Gwen Friesen
Introduction
The purpose of this study was to establish an internal benchmarking system to provide a tool to
continually monitor and evaluate accuracy and efficiency of a hospital tray line assembly. Data
was gathered November 6-8, 2013 at the Stratton VA Medical Center located in Albany, NY.
Benchmarking is "a continuous, systematic management tool for measuring work processes,
products and services for the purpose of organizational comparison and improvement." 1
Initially developed for the manufacturing industry, benchmarking has been shown to be
applicable to other industries including food service.2 Benchmarking has been utilized in the
food service industry as a way to improve production, define performance standards and
establish performance goals.2 In selecting processes to benchmark, it is essential to select those
that are central to the operation of the department.3 Quality has been identified as a critical
performance element in a hospital tray line assembly, with accuracy and efficiency as
measurable indicators of quality. 2, 3, 4, 6 Accuracy and efficiency are vital for any foodservice
operation, but in a healthcare setting they take on even more importance. It is essential for the
health and well-being of the patient that the meal delivered reflects the prescribed diet (accuracy)
and that the assembly is done as quickly as possible (efficiency). Once the critical processes have
been identified for benchmarking the metrics for each must be defined. This involves specifying
what will be measured, establishing the units of measure, and the calculation method.5 In a tray
line assembly, the tray ticket contains information regarding the diet order, allergies and food
preferences. The accuracy rate of the tray line is a measure of how closely the assembled tray
reflects the information on the tray ticket.6 Tray line efficiency was defined as the number of
trays assembled per minute. The fast paced environment in which hospital food service
departments operate dictates that the tray line performs as efficiently as possible. A large
quantity of meals must be assembled within the time allotted for the meal service. The meals are
1
Gwen Friesen
also frequently assembled a distance from where the meals are served. To overcome these
hurdles and still ensure that every patient receives the correct and a quality meal it is critical that
tray assembly efficiency be maximized.
One goal of an internal benchmarking is to establish realistic performance standards and goals
based on the current level of performance.6 Accuracy and efficiency data were collected from the
tray line operation and utilized in the development of these performance standards. A second
objective of internal benchmarking is to continually and systematically evaluate current
performance data against these standards.6, 7 If performance standards are not met a corrective
action is implemented to improve performance. The benchmarking tool defines the process of
implementing and documenting the corrective action, which includes identifying the problem,
assigning a corrective action, establishing deadlines, and monitoring the effectiveness of the
corrective action.
Materials and Methods
A Program Evaluation and Review Chart (PERT) chart was developed to establish a timeline
and coordinate the essential steps of the study (Appendix A). Forms to record accuracy and
efficiency data were developed to ensure data was collected accurately and consistently. The
efficiency tool (Appendix B) documented the beginning and end times of the tray service as well
as the number of trays processed. The formula for trays per minute was determined by dividing
the number of trays processed by the total tray line operation time, in minutes.6 Space was
provided on the form to record observations made during the tray line assembly. Pertinent
observations may include reasons for belt stoppages, food shortages, organization of work
stations, or any related action or behavior that may impact efficiency. The accuracy tool
2
Gwen Friesen
(Appendix C) lists the total number of items on each audited tray as well as the number of
discrepancies found between the assembled tray and the tray ticket. Missing/omitted items can
be documented on the form to allow for more a detailed reporting of errors. For example, if all
discrepancies were associated with the beverage station, the station setup, as well as employee
performance, could be investigated to determine the root cause of the error.
Data was collected from five meal services, two breakfast and three lunch meals. Assembled
trays were audited at the end of the tray line prior to being loaded onto the delivery cart. A total
of 50 assembled trays were audited for accuracy, with ten trays selected randomly from each
meal service. Assembled trays were compared against the items listed on the tray ticket and the
number of discrepancies recorded. In addition, the duration of each meal service was recorded
along with the total number of trays assembled.
The start time of the tray line was designated
when the line supervisor turned on the tray line belt; the end time was when the last tray was
loaded onto the delivery cart. Prior to each meal service the tray tickets were counted to
determine the number of trays assembled.
Results
At the completion of the data collection process, the data was sorted by the five meal service
categories and analyzed to determine the accuracy and efficiency rates for each breakfast and
lunch serving. The tray line accuracy was determined to be 98.9% (365 correct of 369 total
items). Figure 1 contains the accuracy data collected for each of the five meals.
3
Gwen Friesen
Figure 1 - Tray Line – Accuracy
Meal
Total #
of Items
Total #
of Errors
Total # of
Correct Items
Accuracy
Rate
Breakfast 1
80
0
80
100%
Breakfast 2
71
2
69
97.2%
Lunch 1
76
1
75
98.7%
Lunch 2
65
1
64
98.4%
Lunch 3
77
0
77
100%
Total
369
4
365
98.9%
The efficiency rate for the five meal services was 2.13 trays per minute (525 trays assembled in
247 minutes). Figure 2 contains the accuracy data collected.
Figure 2 - Tray Line – Efficiency
Meal
Minutes of
Operation
# of Trays
Trays per
Minute
Breakfast 1
44
87
1.98
Breakfast 2
38
86
2.26
Lunch 1
55
120
2.18
Lunch 2
50
108
2.16
Lunch 3
60
124
2.07
Total
247
525
2.13
4
Gwen Friesen
Discussion and Recommendations
Measurable indicators of quality of the tray line assembly were indentified as accuracy and
efficiency. In a healthcare setting, accuracy is essential to ensure adherence to the prescribed
diet order for each patient. The timeliness of meal delivery is largely dependent on the
efficiency of the tray line assembly. An internal benchmarking system was developed to
establish a method for continually monitoring and improving quality of the tray line operation.
The data collected served to establish baseline performance and was utilized to develop goals
and benchmark performance standards for accuracy and efficiency. The tray line assembly was
determined to operate at a 98.9 accuracy rate for the timeframe studied. Although a high rate of
accuracy was demonstrated, the benchmark goal was set at 100% as any deviation from the tray
ticket could have major implications for the health and well-being of the patient. The study
found the tray line efficiency rate to be 2.13 trays per minute; this rate was adopted as the
benchmark performance standard for efficiency.
An audit schedule (Appendix D) was developed requiring that each meal service be audited for
accuracy once every three months. Efficiency data is gathered at every meal service. The data
collected is entered into an electronic spreadsheet form (Appendix E) that calculates the rates for
accuracy and efficiency and allows performance trends to be easily monitored. When baseline
performance standards or goals are not met, the benchmark system provides a process for
documenting the identified problem, assigning corrective action, establishing deadlines and reauditing to validate the effectiveness of the corrective action.
A major component of benchmarking is the systematic collection of data to establish historical
trends of performance. To accomplish this, data collection must occur at uniform time periods to
5
Gwen Friesen
allow for consistent analysis and comparison of data. The timeframe between audits provides
sufficient time for corrective action, when warranted, to be identified and implemented prior to
the next audit. In this manner evaluation of the corrective action is built into the system. The
audits also occur frequently enough to ensure there are not extended time periods of substandard
performance. It is through this process of monitoring performance trends that best practices, the
ideal methods to complete a task, can be identified.4
Since efficiency data is relatively simple to collect, an efficiency rate is calculated for each meal
service. As with accuracy data, performance trends are established and monitored to determine
best practices. For example, if the lunch service on Thursday is consistently below the
performance standard an analysis can be conducted to determine the root cause and action
required to improve the efficiency. Efficiency data allows for extremely timely feedback on
performance. The tray line supervisor can utilize this information as a tool to motivate
employees and provide tangible evidence of performance. The data could also be utilized in
performance evaluations as quantifiable measure of performance for kitchen workers, tray line
supervisors, as well as the kitchen manager. It is important to acknowledge that an over
emphasis on efficiency can inadvertently cause a decrease in accuracy. Best practices for
efficiency must account for a balance between the two measures of quality.
Although the benchmarking system was not implemented, the demonstrated accuracy rate of
98.9% was below the goal of 100%, indicating the need for corrective action. A potential
problem source was identified as inadequate setup of the tray line stations. A corrective action
plan was developed detailing the proper station configuration and minimum quantities required
for each meal service. The action plan also includes the development of an in-service training
session to communicate the information to all employees, as well as a pre-meal service checklist
6
Gwen Friesen
to be completed by the tray line supervisor. The checklist provides a method for the supervisor
to systematically verify that each station is adequately prepared for the meal service, as well as
identifying workers who may need to be retrained in appropriate station set-up. The kitchen
manager would be tasked with the final responsibility of implementing this corrective action, but
drafting the instructions would be assigned to multiple supervisors.
Benchmarking is clearly more than just a data collection tool. The implementation of an internal
benchmarking system provides the means for a food service department to continually monitor
performance, and when necessary, take action to ensure the desired tray line accuracy and
efficiency rates are maintained.8 In addition to responding to declines in performance standards,
best practices for achieving quality can be established. These best practices are based on
performance statistics and represent methods of operation that consistently result in high
performance standards and the achievement of desired quality goals.
The benchmarking system develop here should be viewed as a template for implementing a
comprehensive benchmarking system for the food service department. The system could be
expanded to include other critical elements such as food waste, food temperatures, food cost, and
patient satisfaction.
7
Gwen Friesen
Appendix A
8
Gwen Friesen
Appendix B
9
Gwen Friesen
Appendix C
10
Gwen Friesen
Appendix D
Benchmarking System
1. Once a month audit for both efficiency and accuracy.
a. Utilize observational tools developed for study
b. Complete tally sheet to determine accuracy rate and trays per minute.
c. Rotate the meal service audited each month so every meal is audited four times a
year.
January: Breakfast
April: Breakfast
July: Breakfast
October: Breakfast
February: Lunch
May: Lunch
August: Lunch
November: Lunch
March: Dinner
June: Dinner
September: Dinner
December: Dinner
2. Input data from tally sheet into benchmarking tracking spreadsheet
3. Review the data and observational notes.
4. Corrective action is warranted when a decrease in either rate is recorded or when
observational notes indicate behaviors not in adherences with operational guidelines.
5. Utilize corrective action form to:
a. Develop action plan
b. Assign ownership
c. Determine deadlines
d. Document specifics of corrective actions
11
Gwen Friesen
Appendix D
Corrective Action Form
Problem:
Correction Needed:
Action Plan:
STEP 1:
Assigned To:
Due Date:
STEP 2:
Assigned To:
Due Date:
STEP 3:
Assigned To:
Due Date:
12
Gwen Friesen
Appendix E
13
Gwen Friesen
Appendix E
14
Gwen Friesen
References
1. Johnson B, Chambers M. Foodservice benchmarking: practices, attitudes, and beliefs of
foodservice directors. J. Am. Diet. Assoc. 2000;100(2):175–180.
2. Johnson,B, Chambers M. Expert panel identifies activities and performance measures for
foodservice benchmarking. J. Am. Diet. Assoc. 2000;100(6):692–695.
3. Jackson R. Benchmarking food costs. Hosp. Food Nutr. Focus. 1996;12(6):1–5.
4. Sawyer C, Richards, R. Continuous quality improvement in hospital foodservice. Food
Technol. 1994;September:154–158.
5. Stroud J. Understanding the purpose and use of benchmarking. i six sigma. 2010.
Available at: http://www.isixsigma.com/methodology/benchmarking/understandingpurpose-and-use-benchmarking/. Accessed November 29, 2013.
6. Puckett R. Food service manual for health care institutions. 3rd ed. San Francisco, CA:
Jossey-Bass; 2004.
7. Mahalik P. Benchmarking: ten practical steps with review points. i six sigma. 2010.
Available at: http://www.isixsigma.com/methodology/benchmarking/benchmarking-tenpractical-steps-review-points/. Accessed November 29, 2013.
8. Schuster K. Benchmarking: how do you measure up. Food Manag. 1997:42–49.
15