Trends in the use of technology in hospital menu system

Rochester Institute of Technology

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1998

Trends in the use of technology in hospital menu

system

Karen Wunder

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TRENDS IN THE USE OF TECHNOLOGY

IN

HOSPITAL MENU SYSTEMS

by

Karen A. Wunder

A thesis submitted to the

Faculty of the School of _Food, Hotel and Travel Management at

Rochester Institute of _Technology

in partial fulfillment of the requirements for the degree

of

Master of Science

FORM I

ROCHESTER INSTITUTE OF TECHNOLOGY School of Food, Hotel and Travel Management

Department of Graduate Studies

M.S. Hospitality Tourism Management Presentation of ThesislProject Findings

Name: Karen A. Wunder Date: 7-20-98 SS#:

-Title of Research: Trends in the Use ofTechnology in Hospital Menu Systems

Thesis Committee:

Faculty Advisor:

(1) (2)

Dr.Carol Whitlock (Chairperson) Elizabeth Kmiecinski. MS

Elizabeth Kmiecinski. MS

Number of Credits Approved:

I1?3

J

_f'!Y

Date

06 Credits

Committee Chairperson's Signature

Department Chairperson's Signature

ROCHESTER INSTITUTE OF TECHNOLOGY Department of Hospitality and Service Management

Graduate Studies

M.S. Service Management

Statement Granting or Denying Permission to Reproduce Thesis/Graduate Project

The Author of a thesis or project should complete one of the following statements and include this statement as the page following the title page.

Title of Thesis/projeet: Trends in the Use of Technology in Hospital Menu Systems

I, KarenA. Wunder , hereby (grant, deny) permission to the Wallace

Memorial Library ofRLT., to reproduce the document titled above in whole or part.

Any reproduction will not be for commercial use or profit.

OR

I, ,prefer to be contacted each time a request

for reproduction is made. I can be reached at the following address:

ABSTRACT

As the trenty-first _{centuryapproaches, hospital} foodservice directors are

facedwith the_conflicting tasks of _cutting costs in response tovarious _budgetary

restraints while also _{providing quality} service to customers with increased

expectations in an _increasing competitive environment. New technologies such

as _{computerized,} interactive menu systems have been developed in an attempt

to offer increased customer satisfaction while also _cutting costs at all levels.

The focus of this_study wasto determine how hospitals nationwide were

responding to the dilemma of cost _cutting while _achieving increased _quality

standards and in what ways technologies were _being embraced to provide

service excellence at cost savings.

The _studysought to _identifythe most_commonly utilized menu systems in

US hospitals and to _identifytrends in the use of recent technologies for such

menu systems.

Questionnaireswere sent to 300 hospitals from 41 states and

Washington, DC. Programs and routines in the Statistical Package forthe

Social Sciences (SPSS-X, version _{2.1, 1986, SPSS,} Chicago, IL) were used

for all data analyses. One hundred and thirty-five _(47%) of questionnaires sent

were returned.

Results indicated that 3 ofthe 135 respondents were _utilizing automated

menu _displaysystems, the _{majority (70%)} of hospitals were still _utilizing

utilized for _recording menu _choices, 12.6% were _using a computer in the diet

office, 3% were _{using hand-held computers,} 2.2% were _using voice activated

computers, and 0.7% were _using scanners. The question was not applicable

for 9.6% of respondents whooffered a non-select _menu, and 1.5% of hospitals

who indicated that _theyserve meals _immediatelyas ordered.

The majority of respondents indicated that _theywere somewhat satisfied

with theircurrent menu system regardless of whether or not_theyhad an

automated system in place. Most respondents indicated that _they would

TABLE OF _CONTENTS

Abstract _ii

Acknowledgments vi

List of Tables vii

Chapter I. INTRODUCTION 1

Problem Statement 3

Background 3

Purpose 6

Significance 6

Hypothesis 7

Assumptions 7

Scope and Limitations 8

Long Range Consequences 8

Definition of Terms 1 0

Chapter II. LITERATURE REVIEW 12

The _Changing Paradigms of Healthcare 12

Obstacles for Change 14

Meeting the Demands of Customers 15

Satisfying the Needs of Customers

Through _Technology 1 6

The _History of _Technology in Foodservice... 1 9

Table of Contents _(continued)

Addressing the Problems of Traditional

Menu _Delivery Systems 21

Implementing Foodservice _Technology 24

Automated Systems in Progress 27

Chapter III. METHODOLOGY 30

Questionnaire Development 30

Data Collection 30

Data Analysis Method 33

Chapter IV. RESULTS AND DISCUSSION 34

General Characteristics of Respondents 34

Characteristics of Menu _Display Systems 37

Chapter V. _{SUMMARY, CONCLUSION,}

RECOMMENDATIONS 51

Summary 51

Conclusions 51

Recommendations 52

Bibliography 53

Appendices 55

A. Cover Letter to Foodservice Directors 5 6

ACKNOWLEDGMENTS

I am grateful to Dr. Carol Whitlock for her constant support, extreme

flexibility, realistic _wisdom, and generous encouragement.

I would like to thank Liz Kmiecinski for her patience and guidance

throughout the project.

I would also liketo thank Sharon _Keys, Jim Frederiksen andthe staff of

Strong Memorial Hospital's Department of Food and Nutrition Services for their

time and assistance in _getting thisproject started.

List of Tables

Table No. _{Page No.}

1. Distribution of _{Questionnaires by State 3 2}

2. Number of _{Patient Beds 3 5}

3. Type of Foodservice System in Use 36

4. Type of Menu Utilized 3 7

5. Menu _Display Systems _Currently in Use 3 8

6. Method of _{Obtaining Patient Menu Selections..} 3 9

7. Method for _Recording Menu Choices 41

8. Goals Considered in _Changing Menu

Recording Systems 43

9. Respondent Satisfaction _Rating of Menu

Entry Systems 45

10. Decision to Consider Future Automation in

Menu Choice _Entry systems Based on

Satisfaction with Current System 4 7

1 1 . Factors Considered in Deciding Whether or

Not to Implement an Automated Menu Choice

Chapter I.

INTRODUCTION

Today's hospital foodservice directors are faced with the _conflicting and

challenging task of _cutting costs in response to _budgetary constraints while

providing service of utmost_quality to customers with increased expectations in an _increasingly competitive environment.

Budget cutting often involves reductions in the areas of department

staffing, availability of menu items and _services, decreased use of high quality, brand-identifiable food items, and _ultimately a reduction in _quality of services.

However, the _quality of the food service often produces positive word of mouth

among patients which is _increasingly significant as competition grows.

Hospital food service and cuisine are fabled for _{literally leaving} a bad

taste in one's mouth. One can envision the traditional scenario. A_trayoffood is

served _byan employee who _simply places the _tray in the room and rushes out. The food is bland in both looks and _taste, and _probably not what the patient

ordered if_{any ordering} was done at all. Ifthepatient staysatthe hospital two or three _days, he or she _{may eventually} select from a menu or converse with a foodservice employee who will record his or her food preferences. For _many

Average hospital stays have now become shorter in response to

increased _ambulatory care and hospitals are _{increasingly responding} to

market-based competition.

It is now imperative that hospital foodservice departments provide competitive

quality at the lowest possible cost. New technologies such as computerized,

interactive menu systems could _{theoretically} allow foodservice departments to

offer increased customer satisfaction while also _cutting costs atall levels. The

focus ofthis_studywas todetermine how hospitals nationwide were _responding

to the dilemma of cost _cutting while _achieving increased _quality standards and

in what ways technologies were _being embraced to provide service excellence

PROBLEM STATEMENT

Numerous strategies _{may be} utilized for _adjusting a hospital menu

system in response to budget constraints and/or increased service quality.

Some hospitals have focused _{predominantly} on financial limitations _{by offering}

less food selections at meals or no choices of food items. Others have been

motivated _by competition and service excellence, offering restaurant or hotel-type service or _{by offering} increased personal interaction between patient and

hospital representative. Still others have attempted to find a _way to both cut

costs and increase customer _{satisfaction,} often _utilizing technologies such as

computerized menu systems. This was an attempt to _identify a wide range of current menu systems strategies and the rationale for such operations.

Specifically, this_studyexamined the extentthatnew technologies were use and

theoutcome or predicted outcome tocost and patient satisfaction.

BACKGROUND

Thetraditional hospital menu service involves printed, paper menus that

are _usually generated from a _dietary department office and passed _by hand to each patient. The patients are given a certain length of time to select menu

choices forall three meals forthe next_daybefore _theyare picked _upby hospital

edited to assure that the selections picked _by the patient _comply with therapeutic diet restrictions.

This system has various shortcomings. _{Usually, many} employees are

involved in the menu _delivery and pick _up process. For _example, one

employee _{may be} in charge of _delivering all menus to a patient unit, another

responsible for _delivering the menus to each _patient, another in charge of

picking up the menus and _returning them to the kitchen, and yet another

employee responsible forreview and _editing the menu selections. Often various departments are involved. Foodservice employees, for example, may be

responsible for _delivering the menus to patients, but it _may be _nursing or unit

staff who are _actually available to patients on the unit to assist in the menu selection and retrieval process. Foodservice staff with clinical nutrition _training

may then be responsible for _reviewing and _editing selections. Ifone of these employees fails in his or herduties, the patients will not receive their own meal

choices.

Paper menus are often expensive to print and are _{environmentally}

wasteful. _Theyofferlimited information to patients, are _{generally inflexible,} and

are _easily lost and soiled. Menus are _usually picked _{up from} patient rooms in the_early afternoon. If a patient arrives after the scheduled menu pick _{up time,} he or she _{usually has} no opportunity to select menu choices. In these cases,

thepatients must accept standard menu fare forall mealsforthe following day. Hospitals as a whole are responding gradually to theproblematic area of

others have made some modifications such as _prescreening some patients for

food preferences and menu selections prior to admission or _installing

computers to print menu selections and store patient food preference data.

Other facilities have taken more user _friendly measures such as _installing

interactive software thatallows patients toselect menu items fromtheir rooms or

providing staff with palm held computers that allow patient selections to be

personally retrieved and _instantly conveyed tothekitchen diet office.

A brief pilot _study of five _Rochester, New York area hospitals was

conducted. Foodservice staff from _Strong Memorial _Hospital, Highland

Hospital, St. Mary's _Hospital, Rochester General Hospital, and Park Ridge

Hospital were asked to _briefly describe the menu presentation and selection

recording systems _currently in place. All five hospitals presented meal choices

to patients via paper menus. Two of the five had computerized diet offices.

Three of the five were _obtaining menu selections from patients _{by collecting}

menus with patient circled food choices. One hospital was _utilizing hand held

computers operated _byfoodservice staffto obtain patient food selections, and

the other was _{experimenting} with palm _top computers at the time of this study.

PURPOSE

The purpose of this _study was to _identify the most _commonly utilized menu systems in US hospitals and to _identify trends in the use of recent technologies forsuch menu systems.

SIGNIFICANCE

Inthisera of_increasing hospital _{downsizing, merging,} and even _closings,

identifying competitive methods involved in the inpatient foodservice menu

delivery system is important. Foodservice administrators will have interest in

this_studyas a method of_obtaining market _survey data to determine whether or

not their present procedures are _up to current market standards and to obtain

ideas for possible systems improvements. The _study is significant to

HYPOTHESIS

Theexpected result ofthis _studywas_that,while automated menu system

technologies are_{becoming increasingly available, they} are _currently not _widely

used to _convey menu choices. The hypothesis was based on the pilot _study

wherein none of the five hospitals surveyed were _utilizing automated methods

to_convey menu choices to patients. As the pilot _study revealed that two of the

five hospitals surveyed _(40%) were _utilizing some form of computerization to

record patient menu selections, it is further hypothesized that the data will

reveal thatlessthan one-half ofhospitals surveyed will be found to be _currently

using software packages toassist inthe _recording of patient menu selections.

ASSUMPTIONS

Ideological

Any analysis to be done in the comparison of hospital menu systems

must guard against personal bias.

Procedural

Itwas assumed that foodservice directors were able to determine which

menu systems were _presently in use or have been used in the past and that

they have provided accurate responses to the questions contained in the

questionnaire. Since the SPSS-X software was used for statistical analysis of

data, it was was assumed that the results were not manipulatable as data was

numerically scored.

SCOPE AND LIMITATIONS

This limitations of this _study were affected _by the selection of the

participants and _by the scope of the study. The _study was focused on

discovering trends in menu systems and does not detail the strengths and

weaknesses of_anyofthe menu systems_{currently being} utilized.

LONG RANGE CONSEQUENCES

The results of this _study can serve to stimulate further research on the

use of _technology to improve customer satisfaction in regard to foodservice in

health care. Should the findings of this _study be in accordance with the

hypothesis, further research should be undertaken to further validate the

hypothesis, will be beneficial for all foodservice directors in _determining the

DEFINITION OF TERMS

Automation Automaticoperation of an _{apparatus, process,} or

system _by mechanical or electronic devicesthat take

the place of human operators _{(Webster, 1964)}

Blast _Chilling Process wherein food is cooked, quicklychilled, and

later reheated.

Continuous _Quality

Improvement - A

long-term, proactive _strategyto improve patient

care and _{satisfaction, increase} utilization, strengthen

productivity, and enhance cost-effectiveness

throughout the organization (Byers et al., 1994)

Cycle Menu A menu that repeats at regular intervals

(Kotschevaretal., 1996)

Entrepreneurship - The _{act of organizing,} managing, and

assuming

Full Time

Equivalent _(FTE) Employeewho works on afull-time basis for a

specific period of time(Byers et al., 1994)

Paradigm A mental frameof reference thatdominates the

behavior and thought processes of an

individual or _group of individuals (Albrecht, 1₉₉₀₎

Paternalism The principle or practice of _governing or of

exercising authority (as over a _group of _employees)

suggesting the care and control exercised _by afather

over his children _{(Webster, 1964)}

Segmentation - The _{process of}

dividing into _many sections (Webster,

1964)

Service Ataskperformed _by one_partyfor thebenefit of

another _{(Albrecht, 1992)}

Technology - A technical method of achieving a practical purpose

(Webster, 1964)

Chapter II.

LITERATURE REVIEW

The Changing Paradigms of Healthcare

The health care _industry is _currently in a vast state of change. Costs are

high, with health care expenditures _up over 800 percent since 1960 (Boyle et

al., 1994). _By 1992, more than 14 percent of the gross domestic product was

spent on health care (Byers et _al., 1994). Various societal factors have

contributed to this rise in health care expenditures, _including an _aging

population, increased demand fostered bymore consumer awareness of health issues, an increased focus on preventitive medicine, and _continuing

technological advances in medicine. The _rising costs associated with the

health insurance process, the healthcare liability insurance for practioners,

innovative technologies, and administrative expenses have also contributed

substantially tothe overall increase in the cost ofhealthare (Boyle etal., 1994).

Efforts to combat _rising health care costs have included the reduction of

length of hospital stays and _increasing copayments and deductibles for

physician reimbursement _{mechanisms, theslowing} ofhospital construction, and

restrictingthe access of new _{technology (Boyle etal., 1994).}

While _contending with _{rising costs, the} health care _industry is also

experiencing such paradigm shifts as increased government intervention and

an increased focus on customer _{satisfaction, high-quality care,} continuous

quality improvement and advances in _technology, and a work force which is

increasingly older, less _literate, and _culturally diverse (Byers etal., 1994).

Zemkecites thedilemma oftoo_many hospital beds _competing fortoofew

patients as the core of the ills _penetrating the American health care system.

Increasingly, overcapacity threatens to undermine hospital profits as patient

volume declines and costs increase (Zemke et al., 1989). Major medical

service providers have undergone vast changes in this world of cost

containment and budget controls. _Shrinking revenues have spurred tight

competition _among health service providers and patients are _increasingly seen

as customers (Wielawski, 1993). Hospitals are now _{understanding} that patients

are _people, people are _actually markets, and market needs must be addressed

to remain in business. _According to _Zemke, hospital administrators must

increasingly devote their predominant efforts on ways to _stay ahead of the

competition, with the focus on _marketing strategies and segmentation.

Hospitals are _{becoming increasingly} hotel-like, with _{many offering luxury} suites

forupscale patients. The focusofpersonnel _training is changing, and hospitals

are now _{routinely offering} people-skills _training programs. Hospitals are _finding

various new ways of_creating revenues from classes in fitness and weight

reduction to _packaging and _selling meals for individuals with special _dietary

needs (Zemke etal., 1989 ).

Obstacles for Change

In this age of change and customer service _{focus, Eisenberg} states that

the health care _industrymustovercome four traditional barriers to_developing a

service orientation. These are:

1. hospitals are extremely regulation governed;

2. _they hold atraditional resistance to_{entrepreneurship;}

3. _they breed a culture of_paternalism; and

4. the traditional medical model serves as a pretextfor interactions

between health care workers and customers. _(Eisenberg, 1997).

Perhaps one of the most recent significant additional government

regulation _facing the health care system of the United States has been the federally instituted plan _calling for payment _by Diagnostic Related _Grouping

(DRG). Under this system, initiated in October of _1983, the government

reimburses the health care provider a flat rate based upon the _{statistically}

estimated amount oftimeinvolved in a given procedure. The _theory is that the time and care required for a medical procedure can be based on a statistical

norm, with reimbursement to the provider _being based on that midpoint.

Hospitals therefore stand to lose revenue on treatments _requiring time above

the norm, but obtain increased profits in_treating patients who move through the

Meeting the Demands of Customers

Thetraditional service _{firms, dating} from the industrial revolution through

the _1970's, built market shares on two main strategies. _First, the focus was to

maximize tangible _quality attributes of products in an effort to raise perceived

value in the eyes of the consumer. _Secondly, firms attempted to increase

productivityand optimize standardization techniques in order to_keep prices low

(Vandermerwe etal., 1988).

The _{1980's, however,} were marked _by significant changes in service

firms. Services were no longer individual components, but rather a part of a

total _marketing package. As value is now associated with overall performance

of the whole _system, today's market leaders must offer product-service

combinations (Vandermerwe etal., 1988).

There are various premises that differentiate the consumer of _today

versus thetraditional customer. Thetraditional consumer associated value with

the_tangible, whereas theconsumer of_todayvalues results over actual products

and services. Modern firms must also _increasingly respond _{by offering} solution

systems _consisting of product-service components which contain _increasingly

moreservices (Vandermerwe etal., 1988).

Belanger and Dube surveyed 102 hospitalized patients in a _specialized,

acute-care, urban hospital in Canada toinvestigate thedimensions of

patients'

emotional experiences of hospitalization and to investigate the correlation

between emotional experiences to satisfaction with foodservice. _They found

that patients'

perceived control over situations had a powerful influence of

patient _emotions, with patients who felt in control of situations _during

hospitalization _{expressing substantially} more positive emotions. Overall

satisfaction with _{foodservice was} based on both interpersonal and technical

dimensions. Of the _two, the interpersonal aspects were scored as _having

substantially greater significance to patients than technical attributes (Belanger etal., 1996).

Satisfying the Needs of Customers Through Technology

Zemke dubs the 1970's and 1980's as the "wonder years"

of technology. In these past two decades civilization has witnessed magnificent advances

such as lasers, fiber _optics, satellite _relays, cellular _networks, voice

synthesization, microwave _{transmission,} digital switching, and a vast _array of others (Zemkeetal., 1989). Between 1970 and _1985, the share of total capital invested _by service industries increased _nearly two-and-a-half times. Of all

technologies, those associated with information _handling have had the greatest

impact in recent years (Heskettet_al., 1990).

While the last _twenty years have been the "wonder years", Zemke

(Zemke et _{al., 1989).} Competitive corporations will combine the technological

advances of the last _twenty years with the service philosophies of the present

and the future.

Adopting new technologies in services is not without its challenges.

Because customers always participate _indirectly, and often _directly in

technologically advanced services, the success of the innovation depends

directly on customer acceptance (Fitzsimmons et _{al., 1994).} Hessket (1990),

Sasser _(1990), and Hart ₍₁₉₉₀₎ describe the introduction of new technologies

as much the same as_{transplanting} a human organ from one _body to another in

thattheorgan _maybe _{perfectlyfunctioning,} yetthe _{body may} still reject it. Both

the customer (the _body) and the service (the _organ) must believe that there are

benefits in _using the new _{technology (Heskett,} 1990).

Martin identifies four basic needs of customers as:

1 . the need to feel important;

2. theneed tofeel welcome;

3. the need tobe understood; and

4. the need forcomfort _(Martin, 1989).

Because customers participate _directly in the service _process, success

will depend on customer acceptance. Corporations must consider whether or

not there will be a loss of personal attention for customers and whether or not

consumers will be required to learn new skills. The implementation of

automatic teller machines did involve a loss of personal attention and some

basic new skills forcustomers. However, because ofthe perceived benefitsof

convenience, minimized customer _waits, and overall time savings, this

automation is now _widely utilized. Acceptance of _technology also depends on

whether or not there will be a perceived loss of consumer benefits. Self-serve

gasoline _pumping stations were _initially perceived as _deleting the benefit of

personal service, although are now _widely accepted _secondary to consumer

cost savings (Fitzsimmons etal., 1994).

At Federal _{Express, early} tests of hand-held shipment _tracking devices

nearly failed because couriers objected to thefactthat_theywere _being asked to

input information that was not _previously required, hence _slowing the _pick-up

and _delivery process. A change in the software was made to reduce the

number of questions which resulted in the positive aspects of the _technology

outweighing the negatives for both couriers and customers (Heskett et _al.,

1990).

Another challenge involved in the investment in _technology involves the

thought that_technology can be substitutedforpeople in an organization. While

this _maybe _{partiallytrue, many}service firms fail to realize their expectations _by

investing too much in the _technology itself and not enough on the _training of

employees touse iteffectively.

According to Heskett, Sasser, and Hart _(1990), technological advances

must enable the creation of services that are more responsive to consumers.

Sasser and Fulmer ₍₁₉₉₁₎ state that this is achieved through identification of

individual customer needs, individualized improvement and execution of

Additionally, technological advances must succeed in the improvement of

overall _quality (Heskettetal., 1990).

Heskett, Sasser, and Hart ₍₁₉₉₀₎ elude toa _"holytrinityof

technology" in

that materials, methods, and information are intertwined in the successful

implementation of technology. For _example, the development of lightweight

metals made possible theconstruction of more efficient aircraftthatresulted in a

change in the_technology of methods used inthe airport business.

The _History of _Technology in Foodservice

Inthe health care _arena, diagnostic and treatmenttechnologies have had

a dramatic impact. Yet, because of the capital expenditures involved in such

technologies, the food and nutrition services departments of _many hospitals

have been left out of the _{technology loop} (Byers et al., 1994). Overall, health

care has been _{traditionally}slow to implement software _{technology, especially} in

the area offood service (Byers et_{al., 1994).}

Technological advances in the food arena have included _{biotechnology,}

sous vide (wherein _freshly prepared foods are processed with low temperature

cooking and vacuum-sealed in pouches), irradiation, and fat replacement. In

hospital food service departments, technological advances include software

systemstomanage information such asprocurement, _inventory control,

of-sale _information, and standardized recipes. _Clinically, usage of software

programs for nutritional analysis and clinical applications is on the rise (Byers

etal., 1994).

While almost nonexistent 1 0 years _ago, software for foodservice is now

abundant. As of _1995, more than 450 hardware and software vendors were

supplying products for the foodservice industry. The _technology services

foodservice in areas such as _{accounting, catering, inventory control,} menu

design, menu _engineering, nutrition _analysis, payroll, recipe costing,

scheduling, and table management _(Sherer, 1995).

Recentadvances in _technology have also attempted to address the vast

restricitions associated with the _{long standing} method of _conveying food

choices to hospital patients: the paper menu. In a traditional paper menu

selection _system, menus are delievered to patients _{by nursing} or foodservice

staff. After patients have been given an _opportunity to make _selections, the

menus are then picked _{up by} staff and returned _manually to the diet office

wherein foodservice staff edits selections to _comply with _dietary restrictions.

One of the most significant limitations to this system involves an overall lack of

efficiency. Menu duties, _{including editing} of individual patient information,

folding, storage, delivery, pick-up, and, in may instances, the manual _tallying of

food choices, all require a significant amount of personnel time and energy.

Menu _forecasting has _{traditionally} been subject toerrors that result in increases

costs and reduced overall patient satisfaction. Additional limitations of this

associated with paper and _{printing, accuracy problems,} and the related costs

associated with the need for abundant personnel ("Better Selection," _1997),

(Jamison etal., 1996).

Addressing the Problems of Traditional Menu _Delivery Systems

Some solutions to this problematic system have included to development

of non-selective menus for patients or limited menus which reduce the number

of modified diets. Printed menus have sometimes been replaced _by verbal

presentatition of entree choices topatients _byfoodservice staff.

Vassar Brothers Hospital in Poughkeepsie, New York answered their

menu problems _{by utilizing} a preadmit selection system. Patients undergoing a

pre-scheduled procedure atthe hospital are given a food preference sheet to

complete atthe timeofpresurgical _{testing, generally four} to seven days prior to

admission. The food preferences are entered into a computer in the hsoptial

kitchen and are _{automatically} printed on menus once the patients arrive. This

system has resolved the hospital's previous two _day average _lag in _filling food

requestsforthese types of patients (Davis etal., 1994).

The Presbyterian Hospital of _Piano, Texasis a 150 bed acute care _facility

which _formerly utilized a traditional seven _day cycle menu. The hospital found

that patients were often unable to select from the paper menus, which were

passed out to patients after admission, because they were either not admitted

long enough or_theywere not accessible to food service employees in order to

receive menus. _Many patients had complained that _they were _being forced to

selectfoods toofar in advance oftheactual meal time_(Schuster, 1995).

The hospital _recently switched to a limited selection _{for patients, offering}

fourteen hot and fourteen cold entrees. The new menu offers one hot and one cold entree atlunch and dinner and is presented _orally to each patient _byfood

service employees. The entire menu was made heart _healthy to eliminate the

need for_many special diets_(Schuster, 1995).

The goals of _implementing the system were to avoid escalation of costs

and to increase patient satisfaction. The hospital found that both goals were met beyond their expectations. The foodservice staff plans meal production

based on theforecastsof selections. Each patient _{is verbally} offered a choice of entree and _beverage, butthesame salad and dessertare placed on mosttrays.

This new system allows formore effective_forecasting and less waste _(Schuster,

1995).

Physicians are pleased to be _writing fewer restricted diet orders as the

standard _{fare already} encapsulates several _{traditionally} restricted _diets, and the

hospital believes that it is a morale boost forpatients to be told _that, in spite of

their _dietary restrictions, theyarefreetoorder _anyofthefood items found on the

menu. _{Additionally, delivering} tomenu _orally to patients gives foodservice staff

the _ability to respond to patients on an immediate basis. For patients who are not satisfied with _any of the food choices on the menu, foodservice staff are empowered to accommodate requests from the hospital's cafeteria menu

Ohio State _University Medical Center is a 600 bed acute care _facility

which _formerly offered six menus with three _varying cycle lengths. The _facility

recently devised a new system _consisting of an eight _day patient menu cycle.

The number of entrees available has been reduced from thirty-five to fifteen.

Patients areofferedtwo hotentree choices and one cold entree choice at lunch

and dinner and one entree at breakfast. As in the case of the Presbyterian

Hospital of _{Piano, many} of the menu items can be served on a _variety of

restricted diets. The new system has fulfilled the hospital's goals of cost

reduction and improvement ofpatient satisfaction _(King, 1995).

The Columbia Health Care Association of Fort Lauderdale, Florida

wished to _develop a paperless system and did so _{by offering} a non-select

menu. The entree, starch, and vegetable are offered to patients as a package.

Patients are able to choose from a selection of _{beverages, condiments,} and

cold items. As an _{alternative, there} is an unpublished list of food items for

patients who cannot or will not eat the preselected meals. The hospital's

primarygoals in the development ofthe non-select system were reduced costs

offood and labor. Asthe patients expected tochoose foods from the hospital's

former traditional cycle menu were _generally not admitted to the _facility for a

long enough period to _actually receive menus and make _selections, the

non-select system _actually deleted perceived ratherthan actual choice _(King, 1995).

When The New York Hospital-Cornell Medical Center in New York _City

opened a new inpatient _facilityin _1997, thegoals were toreplace the kitchen

system while _continuing towork with _{limited space, design a} production system

geared to a _new, upscale menu system. The hospital decided to utilize

technology in the area of _{production, using blast chilling} and central _tray

rethermalization. The hospital's menu goals were met _{by implementing} a

restaurant-style menu in order to increase the _{daily variety} of food choices

offeredto patients. Themenufeatures six entrees at lunch and eight at dinner.

Additionally, there are _{daily soup, sandwiches, bread, beverage, condiment,}

and dessertchoices. The menu highlights the total caloric and fatcontent in all

foodsoffered. Low fat and low cholesterol choices are identified with symbols.

Approximately 3,000 inpatient meals are served per day.

Implementing Foodservice _Technology

Computerization has attempted to address the problems of hospital

menu _delivery and other foodservice data storage and retrieval with the

availably of a _variety of new software (Jamison et _{al., 1996).} A vast _array of

software is _{currently being} advertised through the internet. For example, the

Buckeye _Technology software collection includes services for menu

taking/tallying, adjusting patient choices tosuitdiet requirements, and _supplying

meals to patients unable to select from a menu (www.peg.apc.org).

Computrition offers systems for cost control, inventory and orders, recipe and

menu planning, and administrative duties (www.computrition.com). Geri Menu

offersa full range offood service management and nutritional analysis software

for healthcare institutions and other software such as that offered _by ESHA

research is available _{for recipe,} food analysis, and _labeling (www.sfu.ca).

Other information _regarding new _{foodservice software} can be found in _{Byting In,}

a newsletter about software forfoodservice and nutrition applications.

Byers refers to several steps in the consideration and implementation of

technology, specifically management information systems _(MIS), in the

healthcare arena. These steps are contained in the System Development

Model described _byGordon, Necco and Tsai and are described below:

Step 1_{; Investigate}the Current System

Whatproblems might MIS solve? Whatnew opportunities might MIS

provide? Whatnew software/hardware will be required? Will

computer's presence increase or reduce thedepartment's personnel

requirements? What data bases and operational procedures will need

tobe developed? Whatcosts are involved? Wherewill financial

resources come from? Ifused _byclinical nutrition _staff,who will absorb

the costs ofnutritional services?

Step 2: Analyze theSystem

What isthe_existing system's_abilityto_satisfythe information needs of

managers?

Step 3: Design theSystem

Software: Source (towhatextent is management involved? ₎

Scope: range of application thatcan be performed _bythesoftware

Function: specificjob thatcan be accomplished _bysoftware

Selection: determine whattopurchase

Hardware: _{components, desireable characteristics, data bases,}

telecommunications (will therebe a network linkage between the

healthcare operation?)

Personnel: Whowill manage and run the program?

Procedures

Step 4: Implementthe System

Preparation, installation, testing, and _start-up

Step 5: Maintain the System

Step 6: Review the System

Review software, hardware, telecommunications, data-base, personnel,

Automated Systems in Progress

Jamison et.al. ₍₁₉₉₆₎ conducted a research project with the goal to reduce _dietary department costs through labor reduction while _continuing to

offer menu selections to patients _{by using} two items common to _{nearly every} hospital room: the patient telephone and television. Software was developed

utilizing Windows (version 3.11, 1993, Microsoft Corporation, Redmond, Wash) and built around an automated voice interface subsystem that answers the telephone, collects _information, and prompts the user to follow instructions for the selection of menu items. Thesystem also involves diet office functions such

as the _recording of patient _{admission, transfer,} and _discharge, the _ordering of guest _trays, and diet order changes. The system's interactive communication

multimedia network allows patients to select menu items while _viewing a full-color _display of the hospital menu on _using the in-house video channel. Patientspress numbers onthe touch tone keypad ofthe bedside telephone that

correspond to food items displayed. A personal computer located in the diet

office records selections and provides a printed _tray ticket of patient menu selections _along with a _{daily tally} for production purposes. The system was piloted at a Texas hospital with the expected benefits _being reduction in labor

time, faster and more accurate meal service to patients, improved publice relations for the hospital, and improved patient satisfaction through personal

menu choices. Results of the patient _survey which followed the trial of this

system indicated thatpatients had a significant preference for the computerized

system over theprinted menu system based on interest, convenience,

availability, satisfaction, and motivation. _{Patients did not, however,} consider the

system _{substantially} easiertouse than theprinted menu system (Jamison et _al.,

1996).

Irving Healthcare in _{Irving, TX,} struggled with the problems associated

with paper menus. Patients who did notfill outtheir menus received a standard

non-select menu, _resulting in some patients _receiving foods that _they did not

enjoy. The hospital now utilizes computer software and has installed a terminal

at_{every bedside} for the _entry of meal choices. This 234-bed hospital uses the

Nutrition Care Management _(NCM) software system from Computrition, Inc. for

nutrition service personnel and other health professionals to receive patient

selections and input them into _{the computer,} where _they are _{automatically}

corrected and tallied _bythesoftware. The patient menus are pre-edited before

they appear on the computer _{screen, offering only} those items allowed based

on the patient diet order. The hospital has found that patients have more

opportunityto select food choices, which has resulted in increased satisfaction

with meals. _{Additionally,} the software offers more _flexibility to change menus

instantly. Diet technicians no longer spend the previous 2.5 hours each

distributing and _collecting paper menus, and now have more time for clinical

duties. The foodservice department was able to save 1/2 of a full time

equivalent _(FTE) staff person with the addition of automation _("Irving

Healthcare", 1996).

The initial goals at Ingalls Memorial Hospital in Harvey, Illinois were to

standing menu system involved a _traditional, paper menu which was collected

one _day in advance of meal service. Although patient satisfaction surveys

revealed acceptable responses from _patients, the foodservice department

strived for _outstanding service. In _1995, a spoken menu system was

implemented throughout the entire 450-bed hospital. A non-selective menu is

verbally described to patients _by hospital associates at 9:00 am for _lunch, 2:00

pm for _dinner, and in the _evening for breakfast the next day. The items are

recited, and the patient either accepts the entire menu or is offered alternatives

for foods_theywill not accept. Hospital records reveal that_{approximately 80%} of

patients accept all menu items. The hospital was able to restructure its _staffing,

reducing overall FTE's(Jackson, 1995).

Chapter III.

METHODOLOGY

Application

Hospital foodservice directors composed the sample for this study. In

attempting to reduce _{confounding variables,} the hospitals that were chosen

were classified in the AHA Guide to the Health Care Field (American Hospital

Association, 1996) as general rather than Veterans Administration and were

listed as _having 300 or more inpatient beds.

Questionnaire Development

The questionnaire was composed of 20 questions and is shown in

Appendix I. Questions were _{predominantly} closed-ended with both ordered

and unordered answer choices and also included some _partially closed

questions as well as open ended questions. Questions were developed to be

easily understood and non-bias _utilizing guidelines cited_by Hayes (1992).

Data Collection

Cover letters and questionnaires (Appendices I and _II)were sent to300

hospitals from 41 states and Washington, DC. The hospitals that were chosen

metthecharacteristics asdefined above and were chosen otherwise at random

with thegoal _being toobtain data from as _many states as possible. The 9 states

hospitals which met the criteria for the _{study defined} above. Foodservice

directors were encouraged to complete the questionnaires within two weeks

and instructed to seal the completed questionnaires in the self-addressed

stamped envelopes provided. The disbursement of questionnaires _by state is

illustrated in Table 1 on the_following page.

TABLE 1. DISTRIBUTION OF _{QUESTIONNAIRES} BY STATE

STATE # SENT STATE #SENT

AL 12 MO 4

AK 1 NE 1

AZ 5 NH 1

AR 4 NJ 15

CA 26 NM 1

CO 7 NY 19

CT 6 NC 7

DC 4 OH 11

FL 17 OK 6

GA 9 OR 2

IL 21 PA 11

IN 7 Rl 1

KS 6 SC 3

KY 6 SD 1

LA 5 TN 2

ME 1 TX 13

MD 11 UT 2

MA 4 VA 3

Ml 21 WA 3

MN 8 WV 3

Data Analysis Method

Programs and routines inthe Statistical Packagefor the Social Sciences

(SPSS-X, version _{2.1, 1986, SPSS, Chicago, III)} were used for all data

analyses. Frequencies were calculated forall variables. Means were

computed forall ratings. Factor scores were calculated _{by computing} the mean

ofthe statementsthatcomposed thefactor. _Reliabilityof all resultantfactor

scores was estimated _using a coefficient variable.

CHAPTER IV

RESULTS AND DISCUSSION

One hundred and _{forty (47%)} of the questionnaires distributed were

returned. Five questionnaires were not used in the data analysis: four

because _they were returned incomplete and one because it arrived too late to

be included.

General Characteristics of _Respondents

Foodservice directors were asked to provide general information

regarding their respective facilities to determine an average hospital

foodservice profile.

Inpatient Beds

Table 2 on the_following page illustratesto number of patient beds in the

facilities surveyed. 96% offacilities surveyed had lessthan 300 _beds, while 4%

had over 300 beds. Two respondents added comments _{differentiating} between

available beds and average number of utilized beds. The question did not

specify whether or not "average number of _operating beds" was _being

requested, though, based on respondent _comments, was open to interpretation

TABLE 2: NUMBER OF PATIENT BEDS

# of Beds # of _Respondents

less than 200 7 2

200-299 58

300-399 4

400-499 0

500-599 1

TOTAL 135

Meal Service

96.3% of respondents indicated that their facilities offered full service

breakfast, lunch, and dinner. The _remaining 3.7% offered continental/buffet

style meals at one or moretime throughout theday.

Foodservice System

Table 3 on the _following page illustrates the type of foodservice systems

in place at _responding facilities. 80% of foodservice directors were affiliated

with a conventional foodservice system wherein food is plated hot and served

immediately. 17.7% of respondents were _{currently utilizing} some type of quick

chill system wherein food is cooked ahead of time and plated later. Less than

1% _{predominantly} use a microwave _system, and 1.5% indicated that food is

prepared off-site.

TABLE 3: TYPE OF FOODSERVICE SYSTEM IN USE

Type of System Number of Respondents

Conventional (foodplatedhotand served 10 7

immediately)

Conventional Quick Chill (food cooked

and_quicklychilledin_bulk, reheated, plated,

andserved_immediately)

Computer Driven Central

Rethermalization(food quicklychilled and

reheated ontrays incentral_location)

Computer Driven Decentralized

Rethermalization _{(food quickly}chilled and

reheated ontraysinvariouslocations throughoutthe_facility)

Microwave (foodplated cold andheatedvia

microwave_oven)

Food Predominantly Prepared _by Another _Party Off-Site

7

1 0

Other

TOTAL 135

Menu Styles

Table 4 on the _following page illustrates the type of menu used at

responding facilities. The majority of respondents (73%) offer a select menu to

selections, and 5% offera restaurant style menu wherein the same choices are

available topatients each day.

TABLE 4: TYPE OF MENU UTILIZED

Type of Menu

Complete Non-Select

Modified Non-Select

Select

Restaurant Style

Other

TOTAL

# of Responses

17

10

99

7

2

135

Characteristics of Menu Display Systems

Table 5 on the _following page outlines the methods which hospitals are

currently utilizing tocommunicate topatients.

TABLE 5. MENU DISPLAY SYSTEMS CURRENTLY IN USE

Menu _Display

Method

Preferred

n

Alternate

n

Not Used

n

New in Last 5 Years

n=31

Paper Menu 104 9 22 1 _j

Verbal, InPerson 32 47 56 21

Closed

Captioned TV 1 2 132 1

Verbal,

Telephone

3 29 103 4

Directors were asked to rate each method as _{"preferred", "alternate",} or

"not used"

as well as which systems the _facility within the last five years. As

shown, paper menus are still _widely utilized as the most common method for

communicating menu choices topatients.

Method of _{Obtaining Patient} Menu Selections

Table 6 illustrates the individual responsible for _obtaining menu

selections from thepatient. As_shown, 35% of patients _self-select, while 47% of

facilities delegate the _{responsibility} to _{dietary staff,} 7% to unit _staff, and 1% to

nursing staff. 10% of facilities offer a non-select menu system, and this

question was therefore non-applicable.

TABLE 6: METHOD OF OBTAINING PATIENT MENU

SELECTIONS

Individuals. Delegated to Number of Respondents

Obtain Menu Selections

Patient Self-Selects 4 7

Diet Staff 6 3

Unit Staff 1 0

Nursing Staff 2

Non-Select Menu System 1 3

TOTAL 135

Table 7 outlines the methods for _recording menu selections _currently

being utilized as well as the type of selection systems which respondents

indicated were newto theirfacilities in the last fiveyears.

As shown, most selection _recording systems have been in place longer

than 5 years _(85%), and handwritten _recording systems account for the vast

majority of systems_currently in place. Ofthe automated _{systems, the} diet office

TABLE 7. METHOD FOR RECORDING MENU CHOICES

METHOD TYPE % CURRENTLY % NEW IN LAST 5

USED YRS

(n=135)

(n=21)

HANDWRITTEN 70.4 5

COMPUTER IN DIET 12.6 42

OFFICE

N/A= NONSELECT 9.6 19

HANDHELD 3.0 5

COMPUTER

VOICE ACTIVATED 2.2 19

COMPUTER

N/A=IMMEDIATE 1.5 5

SERVICE

SCANNER 0.7 5

TOTAL 100 100

Respondents were not asked to _specify what brand or type ofdiet office

computer software was _being used.

Respondents were provided with a list of factors and asked to _identify

which were considered when _making the decision to change the menu

selection system in place at their respective facilities. Table 8 on the _following

TABLE 8. GOALS CONSIDERED IN CHANGING MENU

RECORDING SYSTEMS

CONSIDERATIONS % RESPONDING

PATIENT SATISFACTION 33

FOODCOST ₂₇

COMPARABILITYWITH FOOD SERVICE

SYSTEM

18

LABOR COST 16

SKILL LEVELOF LABOR ₄

PAPER COST ! 2

UTILITYCOST 0

When asked if the goals listed in Table 8 were met with change, 86% of

respondents indicated the _affirmative, and 14% stated that the goals were not

met. The respondents were then asked whether data was available to support

this response. Fifty-nine percent indicated that _they had available data in

supportofthese _contentions, while 41% statedthatthedatawas not available.

Satisfaction with Menu Selection System

Table 9 on the _following page illustrates directors' degree of satisfaction

with menu selection _recording systems _currently in use. Directors were asked

to rate their satisfaction level as either _{"extremely satisfied",} "somewhat

satisfied", "neither satisfied nor _{dissatisfied",} "somewhat _{dissatisfied",} or

"extremely dissatisfied". As_{shown, the majority} of respondents were somewhat

satisfied with their current menu system regardless of the type of system in

N 00_CD <. co . -CM -ID CM CM -a- i-1- _II c

o o o o O o CM

t-"" < Q Z UJ s_: UJ </) St= CO m CO Q co CM CM co n c o co ^i 0DCO r: n c

o O o COCM

ii o co V\ o OO n O o CM

<" 5 uj Ul u. <0 Oi= co < CO cn co co II c co ^1 co CD t-1^- II c

CD ,!i LD !. o P O II i-c cn LD

i*

_\

o coY\ c

oo c

'if o

The mean score was _{2.644, indicating that the average foodservice}

supervisor feels somewhere between somewhat satisfied and ambivalent with

his or her current menu selection _entry systems. The median and mode of 2

demonstrate that"somewhat satisfied"

was the most _commonly chosen answer.

As _illustrated, most foodservice directors were somewhat satisfied with their

current systems regardless of what type of system was in place, computerized

or otherwise.

Respondents were asked whether or not _they would consider an

automated menu system in the _future, and Table 10 on the _following page

illustrates responses based on respondent satisfaction with current menu

choice _recording system. As_shown, mostfoodservice directors would consider

automation in thefuture, even though thevast_majority had manual systemsand

were _currently atleast somewhat satisfied withthese systems.

Automation does not follow with a positive level of satisfaction in all

cases. Of note, 1 of the 3 facilities _utilizing voice activated computers

responded to satisfaction level as "somewhat dissatisfied". 18% of those with

computerized diet offices were somewhat dissatisfied as well, while just 6%

TABLE 10. DECISION TO CONSIDER FUTURE

AUTOMATION IN _{MENU CHOICE ENTRY SYSTEMS} BASED

ON SATISFACTION WITH CURRENT SYSTEM

SATISFACTION W/ WOULD

CONSIDER

WOULD NOT

CONSIDER CURRENT

SYSTEM FUTURE FUTURE

AUTOMATION AUTOMATION

EXTREMELY 7 2

SATISFIED

SOMEWHAT 56 3

SATISFIED

NEITHER SATISFIED 10 1

NOR DISSATISFIED

SOMEWHAT 32 0

DISSATISFIED

EXTREMELY 11 1

DISSATISFIED

n= 116 7

The questionnaire concluded _{by asking} respondents whether or not _they

would consider automated menu systemsand asked forcomments as to _why or

why not. Table 1 1 on the _following page displays the grouped responses to

TABLE 11. FACTORS CONSIDERED IN DECIDING WHETHER OR NOT TO

IMPLEMENT AN AUTOMATED MENU CHOICE ENTRY SYSTEM

FACTORS CONSIDERED _(%) n =

YES,ALREADY PLANNING IT 24 21

YES,FOR PATIENT SATISFACTION 21 18

YES,FOR INCREASED EFFICIENCY 15 13

YES,FOR MORE "JUST INTIME"

ALTERNATIVE !

1 1

YES, FOR INCREASED

FORECASTINGOPTIONS

2 2

YES, FOR COSTSAVINGS 9 8

YES, FOR LABORREDUCTION 7 6

YES, FOREASE IN MENU CHANGES 1 1

YES, FORIMPROVED ACCURACY 2 2

YES,FOR WASTEREDUCTION 1 1

NO, HAPPY WFTH CURRENT SYSTEM 5 4

NO,TRIED PREVIOUSLY AND FAILED 1 1

NO,COSTTOO HIGH 1 1

NO, WILLNOTAUTOMATE FURTHER 1 1

NO,QUESTIONPATIENTS'FAMILIARITY

WITH AUTOMATION

4 3

MIGHT,SHOWME 5 4

As _shown, the _majority of foodservice directors would consider

automation and are in fact _already in the _planning stages. Patient satisfaction

prevailed asthe most_commonlycited reason for _choosing an automated menu

system. Cost savings and labor reduction were cited as the second and third

CHAPTER V.

SUMMARY, CONCLUSIONS, AND RECOMMENDATIONS

SUMMARY

While both cost savings and patient satisfaction are important

considerations in the decision to invest in computerization in the hospital

foodservice setting, customer service appears to be the _{prevailing focus} of

today's foodservice director.

Computerization is evolving extremely rapidly in today's society. The

focus of this _study was to determine at what rate hospital foodservice

departments are _embracing food and menu management technologies, the

project sought to answer this question _{by investigating} automation trends in

hospital kitchens nationwide. The researcher surveyed large hospitals _utitizHTg

a written questionnaire.

CONCLUSIONS

The researcher hypothesized that the _study would reveal _that, although

automated menu system technologies are _{becoming increasingly} available,

they are not _{currently widely} utilized. A review of the statistical data _clearly

reveals this hypothesis to be true. Specifically, 77% of surveyed foodservice

directors are still _displaying menu choices via paper menus and 50% of

facilities are _utilizing handwritten means to record patient menu selections.

Most _(74%) of current menu management systems have been in place for

greater than 5years. Automation is not always an indication ofsatisfaction.

The majority of foodservice directors are at least somewhat satisfied with their

current_systems, regardless of whether or notthese systems were automated.

RECOMMENDATIONS

Itis recommended that the _study be repeated, with the results compared

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