THE IMPACT OF TRAY
ACCURACY AND MEAL
APPEARANCE ON
RESIDENT SATISFACTION
AND FOOD WASTE
Sage Dietetic Internship
Spring 2014
Process Improvement
Project for Food Service
Management
Intern: Janna Neitzel
Preceptor: Jennifer
Phelps
Facility: Baptist Health
INTRODUCTION
 In residential, rehab, or long -term care facility, meals serve
several vital functions, providing nourishment, aiding in the
overall care plan of a patient, and helping to create a sense of
home
 Overall satisfaction relies heavily on meal satisfaction
 Many complex elements to meal satisfaction( 2)
 Patient’s rights
 Adequate nutrition through care provided ( 1)
 Reliance on facility to meet needs
 Lack of control over meals (3)
INTRODUCTION
 When patients cannot rely on the food service where they
reside, it is an area of deep frustration and concern to not
only the resident, but their family and the facility as a whole.
 Residents select their meals, believing they will arrive with all
items requested, in the proper consistency and within the diet
type specified by medical professionals.
 Residents expect meals to look attractive and taste desirable,
so they are able to meet their nutritional needs.
INTRODUCTION
 Missing tray items were common source of concern at the
residential and rehabilitation facility used for the purpose of
this project.
 Patients complaints:
 Meals not as they expected and low meal satisfaction
 High rate of meal tray inaccuracy
 The facility loses in two ways: food and staff labor costs increase, as the
meal needs to be corrected, and resident/customer satisfaction
decreases.
 A facility must strive to maintain a level of satisfaction from
their customer in order to function successfully as a business
CURRENT MENU EXAMPLE
OBJECT OF PI PROJECT
 TRAY PRESENTATION: This process encompasses timeliness of
tray delivery, temperature, tray accuracy, the appearance of
foods, and the taste of foods.
 Main goal:
 Increase resident satisfaction through monitoring the meal tray
processes in place, measure the critical areas of concern, and
suggest and/or pilot changes that could improve meal satisfaction.
 The outcome of this process improvement study could
potentially decrease the workload of the kitchen/dietary staf f,
as less time will be spent reconciling unsatisfied residents,
through meal tray correction, fulfilling requests for additional
foods to replace the original meal, etc.
METHODS: OVERVIEW
 The initial stages of this study:
 Observation of the tray line, the system in place at this facility
through which breakfast, lunch, and dinner meal trays were
assembled
 To gain an understanding of the work load on dietary staf f
members, each tray line position was worked following the
observation. Data was collected on days during which
dif ferent staf f members worked dif ferent positions, to gain a
wide perspective when studying tray presentation.
 Resident Meal Satisfaction Surveying
 Surveying the cooks
 Tray accuracy audits
 Meal tray audits: specific diet and consistency, measuring
quality of meals and timeliness of tray passing
 Plate waste studies
METHODS: SURVEY
 At the 225-bed facility, a total of 30 residents from all units
combined were surveyed to obtain a wide mix of responses.
 The surveying was conducted after dif ferent meals, both
meals known to be well-liked and some disliked by residents,
to avoid bias, and at each of the meal times (breakfast, lunch
and dinner).
MEAL SATISFACTION SURVEY
1.What is your favorite item/meal on the current menu?
2.What changes would you make to the current menu?
3.Please respond to the following statements using the chart provided:
Strongly
disagree (1)
a. Food is
always the
temperature to
my liking
b. There is
enough variety
in the menu
c. The time it
takes for my
meal to arrive
is appropriate
d. The food is
presented
attractively
e.Minimizing
waste is
important to
me
f. I am always
able to find
something I
like to eat
Disagree (2)
Neutral (3)
Agree (4)
Strongly
Agree (5)
METHODS: TRAY ACCURACY
 As soon as each full cart carrying meal trays to each unit was
assembled and ready for delivery, trays were pulled from the cart
and checked to see whether the meal ticket listing each item to
be served matched the actual items on the tray.
 In order for a tray to be completely accurate, each item had to be
present, at the right consistency identified on the ticket, and
provided in the correct portion listed.
 Additionally, many meal tickets made specific notes according to
the patient’s needs/wants, such as “no straws” or “no green or
black specs.”
 A meal ticket would also list any adaptive eating equipment that
the resident required.
 All specifications that the meal ticket listed were to be reflected
in the meal provided in order for that meal tray to be 100%
accurate.
METHODS: MEAL TRAY AUDITS
 A separate tray audit was conducted specifically designed to test
temperature of food, appearance and taste of food, as well as
timeliness of tray passing (the time it takes the meal to arrive to
the resident).
 A meal ticket was put into the GeriMenu ticket generator system
with specifications for a made up resident.
 This audit measured the temperature of food on tray line at the
point of service, taking the temperature of foods in the steam
table bins that were portioned onto plates in tray assembly. It
took note of the time at which meals left the kitchen, the time at
which meals arrived to the specified unit, and the time of
service, or when the resident would be served.
 At the time of service, the meal tray was assessed for accuracy
of the meal tray, presentation, temperature, and taste .
 This audit was conducted seven times throughout each daily
meal, breakfast, lunch, and dinner.
METHODS: PLATE WASTE MEASURES
 Plate waste studies were conducted to measure the amount of
waste over three meals assessing 130 meal trays from all
units combined.
 The audit used to measure plate waste categorized the trays
into three groups based on three amounts of consumption.
 When looking at the meal tray, the auditor circled the amount
consumed; 25-50%, 50-75%, or 75-100%.
 Plate waste studies were conducted three dif ferent days,
measuring intake following each of the meals of fered,
breakfast, lunch, and dinner.
STUDY PLAN
 All activities to be per formed for the project and estimated time
needed for completion:
 Observe tray line—3-4 days
 Observe end result of tray coming off tray line —3-4 days
 Work each tray line position and take note of needs for improvement in tray line
process as a whole—1-2 weeks
 Discuss finding with preceptor, cooks, and shift managers —3 days
 Question cooks on taste-testing food and meal satisfaction —1 day
 Develop resident meal satisfaction survey —3 days
 Conduct resident survey—2 weeks
 Conduct tray accuracy audits—2 weeks
 Conduct test tray audits
 Create resident with specific diet and needs on meal ticket
 Audit tray for temperature, presentation, accuracy, timeliness, and taste —7 test
trays over 3-4 days
 Conduct plate waste studies—3days
 Analyze data—1 week
 Propose suggestions for improved process
 Use hard cups in place of plastic and Styrofoam disposable cups
 Use highlighter to indicate missing item being fetched by “runner” position
 Pilot suggested changes —1 week
RESULTS: SURVEY
 1) Favorite meal: 3 of 30 residents surveyed answered
“spaghetti and meatballs.” All other answers varied with no
trends identified.
 2) What would they change: 12 residents responded they
would not change anything about the current food service. 4
residents stated they would change the sandwiches typically
served at dinner. 2 residents stated they would change the
salads of fered and disliked the current salads served. 1
resident stated they would of fer spaghetti and meatballs
more frequently and 1 resident stated they would of fer a
greater variety of foods.
RESULTS: SURVEY
3) Results below:
a. Food is
always the
temperature
to my liking
b. There is
enough
variety in
the menu
c. The time
it takes for
my meal to
arrive is
appropriate
d. The food
is presented
attractively
e.
Minimizing
waste is
important to
me
f. I am
always able
to find
something I
like to eat
Strongly
Disagree
10=33%
Disagree
Neutral
Agree
9=30%
3=10%
8=27%
Strongly
Agree
0
3=10%
7=23%
1=3%
19=63%
0
6=20%
12=40%
3=10%
9=30%
0
2=7%
4=13%
4=13%
20=67%
0
0
6=20%
2=7%
21=70%
1=3%
2=7%
9=30%
1=3%
18=60%
0
RESULTS: TRAY ACCURACY
 Tray audits, conducted over 5 days, during each meal service
to evaluate tray accuracy, revealed 370 out of 500 (74%) meal
items were accurate on average.
 The daily accuracy level ranged from 46% accuracy to 95%
accuracy.
 This wide range in the end product was primarily due to the
range in skill level of the meal tray “checker” staf f member on
duty for that meal.
 Some staf f had more experience in this position than others
and the data reflected this discrepancy.
RESULTS: TRAY AUDITS
 The 7 test trays analyzed for accuracy, presentation,
temperature, timeliness and taste over 3 days during
breakfast, lunch and dinner gave insight to the role of dietary
staf f in maintaining quality food service.
 Temperature: 5 out of 7 trays contained items that were above or
below proper temperature.
 Accuracy: 2 test trays were inaccurate when the meal tray items were
compared to the meal ticket, as there was a missing item on one
occasion and a straw was present on the tray, though the ticket
indicated “NO STRAW” (a common request for residents at the facility
to ensure their safety).
 Taste: adequate and presentation was acceptable on all 7 test trays
audited.
 Time: arrival of meal tray to the proposed resident varied based on
the unit, which identified this as a critical control point which
depends on nursing staff in order to maintain quality, as the
temperature of the foods is greatly impacted.
RESULTS: PLATE WASTE
 Day 1 audits:
 Indicated half of the residents (63 out of 126 trays assessed
consumed 25-50% of their meal and the other half consumed 75 100% of their meal
 Day 2 audits:
 70 (58%) residents consumed >50% of their meal
 Day 3 audits
 75 (63%) residents consumed >50% of their meal.
 As these studies were conducted after each of the three daily
meals (breakfast, lunch, and dinner) and following meals that
were both known to be liked and dislike, the results provide
an accurate assessment of the average level of intake with
the current menu in place at this facility.
IN-SERVICES
 Highlighting missing items at the end of tray line
 “Loader” position
 Piloting this change
 Catch the Wave
 Hydration Station education
 Prevention of dehydration




Identification of at-risk population
Signs and symptoms
Policy and procedure development
Pre/Post questionnaire
DISCUSSION AND RECOMMENDATIONS
 Need for policy and procedure of positions in tray line
 Ownership of tray line position roles
 Variance in accuracy due to which staf f performed “checker”
role
AREAS FOR FURTHER STUDY
 Tray passing:
 Timeliness of meal delivery to the patient
 Auditing nursing staff role
 Conducting resident meal satisfaction surveys after
implementation of changes developed to improve the process
of tray presentation
 Changes in effect that could be studied upon follow -up surveying
 Making more of the food served from scratch and buying fresh foods
 Serving fewer prepared and/or frozen items
 The menu is currently being updated to reflect the goals of the new
management company
 Additionally, a larger sample size of residents surveyed would
yield greater data for consideration.
THEME MEAL
THEME MEAL
Tuesday March 4th
Main entrée: jambalaya with okra and a wheat roll
A traditional dish of rice, shrimp, chicken sausage, and ham with Creole seasoning
and vegetables. A side of steamed okra and a wheat roll make this meal deliciously
satisfying!
Alternate: chicken gumbo
A flavorful tomato-based stew made with chicken, sausage, rice, and veggies,
including okra, carrots, and onions
Dessert: King Cake
Festive yellow cake with delicious sugar glazed topping in the traditional Mardi Gras
colors of purple, green, and gold
**A tasty celebration!**
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