8 HOSPITAL FOOD SERVICE

V. Premala Priyadharsini

epgp books

 

 

1 Introduction

 

Food service in scientific term implies the skill of providing a balanced food in a most appealing and an aesthetic way away from home .Food being a fulcrum of our mere existence the service of the same in hospitals towards patients care is inevitable. Hospitals in general look forward for holistic patient’s care including provision of nutritional support for speedy recovery. As clinical and pathological condition demand for exclusive nutritional supports like enteral and parenteral feeding, the majority of patients depend on simple and nutritious hospital food to improve or maintain their nutritional state for a quick recovery.

 

2 Objectives

  • The learner will gain knowledge on functioning’s of hospital food service.
  • The learner will also understand the different types of hospital food service and their benefits.

3 Hospital food service –an Overview

 

As the name suggest a hospital food service involves a multiple functional activities in a hospital dietary such as , diet planning , food purchasing, food production, management of human resources in the processes of diet setting and distribution system, updating of food service technology and organization of food service. No matter what ever be the disease conditions, maintenance of nutritional status and rising up to the nutritional challenges in response to the metabolic demands is the prime objectives of any hospital food service. Food given to an in – patient cannot solely be regarded as something that is prescribed by a dietitian, their social culture ,food likes and dislikes, metabolic requirements, and palatability must be given due importance. Therefore a hospital meal should be provided in a proper environment, having choices by a co-ordinated effort of a physician, dietitian, nurse and hospital food service personals..

  1. Classification of Hospital Food Service

Based on the number of patients served, the food service system in hospitals are classified as

 

(a) cook-serve,

(b) assembly-serve,

(c) cook-chill-serve.

(d) cook-freeze-serve, a

Irrespective of the food service system, the food ( ingredients) in general are purchased in bulk, they are cleaned, washed and are pre – processed for a bulk production .The cooked food either goes in for a hot transportation( i.e) they are sent for patients distribution immediately or chilled and stored for later use.(cold transportation). The stored foods are assembled in the tray according to the diet prescription and are thawed before serving to the patient. Some food service system also purchase a bulk of cooked food , store it ,does a bulk reheating prior to the distribution to the patients. Now let us understand the different types of hospital food service systems in detail.

 

4.1. COOK- SERVE food service system .– this traditional system of food service cooks food freshly before every service of all the five meals, namely the early morning tea , breakfast, brunch ,lunch, evening tea and dinner. This system is also known as conventional food service system. All hospitals in India commonly practice the cook serve system of food service since it is safe and fresh. Also the food is prepared in the same premise- the hospital dietary where they are held hot or cold and served as soon as possible. Food is generally either plated as in private hospitals or served in bulk like government hospitals.

 

4.1.1.Advantages

 

The advantages of a cook serve systems are

  • Since food is cooked fresh every time before the meal time it ensure a very high degree of quality
  • The dietary department has a freedom of  Flexibility in menu planning and preparation.
  • Food is served soon after preparation and hence requires very less space for storage and minimizes food wastage.
  • Traditional standardized recipes can be used
  •  Novel and innovative recipes can be tried.
  •  Personalized patients care.

4.1.2.Disadvantages

 

The disadvantages of a cook serve system are,

  • Requires extensive manpower.
  • Challenge of meeting a product standard in terms of consistency taste ,texture and quality particularly when cooked in bulk.
  • Higher food costs and therefore calls for strict cost control measures.

4.2. Assembly-serve food service system.

 

The process of serving in patients with a purchased pre prepared or convenient food is called as an assembly service. It is also termed as kitchen less kitchen. The style of service includes highly processed frozen and dried foods that are partially cooked and which requires minimum cooking before the service. The foods are purchased in bulk or proportioned or pre-plated. (fig 2) A bulk purchase usually require portioning before and after heating at the time of food service , whereas proportioned foods are just need to be assembled and thawed. On the other hand since pre-plated foods are all ready portioned and assembled they require only reheating prior to the service. This kind of food service mainly involves storage, assembly, heating and distribution of foods. Since the service relies purely on processed and pre cooked foods, the labor and equipment cost is comparatively less than the other type of service.

 

4.2.1.Advantages of assembly food service.

  • Cost effective in terms of labor cost and equipment cost.
  • Requires less space.
  • Foods normally meets all the quality and safety standards.
  • Food handling and storage is essay and convenient.

4.2.2.Disadvantages

  • A food cost is relatively very high.
  • Offers very limited choice of menu preference.
  • Monotony of menu.
  • Requires high skill of competency in food storage and food handling.

4.3.Cook-chill-serve food service system

 

The process of cook chill serve food service system was introduced in the year 1960 with the main objective to offer the hospital patients , a high quality food with maximum food safety . Food is prepared in advance and is refrigerated for later use. The refrigerated food isrethermalized or retherm (reheated) at the time of service using microwaves, retherm carts or conventional oven. Initially owing to the high electric city and equipment cost, the cook chill serve was not well received in the hospital sector. Later the concept slowly gained momentum in 1990 due to innovative energy efficiency practices adopted in hospital and school food service. A well equipped kitchen to cook food in bulk, large refrigeration and reheating units are the pre request to establish a cook chill serve system. High establishment cost is still serves as a limiting factor in many hospitals.

 

4.4.BENEFITS OF COOK-CHILL Cost effective.

The food and labor cost are dramatically less since food is cooked in advanced and requires only reheating at the time of service. Therefore the need to employee experienced cook is limited. The manpower requirement is also considerably reduced. Additionally since the diet tray is set and refrigerated in advance it is enough for the kitchen staff to work for of straight stretch of eight hours instead of a 24 hours of shifts. Food waste is also minimal as food can be chilled and preserved comfortably for five days.

 

4.5. Feasibility of on -site catering.

 

An on –site catering literally implies service of food for various banquets , meetings and floor activities within the hospital making it more feasible to cook large amount of food in advance.

 

4.6. Ease of Catering and Forecasting

 

Since it is very difficult to forecast the number of patients in the hospitals, In hospital settings it can be difficult to forecast exactly how many patients you will be serving each day; often there is not enough of a product or there is too much and it needs to be wasted.

 

Forecasting the amount of food to be used each day is simpler with cook-chill because there is no need to get an exact amount of trays needed per day. Food is rotated in the walk-in and is available on-demand whenever needed.

 

4.6.1.Disadvantages of Cook-Chill

 

Equipment and Utility Cost although cook-chill seems to be cheaper with labor and food costs, the equipment and costs are significantly more expensive than other food preparation methods.

 

4.7.Patient Satisfaction

 

Cook-chill provides a less demanding workload for the kitchen staff in the hospital setting, but patients have noticed the difference. From being so confined, food is one of the only things a hospital patient can control. Patient satisfaction of the food is a large determinant in the healing process. If a patient doesn’t like the food, chances are that he will not be consuming enough energy and protein for the recovery. Similarly, food quality and satisfaction ratings are important determinants of whether or not an unhealthy person will choose to be hospitalized at a facility or not

 

4.8.Cook-freeze-serve,

 

Cook-freeze food products are treated the same way as cook-chill products, but the final product is either super-chilled (i.e. cooled and maintained at 1–2 °C below the freezing temperature of the product) or frozen-chilled (i.e. frozen at a temperature of below −30 °C and then thawed to 5 °C when needed; O’Leary et al. 2000; Redmond et al. 2004). This allows ‘chilled’ foods’ delivery to more distant markets, facilitates bulk production, and reduces the level of product recalls. The main limitation of the shelf life of cook-chill and sous-vide processed products are the degradation of sensory attributes and microbial growth. These attributes depend on the storage conditions (time and temperature). Diaz et al. (2008) investigated the spoilage over 10 weeks of sous-vide pork loin at chilled condition (i.e. cooked at 70 °C for 12 h, and then chilled at  3   °C)   by  examining   microbial,   physicochemical   and   sensory   attributes.   Their   results demonstrated  that  sensory  spoilage  occurred  prior  to  microbial  spoilage  and  the  pork  was unacceptable  after  10  weeks  of  storage  based  on  its  sensory properties.  Thus  this  method provides extended protection against microbial concerns. The shelf-life of cook-freeze products is limited by structural changes in the food (i.e. ice crystal size and off flavour formation). This is due to the production of chemicals, such as formaldehyde and free fatty acids by hydrolysis and oxidation. The shelf life of cook-freeze products is dependent on the chemical composition of The food, packaging system and storage conditions (i.e. time and temperature). Foods processed using the above technologies are collectively known as refrigerated processed foods (REPFED; Rajkovic et al. 2010

 

The term cook-freeze refers to a catering system that involves the full cooking of food, followed by blast freezing and storage of food at a controlled low temperature of -18°C/-22°C, before controlled and thorough thawing and regeneration prior to service. Food can be stored for 2 months at this controlled temperature. For a cook-freeze system, you require a blast freezer rather than a blast chiller, suitable storage for frozen foods and, preferably, a controlled thawing cabinet. Blast freezing can also be used for raw materials and semi manufactured products.

 

4.8.1.Advantages

 

1. Ability to maintain a pre-stocked inventory that eliminates problems during peak demand and shortage of raw materials’ supply.

2.  Shelf life extension and ability to supply to distant markets.

3.Ability to reduce labour, raw material and other costs by 20–50 % since the food is prepared in advance.

4.Ability to produce larger quantities, which improves the cost and efficiency of production.

Although reports claim up to 50 % reduction in the number of FTEs (Chater 2000), some studies reported little difference among conventional-cook, cook-chill, and cook-freeze systems in terms of operation and costs (Greathouse et al. 1989).

5. Provide better control of food production and ability to utilize technologies that provide desirable results (e.g. irradiation or pulsed electric field) since these may have limitations under a lower production scale.

6. Ability to reduce food waste since by-products/wastes can be used. Unlike con-ventional cooking (cook-serve system), cook-chill and related systems have the ability to cover any un-forecasted demand or lossesProcessing, Storage and Quality of Cook-Chill or Cook-Freeze Foods.

 

4.8.2.Disadvantages of cook-freeze system

  • Simplified employee scheduling. Skilled employees work eight-hour shifts, Mondays – Fridays.B
  • Separate items can be prepared in batches, limiting the number of times the item needs to be prepared.
  • There is no more peak production workloads, ensuring that employees can be used consistently during their shifts without the added stress of peak production.BSince workers are separated from the consumption area, the workers would not feel pressured to work faster, not like the chefs in a kitchen during peak hours.
  • Batch preparation can reduce labour costs.
  •  Seasonal purchasing provides considerable savings.
  • Extended shelf life in the distribution chain. Foods are frozen and then regenerated on site, solving the problem of moving hot foods.
  • Delivery to units will be far less frequent.4 Since batches can be delivered in one large amount in freezer vehicles.
  • Long term planning of production and menus become possible.4
  • Less dependence on price fluctuations.
  • More suitable for vending machines incorporating microwave.4
  • Equipment costs are high, requiring additional freezer space, packaging supplies, reheating equipment.
  • Employees who are required to work weekends may be resentful of employees who don’t work weekends.
  • Large ice crystals formed can damage food, dry it out, and break down the physical structure. The food may lose its appearance, causing dissatisfaction among the guests.
  • Thawing is required.
  • Not all frozen foods can be successfully prepared without extensively modifying the ingredients or recipes. Certain foods lose their flavour or texture after freezing.

 

4.9.Serving systems can be divided into centrally plated and de-centrally plated systems. In the centrally plated system, food is plated at an assembly line in the central food service production unit and then distributed to the wards. In de-centrally plated systems the food is plated either by the nurse (the non-buffet or trolley type) or by the patient (the buffet type). There are advantages and disadvantages by both serving systems Centralized serving is suitable for use in for example geriatric wards, but not in children’s and psychiatric wards. The system involves extensive transport between the wards and the central kitchen before and after every mealtime. It also means that work on the wards must be organized to coincide with mealtimes. Food will have to be served at specific hours, and if patients happen not to be on the ward at those hours, then other ways of providing food must be found

 

In de-central plating the staff must know the nutrient content of the food to be able to secure the patients a sufficient intake. As an alternative, kitchen staff will send or employ personnel to assist the ward staff during the serving of meals. The buffet type of de-central plating makes it easy for the patient to design individual meals. However, the buffet serving systems require kitchen facilities locally at the wards depending on the type of production technology. Both central and de-central plating requiretight logistics and a range of hygienic considerations

 

4.9.1.Advantages of Central plating

 

1. The prescribed/wanted food is served.

2. The portion control is effective.

3. The nutrient content of the food can be secured.

4. The kitchen staff can influence the appearance of the served food, which increases the interest.

5. The food is easy to serve for the staff at the ward.

 

4.9.2.Disadvantages

 

1.  Changes in the patients’ needs and appetite are difficult to cope with.

2.  No extra food is available at the wards to cover unexpected needs.

3. There is a need for extra personnel in the kitchen.

 

4.10.Advantages of de Central plating

 

4.10.1.Advantages

 

1.  The patients’ needs and appetite can be coped with.

2. There is a possibility for a daily discussion of the food between patient and ward (and kitchen) staff.

 

4.10.2.Disadvantages

 

1. The kitchen has less influence on the appearance, composition and nutrient content of the served food.

2. Problems with loss of appetite are easily overlooked.

3. There is a need for extra personnel in the ward with knowledge and time to handle the meals.

 

4.11.Food production

 

Traditional food service systems are based on preparation of the food followed by immediate consumption, also called cook-serve. However, in most hospital environments immediate serving is not possible due to the spread-all-over nature of most hospital wards. Therefore, a warm-holding process is required while the food is distributed. This process or technology is known as “cook, hold and serve”, and is by far the most widely used technology in hospital food service systems.

 

With both of the above systems, production and subsequent distribution of food are directly linked to meal times. All meals are prepared in the central kitchen prior to serving, and therefore induce serious peak hour problems in the food service system. To overcome this problem some hospitals have introduced cook-chill technology. In cook-chill food is prepared and subsequently chilled. After the chilling the food can be held for several days before it is reheated and served. This technology creates limitations in the types of meals that can be handled. The advantage is that meal shelf life can be increased, and that a buffer of meals can be kept locally in a chilled stock. However as for cook-serve, cook-chill operations require strict quality management and control of the microbiological risks is essential.

 

Other production technologies that increase the shelf life and are used in food service systems include cook-freeze, sous-vide and modified atmosphere technologies.

 4.12.Food temperature and hygiene

 

The temperature of served food is of central importance when a food service system is selected, since delayed meals can result in cold food, especially for slow eaters and those who need help to eat (Allison 1999). One study examined the temperature profile of the food from time of distribution from the kitchen until the last patient was served on the ward (Kelly 1999). It was found that the de-centrally plated system resulted in a slightly higher average temperature (79°C) than when the food arrived in the ward as plated (70°C). The range of temperatures for food when served was between 45°C and 76°C, similar to the plated system where the temperatures of the food ranged between 48°C and 68°C. Food hygiene is of growing concern in hospitals. Food borne illnesses are reported from time to time and can be fatal to hospitalized patients. Hygiene can be planned and managed, and, therefore, hygiene in food service systems must be an integrated part of the management issue.

 

The common approach to hygiene management is Hazard Analysis Critical Control Points (HACCP). The EU directive on food hygiene is based on HACCP and has resulted in national legislations. The legislation is most commonly based on a self-control concept. Self-control means that the food service management establishes a control scheme based on written instructions, which is approved and audited by food control authorities.

 

Since hygiene already is an important management subject matter hygiene can be used to place nutrition on the management agenda. In order for activities in relation to nutritional issues to become implemented in the hospital organization management must be involved. A starting point is to adopt a food policy and then follow the steps in the Plan Do Check Act (PDCA) cycle known from the HACCP approach.

 

4.13.Cost management in hospital food service

 

Hospitals also have an important nutritional role in preventing illness and maintaining the health of their patients; this produces a constant need to improve their efficiency and productivity. However, achieving hospital efficiency is not easy, particularly nowadays when there are many hospitals suffering from the absence of administrative and financial autonomy, and also have budgets that ignore the actual services provided by them.

 

People tend to forget the importance of hospital food services when comparing other clinical activities, and meal services are more prone to be subject to a budgetary cut than other services. Therefore, it is difficult to find the balance between delivering quality food services and appropriate costs, mainly because of the lack of competencies required to perform this task and tools to enable proper management of the services. In addition, the quality of hospital food services has a critical effect on patient satisfaction, which influences the patient’s perception of the quality of the services provided by the hospital. The potential impact on both health status and patient satisfaction emphasizes the need to achieve quality in the food and nutritional services provided, which is not independent of the decision of how to allocate limited resources.

 

In any hospital it is a challenge to control health care expenses. In fact, escalating health care costs due to changes in the age distribution of the population increases in the levels of expectation for health care services, and the application of new technologies for health care delivery urge governments towards cost containment solutions. As a result, there is a need for more accurate data on health care services costs, which is useful for policy making as well as internal management decision.

 

4.14. Summary

 

To summaries, Traditional food service systems are based on preparation of the food followed by immediate consumption, also called cook-serve. However, in most hospital environments immediate serving is not possible due to the spread-all-over nature of most hospital wards. Therefore, a warm-holding process is required while the food is distributed. This process or technology is known as “cook, hold and serve”, and is by far the most widely used technology in hospital food service systems.

 

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