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Running head: FACILITY MENU ANALYSIS

Facility Menu Analysis

Alyssa Collins

University of Southern Mississippi

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Introduction

Foodservice is a major component of healthcare within a hospital. Not only does

foodservice impact patients by providing nutrition to aid in the healing process, but also

influences patient satisfaction with overall healthcare. In fact, one study found that 52.8% of

patients who were found to be dissatisfied with their overall health care experience were

dissatisfied due to the foodservice (Abdelhafez, Qurashi, Ziyadi, Kuwair, Shobki & Mograbi,

2012). Interestingly, foodservice patient satisfaction can be improved with room service delivery

over other forms of foodservice (Kim, Kim, & Lee, 2010). Due to foodservices large influence

on overall patient satisfaction, it is important that the standard and therapeutic diets meet the

nutrition requirements while remaining appetizing and enjoyable for patients during their

hospital stay.

Menu Planning

The foodservice for St. Marys Hospital in Grand Junction, Colorado is currently

contracted through Aramark Corporation. Aramark provides foodservice to hospitals, school

systems, and other businesses all over the world. Aramark Corporation created the menu and

standardized recipes that are implemented at St Marys Hospital using the Nutrition Care Manual

from the Academy of Nutrition and Dietetics. The manual is internet-based therapeutic diet

manual created with evidenced-based nutrition information (Academy of Nutrition and

Dietetics). The Aramark Healthcare Corporate Database is the primary database used for

determining the standards for the macro and micro-nutrient information. At St. Marys food

items are ordered through Sysco and then cooked using the standardized recipes created by

Aramark. The menu is designed to fall between acceptable ranges for each nutrient. The non-

select menus for the standard and therapeutic diets for each day were designed to meet the
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Dietary Guidelines and Recommended Dietary Allowances (RDA) of both macro- and

micronutrients set forth by the Food and Nutrition Board of the Institute of Medicine, National

Academy of Sciences. At St. Marys, the standardized recipes are followed exactly to ensure that

each meal is nutritionally adequate.

Menu Communication

The foodservice at St. Marys is room service style, which allows for patients to order

meals anytime from 6:30 am to 6:30 pm. Patients are provided specific diets by the attending

physician or nurse depending on their present condition or medical history. The menu for each

diet does not change; it displays all options that are available to each patient and the patient

chooses what they would like to eat each day. To order food, the patient or nurse calls down to

the diet office and orders items off the specific menu provided to them. The diet office clerk

enters the meal into CBORD, the food ordering system. If a patient has been placed on multiple

diets, the diet office works with the patient to make sure they order correctly from each menu to

meet their needs. If a doctor or nurse feels that a patient is unable to order off the menu, they will

be given the non-select menu. The non-select menu is a three week cyclic menu.

When a patient is placed on a diet, the nurse or physician writes the specific diet(s) on a

white board in the patients room. The nurse or doctor will explain to the patient why they are on

the diet. Sometimes this does not happen, so a dietitian may need to explain to the patient why

they have certain dietary restrictions. Menus for each diet are located on each hospital floor and a

nurse will bring the menu to each patients room. Appendix A provides an example of the

regular menu. Once a patient calls to make an order, the diet office clerk enters the chosen items

into a computer system. The ticket is sent to the tray line, where the tray line employees

assemble each tray. One person, generally a manager, inspects each tray at the end of the tray
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line for accuracy. The trays are then placed on a cart and are brought to the patients rooms. The

goal for foodservice is to deliver a patients meal within 45 minutes of the order being placed.

Therapeutic Diets

The facility offers a variety of therapeutic diets for patients whose medical conditions

prevent them from eating a regular diet. The diets offered are as follows: cardiac, two gram

sodium, carbohydrate-controlled or diabetic, renal, dysphagia I, dysphagia II, dysphagia III, full

liquid, and clear liquid. Therapeutic diets are created to demonstrate what a patient should be

eating when discharged from the hospital.

The most common therapeutic diet prescribed at St. Marys Hospital is the cardiac diet,

also known as the heart healthy diet. This diet is prescribed to patients whose medical conditions

require restricted sodium, fat, and cholesterol. The heart healthy diet is generally prescribed to

patients with hypertension, high cholesterol, cardiovascular disease, heart failure, and other

heart-related medical conditions. This diet emphasizes consumption of whole grains, fruits and

vegetables, omega 3 fatty acids, and lean protein sources. Red meat and egg yolks are limited to

promote lowering cholesterol intake. Instead of a salt package, patients are given a package of

Mrs. Dash and other herbs to season their meal.

Two gram sodium diets are often prescribed to patients with hypertension, edema, heart

disease, liver disease, and kidney disease. The purpose of the diet is to decrease fluid

accumulation in the body through the lowering of sodium. Generally the two gram sodium diet is

combined with a regular, diabetic, or renal diet depending on the patients medical condition.

This diet restricts sodium intake to 2000 milligrams a day. If a physician decides a patient needs

a tighter salt restriction, they may order that. It is then up to the diet office clerk to make sure the

sodium requirements are met. High sodium-containing foods such as bacon, sausage, and salted
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snacks are limited on this diet. Similarly to the heart healthy diet, patients are given herbs and

Mrs. Dash to season their food.

A carbohydrate controlled diet, also referred to as a diabetic diet, is another common diet

prescription at St. Marys Hospital. This diet is prescribed to diabetic patients whose blood

glucose levels appear uncontrolled. The purpose of the diabetic diet is to keep carbohydrate

intake consistent through the day to maintain adequate blood glucose levels. When a patient is

placed on this diet, they may be prescribed certain calorie restrictions such as 1,200, 1,500, 1,800

and 2,000 depending on the patients weight and carbohydrate needs. The diet office clerk who

helps each patient place their order is in charge of making sure the patient does not exceed the

amount of carbohydrate allowed per day. Commonly, allowable intake of carbohydrate is around

three to four servings (15 grams) of carbohydrate per meal and one to two servings per snack.

The diet emphasizes consuming lean protein sources as well as complex carbohydrate

consumption with every meal.

The renal diet is the most restrictive diet offered, as it aims to limit sodium, potassium,

and phosphorus intake. A fluid restriction often accompanies this diet to preserve kidney

function. A renal diet is prescribed to patients with chronic kidney disease, typically for those

with stages four or five. If a patient has chronic kidney disease and their potassium, phosphorus

and electrolyte levels are within normal limits, a renal diet is usually not prescribed. Since the

diet is so restrictive, the menu is quite limited in terms of options. The renal diet at St. Marys

also restricts protein, which limits options further. However, if a patient is on dialysis, they are

allowed to order more protein, as their protein requirements are higher. The doctor or nurse will

specify when ordering the renal diet if it is for a patient on dialysis or not. This is how the protein

requirements are prescribed for each patient.

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Texture-modified diets are an incredibly important therapeutic diets offered at St. Marys

as they are given to patients at risk for aspiration, or who have difficulty chewing and

swallowing. Dysphagia diets are prescribed by the speech language pathologist based on a

patients risk for aspiration and degree of difficulty swallowing. The three texture-modified diets

are dysphagia I, II and III. Dysphagia I consists of pureed foods. The foods on this diet require

no bolus formation or mastication. A dysphagia II diet contains foods that are considered

mechanically altered. The foods are soft and moist and are easily formed into a bolus and

chewed. Generally, meats are ground or minced for this diet. A dysphagia III diet is also known

as a mechanically advanced diet. This diet is the least modified, and usually is small bite size

pieces of moist food. If a patient is considered to have a high risk for aspiration, the speech

language pathologist may also prescribe thickened liquids, which means the patient may only

drink liquids that have been pre-thickened.

Full and clear liquid diets are generally prescribed to a patient following surgery. A clear

liquid diet consists of only clear juices, broths, teas, gelatin and popsicles. This diet is usually

only prescribed for a short period of time to allow the gastrointestinal tract to rest. The clear

liquid diet is advanced to a full liquid diet by the physician when the patient is medically able.

The full liquid diet includes all foods on the clear liquid diet, as well as dairy products such as

milk, cream soups, yogurt and pudding. The liquid diets are nutritionally inadequate, and

therefore are only prescribed for minimal amounts of time.

When patients are placed on two or more of the therapeutic diets, they receive menus for

both diets. The diet office clerks help the patients with ordering their meals to meet their daily

needs. The exception for this is with the dysphagia diets. The patient is only provided the
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specific dysphagia diet menu, and the diet office clerks tell them which items they may choose

from this menu while referencing their specific diet restrictions.

Nutrient Analysis

As previously stated, the non-select menus were created to meet the established RDAs.

However, a nutrient analysis of three days of the non-select menu indicates that not all nutrient

requirements are met on a daily basis. Appendix B displays the nutrient analysis for three days of

the regular menu and five therapeutic non-select menus. Fiber, folate, vitamin D, and potassium

were the nutrients that did not meet the RDAs most frequently for each diet and day. Folate

needs were not met for any diet on all three days. Potassium needs were not met for all diets

either; however potassium should be restricted for a renal diet, and therefore should not meet the

RDA. Sodium requirements were only exceeded on the regular diet and dysphagia III diet. Iron

needs are not met in both the consistent carbohydrate and the dysphagia III diet. This is likely

due to the restrictions from each diet.

The renal diet is the most inconsistent with meeting the RDAs; it does not meet the

requirements for calories, protein, fiber, folate, vitamin D, iron, potassium and sodium. A renal

diet should be lower in potassium and sodium based on the requirements for patients with

chronic kidney disease, so this is not concerning. Protein needs are lower for patients with renal

disease if they are in stages 4 and 5 but not on dialysis. However, if a patient is on dialysis their

protein needs are greater. The nutrient profile of the non-select menu could be problematic for

dialysis patients whose nutrient needs are incredibly specific.

A nutrient analysis is not completed for each tray ordered. The menu states how much of

each menu item a patient may order, and this is how the nutrient profile is regulated. A patient

will order what they please on the menu and leave off items when they are not hungry, or do not
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like certain items. Since room service style is utilized, it is impossible to know if every tray

meets the RDAs. If the patient is not on the non-select menu, their daily needs might not be met

based on what they order. However, for certain diets such as a carbohydrate controlled and a

sodium restricted diet, the diet office tells the patient when they have gone over their required

amount of carbohydrates and sodium and helps them to make the necessary changes.

Unfortunately a nutrient analysis of each tray would increase tray delivery time, which would

likely impact patient satisfaction.

Recommendations to Improve the Nutrient Profiles

Meeting all the macro and micronutrient levels for each therapeutic diet is extremely

difficult for a large foodservice operation like St. Marys. Overall, the non-select menu does

meet most of the nutrient requirements for each day and diet. Had more days been included in

the analysis, the averages might have changed, and more RDAs may have been met. There are

some slight changes to the diets that would make them more nutritionally appropriate.

An easy fix to decrease the amount of sodium would be to use less salt in the

standardized recipes for the regular diet. The dysphagia diet likely exceeds sodium requirements

since the hospital purchases dysphagia diet items, and does not cook them in house meaning

extra sodium is used to preserve the food. Unfortunately, it would be difficult to decrease the

amount of salt in these pre-prepared food items. If the hospital were to make these foods in

house, they would need to purchase the equipment needed to modify the textures of each menu

item. Then they could limit the amount of sodium used and provide the patients with a healthier

meal.

Including more dark green leafy vegetables in the diets would help increase the amount

of folate each patient receives. Offering sides of spinach, kale, broccoli, collard greens, brussels
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sprouts and other high folate foods would increase the amount of folate per meal without

significantly impacting the calorie levels. Additional broccoli would be the least cost-effective

option that would increase the dietary folate levels.

Increasing the serving sizes of protein slightly each day for the consistent carbohydrate

and dysphagia III diets would help increase the amount of iron in the diet. Since the protein

levels for these diets are in the middle of the recommended range, additional protein would not

exceed the recommended amounts. Increasing the portion sizes of the protein options would

impact the budget, as meat is generally more expensive than other food items. However, only a

slight increase in portion size only for these specific diets should not impact the budget too

dramatically. Moreover, encouraging patients to order foods with vitamin C with these foods

would help increase absorption of iron. This would require educating the diet office clerks on the

importance of vitamin C for iron absorption.

Additionally, incorporating a few more fruits and vegetables into the diet would help with

increasing potassium and other micronutrients without significantly affecting the amount of

calories. Especially if the additional vegetables are mostly dark, leafy greens that can be added to

many dishes without impacting taste. Casseroles, soups and other baked dishes are great for

adding in the extra vegetables that can help increase the amount of micronutrients in the meal.

Offering a fruit side such as a half of a banana or apple would help with increasing these

micronutrient levels too, without causing a huge increase in expenditure.

Conclusion

St. Marys Hospital foodservice system is generally well-liked by the patient population,

which is shown through the meal rounds conducted by the foodservice staff and dietitians. Like

all businesses, the foodservice at St. Marys has both strengths and weaknesses. The room
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service style and use of standardized recipes are strengths of the operation. The room service

style of meals allows for the patients to decide what they would like for a meal and when they

would like it, which leads to greater patient satisfaction. A limitation of this style of foodservice

would be when a combination of menus is prescribed to a patient. When a patient is given two

separate menus, it can be very difficult for them to decipher what they are allowed to have. This

increases the time taken to order a meal and can increase patient confusion and dissatisfaction. A

simple fix would be to create menus that combine common therapeutic diets such as a heart

healthy diabetic diet, a renal diabetic diet and a heart healthy renal diet. This would decrease

patient confusion and the ordering time.

Incorporating changes to the standard and therapeutic diet relies greatly on the budget.

When more menu options are added, this increases food cost and requires more labor and time to

prepare each item. Reducing sodium would have a beneficial impact on the budget but may

increase patient complaints on food tasting bland. Offering fruits and vegetables as a side

would help increase vitamins and minerals in the diets, yet would increase food costs and labor

costs. Additionally, incorporating these items does not mean a patient will order it or eat it. Plate

waste could be greater than before, or there may be greater food waste in the kitchen. The menus

rely on patient demand, meaning the changes to the menu would need to be well liked by the

patients in order to make a positive impact.

Overall, the regular menu and therapeutic menus provide adequate nutrition through a

variety of foods. The foodservice employees at St. Marys work incredibly hard to ensure that

the standardized recipes are used for each menu item to provide nutritious meals that meet the

RDAs. They also work to prepare and deliver items efficiently to improve patient satisfaction

with overall quality of care. With a few changes, it is possible that the menu meet all
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requirements for both macro- and micronutrients. The menu prepared by Aramark and used by

St. Marys as a whole provides the adequate amount of nutrients to improve health status during

hospitalization.
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References

Abdelhafez, A. M., Qurashi, L. A., Ziyadi, R. A., Kuwair, A., Shobki, M., & Mograbi, H.

(2012). Analysis of Factors Affecting the Satisfaction Levels of Patients Toward Food

Services at General Hospitals in Makkah, Saudi Arabia. American Journal of Medicine

and Medical Sciences, 2(6), 123-130. doi:10.5923/j.ajmms.20120206.03

Academy of Nutrition and Dietetics. Nutrition Care Manual.

http://www.nutritioncaremanual.org.

Kim, K., Kim, M., & Lee, K. (2010). Assessment of foodservice quality and identification of

improvement strategies using hospital foodservice quality model. Nutrition Research and

Practice, 4(2), 163-172. doi:10.4162/nrp.2010.4.2.163