What are the problems facing the hospital's dietary food service?

What is the cost to the hospital of a minor versus major service upset or failure?

What does the value chain look like? Describe features of each area. Provide examples of opportunities for errors at each stage of the value chain.

Who is responsible for quality?

Select a process and discuss how to mistake proof it and improve process performance.

How do we turn this dietary food service around? What are your recommendations?

The kid almost died! He's a diabetic! How did that patient get the wrong food tray?" said Bonnie Blaine, director of hospital operations, to Drew Owensboro, the director of dietary services. Bonnie Blaine, a woman in her early fifties, had worked in almost every area of the hospital. By going to school in the evenings for three years, she had earned a Master's in business administration. Owensboro had worked in the hospital for 19 years and had a high school education.

"Bonnie, I don't know! I'll try to find out but it may be impossible. The dietary department is really a very complex operation and it's very difficult to audit or trace anything," Owensboro said in frustration. "Drew, I've got enough problems trying to contain hospital costs without having to worry about patient lawsuits due to poor quality control on our part," Blaine continued. "The kid's family and family doctor are furious! Your employees are all blaming one another, but no one is really doing anything about it. Nowfix it or maybe I'll have to get someone else in here to do the job," Blaine said as she turned to answer the telephone.

The Hospital's Dietary DepartmentThe dietary department provides food services to three basic groups: patients, employees, and visitors. The greatest demand for food services comes from the patients, and because of the many different diet requirements which must be fulfilled, this can be rather complex. Each day the patient fills out their required dietetic menu for all three meals for the following day and chooses from several different food items in each food group (entree, vegetable, fruit, dessert, beverage). Since the average patient stay is five days, the dietary department offers different daily menus for two weeks and then repeats the menu selection.

The dietary department, as shown inExhibit 16.9, is a large department with a total of 124 full-time equivalent (FTE) employees, assuming two part-time employees equals one full-time position. The department has 10 managers (that is, directors, supervisors), 8 clinical dieticians, 9 administrative dieticians (7 of which are also managers), 89 full-time employees, and 30 part-time employees. The 89 direct full-time employees have an average education level of 10.8 years. The annual average salary for a part-time employee is $15,000, full-time food service employees excluding cooks earn $28,000, and clerk employees earn $31,000. Benefits for full-time employees average an additional 20 percent of their annual salary.

Exhibit16.9Dietary Department Organizational Chart

Clerical Support in Patient ServicesEight full-time employees in the patient services area fill out diets for each patient, menus for tomorrow's meals, and last-minute changes for today's diets and menus. Central control is necessary due to the myriad of changes, which take place each day because of surgery, discharges, new admittances, or doctor-prescribed diet changes.

The clerks assemble the diets by room and floor and check to see that all menus are properly filled out. When patients are discharged, the clerks pull the patient's diet history from the room number of the floor and file it with the medical records. The prescribed diets of new admittances are to be checked by the clinical nutritionist in charge of the floor, but in the case of emergencies, the clerk calls the floor and speaks to the head nurse about what type of diet is to be presented. Besides the obvious patient health issues with regard to the accuracy of the prescribed diets, the patient and doctor expect the dietary department to "provide timely, neat meals with no errors."

Before each meal, the clerk's office gives the shift supervisor of tray assembly and production the updated list of menus for each patient's room. The clerks sequence the room numbers by floor for easy tray production and delivery. The clerks remain in the office during the day answering phones and messages about diet and menu changes. After each meal, the clerk's office distributes a patient census in terms of trays actually served. Then the process begins all over again for the next meal. Due to the short time between meals, some clerks are working on, say, the breakfast meal while others are working on the lunch meal.

Food ProductionThe kitchen and patient tray assembly lines are located in the basement of the hospital. The kitchen is a beehive of activity for about 18 hours a day. The regular cooks, special diet cooks, kitchen workers, dieticians, and clerks from patient services are constantly visiting or calling the kitchen concerning patient meals. Meanwhile, food constantly arrives at the loading docks that had been ordered from the hospital's purchasing department or the hospital's food service manager.

Employees are assigned to one of three basic shiftsa breakfast shift that begins at 4 A.M., a lunch shift that arrives at staggered times from 6 A.M. until noon, and a dinner shift that begins at 3:30 P.M. Part-time employees help out during peak demand periods and when full-time employees are absent.

PurchasingThe dietary department obtains its food and supplies from several sources. Bulk items are stored in the hospital's central warehouse and are delivered once a week. Many frozen items are delivered weekly from the state contracts warehouse. The remaining supplies, whether refrigerated, nonrefrigerated, or frozen, are delivered by private vendors at various frequencies during the week.

The hospital food service manager has five employees plus himself (seeExhibit 1.15) to coordinate the incoming food and supply orders. Dietary personnel are not responsible for the transportation of goods. However, they are responsible for receiving and accepting high-quality goods and maintaining that quality through the internal storage of food at the hospital.

Patient Tray AssemblyThe food is assembled on each patient tray on a large rotating oval track. Twelve employees staff the tray assembly line. The first position on the tray assembly line is the "caller," who places the patient's menu on a tray and puts the tray on a carrier with the necessary condiments. The second position puts the salad (tossed fruit, macaroni, cottage cheese, tuna, potato, chicken, bean, and chef's salad) and the ordered salad dressing on each tray. The third position puts the breads (white, wheat, rye) and butter on the tray along with jelly. The fourth position is responsible for the ordered cold beverage (soft drink, milk, buttermilk, orange juice, and so on).

Position five places the dessert (pie, fruit jello, and so on) on the tray. The sixth position serves the entrees and starch for each tray. The seventh position serves theordered vegetables and soups. The special diet cook, who both prepares and serves special foods, handles the eighth position. The ninth position is reserved for the supervisor, who checks each menu to determine if the ordered food is on the proper patient tray. The tenth position, the "loader," covers the tray and loads the tray onto the proper cart, now ready for delivery. Two other workers are also considered to work on the linethe coffee pourer, who works just off the line, and the "runner," who gets special items as needed to keep the tray assembly line moving.

Patient Tray DeliveryOnce the clerks in patient services have sequenced the patient menu orders by floor and room numbers and a completed cart of patient trays is assembled in the basement, the tray delivery teams are responsible for the timely delivery and pickup of all patient meals. This particular hospital has 20 floors spread over three wings of the hospital.

Three teams of four delivery aides each deliver trays for each meal. Once the cart is loaded, the delivery team takes the cart and the appropriate hot beverage to the correct floor. After the cart is on the correct floor, the trays are "set up" by the team captain. A "setup" includes putting the correct hot beverage on the tray, checking the patient's name with the room number, and covering the tray. This procedure expedites service, as the other three delivery aides simply deliver trays from room to room. When eight trays are left, the team captain directs one of the aides to go back to the kitchen, get the next cart, and take it to the next floor for which the team is responsible. After delivering all trays to their assigned floors, the team goes back to the initial floor and begins picking up empty trays, putting them on carts, and returning the carts to the kitchen.

The Medical StaffThe doctors and nurses are usually the first to hear complaints about the accuracy of menu orders, the timely delivery and pickup of trays, whether the delivery aides were polite and respectful of the patient's privacy, and the quality of the food. The medical staff is most concerned about the accuracy of prescribed diets for obvious patient health reasons. Occasionally, a doctor would ask a dietician to check or test the content of the food served the patient. At a few hospitals, the nurses deliver the tray to the patient.

Blaine's DecisionAfter completing her telephone conversation, Blaine slowly got up from her desk, told her secretary she was not to be disturbed, shut the door, and began to write down a few notes. Some key questions that need to be answered are listed below.