed by managers to run their
departments effectively. Computer software should be purchased based on individual needs.
What works for a hospital department may not work for a nursing home. Detailed discussion
on management information systems is covered in Chapter 10.
Medical Technology
The delivery of high-quality health care continues to rely on technology, the increased cost of
which tends to affect health care faster than other businesses. This cost dynamic is due to rapid
changes in technology that can be linked to equipment obsolescence over a short time period,
acquisition or replacement costs, and the effects of competition among facilities. Some technological advances have been able to reduce labor needs, but more have required new or higher
skill levels. A more demanding skill requirement has led to specialization within departments
or fields, making it difficult to use staff for a variety of tasks. Technology also can be effective
not only in diagnostics but also in treatment to lower costs and decrease the length of stay.
Technology has been responsible for decreasing patient admissions and for increasing the use
of outpatient services. More general surgery is being performed as laparoscopic surgery, which
can be done in the outpatient setting.
Another type of medical technology with widespread effects on health care involves pharmaceuticals. The number of new medications entering the marketplace yearly is staggering. The
rapid pace of development creates new problems for the FDA and for the public in that a number of medications have been recalled after their extended use was found to cause side effects
not predicted in trials before FDA approval. In view of the AIDS crisis, for instance, demands
for rapid approval and release of pharmaceuticals are not likely to decrease.
Food Technology
This section briefly describes four developments in food technology that food service operators
should become familiar with. These are sous vide, biotechnology, irradiation, and fat replacement.
The sous vide (“under vacuum”) process, developed and perfected in Europe, uses freshly
prepared foods that are processed with low-temperature cooking and vacuum sealed in individual pouches. That process presented some problems with bacterial growth during the 1980s,
but perfection of the slow-cooking methods to achieve pasteurization and improved packaging
has made it a safe, viable option for food service operators. This technology is proving to be
the least controversial and most widely accepted by both food service professionals and customers. Because many of the products prepared and preserved with low-temperature cooking
and vacuum sealing are considered gourmet in nature, food service managers can expand and
improve menu options for patients and other customer groups.
Biotechnology is creating the taste of the future. In this form of genetic engineering, a gene
foreign to a product is spliced or added to its DNA to enhance or inhibit qualities of the original product. This bioengineering technology is being used to improve the current food supply;
for example, vegetables and fruits are engineered to resist spoilage, increase variety, improve
nutritional content, enhance resistance to disease and freezing, and provide a longer shelf life.
The major reason for pursuing these genetically altered products is to decrease the amount of
chemicals used during growing; by altering certain genes, the plants can be made resistant to
Food Service Manual for Health Care Institutions
The FDA has developed a guidance document for companies that wish to declare genetically enhanced ingredients in their food products. The National Food Processors Association
announced before the FDA ruling that, in its view, no new regulation was necessary for food
produced through biotechnology. Groups opposing the FDA guidelines include the Center for
Science in the Public Interest, the Environmental Defense Fund, and the National Wildlife
Federation. Since the FDA decision, many—including a number of chefs—have publicly
renounced bioengineered foods. It is not clear whether this disapproval mirrors sentiments of
the general public or is limited to this group. Nutrition and food service managers should follow development on this topic so as to make informed buying decisions.
Although it has been approved for food since the 1960s, irradiation is a technological
breakthrough affecting current food supplies. Irradiation refers to exposure of substances to
gamma rays or radiant energy. Irradiation has been used since 1985 to control trichinella in
pork and since 1992 to control pathogens and other bacteria in frozen chicken and in some
vegetables and fruits, especially strawberries.
In the late 1990s, after extensive and thorough scientific reviews of studies conducted
worldwide on the effects of irradiation on meat, the FDA approved irradiation of fresh and
frozen red meats, including beef, lamb, and pork, to control disease-causing microorganisms.
Federal law requires that all irradiated foods be labeled with the international symbol identified as the “radura”—simple green petals (representing food) in a broken circle (representing
the rays of the energy source)—and accompanied by the words “Treated by Irradiation” or
“Treated with Radiation.”
After years of research and development, fat replacers or substitutes are beginning to
obtain FDA approval. Fat substitutes are classified by the core ingredient used in their production and are carbohydrate, protein, or fat based. Carbohydrate-based fat substitutes are
made from dextrins, modified food starches, polydextrose, and gums. Many generic forms of
these fats have been approved for use in baking but are not heat stable enough for use in frying. The most common protein-based fat substitute is Simplesse®, produced by the NutraSweet
Company and approved by the FDA in February 1990 for use in frozen desserts. Because protein is not an effective heat conductor, Simplesse cannot be used in frying but can be used at
high temperatures, for example, in cheese melted on pizza. The most widely known fat-based
replacement is Olestra®, produced by Procter and Gamble. The FDA has spent twenty-five
years studying Olestra. As of 2002, the product is moribund, if not totally dead. More than
18,000 people have submitted reports to the FDA of adverse reactions they attributed to the
ingestion of Olestra. That is more reports than for all other food additives in history combined.
Procter and Gamble has not sought FDA approval for the use of Olestra in products other than
snack foods and has sold its factory. Sales of chips prepared with Olestra have steadily declined.
A new no-calorie fat substitute is being tested in the hope that it can eventually be used to
slash calories in everything from cookies to burgers. Z-Trim, the name of the new substitute,
was invented by a government scientist and is an insoluble fiber that goes through the body
without being digested. Z-Trim cannot be used for frying, but it can replace up to half the fat
in many prepared foods. There is some concern that fat substitutes will not decrease the desire
for fatty foods and may in fact increase overall fat consumption, similar to the effect sugar substitutes have had on sugar consumption.
Obesity is a growing national problem. Many calories could be eliminated by the use of
nonsugar sweeteners. Many consumers are hesitant to reduce their sugar intake because of the
many misconceptions about the products. Even with the hesitation and concern about the safety
of nonsugar sweeteners, in April 2003 the World Health Organization stated that Americans’
need for sugar substitutes is on the rise. The FDA has approved the use of saccharin (Sweet ‘N
Low, Sweet Twin, Sweet ‘N Low Brown, Necta Sweet), aspartame (NutraSweet, Equal, Sugar
Twin [blue box]), acesulfame-K (Sunett, Sweet&Safe, Sweet One), and sucralose (Splenda).
Aspartame is found in more than 5,000 products, including Diet Coke. Sucralose is found in many
products, including Diet Rite Cola. Saccharin is found in many products, including Sweet ‘N Low
Food Service Industry: An Overview
brand of cookies and candy. Food service personnel have a responsibility to continue to educate
the public concerning the safety of the products.
Food Service Equipment
Advantages in equipment should be considered annually when making capital equipment plans.
Equipment needs vary from one institution to another and depend on the types of food purchased,
the production methods used, staffing, and the menu. Recent advances in food service equipment
include cook-and-chill units, microwaves, blast chillers, and smaller versions of existing equipment.
Cook-and-chill units have been used in Europe since the 1960s but were not in widespread use in
the United States until the 1980s. Their use is important in institutional food service, as operators
strive to serve high-quality products assisted by a dwindling skilled labor force. Food is prepared
using standard cooking methods with some modification of starch for some items and then chilled
rapidly in a blast chiller for later use. Some managers have also advocated the use of blast chillers
to ensure safe cooling of bulk products before storage so as to prevent spoilage. The cook-and-chill
method can be used with standard production techniques, when food is prepared for one day’s
service, placed in serving pans and chilled, and then used to plate meals cold for rethermalization.
Cook-and-chill systems also can be complex, requiring the purchase of other equipment such as
cook tanks, specially designed pumps, and rethermalization units.
Many smaller versions of ovens and other equipment on the market were developed in
response to limitations on space and the desire of some operators to use equipment in the view
of customers. Other operators have installed preparation equipment—for example, a pizza
oven—in full view of their customers. Microwaves, once used for boiling water or reheating
foods, are finding their way into preparation areas of many food service departments.
Microwaves can be used to reheat the many frozen products on the market and are excellent
for preparing vegetables.
Another equipment advancement is robotics, computerized units that assist with repetitive
motion, such as placing items on patients’ trays and cooking hamburgers. Technology is available to fully automate many kitchen and service activities. Equipment designs no doubt will
consider changes in tomorrow’s labor force. Instructions must be clear and understandable to
workers whose abilities to read English may be limited, and knobs or switches must be
designed for physically challenged individuals.
Background of Food Service Industry
Providing food in an institutional setting has evolved from the Middle Ages when large feudal
groups were fed. Many large royal households fed as many as 250 people at each meal.
Religious orders served quality food in abbeys to thousands of pilgrims on retreats. Florence
Nightingale was the first “dietitian” when she insisted that the troops in field hospitals be provided nourishing food.
Today food is served in homes; restaurants; schools; colleges; universities; health care
organizations; the military; corrections facilities; clubs and other social organizations; day care
centers; and industrial, business, and transportation enterprises. Each of the facilities plan,
price their menus, and provide a variety of eating rooms, from elegant dining to tray service in
health care to fast food that may be eaten in an automobile.
The food service industry is one of the world’s largest businesses, with a sales volume of
about $400 billion. Food service is also the number one employer among all retail businesses,
with more than 11 million persons employed, most being women and about 25 percent being
teenagers. According to the BLS, food service and preparation jobs are the fastest-growing
national occupation. It is predicted that it will continue to increase. The BLS also predicts a
shortage of registered dietitians in the next decade.
Food Service Manual for Health Care Institutions
There are 844,000 food service operations in the United States. Many U.S. households
continuously rely on others for their food preparation. By the year 2010, more than half of
every consumer food dollar will be spent on food service rather than groceries. Restaurants
account for 62 percent of food service sales. Elder care is the fastest-growing market; correctional food service continues to grow and is expected to have a rapid growth in the next few
years, with the greatest increase in federal prisons. More than 10 million meals per year come
from correctional facilities.
Health care institutions, like many of the noncommercial food service operations, serve a
captive audience. Their budgets for expense are included in the hospital room rate, and many
health care food services are subsidized, which means they receive some funds from external
Classifications of Food Service
The food service industry is made up of a broad scope of establishments. These establishments
are classified as commercial, noncommercial, and institutional. Commercial food service has as
its primary activity the preparation and service of food. In noncommercial and institutional
food service, the preparation and service of food is a secondary activity. The commercial segment includes fast-food, quick-service, or limited-menu restaurants; fine-dining restaurants;
airport restaurants; convenience stores; buffet and self-serve restaurants; catering; supermarkets; food courts; and retail outlets such as department stores. These establishments set
their own menu, price structure, and hours of service. Some, like airport restaurants, may serve
the same customer only once or twice a year.
The noncommercial segment, where entities operate their own food service, includes hotel
and motel restaurants, country club restaurants, cruise ships, trains, airlines, zoos, sporting
events, and theme parks. Each of these establishments may depend on the economy. When the
economy is good, customers tend to spend more money to indulge in eating in these restaurants.
The institutional segment includes the military; correctional facilities; hospitals; child care centers; senior care facilities; extended-care facilities such as nursing homes and other health care
centers; employee food service for offices, industrial complexes, and health care facilities;
schools, colleges, and universities; and not-for-profit establishments. All of the institutional segments have several things in common: a captive audience; low cost per meal; many regulatory
agencies’ standards; and local, state, and federal government regulations that must be met.
In-house management of noncommercial institutional food service has remained steady
over the past decade. Many noncommercial operations hire contract food service organizations
that manage the food service department as well as other departments. Contract food service
management is the provision of food service by a third-party company through a contract. The
company meets the objectives of the department but is profit oriented. The contract company
provides management of the food service operation for the organization and in some instances
may also provide clinical services. Some organizations may outsource some of their services,
such as information services or purchasing. Outsourcing means that an outside company will
provide a service that the organization may not have the staff or equipment to do on-site.
Self-operation is the opposite of contract management. Self-operating food service is defined
as the organization or institution being responsible for the management and clinical components
of food service. There is an ongoing discussion of the advantages and disadvantages of contract
management versus self-operation. The advantages of using the contract companies include but
are not limited to expertise, economy of scale, and service:
• Expertise. Provides the knowledge, skills, education, and resources that a company will
use to operate the food service operation.
• Economy of scale. The work involved in developing resources for a food service operation is done economically, at a reduced cost per unit. The company offers buying power for
Food Service Industry: An Overview
food and equipment, expertise and in some instances money for renovation projects, computer
technology, standardized recipes, and menus for a variety of diets.
• Service. Relieves the administration of worry about a department because the company
will handle operational issues, quality control, customer satisfaction, and some staffing responsibilities, and the annual employee count is reduced because the employees are considered
“management company” employees.
Disadvantages of the contract company versus self-operation include loss of control, expense,
and divided loyalty:
• Loss of control. Hiring a contract company means relinquishing some control of the food
service operation. Employees report to the manager of the contract company and are not part
of the organization. Leadership roles are not clear unless they are clearly defined in the contract.
• Expense. The organization pays a management fee and also may pay the salaries and
benefits of employees. The fees may be determined on a cost-per-day basis, plus a percentage
of saving, or the revenue against expenses. Each contract may be different and must be carefully evaluated.
• Divided loyalty. Employees working for a contract company may have divided loyalties—
the company or the organization. The contract should include a meeting between the organization’s representative and the contract company’s representative to plan and promote integrating
loyalty. It is wise to be concerned over a power struggle.
Regardless of who operates the food service, it is vital that the needs of customers be the
primary concern.
Role of Food Service
The role of food service in a health care organization is to provide a variety of food that is
nutritious and well-prepared in a safe and sanitary environment that meets the financial obligation of the department while meeting the needs of customers and is served in a pleasing and
attractive manner. The department will strive to meet the social, cultural, religious, and psychological needs of customers in meal planning and service. The staff provides education to its
customers while they are patients in the health care facility, in outpatient consultations, in the
community, and to the general public, as requested.
Workers in the food service department are leaders within the organization who adhere to
the overall mission, vision, and values of the organization while dovetailing the department’s mission, vision, and values to those of the organization. The role of the food service is to develop
goals and outcome objectives and to seek commitment to achieving the outcomes. The department works with other departments within the organization in a team effort to provide for customers. The largest challenge to face a food service department is to provide food to its customers
while integrating the department’s activities into the overall operation of the organization.
Managerial Ethics and Social Responsibility
Food service directors face ethical challenges and social responsibility as they balance the organization’s need to know and the privacy requests of employees and cultural and ethical behaviors of a diverse workforce and customer base to ensure that the organization is working in a
socially responsible manner. Ethics is defined as the principles of conduct governing an individual or business or the views, attitudes, and practices about what is right or wrong; it concerns
moral standards and basic values. There are professional or business and personal ethics.
Organizations such as the American Dietetic Association and the Dietary Managers Association
have written codes of ethics that are guidelines for members of the organization. These codes are
Food Service Manual for Health Care Institutions
to promote and maintain the highest standards of food and nutrition services and personal
contact among its members. Some organizations have a bill of rights for employees that assists
managers in dealing with employees while ensuring the rights of employees.
All food service directors need to develop a personal code of ethics. The following should
be included:
• Avoidance of conflict of interest
• Honesty and trustworthiness in all activities
• Respect for the rights of others, including cultural, ethnic, religious beliefs, and the right
to privacy
• Loyalty to the employer
• Compliance with all applicable laws, regulations, rules, and policies
• Responsibility for one’s own actions
• Honesty in credentials
• Adherence to a professional code of ethics
• Keeping confidential information confidential
Social responsibility in organizations is changing. Organizations must operate to provide
services to achieve the greatest good for the greatest number of people. This can be accomplished by an organization’s support of charities or events of public interest or issues and time
off for employees to participate in events such as health care fairs, wellness events, and environmental activities.
Social responsibility also includes the promotion of equal rights of all groups, a fair wage
for work performed, and the avoidance of favoritism. Employees should be protected in freedom of speech and assembly. Employees should have the right to unionize. Employers should
provide a safe and drug- and smoke-free work environment.
Job stress can affect all the systems of the body. Stress is a condition that can be physical or
mental strain from situation(s) in the workplace. Food service is considered a high-stress occupation because of constant deadlines and demands, the objective of meeting the needs of customers, and in some instances the uneven distribution of the workload.
A food service director will need to be a buffer between staff and external stress. As an
example, a customer in the cafeteria becomes angry over a perceived error in the amount of
change received from a transaction. The food service director or cafeteria manager should intervene to deal with the problem, rather than leaving the cashier to fend for herself or himself
because the relationship between the cashier and customer in the future could lead to additional
To minimize the stress level in the workplace, food service directors should know
their stress level and develop ways to cope. Many books have been written on how to deal with
stress. The following ideas may be helpful.
• Know what causes you the greatest stress. Accept your own mistakes as positive learning experiences. Do not constantly relive the experience and fret that it will happen again.
• Keep a positive outlook. See the big picture, focus on what you value, and do not let the
little things destroy your attitude. Believe in yourself and your knowledge, skills, and abilities.
• Accept what you cannot change or control. If the administration tells you that you cannot change prices in the cafeteria, let it go. Do not worry about things that are beyond your
scope of responsibility or control.
• Focus on one task at a time. Thinking about all the tasks you need to complete is a waste
of energy and will not allow you to do your best with the task at hand.
Food Service Industry: An Overview
• Use positive results from your work. While working hard and with lots of pressure, bask
in the outcomes of your effort. For example, pleasing a customer, teaching a new employee a
job task, or writing a well-received report to administration is a positive result.
Eliminate as many stresses as possible.
• Clear your desk. Throw out clutter such as papers or materials that are no longer needed
or used.
• Shut your door. Get rid of annoying or distracting background noises.
• Unclutter your life. Give up activities that cause stress and spend more time with yourself, nonstressful friends, or family members.
• When the stress seems overwhelming, take a break. Get away from the situation. Take
a walk, chat with a colleague, listen to music, do relaxation exercises that will help to loosen
muscles, and release negative thoughts about the offending situation.
• Get a massage for overtired, overused muscles because this can relieve stress.
• Let others know you are stressed. Express your feelings without becoming overly angry.
• Be honest, be direct, and be definite. Learn to say “no” to something you do not want
or need to do. Be straightforward without being rude. Do not overreact. Take time out, view
the situation, and try to discuss your feelings quietly.
Food service directors are better leaders and managers when they learn how to cope with
stress and how to provide freedom from undue stress at work. When a work situation becomes
overstressful for the director, it usually affects the staff as well.
Personal and Professional Development
Personal and professional involvement is an individual choice. Effective food service directors
are responsible for maintaining and improving their knowledge and skills to be competent to
carry out their duties. This can be accomplished in a number of ways. The following is a list of
suggestions that other food services directors have found to be beneficial.
• The food service industry offers professional development and ongoing education and
• The American Dietetic Association, the Dietary Managers Association, and many other
professional organizations conduct annual education conventions where speakers provide
information on the latest research on food and nutrition services that can be used to improve
skills and continue professional growth.
• Most professional organizations on both the state and national level lobby for its members on issues of interest to the organization. A good example is reimbursement for medical
nutrition therapy.
• Professional and trade organizations also publish magazines and journals that address
the needs and interests of its members.
• Involvement in professional organizations at local, state, and national levels help improve
the profession and assist younger persons entering the profession.
• Serving as a role model or mentor and sharing ideas with students and staff will help
new members and will give a food service director a sense of “giving back” to the profession.
• Food service directors should use information gained in participating in professional
activities to train staff and in providing written reports to administration of the facility to let
them know how the involvement not only helps food service directors personally but is beneficial to the organization.
• Education is lifelong. To continue the education process, food service directors should
enroll in courses at community colleges, universities, or off-site continuing education programs
or attend seminars or workshops that will benefit them and their organization.
Food Service Manual for Health Care Institutions
• Networking with other professionals is an excellent source of support, ideas, and methods improvement.
• Networking allows food service directors to know that their problems are not unique
and that by sharing, problems may be solved. Networking can be accomplished by attending
local, state, and national professional organization meetings and through Web sites, Internet
chat rooms, telephone calls, and e-mails.
• If possible, participate in research within the organization or as a member of a focus
group or a test site for evaluating a new piece of equipment or a new food product.
• Learn from suppliers. Suppliers have a wealth of information concerning new products
or equipment. They are also available for hands-on demonstrations for incorporating new food
items on menus, latest research reports, and in-service training on sanitation and proper equipment use. Many suppliers also sponsor trade shows where the newest equipment and food
items are available, plus noted speakers in the field.
This chapter analyzed the current and projected external environment for health care food services. The external environment includes trends and issues arising from the government, businesses and industries, health care institutions, workforce demographics, customer needs and
demographics, and technology affecting the delivery of service. Many of these elements are
evolving constantly and will continue to direct the operation of health care nutrition and food
service departments.
As the environment changes, food service managers should modify the goals, objectives,
and operation of their departments. Many trends discussed in this chapter will have a direct
effect on how other information in the text should be applied to individual departments, and
these will be noted in the relevant chapters.
By anticipating trends, successful managers will plan their departmental operations with a
vision—both the department’s and the facility’s—of tomorrow. This is accomplished through
conducting an internal and external environmental analysis and applying the information to
organizing and planning functions, topics that are discussed fully in Chapter 5.
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Food Service Industry: An Overview
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Jones, J. M., and Elam, K. Sugar and health: Is there an issue? Journal of the American Dietetic
Association 103(8):1058–1060, 2003.
Merritt, R. J. Dietary compensation for fat reduction and fat substitutes. Nutrition and the MD
19(3):1–3, 1993.
National organic standards. Dietetics in Practice 2(3):2, 2002.
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Saddle River, N.J.: Prentice Hall, 2000.
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Saddle River, N.J.: Prentice Hall, 2001.
Puckett, R. P. A glimpse into the future. Healthcare Food and Nutrition Focus 20(2):1, 3–8. 2003.
Santerre, C. Food Biotechnology: Dreams from the Fields. Presented at the 41st annual meeting of
Dietary Managers Association, New Orleans, June 7, 2001.
Solovy, A. (J. Towne, researcher). 2003 digest of health care’s future. H&HN/IDX, a supplement to
Hospitals Health Network, 2002, pp. 1–38.
Spears, M. C. Foodservice Procurement: Purchasing for Profit. Upper Saddle River, N.J.: Prentice
Hall, 1999.
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Saddle River, N.J.: Prentice Hall, 2000.
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Part One
Management of
the Food
he management responsibilities of food service managers or directors are the same as
those of other professional managers. All managers and directors plan, direct, control, and organize the tasks or activities of subordinates within their respective department or organization. These managers or directors may be classified as first-line or
middle managers. Some managers or directors may have responsibilities for other departments besides food service. All managers or directors have the responsibility for planning,
organizing, leading, controlling, communicating, making decisions, motivating subordinates, handling complaints, setting performance standards or outcomes, improving quality, satisfying customers, controlling the environment and its resources, marketing, and
managing fiscally. All managers must possess many skills in varying degrees, in particular conceptual, interpersonal, technical, and political skills.
Part One of this book provides information on the role of the manager or director
as well as how to manage the food service operation. Following an introductory chapter,
chapters 2 through 11 cover topics that managers can use to be more efficient and effective in an ever-changing climate and profession in which “doing more with less” has
become the norm.
Chapter 3 outlines methods to market and promote the food service operation while
increasing revenues. These functions continue to gain importance because of greater
demands by surveying agencies and customers for quality food and service. This chapter
also promotes “tooting the department’s horn.”
Chapter 4 gives information on how to develop a continuous quality improvement
program and many of the tools that are used to set up and monitor the program. Many
surveying and accreditation standards are based on continuous quality improvement.
Tools and data are provided to assist in meeting these standards.
Chapter 5 is an important chapter because it discusses planning. Planning is the first
step in managing. Planning may include short- and long-term plans with the possible addition of strategic plans with measurable outcomes. Without planning, the efforts of the
manager or director and the subordinates will fail. Using problem-solving and decision-making
techniques, the manager or director is able to gather data, determine alternatives, and base decisions on facts and objectivity.
Chapter 6 discusses a variety of methods that can be used to organize a food service
department and to use time wisely. Because of the ongoing reduction of staff and the introduction of new and sophisticated equipment and procedures, it becomes vital that the department(s) be organized in the most efficient manner to maintain a high level of productivity. Poor
planning or organizing and time management—falling victim to overbooking, interruptions,
missed deadlines, and a myriad other problems—can cripple a food service department.
Chapter 6 covers all these task.
The managers or directors must develop good communication skills to deal with individuals of diverse cultural and educational backgrounds. They will also need to communicate with
personnel within the facility as well as persons from outside the facility who offer services to
the organization. The ability to communicate in an understandable manner using written, verbal, and nonverbal skills is an essential skill that all managers or directors need to develop.
Listening, sometimes a forgotten skill, is the most important communication skill of all. The
art of communications is discussed in Chapter 7.
Managers or directors, to be successful, need to surround themselves with motivated subordinates. Human resource management is discussed in Chapter 8. The many rules, regulations, and laws that pertain to human resource management are provided. Hiring, orienting,
training, job descriptions, and other personnel processes are also discussed.
Chapter 9 is included because clinical nutrition management is a major component of food
service management, quality improvement, and customer satisfaction. Many forms are
included that can assist clinical managers in screening, assessment, and care planning.
Technology can be used to interface with other departments, vendors, and peers, to reduce
paper, and to provide quick updates on materials and information. Chapter 10 shows how to
manage information systems to enhance the food service operation by providing up-to-date
information on the various systems and subsystems within the operation. A glossary of computer words is provided in the appendix.
Maintaining fiscal responsibility of the food service is important. Chapter 11 provides data
on controls, budgets, and other financial information that can be used by managers or directors to follow and maintain a budget. They need to learn how to control the financial operation, labor hours, materials, personnel, and equipment as a business entity. Strict accounting
and auditing procedures are necessary to ensure that controls are properly in place.
Throughout the chapters, words in italics are defined.
Chapter 2
Leadership: Managing
for Change
The traditional role of nutrition and food service directors or managers has expanded into a
more complex one, due in part to the trends described in Chapter 1. The political environment
calls for a manager who is fiscally responsible, knows regulatory requirements, and understands
how food service department functions affect the facility. Managers also must have a heightened
awareness of workforce issues, customer needs, technological implications, and continuous
quality improvement systems.
Management can be defined in a variety of ways. It is the process of reaching organizational goals by working with and through people and other organizational resources. The management process includes planning, organizing, leading, and controlling an organization’s
human, physical, and financial resources by influencing other people to get the job done, maintaining morale, and guiding the attitudes of an organization’s members in an appropriate direction. The ultimate purpose of influencing is to increase productivity. Employee involvement is
essential for improving service, whether employees participate as department team members or
on cross-functional teams within the facility.
In this chapter, behaviors, traits, and skills that characterize an effective leader are explored,
along with how they can be applied in various situations to guide employees and manage a food
service department. The practical application of these three components is described within the
context of creating a participative work environment that motivates and empowers employees.
Leadership Style
Leadership style is defined by the behaviors, traits, and skills a manager exhibits over time in
influencing the work of others so as to accomplish common goals for the department. Leadership
style can be better understood by exploring certain theories on behavior and reviewing situational
theories that link management behavior to work factors. In other words, an individual employee’s
unique level of job task development within the work environment may derive from or respond
to a particular leadership style.
Food Service Manual for Health Care Institutions
Behavior Theories of Effective Leadership
Theories on effective leadership styles have evolved from early research that focused on analyzing personality traits of individuals who demonstrated leadership ability. Studies conducted
before World War II identified traits such as intelligence, self-confidence, and physical attractiveness as—not surprisingly—being desirable. These studies, however, were unable to isolate
a single trait that could predict leadership ability. Research since World War II has focused
more on behaviors as indicators for identifying what creates an effective leader.
Two recent studies, one by Ohio State University (OSU) in Columbus and another by the
University of Michigan in Ann Arbor, were conducted to identify leadership behaviors. The OSU
studies concluded that leaders exhibit two main types of behavior, structural and consideration.
Structural behavior is leadership activity that either delineates the relationship between the
leader and the leader’s followers or establishes well-defined procedures that the followers should
adhere to in performing their jobs. Consideration behavior is leadership behavior that reflects
friendship, mutual trust, respect, and warmth in relationships between a leader and followers.
The Michigan studies, conducted by Rensis Likert (described by Dessler), defined two
basic types of leader behavior: job-centered and employee-centered behavior. Job-centered
behavior is leader behavior that focuses primarily on the work or production a subordinate is
doing as well as the job’s technical aspects. Employee-centered behavior is leader behavior that
focuses primarily on subordinates as people, personality needs, and on building good interpersonal relationships.
Using the behavioral approach, leadership styles have been defined or categorized using a
variety of terms. Perhaps the most familiar categories (or terms) are autocratic, democratic, and
laissez-faire approaches. Another classification uses terms such as directive, supportive, participative, and achievement. Work conducted by Robert R. Blake and Jane S. Mouton in the late
1970s grouped behaviors into five categories to identify leadership styles:
• Task management describes a behavior that exhibits little concern for employees and
emphasizes production activities. A task-management leader delegates little authority and is
autocratic in dealings with subordinates.
• Country club management is demonstrated by a manager whose primary interest is in
keeping employees happy and satisfied in their work. The work environment is permissive, and
pressure of any kind is avoided.
• Middle-of-the-road management characterizes the style of a manager who seems to
focus on tasks and employees. However, decision making is marked by compromise and
ambivalence, with constant fluctuation between opposing viewpoints.
• Impoverished management describes the management behavior of one who provides virtually no leadership to subordinates, with all productivity attributable to the employees’ own
• Team management is demonstrated by a manager who shows a high level of concern for
both people and productivity. Unlike middle-of-the-road management, however, this behavior
emphasizes the importance of mutual trust, understanding, and common objectives.
These leadership behaviors, and their variations, will be revisited throughout this book as
Situational Leadership
The theories on situational leadership attempt to identify basic factors in the work environment
that determine appropriate leadership behavior. One such theory, called the contingency theory, suggests that effective leadership behavior is based on three factors: the organization’s task,
the relationship between the leader and other members of the organization, and the leader’s
power base within the organization. The contingency theory assumes that a leader is either task
Leadership: Managing for Change
oriented or people oriented and that he or she cannot change leadership styles to suit the work
situation. Therefore, the work situation must be changed to suit the leader’s style.
Numerous other theories dispute the contingency theory, saying the leader, not the work
environment, must be flexible in situational leadership. One such theory was proposed by
Victor H. Vroom and Philip W. Yetton in 1973 and refined and updated in 1988 (described by
Dessler and others), as the Vroom-Yetton-Jago model of leadership. This theory focuses on
how much participation to allow subordinates in the decision-making process. The model is
built on two principles: organizational decisions should have a beneficial effect on performance, and subordinates should accept and be committed to organizational decisions that are
made. The Vroom-Yetton-Jago model suggests that there are five different decision styles or
ways leaders make decisions, from the autocratic to consultative to group focused.
A situational theory that assumes that a leader can be flexible in exhibiting the degree of
control, concern for productivity and employees, structure provided, and risk taken in decision
making is defined in Effective Behavior in Organizations, by Cohen, Fink, Gadon, Willits, and
Josefowitz. The authors define leadership style using five distinct dimensions and arguing that
a leader may respond or exhibit behavior at various points along the dimensions, depending on
the situation. These five dimensions (called herein the five-dimension theory) help describe how
a leader might carry out various functions and may be applied directly to food service department functions.
• Retaining control versus sharing control. The degree of control retained or shared is
apparent based on who makes decisions (manager or employees), how decisions are made (with
or without employee input), whether information is shared with staff, and the amount and
nature of work delegated.
• High task concern versus low task concern. This dimension relates to the emphasis
placed on the quality and quantity of production or output. A food service manager, for example, may place high or low emphasis on employee productivity. Although for financial reasons
a high level of task concern may be desirable, it need not occur to the exclusion of concern for
clients or workers.
• High person concern versus low person concern. Concern for individuals—consumers
or staff—considers the effect of actions or changes on department morale.
• Explicit versus implicit expectations (degree of structure provided). This dimension is
determined by how clearly and in how much detail tasks are identified; the number of written
policies; and the form of communication, whether written or verbal.
• Cautious versus venturous decision making. The level of risk involved in decision making, a manager’s level of visibility within the organization, and how willing the manager is to
push the outer limits characterize this dimension of leadership style.
The situational leadership models discussed so far provide the basis for work presented by
Kenneth Blanchard, Patricia Zigarmi, and Drea Zigarmi in their book Leadership and the One
Minute Manager. The four styles defined by Blanchard and associates, which are progressive
and can be applied by management personnel at all levels, are directing, coaching, supporting,
and delegating. Each style serves to create and nurture a participative work environment. It is
understood that managers will develop a leadership style that is preferable and most compatible with their individual makeup, but it is also desirable that the style be appropriate for dealing with a variety of employees and situations. Ultimately, complex situations or employees
with mixed skill levels (or both) will necessitate the use of more than one leadership style.
The four styles identified by Blanchard and associates depend on the situation and the
developmental levels of employees. Employees who are new to the department or perhaps performing a job for the first time will need a leader whose approach is directive, that is, he or she
provides specific instructions and close supervision until the task is completed. As the employee
becomes more comfortable with the department (or job), the manager will need to move
toward coaching, the second leadership style. A coaching leader continues to be directive and
Food Service Manual for Health Care Institutions
to provide close supervision but explains decisions, encourages progress, and asks for suggestions or input from employees. Coaching as a positive approach to improving performance is
discussed in Chapter 8 on human resource management.
The third style, supportive leadership, is exercised with employees who have knowledge concerning the tasks they are assigned but may still lack confidence in their abilities. A supportive
leader shares responsibility for a task and decision making with employees while helping to
accomplish it. The fourth leadership style recognizes employees who are highly motivated, knowledgeable about their job, and ready for full delegation from a manager. A delegating leadership
style allows a manager to turn over responsibility for both decision making and problem solving to employees. Leaders whose employees are capable of taking on this responsibility should
remember that delegation is not abdication but a sharing of responsibility. Employees will continue to need a leader’s guidance to ensure task completion. Further discussion on delegation can
be found in Chapter 5 on planning and decision making.
Again, depending on the employees’ developmental level and the situation, more than one
style can be used with the same employees. For example, an employee responsible for tray
preparation, meal delivery, and cleanup may have varying levels of expertise in these areas.
Whereas total delegation may be appropriate for meal preparation and cleanup, tasks related
to meal service may require more of a directing or coaching role.
Leader as Manager
Leading and managing are two activities that take place in all organizations, and the two terms
are often used interchangeably. The role of a leader is to create vision for organizations or
units, promote major changes in goals and procedures, set and communicate new directions,
and inspire subordinates. Managing involves most of the kinds of activities that are included
in a leader’s role. A person can be a leader and a manager. Leadership is a component of management, but management involves more than just leadership.
If leadership style is defined by characteristic behaviors and traits in various situations,
then management applies these items in the planning, organizing, staffing, and controlling of
resources to achieve goals. In this context, rather than being part of what defines management,
leading dictates how management is carried out. In other words, good managers place more
emphasis on leadership and apply what they know and learn to the daily and long-term management of their departments.
Leadership Characteristics for Effective Management
Based on the leadership theories discussed earlier, what attributes will a successful health care
food service manager need in the future? Current literature and expert opinion lean toward two
general categories: technical expertise and knowledge and interpersonal skills that promote a participative, enabling environment for employees. The common denominator between the two is
flexibility, the essential ingredient for dealing with the rapid change that will permeate health care
food service throughout the twenty-first century. As identified in Chapter 1, external environmental changes will alter both work methods and those who perform the work. Flexibility allows
food service managers to plan, organize, and lead according to the dictates of the work situation
and employee diversity. Flexibility in leadership style also helps employees deal with change. The
effects of change are addressed in Chapter 5. The two key attributes, technical proficiency and
interpersonal skills, are discussed below, followed by a brief statement on the qualities of a leader.
Technical Expertise and Knowledge
Technical proficiency uses the knowledge, tools, and techniques of a particular profession or
job. A leader’s technical skills include the ability to use administrative knowledge and tools to
carry out basic management functions (described later in the chapter). They also include the
ability to develop and implement standards and policies and procedures, to process paperwork
Leadership: Managing for Change
in an orderly manner, to manage the work of the unit or department with the resources allocated, and to coordinate work and elicit the cooperation of employees and others within the
organization. Administrative skills are used most often by top-level managers and least often
by first-line supervisors. Managers on all levels are responsible for processing paperwork,
whereas the responsibility for implementing standards falls primarily on first-line supervisors.
Technical skills are used frequently by first-line supervisors who have daily contact with
employees and must spend a large portion of their time training, evaluating performance, and
answering task-related questions. First-line supervisors in smaller organizations may be
expected to perform tasks that in larger organizations are assigned to nonmanagerial employees, or they may be expected to act as lead workers on employee teams. Evaluation of technical skills should be one consideration given to employees who show supervisory potential.
Although technical skills are important, an employee highly skilled in task performance but
lacking the administrative and interpersonal skills required by the position may not be a good
candidate for a supervisory position. At the same time, an otherwise competent manager who
lacks technical skills may be less than successful if the position requires monitoring the performance of production-level employees. Put simply, both are needed.
Effective leaders must view development for themselves, for their employees, and for the
organization as a continuous process. Technical knowledge for food service managers, for example, may be enhanced through trade shows, which provide information on the latest equipment,
supplies, and food items. Continuing or higher education classes and professional organization
meetings also may provide an ongoing flow of information to manage a department effectively.
Future demands will include technical expertise and knowledge in the following areas:
Environmental protection rules
The political environment
Marketing and customer satisfaction
Continuous quality improvement
Work redesign and productivity
Innovative cost-containment measures
Food consumption patterns
Food and equipment technology
Human resource trends
Food and water safety
Disaster and emergency planning
Cultural diversity in the workplace
This knowledge will be important to establishing the strategic direction for a department that
is in tune with the vision of the larger organization.
Interpersonal Skills
An effective leader relies on basic interpersonal skills—communication, empathy, understanding, ethical conduct, motivation, interpersonal skills, mentoring, and delegating—to influence
the behavior of others in a positive manner so as to ensure peak performance. The higher the
level of management, the less emphasis is placed on technical skills and the more emphasis is
placed on interpersonal skills. Middle-level managers spend about 50 percent of their time
applying their interpersonal skills. These skills also depend on a manager’s awareness of the
various beliefs, needs, and attitudes of group members and of their perceptions of themselves,
their work, and the organization. Some would argue that these interpersonal skills make the
difference between effective and ineffective leadership.
Interpersonal skills are important to managerial success in a food service department
because they promote harmony among food service workers and try to fit the needs of individual workers into the operating requirements of the department. They also enable food service directors to develop a network of positive relationships with administrators and other
Food Service Manual for Health Care Institutions
hospital staff members (as well as with other health care workers, physicians, patients, and vendors). Without such relationships, few managers would meet their own professional goals or
fulfill the organization’s objectives.
Successful leaders must prove their authenticity to employees, that is, that they are persons
of character and integrity. Employees need to know that their manager can be trusted and that
they consistently will be treated fairly. Managers who remain above reproach win their staff’s
respect and dedication. Department leaders must enforce rules that protect the safety and security of employees and customers. Employees come to know a leader’s values through his or her
actions and interactions with others. The behavior exhibited by managers when interacting
with employees, peers, and vendors says more about their leadership style than does any verbal rhetoric.
Effective leaders consistently follow two practices: promoting an environment or culture
that fosters learning, innovation, and risk taking and believing that employees are the most
important resource in the department and treating them accordingly. In this nurturing environment, a manager has an open-door policy to ensure that employee needs are met, and he or
she most likely will find employees doing things right and will offer praise accordingly.
Effective communication is perhaps one of the most important interpersonal skills, helping to instill in employees a department’s vision and departmental objectives as well as being
attuned to their needs and providing performance feedback. Identifying how a department fits
into an organization’s vision—and clearly articulating this to employees—is a necessary characteristic of an effective leader. Chapter 7 identifies effective communication skills.
Qualities of a Leader
John C. Maxwell has written a book to help recognize, develop, and refine the personal characteristics needed to be an effective leader, the kind people want to follow, in his book The 21
Indispensable Qualities of a Leader (1999).
Managers’ Role
Current and future managers must view their role in light of changes and trends that dictate
the need for strong leadership. The application of leadership can be seen in the traditional roles
of management, as described in the theory developed by Henry Mintzberg. The three roles
identified in the Mintzberg model are interpersonal, informational, and decisional.
The interpersonal role involves building and maintaining contacts and relationships with
a variety of people both inside and outside the department. This role requires the manager to
act as a symbol representing the department; to function as a liaison with others outside the
department; and to provide supervision in hiring, training, and motivating employees. The
importance of interpersonal skills for a leader–manager was discussed in the subsection on
leadership characteristics for effective management. As the demands for quality, customer satisfaction, and employee empowerment continue to evolve, a manager’s interpersonal skills take
on added importance.
The informational role requires a manager to monitor operations through data collection and
analysis, to disseminate information to employees and others, and to act as a spokesperson outside the department. The manager’s informational role can be defined in terms of effective communication, as outlined in Chapter 7. A manager must keep up-to-date on events by attending
organizational and professional meetings, reading current literature, and networking. The manager must then disseminate relevant information to other department members, acting as the
department spokesperson, information conduit, and negotiator who “sells” or persuades others
to buy into plans for additional resources or policy changes that affect patients and coworkers.
In this spokesperson role, a manager keeps others up-to-date on changes within the department.
The decisional role requires a manager to be innovative, to handle conflict and problem
resolution, and to allocate resources. An innovative manager must identify and interpret trends
Leadership: Managing for Change
so as to anticipate and plan for future service opportunities and improvements. He or she must
proactively seek new business or program possibilities and discover new approaches to effective problem solving. Conflict management occurs at all levels of management, and frontline
supervisors are required to deal decisively with disruptions that can arise daily in a health care
environment. In general, the higher the level of management, the less time is spent in dealing
with conflict.
Because the decision-making role also involves the allocation of resources, a manager must
set priorities for departmental functions and how resources—from department personnel to
food and equipment, time, information, and money—are used. Decision-making responsibilities can be closely controlled by a manager or shared with supervisors and frontline employees, depending on the matter being decided and on the leadership style. Decision making is
discussed as it relates to individuals, teams, and a participative work environment later in this
chapter and in Chapter 5.
These three management roles are interdependent. For example, a manager can gather outside information by using interpersonal skills and then use decision-making skills in applying
the information to determine how work is planned and executed within the department. The
roles of management as outlined in this section need not be the sole responsibility of a manager. In fact, it is through sharing of these roles and responsibility that a participative work
environment is created and fostered.
Managers of health care food service departments must fulfill their roles within the context
of providing food and nutrition services to the organization’s customers. To accomplish this
goal, they must use specific functions of management—planning, organizing, staffing, leading,
and controlling—to ensure that a department’s resources are used efficiently and effectively.
Levels of Management
The number of management levels in a food service department depends on many factors,
including the number of employees, hours of operation, complexity and scope of service, and
the department’s organizational structure. In smaller organizations where there are fewer
employees and limited hours of operation, only two levels of management, department director and supervisors or lead employees, may be needed. Most medium to large food service
departments have at least three levels of management: top level (director), middle level (managers), and first line (supervisors).
The scope of service can influence the number of both management positions and levels.
A department responsible only for feeding patients or residents will have fewer management
personnel and levels than one responsible for feeding patients and nonpatients. If additional
services are provided (for example, catering, vending service, coffee shops, child care, extended
care, bakery operations, physician dining facilities), more management levels may be needed,
such as a director, assistant directors, managers, and supervisors. Added meals mean additional
preparation and service requirements and, consequently, more employees.
Traditionally, levels of management have been differentiated using the functional–hierarchical organizational structure shown in Figure 2.1. This structure, developed in the late nineteenth century and supported by the “scientific management” theory of Frederick Taylor, is
based on a rigid chain of command and layers of management with varying levels of authority
and responsibility. Total authority and control in this model rest with management. Using the
functional–hierarchical structure, organizations assign different levels of management according to the responsibilities and authority needed to fulfill them. In this context, responsibility is
a manager’s obligation to perform certain tasks or duties, and authority is his or her power to
allocate specific resources in the performance of those tasks or duties. For example, a hospital’s
CEO has more responsibility for the overall operation of the hospital and therefore more
authority to direct the use of hospital resources than does the food service director.
Food Service Manual for Health Care Institutions
Figure 2.1. Levels of Hospital Management
(top level)
Food Service Director
(middle level)
Dietary Manager
(first-line supervisor)
Food Service Employees
Other management structures used by health care organizations to foster teamwork and
employee empowerment are matrix design, product-line management, and team-based organizational design. These models create an organizational structure that shares responsibility and
authority to move decision making to the lowest possible level in the organization. They also
make it possible to have fewer layers of management by virtue of shared responsibility and
authority. Organizational structure is discussed in more detail in Chapter 6.
All levels of management have one thing in common: All managers must use leadership
skills to plan, organize, coordinate, and control the resources for which they are responsible.
Food service directors must develop departmental plans that are based on the goals, vision,
mission, and objectives of the institution. Middle managers also must guide and monitor the
performance of their departments.
The scope of first-line managers is narrower, but they too must plan, coordinate, and control the daily activities (for example, efficient operation of the tray line in the food preparation
area) of employees they supervise. Again, the more participative the work environment, the
more the functions of management are shared among various levels of management.
Basic Functions of Management
Coordinating the work of individuals, teams, or a department requires managers in any organization and at any level to perform four basic managerial functions: planning, organizing, leading, and controlling. These four functions are interrelated, and the extent to which a manager
exercises them depends on the complexity of the problems or issues in question and on the
manager’s level within the organization. For example, although top- and middle-level managers
typically spend more time on planning and control functions, participative work environments
bid managers at all levels to provide input and be accountable for carrying out the work of the
organization. All management levels contribute to the organizing function, which defines
the scope of jobs and determines staffing requirements. As mentioned earlier in this chapter, the
function of leading places increased demands on all levels of managers in influencing work
completion by employees. The next four subsections take a closer look at each of these basic
functions of management.
Leadership: Managing for Change
Through planning, the future course of an organization or group is determined. The planning
function helps set goals and objectives and define policies and procedures to achieve them.
Planning is a continuous process of reviewing information, weighing alternatives, making decisions about those alternatives, and devising strategies to make the best use of available
resources. Information reviewed includes trends and issues in the external environment and
long-range plans for the organization.
Most organizations engage in two types of planning, operational and strategic, each of
which is defined by the time span covered by the plan. For example, when developing shortrange plans for day-to-day operations, a food service manager engages in operational planning.
These short-range plans generally are based on existing facilities and markets. Strategic planning, on the other hand, emphasizes long-range issues and new opportunities related to the
organization’s mission and objectives. A third type of planning, called performance planning,
is built on individual employee potential, contribution, and achievement. Planning is discussed
further in Chapter 5.
As already noted, planning occurs at every level of management. Top-level management in a
hospital—for instance, the CEO—must work with other decision makers within the organization
and the board of directors to develop the hospital’s vision and strategic plan, which will guide
overall activities and changes in the institution for a long period—five years or more. One element in the strategic plan might be to add a skilled-nursing unit. In turn, a food service director
would need to develop specific policies and operating plans for cooperating with other departments to deliver meals and nutrition services, taking into consideration regulations of the surveying and accreditation agencies. First-line food service managers also would need to participate in
this process, for example, if it appears necessary to restructure meal delivery times to ensure that
meals are delivered within the guidelines established for the unit. The planning function establishes the general picture of what is to be done and how it is to be accomplished.
The organizing function involves defining fine points of job specifications and determining how
work is to be grouped, who is to do the work, what authority is needed, how much staff is needed,
and how work will be accomplished by using what resources. Whether they are responsible for the
whole department or for a smaller unit such as the cafeteria, all food service managers must consider how their objectives can be broken down into specific tasks and assignments and how these
assignments can best relate to one another in authority, responsibility, and communication of
information. Managers must then decide which tasks to accomplish personally and which ones to
delegate. It is vital that the authority needed to make use of appropriate resources be delegated
along with the responsibility. Finally, the organizing function also includes the task of staffing the
positions identified. Recruiting, interviewing, hiring, orienting, and training and developing new
employees are major parts of most managers’ responsibilities. The human resource, or personnel,
department may assist managers in some or all of these staffing responsibilities.
Influencing is a function that has been titled motivating, leading, and directing. Influencing is
guiding the activities of an organization’s members in an appropriate direction by helping the
organization move toward goal attainment. The ultimate purpose is to increase productivity.
Influencing requires managers to use their interpersonal skills to influence individuals and
teams and to communicate information and instructions. Individuals and teams must be motivated to accept and strive to meet departmental and organizational objectives as established
through the planning and organizing functions. Effective influencing requires a manager to
understand how to motivate employees to achieve individual goals and how to coordinate the
work and interactions of employee groups.
Food Service Manual for Health Care Institutions
Exercising control ensures that actual outcomes are consistent with the planned outcomes specified by the goals and objectives. Because goals and objectives should be accomplished with the
most effective and efficient use of resources, control is essential. It is the medium by which
accountability—for instance, adherence to time lines, resource use, and quality of outcomes—
is ensured. Ensuring control involves several actions:
• Establishing standards of performance or outcome and communicating them to the persons who must meet those standards
• Devising systems for measuring performance, either by monitoring the work process or
by examining the work product
• Comparing performance measures with the standards set
• Adjusting performance as necessary by first determining why it does not meet established standards
Managerial Power
Managerial power is the ability to influence someone or something to change the course of
events or overcome resistance and to get people to do something they would not otherwise do.
Just because managers have power does not ensure that they will use it or even use it wisely.
Power may originate from the leader, the subordinate, the position, or the leader’s ability to dispense reward and punishment.
There are basically five types of power: expert, referent, legitimate, reward, and coercive.
Table 2.1 describes each of the types.
The two major types of power based on their sources are position and personal power.
Position power is based on the rank of a manager in an organization, and the power of the
position is given by the manager’s superior. It encompasses legitimate, reward, and coercive
power. Personal power is based on a person’s individual characteristics and is given in part by
subordinates. Personal power encompasses expert and referent power.
Legitimate power is the power granted to the position or formal authority to carry out the
responsibilities of the position. Some managers believe that this power can be used to tell employees what to do by virtue of the position and authority over the person. This power can be ambiguous. A manager and subordinate can disagree on the directive and leave room for open conflict.
The subordinate may do the job as directed but will do only “what has to be done.”
Table 2.1. Types of Power
Source of Power
Description of Power Source
1. Position or legal power
The power to control others because of position or title held
2. Expert power
The power to control others because of expert knowledge,
experience, or information that one possesses
3. Interpersonal or referent power
The power to control others because of personal charisma
or personality
4. Reward power
The power to control others by giving rewards; power based
on control of resources to compensate individuals for good
5. Coercive or punitive power
The power to control others by punishing those who make
mistakes or perform poorly
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Reward or punitive power is the strongest source of power because of the authority to give
rewards or the threat of punishment to subordinates. Not all employees will receive the best
assignments or receive the largest reward. This power must be handled carefully and objectively. This power has the potential to increase motivation in those who receive rewards, but it
can also decrease motivation for those who do not receive them or if the reward is insufficient.
Coercive power is the ability to administer punishment by either withholding a reward
(salary increase) or giving out punishment (letter of reprimand). A major problem with the use
of coercive power is that subordinates can devise methods to disguise their objectionable behavior or they can retaliate. Coercing employees by reducing pay, reducing work hours, or refusing
requested days off can result in work slowdown, absenteeism, or union complaints or grievances.
All personnel within an organization can use coercive power, from the subordinate who withholds needed information, making a situation worse, or uses subtle effective methods to fail to
meet time commitments to the CEO who uses this power as a threat to the manager.
Expert power is based on specialized knowledge in a specific field that others do not possess. The power comes when others need this expertise. An example is the physician-patient
relationship. Expert power is held by all in an organization: the secretary who knows where
certain information is filed, the plumber who can repair a leak, and the computer expert who
can repair the computer and retrieve data.
Interpersonal or referent power is the power to control others through charisma, respect,
and interpersonal relationships. It is also a power of subtle occurrence. Subordinates may emulate the superior by mimicking the superior’s gestures or other mannerisms. This power has
great potential due to relationships with department staff and others within an organization
where the manager has no legal power.
Power should be used to achieve the objectives, but care should be taken to avoid using
excessive power. The right type of power to use depends on the situation and circumstances
surrounding it. Power can be used to influence specific behaviors and to affect the behavior and
attitudes of other people. Power should be shared by empowering others (discussed later in this
Managers’ Responsibilities
Managers are responsible for management functions, resource management, and production of a
service or a product. In the above discussion, the management functions of managers—planning,
organizing, influencing, and controlling—were explained. In later chapters, directing, staffing,
communicating, and representing will be discussed. Resource management is the authority and
responsibility to manage the resources allocated to a department. These resources are made up of
“8 m’s”:
Men: the number of personnel allocated in the budget
Minutes: the number of productive and nonproductive hours/minutes for each worker
Machines: equipment available to meet outcomes
Money: to purchase supplies, pay personnel, and maintain and renovate area
Methods: policies, procedures, goals, and objectives that define what to do and how to
do it
• Materials: needed to prepare food and maintain a safe and sanitary environment
• Markets: regular customers and potential customers through promotion and advertising
• Motivator: to produce the best-quality products to meet expected outcomes
Managers also have the responsibility for meeting the outcomes or organizational goals.
These goals include providing a safe place for employment, providing a quality product, adhering to the mission, vision, and values of the organization, and providing for the wants and
needs of customers.
Food Service Manual for Health Care Institutions
Participative Management
Creating a work environment in which employees are not only allowed but openly encouraged to
participate in job-related decisions takes dedication and persistence on the part of all management
levels. The reason for creating such an environment is to be positioned to respond to changing
demographics and demands of the workforce, increased emphasis on customer satisfaction, and
the demands for continuous quality improvement.
Participative management has positive effects for both the organization and employees.
Because employees are closer to the customers, they can more readily identify and meet customers’ needs. Employees empowered to act instantly to satisfy customers win customer dedication and return business for the organization and gain a feeling of self-worth and further incentive
to complete their jobs. These feelings motivate employees, improve the quality of their work life,
and increase their level of commitment to the department and to the organization. Another benefit to promoting employee autonomy is that the organization gains from employees’ knowledge
and experience, in turn giving them a sense of ownership in the work process.
Creating a Participative Culture
Organizational culture (and therefore departmental culture) is identified by how things get
done. As is true for other social units, a facility’s cultural climate (or personality) is determined
by the accepted norms, values, and beliefs demonstrated through the behaviors and relationships of its management and employees in various situations. It influences how employees view
and perform their jobs, how they work with colleagues, and how they look at their institution’s
future. The internal culture is a blend of the following components:
The external environment (that is, the larger community) in which the organization exists
The employee selection process
Execution of managerial functions
Accepted behaviors within the organization
Organizational structure and processes
The removal of deviate members (unsatisfactory workers)
Creating a participative environment requires a change in the views, beliefs, and behaviors of
managers and employees. These changes in turn influence how things get done and, eventually,
the culture (or “feel”) of the organization.
A culture inventory, or audit (often conducted by consultants), may help an organization
assess its current culture by asking employees to define their ideal culture. For example, questioning employees about how they feel about their jobs, whether they feel comfortable
approaching their supervisors, to what extent they regard customers as being important to the
organization, whether they feel that reward and recognition are linked to satisfying customers,
and so on can disclose much about an organizational climate. Once audit results have been tabulated, analysis of the information can uncover areas in which change is needed to support continuous quality improvement. Audit results should be shared with staff and an action plan
created to define how the ideal continuous quality improvement culture can be promoted.
More on culture as it relates to quality is detailed in Chapter 4.
Management Responsibilities in a Participative Culture
To establish a participative work setting that enables employees and strengthens their commitment, managers must assume a number of responsibilities. Some key tasks are listed below:
• Training and developing employees to their highest potential
• Sharing decision-making authority
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Building a team mind-set
Compensating and rewarding employee achievement
Removing obstacles to employee advancement
Communicating effectively
These responsibilities, summarized in the following subsections, require greater emphasis on
the managerial function of leading.
Training and Development
Managers must assess employee development levels so as to appropriately match capabilities
to work situations. One key to ensuring a participative culture is to provide the right mix of
information, power, and incentive that will positively influence departmental performance.
A positive work environment is fueled by the development of employee potential. This is
accomplished through new employee orientation, continuing education and in-service training,
cross-training across jobs and across department lines, skill enhancement programs both inside
and outside the organization, and daily coaching from managers. In addition, successful
empowerment ensures that roles, relationships, job duties, and performance expectations are
clearly defined up front for new employees. Further discussion on the manager’s training
responsibility can be found in Chapter 8.
Shared Decision Making
As mentioned earlier, shared power and decision-making authority between managers and
employees enables employees to influence their day-to-day work life, which enhances job ownership and commitment. Therefore, when job descriptions are written or revised, when work
processes are designed or reviewed, or when procedures are changed, employees should be
polled for their input. This can be done by using questionnaires that disclose how the work is
done, suggestion forms for how the job should be done, or group meetings in which managers
and employees brainstorm new methods. Brainstorming is an idea- and information-sharing
session at which everyone is allowed to give input without being judged. Authority can be
shared in employee performance appraisals, at which employees can participate in rating the
quality and quantity of their work and in setting goals to improve or enhance their performance. Empowerment is discussed further in a later subsection.
Team Building
Participative management appreciates the benefits of having employees work in teams to influence quality improvement, customer satisfaction, and job performance. Managers must be part
of the team, not above it, providing the information and training needed to foster team success.
Once employees become accustomed to working in groups to influence job design or to solve
problems, they will be capable of meeting with less input or guidance from the manager. This
does not mean a manager should abdicate responsibility for ensuring that meeting time is
scheduled, recommendations are considered fully, and resources are available to implement
team recommendations.
Compensation and Rewards
Employee incentives, either formal (compensation) or informal (rewards), are key to nurturing a
participative work environment. Formal rewards encompass pay policies, employee benefits, and
career paths, all of which usually are set up and administered by the human resource department.
Some organizations have implemented formal employee profit-sharing and gain-sharing programs. Informal rewards can include anything from verbal praise and positive feedback for a job
well done to outside training programs or celebrations (at the work site or elsewhere) on reaching a specific goal or goals. Team and group performance as well as individual performance
should be rewarded. It should be remembered that in a participative environment, improvement
and innovation cannot take place without mistakes. Employees should be rewarded for effort and
Food Service Manual for Health Care Institutions
initiative even if the desired outcome is not reached. Tolerance of minor “failures” and mistakes
encourages employees to try again without fear of being punished or losing their job.
Obstacle Removal
In a participative environment, the department manager must anticipate potential obstacles to
employee advancement and seek to remove them. For example, policies and procedures that
prevent employees from making appropriate decisions to satisfy customers may jeopardize
employee morale, the customer base, and productivity. Appropriate decisions are those that fall
within an employee’s job scope and capabilities. Although policies and procedures provide
adequate structure, efficiency, and safety of operations, procedure overload can result in avoidable delay while stifling employee spirit. Another obstacle is an employee who refuses to participate or support team efforts. It is the manager’s responsibility to identify such persons,
coach them toward involvement, or apply the established disciplinary steps to remove them.
Other obstacles include budget constraints, productivity and labor demands, unrealistic
demands and expectations from other departments, lack of understanding or cooperation (or
both) from other organization members, insufficient employee knowledge or expertise, and
time constraints for meetings and problem solving.
Effective communication in a participative work climate includes (among other methods) conducting meetings for the purposes of identifying strategic plans for the organization and updating
employees on the status of organizational goals. Employees also should be informed of how
department goals fit into the larger organization’s vision, how the employees contribute to accomplishing department goals, and what future planning efforts will include. Good communication
in a participative setting moves in two directions—“downward” from managers and “upward”
from employees—which means that managers must sharpen their listening skills. Chapter 7 is
devoted to the skillful use of communication techniques.
By bridging communication gaps with other departments, managers become more aware of
conditions faced by others in the organization. Thus, they can sensitize their staff and improve
relations throughout the facility. By opening communication across departmental lines, managers learn what is considered politically correct in an organization’s cultural climate, thereby
better protecting their staff against uncomfortable situations.
Employee Involvement
A participative or high-involvement manager understands the values and beliefs that motivate
employee involvement through empowerment. This section explores theories on motivation
and their application in a collaborative work environment. Also, the levels of empowerment
and its application to health care food service are described.
Motivating Employees
Motivation is the process by which individuals are stimulated to act on their innermost needs,
desires, and drives. Motivation is a repetitive, circular process: An individual’s needs cause him
or her to behave in a way that fulfills, or promises to fulfill, those needs. Once needs have been
met (either partially or fully), the individual feels satisfaction. The feeling of satisfaction reinforces the need, and the need–fulfillment–satisfaction cycle of motivation is repeated.
One of the most important managerial responsibilities is to motivate employees to work
toward organizational and departmental goals and objectives. To accomplish this task, the
manager must find a way to make those aims fit each employee’s needs. Of course, motivation
is only part of work performance; individual ability and the work environment also bear on
performance level. In other words, employees need to know how to do their work well (ability); they need to want to do their work well (motivation); and they need adequate equipment,
supplies, facilities, and authority to do their work well (environment). The absence of any one
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of these three factors jeopardizes performance. The way employees are treated and the workplace atmosphere are also important factors. Everyone wants to feel a part of the team and to
be recognized as special and unique individuals. Managers need to recognize the diversity
among employees and respect cultural differences in the workplace. Demographic characteristics can be an issue if staff members do not believe or they question if they are “one of us.” If
a manager’s socioeconomic, ethnic, nationality, sex, or religious backgrounds are different from
those of a subordinate, the manager must create a climate of understanding acceptance and
“togetherness.” The leader must be sensitive to the cultures and social values of the workforce.
Compensation (money) and benefits programs are the most tangible means for motivating
and rewarding employees for their work. (Compensation and benefits are discussed in more
detail in Chapter 8.) However, how well money and benefits alone motivate employees to performance levels beyond the minimum required to accomplish the work at hand is questionable.
Compensation and benefits are extrinsic motivators, having limited long-term effect. In fact,
employees generally rate four things above salary: appreciation for work done, a sense of
“being in on things,” help with personal problems, and job security.
More theories about worker motivation have been proposed than can be described within
the scope of this manual on food service management. It may be useful, however, to explain
basic theories that have influenced modern management practices. The flagship theories can be
divided into three categories: content theories, process theories, and reinforcement theory.
Content Theories of Motivation
Content theories of motivation focus on specific factors that influence an individual to behave
in a certain way. These factors are related to the individual’s basic biological needs and immediate environment.
One proponent of content theory was Abraham H. Maslow, a psychologist who developed
a theory known as the hierarchy of needs, discussed in his book Motivation and Personality
(1954). As shown in Figure 2.2, Maslow believed that certain needs (for example, physiological
and safety needs) are more basic (or primary) than other higher (or secondary) needs (for example, esteem). Maslow concluded that a person’s primary needs will affect his or her behavior
Figure 2.2. Maslow’s Hierarchy of Needs
Secondary needs
Primary needs
Food Service Manual for Health Care Institutions
before any secondary needs have a chance to affect that person’s actions. Once the primary needs
have been fulfilled, however, they no longer operate as strong motivators, and the drive to fulfill needs farther up in the hierarchy begins to dominate the person’s behavior.
According to Maslow, a work environment that allows employees to meet their physiological and safety needs will succeed, for employees will be motivated to better performance
than in an environment that ignores their basic needs. The influence of Maslow’s theory on
modern management practices partially explains the reasoning behind the fair wage and salary
practices in most of today’s organizations. Maslow’s influence also can be seen in medical and
life insurance benefits, safety standards, and retirement plans.
Most food service directors do not directly control the compensation and benefits offered
to their employees (see Chapter 8). Food service directors, however, can reward good performance with promotions and regular salary increases. They also can make sure that their departments are pleasant and safe places in which to work and, by exercising fair and professional
management, can ensure employees of reasonably secure prospects for future employment.
Another content theory that is influential in the development of modern management practices is psychologist Frederick Herzberg’s two-factor theory of motivation, or the maintenancemotivation theory, based on studies he conducted during the 1950s. He concluded that two sets
of factors—which he called hygiene factors and motivation factors—influence employee attitudes and behavior. Hygiene factors include such things as personnel policies, job security,
salary and benefits, seniority benefits, the ability to interact with one’s peers, adequate working conditions, and so on. Herzberg believed that hygiene factors can prevent job dissatisfaction if employees perceive them to be adequate and fair but that these factors cannot increase
motivation levels or job satisfaction. Motivation factors include responsibility, recognition,
achievement, advancement, work that is challenging, feeling of personal accomplishment, and
other elements related to job content. Herzberg believed that these motivation factors are the
conditions under which employee performance is motivated. In other words, giving additional
responsibility or recognition for a job provides motivation.
Herzberg emphasized that managers need to work simultaneously on hygiene and motivation factors to foster a positively motivated workforce. Two major ideas advocated by Herzberg
and his colleagues were that intrinsic motivation—motivation that comes from within the
person—is important for keeping employees motivated and that the nature of the job, such as
whether it was sufficiently engaging and challenging, was also extremely important. The extrinsic factors are associated with dissatisfaction and include such factors as company policy, salary,
supervision, working conditions, and relationships with peers. This theory has important application in the operation of food service departments and should be considered during the process
of job design, job enrichment, or job enlargement because motivation factors may influence the
level of employee productivity in new positions.
Process Theories of Motivation
Another theory about motivation was developed by David McClelland and John Atkinson
(described by Dessler and other writers on management). They agree with Herzberg that
higher-level needs are most important at work. They developed a theory called McClelland’s
achievement, power, and affiliation theory. This theory focuses on the needs that people acquire
through their life experiences. The theory emphasizes three of the many needs developed in a
1. Need for achievement: the desire to do something better or more efficiently than it has
ever been done before. Individuals with a high need to achieve prefer to
• Set achievable goals for themselves
• Work on tasks of moderate difficulty
• Take moderate risks
• Take personal responsibility for their actions
• Receive specific and concrete feedback on their performance
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McClelland claims that “in some businesses people’s needs to achieve are so strong
that it is more motivating than the quest for profits.”
2. Need for power: the desire to control, influence, or be responsible for others.
Managers with a high need for power are likely to seek advancement and take on
increasing work activities to earn advancement. They enjoy decision-making roles and
competitive situations.
3. Need for affiliation: the desire to maintain close, friendly personal relationships.
Managers with a high need for affiliation have a cooperative, team-centered management style. They prefer to influence subordinates to complete tasks through team
efforts. This type of manager must beware that his or her need for social approval and
friendship does not interfere with a willingness to make managerial decisions.
Whereas content theories focus on the why of behavior, process theories focus on how
motivation occurs. Process theories look at motivation from the point at which individual
behavior is energized through the behavior choices that person makes to the quality of the
Among the body of process theories, expectancy theory proposes that motivation begins
with a desire for something, such as more recognition on the job, higher pay, or a stronger feeling of accomplishment. In this theory, individuals would then consider whether the effort to do
a certain job (performance) could be expected to achieve their goals.
Expectancy theory can help managers understand motivation on an employee-by-employee
basis because it takes individual differences among employees into account in a way that
content theories do not. For example, Herzberg’s theory suggests that job enlargement would
increase the level of motivation in all individuals. Expectancy theory admits that not everyone is willing or even able to accept job enlargement as a likely means for achieving what
they want.
Reinforcement Theory of Motivation
Originally, reinforcement theory was based on the behavior of animals under experimental conditions. Rat performance in mazes, for example, tested the psychological theory of reinforcement. B. F. Skinner and other psychologists have demonstrated how the theory can be applied
to human behavior. Basically, reinforcement theory assumes that behavior that brings positive
results probably will be repeated, whereas behavior that has negative results probably will not.
Four basic elements are at work in the theory: Positive reinforcement strengthens a specific
behavior because the result of the behavior is desirable to the individual. Avoidance strengthens a specific behavior because the result allows the individual to escape an undesirable result.
Punishment weakens a specific behavior because the result is undesirable to the individual.
Extinction weakens a specific behavior because no desirable result is provided by the behavior.
For example, a food service director who praises an employee for preparing an especially
attractive casserole provides positive reinforcement, and the employee is likely to repeat the
work behavior. But for employees who are careful to wash their hands after handling uncooked
meat because of past counseling for violating hand-washing procedures, avoidance is at work;
that is, the employees behave in a certain way to avoid another counseling session.
Managers often use punishment to reduce the likelihood that employees will repeat inappropriate behavior. However, this approach (for example, punishing food service employees for
breaking rules or missing work) can lead to anger and resentment among employees. When
practical, reinforcing proper behavior through praise and reward should be used in place of
A food service director might use extinction to discourage inappropriate behavior that was
rewarded in the past. Suppose that an employee who habitually engages in horseplay in the
department was rewarded in the past when a previous director or other managers joined in the
laughter at the employee’s antics. The director could discourage the behavior by ignoring it
instead of rewarding or punishing it.
Food Service Manual for Health Care Institutions
Application of Motivational Theories
No one theory of motivation is completely relevant to every work situation or to every
employee. Managers with effective leadership qualities are sensitive to employee differences, but
they also recognize that each of the theories has some application to their ability to motivate
employees. General motivation guidelines suggested by these theories are summarized below.
• Reinforce desired performance or achievement by providing formal rewards (fair
salaries, benefits, and opportunities for advancement).
• Design jobs that are interesting and challenging as defined by each employee’s skills.
• When an employee’s performance falls short of expectations, praise positive aspects of
the performance and suggest specific improvements without threats or punishment.
• Recognize and reinforce improvements through praise and other rewards.
• Make employees feel important by encouraging, helping, and supporting them in their work.
• Provide for advancement and growth in position by additional training or education.
• Allow employees to set their own goals within the limits of the department’s objectives
and the organization’s goals.
• Provide a work environment that is responsive to employees’ needs.
• Treat employees as the unique individuals they are by learning their names, interests,
and concerns.
• Show trust in employees by delegating responsibilities to them and by emphasizing their
contribution to the organization.
• Keep employees fully informed about policies, procedures, and organizational changes
that affect their jobs.
• Protect employee privacy and confidential information as prescribed by law.
• Encourage employees to participate in planning department activities and solving workrelated problems.
Motivating employees is a challenging responsibility because each employee is unique,
bringing different needs, desires, and perceptions to the work situation. Good managers help
pave the way for employees to realize their full potential and to become satisfied and proud contributors to their organization. To help all employees reach this state, managers must provide
them with opportunities to participate, to gain self-esteem through greater responsibility, and to
achieve a real sense of accomplishment.
Empowering Employees
Employee empowerment is best defined as employees organized into self-divided teams and
empowered to do their jobs and even to change work processes if that will improve product
quality. This is accomplished through intrinsic motivation and is a positive outcome of a participative work environment created by a flexible situational leadership style. Employees are
trained, retrained, and cross-trained in a variety of jobs. Facilitators (supervisors) work with
the employees to provide the resources necessary to meet the customers’ needs. Empowerment
simply means the sharing of power with those who have less. For empowerment to be successful, managers must delegate more formal authority to make specific decisions and avoid the
sudden withdrawal of shared power at the first sign of trouble. Subordinates must be allowed
to learn to use their increased power. Managers need to carefully consider how much power to
share and how to enable others to share that power. To make empowerment successful, managers also need to
Communicate information.
Train subordinates in how to use the “new” power.
Define objectives clearly.
Clarify any policy that will need to be used to enable subordinates to have a solid framework for decisions to be made.
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• Define limits of what situations employees will be supported to handle and when the
managers need to be involved.
• Share decision-making power.
• Provide rewards and recognition.
• Delegate meaningful work.
• Be accessible to coach, answer questions, discuss action, and provide support.
When employees choose responsibility for becoming involved and managers commit to
encouraging that involvement, employee empowerment is under way.
The remainder of this subsection focuses on the varying levels of empowerment and when
it is appropriate to apply these levels.
Levels of Empowerment
David Bowen and Edward Lawler define three levels of employee empowerment: suggestion
involvement, job involvement, and high involvement. Each level has a place in food service operations where employee empowerment is a priority. All three can provide a road map for managers seeking to change a tightly controlled work environment into a highly participative one.
With suggestion involvement, employees are encouraged to contribute ideas through formal suggestion systems, but there is little change in how day-to-day work is accomplished. Or
employees are encouraged to make recommendations for change, but management usually
retains power to decide whether the recommendations are implemented. Suggestion involvement, then, is closely related to a control model of management. Managers may use suggestion
involvement as the first step to leading employees to high (or full) involvement, or they may
decide that this level is appropriate for their department based on the organizational culture.
Suggestion involvement may be appropriate to certain tasks or situations, whereas job involvement or high involvement is better suited to others.
Job involvement takes a large step up from the typical control model. At this level, employees are involved in job design (how to do their work), they exercise a larger variety of skills,
get more feedback on how the work is proceeding, and are responsible for an identifiable piece
of work. This level of involvement offers more employee enrichment, which in turn leads to
higher motivation, commitment, and quality of work. The job involvement level is where many
organizations begin emphasizing a team approach. Teams are especially important in health
care food service because no one individual is responsible for customer contact from beginning
to end. The complex nature of the work and service delivery make it necessary to increase
emphasis on job completion through teamwork. Also at this level of involvement in employee
empowerment, training becomes more important. With more demand for employee involvement, managers must ensure that workers have the knowledge and skills to make decisions
effectively. Finally, managers at the job involvement level become more supportive and less
directive in their situational leadership approach.
High involvement derives from employees’ keen sense of how they do their jobs, how their
group or team performs, and how successfully the organization performs as a whole. This level
of involvement thrives in a culture that promotes employee empowerment and participative
management, where information on the organization’s business performance is shared; skill
development in teamwork, problem solving, and business operations is offered; and employee
participation in job-related decisions is promoted. Managers at this level must be highly competent in participatory management and team-building, coaching, training, and delegation
skills. Strategies of high-involvement empowerment also can be more costly in terms of additional time taken in hiring employees and in their training and development.
Application of Empowerment to Food Service
Is it appropriate in every situation to empower food service employees to make decisions?
Probably not. Recall that policies and procedures are established to provide consistent and
safe service. For example, it is unwise to authorize employees on a patient tray line to make
Food Service Manual for Health Care Institutions
substitutions, which might compromise patients’ nutrition needs or food preferences. Using
another example, a standard greeting for answering the phone or addressing customers in
cafeteria lines promotes an image of continuity and corporate identity. Management judgment
and discretion come into play when the application of empowerment versus strict procedural
adherence is at issue.
Individual differences in value systems and belief systems must be taken into account when
making empowerment application decisions. For those employees whose cultural comfort zone
is more amenable to structure and management-based decisions, tasks requiring strict adherence to procedural protocol are more readily completed. Regardless of whether employees
require more control than autonomy (or vice versa), they should be selected for positions that
allow them to use their skills to maximum potential.
The image a food service department presents is crucial to customer satisfaction. Image is the
perception customers form of the product and service provided. The organizational image is
often found in an organization’s values and culture. It also includes the building, grounds, personnel, logo, stationery, and above all, whether customers’ needs and wants are met.
An organization’s image must also be presented by all units within the organization. Because
all patients are served food while customers in the facility, the image a food service department
presents helps form the image customers have of the facility and the food service department. To
enhance this image, a food service department should ensure that
• Employees are dressed in clean, well-fitting uniforms that identify them as food service
• Materials for patients’ trays—tray covers, napkins, glassware, and china—are color
coordinated, clean, and pleasing to the eye.
• Dining facilities post menus that offer a variety of nutritious foods that meet the ethnic
and cultural needs of customers and that include prices for menu items.
• Service is personalized, and employees are courteous to all customers.
• Dining facilities are accessible to customers with handicaps.
• Dining areas present a pleasant ambiance.
• Surveys and focus groups are used to determine the needs of customers; outcomes are
implemented as appropriate, and the results are shared and used as a marketing tool.
• Current customer needs are met while potential new customers are sought.
• Hours of service are posted; the operation opens and closes as stated.
• Employees are hired and trained to focus on service to customers.
Roadblocks to Participative Management
Participative management and employee empowerment are not always accomplished easily,
and roadblocks may lie ahead if the organization is unsupportive of an empowered workforce.
Although it may be difficult for managers or employees to exert influence outside their department without commitment to participative management from the top, managers can begin with
suggestion involvement, encouraging employee input on how things are done within their
Employee skepticism may present another roadblock to participative management if
employees doubt management’s sincerity to welcome their input in decision making and job
completion. Skepticism can be due to employees’ past experiences with the current organization or a previous one. For example, employees whose participation and input were solicited
in the past but consistently overruled may doubt a manager’s seriousness. Longtime employees
Leadership: Managing for Change
who have seen programs, processes, and managers come and go may feel that this is just
another empty effort. For employees who view the manager as being lazy or abdicating responsibilities, this may be the thought at first glance, but a manager who continues to encourage
and support them eventually wins their allegiance.
A third obstacle to participative management may be the employees’ level of development.
Without adequate training and information, employees are incapable of providing input.
Managers must be responsible for employee education so as to ensure success while providing
constant feedback and praise. Again, not all employees desire autonomy on the job or opportunity for input.
If cultural differences provide a stumbling block to empowerment, managers must recognize this opportunity and find a way to use the differences. Chapter 8 further discusses the issue
of cultural differences.
Fear of failure or job insecurity can hamper employee involvement. Fear that the manager
is “setting me up to fail so I can be fired” may be unfounded, but it is up to the manager to
reassure employees. This can be done by starting at the basic level and allowing the employees
to offer suggestions but taking the ultimate responsibility for the decision until employees are
trusting enough to move beyond this level.
Managers themselves can be obstacles to a participative work environment. Those who “grew
up” (that is, developed their management styles) in non-participative environments may face some
of the same fears their employees do in trying to change to participatory management. They may
not be willing to give up the power and authority that come with their position, feeling that they
worked hard for it and that by sharing it, they somehow admit their inadequacy. It may also appear
to some managers that by sharing their power and authority, they—and therefore their jobs—
become devalued. It may be difficult for some managers to give up responsibility and authority
because they need to be in control and to know what is going on. Being responsible and knowledgeable is possible in a participative environment if the manager is a member of the overall team.
Managers who simply may not have the skills and information necessary to be participative leaders will have to defer to the organization’s responsibility for making this knowledge available.
An emphasis on customer satisfaction, continuous quality improvement, and increased demands
from employees for participation places more demand on managers to become effective leaders.
A practical approach to leadership can be established using the styles identified by Kenneth
Blanchard and colleagues—directing, coaching, supporting, and delegating. Each style requires
leaders to be flexible in the application of their style based on employees’ developmental level
and the task’s complexity.
An effective leader is flexible and possesses both technical expertise and interpersonal
skills. The application of these skills is important to accomplishing the management functions
of planning, organizing, leading, and controlling. Interpersonal skills are extremely important
to creating and nurturing a participative work environment that enables employees and allows
them to be active in decision making. Managers who advocate a participative setting possess
skills for communicating effectively, training, coaching, sharing decision making, team building, providing rewards and recognition, delegating work, removing obstacles, and bridging
gaps with other departments.
Providing a collaborative environment for employees stimulates their feelings of self-worth
and inspires a commitment to the organization. Empowerment can be simplistic and allow only
suggestion involvement or be more complex and allow for involvement with job design and
completion and decision making. Creating a participative work environment takes time and
requires change on the part of managers and employees. It is an evolutionary process that can
suffer setbacks due to obstacles. These roadblocks can be overcome with understanding and
persistence on the part of employees and managers.
Food Service Manual for Health Care Institutions
Benefits of a participative work environment accrue to employees and organization alike.
When allowed to influence their work life, employees develop a higher level of self-esteem and
job satisfaction. Organizations gain from employee loyalty and enhancements in customer service, productivity, and quality.
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Leadership: Managing for Change
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Chapter 3
In the past, health care providers managed operations with little concern for environmental
pressures and changes in the marketplace. However, given that health care technology has
expanded and that the percentage of the gross national product spent on health care has
increased, the health care system now must change its approach to be more consistent with
other sectors. It is no longer immune to the complexities and uncertainties of its environment.
A number of uncontrollable pressures within the health care environment (discussed in
Chapter 1) make health care delivery today increasingly more turbulent and stressful. These
pressures have forced providers to learn and implement new skills to make their operations more
cost-effective while maintaining quality standards. Primary among these responses has been the
implementation of marketing, which has long been used in other consumer-oriented fields.
Marketing is often confused with sales, advertising, and public relations. In fact, these
activities are part of marketing. To produce targeted results, not only must marketing become
a way of doing business in the health care operation, it must become a function of management. In the health care context, marketing is oriented to consumers, as opposed to sales or a
To apply to the health care field, marketing is defined as a tool that strives to meet the
needs, wants, and demands of the customers to obtain products and service of quality and
value. The American Marketing Association defines marketing as “the performance of business
activities that direct the flow of goods and service from the producer to the customer.” Because
many different health care options currently exist and because changes in health care delivery
will continue, providers must design services with the opinions and perceptions of their customers in mind. Therefore, health care nutrition and food service departments are becoming
increasingly—and more overtly—important in facilities’ overall marketing strategies.
This chapter introduces key marketing concepts, including services management, the difference between goods and services, types of markets, market and basis for segmentation, target
markets, marketing mix, and advertising and promotion. These concepts then will be applied to
devising a cyclical, five-phase marketing management model based on the following elements:
• Information: maintaining records; collecting, analyzing, and interpreting data
• Planning: operational and strategic planning, the planning process, documentation and
components of the marketing plan
Food Service Manual for Health Care Institutions
• Implementation: dealing with change, employee training, advertising and promotion
• Evaluation: monitoring and measuring marketing outcome
• Feedback: reporting successes, failures, or both, and returning to the information phase
Key Marketing Concepts
Although relatively new to the health care field, marketing is a discipline of sophisticated and
proven theories, techniques, and concepts. Although a complete discussion of these areas is
beyond the scope of this book, it is critical that managers in health care food service be familiar with at least three of the concepts: services marketing, markets and segmentation, and marketing mix.
Services Marketing
Since the early 1980s, the service sector of the nation’s economy has grown at an astounding
rate. According to the Bureau of the Census, this sector, of which the health care field is a member, accounts for more than 50 percent of both the gross domestic product and consumer
expenditures. Despite the importance of the service sector, only recently has services marketing
been differentiated from goods marketing. Marketing techniques originally developed to sell
goods are not always appropriate for selling services.
Goods Versus Services
Before services marketing is examined, the distinction between goods and services must be
understood. Goods may be objects, devices, or things; when goods are purchased, something
tangible is acquired for possession. Services, on the other hand, are mostly intangible; a service is an activity performed for the benefit of a purchaser. A service often is transacted on a personal basis and usually does not result in ownership (possession) of a physical (or tangible)
item. A service is created by its provider; for example, a facility that employs a meal hostess to
deliver patient trays or a chef to carve roasted meat on a cafeteria line is a service provider.
Most health care food service operations probably deliver a combination of goods and
services. In such operations, acquisition of goods and supplies, preparation and service of
meals, and cleanup afterward are performed for patients by food service employees. Hence,
health care food service is considered an industry—a service industry—even though tangibles
(food and equipment) are involved.
Characteristics of Services
Although service industries themselves are heterogeneous (ranging from barber shops to health
care operations), certain generalizations can be made about the characteristics of services. The
most important of these characteristics are intangibility, simultaneous production and consumption, less uniformity and standardization, and absence of inventories.
Services provided by health care food service operations are consumed but not possessed. What
is being bought is a performance of an activity rendered by a food service employee or group of
employees for the benefit of a customer. Generally, the provision of services is a people-intensive
process. To the patient, the meal hostess’s delivery of the breakfast tray is as much a part of the
meal as the tangible portion, the food.
Simultaneous Production and Consumption
Goods are generally produced, sold, and then consumed, with much emphasis placed on distributing goods at the “right place” and at the “right time.” Services are produced and consumed
Figure 3.1. Production and Consumption of Goods Versus Services
of goods
of goods
of goods
of services
of services
of services
Note: Shaded boxes indicate the points at which buyers and sellers interact. For services, each point can influence buyer satisfaction and must be addressed by the operation’s marketing program.
simultaneously, meaning that the service provider is often physically present while consumption
takes place: The clinical dietitian produces an educational service while (at the same time) the
patient consumes it. Because the dialogue occurs between customer and service provider, the
manner in which services are delivered becomes important. How food service employees conduct themselves in the presence of a customer can influence future business. Figure 3.1 shows
production and consumption of goods versus services over time.
Less Uniformity and Standardization
Because people are involved on both the production and consumption sides, services are less
uniform and standardized than are goods. With extensive involvement of people, a degree of
variability in the outcome is introduced. Whereas a patient may expect his or her favorite
breakfast cereal always to taste the same, two different meal hostesses could do an effective but
different job in delivering the breakfast tray to the patient.
Absence of Inventories
In most service settings, some levels of inventory must be maintained, as is the case with food
and supplies in food service departments. However, some resources cannot be stored for future
sale and thus are considered perishable. A sale is lost (perished) when a hospital guest finds the
wait time in the hospital restaurant to be too long, and it cannot be recovered. Along with
surges in demand, service organizations also experience slack periods. Because of this variability in demand, service operations are often concerned with how to manage demand. For example, the above-described hospital restaurant with long wait times might feature special offers
during low periods of demand in an attempt to manage demand more effectively.
Markets and Segmentation
To maximize the success of a health care food service operation, its manager must be able to
identify the potential market for the operation’s goods and services. A market is simply a group
of individuals or organizations that might want the good or service being offered for sale.
Food Service Manual for Health Care Institutions
Types of Markets
If a buyer is the one who will use the product to satisfy personal needs, the buyer is part of the
consumer market. When a product is purchased for business purposes, the buyer is part of
the organizational market. Different marketing strategies must be used when dealing with consumer versus organizational markets. Clearly, many health care food service operations market
not only to individual consumers but also to organizations. Marketing nutrition counseling services to an individual on an outpatient basis, then, probably would require a different approach
from that used to market the same services on a contract basis to a nearby nursing home.
Most managers find it necessary to further divide consumer and organizational markets into
smaller, more homogeneous “submarkets” that are likely to purchase a specific product. This
process, referred to as market segmentation, recognizes that buyers are not all alike. Appropriately
implemented, market segmentation can be one of the health care food service manager’s most powerful marketing tools.
Basis for Segmentation
Almost any buyer characteristic may be used as a basis for segmenting markets into submarkets.
Common characteristics used to define segments of consumer markets include geographical,
demographical, psychographical, and behavioral dimensions of buyers.
Geographical Dimension
Geographical segmentation is a logical segmentation characteristic because it is based on the
assumption that consumers’ wants and needs vary depending on where they live. Most health
care operations provide services in a specific geographical area, called a service area. Basic statistics about a service area’s population and health care needs should be analyzed by an operation’s management staff, including food service. This could prove beneficial when reviewing
existing services and when considering new ventures. For instance, when menus are developed
or revised, the menu planner must consider the regional food and beverage preferences of
potential customers.
Demographical Dimension
Most health care operations segment their markets according to the diagnosis of a patient.
Other demographical characteristics, such as age, sex, family size, income, stage in the family
life cycle, ethnicity, religion, and nationality, are segmentation variables that have long been
popular bases for determining market segments in the health care industry. The health care
services, including food and nutrition services, used by an individual are highly associated with
demographical variables. These variables have a major effect on most of the functional units of
a food service operation. When a health care operation serves certain diagnostic segments, patient
menus must be developed for those segments (for example, fat-controlled menus for patients with
heart disease and diabetic menus for patients with diabetes). Likewise, the age of the patients
served must be considered. The specific effects of selected demographical variables on menu
planning and meal service are described in chapters 15 and 20, respectively.
Psychographical Dimension
Because individuals within the same demographical group do not always exhibit the same buying
behaviors, other dimensions must be considered. One of these, psychographical segmentation,
divides buyers into groups based on social class, lifestyle, or personality characteristics. Lifestyle
is an important factor because it is a strong predictor of future health care consumption. Likewise,
it has an effect on the types of food and beverages desired by a food service operation’s customers,
both patients and nonpatients. In the lifestyle category, health-conscious consumer segments typically select menu choices with lower fat, sugar, and sodium than regular menu items.
Behavioral Dimension
Behavioral segmentation focuses on the knowledge, attitude, use, or response of consumers to
actual services. A number of factors can be analyzed when attempting to segment a market
according to this dimension. Factors applicable to a health care food service operation include
the benefit sought by consumers in terms of quality, service, and value; consumer usage rate
(that is, how often a consumer will use the operation’s services); and the consumers’ general
attitudes toward an operation’s products.
Target Markets
Based on the dimensions described above, a number of market segments could be created from
the consumer market of a health care food service operation. It might be tempting to create a
large collection of goods and services to meet the wants and needs of each segment. However,
most marketers agree that to market to everyone is to market to no one. Therefore, food service managers need to choose a few meaningful segments and concentrate efforts on satisfying
those selected submarkets. A market segment toward which the organization directs its marketing efforts is called a target market. Most often in a health care operation, this selection
process is not left entirely to the discretion of food service managers. They may be involved in
identifying target markets, but the final decision as to where efforts are concentrated will be
made by the facility as a whole.
The marketing cycle identifies the customers who make up the market and is illustrated in
Figure 3.2. The marketing cycle is complete if a customer’s behavior was changed to produce
a profit for product(s) that were identified to meet the identified needs or wants; feedback from
customers and staff was obtained; and there was a profit that could be reinvested for additional
research and development.
Marketing Mix
A successful health care food service operation focuses on the wants and needs of its customers
and markets the operation’s products efficiently. To accomplish this objective, food service
management must adjust specific elements of its operation as necessary so that its products will
appeal to potential customers. Elements over which an operation has control so as to influence
the salability of its products are called the marketing mix (see Figure 3.3).
Traditionally, elements of the marketing mix considered common among all businesses and
industries include product, place, promotion, and price. A fifth element that must be included
for most service sector businesses, including health care food service, is public image. When
considering a specific type of business or industry, this list can be customized. Each element is
essential to ensuring that a health care food service positions its products optimally to meet the
wants and needs of its customers.
A health care food service’s product is a combination of goods, services, place, ideas, activities,
organizations, and people that are unique to food service and that meet the wants and needs
of targeted customers. Of several factors that influence how acceptable a product is to customers, quality is a key measure. Quality is discussed in Chapter 4, but the main point here is
that food service managers can adjust quality to meet customer expectations. Other adjustable
product characteristics include labeling (such as naming the employee cafeteria or cafeteria products in inviting and interesting ways) and packaging (how goods and services are
combined to affect sales). Closely related to packaging is accommodation. For instance, when
a food service operation joins forces (combines) with a health care operation as a whole to provide an elegant dinner for new parents, the product has been qualitatively adjusted, resulting
in a special accommodation.
Food Service Manual for Health Care Institutions
Figure 3.2. Determining the Market Cycle
Identify customer needs and wants (survey, past records, and the like)
Develop product(s), pricing, and distribution method
Customer purchases product(s)
Determine if product met needs or wants (sales records, feedback from staff)
Figure 3.3. Health Care Food Service Marketing Mix
Public image
Health care food service products are offered for sale in a specific place. The location and
method of distribution must be convenient and attractive to customers. Because the typical
operation serves a variety of patients and nonpatients, multiple locations for food service facilities may be a major marketing consideration. Sales may be enhanced by implementing new
methods of distribution, such as offering take-out services. Physical characteristics of place—
shape, size, and certainly the facility’s decor—are important to a marketing effort.
Promotion includes those methods by which an operation makes potential customers aware of
its products. Many forms of communication take place between an operation and its potential
customers. Advertising and sales promotion facilitate customization of the message and image
conveyed to groups identified as potential customers (for example, visitors). As an example,
table tents can be used in hospital coffee shops to describe a new food item and therefore promote its sale to coffee shop patrons who might not normally purchase such an item. Most food
service managers know that word-of-mouth communication by satisfied customers can have a
positive effect on sales. For example, the popularity of a Sunday brunch for hospital visitors
could increase significantly from the endorsement of satisfied customers.
The following methods can be used to enhance advertising and promotion of products and
service in a food service operation:
• Design menus that use a simple format, familiar menu terms or explanations of product, photos of a finished product, contrasting colors for paper, and print and typeface large
enough to be read easily. Provide items that promote a healthy lifestyle and include a breakdown of nutrients.
• Post menus in the cafeteria or send out on the Internet; include them in the organization’s newsletter.
• Distribute menus to customers. In health care, menus may be kept and used by customers
as educational tools. Attach any daily special item to the menu. Include hours of service, location, telephone numbers, and payment options.
• Carefully name menu items. Use a name that will portray an image of the food and be
clear and descriptive. Use a name to convey information to avoid confusion or surprises. In
health care, a brief description of a product will tell patients something about the food.
• Add new items. Use fliers or the Internet to promote the item, explain how it is prepared,
its nutritive value, the recipe, the name of the person who prepared it, and a short acceptance
survey for patrons to fill out and give to the cashier for possible incorporation into the menu
• Institute theme meals or weeks or months. Make theme meals and holiday meals special. Vendors and the Internet list special days, weeks, and months. Food for a theme day is
important, but it takes more than just food. Advertise, promote, reduce prices (if there is an
employee dining area), and involve an interdisciplinary team in the event, as well as customers.
Have employees dress in costumes as appropriate, and decorate the dining area and patient
trays (as appropriate). Change the ambiance and the sound (music, special entertainment,
games or activities), if appropriate, and use theme-day napkins, placements, and other decorations as appropriate and that meet budgetary constraints.
To promote nutrition and food service, develop special events for National Nutrition
Month, Pride in Food Service Week, and other health care–related weeks such as Nursing Week
(see Figures 3.4 and 3.5).
• As appropriate, use discounts, coupons, and meal deals as another form of advertising
and promotion. Any discounts may need budgetary approval from the administration. Discounts
may be used for specials, such as “buy one, get the second one at half-price,” the introduction
of a new product, or for the delivery of multiple meals to a patient unit. Coupons for discounts
could be included in payroll envelopes and an in-house newsletter. Meal deals usually constitute an entire meal, without substitution, usually at a reduced price. Bundling of a group of
products under one price encourages increased sales and offers faster service. Bundled meals
usually are given special names such as “blue plate special,” “chef’s choice,” and the like (see
Figures 3.6 and 3.7).
• Use a departmental or organization newsletter to highlight the food service department.
A newsletter is a simple tool for informing customers about the food service operation, a new
menu item or recipe, or nutritional facts. These newsletters are usually one page (front and
back) with food service news such as a new service. Newsletters are an excellent way to tell
customers more about what, how, and why certain services and products are offered. Copies
should be placed in lobbies, on patients’ trays, and in the cafeteria.
• Use self-branding, defined as creating a special product line and creating a unique
name for the product. Develop a line of products that are unique to the department and label
as “XYZ health care cookies” or “Chef Laurie’s fried chicken.” Advertise and promote the
• Stage an open house as a way to inform clients, families, physicians, and other health
care providers of the department’s efforts. Holidays, the organization’s anniversary day, and
renovation completion are all good opportunities for an open house.
Food Service Manual for Health Care Institutions
Figure 3.4. A Gift Certificate Used in a Promotion
Acorn Hospital
Jonesville, Mississippi
Gift Certificate
Issued by:
Redeemable at any of the foodservice dining areas.
Must be used within three months of date issued.
Figure 3.5. A Menu Used for a Special Event or Theme Day Promotion
1950's Menu
June 3rd — 11:30 A.M. – 2:00 P.M.
1950's Party
Roll Back the Price Day
June 3rd
Enter the Best Dressed Costume of the 1950's
Win a Prize
(Elvis may appear)
All beef hot dogs
Additional tomatoes & lettuce
French fries
Chicken baskets
(Chicken, fries & drink)
Fountain drinks
Cherry Coke
Chocolate rootbeer
Regular fountain drinks
Sundaes (choice of toppings)
Sodas (choice of flavors)
*Other items available at regular price
Remember: Bring canned food for
City Food Cabinet
Figure 3.6. A Reduced-Price Coupon Used in a Promotion
This coupon entitles bearer to one free
$1.00 size drink in Employee's cafeteria
Figure 3.7. Another Example of a Reduced-Price Coupon Used in a Promotion
Buy 6 bagels at regular price and
receive the 7th one FREE.
Redeemable in Bake Shop in lobby
• Develop friendships with writers in local media. The media can be a friend or an enemy.
In using outside media, it is always best to check with the administration and public relations
for assistance and permission for publication. When applicable, provide accurate information
and a press release and include photos, contact names, e-mail addresses, and telephone numbers. Give enough description to avoid delay or misinformation. Where photos of individuals
are used, a signed released form may be necessary.
Food Service Manual for Health Care Institutions
• Make use of the ever-evolving Internet technology. Web sites are an excellent way to communicate with the public concerning products and service. Web sites can be used to promote new
products, menus, nutrition information, food safety tips, recipes, culinary tips, and special offerings. Include contact information such as address, telephone and fax numbers, and e-mail
addresses. Web sites must be kept up-to-date, and all information must be current and accurate.
• Use brochures and fliers to advertise and promote a special food service project for such
things as daily specials, hours of operation, catering, nutritional counseling, and food safety
information. This is an excellent way to let customers know about the happenings. All
brochures must contain accurate information, be easy to read and attractive, and include
descriptions of how the product(s) and service(s) will help customers.
• Catering is a good method to use to market the food service to both in-facility customers
and the community. Catering places the food service in a different light and provides an opportunity to enhance the image of food service and to generate revenue.
• Use payroll stuffers to promote upcoming events, changes, and so forth that are “stuffed”
into employees’ paycheck envelopes.
A price must be established that reconciles the value of the product to customers with the value
of the exchange to the food service operation. Before purchase, price is one of the few indicators of quality. Unfortunately, it also may be one of the least reliable quality indicators because
a variety of variables, some related to quality and some not, are used to establish prices.
Accurate cost information is critical to effective pricing. When establishing product prices, food
service managers must consider not only their costs but other factors, key among which are the
demand of consumers for products and the prices charged by competitors for comparable products. Because the cost, demand, and competition variables differ from one geographical region
to another, price variations for similar products are often noted.
Public Image
Public image, or how service sector businesses are viewed by current and potential customers,
affects the salability of services. A food service facility’s reputation among customers and
potential customers, peers, community, and the public at large can be enhanced. Participating
in nutrition-related interviews in print or broadcast media is one approach. Another might be
participating in annual tasting events sponsored by a local restaurant association. Both could
influence the public’s perception of food quality at the facility. Responding to community needs
by donating prepared foods to congregate feeding programs, such as soup kitchens, could be
viewed positively.
The preceding discussion on the five elements of a marketing mix gives only a broad look
as related to the health care food service industry. For these concepts to be of value to a specific food service operation, they must be tailored to the facility and implemented systematically (see Chapter 15). This might be accomplished by means of a customized self-evaluation
checklist. The initial evaluation of the salability of an operation’s products could serve as the
foundation of a comprehensive, structured marketing plan.
Marketing Management Model
Successful marketing of health care food service products is a challenging task, unachievable
without managerial involvement and a systematic approach. The marketing management
process is a sequence of steps designed to ensure that the right decisions are made to sell an
organization’s goods and services effectively. In many health care organizations, the coordination of this process is centralized in a functional unit of at least department standing. Regardless
of whether this is the case, food service managers, along with other operational managers,
should be actively involved in this process. Their level of participation depends on the complexity of the marketing unit. Although market research may be conducted by an organization’s
marketing unit, food service managers should be involved in translating resulting information
into new ventures and services.
Numerous models depict the marketing management process, and the following discussion
extracts those minimum essential elements that make up a tried-and-true marketing management continuum. A review of marketing management models reveals that they differ primarily
in the number of elements around which they are organized. Elements may range from as few
as three to as many as ten. The model in this discussion uses five: information, planning, implementation, evaluation, and feedback. These elements are best described as cyclical, with each
element—or phase—evolving from the previous one. Feedback is composed of the processes
that enable information to flow from the evaluation element back to the information element.
Phase 1: Information
Sound information makes for sound decision making. Thus, marketing information, provided
either by routine record keeping or as a result of market research, is extremely valuable to the
marketing management process. Especially in light of today’s health care environment, it is
imperative that organizational and departmental managers, including food service, develop
effective and efficient marketing information systems to get the precise information required
for sound and timely decision making.
A marketing information system is a set of ongoing organized procedures, personnel, and
equipment that collects, sorts, analyzes, stores, and retrieves information for use by marketing
decision makers. According to Philip Kotler and Roberta N. Clarke, the marketing information
system is composed of four subsystems: internal records, marketing intelligence, research, and
analytical marketing.
Internal Records
Probably the most well-established subsystem of the information element is made up of internal records, routine data sources generated many times during the course of day-to-day operations. The data generally focus on issues of cost, inventory, dollar sales, volume of services,
and other recurrent data that are routinely collected. From these records, a food service manager can develop basic statistics such as number of meals by diet type, average customer check
in the employee cafeteria, and restaurant seat turnover.
The internal records should be evaluated routinely to determine where problems might
exist. The goal is to design a resource network that meets the food service manager’s information needs cost-effectively. The ability to use these statistics to support future decision making
can be greatly enhanced if the data are computerized, as detailed in Chapter 10.
Marketing Intelligence
Environmental intelligence describes a network of procedures and sources that provide managers
with information about the organization’s external marketing environment. This subsystem yields
valuable information from a routine scan of relevant articles from magazines and journals and
from outside parties, such as suppliers. A particularly effective method for gathering this type of
information is to hire “mystery shoppers” for the purpose of purchasing and evaluating services
from the operation and to compare them with those purchased from competing food service operations. This provides information about the types of service offered, prices charged by competitors, and staff performance in the manager’s own and similar operations.
Market research, the systematic assembly of data that uses statistical technology to analyze the
potential sales success of a good or service, is a highly developed field of study. Because market
Food Service Manual for Health Care Institutions
research provides information on the basis of which business decisions are made, it must be conducted carefully to ensure that the results reflect the situation accurately. It also can be costly.
Unless a food service manager has the training to carry out market research, it is wise to enlist
the services of the facility’s marketing department or hire a consultant. Regardless of who conducts the research, the food service manager should monitor its progress to ensure that appropriate methods are carried out in the proper sequence. A recommended sequence is to define the
problem, collect the data, analyze the data, and interpret the research findings.
Step 1: Define the Problem
The problem must be defined in enough detail that subsequent steps in the research process can
be planned and carried out based on reality of purpose. Problems that might be defined include
Whether opportunities exist for off-premises catering services
Why competitors are gaining a bigger share of the outpatient weight loss business
Whether implementation of a take-out bakery counter would be profitable
What promotional activities would have a positive effect on demand in a hospital’s
restaurant during slack periods
Step 2: Collect the Data
Data collection involves determining what data are needed, what collection method(s) will be
used, and the actual collection of data. After the problem has been defined clearly, researchers
must review already-existing departmental and hospital data. Because the implementation of
new promotional activities in the hospital restaurant might require expenditures for equipment,
supplies, and training, the food service manager might want to investigate the cost-effectiveness
of various techniques. In this case, past sales records (including average check amount) and seat
turnover would be reviewed in terms of previous promotions. Interviews with the restaurant
waitstaff might provide additional insight into customer reactions to promotions.
The next step is to review secondary or previously published data. A number of governmental and public agencies can provide valuable data, but with regard to a hospital restaurant
study, the best sources of secondary data most likely are found in the publications of trade and
professional associations.
If secondary data fail to yield the documentation required, researchers must turn to primary data. Normally, primary data are collected by relying on a predetermined research design
that uses an observational, survey, or experimental approach. Each design involves standardized techniques so that data will be valid and reliable. In considering which promotional techniques to implement in a hospital restaurant, for example, researchers might use the
observational method by recording reactions of customers to various promotional techniques.
As an alternative, a customer survey questionnaire could be used to determine what techniques
to consider. The effectiveness of the techniques could be evaluated by means of the experimental design by determining the effect of each technique on sales in the hospital restaurant.
Step 3: Analyze the Data
Once data have been collected, they must be analyzed. If valid and reliable, data can be tested
statistically to measure relationships among the data. The appropriate statistical testing would
help the food service manager determine the relative effectiveness of two or more promotional
techniques—for example, whether a table tent or cafeteria signage would introduce a new
menu item with better results.
Step 4: Interpret the Research Findings
Following data analysis, study results should be interpreted and recommendations made. At this
point, the food service manager would decide which promotional technique(s) to implement in the
restaurant. Study results should be documented in report form for the benefit of future studies.
Market research techniques can be highly technical and, if not conducted carefully, could
result in flawed information on which decisions are made. Food service managers might find
this an appropriate topic to include in their personal continuing education plans. A less formal
technique includes development and completion of a marketing mix checklist, discussed earlier
in the chapter. Other informal, qualitative market research tools that can provide valuable
information about an operation’s products, customers, and competition are focus groups and
analyses of strengths, weaknesses, opportunities, and threats.
Analytical Marketing
The fourth subsystem, called analytical marketing, comprises a set of advanced techniques for
analyzing data. Usually it incorporates statistical, spreadsheet, and database software systems.
Large organizations use analytical marketing extensively because it focuses on diagnosing relationships within a set of data, determining statistical reliability, and using mathematical models to predict outcome. Because it is highly technical, this technique generally is not used in
smaller organizations or at the departmental level. The information generated from this subsystem flows into phase 2, planning, and is used for decision-making purposes.
Phase 2: Planning
Planning, the second phase in the marketing management cycle, usually occurs at two levels in
a health care organization. Planning at the organizational level, called corporate marketing,
focuses on organizational objectives, management’s view of mission, and resource allocation
for the organization as a whole. At the departmental level, the planning process may be as
focused as arranging for the implementation of promotional activities in the restaurant or
as broad as developing a three-year departmental marketing plan. Regardless of its scope,
the planning process should be driven by the information collected in phase 1 of the cycle. The
planning process results in marketing goals and programs to be implemented.
Planning Process
Each phase (and all its components) of the marketing management cycle must be aimed at satisfying customers’ wants and needs. Therefore, most health care operations satisfy three
requirements before adopting a specific model for their planning process. These requirements
are discussed in the following subsections.
Identify and Evaluate Opportunities and Threats
At the outset of the planning process, the health care operation’s mission statement and objectives established for the plan’s time span should be reviewed. Next, the food service manager
should review the market information system to identify marketplace opportunities that are consistent with the organization’s objectives. This activity, called a marketing opportunity analysis,
apprises managers not only of benefits associated with specific opportunities but also potential
problems. Marketing opportunity analysis pays close attention to the environment in which the
health care organization and food service facility operate. It identifies competitor facilities and
compares their strengths and weaknesses with those of the food service operation. Such analysis allows the food service manager to select opportunities that are best suited to the operation.
At the same time, effort should be made to correct weaknesses disclosed by the analysis.
Marketing opportunity analysis should be conducted by the food service manager when
considering projects such as expanding existing catering services to off-premises events. Even
though the market information system may indicate that this is a likely opportunity, careful
analysis should be made before further action.
Analyze Market Segments and Select Target Markets
The results of opportunity analysis lead to decisions about where marketing efforts will be
directed. It is important to stress that the health care food service manager must identify spe-
Food Service Manual for Health Care Institutions
cific markets from all the possible market segments. To accomplish this, the market segments
should be analyzed carefully to determine which ones are likely to have heavy users of the services and which hold little potential or present unreasonable risk. Specific targeting can improve
revenue and may help control costs.
Referring back to the catering expansion example, based on the principles of segmenting
and targeting markets, the food service manager must determine the focus for the proposed project. Operational characteristics necessary to support the venture for each segment under consideration must be explored. Examples of operational characteristics include hours of operation,
the number of employees to consider, the addition of new employees, and cost-effectiveness of
the venture. If the most promising market appears to be current hospital employees, a possible
outcome of this analysis would be to design the off-premises business primarily for this segment.
Plan and Develop a Marketing Mix
The third requirement in the planning process is to construct the marketing mix, discussed earlier in this chapter. The main objective here is to manipulate the characteristics of product,
place, promotion, price, and public image so that the wants and needs of target markets can be
satisfied and the desired outcome of the marketing project can be achieved.
For the off-premises catering project, the existing marketing mix of the on-premises catering program can serve as the basis. For example, the product element (food) must be analyzed
to determine service characteristics to be offered by the off-premises facility. Specifically, menu
offerings, hours of service, and methods of service would be considered. Simply offering the
services off premises changes the place element of the mix. The remaining elements of promotion, price, and the public image would require analysis and revision as well.
Marketing Plan
All details resulting from the planning process should be documented in a working document
called a marketing plan. The marketing plan identifies a systematic, structured program of action
to be undertaken over a specified period (for example, one year) to achieve targeted financial
results. Simply stated, the marketing plan provides the details necessary to achieve the stated goals.
Many health care operations specify a format for the marketing plan. Otherwise, the food
service manager should adopt a format similar to that suggested in the book Marketing for Health
Care Organizations, by Kotler and Clarke. Format components for the plan are as follows:
• Executive summary. The plan’s main goals and recommendations are summarized so that
readers can determine areas of major emphasis. The summary also facilitates plan evaluation.
• Marketing opportunity analysis. Results of the marketing opportunity analysis are provided, along with background information, forecasts, and assumptions. This section also should
include a comparison of the operation’s strengths and weaknesses with those of its competitors.
• Goals and objectives. Measurable goals and objectives for the food service department
and its projects must be specified. Generally, these must be related to overall organizational
goals for the coming period (as specified).
• Marketing strategy. The food service marketing strategy consists of a coordinated set of
decisions about target markets and the marketing mix that will be developed to appeal to these
• Action plans. Action plans turn the marketing strategy into a specific set of actions
required to achieve the operation’s goals and objectives. A table is an appropriate format for
an action plan because it can include a time line, which enables readers to determine when various activities will be initiated and completed (Figure 3.8).
• Budgets. Resources must support the proposals recommended in the marketing plan. A
budget that shows projected revenues and expenses related to marketing activities must be provided.
• Controls. This section describes controls that will be used to monitor the plan’s progress.
For example, by arranging goals and budgets by appropriate time periods (usually monthly or
quarterly), the health care operation’s management can review results periodically.
Figure 3.8. Sample Action Plan
Action Plan
Off-premise catering
Strategy: Distribute brochure promoting off-premise catering to supervisory and managerial staff
Completion Date
Person Responsible
(Coordinated by)
Establish format for brochure
September 15
M. Bloom
Identify possible photographs and topics for copy
September 22
T. Warren
Take photographs
September 30
Contracted out (T. Warren)
Write copy
October 5
T. Hardy
Design layout of brochure
October 12
T. Warren
Approve layout, copy, and photographs
October 19
M. Bloom
Obtain mailing labels
October 26
L. Williams
Print brochures
October 26
Contracted out (T. Warren)
Mail brochures
November 6
L. Williams
Phase 3: Implementation
Implementation of the marketing management process begins once actions are taken to initiate
the marketing plan. These actions include organizing and coordinating procedures, people,
resources, and tasks. For instance, before a new menu is introduced, a number of operational
procedures must be developed, changed, or both. To ensure that all necessary ingredients are
available for the proposed menu items, new vendors may need to be located, and new purchasing contracts may need to be signed. The food storage, inventory, and requisition systems
will require revision to incorporate new ingredients. Production records such as recipes and
production schedules will have to be developed to support the new menu.
In preparation for the introduction of new products, the responsibilities for preparing and
serving food items on the new menu must be assigned. As a result, employee training may be
required. Physical facilities, such as equipment or storage facilities, may need to be modified.
Advertising and promoting the new menu by means of signage, merchandising, and personal
selling are important implementation activities that the manager will need to oversee both
before and during the actual introduction of a new menu.
Although it may sound simple, implementation is only the beginning. Managers must monitor the process continually by techniques such as sales analysis, operating ratios (food cost to
revenue), and customer comments. All procedures specified in the marketing plan must be
reviewed and operations altered as necessary to ensure success. Without the proper implementation and effective monitoring procedures, even the best marketing plan will fail.
Phase 4: Evaluation
Results of the marketing effort must be measured and evaluated to determine whether the plan
objectives have been achieved. A variety of qualitative, quantitative, and financial analysis
methods can help make this determination. For example, recall the promotional technique of
special offers during low-demand periods in the hospital restaurant (discussed under “Absence
of Inventories” earlier in this chapter). Sales analyses should be conducted to show whether
dollar sales increased during those slack periods. If sales did increase, the food service manager
Food Service Manual for Health Care Institutions
would then compare the actual increase with the increase forecast. Customer counts during
hours of operation must also be monitored to see whether volume objectives were reached.
Sometimes a comprehensive review and appraisal of the marketing effort can be beneficial.
Called a marketing audit, this activity evaluates an operation’s marketing environment within
the framework of operations organization wide. Because the marketing audit must be conducted systematically and impartially to produce valid results, it may be necessary to contract
an outside consultant to perform it to ensure an unbiased analysis of the operation’s strengths
and weaknesses.
Phase 5: Feedback
The marketing management process is not linear but cyclical in nature. Therefore, at the end
of the evaluation phase, information about the programs presented in the marketing plan
should flow back to the information phase. Feedback is composed of a wide variety of techniques designed to facilitate this process. For instance, the implications of a status report could
be discussed in a management staff meeting. Feedback information on successes and failures
identified by this process could provide valuable input and create new marketing opportunities. This feature of cyclicity acknowledges the dynamic nature of health care food service operations and allows for adjustments in response to ongoing competitive and environmental
changes. Implementing new strategies and ventures can be both frightening and exciting for a
food service manager. Using this five-phase model can help managers design programs for
almost any situation that may arise.
All too often, health care food service managers try to advertise, promote, and sell goods and services without giving adequate thought to marketing. In times of intense competition and rapid
change in this environment, a thorough understanding of marketing principles and techniques
maximizes service to customers and revenues for the operation and its parent organization.
This chapter covered several key marketing concepts that food service managers must grasp
to design, plan, and implement effective marketing programs. Ideally, these concepts should be
implemented within the context of the five-phase marketing management model presented.
Finally, managers should assess their operations continuously for opportunities to apply
marketing principles and techniques. The marketing orientation is critical in these times
because of the pressure to satisfy increasingly complex and sophisticated wants and needs of
health care food service customers.
Berry, L. L. Services marketing is different. In P. Kotler and K. K. Cox (eds.). Marketing Management
and Strategy: A Reader. Englewood Cliffs, N.J.: Prentice Hall, 1988.
Chaudhry, R. Whining and dining. Restaurants & Institutions 102(17):12–22, 1992.
Dodd, J. L. President’s page: The fifth p. Journal of the American Dietetic Association 92(5):616–617,
Hudson, N. R. Management Practice in Dietetics. Belmont, Calif.: Wadsworth, 2000.
Johnson, J. Survey: Many CEOs overlook PR staff’s role in strategic planning. Hospitals
66(17):34–42, 1992.
Kotler, P., and Armstrong, G. Principles of Marketing. 9th ed. Upper Saddle River, N.J.: Prentice
Hall, 2001.
Marketing skills in the 1990s: Practical steps for promoting dietetics professionals. Journal of the
American Dietetic Association 90(1):37–39, 1990.
Kotler, P. and Clarke, R. N. Marketing for Health Care Organizations. Englewood Cliffs, N.J.:
Prentice Hall, 1987.
Nelson, C. W. Patient satisfaction surveys: An opportunity for total quality improvement. Hospital
& Health Services Administration 35(3):409–423, 1990.
Parry, M., and Parry, A. E. Strategy and marketing tactics in non-profit hospitals. Health Care
Management Review 17(1):51–62, 1992.
Payne-Palacio, J., and Theis, M. West and Wood’s Introduction to Foodservice. 8th ed. Upper Saddle
River, N.J.: Prentice Hall, 2001.
Powers, T. Marketing Hospitality. New York: Wiley, 1990.
Puckett, R. P. Dietary Manager’s Training Guide. Gainesville, Fla.: Division of Continuing
Education, 2002. Lesson 16, pp. 741–758, and Lesson 2, pp. 61–63.
Reid, R. D. Hospitality Marketing Management. 2nd ed. New York: Van Nostrand Reinhold, 1989.
Spears, M. C. Foodservice Organizations: A Managerial and Systems Approach. 4th ed. Upper
Saddle River, N.J.: Prentice Hall, 2000.
Solomon, M. R., and Stuart, E. W. Marketing Real People and Real Choices. 2nd ed. Upper Saddle
River, N.J.: Prentice Hall, 2000.
Zikmund, W. Exploring Marketing Research. Chicago: Dryden Press, 1989.
Zikmund, W., and D’Amico, M. Marketing. New York: Wiley, 1989.
Chapter 4
Quality Management
A primary responsibility of nutrition and food service managers is to help ensure the highest
quality of patient care through the provision of high-quality food products and service to all
consumers. The trends mentioned in Chapter 1 have caused renewed interest in health care
quality management—in particular, health care reform issues, an expanding body of regulations, a shrinking and changing labor force, increased customer demands, and computer technology.
Health care organizations have become value driven, stressing both quality and cost containment. Value is defined here as the relationship between quality and cost, or a focus on
delivering the highest quality at the lowest possible cost. A value-driven approach requires
more emphasis on quality of care and service, with cost containment becoming the added benefit of delivering high quality.
This chapter provides a brief background of quality in general industry and in health care,
with Joint Commission on Accreditation of Healthcare Organizations (JCAHO) information
that relates to quality and patient service. Specific characteristics of organizational culture that
are supportive of continuous quality improvement (CQI) are presented, together with a description of the infrastructure necessary for implementing a CQI program. The chapter also gives
guidelines for developing a CQI plan that ensures service quality, quality control, and quality
assessment related to clinical care. Finally, various quality-enhancing techniques and devices
applicable to the nutrition and food service department are offered.
Development of Quality in Health Care
Health care reform has forced administrators to transform their view of quality as an intangible to one that recognizes quality as an identifiable, measurable, and improvable entity.
Although responsibility for quality was once delegated to a single department, managers now
recognize quality improvement as the responsibility of each individual in an organization.
Quality improvement is seen as a long-term proactive (rather than retrospective) strategy to
improve patient care and satisfaction, increase utilization, strengthen productivity, and enhance
cost-effectiveness throughout the organization.
Food Service Manual for Health Care Institutions
General History of Quality Management
In the 1930s, Walter A. Shewhart provided a scientific foundation for quality control measurement in industry and manufacturing. He believed that efforts should focus on identifying
and correcting problems during the manufacture of products rather than on correcting the final
product. Shewhart is credited with designing the plan-do-check-act (PDCA) cycle shown in
Figure 4.1.
W. Edwards Deming, who was originally trained as a statistician, began teaching statistical quality control in Japan shortly after World War II. He is recognized internationally as a
primary contributor to the Japanese quality improvement program. Deming advocated that the
way to achieve product quality is to continuously improve the design of a product and the
process used to manufacture it by reducing waste. He expanded the PDCA cycle, defining each
of the four quadrants in Shewhart’s model and providing specific suggestions to foster improvement (Figure 4.2). He was a prominent pioneer in the quality movement, maintaining that 90
percent of variations in quality are due to systemic factors such as procedures, suppliers, and
equipment not under employees’ control. He thought that it was management’s responsibility
to reduce variation and to involve employees in the continuous improvement of system
Deming also is credited with the use of statistical process control tools that are the foundation of total quality management (TQM). In Causey’s handbook An Executive’s Pocket
Guide to QI/TQM Terminology (1992), TQM is defined as “a continuous quality improvement management system, directed from the top, empowering employees and focused on
Figure 4.1. Shewhart’s PDCA Cycle for Process Improvement
• Revise
• Set goals
• Design
• Adopt the
• Results
• Data collection
• Lessons
• Analysis
Quality Management
Figure 4.2. Deming’s PDCA Cycle
Determine goals
and targets
Check the
effects of
methods of
reaching goals
Engage in
education and
systemic, not individual employee problems, and continually strives to make improvements and
satisfy customers.”
In 1951, in his Quality Control Handbook, Joseph Juran introduced the dimension of economics to quality by categorizing the costs of quality as “avoidable” and “unavoidable.”
According to Juran, avoidable costs are associated with defects and product failures, scrapped
materials, labor hours for rework and repair, complaint processing, and losses resulting from
unhappy customers. Unavoidable costs, he explains, are associated with prevention, inspection,
sampling, sorting, and other quality control initiatives. Juran’s work provided managers with
objective measures for deciding how much to invest in quality improvement.
According to Garvin (1988), Armand Feigenbaum expanded manufacturing quality control in 1956 by proposing a total quality control system, adding product development, vendor
selection, and customer service to the existing quality system. Feigenbaum supported reliability engineering designed to prevent defects and to emphasize attention to quality throughout
the design process.
Another well-known name in the quality movement is Philip Crosby, who focused on management expectations and human relations. Crosby believed in getting the job done correctly
the first time—or zero defects. Zero defects was achieved through training, communicating
quality results, goal setting, and personal feedback.
Food Service Manual for Health Care Institutions
History of JCAHO’s Influence on Health Care Quality
The JCAHO is a private, not-for-profit organization dedicated to improving the quality of
patient care for all types of hospitals, home care organizations, nursing homes, and other longterm care facilities; behavioral health care and managed behavior health care organizations;
ambulatory care providers, including outpatient surgery facilities, rehabilitation centers, infusion centers, physician group practices, and clinical laboratories; and health care networks,
including health plans, integrated delivery networks, and preferred provider organizations.
In 1999 JCAHO’s mission statement was revised to emphasize the need to continually
improve quality of care and patient safety The mission (according to its mission statement) is
to continuously improve the safety and quality of care provided to the public through the provision of health care accreditation and related services that support performance improvement
in health care organizations. Health care organizations voluntarily seek JCAHO accreditation
because it raises community confidence and provides educational tools to improve care, service, and programs. When “accredited,” an organization has proved its commitment to patient
focus as measured against the highest and most rigorous standards of performance.
Standards of performance vary according to the classification of the health care environment.
These standards are developed by the JCAHO and its board, which includes administrators, nurses,
physicians, and consumers, with input from professional organizations such as the American
Dietetic Association. This group of people sets the standards by which health care is measured.
To earn and maintain accreditation, at least once every three years an organization undergoes an on-site survey by a select team that has been trained externally by JCAHO. The team
usually is composed of a physician, an administrator, and a nurse. In large complex organizations, a survey may include a clinical laboratory, a behavioral health care provider, and an outpatient surveyor. These surveyors make firsthand observations, visit patients and staff, and
review paperwork. The survey team helps identify the organization’s strengths and weaknesses
in such areas as patient care, patient rights, organizational ethics, ongoing improvement procedures, and organizational leadership. The emphasis of the survey is on performance improvement and positive health outcomes as measured against the standards that were designed from
patients’ point of view. The survey is flexible and customized for the type of organization being
evaluated. It is more consultative and educational in its approach.
Surveyors provide a preliminary report at the conclusion of the survey. The accreditation
may be awarded on several levels based on the organization’s compliance with JCAHO standards. Organizations receiving recommendation for improvement are required to bring the
areas cited into compliance within a specific time.
In 1997 the JCAHO developed an adjunct to the accreditation process: ORYX—The Next
Evaluation in Accreditation. (ORYX is a proprietary term; the letters do not stand for anything.)
ORYX requires organizations to provide the JCAHO with data regarding their “outcomes” (actual
patient care results) that show patterns and trends leading to improvements in patient care.
The ORYX includes performance measures: “quantitative tools that provide an indication
of an organization’s performance in relation to a specified process or outcome.” The use of
these data should motivate the organization to examine its processes of patient care and take
action to improve the results of patient care. Another component of ORYX is the identification
by the JCAHO of care performance measures to eventually permit comparisons of performance
across hospitals. Data derived from care measures are used to monitor a health care organization’s performance on a continuous basis, focus surveys on areas that need the most clinical
improvements, and help to identify best practices to facilitate benchmarking.
Until the late 1980s, the quality process in health care institutions was designed to meet
the demands of outside regulations or guidelines. For nutrition and food service departments,
reviews have come from the Health Care Financing Administration, now called the Center for
Medicare and Medicaid Services (CMS), and the JCAHO. The CMS is responsible for reviewing organizations that serve patients who receive Medicare funds. The JCAHO reviews are educational and must be requested by the facility being surveyed.
Quality Management
Move to CQI in Health Care
The term continuous quality improvement, or CQI, has been selected by many to identify their
quality initiatives. For the purposes of this text, CQI is defined as “the base theory that quality can be improved on a continuous, or never-ending basis,” a definition taken from An
Executive’s Pocket Guide to QI/TQM Terminology. The concept of CQI is based on the principle that poor quality is the result of poorly functioning or poorly structured processes that
can be improved.
The person credited with moving CQI from the manufacturing arena to health care is
Donald Berwick, who was trained as a physician. Berwick was codesigner of the National
Demonstration Project on Quality Improvement in Healthcare, which was designed using the
TQM approach. The project was led by the Harvard Community Health Plan in Boston in the
late 1980s and ended in 1991. The demonstration project included twenty-one health care
organizations, many of which have become leaders in TQM. This demonstration project has
been credited with beginning the shift that brought more than 60 percent of the health care
organizations in this country to CQI.
The CQI concept was first introduced in the JCAHO Accreditation Manual for Healthcare
in 1992. The JCAHO’s position is that 95 percent of an organization’s problems can be solved
through process improvement, and the JCAHO encouraged all hospitals to have some type of
CQI process in place. The remaining 5 percent of problems should be handled through traditional quality assessment and peer review.
The JCAHO had renamed the “Quality Assessment and Improvement” chapter as
“Organizational Performance Improvement.” Representatives for the JCAHO advise hospitals
to learn the concepts of CQI without abandoning traditional monitoring and evaluation of
quality assurance. This advice means that traditional quality assurance will continue to play a
major role in accreditation standards with the JCAHO.
The JCAHO concedes that many different approaches lead to CQI and that it endorses no
one method. However, elements of CQI have been incorporated into the standards for accreditation as follows:
• The key role that leaders (individually and collectively) play in enabling the assessment
and improvement of performance
• The fact that most problems or opportunities for improvement derive from process
weaknesses, not from individual incompetence
• The need for careful coordination of work across departments and professional groups
• The importance of seeking judgments about quality from patients and other “customers” and using such judgments to identify areas for improvement
• The importance of carefully setting priorities for improvement
• The need for both systematic improvement of the performance of important functions
and maintenance of the stability of these functions
Another standard addresses the education of health care executives about quality improvement. The standard requires facilities to demonstrate that the executive team has acquired education in the approaches and methods of quality improvement. A plan must be in place to
demonstrate how the organization will meet quality improvement standards for
Setting priorities for quality improvement activities
Allocating resources for improvement activities
Training staff members regarding quality improvement
Fostering better communication and coordination of quality improvement activities
Determining how the effectiveness of their contributions to quality improvement is
Food Service Manual for Health Care Institutions
Creating a CQI Culture
To create a culture that fosters CQI, an organization or department must adhere to the principles for creating a participative culture as described in Chapter 2. Culture, identified as the way
things get done in an organization, influences not only how employees view and perform their
jobs and how they work with colleagues but also how they view their customers and how they
view quality.
Principles That Drive a CQI Culture
CQI requires the integration of quality and change management methods, practices, concepts,
and beliefs into an organization’s current culture. Adopting any CQI process means integrating a focus on quality into all aspects of the organization, making it everyone’s priority. Three
principles are essential to establishing a CQI culture:
• Leadership and commitment from the top
• Customer orientation and focus
• Involvement of the total organization in improving quality for customer satisfaction
Leadership and Commitment from the Top
Ideally, an organizational culture that promotes CQI has commitment from top leadership,
including the board and other management staff. CEOs who were interviewed spent an average of 17 percent of their workweek time directing or reviewing their organization’s CQI
efforts. Each decade this percentage increases, mainly due to patients’ demands and surveying
agencies’ standards. This type of commitment from upper leadership is necessary to sustain
CQI. Leaders in CQI organizations recognize the need for employee participation and team
building. Their role consists of coaching, teaching, facilitating, and empowering.
Creating a CQI environment takes structure, planning, training, trust, patience, rewarding
positive change, and most important, time. Developing a CQI culture can take five to ten years,
which is not surprising considering the complexity of most health care organizations. For suggestions on creating a participative environment that empowers employees and fosters teamwork, see chapters 2 and 6.
Gauging commitment from the top may include assembling leadership profiles of all managers and their leadership philosophies and practices. Once the profiles are completed and
assessed, training sessions can be developed to address specific areas and move managers
toward participative leadership. Some of these areas may include team building, change management, coaching for quality-oriented performance, and developing a customer orientation.
Starting at the management level before introducing CQI to an entire organization is important; without top-level commitment and support, employees become frustrated in their
attempts to practice CQI.
Leadership commitment must be ongoing, even after employee CQI practices have been
implemented. Employees need time to attend scheduled team meetings and carry out improvement plans. Nutrition and food service managers may find it difficult to encourage employee
involvement without first leading a few teams as success models. Management is responsible
for providing structure by ensuring that all employees participate in training sessions and
understand their role in achieving customer satisfaction.
Customer Orientation and Focus
A customer-focused organization recognizes the need to identify and exceed customers’ expectations. An organization focused on quality improvement recognizes that the purpose of
improvement is to provide the best service at the lowest possible cost and that without this
value-driven goal, customer orientation is futile. Potential customers—individual patients,
physicians, and managed care organizations—have choices when it comes to selecting health
Quality Management
care. Often these choices conflict. For example, patients may want some say in the health care
facility they use and the physician they see. To remain competitive, organizations must seek to
be the provider of choice for all of these customer groups.
Customers are more likely to take their business elsewhere because of poor service than for
any other reason. Changing patronage due to unsatisfactory service is more common than
changing due to unsatisfactory quality or cost of the product. Research has shown that customers will even pay more for products if they perceive the service to be of excellent quality.
In health care, a customer orientation often has focused only on external customers
(patients, for example). However, internal customers include nurses, physicians, laboratory
technicians, nurses’ aides, and other health care professionals. This is especially important to
food service managers, who must understand the needs of internal customers and balance them
with those of external customers. For example, nurses can influence how patients and their
families perceive product service and quality. If nurses are dissatisfied when calling for patient
tray service or if they find the cafeteria service to be inferior, they can affect how the department’s service is interpreted by patients and physicians.
An effective technique for helping employees develop a customer focus is to have them
meet as a group to identify their customers. Then “customer-focused” posters can be designed
and displayed throughout the department as a reminder to new and veteran employees.
Organization-Wide Involvement
Although having a quality assurance department staffed by experts is necessary, it is equally
important that employees not rely solely on one department to be responsible for quality for the
entire organization. Through training programs and management support, organization-wide
involvement on the part of each employee can be enhanced. Once employees are trained in
teamwork and the tools of quality improvement, they should be encouraged to participate
in teams. With this training and support comes accountability. Often employees are reluctant to
participate without understanding the importance of their roles. Accountability and employees’
value to the organization are conveyed by including guidelines in general duties and responsibilities in job descriptions. Performance appraisal criteria can be set that reward employees for
concentrating on customer satisfaction, working in teams, and improving processes.
Characteristics of a CQI Culture
Health care organizations that embrace CQI have been found to have certain cultural characteristics in common. The remainder of this section describes thirteen of these characteristics,
which are summarized in Table 4.1.
Quality Definition
Each organization—and each of its departments—has defined “what quality looks like” for its
products and services. The definition provides a baseline for meeting or exceeding customer
expectations for quality. The quality definition is subject to change in tandem with changes in
the customer population. Once developed (or revised), the quality definition is shared with all
employees. Defining quality allows for the measurement of whether service provision meets
expectations. A quality definition must be accompanied by a policy of how service will be delivered. How quality is defined in food service is addressed fully in the subsection on customer
service and satisfaction later in this chapter.
Quality as a Business Strategy
Having incorporated quality as a long-term business strategy, organizations using CQI set
organizational goals and objectives and require departments to design a plan for meeting and
exceeding those objectives. Food service department managers are required to have a written
plan for monitoring, measuring, and improving quality. The quality plan should be integrated
into the department business plan (see Chapter 5).
Food Service Manual for Health Care Institutions
Table 4.1. Cultural Traits Shared by CQI Organizations
Quality definition
Knowing what quality “looks like” in an organization (for
example, a statement on how to greet customers)
Business strategy
Business plan incorporating strategies for quality goals and
objectives, along with written plans for meeting them
Two-way flow between employees and leaders
Supplier partnerships
Organization-vendor commitment to provide best value at
lowest possible cost
Error-free attitude
Mind-set to “do it right the first time—every time”
Fact-based versus
result-based management
Process versus outcome (quantity) orientation; long-term
versus short-term results
Employee empowerment
Employee autonomy, involvement, ownership of work
Physician involvement
Improved quality of practice patterns through multidisciplinary teamwork, critical paths, physician liaisons
Training and retraining
Continuing education through hands-on learning, crossfunctional training, development of in-house expertise, for
Problem solving through teamwork
Inter- and intradepartmental evaluation, decision making,
prioritizing; some accountability to quality council
Work process focus
Realization that processes account for 85 to 95 percent of
problems and that individuals may or may not account for
remaining 5 to 15 percent
Innovation and risk taking
Employee freedom to be creative and experiment without
fear of reprisal or job loss
Reward and recognition
Social (verbal congratulations), tangible (success celebrations), or symbolic (plaques or pins) acknowledgment for
effort and accomplishment
Employees in a CQI culture are clear about what direction the organization is taking and are
able to articulate both the organization’s vision and their department’s quality definition.
Communication from upper leadership is critical to ensuring continuous improvement because
as goals and objectives change, staff members must be informed. Top-level leaders also must
convey information on the organization’s successes, including its financial status.
Remember, communication also should flow from the bottom up. Employees must feel free
to express concerns and to give managers their input on what changes are needed for improvement. Employee-generated communication is a must for quality improvement teams and for
interdepartmental teams.
One method for communicating the plan, quality definition, and reporting requirements is
an employee handbook or manual that includes a list of trainer–facilitators, references to assist
with teamwork and measurement, and forms for reporting and monitoring team activities.
A loose-leaf binder should be used so that material can be added to reflect CQI changes.
Communication is discussed further in Chapter 7.
Quality Management
Supplier Partnerships
A customer orientation requires health care organizations to focus on supplier partnerships
from two aspects: the health care organization as a supplier and as a customer. It is important
to develop strong relationships with vendors and with purchasing groups that buy their services. As suppliers, health care institutions must prove their ability to offer the best possible care
at the lowest cost.
Institutions must develop strong relationships with supply companies so that value becomes
more than simply the best price. Quality must become a factor of the product purchased and
of the service rendered in delivering that product. Long-term relationships between purchaser
and supplier should serve to ensure loyalty on both sides and improved quality and cost savings for all concerned.
The caliber of service offered by food service vendors in turn affects the level of quality and
service provided to the department’s customers. Before awarding bids or selecting a primary
vendor, food service managers must assess vendor flexibility and willingness to understand and
meet the needs of the organization’s customers. Today, more food vendors practice CQI and
customer service and therefore understand that to remain competitive and retain business, they
must be customer responsive and willing to make adjustments. Food service managers should
meet with vendors routinely to share information from their customers or determine other
ways to communicate needs. Improvements in products and packaging and the development of
new products are possible if suppliers listen and respond to customers’ needs.
Employees can be key individuals in these supplier partnerships. For example, taste panels
can allow employees to sample and compare products before making purchasing decisions. Not
only will this involve employees and educate them about the product served, but taste panels
will also disclose information regarding product cost. As an added benefit for managers, less
time is spent reviewing products, leaving more time to promote employee involvement.
Error-Free Attitude
Organizations must move from a focus on quantity to a focus on quality of work done, thus
encouraging an error-free attitude. This includes setting goals for continuously improving
results rather than setting productivity or volume thresholds. A threshold is the level, pattern,
or trend in data that would trigger intensive evaluation. Instead of a single focus on work standards and productivity levels, employee time must be evaluated from a value-added standpoint.
Do a few extra minutes spent with a patient or other customer outweigh the cost of completing every task in the allotted time frame? Rather than only viewing a job as completed if it is
done “in time,” the focus must include the percentage error rate for all tasks completed. That
is, if the job is not done right, is it worth doing? In a true CQI environment, employees instead
of supervisors are encouraged to inspect the quality of their work.
Creating an environment driven by an error-free attitude also means working proactively
to encourage systems in which everyone knows how to reduce variation and eliminate errors.
In a proactive culture, employees seek to avoid mistakes before they happen or at least to prevent their recurrence. A proactive culture asks, Why did this event occur? and determines how
it can be corrected or prevented in the future. For example, if a hostess delivered a patient’s tray
that contained a wrong menu item, she would attempt to determine how the mistake occurred
in addition to obtaining the correct item for the patient.
Management by Fact Versus Management by Result
Management by fact requires everyone in the organization to understand and regularly use
standard tools to measure and improve quality. Later in this chapter, measurement, data collection, and analysis tools are described. Continuous improvement does not stop at measuring
whether the desired outcome was achieved but goes deeper to question whether the intervention was appropriate and whether appropriate skills and level of competence were applied. To
do this, managers must have accurate facts about the processes and systems used so as to assist
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in determining the need for change. These facts provide information about customers and their
needs and help determine where processes fall short of achieving satisfaction.
Management by fact is not to be confused with management by result. Management by
result, a tradition in American industry, pays little or no attention to the process that leads to
end results. This type of management is concerned primarily with final outcome and is based
on numerical goals. Too frequently, employees and supervisors find ways to meet these shortterm numerical goals but at the expense of improving the process for the long term.
Management by result perpetuates short-term thinking that looks for what is accomplished
today versus what serves to meet future needs. This type of thinking has caused many health
care workers to disagree with the JCAHO and others who use outcome indicators. An indicator is a measure whose deviation from accepted standards of care signals the existence of a
potential problem with quality. However, outcome indicators can identify areas of concern with
a process so that the process can then be charted and analyzed for improvement needs.
Management by fact, then, allows managers to create the best possible results while monitoring the systems and processes involved.
Employee Empowerment
Pro-CQI organizations recognize that the employee closest to the customer knows the customer
best. As noted in Chapter 2, empowered employees are free to use their creativity to design
improvements. Managers must view employees as wanting to do their best and must provide
the leadership necessary to assist them.
Establishing expectations for employee involvement starts at a basic level and grows with
experience—for example, requiring involvement on at least one quality improvement team for
the first year. Accountability should be based on involvement, not necessarily on accomplishment, so that initially at least, it is more important to help employees feel comfortable working in teams. Another expectation measure for employee involvement is to require cafeteria
servers or cashiers to ask a specified number of customers questions regarding wait time, adequacy of menu variety, or their suggestions for menu items. To ensure that the questions asked
are consistent and to provide documentation, a standard questionnaire can be developed.
Employees also can be responsible for passing out comment cards, for submitting suggestions
for improvements or for processes that need analysis, or for brainstorming and then prioritizing a list of processes or customer issues that teams can work on. In the last example, a list of
projects can be posted, and employees can sign up to participate in their areas of interest.
Physician Involvement
Physician involvement is critical to health care culture changes and quality improvement. Health
care organizations are unique in that physicians, who are major players in the care of the primary customers, are individuals outside of operations. Physician practice patterns are influenced
by physicians’ trust in operational systems within facilities. For example, if it is difficult to get
laboratory results for a simple and inexpensive test, physicians may order more complex and
expensive tests, creating a costly pattern of practice that does not improve patient care.
Physician involvement, then, can strengthen multidisciplinary teams. For example, physician involvement is essential in developing critical paths. Critical paths, suggested as a means
to decrease variation in patient outcome, are standardized specifications for care of the typical
patient in the typical situation. They cannot improve quality if they are not interfaced with the
hospital’s systems. Critical paths (discussed later in the chapter) are designed to reflect the best
method of care and must have systems and processes that support them.
Some organizations involve physicians early in the decision-making and implementation
phases of CQI. Medical staff participation can be enhanced by including a physician liaison on
the quality council (discussed in the following section) who can assist with coordinating physician participation on quality improvement teams. This individual also can coordinate activities
between consultants and management, help establish goals, and assist with data collection and
Quality Management
analysis. Key benefits to having a physician liaison are that he or she can be an advocate and
a source of expertise for the medical staff. Finally, the liaison can maintain clear communication between the medical staff and the organization while assisting with the education of medical staff members regarding hospital improvements and the need for changes in their practice
Training and Retraining
Organizations committed to CQI recognize that training is an ongoing process and that continuous training is the basis for success. Continued education can be done in a number of ways,
but memorization of philosophy and methods alone is not one of them. Learning can be done
in a hands-on manner or simulated to bring the activity to life. Both methods allow the participant to learn by doing in a reality-based context. Some of the best learning occurs in small
groups where everyone is allowed to participate in applying the techniques learned.
For any CQI initiative to succeed, employees must receive training in the process, methods, and tools used by the institution. Training consultants can be contracted, but to sustain
the process and be cost-effective, it is wise to create in-house experts. This can be accomplished
with “cascade” training or “train-the-trainer” sessions. With this type of training, a number of
managers, employees, or both are trained (perhaps by consultants), and they in turn train others in the organization. Thus, those trained become trainers and facilitators for the CQI
The role of trainer–facilitators depends on the CQI process selected. They might conduct
overview sessions to familiarize all employees in the organization with CQI, or they might provide guidance to teams and their leaders. As an added benefit, managers involved as trainers
further develop their coaching skills, which are essential for participative management and
employee empowerment. This technique provides increased job satisfaction among managers,
allowing them to break out of their daily departmental role while enhancing their view of the
organization as process oriented across departmental lines.
The trainer–facilitator role becomes increasingly important to cross-functional teams,
which often need neutral leadership that can downplay turf battles and lend insight on hospital operations. Specific areas to address in facilitator training include
Skills in group dynamics
Roles and behaviors in meetings
Interpersonal skills
The stages of team development (see Chapter 6)
Use of CQI tools for data collection, analysis, and decision making
Trainer–facilitators can provide team members with “just-in-time” training in statistical
process or control tools (charts, graphs, diagrams, and the like). This training allows more
employees to become involved initially with only the information they need to start the process.
As their need for more information grows, trainers can provide it.
Problem Solving Through Teamwork
One of the principles of CQI is involving the entire organization in improving quality. This is
best accomplished through intradepartmental or interdepartmental teams. Intradepartmental
teams usually focus on processes or service areas within one department (sometimes as related
to one other department, which acts as a “customer”). Interdepartmental, or cross-functional,
teams are formed when a process needs to be evaluated and spans two or more departments.
Intradepartmental teams usually identify the project or process to be worked on. This may
be done during an initial meeting of a team created to identify customer needs, or it may be done
as a department task. As mentioned earlier, processes and problems can be listed, prioritized, and
then posted so that employees can volunteer. Accountability for actions of intradepartmental
Food Service Manual for Health Care Institutions
teams lies with the department manager and the team leader, although team members should
have some understanding and “ownership” of the process being studied. The team leader is generally selected by the team or may be appointed by a manager based on the knowledge of an
individual. An intradepartmental team can have up to ten members and usually will include a
supervisor. Once they become experienced with CQI, employees can form teams and meet
without a supervisor. However, it should be made clear that the progress, actions, and outcomes of the team must be shared with the department manager. Team meetings can take anywhere from thirty minutes up to one hour per week. The life span of intradepartmental teams
can vary from short term to indefinite, depending on how productive they are in identifying
and addressing CQI issues. Implementation of the team recommendations will be department
based and will occur based on complexity. For example, if a team’s goal was to decrease the
amount of time it takes for a patient to receive a late tray, the action plan may include steps to
shorten the time between receiving the order and preparing the tray. All of these steps would
occur inside the department.
Interdepartmental (cross-functional) teams are selected based on input and priority level
established by the quality council, to which they are accountable. Membership (commonly limited to eight members) should be representative of each functional area involved in the process
under investigation and should include department managers and supervisors. The team’s life
span depends on the complexity of the process under investigation and of the recommendations
to be implemented. Generally, the team will have to meet for more than one hour per week.
The quality council should monitor the performance of cross-functional teams to determine
whether politics or turf battles might compromise final recommendations. As a rule, the “owners” of the process under study are accountable for implementation of recommendations, with
assistance from team members and the quality council.
Generally speaking, CQI teams, whether intradepartmental or cross-functional, consist of a
team facilitator, team leader, and team members. The facilitator is responsible for providing
training and information about the process under study, suggesting tools for problem solving or
measurement, providing feedback and support, ensuring equal participation, and if necessary,
mediating and resolving conflicts. A facilitator may not be necessary for every process improvement. For example, an intradepartmental team whose leader has had experience in teamwork
and understands the fundamentals of process improvement may not need a facilitator.
The leader of a CQI team is responsible for guiding the team to resolution through achieving the desired objectives or problem resolution. Conducting team meetings, providing direction and focus to the team, and keeping the group on track and on time are some of the leader’s
responsibilities. (It may be necessary to appoint a team member to be a timekeeper to ensure
efficient use of time.) The leader also is responsible for conveying the team’s need for resources,
recommendations, and other concerns to the quality council or to management.
Documentation and reporting of team activity and progress is an important function of the
team leader. A sample team documentation form is shown in Exhibit 4.1.
As already shown, team members should be vested with some sense of ownership in, and
knowledge of, the process or problem being investigated. Members provide ideas and different
perspectives through their active participation. They must agree to adhere to meeting ground
rules, to support the leader, and to support implementation of the recommendations agreed on
by the team. Assignments must be performed on time to ensure smooth progress during team
meetings. More information for conducting team meetings is provided in Chapter 7.
Work Process Focus
Organizations successful in creating a CQI culture understand that processes, not individuals,
create inefficiencies or problems. A process is a sequence of events or tasks performed to reach
a desired outcome. For example, a patient’s receiving his or her tray late is the outcome of a
late-tray process, which comprises several steps from receipt of an order by the food service
department to delivery of the tray to the patient. Productivity is improved when unnecessary
Quality Management
Exhibit 4.1. Team Documentation Form
Name of project/issue: _________________________________________________________________
Date: _________ Assigned by (title) _____________________________________________________
Team leader: _________________________________________________________________________
Team members: (inter- or intradepartmental) [9 members maximum]
List who the customers are: _____________________________________________________________
What is the proposed outcome? _________________________________________________________
Tools and resources to be used:__________________________________________________________
Action plan: _________ Who is responsible? ______________________________________________
How will outcomes be measured? _______________________________________________________
Meeting dates: _________ Finish date: ___________________________________________________
Report outcomes to: ___________________________________________________________________
Source: Developed by Ruby P. Puckett, 2003. Used by permission.
steps in a process are eliminated or when steps can be combined. Although some processes can
be improved by making minor adjustments, others must be replaced or redesigned entirely.
Quality management experts estimate that 85 to 95 percent of all problems within an organization are caused by work processes and systems, leaving only 5 to 15 percent that are controlled (not necessarily caused) by individuals. Viewing related tasks as processes provides
employees with a broader view of how work is accomplished. This type of thinking allows
them to understand that quality of output (outcome) is affected by quality of input (process or
Innovation and Risk Taking
Testing the unknown and trying unproven solutions and ideas is another characteristic of a
CQI culture. An environment that encourages innovation and experimentation leads to creative
thinking on the part of all workers. Once employees are assured that they can take reasonable
chances to improve care or service without fear of punishment for failure, more ideas will be
tested. Thus, creativity among all department members can be nurtured, rather than depending on the experiences and ideas of a few.
Reward and Recognition
Without properly recognizing and rewarding employees and managers who are successful with
CQI initiatives, it will be difficult to sustain their long-term commitment. Rewards and recognition may be social, tangible, or symbolic. Congratulations to a team from the manager or
upper leadership is a type of social reward. Celebrations, such as fairs where teams are encouraged to display the work and results of their efforts, are more tangible. Plaques, pins, or ribbons are examples of symbolic reward and recognition for involvement as well as for success.
Positive reinforcement is crucial to sustaining long-term empowerment and assisting with
success. It is important that the reward and recognition be genuine. Some CQI proponents
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caution that team-of-the-month awards or other such distinctions may prove counterproductive to the CQI process because they honor only one group among many and create negative
competition and possible resentment among those who did not “win.” However, these types of
programs have also been advocated to establish friendly competition, which leads to more staff
members becoming involved in the organizational culture.
Role of the QC in CQI Infrastructure
The infrastructure for CQI is the foundation on which it is implemented, that is, the vision for
the organization. To create a cultural change, the organization’s leadership must send a strong
message to emphasize the importance of quality, which includes making quality a key initiative
in the strategic- and business-planning process and in the budgeting process. The budget must
include financial resources necessary for training and rewarding employees.
Creation of an infrastructure, or framework, includes deciding whether there will be a quality council or a steering committee. Individuals on the quality council may vary from one organization to another. One recommended hierarchical structure for membership is as follows:
Chief operating officer
Senior executives (line and staff)
Medical staff liaison
Quality coordinator or director
Other members (may include representatives from the medical staff, board of trustees,
department heads, and employees)
This type of quality council is recommended to be installed for three to five years to assist
with implementation and monitoring. Although the council will be important for implementing, monitoring, and nurturing CQI, it may wish to continue the reporting of CQI efforts
through the organization’s quality assessment committee established to review and monitor the
organization’s quality assessment activities.
The role of the quality council evolves with the investigation and implementation of CQI.
The initial role is to create the vision, to develop the quality definition, and to develop the
change strategy needed to create a continuous quality culture. This means creating the policies
for reporting and monitoring quality initiatives, the plan for training and implementing continuous quality, and method(s) of CQI to be adopted.
Once implementation of the CQI effort has begun, the council’s role will change to include
eliminating barriers, establishing guidelines for team activities, ensuring implementation of
appropriate solutions, and supporting medical staff involvement. The quality council also may
recommend changes in the facility’s management structure. The council is an important
resource for training, reward and recognition, budgeting guidelines, communication of CQI
activities, and ensuring that teams are given the time they need to fulfill their commitments.
As a monitoring body for assessment of CQI progress, the quality council communicates
plan updates to reflect changing directions based on improvements made. Although reporting
may be accomplished through the organization’s quality assessment committee, the quality
council must perform monitoring activities that ensure organization-wide involvement. A sample reporting structure is shown in Figure 4.3. The board of directors reads the flowchart
because, to meet JCAHO standards, the board must be informed of quality activities within the
organization. Whether an organization is JCAHO certified or not, reporting would likely occur
at the board level. The CEO (or his or her designate), the next reporting level, is informed of
the implementation and training activities for CQI, of the consultants’ progress or role, and of
the quality assessment activities of both the medical staff and the hospital.
Although the flowchart becomes slightly more complicated below the CEO level, keep in
mind that the structure is short term. Both the consultants and the quality council will cease
Quality Management
Figure 4.3. CQI Flowchart
Board of directors
Quality council
for CQI
Hospital quality
assessment committee
Medical staff quality
assessment committee
Quality improvement
quality assessment
to exist when the organization’s culture has changed sufficiently to emphasize quality in all
activities. Once this transition has been made, the medical staff quality assessment committee
and the hospital quality assessment committee will continue to work together and interact with
quality improvement teams. Existing hospital and medical staff committees can be used to
process information or to act as quality teams for process improvement. Nonclinical departments should be included in the reporting process to allow full organizational participation in
quality improvement.
The quality council may decide to create critical indicators for the organization to determine whether customer satisfaction is being met. This may include developing and administering—or contracting with an outside source to develop and administer—a customer satisfaction
survey. The council must decide whether the survey will be used to assess internal performance
only or to measure performance against other similar institutions. The quality council also will
coordinate with the human resource department to develop a performance management system
that supports and encourages participation in quality initiatives by all individuals throughout
the institution.
Components of the Food Service CQI Plan
A CQI plan for health care nutrition and food services has three components: quality control
to ensure safe and wholesome products, customer service, and clinical quality assessment. The
following sections describe each component.
Quality Control
Quality assessment measures the overall quality of care delivered to patients, whereas quality
control as it relates to food service management measures systems for handling, preparing, and
serving food. Customer satisfaction is gauged by addressing quality from the customer’s point
of view—for example, food temperature, appearance, palatability, and nutrition content. The
Food Service Manual for Health Care Institutions
handling, preparation, and service of food also are measured against standards for infection
control, aesthetic appeal, and safety. Feedback tools in a quality control program may include
the following:
Sanitation reports (internal, external)
Safety reports
Temperatures of refrigerators, walk-in refrigeration units, and dish machines
Downtime on the tray line
Cart delivery time
Trays per labor minute
Portion control
Food temperatures
Patient questionnaires or surveys
Verbal compliments and complaints
Comment cards
Observation of customer service as measured against preestablished guidelines
Timeliness of cafeteria service and other meal service
The quality control program must be adhered to in every food and nutrition service department. If the program is carefully developed, monitored, and evaluated, and if it has built-in
routine follow-up procedures, CQI and customer satisfaction are enhanced.
A comprehensive quality control program includes written policies and procedures with
established standards that help identify strengths and weaknesses in food and service quality.
Once standards or guidelines are in place, appropriate training must be completed to convey
responsibility and expectations to staff and supervisors. The standards are then used to measure compliance so as to ensure consistent and safe operations.
Quality Control of Food Products
The sampling of food products, measurement of food temperatures, and sensory appraisal of
product characteristics allow comparison of observed quality with the standard established for
each item. Inspection criteria for food production and service include food appearance, taste,
texture, and safety and tray appearance. Through evaluation and analysis, food service directors can identify what went wrong, how often, and why. For example, evaluating a patient tray
would include making sure that an attractive garnish is present, that the meat is adequately
browned, that the vegetables complement the meal in color and are not overcooked, and that
everything is at appropriate serving temperature. Then corrective action can eliminate or
reduce quality deficiencies.
Success of a quality control program depends on the commitment of all employees to the
provision of high-quality food. Quality control activities should be incorporated into regular job
routines and duties for each position. For example, each position on the tray line can be responsible for checking temperatures and ensuring that each menu item is attractively served on the
plate. Failure of staff members to follow established criteria for food product safety should be
documented and addressed. The director should prepare a food service quality checklist as a routine evaluation tool. Exhibit 4.2 is an example of quality checklist inspection criteria.
Customer Service and Satisfaction
Whether it is called guest relations, customer service, or customer relations, the concept is the
same. It is estimated that more than 60 percent of the nation’s hospitals have introduced some
type of customer relations training for their employees. The purpose of these programs is to
improve customer satisfaction to obtain repeat business and to increase market share through
word-of-mouth referrals. Often customer satisfaction is based on the interaction between
Quality Management
Exhibit 4.2. Inspection Criteria for Food Production and Service
Food appearance
Satisfactory and appropriate color and texture
Pleasing and varied food color-texture combinations
Attractive garnishes
Variety in shape and size of food items
Adequate portion size
Food taste
Pleasant flavor combinations
Taste integrity of each item
Adequate seasoning
No undesirable or odd flavors
Pleasing aroma
Proper temperature
Food texture
No item overcooked or undercooked
Variety of textures
Suitable moisture content
No toughness or stringiness
Suitable for consumers being served
Food safety
Proper hot serving temperatures: for liquids, 185°F (85°C); for cooked cereals, 175°F (79°C); for
soups, 180°F (82°C); for meats, 150°F (65°C); for eggs, 145°F (63°C); for vegetables, 160°F (71°C)
Proper cold serving temperatures: for liquids, 35°F (2°C); for solid foods, 45°F (7°C)
Foods prepared and portioned using utensils or disposable gloves to avoid contamination by
employees’ hands
Two clean spoons used for tasting food products
Special care used in handling clean dishes and flatware to prevent contamination
Unused raw ingredients or cooked leftover foods labeled, refrigerated promptly, and used
within 24 to 48 hours, frozen immediately, or discarded
No reuse of single-use utensils and containers
Employees’ clothing and personal hygiene at established standards
Tray appearance
Adequate tray size, no overcrowding
Specified setup used
Each item placed on tray correctly and arranged for eating convenience
Dishes and flatware in good condition
Food neatly served
Separate dishes for foods that contain liquid
Neat overall appearance, no spills
Tray accuracy
All food items specified on menu present on tray
Food on tray allowed on patient diet
No unnecessary utensils on tray
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the customer and service personnel and occurs at the time service is delivered. In this respect,
customer satisfaction depends on employee performance. Research conducted on the results of
meeting customer needs has shown measurable benefits in profits, cost savings, and market
share. Customers often do not complain when they have received less-than-satisfactory service;
however, they do tell nine or ten other people about the problem. It is estimated that it costs
an organization five to six times as much to gain a new customer as it does to keep a current
one. To retain current customers while attracting new ones, health care food service managers
must strive toward two goals. First, they must instill in employees the fact that customer orientation drives customer satisfaction. Next, they must design and launch a strategic quality
service plan.
From Customer Orientation to Customer Satisfaction
To embrace the concept of customer relations, employees must first recognize that they have
customers. Customers include patients, residents, their families and significant others, physicians, and other staff members. The thought of identifying a patient as a customer has been disconcerting for some health care professionals, but without viewing patients as end users of their
services, providers do nothing more than develop systems and processes for their own convenience. Although these systems and processes may be based on the best medical practice and perceived need, they often are created at the expense of customer satisfaction. Referring to patients
as customers recognizes their autonomy and capability of demanding high-quality care and
information about the services they buy.
The nutrition and food service department can play a key role in developing a positive
image for patients and their caregivers. Although much of what customer–patients come in contact with in the hospital setting is technical and beyond their general understanding, food is the
one thing they do know. They know whether the food is prepared to their satisfaction, whether
it is delivered when they are hungry, whether it is at the right temperature, and whether the person delivering the meal is polite and attentive to their needs. Therefore, it is vitally important
for the food service manager to ensure that staff understand their role in customer satisfaction.
Although the customer–patient is certainly a key focus, this is not the only type of customer encountered by food service employees. Physicians, family members, and other hospital
staff are served in the cafeteria, physician dining rooms, coffee shops, and so on. Service quality can be compromised not only because it may be difficult to persuade food service staff to
accept other hospital employees as customers but also because satisfaction is based on customer
expectations and perceptions. By comparing their expectations of service quality with actual
service delivery, they judge whether satisfaction has been attained.
From Service Plan to Customer Satisfaction
In the book Service America, Karl Albrecht and Ron Zemke identify three features of outstanding service organizations: a defined, customer-focused service strategy; customer-oriented
frontline employees; and customer-friendly systems.
It is impossible to expect employees to provide exemplary service if no quality service plan
or strategy is in place. A service strategy is based on feedback from the customer and also on
the organization’s strategy and mission. The plan should include a written statement or mission
that all employees can understand and support. A health care food service strategy may include
the following elements:
Greeting customers appropriately, making eye contact
Extending extra effort to be helpful
Providing timely and prompt service
Listening to customers’ needs and responding to them
Maintaining appropriate appearance according to departmental policy
Maintaining a safe and pleasant environment
Providing what was promised
Quality Management
Once the departmental strategy is written, employees must be trained to deliver the service as outlined. Training may be done through modeling behavior, scripting phrases for greeting customers, or practical examples of ways to handle specific customer issues or requests.
This strategy and training are useful in developing customer-oriented frontline employees.
Comment cards on patient trays or on cafeteria tables can be used to identify what customers want. Traditionally, institutional food service has been viewed as less than satisfactory by the general public, a perception confirmed by national surveys on hospital food
service. This perception can be overcome by a commitment to ask customers consistently
what they want and whether their expectations are being met. This can be done with written surveys or, for inpatients or residents, through one-on-one interviews during meal
rounds. Cafeteria customers can be given a written survey or asked by frontline employees
to participate in a focus group to gauge their acceptance of meal items and the quality of
service provided.
Used consistently as monitoring and measuring devices for service performance, these
feedback mechanisms keep managers up-to-date regarding customer perception of timeliness of
meal service, temperature of food items, and staff courtesy. Once surveys are tabulated, they
should be analyzed for potential problem areas so that action plans can be created and implemented for improvement. Ongoing surveys provide feedback to determine in turn whether the
action plans were effective.
Customer-friendly systems are based on understanding what the customer wants, and in a
quality-oriented and participative work environment, feedback is encouraged so as to get this
information. Employees are best positioned to know which systems or processes are not customer friendly and in some instances can work around these systems to offer better service.
Policies and procedures are developed to ensure safe, consistent service, but before being implemented, they should be evaluated from both the customer and employee points of view.
Management can then evaluate how relevant these guidelines are to promoting customer satisfaction. Once a system or process is identified as not being customer friendly, customers’ input
must be obtained to correct the situation.
Clinical Quality Assessment
The quality assessment program, according to the JCAHO, is an ongoing, planned, and systematic process to monitor and evaluate the quality and appropriateness of patient care. It is
used to improve clinical patient care and to identify problems. The minimum requirements of
the quality assessment plan include
• The use of relative indicators or performance measures
• Ongoing monitoring (that is, a process that tracks quality assessment system components to determine the system’s level of compliance to the indicators)
• Analysis of performance data against reference databases (benchmarking)
• The use of multidisciplinary teams when processes and systems are being evaluated
across departmental lines
• The use of individual peer review when the performance of an individual practitioner is
being evaluated
• Annual review and revision of the plan to ensure effectiveness
Although the JCAHO appears to be moving away from thresholds, currently it requires
ongoing monitoring against established thresholds. CQI, on the other hand, emphasizes changing the target as improvement occurs. However, ongoing monitoring is compatible with the
quality control aspects of CQI. The JCAHO is looking for sustained improvement over time,
and if the threshold is met consistently, monitoring can be deferred until a later date but must
occur again to ensure sustained improvement or compliance.
Food Service Manual for Health Care Institutions
The JCAHO still emphasizes the concept of individual competency—that good results occur
when competent people work in effective systems. The JCAHO also recognizes that ineffective
systems can hinder good performance and results. Thus, when individual weaknesses do occur,
the organization is expected to identify them and provide guidance or training for improvement.
Peer review continues to be a part of the JCAHO’s standards, indicating the persistent need
for professional judgments in the review of process and of individual performance. The best
judgments must be made based on the latest information available. In the JCAHO’s view, those
best qualified to determine whether the best judgment was made are peers.
Methods and Tools for Assisting with CQI
Health care quality programs are following many paths to provide improved care at the lowest
cost. Some programs strictly adhere to the TQM model established for industry, and others adapt
some of the tools from TQM or other methods. Alternative methods in use include (but are not
limited to) critical paths, comparative outcome measures, case management, and process reengineering. This section first examines the role of consultants and their value to the CQI effort. Then
a brief overview of each of the four cited tools and methods of achieving CQI is presented.
Role of Consultants
As more health care organizations implement a CQI process, more individuals will become proficient in its implementation and facilitation. When this occurs, consultants may not be the first
choice for health care institutions, especially if the organizations have strong management
teams capable of coaching, teaching, and facilitating. However, it may be necessary for an
organization to contract consultants to begin the quality improvement process. If this is the
case, care should be taken to ensure that dependence on their expertise is not created. As soon
as possible, the organization should move to in-house trainer–facilitators to promote a sense of
ownership and to reduce cost. Consultants should be selected based on the quality of their
training materials and on their commitment to make the organization self-reliant. Future support from the consulting firm also must be considered. For example, if the company continues
to revise and update training materials, what provision will be made for the health care facility to acquire those materials?
A consultant can be beneficial to a facility seeking to implement a CQI process. The consultant can serve many roles and offer an outside unbiased assessment of the organization.
Roles might include the following features:
• Providing expert advice and information on CQI processes as they relate to health care
• Providing information about what has and what has not worked based on their experiences with other health care institutions
• Using their expertise and objectivity to identify barriers and problems within the organization that may hamper the implementation of CQI
• Assisting with an audit or assessment of organizational culture and acting as an agent
of change to move to a culture that supports CQI
• Assisting individual managers and departments that may have difficulty accepting or
persuading employees to accept the CQI philosophy
• Providing initial training and assisting in-house trainer–facilitators with techniques for
becoming self-sufficient
• Customizing quality processes and concepts to meet the needs of the facility
• Serving as continued outside support for training material, networking with other facilities, and promoting a positive image of the organization and its CQI efforts
Quality Management
Before hiring a consultant, management must evaluate the pros and cons of its decisions.
On the positive side are the reasons cited above. In addition, an outside consultant may be seen
as more knowledgeable and creditable than anyone inside the organization. To “groom” an
internal expert is both time-consuming and costly. Even after he or she is trained, an in-house
expert may be confronted with organizational politics, resistance from managers who reject
them as experts, or both. Qualified outside consultants can speed the learning process, thus
accelerating the CQI effort. Although sharing information from other industries is helpful, it is
important that the consultant hired have experience in health care. If hired specifically for food
service, the consultant should be knowledgeable of health care food service operations. Finally,
a consultant can help assess the readiness of the management team and the organization to
move toward a quality-focused culture.
Disadvantages of using a consultant also must be weighed before the decision is made.
Using consultants can be expensive for the organization and, if not handled carefully, consultant dependency can occur. Because a consultant is there to answer all the questions that arise,
internal knowledge may be slow to develop, and employees may be slow to take ownership of
the process. Ownership also may be hampered because employees view the approach as canned
and not responsive to the organization’s individual needs. This may lead them to believe that
once the consultants are gone, the “program” will be over and gone. In addition, consultants
unfamiliar with the priority of organizational commitments may fail to consider the time constraints on managers.
Quality Programs
Quality programs continually change and have evolved from quality control ➞ quality assurance
➞ continuous quality improvement ➞ total quality management ➞ satisfying the customer ➞
ISO 9000 (described in detail later in this chapter).
Quality control is a method or process to ensure that what is produced meets some preestablished standards. Quality control monitors quality at all steps of the operation to the finished product. Quality control ensures early detection of a defective part, procedure, and
process and can save the cost of further work on the item. Measures need to be developed
before implementing the program if less than 100 percent acceptable.
Quality assurance is the next step in the evolution of quality. Quality assurance is a process
of identifying and solving problems within a department or area of an organization. TQM
tools can be used to monitor quality assurance within a food service department.
Continuous quality improvement, CQI, is the process of evaluating which things within an
organization can be improved and what can be done to achieve the improvement. A patient
questionnaire not only indicates what is acceptable but also evaluates what category of food or
service needs to be targeted to achieve improvement. It requires integration of quality and
change targeted to achieve improved management methods, practices, concepts, and beliefs
into the organization’s culture.
Even with these three processes, problems seem to occur that do not have a solution. CQI
uses the tools of TQM, which seeks to achieve continuous process improvement so that variability is reduced. TQM is a management system that has the following six components:
Change the processes, not the people
Focus on the customer
Empower employees
Use a team approach to accomplish change
Control processes through sequential steps
Expect a long-term organizational commitment
Food Service Manual for Health Care Institutions
TQM was designed to look at problems and improvements that could be made across
departmental boundaries. An example would be an interdisciplinary approach to the education
of a patient. TQM puts the focus on the problem or product to be improved. The process is
interdepartmental, and administration usually assigns it to a committee composed of representatives of departments affected by the problem. The committee should focus on a workable
positive outcome for all departments. The committee may be a self-managed group assigned to
work on a specific problem or process, and when the task is completed, it is disbanded. Ideally,
administration assigns a leader who is disinterested, has no vested interest in the outcome, is
able to be objective, and is a good negotiator. A group works best when it can reach an agreeable solution; the solution is implemented, evaluated, and monitored; and necessary adjustments are made.
When a TQM team follows a “standard guide,” consistency and group acceptance seem
to improve. A guide may suggest the following:
• Choose the product or process that needs to be improved. This may be a management
decision or a regulatory problem. For a food service department, this may include
Late tray service
Height or weight of patients
Use of floor stock
Weekend coverage
• Organize the team and appoint a facilitator and a recorder. Depending on the product
or process to be improved, members could include but not be limited to
Personnel from the area of problem
Member of management
Members of departments that are affected by the process or problem
• Use benchmarking data to determine the best performance. Use other data that will provide needed information.
• Perform an analysis to determine how performance standards can be met, improved, or
beat. For example, XYZ hospital can serve nine trays per minute; your facility serves only
seven. What makes the difference: equipment, menu, personnel, materials available, work
methods, or physical conditions? Who serves patients’ trays, food service or cross-functional
trained personnel?
• Devise and perform a pilot study and analyze data: Can time be improved, what is the
cost of improvement, should schedules change or should personnel (or both)?
• Implement and monitor improvements. Will improvements enhance patient services and
meet the needs, wants, and perceptions of patients?
Total Quality Management
TQM provides the techniques, concepts, and tools to analyze data for application in CQI. The
tools of TQM help identify and analyze current processes either within or across departmental
lines. Once data are collected and analyzed, steps can be taken to improve a complex process.
Unnecessary or non-value-added steps can be eliminated and the process streamlined to provide better care or service.
TQM Tools
Statistics-based process control is the foundation of TQM. Tools of TQM, such as flowcharts,
pareto charts, and cause-and-effect diagrams, provide a common statistical language and visual
aids for analyzing a process or problem. Not all TQM tools are required to evaluate any one
process or problem, and only those that clearly will facilitate decision making should be
Quality Management
selected for the issue in question. Quality improvement tools can be divided into two general
categories: those used for problem identification and those used for problem analysis. However,
some tools can be used for problem identification and analysis.
Tools used for problem identification include flowcharts and brainstorming. Recall from
Chapter 2 that brainstorming is a group session devoted to sharing ideas and information without judging their value. A top-down flowchart is explained in Chapter 5. Another type of flowchart is a detailed flowchart that is used to identify steps or tasks in a process. This flowchart
may identify the current path or establish a new road map or direction. Flowcharts are usually
drawn using squares, rectangles, diamonds, and circles, with circles specifying the beginning
and final steps in the process. Squares or rectangles represent the in-between steps, and diamonds represent decision points and questions. Flowcharts are beneficial in that they disclose
duplicate steps and steps that can be combined or performed in a different order to prevent
unnecessary feedback loops. Feedback loops are steps or events that require a product or customer to return to a previous step in the process. An example of a flowchart for the late tray
process is shown in Figure 4.4.
Tools used for problem identification or analysis include pareto charts, cause-and-effect
diagrams, and run charts. A pareto chart is simply a bar graph used to prioritize problems and
determine which should be solved first. In constructing a pareto chart, categories must be
designed and the unit of measure (for example, hour, error, dollar, or job category) selected.
After data are gathered, they must be broken down, or aggregated, by category; items should
be ranked in descending order from left to right. Efforts can then focus on the categories with
the greatest effect or frequency. An example of a pareto chart reflecting the problems associated with late tray delivery is provided in Figure 4.5.
Cause-and-effect diagrams, also called fishbone or Ishikawa diagrams, are used to represent the relationship between an effect and all the possible causes contributing to it. Team
brainstorming may be used to create a fishbone diagram. Causes are generally divided into four
categories: materials, methods, equipment, and employees. An example of a cause-and-effect
diagram related to late tray delivery is provided in Figure 4.6.
Figure 4.4. Flowchart for Patient Late Tray Process
Food Service Manual for Health Care Institutions
Figure 4.5. Pareto Chart of Problems Associated with Patient Late Trays
Primary focus
Secondary focus
Waiting to
prepare all
trays before
Not enough
staff during
peak time
A run chart can be used to identify trends or shifts over several observation periods. Run
charts provide information regarding long-range averages to determine whether changes are
occurring. This allows for an investigation of increases and decreases in averages. For example, a run chart can disclose the number of patients over a twelve-month period who waited
longer than 15 minutes to receive a late tray. Figure 4.7 charts this scenario.
Another common tool used for problem analysis is a control chart. Process control charts
are run charts that allow the use of probability and statistics to set upper and lower control
limits for tasks to study those above or below the norm. A control chart assists in determining
which variations are acceptable and to be expected versus those that are unacceptable.
Unacceptable variations are usually unpredictable and are related to a special cause. Correction
of the variation requires removal of the special cause. Acceptable or expected variations are
usually caused by the process itself, and the only way to correct these variations is to change
the process. Special causes must be eliminated before the control chart can be used as a monitoring tool because as a monitoring tool, chart measurements are expected to stay between the
upper and lower limits established. For example, the start of a tray line may be within plus or
minus 10 minutes of the preestablished time. If a time occurs outside this control, investigation
should occur (Figure 4.8).
Some food service employees may require training in the proper use of improvement
process tools of TQM. A manager or supervisor should work with these individuals to model
the behavior of conducting a meeting, using the tools, and making decisions for improvement
based on the results.
Quality Management
Figure 4.6. Cause-and-Effect Diagram for Patients Not Receiving Late Trays
Input incorrect
from unit
Looking up diet
Menu not delivered by clerk
Record keeping
Tray not prepared by tray line
Changing menus
Staffing during peak times
Patient waiting
longer than
15 minutes for
late tray
Item requested
not in-house
Printer not
Figure 4.7. Run Chart for Late Trays Longer Than 15 Minutes
Number of
Mean =15
Jan. Feb. Mar. Apr. May June July Aug. Sept. Oct. Nov. Dec.
Food Service Manual for Health Care Institutions
Figure 4.8. Control Chart of Tray-Line Start Times
Upper control limit: +10
Number of
Mean: 0
Lower control limit: –10
Jan. Feb. Mar. Apr. May June July Aug. Sept. Oct. Nov. Dec.
Other Regulatory Agencies
The CMS requires an ongoing quality assurance and assessment program that monitors client
care and outcomes. The National Social Security Act mandates that facilities participating in
Medicare and Medicaid programs meet minimum health and safety standards. The requirements pertain to hospitals, skilled-nursing facilities, and a wide range of other providers and
suppliers of health services. State-level officials are generally responsible for conducting on-site
surveys for Medicare and Medicaid requirements. The federal government has the following
Review survey and certification reports submitted by state agencies.
Evaluate fiscal, administrative, and procedural aspects of its agreements with the state.
Conduct some on-site inspections.
Review and approve state budgets and expense reports dealing with survey and certification activities.
Food service professionals have the responsibility to be familiar with the regulations established by the federal government and state regulations for the facility in which they are
Coordination of state licensing requirements and JCAHO and other regulations require
interdisciplinary cooperation and exchange of information. The JCAHO standards generally
meet many of the federal standards. All of these guidelines, recommendations, standards, and
interpretations of each regulatory or professional organization intersect to provide guidelines
for quality of care to clients.
Center for Medicare and Medicaid Services
CMS as an agency of the U. S. Department of Health and Human Services administers the
Medicare program. CMS issues standards that must be honored by institutions such as nursing facilities that receive Medicare funds. CMS and JCAHO standards are similar, but they are
Quality Management
not identical. CMS standards vary in their administration from state to state. Many standards
in CMS address dietetic and food services and are too numerous to detail in this book.
CMS also manages reimbursement through the prospective payment system. This system
dictates that reimbursement for care be based on certain clinical factors that have been defined
and documented.
Standards for documentation are required to help ensure that a facility can receive all reimbursement to which it is entitled. The documentation system uses minimum data sets that identify all the data that feed into the prospective payment system and defines reimbursement.
Minimum data sets must be provided to CMS in an electronic format.
All of the standards deal with reimbursement; however, if quality of service is not geared
toward each client’s need, reimbursement may be limited. CMS uses quality indicators for
tracking and benchmarking care, and these may be found in the standards.
The Food and Drug Administration, U.S. Department of Agriculture, and other governmental agencies ensure that businesses and organizations are accountable to the public. The
Centers for Disease Control and Prevention also evaluate an organization and its procedures in
case of food-borne illness. The Commission on the Accreditation for Dietetic Education oversees dietetic education for both a written review of the programs and a site visit. The Certifying
Board, a separate entity of the Dietary Managers Association, also reviews all of its programs.
ISO 9000 Series
In the 1980s, global corporations began pushing for standards that measure quality management. To compete in a global market, many companies had to offer assurance to purchasers of
their products and services that what they were buying was what was expected. If a company
wants to be able to convey to its customers that its products meet the highest quality, they can
obtain ISO 9000 certification. ISO 9000 is a certificate attesting that an organization’s factor,
laboratory, or office has met quality management requirements determined by the International
Organization for Standardization in Geneva. It demonstrates process quality and consistency
but does not focus on end products. The standards, once met, assure customers that a company
uses specific steps to test products it sells; continuously trains its employees to ensure they have
up-to-date skills, knowledge, and abilities; maintains satisfactory records of operations; and
corrects problems when they occur. Companies achieving this certification have demonstrated
that they are environmentally responsible. The certification is costly (may be several hundreds
of thousands of dollars) and may take a year or more to meet the goal.
JCAHO Dietetic Standards
JCAHO has established specific standards for nutrition services. Other standards that relate to
dietetic services have been integrated into other unit standards such as leadership, infection control, engineering, and patient rights. These standards are universal throughout the organization.
JCAHO issues its Accreditation Manual for Healthcare once a year. Annual reviews of
these standards ensure continued compliance. A rating scale of 1 to 5 (with NA for “not applicable”) is used to help an institution and the JCAHO surveyor determine the degree of compliance with the standards for each department.
An organization that is routinely surveyed by the JCAHO must obtain a new Accreditation
Manual for Healthcare annually to ensure continued compliance. Some of the recent changes
have specific effects on nutrition and food service departments.
The specific standards for nutrition service will not be discussed in this book. Standards
should be reviewed annually and, as applicable, processes should be implemented to focus on
patient care. An organization’s quality control or quality assurances educator should be consulted for input. The JCAHO Web site ( is updated frequently. It contains
information on preparing for a hospital survey, changes in standards, and the latest information relating to JCAHO.
Food Service Manual for Health Care Institutions
Critical Paths
The JCAHO defines critical paths as a “[d]escriptive tool or standardized specification(s) for
care of the typical patient in the typical situation; developed by a formal process that incorporates the best scientific evidence of effectiveness with expert opinion. Synonyms or near-synonyms include clinical policy, clinical standard, parameter (or practice parameter), protocol,
algorithm, review criteria, and preferred practice pattern.” Interdisciplinary standards of care
for particular patient types can be used to establish quality criteria for measurement. If databases that include a large number of facilities are used, practice patterns can be developed and
tracked for improved patient outcomes. Dietitians should be involved in developing critical
paths to ensure that the appropriate nutritional intervention is included.
These types of protocols or practice guidelines provide a means of bringing physicians into
CQI. Independent of the TQM movement, for many years the American Medical Association
has been a proponent of practice guidelines. These guidelines become critical paths and help to
define when there are variations in care. Once the critical paths have been used for long periods, it is possible to identify expected variations versus unexpected variations in care and outcome. Critical paths are used to reduce variations in treatment from a clinical standpoint.
However, these variations should concentrate not just on variations of practitioners but also on
the hospital systems that may contribute to the variations. Health care institutions must pay
attention to operational systems as well as to clinical systems to effect a true picture of CQI.
Comparative Outcome Measures
As stressed throughout this chapter, information and data are of primary importance in quality improvement. Data provide the information necessary to determine where efforts should be
concentrated. Severity-adjusted databases have become more common over the past few years
and are being used by a number of businesses to provide comparisons on physicians and hospitals during provider contract negotiations. Health care institutions, through cooperative partnerships, have established comparative databases to assess variations in practice patterns that
are used as indicators of quality. Through the use of these databases, hospitals can determine
which diagnosis-related groups should receive special emphasis and will have the greatest
return in improving patient care and reducing associated costs.
Standards established by databases with many contributing hospitals can provide information on length of stay, charge or cost of care, and mortality. This information can be used
to focus quality initiatives within a facility. Morbidity can be indirectly assessed by length of
stay. No outcome data currently in use can define absolute medical quality, but measurements
of these aspects of quality can be useful for physicians and health care organizations to use their
time and other resources more wisely and begin problem solving. Such comparisons must be
adjusted for severity against an established norm. There is no consensus among health care
practitioners regarding the use of severity-adjusted databases because of fear that not every
variation between facilities can be taken into consideration and boiled down for a simple comparison. However, these types of comparisons seem inevitable, and at least twelve states currently have established severity-adjusted databases.
The federal government uses a similar database, called MEDPAR, with Medicare patient
information. Although proponents recognize that only practitioners with the patient and medical record in front of them can truly define the quality of care, they think that some aspects of
care are measurable.
Case Management
Closely related to critical paths is the concept of case management, which furthers continuous
quality initiatives by allowing a coordinated prospective review of patient care, that is, review
before admission. A case manager participates in planning for a patient’s admission, monitoring
Quality Management
the concurrent stay using critical paths, and retrospectively evaluating the stay after discharge.
A nurse or other health care professional is responsible for coordinating all aspects of care during the patient’s stay. This may also be referred to as outcome management.
Case management is seen as a method to improve inpatient care; decrease length of stay;
reduce rate of readmission, negative outcome, or both; and provide cost-effective care.
Discharge planning begins at the time of admission to ensure a smooth transition to home with
no additional care, to home with home care services, or to a long-term care facility.
Process Reengineering
TQM stresses the use of statistical tools to identify and modify work processes on a continuous basis. These modifications are generally incremental and implemented over short time
frames. Process reengineering, on the other hand, makes radical changes by creating new
processes to replace inefficient ones. Accomplished through team effort in a concentrated time
frame and generally taking longer than the time needed to make minor quality improvements,
process reengineering is most useful when the scope of the project is cross-functional and complex. Reengineering may require a structural change as well as a cultural change in the organization. Rather than using statistical tools, a modeling process involving computer technology
is used.
Process reengineering is an analytical approach to quality improvement, with analysis
occurring from the top down. For example, the late tray process diagrammed in Figure 4.5
would begin with providing a patient with a late tray. From this point, the various steps would
be charted with second-level steps and possibly even substeps to the process. This breakdown
allows each activity to be subcategorized to the lowest level necessary to facilitate transformation or improvement. Process reengineering also provides information regarding the inputs to
the process, outputs of the process, controls affecting the process, and mechanisms used to
complete the process.
Benchmarking is the practice of comparing the performance of key indicators of an organization or company’s operation in-house vis-à-vis with similar operations in other organizations
producing the same type of products using a measurable scale. Benchmarking also measures
performance and quantitative productivity against standards. Benchmarking is a TQM tool
that allows an organization or company to set attainable goals based on what other organizations or companies are achieving. Benchmarking can also identify trends that need to be monitored. Benchmarking food service is easier to quantify than clinical (patient care) productivity;
however, clinical productivity can also be measured using different tools to monitor quality,
quantity, and outcomes.
Benchmarking may be internal and external. Internal benchmarking compares current
data with records of past data (performances or standards) to determine if its own standards
are met or surpassed. External benchmarking compares an organization or department’s performance and productivity with that of other organizations of comparable size or service to
determine whether the organization is performing at, above, or below the established industry
standards. Internal benchmarking allows a manager to compare data, note variation, identify
why something occurred, and justify the reason. If there is a pattern developing, the manager
can use the data to change schedules or production methods or revise standards. Whatever the
reason for a change in quantity, quality, or outcomes, it must be evaluated for positive or negative effects on the organization. When changes are made, they will need to be monitored and
evaluated for effectiveness and for meeting outcome goals.
External benchmarking is more difficult because it involves comparing organizations within
an industry. Comparing the performance of a small community hospital with that of a large
university hospital is difficult and perhaps invalid. To obtain data that is valid and useful, the
Food Service Manual for Health Care Institutions
comparisons should be made using standards that are similar to each other in size, governing
authority, self-operation, management, services provided, or the ability to share meaningful
Many professional food service organizations offer benchmarking services. There are also
benchmarking companies that collect data on a nationwide scale and that will compare one
organization against another. These companies set standards and costs for their services.
In the past, health care institutions measured the quality of clinical care with an emphasis on
quality assessment. Quality assessment focused on reactive or retrospective monitoring of individual variance and performance. The recent emphasis on CQI views quality in terms of both
process improvement and customer perspective.
Continuous quality improvement is influenced by regulatory agencies, but a qualitycommitted organization will practice it with or without outside influence. Benefits of CQI include
customer satisfaction, employee morale through involvement and ownership, and a costeffective business approach that offers better value to the customer. The best reason for an organization to adopt a CQI agenda is to compete at a higher level, improve quality, and reduce cost.
An organization can expect to generate from 20 to 30 percent in cost savings by implementing a CQI process. The costs of implementing a CQI process include the labor for training and conducting team meetings, training materials, and possibly the use of a consultant.
These costs are more than offset by the savings generated when processes are improved to
decrease non-value-added steps. Occasionally the solution to a process or system problem will
cost more in the short term to correct than to leave it as is. But when the cost of the solution
is considered over the long term, with the customer in mind and in regard to total savings from
process improvement, it may be determined to be the best solution.
Albrecht, K., and Zemke, R. Service America. Homewood, Ill.: Dow Jones-Irwin, 1985.
Black, J. S., and Porter, L. W. Management Meeting New Challenges. Upper Saddle River, N.J.:
Prentice Hall, 2000.
Briefings on Joint Commission on Accreditation of Healthcare Organizations and on Long-Term
Care Regulations. Marblehead, Mass.: Opus Communication, 1999–2000.
Causey, W. B. An Executive’s Pocket Guide to QI/TQM Terminology. Atlanta: American Health
Consultants, 1992.
Causey, W. B. Business coalitions pushing Deming-style “bonding” with hospitals. Quality
Improvement Through Total Quality Management 2(9):129–131, 1992.
Causey, W. B. Clinical guideline movement merging with, supporting TQM. Quality Improvement
Through Total Quality Management 2(12):179–180, 1992.
Causey, W. B. Converting patients to customers a hard struggle in health care. Quality Improvement
Through Total Quality Management 3(1):8–10, 1993.
Causey, W. B. You can’t separate administrative, clinical systems, TQM experts say. Quality
Improvement Through Total Quality Management 3(1):1–8, 1993.
Deming, W. E. Improvement of quality and productivity through actions by management. National
Productivity Review 2(1):12–22, 1982.
Drummond, K., and Raffetto, K. Regulatory Update. Healthcare Food Service Trends, Winter 2000,
pp. 24–26.
Quality Management
Garvin, D. A. Managing Quality: The Strategic and Competitive Edge. New York: Free Press, 1988.
Hogue, M. A. Guidelines to service quality control. Hospital Food & Nutrition Focus 6(7):1–4,
Jackson, R. Continuous quality improvement for nutrition care. American Nutri-Tech [Amelia
Island, Fla.], 1992.
Joint Commission on Accreditation of Healthcare Organizations. 2003 Joint Commission
Accreditation Manual for Healthcare. Vol. 2, Scoring Guidelines. Oak Brook Terrace, Ill.: Joint
Commission on Accreditation of Healthcare Organizations, 2002.
Juran, J. M. Quality Control Handbook. New York: McGraw-Hill, 1951.
Martin, C. A., and Dent, J. N. The impact of TQM implementation on JCAHO accreditation. Total
Quality Management 18(4):357–363, 1993.
Polzini B. Quality: If it’s going to be, it’s up to me. Dietary Managers 10(3):10–14, 2001.
Posthauer, M. E. New JCAHO Standards. Presented at the Food and Nutrition Expo and
Conference, San Antonio, Texas, Aug. 25, 2003.
Puckett, R. P. JCAHO’s agenda for change. Journal of the American Dietetic Association
91:1225–1226, 1991.
Puckett, R. P. Continuous quality improvement: Where are we going in health care? Topics in
Clinical Nutrition 7(4):60–68, 1992.
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Rodriguez, S. Culture shock—the road to TQM. Quality Management 58(4):8–9, 1992.
Schiller, M. R., Miller-Kovach, K., and Miller, M. A. Total Management for Hospital Nutrition
Services. Gaithersburg, Md.: Aspen, 1994.
Walton, M. The Deming Management Method. New York: Dodd, Mead, 1986.
Chapter 5
Planning and Decision Making
Planning has been identified as the first function or step in management and is applicable at
all levels of management. It also defines an organization’s goals and establishes a process of
determining how the management system will achieve its goals, how it will get where it wants
to go. The purpose of planning is to help organizations reach their objectives. Generally speaking, the higher the level of management, the more time is spent in formal planning activities. Formal planning is performed on a regular time cycle by a group of people working
together. Formal planning involves the use of systematic procedures and comprehensive data
and is recorded in writing. Upper management may spend as much as 50 percent of the time
planning, compared with less than 10 percent by first-line managers. Planning can be defined
as the process of identifying expected outcomes and determining possible courses of action
using appropriate resources to achieve the desired outcome.
Planning involves setting goals and objectives for the organization and its various units. A
goal is a broad term used to describe what an organization hopes to accomplish over a relatively long period. Objectives are more concrete and specific statements of how an organization or a unit in the organization intends to accomplish a goal. In addition to setting goals and
objectives, planning involves developing strategies. Strategies are precise action plans for
achieving the organization’s goals and objectives while making the best use of its resources.
Health care food service planning is designed to support organizational goals or mission,
meet customers’ needs, and provide for efficient and effective use of departmental resources.
To accomplish this, planning must respond to the demands of the external and internal environmental trends and issues addressed in Chapter 1. Knowledge of these trends allows a manager to
be proactive in establishing future objectives and strategies or action plans that take advantage of
projected shifts in the business environment. Planning sets the framework within which the other
management functions—decision making, organizing, staffing, leading, and controlling—can be
Planning applies to diverse activities in the food service department and varies in complexity from writing an annual business plan to preparing daily menus or work schedules. Food
service managers may be required to plan or help plan any number of organizational agendas.
Some of these are
• Annual objectives as part of the institution’s business plan
• Policies and procedures
• Projects or new business opportunities
Food Service Manual for Health Care Institutions
Human resource recruitment and retention
New or remodeled facilities
Departmental safety
Continuous quality improvement and customer satisfaction activities
Strategies for support of a new product line
Patient-centered care strategies
Employee performance planning
In this chapter, steps in the planning process are discussed, including key types of planning
and how they apply to nutrition and food service department operations. A model and steps
are provided for writing a department business plan based on the organization’s strategic focus.
An approach to writing up departmental policies and procedures is presented, as are tools for
monitoring planning efforts and specific suggestions for writing effective objectives. Finally, the
decision-making process, including group decision making, and planning for change are
Planning Process
The planning process in a participative organization is characterized by involvement of managers
and employees at as many levels as is feasible. In Chapter 2, three levels of employee empowerment (participation) were identified as suggestion involvement, job involvement, and high
involvement. The extent of involvement by various levels of management and employees
depends on the type of planning and the level of participation with which the organization or
department is comfortable. In most organizations, top managers set the organization’s overall
goals, middle managers set their departments’ objectives for meeting those goals, and first-line
managers make everyday strategy decisions in fulfilling their departments’ objectives.
Kinds of Planning
There are three basic kinds of organizational planning: strategic planning, operational planning, and individual performance planning. Strategic planning assists management in making
nonrecurring, significant decisions that affect the culture and direction of the organization. It
also assists the organization in adapting to the external business environment. Strategic planning is based on the values and purpose of the organization, in addition to the expectations of
customers and the community at large.
Operational planning deals with the process by which the organization’s larger mission
and long-range goals are broken down into shorter-range objectives and activities. This type of
planning is accomplished by members of a particular department or unit.
As they develop operational plans, managers prepare standing plans, periodic plans, or
single-use plans. Standing plans guide activities that tend to be repeated frequently in the
organization over long periods. Standing plans include policies and procedures and standards
of operation. Periodic plans identify a specific course of action for a designated period and are
rewritten at the end of that period. Annual department business plans and budgets are examples of periodic plans. Single-use plans define a course of action that is not likely to be repeated,
such as program or project plans (for example, remodeling the cafeteria). Standing plans, periodic plans, and single-use plans represent the major outcomes of operational planning.
The third kind of planning, performance planning with individuals within the department,
is often overlooked by managers but is essential in setting goals for individual performance.
Performance planning attempts to elicit maximum motivation and commitment from individual employees to contribute to departmental and organizational goal achievement. Individual
performance planning as it relates to coaching is discussed in Chapter 8. The remainder of this
chapter focuses on strategic and operational planning.
Planning and Decision Making
Steps in the Planning Process
To plan effectively, it is important to know the organization’s current status; what factors influence its future; and how the organization, department, or employees must be positioned to
attain success in that future. Although the following seven basic steps apply more directly to
strategic planning than to operational planning, they have applicability in all levels of organizational planning.
1. State organizational objectives in a clear concise method before beginning to plan.
2. Collect data. Gathering information such as forecasts, benchmarking, competition,
and the like to identify the organization’s or department’s current status and strategies
and to predict future implications will yield details of internal strengths and weaknesses and external opportunities and threats.
3. Analyze the data collected. Analyzing the information assesses what effect it has on
current organizational strategies and identifies alternative or new strategies.
4. Develop goals and objectives. Based on the information gathered and the strategic
focus established, long-term and short-term desired outcomes can be identified. This
step also includes assigning specific time lines for meeting objectives.
5. Develop action plans. These delineate specific assigned responsibilities, contingency
plans, and time frames for task completion.
6. Implement the action plans. This step begins movement toward the established
7. Monitor or evaluate plan effectiveness. Was the action plan appropriate to the objectives set and to the degree of goal attainment accomplished? If not, the action plans
and objectives should be reevaluated. Feedback is necessary at every process.
The seven steps of the planning process can be examined by grouping similar activities into
three phases: first, data gathering and analysis, including current status, strengths and weaknesses, and opportunities and threats; second, development of goals and objectives with appropriate strategies or action plans; and third, implementation, evaluation, and modification of the
goals and action plans.
Time and the Planning Process
The dimension of time is a major element in all planning activities. Time lines serve to enforce
operational controls, structure, a sense of focus, and direction for everyone charged with carrying out plan objectives. The terms long-range planning and short-range planning are sometimes used to describe strategic planning and operational planning, respectively. As mentioned,
long-range planning involves the major activities or strategic changes an organization will
undertake during the next two to five years, sometimes even as far as ten or more years into
the future. Long-range planning, such as deciding on the organization’s mission and goals, rests
in the hands of top-level managers and the board of trustees. Intermediate-range planning is a
type of operational planning that covers shorter periods, perhaps one to three years.
Responsibility for intermediate-range planning is shared by top- and middle-level managers.
Finally, short-range planning covers operational activities that are to take place in the near
future, for example, the next week or the next fiscal year. Such planning usually involves the
participation of first-line managers and employees.
The time frame for long-range planning depends on the degree of uncertainty in forecasts
and predictions. The further into the future planning efforts extend, the more they are based
on speculation and guesswork and, therefore, the less valid the predictions and subsequent
planning become. For this reason, careful research is conducted to validate forecasts and predictions before long-range planning is undertaken.
Food Service Manual for Health Care Institutions
Planning time frames also are influenced by need. This is especially true for short-range
planning. For example, in planning departmental involvement in implementation of a new
organization-wide safety program, dates for implementation may be set by upper management
based on immediacy of need for the program to control injuries. Department managers would
then be required to develop and implement the necessary objectives and action plan within the
established time frame. Time lines may be influenced by the item being planned, such as the
development and implementation of a particular product line. The organization may wish to
have the new product line available in six months to meet the demands of the market and customers. However, the influence of technology, need for infrastructure changes, or difficulty in
attracting the appropriate human resources may prevent meeting the established time line. In
this case, the nature and complexity of the planning event set the time frame.
Strategic Planning
In health care organizations, the CEO usually is responsible for strategic planning, together
with the board of directors (also referred to as the board of trustees, the governing board, or
the board of commissioners). Most of the time, the board has ultimate responsibility for how
the institution is run, with the CEO representing the board in his or her management capacity.
Depending on the size of the organization and the complexity of its structure, there may
be a planning committee or a department responsible for planning activities. Commonly, a
planning department led by a vice president or director is responsible for gathering and disseminating information for individuals at various levels who assist in planning activities. Often
large organizations use outside consultants to conduct an internal analysis and make suggestions for areas that need attention. Strategic planning is long-range planning that focuses on
the organization as a whole and that matches an organization’s resources and capabilities to its
market opportunity for long-term growth and survival. It involves defining a clear organizational mission, setting appropriate objectives, designing a sound business plan, and coordinating functional strategies. The following sections describe the three phases of strategic planning.
Phase 1: Data Gathering and Analysis
Collecting and analyzing data are the basis of long-term strategic planning for the organization. Organizations with planning departments have the capacity to gather and analyze data on
an ongoing basis. Others may assign this responsibility to individuals in the organization or
rely entirely on consultants. Either way, a number of activities must be carried out continuously
to ensure availability of adequate information for long-range planning. These include
• Conducting market research and analysis to identify current and potential customers;
this includes collecting data on consumer markets
• Gathering information on customers’ profiles, including average age, which services
they use, their sources of payment for these services, how long they stay in the institution, why
they choose to use the services, and what other services they may want
• Monitoring current market share and forecasting future market share activity; market
share is defined as the percentage of patients using the institution compared with the total
number of possible patients in a designated area
• Conducting an internal analysis of the services offered, number of admissions (inpatient
and outpatient), emergency department visits, length of stay, patient days, surgical procedures,
meals served, and other specific departmental activity and financial reports that may help guide
• Gathering information on physician referral patterns to other hospitals and physicians;
other physician-related information includes average physician age, specialties, number of
admissions, and level of satisfaction with the services offered by the institution
Planning and Decision Making
• Studying the market for new business opportunities or product lines and making feasibility, pricing, and promotion recommendations
• Collecting information on the external environment (competition, business environment, political and economic trends); information about other health care organizations may
include their past growth and performance, their current position and image in their service
areas, and their current services and future plans
• Collecting information on new technology developments and their effects on the future
of health care delivery
• Collecting and analyzing data on workforce issues to predict labor requirements
• Monitoring and collecting information on the facility’s financial operation; for example,
data on expenditures for personnel and equipment and supplies
Designing systems and methods for gathering the above information may fall to the planning department or committee or be handled by the institution’s marketing department. The
methods for acquiring this information are reviewed in detail in Chapter 3.
Once the appropriate data have been gathered, the organization’s current business position
must be evaluated. This evaluation is conducted by the board, the CEO, top-level managers,
and possibly a consultant. Analysis of the internal environment includes identifying the organization’s current strengths and weaknesses as well as opportunities and threats (SWOTs)
posed by the external environment (see the section “Business Planning Phases” for further discussion of this). The external environment is influenced by events and circumstances beyond
the organization’s control. In contrast, the internal environment, although based on external
pressures, is within the organization’s control. Analysis is taken a step further to predict what
probable effect environmental pressures will have on the organization’s operation in the foreseeable future. Based on the information collected, the strategic planning team prepares strategies for responding to the projected environmental influences. For example, the shift from
inpatients to outpatients is an external factor that affects the organization’s future plans for
delivery of service.
As part of the strategic planning process, managers and the board may reconsider the institution’s mission as represented in its mission statement. Typically, the mission statement is a
written document developed by management, with input from managers and nonmanagers,
that describes and explains the organization’s mission and what it intends to achieve in terms
of its customers, products, and resources. The organizational mission is the purpose for which,
or the reason why, an organization exists. For example, the statement may include a description
of the hospital’s primary functions, its philosophy and values, the levels of care and types of
service it offers, the population or special groups it intends to serve, and its special relationship
with other organizations. A mission is defined by what organizations stand for and how they
perceive their function in the community and to their customer base.
In addition to a mission statement, an organization may write a vision statement. The
vision statement is designed to denote where the organization would like to be positioned in
the future. Without a vision of where the organization is going, it is impossible to devise a plan
to get there.
A value statement may be included in the mission statement but more frequently is a standalone statement of beliefs about what is right or wrong or what the organization values. Values
shape the way an organization and individual behaves. Values must be accepted by the organization, be clearly written, and be carried out by top management on a daily basis.
Phase 2: Establishing Goals, Objectives, Strategies, and Plans
Based on evaluation of the data, goals and strategies are set for the entire organization and are
the basis of the departmental business plan and objectives. Strategic plans focus on the future
of the organization and incorporate both internal and external environmental demands and
Food Service Manual for Health Care Institutions
resources needed to achieve these plans. Tactical plans are plans that translate the strategic
plans into specific goals for specific units within the organization, plans that departments will
carry out in the short term. Once goals and strategies are written, they are evaluated to determine whether and how they best fit the organization and their potential for leading the organization to success. Selection of strategies should reflect a balance between the organization’s
potential for taking advantage of opportunities or overcoming threats and the values of its
management and established mission.
In addition to forming the basis for department planning, the identification of goals and
strategies for the entire organization requires upper management to form and be responsible
for specific action plans at their level. An example of an objective and action plan is the development of the organization’s long-term capital expenditure plan. This budget is based on the
need for resources identified in both the long-range strategic planning and the departmental
planning process. The long-term capital budget must be approved by the governing body
or board. The capital budget is the organization’s action plan for fiscal and other resource
Action plans focus on how the goal and objectives of the strategic planning process are to
be accomplished. Department directors can expect to become involved in this phase when the
chosen strategic alternatives affect their departments or are relevant to all managers throughout the organization. For example, the planning committee may decide that the institution
must improve its management competence at all levels and, therefore, establishes a plan for
organization-wide management training.
Action plans include designating the person (or group) responsible for completing the
activities, along with specific statements of the measurements used to identify when the objective has been met. Time lines are specified for each step in the action plan to ensure that
objectives are met according to the established strategic plan.
Phase 3: Implementing, Evaluating, and Modifying Goals and
Action Plans
Once an organization knows its mission, vision, values, and strategic direction, it has a strong
foundation for implementing operational planning and setting objectives. However, an organization concerned with long-term success will not stop at implementation but will continue to
gather information, evaluate its mission in light of that information, and adjust its strategic
plan as necessary.
Strategic thinking moves with the environment; as the environment changes, the organization must respond and adapt accordingly. An example is a change in an organization’s financial status, a real issue for many institutions across the country. Even organizations that were
once in financial trouble but managed to recover have to modify their strategic focus for future
advancement, not just recovery.
Middle Manager’s Role in Strategic Planning
Although information collection is important to strategic planning, much of it also is valuable
to operational planning. Department managers must be aware of what is being monitored or
surveyed in their organizations and use these data in operations planning. Upper management
must communicate to department managers and staff the organization’s future direction and
provide regular updates on goal accomplishment. Providing communication on these issues is
important to having a highly committed and motivated workforce.
During the early phases of strategic planning, middle managers are often a source of data,
reports, and knowledge for strategic planners. If appropriate for the alternatives being considered, department directors also may be asked to respond. For example, the food service director might be called on to find outreach contracts for the delivery of nutrition services in
Planning and Decision Making
physicians’ offices, wellness centers, and extended care facilities. A food service director might
need to answer any number of questions about suggested alternatives. For example:
• How would the new strategy fit the established objectives of the department as well as
the values and beliefs of its staff?
• Would the department be able to implement the new strategy with its current resources,
or would new resources be needed?
• How much would it cost the department—in human resources, time, money, equipment,
training for new methods, and other support systems—to implement the strategy?
• How would the department need to change its structure or its relationship with other
departments to ensure that the strategy would be implemented most effectively?
• Would this strategy be relevant to the market the department currently serves?
• Would the strategy represent a risk that the department is ready to assume?
These questions would be addressed in the department’s business plan, and objectives
would be written to meet the challenges identified. The department director needs to have a
considerable amount of information before responding to such questions and making recommendations to strategic planners. In addition to increased commitment, motivation, and
involvement of others in the department, gathering this information and evaluating the suggested changes offer two other advantages for the director: having access to more comprehensive information and being equipped to inform and prepare department employees for major
changes that might take place over the long term.
Standing Operational Planning
Primary responsibility for operational planning rests with the manager or director of the food
service department. Standing operational planning is the basis for daily recurring departmental functions and assists in establishing structure and accountability for all members of the
department. The largest portion of this planning are policies and procedures, in addition to
which are departmental reports that monitor financial success and provide information to others within the organization. These reports also form the foundation for information necessary
for periodic planning, such as budgets or business plans. Examples of various reports include
productivity reports; cash register reports; turnover, overtime, and other payroll reports; and
meal equivalent information (that is, the number of meals served).
Policies and Procedures
Policies are general guidelines—usually written—that tell “what to do”—when carrying out
essential and frequently repeated activities. Policies give direction for action and therefore are
helpful in reducing the need to make operating decisions each time an activity takes place.
Procedures can be defined as prescribed ways to accomplish an objective or “how to do it.”
Procedures specify how to do something; who will do it using what skills, materials, equipment, and other resources; and what the time frame will be for accomplishing the task. In contrast to policies, procedures list in chronological order the steps required to achieve an objective
or to carry out a policy. Rules are written statements of what is to be done. An example of a
rule is that the employee dining room will open at the stated times.
Although the policies of the food service department must be relevant to its activities, the
policies also must be consistent with policies of the institution and reflect the requirements of
standard-setting organizations (for example, the Joint Commission on Accreditation of
Healthcare Organizations [JCAHO], discussed in more detail in chapters 4, 9, and 11). The
JCAHO’s standards for dietetic services mandate that policies and procedures be in written
form. The standards must be reviewed annually to ensure departmental compliance.
Food Service Manual for Health Care Institutions
Department Policies and Procedures Manual
Writing a policies and procedures manual is the final phase in a long process of planning
departmental activities. A well-written manual depends on input from a number of sources:
Managers and professionals in the department
The department’s records
Relevant standard-setting organizations and regulatory agencies
Manuals written for other departments
The food service director’s own experience
The policy and procedures manual should be written for the unique operation of the department. Other materials may be useful as guidelines and references. All policies and procedures
in the manual must be consistent with the organization’s policies and accrediting agents.
Although each department’s manual is based on input from many sources and can be written by different individuals, the food service director completes the final editing and approval
of each policy and procedure. Having only one editor will ensure that the writing style and format are consistent throughout the manual. Exhibit 5.1 illustrates the basic format for a policy
and procedure statement. Exhibit 5.2 shows an example of a food service policy. Only policies
that are actually used by the department should be included in the manual.
Once policies have been established, procedures can be developed for carrying them out.
Like policies, procedures should be written for every area of the food service department’s
activities—purchasing, production, service, clinical care, sanitation, and personal hygiene,
among others.
Procedures are usually specific, step-by-step descriptions of a particular technique and
often include illustrations that enhance the description. Each procedure should be described in
a separate entry in the manual.
In addition to a written policies and procedures manual, the accrediting agents also require
the food service department to review and update the manual annually. The department director is responsible for this process but may enlist the help of the food service staff. Policies and
procedures no longer relevant or now obsolete must be revised. Once revisions have been
approved by appropriate administrative and medical staff in accordance with the organization’s policy, their signatures must appear on the relevant pages of the manual or on a cover
page. Such changes include, for example, price increases in the cafeteria, changes in nutrition
care policies, and changes in the services offered that would affect staffing levels and budgets.
When policies and procedures involve another department, the two departments should meet
and jointly agree on them. Copies of the joint policies and procedures should be signed by both
department heads and placed in each department’s manual. An example of a joint policy would
be between engineering and food service for the maintenance of the food service equipment.
Finally, the director must communicate changes to department employees to ensure that everyone involved in implementing the changes knows how they are to be carried out. Copies of the
revised or deleted materials should be destroyed.
The manual is a tool for routine decision making, new employee training, and veteran
employee retraining. Regular updating of the policies and procedures manual also is important
to ensuring smooth departmental operations. Finally, the manual serves as documentation of
the standards against which employees’ performance will be evaluated.
Periodic Operational Planning
Periodic operational planning is conducted for specific purposes and within designated time
frames. Examples of this type of planning include development of the department budgets
(including operating budget, capital budget, and cash budget, for example) and the annual
Planning and Decision Making
Exhibit 5.1. Policy and Procedure Format for the Food Service Department
Department of Food and
Nutrition Services,
Community Hospital
Policy number: __________
Effective date: ___________
Subject: ________________________________________________________________________
Area of responsibility: ____________________________________________________________
Classification: ___________________________________________________________________
Approved by: ___________________________________________________________________
Primary responsibility: ____________________________________________________________
Distribution: ____________________________________________________________________
Review date: ____________________________________________________________________
Revise date: ____________________________________________________________________
Person responsible: ______________________________________________________________
Special instructions or illustrations:
Food Service Manual for Health Care Institutions
Exhibit 5.2. Sample Policy and Procedure for the Food Service Department’s Policies
and Procedures Manual
Department of Food and
Nutrition Services,
Community Hospital
Policy number: 1306
Effective date: March 2004
Page 1 of 2
Subject: Taste Panels
Area of responsibility: General administration
Classification: Purchasing
Approved by: Director, Food and Nutrition Services
Primary responsibility: Assistant Director,
Procurement and Production, and
Food Stores Manager
Distribution: Standard
Review date:
Revise date:
Person responsible:
Purpose: To determine the acceptability of a product before purchase and service.
Policy: Taste panels will be conducted at least monthly, more often if deemed necessary, to
objectively evaluate products.
1. Taste panels will be regularly scheduled on the third Friday of each month at 1:30 p.m.
2. A group of no more than 10 and no fewer than 5 people will be selected prior to the
date of the panel by the Food Stores Manager and as appointed by the Director.
3. The panel will include representatives from Purchasing, Nursing Services, Food and
Nutrition Services, Administration, and other interested personnel.
4. Tabulation of the results of the panel will be completed by the Food Stores Manager and
kept on file for future reference.
5. Results of the panel will be discussed with the Director, Assistant Director, Clinical
Dietitians, and/or Production Manager.
6. The Clinical Dietitian, Production Manager, Assistant Directors, and Director may recommend products for testing. This should be done at least a month prior to scheduled panel.
7. Procedure outlined in policy for taste panels dated 10/04/87 is still applicable (attached).
Planning and Decision Making
Exhibit 5.2. Sample Policy and Procedure for the Food Service Department’s Policies
and Procedures Manual (continued)
Department of Food and
Nutrition Services,
Community Hospital
Policy number: 1306
Effective date: March 2004
Page 2 of 2
Before a new product is to be used on the menu, it will be tested for acceptance.
1. Except on approved occasions, the taste panel will be conducted on the third Friday of
each month at 1:30 p.m.
2. The Assistant Director for Production and Service will have the overall responsibility of
the panel.
3. Assistance will be given by the Food Stores Manager (that is, he or she will invite participants, tabulate forms, and so on).
4. Water, cups, plates, napkins, and utensils will be made available for each participant.
5. There will be no talking, except to ask questions, during the taste panel.
6. Each product is to be individually evaluated by each participant.
7. Each individual is to independently score the results.
8. There will be no joking, horseplay, and so forth allowed during the meeting.
9. Answering pages and telephone calls will be kept to a minimum.
10. There will be no more than 12 people at each panel (including the Production Manager
and the Assistant Director, Procurement and Production).
11. No food is to be taken out of the conference room by the participants.
12. The panel will be made up of:
Assistant Director, Procurement and Production
Assistant Director, Nutrition Services or Clinical Dietitian
Food Stores Manager
Production Manager
Other food service personnel as invited
Nursing Services representative
Purchasing representative
Administration representative
The Assistant Director, Procurement and Production, will invite persons from the preceding
list to participate. Invitations will be issued a week in advance. Those unable to attend
should notify the Assistant Director as soon as possible. After participants have tasted products and finished the evaluation phase, they are to return to their work area.
Everyone should be honest and objective in the evaluation.
Food Service Manual for Health Care Institutions
department business plan. Annual department business planning is similar to strategic planning
in that the same seven steps are applied in the three phases previously identified. Information
affecting the department must be gathered and analyzed, objectives and action plans must be
developed and implemented, and goals and action plans must be evaluated and modified as
deemed necessary.
Department Budget
The budget, a planning tool, is a good means of forecasting long-range expenditures for personnel, equipment, supplies, and other resources. Therefore, it is important that managers learn
to use department budgets to ensure that necessary resources are available to meet department
The department budget actually is a composite of different types of budgets. The operating budget, for example, projects the number, types, and levels of service to be offered over the
defined period and the resources needed to support service delivery. The capital budget forecasts major purchases in plant and equipment, new construction or facilities renovation (or
both), and furnishings. The cash budget estimates cash income and expenditures over the
budget period so as to ensure sufficient cash availability to meet the department’s and organization’s financial obligations. The operating and capital budgets are primary components of the
department’s financial plan and become part of its business plan.
Because the overall department budget also is a tool for controlling departmental performance, each of these components will be discussed in greater detail in Chapter 11.
Department Business Plan
A department business plan is a tool or process that can be used to organize department-specific operational planning. As mentioned earlier, the strategic direction is set by upper management and the board of directors and is the foundation for departmental operational
planning. During the strategic planning process, specific areas are targeted for development or
concentration of effort. Based on the direction set and the specific goals the organization wishes
to accomplish, the department must assess how its role fits in the larger picture and plan
accordingly. Once the strategic focus has been determined, the food service director must evaluate his or her current ability to assist in accomplishing the organizational goals and then set
the necessary objectives to assist in goal attainment.
Depending on an organization’s size, structure, and level of service offered, departmental
business planning may or may not be part of the organization’s process and may or may not
be required of managers. However, many benefits are to be gained by developing a business
plan. One benefit is improved performance by clearly identifying and understanding the
strengths and weaknesses of the department, which allows management to plan proactively for
potential problems instead of becoming embroiled in crisis management. Clarity of objectives
as delineated in a business plan in turn sets clear performance, priority, and accountability
expectations by providing standards against which to measure. The instrument coordinates the
planning effort throughout the department and provides a framework for making key decisions. As an educational tool, the business plan can present an opportunity to promote staff
involvement and ownership in the department’s future.
The department business plan can be utilized externally. For example, in a business expansion effort to provide meal service to a smaller organization, a well-written business plan could
help “sell” the idea to the potential client. The complexity of the business plan is directly
related to the size and makeup of the organization and department.
Lessons from Other Industries
To better understand business plans, it is helpful to look at their use in other industries.
Generally, business plans are composed of five components: market strategy, production or
service strategy, research and development strategy, organization and management strategy,
and financial strategy.
Planning and Decision Making
Each of these areas can be applied to health care food service and included in the planning
process. The market strategy (or plan) identifies who customers are; what products or services
will be sold to them; and the policies regarding pricing, promotions, and distribution as
explained in Chapter 3. Marketing strategy information applies to both the data gathering and
analysis phase and the objective and action plan phase.
As in other planning activities, production strategy begins with gathering and analyzing
data to identify current capabilities of meal production and service and to predict future needs
based on the objectives. The food service director must learn whether changes are needed in the
department’s infrastructure, whether additional capital equipment or technology is needed, or
whether changes in the marketing mix are needed. For example, if a department was using a
hot pellet system for meal delivery and determined there was a need to change to a cook–chill
system, changes would be necessary in the production strategy so as to modify preparation,
storage, tray assembly, and service.
The third strategy in the general industry model is research and development. This applies
to food service departments that wish to develop new programs for clinical services or new revenue-producing ventures. New development may include expanding catering to the outside,
implementing a vending program, opening a coffee shop, or opening a branded chain operation within the facility. The research and development portion of the business plan is based on
market analysis of who customers are and what they want. Often this portion of the business
plan is completed by managers as a single-use program plan. However, for its effectiveness to
be monitored, it must be an ongoing element of the overall business plan.
The organization and management strategy of the business plan includes an explanation
of the functions that must be performed and who is to perform them. This portion includes
staffing needs, training and skill development needs, procedures and control measures necessary to support the department or new programs, and the level of employee involvement. The
organization and management strategy may include an explanation of how things currently are
done in the department and what procedural changes will be necessary to support new objectives. This portion of the business plan may include training programs that will be needed or
will assist in translating customer needs into continuous quality improvement.
The last strategy of the model used by business and industry is the financial strategy. As
mentioned above, both the operating and capital budgets become a part of the annual business
plan. Furthermore, when new programs or products are proposed, the financial plan must
address revenues and cost of the investment. It may be necessary to establish a pro forma or
projected profit-and-loss statement. The pro forma is usually based on one budget year and on
the projections made from the marketing, production, research and development, and organization and management strategies.
Business Planning Phases
Although the five components mentioned above should be addressed in the department business plan, the three phases used for strategic planning discussed earlier in this chapter should
be used to develop the business plan. Figure 5.1 illustrates a top-down flowchart of the business planning process for the department. A top-down flowchart is another tool that can be
used by the manager, especially for project planning.
Before the process can begin, deadlines must be set, and the manager must determine who
is to be involved, when, and in what capacity. Staff may be involved through small group meetings, employee meetings, management meetings, or one-on-one sessions with the director. The
director in a high-involvement department may ask employees to participate in the data-gathering and analysis phase or wait and include input on the writing of the objective and action plan.
Either way, providing opportunity for involvement ensures commitment from the staff
who will have to assist in carrying out the action plan. Once the method and time for employee
involvement have been established, the director needs to provide the necessary information
regarding the organization’s strategic plan, without which managers and employees will be
unable to contribute informed suggestions.
Food Service Manual for Health Care Institutions
Figure 5.1. Top-Down Flowchart of the Major Steps in a Business Planning Process
Before beginning
the planning process
Phase 1
Organize the
Gather and
analyze data
1. Who is to be
1. Organization's
strategic plan
2. Decide roles
2. Existing business
3. Method of
3. Gather reports
4. Establish deadline
and data
4. Internal strengths
5. Internal
6. External
7. External threats
During the business
planning process
After the business
planning process
Phase 2
Write objectives
and action plans
1. Write objectives
2. Write action
3. Set time lines
and dates
4. Assign
5. Develop
Phase 3
Write the
business plan
1. Decide on format
2. Develop cover
3. Write executive
evaluate, and
1. Follow steps in
action plan
2. Evaluate
3. Modify objectives
or action plans
4. Implement
Once deadlines are set and staff involvement has been identified, phase 1 of the planning
process begins. A situational diagnosis is conducted to determine internal strengths and weaknesses and external opportunities and threats, or SWOTs. This portion of the situational analysis might be conducted through staff brainstorming. A list of SWOTs may look like the one in
Figure 5.2. This portion of the analysis and the next portion, defining the current business definition, form the foundation of objectives needed for the coming year for improvement and
those needed to support the organizational strategy.
The internal analysis will include the business definition—what is being done now—and
the number of meals served, customer groups served, where services are being provided, and
the clinical services provided. Analysis also will include the number of employees, hours of
operation, and service. Internal environment will include the strategic plans made by the organization. An example of a strategic goal for the organization that affects departmental planning
is focusing on the customer while implementing continuous quality improvement. The department is then responsible for making its contribution and setting specific objectives for how its
members will contribute. Questions to be asked may include
• What does the strategic direction mean in relation to what is going on in the department
now and the forces in the external environment?
• What objectives must be set to assist in accomplishing the organizational goal?
Another example of building on strategic plans is the organization’s decision to undertake
a major building project. The department director would have to assess whether adequate facilities and staff are available to provide the needed meal service. If not, necessary data would be
gathered and analyzed to determine needs. Objectives for the department would be based on
the information gathered.
Planning and Decision Making
Figure 5.2. Food Service Department SWOT Analysis
• Highly qualified and concerned staff
• Low employee turnover
• High employee morale
• Positive internal image, especially in catering and cafeteria
• Ability to function within operating budget
• Strong inventory control and purchasing procedures
• High department productivity
• Timeliness of patient late trays
• Timeliness of food production
• Constraints of the physical plant in relationship to meal delivery
• Aging equipment
• Limited computer access
• Train employees for enhanced quality of service
• Replace current patient tray line
• Improve patient satisfaction with a new patient tray delivery system
• Convert production to a cook–chill system
• Shortage of qualified service employees due to changes in the workforce
• Difficulty of serving patient meals if tray assembly and delivery systems are not updated
In phase 2, specific departmental objectives are written to assist in accomplishing the organizational goal. The objectives must be measurable and include time frames for accomplishment as well as specific action plans. Action plans are then developed to support the objectives.
The action plan must be specific in terms of time frame for accomplishment, who is responsible, and how success will be measured. Also included are contingency plans in the event the initial plan was either ineffective or the objective needed to be modified. If the objective involves
capital expenditures, the appropriate financial information is included in the action plan.
Details for writing appropriate, measurable objectives are covered later in this chapter.
Phase 3 of the business plan, like the strategic organizational plan, requires the manager
to provide leadership for implementing the agreed-on action plans. The steps of the implementation process are delegated by the manager. The food service director’s responsibility does
not end with implementation of the action plan, the effectiveness of which in meeting established objectives must be monitored and changes made as necessary. As mentioned, the validity of the objectives must be continuously evaluated in relationship to the changing
environment. For example, if the food service department based one of its objectives on providing meal service to a long-term care facility to be acquired by the institution, but upper management decided to forgo the purchase, the objective and action plan would need modification.
Food Service Manual for Health Care Institutions
Business Plan Format
A written plan should be made even if only for inside use. This will help solidify the importance of the planning process and provide documentation for coordination of efforts. The format for the business plan may vary by organization, but the fundamentals are similar across
organizations. The first thing the manager needs to do is determine whether the organization
has adopted a format. If not, guidelines built on the five components mentioned previously—
market plan, production plan, research and development plan, organization and management
plan, and financial plan—may be used. Another approach, used by Rotanz Associates and
specific to health care, is represented in Figure 5.3. Not used in the Rotanz model but added
by the author is a table of contents and an executive summary briefly highlighting each major
The executive summary is the most important component of a business plan and must be
written in a positive tone. It must be short and concise. If it is too long, the executive may put
it aside, throw it out, or read it at a later date.
The summary should avoid threats—implied by words such as “shall” and “will”—but
choose words that show action as if the project was in existence. Use short sentences and paragraphs, and do not use boldface type or highlighted text except as absolutely necessary. Do not
be trite or whine. Be sure all pertinent and essential information is included.
Scheduling Techniques
Managers often find that a visual representation of work over time is helpful in scheduling routine activities. The Gantt chart, a nonmathematical graphic method of coordinating and organizing multiple tasks to complete a project on time, is one such device. It can help a manager
plan a variety of related tasks or schedule the work of a group of employees who perform the
same task. The chart in Exhibit 5.3 is an example of a schedule for a catering service. The Gantt
technique is useful for relatively simple planning tasks. More sophisticated methods must be
applied as a project grows more complex.
A planning technique used for short-term projects is the planning grid, shown in Exhibit 5.4,
which provides the planning team with an organized format for reaching a goal. The first
step in completing a planning grid is to identify the objective or outcome of the planning
effort. The achievement of the outcome with the final action step is the measurement
that determines when the planning is complete. The first action step might simply be to
schedule the first planning session with the relevant team. The rest of the planning grid is
completed by the team using various techniques of teamwork participation (see chapters 4
and 6).
Another tool, the program evaluation and review technique (PERT), can be used for planning as well as for controlling more complex departmental activities. Much more quantitative
than the Gantt chart, PERT is best used by managers who are skilled in using mathematical
methods for planning complex projects. Briefly, PERT helps to define a network of relationships among activities and events that occur in the course of a project and then to calculate the
time needed for each event and the time lapse between one event and another. PERT is often
used to reduce the total time needed to complete a project and to keep the project on schedule
by making adjustments in the network of relationships. A similar quantitative planning tool for
sophisticated, nonrepetitive technical projects is the critical plan method. Both the critical plan
method and PERT are used by industrial and management engineers to plan and schedule activities for a one-time project (such as a major renovation of a department) and can, therefore, be
considered methods for single-use planning.
Planning and Decision Making
Figure 5.3. Sample Business Plan Outline for the Food Service Department
I. Title page
A. Name of the institution
B. Name of department or functional
C. Date of preparation and time period
covered by the plan
D. Name(s) of person(s) preparing the
II. Table of contents
A. Major headings with page numbers
B. Appendix of figures, charts, graphs,
tables, or other supporting documentation
III. Executive summary
A. Brief description of the department
(business definition)
B. Current position or changes, or how
plan is consistent with current status
C. Significant strengths, weaknesses,
opportunities, and threats that directly
affect goals
D. Financial and other resource requirements
E. Main objectives, strategies, or plans
IV. Development process
A. Details how the information was gathered
B. Identifies sources used to develop the
V. Business definition
A. Overview of current department status
B. Resources
1. Technologies that affect services
2. Facilities that affect services
3. Human resources
a. Department-based employees
b. Common interfaces with other
4. Current budget
a. Capital
b. Operating
C. Principal customers
1. Identify various groups (patients,
physicians, employees, and so on)
2. Identify characteristics (age, needs,
changing environment, and so on)
D. Sustainable competitive advantage
1. Strengths that have long-term
VI. Strategic focus of the department
A. Brief statement of major emphasis for
VII. Key results areas (identify those areas
important to department—may come from
strategic plan or department environmental analysis). Examples:
A. Human resources (attraction, retention, or training)
B. New products or business opportunities
C. Financial performance
D. Facilities development
E. Quality and customer satisfaction
VIII. Environmental assessment
A. Business or health care environment
B. Market segmentation
1. Specific breakdown of groups
2. Brief details that identify
C. Market needs assessment
1. How were needs of the specific
markets determined?
2. Do these needs vary?
D. Customer concentration
1. Location of customer groups
2. Demographics
3. Common disease entity
4. Age category
5. Professional category
E. Competitive (SWOT) analysis
1. Strengths
2. Weaknesses
3. Opportunities
4. Threats
IX. Business objectives
A. Action steps
B. Person(s) responsible
D. Completion dates
E. Measurement of success
X. Appendix
Source: Adapted from Rotanz, 1990.
Food Service Manual for Health Care Institutions
Exhibit 5.3. Sample Gantt Chart for Planning a Catered Dinner
Activity A
Activity B
Activity C
Activity D
Activity E
Activity F
Week 1
Week 2
Week 3
Week 4
Week 5
Week 6
Activity A:
Plan menu.
Activity B:
Order supplies (including tables, linens, chairs, and flowers).
Activity C:
Order food (after checking recipes).
Activity D:
Make arrangements for security (including parking facilities and coatroom).
Activity E:
Hire and train additional workers.
Activity F:
Set tables and make general arrangements.
Exhibit 5.4. Planning Grid Format for Short-Term or Project Planning
Objective or outcome:
Team members:
Item #
Action Step
Whom to
or Cost
Final step
Although the use of a business plan can assist the department manager in determining which
areas need attention and what specific objectives should be, a business plan is not necessary
to establish operational objectives. Operational objectives are the foundation for directing
Planning and Decision Making
performance expectations. Writing and executing clear objectives avoid crisis management and
allow managers time to further develop employees (Figure 5.4). Objectives also assist in bringing the department together, with everyone moving in the same direction.
Figure 5.4. Steps in the Development of Departmental Objectives
Director meets with lowerlevel managers to discuss
the organization's overall
Managers meet with
employees to discuss the
organization's overall goals
Employees and managers
submit suggested objectives
to director and discuss in
Employees and managers
discuss and propose
realistic objectives for the
Director, managers, and
employees agree on objectives to be accomplished
Director writes objectives
and formulates measurable
output targets and discusses
them with managers and
employees in person
Director prepares a written
report of results on a
monthly basis
Director compares results
to objectives (time,
Director eliminates nonessential objectives
Director prepares cumulative
review of objectives and
Source: Ruby P. Puckett; used by permission.
Director prepares revised
objectives and undertakes
counseling and training
Director judges degree of
success and conducts
performance evaluation
Food Service Manual for Health Care Institutions
Characteristics of a Well-Written Objective
Objectives must be specific statements that explain how the broader goals of the organization
are to be accomplished. The more specific an objective is, the more efficiently it can be reached.
In addition, specific objectives are essential as tools for adequately evaluating and controlling
the performance of the organization as a whole, of specific departments, and of individual
employees. A well-written objective has the following characteristics:
• Specificity. The objective identifies the specific outcome of an activity. The results of
quantitative objectives (that is, those whose results can be measured mathematically) are easier to determine than the results of qualitative objectives. For example, the objective of increasing the productivity of the tray preparation line by 2 percent is a quantitative objective. The
objective of improving employee morale is qualitative and is, therefore, harder to measure.
However, a manager should not be discouraged from setting qualitative objectives because
other factors can be measured that are good evidence of employee morale, such as the number
of employee grievances filed or the rate of absenteeism.
• Conciseness. The objective is succinct, uncluttered by identification of the method for
accomplishing a task, for example; that is, it contains no extra information.
• Time dimension. The objective is time related in that everyone involved understands by
what point a task must be accomplished.
• Reality. The objective is achievable and within the work group’s capabilities and available resources. On the other hand, an objective should not be so easily achieved that the work
group does not feel challenged to give its best performance.
• Method. Each objective is accomplished by an action plan that outlines the steps for
achieving the objective.
• Value dimension. Objectives should have value to the department and to those responsible for carrying them out.
In the following example, a food service department objective reflects one of the hospital’s
overall goals: to provide service in a cost-effective manner. The department implements this
goal by stating its own objective:
To reduce the overall cost of each patient meal by 1 percent by the end of the current fiscal year.
This objective is specific, and its achievement can be measured (quantified) against the
financial information from department records. The objective is stated concisely, clearly, and
within a designated time frame. To decide whether the objective is realistic, the food service
director would need to assess the costs involved in current meal preparation and delivery and
decide whether a 1 percent reduction is feasible and, if so, through what means—reductions in
staff, changes in methods of preparation, or some other adjustment. Devising or amending production methods involves the creation of action plans. It also incorporates a value element in
that doing so must be worth while to those who must perform the tasks that lead to attainment of the objective.
To implement departmental objectives effectively, each one must be prioritized in relation
to the others. In addition, each objective must be broken down into its component tasks in an
action plan. The resources available for accomplishing each task should be assigned according
to the objective’s relative priority.
Steps for Writing Objectives with Outcome Measures
A manager who uses a department business plan will have a clear idea of what areas would benefit from having objectives established. Otherwise, the first step is to determine which areas need
objectives. Experts estimate that about 20 percent of the activities in any business necessitate
Planning and Decision Making
having specific objectives in place. Setting objectives for everything in the department is
extremely time-consuming and can frustrate the monitoring process. Once the determination is
made as to which areas need objectives, five steps can be used to establish clear ones:
State the problem or opportunity clearly.
Decide what the expected outcome is to be.
State the end product—what will be achieved by the outcome.
Establish possible action steps, including the measurement to be used.
Refine the possible action steps into a concrete plan.
After the target areas for objectives have been identified, the next step is to identify the
challenge or opportunity at issue. A general statement is then written to identify what the
desired outcome or change would look like. The next activity is to refine the general statement,
keeping in mind how the outcome will be tracked and measured. Once the objective is clearly
written, all possible actions are listed. From this list, an organized sequential list is formed. The
action steps to be followed to accomplish each task should be described in specific procedures
(discussed in the previous section). A time frame for completing each task also must be established. Scheduling becomes a more complex process as tasks require more steps and more people to perform them. Action plans that lead to attaining objectives identify who is responsible
for each step and provide time lines for completion.
Assigning responsibility for fulfilling each objective and completing its component tasks is
the food service director’s role. One person may be involved in a task, or the whole department
may work to fulfill the overall objective. It is vital that the person assigned primary responsibility for completing the task be given sufficient authority and resources. As mentioned earlier
in this chapter, once the action steps have been outlined with responsibilities and time lines,
monitoring must occur to ensure success. Progress reports should also be kept as records of the
department’s objective-setting and fulfillment process so as to document for top-level managers
the department’s progress in fulfilling institutional goals. The reports can also be used as part
of the institution’s evaluation and control system. The objective and action plan should be put
in writing and shared with everyone who will be affected either directly or indirectly.
Management by Objectives
Peter Drucker is usually credited with developing the systematic technique of goal setting and
implementation called management by objectives (MBO). This tool is best applied by a department director as part of an organization-wide program for meeting the organization’s goals.
Briefly, MBO is a method by which a manager and a subordinate (a person directly supervised
by that manager) cooperate in setting objectives that the subordinate intends to accomplish in
his or her position. Usually, both agree to document in the subordinate’s personnel file the
objectives to be reached by a certain date, at which time the manager evaluates the subordinate’s success in achieving the objectives. If performance has been satisfactory, the manager can
reward the subordinate according to the personnel policies established by the organization for
salary increases, benefits, promotions, and so forth. If performance has not been successful,
both must reach agreement about the problem and identify ways to solve it. That is, they must
define a new set of objectives.
The MBO tool has several advantages when used carefully and cooperatively. First, it is a powerful morale booster and motivator of employee productivity. By involving employees in defining
objectives, MBO fosters a greater commitment to the organization by demonstrating how the
employees’ objectives are intertwined with the organization’s goals and strategies. Furthermore,
MBO makes a clear connection between performance and reward, thus ensuring for both
employee and manager that evaluation is an objective and fair process rather than a subjective one.
Finally, MBO provides a systematic tool for planning employee activities as well as for controlling
them and keeping them on the same course as the department and the organization.
Food Service Manual for Health Care Institutions
Decision Making
Decision making can be defined as the process of assessing a situation or objective, considering options or alternatives, and selecting the one most likely to provide the best possible outcome for those involved. As discussed in Chapter 2, decision making is a key managerial
activity and a significant part of the four basic management functions of planning, organizing,
leading, and controlling. The purpose of decision making in health care food service is to coordinate objectives and activities of the department so that its members deliver optimal nutrition
care and meal service to designated customers.
Managers are required to make decisions for problem or conflict resolution and for identifying objectives. Throughout the planning process, managers make decisions in determining
which objectives the department should pursue in the future. They also make decisions during
implementation of the objectives. Additional decisions are made regarding effectiveness of the
objectives, appropriateness of the action plans, and alternatives in the event neither is determined to be appropriate.
Planning drives much of the daily work in health care food service by establishing appropriate written policies and procedures. However, problems may occur that require decisions
and changes in these policies and procedures. Even with problem resolution, decision making
is more effective when based on information-gathering procedures that contribute to developing appropriate actions.
Three Elements Essential to Effective Decision Making
Three elements are critical to making decisions effectively and in a timely manner. These are
the authority or freedom to take action, knowledge of the situation or issue under consideration, and motivation to make the decision. Having authority to act is especially important if
employees are to participate in the decision-making process. For instance, unless authorized to
do so as part of his or her job description or as defined under a specific policy or procedure, a
tray line worker cannot make menu substitutions for patients receiving a diabetic diet. Even if
so authorized, the employee cannot do so without knowledge and expertise in diabetic diets
and in the nutritive value of foods and food equivalents. Even if authorized and properly
trained, without sufficient motivation—for example, a line employee being evaluated for promotion to a supervisory position requiring more of a decision-making role—there is little or no
will to make the decision.
Obstacles to Effective Decision Making
Unfortunately, more obstacles can preclude good decision making than there are factors that
promote it. This section identifies six such roadblocks.
One obstacle is individual bias that locks a decision maker into a perspective that can sabotage the best choice for a given situation or even eliminate other alternatives from consideration. Another, obvious from the preceding section, is lack of knowledge or ability. Third, the
lack of clear objectives can inhibit the decision-making process. Fourth, without availability of
crucial resources (for example, finances, time, or staff), less-than-satisfactory decisions can
result. One barrier that should be avoided, especially by new managers or new line employees,
is fear of taking risks or making mistakes. Finally, resistance to change can bottleneck even the
simplest decisions. (Planning and managing for change are covered later in this chapter.)
Influences on Decision Making
When making decisions that will affect the entire organization, the manager must be able to
identify elements that may influence the decision-making process and understand how their
influence plays a part. For example, decisions are often made based on past experiences of the
Planning and Decision Making
decision maker; a manager who tried an approach that proved to be ineffective may be reluctant to make that choice again (even if the situation is different). Although learning from the
past is desirable, it is also important to ensure that logical choices are not precluded because of
limited failures. The same is true for experimentation: A manager who tries a decision in a limited setting and finds it to prove effective may fear applying it in a larger context. Each person
brings to the decision-making process his or her own personal and social views and values that
will have an effect on the outcome. In addition, decisions are influenced by the departmental
or organizational values. The final influence on the decision-making process comes from other
managers or people whose judgment the decision maker trusts.
Decision-Making Process
The decision-making process follows the same steps whether a first-line manager is solving a
minor production problem or a top-level manager is deciding what the objectives are to be for
the coming year. The following are six steps to any decision-making process that should be followed to provide for an optimal outcome:
Establish objectives or define the problem.
Gather data.
Identify alternative solutions or outcomes.
Evaluate relative values of alternatives.
Activate action plan to implement best choice.
Follow up and evaluate the decision.
Establish Objectives or Define the Problem
Decisions are made based on a clearly defined expectation of the outcome. This is true whether
the decisions are being made in connection with solving a problem, resolving a conflict, or allocating resources. To make the best possible decision, it is necessary to establish clear objectives
that will lead to the optimal outcome or resolution. Defining the problem allows the manager
to understand the full implication of his or her decisions. What may appear to be a small, simple problem can turn out to be much larger and involve multiple processes or systems. For
example, on noticing a rise in employee complaints about work conditions, higher-thanaverage absenteeism, an increase in the number of kitchen accidents, or a falling off of employee
dependability in timely task completion, a manager might easily jump to the conclusion that
“today’s employees are unreliable and careless.” In fact, such symptoms may signal an operational crisis on the horizon.
An alert manager thoroughly explores a problem to find its possible causes. For instance,
rumors of layoffs, a wage freeze, or employee perception of supervisory apathy could explain
any one of the observations cited above. Whatever the cause of disruptions or negative changes
in the department’s operations, investigating beyond the first impression is worth the time and
effort. The manager avoids wasting time on treating symptoms while the real problem may
remain undetected. It also avoids time spent in crisis management once the problem erupts.
Clarity in defining the problem simplifies the rest of the decision-making process and, indeed,
may make the rest of the process unnecessary.
Gather Data
The second step in decision making is to gather data that have a bearing on the decision. A
manager should not settle for an assumption that involves any reasonable doubt on any point.
Two major points should be considered when gathering data. First, how can the facts be
gathered and, second, how much data should be gathered. Facts may be gathered by
• Reviewing existing policies and procedures and mission and value statements.
• Reviewing past events when a similar problem was encountered.
Food Service Manual for Health Care Institutions
• Personally observing and thinking why the situation is usually inaccurate. The manager
needs to observe employees, equipment, and so forth. Write down the facts observed, and accurately describe what was found. List all facts and any related conditions that have a bearing on
the decision. Take the time to be thorough.
• Interviewing anyone who will be affected by the decision. Listen to what is being said.
Observe behavior. Do not rush, do not criticize. Be objective and nonjudgmental.
Once all the facts have been gathered, organize and evaluate them. Decide what are facts
and what are opinions. Are these facts reliable? Additional observations and interviews may be
Identify Alternative Solutions or Outcomes
With the problem clearly defined, the manager can move on to the third step in the decisionmaking process, developing alternative courses of action to deal with the problem. In some situations, alternatives may already have been defined by the organization’s policies and
procedures, and the manager must simply carry them out. For example, if an employee repeatedly ignored a work schedule by arriving late and had received first an unofficial reprimand and
later a written warning about the consequences of repeated tardiness, the manager usually has
only one choice in dealing with the problem, according to the organization’s personnel policies.
With other scenarios, however, the manager will have to collect information to arrive at
relevant and valid alternatives. Depending on how quickly the decision must be made, the manager may involve employees or other managers to brainstorm ideas and possible alternatives.
When making decisions about nonroutine problems or conflicts all possible outcomes of the
alternatives outlined must be considered to ensure a winning situation.
Evaluate Relative Values of Alternatives
Each alternative must be carefully examined for its strong and weak points. To do this, the manager must gather all information pertinent to each alternative and then answer these questions:
• Is the alternative feasible? For example, does it violate any departmental policy or procedure? Does it conform to legal, regulatory, or code restrictions? Does the alternative risk
overstepping firmly established bounds of authority?
• Is the alternative satisfactory? Even when an option is feasible—that is, even if no strict
organizational barriers are in its way—the option may not suit the unofficial social norms of
the work group. Implementing changes that are socially unacceptable to the staff would meet
with stiff resistance.
• If the alternative is both feasible and satisfactory, will its consequences be acceptable to
the manager, the department, and the organization?
Information gathering for each option may require a review of policies and procedures, an
examination of previous memos or other documentation on the same or a similar problem, or
an analysis of job descriptions. Additional information may be gained from personal experience and observation and from discussions with other managers in the organization.
Activate Action Plan to Implement Best Choice
Answering the above questions will help eliminate all but a few options. The best of these probably will be the one that allows the most positive answers to the questions of feasibility, satisfaction, and potential consequences. However, not all options are mutually exclusive. If two
seem to be equally good solutions to a problem, perhaps they can be used in tandem or sequentially. For example, offering a new special diet menu to patients might require them to make
choices that are somewhat more complicated than what they are accustomed to. Should the
nutrition staff show the staff nurses how to help patients fill out their menus, or should
Planning and Decision Making
the nutrition staff urge patients to call the food service department with questions or problems?
The staff may be able to implement both alternatives and, in doing so, provide two options that
will ensure that patient menus are filled out properly.
Implementing the most appropriate solution may in turn require another set of decisions.
The manager may need to choose the most efficient and effective method for carrying out the
solution from several possible alternatives. On learning that standing plans have already been
developed that would be workable for the proposed activity, the manager may need to prepare
a single-use plan for a brand-new effort. For example, the existing policy on the delivery of
meal carts would need revision if the number of personnel assigned to cart delivery was reduced
because of a low patient census.
Follow Up and Evaluate the Decision
The final step in the decision-making process is to evaluate the option(s) chosen. Do the chosen actions have the desired effect? If not, why? At this point, the decision-making process may
have to begin again from step 1, and the problem may need to be reanalyzed in light of the
failed attempt to solve it. If the chosen actions fail to meet expectations, the manager should
not assume that the problem was incorrectly identified. Indeed, the action may have been well
chosen and well planned but may have lacked good implementation. In any case, timely follow-up is essential to the decision-making process because it keeps poor decisions from wasting department resources and derailing its efforts.
Team Decision Making
All steps in the decision-making process can be taken by an individual manager or by a team.
For the sake of time and efficiency, a manager can and should make certain decisions independently. However, research studies and management experience have shown that managers
who involve subordinates significantly in the decision-making process have a more satisfied,
committed, and productive staff. Research has further demonstrated that team efforts make for
more sound decisions than does an individual effort to resolve the same problem.
Team decision making can offer other advantages as well. For one thing, individuals working together bring their cumulative knowledge and experience to the decision-making process.
Therefore, a group is likely to generate not only more but better alternatives and be better able
to evaluate them. Once a decision is made, group members are likely more motivated to implement it because of their ownership in formulating it. Also, routinely sharing decision making
makes a stronger working team.
Team decision making has its limitations, however. A significant drawback is that it can be
time-consuming and therefore not the best approach if a decision must be made quickly. Other
problems arise if the decision-making process is not carefully carried out. For example, if decision makers fail to assign responsibility for specific tasks in the action plan, no one assumes
responsibility, even though the manager’s superiors will hold the manager responsible.
Furthermore, fear of suggesting what may be workable but radical alternatives could discourage creativity in suggesting options. Therefore, the team may generate a decision that appears
to be endorsed by most members but is really a less-than-satisfactory compromise. Often this
is a problem when a manager or other group member resistant to suggestions tries to dominate
the decision-making process.
As a decision-making technique, brainstorming (discussed earlier) is applied most often to
solving problems that are unusual and especially challenging. To generate the most creative
alternatives for the group to consider, brainstorming encourages participants to suggest novel,
even radical, ideas. Everyone in the group must agree in advance to conform to an important
ground rule of brainstorming: Criticizing the ideas of other participants is not permitted.
Instead, participants must try to build on the ideas advanced until a solution is found that is
feasible and satisfactory and that has the fewest negative consequences.
Food Service Manual for Health Care Institutions
Another technique that engages a work group in participative decision making is quality
circles. Quality circles are made up of small groups of usually five to ten people who perform
the same type of work and who voluntarily meet on a regular basis while on duty to discuss
work-related problems. The group strives to improve quality of products, service, or work
processes while seeking solutions that can be sent to management for approval and to be implemented by the quality circle group. In a wider sense, however, a quality circle is an environment in which a team decision-making process takes place. Various decision-making
techniques, including brainstorming, can be used by a quality circle to arrive at decisions,
depending on what kind of problem the group is attempting to solve.
Whatever techniques are used, according to Megginson and others, effective team decision
making is characterized by the following:
• It is fair to all members of the group.
• It provides an opportunity to gather together people with different attitudes.
• It permits members of the group to explain what they think should be done to solve the
• It fosters group discipline through social pressure and persuasion.
• It permits the cooperative solution of problems.
In contrast, team decision making is ineffective when any of the following conditions
• It tries to give each member what he or she wants.
• The manager or some other group member tries to manipulate participants to reach his
or her “right” decision.
• The manager considers the team decision-making process as only a forum to sell his or
her idea to the group and does not listen to alternative ideas.
• Discipline is ignored in the process of exchanging ideas.
• The manager only appears to seek the advice of the group, without actually planning to
implement it.
Planning, Decision Making, and Resistance to Change
Most decisions, whether made by top-level managers, department heads, or groups within
departments, require some change in the way things work. As in other aspects of everyday life,
change is a constant in the work setting. Therefore, resistance to change, no matter how
insignificant it is, might seem a curious phenomenon. Managers must contend with this resistance, both in employees and in themselves. A positive attitude toward change is critical to an
effective management and leadership style. Change in products, equipment, methods, and
clientele is a fact of life and a necessity for survival in health care institutions. Effective managers not only accept change but strive to be instrumental in bringing it about by constantly
searching for ways to improve their departments.
Managing change begins with a self-examination of the manager’s own attitudes toward
impending change and his or her sensitivity to the reasons why employees resist change. These
reasons include a fear of losing status or economic well-being and a general fear of the
unknown. Many times employee concerns are unwarranted and are the result of a manager’s
failure to explain the changes adequately. Fear of change is further exacerbated when employees are not allowed to participate in making decisions that affect them. For this reason, group
decision making is becoming an important element of effective management.
Attempts to change the way a group works often imply criticism of the status quo.
Suggested changes in procedures or products may cause employees to feel that their past performance has been less than satisfactory and that their work is being criticized. Unfortunately,
Planning and Decision Making
many employees have previous experience with poorly implemented procedural changes and
tend to be suspicious, even angry, when new methods are proposed. An alert manager anticipates this problem and makes every effort to prepare employees for changes in procedures,
products, or services. Extra effort should be made to assure employees that suggested changes
are not a criticism of their past performance but merely represent more efficient procedures.
Because change almost always causes some negative reaction among employees, managing
change well also means managing employee emotions so that sensitivity to the emotional connotations of change helps a manager effect change smoothly. Setting the stage by creating a positive work environment within the food service department is the first step in the right
The next step is for managers to cultivate employee awareness of, and interest in, the
change process. This will make the trial and adoption stages easier for everyone involved.
Apprising employees of possible changes can help lessen their anxiety and distrust.
Generating employee interest and their suggestions for ways to try out new plans can result in
a more cohesive work group and in helping employees develop their own management skills.
Employees must feel that the change will be good for them. Therefore, changes that are
well planned and well executed enhance growth and positive development toward the goals
and objectives of the organization. In contrast, hasty or poorly planned changes may lead to
problems and lack of productivity. A manager’s effectiveness can be measured in part by his or
her skill in initiating and leading constructive planning for change.
Planning is the most basic of all management functions. It determines the purpose of an organization and its many parts. It forms the basis for controlling the numerous activities that help
the organization achieve its purpose. Long-term planning often involves a consideration of the
organization’s business environment and ways the organization intends to respond to change
in the environment.
Effective business plans rely on upper management’s commitment and involvement.
Objectives and action plans should address all significant factors that affect the department’s
short- and long-term performance. The business plan must be forward looking and based on a
realistic analysis of the situation. Key management and staff members charged with implementing plans should be involved in plan development. Plans should foresee contingencies and
outline courses of action in the event that organizational plans or direction change. For example, if a decision is made to remodel an existing part of the department and then a decision is
made to build a new kitchen, contingency plans would be needed.
Black, J. S., and Porter, L. W. Management Meeting New Challenges. Upper Saddle River, N.J.:
Prentice Hall, 2000.
Bolten, L., Aydin, C., Popolow, G., and Ramseyer, J. Ten steps for managing organizational change.
Journal of Nursing Administration 22(6):14–20, 1992.
Certo, S. C. Modern Management. 8th ed. Upper Saddle River, N.J.: Prentice Hall, 2000.
Cohen, A. R., Fink, S. L., Gadon, H., Willits, R. D., and Josefowitz, N. Effective Behavior in
Organizations. 4th ed. Homewood, Ill.: Irwin, 1988.
Cohen, M. W. Arguments for and against MBO. Hospital and Health Service Administration, special issue, Jan. 1980.
Dessler, G. Leading People and Organizations in the 21st Century. Upper Saddle River, N.J.: Prentice
Hall, 2000.
Food Service Manual for Health Care Institutions
Drucker, P. The Practice of Management. New York: Harper & Row, 1954.
Fannin, W. R. Making MBO work: Matching management style to MBO program. Supervisory
Management 26:20–27, 1981.
Flippo, E. B., and Munsinger, G. M. Management. 5th ed. Boston: Allyn & Bacon, 1982.
Gibson, J. L., Ivancevich, J. M., and Donnelly, J. H., Jr. Organizations’ Behavior Structure Processes.
7th ed. Homewood, Ill.: Irwin, 1991.
Griffin, R. W. Management. 2nd ed. Boston: Houghton Mifflin, 1987.
Gryna, F. M. Quality Circles: A Team Approach to Problem Solving. New York: AMACOM, 1981.
Haimann, T., Scott, W. G., and Connor, P. E. Management. 4th ed. Boston: Houghton Mifflin, 1982.
Ingle, S., and Ingle, N. Quality Circles in Service Industries. Englewood Cliffs, N.J.: Prentice Hall,
Joint Commission on Accreditation of Healthcare Organizations. Joint Commission Accreditation
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Kerrigan, K. Decision making in today’s complex environment. Nursing Administration Quarterly
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Koontz, H., O’Donnell, C., and Weihrich, H. Management. 7th ed. New York: McGraw-Hill, 1980.
McCoy, J. T. The Management of Time. Englewood Cliffs, N.J.: Prentice Hall, 1982.
Megginson, L., Mosley, D., and Pietri, P., Jr. Management: Concepts and Applications. New York:
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Mosley, D., Megginson, L., and Pietri, P., Jr. Supervisory Management: The Art of Working with and
Through People. Cincinnati: South-Western, 1985.
Munn, E. M., and Saulsbery, P. A. Facility planning. Journal of Nursing Administration
22(1):13–17, 1992.
Odiorne, G. S. The Practice of Management by Objectives in the Eighties. Westerfield, Mass.: MBO,
Peters, J. P. A Strategic Planning Process for Hospitals. Chicago: American Hospital Publishing,
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Pritchett, P., and Pound, R. The Employee Handbook for Organizational Change. Dallas: Pritchett
Publishing, 1990.
Puckett, R. P. Dietary Manager Training Guide. Gainesville, Fla.: Division of Continuing Education,
2002. Lesson 12, pp. 579–623, and Lesson 18, pp. 793–814.
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Planning and Decision Making
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Chapter 6
Organization and Time
Organizing is the process of dividing the work done in an organization (or a unit within the
organization) into smaller parts and assigning responsibility for those parts to specific positions. Historically, organizations believed work was accomplished most efficiently when
divided into specialized tasks and given to specialists of those tasks. More recently, the idea of
specialization is being questioned in light of job diversity that creates multiskilled workers, a
more desirable approach. The change from a specialized skills approach to a multiple-skills
approach is attributed to a number of trends. These include demands for a customer orientation and patient-centered care, the movement toward continuous quality improvement,
changes in workforce demographics, and the demand for participative management.
To answer the question of how health care facilities should be organized to meet their goals
efficiently and effectively, this chapter explores various organizational structures. Each structure
is reviewed in terms of the extent and type of departmentalization within an institution, the
degree to which decentralization of tasks and decision making is a prominent feature of an institution, and job design factors in a specific corporate climate. Organizational structure is applied
to how the role of a food service department is defined in the larger organization (for example,
through teams). In addition, food service department organization is addressed, including the
proper exercise of authority, staffing, and scheduling. Time management is discussed from
the point of view of time as a resource whose function is to maximize productivity.
Determining Organizational Structure
The system a facility chooses as most appropriate for conducting its work is called the organizational structure. Health care facilities are exploring various organizational structures to
determine the one best suited to meet quality demands within limitations imposed by cost constraints. It is important that decisions be made quickly, that employees participate in decision
making, and that customer demands (especially those of patients) be met to ensure a health care
institution’s long-term viability. With these considerations in mind, the following sections discuss three common entities in health care organizational structure: departments, committees,
and teams.
Food Service Manual for Health Care Institutions
The formation of departments, or departmentalization, can fall into any of several categories:
functional, product, geographical, customer, process or equipment, and time. In the past, only functional and time departmentalization were relevant to food service departments in health care
institutions. However, changes in health care focus have made product, customer, and process
departmentalization pertinent components of a facility’s structure. For departmentalization to
be effective, the concept of separation and reintegration must be taken into account when
deciding how to form an organization. Separation represents division of labor by pulling the
organization apart and making it more complex. The value of separation becomes evident
when groups are reintegrated, forming the support structure for operations. Reintegration
refers to the degree of coordination, cooperation, and communication that flow among units
in the organization.
Usually top-level managers determine which department structure is appropriate for their
institutions. Most likely, a combination of categories will be the best choice. Six departmentalization types are briefly described here.
Functional Departmentalization
Functional departmentalization groups jobs into departments or units in which employees perform the same or similar activities. Most units within hospital food service departments are
organized according to function, such as nutrition services, food production, purchasing and
storage, and nonpatient services (Figure 6.1). A manager or supervisor is usually in charge of
each unit’s activities. Functional departmentalization makes sense from the standpoint of having
like functions centralized. For example, although decentralizing meal service may be desirable,
it does not make sense to decentralize food preparation.
Functional departmentalization can cause conflicts between departments in meeting customer demands. Those closest to patients (for example, nurses) have a unique perspective
of patients’ requirements and may fault another department, such as food service, whenever
patients’ needs go unmet. Because food service staff are removed from the customer, they may
not comprehend the urgency of nurses’ requests. For example, interrupting a work activity to
get an item requested by a nurse interferes with getting items ready for the tray line. This type
of functional cross-purpose does not allow employees to engage in the full cycle of their work.
In this example, a conflict occurs between nursing and food service. However, if the food service employee was involved in the full cycle of fulfilling a patient’s dietary needs, he or she would
understand that both tasks are of equal importance. The employee could then understand that
the choice is not between completing a department task versus a nursing request but a choice
of meeting an immediate patient need and scheduling or postponing a task for a future need.
With the patient in clear focus, the food service staff could see that the positive consequences
of meeting the patient’s need would outweigh the negative consequences of not having all items
ready for the tray line to start.
Product Departmentalization
Product departmentalization creates work units based on the product or service the unit delivers. This form of departmentalization is used most often in large manufacturing companies and
financial institutions. In recent years, health care institutions have experimented with productline departmentalization, defined by body system units or by the traditional nursing care units.
Therefore, product lines may include cardiac care, obstetrics, oncology, or orthopedics, among
The idea of product-line departmentalization is to coordinate the efforts of all health professionals involved in caring for a particular patient type. This coordination enhances the quality of care and improves costs associated with that care. Product-line management is further
enhanced by critical paths that standardize the intervention at various stages of a patient’s stay.
(Critical paths are covered in detail in Chapter 4 on quality management.) Dietitians are among
Organization and Time Management
Figure 6.1. Functional Organization of a Food Service Department
Governing authority
Medical staff
Hospital administration
Food service administration
• Planning (goals, objectives,
• Organizing and leading
(staff selection and supervision)
• Controlling (budget and
records, quality assurance,
analysis and action)
Nutrition service
• Nutrition care plans
• Patient visitation
and instruction
• Physician
• Charting and records
• Tray service
• Employee training
• Quality assurance
Food production
• Menu planning
• Food preparation
• Meal assembly and
• Sanitation
• Cost control and
• Employee training
• Quality assurance
Purchasing and
• Specifications
• Purchasing
• Receiving
• Storage
• Distribution
• Inventory control
and records
Nonpatient service
• Employees
• Visitors
• Special functions
and catering
• Sanitation
• Cost control and
• Employee training
the practitioners who will have a role in product-line management and interdisciplinary care of
customers. Although most product lines will likely be managed by a nurse, other professionals
may lead. An example of this type of product line is an orthopedic or rehabilitation unit where
a physical therapist may be the manager. Product-line departmentalization may or may not
require that dietitians and others from food service report to the manager of the product line.
If, for example, 100 percent of a dietitian’s time is devoted to a particular unit, he or she could
conceivably report to the product-line manager.
Geographical Departmentalization
Geographical departmentalization groups an organization’s activities according to the places in
which the activities are carried out. This type of departmentalization is used in fast-food operations, contract feeding services, and large school districts. For example, food may be purchased, delivered, and stored in a central warehouse. The food may be prepared at a single
second location or be disseminated to individual sites for preparation and service. Geographical
departmentalization allows concentrated effort around fewer tasks.
Customer Departmentalization
Customer departmentalization focuses each department’s or unit’s work on the customer to be
served. For example, a contract feeding company might service hotels, health care institutions,
Food Service Manual for Health Care Institutions
and schools. Therefore, it would structure its departments according to the different needs of
these three customer types.
Customer departmentalization can be seen in large hospitals in which patient-focused or
patient-centered care groups professionals and nonprofessionals as a team around a patient
care unit. The traditional term nursing unit is being replaced with patient care unit, which
attests to the influence patients have on how care is delivered. During a typical hospital stay,
the average patient will come in contact with more than twenty-five individuals a day. It is estimated that nursing personnel spend more than 52 percent of their time in nonprofessional tasks
such as ordering supplies, handling communication, housekeeping, and performing personal
service duties. Services related to patient support take about 22 percent of their time, leaving
only 26 percent available for direct patient care. This revelation has led many organizations to
patient-focused care units.
Patient-focused care units are designed to rely on a highly cross-trained staff that functions
as a team. Patients are treated by the same team members during their stay, which reduces the
number of caregivers they have to see. This care allows a high level of comfort for patients and
their families. Many organizations have dissolved the nursing station and provided bedside terminals and decentralized supplies, which allow staff to “float,” thereby leaving them available
to meet patients’ needs. With customer departmentalization, patient admission is frequently
handled at the bedside by a clerical person in the unit. Support generalists may be responsible
for housekeeping, food service, and stocking and ordering supplies.
In addition to providing better care, patient-centered care acts to improve staff’s work
environment. Everyone has an equal place on the team and in patient care. This can be especially rewarding to food service employees who have traditionally felt left out of caring for
patients. Rewards are based on team effort and quality of care. To ensure high-quality care,
measurements must include clinical outcomes as well as patient satisfaction. Cross-functional
or cross-trained employees are an effective means of allowing people from diverse areas within
an organization to exchange information, solve problems, reduce duplication, and coordinate
projects. In the beginning, it takes time for members to learn to work with diversity. It takes
time to build trust and teamwork, especially among people from different professional backgrounds, experiences, and perspectives. A good example of this type of a team is the interdisciplinary team for “special diseases” such as the parenteral-enteral nutrition team.
For food service departments, this means that some of their work may be decentralized to
these units, which also means that the staff may be decentralized. As team members, they will
be allowed to contribute to the care of patients while increasing their skills and the number of
tasks they are capable of completing.
In recent reports, this type of decentralization has not been successful. Many food service
departments are again serving and retrieving trays. Dietitians and dietetic technicians are still
employees of food service departments but serve as members of interdisciplinary teams with the
same rights of input as any other member. Because of the critical shortage of nurses, various
methods are being tested to enable nurses to provide more direct patient care.
Process or Equipment Departmentalization
Process departmentalization divides work groups according to their different production processes
or the specialized equipment their work requires. This form of departmentalization also is being
explored by health care and food service departments. Employee involvement and teamwork have
placed new emphasis on process departmentalization, and employees are grouped together to manage a process from beginning to end, rather than seeing only one specialized piece of the process.
For example, a process team established for patient feeding would include not only servers on the
tray line but also cooks, dietitians, hostesses, purchasing personnel, and a supervisor or manager.
This departmentalization requires the manager of the process to have a broad knowledge base and
understanding of the interactions of various parts of the process. Process focus has been shown to
improve not only the quality of work produced but also employee commitment to work. Teams
and self-managed teams are discussed later in this chapter.
Organization and Time Management
Process departmentalization allows employees to cross-train and gain information about all
steps of the process. This way, they no longer place blame on one step in the process; instead,
they see how everyone working together can enhance the overall process to improve outcome.
This type of work unit division can go further than food service department units and can
include nurses or other professionals on the patient unit. If an organization is using customer
departmentalization and patient care units, a person on this work team may be a service generalist from the patient unit.
Time Departmentalization
Time departmentalization is often used along with another form of departmentalization when
the work to be done fills more than a standard eight-hour workday. Hospitals use time departmentalization in grouping work according to shifts. In most food service departments, two
shifts are needed to cover the twelve- to fourteen-hour period of meal service for patients and
Although most work in health care organizations continues to be accomplished in departments
and intradepartmental units, some activities require that individuals from different departments (or from different units within a department) work together on a common task. In this
case, a work team such as a committee, task force, or project team is formed. Historically, team
members come from about the same level in the organization. However, with participative
management and continuous quality improvement, this no longer may be the case. For example, a task force whose assignment is to explore a new process for preparing department budgets might consist of persons from the same level. Members of the work team would include all
department directors and a representative from the finance department. A different type of
work team might review the patient admission process for improvement. This team would
include clerks who actually complete the process as well as managers, directors, and perhaps
administrators. To build a team that works in harmony requires substantial effort; teams must
be given high priority and attention. Some employees do not make good team players but are
good employees. Usually a team can achieve more than an individual. Teams contribute significant achievements in all phases of life. The military would never win a battle if it did not work
as a team with the same objective of winning with as few casualties as possible.
Work teams can take several forms, some of which are listed here:
• Ad hoc committees are created for a short period to perform a specific task (for example, evaluating new computer training packages).
• Standing committees work together for a longer period than do ad hoc committees to
deal with an ongoing subject of relevance to all committee members. For example, several
departments might send representatives to a multidisciplinary patient education committee
whose task is to develop materials and programs to teach patients about topics that draw from
the department’s knowledge. For example, a program on diabetic patient education might
require help from the medical staff, nursing staff, pharmacy, laboratory, and a dietitian.
• Task forces are similar to ad hoc committees in that they are short term and have a narrow purpose. Usually, however, task forces are formal teams charged with solving or reporting
on specific problems. Another difference is that a task force always has representatives from
various departments, whereas committee members may be from the same department. The purpose of a task force is to integrate the work of discrete departments that on a daily basis work
independently. Another difference is that the task force membership may change as the team
works through a project. For example, a task force whose purpose is to evaluate a hospital’s
eating disorders program might be composed of nutritionists, psychologists, and physicians initially, with marketing specialists brought in later to suggest ways the program could improve
so as to better fulfill the community’s needs.
Food Service Manual for Health Care Institutions
• Project teams are similar to task forces and ad hoc committees in that their purpose and
duration are limited. However, the task that a project team is to accomplish may take as much
as a third or half of members’ work time. For example, the development of an eating disorders
program might be assigned to a project team so that the program can get under way as quickly
as possible. A project team manager coordinates the work of the different specialists. These
specialists must report to the project manager as well as to their regular department or unit
directors until their work on the project is completed.
• Cross-functional teams are made up of employees from about the same hierarchical level
(dietitians, nurses, pharmacists, and the like) but different work areas who work together to
accomplish a task or job. These employees work in the same organization and blend their
knowledge, experience, and talents to meet outcome objectives and goals.
• Virtual teams are an extension of electronic meetings. Virtual teams allow groups to
meet without concern for space or time. This is accomplished through communication links
such as conference calls, video conferencing, e-mails, and chat rooms. The members may be
geographically distant and in various time zones.
Work teams are useful in carrying out essential activities in organizations. Food service
directors can benefit from both participating in such teams and using them to accomplish the
work of the food service department. Such teams offer several advantages:
• They foster effective communication among departments that share common goals and
• They permit integration of departments with similar goals and objectives.
• They offer a medium for coordinating the opinions and experience of specialists from
several different functional areas.
• They provide a forum for team decision making.
• They create broad-based support for projects that demand the involvement of several
different departments or units within departments.
Generally speaking, food service directors are required to serve on various hospital committees,
among them the disaster-planning committee, quality assessment committee, safety committee, or
infection control committee. (The advantages of team decision making are discussed in Chapter 5.)
The importance of teamwork in a participative management structure is emphasized throughout this segment of the manual. Teamwork is important at the job-involvement level of empowerment to help employees make decisions that affect their work group. Teamwork is valuable in
health care food service because of department complexity and job interrelationships; the more
complex the organization or department, the greater will be the return on an investment in teamwork. For example, because many individuals are involved in providing a patient with a meal
tray, collaborating on the task provides a clear goal to be accomplished. In a complex department like health care food service, the various sections of the department have a variety of goals.
For instance, those purchasing food see their goal as obtaining and providing raw materials to
the cooks. The cooks see their goal as preparing food for the tray line to serve. The tray line
server’s goal is to complete the tray for a hostess to deliver. When all of these members act as a
team, the goal becomes serving patients. In addition, an organization with a focus on customers
and continuous quality improvement can benefit from the ideas and accomplishments created
by teams. Risk taking also is a positive outcome of teamwork, and research has shown that team
workers are more likely to take risks than are individuals. These statements, while supported by
the author, are based on the information presented by various leaders in business and specifically in health care and food service. (See the Bibliography for specific references to teamwork.)
Organization and Time Management
Characteristics of High-Performance Teams
Much time and research have been devoted to singling out competencies or characteristics of
high-performance teams. Stellar teams exhibit the following characteristics:
• Clear definition of roles and purposes. The team has clear goals and strategies for goal
• Interpersonal relationships. Interactions among team members and with key people outside the team are ruled by trust, collaboration, responsiveness, and support.
• Member empowerment. Team workers have access to necessary skills and resources.
Policies and practices support team objectives.
• Open and honest communication. Members express understanding and acceptance of
others, practice active listening, and value different opinions and perspectives.
• Member participation. Members perform roles and functions as needed, share responsibility for leadership and team development, are adaptable, and explore various ideas and approaches.
• High performance. High output, excellent quality, effective decisions, and an efficient
problem-solving process are apparent.
• Exemplary individual contributions. Workers’ efforts are recognized by everyone. Team
accomplishments are recognized, and members feel respected and recognized by the organization.
Individual motivation. Workers feel good about their membership, are confident and motivated, have a sense of pride and satisfaction, and have a strong sense of cohesion and team spirit.
• Mutual accountability. Each member is accountable for the success of the goals of the
project or task.
• Commitment. Members are committed to the goals of the team, a meaningful purpose.
• Specific outcome. performance goals.
• Complementary skills. Members have complementary skills (technical or functional)—
problem solving, decision making, communication, and interpersonal.
Leader or Manager Responsibility to Teams
An environment that fosters teamwork is created through participative management and
employee empowerment. The manager is responsible for communicating a clear vision or purpose for the team. (Communication related to teams is detailed in Chapter 7.) The working
environment culture must support team members and efforts for goal accomplishment. Many
of the necessities for a participative work environment also are critical to effective teamwork.
These include providing flexibility by eliminating unnecessary procedures and allowing
employees freedom to develop new ideas, permitting people to take risks and make mistakes,
setting challenging goals with clear standards for accomplishment, providing recognition and
praise, clearly communicating expectations and plans, and being committed to provide whatever is necessary for goal accomplishment.
The manager is responsible for providing employee training so that employees have the
skills needed for problem solving and team interaction. Education and reeducation are based
on the demands and needs of the team members and individual levels of competency. It is the
manager’s responsibility to assess level of competency and, if needed, to provide individual
coaching for employees. The manager must ensure that everyone is given ample opportunity to
participate and that outspoken members do not make all decisions and dominate the group.
Before employees are asked to work in a team, they must be trained in how to conduct team
meetings, how to participate, how to make decisions, and how to follow the ground rules for
team meetings (see Chapter 7). Once everyone is provided with the training, individual abilities can be addressed. The competency of team members can be assessed through observation
by a manager and can frequently be measured by the output or lack of output by the team.
The manager may have to assist with resolving conflict and with providing problem-solving tools. Statistical tools used to measure and analyze problems (reviewed in Chapter 4) and
situational leadership (see Chapter 2) should be kept in mind with teams.
Food Service Manual for Health Care Institutions
Group Development or Team Stages
Blanchard and associates identify four distinct stages of team or group development: orientation,
dissatisfaction, resolution, and production. (Other writers refer to these four stages as forming,
storming, norming, and performing.) Orientation, or stage 1, characterizes a newly formed
group whose members have high expectations and some enthusiasm but may experience anxiety about their role and feel a need to find their place. They test the leader but at the same time
are dependent on authority and the hierarchy to provide guidance. During this stage, the group
will have a low productivity level but a high commitment level. The leader will have to provide
specific directions and a clear vision with desired outcomes to decrease anxiety and allow members to understand what is expected.
At stage 2, dissatisfaction, teams are somewhat disillusioned about team accomplishment.
They may feel dissatisfaction with authority; be frustrated with goals, tasks, or action plans;
feel confused and incompetent; compete for power, attention, or both; and experience dependence and counterdependence. Although their morale and commitment may be waning, their
level of productivity is on the upswing. The manager or leader will have to create a supportive
environment that allows members to explore their feelings of discontent while providing
enough coaching to move the group forward. Understanding that this stage of team growth is
normal will allow members to stay focused and committed.
At stage 3, teams have moved toward some resolution of what dissatisfied them at stage 2.
Members begin to develop harmony, trust, support, and respect for one another. Self-esteem and
confidence are strong, leading to more open communication and feedback. Responsibility
and control are shared by group members, and a team language begins to develop. The manager
or leader must continue to provide support but from a distance as team members begin to take
active roles and become responsible for the outcome of the group.
The final stage, production, is represented by a high level of productivity and morale.
Members feel excited about their team and collaborate and work interdependently as a whole
and within subgroups. There is a feeling of team strength, leadership is shared, tasks are being
accomplished, and the team members have a high level of confidence. The team leader will have
to further remove himself or herself from the leadership role and move toward delegation,
allowing team members to accomplish desired outcomes.
Team Building
Team building is important to producing a desired outcome or high performance. Otherwise,
both loyalty and performance will be jeopardized. Trust is developed through team building,
which allows open discussion and feedback among members. The first step to building highperformance teams is to nurture a collaborative relationship between managers and team
members. Managers must share their power and authority in an effort to reinforce the responsibility given teams. A commitment from the manager means giving the time necessary for team
development and always attending scheduled meetings.
To form a high-performance team, members must understand and believe in the purpose of
the team and in their ability to influence work. Team building allows for personal growth of
members and should provide enjoyment. For department members to begin functioning in
teams, the manager will have to ensure commitment from them to join in. For the best results,
participation in teamwork should be voluntary because some individuals feel uncomfortable
functioning in teams, just as they feel uncomfortable giving opinions. These employees should
be given other individual tasks to complete. It is also possible that individuals who are reluctant
to join teams will come around after they see there is nothing to fear and after team members
provide positive feedback.
Team-building efforts must focus on the task or content of the meeting and the process.
Usually if team members are selected on the basis of their knowledge, the task portion of teamwork is effective. It is the process portion—or how members relate, go about the task, and
communicate—that must be addressed in team building. The team process can affect the
Organization and Time Management
outcome. Team building should concentrate on how things are going, encourage full participation, and emphasize listening and building consensus rather than majority rule. Two ways to
increase awareness of process have been suggested by Byron Lane:
• When process problems develop in which people are dropping out, forming subgroups,
or not listening, stop the meeting. Ask members to discuss how they feel about what is happening. They may be apprehensive at first, but as teams develop, they will be more willing to
share their concerns.
• At the end of each meeting, allow ten to fifteen minutes to discuss the process. Ask the
team members, “How did we do today?” Once they realize that process is important enough
to discuss, they will pay closer attention.
Team building should be fun. If possible, off-site training and development sessions should
be held with team members. If this is not possible, time should be set aside for the department
to celebrate and reward team participation. Effective team building requires as much interaction time as possible for team members. Early meetings should focus on how they can work
together, what they think they can accomplish, and what issues are important to them in terms
of decision making. (Team decision making is discussed in Chapter 5.)
Self-Managed Teams
The highest level of employee involvement or empowerment is self-managed or self-directed
work teams. Historically, teams required employees to work within traditional job descriptions
with traditional supervisor–employee reporting relationships. Self-managed work teams are
groups of interdependent individuals who select their own teams and can self-regulate their
behavior to complete a whole task. These employees are allowed to control their own work
schedules and performance goals, and team members deal with employees at all levels of the
organization. The team manages a budget and takes responsibility for productivity, cost, and
quality. Members are empowered to make major changes in their work processes without going
through management.
Self-managed work teams benefit the organization because people are taking more responsibility. Downsizing in organizations has caused a decrease in the number of middle managers,
making self-directed teams more important.
Self-managed teams may work in some areas of the food service department. For example, dietitians, technicians, and clerical support personnel can be made responsible for making
decisions that relate to the tasks they perform for patient care and supporting meal service to
Systems Approach to Food Service Organizations
M. C. Spears, R. P. Puckett, and other management food service professionals advocate the use
of a systems approach in food service organizations. A system is a collection of interrelated
parts, facts, principles, rules, or subsystems unified by design to obtain stated objectives or outcomes. A system that interacts with external environments is called an open system. A system
that does not interact with its environment is called a closed system. The systems approach to
management involves keeping the objectives or outcomes in mind throughout the performance
of all activities. This approach requires communication and coordination among all parts of
the organization. The basic systems model of an organization is depicted in Figure 6.2.
A system is composed of subsystems. A subsystem is a complete system within itself but is
not independent; it is dependent on the whole system.
The system also has controls, records, feedback, decision making, linking processes, and
balance. The linking process is needed to coordinate the functional subsystems from resources
Food Service Manual for Health Care Institutions
Figure 6.2. Making Coleslaw Using a Systems Approach
Federal, state, local,
rules, regulations, standards
menu, quality control
Action system
To buy cabbage
To prepare
To transform
Dishes to
serve coleslaw
Motivation: To prepare
best product
Specification for
cabbage, etc.
Coleslaw that
meets standards
of quality
Memory records
Communication from patient
Plate waste
Internal, external
to goals or outcomes. Decisions can be made by management at any point to alter the action.
Communication is vital and includes all types of information: oral, written, computer forms or
data throughout the system. The system must be kept in balance by the manager’s ability to
maintain organizational stability during changes in technology, economics, and political and
social conditions.
A food service department usually has at least the following major systems: management
system, action system, control system, and output system. Each of these systems is made up of
smaller systems with rules and regulations that must be followed.
The input is made up of management systems and basically defines the resources available.
The management system is made up of the seven Ms: man (personnel), machines (equipment
and physical resources), money (budget), motivation, materials, methods, and minutes. The
action or transformation system transforms the raw materials into finished products and services. This action must use the seven Ms of other functional subsystems and the linking
processes. These systems work together to produce the output, which are the finished products
and services of the department.
Records are important and are used to forecast and to meet budget requirements and personnel needs. These records are used in the action or transformation systems.
The control system refers to the plans, goals, and objectives of the organization and to outside influences (such as local, state, and federal laws and regulations). The control system is
Organization and Time Management
necessary to assure that food service personnel use the management system in concert with the
action system to have an efficient and effective output system. The menu is the most important
aspect of the control system. The menu also relates to the management and action systems.
The output system is the result of the other systems working together to produce a finished
product that meets quality and quantity, customer satisfaction, and financial accountability.
For example, a patient cannot be served whole raw cabbage, but coleslaw is an acceptable
product. Coleslaw is served to a patient as a result of the output system. Feedback gives the
manager the opportunity to make necessary changes at all steps of the system, to refine the
action or transformation process.
The system must know the environment in which it exists. It must comply with all local
and state rules and regulations as well as internal policies and procedures.
Organizing the Food Service Department
The division of work and its efficient coordination are important in every health care institution, and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO; recognizes this importance in its standards. The JCAHO standards
require that all departments or services be organized, directed and staffed, and integrated with
other units and departments or services of the organization. For food service, the standards
stress organization in a manner designed to ensure provision of optimal nutrition care and
high-quality food services.
All health care employees must be aware of their place in the organization—who their
supervisor is and who their peers are. This is called organization structure because it divides
labor into distinct tasks and coordinates them. This information must be posted in the food
service department in the form of an organizational chart. An organizational chart is a visual
representation of the division and coordination of work within an organization or department
within an organization. It illustrates relationships among units and lines of authority through
the use of boxes and connecting lines. The chart is an unbroken line of authority that extends
from the top of the organization to the lowest subordinate and clarifies to whom and how
information and discussions should flow. The food service department’s organizational chart
should be reviewed and revised at least once a year or whenever changes are made in the
department’s structure.
An organizational chart is a useful tool because it shows the characteristics of the larger
organization and its units. For example, the organizational chart in Figure 6.3 shows how the
various positions in one type of food service department relate to each other and to the administration of the hospital. However, no chart can show the dynamic interconnections and interactions among members of the organization. The following items are depicted on an organizational
• Chain of command. The solid lines in Figure 6.3 demonstrate that the upper levels of
the organization are linked to each of the lower levels through a defined set of relationships.
Authority is the right to perform or command. Managers are given authority to direct the operation of the food service department, and with this authority the manager can give orders or
directions and expect them to be obeyed or followed.
• Unity of command. Each employee is linked by a vertical line to only one supervisor.
This ensures that each employee reports to, and is accountable only to, his or her immediate
superior, an unbroken line of authority. When the unity of command is broken, the employee
usually has to cope with conflicting demands from several supervisors.
• Departmentalization. The organizational chart also shows how jobs are grouped into
those that have common tasks that can be coordinated by a supervisor. For example, Figure 6.3
shows that the food service department is split into three units: nutrition care services, food
procurement and production, and nonpatient operations. Each unit is further divided into areas
of specialization.
Food Service Manual for Health Care Institutions
Figure 6.3. Organization of a Food Service Department with a
Food Service Director in a Large Hospital
Governing authority
Medical staff
Vice president, operations
Food service director
Secretarial and
financial staff
Assistant director,
nutrition services
Assistant director,
procurement and production
Assistant director,
nonpatient operations
Education and
Food stores
• Lines of communication. In addition to showing the chain of command, organizational
charts show how information should flow through the organization. Solid lines in all the flowcharts shown (see Figure 6.1 and figures 6.3 through 6.9) indicate both the flow of authority
and the flow of formal communication among different positions in the chart. Broken lines
show that information must also flow outside the chain of command. For example, in Figure
6.3, although the assistant directors of nutrition care services, food procurement and production, and nonpatient operations do not supervise each other, they must communicate and coordinate their efforts to ensure efficient operation of the whole department. In addition, the
broken line in Figure 6.3 between the medical staff and the food service director indicates that
the medical staff advises the food service department on the most appropriate service for particular patients but does not have direct authority over the department.
Organization and Time Management
Figure 6.4. Organization of a Small Institution’s Top-Level Management
Food service
Nursing services
Social work
services director
Figure 6.5. One Management Level in a Small Food Service Department
Dietary manager
Figure 6.6. Two Management Levels in a Large Food Service Department
Director, food service
Finance clerk
Patient nutrition
Food production
Food Service Manual for Health Care Institutions
Figure 6.7. Matrix Structure for a Health Care Institution Showing Project Management
Board of directors
Vice president,
patient services
Vice president,
Vice president
product line management
(Project leader)
Patient-focused care
unit project
Nursing services
Nutrition and
food services
Figure 6.8. Nutrition and Food Services Process Structure
Nonpatient meal
delivery team
Sanitation and
work safety team
meal delivery
management team
management team
Note: The lines in this figure represent communication that may occur between any of the teams.
Organization and Time Management
Figure 6.9. Organization of a Food Service Department with a Dietary Consultant
in a Small Hospital or Extended-Care Facility
Governing authority
Medical director
advisory physician
Hospital administrator
Clerical workers
Dietary consultant
(advisory position)
Food service
Dietetic supervisor
Tray assemblers
Food service workers
• Span of control. Span of control refers to the number of employees each manager must
supervise directly. In a large organizational structure (see Figure 6.3), each manager tends to
have a narrow span of control, whereas in a less complex structure (see Figure 6.6), each manager’s span of control is wider.
• A tall organizational structure (Figure 6.3) is multireporting layers within the organization, giving span of control to three assistant directors.
• A flat organizational structure (Figure 6.5) has fewer layers of supervisors and subordinates.
• The wider or larger the span, the more efficient the organization.
• The wide span of control speeds up decision making, increases flexibility, empowers
employees, and allows employees to get closer to customers. Employee training is necessary in a
wide span of control.
Functional–Hierarchical Structure
Most health care organizations and food service departments continue to use the functional–
hierarchical structure. The functional–hierarchical structure is present in organizations that
group similar tasks (functions) together (for example, food production), with the chain of command and span of control increasing as one moves to the top of the pyramid (hierarchy). The
Food Service Manual for Health Care Institutions
more management levels there are in an organization, the more complex the organization is.
For example, Figure 6.3 represents five management levels: CEO, vice president of operations,
food service director, food service assistant directors, and managers. A large organization such
as this has what is called a tall organizational chart. Smaller organizations tend to have what
is called a flat structure because they have fewer levels of management.
Figure 6.4 is an example of an organizational chart for a small health care institution. Small
hospitals and extended care facilities, particularly those in small communities or rural settings,
frequently do not have the services of a full-time registered dietitian. Therefore, to meet the
JCAHO, Omnibus Budget Reconciliation Act, and Medicare-Medicaid requirements for supervision of patient nutritional care, such institutions hire a dietetic consultant or part-time registered dietitian. A dietary manager has responsibility for the day-to-day supervision of the food
service department in such institutions. (The certified dietary manager has completed a course
of study approved by the Dietary Managers Association.) The organizational chart for a small
food service department is shown in Figure 6.5. Figure 6.6 illustrates two levels of management
within a much larger food service department.
Although the functional–hierarchical structure has been credited with contributing to the
large economic growth of the U.S. economy during the past hundred years, it appears to have
outlived its usefulness. Its limitations include turf orientation around departments or functions;
limited information to employees, rendering them incapable of contributing to the big picture;
communication difficulties due to the number of layers employees must go through; limited
career growth; and rewards based on competitive individual or departmental progress, which
limits contributions to the organization as a whole.
Alternative Organizational Structures
Changes in health care have required organizations to revisit the traditional functional–
hierarchical structure to look for alternative structures. Options considered by some organizations have included removing a level of management by phasing out middle managers or reducing the number of managers at all levels, supposedly to improve communication with less
vertical and horizontal boundaries. Still other attempts have been to invert the pyramid, putting employees at the top and the CEO at the bottom. However, this latter attempt did nothing with the direction of the power and authority. For managers to empower employees, a new
structure must be developed, one that is not designed to direct and control.
One possibility, the matrix model, consists of two organizational structures superimposed
on each other (see Figure 6.7). This type of organizational chart allows for the continuation of
the functional–hierarchical structure with the addition of project leaders. Top levels of the
organization are still preeminent in regard to the chain of command and span of control in
these two models. These two models differ in that the matrix structure in Figure 6.7 shows individuals or teams reporting to two different supervisors. Many of the relationships depicted in
the matrix model occur in the traditional hierarchical structure without being “legitimized” on
the organizational chart.
This type of structure is felt to be effective at cutting the time for decision making and is flexible enough to accommodate temporary teams such as committees, task forces, and project teams.
It allows for changes in the informal structure without creating problems for the fixed hierarchical structure. It also allows a clear picture of product lines and customer or service units.
Although the matrix model is more accommodating to organizational teams, there are problems
associated with it. One such problem is ambiguity regarding the reporting structure. For this reason, the appropriateness of such a structure for frontline employees is questionable. The matrix
model may prove more beneficial at the supervisory or professional staff level, where ambiguity
regarding reporting structure is more comfortable. Good interpersonal skills and conflictmanagement skills are essential for managers and employees if a matrix structure is used. These
skills are helpful in improving communication and building relationships that facilitate dealing
with ambiguity. For example, a dietitian may be asked to join a project team for developing a
Organization and Time Management
skilled-nursing unit in the hospital. Conflict may arise if the team decides that meals should be
delivered at a specific time. Good interpersonal skills will allow the dietitian to communicate the
needs of the unit and the limitations of the department in meeting these needs.
Functioning in teams requires an organizational structure that is designed to depict crossfunctional processes rather than functional departmentalization. It is difficult to assign a specific
chain of command because process management functions tend to intersect. The organizational
chart in Figure 6.8 shows a bubble diagram for a nutrition and food service department. This
structure represents different teams focused on the major core process of delivering patient care
and food services. Comparing this diagram with the functional–hierarchical diagrams in Figures
6.3 through 6.6 uncovers the following innovations afforded by a bubble structure:
• Management layers have been replaced with team leaders and facilitators who coach
and facilitate rather than control.
• Team members are responsible for decision making. Consensus building becomes important in this type of decision making, requiring a coordinated communication process as discussed in Chapter 7.
• Team empowerment allows communication with other teams, customers, suppliers,
executive teams, and so on.
• Teams have a broader view of the organization and their contribution to its vision.
• Turf protection is replaced with cooperation within and across teams.
• Mobility of team members is increased through cross-functional participation on other
teams within the department and organization.
• Team rewards can be provided in addition to rewards for individual development.
Organizational Culture
Organizational culture is the mechanism for guiding employee behavior; it is the personality of
the organization. Organizational culture determines how employees view their jobs, how they
act toward fellow employees and customers, and what style of leadership the manager uses. It
also means the values they and the organization possess and the manner in which they behave.
The organizational culture usually reflects the mission, vision, and values of the organization. An organization’s culture may have an effect on its structure, depending on how weak the
Characteristics of Organizational Culture
Robbins and Decenzo, in the third edition of their book, Fundamentals of Management (2001),
define organizational culture as having the following characteristics:
• Member identity: the degree to which employees identify with the organization as a
whole rather than with their type of job or field of professional expertise
• Group emphasis: the degree to which work activities are organized around groups
rather than individuals
• People focus: the degree to which management decisions take into consideration the
effect of outcomes on people within the organization
• Unit integration: the degree to which units within the organization are encouraged to
operate in a coordinated or interdependent manner
• Control: the degree to which rules, regulations, and direct supervision are used to oversee and control employee behavior
• Risk tolerance: the degree to which employees are encouraged to be aggressive, innovative, and risk seeking
• Reward tolerance: the degree to which rewards such as salary increases and promotions
are allocated on employee performance criteria, in contrast to seniority, favoritism, or
other nonperformance factors
Food Service Manual for Health Care Institutions
• Conflict tolerance: the degree to which employees are encouraged to air conflicts and
criticisms openly
• Means-end orientation: the degree to which management focuses on results or outcomes
rather than on techniques and proceeds
• Open-system focus: the degree to which the organization monitors and responds to
changes in the external environment
Factors That Influence Department Structure
Although health care food service departments typically perform the same basic functions, several factors influence how these functions are organized and staffed: the type of health care
institution (acute care hospital, nursing home, for example), its size (that is, the number of beds
it contains or the number of residents it cares for), and the type of services it offers (patient
meal service, nutrition care service, cafeteria service, and so on).
In addition, an organization’s philosophy and leadership style will affect the department
structure selected. For example, an organization that promotes process development, teamwork, and employee involvement will seek a structure that depicts a dynamic, cross-functional
Department Members and Responsibilities
As the sample organizational charts for food service departments demonstrate, the manager,
staff members, and food service workers in various organizations have different titles and cultures. In addition, directors and managers have various levels of skill and responsibility and different levels of formal training and education. The food service director in Figure 6.3 heads a
large and complex department in a large acute care hospital. Two levels of management below
the level of director manage numerous department services and employees. In contrast, a consultant (a part-time registered dietitian) advises the manager of a food service department in a
small hospital or extended care facility like the one shown in Figure 6.9. The consultant might
work only eight to forty hours per month in such a facility.
The titles, responsibilities, and educational backgrounds of food service managers in various health care institutions can be described as follows:
• Food service director. In most large health care institutions and in many medium and small
ones, the food service director is responsible for the overall operation of the nutrition and food
service department. The director usually holds a bachelor of science degree. In large organizations, advanced education in business management, health science education, institutional
administration, or other related fields may be required. The food service director may or may
not be a registered dietitian (R.D.). The director may belong to a number of professional organizations such as Healthcare Foodservice Management; the Society of Foodservice Management;
the American Society of Healthcare Food Service Administrators, a subgroup of the American
Hospital Association; and if an R.D., to the American Dietetic Association (ADA) and the management practice group or, if a certified dietary manager, to the Dietary Managers Association
(DMA). Other titles that correspond to this position include director of dietetics, director of
nutrition and food service, and food service administrator.
• Certified dietary manager. The certified dietary manager (C.D.M.) has satisfactorily
completed a course of study approved by the Certifying Board of the DMA. The approved
course usually requires 120 or more classroom hours and 150 hours of on-the-job training. The
dietary manager (D.M.) is certified by passing a national credentialing examination and a
national examination in food protection and earning 45 continuing education clock hours in
each of the three years during the certification period. According to the DMA, a C.D.M. “is a
skilled and experienced generalist capable of assuming the responsibility of all aspects of food
Organization and Time Management
service operations other than the clinical and in some instances the business aspects. In regard
to the clinical or nutritional science areas, the D.M. would utilize a dietitian consultant, with
a recognition that this is a consultative service rather than occasional or visiting supervision. In
some instances the business aspects such as financial/budgets may be the main responsibility of
an organization administrator.” C.D.M.s belong to the DMA. Other titles that correspond to
this position include food service director or manager, dietetic assistant, and lead cook.
• Dietetic technician. A dietetic technician has successfully completed an associate’s degree
program that meets the educational standards established by the ADA and has 450 hours of
supervised field experience. A dietetic technician may become registered (D.T.R.) by successfully
passing a national certifying examination and maintaining 50 clock hours of ADA-approved
continuing education over a five-year period. The dietetic technician may work in food systems
management under the supervision of, or in consultation with, an R.D. The dietetic technician
may also work as a member of a health care team under the supervision of an R.D. Dietetic technicians may belong to the ADA under the category of technician members. In addition, graduates of dietetic technician programs approved by the DMA may also become C.D.M.s through
the DMA credentialing process.
• Registered dietitian. An R.D. has earned a bachelor of science degree in dietetics, nutrition, or food systems management from a college or university, the program being approved by
the Commission on the Accreditation of Dietetic Education. On successful completion of the
academic and on-the-job training components of the program, students become eligible to take
the national registration examination for dietitians. The successful applicant becomes an R.D.
R.D.s work as clinical dietitians in a variety of health care institutions. Some clinical dietitians are certified in diabetes care, weight management, and other special areas of practice.
Community dietitians work as counselors and coordinators of nutrition awareness and disease
prevention programs. Management dietitians specialize in food systems, clinical management,
or other areas of management and work in health care institutions, schools, colleges, cafeterias,
and restaurants and as advisers to the food service industry. Business dietitians work in related
business areas such as sales, marketing, and public relations. Education dietitians teach nutrition and food systems in colleges, universities, and hospitals; conduct research; and write books
and articles on food service. Consultant dietitians, who practice independently and advise business and industry, counsel patients in a variety of settings.
In some states, R.D.s are also licensed by the state and are entitled to use the L.D. (licensed
dietitian) designation or other titles following their names. All dietitians are eligible for ADA
Shared Services
Given the high cost of food and substantial increases in labor costs, it is difficult for a food
service manager to stay within a budget and to forecast realistically for the following year. The
pressure to contain costs and at the same time improve the quality of food service is unrelenting. As a result, more and more food service managers are looking at shared food service systems as a means of providing high-quality food for patients and staff at a reasonable cost.
Shared service systems can be categorized according to the degree of control and responsibility exercised by the participating institutions. Thus, a shared service can be classified as a referred
service, a purchased service, a multiple-sponsor service, or a regional service. Usually shared food
service systems are either a purchased service or a multiple-sponsor service. A purchased service is
paid for directly by the institution. The purchasing institution acts as an intermediary between the
patient and the provider and therefore assumes some responsibility for quality of service. In a multiple-sponsor service, several institutions jointly control and operate the service. Control can be
established through an agreement among the institutions or through a separate corporation or
cooperative. Although the nature and extent of shared food services vary, the major types of sharing are in professional and managerial expertise, food purchasing, and food production systems.
Food Service Manual for Health Care Institutions
Shared Professional and Managerial Expertise
The sharing of professional and managerial expertise is of major importance to small and rural
hospitals and extended care facilities. The opportunity to use the services of highly trained personnel on a part-time basis allows a health care institution to provide patient services that it
otherwise could not afford to offer. Although large hospitals seldom share dietetic and other
professional food service personnel among themselves, these institutions sometimes do so with
small institutions. Usually, fees for this service are paid directly to the large hospital, which pays
the shared personnel their salary, with additional compensation for travel when necessary. The
shared personnel usually are required to submit reports to the administrators of both institutions, to meet accreditation requirements, and to evaluate the shared program.
Shared managerial services are similar to shared professional personnel services. Management
services that can be shared include meal planning, financial record keeping, data processing for
food service functions, payroll operations, in-service training and education, and policies and procedures planning.
Shared Food Purchasing and Production
Shared food-purchasing systems are the most common of the shared services. Standardized and
least-perishable items are most often purchased through shared systems, but dairy products,
frozen meat, poultry, fish, frozen entrees, and nonfood supplies are also frequently available.
Agreement on product specifications among participating institutions is essential in attaining
the greatest cost savings in shared purchasing arrangements. Shared food purchasing also
implies sharing ideas about food quality, processing techniques, consumer acceptance data, and
reliable information on new products. Management time is saved in shared purchasing arrangements because the buyer in the participating institution does not have to negotiate prices or see
as many vendors, a benefit discussed further in Chapter 17.
Shared food production systems are feasible, provided a comprehensive planning and evaluation procedure is used in the developmental stages. Food service managers and CEOs of the
institutions involved must agree on long-range goals in level of service, quality, nutrition counseling, bacteriological control, menu variety, and flexibility of the system in the face of changing
The decision of whether to enter a shared production system or to maintain independent
status should be documented. One method of documentation is to survey patients, medical
staff, employees, and outpatients about availability, quality, and level of service currently being
provided or desired. Opportunities for sharing often involve a shift to different systems of food
production and service. Careful consideration of the food service systems will help identify the
strengths and weaknesses of the present or proposed system. Data to be collected include
capital investment requirements, operating costs, quality and comprehensiveness of services,
acceptability of services to client groups, and legal considerations such as taxes and contracts.
Multidepartments and Multifacilities
In an effort to flatten organizations, a facility may opt for multidepartment management,
which has food service directors responsible for the management of more than one department
within an organization, such as housekeeping, grounds, laundry, or other service departments.
Another possibility is that food service directors may be required to provide management services to more than one facility within a corporation. For example, separate departments for
dietetic education programs, wellness, weight management, or community education could be
incorporated into a food service director’s responsibilities in a large facility. A multifacility corporation that has a number of hospitals or extended care institutions may require a food service director to oversee more than one of the corporation’s units. These services may include the
shared management services mentioned earlier.
Organization and Time Management
Distributing Authority
Authority, the legitimate power an organization grants to some of its members, is used to direct
and manage the actions of employees of the organization in achieving its goals. (Authority and
leadership are discussed in Chapter 2.) Just as there are patterns for grouping work in organizations, there are also patterns for the way authority is shared among managers at various levels, depending on the structure selected.
Two terms are commonly used to describe the degree to which power is distributed in an
organization: centralization and decentralization. Centralization refers to the concentration of
authority at the top levels of management, where a high proportion of power to make important decisions lies. In contrast, decentralization refers to a more widespread sharing of decisionmaking power throughout the various management levels. Decentralization of authority is
evident in organizations that promote teamwork, employee empowerment, and creative decision making and is effective for complex organizations that experience constant change (such
as health care facilities). The process by which managers allocate authority to workers who
report to them is called delegation.
By allowing another person (for example, a line employee) to act for him or her in the workings of an organization, a manager is sharing authority and responsibility. A manager can share
power through delegation but does not give power away. Delegation enables managers to
accomplish more than they could if they attempted to do every task themselves. By delegating
tasks, managers can spend time on the functions of planning and staff development. Delegation
of responsibility and authority is especially important during a manager’s absence, when an
assistant (or understudy) can assume interim responsibility for the unit’s performance and has
the authority to carry out the responsibility. In large departments, a manager may need to train
more than one assistant to assume certain portions of the manager’s work.
Another advantage of delegation is that it permits the manager to share responsibility for
a task with an employee who has more skill or training to perform that task. Delegation is
important as a training device, providing employees with additional skills and knowledge.
If poorly managed, however, the process of delegation can have some negative side effects.
The most obvious problem is that some essential task may not be accomplished or it may be
performed badly or late.
To work well, the process of delegation should follow these steps:
1. The manager must assign a clear objective or a well-defined task to the employee.
2. The manager must grant the employee the necessary authority to accomplish the task
and must ensure that everyone involved in the activity understands that the employee
has been given this authority.
3. The employee in turn must understand the objective and accept the authority and
responsibility for accomplishing it. This acceptance creates an obligation on the part
of the employee to accomplish the task.
4. The manager must hold the employee accountable for accomplishing the task
In addition to these basic elements of delegation, managers should consider several other
factors when deciding to share their responsibility. For example,
• Managers must select employees who have the skills to accomplish the task or are willing to learn the required skills.
Food Service Manual for Health Care Institutions
• Although managers should allow employees to assume responsibility for the whole task,
they should monitor the employees’ progress (especially if an employee is new to the assignment) to ensure success.
• Managers should anticipate some mistakes and be prepared to guide employees in correcting them.
• Managers should be certain that the lines of communication with employees are always
open and that employees can rely on the managers’ advice and support when needed and on
praise when it is deserved.
Delegation becomes increasingly important as a manager rises to higher levels of management in the organization. How well the manager can accomplish the work of the organization
is reflected by how well the manager leads the work of employees who report to him or her.
Some management duties do not lend themselves to delegation and are better shared or left to
the manager. They include
• Establishing missions, goals, and objectives for the entire unit under the manager’s
• Making policy decisions
• Defining standards of performance for the entire unit
• Monitoring the unit’s achievement of these standards
• Taking corrective action when the standards are not met
Line and Staff Responsibilities
When managers delegate authority, they must consider the difference between employees in line
positions and employees in staff positions. A line employee is part of the direct chain of command
that has been established to accomplish the primary work of the organization. Staff support the
line positions with their advice and special knowledge. In health care institutions, staff positions
are found in departments of finance, human resources, marketing, legal affairs, planning, infection control, safety, management engineering, and data processing, among others. Staff positions
usually do not have authority over line positions except when application of staff advice is crucial to the effective performance of line responsibilities. For example, the human resources director usually has no direct authority over tray line workers. However, because he or she has special
knowledge about Occupational Safety and Health Administration (OSHA) safety standards, the
human resources director knows that a worker without proper hair covering poses a risk and so
apprises the food service director, who has authority in this case.
Staffing the Food Service Department
Organizing the work of a department presumes that a competent staff is in place to accomplish the
tasks that have been assigned. Building an effective staff involves making decisions about the tasks
that need to be performed, the skills required to perform those tasks, the time needed to complete
performance, and the number of employees needed to perform the work of the department.
Determination of Employee Staffing Needs
In a health care institution, several variables affect the type and number of job tasks to be performed by the food service department. In determining department workload, managers should
ask the following questions:
Organization and Time Management
• What types of service does the department offer? Is the department responsible for an
employee cafeteria, a coffee shop, a patient dining room, patient tray service, outpatient clinics,
or multidepartment management?
• What type of meal plan is required for the institution’s patient population? Are patients
offered three, four, or five meals per day, room services, tray service?
• How varied are the menu items (for example, limited, spoken, on demand, or extensive
variation)? How complex are the recipes (simple, average, involved)?
• In what form are foods purchased? Do prepared foods require less processing than fresh
or whole ingredients?
• How many and what types of modified diets will the department need to accommodate?
• Which type of service system is used, centralized or decentralized?
• Who determines the division of labor between food service and nursing?
• What percentage of convenience foods are used?
• Are disposable or china tableware used?
• How much time is available for meal preparation and service?
• How efficient are the department’s physical facilities and equipment?
• What type of washing system is used for service ware and dishware?
• To what extent are the department’s information systems automated? What are the computer links with hospital information systems?
Determining workload, type and number of meals, service location, and so on provides
information used to determine staff numbers. For example, a department that provides meal
service to patients only will need less staff than a department that must staff a cafeteria. An
organization using convenience food items needs fewer skilled cooks than one choosing to cook
everything from scratch. All of the preceding questions assist in determining the number and
skill level of employees needed by the department.
Job Analysis
Once workload has been identified, managers must perform a job analysis. Job analysis is an
assessment of the kinds of skills, knowledge, and abilities needed for performing various job
tasks successfully. Each food service task must be evaluated according to the mental and physical effort it requires, the equipment it uses, and the time and work conditions it demands. Job
analysis is a tool for identifying the standard operating procedures, tools and equipment
needed, and orientation and training programs. It can be used to determine the pay scale. A
manager can gather this information by observing food service workers as they perform each
task and by discussing their work with them. A manager should ask all relevant questions
about the job:
Who is responsible for performing the task?
What supplies are needed, and what equipment is required?
Why is the task performed, and why is it performed this way?
When must the task be started, and when must it be completed?
Where is the task performed?
How exactly is the task performed?
Job analysis and recording of the information gathered during the analysis often benefit
from the use of a questionnaire (Exhibit 6.1). Organizing the information in this way helps
ensure that all tasks are analyzed on the basis of comparable observations.
Food Service Manual for Health Care Institutions
Exhibit 6.1. Job Questionnaire
(To Be Completed by Student and Submitted with Lesson)
Many employees see their job and its duties differently from the way their supervisors do. Before
writing job descriptions and work schedules, it is a good idea to have each employee fill out a job
study questionnaire. The following questionnaire can be used to determine if you and your
employees see the duties and other facets of the job in the same way. This form can also be used as
an evaluation and management tool to determine if the quality and quantity of work performed
meet the expectations in the work standards.
Job title
Food and Nutrition Services
Hours on duty
Your immediate supervisor
Length of employment in present position
List your duties in order of importance as you think they are. List the most important duty as no. 1,
the next as no. 2, and so forth.
What do you think is the least important duty (or duties) of your job?
Could this work be done by people who are less trained? _________ If so, and considering the task
was taken by another person, how much more time would you have available per week?
Does your job require you to operate any equipment? Yes ______ No ______
If so, list the kinds of equipment you use.
Were you trained to use the equipment properly? Yes ______ No ______
In your opinion, how much education should be required for your job?
What training was necessary to do your job?
If you failed to complete your duties or do your work properly, would anyone know?
Yes _________ No _________ Who?
What would be the results?
Would the error be connected directly to you?
If not, what job (or position) would assume the responsibility?
Under the present organizational system, do you clearly understand:
A. Who your supervisor is?
Yes ______ No _______
B. Who directs the work of your supervisor?
Yes ______ No _______
Does your position give you authority over other employees in the department?
Yes _________ No ________ If yes, what positions?
Do other departments in the hospital have control over your job duties (medical, nursing, ward
clerks)? Yes _________ No _________
Considering all the duties required of you, which is most pleasant?
Organization and Time Management
Exhibit 6.1. (continued)
Which duty is most unpleasant to you?
To be discussed by employee and immediate supervisor:
A. Quality of work
D. Job satisfaction
B. Quantity of work
E. Suggestions to make job more pleasant
C. Safety and sanitary standards
Signature ___________________________________________ Date______________________
Source: Puckett, 2002. Used by permission.
Job Descriptions and Specifications
The results of job analyses are documented in the form of job descriptions and job specifications for all positions in the organization. A job description is a written record of the set of
tasks to be performed by the employee and the conditions under which the tasks are to be
accomplished. Job descriptions should be criteria based. Criteria-based job descriptions state
the task to be accomplished and how the job is to be accomplished. The JCAHO has also stated
that job descriptions should be age or population specific, for example, pediatrics, adult or
geriatrics or both. A job specification describes the qualifications required of the person responsible for performing those tasks and applies to all candidates who apply for that job. In most
organizations, the job description and job specification are combined on one standard form.
In recent years, the JCAHO has placed increased emphasis on staff competency. Professionals
are being forced to be accountable to the public to ensure competency. Professional and continuing education plus licensure or certification are several ways to determine competency. Job
descriptions and performance evaluations written in competency terms is another method that
can be used to ensure competency. Competency is multidimensional and includes “knowledge,
psychomotor skills, critical thinking abilities, and interpersonal attributes.” These traits need to
be incorporated into the professional food and nutrition job description. Competencies for clinical R.D.s need to be for age-specific populations of customers (infants, adolescents, adults, elderly). The JCAHO human resources standards define the key processes that should be carried out
by leaders of the organization to ensure competent staff.
An up-to-date job description and specification form must be kept for every job in the food service department. The form must be closely followed when a new employee is hired for a position, when
a current employee and his or her supervisor develop objectives for the employee’s performance, and
when the employee’s performance is evaluated by the supervisor. Exhibit 6.2 is an example of a combined job description and job specification for a position in the food service department.
Food Service Manual for Health Care Institutions
Exhibit 6.2. Sample Job Description and Job Specification
Job Title:
Tray Line Server
Nutrition/Food Services
Reports to:
Food Service Supervisor
Job Code:
Position Summary: Responsible for food service to patients and other related duties including sanitation. Has a working knowledge of food service procedures and delivery. There are seven tray line
positions, which are rotated either monthly or bimonthly.
Minimum Qualifications: Ability to read and write English to communicate with staff, patients, and
other customers; a basic understanding of weights and measures. Experience is not required, but
one year’s experience in quantity food service is preferred.
Licenses, Certificates, or Similar Qualifications: None required
Essential Functions:
1. Checks daily assignment sheet for shift duties.
2. Prepares station for serving food. Physical requirements include:
• Transporting 22.5-inch-by-16-inch trays of food weighing up to 25 pounds. Trays are stored
at heights between 5 and 62 inches.
• Stocking food steam tables. Requires lifting food pans weighing up to 20 pounds from
heights of 11 to 62 inches and loading them onto a food bar 35 inches in height.
• Stocking beverage/ice-cream cooling units. Requires reaching over edge of cooling unit
35 inches in height with a forward reach up to 28 inches.
• Starter position responsible for placing hot pellets on the tray with the assistance of a delifter.
3. Checks quality, temperature, and appearance of food, relaying any problems to supervisor.
Physical requirements include corrected visual acuity of 20/20 and good sense of smell.
4. Serves food from station on tray line. Requires using appropriate utensils, such as large spoons and
knives, for proper portion control. Beverages are served from dispensers, pitchers, or taken from
cooling units. All food and beverage items are placed on a tray on the conveyor belt. Full plates of
food may weigh up to 2 pounds and are placed on a conveyor belt 33 inches in height.
5. Loads completed trays, weighing up to 10 pounds, into transport carts. Shelf heights are 8 to
50 inches from the floor.
6. Cleaning tech position or tray line server transports food carts weighing up to 730 pounds to
patient floors for distances up to 50 feet. Also returns carts with empty trays to the dish room.
Porter duties include dish room duties and emptying 50-gallon trash cans in an outside dumpster. Trash can lift is 48 inches from ground.
7. Performs floor stocking duties. Requires reaching overhead to a 73-inch height and a forward
reach of 13 inches. Boxes lifted may weigh up to 11.25 pounds.
8. Checks assigned stations hourly for cleanliness and operates equipment as required.
9. Performs dish room duties as assigned, including unloading and loading dishes between carts
and various workstations. Maximum weight lifted is 50 pounds occasionally to move loaded
bins to different shelves on cart (11 to 34 inches). Duties require a forward reach up to 40
inches, and lifting ranges from 11 to 75 inches from the floor. Inspects dishes for cleanliness
before taking to the serving line and before use.
10. Washes, drains, and dries empty food carts. Includes using spray hose and tilting 289-pound
cart to drain water.
11. Cleans and sanitizes station before leaving area with approved cleaning solution.
12. Completes all line server shift assignments by end of shift. Responds to changes in the workload as assigned by the supervisor or manager. No eating or drinking in work area.
Organization and Time Management
Exhibit 6.2. Sample Job Description and Job Specification (continued)
13. Uses disposable gloves and hair coverings. Facial hair and sculptured nails are not permitted in
food service areas. Observes all sanitation, safety, and infection control procedures.
14. Complies with policies and procedures in departmental manual and ASH employee handbook.
Job-Related Equipment: Carts, trays, delifter, beverage dispensers, reach-in and walk-in refrigerated
and freezer units, hot food storage units, steam tables, cartlift, dumbwaiter, microwave, dish
machine, pulper, conveyor belt, serving utensils, blender, knives, disposable gloves, hair coverings,
and safety belts.
Work Environment: Working in hospital nutrition and food service increases the risk of exposure to
sharp instruments and noise. Temperature varies in the area due to refrigerating and heating equipment. Cleaning duties include using various solutions to clean, disinfect, and polish surfaces. Tray
line servers may be required to work different shifts including evenings and weekends. Standing
and walking required for approximately seven hours out of an eight-hour day.
Safety Responsibility: All nutrition and food service employees must use good body mechanics and
follow safe working procedures including infection control and OSHA guidelines. The employee
must report any unsafe condition to a supervisor and demonstrate no on-the-job injuries due to a
lack of good safety practices. On-the-job injuries must be reported immediately to the supervisor
and an occurrence report completed.
Career Ladder: Through on-the-job training, advancement is possible to other positions including,
but not limited to: hostess, cashier, vending, catering, cook, or clerk.
This job description reflects the general duties and principal functions of line server. It is not a
detailed description of all the work requirements that may be inherent in the position.
Every job description and job specification form must include the following elements:
• Job title and its classification or code (usually established with the help of the human
resources department and used in defining salary levels and routes for promotion)
• Summary of major responsibilities of the position
• Clear statement of the minimum standards of performance for each essential function
• Description of the work environment—equipment used, possible health hazards involved,
responsibility to safety, and other such essential information
• Outline of opportunities for promotion that are relevant to the position
• Minimum qualifications for eligibility to hold the job—education, training, experience,
and any other special considerations
A job description and specification for every position in the food service department
should be on file in the department director’s office, as well as in the human resources department. In addition, employees should be given copies of their job descriptions and specifications
on their first day of work and whenever the materials are revised. Using this document can lead
to improved efficiency in the food service department by increasing the current employees’
understanding of their responsibilities and by providing guidelines for training new employees.
As managers reevaluate current job descriptions and specifications or develop new ones,
they must avoid establishing requirements that do not match the actual demands of the job. To
cite an extreme example, managers cannot require that a patient nutrition aide have a college
education or be a certified dietitian. Setting too high a standard for a position may violate certain regulations of the Equal Employment Opportunity Commission. Job descriptions should
clearly identify physical requirements for the position as a reference in screening job applicants
with disabilities. The Americans with Disabilities Act requires that Americans with disabilities
be employed when they can perform essential functions and that reasonable accommodations
Food Service Manual for Health Care Institutions
be made to assist them in performing essential job functions. To ensure that job descriptions
and specifications are in compliance with all federal and state laws, the food service director
should work closely with the human resources department.*
Work Division and Job Enrichment
The writing of job descriptions and specifications provides managers with the opportunity to
consider how the work can be divided in such a way that employee productivity and satisfaction are maximized. At one time, the traditional method of assigning work in the food service
department was to have employees perform specific jobs that they followed through on from
start to finish. Therefore, a cook was responsible for preparing, portioning, and serving specific menu items as well as for cleanup of the equipment and work space. In recent years, this
method of assigning work has been replaced in many institutions by a greater division of labor
that makes more efficient use of skilled employees. In this system, skilled employees are
assigned work according to the degree of skill needed to complete each task. This division-oflabor method allows highly skilled employees to perform fewer unskilled tasks, such as preliminary preparation of recipe ingredients and cleanup. Instead, skilled employees are
responsible for tasks that use their skills to greater advantage.
Both the traditional approach and the division-of-labor approach have inherent advantages and disadvantages. In the traditional approach, employees who can do a task from start
to finish feel more personal commitment to their job and may be more highly motivated and
accountable for the quality of the work. However, skilled employees must spend a lot of work
time on portions of the job that do not require all of their expertise. From a manager’s perspective, a greater division of labor is a more efficient use of the department’s resources because
preparation and cleanup tasks can be assigned to unskilled employees who are paid less than
skilled employees.
The traditional approach is once again finding favor in food service departments. However,
a combination of both approaches may be the most beneficial arrangement for managers and
workers. In the food service department, for example, the measuring, weighing, and preparing
of ingredients in a centralized ingredient area permits greater control of inventory and quality
and modifies the division of labor so that all employees have more than one narrow set of tasks
to perform. The repetitive tasks of measuring, weighing, and preparing the ingredients used in
all recipes are transferred from skilled to less-skilled employees. Cleanup and maintenance
responsibilities are also reassigned to those who are less skilled. To make the work of lessskilled employees more varied, their work assignments are typically enlarged to include greater
responsibility, accomplishment, and achievement. This process is called job enrichment or job
enlargement. For example, a tray line employee may be assigned to patient service for part of
the workday, or he or she may work in the ingredient area for some portion of the workweek.
Research on work in different kinds of organizations has demonstrated the feasibility and
benefit of job enrichment to provide greater employee satisfaction and to increase productivity. Both benefits can help an organization better meet the pressures of rising labor costs and
diminishing availability of skilled employees. Most employees are happier when work incorporates a challenge to them and permits reasonable flexibility in determining how an assigned
task is to be performed. Worker satisfaction tends to reduce turnover and the costs associated
with recruiting and training new employees.
To implement job enrichment effectively, managers must be aware of the work to be
accomplished, the most efficient methods for accomplishing that work, the skills each task
*For a complete guide for job descriptions, contact The American Dietetic Association, Products and Service,
120 South Riverside Plaza, Suite 2000, Chicago, IL 60606; telephone 1–800–877–1600, Ext. 5000 (Item 3177
Job Description Models for the Dietetic Professional).
Organization and Time Management
requires, and the best means of motivating employees. The processes of job analysis and work
division must be an ongoing part of the manager’s responsibility. They are also the bases for
making decisions about staff size, schedules, and performance standards to be met. (Chapter
11 discusses performance standards in the context of financial management and control for the
food service department.)
Determination of Staff Size
Once the type and number of food service tasks have been determined, job analyses have been
performed, and job descriptions and specifications have been written, managers can begin to
estimate the number of employees required by the operation to perform work that needs to be
accomplished. This is called staffing. The variables that specifically affect how much labor time
the food service department requires can be identified by answering the following questions:
• How much time is allocated for meal preparation and service? Are additional staff needed
at certain times of the day?
• Is the service system centralized or decentralized? (Decentralized systems usually require
more personnel owing to the staffing needed in areas outside the food service department.)
• How efficient are the department’s physical layout and equipment?
• What type of washing system is to be used for service ware and dishware? (When disposable service ware is used, the time required for washing is greatly reduced.)
• What quality of work is expected from the employees?
Careful consideration of these variables helps ensure that the food service department has sufficient staff. The manager must next calculate productivity, full-time equivalent (FTE), and
overtime needs based on the number of staff projected.
Estimating Productivity Levels
Staffing requirements must be based on the department’s output. Output is defined as the end
result of a work process, or the transformation of inputs. Output in the nutrition and food service department includes a variety of meal types and nutritional units of service. Input includes
food and other resources, including labor. Transformation refers to the processes that convert
input to output. The ratio of input to output is defined as productivity.
The use of a preestablished productivity factor allows a food service manager to determine
the staffing required to produce the number of meals provided. The first step in determining a
productivity level is to establish guidelines for calculating a single unit of service or a meal.
Output can be determined as actual meals, which is usually the case for patient meals, guest
trays, late trays between meal nourishments, and infant formulas and feedings when the food
service department purchases and delivers the product. However, for areas such as a cafeteria,
a meal equivalent is used. Meal equivalents are determined by first calculating a meal equivalent factor.
One accepted method of determining a meal equivalent factor for a cafeteria is to use an
average meal ticket. The average meal ticket is determined by dividing total sales by the number of customers over a predetermined length of time: average meal ticket = total sales ÷ number of customers. This figure represents the average ticket for meal service and can be used to
establish meal equivalents. For example, if total sales for the cafeteria equal $550 for lunch and
200 customers were served over a defined period of time, the meal equivalent would be $2.75
($550 ÷ 200 = $2.75). The average meal ticket meal equivalent should be established after gathering at least one week of ticket averages for lunch. The meal equivalent should be verified on
a quarterly basis. Another method of determining an equivalent meal factor is to use the sum
of the selling price for an entree, starch, vegetable, salad, dessert, bread, butter, and beverage
at the noon meal.
Food Service Manual for Health Care Institutions
Once the meal equivalent factor is determined, the number of meals produced can be calculated. Equivalent meals are calculated by dividing cafeteria sales for the period by the meal
equivalent factor (equivalent meals = sales ÷ equivalent meal factor). Using the $2.75 meal
equivalent factor calculated above and a sales figure of $45,000 for the month, equivalent
meals can be calculated as follows:
Equivalent meals = $45,000 ÷ $2.75 = 16,364 meals
The number of equivalent meals is used to calculate productivity. Productivity in food service is usually expressed as meals produced per labor hour or labor hours per meal produced:
Meals per labor hour
= Number of meals produced
Number of labor hours
For the 16,364 equivalent meals produced in the cafeteria in the preceding example, a total of
2,975 hours were worked. Using the meals per labor hour calculation:
Meals per labor hour = 16,364 meals ÷ 2,975 labor hours = 5.5 meals per labor hour
Expressing this same productivity as labor hours per meal:
Labor hours per meal
= Number of labor hours
Number of meals
Using the same numbers as in the preceding example:
Labor hours per meal = 2,975 labor hours ÷ 16,364 meals = 0.19 labor hours per meal
The following represent industry averages (from Sneed and Dresse, 1989) for various types
of food service operations:
Facility Type
Acute care facility
Extended care facility
Meals per Labor Hour
Labor Hours per Meal
Guidelines for small hospitals use the standard of three to six meals per labor hour and for
large hospitals, twelve meals per labor hour. Puckett suggested 14 minutes per meal. Others
have suggested eleven to twelve employees for each one hundred beds. For larger institutions,
each employee can produce 7,200 meals per year.
The best and most accurate method of determining a meal equivalent is the adjusted occupied beds. Adjusted occupied beds is based on a mathematical formula used to correct the number of occupied beds to include care given to patients who are officially admitted as inpatients for
at least 24 hours. At the end of each month, the accounting or admissions department provides
the food service department with the number.
Because nonpatient services are similar to commercial food service establishments, the best
and most accurate method of calculating the profit margin is that used by the restaurant industry. The figures for patients and nonpatients should be reported separately.
Organization and Time Management
Calculating FTE Needs
Full-time equivalency refers to an employee who works on a full-time basis for a specific period
of time. The following hours and specific time periods are used in reference to FTEs:
8 hours per day
40 hours per week
173.33 hours per month
2,080 hours per year
Staffing needs are usually expressed as the number of FTEs needed for the department.
FTE needs are calculated using the productivity factor in the preceding section. First, the total
number of labor hours must be calculated for the time period in question. Second, the number
of labor hours is converted to FTEs needed. For example, if the cafeteria produced 16,364 meal
equivalents in a month and the productivity standard being used is equal to 5.5 meals per labor
hour, FTE needs are calculated as follows:
Labor hours = 16,364 meals per month = 2,975 labor hours per month
5.5 meals per labor hour
Number of FTEs = 2,975 labor hours per month = 17.2 FTEs
173.33 hours per FTE per month
The number of FTEs can be calculated for the day, week, month, or year by determining
the number of labor hours needed in the period and dividing by the FTE factor identified earlier. For example, if department responsibilities require 40 hours of work per week, 40 hours
÷ 8 hours per FTE per day = 5 FTEs. For a department that needs 300 hours per week, 300
hours ÷ 40 hours per FTE per week = 7.5 FTEs. The monthly need of FTEs would be 2,113
hours per month ÷ 173.3 = 12.2 FTEs. Yearly the number of FTEs would be 25,536 hours ÷
2,080 hours = 12.1 employees. FTEs required for the department do not necessarily reflect the
number of staff members employed by the department. For example, if the department needs
10.5 FTEs on an annual basis to run the department, it may have a total of 13 employees. Nine
of the employees may be full-time employees working a total of 40 hours a week, and three of
the employees may be 0.5 FTEs, or those who work 20 hours per week.
9 × 40 = 360 hours per week
3 × 20 = 60 hours per week
420 hours per week
420 hours per week ÷ 40 hours per FTE per week = 10.5 FTEs
Anticipating Overtime Needs
In the preceding examples, the number of FTEs required as regular productive hours was calculated. This figure represents core staffing based on the number of meals served. To determine
complete staffing, the manager must consider the number of overtime, benefit, and nonproductive hours to be paid. (Budgeting is covered in detail in Chapter 11.)
The amount of overtime used in the food service department depends on several factors,
including fluctuations in demand, inefficient work processes or equipment, employee injuries,
availability of workers, and department size. Some industry experts consider overtime above 2
Food Service Manual for Health Care Institutions
percent of productive hours paid to be excessive and in need of attention. Most organizations
establish an overtime percentage based on historical data and environmental information
before completing the annual operating budget. In an effort to lower the amount of overtime,
the number of part-time or occasional (on-call) employees can be increased. To determine the
number of FTEs required to cover overtime, the following formula is used:
Total FTEs × overtime percentage = number of FTEs for overtime
For example,
10.5 FTEs × 1 percent overtime = 0.11 FTE
Preparation for Outside Consultants
Effective control of labor costs requires a productivity measurement system to facilitate decision
making. Many health care organizations are using outside consultants who attempt to generate
productivity standards for the food service department. To prepare for outside consultants, it is
incumbent on food service directors to identify and establish productivity measurements for their
departments. Having departmental statistics available for outside consultants allows the food
service manager to be in control of productivity demands. Exhibit 6.3 shows a productivity form
that can be used to track internal productivity. This type of internal monitoring provides the food
service manager with information for consultants or support documentation for staff or service
Scheduling Work in a Food Service Department
Because health care institutions require round-the-clock staffing, the food service director must
make sure that the jobs in his or her department are filled at the appropriate times in each 24hour period. Scheduling is having an adequate number of workers on duty to perform work
that needs to be accomplished. Therefore, scheduling the workweek and specific hours each
employee must be on duty is a key step in achieving efficiency in the use of labor dollars while
meeting the institution’s service objectives.
The 40-hour workweek is common for full-time employees in most of the nation’s businesses. Actually, this period includes only 35 working hours because each hourly employee has
a 15-minute paid rest period every 4 hours and a 30-minute unpaid meal period each day.
Although the workweek has commonly been divided into five equal workdays, some innovative food service directors have developed schedules in which employees work 101⁄2 hours per
day and 4 days per week. Such schedules have produced notable improvements in employee
productivity and job satisfaction. Another type of schedule calls for employees to work 4 days,
take 3 days off, work 5 days, take 2 days off, and then begin the cycle again without working
more than 8 days in any two-week pay period.
Flexible Schedules
Overlapping schedules among employees can be avoided by retraining them to perform a broader
range of duties as part of their job enlargement plan. For example, tray line workers could learn
to perform production tasks and some sanitation duties, and sanitation workers could learn to
perform some food production and tray line duties. This flexibility in scheduling significantly
Organization and Time Management
Exhibit 6.3. Sample Productivity Form
ABC Hospital
Food Service Department Productivity Report for the Year:
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Average
Worked hours
Paid hours
Inpatient meals
Outpatient meals
Other meals
Cafeteria meals
Cafeteria sales
Meal equivalent
Total meals
Payroll costs
Food costs
Supply costs
Other costs
Total direct costs
Adjusted patient days
Internal Trends
Worked hours/meal
Meals/labor hour
Paid time (%) off
Total salary/meal
Food cost/meal
Supply cost/meal
Total cost/meal
Other meals (%)
% labor/total cost
Labor cost/adjusted
patient day
Total cost/adjusted
patient day
Total meals/adjusted
patient day
Worked FTEs
Paid FTEs
Food Service Manual for Health Care Institutions
reduces the total number of employees needed to meet labor needs. It also may result in less
absenteeism and turnover because of improved employee morale and job satisfaction. The new
schedule provides each employee with the opportunity for a wider set of duties and is an important element in any job enrichment effort.
Professional employees in the department also may wish to take advantage of flexible
scheduling. For example, a registered dietitian might choose to work during the institution’s
most active period between 6:30 A.M. and 3:00 P.M. Two part-time professional employees
might arrange their schedules so that together they meet the requirements of an FTE position;
that is, one might work three 8-hour days, and the other two 8-hour days. This arrangement
is called job sharing or job splitting. A nutrition host might choose to work four 10-hour days
instead of five 8-hour days so that he or she could cover all three meals served on the days
worked. Others might choose to work 9 hours for four days and then take half a day off on
the day of the week when there are fewer rounds and admissions.
Master Schedules
No matter which system of scheduling is best suited for a particular institution, the work schedule should be charted and posted so that it is readily accessible to all employees. The schedule
should indicate the days on duty for each employee, daily scheduled hours (when they vary from
one day to the next), days off, vacation days, and so forth. A rotating master schedule should
be developed to reduce the amount of time the director spends in scheduling employees each
week. Rotating master schedules are used to regularly schedule employee days off. A rotating
master schedule may complete the scheduling cycle every three, five, six, or seven weeks. It also
helps ensure that employees share responsibility for working weekends so that the same people
are not scheduled to work every weekend.
Master schedules are usually designed to correspond to the length of the pay period so that
each employee is assured of working an equal number of hours during each period. In addition, the number of overtime hours can be minimized when the schedule is designed to coincide with pay periods.
The food service director should examine the schedule of every employee. The daily hours
to be worked and the scheduled days off should be assigned fairly, without favoritism. Also,
situations in which an employee has the late shift on one day and an early shift the following
day should be avoided, as should split shifts because most employees prefer a continuous workday. Rotating shifts (in which an employee is scheduled for varying work periods from one
week or pay period to the next) are frequently used to provide more flexibility for management
and employees. Once the master schedule has been set, frequent major revisions should be
avoided. Although rigidity is not the goal here, a relatively consistent work schedule that
repeats with every pay period helps establish smooth work patterns for individual employees.
Furthermore, within certain work groups, employees must depend on being familiar with one
another’s pace of work to both ensure an adequate level of productivity and minimize the risk
of accidents and injuries. Finally, consistent schedules permit employees to plan their personal
time better, thus reducing the likelihood of absenteeism and employee turnover.
Other Schedule Types
In addition to scheduling employee workweeks, the food service director and his or her managers need to construct several types of schedules to ensure that all department work flows
smoothly during a given day. The daily schedule pattern illustrated in Figure 6.10 indicates the
different food service positions that need to be filled within the department and the daily hours
during which the functions of those positions usually must be accomplished.
Organization and Time Management
Figure 6.10. Example of a Daily Schedule Pattern
Food service director
Food production manager
Cook A
Cook B
Cook C
Stores clerk
Food service employees
Food service employees
Food service employees
Figure 6.11 shows an example of a shift schedule for eight cooks working in a department
that serves three meals per day seven days per week. Cooks A, B, and C together cover the
morning shift from 6:00 A.M. to 2:30 P.M. during which two cooks are usually needed. On the
one day per week that all three are scheduled to work—Thursday on this schedule—they may
perform extra cleaning duties or prepare special foods. The cooks on the afternoon shift, 10:00
A.M. to 7:30 P.M., are scheduled in the same way. Cooks D and E relieve each other so that four
days per week, only one of the two cooks is on duty. Cooks D and E prepare foods for modified diets or special salads and desserts.
Written daily work schedules guide each employee’s activities during the workday, listing
the duties to be performed during specified time periods and the routine cleaning tasks that
must be completed. An example of an individual employee work schedule is shown in Figure
6.12. Providing this type of breakdown for employees has several advantages:
• The employee has written instructions on hand for each task and does not need to rely
on verbal orders, which are more easily misunderstood or forgotten.
• Deadlines help an employee set objectives for each portion of the workday.
• Work can proceed more smoothly, with less time spent waiting for a new set of instructions or explanations.
The manager can use the individual schedule to maintain workload balance among
Some organizations set up separate cleaning schedules and rotate cleaning duties among
employees. Rotating unpleasant jobs is usually desirable, but most of the daily and weekly
cleaning tasks should be incorporated into individual schedules.
B. Tyler—Cook G
B. James—Cook H
I. Shenk—Cook D
J. Foot—Cook C
A. Frank—Cook F
Day off
T. Walker—Cook B
M. Smith—Cook E
J. Lloyd—Cook A
Week Ending:
Day off
Day off
Day off
Figure 6.11. Example of a Shift Schedule
Day off
Day off
Day off
Day off
Day off
Day off
Day off
Day off
Day off
Day off
Day off
Day off
Organization and Time Management
Figure 6.12. Example of a Work Schedule for an Individual Employee
Work Schedule for Cafeteria Counter Employee
Hours: 5:30 A.M. to 2:00 P.M.
30 minutes for breakfast
15 minutes for coffee break
Position: Cafeteria Counter Employee No. 1
Days Off:
5:30 to 7:15 A.M.
Supervised by:
Relieved by:
1. Read breakfast menu
2. Ready equipment for breakfast meal
a. Turn on heat in cafeteria counter units for hot foods, grill, and
dish warmers at 6 A.M.
b. Prepare counter units for cold food at 6 A.M.
c. Obtain required serving utensils and put in position for use
d. Place dishes where needed, those required for hot food in
dish warmer
3. Make coffee (consult supervisor for instructions and amount to
be made)
4. Fill milk dispenser
5. Obtain food items to be served cold: fruit, fruit juice, dry cereals, butter, cream, etc.; place in proper location on cafeteria
6. Obtain hot food and put in hot section of counter
7. Check with supervisor for correct portion sizes if this has not
been decided previously
6:30 to 8:00 A.M.
1. Open cafeteria doors for breakfast service
2. Replenish cold food items, dishes, and tableware
3. Notify cook before hot items are depleted
4. Make additional coffee as needed
5. Keep counters clean; wipe up spilled food
8:00 to 8:30 A.M.
Eat breakfast
8:30 to 10:30 A.M.
1. Break down serving line and return leftover foods to refrigerators
and cook’s area as directed by supervisor
2. Clean equipment, serving counters, and tables in dining area
3. Prepare serving counters for coffee break
a. Get a supply of cups, saucers, and tableware
b. Make coffee
c. Fill cream dispensers
d. Keep counter supplied during coffee break period (9:30–10:30)
4. Fill salad dressing, relish, and condiment containers for noon
10:00 to 11:30 A.M.
1. Confer with supervisor regarding menu items and portion sizes
for noon meal
2. Clean equipment, counters, and tables in dining area
3. Prepare counters for lunch
a. Turn on heat in hot counter and dish warmers at 11 A.M.
b. Set up beverage area
c. Place service utensils and dishes in position for use
Food Service Manual for Health Care Institutions
Figure 6.12. Example of a Work Schedule for an Individual Employee (continued)
4. Make coffee
5. Set portioned cold foods on cold counter
11:00 to 11:15 A.M.
Coffee break
11:30 A.M. to 1:30 P.M.
1. Open cafeteria doors for noon meal service
2. Replenish cold food items, dishes, and tableware as needed
3. Keep counters clean; wipe up spilled food
4. Make additional coffee as needed
1:30 to 2:00 P.M.
1. Turn off heating and cooling elements in serving counters
2. Help break down serving line
3. Return leftover foods to proper places
4. Clean equipment and serving counter as directed by supervisor
2:00 P.M.
Off duty
Computerized Scheduling
Scheduling for the food service department is a complex task requiring a large amount of information. Because of the complexity and time involved in scheduling, some departments have
turned to computer software for this activity. Scheduling software can track the number of fulland part-time employees, the number of hours worked, vacation or other days off, specific
times requested off by employees, and when an employee goes into overtime. Computerized
scheduling also consistently provides management with timely reports of hours worked, which
is necessary to track department productivity. In addition, workload and peak times can be predicted, allowing flexible staffing; management time is freed for other duties; and computer
objectivity ensures scheduling equity among employees. Unlike manual schedules, computer
scheduling can accommodate last-minute changes with little effort and time.
Scheduling software usually includes information about the job requirements for each position and information regarding employee capabilities. Based on this information, the manager
can set features that allow the software to make the match of employees to days, times, and tasks
to be performed. Scheduling software can offer many benefits to a department, as long as program users are adequately trained.
Managing Time Effectively
Although managers assume responsibility for developing work schedules for their employees,
they often fail to schedule their own time to best advantage. One step toward effective time
management is for managers to analyze the way they currently use their time. A detailed log of
daily activities helps managers keep track of what they do, the amount of time spent on each
activity, others involved in the activities, and how important each act is to the day’s objectives.
Analysis of these logs helps managers determine how effectively they spent their time and some
of the reasons they do not reach their objectives during a particular week. For example, unnecessary phone calls, avoidable interruptions, or lack of a good work plan all contribute to an inefficient use of time. Using this analysis allows the manager to do first things first. Maintaining a
daily planner allows a manager to keep track of necessary activities and aids in the appropriate
use of time (Figure 6.13).
Organization and Time Management
Figure 6.13. Example of a Manager’s Daily Planner
Time of Day
Already Planned
Must Do
Staff meeting
1. Budget review
2. Write QA report
3. Procedure for use
of new dishwasher
Start budget review
Write QA report
Complete QA report tomorrow
Complete tomorrow
See DB about figures
Complete budget review
Call engineer–dishmachine
Infection Control Committee
on Wednesday
Prioritizing Work
Once managers have monitored their daily activities, they are in a better position to list the
essential tasks of the coming week and assign each a priority: A for tasks that are critical, B for
tasks that are important but not critical, and C for tasks that might be delegated (Figure 6.14).
Food Service Manual for Health Care Institutions
Look for duplication of efforts and eliminate them. Priorities should be set for the tasks that are
to be accomplished daily and for longer-term projects, such as recruiting a new staff member,
developing a budget, or gathering information to plan a new program. Large projects are more
easily handled and prioritized when they are broken down into their component parts and tackled one step at a time. Adjust estimated time to do a job. Build in time for emergencies.
Another method of prioritizing work has been suggested by Stephen Covey in his book 7
Habits of Highly Effective People. The focus of Covey’s priority system is to manage “self”
rather than time, using four quadrants for time management:
1. Urgent and important. This quadrant encompasses crisis situations or problems. Being
problem oriented and driven by deadlines prevents managers from focusing on more
important tasks.
2. Not urgent and important. This quadrant has to do with effective personal management as represented by planning functions. Functioning in quadrant 2 requires the
manager to seek balance in work and personal activities and to undertake important
activities that are not urgent.
3. Urgent and not important. Like quadrant 1, the driving force for quadrant 3 is urgency.
Unlike quadrant 1, however, task urgency here is determined by others. That is, these
tasks may be urgent to someone else but not for the manager’s goals and focus.
4. Not urgent and not important. The activities in this quadrant are referred to as “comfort” activities, those tasks that require no great amount of thought and may be relaxing. The biggest problem with focusing on tasks in this area is that comfort tasks
prevent managers from focusing on the tasks in quadrants 1 and 2.
With the self-management theory, time management is the responsibility of the manager
and not determined by the tasks. Managers must choose the activities they will spend time on.
To meet the challenges of a rapidly changing health care environment, managers should focus
energy on the tasks of planning outlined in quadrant 2.
Setting Limits
Managers should avoid the four biggest time wasters: excessive telephone calls, unnecessarily
long meetings, unexpected visitors, and paperwork. To reduce the time spent on each, managers should set their own limits:
• If possible, schedule no more than one hour each day for returning telephone calls. Each
conversation should be related to the work at hand.
• Although meetings can be useful, make sure that the meeting time is used productively by
planning an agenda or proposing an outcome and by ending the meeting at a predetermined time.
• To better minimize unexpected visitors, avoid making them feel too welcome or too
comfortable. When possible, a closed door and being screened by a secretary should do much
to discourage unscheduled visitors. If that does not suit a manager’s style or the institution’s
working climate, a manager might stand when an unscheduled visitor enters the room and
remain standing until he or she leaves. Other options are to suggest a better time for a meeting, make an appointment to see the person in his or her own work area, and end the meeting
as soon as the business is completed.
• Managers can reduce their share of paperwork by using several tactics. Have someone
screen the paperwork and sort it according to its relative importance. Do not handle any piece
of paper more than once. Write responses directly on memos and return them to the sender.
Whenever possible and appropriate, delegate responsibility for handling paperwork.
• Minimize details by trying to find a way to handle them accurately and with a minimum
of effort. Delegate some of the details to staff.
Organization and Time Management
Figure 6.14. Example of a Food Service Director’s Weekly Planner
Goals (Priorities)
Estimated Time Day Completed
1. Complete budget (A)
61⁄2 hours
Give budget to secretary to type
by Wed. noon; review Thurs.;
turn in by Fri., 3 P.M.
2. Discuss disciplinary
action (A)
21⁄2 hours
Meet with Human
Resources Department
3. Attend meetings (B)
31⁄2 hours
Monday, Thursday
Be sure to go to staff meeting
1 hour
4. Handle mail, meet
with employees (B)
5. Review magazines (C)
Turn in budget!
• Set specific times to review and answer all electronic mail. Delete items that do not apply
to the job.
Time management, like any other management skill, can be learned with practice. Managers
need to begin applying time management techniques to their own schedules to achieve the full
range of their professional and personal objectives.
The organizing function of management involves designing appropriate organizational structures, grouping work according to some common criteria such as function or product, and
establishing relationships between the organization’s activities and its job positions. In addition
to divisions of authority and responsibility according to departments or units, managers often
Food Service Manual for Health Care Institutions
find that work groups such as committees, task forces, and project teams are useful in completing certain types of activities that require the expertise and cooperation of several departments. Food service departments benefit in many ways from participation in such work groups.
When coordinating work, managers also must organize the way authority is distributed
throughout an organization. The sharing of authority by managers with their employees is
called delegation and is instrumental in obtaining for managers the support, advice, and special knowledge of staff outside the direct chain of command.
The building of a competent staff to carry out the work of an organization involves assessment of the tasks to be performed and the employees needed for performing those tasks.
Managers determine staffing needs by assessing workload, undertaking job analyses, and preparing job descriptions and specifications. The smooth flow of work throughout an organization is
ensured through the careful scheduling of employees’ time and by the managers’ vigilance over
the expenditures of their own time.
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Chapter 7
Communication can be defined as the process of conveying verbal or written information from
one party to another; it involves a sender’s transmitting a message and a receiver’s understanding it. Communicating effectively is both a language process and a people process that requires
interpersonal skills. Communication skills are vital to performing the basic functions of management: planning, organizing, controlling, and especially leading. In fact, managers spend
most of their time in activities that involve some form of communication.
To run smoothly, organizations must have efficient information distribution systems that
ensure that messages are received in the manner intended. The kinds of information disseminated throughout an organization include goals and objectives, change strategies, policies and
procedures, behaviors and concerns, and problems and solutions. Communication is essential
for obtaining information from customers because it allows managers to enhance service delivery. Furthermore, harmony, cooperation, and efficiency within a work team depend on effective communication as a means of ensuring that all members understand the team’s objectives
and the tasks to be performed.
Communicating in health care organizations requires the manager to fulfill the following roles:
• Receptive listener in interactions with customers, superiors, peers, and employees
• Distributor of information in both sending work plans and instructions to employees
and reporting activities and results to peers and superiors
• Spokesperson for top-level managers in communicating with employees and spokesperson for employees in communicating with top-level managers
This chapter examines the elements and process of communication, that is, factors that
affect how messages are sent and how they are received and interpreted. Three barriers to effective communication—environmental, experiential, and behavioral—are looked at. The two
means of communication, the spoken word and the written word, are discussed, as well as a
third medium of nonverbal communication through body language. In discussing methods of
communication, I give pointers on how to plan and conduct meetings, make oral presentations,
and design effective written communications. The chapter closes with a brief description of the
manager’s role in mediating and resolving conflict.
Food Service Manual for Health Care Institutions
Communication Process
The communication process is complex, consisting of the formation, transmission, and translation of information. Five basic elements are involved in the communication process:
• The message sender—the person who creates and transmits a message to another person or people
• The message (information)
• The medium used to transmit the message, such as print, telephone, fax, or e-mail
• The message receiver who receives message from sender
• The feedback exchanged between receiver and sender (Figure 7.1)
The message is the actual physical product that may be typically words and nonverbal
cues. The medium or channel is how the message travels.
The sender not only determines the message to be sent but is also responsible to deliver the
message in a way that minimizes the chance that the message will be distorted.
The receiver is the person who receives the message and decodes (deciphers) the message
that was received. The receiver must also interpret the message based on personal experience.
Feedback is exchanged between the sender and the receiver to determine whether the message
received was the message intended (see Figure 7.1).
Each element affects the creation, transmission, and translation of information in the communication process. Influences outside the communication process, called distracters or barriers, can affect each element of the process.
Both sender and receiver are influenced by their respective personal characteristics, shaped
over a lifetime by language, education, religion, life experiences, culture, environment, work,
and physical traits. Because lifetime experiences affect the perception of both sender and
receiver, understanding the message sent means understanding the sender. Likewise, ensuring
that the message is interpreted as intended implies understanding the receiver.
The medium selected often depends on the message to be conveyed. Sometimes—for example, when immediate feedback is desired—it is appropriate to convey a message verbally in person rather than by a written memorandum. Feedback is exchanged between sender and receiver
to confirm whether the message received was the one the messenger intended. The feedback
process is affected by the medium used and by the personal characteristics of sender and
receiver. In other words, the five elements of the communication process are interrelated.
Communication Barriers
At any point the communication process could be interrupted or interfered with by distracters.
Distracters are circumstances that interfere with the sender’s or receiver’s attention and draw it
away from the message sent or that alter or otherwise compromise the message. Barriers can
Figure 7.1. Communication Process
cause miscommunication of even the simplest facts in the communication process, and as messages increase in complexity, the potential for miscommunication increases. Communication
barriers can be divided into four broad categories: environmental, experiential, behavioral, and
Barriers Due to the Environment
An obvious distracter in the communication process is an environmental interference that distorts or breaks the information flow between sender and receiver. Two types of environmental
barriers exist: physical (or mechanical) and operational.
Examples of physical or mechanical environmental barriers are broken connectors or static
on telephone lines, conversations interrupted by ringing phones or knocks on office doors, or
loud laughter that disrupts a meeting. Operational barriers have to do with system breakdowns. Examples are letters that are lost in the mail, misplacement of a critical memo due to
an inadequate filing system, or loss of data due to a programming error.
A food service manager whose office is near a cafeteria entrance can anticipate certain
physical environmental barriers (such as noise). Therefore, the manager should schedule a oneon-one, manager–employee conference in a private conference room. Otherwise, it could be
difficult for the sender (the manager) to communicate the message (the consequences of a specific inappropriate behavior and what must be done to change it) to the receiver (the employee)
because the medium (the sender’s voice) might be drowned out by the cafeteria’s noise. Unless
the message is conveyed and received accurately and without distraction, feedback can be virtually impossible.
Managers cannot anticipate all environmental distracters. In a situation where a patient
with diabetes was given the wrong meal tray, the manager’s responsibility is to recognize the
probability of an operational environmental barrier. The manager should then investigate the
food service department’s information systems to discover the reason for the miscommunication of patient tray information.
Barriers Due to Experience or Personal Perception
In Chapter 1, the increasing cultural diversity of the workforce and the effect this has on daily
management functions and service operations were noted. In the communication process, both
sender and receiver are products not only of life experiences but also of accumulative cultural
experiences. Collectively, these experiences define their personal perception in terms of who
they are, how they feel about themselves, and how accepting they are of similarities and differences in customers, peers, coworkers, superiors, and subordinates. Words, actions, and situations are perceived by different people and groups and who may act differently to the same
Personal bias can create barriers to communication. For example, a cook asked to clean
up a spill on the floor during lunch meal preparation to prevent someone from falling might
interpret the request as a waste of time, even a form of punishment if the cook perceives the
job of a cleaning technician to be less important than his or her own.
In the situation described above, the same message also might be received negatively if the
cook is already busy preparing meatloaf. In addition to being influenced by personal outlook,
messages and their interpretation can be affected by the circumstances of the moment.
Pressures and stressors—those imposed by the work environment and those that are the result
of personal perception—can affect all five elements of the communication process. Therefore,
managers must be in touch not only with their own stress levels but also with those of others
with whom they come in contact.
Savvy managers make every effort to suspend judgments that are based on differences in
appearance or use of language, for example. Otherwise, they risk a loss of opportunity that may
be conveyed in information exchanges. A menu planner’s suggestion to incorporate more ethnic
entrees into patients’ menus can be seen as a business opportunity because these managers are
Food Service Manual for Health Care Institutions
able to interpret the message with objectivity. Such managers demonstrate the valuable skill of
separating the message from the messenger.
Barriers Due to Behavior
Personal perspectives and life experiences may precipitate certain behaviors that can block or
distort the flow of information. Sometimes the behavior (the action) is the product of an emotion (a feeling). Emotions can affect the transmission and interpretation of messages. Emotions
can be conscious or unconscious. A tray assembler angry at being refused a promotion might
deliberately miscommunicate patient menu orders. A cook denied approval to purchase precooked roast beef rather than preparing it might fail to take the meat out of the oven before it
burns. In both cases, the flow of information is impeded because of what can be described as
an emotional behavior barrier to communication. The emotions in the above examples are
anger and disappointment, respectively.
An effective tool for removing the negative influence of emotional behavior is acknowledgment. Acknowledgment does not mean making judgments about the legitimacy of the feeling. If the tray assembler and the manager are “found out” and held accountable, their
respective superiors should not judge the unacceptable behavior but simply state that the listener understands: “I understand that you are upset about ______; however, it is important to
discuss how the situation can be handled.”
Another method of handling emotional behavior is to continue the conversation while
allowing—but not acknowledging—the behavior. For example, if an employee cries while the
manager attempts to discuss a performance problem, the manager can simply continue the conversation. This is effective only if both manager and employee can continue to focus on the
issue without allowing it to influence the outcome. If not, the conversation should be rescheduled. In emotional situations, it is important that the manager understand the other person’s
position before he or she can be expected to hear and understand the manager’s message.
Barriers Due to Culture
Cultural factors can ease or hinder communication. A similarity in culture between senders and
receivers facilitates successful communication, and the intended meaning has a higher probability of getting transferred. A difference in culture hinders the communication process, and the
greater the cultural difference between sender and receiver, the greater the expected difficulty in
communicating. This is especially the case in states such as California, Florida, New York,
Texas, and Michigan where language (words) may not translate directly. Other cultural differences that managers need to be aware of when dealing with a culturally mixed work group
include the following:
• The other’s communication approach is interpreted negatively.
• The rank of the receiver may affect the message and the process.
• Nonverbal cues such as spatial separation, body language, touching, behavior, and customs may be distracters.
• The message and method used to send it may be misinterpreted if the receiver is not fluent in English.
• Ethnocentrism, the belief in the superiority of one’s group and the related tendency to
view others in terms of the values of one’s own group, is probably the largest single barrier.
• Stereotyping, the tendency to oversimplify and generalize about a group of people, is
another major barrier to effective communication. Stereotyping occurs between and within cultures. For example, some people think all people who work in food service are lazy and uneducated and could get a better job if they wanted to.
• Differences between “the haves” and the “have nots” create barriers predicated on
language, economics, social standing, location, job status, and general cultural and custom
Use “politically correct” (that is, culturally sensitive) terms when communicating with
coworkers. A manager should use terms that are nonoffensive or neutral to replace words or
phases in common usage that are disparaging, offensive, or insensitive.
When working with diverse cultural groups, a manager should know and learn that cultural
differences will likely exist. When a misunderstanding occurs, and the other categories of barriers to communication have been eliminated, the manager should be aware that the cause may
be cultural. For example, people from Japan rarely speak first in meetings because they think it
is unwise. Avoid ethnocentrism and stereotyping. Be objective and appreciate the differences in
the members of the work group. Be conscientious of how individuals or groups are designated.
Many politically correct words have replaced many terms that were offensive. However, racial,
sexual, and other slurs that hurt and offend individuals and groups are still commonly used.
Managers should learn the preferred ethnic terms of their workers. Some people of African heritage may prefer being called “black,” whereas others may want to be called “African American.”
Depending on ancestry, Spanish-speaking persons may be called “Latino,” “Chicano,” “Hispanic,”
or other terms related to their country of origin (such as Puerto Rican). People from the Pacific
Rim may wish to be referred to as “Asian American” or a term reflecting their country of origin
(such as “Korean,” “Japanese,” “Filipino,” and so forth).
Barriers Due to Other Factors
Often behavior called nonverbal communication can communicate just as effectively as emotional displays. This behavior is conveyed through body language rather than spoken or written words. Facial expressions, gestures, and posture send “wordless transmissions” about
attitudes, perceptions, and emotions. Smiling, shrugging, or sitting slumped in a chair are common expressions in the nonverbal vocabulary. Sometimes nonverbal communication can serve
to support verbal communication, such as when a manager’s words of encouragement to an
employee are accompanied by smiles and nods.
When either the sender or the receiver does not have adequate knowledge to understand
the other, the process is not effective. Other barriers include
• Lack of interest. Either the receiver or the sender does not have an interest in the message being conveyed.
• Use of jargon. Physicians or administrators may use technical language, terms, and
phrases that are unique to food service or health care operations that can be mystifying to food
service employees not familiar with terms.
• Source of the message. Evaluating the source of the message can cause the receiver to
“filter” or manipulate the information as to its importance.
• Personality conflict. When there is a conflict between the sender and the receiver, problems can arise. If the receiver does not like the sender, the message is less likely to be received.
• Selective communications. Receiving communications on the basis of what one selectively hears and sees, depending on his or her needs, motivation, experiences, background, and
other personal characteristics.
• Information overload. This occurs when the amount of information is so great and
detailed that it exceeds a person’s processing capacity.
• Appearance. The way a person dresses and speaks as well as body size may distract from
the effectiveness of a communication.
• Regional language. Despite the pervasiveness of the popular media, regional phrases are
still common throughout the United States. For example, in some regions, “hurry up and fix
it” may mean repair it quickly. Each region has its own particular variations that should be
carefully avoided when messages are widely distributed out of the region.
Nonverbal behavior also can contribute to another behavioral barrier known as the mixed
message, which results when a verbal message and a nonverbal message do not coincide. For
Food Service Manual for Health Care Institutions
example, while leaning back in a chair and shuffling papers without looking up, a manager
might say to an employee, “I’m very interested in your suggestion.” The employee leaves the
office confused, having received two seemingly contradictory messages: Although the manager’s words convey interest, the manager’s body language (absence of eye contact and preoccupation with desk papers) conveys apathy.
Workers throughout an organization rely daily on each others’ nonverbal cues in gauging intent, acceptance, and comprehension of messages. All groups must remain alert to the
information—verbal and nonverbal—that they send.
Methods of Communication
Direct communication can take two forms as determined by the medium used in the process.
Verbal communication uses the medium of the spoken word: in face-to-face conversations, telephone conversations, and meetings. Written communication includes letters, reports, proposals, e-mail messages, justifications, and memos.
Verbal Communication
Verbal communication involves face-to-face contact between people in conversations or group
discussions, sharing information through words, either written or spoken. Telephone calls are
also common forms of verbal communication. The central avenue of communication for most
managers, verbal communication is immediate in that it permits prompt feedback about the
message, and it does not require the technical skills of typing or word processing. However, verbal communication is not always the best way to communicate messages in management situations. Aside from the environmental distractions of noise and static mentioned earlier, verbal
exchanges provide no written record of conversations. Therefore, decisions and compromises
reached verbally could be subject to debate later on. Verbal communication also may not give
communicators time to reflect on their responses to questions raised and decisions discussed.
In organizations, verbal communication is used extensively when managers direct
employee work activities, give instructions to employees, conduct meetings, lead work or
process improvement teams, and make formal presentations. These formats are discussed in the
following subsections.
Directing or Instructing Employees
Managers’ verbal directions and instructions to employees should be thoughtfully prepared and
carefully delivered to keep misunderstandings to a minimum. Every verbal direction given to
an employee should be framed so that its meaning is clear, complete, and reasonable. The manager should always keep the employee’s viewpoint in mind. New terms should be explained and
simple words and sentences used. The manager should ask employees regularly whether they
have any questions about the directions given.
When it is clear that the employees understand the directions, the manager should indicate
when the task is to be completed and how the employees are to report back after it is completed. Complicated directions may require the manager to follow up and, if necessary, clarify
the instructions to ensure that tasks are completed as directed. However, it is important that
the manager show confidence in employees and allow them reasonable independence in performing their regular duties.
New or particularly complex tasks should be described in written detail in addition to
being explained verbally. The manager should be careful to ensure that the written information
matches the information given verbally. Conflicting sets of instructions for the same task can
only cause misunderstanding and confusion.
Planning and Conducting Meetings
Managers spend a great deal of time attending meetings with superiors, peers, and employees
in the organization. Many complain that most meetings are a waste of their time. However,
meetings are the means by which organizations conduct a large part of their business. Planning
is the key to conducting productive, informative, and cost-efficient meetings. There are several
types of meetings that include informal, formal, committee, problem solving, and information
passing. For the purpose of this text, meetings will be categorized as business meetings and
team meetings.
Business Meetings
The purpose of business meetings is to provide or share information and to delineate planning
or development functions. These meetings are usually formal. For the most part, the departmentlevel planning and development meetings that food service directors attend deal with menu
planning, production planning, and nutrition care planning. The director or manager also
attends informational meetings of the management staff and, depending on the size of the
department, employee meetings. Meetings held for the sole purpose of providing information
should be carefully evaluated. If the information could easily be shared in a memo, via e-mail,
fax, conference call, or a chat room (a real-time online discussion group), a meeting may not
be necessary. However, many food service department employees appreciate and enjoy hearing
information from the department manager. Also, this type of meeting allows for questions and
discussion of the information presented to ensure understanding.
Each meeting requires a coordinated plan for conducting business and for decision making. The director or manager responsible for conducting such meetings should plan the meetings by routinely following a simple seven-step process:
1. Clearly define the goal(s) of the meeting. Be careful to avoid covering too much in any
one session. It is better to discuss thoroughly and solve one problem than to discuss
many subjects but reach no clear-cut conclusions.
2. Determine how much time should be allotted for accomplishing the meeting’s goals.
Most meetings should last no longer than 60 or, at most, 90 minutes. When longer
meetings are planned, a break should be provided after the first hour.
3. Decide who should attend the meeting. Factors to consider are the authority levels of
the participants and the most cost-effective and efficient size for the group.
Participants must have authority to make and act on any decisions that come out of
the meeting. The number of attendants should be kept to a minimum to control the
cost in time expenditures. It should also be kept in mind that the larger the group, the
less likely it is that the meeting’s goals will be fulfilled.
4. Determine the format that will best suit the goal of the meeting. If the goal is to solve
a problem, the meeting should be a free exchange of ideas and suggestions. If the goal
is to distribute information, the meeting should be a preplanned discussion and explanation of data or other information. If the goal is to win the group’s acceptance of a
new proposal, the meeting should be a carefully constructed presentation of background materials and projections.
5. Plan a strategy for accomplishing the goal of the meeting. Anticipate potential resistance to change, conflict within the group, and other problems. Formulate methods for
handling such problems and securing the support of other group members before the
6. Write an agenda for the meeting. An agenda is a written statement of the order of
events in a meeting and is called an operational agenda (Figure 7.2). If anyone other
Food Service Manual for Health Care Institutions
than the meeting planner is to be responsible for presenting topics, that person should
be notified ahead of time. The final agenda should be distributed in advance to everyone who is to attend the meeting. To save time, combine routine items into one item
for the group’s approval. This is called a consent agenda. Items in the consent agenda
should be things that are generally agreed upon and that do not need to be discussed
before a vote. Items to be included in a consent agenda include
Approval of agenda
Committee and previous meeting minutes
Minor changes in procedure
Routine revision of a policy
Updating of documents
Treasurer’s report (as appropriate)
The items should be standard, noncontroversial, and self-explanatory.
The consent agenda and any supporting materials should be distributed before the
meeting. When using a consent agenda, make sure everyone knows the rules. Any
member can ask for any item to be removed from the consent agenda and open for
discussion. If no one asks for the removal of an item, the entire group is voted on without discussion (see Figure 7.3).
7. Record meeting minutes. If a written record of the meeting is required, appoint a
group member before the meeting to be the secretary.
Figure 7.2. An Operational Agenda
Clinical Management Meeting
January 20
General Business
Place: Conference Room H20
Time: 1:30 P.M. – 3:00 P.M.
(30 minutes)
Call to order, attendance
Approval of agenda
Approval of minutes
Report of director’s retreat
Approval and discussion of policy Q16
Approval of update call list
(45 minutes)
Diet manual revision
Update formulary
Quality Indicators for Food and Drug Interaction
(15 minutes)
National Nutrition Month
New RN on 4th West
Special event in cafeteria
Next meeting
Note: An asterisk indicates that it needs individual motions or approval rather than one motion as in a consent
Figure 7.3. A Consent Agenda
Clinical Staff Meeting
January 20
Call to order
Consent agenda* (materials sent Jan. 10)
Approval of minutes from previous meeting
Approval of agenda
Report of director’s retreat
Approval of policy #Q106
Approval of updated call list
Place: Conference Room H20
Time: 1:00 P.M. – 2:00 P.M.
Diet manual revision—Jones
Update on enteral formulary—Smith
Quality Program Indicators for Food and Drug Inactions—Brown
Note: An asterisk indicates that it needs one motion and approval.
The person designated to conduct the meeting (referred to as the chairperson or chair) is
responsible for moving the meeting toward accomplishment of its goals. The chairperson should
schedule the meeting room and the meeting room setup well ahead of time, making sure that it
is large enough to accommodate the group and that the physical environment is comfortable
(Table 7.1). Any audiovisual equipment, displays, and handouts should be arranged for ahead
of time. Equipment should be checked in advance to ensure that it is in good working order.
During the meeting, the leader should follow a few simple rules of courtesy:
• Arrive early so that he or she can greet people as they arrive.
• Start the meeting on time unless several people are late, in which case the leader should
send out reminders, such as a telephone call, and then proceed with the meeting.
• Direct discussions with open-ended questions that give everyone a chance to contribute.
• Stick to the agenda and make sure that other group members do so as well. If items or
issues are raised that are not on the agenda, a “parking lot” can be created by writing on a
board or flip chart a list of items that may need further discussion outside the meeting or to be
added to the agenda in the future. The meeting can then move forward while providing a
record of issues that require future attention.
• Use consent agendas.
• Limit the discussion to one point at a time to avoid conflict.
• Avoid unnecessary interruptions (such as telephone calls) and discourage distractions
(such as shuffling of papers and whispering among attendees).
• The chair should remain neutral. If he or she has a strong opinion on a topic, the chair
should relinquish authority to provide input into the discussion.
• Ask for input from attendees regarding how the meeting went, its structure, and whether
they feel goals were met, topics were given appropriate time, and their participation was valued. Express sincere thanks to the group’s members for their attendance and participation.
Taking time to ask members to evaluate effectiveness can enhance future meetings of the group.
• End the meeting at the appointed time by reviewing key points, assigning follow-up
tasks, and setting the date, time, and place for the next meeting.
Food Service Manual for Health Care Institutions
Table 7.1. Meeting Room Setup
Schoolroom or classroom
Rows of tables with chairs: allows participants to take notes and spread out materials but
limits interaction with other attendees
Banquet round
Usually used for food functions but works well for small groups
U-shaped setup
A hollow square or rectangle with one side removed works well for visual aids
Theater or auditorium
Features a platform with a podium as a focal point and maximizes the number of people
that can be accommodated
Conference boardroom
For small groups that require a lot of interaction
Crescent round
Round banquet tables with chairs around half to three-quarters of the table, all facing the
front; use when networking and note taking are important
Hollow square
Works for a schoolroom-type presentation; no one sits “inside” the hollow
After formal meetings, the minutes should be reviewed and then distributed to the participants to ensure accuracy. The names of those attending should also be recorded as part of the
minutes, which should be signed by the chairperson and kept on file for future reference and
At least once a year, the food service director should evaluate all formal meetings held in
the department. Committees, task forces, and other formal groups should be dissolved if their
goals have been met. The director should also review the cost of the department’s meetings in
terms of the supplies used, the salaries of the staff members who attended, the refreshments
provided, and so forth. The director should ask basic questions about the meetings to determine their effectiveness: Did too many people attend? Were the costs of the meeting justified
by its results? Did the meeting meet the mission of the department? Did the meeting establish
outcomes and were they met? If not, how can future meetings be planned to meet outcome
Team Meetings
Team meetings are conducted with employees in the department or as cross-functional teams
with employees across the organization. Team meetings, which may or may not have a manager as the team leader, can be designed to discuss work methods, customer satisfaction, or
process improvement. Their goal is to improve quality, that is, quality of work life, quality of
customer satisfaction, or quality of work accomplishment. Before a quality improvement team
can be initiated, several questions must be answered.
• What is the purpose or mission of the team? This question helps identify the process or
issue under discussion, the background information surrounding the process or issue, and what
information or data are available regarding the process or issue.
• What is the scope of the project? It is important to understand what is not being
included in the activities. Once boundaries are identified, budget constraints must be explored.
The decision-making authority of the team members and leader also must be clarified.
• Who should be on the improvement team? This question involves identifying who has
ownership of the process, who knows what the issues and concerns are for the customer, and
who is needed to offer a different perspective. This is the time to decide whether a facilitator is
• What are the expectations for improvement? Questioning the expectations identifies the
outcome or goals, time lines for recommendations, the magnitude of improvement expected,
and who is responsible for approval and implementation of the recommendations.
• What resources are available to the team? Resources may include consultants or internal experts, facilitators, coworkers who perform extra work so that team members can attend
meetings, and support staff who can create presentation materials. Materials for data collection and analysis also are needed. They may include computers and software.
Answering these questions provides team members with a clear picture of their charter or
mission. When the team meets for the first time, the information compiled from these questions
is presented for review and discussion by the team leader. It also may be necessary to provide
the answers in the form of a proposal to the administrator and other department administrative personnel for its approval before the meeting, especially if the process requires a crossfunctional team (see Chapter 4). Once approved and the team members are clear about the
team’s mission and purpose, ground rules for the meetings should be discussed. Ground rules
may be a part of the training program provided for all employees involved in quality improvement but should be covered as a reminder in the first team meeting. Ground rules include the
• Attendance: Time and place for meeting, how to notify team of absence, acceptable
number of absences, designation of a replacement, and so on
• Time management: Punctuality with regard to meeting start and end, timekeeper responsibilities, appointment of timekeeper, what must be accomplished during meeting, agenda for
• Participation: Being prepared for meetings, completing assignments, sharing responsibilities, and so on
• Communication: Confidentiality, candor, orderly and focused discussion, one speaker at
a time, active listening, respect for others’ opinions
• Decision making: How decisions are made (majority vote), open discussion permitted
before voting, conflict acceptable and handled in the open, number of members who must be
present for decision making
• Documentation: Format for agenda, format used for minutes, distribution of agenda
and minutes, storage of and access to documentation
• Miscellaneous: Breaks, refreshments, room setup and cleanup, need for support services,
how they will be coordinated
The same guidelines should be followed for conducting team meetings as for business
meetings. The leader (not necessarily the manager) is responsible for conducting the meeting,
setting up the next meeting, and providing follow-up information or information needed before
the next meeting. When conducting team meetings, the leader must keep individuals on target
to reach established goals.
Making Presentations
Sometimes the food service manager may be asked to provide information in a formal presentation. Presentations may include training sessions for employees or students or delivery of
information regarding the department business plan, budget, or special project to decision
makers. Managers can give successful presentations by being prepared and by understanding
how to deal positively with the anxiety or stress related to this activity.
Food Service Manual for Health Care Institutions
A substantial body of literature is available to assist managers with gaining skills in business or technical presentations. The limited scope of this text prevents a detailed review of technique, but the following basic guidelines can serve to help managers prepare to present
information to a group.
• Plan the presentation by identifying objectives to be achieved. Next, assess the needs and
level of knowledge of the audience. For example, in speaking to students regarding the
cook–chill process, a manager might relate the history or evolution of this food production
method. On the other hand, in presenting a request to decision makers for conversion of the
food production system to cook–chill, the focus might be on costs associated with the current
system versus savings to be realized on conversion.
• Organize the information to be presented. Using the objectives for the presentation will
help determine the order of presentation. Organizing should include the development of an outline, and main ideas should be developed with their subpoints. The presentation should have
an introduction and a conclusion that summarize the main idea(s) from the body of the presentation. In other words, to use a well-known phrase: “Tell them what you’re going to tell
them; tell them; then tell them what you told them.” Deliver the most important point(s) first.
Concentrate on the listener. Practice ahead of time to become familiar with material.
• Use handouts and visual aids to enhance the presentation. Visual aids focus the audience’s attention, reinforce the verbal message, stimulate interest in the topic, or illustrate hardto-visualize factors. They should not be used if they do not improve the presentation’s
effectiveness. Nor should they be used to avoid interacting with the audience. If handouts are
used, the manager must decide at what point to distribute them: If they are handed out in the
beginning, the audience may spend time reviewing rather than listening; if they are handed out
during the presentation, they should be distributed quickly to prevent distracting from the presentation. It also may be appropriate to distribute handouts at the end to provide written support of the verbal presentation.
Add variety to a presentation. Use demonstrations, such as how to clean a new piece of
equipment. Role-play a situation, or use case studies or panel discussions. Make eye contact
with the group, walk around the room but do not pace. Use persuasion to change beliefs, feelings, or attitudes of the audience.
• Gather in advance all handouts, visual aids, supplies, and equipment necessary. Visit the
meeting room ahead of time so as to be familiar with the room layout. Make sure the room is
comfortable and free of distractions. If this is not possible, arrive early and organize notes,
handouts, and visual aids. Practice the entire presentation beforehand to uncover possible difficulties with terminology or ambiguous points. Practice also gives a clue as to whether the predetermined time frame is realistic.
• Be natural and show enthusiasm for the topic. Avoid standing stiffly or speaking in a
monotone. Maintain eye contact with the audience and move naturally using hand movements
and a conversational style of speech. Show confidence, objectivity, tact, and as appropriate,
humor. Be knowledgeable on the topic, use simple and understandable language, be prepared
to answer questions to back up the topic, use a pleasant voice, control emotions, and use
charisma. Be well groomed and know and understand the needs of the audience. Stay on
timetable. Finish early so there is plenty of time for questions and discussion. When a question
is asked, repeat each question for the audience before answering.
It is natural to have some anxiety about presenting to a group. However, effective speakers have learned to use this anxiety to their advantage. Following the steps listed above helps
to decrease anxiety by being prepared for the presentation. In addition, use positive visualization and imagery, which have been shown by researchers to ensure success in accomplishing a
task. Other techniques for decreasing anxiety include deep breathing and tightening and relaxing muscles.
Nonverbal Communication
Some of the most meaningful communication is neither verbal nor written. These are nonverbal communications. Managers and subordinates use a number of nonverbal communications
on a daily basis, such as “props” that are used to send a message. This could include frequent
looking at a wall-mounted clock during an interview or meeting (“let’s get this over with”)
rather than looking at a small clock on the desk. The amount of personal space between the
sender and receiver is another example. Small space is more personal, and conversation can be
more intimate. Invading one’s personal space can cause discomfort and even resentful feelings,
depending on the culture of the people involved.
Perhaps the best-known and most frequently used nonverbal language is body language.
Body language may be unconscious behavior, but some of it may be due to nervous behavior
or cultural or ethnic customs. Some typical body action includes smiling, blushing, frowning,
shrugging, shaking the head, putting hands on hips, kicking the foot, pointing a finger, sighing,
stomping the foot, making steeple fingers, winking, slamming doors, tightly crossing the arms
against the chest, or nodding and patting another on the shoulder. Even though scientists have
studied nonverbal actions of people and have correlated certain actions with specific nonverbal language, managers must be careful not to misinterpret meanings. Some actions are subtle,
and it is difficult to determine their meaning. Interpreting the meaning wrongly can cause problems for both the sender and receiver.
Touching is also a form of nonverbal communication. Touching involves hand shaking,
pats on the back, hugs, or hand holding. Touching is usually unplanned and can convey
warmth, acceptance, strength, or authority. Touching an employee who has had a bad day can
convey understanding or authority, sexual harassment, or invading one’s personal space.
Written Communication
Written communication has benefits for writer and reader alike. The writer has the satisfaction
of immediacy, of communicating his or her message right away without waiting to see the
receiver in person. The receiver benefits from having a written record, especially of complex
information. Although written communication is unavoidable much of the time, it has some
disadvantages. One key disadvantage is that written communication takes longer to reach its
destination than does verbal communication. A second and related disadvantage is that feedback for written communication is delayed. However, when important details must be communicated, written messages provide a record of facts that can be referred to again and again,
and they give the receiver time to study and absorb those facts before responding to the
At its best, good written communication is clear and concisely worded, with short sentences and simple words. Jargon should be avoided except, of course, for the use of appropriate technical language. The ultimate measure of a good exchange is that both sender and
receiver understand the message.
Effective written communication anticipates and answers any questions the reader might
have, not only to better communicate the whole message but also to avoid delays in the receiver’s
response. The tone of the written message is also important, in the same way that it is important for a sender to consider the receiver’s point of view. In the age of word processors and personal computers, managers should use all the technical support that such equipment provides to
make sure that their written messages are not distorted by poor spelling and grammatical errors
that might reflect poorly on their abilities to communicate with and influence others.
Types of Written Communication
The kinds of written communication used most often in the food service department, and in
most business operations for that matter, include letters, internal memorandums, proposals,
justifications, reports, policies and procedures, and materials for distribution to customers.
Food Service Manual for Health Care Institutions
Figure 7.4 shows a sample format for formal business correspondence. Figure 7.5 shows a sample format for an interoffice memorandum.
In writing a business letter, the sender should clearly state the purpose of the letter in the
first paragraph or sentence. The rest of the letter should be organized logically, and each paragraph should contain one main idea. Short paragraphs are usually better than long paragraphs.
A letter should be no longer than it needs to be to make its point. Extra information or materials should be attached as addenda to the main letter.
Figure 7.4. Sample Business Letter
ABC Hospital
300 Main Street
Any City, State 55555
August 20, 2004
Jane Smith, Sales Representative
XYZ Food Service Company
xxx Street
Any City, State 55555
Dear Ms. Smith:
I am writing to follow up on our telephone conversation on August 5, regarding. . . .
During our conversation, you indicated that your company would be willing to supply the following
items. . . .
Please contact me if any other information regarding. . . .
Bob Jones, RD
Director, Nutrition and Food Services
Figure 7.5. Sample Memorandum
All Department Managers
Julie Jones, RD, Director Nutrition and Food Services
Ordering Food Supplies via the Fax Machine
August 20, 2004
Attached are the new forms for obtaining food supplies for your department or unit. Use of the
forms will begin effective September 1, 1994. Additional forms can be obtained by calling extension 0000. The completed form can be faxed to the department storeroom by ____________.Your
order will be filled by _____________.
Thanks you in advance for supporting this new order system designed to benefit the department in
better meeting the needs of our customers. Please contact ___________ at _____________ if you
have any questions or problems with the new process.
Internal memorandums are an efficient way to communicate with department employees,
with higher levels of management, and with peers in other departments. Note that everyday
communications with employees for the purpose of giving directions and feedback should be
more informal, and verbal communications are best on the supervisory level. A few basic guidelines for writing memorandums follow:
Each memorandum should have just one subject.
The memorandum should be direct, concise, and to the point.
It should be typewritten or prepared on a word processor.
It should be kept to one page in length, if possible.
It should ask for a response and feedback, if required.
It should close with a thank you.
A copy of the memorandum should be kept on file in the manager’s office for future
Written communication is often used to make a position known or to persuade someone
of something—for example, written proposals and justifications. Skills for writing persuasive
communications are increasingly important to food service directors, whose purpose might be
to inform and provide rationale for a decision that may require input from upper management.
For example, a manager may wish to develop an outpatient nutrition education program in
conjunction with the rehabilitation department or outside fitness center. To move forward with
this decision, a proposal must be submitted to top managers to outline the need for such a program, the benefits of the program for the organization and community, the costs of the program,
and the resources needed to implement the program.
A justification may be necessary to receive approval for capital equipment investments or
for the addition of staff. With each of these types of justifications, the manager must present
the facts used in making the decision for the request and answer questions that may be asked
by administration. Anticipating questions will prompt the director to include information that
can speed up the approval process. Justifications and proposals are designed to influence the
decision maker based on the needs of the department. A sample justification for an additional
cook’s position is provided in Figure 7.6. When writing justifications or proposals, the sender
should be clear what action is expected from the receiver. For example, if it is necessary to have
a signature on a requisition for an additional position, clearly state that the requisition is
attached for signature. A statement inviting questions or requests for further information can
be helpful, as would an offer to pick up the requisition on being notified that it has been signed.
This type of clarification allows the manager to know when the next step has been taken and
when the issue has been closed.
Reports are another form of written communication frequently prepared by managers.
Financial and departmental activity reports are generally completed on a monthly basis.
(Financial reports are discussed in Chapter 11.) Employee handbooks are written documents
produced by the organization or department to provide information that relates to the mission,
values, policies, rules, benefits, and other pertinent information. Written departmental policy
and procedures manuals need to be developed to guide the department.
Written materials are often prepared and distributed to patients and other customers of the
department. These materials include dietary instructions, menus, brochures of services offered,
and in some cases, department newsletters. Because these materials represent the department, it
is important that the materials be professional in appearance. Although many large organizations
have in-house print shops, most small organizations use outside sources. Regardless of where
printing occurs, development should be the responsibility of individuals professionally trained to
create high-quality materials. Large organizations generally have a marketing department to assist
managers. Small organizations can take advantage of preprinted materials or support from food
vendors willing to supply materials, or they can work with outside printing companies.
Food Service Manual for Health Care Institutions
Figure 7.6. Sample Justification Statement
Justification for an Additional Position
August 20, 2004
Need for an Additional Cook’s Position
Based on departmental productivity and meal equivalents, I would like to add 1 FTE as a cook’s position.
Maintaining coverage for the production area for meal preparation and sanitation has become increasingly more difficult as the number of meals continue to increase.
Productivity for the department has met or exceeded the 1000% goal set with labor hours per meal at
0.21. The labor hour per meal goal set for this year is 0.23. The total complement for paid FTEs is currently 70, which is well below the 73 to 77 shown, as required on the productivity reports.
Validity of Productivity Figures
I have reviewed the validity of the paid FTE number with the changes made in the cafeteria renovations.
It stands to reason that enough efficiencies have been gained with the renovation and number of meals
served to make adjustments in the factor used to measure departmental productivity. The following steps
have been taken or are in the process of being taken to ensure accuracy of our productivity numbers.
1. A two-week review of sales and counts in the cafeteria was conducted using figures from
_____ through _____. The attached chart shows the current average meal or meal equivalent to
be $_____, slightly below the $_____ now used to determine cafeteria meals. These numbers
also indicate that roughly 2,000 more individual customers enter the cafeteria than is verified
by the average ticket or meal.
2. The number of meals prepared for patient and all nonpatient areas have been charted and
compared with the counts from a year ago. The attached table shows an increase in meals for
all areas except vending. The total increase is 4.11% over last year. Patient meals show a significant increase and also are the most labor intensive.
3. In addition to the above two steps, observations will be made to determine the overall effect of
changes made with the layout of the new cafeteria service area. If it is determined that these
meals are now being served more efficiently, I will evaluate and modify the other meal factor
used to determine departmental productivity.
Benefits and Rationales for Adding a Cook
The cook’s position is being requested at this time based on the following:
1. Meal preparation for the physicians’ dining area is consistently being done by the production
2. Either the production supervisor or the purchasing supervisor must fill a line slot when time off
is granted to a cook, baker, or salad maker.
3. Cooks are voicing concern that they are unable to complete their meal preparation in a timely
manner. They also state they are under excessive stress and feel overworked.
4. Although we have been able to decrease our injuries, last year’s experience revealed that a
high level of productivity directly affects the number of injuries.
5. Efforts to increase sales and therefore the number of customers in the cafeteria will continue.
These efforts have been shown over the past three months to increase counts.
6. meal counts are higher in all areas other than vending. Patient meals are more labor intensive
and are higher than budgeted due to an increased census.
Effect on Departmental Budget
The budget for this fiscal year will not be negatively affected by the addition of a cook for the next six
months. We are currently $50,000 under budget for the year. Adding a cook for the remainder of the
year will cost $15,600.
Average cook salary = $15/hour × 1,040 hours = $15,600
Thank you for your consideration in filling this position Please let me know if this position is approved or
if additional justification is needed.
Julie Roberts, RD, Director
Nutrition and Food Services
Although most written communication is in paper form, it also can be in the form of output from personal computer networks. Electronic mail (e-mail) can communicate information
to a single department or distribute information to every department. E-mail is fast, convenient, and cheap, and the same message can be sent to several persons at the same time. It is the
fastest-growing and most widely used way for organizations to communicate. E-mail is public
information and should never be used for sending sensitive information. When using e-mail,
the following etiquette should be followed.
Use subject heading.
Proofread all messages before sending.
Check spelling for accuracy.
Use name, position, or signature to identify self to recipients.
Send e-mail only to those who need the information.
Keep messages and attachments short.
Learn how to send and receive attachments.
Do not react if message does not apply to you, your organization, or department;
simply delete it.
In replying to e-mail, use the appropriate reply key to verify that the message is going to
the intended person(s). When replying to a group message, use the key for replying to all.
Maintain copies of outgoing mail even if it has to be sent to yourself.
Set up a filing system to sort and organize e-mail.
Use the address book and update periodically.
Run virus checks frequently.
If desired, subscribe to list serves.
Delete any unnecessary or dated messages.
Be courteous and use business etiquette when sending and receiving messages.
It is not necessary to reply to every e-mail.
Do not forward messages to other groups unless necessary and with the approval of
the sender.
Do not send copyrighted materials unless so noted or used by permission.
Never send confidential information.
With the use of handheld computers that are capable of sending pictures as well as messages, the sender needs to be aware of invading the privacy of others. A list serve, an electronic
mailing list that is used as a means of communication among colleagues wishing to interact
with one another in areas of mutual interest, is another form of written communication.
Facsimile (fax) machines also have enhanced the capability to send information within and outside organizations. A memorandum may be typed as usual, but the information is distributed
not through the mail system but through a facsimile machine. Hard-copy fax machines have
enhanced this form of written communication, making permanent copies available. Regular fax
paper will not hold the image transmitted, which necessitates copying the memorandum or
using another form of communication if a long-term copy is needed.
Rules for Effective Communication
It is important to remember that communication depends on two dynamics. One has to do with
how a message is sent, and the other has to do with how the message is received. As senders of
messages, managers should consider the following guidelines:
• Plan the message by identifying the objective to be achieved through the communication.
For example, if the objective is to seek information, formulate specific questions about the subject on which information is needed. If the objective is to change employee behavior or persuade decision makers, plan well-reasoned arguments in support of the change or decision.
Food Service Manual for Health Care Institutions
• Determine the type of language appropriate to the communication. For example, if a manager is seeking to persuade hospital administrators to approve implementation of a cook–chill
system, the language should be in lay terms. But in a conversation between two technicians, technical language is entirely appropriate.
• Seek to maintain credibility by being honest and accurate, by gathering facts to support
opinions, and by not pretending to be an expert on subjects on which the sender has limited
knowledge. Managers who fail to follow this simple rule are likely to find their messages met
with suspicion from employees, peers, and superiors.
• Be aware of the message behind the message—that is, the one conveyed by tone of voice
and body language. Ensure that body language is congruent with the spoken message. Anticipate
different ways the message might be interpreted and ask questions to ensure that it is received
as intended. Avoid letting minor points of disagreement distract from the message.
• Be sensitive to the receiver’s perspective, especially when the message deals with a sensitive issue, such as an employee denied a promotion. Avoid raising emotionally loaded issues
when the receiver appears preoccupied or when time does not permit dealing with the issue
• Ensure that the setting is appropriate to the conversation. If it is too public and surrounded by distractions, relocate. For example, it would be inappropriate to discuss performance with a cafeteria tray line worker during a heavy-traffic period.
• Encourage feedback in communications. Invite receivers to ask questions, request clarification, or express opinions.
As receivers of messages, managers should fine-tune listening skills, try to remain open and
receptive, and accommodate the sender.
Listening and hearing are two different things. Hearing is a physical sense that takes place automatically. People hear noises around them, such as music, car horns, and dish machines, without paying much attention to them. Listening is an active process that requires effort or
attention from the listener. Listening completes the communication cycle. Listening demands
concentration on the implied meaning as well as the stated meaning. The undertones or unspoken words are gleaned by developing listening power. With today’s nonpersonal automated
telephone messages, a person has to listen actively to push the correct button before proceeding to the next instruction. The listener must be attentive to the prompting or risk having to
start the procedure again.
To become effective listeners, managers need to
• Be attentive. Concentrate on what the person is saying. A manager should not turn off
the speaker as uninteresting or because it is a subject that he or she is not interested in or
already knows. A manager should listen without making premature judgments about the
speaker’s message.
• Be open-minded. Stereotyping, ethnocentricity, and rigid frames of reference are barriers that interfere with receiving an intended message.
• Develop empathy. Empathy is understanding others’ feelings, situations, and motives.
Why are they motivated to speak on this issue? How do they really feel about the issue?
• Wait before responding. A manager should not rush a response to only a portion of
what has been said but wait until everything has been said. While forming the response, the
manager may miss a salient point.
• Observe nonverbal cues. Observe gestures, tone of voice, body position, eye movement,
breathing patterns, and verbal cues without underreacting or overreacting and relating them to
the ethnicity or culture of the speaker.
• Listen to the whole message. Managers should listen not only for facts but to the whole
message before making a judgment or formulating a response.
• Keep distractions to a minimum. The manager should try to find a quiet, private place.
Face the person who is talking. If the listener is near his or her desk or work area, the listener
should turn his or her back to it. Listen actively, and do not fiddle with papers or take phone
• Be aware of impatience. Do not rush the speaker in order to reply.
• Not pretend to listen. This type of listening frequently leads to “Pardon me, what did
you say?” The manager should be sincere, and listen attentively. Lending undivided attention
may solve problems.
• Be prepared to compromise. Compromise may be necessary to achieve agreement or
• Not show favoritism. Managers must listen to all employees.
Four good rules to follow will improve listening skills and help to uncover a whole new
world of useful information. These are
• Repeat what has been told. Repeat what was heard using neutral tones. This is not a
sales job but a way to determine if what was heard is to be believed.
• Consider the source. Is the speaker biased? Is the speaker exaggerating? Is the speaker
looking for attention? Does the speaker really want an answer?
• Use self-discipline. Lack of empathy or sympathy and an angry manner cause loss of
objectivity and cloud the message.
• Summarize. Ask exploratory, open-ended questions to confirm the meaning of the message. “Is this what I heard?” or “What I hear you saying is. . . .” This technique, called mirroring, validates the speaker’s effort to communicate by allowing him or her to confirm,
correct, or clarify intent.
Both senders and receivers should remember to
• Follow up on a message to make sure it was sent as intended and received as intended.
In face-to-face communication, this is simply a matter of asking a question. In written communication, follow-up can be accomplished with a telephone call, a brief office (or hallway)
conference, or written confirmation.
• A manager should avoid the temptation to provide too much information in sending a
communication or in giving feedback on it.
This last guideline suggests a common problem, especially in large organizations: the burden of handling too much paperwork and trying to process too much information. Simple written messages probably do not require written responses, and it wastes everyone’s time to ask
for them. Not all telephone conversations require confirming letters. In addition, a manager
should not expect to read from cover to cover every journal that crosses his or her desk. Some
sensible decisions must be made about what kind of information exchange is essential, what
kind must be committed to paper, what types of information employees need, and what might
be left to casual conversation.
As noted earlier, managers should choose the medium that is best suited to a particular
message. For example, a sudden and drastic change in an employee’s work schedule might best
be discussed in a face-to-face conversation rather than in an impersonal memorandum.
However, a request for funds to hire a consultant for a special project should be formally presented in writing, with solid supporting evidence for the request, rather than in a drop-in conversation. The choice of the appropriate medium should always be made with the receiver’s
perspective in mind.
Food Service Manual for Health Care Institutions
Channels of Communication Within Organizations
Because information exchange is essential to the operation of an organization, formal and informal channels of communication ensure that information moves from one point to another efficiently. Formal channels include a vertical track and a horizontal track of communication. The
vertical track runs in two directions, upward and downward between the top of the organizational structure and the bottom. The horizontal track carries communications laterally across
the organizational structure between departments and individuals on about the same levels. The
most common informal channel of communication in organizations is the grapevine.
Upward Communication on the Vertical Track
Upward communication includes verbal and written messages (problems, perceptions, or suggestions) that subordinates send to superiors. Sometimes messages may seek clarification of
instructions or advice. Top-level management depends on this vertical flow as a way to monitor each department’s or unit’s performance so as to make the best decisions possible in planning future activities of the organization.
Activity and performance reports are the most frequent form of upward communication.
These provide information necessary for making decisions regarding capital purchases, FTE
additions, or other such operational changes. Directors are responsible for adequately communicating to upper management the goals and objectives of the department and how these
interface with other departments and with the broader vision of the organization.
Research has shown that the greater the difference in level between an employee and the
superior to whom the message is being sent, the more likely it is that the message will be distorted or incomplete. Although department directors should communicate a sincere desire to
listen to employees’ suggestions and ideas, they must be conscious of employees’ tendencies to
provide incomplete or inaccurate information. The director should also avoid depending on
lower-level employees for essential information.
Downward Communication on the Vertical Track
Downward communication occurs when information flows from superiors in the organizational hierarchy to employees. Top-level managers communicate the organization’s goals and
objectives and specify policies and procedures. They also explain the rationale for various operational decisions, give instructions about specific tasks, provide feedback to employees about
their performance, and respond to messages from employees. Research suggests that most managers believe that they communicate information to their employees better than they actually
do. Because information is often the lifeline of an operation and because accurate information
is especially crucial in health care institutions, food service directors should examine their own
patterns of downward communication for any possible shortcomings. For example, they
should never assume that information supplied to higher-level managers will automatically be
communicated to lower-level employees. Information that affects employees should be communicated to them deliberately and directly.
Horizontal Communication Track
Communication that follows the horizontal channel consists of verbal and written information
flow between organizational units that are at about the same level. This flow is particularly
important in health care institutions because service to patients depends on efficient communication among several different departments. For example, the food service department cannot
provide appropriate nutrition care services without information about patients from nursing
staff. Such interdependence is apparent in daily activities such as meal service, but it also influences the department’s long-term ability to plan major projects.
In addition, horizontal communication between units is more direct, thereby relieving some
of the strain imposed on the vertical track. Interdepartmental communication minimizes the distortion and slowness of message relay that can hamper upward and downward communication.
For example, the food service director and the nursing service director can communicate with
one another directly and more immediately about a common project without necessarily
exchanging information through their respective superiors.
The grapevine is an important route for informal information flow in organizations. It is a natural result of the universal human need for social contact. Unlike formal communication channels, the grapevine operates without planning or documentation. Despite its haphazard nature,
the grapevine is sometimes more informative than the messages sent through formal channels.
In this sense, the grapevine can work either for or against the interests of management and the
well-being of the organization.
Managers can use the grapevine to get a sense of the attitudes and perceptions among their
subordinates and respond to them more quickly than if they waited for problems to surface
through formal methods. To minimize the potentially negative effects of grapevine information,
managers should share as much information as possible with subordinates about organizational activities. If everyone in the organization has appropriate access to up-to-date and accurate information, the speculation that leads to rumor can be dispelled.
Conflict Resolution
Occasionally a manager must act as a mediator and resolve conflicts between employees or
between an employee and a supervisor. A conflict is a perceived incompatible difference resulting in interference or opposition. (Mediation is the process of working with conflicting parties
to suggest settlements and compromises.) Although full treatment of conflict resolution is
beyond the scope of this book, this is one of the most important management skills a manager
needs to possess. Mediation should be conducted so that, if possible, both parties can be winners. There are times when a manager will be required to end a conflict by making a decision
that will be unpopular with one of the parties involved.
Generally, when conflict arises, most people make a “fight-or-flight” decision. If they
choose to fight, they expect to win. If they choose flight, they will ignore the person with whom
they are in conflict and refuse to talk about the issues. For effective teamwork and management, the manager must have an empowered response to conflict resolution and should understand that neither fight nor flight is appropriate for creating winning solutions to conflict.
Communication is the key to resolving conflicts. In meeting privately with opposing parties to mediate issues, the manager should make it clear at the beginning that both parties will
have an opportunity to state their point of view. He or she also must emphasize that it is unacceptable for one party to interrupt the other. The meeting should be held in an appropriate
location, such as the manager’s office or a conference room. Adequate time must be set aside
to work out the conflict.
When the mediation session begins, the manager should express concern about the effects
the conflict has on both individuals. The manager also should express optimism that a solution
can be reached that is in the best interest of both parties. The outcome should be a solution that
both can agree to.
In a conflict situation, reactions can be displayed in an eruption of emotions and hurt feelings. Again, these feelings probably are tied to past experiences. The issue at conflict may
remind the parties involved of previous situations or topics that, although unrelated, are present in their subconscious. In dealing with conflict, it is important to get individuals to understand why they are angry and what they would consider a suitable outcome.
Food Service Manual for Health Care Institutions
Communication is the process of sending and receiving verbal and written information from
one person to another. Effective communication is achieved when the message received is in
harmony with the message sent. The basic management functions all depend on the communication of information, especially the function of leading and directing employee activities.
Active listening is a vital component of communication.
Communication among people on all levels in an organization is vital to accomplishing the
organization’s work and achieving its goals. In their working relationships, successful managers
tend to find and use the most appropriate and effective channels for communication within their
organizations. They also develop and use effective interpersonal communication skills while
remaining objective and nonjudgmental, always separating the message from the messenger.
Black, J. S., and Porter, L. W. Management Meeting New Challenges. Upper Saddle River, N.J.:
Prentice Hall, 2000.
Blanke, V. Political power and hospital dietitians. Ross Dietetic Currents 19(5):21, 1982.
Boss, D., and Moore, D. The body speaks. Food Management 16:39, 1981.
Certo, S. C. Modern Management. 8th ed. Upper Saddle River, N.J.: Prentice Hall, 2000.
Dessler, G. Management: Leading People and Organizations in the 21st Century. Upper Saddle River,
N.J.: Prentice Hall, 2001.
Dougherty, D. A. Are you listening? Hospital Food & Nutrition Focus 8(9):1–5, 1992.
Frank, M. O. How to Get Your Point Across in Thirty Seconds or Less. New York: Simon &
Schuster, 1986.
Haggerty, D. Getting It Done: Communicate Better . Milwaukee, Wisc.: Credit Union Management,
Haney, W. V. Communication and Interpersonal Relations: Texts and Cases. 5th ed. Homewood,
Ill.: Irwin, 1986.
Kuppersmith, N. C., and Wheeler, S. F. Communication between family physicians and registered
dietitians in outpatient setting. Journal of the American Dietetic Association 102(12):1756–1763,
McConnell, C. R. The Effective Health Care Supervisor. Rockville, Md.: Aspen, 1998.
National Center for Non Profit Boards. Kit: 20 Ideas for Jumpstarting Your Board Meeting.
Washington, D.C.: National Center for Non Profit Boards, 2001.
Odiorne, G. S. Personal Effectiveness: A Strategy for Success. Westerfield, Mass.: MBO, 1979.
Puckett, R. P. Are meetings necessary? Contemporary Administrator 6(6):18–20, 1983.
Robbins, S. P. Managing Today, 2.0 Edition. Upper Saddle River, N.J.: Prentice Hall, 2002.
Spears, M. C. Foodservice Organizations: A Managerial and Systems Approach. 4th ed. Upper
Saddle River, N.J.: Prentice Hall, 2000.
Chapter 8
Human Resource Management
An organization’s most valuable resources are the people who perform the work—its human
resources—without whom no organization could function. Employers who recognize this fact
understand the importance of involving employees in meaningful work to ensure their longterm retention. Consequently, human resource departments have become a mainstay in organizations of all kinds. The department advocates employee rights and serves as a source of
counsel for managers on all levels.
The structure of a health care organization’s human resource department varies with the
size of the institution. Specific departmental activities also vary with type and size of the facility. In any case, a food service director must work closely with human resource specialists to
make sure that the department’s service delivery complies with labor laws and with the organization’s personnel policies and procedures.
This chapter discusses the following specific areas of concern in human resource management:
Laws that affect the employer–employee relationship
Role of the human resource department
The employment process (recruiting, screening, interviewing, hiring, orienting)
Employee training and coaching
Employee performance evaluation
Maintenance of personnel records
Development and application of personnel policies and procedures
Compensation and benefits administration
Labor relations
Although food service directors may not be directly responsible for performing all of these
activities, they are involved in or affected by each one in some way. In small health care organizations, the food service department may be directly responsible for performing some of the
activities usually performed by human resource departments in large organizations—for example, conducting its own training and orientation programs. In addition, food service supervisors may be charged with interviewing and hiring new employees they will supervise directly,
evaluating employee work performance, and maintaining certain employee records.
Food Service Manual for Health Care Institutions
Laws That Affect the Employer–Employee Relationship
Federal, state, and local laws and regulations affect the way employers hire, pay, and manage
their employees. In most health care organizations, the human resource department is primarily
responsible for making sure the organization’s personnel policies are fair and legal. However,
anyone whose job is to supervise or manage other people also must be aware of workers’ legal
Most of the laws that affect human resource management fall into one of the following five
Equal employment opportunity
Compensation and benefits
Labor relations
Health and safety
Immigration reform
The remainder of this section describes briefly the major federal laws that affect human
resource management.
Equal Employment Opportunity Legislation
Equal employment legislation forbids employers to discriminate against employees on the basis
of race, color, religion, sex, disability, or national origin. The Equal Employment Opportunity
Commission (EEOC) is the federal agency charged with making sure workers are not discriminated against unfairly. All areas of employment are regulated, including
Dismissals, work reductions, and layoffs
Disciplinary actions
Compensation policies
Access to training and advancement
The EEOC’s regulations are based primarily on Title VII of the Civil Rights Act of 1964.
Several other laws have made other kinds of discrimination illegal as well.
Civil Rights Act of 1964 (Amended 1972)
Title VII of the Civil Rights Act of 1964, and later laws that amended (or legally changed) the
act, regulates the employment practices of most U.S. employers having fifteen or more employees. (The Equal Employment Opportunity Act is one of the laws that amended Title VII.)
Under Title VII, it is illegal for employers to discriminate based on race, color, religion, sex, or
national origin in hiring, firing, promoting, compensating, or in terms, conditions, or privileges
of employment.
Age Discrimination in Employment Act of 1967 (Amended 1978 and 1986)
The Age Discrimination in Employment Act protects persons aged 40 years or older from age
discrimination in selection, discharge, and job assignments. The law prohibits employers from
replacing employees with younger workers, regardless of whether the purpose is to save money
in wages or to give a company a more youthful image.
Vocational Rehabilitation Act of 1973
Section 503 of the Rehabilitation Act of 1973, as amended by the Rehabilitation Act
Amendments of 1986, affects all companies that hold federal contracts for $2,500 or more.
According to the amendments, such employers must take affirmative action to avoid breaking
Human Resource Management
the law. That is, they must seek out, hire, and advance reasonably well-qualified individuals
who belong to racial, sexual, or ethnic groups that because of discrimination have been underrepresented in the past. Also protected by the affirmative action mandate are individuals with
physical and mental challenges.
Vietnam Era Veterans Readjustment Assistance Act of 1974
Section 402 of the Vietnam Era Veterans Readjustment Assistance Act prohibits discrimination
against disabled veterans in general. It applies specifically to veterans of the Vietnam war.
Pregnancy Discrimination Act of 1978
The Pregnancy Discrimination Act represents an amendment to Title VII of the 1964 Civil
Rights Act. This law prohibits discrimination against workers on the basis of pregnancy, recent
childbirth, or related medical conditions. It applies to employment practices and to qualification for employee benefits.
Interpretive Guidelines on Discrimination Because of Sex, National Origin, and Religion
Under Title VII of the Civil Rights Act amended in 1972, the EEOC generally prohibits discrimination in employment on the basis of gender. The EEOC has issued interpretive guidelines
that state that employers have an affirmative duty to maintain a workplace free from sexual
harassment and intimidation. Under these guidelines, employers are totally liable for the acts
of their supervisors, regardless of whether the employer is aware of the sexual harassment. The
guidelines state that harassment on the basis of sex is a violation of Title VII when such conduct has the purpose or effect of substantially interfering with a person’s work performance or
creating an intimidating, hostile, or offensive work environment. Sexual harassment in the
workplace is defined as subjecting a person to unwelcome sexual advances, requests for sexual
favors, and other verbal or physical conduct of a sexual nature. Sexual harassment is illegal
under any one of the following conditions:
• When an employee is required to submit to such conduct as a condition of his or her
continued employment
• When an employee’s submission to such conduct is made the basis of a hiring decision
• When an employee’s subjection to such conduct has the purpose or effect of unreasonably interfering with his or her work performance
• When such conduct creates an intimidating, hostile, or offensive working environment
for employees
In 1993 EEOC issued a definition of harassment: “It is unlawful harassment if there is verbal or physical conduct that denigrates or shows hostility or aversion towards an individual
because of race, color, religion, gender, national origin, age or disability, or that of their relatives, friends, or associations and that:
• has the purpose or effect of creating an intimidating, hostile, or offensive working
• has the purpose or effect of unreasonably interfering with an individual’s work performance; or
• otherwise adversely affects an individual’s employment opportunities.”
Ethnic slurs and other verbal or physical conduct relating to an individual’s national origin
constitutes harassment. Racial jokes are an example of what might constitute ethnic harassment.
Employers have an obligation to accommodate religious practices unless they can demonstrate a resulting hardship. The guidelines identify methods that would accommodate religious
practices that include voluntary substitutes, flexible scheduling, lateral transfer, and change of
job assignment.
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EEOC policy guidelines on sexual harassment require employers to install a distinct policy
against sexual harassment. To meet this requirement, the policy should demonstrate examples
of exactly what is considered sexual harassment, an explanation of whom to talk to (other than
a direct supervisor), the importance of confidentiality, and the fact that reprisal actions against
a person claiming sexual harassment are not tolerated by the organization. The policy also
should state that disciplinary action could include termination and that management is responsible for monitoring and preventing sexual harassment in the workplace.
Civil Rights Act of 1991
In 1991 Congress passed a comprehensive set of amendments to Title VII. Among the most
important aspects of the law are “Quotas—are prohibited under this law. Quotas have been
used by employers to adjust the hiring decision to ensure that a certain number of people from
certain protected classes are hired. . . . Collection for damages either punitive or compensatory
are allowed. Punitive damages are fines awarded to a plaintiff to punish the defendant; compensatory damages are fines awarded to a plaintiff to compensate for financial or psychological harm the plaintiff has suffered as a result of discrimination act.”
The term glass ceiling is included in the 1991 Civil Rights Act. The glass ceiling is the invisible barrier of an organization that prevents many women and minorities from achieving toplevel management positions. An aspect of the act was the establishment of a Glass Ceiling
Commission to study how management fills higher-level positions, the qualifications needed for
advancement, and the compensation plan and reward structures that are in place.
Executive Order 11246, Amended by Executive Order 11375
In 1965 Executive Order 11246 was established by then-president Lyndon Johnson. It prohibits discrimination in employment due to race, creed, color, or national origin. The major
provision of Executive Order 11246 was the affirmative action that requires covered employers to take positive steps to ensure employment of applicants and treatment of employees during employment without regard to race, creed, color, or national origin. In 1968 Executive
Order 11246 was amended to Executive Order 11375, which changed the word “creed” to
religion and added sex discrimination to the other prohibited terms.
Privacy Act of 1974
Employees of the U.S. federal government have the privacy of their personnel files protected as
well as lockers and personal inspections, background investigations, and other matters. The act
requires federal agencies to permit employees to examine, copy, correct, or amend employee
information in their personnel files. The act includes a provision for an appeal over disputed
material in the file.
Americans with Disabilities Act of 1990 (Title I)
Title I of the Americans with Disabilities Act became effective July 26, 1992, for employers
with twenty-five or more employees and July 26, 1994, for employers with fifteen to twentyfour employees. Title I of the act prohibits employment discrimination against disabled workers who are qualified to perform the essential functions of a job. The law in this regard covers
all aspects of employment, including the application process and hiring, on-the-job training,
advancement and wages, benefits, and employer-sponsored social activities. An employer must
provide reasonable accommodations unless it can be proved that such accommodations would
impose undue hardship on the employer.
Disability under the Americans with Disabilities Act is defined as:
• Any physical or mental impairment that substantially limits one or more major life
• A record of such impairment
• An individual regarded as having such an impairment
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In this definition, major life activities include—but are not limited to—seeing, hearing, speaking, walking, breathing, learning, working, performing manual tasks, and caring for oneself.
Employers are required to make reasonable accommodations or modifications that help
impaired individuals in completing essential functions of a job. Reasonable accommodations
or modifications are identified as adjustments to a job or the work environment that will allow
a qualified disabled person to perform essential job functions if these accommodations do not
create undue hardship. With respect to the provision of an accommodation, undue hardship is
defined as significant difficulty or expense incurred by a covered entity.
As related to nutrition and food service, department directors are required to consider
carefully what are outlined in job descriptions as essential job functions and what could be
reassigned so as to provide reasonable accommodations. During an interview, neither employers nor their representatives can ask whether an applicant has a disability, but they may ask
whether the applicant can perform the job with or without accommodation.
Compensation and Benefits Legislation
Several important federal laws regulate how employers pay their employees and provide
employee benefits. The following subsections briefly describe this body of legislation.
Social Security Act of 1935
The Social Security Act of 1935 created a system of retirement benefits. The act established a
federal payroll tax to fund unemployment and retirement benefits. Employers are required to
share equally with employees the cost of old age, survivors, and disability insurance. Employers
are required to pay the full cost of unemployment insurance.
Social Security provides retirement income to people who retired at age 62 in 2000; the
retirement age will be increased gradually until 2007, when it reaches age 66. After stabilizing
at this age for a period of time, it will again increase in 2027, when it reaches age 67.
For people who become disabled and cannot work for at least twelve months, Social
Security provides a monthly income comparable to retirement benefits.
Medicine is a part of the Social Security program that provides health insurance coverage
for people aged 65 and older. Medicare has two parts: Part A covers hospital costs, and Part B
covers medical expenses. People pay an annual deduction for Parts A and B.
Survivors’ benefits are paid to the deceased employee’s family members if they qualify.
Fair Labor Standards Act of 1938
The Fair Labor Standards Act (FLSA), also called the Wage and Hour Law, requires all organizations covered by the act to pay nonsalaried employees at least the minimum wage, an hourly
wage that is fixed by the federal government and is considered to be the lowest wage on which
an individual can live under current economic conditions. The federal minimum wage was
$4.25 per hour in 1993. However, in August 1993, a bill introduced in Congress raised the
federal minimum wage to $4.50 and further increases would be tied to the rate of inflation.
Congress sets the minimum wage for nonexempt employees. States may have a legal rate that
is higher than the federal rate; where such laws exist, the higher rate prevails.
The FLSA defines two categories of employees: exempt and nonexempt. Exempt employees include professional, executive, administrative, and outside sales jobs. The Department of
Labor provides guidelines to determine if a job is exempt or nonexempt. Exempt employees are
not covered by the provision of the FLSA. Nonexempt employees are covered by the FLSA.
Nonexempt employees who are paid an hourly salary must be paid overtime at the rate for the
number of hours worked beyond 40 hours in one week. The usual overtime rate is time and a
half. Congress is in the process of redefining overtime, the rate of pay, and employees who are
eligible to receive overtime pay.
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Equal Pay Act of 1963
The Equal Pay Act, an amendment to the FLSA, requires employers to pay equal wages to men
and women for doing the same jobs. The jobs must require equal skill, effort, and responsibility, and they must be performed under similar working conditions.
There are four exceptions that allow employees to pay one sex more than the other—more
seniority, better job performance, greater quantity or quality of production, and certain other
factors such as paying extra compensation to employees working a night shift. Although sexual equality is law, the Census Bureau stated in 2000, “of the 282.1 million US residents, 51
percent are women, nearly 16 percent of men age 15 and older who worked full-time earned
$75,000 a year compared to 6 percent of women. In all instances women earned less than men.
Women are moving forward in the workplace with an increase in executive/managerial positions, and women hold the majority of the jobs in the field of technical and related support
service.” In some occupations, women’s salaries surpass men’s.
Unemployment Insurance
The Social Security Act of 1935 established unemployment insurance to provide temporary
income for people during periods of involuntary unemployment. Unemployment insurance is
funded by a tax paid by employers on all employee’s earnings. The proceeds of the tax are split
between the state and federal governments, which provide different services for the unemployed.
To be eligible for unemployment insurance, employees must meet these qualifications:
• Must be available for and actively seeking employment.
• Must have worked a minimum of four quarter-year periods out of the past five quarteryear periods and earned at least $1,000 during the four quarter periods.
• Must have left the job involuntarily or became unemployed through no fault of their own.
The following conditions render employees ineligible for unemployment insurance:
• Quit their job voluntarily.
• Discharged for gross misconduct.
• Participated in a strike.
Workers’ Compensation Insurance
Both state and federal workers’ compensation insurance compensates employees or their families for the cost of work-related accidents and illnesses. In most states, workers’ compensation
insurance is compulsory. Workers’ compensation laws typically stipulate that insured employees will be paid a disability benefit that is usually based on a percentage of their wages. Benefits
vary from state to state, but there are usually four types of disabilities: permanent partial disability, permanent total disability, temporary partial disability, and temporary total disability.
Disabilities may result from injuries or accidents, occupational diseases, radiation illness,
and asbestosis.
Employee Retirement Income Security Act of 1974
The Employee Retirement Income Security Act (ERISA) sets standards for companies that protect private pension plans for employees from mismanagement. However, ERISA does not
require companies to offer employee pension plans. As mandated by the act, employers must
have a system for providing federal retirement insurance for cases in which employers’ pension
plans go bankrupt. The goal of ERISA is to ensure that employees who are covered by pension plans receive all of the benefits to which they are entitled; this is called vesting.
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Family and Medical Leave Act of 1993
The Family and Medical Leave Act requires employers with at least fifty employees to provide
up to twelve weeks of unpaid, job-protected leave to eligible employees for certain family and
medical reasons. Employees are eligible if they have worked for a covered employer for at least
one year and for 1,250 hours during the previous twelve months. Reasons for taking the leave
include the employee’s need to care for his or her newborn child or a child placed with the
employee for adoption or foster care; to care for a spouse, son, daughter, or parent who has a
serious health condition; or to attend to the employee’s own serious health condition that
makes the employee unable to perform his or her job.
Labor Relations Legislation
The federal government regulates how unions conduct their activities and how companies deal
with unions. Managers should understand the requirements of the three main labor relations
laws, as described below.
National Labor Relations Act of 1935 (Wagner Act)
The primary purpose of the National Labor Relations Act is to prevent management from taking unfair actions against employees who wish to join unions to engage in such activities as
strikes, picketing, and collective bargaining. Unfair management practices are defined by the
act in an attempt to balance power between management and labor. Unfair management practices include firing employees who support unionization, threatening or bribing employees, and
sending spies to union meetings.
Lawmakers gave the National Labor Relations Board the power to enforce the act. The
National Labor Relations Board can look into any labor dispute that affects interstate commerce (business dealings between companies in different states).
Labor–Management Relations Act of 1947 (Taft-Hartley Act)
The National Labor Relations Act was amended in 1947 by the Labor–Management Relations
Act, better known as the Taft–Hartley Act. After a series of violent strikes in 1946, the act was
passed so as to limit the power of unions and to protect the rights of management and employees.
Among other things, the law defines specific unfair labor practices by unions, bans union shops,
and establishes procedures for secret ballot elections. In secret ballot elections, employees decide
whether a union will represent them in collective-bargaining negotiations with management.
Labor–Management Reporting and Disclosure Act of 1959 (Landrum-Griffin Act)
The Labor–Management Reporting and Disclosure Act was passed to strengthen democracy
within unions. The act protects the individual rights of union members and limits the economic
and political power of unions. It also requires that unions report their financial status to the
government. Regulations based on the law affect secondary boycotts, informational picketing,
and recognitional and jurisdictional strikes.
Health and Safety Legislation
Many federal and state laws protect the health and safety of employees in the workplace.
Regulations that affect food service departments in health care organizations are discussed in
detail in chapters 13 and 14. However, the most far-reaching federal law that affects the health
and safety of U.S. workers is briefly described below.
Occupational Safety and Health Act of 1970
Under the Occupational Safety and Health Act, employers are required to provide employees
with “employment and a place of employment which are free from recognized hazards that are
causing or are likely to cause death or serious physical harm.” Employers also are required to
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obey all safety and health standards established by the Occupational Safety and Health
Administration (OSHA). One such standard deals with blood-borne pathogens. The OSHA
standards are enforced through on-site inspections, and employers found to be in violation are
subject to fines and other penalties. (The OSHA standards related specifically to the food service department also will be discussed in chapters 13 and 14.)
Immigration Reform Legislation
Federal legislation affects all U.S. employers. It has specific effects on those employers who
employ or seek to employ citizens of countries other than the United States. The body of law
that covers employment of immigrant (or alien) workers in the United States is described in the
following subsection.
Immigration Reform and Control Act of 1986
The Immigration Reform and Control Act of 1986 was passed to stop the unlawful employment
of unauthorized aliens in the United States. The act requires employers to verify the citizenship
status and employment eligibility of all employees hired after June 1, 1987, as well as all current
employees hired after November 6, 1986. To comply with this law, employers must request all
new employees to supply proof of their identity and employment eligibility. Proof may be in the
form of a valid driver’s license, a Social Security card, or an unexpired reentry permit, among
others. They also must complete a Form I-9 certifying that they are eligible for employment.
The Immigration Reform and Control Act imposes substantial civil and criminal penalties
on employers who knowingly violate this law. In addition, the law makes it illegal to discriminate against any individual other than unauthorized aliens on the basis of national origin or
status as a citizen or an “intending citizen.” All areas of human resource management are covered, including hiring, recruitment, referral, and discharge. A separate enforcement procedure
has been established to handle discrimination violations. However, any alleged discrimination
that is covered under Title VII of the Civil Rights Act of 1964 would still be addressed under
the provisions of that act.
Illegal Immigration Reform and Immigrant Responsibility Act
In 1990 the Immigration Act revised U.S. policy on legal immigration that increased levels of
immigration of highly skilled professionals and executives. In 1996 the Illegal Immigration
Reform and Immigrant Responsibility Act was signed into law. This law placed limitations on
persons who have come to the United States and remained in the country longer than permitted by their visas or persons who have violated their nonimmigrant status.
Role of the Human Resource Department
Most organizations today have some form of human resource department. In large organizations especially (those with more than two hundred employees), this department will be a separate, discrete entity whose role is to perform unique functions. In some organizations, the human
resource department may be called the personnel department or employee relations department.
Health care human resource departments are charged with four major areas of responsibility:
Recruitment and employee activities
Performance evaluation policies and procedures
Compensation and benefits administration
Labor relations
Specific responsibilities of the department vary from one organization to another, depending in part on the organization’s structure and number of people it employs. For example, in a
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large teaching hospital, the human resource department might be responsible for the initial
screening and interviewing of potential employees. In addition, it might be active in developing standards for evaluating employee performance, maintaining employee records, and operating employee training and orientation programs. In most health care organizations, the
human resource department is directly responsible for administering the compensation and
benefits program, managing the overall employment process, and overseeing labor relations.
Functions of the human resource department revolve around recruitment and retention of
competent employees to staff the organization. Responsibility for successfully performing these
functions generally is shared with department and unit managers. Human resource specialists
advise, counsel, and assist health care managers from all departments in a variety of activities
related to employee management. For example, human resource specialists may perform the
following functions:
Recruit new employees and offer advice on hiring decisions
Help determine what new employees should be paid
Set up standards for evaluating the performance of current employees
Help initiate disciplinary procedures
Handle employee grievances
Resolve benefit issues
Interpret personnel policies and procedures
Coordinate the negotiation and implementation of labor contracts
In health care, as in other businesses, the human resource department acts as a communications link between employees and their managers. As a trusted employee advocate, a human
resource representative is available to help resolve employee issues and problems. For example,
an employee may wish to discuss a work-related issue, such as perceived discrimination, or a
personal problem that affects work performance, such as stress or chemical dependency. In this
capacity, the representative works to resolve the issue or problem by taking appropriate action.
Another key function of a human resource department is to ensure fair treatment to all
employees. Accomplishment of this priority depends on having the support and cooperation of
management, administration, and the board of directors. The department also is responsible
for ensuring compliance with federal, state, and local laws regulating employment, prohibiting
discrimination, and promoting equal employment opportunities for protected classes, such as
women, minorities, and persons with disabilities. If the organization is required by law to have
an affirmative action plan, the human resource department is responsible for its development
and implementation.
The food service director must work closely with human resource specialists to keep the
nutrition and food service department in compliance with the law and with the institution’s
personnel policies and procedures. In addition, the director should make sure that his or her
department’s employee performance records contain all information required by law. In managing conflict resolution, the director must carefully follow human resource policies on disciplinary, probation, and grievance procedures. Finally, the director should discuss special
problems—for example, claims of sexual harassment within the department—with representatives of the human resource department. In addition, the organization’s legal affairs staff may
need to be consulted at times to ensure nondiscrimination.
Employment Process
The food service director may share responsibility for recruiting and hiring new employees with
the human resource department. No matter where this responsibility falls, nine basic steps are
almost always followed in the process of recruiting and hiring employees (sometimes referred
to here as the employment process) (Figure 8.1):
Food Service Manual for Health Care Institutions
Figure 8.1. The Employment Process
Refer to laws that
govern process
Avoid illegal questions
Check references
Physical examination
Offer job
Prepare the personnel requisition
Recruit qualified applicants
Take applications
Screen applicants
Interview applicants
Check references
Make the final hiring decision
Arrange for a physical examination and drug screen, if applicable
Conduct a new employee orientation program
The operation of a food service department is like the operation of any business organization in that its success depends on the skills and commitment of its human resources—the people who do the work. For this reason, it is extremely important that the recruitment and hiring
process be conducted with careful adherence to the letter and spirit of the law. When recruiting for food service personnel, the human resource department needs to be knowledgeable
concerning the types of personnel required and the hours worked. The food service department
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is composed of a variety of professional and nonprofessional employees. Professional employees have extensive academic training, experience, and skills to make independent judgments
and work with minimum supervision. This group is made up of directors, dietitians, dietetics
technicians, and dietary managers. Some food service jobs may be entry level, that is, suitable
for persons just entering the profession who have the education and basic skills required to do
the job, but they may need additional supervision in the beginning. Some of the professionals
may have advanced education, training, or skills and be specialized, such as a certified diabetes
educator. Supervisory personnel have the authority and responsibility for a group of subordinate workers and are accountable for their own work. The supervisor is responsible to ensure
that standards are maintained and for the output of the group. The department also employs
skilled and unskilled workers. Skilled workers have received special training or have the ability to perform the job functions. A skilled worker is a cook or baker. Unskilled workers usually have no marketable skills and are trained on the job. The department also employs
full-time employees. A full-time employee is one who usually works 40 hours a week. Some
organizations consider 32 hours per week as full-time. Part-time employees are those who work
a set number of hours per week, usually 16 to 20. Some employees job share: Two or more people work together in the same job to equal the hours of a full-time employee. Some dietitians
like this type of position, the hours and days being decided by the dietitians and directors.
Temporary employees may be used during times of high census, to complete a project, to
fill in for illness, or for other leave reasons. Temporary employees may be professional or nonprofessional.
Contract employees are hired for a specific task or project such as a dietitian or engineer
to install a new tray line system. These people are usually consultants who are paid a set fee.
Consultants pay their own benefits and taxes.
Food service personnel may be paid by the hour. An hourly employee receives a set fee for
the hours worked. This may be minimum wage or a higher scale determined by the competition, the organization’s compensation plan, or both. Other food service employees may be paid
a salary and are considered salaried employees; they are paid for the job.
A food service department also employs a diverse work group. Workers may have different ethnic backgrounds, racial diversity, age, gender, religion, and other differences. All of these
factors must be considered by the human resource department and the food service professionals during the employment process.
Hiring employees who lack the skill, experience, and incentive to perform their jobs contributes to an organization’s turnover rate. Turnover is expensive because the process involved
in recruiting, hiring, and training new employees draws on many resources, including time,
energy, staff, money, and materials. During this process, the department’s productivity can fall
and so can employee morale. Therefore, excessive repetition of this cycle should be guarded
The legislation described at the beginning of this chapter is intended to ensure that employers conduct the employment process fairly. To avoid illegal discrimination against applicants on
the basis of sex, age, race, color, religion, or national origin and to refrain from asking illegal
questions on application forms and during interviews, managers who take part in this process
must remember one critical fact: Their organization can be sued by unsuccessful applicants
who claim unfair treatment or discrimination.
Preparing a Personnel Requisition
A food service department’s operating budget specifies how many full-time-equivalent employees it may employ. A position becomes vacant when an employee resigns or is dismissed or
when a new position is added because of increased workload. At this point, the food service
director should start the recruitment and hiring process to avoid problems associated with
Food Service Manual for Health Care Institutions
The first step is to fill out a personnel requisition. The official title of the vacant position,
the pay grade, job description, qualifications and experience required, and any other information needed by the human resource department should be completed on this form. The director then signs the request and, if applicable, submits it to his or her immediate supervisor for
Once approved, the personnel requisition is sent to the human resource department, where
it is checked for accuracy and completeness. In large organizations, the requisition is handled by
an employment manager; in small facilities, it may be handled by the director of the human
resource department or by one of the department’s clerical assistants. The next step is recruitment.
Recruiting Qualified Applicants
Recruitment is the process of identifying and attracting qualified potential employees on a
timely basis and in sufficient number. Usually the human resource department is directly
responsible for recruiting applicants from inside and outside the organization. However, qualified candidates can be recommended or referred by members of the food service staff or by
outside referral sources (for example, another health care facility).
In filling job openings, many organizations have a policy of hiring from within the organization. This policy encourages employees’ commitment and allows them to advance within the
organization. Also, such a policy may be part of the organization’s contractual agreement with
an organized labor union. With a policy of internal recruiting, the vacancy must be publicized
in-house before outside applicants are sought. For a certain length of time as specified by policy, job openings are routinely posted on bulletin boards in the human resource department, in
staff lounges, or in other designated posting places in the facility. Job posting is publicizing the
open job; it lists qualifications, supervisor, working schedule, and pay grade (rate).
Job bidding is a technique that permits employees who believe that they possess the
required qualifications to apply for the posted job.
Once internal candidates have been given the chance to apply, the department begins the
external recruiting process. One possible source for external applicants is current staff members who may recommend people they know. Government and private employment agencies
are another source. Public and private employment agencies help organizations recruit employees. Private agencies usually recruit employees for white-collar jobs. Private employment agencies charge a fee that may or may not be paid by the recruiting organization. Public employment
agencies’ main recruitment is for operative jobs, but they also recruit for technical and management positions. Public employment agencies provide their services without charge to either the
employer or the prospective employee. High schools, vocational schools, and community colleges are a good source for recruiting full-time and part-time employees.
Executive search firms are organizations that seek the most qualified executive available
for a specific position and are generally retained by an organization or company needing specific types of individuals. These firms usually search nationwide. A search firm’s fee is usually
a percentage of the individual’s compensation for the first year. The client pays expenses as well
as the fee.
Professional associations such as the American Dietetic Association, the Dietary Managers
Association, and others provide recruitment services for their members by including job advertisements in journals and job markets at national meetings.
Some health care organizations hold open houses as a means of recruiting. This method is
being used to recruit nurses because of the nursing shortage.
Colleges with food service programs and dietitian training programs have placement
offices that are eager to help students and graduates find jobs. Advertisements can be run in
local and out-of-town newspapers and in food service industry publications. Job fairs are usually held on college campuses. People seeking employment meet recruiters face-to-face to discuss job availability and for matching individuals to specific jobs. The Internet is being used by
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organizations to post jobs, and individuals use it to post their resumé. This is among the newest
methods of recruiting.
Advertisements in local newspapers, magazines, and professional journals should briefly
describe the duties and responsibilities of the position and the qualifications required. Such
information should be taken from a current job specification that corresponds to the official
job description for the position. For a new position, a job description and job specifications
must be developed by the appropriate team. (Job descriptions and specifications are discussed
in Chapter 6.) All recruitment activities must comply with equal employment opportunity law
as outlined earlier in this chapter.
Taking Applications
The application blank provides an opportunity to gather basic nondiscriminatory information
on all persons who apply for a job position. Each external applicant should personally fill
out a written employment application. Internal candidates should fill out whatever forms
are required by the institution’s personnel policies and procedures. Application forms should
ask only for job-related information needed to determine an applicant’s qualifications for the
position. Forms should be supplied or approved by the human resource department to ensure
compliance with EEOC guidelines, immigration regulations, and affirmative action program
The application blank is a useful tool in the employment process. It contains name, address,
telephone number, Social Security number, and who to contact in case of an emergency. The
information on education, military service, experience, work record, and references can be used
to determine if the applicant meets the job requirements and needs to be given further consideration. The main purpose of the application blank is to aid in the selection process.
No application may ask questions that violate the legal rights of an applicant. For example, employers may not ask—on written application forms or during personal interviews—
whether an applicant has ever been arrested or has organizational affiliations that do not relate
directly to the position applied for. Civil rights laws forbid employers from asking questions
related to age, race, religion, or national origin. Questions related to disabilities or medical conditions also may not be asked as part of the hiring process. Applicants may not be asked about
their familial status or whether they plan to have children. However, questions about age, medical condition, marital status, and number of dependents may be asked after an applicant has
been officially hired. This is because such information is needed on applications for the health
and life insurance coverage offered to new employees as part of their employee benefits.
Screening Applicants
The sequence of activities in the screening stage may vary. Many times, unqualified applicants
are screened out, or eliminated, when they inquire about the position by telephone or mail
before filling out an application. Furthermore, the human resource representative may either
screen out unqualified applicants soon after they apply or wait until all potential candidates
have filled out applications and then eliminate those whose skills, training, or experience do
not match requirements for the position.
If the position requires special skills, such as typing, computer literacy, or experience using
technical office equipment, the human resource department may test the applicants to determine whether their skills meet the criteria specified for the job. Some organizations may administer intelligence, personality, and aptitude tests as well. However, test results cannot be used
for purposes of discrimination. In addition, these tests must be standardized and proved to be
ethnically and sexually unbiased by independent testing authorities. The use of all such tests
must be coordinated and monitored by professionals trained in their administration and fair
Food Service Manual for Health Care Institutions
The food service director may further screen qualified applicants to determine which individuals will be interviewed. Interviewing is time-consuming and costly and should be reserved
for the best-qualified applicants. There is no magic formula for the number of candidates who
should be interviewed, but enough people should be seen to ensure that the best candidate
available is offered the job.
Interviewing Applicants
After unqualified applicants have been screened out, interviews with potential employees are
scheduled by the human resource department. In some organizations, the employment manager
interviews the candidates before the food service manager does. In others, the food service
director or a designee may be the only person who actually interviews the candidates. An organization’s personnel procedures dictate who has this responsibility.
Several methods can be used to interview a job candidate who may be from out of state.
Preliminary interviews may include a telephone interview. Telephone interviews are made to
keep cost down, to exchange information with applicants in distant places, and to screen a
large number of applicants.
Videotaping can also reduce cost. The applicant is provided questions that are answered
while the applicant is being videotaped. This can be expensive if outside consultants are used.
Other methods include panel or group interviews when the applicant is screened by a panel
of administrators, employees, or both that will be working with the selected applicant. The
method reduces single-interview bias. The most common method is the personal interview.
Interviewing is not an exact science. Interviewers have responsibility for treating candidates
fairly, cordially, and professionally. They must make every effort to suspend negative judgment
of candidates based on appearance or language and conduct the interview with an open mind.
Interviewers should remember, too, that the candidates are judging them as well. The interviewer must dress professionally and give the candidate a positive impression of the job and the
The interview should be a positive experience for both managers and prospective employees. A well-conducted interview is the first step in establishing a constructive and professional
relationship with new employees and in creating goodwill with those who are not hired.
Unsuccessful applicants may be qualified for future openings or may recommend the organization to others who may be interested in applying for future openings.
Well before the scheduled time for the interview, certain preparatory steps should be taken.
These are listed below:
• The human resource department should give the interviewer copies of all information
available on individual candidates. The information must include application forms, screening
notes, letters of reference, resumés, and applicable test results.
• The interviewer should review the job description for the vacant position, making notes
on the specific qualifications required and ranking them in importance.
• The interviewer should write an interview plan that includes direct questions intended
to elicit information on each candidate’s qualifications as compared with the qualifications
shown on the job description.
• Next, the interviewer should thoroughly review all candidate information supplied by
the human resource department, looking for points of compatibility between the candidate and
the position requirements.
• The interviewer should compile a list of open-ended questions designed to reveal or clarify information about the candidate’s education and training, work history, and career goals.
Questions about the candidate’s salary expectations also should be planned. Open-ended questions give an applicant the chance to demonstrate his or her knowledge, experience, and ability to communicate that yes-or-no questions do not.
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• The interviewer should reserve a private setting in which to conduct the interview.
Interruptions from phone calls and would-be visitors interfere with privacy, making it difficult
for both candidate and interviewer to give their full attention to the interview.
• The interviewer should set aside enough time to make sure that all questions planned
are asked of the candidate and that the candidate has enough time to ask questions he or she
has about the job and the organization.
Following are some questions that might be asked of candidates for food service jobs:
Why did you choose food service as a field of work?
What type of position are you most interested in? Why?
What qualifications do you have that would make you a success in this job?
What are your strengths and weaknesses as a food service worker?
What hours of work do you prefer? Why? Could you work overtime in case of an
What did you like and dislike about your previous job? Why?
What did you do in your last job?
Why did you leave your last job?
What do you enjoy doing most in food service?
Do you work better in a group or alone? Please explain.
What do you know about food service in a health care operation?
During the interview, certain steps establish an atmosphere conducive to conducting an
effective session. Interviewers can follow the steps outlined below.
1. Greet the candidate cordially while shaking the candidate’s hand, identifying yourself,
and telling the candidate what position you hold. Then ask the candidate what name
he or she prefers to be addressed by.
2. Describe how the interview will proceed so that the candidate knows what to expect.
Ask whether the candidate minds if the interviewer takes notes during the interview.
Notes are extremely valuable for making evaluations and comparisons of candidates
after the interview process. However, note taking can make some candidates apprehensive. In addition, interview notes may be examined as part of legal proceedings if
an unsuccessful candidate later sues the organization for discrimination. Therefore,
interview notes must contain only objective and relevant comments. The same questions must be asked of all applicants.
3. First, ask general questions about training and work history, but questions already
answered on the application form should not be repeated unless clarification or additional information is needed. For example, the interviewer might ask, “I notice that
you left your previous job for personal reasons after just six months there. Can you
tell me why you stayed at that job for such a short time?” Because most interviewers
make the mistake of talking too much, the interviewer should be careful to allow the
candidate to answer all questions completely and to be given enough time to ask questions in turn.
4. After the candidate’s educational background and work history have been explored
fully, describe the position and give the candidate a copy of the job description.
5. Ask a series of open-ended questions to see whether the candidate understands what
the position involves and whether he or she has the skills and knowledge needed to
perform the job. Again, avoid questions that can be answered with a simple yes or no.
6. Encourage the candidate to ask questions about the job itself, the organization, wage
levels and work schedules, the employment benefits available, and opportunities for
advancement or promotion.
Food Service Manual for Health Care Institutions
7. Once the candidate has been given every opportunity to ask questions and seems satisfied with the information provided, move the interview toward conclusion. Tell the
candidate what will happen next and when he or she may expect to hear a decision.
Be friendly and positive, but be careful not to give the impression that the candidate
definitely will be offered the job. It is especially important not to create false hopes for
candidates who did not perform well in the interview or who obviously are much less
qualified for the position than other candidates being considered. Disappointed candidates may feel that they have been treated unfairly when they are not offered
8. Express sincere appreciation for the interest the candidate has shown in working for
the organization.
The following are things an interviewer should not do:
Interrupt the applicant, talk too much about self, job, organization, or the like.
Rush the interview or appear disinterested.
Ask leading or embarrassing questions
Ask personal questions about applicant’s life, religion, and so forth.
“Talk down,” preach, or argue.
Agree or disagree with the answers the applicant gives.
Lose self-control or become angry at the applicant.
After the interview, the interviewer should take the following additional steps. He or she
1. Review the notes taken during the interview immediately, adding missing information
and noting final impressions of the candidate. Make a preliminary notation on the
candidate’s qualifications and a preliminary ranking compared with other candidates.
For example: “Mary Johnson appears to be well qualified for the job. She has four
years’ experience and a steady work record. One of the top three candidates so far.”
In making such appraisals, consciously try to overcome biases based on the candidate’s
personal qualities and physical characteristics.
2. After all candidates have been interviewed, review all notes and preliminary rankings
again. Then rank the candidates a final time according to their skills, knowledge, and
experience. The rankings also should take into account the candidates’ degree of interest, usually expressed during the interview by the number of questions candidates ask
and by their general attitudes toward the interview process and the position being
offered. An enthusiastic candidate with two years’ experience may make a better
employee than a disinterested candidate with five years’ experience. Such decisions are
always based on the experience and judgment of the interviewer.
3. Decide which candidate seems to be best suited for the job. At this point, it may be
appropriate to seek the advice of the human resource department, especially if one of
its representatives also interviewed candidates. For professional positions, it is customary to conduct more than one interview with one or more candidates before a
decision can be made.
4. Inform the human resource department of the decision to offer a particular candidate
the position.
Checking References
After the decision is made to offer the job, a human resource representative is informed so that
the chosen candidate’s references can be checked. The reference check involves contacting at
least the candidate’s most recent employer by telephone or letter. The present employer should
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not be contacted before the applicant resigns, unless there is written permission to do so. If dismissal results, the applicant may take legal action. Often other former employers are contacted
as well. The educational credentials of professional employees also should be verified at this time.
Because employers are sensitive to the legal liability associated with supplying potentially
damaging information about former employees to prospective new employers, many organizations have a personnel policy that forbids disclosure of employee information beyond dates of
employment, job titles, and final salaries or wages. If there is any doubt about the candidate’s
work record or personal integrity, the human resource representative may contact all previous
employers, confirm the candidate’s personal references, or check the candidate’s record with
legal authorities.
In checking references, employers must avoid questions that are prohibited under the federal Privacy Act and the Fair Credit Reporting Act. It is for this reason that most organizations
have a personnel policy that requires the human resource department, instead of the interviewing department manager, to check the references of potential employees. Human resource
specialists usually are fully aware of what questions may and may not be asked in the employment process.
Making the Final Hiring Decision
The final decision to hire a new employee is one of the most important any manager will make.
Hiring unqualified or uncooperative employees can waste training dollars and damage department morale. The wrong decision also may cost the organization hundreds or thousands of dollars. The employment process is expensive because it requires a great deal of the manager’s and
the human resource department’s time. Advertisements in publications and fees charged by private employment agencies and recruitment firms are increasingly expensive.
Therefore, the hiring decision must be based on careful screening of all candidates available, a fair and well-thought-out interview, and thorough reference checking. The hiring decision should never be rushed, and it should never be based on superficial first impressions or
personal biases.
Once the final hiring decision has been made and it is agreed that the best-qualified candidate has been found, the human resource representative and the food service director jointly
decide what starting salary or wage the candidate should be offered. The starting salary is
based on the wage or salary range for the position and on the candidate’s work experience and
educational training.
The human resources representative then contacts the candidate (by letter or telephone) to
offer the position at the salary assigned. In some organizations, the employing manager may
make the actual job offer. However, again because human resource specialists are trained to
address sensitive legal issues that surround the employment process, the trend is toward having them make job offer contacts with candidates. One important area of concern is that the
offer of employment be made in such a way that the candidate is not led to misconstrue the
offer to be an employment contract.
Making the job offer includes giving the candidate specific information about the starting
salary or wage, anticipated date of employment, official job title, and other information about
employment with the organization. Other information might include details about qualifying
for health benefits and vacation time. Often the candidate may ask for some time to think
about the offer. Setting a definite time for a follow-up contact for a final decision prevents
delays in filling the position.
If the candidate accepts the offer, the human resource representative arranges for the new
employee to undergo a physical examination and other tests as designed by the organization.
If the candidate decides not to accept the position, the representative notifies the food service
director so that a second candidate can be chosen and the cycle repeated.
The application forms, test scores, interview notes, reference-check notes, and any other
information on unsuccessful candidates should be filed in the human resource department.
Food Service Manual for Health Care Institutions
Such materials will be extremely valuable in the event that unsuccessful candidates take legal
action against the organization. (However, this material can become a double-edged sword if
records reveal that the organization failed to follow its own policies and procedures—for example, to check references.) In addition, the files may be a source of information on potential candidates in recruitment efforts to fill future openings for similar positions. The files should
include clear statements indicating the reasons the candidates were not hired. The application
forms and other information gathered on successful candidates should be kept as part of the
permanent personnel records, discussed later in this chapter.
Arranging for a Physical Examination and Other Tests
Before the implementation of the Americans with Disabilities Act of 1992, employees were usually given a preemployment physical before a job offer was made. Because organizations must
be careful not to discriminate against disabled individuals, most now make a preliminary job
offer pending completion of a medical examination, agility evaluation, or other testing. On the
applicant’s acceptance of the initial job offer, the human resource department schedules the
candidate for a physical examination to be performed by a physician, nurse, or nurse practitioner, who should be given a copy of the candidate’s job description.
The examination is intended to determine whether the new employee can meet the physical demands of the job or needs reasonable accommodations, to detect health conditions that
might pose a risk to the employee if he or she were placed in a specific job or area, and to protect the organization’s customers and staff from exposure to potentially infectious illnesses.
This step is especially important for food service workers because of the danger of spreading
communicable diseases through food handling and because much of the work involved is physically taxing. During the preplacement examination, the employee generally is asked to provide
a cardiopulmonary history and to take a tuberculin skin test.
Screening for illegal or controlled drug usage has been implemented by many health care
organizations. Drug screens are meant to combat absenteeism, accidents, work-related injuries,
equipment damage, and inefficient performance due to substance abuse among employees.
Screening for substance abuse also can help employers control the cost of health care and
workers’ compensation. Employers may deny employment to individuals who are using illegal
or controlled substances at the time of a preemployment screen, but applicants with prior
addictions are covered under the Americans with Disabilities Act.
Organizations that decide to use drug screening must use a nationally approved laboratory
and follow strict protocols for chain of custody to ensure the validity of the test results.
Confidentiality is of critical importance and is generally ensured through minimal handling of
the specimen as outlined in the organization’s human resources policy and procedures. The
manager of the food service department should become familiar with the policy and procedures
of the organization to ensure compliance.
Other tests may be required by the organization and must be given to all applicants to avoid
discrimination. Some organizations may require a polygraph (sometimes called a lie detector
test). The Federal Employee Polygraph Act of 1988 prohibits most private employers from
using a polygraph as a selection device; however, in those situations involving cash or the manufacture of controlled substances, the use is sometimes permitted.
Graphology is a handwriting analysis in which a graphologist evaluates the applicant’s
handwriting using certain methods to make inference about the applicant’s personality.
Some organizations may require a personality and interest test, an indicator test such as
the Myers-Briggs Type Indicator (a personality inventory that helps employees and employers
understand how employees like to take in information or look at things, make decisions, use
time, and in general organize themselves ), or an achievement test.
Human Resource Management
Motor and physical abilities tests may be used if all applicants are given the test and the
results are not used as a discrimination tool. Any skill test, such as computer use or simple arithmetic for recipes, should be administered by a qualified person using standardized methods.
Personnel Records
After the employee has been hired, the human resource department will set up the organization’s personnel file on the employee. The food service department should also set up a file that
contains who to inform in case of an emergency, current address, telephone number, date of
hire, job classification, rate of pay, orientation and insurance records, leave slips, and any other
information the department may deem necessary. This file may be on cards, loose-leaf notebook, or computerized.
Conducting a New Employee Orientation Program
The first few days on the job are crucial for new employees. Not only must they be introduced
to the job, other employees, and the organization, but their future performance may depend on
the attitudes and impressions they form during these first days. Therefore, well-organized orientation procedures are needed to help new employees quickly become productive members of
the staff. A well-planned and implemented orientation helps to prevent or reduce turnover.
Employees who are provided an orientation at the beginning of their employment are more
likely to be loyal, content, and successful in their job.
Orientation to the Organization
In many medium-sized and large health care organizations, the human resource department is
responsible for explaining the organization’s personnel policies, regulations, and employee benefit programs. During general orientation sessions, new employees fill out tax-withholding
statements for the Internal Revenue Service and application forms for health insurance, life
insurance, and other group benefits. This is usually done the first day.
Also during this time, new employees may be given a guided tour of the facility. This
inspires pride in the organization and helps the employee understand his or her role. A brief
history of the organization and an introduction to the organization’s mission and goals also are
common elements of employee orientation programs. The new employee may be given a copy
of the organization’s employee handbook at this time. (The employee handbook will be discussed later in this chapter.)
In smaller health care facilities, the food service director may be responsible for conducting
general orientation for new employees as well as their orientation to the food service department. When this is the case, the director should make every effort to make the general orientation an interesting and thorough introduction to the operation of the organization as a whole.
Specific training for work tasks should be conducted only after the general orientation session.
Orientation to the Food Service Department
A new employee’s introduction to the food service department should be warm and friendly.
Orientation is a form of courtesy. It helps a new employee feel welcome. The director and any
other department managers who will work with the new employee should set aside time to welcome and introduce him or her to others in the department. People should be introduced by
name and a brief description of their duties given. Such introductions will make it easier for the
new member to understand who does what in the department.
After all introductions have been made, the person who will supervise the employee directly
should begin the gradual process of easing the new person into department operations and his
or her specific job requirements. By conveying a sincere interest in making the orientation and
training period a pleasant experience, the supervisor supports a new employee’s eagerness to do
Food Service Manual for Health Care Institutions
the job well, be accepted by coworkers and supervisors, and overcome being nervous in a new
The supervisor should not cover too much information at once, reassuring the new worker
that additional information will be given gradually throughout the orientation period.
Information overload may cause a new employee to become confused and even more apprehensive. The new employee should be given a copy of the department’s procedures handbook
and be allowed enough time to read it thoroughly before beginning work.
In the next section of this chapter, we discuss in detail some methods for training new
employees to perform their jobs. However, it first may be helpful to offer guidelines for a typical orientation and training program for a production worker. Managers should keep in mind
that these guidelines would not be suitable for orienting professional or managerial employees.
For example, an orientation and training program for registered dietitians and other nutrition
professionals should be arranged on an individual basis so as to be suited to the various levels
of experience and knowledge such professionals would have.
The following guidelines cover the first five days (one workweek) of a new employee’s orientation as a food service production worker in a hospital:
• Day 1. The supervisor explains the general departmental routine and where the new
employee’s job fits in; shows the employee the general work area, the employees’ lounge, and
the employees’ locker room; assigns the new employee to an experienced employee whose
duties are identical or similar to those the new employee will perform; and gives the new hire
a copy of the department procedures handbook. The new employee spends the rest of day 1
observing and working with the experienced employee.
• Day 2. The supervisor checks with the new employee to see whether he or she has questions about yesterday’s activities, clarifies any task or departmental routine, and reaffirms a
friendly and supportive atmosphere by offering encouragement and helpful suggestions rather
than criticism. The new employee spends the rest of day 2 working with and observing the
mentor employee perform tasks the new employee eventually will perform.
• Day 3. The new employee spends more time working independently. The supervisor
observes his or her job behavior and corrects or clarifies work performance as necessary.
• Day 4. The new employee continues to work independently, but the supervisor and
coworkers remain available to answer questions and offer advice. The supervisor begins to
review the job description as well as key points of departmental policies—especially those on
infection control, disaster planning, fire safety, and hazardous substance handling—offering the
new member opportunity to raise questions and clarify points as necessary (for example, fine
points of the department’s or organization’s personnel policies such as employee benefits, grievance procedures, and performance evaluation).
• Day 5. The new employee assumes job tasks independently. The supervisor may apprise
the employee of training opportunities in specific production procedures and techniques once
the employee has adjusted to his or her new work setting. All orientation checklists are filed in
the department’s employee personnel file.
Employee training is one of a food service director’s most important responsibilities. A continuous, well-organized training program for all levels of employees increases productivity, quality level, safety consciousness, and department morale. New employees may require a complete
training regimen. Experienced employees may need training in new or updated production
methods, equipment, and approaches to handling set job tasks. Most new employee training is
conducted one-on-one, whereas experienced food service employees usually are taught new or
updated skills and concepts during in-service group training sessions.
Human Resource Management
The department director responsible for the performance and training of unit managers
and nonmanagerial employees in a hospital setting has access to more resources than ever.
Many hospital human resource departments now employ training specialists (sometimes called
education coordinators) who serve as instructors or advisers in helping facilities plan their
training programs. These specialists coordinate department-level in-service programs or design
individual training plans for all levels of department employees.
Nonprofessional employees in the food service department have varied educational and
social backgrounds. Some may lack skill in food service work on being hired. Despite the differences in abilities, social backgrounds, and basic skill levels (for example, in math and reading), it is essential that all food service employees receive adequate training. Part of that
training is understanding the responsibility of the food service department to provide safe,
nutritious, and high-quality food to customers.
Training for physically or mentally challenged employees must be conducted on the basis
of any accommodations needed by these individuals. For example, if an employee is learning
disabled, training requires verbal instructions and demonstrations. If modifications are made
to equipment to enable a physically challenged worker to complete a task, it might be necessary to train other staff to use the modified equipment.
In the United States, billions of dollars are invested annually in job training. This level of
investment makes it incumbent on managers to ensure the highest return possible. Training can
pay for itself many times over when an employee is consistently and adequately trained from
day one. Training programs should be planned and designed with specific and objective outcomes for knowledge or skill enhancement in mind. The purpose of training should include
Meeting the basic needs of employees and improving moral
Improving productivity
Improving customers’ satisfaction
Improving compliance with regulatory agents
Meeting or exceeding established standards
Reducing turnover
Reducing accidents, injuries, and mistakes
Maintaining cost
Planning and determining objectives are discussed later in this section.
Understanding the Instructor’s Role
The instructor, a key to successful training, must maintain a positive attitude toward the work
to be learned and toward the employees who must be trained to perform it. To facilitate the
learning process, the instructor must first earn employees’ respect and confidence by demonstrating his or her skills, explaining convincingly why tasks are performed in particular ways,
and showing fairness and patience. The instructor also should be careful to gauge the employees’ knowledge beforehand so as to avoid unnecessary training as well as training for which
they may be inadequately prepared. For example, training in the use of new cook–chill or
cook–freeze procedures is futile unless employees understand the importance of maintaining
the structural and textural integrity of the food prepared with these systems. Assessing an
employee’s knowledge can be accomplished through observation or written pretesting. For
example, if training involved the proper method of steaming vegetables, the employee should
be asked to demonstrate the technique. A written pretest should ask questions regarding the
key concepts the trainer wishes the employee to learn. For example, a pretest on proper food
handling should ask specific questions regarding holding temperatures and proper labeling of
the product.
Food Service Manual for Health Care Institutions
The instructor also must understand basic principles of training adults. Some of these
include the following:
The desire to learn must come from the learner.
People learn at different rates.
All training does not progress smoothly but in up-and-down cycles.
If treated with disrespect, adults resist taking part in activities.
Learners become discouraged when they reach a plateau in their skill levels.
Adults come to the learning situation with a great deal of life experience and want to
contribute actively.
A certain amount of apprehensiveness is a natural part of learning.
Adults require practical outcomes from their learning experience.
A whole task should be demonstrated before it is broken down into its component parts
for learning purposes.
Poor training methods hinder learning.
Adults learn more efficiently in well-timed training periods that last no longer than an
hour without a break.
The reasoning behind every element of the skill being taught must be explained to help
employees understand the whole process.
Learners need to be told how well they are doing as the learning progresses.
Although, as stated above, a positive attitude is important, instructors should not expect
maximum skills to be attained by the end of the training session. Full learning of tasks requires
on-the-job practice.
Conducting Individual Training Programs
In many food service departments, individualized training of new nonprofessional employees is
delegated to experienced employees who perform identical or similar jobs. The employee
selected for this task should know how to teach, so the manager must work with this person
to plan step-by-step how the new employee is to be trained. This way, common errors made by
inexperienced trainers can be circumvented. Some of these errors include the following:
Trying to teach too much at one time
Describing how to perform a task without first demonstrating it
Lacking patience
Failing to give and receive feedback as the learning progresses
Failing to prepare adequately
Forgetting, overlooking, or inadequately explaining key points
The director or manager who delegates training responsibility must check periodically to
ensure that training is proceeding appropriately. Any shortcomings in the process must be
addressed so that both employee trainer and manager can learn from mistakes.
The step-by-step plan worked out between manager and designated trainer must be
designed carefully for maximum benefit to the new employee. Following are some basic guidelines for training new nonprofessional food service employees:
• Use the new employee’s job description to plan which tasks and skills need to be taught.
• Outline a step-by-step procedure for teaching each task or skill. The goal of each training session should be stated and communicated to the trainee.
• Set aside a specific time for each training session so that interruptions are kept to a
Human Resource Management
• Gather and arrange all supplies, utensils, equipment, and teaching aids before the session begins. The workplace should be set up just as the employee will be expected to keep it.
• Prepare for each session by first learning what the new employee already knows about
the task.
• Demonstrate each task before teaching it. Explain each step completely and clearly,
stressing and repeating key points and demonstrating acceptable shortcuts that make the task
easier, faster, or more effective.
• Ask and invite questions at each juncture of the demonstration to ensure the trainee’s
• Give the trainee ample opportunity to perform the task and explain its steps along the
way while observing and correcting errors patiently. Have the trainee repeat the task until it is
clear that he or she understands it fully.
• Allow the trainee to practice the task independently after all safety procedures have been
learned fully. However, remain close at hand to answer questions and provide feedback or help
if needed.
• Withdraw direct supervision gradually as the trainee becomes proficient at the task.
• Acknowledge the trainee’s progress and congratulate him or her on successful completion of the assigned task.
• Discuss the schedule for additional training and set reasonable goals for learning related
Conducting Group In-Service Training Programs
An in-service training program is essential for maintaining an efficient and cost-effective food
service department. Continuing education enables employees to grow in their jobs by learning
new techniques or gaining new knowledge that will help them become more productive and
increase job satisfaction and ownership. Well-organized group training sessions are the primary
method of conducting in-service training. They are an efficient means of communicating vital
information in a structured training environment. Most states require official in-service training programs for health care providers.
Program Planning and Scheduling
Programs or in-service sessions should not be planned or conducted until a needs assessment is
made. Needs assessment is a tool, a fact-finding process. Needs assessment helps the supervisor determine where training efforts should be focused. It helps to determine whether a problem is being caused by the job or the working conditions. Needs assessment allows the trainer
to provide positive reinforcement for correct action. It also removes obstacles and provides the
supervisor with an idea of what is needed for the employee, department, or both to perform
correctly when determining needs. The main priority should be not only to provide quality
service to the client but also to constantly improve the quality of that service as well. When
developing training needs, consider the following:
• Knowledge: What is needed to perform the job. Information may include policies, procedures, budget limitations, and the like.
• Skills: How the job is to be done.
• Assessment: More training to increase skills and knowledge.
Once staff needs have been assessed, the topics for in-service training can be rated by
importance, and the employees who require training can be identified. A successful program is
based on employee needs: What problems, issues, or changes need to be explained? What attitudes, knowledge, and skills will help employees do their jobs effectively, now and in the
future? Some topics may be relevant to the work of the whole department (for example, safety
Food Service Manual for Health Care Institutions
procedures). Other topics apply to only a few employees (for example, salad preparation techniques). A firm schedule for training sessions must be established several months in advance.
The date, time, and subject of each session should be stated on the schedule and made available to all employees.
The food service director or education coordinator (or both) should plan the entire year’s
in-service program in conjunction with the organization’s annual business plan. The program
should take into consideration overall organizational requirements and legislative and regulatory agency requirements. For example, programs may cover disaster or emergency preparedness, fire and safety procedures, infection control, OSHA regulations, or quality assurance and
quality control procedures.
Because most food service employees work in shifts, two or more sessions on each topic
need to be planned. Work schedules and workloads should always be considered when designing training schedules. Whenever the work volume does not allow enough time to schedule
group meetings during the workday, sessions should be scheduled at the end of the workday or
between two overlapping shifts. Personnel policies should be followed to determine whether
hourly employees are paid overtime for attending sessions outside their regular working hours.
The topic to be presented for each in-service meeting should be defined narrowly so that the
subject can be covered adequately. Most sessions conducted during a regular workday should be
short (twenty to forty minutes) because employees may be too fatigued to learn effectively.
Behavioral objectives should be developed with a method to evaluate the results of training. Objectives and results can be identified by asking two basic questions: What do the
employees need to know? How can the outcomes of training be evaluated?
A behavioral objective states in specific terms what the outcome of the training should be
and how it is to be measured. Behavioral objectives should be based on the kind of material to
be learned. Should it be a skills objective, an attitude objective, or a knowledge objective?
A skills objective involves teaching some kind of manipulative skill, in psychology called a
psychomotor skill. The level of psychomotor skill can be easily measured. An example of a
skills objective could be the following: At the end of training, the employee will be able to disassemble the dish machine, clean it, and reassemble it correctly 100 percent of the time.
Attitude objectives involve developing in participants new or modified feelings (attitudes)
toward the topic covered in the training session. (Such emotional components are called affects
in psychology.) Attitude objectives also involve individual interests, values, and feelings of
appreciation. The level of accomplishment in fulfilling attitude objectives is difficult to measure because personal emotions and beliefs are intangible and elude assessment. An example of
an attitude objective could be the following: At the end of training, the employee will have an
increased appreciation of the need to practice good guest relations when serving patients and
other customers.
A knowledge objective involves teaching intellectual skills (called cognitive skills in psychology). The level of knowledge or understanding gained through in-service training is relatively easy to test and observe. An example of a knowledge objective could be the following:
At the end of training, the employee will be able to calculate the composition of a 1,200-calorie, low-fat diet correctly 100 percent of the time.
No matter what skills or attitudes are being taught, all behavioral objectives should accomplish six things:
State the action to be accomplished.
State what the action is directed toward.
Describe how the action is to be accomplished.
State how accomplishment of the action is to be measured.
Include clarifications of the preceding components as necessary.
Include training method and materials.
Human Resource Management
After the type of objective has been determined, the behavioral change or changes being
sought as the goal of the training should be determined. This can be done by asking one of the
following questions: What can the employees now do that they could not do before? What do
they now understand that they did not understand before? What do they now know that they
did not know before? What will they now do that they would not do before?
Training Methods
The person who attends a training session must have the desire to learn. No one can be forced
to learn. Training must meet the wants, needs, and goals of the trainee. Employees (adults)
want an active part in training activities; they learn best by doing, not listening, and reading.
The following are examples of training methods:
• Lectures and videotapes involve a one-way flow of communication. This type of training is the least effective unless follow-up activities are planned that help the learner to participate in a hands-on practice.
• Computer-based training can enhance motivation and feedback when the programs are
interactive and allow the trainees to progress through the materials at their own pace.
• Conferences are effective when used by in-house educators to meet a specific purpose
such as explaining a new organization-wide safety program. They are also used by professional
organizations where members meet to listen to expert speakers and share information.
• Case studies are used to present a case or problem, and the trainees analyze and discuss
the problem and come up with a solution. Nursing and grand rounds are a good example of
this method.
• Incident reports are training sessions using a recent incident, evaluating why it happened, and devising methods to avoid its happening again. An example would be a recent
injury to an employee due to a wet floor.
• Demonstrations break a job down into its various parts. Once the job has been demonstrated, employees practice the procedure while receiving feedback from the trainer. This
method of training is an excellent tool to use when new baking items are added to a menu.
• On-the-job training is used to teach a trainee how to do a job while on location. The
trainee actually performs the job.
• Coaching is used to assist a trainee while practicing the job. The coach observes the task
and makes friendly suggestions about the job. The coach should compliment the trainee when
he or she meets the quality and quantity standards.
In all of these methods, the trainer will need to follow up to ensure that the trainee can do
the job as taught without constant supervision. Feedback is important.
Evaluating In-Service Training Sessions
To determine whether the desired outcome has been achieved at an in-service meeting, a
method must be devised to evaluate its end results. Tests, reports, demonstrations, questionnaires, case studies, observations, and so forth can measure the level of employee competency.
In some cases, post-training follow-up may indicate that some employees need individual training to achieve the level of competency required.
Once the outcome of training and an evaluation method are determined, a task analysis is
completed. A task analysis is a written description outlining the main steps of a specific work
activity in order of occurrence. Figure 8.2 is an example of a task analysis. The task analysis
may be supported by notes on the main points to be emphasized in the training. These materials also are used as the basis for the instructor’s plans for the training session.
Food Service Manual for Health Care Institutions
Figure 8.2. Example of a Task Analysis for a Food Service Department Training Session
Task Analysis
Dining room cashier
Cash transactions
For each cash customer
190 Cash register cash drawer
Café manager or head cashier
Important Steps in Job
1. Tally each food item on the tray.
Key Points
Tally each item under the proper food category.
2. Push subtotal button.
3. Push the tax button.
4. Push total button.
Be sure the tax has been added.
5. Check the amount on the indicator.
Be sure it agrees with the amount of sale.
6. Tell the customer the amount.
Speak clearly.
7. Take the money from the customer.
Hold the palm of your hand upward.
8. Punch value received.
Be sure to punch value in correctly.
9. Place the money in drawer.
Be sure to place in appropriate value category.
10. Punch the change indicator button.
Check the indicator for the amount of change to
be returned to the customer.
11. Count bills back to customer.
Start with ones, fives, tens, and so on. Tell the
customer to pick up change from counter.
12. Close cash drawer.
Do not lock cash drawer.
13. Give receipt to customer.
Do not drop it.
14. Say thank you.
If the session’s instructor is from outside the department or the organization, a department
representative must contact him or her well in advance to explain what skills or concepts are
to be taught. The representative also should offer help in setting up demonstrations or obtaining audiovisual equipment.
Identifying In-Service Training Topics and Resources
As a result of the employee needs analysis for in-service training, a number of issues or themes
may surface. Some possible topics for a continuing education program for the food service staff
• Standards for personal hygiene, infection control, AIDS [acquired immunodeficiency
syndrome] training
• Advances in food-handling procedures, hazard analysis critical control points
• Changes in cleaning techniques and procedures
• Operation and maintenance of new equipment
• Current fire safety, disaster and emergency preparedness procedures
• Injury or accident prevention
• Risk management
Human Resource Management
Future operational changes in the department and in the organization
Basic concepts of nutrition
Procedures for preparing and serving foods for modified diets
Changes in personnel policies, sexual harassment
Meeting the needs of special patient populations (for example, the elderly and the physically or mentally challenged)
• Safety precautions related to equipment, hazardous chemicals, cuts, burns, falls, and
right to know
• Customer satisfaction
It may be useful to maintain a list of people who demonstrate interest in teaching in-service training sessions in their areas of expertise. Speakers and instructors from the community
and employees of state and local public health agencies, universities, and technical colleges
may be helpful in training employees in specific skills and knowledge. Possible speakers also
may be identified at meetings of professional organizations serving the food service and health
care fields or through national speakers’ bureaus. Staff members from other departments in the
organization and from nearby health care organizations are additional resources.
Training materials are available from a number of sources and in varying formats, including videotapes, filmstrips, slides, and printed materials. Employees from colleges, universities,
vocational schools, and extension programs may be asked to present an in-service training session on a specific topic. Other groups such as sales representatives, equipment manufacturers,
special counseling services, community service organizations, outside consultants, and government agencies have trainers or speakers who will present special training programs. Trainers
should prescreen all materials before renting or purchasing them to ensure their appropriateness for the training planned. Screening further ensures that the department’s training dollars
are being put to good use.
Program Implementation
The instructor for a particular in-service training session should prepare a detailed instruction
plan based on the objectives previously identified. A lesson plan, a written blueprint of how a
lesson is to be conducted, describes key points to be covered and how they are to be taught (for
example, by demonstration or discussion) and lists all materials needed to conduct the lesson.
Lesson materials may include printed handouts, wall charts, audiovisual materials, equipment,
and supplies, among others. The lesson plan also should include written questions to be discussed with the group. The instructor should be sure that the elements in the lesson plan can
be covered adequately in the amount of time scheduled.
Well before the session is scheduled to begin, the instructor should check whether all
audiovisual equipment needed is available and in good working order. Similarly, he or she
should have any posters, charts, handouts, and other printed materials prepared in advance.
Such materials should be well organized and neatly prepared. Posters and charts should be
large enough to be seen from all areas of the training room.
The session should start on schedule. At the beginning of the session, the instructor should
introduce himself or herself to the group, if necessary. Next, other members of the group should
introduce themselves in the event they are not known by name to all present.
The session should begin with an overview of the topics to be discussed or demonstrated.
Any supplementary teaching aids should be set up or passed out when appropriate. The
instructor should involve members of the group in as many demonstrations and role-playing
activities as possible, asking questions all along so as to encourage further discussion and
At the end of the session, the subject should be summarized, with time allowed for any
additional questions to further ensure that all key points have been covered adequately and are
understood by all participants. Finally, the group should be asked to give specific examples of
Food Service Manual for Health Care Institutions
how the skills and concepts learned in the session can be applied to the everyday work of the
food service department.
Program Evaluation
Measuring the outcome of in-service training and evaluating the overall program are important
to the training process. Employee performance should be assessed on an ongoing basis to determine the need for further training or retraining. Employees’ skills can be tested and measured
immediately before and shortly after a program to determine its effectiveness. On-the-job performance tests and observations, interviews, questionnaires, and department records also serve
as indicators. Department accident and event reports, as well as quality control assessments,
are reliable gauges of job-related skills and attitudes and, therefore, of the merits of the department’s training program.
An instructor’s training skills also can be evaluated by asking questions about how well the
instructor knew the material and how well the material was presented. Were the teaching aids
helpful and interesting? Was the class discussion informative? Did the instructor answer all
questions thoroughly and respectfully?
Participants can be asked to complete written evaluation forms at the end of each training
session. Survey questions might include the following:
Will information from this session help you to improve your job skills?
What did you learn that will help you in your work?
Was this subject interesting to you?
Was this session worthwhile?
Did the session contain enough practical information, or was it too theoretical?
Was the session long enough? too long?
How could the session have been better?
What subjects would you like to learn more about in future sessions?
Was the learning environment comfortable physically and socially (too crowded or too
Maintaining Records of Individual and Group In-Service Training
Records of individual and group training efforts must be maintained by the food service
department (Exhibit 8.1). Employees should sign attendance sheets for each training session
they attend. A monthly report showing the number of sessions conducted and the level of staff
attendance can be a valuable part of the department’s continuous quality improvement program. Such records may be examined by surveyors from the Joint Commission on the
Accreditation of Healthcare Organizations (JCAHO) and by state regulatory agents. The
human resource department should also keep records of in-service training for the organization
(Exhibit 8.2).
Performance Evaluation Systems
The level of success attained by a business organization is directly related to the level of performance attained by its employees. Therefore, managers must be thoroughly familiar with the
job-related activities and abilities of each employee they supervise. A system for regular and fair
evaluation of individual employee performance is instrumental to the success of the department
and the organization in a number of ways. A performance evaluation system is a formal
method of providing feedback to the employees’ performance over a specific period of time. It
tracks progress in the development of job skills while identifying and correcting substandard
performance. It further serves as a basis for recognizing and rewarding employee achievements
through promotions, salary increases, and other incentives. In providing a means of giving verbal
Human Resource Management
Exhibit 8.1. Sample of an Employee’s In-Service Record
In-Service Record
Food and Nutrition Service
In-Service Record [year]
Name ________________________________
Social Security [Employee] No. _______________
In-Services Title (required)
Date attended
Risk Management
Patients’ Rights
Disaster Planning
Fire Safety
Infection Control and Sanitation
Hazard analysis, “right to know”
Safety and Equipment Handling
Improving Organization Performance
Note: Each employee has a separate record.
and written feedback on individual employee performance, an evaluation system benefits the
overall functioning of the department and the organization and promotes employees’ wellbeing, job satisfaction, and sense of ownership in their work. It also identifies needs for
improvement and growth and gives employees an opportunity to set personal work goals.
Finally, equitable and well-prepared evaluations given constantly can improve working relations and communications among employees and between employees and their supervisors. All
of these pluses ultimately boost morale and productivity while minimizing costly employee
absenteeism and turnover.
In most medium-sized and large organizations, the performance evaluation system is
administered by the human resource department. However, the food service director or manager still has direct responsibility for rating employees according to objective performance standards. These standards usually are developed by the director, who follows procedures,
established by the human resource department. Generally, the performance evaluation process
includes two components: a written evaluation and a verbal review. Regular increases in
employee salaries or wages are based in large part on their performance evaluations.
(Compensation and benefits will be discussed later in this chapter.) In addition to determining
salary increases, performance reviews can identify areas where training and coaching can
improve performance.
Food Service Manual for Health Care Institutions
Exhibit 8.2. In-Service Record for Human Resource Management
DATE:_____________ TIME: From __________To __________ PLACE OF TRAINING: _________
GROUP TO BE TRAINED: ____________________________________________________________
TOPIC: ____________________________________________________________________________
DISCUSSION LEADER:_______________________________________________________________
PURPOSE: _________________________________________________________________________
OBJECTIVES: At the end of this training period, the participant should be able to: _____________
EVALUATION CRITERIA: _____________________________________________________________
1. Overhead projector____ 2. video _____ 3. Slides ____ 4. Tape ___
5. Poster _____ 6. Food models _____ 7. Chalkboard _____
8. Self-paced video _____ 9. Computer games _____ 10. Other: ______.
HANDOUTS: Yes _____ No _____ Attached _____________________________________________
FOLLOW-UP EVALUATION: Participant comments_______________________________________
Evaluation form used
Yes _____ No _____
Form attached:
Developing and Using the Performance Evaluation Form
Fair performance standards must be developed before a fair performance evaluation can be
made. Performance standards are based on the responsibilities outlined in the job description.
Each performance standard should reflect a required work-related behavior and should be
clearly stated in written form. The standard should cite specific task-related activities that can
be measured or observed.
General factors that should be evaluated by written performance standards include the following:
Quality of work performed
Quantity of work performed
Employee’s working relationships with coworkers and superiors
Employee’s attendance record
Employee’s work habits
Employee’s personal grooming and hygiene
Employee’s initiative
Human Resource Management
An employee’s attitudes also affect overall performance but are difficult to rate. How an
employee behaves toward other employees and how well he or she accepts supervision provide
observable attitude indicators that can be rated.
The rating scale for each performance standard should follow the system developed by the
human resource department. In most systems, the rating scale is based on descriptive terms that
correspond to the points on a scale. Figure 8.3 lists examples of performance standards and
shows a commonly used rating scale.
Several errors often occur during the evaluation process. One is the halo effect, the tendency on the part of certain supervisors to let very good or very poor performance in one task
affect the evaluation of other unrelated tasks. Some supervisors also make the mistake of consistently giving too-lenient or too-severe ratings. Others tend to make the overall evaluation
task easier for themselves by giving everyone in similar jobs average ratings instead of ratings
based on individual performance. Another common problem is the recency error. Here, the
supervisor mistakenly judges a whole review period’s performance on the basis of the
employee’s most recent behavior. Because most employees are rated only once or twice a year,
much of the employee’s work performance could be misevaluated if only recent performance is
To avoid such problems, use of a rating scale based on descriptive gradations (such as those
given in Figure 8.3) is helpful. Scales based on general terms such as outstanding, superior,
average, and poor should be avoided because they make it too easy to give average ratings to
every employee’s performance on every standard. In addition, supervisors can avoid the natural tendency to be influenced by recency error if they make evaluation an ongoing part of everyday department management. Ongoing review is the basis for performance coaching, which is
covered later in this section. Notes on individual work performance and coaching sessions
could be made regularly—monthly, for example—and then used as the basis for a performance
evaluation at the end of the review period.
Figure 8.3. Excerpt from a Performance Evaluation Form for a Food Service Employee
Job Title: ___________________________________________________
Circle the number on the rating scale that most accurately describes this employee’s performance.
Performance Standard
Always Always Sometimes Rarely Never
Accurately measures and/or weighs ingredients
according to instructions in recipes or on boxes.
Requisitions food, stores food items for next day,
checks and properly stores issues.
Pulls recipes, computer sheets, and menus for
next day’s work before going off duty.
Keeps work area clean and in sanitary condition.
Cooperates with fellow employees and willingly
assists where and when needed.
Reports to work on time and in uniform.
Food Service Manual for Health Care Institutions
The human resource department’s policy on scheduling regular performance evaluations
should be followed. Many organizations have a system of annual review and performance
appraisal, whereas others may follow a schedule of quarterly or semiannual reviews. Informal
ratings of new employees are sometimes made monthly during the training or probationary
periods of their employment.
Conducting Verbal Performance Reviews
The second component in the individual evaluation process is the review conference held
between the employee and his or her direct supervisor. Individual conferences should be scheduled well in advance so that supervisor and employees have enough time to prepare questions
and comments. The reviewer should also schedule enough time for a thorough and unrushed
private discussion of each employee’s past and future performance. The supervisor needs to
prepare for the meeting using a checklist to appraise the work of the employee. Check
employee records for attendance at in-service training sessions, corrective action notes, absentee rate, and any commendations.
Conferences should be conducted in private using a positive and cooperative manner. Be
sincere and flexible. Once areas of good performance have been covered, the supervisor and
employee will need to set realistic goals. Finally, employee and supervisor can reach agreement
as to what steps are needed to improve specific areas of performance, along with a timetable
for reaching the desired outcomes. Following up on the mutually agreed-on steps is part of
coaching for positive outcomes (discussed in the next section).
It is important that the reviewer remain open-minded throughout the evaluation process
by respecting and noting the employee’s opinions. The employee also should be given opportunity to include written responses to the evaluation, to be included with the documents filed
in the human resource department. It is the supervisor’s responsibility to appraise performance,
not personality. Do not show favoritism.
Once the conference is over, both employee and supervisor should sign the evaluation
form. In some organizations, the next level of management also may be required to review
and approve completed evaluation forms. A copy of the form should be made for the supervisor’s files and for the employee. The original form, with all the necessary signatures, should
be placed in the employee’s permanent personnel file, which usually is kept in the human
resource department. In many organizations, a representative of the human resource department may check that the evaluation form has been completed according to accepted personnel policies.
The JCAHO continues to strengthen its human resource standards by addressing competence.
The commission defines “competence as a determination of a person’s capability to perform up
to defined expectations.” In an article, Ruby P. Puckett defined competence as “improving performance within the organization by employees qualified to perform tasks as outlined in job
descriptions/performance outcome descriptions and performance appraisal process through
measurable, demonstrated abilities.” The American Dietetic Association states that “competence is the demonstrated ability to perform in one’s current practice and specific setting.”
The managers or leaders are responsible to ensure that the competence of all staff members is assessed, maintained, demonstrated, and improved continually. Competence begins with
the development of competence-based job descriptions and performance standards and proceeds to the employment process (hiring the right person for the job); then to orientation; training, development, and continuing education; performance appraisals; and thus to retention.
Human Resource Management
A number of methods can be used to check competence, including
Training records
Peer reviews
Patient surveys
Formal assessment
Quality improvement and problem-solving issues
Self-assessment using objective criteria
Assessment against measurable performance standards
Evaluation on agreed-on objectives for performance
Counseling records
Pretesting and posttesting for in-service training
Level of participation in mandated in-service sessions and committee or team activities
(The JCAHO Resources has published a book entitled Assessing Hospital Competence that can
be used as a guide toward compliance with one of the major human resource standards.)
Coaching for Peak Performance
In addition to the regular written and verbal employee reviews, managers should make informal, day-to-day observations of employee performance, accomplishments, or problems. Unlike
performance reviews, which are retrospective and infrequent, coaching requires concurrent
ongoing performance monitoring and feedback for improvement. Regular feedback, or coaching, is basic to effective employee management and can prevent minor work-related problems
from becoming major performance problems.
A positive approach to performance improvement, coaching provides individualized direction, information, and support on a daily basis. As a “performance coach,” the manager is
committed to the employee’s development and to helping the employee reach full potential. A
participative management style fosters a constructive environment in which coaching can be
used to improve individual, team, and department performance. An effective manager provides
both opportunity for employees to become involved and the necessary learning through performance coaching. Effective coaching helps people trust their instincts and take responsibility
for the organization’s success.
The first step in performance coaching is to diagnose performance deficiencies and their
causes. Performance gaps exist when employees are not meeting goals, standards, or expectations agreed on with their manager. To identify performance deficiencies, employees must be
observed over time. A number of causes may contribute to less-than-satisfactory performance.
Some of these are
Poor orientation and in-service training
Lack of ability or knowledge to accomplish assigned tasks
Lack of interest in doing the job
Absence of opportunity to grow and advance that creates feelings of helplessness in the
Lack of clearly defined departmental goals
Employee uncertainty about what is expected of him or her
Absence of feedback on how well the employee is performing
No rewards for high performance
Food Service Manual for Health Care Institutions
• No negative consequences for poor performance
• Lack of resources to do the job
• Limitations or misunderstandings created by cultural differences
In diagnosing a problem, the first question the manager must ask is whether the employee
knows what is expected and has the requisite skills to do the job. If not, the manager as coach
must arrange for employee training as outlined earlier in this chapter.
Lack of information or skills is the most common reason for poor performance or goal
accomplishment. Causes ascribed to other reasons will make the coaching session even more
complex. When coaching, the manager must remain focused on measurable behaviors that can
be identified and shared with the employee. Measurable performance behaviors are behaviors
that can be assessed in comparison to established standards for performance. For example, the
supervisor could make a statement like the following in a coaching session: “The standard for
preparing and delivering late trays is 15 minutes. However, when you work this station, more
than 50 percent of the trays are delivered to patients after 30 minutes. The delay causes a backlog of trays and results in poor customer satisfaction.” Coaching can be divided into three segments: creating the game plan, conducting the coaching session, and following up to ensure
success and provide positive feedback.
Create a Game Plan
Coaching takes time because of the preparation involved and the commitment to involve the
employee in making performance-related decisions. The following steps will help create a game
plan for discussing performance problems with employees:
1. Identify the behavior or habit that is nonproductive or contrary to policy, quality, or
customer service.
2. Decide how the behavior affects the manager, work unit, fellow employees, or customers.
3. Determine why the behavior has this effect on those mentioned.
4. Determine how the behavior should change and the benefits those changes will bring
These steps will help the manager stay focused on the behavior in question and keep judgments about the employee from concealing the issue. The game plan must be flexible and capable of being changed as the employee’s perceptions and needs change. Flexibility also is
necessary for determining what actions should be taken to correct undesirable behavior.
Conduct the Coaching Session
Coaching sessions require the use of effective communication skills on the manager’s part. The
coaching action plan shown in Exhibit 8.3 may be helpful in providing written documentation
of the coaching session. Typically, a coaching session has six steps:
1. Describe performance in terms of specific behaviors. Inform the employee of observations of what he or she did or said inappropriately. Describe how the inappropriate
behavior affects the manager, the organization, the department, the team, and the
employee. Pause to allow feedback from the employee.
2. Obtain agreement from the employee on the information presented in step 1. An
employee who disagrees with or cannot understand the implications of the offending
behavior is less likely to move toward changing it.
3. Discuss solutions that can be implemented to resolve the performance problem.
Solutions should be mutually agreed on and should involve the employee in the decision-making process to arrive at a resolution.
Human Resource Management
Exhibit 8.3. Example of a Coaching Action Plan
Coaching Action Plan
Job Title:
Current behavior:
Expected behavior:
Action Step
Completion Date
4. Agree on an action plan to be implemented for correcting the situation. Summarize the
information shared in the coaching session to ensure that both parties understand the
behavior that led to the problem and the agreement on how improvement will occur.
5. Establish a time line for the action plan. Having a time frame in which to assess the
employee’s progress helps keep the action plan and both parties’ efforts focused.
6. Acknowledge the employee’s achievement in correcting the behavior and, in turn, his
or her performance. The manager should document this improvement for the next performance evaluation.
When describing employee performance, it is important to remain objective and to give
examples of actual behaviors. Avoid the following approaches:
• Labeling employee behavior (for example, “unprofessional” or “childish”).
• Using absolutes or exaggerations for behavior that was observed only once or twice
(for example, “You always do that”). These comments increase the potential for employee
• Judging the employee as “good,” “better,” or “worse”; such value judgments imply that
the manager is always right and inhibits open discussion of the problem.
• Using someone else’s words or implying that the problem is due to another person’s
observations (for example, “Jim says you often return from lunch late”).
Coaching is a positive approach the manager can use continuously to provide information
about expectations, observed performance, and skill development and to provide praise and
improve self-esteem. Managers and supervisors should have regular meetings with individual
employees who report to them. The length of these meetings will depend on the nature of the
problem, the complexity of the work, and the responsibility charged to the employee. Coaching
should not be confused with discipline, which may be necessary if efforts to improve performance are not successful. (Disciplinary policies and procedures will be covered later in this chapter.) Training and coaching employees to achieve peak performance allows the manager to
delegate work effectively.
Food Service Manual for Health Care Institutions
Follow-up Coaching Efforts
Consistent follow-up with employees demonstrates the manager’s support and commitment to
improving their performance and helping them to be successful in their jobs. This step is frequently overlooked by managers, but without follow-up, it is difficult to sustain improvement and
assist with future growth. The amount of follow-up should be based on the individual skill levels
and needs of the employees. For example, an employee who has difficulty greeting and assisting
customers in the cafeteria may need to frequently discuss his or her comfort level with public contact and get suggestions for how to answer customers’ questions as well as receive praise for success
from the manager. A star performer who is being asked to create a quality control checklist for
the first time may need follow-up to ensure that the assignment has been completed successfully.
Personnel Records
Every organization is required to keep certain kinds of records on each employee. Official personnel records are usually maintained by the human resource department. Individual departments may keep records on their own employees as well. Generally speaking, department
personnel records are less formal than the human resource files. Department records may contain managers’ notations on an employee’s work performance, coaching action plans, attendance records, copies of vacation requests, notes on scheduling availability, and so forth. The
official personnel files should contain the following information for each employee:
• Complete name, home address, telephone number, Social Security number, and name of
the nearest relative or person to contact in case of an emergency
• Job title or classification and rate of pay (hourly, weekly, or monthly)
• Reports of initial and periodic physical examinations
• Promotion records (start date, changes in job classification, pay increases)
• All records from the hiring process (application form, interview notes, records of education, references)
• Records on initial training
• Records of attendance (including vacation days, holidays, and sick days)
• Records of regular and overtime hours worked (for hourly employees only)
• Safety records (accident reports, workers’ compensation claims)
• Information on benefits (health insurance, life insurance, pension plan, savings plans,
and so forth)
• Records of performance evaluations (written evaluation forms signed by employee and
supervisor, special awards and notes of commendation, and written comments on performance made outside the formal evaluation process)
• Records of disciplinary actions, grievances, or complaints
• Termination date and acceptability for reemployment, when appropriate
Keeping records of all disciplinary actions and dismissal procedures is absolutely necessary.
Complete documentation of work-related problems will be needed if a former employee takes
legal action against the organization for any reason. Because of the confidential nature of personnel records, they should be stored in a place that is inaccessible to unauthorized employees.
All managers should have a locked drawer or filing cabinet for personnel files kept in the
Personnel Policies and Procedures
Most human resource departments in health care organizations develop and administer general
policies on how employment issues are to be handled. In turn, formal, written personnel procedures based on general policies are adopted. Step-by-step procedures are valuable tools for
Human Resource Management
managers’ use in administering policies consistently and fairly throughout the organization.
Policies and procedures that are understood by all employees and followed by all managers
protect everyone from potentially unfair treatment. In addition, they help protect the organization from lawsuits, union and employee grievances, and accusations of illegal discrimination.
Comprehensive organizational policies should cover at least the following basic employment-related topics:
Mission, vision, and values of organization
Organizational chart
Hours of operation, work hours
Pay periods, overtime pay
Physical examinations, other health policies, accident and injury reporting
Performance evaluation
Promotions and job postings
Vacations, holidays, and holiday pay
Confidentially of information
Training and educational opportunities
Personal leaves (maternity, bereavement, family, medical, nonmedical, and military)
Availability of nonpatient food service, hours of operation
Name tags
Visitors during work hours
Employee grievances
Disciplinary and corrective actions, termination
Tardiness and absenteeism
Sexual harassment
Emergency preparedness and safety rules
The organization’s personnel policies usually are written and distributed in an employee
handbook, which is given routinely to all new employees and updated regularly. When a personnel policy changes significantly, the change is publicized through memorandums, posters,
and other appropriate means. New policies often emerge from topics covered during in-service
training sessions.
Every manager is responsible for applying the organization’s personnel policies uniformly
and consistently to all employees. Personnel policies on employee discipline, promotions, dismissals, and so on must be followed closely to avoid liability risk to the organization as a result
of failure to follow its own policies. For example, an organization whose policy on termination
stated that an employee would be given a written warning and placed on probation before
being dismissed could be sued by an employee who was terminated without warning, even if
the termination was justifiable. In addition to legal problems, consistent failure to follow its
policies and procedures can expose a facility to charges of favoritism, discrimination, or both.
Employee morale problems might be created as well.
Developing a Food Service Department Employee Handbook
An employee handbook that clearly sets down policies and procedures to be followed in the
food service department is a useful training and management tool. This handbook could be
used as the basis for training new employees and as a handy reference for experienced food
service workers. The handbook, which should be reviewed annually by the department director and updated as necessary, can include at least the following information:
Food Service Manual for Health Care Institutions
Welcome letter from director
Mission, values of department
Organizational charts
Patients’ rights
Personal appearance, dress code requirements
Proper hand-washing procedures and use of gloves
Universal precautions, infection control standards
Personal conduct (smoking policy)
Guest relations with patients and staff
Personnel policies of food and nutrition service
Competence evaluations and standards
Work schedules
Payroll check distribution
Food safety and sanitation
Food and nutrition fire safety and emergency preparedness procedures, right-to-know
information on hazardous substances used in the workplace
In-service training programs
Relationships between food service departments and other departments
Employee accident report
Incident reports
Termination procedure
Table of contents
Employees receive this handbook during departmental orientation. Materials in the handbook are reviewed by the supervisor. The handbook provides written reference to the policies
and procedures of the department. An employee signs that he or she has received the book and
that its contents have been reviewed with the employee by the supervisor. The signed form
becomes a part of the employee’s personnel file.
Maintaining Positive Approach to Corrective Action
Most employees accept policies and procedures as a necessary condition of working, and they
expect the rules to be enforced fairly and evenhandedly. Employee morale suffers when certain
employees are permitted to violate policies and procedures, which promotes favoritism. More
important, employee safety may be at risk if policies and procedures are violated. For example,
violation of safety procedures can cause equipment damage and endanger workers, for which
the organization might be held accountable. This is especially the case in the food service
department, where fire safety and safe food-handling procedures are doubly crucial. For these
reasons, prompt and fair disciplinary action is a necessary element of managing employees.
Corrective action is taken in an effort to modify employee behavior. Corrective action can
be positive in order to strengthen employee behavior or improve performance. It does not need
to be negative or punitive except in rare cases.
When corrective action must be taken, the appropriate manager should do so immediately.
However, the facility’s formal written disciplinary procedures must be followed assiduously to
ensure that the employees involved are treated fairly and lawfully. Most important, situations
requiring disciplinary action should be regarded as teaching opportunities rather than as
excuses to impose punishment.
As a form of discipline, corrective rather than punitive action is more appropriate for the
work setting. With a corrective approach, acceptable behavior is encouraged based on known
standards, policies, and procedures whereas unacceptable behavior is discouraged on the basis of
its being inefficient, unfair, or potentially dangerous—or all three. Often employees respond reasonably to what should be the first—and, it is hoped, the last—step in disciplinary action: a verbal reprimand. Actual penalties such as fines, suspensions, and dismissals should be rare events.
Human Resource Management
Increasing Severity of Offense or Related Offenses
Figure 8.4. Progressive Corrective Action
• Informal discussion of the problem (Low-level problems are
initially handled in this way. Example: Forgetting to follow
standard procedures.)
• Oral reprimand (A more serious or repeated problem.
Example: Gambling on the job may draw an oral reprimand
as a first step.)
• Written reprimand or warning (This is a very serious step to
take. Example: Repeated use of profane or abusive
language to others may result in a written reprimand.)
• Disciplinary suspension (An alternative to transfer or
demotion, this is the last step before discharge. Example:
• Dismissal (Obviously the most serious step, and usually the
last step after others have been tried. In some cases, this
may be the first level of disciplinary action. Example: willful
falsification of records.)
Although violations of procedure should be dealt with immediately, they should not be
addressed hastily or in anger. Before taking action, the manager should thoroughly investigate
the situation and determine whether the employee understood that he or she was violating a
policy. If it becomes necessary to reprimand the employee, the manager should do so in private
and with diplomacy. The disciplinary action should fit the seriousness of the offense, with the
manager having considered fully the circumstance, implication, and effect of the infraction
beforehand. An extreme example would be the difference between an employee observed serving himself or herself a meal from the patient tray line versus an employee discovered loading
a box of steaks into a car. The employee who consumed food without paying for it would likely
receive a verbal reprimand with an explanation of how his or her actions constitute theft. The
employee who stole the steaks, on the other hand, would likely be dismissed.
The primary purpose of a corrective action is to prevent the violation from recurring. For
repeated violations, most employers use a system of progressive discipline under which the
penalty becomes more severe with each repeated violation (Figure 8.4).
The first step in disciplinary action should be a verbal reprimand. A second violation
would incur a written reprimand to be placed in the employee’s permanent personnel record
for a predetermined time. With a third offense, a written warning delineating the potential consequences of future violations would be issued to the offending employee. If the problem is not
resolved, the manager might issue another written warning to the effect that a subsequent violation will result in dismissal or demotion (the reassignment of an employee to a job with less
responsibility and a lower pay scale). Although demotion is sometimes used as a disciplinary
action, it has severe drawbacks. For one thing, the demoted employee could become a demoralizing element within the workforce. Also, he or she might do damage to supplies or equipment
or otherwise sabotage operations. Employee transfers to other work groups as a disciplinary
action usually have the same effects.
Food Service Manual for Health Care Institutions
With few exceptions, dismissal is appropriate only for the most serious or habitual
offenses. For example, some personnel policies require the immediate suspension and possible
dismissal of any employee who uses or sells illegal drugs anywhere on the work premises.
Whenever dismissal is the only solution to an ongoing personnel problem, such as repeated
complaints from other employees or patients, the supervisor must follow the organization’s
procedures exactly to avoid potential liability consequences for the organization. Employee
offenses must be thoroughly documented in writing, as must each step in the progressive chain
of disciplinary action (Exhibit 8.4). This evidence must be recorded in the employee’s permanent personnel record. The human resource department should be consulted before actual dismissal to make sure that all necessary documentation has been prepared.
No matter how severe or how minor the department’s disciplinary problems, two principles must be borne in mind: consistency of enforcement and objectivity of approach. Every time
a violation occurs, disciplinary action must be taken. Without relentless enforcement of policy
and procedure in the workplace, employee morale and security can disintegrate, with employees eventually losing respect for their managers. Consistency, however, does not mean rigidity.
Each case must be addressed individually and complete information gathered before action is
Exhibit 8.4. Corrective Action Record
Corrective Action Record
First offense__________________________________________________________________________
Second offense_______________________________________________________________________
Third offense_________________________________________________________________________
Name of employee____________________________________________________________________
Date of action________________________________________________________________________
Reason for action_____________________________________________________________________
Corrective instruction given____________________________________________________________
Date review will be made to determine effectiveness of instructions
Your signature on this
form does not indicate
you agree with the
Signature of Employee
Signature of Supervisor
Signature of Department Head
Human Resource Management
As for objectivity of approach, disciplinary decisions must be fact based, not gossip or
rumor based. That is, an employee must be given opportunity to present his or her side. As
mentioned earlier, it cannot be assumed that an employee knowingly violated a policy or procedure. In remaining objective, a manager must exercise unbiased discretion in listening to the
employee’s side. As shown in the discussion on communication, objectivity is best maintained
by separating the message from the messenger; that is, by suppressing personal bias in efforts
to resolve a disciplinary problem.
Following Grievance Procedures
Employees have the right to register complaints and to have them considered with fairness and
objectivity. A grievance is a formal complaint about a practice that is regarded as unfair and violates the union contract. A written procedure for conducting grievance hearings should be established whether or not employees are union members. However, under collective-bargaining
agreements between employers and unions, grievance procedures are always made part of the
labor contract. Usually, the union steward, who has been elected by the union members and represents all unionized staff in specific departments, is responsible for helping union members prepare and present grievances to management. Both the union president and union steward have
regular jobs, are paid by the employer, and use some time from the job—in addition to personal
time—for required union activities. A sound and fair grievance procedure permits union and
nonunion employees alike to express their complaints without fear of reprisal or job loss.
Steps in a grievance procedure may vary among organizations, but most follow a pattern.
Again, it is vital that managers follow to the letter procedures dictated by organizational policy. In a nonunionized hospital, the procedure typically begins when an employee brings a complaint or employment-related problem to his or her immediate supervisor. The supervisor is
usually able to settle the problem at this stage by either granting or denying the grievance. A
written record of the decision and of any action taken should be kept in the employee’s personnel record (Exhibit 8.5).
When the problem cannot be resolved by the supervisor and employee’s joint efforts and
the supervisor denies the grievance, the employee can take it to the next level of management.
In most cases, the employee’s supervisor will have informed his or her own supervisor of the
situation so that the grievance will come as no surprise to the next higher authority, usually a
department director. If dissatisfied by the decision on this level, the employee may take the
grievance higher up, eventually to the topmost authority—in most hospitals, the CEO.
Meanwhile, the human resource director may have been consulted at any point for advice on
solving the problem. In a nonunion setting, the CEO’s decision is final.
In a unionized hospital, a grievance procedure follows similar steps except that a union
steward or other union representative would assist the employee through all stages. A union
business agent would participate in arriving at a final agreement on the solution if the problem
was brought to top-level management. A matter that cannot be settled by the CEO and the
union agent may be submitted for arbitration (discussed later in this chapter). Conciliation, the
act of bringing in a person from outside the organization to reconcile opposing parties, is an
alternative to arbitration. The conciliator’s role is to help the parties find a common ground for
agreeing on a solution to the problem.
The grievance procedure is reviewed at regular intervals by the human resource department to make certain that it is progressing in a satisfactory manner. However, it should be the
goal of every manager to handle as many employee grievances as possible within the department. To deal successfully with employee complaints, managers must listen carefully to the
facts and deal calmly with the emotions involved. Anger and snap judgments must be avoided,
despite pressure to make a decision immediately. The manager should communicate the reasoning behind his or her decision whether to take action on the employee’s grievance.
Responding to complaints fairly and quickly encourages employees to speak openly about
department problems. Productivity and morale may be improved greatly as a result.
Food Service Manual for Health Care Institutions
Exhibit 8.5. Record of Employee Counseling
Record of Employee Counseling
To be filled out in duplicate
Date: _____________
Permanent record of verbal conference with employee (name)
Nature of conference (specify, in detail, event(s) leading to conference)
(Attach additional sheet if more space is needed)
Employee’s Signature
Supervisor’s Signature
Director’s Signature
Copy Number 1 will be retained by employee. Copy Number 2 will be sent to the Personnel Clerk to become part of the
employee’s permanent record.
The final authority for hiring and firing is usually the responsibility of the department head.
However, it is necessary to instruct others on how to carry out this function. Probably a supervisor’s most unpleasant job is having to dismiss an employee. The following are suggestions to
help supervisors handle the situation:
1. Prepare your case.
Plan your action. Never stand in the middle of the kitchen and yell “You’re fired!”
Be sure the right thing is being done.
Do not act too hastily; gather all the facts. Do not overlook any detail, no matter
how small.
Follow the health care organization’s policies.
Human Resource Management
Make sure all obligations have been fulfilled. Was this employee properly oriented?
Were the policies explained?
Make a decision and stick to it.
2. After the case has been carefully prepared, schedule an interview.
Ask the employee if he or she wants union representation.
Have a witness available throughout the discharge action.
Keep the interview short. Do not keep the employee in suspense.
Do not use clichés of regret: ”This hurts me as much as it does you.”
Use facts to explain why the employee is being dismissed. Do not attack the
employee’s personality.
Do not give advice. This is not the time, and it will not be appreciated.
Be considerate. Do not try to destroy the employee.
Be positive.
3. Employees should be given the opportunity to appeal, or grieve, any action taken
against them.
Give the employee a copy of the dismissal letter.
Explain the reason for the action to the employee.
Explain the loss of benefits to the employee. Be polite, and answer any questions
with honesty.
Explain about the last paycheck.
If appropriate, inform the employee about the appeal or grievance procedure.
Conducting Exit Interviews
Employees leave jobs voluntarily for any number of reasons: to take new jobs for better pay or
career advancement, to retire, or to relocate to other parts of the country, for example.
Inevitably, some employees are dismissed because of poor job performance, chronic absenteeism, or other serious problems. In today’s changing business climate, employee cutbacks and
layoffs have also become common.
Many human resource departments routinely conduct exit interviews with employees
shortly before they leave the organization. During an exit interview, the outgoing employee is
advised of his or her right to continued medical and life insurance coverage or to receive vacation or severance pay. This is also an opportunity to discuss why the employee is leaving the
organization, the quality of supervision and training received, the adequacy of advancement
opportunities, benefits and incentives, and other related topics.
The information disclosed during exit interviews can be valuable to department managers,
including human resource managers (Exhibit 8.6). For example, managers may learn where
problems lie in their training programs and management skills. Or light may be shed on shortcomings in the compensation and benefits structure or in working conditions.
Reducing Employee Turnover
It is wise to try to retain valuable employees and to reduce the cost of the employment cycle.
Employees like to have interesting work; be involved in decision making, feedback, and training; and receive respect for abilities and differences. They want to work in an environment that
is relatively stress free, to be empowered, and to be part of the department organization.
However, some employees still leave jobs for a number of reasons.
Whenever an employee leaves a job—either voluntarily or involuntarily—it costs the
organization money, time, goodwill, and other resources. The more skilled the employee, the
higher the replacement cost. The rate at which employees leave their jobs—called employee
turnover—can be determined by using a simple formula. The rate of turnover equals the total
Food Service Manual for Health Care Institutions
Exhibit 8.6. Resignation Form
Resignation Form
Instructions: Please fill out this form if you are planning to resign. Present it to the Food and
Nutrition Services Personnel Clerk. The clerk will arrange an Exit Interview for you with Personnel,
Room H-9, Ground Floor. Comments in the remarks section on your term of employment will
assist us in evaluating our services. Thank you.
To Whom It May Concern:
I wish to tender my resignation from the Department of Food and Nutrition Services, XYZ Hospital.
Effective date:
Reason for leaving (please be specific):____________________________________________________
Forwarding address (if not known, give family’s address):_____________________________________
How would you rate this department? Circle your choices. E = Excellent, G = Good, F = Fair P = Poor
Job security
Chance for promotion
Working conditions
On-the-job training
Were the supervisors interested in you
as a person?
Not at all
Were you shown appreciation for work done?
Not at all
Was discipline handled in a fair manner?
Not at all
Were you kept informed about changes
in the department?
Not at all
Would you recommend this department
as a good place in which to work?
Not at all
Human Resource Management
number of separations per year divided by the average number of employees on the payroll and
multiplied by 100. Or:
Turnover rate (%) =
Number of separations per year × 100
Average number of payroll employees
For obvious economic reasons, it is to the organization’s advantage to keep the turnover
rate as low as possible. Furthermore, because high turnover endangers employee morale and
reduces productivity, managers should try to identify the causes of high turnover and, when
possible, take action to improve the conditions that have led to the unacceptable levels. It is difficult to define which levels of turnover are acceptable and which are not: Turnover rates are
affected by the geographical location of the organization as well as by the availability of other
employment opportunities in the area. For example, an annual turnover rate of about 10 percent might be acceptable in a large urban area on the West Coast but would be considered
unusually high in a rural community in the South.
High rates of turnover frequently are caused by errors in the employment process, specifically, hiring the wrong person for the job. Managers can help correct this situation by taking
more time to analyze the employee qualities for specific jobs before screening, interviewing, and
selecting employees. Other reasons for high turnover rates include the following:
Choosing the wrong person for the job
Poor employee orientation procedures
Insufficient training of new employees
Lack of retraining opportunities for current employees
Poor supervision and management of employees
Lack of consistency and objectivity in enforcing policies and procedures, which can lead
to favoritism
Failure to appreciate and recognize employee achievements
Lack of team work
Ongoing unresolved conflicts
Quality-of-life issues
Lack of control by supervisor
Politics of department or organization
Poor recruiting methods
Poor communication between employee and supervisor
Lack of job security
No opportunity for advancement
Sexual harassment
Lack of respect
Personal reasons
Reducing Absenteeism
High levels of employee absenteeism often are tied to the same factors that cause high turnover.
Although employees miss work for any number of personal reasons (such as illness and family
emergencies), unacceptable surges in absenteeism usually signal work-related problems such as
poor working conditions (inefficient systems or outdated equipment), slumping morale (due to
favoritism or lack of incentive, for example), and inadequate supervision (supervisor apathy or
poor interpersonal skills). Thus, a manager who notices excessive absenteeism should first look
Food Service Manual for Health Care Institutions
within the environment for clues and then take steps to improve the situation. An employee
attitude survey or a culture audit (described in Chapter 4) would be a useful tool in this respect.
The rate of absenteeism can be determined by using another simple formula. The rate of
absenteeism equals the number of workdays lost per pay period divided by the average number of employees, multiplied by the number of days worked, and then multiplied by 100. Or:
Absenteeism rate (%) =
Number of workdays lost per pay period
Average number of employees × number of days worked × 100
Unusual levels of absenteeism among employees also may signal potentially serious personal problems that should be investigated. The most frequent reason given for missing work
is illness, but illness may be an excuse to cover up serious chronic problems such as alcoholism,
substance abuse, or debilitating physical or mental conditions. If a manager suspects that an
employee’s attendance and work performance are adversely affected by such problems, he or
she should refer the employee to the organization’s employee assistance program if one is available. An employee assistance program is a formal program that provides employees with counseling or treatment for problems such as alcoholism, gambling, or stress. The employee
assistance program may be an in-house or an out-of-house program provided by the organization’s contract with a vendor to provide assistance. Regardless whether it is in-house or out-ofhouse, the program should provide service to assist the employee. The program needs to
include the following:
• Goals: short- and long-term goals that are expected to be achieved by employees and
• Professional staffing: the organization should be staffed by professional licensed persons
• Written purpose: of program, employee eligibility, role, and responsibility of personnel
• Confidentiality: confidential records are maintained
• Legal requirements: all legal requirements are known and followed
The manager should never attempt to diagnose a suspected problem, openly accuse an
employee, or give advice on sensitive subjects such as alcoholism or chemical dependency. If the
organization has no employee assistance program, the manager should strongly recommend
that the employee seek qualified professional assistance to identify a possible problem.
Compensation and Benefits Administration
The human resource department is responsible for establishing and maintaining an organization’s compensation and benefits program. An equitable and competitive program is essential
to the organization’s ability to attract and retain competent and qualified employees. The compensation system is the mechanism by which the human resource department sets salary and
wage rates for new employees, approves increases for current employees, maintains and
updates wage and salary schedules and job classification schedules, authorizes position
changes, and authorizes the creation of new positions.
The employee benefits component of the compensation program includes a number of traditional “perks” as well as more innovative ones. Traditional benefits commonly include vacation
and holiday pay, health insurance, life insurance, short-term and long-term disability insurance,
and pension plans. More and more organizations are offering dental coverage (including orthodontics), vision coverage, profit sharing, and gain sharing. Limited coverage for holistic or alternative healing methods is not unheard of in some institutions.
Managers outside the human resource department play a role in compensation administration when they recommend salary or wage adjustments for individual employees, when they
recommend changes in the pay scale for positions under their management, and when they recommend salaries or wages for new or newly promoted employees.
Human Resource Management
Role of the Human Resource Department in Compensation
Compensation programs of all but the smallest health care organizations are directly administered by the human resource department. Typically, human resource managers develop and
maintain programs through a series of ongoing activities, including the following:
• Formulating and regularly updating a job description for every position
• Evaluating each position and ranking it according to standard factors such as educational level required, degree of job responsibility, level of skill needed, number of employees
supervised, amount of experience required, and so forth
• Assigning each position to a wage grade on the basis of the position’s rank in comparison to all other positions in the institution
• Establishing a pay scale for each wage grade
• Conducting regular (usually annual) wage surveys of comparable employers in the same
geographical area
• Using the results of wage surveys to adjust pay scales so that the organization remains
competitive in its labor market
• Reviewing and approving the salary and wage adjustments recommended by managers
on the basis of individual employee performance reviews
• Reviewing and approving the salary and wage adjustments recommended by managers
for employees who have been promoted or assigned to newly created positions
• Reviewing and approving salaries or wages recommended by managers for new employees
• Taking part in negotiations to determine compensation agreements for unionized
Role of the Food Service Director in Compensation Administration
The food service director must work within the compensation program set up by the organization’s human resource department. Although position pay scales within the department are
determined by human resources or by a compensation committee, the food service director may
suggest changes in pay scales when the responsibilities of individual positions are increased or
decreased or when the director becomes aware that salaries or wages are no longer competitive.
The food service director determines the salaries or wages of individual food service workers, within the limits of the compensation system. Most positions are compensated by a range
of pay. For example, the position of food service assistant might be assigned to job grade C,
which has a pay scale that ranges from $6.10 per hour to $6.80 per hour. When a new food
service assistant is hired, the director decides whether to pay the new employee at the bottom
of the range, the middle, or the top. The new employee’s starting wage is based on his or her
level of experience or training. Therefore, a new employee with three years’ experience as a
food service assistant would be considered well qualified and be offered a salary at least at the
middle of the range for that position.
Performance evaluations have a direct influence on the pay increases awarded employees.
Generally, the process of performance evaluation culminates in the reviewer’s recommendation
for a pay increase based on the employee’s work performance. Here again, the food service
director works within the limits of the overall compensation system. In many organizations, the
human resource department determines a range of pay increases for current employees. This
range is based on the organization’s current level of profits (for-profit health care facilities) or
current level of assets (not-for-profit facilities) and current economic conditions.
Most employers of nonunionized workers use a system of merit increases for rewarding
employee performance as determined during the performance evaluation process. Merit increases
are intended to reward some employees more than others on the basis of their overall productivity and quality of work. For example, employees who were rated by their supervisors as
Food Service Manual for Health Care Institutions
“outstanding” in all aspects of their work might receive a higher raise (merit increase) than
employees who were rated as “acceptable.”
The merit increase system is based on the idea that employees will work harder if they
know they will be rewarded monetarily for their increased effort. However, as shown in
Chapter 2, many other factors play a role in worker motivation, and merit pay increases may
or may not result in increased productivity. Effectiveness of the merit increase system is also
affected by the fact that because of current economic conditions, health care providers have
been forced to limit their compensation spending. As a result, the difference between consistently outstanding performance and acceptable performance might mean a differential of only
one or two percentage points in merit increases. For the merit increase system to surely boost
employee productivity, pay differences based on performance differences must be more than
marginal. Unfortunately, many health care organizations no doubt will be unable to meet this
demand in the foreseeable future.
Other methods of compensation include cost-of-living increases. These increases are based
on the inflation rates and are used to keep employees’ purchasing power intact despite the economic changes over time. When this type of compensation is used, it applies to all employees.
This is a permanent increase to the base pay. Pay for performance is an incentive pay program
that may be used in combination with other compensation plans. Incentive plans involve accomplishing predetermined goals. This type of compensation is a one-time pay and is not added to
the base pay. Annual bonus is a type of payment that is given one time a year for outstanding
performance. The bonus paid to groups of employees may be the same, whereas managementlevel personnel receive a larger bonus. This is a one-time payment and does not change the base
pay. Cash award is a one-time pay for performance for outstanding and significant contributions. It does not change the base pay. Improved skills is a compensation that is added to the
base pay when employees increase their skills through education or acquiring additional skills.
Benefits Administration
As shown, monetary compensation is one element of the compensation package. Benefits are
the other. A competitive benefits program is key to attracting and retaining qualified employees, but it has little effect on employee performance because the benefits offered are tied to
employee status. In other words, all full-time employees are covered by the same benefits, but
certain benefits (such as the amount of life insurance coverage) may be linked to salary level.
Large employers may offer a full range of benefits whereas the benefits offered by small
employers usually are more modest. Several kinds of benefits may make up a compensation
package. One is pay for time not actually worked—vacations, sick leaves, paid holidays, and
unemployment compensation. Insurance benefits, extremely important to most employees,
include medical coverage for the employee and (sometimes) the employee’s spouse and dependents, life insurance, disability insurance, dental insurance, and (sometimes) vision insurance.
Retirement benefits may include a private pension plan administered by the employer. Social
Security is also considered a retirement benefit because employers make contributions to the
fund on behalf of their employees. (Employees are required to make contributions as well.)
Another kind of benefit is employee services such as employee credit unions and tuition reimbursement programs.
Benefits provision is costly for U.S. employers, estimated by authorities to equal more than
one-third of the average employee’s annual salary. Employee benefits have become a major
expense during the past fifteen years or so because of rising health insurance premiums,
increased Social Security payments, and changes in the way pension plans are administered.
Because of the economic pressures in the health care industry, human resource departments
are continually reviewing and revising benefits plans in terms of their cost, relevance, and
value. As a result, food service directors are often called on to explain benefit changes to food
service workers.
Human Resource Management
Labor Relations
In 1974, health care employees became a class of workers covered by the federal laws that govern collective bargaining between unions and management in the private sector. Collective bargaining is the activity engaged in when representatives of an employee’s organization,
association, or union and representatives of the employer’s management negotiate wages,
hours, and other conditions of employment. Before 1974, the collective-bargaining activities of
health care workers were covered by state law. However, when health care came under federal
jurisdiction by authority of the Health Care Amendments to the National Labor Relations Act
(the Taft–Hartley Act) in 1974, union organization activities in hospitals increased significantly. Today, it is not uncommon for hospitals to have one or more bargaining units or even
for the entire workforce, except for supervisors and administrators, to be unionized.
The human resource department is responsible for interpreting and applying the provisions of a labor contract between the health care organization and the union. Problems with
enforcing the contract or with the work of individual employees covered by the contract are
handled according to a strict grievance procedure dictated by the terms of the contract. When
grievances involving union employees cannot be settled within the organization, a special form
of negotiation is required as set forth in the union contract. Binding arbitration is the process
by which an impartial outside party is called in to settle a labor dispute. The arbitrator is an
expert in labor law hired by the organization and the union to analyze the labor contract, listen to both sides of the issue, and make a decision on the validity of the grievance. The arbitrator’s decision is binding in that both the organization and the union must abide by it. The
system of binding arbitration prevents any kind of strike during the period covered by the labor
Human resource management deals with the organization’s most important resource—its
workers. Many aspects of human resource management are covered by federal, state, and local
laws and regulations that are intended to protect the rights of employees and employers.
Human resource management involves the same management functions (organizing, planning, controlling, leading) and skills (technical, administrative, interpersonal, and the like) discussed in earlier chapters. The work of the organization’s employees is organized through the
use of job descriptions, which in turn are used as the basis for formulating the compensation
program. Employee activities are planned, and the plans are carried out by qualified employees recruited and hired to do the work. Training also depends on planning for the human
resource needs of specific activities within the organization. Employee performance and productivity are controlled through systematic performance evaluations. Leadership and communication skills are required in every aspect of recruiting, screening, interviewing, and hiring new
employees. These skills are also required in handling personnel problems and in making valid
employee evaluations based on performance merit. Productivity, leadership, and employee
motivation are also required for effective human resource management.
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Attard Communications, Inc. Women still earn less than men. 1999. [http://www.careerknowhow.
com/ceiling99.htm]. Accessed Feb. 28, 2004.
Your rights under the Family and Medical Leave Act of 1993. Federal Register 58(106):31837–31839,
Chapter 9
Clinical Nutrition Care
In 1983, significant changes in nutrition care management began to occur when Medicare reimbursement to hospitals changed from a cost-based to a service-based structure. Under the new
prospective payment system, payment rates to Medicare providers for most inpatient services
are established in advance, with providers paid on the basis of these prospective rates regardless of the actual costs of service provision. Medicare has approved reimbursement to registered
dietitians for specific diseases. Unfortunately, the rate of reimbursement is low. In 2003 a new
Medicare bill was passed and signed into law by President George W. Bush. It provides two
major expansions of the medical nutrition therapy benefits. First, Medicare will pay for an initial physical examination designed to determine the physical condition of new beneficiaries as
they become eligible for Medicare. This bill provides for screening and other preventive services, including medical nutrition therapy services provided by a registered dietitian. This provision becomes effective January 1, 2005.
The second expansion of medical nutrition therapy is within the context of disease management for chronic diseases. The bill defines chronic diseases as “congestive heart failure, diabetes, chronic obstruction pulmonary disease, or other diseases or conditions as selected by the
Secretary of Health and Human Services.” This provision goes into effect January 1, 2006.
Because of ongoing concerns of reimbursement by Medicare, it will not be discussed in this
chapter. Some private insurance companies reimburse for nutrition care provided by a registered dietitian.
Along with the prospective payment system came an era of increased competition among
health care providers. In the late 1990s, the prospective payment system was changed, especially
for long-term care. Because of many new regulations, they will not be included in this chapter.
To survive in this new reimbursement environment, hospitals must scrutinize closely every
department’s level of clinical productivity and competence, including that of the nutrition and
food service department. In addition to careful planning, monitoring, and evaluation of departmental productivity and competence, the department’s quality assessment and control programs
and its marketing efforts must be seen as essential components of the organization’s success.
Environmental trends in health care affect the nutrition care manager’s role and responsibilities, just as they affect those of other food service functions. With the continuing escalation
of health care costs and demands for shorter lengths of stay, assessing and improving patients’
nutritional status becomes even more crucial. Early nutrition intervention has been identified
Food Service Manual for Health Care Institutions
as a preferred preventive measure for high-risk populations such as women, children, and the
elderly. For the elderly, in particular—a population already shown to be growing—improvement in quality of life and minimization of the ongoing need for health care is a decided priority. It is within this context of assessment and intervention that the role of nutrition
specialists takes on added significance.
Shorter lengths of stay also will increase the number of individuals served by alternative
health care delivery systems such as nutrition management. Despite this projection, dietitians
have yet to be “legitimized” by the federal government and other third-party payers as a necessary adjunct to the home health team. It is through the support of dietitians that the nutritional needs of home health care patients can be assessed and a plan developed to eliminate or
minimize patient readmissions. Dietitians play a major role in long-term care facilities in both
the nutrition care of residents and the smooth operation of facilities’ kitchens.
Another environmental trend discussed earlier in the book, one that affects nutrition specialists, is the average consumer’s heightened awareness of the nutrition–health ratio. Although
selecting healthier foods over nutritionally inferior ones has not yet become routine, today’s
health care consumers are asking more questions and requesting more products to meet their
nutritional needs.
This chapter examines the dual role of the nutrition manager in health care operations:
service manager and service provider. The first part of the chapter discusses the management
of nutrition services with an emphasis on requirements unique to the planning, organizing,
leading, and controlling functions of management. The second segment presents information
relevant to providing nutrition services to various customer types. These services include
screening for nutritional risks, assessing nutritional status, developing a nutrition care plan
(critical care paths, patient education, discharge planning), and documenting nutrition care.
Managing Nutrition Care Services
The nutrition care manager is responsible for managing human and other resources to accomplish the objective of delivering high-quality and cost-effective nutrition care to patients. The
nutrition manager’s roles encompass the following activities and skills:
• Ensuring compliance with the Joint Commission on Accreditation of Healthcare
Organizations (JCAHO) and other regulatory bodies
• Maintaining open lines of effective oral and written communication
• Providing leadership as a liaison with medical, nursing, and allied health professionals
as a member of the interdisciplinary team
• Developing standards of care
• Developing patient educational material
• Developing long-range plans and implementing objectives
• Developing departmental policies and procedures
• Applying clinical nutrition training, knowledge, and expertise
• Overseeing staff development, evaluation, job descriptions, and counseling
• Keeping abreast of departmental productivity, budget, and other control measures
• Assisting in marketing of the organization’s nutrition services
• Monitoring department operations such as patient tray system, food spoilage and inventory, vendor relations, menu planning, and so forth
• Maintaining competency by participating in professional activities, continuing education, literature review, and so forth
• Serving as a change agent for improving performance to meet measurable outcome goals
Some responsibilities within each of the four management functions—planning, organizing, leading, and controlling—require a unique application of skills. These responsibilities are
reviewed here in detail.
Clinical Nutrition Care Management
As already shown, a manager must develop departmental goals and objectives that are consistent with those of the larger organization. Planning affords an assessment of future needs of the
organization’s patient mix and a determination of changes needed in staffing and services.
Nutrition care planning assesses the current patient care process and the need for changes
based on the evolving standards of practice for the community. Adapting to change includes
modifying policies and procedures and standards of nutrition care.
Planning efforts include investigating and developing new business opportunities to
enhance the distribution of nutrition information and to increase the department’s revenue
flow. Responding to changes in the patient mix may necessitate dietitians’ relocating to an outpatient setting, implementing educational classes for the elderly, or meeting the community’s
need for better nutrition education by conducting grocery store tours. (Review Chapter 5 for
details of the planning function related to writing policies and procedures and developing business plans for new business opportunities.)
Policies and Procedures
Policies and procedures and standards of care must be maintained to provide effective nutrition services to customers. Policies and procedures should cover at least the following areas:
Diet orders, liberalized orders, and use of seasoning packets
Nutritional status
Nutrition screening, including priority ratings, patients’ preference form
Nutrition assessment and reassessment
Anthropometrics measurement
Nutrition care plans, including need for eating devices and feeding program
Documentation protocols
Instruction and counseling for patients, families, and interdisciplinary team
Education (specific for each type of class offered)
Specialized nutritional support (such as enteral and parenteral nutrition)
Enteral formulary
Recording patient data in patient’s medical record
Discharge planning and referrals
Intervention for patients with NPO (nothing by mouth) orders or on a clear-liquid diet
for extended periods
Standards of nutrition care
Nourishment and between-meal supplemental feedings
Education for drug–nutrient interactions
Requirements and protocol for student rotations
Approved clinical nutrition manual
Outpatient education
Nutritional analysis of patient resident menus
Community education programs
Performing calorie counts
Role in the interdisciplinary team adhering to regulatory agencies’ standards
New-admission dietary handout
Hydration program, including fluid-restricted diets
Weight loss protocol
Pressure sore
Dysphagia protocol (may coordinate with speech pathologist and occupational therapist)
Tray identification system
Menu system
Kardex or patient identity system
Food Service Manual for Health Care Institutions
Charting—who may, where
Serving alcoholic beverages
Food from the outside
Develop a drug and nutrient procedure in conjunction with nursing and pharmacy
JCAHO’s and other surveys’ standards for nutrition
Nutrition team
Nutrition committee
Measurement for competency of staff
Productivity measurement
Policies and procedures should be updated as needed (at least annually). Usually, the policies and procedures related to nutrition care will require medical staff approval, as will the
dietary manual used by the facility. The approved dietary manual must be made available on
all patient units as a reference for physicians and nursing and other medical personnel. The
clinical nutrition care manual may be hard copy or electronically based.
Policies and procedures that describe responsibilities for interdisciplinary roles should be
approved by the affected department. For example, because the policy related to drug–nutrient
interactions involves both the pharmacy and nursing services, these departments should be
involved in the development and approval process for this policy. In addition, each department
will need to provide copies of the policies to its staff.
Marketing and Program Development
Today’s hospitals face the challenge of maintaining the quality of care provided to patients while
simultaneously striving to deliver cost-effective, patient-centered care. Prospective pricing has
been adopted by other third-party payers, such as state-administered Medicaid programs and
private insurers. Overall, prospective pricing rewards hospitals that reduce their costs.
Patient-focused health care organizations conduct market research to identify customer
preferences. As a result of these efforts to identify consumer wants and needs, many institutions
have added the following departments: public relations, planning and development, and marketing. Health care providers continue to identify new markets for the services they offer and
to propose new services for larger or redefined consumer groups. For example, many hospitals
have initiated programs specifically designed to meet women’s health care needs as well as fitness programs.
To accommodate the needs of a unique marketing niche, dietitians and food service directors can offer personal expertise as well as actual nutrition and food services. Planning, then,
as a key to program development and marketing, can help boost wellness or health promotion
as one area that lends itself to nutrition program development and marketing. Nutrition services are an integral part of these programs, which generally involve screening, education, and
specific interventions if the screening identifies a need. Many chronic diseases have been attributed to controllable lifestyle patterns or habits.
New areas that a nutrition care manager may need to include in planning are skilled-nursing and rehabilitation units within the hospital, especially beneficial to the patient and the institutions with Medicare reimbursement guidelines. The patient is able to stay in the same facility
and continue to receive care from the same individuals. At the same time, the facility can maximize reimbursement for the patient’s length of stay because patients who meet the criteria for
long-term or rehabilitation care are granted a longer length of stay and higher reimbursement
levels under Medicare.
Other areas in the nutrition and food service department could be developed into new programs and services to be offered inside and outside the hospital. Examples include
• Inpatient gourmet meal service
• On-site bakeries for patients, visitors, and staff
Clinical Nutrition Care Management
Room service for inpatients and visitors
Storefront nutrition assessment facilities
Outpatient weight reduction and fitness programs
Nutrition education publications and programs
Changes in health care will continue, not only in the ways in which care is provided, but
also in the ways services are marketed to consumers. Patient-centered, cost-effective care will
remain a driving force. Thus, services must be designed around the opinions and perceptions
of patients, medical staff, and the public.
Nutrition and food service departments must determine strategies to promote patient satisfaction and enhance the reputation of the facility and the department. Improving hospitality
services, providing patients what they want to eat when they want to eat it, and offering good
basic nutrition information should promote a facility’s favorable public image. On discharge,
patients tell their families and friends about the quality of food and service they received while
hospitalized. In some cases, these word-of-mouth reports influence the choices of potential
All nutrition and food service employees are responsible for providing and promoting
appropriate quality of care for patients. This can be accomplished best when all employees
work toward a common mission and goal. The nutrition manager is responsible for marketing
nutrition services to patients, physicians, other health care providers, and administrators of
their facilities. (Refer to Chapter 3 for ways in which the nutrition manager can incorporate
marketing into the department’s planning functions.)
Organizing and Staffing
Organization and staffing functions include creating the structure needed to provide nutrition
services and recruiting, retaining, and developing the staff necessary to implement these services. Staffing of the nutrition management unit of the food service department mandates hiring
clinically competent people who can be trained to provide high-quality patient care.
Depending on the size and organizational structure of the institution, the nutrition staff
may include all of the staff members shown in Figure 9.1 or only registered dietitians and nutrition assistants. For example, in a small health care institution, patient nutrition services might
be managed by a registered dietitian, with nutrition assistants and aides processing diet changes
or serving meal trays.
In a major organization such as the one illustrated in Figure 9.1, several levels of employees might fulfill specific duties in the nutrition care of patients. The nutrition team might
include registered dietitians, dietetic technicians, nutrition managers, nutrition hosts and hostesses, and nutrition assistants and aides. (In many institutions, nutrition assistants and aides are
called clerks. Their functions are basically the same, even though the job titles are different.)
Each team member has specific responsibilities in patient care, but responsibilities merge to
serve all of the patients’ needs, as delineated in Table 9.1.
Role Responsibilities
The nutrition care manager monitors day-to-day nutrition care activities and usually supervises
other dietitians, dietetic technicians, and dietary managers, as well as patient nutrition hosts or
hostesses, associates, and assistants. In large organizations, the nutrition care manager usually
is a registered dietitian. In smaller or extended care facilities, this person may be a dietetic technician with management skills or a certified dietary manager (C.D.M.). Many facilities are
adopting a flatter organizational structure, requiring the nutrition manager to assume additional management responsibilities. This is especially the case in medium-sized facilities where
the manager may be responsible for patient service and nutrition management (Figure 9.2).
Food Service Manual for Health Care Institutions
Figure 9.1. Clinical Nutrition Staff for a Major Medical Center
Director of Clinical Management
Inpatient care
Oupatient care
Nutrition assistants
and aides
Table 9.1. Nutrition Management Team
Registered dietitian registered dietetic
technician, or certified dietary manager
Plans, organizes, staffs, directs
day-to-day nutrition care, supervises,
and provides leadership
Registered dietitian or state licensed
if applicable
Team leader, nutrition care plans,
assessments, counseling, education,
Registered dietetic technician or
nonregistered equivalent with a
degree in nutrition
Patient screening, counseling,
menu editing, education
High school diploma or equivalent
aides, or clerks
Process patient menus, diet order
changes, nourishment orders, late
tray requests
Nutrition host
or hostess
Serves trays and nourishments,
assists with menu selection,
stocks units
High school diploma or equivalent
aQualifications will vary depending on size of facility.
Clinical Nutrition Care Management
Figure 9.2. Organizational Chart—for a Medium-Sized Facility
Patient feeding
Hosts or hostesses
The registered dietitian (R.D.) functions as the team leader and is responsible for developing nutrition care plans, performing nutrition assessments, counseling patients, formulating
educational materials, and performing research. Dietitians often function either as a nutrition
specialist or as an administrative or management specialist. Whether the dietitian selects nutrition or management as an area of focus, he or she may be employed in hospitals, extended care
facilities, fitness centers, outpatient clinics, weight management clinics, home health care, food
and nutrition product or equipment sales, or with food service management companies. A dietitian who selects health care as an area of employment must have management abilities,
whether his or her focus is in the nutrition or administrative area. To provide effective quality
nutrition services, dietitians must network and work with colleagues in the community.
Employment in health care nutrition may be full-time, part-time, or on a consultant basis.
The dietetic technician works with the dietitian to provide nutrition care services to
patients. A registered dietetic technician (D.T.R.) is technically skilled in nutrition care and has
an associate’s degree from a program approved by the American Dietetic Association. In addition, the dietetic technician must pass a registration examination administered by the
Commission on Dietetic Registration. The D.T.R. is often responsible for conducting nutrition
screening, menu editing, planning between-meal feedings, and nutrition counseling. The role
of the D.T.R. varies significantly depending on the size of the organization. In smaller facilities,
the D.T.R. may have supervisory responsibilities in addition to the nutrition care of patients.
The certified dietary manager has completed a course of study and passed a national certifying examination. The type and size of an organization and the state where a C.D.M. is
employed will determine his or her role in nutrition care. He or she may gather data for use by
an R.D. or a D.T.R., conduct interviews with families and patients for nutrition histories, conduct routine nutrition assessments, identify problems and needs, implement diet orders, use
standard nutrition care procedures, chart in the patient’s medical record, and be a member of
the nutrition team.
Patient nutrition associates and assistants process patient menus, diet order changes, nourishment orders, and late tray requests. In some facilities, especially those with decentralized
meal service, these positions may assume the roles outlined for the nutrition host or hostess. In
other facilities, they may assume duties strictly within the department and are referred to as
diet clerks.
Food Service Manual for Health Care Institutions
The nutrition host or hostess serves trays and nourishments to patients and may be
involved in some food preparation. He or she also answers simple questions about the menu
and the services the food service department offers.
Both nutrition assistants and hosts may have completed an approved organization’s onthe-job training program. Most associates and assistants are high school (or equivalent) graduates. These individuals are generally supervised by the nutrition manager in institutions that
employ a large nutrition staff or by the director in institutions with small nutrition staffs.
All members of the nutrition team have an influence on, and a responsibility to, patients.
They need to know and practice good guest-relations skills, which include being friendly and
polite to patients and greeting them by name. Members of the team need to be knowledgeable
enough to answer questions about the hospital, provide guidance as needed, and promote a
positive impression of the facility.
At all times, the team must protect patients’ right to confidentiality. Confidentiality should
be stressed in training programs for team members, and the policy should be reviewed at least
annually. Some organizations are requiring staff to sign confidentiality statements.
The nutrition staff interacts with many other health care providers in the hospital, including physicians, nurses, unit secretaries, pharmacists, therapists, and medical records personnel.
R.D.s (or, in some institutions, skilled and experienced dietetic technicians and C.D.M.s) may
be asked to communicate individual nutrition histories and care plans at patient care conferences, on rounds, during family conferences, and in other situations.
Nutrition care managers also may be involved in outpatient and community services.
Outpatient services continue to grow in importance with decreased lengths of stay and the
increased number of patients seen in outpatient clinics. There are many advantages to instructing patients in an outpatient setting. The dietitian is notified of the need for an instruction in
adequate time to provide the patient or family members (or both) with the details needed for
success. Early discharge may result in a patient’s not being emotionally prepared to accept drastic changes in his or her lifestyle as they relate to food. An R.D. can provide more relaxed and
informative medical nutrition therapy instruction if the patient can be scheduled to return at a
later date.
Patient-Centered Care
In the past several years, special interest has been placed on developing patient-centered care
units to replace traditional nursing units. The principle behind such units is to centralize staff to
the units, thus minimizing the number of caregivers who interact with a patient. This allows the
caregivers to provide a better continuation of care and increases the patient’s comfort level. The
patient and family become familiar with caregivers and can expect to see them on a daily basis.
Patient-centered care units have implications for nutrition care and food service delivery.
Duties typically provided by a dietetic technician, or hostess, may be assumed by unit staff. For
example, a patient care assistant may be responsible for conducting nutrition screening. A support person assigned specifically to the unit may assume the responsibilities of passing trays,
assisting with menu selection, producing and delivering between-meal feedings, and preparing
late trays. The nutrition care manager will have to consider the number of duties to be assumed
by these personnel and adjust staff accordingly. He or she also will have to assist with monitoring the activities of these persons to ensure that the patient receives the appropriate level of care.
Clinical Manager as Leader
Providing leadership to the nutrition staff is a central function in that the nutrition care manager must direct the staff to accomplishing the outcome goals (as discussed in Chapter 2). As
always, interpersonal skills and technical expertise are critical.
A high level of trust in the manager is necessary for managers to create a vision that leads the
nutrition staff to goal accomplishment. Trust in the leader’s knowledge is especially important
Clinical Nutrition Care Management
among professional staff whose members need less direction on a daily basis and may prefer to
work in self-directed teams. However, the need for less direction does not imply that structure
and control mechanisms are not necessary. Providing structure allows the manager to spend
less time on direct supervision and more time on the important function of planning and organizing for the future.
In many health care facilities, the nutrition care manager’s leadership responsibilities also
include serving as a mentor and providing direction for students. Student education programs
may include internships for dietitians or practical experience in conjunction with programs for
dietitians or dietetic technicians. The nutrition care manager and the facility both benefit from
providing direction and leadership to students. While in the facility, these individuals can assist
with the nutrition care of patients and serve as a resource for future recruiting efforts.
In larger institutions, the nutrition care manager may be involved with research within the
facility. This may include supervision of the dietitians involved in coordinating and directing a
specific research project.
As always, providing leadership means communicating effectively, as outlined in Chapter
7. The nutrition care manager plays a significant role in establishing interdepartmental relationships among the medical staff, nursing services, and the pharmacy, for example. Many of
the policies and procedures related to the nutrition care of patients require cooperation and
input from these various departments.
Responsibilities assigned the nutrition care manager (evaluation and control, for example)
ensure that standards, policies, procedures, and budgets are followed as delineated by the leadership function. Control mechanisms provide structure for evaluation and monitoring to assess
In that fiscal responsibilities continue as an overriding concern of food service managers,
the nutrition care manager must create and monitor the department’s budget and establish
standards for monitoring staff productivity. The nutrition care manager can improve the fiscal
situation by creating and marketing new programs that will provide revenue, as discussed in
the planning section. Information on determining needs and monitoring other financial indicators is presented in Chapter 11.
Another controlling function of the nutrition care manager includes quality improvement
and assessment, that is, responsibility for ensuring that the standards of care and policies and
procedures related to patient care are followed as outlined. These standards are reviewed in
Chapter 4.
Measuring Productivity of the Nutrition Staff
Cost containment in nutrition management is focused on the best use of the professional staff,
as assessed here by the productivity of the nutrition staff. Three aspects must be considered in
the productivity review: determination of the time spent to provide services, assessment of
whether the skill level of the dietitian is appropriately used, and establishment of the benefit or
outcome of nutrition intervention.
First, the amount of time spent on each task performed by the R.D., D.T.R., and C.D.M.
should be carefully determined. This is best accomplished by asking the professional to keep
accurate records of the patients he or she sees, the amount of time spent, and the type of activity completed. This can be facilitated by creating a department-specific form with the most
common tasks listed or by using one of the many accepted forms created by the American
Dietetic Association or other professional organizations. This type of record allows the manager
to assess the time spent on various tasks as a portion of the whole, as illustrated in Figure 9.3.
Food Service Manual for Health Care Institutions
Figure 9.3. Proportion of Registered Dietitian’s Time Spent on Various Tasks
Management Activities
of Others
Patient Care
Patient Care
The second consideration in establishing cost-effective nutrition services is to ensure that
the job responsibility is matched to the appropriate skill level of individuals on the team. For
example, the dietitian should perform more complex nutrition intervention activities while
dietetic technicians are available to conduct assessments and diet instructions. The dietitian and
dietetic technician need not be used to perform the initial screening of patients for an existing
or potential nutritional risk. This task is easily performed by a C.D.M. using a designated
screening protocol.
The third aspect the nutrition care manager should consider when assessing the costefficiency of staff utilization is determining the benefits associated with the nutrition intervention offered. Quality assessment must be done to determine whether patient outcome is
improved by providing the service. Cost-benefit analysis is a method commonly used to assess
whether the benefit of a particular product or program is greater than the cost of providing it.
Although this technique works effectively for services with a direct charge attached, it is less
effective in evaluating nutrition-related programs.
Nutrition intervention should provide a positive outcome for the patient and improve the
quality of life. Many nutrition intervention programs are being designed to prevent long-term
illnesses and to keep individuals from using the health care system unnecessarily. To measure
the benefit of these types of programs, a cost-effective analysis is needed. Conducting a costeffective analysis also identifies the cost of the service or program in monetary terms. The benefits, such as decreased length of stay or improved quality of life, are identified as outcomes for
the patient and the organization.
Clinical Nutrition Care Management
Designing a Nutrition Services Payment System
Services that could be provided for a fee by the nutrition and food service department include
computerized nutrient analysis, computerized menu planning, inpatient and outpatient nutrition counseling, weight reduction counseling, diet and exercise programs, and other specialized
nutrition programs. However, before these services are developed for distribution, a market
analysis must be completed to determine whether the customer or other reimbursement agencies are willing to pay for them. Before the nutrition manager can initiate a charge directly for
nutrition services, he or she will need to determine how dietitians spend their time and the dollar value of their services. The costs involved in providing the services and the price to be
charged for them can then be determined realistically. All costs involved in providing the service must be included in determining the total cost per unit of service. Because a portion of all
bills will be uncollectible even though the service has been provided, a provision for bad debts
must be included in the overall cost. An example of such a cost calculation is illustrated in
Table 9.2. Other authors have used other methods (see Jackson, Laramee, and Puckett [1997],
and Hospital Food and Nutrition Focus [1996] in the bibliography).
Table 9.2. Cost Calculation for the Services of a Registered Dietitian
Hours or Dollars
Total number of work hours per year, hra
Less: vacation time (10 days)
holidays (8 days)
sick leave (8 days)
education leave (8 days)
nonproductive timeb
Actual number of work hours available per year, hr
Approximate number of units of service per yearc
Average yearly salary, $
Plus fringe benefitsd
Total yearly compensation, $
Salary per hour ($52,800 ÷ 1,496), $
Labor cost per unit of service (2.5 hours × $35.30), $
Yearly indirect costs, $e
Indirect cost per unit of service ($18,000 + 600), $
Labor cost per unit of service, $
Indirect cost per unit of service, $
Profit (12 percent of labor and indirect costs), $
Total cost per unit of service, $
aThe number of work hours per year is based on a 40-hour workweek.
bNonproductive time accounts for about 15 percent of the total work hours and includes coffee breaks, time spent waiting,
and so forth.
cThe standard amount of time allowed per patient referral, on unit of service (as determined by work analysis; includes evaluating the order, securing counseling materials, and performing counseling, charting, and the like), is 2.5 hours. 1,496 hours ÷
2.5 = 598, or, for the sake of computation, 600 units of service per year.
dFringe benefits are assumed to equal 32 percent of the average salary and include insurance benefits, Social Security payments
made by the employer, and so forth.
eIndirect costs include expenses for telephone service, postage, copying service, general overhead, allowances for uncollectible payments, and administrative expenses.
Source: Based on J. C. Rose. Hospital Food and Nutrition Focus 2(3), Nov. 1985, revised in 2003 by R. P. Puckett, pp. 2–4.
Food Service Manual for Health Care Institutions
Maximizing Reimbursement for Services
Payment systems for nutrition services must be created with a clear vision of health care reform
and the future direction of reimbursement. Currently, reimbursement systems work in one of
two ways. With the fee-for-service model, the payer controls the price for the service and determines which services are necessary for the covered individual. The second model is used by
Medicare’s prospective payment systems and health maintenance organizations. These managed care organizations provide capitated payments for the care of the covered individual and
have determined a number of services to be included.
The existing methods used to determine fees for nutrition services are based on the fee-forservice model. Increasingly, however, fee for service is being replaced by managed care. Because
of this trend and the known positive effect of nutrition care on patient outcome, identifying
nutrition intervention as a quality-of-care issue is appropriate.
Using cost-effectiveness analysis, the nutrition manager must prove that nutrition intervention, rather than being an add-on cost, can replace more costly interventions and provide a
positive outcome for the patient. With the cost of health care continuing to rise, it is not likely
that managed care providers will indiscriminately pay for nutrition services. The positive benefits must be well documented. However, on the opposite end of the spectrum, if adequate
nutrition is not occurring, the provider in question will have difficulties with regulatory issues.
The American Dietetic Association continues to support efforts to establish the appropriate
role of nutrition intervention in the treatment and prevention of disease as it relates to health
care reform.
Providing Nutrition Services
The goal of a nutrition team is to fulfill the nutritional needs of a patient or client. The nutrition services offered in health care institutions generally include screening for nutrition risk,
assessment of nutrition status, development of a nutrition care plan, reassessment, discharge
planning, nutrition counseling, and evaluation of the adequacy of and adherence to each
patient’s diet order. Nutrition services are the responsibility of R.D.s, D.T.R.s, C.D.M.s, and
other nutrition care workers within the department. Malnutrition in hospitals continues to
receive attention from the community, physicians, and other medical professionals. In their role
as nutrition experts, clinical dietitians play an important part in solving malnutrition and other
nutrition-related problems and in providing cost-effective nutrition services. Related activities
• Working in partnership with the nutrition support team to provide total parenteral
nutrition or enteral feedings to patients who are at high nutrition risk (such as patients
with burns and protein- or calorie-deficient patients)
• Identifying malnutrition, which is considered a secondary diagnosis or a co-morbidity
or co-mortality factor
• Identifying patients who frequently return to the hospital because of disease complications
• Investigating the average length of stay for the patients in the ten most frequently admitted diagnosis-related groups and determining whether nutritional intervention might be
beneficial in decreasing average length of stay
• Implementing ICD [International Classification of Diseases] codes as they pertain to
• Seeking reimbursement for services
Clinical Nutrition Care Management
Nutrition service professionals can contribute to department visibility in a number of
ways; for example:
• Being the nutrition experts
• Implementing programs to encourage public acceptance of the need for nutrition services
• Providing educational programs in the community and for the hospital staff
• Integrating health and fitness with wholesome food and education in community outreach programs
• Providing quality services to the aging population through home care
• Seeking physician referrals for nutrition analysis and counseling
• Using computerized information systems to perform nutrition analyses for patients,
thereby enhancing the quality of nutrition services
• Developing contractual agreements for providing services to extended care facilities,
halfway houses, day care centers, correctional institutions, and other organizations outside the hospital
Some of these service applications are briefly described in the following subsections.
Nutritional Risk Screening
The first step in establishing nutritional needs is to develop and administer a screening protocol
for all patients or residents entering the facility. Screening protocols should outline the variables
to be evaluated for diagnosing any existing or potential nutritional risk. A first-level screening
may simply be a review by age, diagnosis, and type of diet (criteria will vary from one facility to
another). Some general screening guidelines are included in Figure 9.4 and Figure 9.5.
A more in-depth screening would include patient’s height, weight, recent unintentional
weight loss, percentage of usual body weight, percentage of ideal body weight, and albumin level
(Figure 9.6). During the second-level screening, usually conducted by the dietetic technician, questions on intake, digestion, or elimination problems may be asked. If the patient is on a special
diet, the D.T.R. should ensure that the patient has been instructed on the diet. General guidelines
for a secondary screening are outlined in Figure 9.5. Composite nutrition screening information
may be recorded and kept in the nutrition department for reference during the patient’s stay.
Nutritional Status Assessment
In most health care facilities, physicians work with a dietitian, a dietetic technician, a nurse, a
pharmacist, or a dietary manager to provide nutrition care for their patients. However, basic
nutrition services are provided as standard protocol and do not require a physician’s order (for
example, screening patients for nutritional risk, providing assessment, and implementing
between-meal feedings).
Nutrition assessment should not be performed only when there is an obvious problem.
Patients or residents determined to be at nutritional risk through screening should be assessed
by the R.D. or D.T.R. The purpose of the assessment is to evaluate the patient’s current nutritional status.
The procedure for nutrition assessment varies depending on the availability of staff and the
needs of the patient or resident. The evaluation may be relatively simple for a patient in apparent overall good health. A more thorough assessment should be carried out for patients who
have chronic debilitating medical problems, acute illnesses, or injuries that increase their nutritional needs or hinder their food intake.
Food Service Manual for Health Care Institutions
Figure 9.4. Initial Screening and Data Collection for Medical Nutrition Therapy
Date of admission________________ Physician _____________________________________________
Room No.______________ Patient initialsa ________________________________________________
Diet order_____________________ Diagnosis ______________________________________________
Cultural or religious preferences __________________________________________________________
M______ F______ Child_______ Amputee _______ Ht_________ Wt__________ Usual wt_________
Gain____________ Loss___________ in last 3 months________________________________________
C.D.M. or D.T.R. visits patient or family
Observe or ask about:
Social habits: Smokes cigarettes__________ Cigars__________Pipe__________ Dips snuff_________
Chews tobacco________ Drinks alcoholic beverages: Wine_______ Beer________ Whiskey_______
Mixed drinks_______ How much___________________ How often____________________________
Drinks carbonated beverages______ How often_________________ How much__________________
Drinks caffeinated beverages_____________ Colas_____________ Coffee____________ Tea________
How much____________ How often______________ Herbal teas_______ How often_____________
How much____________________ Eats away from home_______ How often____________________
Eats fast foods_______ How often_______________ What kind________________________________
Lives alone_______ Lives with family_______ Who does food shopping and food preparation?
Self________ Family member___________ Other____________________________________________
Exercises______ Regularly________ Not at all________ Type of exercise________________________
Dental problems: Dentures (full plate)_______________ Uppers_____________ Lowers___________
Will not wear_____________ Own teeth___________ Good condition__________________________
Vision: Glasses______ Blind________ Impaired__________ No problems_______________________
Ambulation: Wheelchair______ Crutches_______ Walker______ Cane______ Paralysis____________
Communication problems: Hearing aid__________ Signs or writes to express needs______________
Language other than English____________________________ Hard of hearing___________________
Uses hearing aid _______________________________________________________________________
Eating ability: Feeds self_______________ Needs assistance___________________________________
Needs adaptive equipment_______ What type_____________________ Chewing problems________
Dysphagia______ Dehydrated_______ Fluid needs_____________________ Needs I/O record______
TPN/EN_________Type____________________________________ Bolus__________ Pump_________
Nausea or vomiting________ Constipation________ Diarrhea_________ Pain constant____________
After eating_________________ Medication relieves_________________________________________
Clinical Nutrition Care Management
Figure 9.4. (continued)
Food history:
Anorexia_____________ Bulimia______________ Obese_____________ Underweight____________
Modified diet_________ What restrictions__________________________________________________
Allergies ______________________________________________________________________________
Needs ethnic foods for religious or cultural reasons______ Types of foods restricted______________
Portion sizes: Small__________ Medium____________ Large____________ Extra large____________
Appetite: Good___________ Fair___________ Poor___________ Not hungry_____________________
Menu options: Three regular meals___________ Between-meal nourishments___________________
Drink preference: Breakfast_________________ Lunch________________ Dinner________________
Likes and dislikes: _____________________________________________________________________
Needs food diary_________ Calorie count for 3 days_____________ Check tray for portions of food
eaten1/4_____________ 1/3____________ 1/2 ___________ 3/4____________ all_________________
C.D.M. or D.T.R. to secure the following data from patient’s medical record:
Laboratory values: Serum albumin level below 3.5 g/dL _____________________________________
Serum cholesterol level below 160 mg/dL__________________________________________________
above 240 mg/dL__________________________________________________
Glucose____________ Total protein_______________ Sodium____________ Potassium____________
Hemoglobin__________________ Hematocrit____________________ BUN_____________________
List medications (include over-the-counter and herbal supplements):
Name of person filling out form
Professional initials:
Date _________________________________________________________________________________
aUse patient’s initials only (per the Health Insurance Portability and Accountability Act).
Note: Initial screening to be completed by R.N., C.D.M., or D.T.R. within 24 hours of admission. R.N. may do
basic screening on admission and provide information to the nutrition department. C.D.M. or D.T.R. to collect
data or screen within 48 hours. If no other screening or assessment needed, C.D.M. or D.T.R. and consultant
R.D. will develop a care plan. If additional screening or assessment is needed, an R.D. consultation for medical
nutrition should be made. Form is to be filled out in duplicate, one copy for the medical record and the other
for the nutrition department. Abbreviations: I/O, intake and output; TPN/EN, total parenteral or enteral nutrition;
BUN, blood urea nitrogen.
Source: Developed by Ruby P. Puckett, 2003. Used by permission.
Food Service Manual for Health Care Institutions
Figure 9.5. R.D. Consultation for Medical Nutrition Therapy Intervention
Areas of concern:
Unintentional weight loss, from 5% to 7.5% of usual body weight, in 3 months
Serum cholesterol below 160 mg/dL or above 240 mg/dL
Patient eats less than 25% of food, dehydrated
Bulimic, anorexic, morbid obesity, malnutrition
Patient on TPN/EN (bolus or continuous feeding)
Serum albumin level <3.0 g/dL (other changes in lab results)
Drug–nutrient interaction (change in medications that interferes with food absorption)
Pressure ulcers, AIDS
Dysphagia, malabsorption, celiac disease, GI bleeding
Cancer (especially of mouth or throat, and currently on chemotherapy)
Organ transplant (kidney, heart, liver, lung, pancreas, bone marrow)
Newly diagnosed diabetes mellitus
Kidney disease, COPD, bowel obstruction, pancreatitis, liver disease
Cardiovascular disease
Burn, sepsis, or prolonged infection
High-risk pregnancy
Inborn errors of metabolism
Cystic fibrosis
Clinical evidence of mental impairment, depression, constant pain
Education and discharge planning
Name of R.D.________________________________________ Professional initials ________________
Reevaluate in 3 days if change in status
Note: This form is to be used by the R.D. when any of the abnormalities noted on this form are discovered during the initial screening and data collection. This form is also to be used in revising care plans, interdisciplinary
care conferences, and communications with physicians and for assistance in discharge planning. Abbreviations
used: AIDS, acquired immunodeficiency syndrome; COPD, chronic obstructive pulmonary disease; GI, gastrointestinal, TPN/EN, total parenteral or enteral nutrition;
Source: Developed by Ruby P. Puckett, 2003. Used by permission.
The features reviewed will depend on the standard of care specific to the diagnosis.
Generally, a nutrition status assessment involves evaluating the adequacy of the patient’s nutrition on the basis of food intake records, assessing relevant physical measurements, and analyzing laboratory test results (Exhibit 9.1). The following information may be obtained from
the patient or a family member:
• Patient’s past and present eating habits
• Patient’s food intolerances, if any
Clinical Nutrition Care Management
• Patient’s lifestyle (including physical, psychological, socioeconomic, psychosocial, and
religious background)
• Any handicapping conditions that might affect the patient’s food intake and mobility
(energy needs)
• Patient’s weight history and current height and weight
Some of this information may be available from the medical record. The information gathered
should be summarized, evaluated, and then recorded in the patient’s medical record.
Nutrition information should be evaluated to identify poor nutrient intake or significant
weight loss or gain. If the patient’s nutrient intake seems inadequate or the relationship
between weight and height is not within normal limits, further assessment should be done. A
comprehensive physical examination should include checking the patient’s eyes, mucous membranes, hair, and skin for obvious signs of malnutrition. Table 9.3 lists malnutrition indicators.
Figure 9.6. Goal of Nutrition Screening: Identify High-Risk Patients Who May Be
Prone to Poor Nutritional Status
Patient admission
Omit short stays
Low-risk services
Nutrition screening
At nutritional risk?
Patient nutrition
Dietetic tech. intervention
At high risk?
Patient nutrition
Outcome assessment
Review of patient census
Intervention follow-up
Intervention follow-up
MD referral
Dietetic tech. intervention
Nutrition consult
Outcome assessment
Patient nutrition
RD intervention
Enteral support technician
Dietetic technician
Patient nutrition representative
Note: Abbreviation: QAI, quality assurance improvement
Food Service Manual for Health Care Institutions
Exhibit 9.1. Food and Nutrition Screening Form
Name__________________________________________________ Room No.________ Age_________
Male___________ Female___________ Child___________ Adult___________ Elderly______________
Diet order_______________________________ Physician_____________________________________
Medical history before admission: (past 1–3 months)
Decubitus ulcer?_____________ Radiation therapy?______________ Chemotherapy?______________
Surgery?____________________ Acute illness longer than 3 days?__________ Height_____________
Weight___________ Loss past 3 months___________ Gain past 3 months_________ UBW________
IBW_____________ Condition of mouth, lips, tongue, gums__________________________________
Pain that interferes with eating? Yes_____ No_____ Where?___________________________________
Are you being treated for pain? Yes_____ No_____
Serum albumin__________________ Transferrin_______________ Nitrogen balance______________
Diarrhea_______________ Constipation____________________ Nausea/vomiting________________
Heartburn_________________ Bloating_____________________ Cramping______________________
Appetite_________ Loss_________ Increased__________ Chewing/swallowing problems___________
What is your fluid intake?________________________ Fiber included in daily diet? Yes____ No____
NPO or limited intake longer than 3 days?_________________ Home TPN/EN?__________________
Diabetic?___________ IDDM_____________ NIDDM___________ Number of calories____________
Any other diet modifications? Yes____ No____ What?________________________________________
Bulimia? Yes____ No____ Anorexia nervosa? Yes____ No____
Other supplements (include all herbs)_____________________________________________________
_____ Patient screened at Level I—no nutritional intervention required at this time.
Provide basic food service (selective menu, etc.)
_____ Patient screened at Level II—requires assistance of nutritional care team; no malnutrition
but may be at low risk.
Provide basic food service, follow-up in 3–5 days. Document in patient’s medical history.
_____ Patient screened, severe malnutrition, referred to the TPN/EN team and R.D. Referenced to
outpatient nutrition clinic, referring physician and/or community agency.
Document outcome in medical history. Forward data to appropriate person/agency.
Screened by:______________________________________Date:_______________Time:____________
Note: Abbreviations: IBW, ideal body weight; IDDM, insulin-dependent diabetes mellitus; NIDDM, noninsulin-dependent diabetes mellitus; NPO, nothing by mouth; TPN/EN, total parenteral or enteral nutrition;
UBW, usual body weight.
Source: © Ruby P. Puckett, used by permission.
Clinical Nutrition Care Management
Table 9.3. Physical Signs Indicative of Malnutrition
Body Area
Normal Appearance
Signs Associated with Malnutrition
Shiny; firm; not easily
Lack of natural shine, dull and dry; thin and
sparse; fine, silky, and straight; color changes (flag
sign); easily plucked
Skin color uniform;
smooth, pink, healthy
appearance; not swollen
Skin color loss (depigmentation); skin dark over
cheeks and under eyes (malar and supraorbital
pigmentation); lumpiness or flakiness of skin of
nose and mouth; swollen face; enlarged parotid
glands; scaling of skin around nostrils (nasolabial
Bright, clear, shiny; no
sores at corners of eyelids;
membranes healthy, pink
and moist; no prominent
blood vessels or mound of
tissue or sclera
Pale eye membranes (pale conjunctivae); redness
of membranes (conjunctival infection); Bitot’s
spots; redness and fissuring of eyelid corners
(angular palpebritis); dryness of eye membranes
(conjunctival xerosis); dull appearance of cornea
(corneal xerosis); soft cornea (keratomalacia); scar
on cornea; ring of fine blood vessels around
cornea (circumcorneal injection)
Smooth, not chapped or
Redness and swelling of mouth or lips (cheilosis),
especially at corners of mouth (angular fissures
and scars)
Deep red in appearance,
not swollen or smooth
Swelling; scarlet and raw tongue; magenta
(purplish color) tongue; smooth tongue; swollen
sores; hyperemic and hypertrophic papillae;
atrophic papillae
No cavities, no pain, bright
Missing or erupting abnormally; gray or black
spots (fluorosis); cavities (caries)
Healthy, red, not
bleeding, not swollen
Spongy and bleed easily; recession of gums
Face not swollen
Thyroid enlargement (front of neck); parotid
enlargement (cheeks become swollen)
No signs of rashes,
swellings, dark or
light spots
Dryness of skin (xerosis); sandpaper feel of skin
(follicular hyperkeratosis); flakiness of skin; skin
swollen and dark; red swollen pigmentation of
exposed areas (pellagrous dermatosis); excessive
lightness or darkness of skin (dyspigmentation);
black and blue marks due to skin bleeding
(petechiae); lack of fat under skin
Firm, pink
Spoon-shaped nails (koilonychia); brittle, ridged
and skeletal
Good muscle tone,
some fat under skin,
ability to walk or run
without pain
Wasted appearance of muscles; baby’s skull
bones thin and soft (craniotabes); round swelling
of front and side of head (frontal and parietal
bossing); swelling of ends of bones (epiphyseal
enlargement); small bumps on both sides of chest
wall (on ribs); beading of ribs; baby’s soft spot on
head not hardened at proper time (persistently
open anterior fontanelle); knock-knees or
bowlegs; bleeding into muscle (musculoskeletal
hemorrhages); inability to get up or walk properly
Normal heart rate and
rhythm, no murmurs or
abnormal rhythms, normal
blood pressure for age
Rapid heart rate (above 100 beats per minute;
tachycardia); enlarged heart; abnormal rhythm;
elevated blood pressure
continued on next page
Food Service Manual for Health Care Institutions
Table 9.3. Physical Signs Indicative of Malnutrition (continued)
Body Area
Normal Appearance
Signs Associated with Malnutrition
No palpable organs or
masses (in children,
however, liver edge may
be palpable)
Liver enlargement; enlargement of spleen
(usually indicates other associated diseases)
Psychological stability,
normal reflexes
Mental irritability and confusion; burning and
tingling of hands and feet (paresthesia); loss of
position and vibratory sense; weakness and tenderness of muscles (may result in inability to
walk); decrease and loss of ankle and knee
Source: Adapted from Christakis.
Laboratory analysis may be necessary to determine serum or blood levels of various nutrients, and the reason for any abnormal values should be identified. Abnormal laboratory values
that correlate with poor intake of a particular nutrient warrant changes in food intake. For
example, if the serum protein or serum albumin level is low and the patient’s dietary intake of
protein is low, increasing protein intake might be advisable, along with adding high-protein
supplements. Nutritional status should be reevaluated at appropriate intervals according to the
patient’s medical condition.
In extended care facilities such as nursing homes, residents’ food intake patterns can be
changed gradually, and low intake can be overlooked. These patients’ food intake should be
noted daily, and their weight should be monitored regularly. Laboratory tests should be done
whenever there is significant change in a patient’s food intake or weight. An assessment should
be completed by a consulting dietitian and a care plan developed for the certified dietary manager or other staff members to follow. These care plans should be updated with each visit from
the dietitian and the dietitian notified should significant changes occur between visits.
Assessments of patients on hospital skilled-nursing units and rehabilitation units generally
are more time-consuming for dietitians. Frequently, these patients have more eating, swallowing, digestion, and elimination difficulties than other patients. Regulations provide specific
guidelines for conducting team conferences and patient–family conferences. Guidelines also
specify the type and frequency of assessments and documentation of care plans expected. The
dietitian attends family conferences with other health care professionals. Generally, team conferences are held once a week, and the dietitian must be present to provide input and to update
the patient’s overall care plan.
Nutrition Care Plan
When a nutrition assessment indicates that a patient is at risk, a nutrition care plan should outline what nutrition care is needed and how it is to be provided. Results of the nutrition assessment and the nutrition care plan should be charted in the patient’s medical record and
communicated to the physician. Although the physician will use the medical record, it may be
necessary to place a sticker on the record to call the physician’s attention to the nutrition note.
The medical record then serves as
A means of communication among all members of the treatment team
A resource to be used in treating the patient’s illness
A means of providing continuing patient care in different health care settings
An important tool in utilization management and quality assessment programs
Clinical Nutrition Care Management
• A constant and valuable source of information for research and educational and statistical studies
• Proof of services provided (to be used for reimbursement documentation)
• A document that can afford legal protection to the health care facility, its employees, and
its patients
The nutrition care plan is based on the standards of care for specific diseases. Standards
for nutritional care are guidelines that outline the acceptable level of intervention or care for a
particular diagnosis. These standards are based on the latest available scientific information
and the best demonstrated practice of nutrition care. Care plans should follow the standards
of care but be individualized to each patient’s needs (Exhibit 9.2 and Exhibit 9.3).
Critical Paths
Critical paths are plans of care developed by an interdisciplinary team that delineate responsibilities of each care provider and time (days) they are to provide specific care from admission
to discharge. Nutrition care plans should be based on critical paths. For example, the care plan
for a patient with cardiac disease would specifically state when nutrition education should
begin. A dietitian developing a care plan should record when the instruction is to occur and
document in the medical record when it is completed.
The use of critical paths allows a patient’s care team to anticipate the patient’s needs and
to be prepared in advance. Critical paths also serve as valuable thresholds to identify when a
patient is not responding to treatment as expected and to provide the team with the information needed to pursue other avenues of treatment. Critical paths provide objective measurements for assessing quality of care because the care to be given for a delineated set of outcomes
is clearly stated, and any exceptions can be detected readily. Although a critical path identifies
standards for patient care, individualized treatment is not ruled out; deviations should be documented, along with the appropriate rationale.
Nutrition Education
Nutrition education should be provided to a patient or family as determined by the organization’s policy. Some organizations may require a physician’s order before nutrition education is
provided, but once the determination is made for nutrition education, the dietitian or dietetic
technician contacts the unit staff to assess the patient’s schedule.
Nutrition education is based on a patient’s lifestyle and current eating habits, as disclosed
by a food history. Food intolerances also must be considered in developing diet patterns for
patients. As stated earlier, because of shorter lengths of stay and the fact that news of patients’
medical condition and prescribed lifestyle changes may require an adjustment period, inpatient
instructions may be less effective. If possible, the patient should be scheduled for an outpatient
return visit for the dietary instruction or clarification.
Nutrition education should be tailored to a patient’s needs, education level, diagnosis, and
lifestyle. For example, a diabetic patient who works a night shift should not be prescribed a
meal pattern that accommodates the lifestyle of a day-shift worker.
Discharge Planning
Discharge planning should begin with the initial screening or assessment. Possible nutrition
needs and risk factors should be evaluated and steps taken to ensure adequate nutrition intervention. The dietitian should complete a discharge summary and send information regarding a
patient’s nutrition needs to the extended care facility. If a patient will need assistance from
home care or a community agency, these services should be arranged for before discharge. Such
services are usually arranged through the organization’s social work department.
Discharge planning may include arranging for the patient to leave the hospital on tube
feeding or on total parenteral nutrition. Written discharge instructions may be necessary for the
patient, family member, or organization to which the patient is being discharged. As mentioned
Food Service Manual for Health Care Institutions
Exhibit 9.2. Counseling, Education, and Discharge Planning
Room no._____________________ Patient’s initialsa_________________________________________
Physician’s name_______________________________________________________________________
Counseling: R.D. provides data on nutrition or medical nutrition therapy_______________________
Consulted with interdisciplinary team________________ Individual counseling__________________
Family member present _________________________________________________________________
Comprehensive plan for education or discharge planning (any of the following that may be a
hindrance to the education process)
Psychosocial_____________ Spiritual___________ Cultural___________ Language barrier_________
Age______ Inability to read or write_____________ Emotional barriers_________________________
Economics of the care choice____________________________________________________________
Training in: Adaptive eating devices__________ Feeding pump_________ Portion control_________
Grocery shopping____________ Food preparation___________
Name of modification __________________________________________________________________
Method used: Formal___________ Informal____________ Group sessions______________________
Tools used in education or discharge planning: (list) Audiovisual materials______________________
Food models __________________________________________________________________________
Other ________________________________________________________________________________
Ability of client or family to understand instructions_________________________________________
Will likely follow instructions: Client_____________________ Family__________________________
Client demonstrated learning took place by (list)____________________________________________
Care plan was realistic and attainable, and goals were developed and agreed on by client or
family___________________________________________________ Everyone can articulate outcome
Return appointment___________________________________________ R.D. telephone no. or e-mail
address _______________________________________________________________________________
Community resources __________________________________________________________________
Home health________________________________ Hospice__________________________________
Referring physician_____________________________________________________________________
Public health (WIC/MIC) ________________________________________________________________
aUse patient’s initials only (per the Health Insurance Portability and Accountability Act). Document information
in patient’s medical record.
Note: Begin the counseling, education, and discharge planning after the screening data collection.
Abbreviations: WIC, Women, Infants, and Children Supplemental Food Program.
Source: Developed by Ruby P. Puckett, 2003. Used by permission.
Clinical Nutrition Care Management
earlier, the patient may need to be scheduled for outpatient dietary instruction or for a followup to an inpatient instruction. Immediately, the dietitian should carefully review the medical
records of patients readmitted to assess whether a lack of nutrition intervention or an inadequate care plan led to the readmission.
Documentation of Nutrition Care
It is up to the individual facility to authorize specific staff members to make entries into medical records. If a full-time registered dietitian is not available on a regular basis, dietetic technicians or dietary managers may be authorized to record pertinent information about nutrition
care plans. Documentation in a patient’s medical record may either be on a separate sheet that
may be colored coded to designate the department, on an interdisciplinary sheet, directly on
the physician’s progress notes, or on any other place designated by the medical records committee and policies and procedures of the organization. All entries must be dated, legibly written, preferably in black ink, words spelled correctly, and signed by the person writing the note
and with his or her credentials. Never erase anything, cross out words, write “error” above the
note or in any way change the message. Record missed appointments and poor or no compliance to outcome goals. To ensure that a procedure has been done, it must be documented.
Accurate documentation of nutrition services provided to patients is vital to hospital systems for utilization management, quality control and assessment, and reimbursement.
Basically, services are documented in the same way, and by the same staff members, as nutrition assessments and care plans. In addition to descriptions of the nutrition assessments, care
plans, and services provided, the medical record should reflect periodic evaluations and revisions of the plan based on the overall effectiveness and objectivity of a patient’s treatment.
The frequency with which nutrition services are recorded depends on a patient’s condition
and the institution’s policies. For example, daily progress notes might be required for a critically ill patient or a patient whose condition is rapidly improving or deteriorating. A hospital
policy might mandate a progress note each time a nutrition care plan is revised or reviewed, in
which case a statement of the new plan or review findings would be included. Documentation
is important for quality management because changes in status, especially incremental
improvements, can be useful in justifying nutrition intervention.
The actual format used for writing progress notes depends on the policies of the individual organization. Whatever the format, information should be as clear and concise as possible
without omitting pertinent details. Usually, either source-oriented or problem-oriented medical
records are used (Exhibit 9.3).
In the source-oriented format, entries are structured according to the source of information, with entries included in order of occurrence. Nutrition care information should be
included in the appropriately designated section of the medical record. In some organizations,
the designated section may be the physician’s progress notes whereas in others a separate section is identified for ancillary departments. Entries are written in brief paragraph form; sentence fragments or key phrases are acceptable. The entry is signed with the name and title of
the person writing it, the month, day, year, and time of day.
The problem-oriented format focuses on the patient’s problems, personal profile, plans for
care and education, assessment of progress, and results. An initial database consisting of the
patient’s medical and social history is gathered in which problems are listed and assigned a number. The initial treatment of these problems is recorded, and progress notes are added as they pertain to specific problems in the problem list. An approach referred to as “SOAP” is used for each
progress note, SOAP being the acronym for the elements of information in each progress note:
• Subjective information: what the patient or family says
• Objective information: what the facts relate about the patient’s progress, such as laboratory values, results of diagnostic tests, changes in weight, observations and examinations by health professionals, and nutrient intake calculated from diet history
Food Service Manual for Health Care Institutions
Exhibit 9.3. Nutrition Care Documentation
Nutrition Order:_______________________________________________________________________
Completed by: R.D.________ D.T._________ Patient Rep.________ Team_________ Others________
Level 1____________________ Level 2_______________________ Level 3______________________
Intervention: No further screening needed. Yes___ No___
ASSESSMENT: Intervention needed because:
Albumin below 3.0 g/dL___________ Weight loss unplanned, 1 month________ 6 months________
Anthropometrics_____________________ failure to thrive_____________ malnutrition____________
Modified diet_________ TPN/EN___________ age___________ transferrin level, mg/dL___________
Disabilities: chewing___________ visual____________ hearing____________ speech_____________
Emotional barriers___________ cognitive limitations___________ physical limitations____________
motivation or desire to learn_____________ other___________________________________________
Needs: cultural___________________ religious____________________ ethnic___________________
REASSESSMENT to be completed by (date)_________________________________________________
Involved: Patient: Yes___ No___ Family: Yes___ No___ Team: Yes___ No___
Patient/family understands plan: Yes___ No___ Will follow plan: Yes___ No___
Critical pathway: Yes___ No___
Food is brought in from other sources: Yes___ No___ What source? (list)_______________________
Modified diet_____________________ Diet orders consistent with diets in approved diet manual:
Yes___ No___ Diet individualized for age: Yes___ No___
Food–nutrient interaction: (list drugs)
Name of modified diet instructions:_______________________________________________________
Individualized and age specific to meet specific needs of patient/family: Yes___ No___
Effectiveness of education: Patient/family: understands instructions and used information to
incorporate dietary changes: Yes___ No___ verbalizes the special instructions: Yes___ No___
constructs a sample menu: Yes___ No___ lists foods to include or omit: Yes___ No___
R.D. phone no. included: Yes___ No___ recommends follow-up appointment with R.D.:
Yes___ No___ recommends contacting community source: Yes___ No___
Nutrition care plan forwarded to:_________________________________________________________
Discharge supplies provided: ____________________________________________________________
________________ R.D.
© Copyrighted by Ruby P. Puckett. Used by permission.
Clinical Nutrition Care Management
• Assessment: what the data mean
• Plan: recommendation of what should be done for the patient
Several other methods may be used to document in a patient’s medical record:
P: Problem: state in objective terms (data gathered from medical record, dietary order,
dietary history, screening and assessment)
I: Intervention: care plan, outcome goals, family conference, interdisciplinary input, recommendations, referrals
E: Evaluation: method to determine how goals will be met, reassessment
P: Problem: same as above
A: Approach: how team determines how to approach problem, similar to intervention
G: Goal: what outcome is expected
E: Evaluation: where goals met, reassessment
Other methods include charting by exception, running narrative, and computerized.
Medical errors have been identified as the fourth most common cause of patient deaths in
the United States. To help reduce the number of errors related to incorrect use of terminology, the
JCAHO has issued a “do-not-use” list of abbreviations, acronyms, and symbols to help reduce
the incidence of medical errors. This action supports one of JCAHO’s national patient safety goals
to improve the effectiveness of communication among caregivers. Nutrition experts working in
the clinical area must be aware of this initiative. These goals are not accreditation standards; they
are prescriptive accreditation requirements. For nutritional professionals working in JCAHOaccredited systems, meeting the national patient safety goal is required. This action applies to all
clinical documentation, including medication orders, other orders, progress notes, consultation
reports, and operative reports, as well as educational materials and protocols or pathways.
Standards and Regulations Related to Nutrient Care
The JCAHO has developed “shared visions—-new pathways,” a project that reflects JCAHO’s
commitment to continually improving the accreditation process. It focuses on operational
improvement and continuous safe and high-quality care. JCAHO has outlined three core elements: assessment, planning of care, and provision of care. It has established standards of care
that define the following:
• The time frame(s) for conducting an initial assessment
• That initial assessments be performed for patients at risk for nutritional problems and
that they be referred to dietitians or other qualified individuals for further assessment
• That nutritional intervention, as formulated by goals, be implemented and documented
• The monitoring of progress, measurement and evaluation of outcomes, and documentation of results
• The preparation and distribution of food that is nutritional for the care and treatment
of patients
• The honoring of individual cultural, religious, or ethnic food preferences (see the 2003
Accreditation Manual for Healthcare or the JCAHO Web site []
for the full text).
Other standards such as infection control also apply to nutrition services. Quality assessment and assurance is a regulation of the Center for Medicare and Medicaid Services (CMS)
(formerly the Health Care Financing Administration) that requires an ongoing program that
monitors patient care and outcomes. The program must identify where problems exist and how
Food Service Manual for Health Care Institutions
the problems were corrected. Section 483.75(1) of the regulations explains what the responsibilities of a quality assessment and assurance committee entail. Quality assessment and assurance in nursing homes was initiated in 1999. New survey processes were instituted that include
the use of in-depth investigating protocols. There are twelve domains and thirty quality indicators, which serve as flags to measure the quality of care provided in a facility. Data from the
electronically transmitted “minimum data sheets” are used to generate the quality indicators.
Nursing facilities participating in the Medicare and Medicaid programs must follow federal regulations developed by CMS. These regulations are found in Section 483.25, quality of
care, and relate to resident assessment instructions, which include two components: minimum
data sheets and resident assessment protocols.
Surveys of long-term facilities follow the standards that have been established by the federal government and are referred to as Tag numbers, as outlined in Guidelines to Surveyors—
Long-Term Care Facilities. The major Tag numbers begin with F321 to F327 and for dietary
services, F360 to F372. These Tag numbers contain specific requirements that are used by the
surveyors and include standards for nasogastric tubes; acceptable body weights; therapeutic
diet when there is a nutritional problem; hydration; staffing, including the need for a qualified
dietitian; other staffing needs; menus; food that is nutritious; assistive devices for eating; and
sanitary surroundings.
Section K of minimum data set 2.0, to be completed by the dietitian or dietary manager,
covers oral problems, height and weight, weight changes, nutritional problems, nutritional
approach, and parenteral and enteral intake. The intent is to prevent malnutrition and dehydration and to ensure the appropriate use of tube feedings.
The resident assessment protocols are designed to help improve the outcome of care and
quality of life of nursing home residents. The information is used to develop a care plan. There
are eighteen resident assessment protocols, three of which are directly related to nutrition:
nutritional status, feeding tubes, and hydration or fluid maintenance. Each resident assessment
protocol has four sections: problem (the problem addressed by the protocol), trigger (a list of
minimum data set items that cause the resident assessment protocols to be triggered when
checked; they also identify actual and potential problems), guidelines (to provide a framework
for the dietitian and the dietary manager to evaluate the resident and help identify the problem, causal factors, and risk complications), and the “key” (the final section that summarizes
the trigger list and guidelines).
CMS also has guidelines for writing care plans that involve the interdisciplinary team, the
resident, the resident’s family, or others to develop “quantifiable objectives for the highest level
of functioning the resident may be expected to attain, based on the comprehensive assessment.”
Another major change is the Health Insurance Portability and Accountability Act privacy
rule that was finalized on August 14, 2002, and became effective April 2003. This federal regulation ensures that personal medical information that is shared with physicians, hospitals, and
others who provide and pay for health care is protected.
The act covers the following four areas:
• Electronic transactions
• National identifications for providers, health plans, and employees
• Security of protected health information; systems must be in place to control access and
protect information
• Privacy of protected health information: who is authorized to use this information and
what written policies give this access
The privacy rule does the following:
• Imposes new restrictions on the use and disclosure of personal health information
• Gives patients greater access to their medical records
Clinical Nutrition Care Management
• Gives patients greater protection of their medical records
• Holds violators accountable with civil and criminal penalties
• Imposes new restrictions on health care providers, health plans, health care clearing
houses, and business associates who have access to medical records and determines who
may conduct electronic transactions (for more information, see the Web site of the
American Health Information Management Association []
or their manual listed in the Bibliography.
The role of a nutrition manager is similar to that of other health care managers. Planning
includes creating policies and procedures for providing nutrition care, writing goals and objectives consistent with those of the department, and developing and marketing new programs.
Organization of the nutrition section of the food service department depends on the size of the
facility and patient types. The nutrition team generally consists of some configuration of nutrition managers, R.D.s, dietetic technicians, nutrition assistants and aides (or clerks), and hosts
and hostesses.
The nutrition manager must develop and use leadership skills that motivate the staff
toward the department and organization’s vision. Financial expertise on the manager’s part has
become increasingly important with the demand for cost-effective services. The nutrition manager must seek to prove the necessity of nutrition intervention in health care delivery through
the measurement of positive patient outcomes.
Patient nutrition services include screening to determine nutritional risk, assessment and
reassessment, education, and discharge planning. All of these are accomplished through the use
of care plans and may be based on interdisciplinary critical paths. In addition, the nutrition
staff may provide intervention through enteral or parenteral feeding. Regardless of what nutrition intervention or treatment is provided, the care must be fully documented in the appropriate section of a patient’s medical record. Entries must be made by the person performing the
treatment. When verbal orders are given, the order should be noted in the patient’s medical
record as a verbal order and tabbed for the physician’s signature at a later date, usually within
24 hours.
American Dietetic Association, Future Practice Roles Task Force. Future Report to the House of
Delegates. 2001. [].
American Health Information Management Association. Boost Your Expertise with HIPAA and
Privacy Tools from AHIMA. Chicago: American Health Information Management Association,
American Hospital Association. Recording Nutrition Information in Medical Records [Management
Advisory]. Chicago: American Hospital Association, 1990.
Bradley, R. T., Ebbs, P., Young, W. Y., and Martin, J. Characteristics of advance-level practice: A
model and empirical results. Journal of the American Dietetic Association 93:196–202, 1993.
Briggs Corporation. Minimum Data Set and Resident Assessment Protocols–Version 2.0. Des
Moines, Iowa: Briggs Corporation, Sept. 2000.
Charles, E. J. Charting by exception: A solution to the challenge of 1996 JCAHO’s Nutrition Care
Standards. Journal of the American Dietetic Association 97(2):5131–5138, 1997 [suppl.].
Christakis, G. (ed.). Nutritional assessment in health programs. American Journal of Public Health
63(11), 1973 [suppl.].
Food Service Manual for Health Care Institutions
Choose the Right Tool—HIPAA Compliance. St. Louis: MDI Technologies, 2003 [CD ROM].
Escott-Stump, S. Managing nutrition services. Chap. 4. In R. Jackson (ed.), Nutrition and Food
Service for Integrated Health Care: A Handbook for Leaders. Gaithersburg, Md.: Aspen, 1997, pp.
Health Care Financing Administration. Survey Certification and Enforcement, State Operations
Manual 274. Washington, D.C.: Health Care Financing Administration, U.S. Department of Health
and Human Services, 1995.
Health Care Financing Administration. Guidelines to Surveyors—Long-Term Care Facilities.
Washington, D.C.: Health Care Financing Administration, U.S. Department of Health and Human
Services, 1999.
Hoppszallern, S., and Hughes, L. HIPAA: The patient privacy challenge. Hospital and Health
Network 76(12):[7-page insert], 2003.
Joint Commission on Accreditation of Healthcare Organizations. Accreditation Manual for
Healthcare. Oak Brook Terrace, Ill.: Joint Commission on Accreditation of Healthcare
Organizations, 2002.
Laramee, S. L. Monitoring productivity of the clinical staff hospital. Food and Nutrition Focus
11(10):4–5, June 1995 [insert].
Payne-Palacio, J., and Canter, D. D. The Profession of Dietetics: A Team Approach. 2nd ed. Upper
Saddle River, N.J.: Prentice Hall, 2000.
Phillips, M. W., Jr. Avoiding medical errors: JCAHO documentation requirements. Journal of the
American Dietetic Association 104(2):171–173, 2004.
Puckett, R. P., and Danks, S. L. Nutrition, Diet Modification, and Meal Plans. 3rd ed. Dubuque,
Iowa: Hunt Publishing, 2002.
Puckett R. P., and Jackson, R. Chap. 13. In R. Jackson (ed.), A System Approach to Productivity.
Gaithersburg, Md.: Aspen, 1997, pp. 441–473.
Quarterly summary of RVUs. Hospital Food and Nutrition Focus, 1996.
Schiller, M. R., Gilbride, J. A., and Maillet, J. O. Handbook for Clinical Nutrition Services
Management. Gaithersburg, Md.: Aspen, 1991.
Splett, P. L. Effectiveness and cost effectiveness of nutrition care: A critical analysis with recommendations. Journal of The American Dietetic Association, Nov. 1991 [suppl.].
Vogelzang, J. L. Ethical thinking for the dietetic profession. Consultant Dietitian 27(3):1, 6–7, 2003.
Wagner, L. HIPAA countdown. Provider 28(3):20, 22, 25–26, 29–30, 32–34, 2002.
Ward, M. Marketing Strategies: A Resource for Registered Dietitians. Johnson City, N.Y.: Marcia
Ward, 1984.
Chapter 10
Management Information
The complexities faced by today’s health care food service managers make it necessary to
implement methods for producing precise, sophisticated information. This need has led to the
development of the management information system (MIS), a network of people, procedures,
and equipment used to gather and process data to provide routine information to managers
and decision makers. Its techniques include selecting, storing, processing, and retrieving operational data. In so doing, the MIS supports the food service department’s functional units, such
as marketing, purchasing, production, menu planning, clinical management and meal service
forecasting, inventory control, food safety, payroll and special reports, and financial management by providing routine reports about these units. The reports are used by management to
support decision making, with a focus on operational efficiency.
This chapter discusses concepts of information—what it is and how it differs from data,
the value of information, and features of an effective MIS. The tasks that go into information
production (developing, implementing, and operating an MIS) will be described, as will the
four elements that make up an MIS: input, processing, output, and feedback. After MIS methods, such as manual systems and computer-assisted systems, are examined, an outline is provided of a six-stage process of developing a computerized MIS from a manual system:
Investigating the current system
Analyzing the current system
Designing the MIS
Implementing the MIS
Maintaining the MIS
Reviewing the MIS
Based on information in this chapter, a food service manager can facilitate the development of
an MIS that is capable of generating any number of information-bearing instruments (for
example, reports, cost analyses, electronic spreadsheets). The use of computers and programs
specified to food service is discussed, and a list of terms is provided to assist users (see
Appendix 10.1 at the end of the chapter).
Food Service Manual for Health Care Institutions
Information Concepts
Information is one of a health care food service operation’s most valuable resources. Current
environmental pressures such as cost-containment mandates, changing patient demographics,
and workforce diversity require that the department’s MIS produce accurate information in a
timely manner. Developing, implementing, and operating an MIS are probably among the most
time-consuming tasks faced by a food service manager. Although the terms information and
data frequently are used interchangeably, they are not to be confused with one another in discussing an MIS.
Distinguishing Data from Information
Data consist of raw facts about the transactions that occur during the course of providing
goods and services to customers. The check total for a single cafeteria customer is an example
of one unit of data (or datum). If a health care food service manager were to sort through all
single or unit transactions (that is, all data) generated by the cafeteria, he or she would be
unable to carry out other managerial responsibilities. Therefore, data must be transformed into
a more accessible form; that form is information. Data are held in a database, a computerbased set of information. Information is the product that results from sorting, processing, and
combining data to produce a collection of facts that has value beyond the value of the individual, separate facts. Thus, a manager would find the total weekly cafeteria sales to be more valuable than individual check totals. Information technology is the use of computer technology in
managing, processing, and accessing information.
Measuring the Value of Information
The value of information is directly linked to how it helps a food service manager achieve the
operation’s goals and objectives. That value typically is measured in money or time. In monetary terms, value equals either increased revenues or decreased expenses. In terms of time, the
value of information might be measured by how much less time is spent on making a decision.
In his book Principles of Information Systems: A Managerial Approach, R. M. Stair says that
information should have certain characteristics before it can be deemed valuable to managers.
In most cases, it must be accurate, complete, economical, flexible, reliable, simple, timely, and
verifiable to qualify as valuable.
Characterizing an Effective MIS
Information, as indicated above, can only result from carefully designed systems. Although
MIS design varies from operation to operation, certain characteristics are common among
effective systems. In the book Computer Systems for Foodservice Operations, Kasavana lists
these five features:
• The MIS provides a means by which to achieve organizational goals and objectives.
• The MIS treats information as an important resource and is responsible for its proper
handling, flow, and distribution.
• The MIS enables improved integration of operations, communications, and coordination.
• The MIS interconnects people and equipment in relationships designed to free personnel to fulfill jobs requiring human capabilities.
• The MIS stores large volumes of transactional data to support planning, decision making, and analytical activities.
Management Information Systems
Elements of an MIS
In addition to the characteristics enumerated above, an effective MIS design meets the specific
needs of an individual food service operation. Although this tailoring requires a variety of
approaches and designs, all effective systems typically evolve from the four interrelated elements or components mentioned earlier: input, processing, output, and feedback. These components are illustrated in Figure 10.1 and detailed in the following sections.
Input involves the capturing and gathering of raw data for each business transaction. In producing monthly checks for a cafeteria’s vendors, for example, the dollar value of each delivery
by each vendor during the month must be arrived at before checks can be calculated by the
accounts payable office or printed. Input can take many forms but is usually supported in writing by a source document. Input errors may occur while the data are being entered into a system, which often accounts for the failure of information systems to produce desired results. A
source document provides a permanent record of an individual transaction. In an MIS designed
to produce vendor checks, then, an invoice provided by the vendor at the point of delivery
would serve as the source document. Source documents for the operation’s marketing unit
could include cafeteria customer surveys or records of patient interviews.
The typical health care food service operation collects volumes of source documents during the course of business. This creates numerous problems for handling, storing, and retrieving original source documents. Due to advances in MIS technology, certain aspects of the MIS
are available in a paperless, electronic format. But before this format can be implemented successfully, the accuracy and security of data must be assessed, which occurs in data processing.
Figure 10.1. Four Elements of an MIS
• Source documents
• Sorting
• Documents
• Classifying
• Reports
• Calculating
• Summarizing
• Storing
• Comparing
• Evaluating
Food Service Manual for Health Care Institutions
Processing involves the actions or treatments required to convert data into useful information.
Processing usually involves sorting and classifying data into categories, performing calculations, summarizing results, and storing both data and information for further processing. In the
accounts payable example described above, data manipulation involves determining the dollar
value of all purchases made from individual vendors, as documented by invoices, to determine
what is owed each vendor.
Data may be further coded by classifying each purchase by type of commodity (such as
produce, meat, dairy product, chemicals, or paper supplies). This allows the system not only to
produce checks for vendors but also to generate information that allows the food service director to monitor the dollar value of different categories of purchases.
Data-processing functions are similar for all the various units of a food service operation—
such as marketing, purchasing, inventory control, and meal service. According to Stair, all processing elements have a number of characteristics in common, including:
A large volume of input data
A large volume of output
Numerous users affected by the system
A need for efficient processing
Large-volume storage requirements
Fast input and output capabilities
Low computational complexity
A high degree of repetition in processing
A high potential for problems related to security
A severe adverse effect on the organization if the processing element breaks down or
fails to operate correctly
Each of these characteristics must be considered when developing the MIS and particularly
when designing the system’s processing element.
In an MIS, output involves producing information, usually in the form of report documents,
that is appropriately relevant for the food service operation and its decision makers. Other outputs may include vendor checks, reports of purchases by food category, and analyses of patient
food costs for the administration’s use. The MIS can produce reports required by local, state,
or federal agencies—for example, sales tax reports for cafeteria operations. Three broad report
categories are described briefly below.
Types of Reports
The reports output by an MIS can be classified as scheduled, demand, or exception reports.
Scheduled reports are produced periodically based on a set schedule (daily, weekly, or
monthly). For example, the food service manager might receive a weekly report of sales for
each revenue-producing food unit in the health care operation. Or, an inventory report might
be produced on a monthly basis so that the value of each category of food inventory can be
Demand reports, on the other hand, are developed and produced to provide specific information requested by a manager. In other words, these reports are not generated on a routine
basis. Thus, a manager who needed to know total sales for a specific menu item during the year
would rely on the information generated by a demand report.
Exception reports are produced when a situation occurs outside the limits set by management and require manager action. For example, an exception report could be generated
Management Information Systems
automatically to report all vending food items that fall below a certain level of sales activity. In
this case, the manager might want to consider replacing the item with a more popular product.
If none of the food items offered by the vending operation fall below the minimum sales level,
no exception report need be generated.
Design and Development of Reports
The purpose of MIS reports is to help managers in their planning, decision making, and controlling functions as they relate to various department operations. According to Stair, the guidelines that should be followed in designing and developing effective reports include
• Tailoring each report to satisfy specific user needs
• Spending time and effort on producing only those reports that are necessary and will be
• Paying attention to report content and layout
• Using exception reporting
• Producing all reports in a timely manner
Another function of the MIS is to provide feedback so as to make managers aware of the level
of performance within their operations. Feedback enables food service managers to take preventive and corrective action. For instance, an MIS report might indicate that the inventory levels of specific chemicals and cleaning supplies are too low, thus prompting the manager to place
an order with the appropriate vendor. On delivery of supplies, the data generated by this transaction (invoices, bill of receipts, for example) are input into the system.
Information Management
A variety of methods can help managers generate information from operational data. In some
cases, the manager can process data mentally, for example, by estimating the appropriate menu
price based on cost data. Other informal information systems, such as oral communication during training sessions, have been used with some success. Because of the volume of data generated by most health care food service operations, formal systems for data processing and
transformation have become commonplace. Information management is the effective production, storage, and dissemination of information in any format and on any medium.
Manual Systems
Originally, a food service operation’s MIS relied on repetitive manual procedures whereby
input was provided for each transaction by means of a source document, usually in paper format. Each transaction was then posted by hand and calculations performed either by hand or
by means of a calculator. Reports were handwritten or typed up individually. At best, manual
systems could generate elementary outputs on meal equivalents, customer counts and sales,
labor hours and costs, food and supply costs, and personnel records.
Computer-Assisted Systems
Although manual systems are still used in some health care food service operations, as the complexity of operations increases, so, too, does the demand for an MIS that can provide more
information with more accuracy and within a shorter period of time than can be generated by
traditional manual systems. Undoubtedly, the most important advancement in collecting, maintaining, and processing data has been the development of computers. Once available data are
entered (input) into the computer, the data can be stored, retrieved, and processed rapidly and
Food Service Manual for Health Care Institutions
accurately as many times as needed to meet the operation’s information needs. More and more
facilities that formerly depended on manual systems are now converting to computerized MIS.
Converting from a manual to a computerized system requires a great deal of time and
expense. Therefore, the conversion process should yield concrete benefits for a facility’s operations. Again according to Stair, benefits include
• A higher degree of accuracy. With manual systems, because more than one employee
might be responsible for reviewing reports for accuracy, inaccurate reporting may occur due to
faulty cross-checking. With computerized systems, accuracy can be checked not only by
employees but by the computerized system as well.
• Timeliness of documentation and reporting. Manual systems can take days, weeks, or
months to produce even the most routine reports. Computerized systems can significantly
reduce this time. This can prove to be a valuable attribute in data processing for functions such
as payroll or nutrient analysis of menus.
• Service expansion and enhancement. Manual systems may not afford the rapidity with
which operations need to meet their customers’ expectations. Computerized systems that link
functions (such as customer orders and inventory) can facilitate improved customer service.
• Labor efficiency. Manual systems are extremely labor-intensive. Computerized systems
can substantially reduce clerical labor requirements. This is the case when data are used for
multiple purposes. For instance, after cost data have been entered and stored by the computer,
they can be processed into information for financial statements, variance reports, and menu
• Data and information integrity. Only information that is accurate, current, and relevant
can be of value to the operation. Because manual systems have no determinants for information discrimination, systems with inherent check-and-error prompts are a decided advantage.
Note that computerization of a manual information system does not guarantee improved
MIS performance. If the basis on which the manual system was built is flawed, computerization will only serve to magnify rather than diminish an operation’s problems—and those of its
MIS. A successful computer-assisted system can evolve only from an effective manual system.
Development of a Computerized MIS
Computers were first used in the industrial sector to produce payroll and personnel records,
purchasing and inventory control, assembly-line schedules, productivity reports, and job-costing
reports. The introduction and acceptance of computerization by the food service sector has
been slower, traceable to the early 1960s when computer-assisted menu planning was originally
As an outgrowth of this early effort, a number of systems now enhance managers’ control
of food service operations. As a result, the past few years have seen an increase in the use of
computerized MISs in health care food service operations.
A variety of formal and informal approaches serve to develop computerized MISs for
health care food service operations, with steps for systems development varying from one operation to the next. The model described here is based on the work of Gordon, Necco, and Tsai.
Step 1: Investigate the Current System
Computers can process information rapidly and store vast amounts of data. They are useful for
almost all food service operations but do not present a cure for every management problem.
Before implementing a computerized MIS, the food service director should spend time
and effort to justify the expenses involved and to weigh them against anticipated benefits of
Management Information Systems
Usually, systems investigation is the first step in this investigation process, whose purpose
is to determine whether information generated by the existing system satisfies and supports the
goals and objectives of the operation. Major functions of the current system must be evaluated
to determine if improvements are possible and, if so, what effect they might have on the department’s revenues and expenses. Specifically, this step attempts to answer the following questions:
What problems might an MIS solve?
What new opportunities might an MIS provide?
What new software or hardware will be required?
Will the computer’s presence increase or reduce the department’s personnel requirements?
What databases and operational procedures will need to be developed?
What costs will be involved?
Where will the financial resources come from to develop the MIS?
If the system is to be used by clinical nutrition staff, who will absorb the costs of nutrition services?
Will the system interface with the Internet, personal palm-held computers, and organization-wide MIS? (See Appendix 10.1 for the definition of interface.)
Will desktop applications such as word processing, spreadsheets, Web browsing, and
e-mail assist with presentation for education of patients and staff?
Step 2: Analyze the System
The existing system’s ability to satisfy the information needs of managers and decision makers
must be determined. Emphasis is on determining the problems and limitations of the existing
system and, at the same time, identifying its strengths. Typically, this is accomplished by direct
observation, structured interviews of managers and users, and questionnaires.
Step 3: Design the System
Although the design of a computerized MIS often focuses on computer selection, computers
constitute only part of the MIS. The purpose of systems design is to develop the best possible
system that helps the operation achieve its goals and objectives and at the same time overcomes
some problems of the existing system. If this involves converting a manual system to a computerized MIS, major investments may be necessary.
A computerized MIS consists of software, hardware, databases, telecommunications, personnel, and procedures. A common mistake made in the design of a computerized MIS is the
selection of hardware without consideration of software capabilities. The selection of software
is the most critical decision and must occur before all other system components are selected (see
Appendix 10.1 for a glossary of computer terms).
Software consists of specific instructions or programs given the computer. These instructions
enable the computer to transform data into information, which ideally results in increased profits, decreased costs, and improved customer service.
Microcomputers use two types of software: systems software and applications software.
Systems software is designed to support the overall computer system by controlling and
enhancing the capabilities of the hardware and application software, rather than performing a
specific function. Applications software programs are designed to solve specific user-oriented
problems. Examples of application software are word-processing systems, database management systems, and decision support systems including electronic spreadsheets. Because of the
important nature of applications software, outside discussion is warranted. Characteristics that
Food Service Manual for Health Care Institutions
must be considered when matching software to a specific business application include the
source, scope, and function of the software. Food services’ common features of software
include menu planning, forecasting, purchasing, inventory, management, and medical nutrition
Source refers to the degree to which the manager is involved in the design of the software, the
development of the instructions provided to the hardware, or both. Most software can be classified as customized, full-featured, or generic.
In health care food service operations, many early users of computer technology found it
necessary to design and develop customized software. This type of software was written specifically for their operations, and the managers were actively involved in determining the functions to be performed by the software. Many times the written reports generated by the existing
manual system were used as the basis for the design of the computer-generated reports. This
resulted in software that generated reports tailored to meet the specific needs of a specific operation. However, many operations do not have the resources necessary to develop their own systems. In addition, errors or bugs in these types of systems usually had to be caught and
corrected after the system had been implemented.
An alternative to customized software is full-featured software. A wide variety of full-featured software systems has been developed for use by health care food service operations.
Systems have been developed by more than two hundred companies to perform functions ranging from inventory and purchasing control to nutrient analysis of both menus and intake of
individual patients.
Full-featured software generally is less expensive than customized software and usually has
been widely tested and sold. This software can be seen through demonstrations at trade shows
or by previewing program copies. With so many choices available, guidelines for evaluating
these programs must be developed for the food service director who is considering the purchase
of full-featured software.
An economical alternative to customized and full-featured software is generic software. A
variety of generic programs can be purchased at retail software stores or from mail-order
houses. Generic software programs include word processing that handles word applications,
electronic spreadsheets for mathematical applications, database management that equates to
an electronic filing system, and graphics to display information in graph form. These generalpurpose programs can be modeled to meet a variety of needs for a specific food service operation. Many operations choose to supplement their full-featured systems with generic software.
The scope of software refers to the range of applications or functions that can be performed by
the software. Software is either single application or integrated in its orientation. Single-application software is designed to handle one specific function. Three common single-application
software packages are word processing, database managers, and electronic spreadsheets.
Single-application programs also are available to support such functions as inventory control
and nutrient analysis. These systems generally are easier to evaluate and less expensive than
integrated systems. However, they may be less efficient because each application requires that
the same data be entered before being used by the program.
In most food service operations, some of the same data are used for numerous applications. Data about an individual food item might be used in ordering, receiving, issuing, recipes,
production, sales control, and nutrient analysis. Integrated food service software allows for
easy transfer of data directly from one application to another. The data are entered only once.
Thereafter, the data can be used to provide information for planning and control purposes for
a variety of functions with a minimum of user interaction.
Management Information Systems
Function refers to the specific job or tasks that can be accomplished with the software.
Software designed for health care food service operations performs a wide variety of functions,
Point-of-sale record keeping and sales analysis
Menu planning and cost analysis
Inventory and purchasing control
Maintenance of purchasing and receiving records
Recording production schedules
Production control and forecasting
Labor productivity and payroll records
Financial management
Clinical nutrition care
When determining what to purchase, there are literally tens of thousands of application software packages to choose from. In their book Microcomputers: Business and Personal
Applications, Burns and Eubanks recommend the following procedure for selecting software:
Define the application to be computerized.
Develop a list of available software.
Gather information about available packages.
Narrow down the list of possible choices.
Obtain hands-on demonstrations.
Perform a final evaluation.
Make a decision.
Once software has been selected, hardware that can run the software must be identified. The
computers used in health care operations vary from microcomputers used at individual workstations to large mainframes used for major organizational data-processing functions. The following discussion focuses on characteristics of microcomputers because of their prevalent use
by health care food service managers.
Microcomputers consist of basic hardware components to perform input, processing, and output activities. Input devices include such formats as keyboards and optical scanners. Processing
devices include the central processing unit (CPU), memory, and storage. The most common
output devices are printers and displays on computer screens. Microcomputers, available in a
variety of formats based on their anticipated use, include desktop computers, transportable
computers, laptop computers, and handheld computers.
Desirable Characteristics
Selection of equipment is a major decision. Hardware features that should be considered
include CPU speed, types of input and output devices, primary storage capacity, secondary storage capacity, and number of workstations supported. Expandability of the system is an important feature, and expansion products can be used to increase the power, enlarge the storage
space, and customize the computer for special functions. Additional features to consider are
warranties, user-support services, and maintenance contracts that may be provided by computer vendors.
Food Service Manual for Health Care Institutions
Once the food service operation has selected the software and hardware components, a database
must be designed. A database consists of an organized collection of raw facts. These facts can
be about the operation’s customers, employees, food items in inventory, and many others. Most
managers believe that the database is one of the most valuable components of a computerized
MIS, and in fact, a great deal of time and effort must be contributed to database design and
development. Some vendors may provide data about their products in a format that can be used
by computerized systems, thus minimizing the time required to develop the database. For example, data concerning the nutritional composition of frozen entrees could be provided on a
diskette for use during analyses of the nutritional adequacy of menus offered to patients.
Telecommunications allow a health care operation to link discrete computer systems to create networks. Local-area networks can connect computer equipment within the department or within a
single building for purposes of resource sharing and information dissemination. With capability
for connecting a variety of computer systems and supporting electronic mail, these networks must
be supported by both network software and specially designed application software.
Perhaps the most important components of a computerized information system are the people
who manage, run, program, and maintain the system. Personnel requirements for support of a
computerized MIS must be carefully assessed: Will a computerized MIS mean adding new
employees to realize project objectives? Will the nature of projects dictate whether tasks are
modified or changed altogether? System design also must consider user needs and expectations.
System users include managers, decision makers, employees, and other individuals who access
the systems to carry out the department’s work.
The final MIS design component to consider is the body of procedures that detail how the systems are to be operated. Procedures include strategies, policies, methods, and rules for operation of the system. Procedures must be developed to define when reports are to be generated,
who has access to the database, and contingency measures to be taken in case of a disaster or
system malfunction.
Step 4: Implement the System
On conclusion of the system design stage, specifications for each of the six basic components
of the computerized MIS should have been developed. These specifications dictate which software, hardware, databases, telecommunications systems, and personnel should be acquired.
Acquisitions are made by following the health care operation’s purchasing and hiring policies.
Operating procedures for the computerized MIS, as discussed previously, must be made available to all users. Then implementation can take place.
Preparation of Users, Site, and Data
Before implementation, users, site, and data must be prepared. Preparation may involve nothing more than promoting the new computerized MIS so as to minimize resistance to change;
even so, this step generally involves training user personnel to ensure that they get the most
from the new system. Training may be conducted by the software vendor, an outside contracted
source, or even departmental personnel who have received in-depth training. In any case, online tutorials that accompany some software also can be useful.
The site selected for hardware placement must be carefully considered. The location must
have a power supply that is relatively free from power surges, and the equipment should be
Management Information Systems
located in a relatively clean environment, free from temperature extremes. Additional furniture
may be needed to promote efficiency and ensure the comfort of users.
All data that previously have been maintained manually must be converted and saved in a
format that the MIS can access. This conversion-and-save process is a time-consuming task,
and the food service director may elect to hire temporary part-time data-entry clerks.
Installation, Testing, and Start-Up
The hardware and software must be installed on-site so that the system can be tested. Each system application program must be tested with data so that potential problems can be identified
and circumvented before system start-up. Several approaches to start-up can be used, but when
several applications are to be computerized, the preferred method is to keep things simple by
starting up one application at a time. Once the new application is performing as expected,
another application can be implemented.
Step 5: Maintain the System
The purpose of system maintenance is to keep the computerized MIS operating as efficiently,
effectively, and error free as possible. This step involves monitoring and modifying the MIS to
make it more useful and valuable to users. Maintenance may be required to resolve major problems or to make minor modifications. Given that most computerized MISs require substantial
maintenance, the quantity and availability of maintenance support is an important factor to
consider when comparing vendors of full-featured programs.
Step 6: Review the System
The final step of systems development is the process of evaluating all systems components to
make sure that they are operating as intended. All six components are subject to review. This
means that applications software, hardware, telecommunications systems, databases (containing all facts used by the system), personnel (either full-time or part-time) who work with the
system, and the procedures that provide guidelines for system operations must be evaluated,
troubleshot, and adjusted as necessary. System review should take place on a regularly scheduled basis, with backup provisions made to guard against loss of data.
Computers in Food Service Operations
Every health care institution in the nation makes use of computers in some phases of its operation. Although the computers cannot do any original thinking, they are excellent tools for
keeping records, doing computations, and producing reports. The most common use of computer time is to absorb a variety of boring and repetitive tasks, thereby releasing the user for
the more important tasks of deciding, planning, and managing.
In food service operations, there are many applications for computers and computer programmers. They help to assure quality and variety in food service, to reduce costs of operation,
to reduce the hours spent doing paperwork, and to produce required documents (such as recommended daily allowance computations, menu plans, food inventories, and purchase orders).
Many people take to using computers so naturally that it seems they have been around
them all their life. Others are more hesitant and worry (incorrectly) that computers may be too
complex to use or that some embarrassing or costly mistake is sure to occur. Whether one is
experienced with or new to computers, virtually all users have two things in common. First,
almost every food service operator is interested in building computer skills for application on
the job. Second, everyone is pleased to discover that commercial packaged programs are available that are simple to operate and do not require technical skills to use.
Food Service Manual for Health Care Institutions
In a large hospital, computer software (see the glossary in Appendix 10.1) is apt to run on
a large mainframe computer at some distance from the food service department. Usually a computer professional is on hand who instructs on how to use the equipment. It is not unusual to
have one or more PCs (personal computers) in the food service department. Instruction must
come from manuals or consultants. Some of the producers of dietary management computer
systems have designed versions of their software that will run on either mainframe computers
or PCs, and some provide instructional services to users. Many food service software programs
are available. Some programs are packaged to cover all of the operations of the food service
operations; others are stand-alone programs for a specific task such as nutrient analysis. A food
service manager must know what he or she wants the programs to do and what are the initial
costs, ongoing maintenance fees, telephones, technical support, labor and supply cost, training
of personnel, and the motivation of staff.
Below are some common applications for computer software that has been designed for
dietary use. Each permits managers to apply their knowledge from this course while the computer performs the extensive record keeping, computations, and report preparation that make
use of this knowledge.
Purchasing and Inventory
A computer is capable of analyzing planned menus and calculating the quantity of each item
needed and when it will be needed. It can take current food inventory into consideration and
generate purchase orders or storeroom requisitions in the right form (Figure 10.2). It can assure
that a seven-day supply of nonperishable items is on the shelf. Orders can be prepared using
different vendors for various products. Inventory records of all foods can be produced at any
time (Figure 10.3 and Figure 10.4). This helps reduce unnecessary investment in inventory and
is able to detect employee theft.
Ingredient File
The ingredient file is a file that contains all ingredients listed on a recipe (Figure 10.5). Ingredients
are identified by code name or code number. The ingredient code name or number should correlate to the purchasing and inventory file. When changes are made in a food item (such as from
heavy syrup to light syrup), the change should be input into the computer. Changes in cost should
also be input to assure an accurate cost of recipes, food, and the like (Figure 10.6).
Recipe Filing
All recipes that have previously been standardized can be entered into the computer. Recipes
should be given a code number or name, and the total amount of food produced, the number of
portions, the portion size, the ingredients, the amount of each ingredient used, the method of handling ingredients to produce the recipe (hazard analysis critical control point [HACCP] format),
the cooking time, cooking temperatures, and any other relevant information specified. Variation,
substitutions, total cost of the recipes, cost per portion, and selling price may also be included.
Menu Preparation and Analysis
A computer can maintain a file of hundreds of recipes, which can be modified or added to as
needed. After the style of menu has been selected, the computer can print finished menus for
every meal. Some computer programs will remind the data-entry clerk if the same recipe has
been used within the past few days; this helps to ensure variety in planning. The nutritional
values of recipes and menus can be generated to assist the dietitian in assessing the adequacy
of diets. Nutrient values can be shown in comparison with recommended daily allowances.
Management Information Systems
Figure 10.2. Sample Purchase Order
Purchase Order
19808 Nordhoff Place
Delivery: Mon, 05/12/2003
Chatsworth, CA 91311
PO #: P-021602
Terms: Net 15 Days
Ordered By: FSD, Thu, 05/08/2003
Status: Locked
Comment: Do not deliver between
11:00 & 1:00.
Item Name
Apples,Fresh,80 Count
CASE (40 Pounds)
BAG (40 Pounds)
POUND (Pound)
3 Pounds) 1
BAG (10 Pounds)
BOX (5 Pounds)
CASE (15
Cauliflower Florets,
CASE (3 Pounds)
Celery Sticks,Fresh
BAG (5 Pounds)
BAG (5.5 Pounds)
BAG (5.5 Pounds)
Eggplant,Fresh,18 Count
CASE (25 Pounds)
CASE (19 Pounds)
BAG (5 Pounds)
Pears,Bartlett,Fresh,90 Count
CASE (50 Pounds)
1 Each)
Grand Total $253.70
Authorized by ___________________________________ Date ___________________________
Received by ____________________________________ Date & Time ____________________
Source: Computrition, Inc. Used by permission.
Food Service Manual for Health Care Institutions
Figure 10.3. Inventory Template
Inventory Template (Blank) Report
Sorted by Bin Sequence then Item Name
Dry Storeroom
#10 Cans
#10 Cans
Incl Liquids
#10 Cans
Incl Liquids
#10 Cans
Beans,Kidney,Dark Red,
Canned,Incl Liquids
#10 Cans
Incl Liquids
#10 Cans
#10 Cans
Incl Liquids
#10 Cans
Juice Pack,Incl Liquids
#10 Cans
Juice Pack,Incl Liquids
#10 Cans
Pears,Canned,Juice Pack,
Halves,Incl Liquids
#10 Cans
Pears,Canned,Juice Pack,
Slices,Incl Liquid
#10 Cans
Juice Pack,Incl Liquids
#10 Cans
Juice Pack,Incl Liquids
#10 Cans
Light Syrup,Incl Liquids
#10 Cans
Light Syrup,Incl Liquids
#10 Cans
Juice Pack,Incl Liquids
#10 Cans
Juice Pack,Incl Liquids
#10 Cans
Item Name
Source: Computrition, Inc. Used by permission.
Management Information Systems
Figure 10.3. (continued)
Inventory Template (Blank) Report
Sorted by Bin Sequence then Item Name
Dry Storeroom
#10 Cans
Fruit Cocktail,Canned,
Light Syrup,Incl Liquids
#10 Cans
Light Syrup,Incl Liquids
#10 Cans
Cereal,All Bran,Ind
Cereal,Corn Flakes,
Low Sodium,Ind
Cereal,Frosted Flakes,Ind
Cereal,Raisin Bran,Ind
Cereal,Rice Krispies,Ind
Cereal,Special K,Ind
Cookies,Chocolate Chip
16 Ounce
Cookies,Vanilla Wafer
12 Ounce
Corn Chips
Corn Chips,Ind Bag
Potato Chips,Ind Package
Potato Chips,No Salt
Pie Filling,Apple,Canned
#10 Cans
Pie Filling,Apple,Canned,Diet
#10 Cans
Pie Filling,Apricot
#10 Cans
Cereal,All Bran,Bulk
42 Ounce
Cereal,Bran Buds,Bulk
42 Ounce
Item Name
Fruit Cocktail,Canned,
Juice Pack,Incl Liquids
Source: Computrition, Inc. Used by permission.
Produce: Fruits
Apples,Fresh,80 Count
Pears,Bartlett,Fresh,90 Count
Subtotal for Produce: Fruits
Produce: Vegetables
Celery Sticks,Fresh
Eggland,Fresh,18 Count
Subtotal for Produce: Vegetables
Subtotal for Produce
Item Name
Source: Computrition, Inc. Used by permission.
Logged By
POUND (Pound)
CASE (4 3 Pounds)
BAG (10 Pounds)
BOX (5 Pounds)
CASE (15 1 Each)
BAG (5 Pounds)
BAG (5.5 Pounds)
BAG (5.5 Pounds)
CASE (25 Pounds)
CASE (40 1 Each)
POUND (40 Pounds)
CASE (15 1 Each)
CASE (19 Pounds)
BAG (5 Pounds)
CASE (50 Pounds)
Delivery: Mon, 05/12/2003
PO#: P-17050
Ordered By: FSD, Thu, 05/08/2003
+ indicates the item was added during receiving and not on original order.
Received By
Product Code
Account #: 33025
Status: Partially Received
Terms: Net 15 Days
Comment: Do not deliver between 11:00 & 1:00
Sorted by Item Name within Inventory Group
Figure 10.4. Receipts Report
Not Received
Damaged-Credit Due
Item Status
Grand Total
Invoice #:
Vehicle Cleanliness:
Refrigerated Temp:
Frozen Temp:
2-1/3 each
4 oz
1 gal
2-3/4 cup
Soup Base,Beef,Dry
1/2 tsp
1/3 each
4 oz.
Bay Leaf,Whole,Dried
3/4 each
7-3/4 oz
3/4 tsp
50 Servings
1-1/8 each
11-3/4 oz
1-1/8 tsp
1-1/8 tsp
3-1/2 gal
1/4 cup
75 Servings
4-1/2 gal
3 cup
100 Servings
125 Servings
150 Servings
Portion: 6 ounces
Brown beef cubes in kettle. Drain off fat.
Add celery, onions, and carrots to beef. Saute until tender.
Add remaining ingredients. Bring to a boil. Lower heat and simmer for 1 hour. Taste for seasoning and add salt if needed.
1/2 tsp
Source: Computrition, Inc. Used by permission.
Beef,Stew Meat,Raw
25 Servings
Master Ref:
Starters: Soups
Figure 10.5. Beef Barley Soup, Scratch
Food Service Manual for Health Care Institutions
Figure 10.6. Menu Cost Report
Sorted by Recipe Name within each Menu Category. For 04 May 2003, Sun - 10 May 2003, Sat
* Denotes Main Item
Recipe Name
1/2 cup
$ 0.11
04 May 2003, Sun, Breakfast
*Cantaloupe Cubes
*Cranberry Juice, 4 ounces
1 each
$ 0.07
*Scrambled Eggs
3 ounce
$ 0.11
*Wheat Toast
1 slice
$ 0.07
*Butter Pat
1 pat
$ 0.02
*Hot Tea
1 cup
$ 0.01
*Sugar Packet
1 each
$ 0.03
$ 0.42
Breakfast Totals
04 May 2003, Sun, Lunch
*Tossed Green Salad
1/2 cup
$ 0.14
*Cheese Ravioli with Garlic Butter
6 ounce
$ 0.02
*Marinara Sauce
2 ounce
$ 0.05
1/2 cup
$ 0.24
*Garlic Bread
1/2 each
$ 0.06
*Lemon Cake with Lemon Glaze
1 square
$ 0.15
*Iced Tea
1 cup
$ 0.01
*Lemon Wedge
1 each
$ 0.05
*Sugar Packet
1 each
Lunch Totals
$ 0.03
$ 0.75
04 May 2003, Sun, Dinner
*Beef Barley Soup, Scratch
6 ounce
$ 0.03
*Cracker Packet
1 packet
$ 0.02
*Scalloped Ham and Noodles
6 ounce
$ 0.45
*Asparagus Cuts
1/2 cup
$ 0.25
*Fruit Cup, Fresh
1/2 cup
$ 0.23
6 ounce
$ 0.01
*Sugar Packet
1 each
$ 0.03
*Creamer Packet
1 packet
$ 0.01
$ 1.02
$ 110.58
Totals for 04 May 2003, Sun
$ 2.17
$ 229.41
Week Total
$ 15.30
Breakfast Average for this Week
$ 0.42
Dinner Totals
04 May 2003, Sun - 10 May 2003, Sat
Lunch Average for this Week
$ 0.75
Dinner Average for this Week
$ 1.02
$ 109.12
Daily Averages for this Week
$ 2.19
$ 230.51
Source: Computrition, Inc. Used by permission.
3 ounces
Cater Evnt
3 ounces
3 ounces
Need to Produce (3 ounces)
1/2 cup
Cater Evnt
1/2 cup
1/2 cup
Need to Produce (1/2 cup)
1/2 cup
Cater Evnt
1/2 cup
1/2 cup
Need to Produce (1/2 cup)
1 each
Cater Evnt
1 each
1 each
1/2 cup
Cater Evnt
1/2 cup
1/2 cup
Need to Produce (1/2 cup)
Source: Computrition, Inc. Used by permission.
Roast Pork
Rice Pilaf
Mixed Vegetables
Mashed Potatoes
Hot Turkey Pastrami
1/2 cup
Cater Evnt
1/2 cup
1/2 cup
Need to Produce (1/2 cup)
Asparagus Cuts
Portion Size
Recipe Name
Hot Food
2 batches of (100)
1 batch of (37)
2 batches of (100)
1 batch of (37)
2 batches of (100)
1 batch of (37)
2 batches of (100)
1 batch of (37)
2 batches of (100)
1 batch of (37)
Sorted by Production Area then by Recipe within each Category and Class
Figure 10.7. Production Work Sheets Report
Leftover Temp
Cook’s Quantity
Management Information Systems
Patients’ tray cards can be printed showing special diets. Some programs include information on
the effects of drugs on nutritional status, and others can produce reports on food–medication
interactions. Other programs analyze individual intakes in light of client weight profiles.
Food Production
Using the inputted menu, the software program can produce schedules for thawing and prepreparation of menu items and generate production sheets with employee assignments.
Programs are available for estimating the costs of the recipes (as prices change, new data must
be entered) and providing an analysis of the nutrients for all recipes (Figure 10.7).
Food Service Manual for Health Care Institutions
Food Safety
Maintenance equipment software programs can be programmed to collect data automatically—
temperature logs, for example. Using existing software programs for HACCP, the software
program can be modified to meet individual organizational needs.
Employee Schedules and Compensation
Automated timekeeping programs are available. When an employee swipes his or her identification badge through a reader, the information may be sent to the food service department and payroll administration. Employee schedules may be created, ensuring adequate full-time-equivalent
employees on duty for each shift and each day.
Using historical data, a computer can forecast (project) the number of menu items needed for
any meal and the number of menu items that will be sold. The software program an organization chooses for forecasting should meet the needs of its facility.
Nutrient Analysis
Nutrient analysis programs are software programs that will calculate the nutrient value of each
food, using data inputted from a menu and recipes. Many commercial programs are available;
these vary from relatively inexpensive (hundreds of dollars) to expensive (thousands of dollars).
Each food service department should choose the one that meets the needs of its facility.
Financial Management
Recipe costs can be calculated by a computer using correct costs from vendors. Using this information, as well as the number of current or forecasted clients, the computer can determine the
cost of each menu that has been prepared. Some software systems are capable of monitoring several thousand food items. Reports of menu costs can be printed for review by the food service
supervisor or administrator. The computer can generate a daily food cost report and sales records
(point-of-sales system), track labor costs, track budget compliance, and calculate new budgets.
Clinical Management
Software programs have been developed that have replaced calorie counts and nutrient analyses,
time-consuming tasks that dietitians at one time performed manually. An experienced data-entry
employee can enter the following data and provide reports to the dietitian, dietetic technician, or
dietary manager.
Print, tally, and generate tray cards and sort them for tray line sequence
Perform nutritive analyses of menus
Perform nutrition screening and assessments
Perform drug–nutrient interaction analyses
Calculate calorie counts
Develop a consulting schedule and follow-up appointments
Monitor outpatient return visits
Meet other specialized needs of the clinical staff
Menu Planning
Software programs are available that will plan the regular menu, modify for needed diets, complete a nutrient analysis, and determine how often an item is on a menu. When other data have
Management Information Systems
been entered into the menu, each item can be priced. Menus can be printed on a computer
screen, and where patients choose from a menu on the screen in their rooms, the program will
tally the needed portions for each menu item. Data can be stored for catered events, special holidays, kosher foods, and so forth.
Special Reporting
Minimum data sheets are forms that must be completed for assessment and care screening of
residents in skilled-nursing facilities.
Food service software that is entirely appropriate for an individual department’s use may
not have all of the features listed above, but all are available.
Information from nutrition screening and assessment that has been performed by dietitians
and dietetic technicians can be entered and compared with standards to determine the need for
additional follow-up. Analysis of drug–nutrient interactions is a dual program between the pharmacy and clinical nutrition services. The pharmacy department sends to the nutrition manager
a list of specific drugs that may cause an interaction with certain foods. From this information,
the nutrition clinical staff can revise menus as applicable and provide instructions to the patient.
Management Issues
Policies and procedures need to be developed concerning employees’ use of computers and computer software while on duty. The food service manager needs to monitor how the programs are
used. Game playing, excessive Web search, nonbusiness e-mails, and pornography should not be
allowed. The policy and procedures must be specific in the authorization of computer use.
Persons authorized to use a computer should be provided with a password that will need to be
changed frequently. Passwords should not be written down or passed on for others to use.
A systems manager should be designated with a specific job description and the authority
to oversee all operations. Back-up personnel need to be trained to assist the manager and train
other users. The system manager should be on the alert for viruses or spam to the system and
devise a system to run virus-detection software at least weekly. Viruses can wipe out programs
and damage the computer’s hard drive (see App