Assessment of the Food Service and Management in a Hospital in Leyte Province

A Research Presented to
Prof. Amy Joan Exconde
Faculty of the Division of Management
University of the Philippines Visayas
Tacloban College
Tacloban City

Presented by:
Bucatcat, Hesus
Padullo, Jan Loressa
Young, Charles Arvin

June 4, 2019
 CHAPTER I

INTRODUCTION

The Philippines has experienced the revival of civil society as mass mobilizations have led

to the overthrowing of the strongman rule of President Ferdinand E. Marcos. As part of the shift

of the government towards democracy, the crafted constitution acknowledges the importance of

civil society and participation in the nation’s development.

The 1987 Constitution emphasizes the right of Filipinos, individually and collectively, to

have substantial participation in the government’s decision-making process.

“The state shall encourage non-governmental, community-based, or sectoral organizations that promote the
welfare of the nation. (Article II, Section 23 of the 1987 Constitution)”

It further obligates the state to facilitate consultative measure at “all levels of political and

economic decision making”:

“The right of the people and their organizations to effective and reasonable participation at all levels of
social, political and economic decision-making shall not be abridged. The state shall, by law, facilitate the
establishment of adequate consultation mechanisms. (Article III, Section 8 of the 1987 Constitution)”

Due to the encouraging legislative foundations for civil society to thrive, Habito (2005)

notes that:

“This is the country that has been acknowledged to have among the most, if not the most, vibrant civil society
movements around the globe, and especially within the Asia-Pacific region. It is also a country wherein a
relatively wide variety of avenues for civil society engagement with the state have been made available,
especially after the overthrow of the Marcos dictatorship with the EDSA People Power Revolution. Thus, a
similar study focused on another country probably would not have been [as] rich and substantive.”

The United Nations Economic and Social Council (2007) recognizes that participation aids

in deepening democracy, strengthen social capital, facilitate efficiency and sustained growth, and

promote pro-poor initiatives, equity and social justice. The council furthers the discussion that

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participation has its implications for economic growth and development, human rights, democracy,

social capital, decentralized governance, efficiency of resources use, equity and social justice, and

sustainable use of environmental resources, among others.

While participation by civil society has been credited mainly for its mostly altruistic,

development-focused role in government decision making, Goetz and Jenkins (2005) asserts that

there is a failure in recognizing faulty assumptions upon which civil society and accountability are

conceived. Furthermore, both underscore the need to recognize the problem in the relationship of

participation in democratic accountability.

Goetz and Jenkins noted cases of which civil society was expected to promote

accountability and consolidate democracy by eliminating patronage, such was neutralized by “non-

democratic” forms of politics. The groups instead became entrenched within networks of

patronage. Goetz and Jenkins stressed that the possibility of “development actors checking the

power of elites transforming identity-based forms of political organization into those built around

modern/interest-based solidarities is a dangerous myth”.

Objectives of the Study:

1. To document the presence or absence of participatory mechanisms of BLGUs in its

implementation of programs and projects.

2. To determine the issues and concerns raised by the residents through the different

participatory mechanisms

3. To know how the BLGU responded to the utilization of the said mechanisms by its

residents.

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Conceptual Framework:

Quality
DOH Food
Standards Service

HOSPITAL A
- Food Service
policies
- Management
Practices
- Food Service
Personnel

This framework suggests that DOH standards must govern Hospital A food service

policies, management practices, and hiring of food service personnel. Compliance with the

standards shall translate to the delivery of quality food and service to the patients.

Significance of the Study

This research sought to evaluate food service operation and management in Hospital A.

As such, this study is one of the few locally conducted studies in Eastern Visayas to view the

dynamics of management practices in operations as well as compliance with government standards

of a nutrition and dietetics department of a hospital. Thus, this study will serve as a supplement to

a scarce literature of hospital management practices in the region which may immensely benefit

academic and policy-making bodies.

This study is distinct since it focused on the relationship of the hospital’s compliance with

the Department of Health (DOH) standards and management practices of the Nutrition and

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Dietetics Department. Added focus also applied to the food service operations and the

implemented policies of the department.

In each of the objectives of this study, the researchers recommended improvements to the

current practices and policies to better serve the hospital patients, improve efficiency in food

service operations, and increase adherence to the standards provided by the government health

regulating agency.

Finally, this research provided an example in which future researchers, and the academe in

general, could base or anchor their studies and researches.

Scope and Limitations

This study is limited to the food service operation and management in Hospital A. This

study limits itself into documenting the policies that govern hospital food service in the Hospital

A Nutrition and Dietetics Department.

The study only involved Hospital A which is a public tertiary hospital. The findings of this

research may not apply to other private hospitals and smaller hospitals due to different social,

political and geographical factors to note a few.

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 Chapter II

REVIEW OF RELATED LITERATURE

Food Service in Hospitals

Food service in hospitals is deemed as important as any treatment patients are exposed to.

(Fallon, Gurr, & Hannan-Jones, 2008) notes that food service is delivery is an important part of

the patients’ overall perception and hospital experience. Nutrition and food available for patients

in hospitals are vital factors that could help patients’ recovery. It is manifested through

scientifically prepared diets; educating the patients attending the hospitals for treatment regarding

use and utility of different foods and balanced diets

As nutrition services within health care systems have become increasingly important and

significant, hospitals strive to provide food that meets their nutritional requirements and aids them

in their well-being. Hospital service quality depends on standardized procedures (standards) and

guidelines, improved management, and continuous assessment of quality indicators for periodic

comparisons (Diez, Martinez, de Oliviera Penaforte, & Japur, 2015).

Today, scientific methods based on a standardized nutrition care process and consistent

standardized language can now guide nutrition practitioner’s clinical judgments, critical thinking

process, and document information linking nutrition care to patient outcomes (Smith and Lewis,

2004).

Elements of Nutrition Service Environment in Hospitals

Ford and Fairchild (1990) have described some basic elements for nutrition services environment

in hospitals. these are:

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- a departmental statement of mission or purpose and a strategic plan for delivery of services

congruent with the mission, that can be changed as needed in response to adjustments in

either the internal environment or the external environment, or both.

- nutritional standards of practice customized to meet the needs, resources and milieu of the

department.

- written, up-to-date policies and procedures to guide major responsibilities such as

screening and nutritional status assessment, care planning, documentation, nutritional

counselling, consultations and responsiveness to nutritional needs of patients.

- a method and tool for screening patients to identify efficiently those at nutritional risk and

to set priorities for nutritional care services and a system of documentation that facilitates

both communication and data retrieval.

- a method for determining patient acuity levels as a basis for setting clinical priorities and

managing both time and resources.

- an observable and measurable system for tracking productivity, especially of

professional staff members.

- appropriate and effective staffing patterns and maximizing the potential of each

dietetic team member.

- criteria based performance standards to serve as the basis for competent practice,

performance appraisal and professional development.

- an evaluation system to assess and monitor compliance with mandated regulations of

government, healthcare agencies and commissions. an environment in which personnel are

committed to the mission statement and strategic plan, kept informed, supported with

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 recognition and reward systems and empowered to take responsibility for the quality of

services provided.

Barriers To Good Food Service In Hospitals

Hospital food service practice has evolved throughout the years, but challenges persist.

These challenges are primarily due to policy and organizational components in the food service.

The Food and Nutritional Care in Hospitals: How to Prevent Under-Nutrition, published

by the Council of Europe in 2002 outlined five major factors that still affect good food service in

hospitals :

1. Lack of clearly defined responsibilities in planning and managing nutritional care;

2. Lack of sufficient education in nutrition among all staff groups in hospitals;

3. Lack of influence of patients;

4. Lack of cooperation between staff groups;

5. Lack of involvement by the administration.

The report notes that the responsibilities, duties, and tasks of different staff categories in

nutritional care and support and food service are unclear which results to routine nutritional risk

screening and assessment not being performed. Nutritional counselling is not commonly practiced

and the use of nutritional support for undernourished patients and at-risk patients needs

improvement. There is a need for a clear assignment of responsibilities of both management and

staff for nutritional care.

On education, physicians' curriculum contains few lessons addressing nutrition-related

topics. Teaching has lagged nutritional research, increasing the gap between knowledge and

practice. Food-service staff may not be aware of the importance of providing highly nutritious

food to ill patients. As a result, they may not have a strong enough influence in the allocation of

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budgets. Also, management may lack sufficient awareness about the benefits of nutrition and thus

not recognize its importance. A general improvement in the level of nutrition education of all staff

groups is needed.

Furthermore, patients attending hospital often find it difficult to adjust, from food cooked

in their own homes, to meals produced through large-scale methods of production and service.

This may result in poor intake of food and weight loss, without the patient recognising that losing

weight will increase their chances of complications from a disease. Patients can miss meals

because of fasting or tests and are often unaware that extra meals and snacks are available. Patients

should be involved in planning their meals and have some control over food selection.

The food service is often regarded as an issue that can be addressed apart from patient

treatment and as a simple task that any food operator can handle. But good hospital food service

requires skilled food-service operators. Management should be able to define exactly what the

food service should include. Providing meals should be regarded as an essential part of treating

patients and not just as a ‘hotel service’. Hospital management should acknowledge responsibility

for the food service and the nutritional care of patients and give priority to hospital food policy.

National Policy on Hospital Nutrition and Dietetics Service Management

The Hospital Nutrition and Dietetics Service Management Manual serves as the standard

reference material for Department of Health (DOH) health facilities/hospitals to aid administrators

and Nutritionist-Dieticians in the management and operations of the various activities in the

Nutrition and Dietetics Service that contribute to patient safety and quality patient care. The

following are the important policies involved in the Human Resource and the Administration and

Management in the Nutrition and Dietetics Service.

Nutrition and Dietetics Service Human Resource Management

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 Opportunities for government employment shall be open to all qualified individuals.

Employees shall be selected based on fitness, determined by the appointing authority, to perform

the duties and responsibilities of the position on the basis of merit as provided for in the Civil

Service Commission (CSC) rules and regulations.

Only the registered Nutritionist-Dietician who passed the Nutritionist-Dietician Licensure

Examinations given once a year by the Professional Regulation Commission (PRC) shall be

considered for appointment to the classified professional positions in the Nutrition and dietetics

Service and are therefore legally authorized to practice nutrition and dietetics in government or

private hospitals, with a bed capacity of 25 or more.

Organization
The Nutrition and Dietetics Service is one of the major services of the ND plays an integral

part of the total patient care service. It is headed by the Chief Dietician who directly reports either

to the Chief of Hospital (COH) or to the Chief Administrative Officer, depending on the

classification of the Hospital.

The Administrative Nutritionist-Dietician assists the Chief Dietician. However, any

member of the Nutrition and Dietetics Staff can assist, depending on the classification of the

hospital.

The Chief Dietician exercises direct supervision over the administrative, clinical,

education, research, teaching, and training activities of the service. He/she coordinates the

professional activities of the Nutrition and Dietetics Service with the nursing, medical, and

administrative divisions.

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 In a Level I or Primary Hospital with 10-15 bed capacity, the Cook and Administrative

Aide (Food Server) are directly responsible to the Nutritionist- Dietician.

In the Level II or District Hospital with 25-50 bed capacity, the Cooks and Administrative

Aide (Food Server) are directly responsible to the Nutritionist-Dietician.

In a Level III or Provincial Hospital with a 100-119 bed capacity and Level IV or Regional

Hospital with 200-249 bed capacity, the Cook and Administrative Aide (Food Server) are directly

responsible to a Food Service Supervisor for both food production and food service activities.

While in Level IV or Regional Hospital with 250-299 bed capacity and Medical Center

with a 300 and above bed capacity, the direct responsibility for these two activities is vested on

the Nutritionist-Dietician and the Food Service Supervisor.

Staffing
The staffing needs of the Nutrition and Dietetics Service can be determined by the specific

tasks performed. The number and skill level of employees needed at a critical period is identified

in a full day operation. Other duties are then divided between these workers. Considering each

hours of employee time as a Full Time Equivalent (FTE), it takes at least 1-2/5 full-time

equivalents, working 5-days a week, to fill each position. To allow fringe benefits, 1-2/5 full-time

equivalents may be allowed for each position. A department requiring 6-1/2 full time equivalents

would need a 10-2/5 full time equivalents, working 5 days each, to staff a 7-day week (6.5 FTE x

1.6=10.4 FTE).

Another method for planning the staff uses the number of minutes of labor required to serve

one meal to one person as its base. This example uses 14 minutes for each meal served. The

standard variable is 9-15 minutes per meal.

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  (NO. OF PATIENTS) X (21 MEALS/WEEK) + (GUEST/EMPLOYEE MEAL/WEEK) =

(TOTAL MEALS/WEEK)

 (TOTAL MEALS/WEEK) X (14 MINUTES) = (LABOR/WEEK IN MINUTES)

 (LABOR/WEEK) – 7 – (60) = (LABOR/WEEK IN HOURS)

 (HOURS/WEEK) – (NO. OF HOURS FULL-TIME EMPLOYEE WORKS) = (APPROX.

NO. OF FULL-TIME EMPLOYEES NEEDED, INCLUDING SUPERVISORS AND

RELIEVERS)

Another formula is based on the average number of Nutrition and Dietetics Service Employees

in hospitals of varying sizes and locations, where in the total bed capacity of the facility is divided

by eight to find rough estimates of the total number of dietetic service employees needed, including

the relief personnel.

Total bed capacity = total no. of employees needed

The scope of service and functions of the Nutrition and Dietetics Service also serves as the

primary guideline for determining the staffing pattern for the organization. Efficient dietary care

always depends on the number and quality of Nutrition and Dietetics Personnel on duty.

Administration and Management

The Head of the Nutrition and Dietetics Service of the Chief Dietician is the one in charge

of carrying out the objectives of the service, towards the attainment of the goal of the hospital. In

any operation, regardless of types or size, the manager is responsible for getting things done by

planning, organizing, directing, and controlling the use of resources. These are the basic principles

of management.

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Planning and Budgeting
Budgeting is a method of estimating future needs and their concomitant cost in the terms

of personnel, logistics, or time frame of an organization. It covers all activities for the specific

period and contains details of expected needs. It is an essential tool, which serves basis for

comparison and control, especially for expenditures.

Guidelines for the preparation of budget:

 The Dietary Budget Must Be Divided Into Three Categories: Food, Personnel, And

Operating Expenses

 The Chief Dietician Is Responsible For The Economical And Efficient Financial

Management Of The Service. He/She Must Establish Priorities Planned For The Period

Covered By The Budget, An Annual Procurement Plan Is Required And Must Be

Submitted For The Approval Of The Chief Of Hospital (Coh)

 Additional Needs For Both Personnel And Materials Should Be Included With The

Supporting Data And Justifications

 The Budget Office Should Allocate The Food Budget Based On Per Capita Per Day, The

Per Capita Allowance Per Patient Per Day Is Determined By The Nutritionist-Dietitian

After Due Consideration Of The Current Cost Of Food And Standards Of Food Service To

Be Maintained . This Is Recommended By The Chief Dietician For The Approval Of Coh.

Cost Control
Cost control is a management tool used for determining and evaluating performance. With cost

control, the efficiency or inefficiency of the operation can be determined, thus, unfavorable trends

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can be traced, hit and miss practices prevented, and corrective measures applied to ensure

satisfactory completion of tasks as planned.

Cost control is the responsibility of the whole N and D Service as it affects all aspects of

operation. When the policies and procedures in cost fail, the aim of the service may remain

unsatisfactory fulfilled. It is therefore imperative that the varied aspects of cost control be

considered.

Records
Records are the basic tool in cost control. They contain the data needed to determine the

Nutrition and Dietetics Service function. Records vary with the type and size of the service, the

policies set, the data desired, and how these can be obtained efficiently and with the least cost.

Records likewise differ with the type of purpose where they will be used for the Nutrition and

Dietetics Service. The following records are used in the Service:

A. Procurement and Receiving Records

B. Storeroom Records

C. Production Records

D. Dining Room Service and Patient Meal Census Records

Menu Planning

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 Menu Planning is the basic and essential activity in the Nutrition and Dietetics Service. It

is therefore important that the policies and procedures, as well as guidelines, should be carefully

considered.

Menus should be planned to ensure that patients receive nourishing and safe meals, and

variety of foods within the budget of the institution.

Purchasing
Purchasing is an operational procedure through which food items and other goods needed

in the service are acquired.

Policies and practices in purchasing and receiving foodstuff deliveries vary among

institutions.

The Administrative Dietician should be responsible for ordering the needed foodstuffs

based on the daily menu and patient census, with the approval of the Chief Nutritionist-Dietician

and the COH.

Purchasing decisions should be determined by the following:

- type of people to be served

- size and location of the facility
- area available for storage of staples, refrigerated, and frozen foods
- capabilities of the dietetic staff
- available equipment
- budget allocation
- availability of the supplies/foodstuffs

The person in charge of purchasing should strive to obtain the right product at the right time,

in the right quantity, and at the right cost.

Foodstuffs should be purchased either by open market of competitive bidding.

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Receiving
Receiving is a management responsibility which involves making certain that the items

ordered are satisfactorily received in terms of quantity and quality. Losses will result when food

of poor quality is delivered, or items are under weighed. Extra care should be expected in the

checking orders and weighing food being received.

Storing
Storing is the responsibility supplementary to receiving. The proper storage of food

immediately after it has been received and checked, is an important factor in the prevention and

control of loss or waste. Adequate space for storage should be provided in a location accessible to

receiving and preparation area.

Issuing
Dietary supplies may be issued from the Nutrition and Dietary Service storeroom or from the

Property Section storeroom. The process of issuing foodstuffs from the Nutrition and Dietetics

Service storeroom should be guided by the following steps:

1. Food should be issued only upon presentation of a properly prepared and signed requisition

slip;

2. The requisition slip must contain a list of all items and quantities requested and must

include the signature of the requesting personnel;

3. Prepared and duly signed requisition slips should be presented to the storekeeper;

4. The storekeeper should dispense the food items requested and then record them on the

stock card;

5. The storeroom keeper shall be responsible for all the food items issued out.

Food Production

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 Food production covers all phases in the processing and preparation of food for patients

and hospital personnel. Systems in food production vary in accordance with supply, size of serving

portions, number of patients and personnel, and time of service. Use of standardized recipes and

proper cooking methods should be followed in order to attain a quality product served in the

Nutrition and Dietetics Service.

In food production, standardized recipes are important tools that could be made available

to all types of Nutrition and Dietetics Service operations for the maintaining quality and cost

control. A standardized recipe includes the ingredients, quantities by weight or measure, procedure

and portion size, and yield. It should be especially adapted to the available equipment and

capabilities of the food production staff.

Meal Service
Excellent food service includes the quality of the menu, food preparation and service.

Service refers to patients, hospital personnel and guests, as well.

Since patient care is the primary purpose of hospitals, quality meal service should be

rendered to all patients, whether in the private room, suite room or ward. Most of the hospitals

under the DOH commute the subsistence allowance of personnel to cash and hence, they are no

longer provided with free meals. When this is not practiced, the personnel should be given

adequate meals and quality service.

A centralized type of service for both patient and personnel is the most commonly used

type of service in hospitals under the DOH, although there are still a few who are using the

decentralized type of service.

Sanitation, Safety and Maintenance

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 To safeguard the health of patients and personnel, the Nutrition and Dietetics Service

should maintain highest standards of sanitation and safety in all areas of food service. An

understanding of sanitation and safety standards among nutrition and dietetics personnel is a must.

This can be attained through a well-structured training program with the emphasis on sanitary and

safety practices. Routine inspection of all nutrition and dietetics areas and personnel shall likewise

emphasize the importance of sanitation and safety.

The Nutrition and Dietetics Service follows infection control practices to reduce the risk

of food-borne illness utilizing safe food storage, handling and preparation methods compliant with

government and local health standards.

Pest/Vermin Control

Foods that are not properly protected from contamination by pest and rodents are a public

health hazard. Flies and cockroaches may contaminate the food with the germs that can cause

outbreaks of intestinal diseases like diarrhea, dysentery, gastroenteritis and cholera. The premises

should always be kept clean and dry, free from flies, vermin, and rodents.

Since management emphasis is on the internal environment of the organization, the Chief

Dietician performs these tasks well with clear understanding of and is responsive to the many

elements of the social, ethical, economic, technical, and political environment which affects his/her

area of operation.

International Policy on Standards For Dietitians-Nutritionists

According to the International Confederation of Dietetic Associations (ICDA, 2016),

newly qualified dietitian-nutritionists should have the necessary knowledge, skills and attitudes to

perform their role when they first start to practice. The ICDA Competency Standards for Dietitian-

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Nutritionists (the Standards) defines those minimum competences that any dietetics practitioner

should demonstrate at the point of entry to the profession and will act as a framework for their

continued professional development throughout their professional life.

There are three (3) domains of practice for nutritionist-dietitians namely clinical practice,

public health nutrition and foodservice management and it is recognized that nutritionist-dietitians

do not necessarily undertake practice in all these domains in every country.

The following were the competency standards for dietitians:

1.Dietetic Process and Professional Reasoning

COMPETENCIES applies the nutrition care process based on the
expectations and priorities of individuals, group,
community or population
applies the nutrition care process based on the
expectations and priorities of individuals, group,
community or population
engages in collaborative (shared) practice in providing
high quality, cost efficient services to achieve positive
health outcomes
reflects and reviews own dietetic practice
Works independently and in partnership to integrate
nutrition and dietetics into overall professional
care/service
Respects the unique emotional, social, cultural, religious,
ecological needs of individuals, groups, communities or
populations
2.Evidence Based Practice and Application of Research
Competencies Systematically search, judge, interpret and apply findings
from food, nutrition, dietetic, social, behavioral and
education sciences into practice
Identify, design and participate in research and audit to
enhance the practice of dietetics
Apply food and nutrition science to solve problems
Adopts an evidence-based approach to dietetics practice

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 Shares evidence-based dietetics and nutrition with
colleagues and key stakeholders
3.Quality Assurance of Dietetics Practice
Competencies Improve practice through continuous and systematic
evaluation maintaining clear and concise records of all
activities
Maintain competence to practice through lifelong learning
(LLL)
Assumes leadership, educational and mentoring roles
Use current technologies, to collect and manage data
responsibly and professionally for information and
reporting purposes
Accepts responsibility for ensuring practice meets
legislative requirements
4.Professional relationships, communication and partnerships
Competencies Communicate effectively and responsibly using multiple
means
Demonstrate interpersonal skills, professional autonomy
and accountability
Build partnerships, networks and promote the dietetics
profession
Seek, support and promote opportunities for learning
among peers, and others
Advocate for the contribution that nutrition and dietetics
can make to improve health
5. Knowledge essential for the practice of Dietetics
Competencies Integrates knowledge of food and food systems, human
nutrition and dietetics in the provision of services
Integrates knowledge of biomedical sciences in the
provision of services
Integrates a knowledge of behavioral and social sciences
in the provision of dietetic services
Integrates business and management principles and skills
in the provision of service
Integrates a knowledge of organizational, professional and
legislative requirements in the provision of dietetic
services

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 Chapter III

RESEARCH METHODOLOGY

Research Design

To generate valuable data in attaining the objectives of this study, the researchers utilized

an evaluative research through a case study design in gathering and analyzing the data. According

to Gerring (2007), a case study may be understood as an intensive study of a single or few cases

whether the purpose is, or at least in part, to shed light on a larger class of cases. Gerring (2007)

defined cases as “a spatially delimited phenomenon (a unit) observed at a single point in time or

over some period of time. It comprises the type of phenomenon that an inference attempts to

explain”.

The strengths of case study research lies on its ability to “…generate high conceptual

validity; strong procedures for fostering new hypotheses; their value as useful means to closely

examine the hypothesized role of causal mechanisms in the context of individual cases; and their

capacity for addressing causal complexity” (George and Bennett, 2005).

Research Respondents

The researchers proposed that the respondents of this study are the personnel of the

Hospital A Nutrition and Dietetics Service.

Research Instruments

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Research Locale

This study was conducted in a hospital situated in Leyte Province. The hospital was

selected because of its proximity and accessibility from where the researchers reside.

Data Collection

Semi-structured interviews and focus group discussions (FGDs) are utilized in collecting

the data for this research. According to Vanderstoep and Johnston (2009), “…techniques such as

interviews and focus groups allow research participants to give very detailed and specific

answers”. The data are obtained from the in-depth, key informant interviews with the Hospital A

Nutrition and Dietetics Service personnel. Interviews would include how the Nutrition and

Dietetics Service implement the food service policies and management practices of the hospital.

Data Analysis

The authors utilized deductive content analysis in this research. The analysis involved three

main phases, namely: preparation, organization and reporting of the results (Elo et. al, 2014).

The preparation phase consisted of collecting suitable data for content analysis, making

sense of the data, and selecting the unit of analysis (ibid.). In deductive content analysis, the

organization phase involved categorization matrix development, whereby all the data are reviewed

for content and coded for correspondence to or exemplification of the identified categories (Polit

& Beck, 2012). In the reporting phase, results are described by the content of the categories

describing the phenomenon using a selected approach (ibid.)

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 Chapter IV

RESULTS AND DISCUSSION

This research focused on the assessment of food service operations in a hospital in Leyte

with the standards set by the Department of Health. The researchers opted to conduct interviews

with key informants considered as respondents for the survey. It was agreed by the researchers to

not divulge the identity of key informants and the subject institution for security and confidentiality

purposes. The selected locale for this study is a hospital situated in Leyte Province.

MENU PLANNING

Menu Planning is the basic and essential activity in the Nutrition and Dietetics Service. It

is therefore important that the policies and procedures, as well as guidelines, should be carefully

considered. Menus are planned to ensure that patients receive nourishing and safe meals, and

variety of foods within the budget of the institution. The Nutrition and Dietetics Service should

use a 15 to 30-day cycle menu for patients and personnel. The factors to be considered in menu

planning are: available budget, supplies, manpower, and equipment.

In the standards prepared by Hospital A, their Administrative Dietitian shall consider

budgetary allowances, personnel equipment and seasonal food items availability in menu planning.

The Section Head will review the 28-day cycle menu and shall recommend its approval to the

Chief Administrative Officer (CAO). The NDS staff shared:

“Kada bulan kami kami nag aandam ngan nagplaplano hin menu.”

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 “We prepare the menu plan every month.”

A cycle menu is used for the guidance of all production areas. As much as possible, planned

menus should include foods that are in season and are available locally and should be within the

skill and capabilities of the dietary personnel. They should also be within the capacity, condition,

and scope of the available kitchen equipment. Also, the planned menus should be flexible. A cycle

menu should meet the nutritional requirements of the person to be served. It must please and satisfy

the patients. Differences in ethnic, religious, and cultural background should be considered. For

Hospital A, they prepare special meals for Muslim patients when pork is their menu for the day.

PURCHASING

Policies and practices in purchasing and receiving foodstuff deliveries vary among institutions.

Based on the DOH Manual, the Administrative Dietician should be responsible for ordering the

needed foodstuffs based on the daily menu and patient census, with the approval of the Chief

Nutritionist-Dietician and the Chief of Hospital.

Purchasing decisions should be determined by the following:

- type of people to be served

- size and location of the facility

- area available for storage of staples, refrigerated, and frozen foods

- capabilities of the dietetic staff

- available equipment

- budget allocation

- availability of the supplies/foodstuffs

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 The person in charge of purchasing should strive to obtain the right product at the right

time, in the right quantity, and at the right cost. Foodstuffs should be purchased either by open

market of competitive bidding. Competitive bidding is established as the principal mode of

procurement but the existence of certain procurement conditions warrants the use of alternative

mode of procurement such as Negotiated Procurement, Shopping, Limited Source Bidding, Repeat

Order, and Direct Contracting. For those procurement projects undertaken through competitive

bidding, procurement tenders/invitations must be publicized in the prescribed media and locations.

Submission of eligibility documents forms a crucial role in the public bidding (DOH Customized

Procurement Manual Volume 2, 2010). As for Hospital A, they practice shopping almost all the

time.

RECEIVING

Receiving is a management responsibility which involves making certain that the items

ordered are satisfactorily received in terms of quantity and quality. Losses will result when food

of poor quality is delivered or items are under weighed. Extra care should be expected in the

checking orders and weighing food being received.

The receiving officer should be a staff Nutritionist-Dietician or well-trained competent

Nutrition and Dietetics Service personnel. The agency inspector should be present (Internal

Control Service). In Hospital A’s standard of procedures, the Food Production Supervisor will

receive all items in agreement with the original order. The Market Orders slip must always be on

hand to check all delivered against specifications and quantity called for. The Food Production

Supervisor together with the Representative of the Inspection Committee will check for quantity,

quality, weight, labels, etc. of all foods ordered. They shall not accept and shall return to the

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supplier any item that is not what was ordered, dented, rusted, damaged cans, thawed frozen food,

damaged produce, poor quality produce (i.e. meat) and items with incorrect weight.

The Food Production Supervisor will sort the received items; direct to food production, dry

storage, and cold storage. He/She will supervise the piling of received items into the proper storage

area. However, this is not always the case oin Hospital A. They sometimes allow unauthorized

personnel (i.e their cook) to receive the goods. An informant stated:

“Mayda la kami staff nga parag receive hit gindedeliver nga raw materials ngan

pansahog. Pero kun danay busy hya pagbulig pagdispatch hit mga pagkaon para

ngadto ha wards, it amon cook it nareceive. Ginsisigurado namon it kalidad,

ginrereject it diri napasar ngan iginbabalik ha supplier.”

“We have a staff for receiving deliveries which include raw materials and

ingredients. However, when he’s busy helping in dispatching cooked food for the

wards, one of our cooks receive the deliveries. We make sure the quality of the

products delivered. We reject those that don’t pass the quality control and return

them to the supplier.”

They always check if the deliveries are complete and not yet spoiled nor expired because

these will affect the quality of the food and worse, these will worsen the condition of the patients.

Sometimes, the hospital encounters problems in the delivery of raw materials. The staff shared:

“Sometimes replenishment of supply gets delayed and sometimes the supply changes all of

a sudden like for example we wanted fish to be delivered but instead we got a different

meat.”

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In addition, the NDS staff shared that whenever they encounter problem/s with the delivery of

ingredients and raw materials, they adjust the menu planned for the day.

STORING AND INVENTORY

Storing is the responsibility supplementary to receiving. The proper storage of food

immediately after it has been received and checked, is an important factor in the prevention and

control of loss or waste. Adequate space for storage should be provided in a location accessible to

receiving and preparation area.

In the DOH Manual, a store side or trained reliable NDS personnel should be in charge of

the storeroom, under the supervision of a Nutritionist-Dietician. In the Hospital A’s customized

standards, the stock clerk, with the supervision of the dietitian, will store the goods received and

all products will be dated upon receipt or when they are prepared.

Hospital A has a walk-in freezer for storing meat products. They also have different

refrigerators for storing other raw materials. Their food storage area door is equipped with lock for

security and for adequate control against loss and pilferage.

Dietary supplies may be issued from the Nutrition and Dietary Service storeroom or from the

Property Section storeroom. The process of issuing foodstuffs from the Nutrition and Dietetics

Service storeroom should be guided by the following steps:

 food should be issued only upon presentation of a properly prepared and signed requisition

slip.

 the requisition slip must contain a list of all items and quantities requested and must include

the signature of the requesting personnel. prepared and duly signed requisition slips should

be presented to the storekeeper.

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  the storekeeper should dispense the food items requested and then record them on the stock

card.

 the storeroom keeper shall be responsible for all the food items issued out.

HYGIENE, SAFETY AND SANITATION

To safeguard the health of patients and personnel, the Nutrition and Dietetics Service

should maintain highest standards of sanitation and safety in all areas of food service. An

understanding of sanitation and safety standards among nutrition and dietetics personnel is a must.

This can be attained through a well-structured training program with the emphasis on sanitary and

safety practices. Routine inspection of all nutrition and dietetics areas and personnel shall likewise

emphasize the importance of sanitation and safety. The Nutrition and Dietetics Service follows

infection control practices to reduce the risk of food-borne illness utilizing safe food storage,

handling and preparation methods compliant with government and local health standards. When it

comes to cleaning the kitchen, one of the staff mentioned that:

“We have a separate sanitary staff but us cooks usually help in cleaning, we sometimes

clean our workplace/kitchen by ourselves.”

Pest/Vermin Control

Foods that are not properly protected from contamination by pest and rodents are a public

health hazard. Flies and cockroaches may contaminate the food wiith the germs that can cause

outbreaks of intestinal diseases like diarrhea, dysentery, gastroenteritis and cholera. The premises

should always be kept clean and dry, free from flies, vermin, and rodents.

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 Since management emphasis is on the internal environment of the organization, the Chief

Dietician performs these tasks well with clear understanding of and is responsive to the many

elements of the social, ethical, economic, technical, and political environment which affects his/her

area of operation.

An NDS staff mentioned that:

“We make sure all our staff follows strict proper hygiene and are of proper health to handle

food or go to work. we do not allow sick employees to go to work to avoid food

contamination.”

Accident Prevention

One of the major concerns of the cooks in Hospital A is the poor ventilation in the food

preparation area. Per DOH Manual, safety measures to be observed to prevent accident among

Nutrition and Dietetics personnel and these include preparation, cooking, serving area and

corridors should be adequately lighted and ventilated.

In addition to government standards, floors should be cleaned and dried daily, equipment should

be checked and inspected regularly, and first aid kit should be made available all the time.

POLICY AWARENESS

Policies and procedures are important aspects when addressing relevant issues in any

organization whether it would be from public or private organizations.

Policy awareness in this paper is defined as the knowingness of the staffs on all of the

Nutrition and Dietetics Department’s policies and procedures. Examples are the code of conduct,

diet counseling, garbage disposal, handwashing, hiring, food production etc.

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Mission and Vision and Commitment of Employees

Mission and Vision is essential in aligning everyone in the organization in working on a

single purpose or goal. However during the interview, not only the Nutrition and Dietetics Section

(NDS) has mission and vision of the hospital, they also have their own section’s objectives. Their

main objective is to deliver safe and quality food to patients, staff and other stakeholders.

Moreover, all the staff under NDS is committed to its mission and vision and it is clearly

being manifested at the workplace. As stated by Staff Dietician B in the interview:

“Before we start our day, we make sure all things are ready and prepared which includes

all raw materials or ingredients. We double check the quality and reject those ingredients

that are of less quality and return it back to our suppliers. Moreover, we make sure all our

staffs follows strict proper hygiene and are of proper health to handle food or go to work.

We do not allow sick employees to go to work to avoid food contamination.”

Staff Dietician A also added in the interview:

“We dieticians use a monitoring tool in a form of a checklist like for example if a certain

food handler smell something unusual, or wears mask, hair nets, or if he or she uses a

measuring cup while cooking. “

Policy on Cleaning and Sanitation Procedures

The policy on maintaining cleanliness and sanitation of all the kitchen tools and

equipment involves all NDS staff that follows a strict procedure and frequency of cleaning on the

following kitchen area and equipment: blender, can opener, carts (tray carts,dish carts utility

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carts), refrigerator, walk-in freezer, trashcans, grill-gas, hoods and filters, microwave oven, pots

and pans, stove top, cabinets/drawers, floor and walls and ceilings.

Moreover the hospital policy states that:

1. All nutrition and dietetics section staff shall allot 30 minutes to conduct cleaning and

sanitation pre-and post-production.

2. The NDS staff shall maintain the sanitation of the section through compliance with

written and comprehensive cleaning schedules developed for the facility by the ndod.

3. A cleaning schedule shall be posted with tasks enumerated and assigned personnel for

each one.

The rationale behind this policy is to safe guard and ensures clean food service to patients

and stakeholders involved. As mentioned by Staff Dietician B during the interview:

“Moreover, we make sure all our staffs follow strict proper hygiene and are of proper

health to handle food or go to work. We do not allow sick employees to go to work to avoid

food contamination.”

Policy on Clinical Nutrition

The rationale behind this policy is to assist outpatient adhere to the diet regimen provided

by the registered Nutritionist-Dietician.

Clinical Nutritional policy is as follows:

1. The nutrition clinic shall set specific schedule for its operation in each department.

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 2. Patients shall have the physician’s referral for diet instructions. The hospital referral

slip should have the diagnosis of the patient, pertinent data and diet prescription of

the physician.

3. Patient’s caregiver or family shall be encouraged to participate in the discussion of

the meal plan.

4. The nutrition clinic shall provide special lane for senior citizens, pregnant women and

persons with disability.

5. The nutrition clinic shall give immediate attention to all clients in the special lane.

However, during the interview it was discovered that certain data or diagnosis essential in

making a proper and accurate diet plan coming from physicians are sometimes lacking of

information. As stated by Staff C during the interview:

“This is one of our limitations because we wanted to assess the patient from the start like

in the emergency room so we can access accurately what the patient needs, like we have

instances when we ourselves personally check the history chart of a patient. Some doctors

would say “this patient is for soft diet” but the patient is actually anemic which requires a

specialized diet, added vitamins or adjustment with the diet.”

Recruitment, Development and Evaluation of Staff

The recruitment process in the hospital follows a strict compliance that is bound by laws

and regulations in handling all applicants with the unbiased opportunity at applying for a job.

The hospital has its own Human Resource Department that follows these steps:

1. Defining the job description and specification in the pre-recruitment strategy.

2. Reviewing the applicant’s credentials diligently.

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 3. Interview of qualified candidates.

4. Employment testing which may include cognitive tests, personality tests, and

medical tests among others.

5. Background investigation or reference checking.

6. Final selection in coordination with nds.

7. Final employment decisions/ job offer or placement to successful applicant.

The hospital strictly follows the steps above to ensure that the organization will be able to

hire the most suitable applicant for the vacant position. As per Staff A’s statement on selection

process:

“During the selection process we look into the applicant’s minimum requirement.

HR makes sure they qualify for the position being applied and we together with

the HR conduct document review for further evaluation.”

Current Staffing Pattern of NDS

The NDS currently has all its positions filled however, current staff has urged

management to open more positions due to lack of adequate manpower that prevents the NDS

from completing the tasks at hand more effectively. In addition, one staff who is supposed to be

assigned or working for NDS is instead working for a different department. Despite the lack of

manpower, NDS considers the current staff pattern as very efficient.

As stated by Staff Dietician A:

“One staff is to two hundred patients (1:200) ratio during early duties and incase of

absences. “

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And Staff Dietician C added:

“So the ideal ratio is around one is to fifty (1:50) especially because we serve 800 patients

per shift ideally 16 staff per shift but now we are currently operating with 8-9 staff

excluding special functions of nds like additional guests, employees, meetings, and

seminars.”

As mentioned above, NDS occasionally caters food service on certain special occasions

like in-house seminars, hospital meetings and to other additional guests.

Employee Development

NDS is divided into two groups: first are the cooks/servers, which caters to the actually

cooking and serving of meals and the other one are the registered nutritionists and dieticians which

serves as the supervisors, planners and professionals on the nutritional requirement of patients.

New employees especially employees who applied for regular positions are given six

months probationary status. New employees during this period are given proper training with

regards to NDS’ operations and policies. Moreover, new employees are provided with some basic

background information about the NDS’, culture, and the job itself. This is called as ‘Socialization’

which is defined as the process when an employee learns the norms, values, goals, work

procedures, and patterns of behavior that are expected by the organization.1

Nutritionists rarely undergo official trainings or attend seminars as per interview. They

only had one (1) training in the last three (3) years. This is far from the planned and ideal trainings

and seminars required per employee which should include a minimum of forty (40) hours per

1
Irwin Goldstein and Patrice Gilliam, “Training system issues in the year 2000,” American Psychologist (1990).

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employee per six (6) months. Moreover, nutritionists admitted that they are having a hard time

complying with the required CPD activities under the Continuing Professional Development

(CPD) Law Republic Act No. 10912 of 2016.

As pointed out by Staff Dietician C:

“Unless if it is a government sponsored trainings/seminars like DOH. However, if we

would want to attend other trainings not sponsored by the government, we have to pay out

of our pockets to attend these trainings and seminars.”

For cooks, they are given occasional trainings not only solely on cooking but also trainings

on handling leftover food and minimizing food waste.

Staff Evaluation

One of the most crucial activities of a HR manager in an organization is maintaining and

enhancing the workforce. Performance review is the process in which an employee is assessed and

evaluated carefully by the management.2 Moreover, performance management is defined as the

ongoing communication process, undertaken in a partnership between an employee and his/her

supervisor.3

The hospital conducts performance reviews or evaluation twice a year to all of its

employees. Bonuses will be given to those employees exerting beyond expected performance

during the end of the year. The form used by the hospital is called the Individual Performance

Commitment and Review (IPCR) which monitors the performance of an employee.

2
D. Turacano, “How am I doing?” HR Magazine (1992).
3
Robert Bacal, Performance Management (McGraw-Hill, 1999).

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 However, there are a few employees who are underperforming but were not removed by

the hospital due to powerful inside connections. As mentioned by Staff Dietician B:

“We submitted several complaints but no action was done by our HR. We cannot do

anything about it since the employee is well connected with someone powerful in the

hospital.”

Staff Dietician A also added:

“We also cited a civil service rule because the employee was incurring excessive absences.

We recommended and hopeful that this employee would be sanctioned but nothing really

happened.”

IMPLEMENTATION OF EVRMC NDS POLICIES AND PROCEDURES

In line with the implementation of the ISO 9001:2015 accreditation of the hospital,

nutritional standards have been customized for compliance of the Nutrition Service. It was

discussed that these standards comply with the Department of Health policies on Nutrition and

Dietetics. Such customized policies have served as their reference in their conduct of daily

operations in the hospital.

An informant stated that:

“Yes, it [Customized Nutritional Standards] are being applied based on the manual. It

serves as our guidelines and basis in order to deliver quality service like on how we go

about certain procedures.”

It was emphasized by the key informants that all procedures and policies are patterned with

the Department of Health Nutrition and Dietetics Manual. However, when it comes to the

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monitoring and evaluation of such policies by the Department of Health, no inspections or

documentation audits were being performed by the latter. Such policy review was only raised

during the ISO Quality Management System Audit done by its internal auditors.

The informant stated:

“We just submit results, DOH do not conduct inspections or documentation audits except

once during our ISO certification by internal auditors.”

Furthermore, it was discussed that most of the major policies on Nutritional Services,

which is the core role of the Nutrition and Dietetics Service, are absent or are yet to be formulated.

Major responsibilities of a hospital’s nutrition and dietetics service include Nutritional Screening

and Assessment, Nutritional Care and Planning, Nutritional Counselling and Consultation and

Responsiveness to the Nutritional Needs of Patients.

For Procedure and Policy on Nutritional Screening and Assessment, a tool of the Nutrition

Service that efficiently determines patients who are In Nutritional risk is still being currently

worked on as of this writing.

The informants noted:

Staff A: We are still currently working on it, as of now we have a simplified tool, the

nutrition tool not necessarily the DOH standard we use a more simplified one but making

sure not to compromise anything.

Staff C: The DOH standard kasi kay bagat ka-daan na adto pan estudyante, very idealistic

and not usually fit for the real situation happening.

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 The DOH standard seems outdated and too academic, very idealistic and not

usually fit for the real situation happening.

Staff B: Mayda kasi nagvisit dd na Doctor na at the same time nutritionist nagteach ha

amon how to simplify [Nutritional Screening and Assessment]. Taga US, pacific

partnership kanan Balikatan(military outreach).

Due to the US Pacific Partnership (military outreach), a doctor at the same time

nutritionist visited and taught us how to simplify [Nutritional Screening and

Assessment].

Staff E: It’s not exactly the same an DOH standard because it is complicated.

On the Procedure and Policy on Nutritional Care and Planning, the staff admitted that such

policy is absent due to limitations on manpower and hospital procedure.

The staff discussed:

Staff A: Amo ito hiya, nutrition care process amo iton it waray pa kami talaga, ada la it

assessment plan, monitoring, evaluation.

Staff B: Usa ito it process when the patient comes we only cater the high risk ones for the

fact that we cannot serve all patients due to lack of manpower.

Staff C: May limitation talaga like pagstart talaga pagsulod it patiente, dapat ha ER pala

ma assess na namon it patiente, like kami pa mismo na check it chart an history an patient.

Like mayda doctor would say “this patient is for soft diet” pero anemic man ngean geap

hiya so kelangan an patient hin additional vitamins or adjustment a diet.

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 The Procedure and Policy on Nutritional Counselling is present in the office, however, the

Nutrition and Dietetics Service awaits orders from the Hospital Management and the Department

of Health to enact such policy. furthermore, a staff aired out the concern that such policy be

implemented across all hospitals.

The staff mentioned:

Staff C: “…nagstart pala kami ito and we will present this to the higher ups so we can start

to directly implement this however we do not have any administrative order by DOH with

regards to this.”

Staff C: “… we just started [making that policy] and we will present this to the higher ups

so we can start to directly implement this however we do not have any administrative order

by DOH with regards to this.”

Staff B: “Hopefully masignan na ngani ito natanan na hospitals kelangan mag nutritional

health care.”

Staff B: Hopefully all hospitals should be made aware that they need to implement

nutritional health care

On Procedure and Policy on Consultation and Responsiveness to Nutritional Needs of Patients,

there is an established policy where food for patients needing special care are prepared with special

food.

Staff C: “We receive referral forms from doctors then we are given 30 mins to handle the

request. We receive various request such as renal problems, hypertensive etc.”

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 The DOH Hospital Nutrition and Dietetics Service Management Manual explicitly states

the Clinical and Educational Functions of Nutrition and Dietetics personnel on nutrition care

specifically on nutritionally screening, assessment, diagnosis and intervention (p. 131 – 136).

These policies form the “heart of nutritional care” which aids in the improvement of nutritional

status of individual patients (p. 131).

As these Nutritional Care procedures are absent or at its infancy in the hospital, a crucial

function of the Nutrition and Dietetics Service is not being implemented.

EVALUATION OF POLICIES AND PROCEDURES

The evaluation of policies and procedures come in a form of the mechanism provided by

the ISO 9001; 2015 Quality Management System. However, such mechanism is not tailored fit

towards the assessment of the department in the DOH standards. The staff claims that their

conformance to the DOH manual makes them compliant to the document.

Since the Department of Health, as the staff claim, do not conduct nutrition policy

evaluation and procedure, mechanisms such as Internal Audits are being adapted by the hospital

to look after such policy. ISO Internal Audits a

The informants said:

I think the ISO [serves as the evaluation mechanism], kasi ginsusunod namon an manual.

We are not aware of our next audit, but we expect a surveillance audit maybe after 6

months. We passed the internal audit with some minor changes to be done.

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 I think the ISO [serves as the evaluation mechanism], because we followed the manual. We

are not aware of our next audit, but we expect a surveillance audit maybe after 6 months.

We passed the internal audit with some minor changes to be done.

In reference to the DOH Hospital Nutrition and Dietetics Service Management Manual (p.

163), it refers to the establishment of the Continuous Quality Improvement (CQI) for Nutrition

and Dietetics Service with emphasis on Total Quality Management (TQM). This initiative is to

assist health care professionals in achieving and maintaining the highest level of quality care of all

patients of the facility (p. 167). Components of this program primarily include objective

assessment of the cause and scope of problem(s), implementation of decisions or actions design to

eliminate identified problems and monitoring of activities designed to ensure that the desired result

has been achieved and sustained (p. 180). Inasmuch as the TQM Program includes the

implementation of the ISO 9001:2015 QMS in hospital service, the ISO accreditation is a

compliment to the supposed to be established TQM Program in the hospital.

Based on the interviews conducted, the TQM Program is not present in the established

operations of the Nutrition and Dietetics Service of the hospital.

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 Chapter V
CONCLUSIONS & RECOMMENDATIONS

Conclusions:

The gathered data were able to substantiate the extent of implementation and compliance

of the hospital vis-à-vis DOH Hospital Nutrition and Dietetics Service Management Manual.

Specifically:

1.) The NDS customized policies and its implementation does not fully conform with the

DOH Hospital Nutrition and Dietetics Service Management Manual;

2.) The NDS policies governing food service are inconsistently enforced.

Recommendations

1.) The NDS to reassess its customized policies and its implementation to fully conform

with the DOH hospital nutrition and dietetics service management manual

2.) The NDS must ensure that employees fulfill the target no. of hours of training for all

its employees to provide equal opportunity for trainings with added support from the

hospital management.

3.) The hospital policies on human resource, especially pertaining to conduct of employees

must be strictly enforced (absenteeism, staffing plan).

4.) The facilities of the NDS must be improved to provide better service among its client

(e.g. dedicated office space for receiving raw materials and ingredients, lack of

equipment and repair/replacement of unserviceable equipment, proper ventilation of

the cooking area must be addressed, proper isolation and disposal of food waste).

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5.) The NDS policy on sanitation must be strictly and consistently enforced (e.g. rat

proofing of the facility, functional water supply for dishwashing, cooking and other

usage, cleaning of kitchen area and equipment).

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