ARTICLE IN PRESS

Improvement in the quality of the catering service

of a rehabilitation hospital
L.M. Doninia,, E. Castellanetab, S. De Guglielmib, M.R. De Feliceb, C. Savinab,
C. Colettia, M. Paolinia, C. Cannellaa

a
Dipartimento di Fisiopatologia Medica, Sezione di Scienza dell’Alimentazione, Università degli Studi di Roma ‘‘La
Sapienza’’, Ple Aldo Moro, 5-00185 Rome, Italy
b
Istituto Clinico Riabilitativo ‘‘Villa delle Querce’’, Nemi, RM, Italy

KEYWORDS Summary
Nutrition; Background: Malnutrition due to undernutrition or overnutrition is highly prevalent in
Nutritional care hospital in-patients and it decisively conditions patients clinical outcome. One of the most
in hospital; influencing factors of malnutrition in hospitalized patients is—at least in part—the
Catering service Catering Service Quality.
system; Aim: Is to verify, over a 5 year period, the course of the quality of the institutional
Rehabilitation Catering Service, verifying the effectiveness of the quality improvement process used.
Methods: Quality control was performed by objective (meal order accuracy, proper
distribution of food in trolleys, route time from the kitchen to the ward and time of food
distribution, food weight and temperature, waste assessment) and subjective assessment
(quality was measured by giving the patients a questionnaire after meals).
Results: The survey included: 572 meals and 591 interviews. A significant amount of
‘‘qualitative’’ errors (lack of respect for patient preferences or at the moment of supplying
the food trolley) have been found. Over the time and the amount of patients that wasted a
considerable amount of the portion served was considerably reduced food temperature
have been improved. Also patient satisfaction with menu variability, portion size,
temperature and cooking quality improved over time. The overall ratings of meals under
observation improved too in fact, positive opinions ranged from 18% in 2002 to 48.3%
in 2006.
Conclusion: Ongoing research and quality verification, which include all catering service
workers, yields a constant improvement in quality. Patients in healthcare settings should
receive a service they appreciates, but it should be—at the same time—correct from a
nutritional point of view. For this reason, it is necessary a continuous mediation between
customers satisfaction and nutritionists work, dieticians and nursing staff. From this point

Corresponding author. Tel.: +39 06 4991 0996; fax: +39 06 4991 0699.
E-mail address: lorenzomaria.donini@uniroma1.it (L.M. Donini).
 ARTICLE IN PRESS
of view the educational approach becomes essential to feed patient compliance to dietetic
treatment that will continue after discharge.
& 2007 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights
reserved.
Introduction
Malnutrition, due to overeating or undereating is very
common in hospital in-patients,1–5 it is crucial for patients
clinical outcome and it is determined—at least in part—by
the Catering Service Quality (CSQ) (‘‘Food and Nutritional
Care in Hospitals: How to Prevent Undernutrition’’ 2002.)6
From a subsidized reality, hospital catering is going to
assume a new look and a different organization that takes
into account both the hotel aspect and the clinical-
nutritional one. Therefore, CSQ plays an important role
from a healthcare point of view providing all patients with
healthy, balanced and varied nutrition; targeting individual
clinical and metabolic needs, in a context where the
homeostasis of the individual is already at risk.7,8
Hospital catering can also become an educational tool, in
fact by it patients may be stimulated to maintain healthy
eating habits even after they have been discharged from the
hospital and moreover, making the recurrence or worsening
of malnutrition caused by overeating or undereating
less likely.7
The CSQ—that is, its ability to fill the clinical-nutritional
needs of each individual admitted and, at the same time, its
ability to deliver a diet that is ‘‘acceptable’’ for the
patient—depends on different and various factors such
as: food quality, sensory component, emotional and affec-
tive conditions, environmental situations, organization,
interaction between different participants involved in the
management.
In a previous study,9 we proposed a model for measuring
the CSQ in a rehabilitation and long-term care facility, based
on both objective and subjective parameters. We also noted
a substantially unsatisfactory level of quality that we
wanted to improve.
The aim of the present study is that of verifying, over a
2-year period, the CSQ, checking the effectiveness of the
quality improvement undertaken.
Materials and methods
Admission facility
The survey was carried out in a private Hospital facility
accredited to the National Health Service in the province of
Rome from January 2002 to December 2006. The facility has
beds for about 600 patients: two nursing-homes have a total
of 150 places, three rehabilitation wards have 250 places,
and medical long-term service has 200 places.
The hospitalized population is generally made up of
elderly subjects with an average age of about 65 years in
nursing homes and medical long-term service and of
subjects with an average age of about 50 years, who have
osteoarticular, dismetabolic and cardiovascular diseases in
the rehabilitation wards. Due to this fact, particular care
must be taken regarding both their clinical needs and their
nutrition.
Organization of the catering service
The organization of the Catering Service also remained
substantially unchanged since the previous survey9 and was
provided by an external firm.
Briefly, about 2000 kcal/day with 90 g of proteins are
given to the patients. The non-protein caloric amount is
covered for 65% by mainly complex carbohydrates and for a
third by fats. The supply of mineral salts, vitamins and trace
elements is that stated by the RDA for the Italian population
(LARN—Livelli di Assunzione Raccomandati di Energia e
Nutrienti—Società Italiana Nutrizione Umana—1996) with
special attention to Ca (ideally 1 g/day per head), Fe
(10 mg/day) and Na (that should not go over 3 g/day per
head). The supply of fibres is about 30–35 g/day.
Three main meals and a snack in the afternoon or evening
are provided.
There is only one daily menu with fixed alternatives for
each dish (standard plain dishes of pasta, meat, fresh dairy
products). As regards the second courses frequency during
the week (14 main meals), it provides meat for five times
and fish, eggs, fresh cheeses for three times each. Due to
their high content of sodium, cold cuts and seasoned
cheeses are excluded. Generally, the same dishes are not
repeated during a 4 weeks time.
The menu is stuck up in a notice board in each Ward and
at the moment of distribution, the nursing staff tries to
meet patients’ requests using from time to time the daily
menu dishes or the fixed alternative available.
The Clinical Nutrition Service (CNS) establishes the meal-
quality criteria and the guidelines for the organization of the
Catering Service. Moreover, the CNS itself prescribes
individual diets for patients with obesity, type 2 diabetes
mellitus, renal or hepatic failure, etc.
For patients on a therapeutic diet, the dietician makes a
recognition of their foods preferences and communicates to
the kitchen the dishes the patient does not tolerate.
Especially for those patients for whom the diet must also
have an educational purpose, the attention is paid more to
nutritional quality of diet than to preferences: food
substitutions occur only within the same food group and it
is not allowed to eliminate entire food categories (milk and
milk by-products, fruit, vegetables, y). The dietician also
informs the ward about the presence of a patient on a
nutritional treatment.
The kitchen is centralized and works with a standard hot-
bond system of warming up food able to provide either food
preparation and immediate food distribution in the wards
using trolleys equipped with large multi-portion stainless
 ARTICLE IN PRESS
steel trays. The service distributes about 1800 meals each
day. Meal preparation is done in a period before its
consumption and the time lapse between preparation and
consumption is a maximum of 3 h. The distribution schedule
provides for the serving of breakfast at 8.15 a.m., lunch at
12.15 p.m., and dinner at 6.00 p.m.
Standard meals are carried in multi-portion trolleys and,
once in the ward, plated and distributed to patients by the
service staff. Therapeutic diets, prepared separately, are
carried in the same trolley. At the moment of food
distribution, plastic trays, plates and disposable glasses,
paper towels and aluminium cutlery are given. The meal is
eaten in patients’ rooms in all wards, except in the nursing
homes where dining rooms are available.
Quality control
Controls performed
The survey was carried out from January 31, 2002, to
December 31, 2006, and concerned:
a. Objective assessment: 572 meals (52 breakfasts, 397
lunches, 102 dinners)
b. Subjective assessment: 591 interviews (292 to patients
on regular diets and 299 to those on therapeutic diets).
Controls were performed only in the Rehabilitation Wards
in order to have a higher reliability in the subjective
judgments, taking into account the high prevalence of
cognitive impairment among the patients hospitalized in
long-term care ward or among the nursing home population.
Objective assessment
It was done by measuring the index parameters of diet
quality. One food trolley route was analysed generally on a
tri-weekly basis. Standard diets and one of the therapeutic
diets were checked. The following indicators were used:
(a) Meal order accuracy: Discrepancies between what was
supplied and the orders placed by the floor supervisor or
the diet prescriptions, mistakes in supplying the trolley
at the moment of preparation in the kitchen.
(b) Proper distribution of food on the trolley, paying attention
when hot meal was not separated from cold ones.
(c) Route time from the kitchen to the ward and time of
food distribution. The Rehabilitation Wards—where
nearly all the recordings were done—are on the 21, 31
and 41 floor of the Hospital, at a distance of about 150 m
from the kitchen that is located at the ground floor.
(d) Food weight: Food was weighed at the moment of
trolleys preparation. The portion per patient was
calculated from this data. The latter data was converted
into raw weight using the Italian ‘‘Composition Tables
for Food’’10 and then compared to the portions stated in
the menu. In regard to the regular diets, we considered
a food quantity at least 10% lower than that stated in the
contract as unacceptable. For therapeutic diets also a
quantity at least 10% higher than what stated in each
single diet was considered as improper.
(e) Food temperature was recorded at the moment the
meals arrived on the floor. In 2002, this measurement
was done with an Oregon Scientific thermometer (only
liquid foods were measured). Since 2003, a Hanna’s
Instruments thermometer was used; therefore, solid
foods can also be checked.
(f) Waste assessment: we evaluated
1. the percentage of subjects wasting a considerable
amount of food (about 50%) in respect to the portion
distributed and
2. the items on the menu that were wasted in the
amount of 50% by more than 20% of subjects.
Subjective assessment
To assess patients’ perception of food quality, two different
questionnaires were administered after the meal for
patients on regular or therapeutic diets. The patient could
answer giving a four level judgment going from ‘‘true’’ to
‘‘false’’ or from ‘‘good’’ to ‘‘bad’’ depending on the
question. The interview was always given to each patient
in a room and it regarded: the place where the meal was
eaten, the possibility of having alternatives to the basic
menu, opinions about the menu variability, how the meal
was served, if timetables were respected, the food quantity,
the cooking quality, the food temperature, and the hygienic
standards. The detail of the questions inserted in the
questionnaires is in Table 4.
Improvement of quality
The Management of the Hospital, the Catering Service
Company (CSC) and the CNS decided to adopt some tools for
improving the quality of service, on the basis of the Official
Document of the Committee of Experts on Nutrition, Food
Safety and Consumer Protection of the Council of Europe
‘‘Food and Nutritional Care in Hospitals: how to prevent
undernutrition’’6 and the results of previous research. The
tools are the following:
 Better cooperation and more communication between
CNS, CSC and in-patient wards (medical and nursing staff)
in order to have more effective, direct and immediate
feedback information. To this purpose, meetings among
the above-mentioned three components were organized
and specific forms were drawn up to signal problems,
changes proposals. Forms to prescribe therapeutic diets
or to point out patients’ not suited foods listening, the
opinion of the catering service company and in-patient
Wards were also drawn up.
 Refresher courses for the nursing staff were organized
(according to the CME program of the Italian Ministry of
Health) while it was not possible, at that given time, for
the kitchen staff.
 ‘‘Punctual’’ warnings:
J to the kitchen, about any problems (plates with
significant waste in more than 20% of patients,
mistakes in loading the trolleys, etc.) and
J to the Healthcare Management and to the Technical
Service of the Hospital about the occasional struc-
tural problems that complicated the achievement of
 ARTICLE IN PRESS
optimal quality levels (inefficient insulation of food
trolleys, difficulties in transfers inside the facility,
etc.).
 Adoption of corrective measures:
J improvement of kitchen equipment particularly those
ones able to maintain adequate temperatures accord-
ing to HACCP (Hazard Analysis Critical Control Points)
procedures,
J correction of menus through the elimination of those
dishes that received negative opinions from the
patients in a high percentage of cases,
J simplification of the work in the kitchen in the
preparation of therapeutic diets,
J recording patient food preferences as regards food
choice,
J educating the medical and the nursing staff about the
problems of managing the catering service: need
to have precise and not generic signals, and clear
requests, and
J educating patients about the need for a dietetic
therapy through the elaboration of leaflets and
educational therapy regarding the risks connected
with malnutrition due to overeating and undereating.
Kitchen work simplification in therapeutic diets prepara-
tion was obtained focusing our attention on main and second
courses and on oil seasoning. For the above-mentioned
foods, the portions were modulated (on the basis of CNS
prescription) while for milk, bread, biscuits, fruits, salad
and vegetables standard portions were served.
As regards particularly patients education, questions
about previous eating habits of the patients that needed a
therapeutic intervention were added in the subjective
evaluation questionnaire. The data collected (data not
shown) pointed out bad eating habits in most part of those
patients (low intake of fruit and vegetables, low tendency to
have breakfast, high intake of foods rich in salt) and allowed
us to intervene more precisely towards single subjects.
Finally, we can assume that three dieticians dedicated
one-third of their working time, that is to say 72 h per week
each, to collect and process data (concerning the Catering
Service objective and subjective evaluation), to correct
deficiencies pointed out, to maintain relationship with
various facilities involved.
Data analysis
Data related to subjective and objective evaluation of the
quality obtained in the years 2002–2006 were compared.
Student’s t-test was used to assess differences in-group
means. Statistical significance was set at the po0.05 level.
Data were analysed using the SPSS for Windows 10.0 (SPSS
Inc., 1989–1999) statistical software packages.
The study was approved by the local Ethics Committee.
Results
Sample examined
The sample of subjects examined since 2002 up to now
resulted made-up of subjects whose average age has
diminished during the years (from 67.0710 in 2002 to
53.4716 years in 2006), who were mostly admitted in
rehabilitation wards and affected by osteoarticular, cardi-
ovascular and dismetabolic pathologies. Patients stayed in
the hospital for a period of 2 months maximum (range:
21–60 days). Controls were programmed randomly (although
not randomised) choosing each day a different ward and a
different stay-in-bed room for the interviews.
Objective assessment
Qualitative and quantitative food assessment
a. Portions, conformity to the orders (Table 1)
Two types of errors were noted: ‘‘quantitative’’ and
‘‘qualitative’’ type. Portion weights were increasingly in
line with the contract standards or the diet orders, both
for standard and therapeutic diets. Errors made for
therapeutic diets were, however, nearly two-folds great-
er than for standard ones with few variation during
the years.
‘‘Qualitative’’ errors progressively decreased during time
except the lack of keeping of the timetable that,
especially in 2005, was particularly frequent and the
lack of products for specific conditions (celiac disease,
for example).
b. Food temperature (Table 2)
In 2002, only liquid ‘‘foods’’ were measured. Since 2003,
solid foods temperature could also be measured. Even
though it was not up to contract standards and within the
hygienic safety norms, there was a considerable im-
provement over the course of the years. An exception is
the temperature of cooked side dishes that remains low
and tends to decrease during the years: these dishes are
generally prepared before the main and second courses.
Lower temperatures were recorded for therapeutic diets.
Only hot foods temperatures were reported; cold dishes
(mainly second courses and side dishes) are rarely served
and the measurements recorded do not allow any
significant comparison.
c. Assessment of wasted foods amounts (Table 3)
The number of patients who wasted a considerable
amount of the portion served (50%) for all foods, for
standard diets and for therapeutic ones declined con-
siderably from 2002 to 2006 even if in this years we had a
slight worsening for first course and side dishes of
standard diets. The percentage of wasted bread and
fruit was never checked since many patients tended to
keep those foods in order to eat them later in the day.
The amount of the menu items wasted also decreased
(for a considerable amount of each portion served) in
more than 20% of subjects.
Subjective assessment (Table 4)
The percentage of the patients thinking that the place
where they consumed meals (generally their room) as
adequate to their needs decreased more and more over
the years (64% in 2002 vs 48% in 2006).
 ARTICLE IN PRESS

Table 1 Objective assessment of the Catering Service Quality—percentage amount of errors for portion weights and
qualitative errors.

2002 2003 2004 2005 2006

Controls performed 65 137 109 113 148

Regular diets (%)

Lunch and dinner
11 course 16.2 0 0 1.7 2.5
21 course 17.8 8.4 6.6 3.4 7.5,y
Side dish 16.8 5.5 2.4 13.6 25,y
Bread 1.3 15.3 5,y
Fruit 1.3 10.2 17.5,y
Therapeutic diets (%)
Lunch
11 course 40.2 10.5 6.0 8.5 5,y
21 course 50.8 11.4 2.1 2.5 7.5,y
Side dish 34.0 5.5 0 0 0
Bread 0 1.7 0
Fruit 1 0 0

Qualitative errors (%)

No respect for timetables 2.8 39.0
Improper trolley supply 87.5 17.2 16.4 28.3
No respect of the menu 3.6 8.3
No respect for patient preferences 11.8 6.7
Repetition of main courses 31.8 12.7 0
Lack of products for specific conditions (celiac 5
disease, hypoproteic, y)

The portion was judged substandard if it was lower by at least 10% compared to what was indicated in the contract or in the individual
diet order; it was considered excessive if it exceeded by about 10% that provided by the individual diet order. For the regular diet only
the error by defect was considered, while for the therapeutic diets both that by defect or by excess.
Blank cell indicates not available data.
Data were analysed comparing year 2006 to the first year of observation (generally 2002) and to 2005.
 Significantly different (po0.05) by Student t-test from the first year of observation.
y
Significantly different (po0.05) by Student t-test from year 2005.

Menu variability was judged as adequate by 4% of the
patients in 2002 and by 50% in 2003–2004. This percentage
decreased to about 40–45% in the 2-year period 2005–2006.
Today, more than a half of patients still think the menu is not
varied enough and sustain that dishes are repeated too often
during the week. This percentage is similar in the subjects
on a special diet.
Opinions about meal presentation and food quality
were contradictory and not satisfactory particularly for
the first one.
The percentage of patients considering that meals arrived
according to schedule increased until 2005 and then
decreased to 72.4% over the last year.
Patients were asked to give an opinion on food portions,
temperature and cooking quality. In this case, too, the
opinions improved over time at least until 2004. In this year,
85.2% of the patients considered the portions to be
sufficient, 70.7% thought the food tasted good and 85.2%
considered the temperature to be adequate. In 2006, these
percentages decreased respectively to 79.3, 75.9 and 58.6.
Regarding the patients who were on a special diet, these
percentages were significantly lower and did not follow a
positive, satisfactory course over the time.
The patients were also asked to give an opinion on the
saltiness of the food: the percentage of satisfied subjects
decreased from 63 in 2002 to 41.4 in 2006.
Moreover, the patients were asked to give an opinion on
the sanitation of the Catering Service from an hygienic point
of view (hygiene of the serving pieces and of the place were
the meal was eaten): in this case, too, the results improved
over time: a positive judgement was given by 32% of
patients in 2002, and by 75.9% in 2006.
The interview ended by asking patients an overall opinion
on the meals under study: positive opinions went from 18% in
2002 to 48.3% in 2006. Subjects on a special diet continued
to have substantially negative opinions.
Discussion
Quality of the catering service
It has been demonstrated that one of the major factors
causing weight loss among hospital patients is inadequate
food intake resulting from the unsatisfactory nature
of present feeding arrangements.11 Elements that can
 ARTICLE IN PRESS

Table 2 Objective assessment of the Catering Service Quality—temperature (1C).

2002 2003 2004 2005 2006

Mean Interval Mean Interval Mean Interval Mean Interval Mean Interval

Regular diets
First course 39.1 25–55 67.5 36–85 70.7 56–88 66.5 57.9–86 70.6 41.9–88.2
Second course 35.2 31–56 52.8 40–58 52.1 15–67 51 27.8–72.4
Side dish (cooked) 48.1 33–78 54.1 45–61 53.2 12–67 51 30.1–84.3

Therapeutic diets
First course 32.2 28–43 47.4 31–63 53.2 44–62 50.6 25–60 53.2 45.2–74.4
Second course 38.3 34–53 47.7 48–60 46.8 32.1–58.5 48.2 27.6–67.4
Side dish (cooked) 62.0 40–70 47.3 27–57 48 35.1–58.3 46.3 29.1–63

Starting in 2003, it was possible to take the temperature of solid food, while in 2002 the thermometer available allowed only for
recording of the temperature of liquid foods. Only the temperatures of warm foods are reported; cold dishes (mostly second courses
and side dishes) are served separately and the measurements recorded do not allow any significant comparison.
Blank cell indicates not available data.
Data were analysed comparing year 2006 to the first year of observation (generally 2002) and to 2005.
 Significantly different (po0.05) by Student t-test from the first year of observation.

Table 3 Objective assessment of Catering Service Quality—waste control.

2002 2003 2004 2005 2006

Percentage amount of patients discarding a quantity of served foods 450%

Regular diets
First course (%) 23.1 15.2 13.2 9.9 11.1
Second course 38.1 17.1 10.9 10.4 6.4,y
Side dishes 40.1 23.1 16.8 13.2 14.5

Therapeutic diets
First course 51.2 13.3 4.5 2.6 0
Second course 52.1 19.1 2.5 0.3 4.3,y
Side dishes 72.2 39.0 11.4 6.3 3.3

Percentage amount of dishes in the menu that waste 420%

Regular diets
First course 22.2 18.4 11.5 20.6y
Second course 23.3 23.2 14 5.9,y
Side dishes 48.1 35.1 19 31.4,y

Therapeutic diets
First course 17.5 8.3 2.4 0
Second course 25.2 2.8 0.4 4.3,y
Side dishes 48.3 16.7 6.3 3.3

Breakfast wastes of bread and fruit were not recorded, taking into account that patients have a habit of keeping these foods to eat
later in the day.
Blank cell indicates not available data.
Data were analysed comparing year 2006 to the first year of observation (generally 2002) and to 2005.
 Significantly different (po0.05) by Student t-test from the first year of observation.
y
Significantly different (po0.05) by Student t-test from year 2005.

determine the CSQ, and that can therefore affect patient  co-operation between different staff groups and involve-
nutritional status—that are largely reported in the ‘‘Food ment of the hospital management; and
and Nutritional Care in Hospitals: How to Prevent Under-  information and educational level, regarding nutrition,
nutrition’’,6 may be classified into three groups: among all staff groups and patients.

 organization of a service that meets the patient’s In this paper we focused our attention to the last two
nutritional needs; points.
 ARTICLE IN PRESS

Table 4 Subjective assessment of the Catering Service Quality.

Positive response 2002 2003 2004 2005 2006

Controls performed

33 70 56 58 75

Regular diets
Do you consider the place where you had your meals? (%) 64.0 61.0 57.1 52.6 48,y
Is menu variability adequate? 4.3 50.2 50.4 42.1 44.8
Are you satisfied by the presentation of dishes? 22.2 49.1 26.6 10.5 37.9,y
Are you satisfied with the utensils you were given (cutlery, glasses, napkins)? 9.6 58.2 68-0 57.9 69,y
Was the meals distribution timetable respected? 79.6 87.2 94.9 100 72.4
Are the portions served up to your expectations? 84.2 84.2 85.2 73.7 79.3
Is the food temperature optimal? 41.2 75.1 85.2 94.7 75.9,y
Was the food well-cooked? 35.3 58.1 70.7 52.6 58.6,y
Was the quantity of salt right? 63.3 60.4 67.6 57.9 41.4,y
How do you judge the service from an hygienic point of view? 32.2 63.3 87.0 68.4 75.9,y
In conclusion, how do you rate today’s food? 18.1 44.2. 50.3 52.6 48.3,y

72 57 59 111

Therapeutic diets
Is menu variability adequate? 53.2 46.2 48.8 42.1,y
Are you satisfied by the presentation of dishes? 38.2 36.0 19.5 23.4
Is the food temperature optimal? 43.1 64.5 53.7 72.9,y
Was the food well-cooked? 66.1 58.6 51.2 46.7
Was the quantity of salt right? 68.0 70.1 53.7 57.9
In conclusion, how do you rate today’s food? 37.0 34.2 36.6 27.1,y

In 2002, we interviewed only subjects on regular diets.

Blank cell indicates not available data.
Data were analysed comparing year 2006 to the first year of observation (generally 2002) and to 2005.
 Significantly different (po0.05) by Student t-test from the first year of observation.
y
Significantly different (po0.05) by Student t-test from year 2005.

Co-operation between different staff groups and hospital
management involvement
A major common problem in all the European countries is
the lack of involvement of hospital management in the
organization of food and nutritional care: in most hospitals,
the provision of a meal is seen as a routine task. It is,
however, important to look at the provision of meals in
hospital food service systems as a management issue.
Hospital managers should take into account the costs
of medical complications and prolonged hospital stays
due to undernutrition when assessing the cost of food
service. In general, better hospital food provision may
diminish the necessity to use sip feeding and arti-
ficial nutrition, and allow earlier weaning from these
treatments.12,13
In the last years of our study, one of our main goals was
that of creating an efficient system of communication
between all the different components. At the moment—ex-
cept few exceptions and with a constant reinforcement—we
are able to receive constant and reliable information from
the wards, to alert both the kitchen staff and the hospital
management of any problems, and to have answers to them
in a relatively short time. In this case, the role of the nursing
staff is essential to have reliable information and possible
solutions to the problems pointed out.
Information and educational level, with regard to
nutrition, among all staff groups and patients
Educational level. In general, food service practices receive
little attention from both the political/management level
and the physicians. However, food service is not merely a
hotel function and the food served is part of the clinical
treatment. The majority of patients receive their nourish-
ment from the hospital kitchen, which is generally organized
on the hotel or institutional model, rather than being
targeted to groups of sick patients with their own particular
needs.14 All hospital staff—clinical and non-clinical—should
acknowledge food service as an important part of treatment
and care of patients (Ref. [6], p. 57) and different
educational and information measures may allow the raise
of the awareness of medical and nursing staffs with regard
to patients’ nutritional needs and barriers to food intake.7,15
For this reason, a general improvement in the educational
level of all staff groups (including non-clinical staff
members) is needed specifically on general nutrition and
techniques of nutritional support with the definitions of
their area of responsibility.
Over the past 4 years, we organized four courses for the
ward staff. In our opinion this was not sufficient and more
work needs to be done. In fact, the responsibility of the
hospital with regard to the nutritional care and support of
 ARTICLE IN PRESS
the patient cannot be limited to the hospital stay (Ref. [6],
p. 15) and therefore the nursing staff needs be involved in
the educational process of the patient.
Customer satisfaction research, either by the nursing or
food service staff, should end where the nutritional
problems of the patient start. Of course, this transition
requires that the patients be informed and motivated. In our
case, survey on patient eating habits brought out poor
habits, especially in those on therapeutic diets. Negative
opinions about the salt content or the food in general should
also be interpreted in light of this data.
Information to the patient. The current trend is to consider
that patients have the right to nutritional care and,
whenever able to eat, to choose what they want to eat,
and when and with whom (Ref. [6], p. 17). For this reason,
the provision of meals should be individualized and flexible,
and all patients should have the possibility to order food and
extra food—and be informed about this possibility. Also,
patients should be involved in planning their meals and have
some control over food selection. This should include the
possibility of immediate feedback about the patients’ likes
and dislikes of the food served—and the use of this feedback
to develop appropriate, target group specific menus.
Patients should be informed of the importance of good
nutritional status for successful treatment prior to admission
and at discharge.
In most hospitals, the patients have a multiple choice of
menus. This is not necessarily beneficial, for example, if
undernourished patients choose food from the low nutrient
density healthy eating option or if hypertensive patients
choose foods with a high concentration of Na (Ref. [6], p. 76).
This implies a tight connection between information, menu
choice and the patient’s nutritional education. This change
needs the mediation of dieticians and nursing staff. Few
patients are, in fact, aware that disease related weight loss
will increase their risk of medical complications and that
obesity is related to diabetes, hypertension, cardiovascular
diseases. Assistance with menu choice helps to prevent
patients from choosing foods, which are unsuitable for their
clinical condition.16
In confirmation of this, in our case the sharp reduction in
the quantity of salt used in cooking (about 50% less, going
back to a supply of about 3 g/day of Na–7.5 g NaCl, as stated
in the national and international recommended dietary
allowances) and salty foods like cold cuts and seasoned
cheeses that disappeared from the menu was not appre-
ciated by our patients. Probably the change was not
accompanied by an efficient work of sensitization of
patients about the risks connected with an excessive intake
of Na, particularly in subjects with cardiovascular diseases.
The involvement of patients in planning hospital meals, the
assistance with menu choice, the realization of courses
addressed to patients on a nutritional treatment may help
hospital catering to become an educational tool in main-
taining healthy eating habits.
Assessment of the quality of the catering service
system
Besides identifying the elements that determine the QCS,
from the analysis carried out in the ‘‘Food and Nutritional
Care in Hospitals: How to Prevent Undernutrition’’,6 it
raises the need for creating objective and subjective
measurement systems of the efficacy of the system
(screening methods for malnutrition, food recording meth-
ods, methods for assessing patient satisfaction), allowing for
a constant quality monitoring and fast and efficient
interventions.
Objective assessment of the catering service system
quality
In addition to standard tools for objective control (tem-
perature, portion weight), other tools may have an
important role in measuring the Catering Service System
efficacy such as the assessment of food intake and waste
control. In particular, studies of hospital food wastage show
high levels of waste: recent studies from the United
Kingdom, France and Denmark have shown that the
percentage of food wasted is even higher than previously
thought, corresponding to 40% of the amount pro-
duced.13,17–20 And it may happen that, although hospital
food provision exceeded energy and protein needs of
patients, a great number of patients do not eat enough to
cover their minimum needs.7
There are many factors involved in determining how much
food is wasted: food palatability, ethnic and/or cultural
background, food preferences, temperature of the food,
portion size, hours of served meals, length of mealtimes,
individual patients’ appetites, negative effect related to
stress and treatments and the availability of help with
feeding. In general, waste represents a major clinical
problem because it reflects inadequate food intake. It is
also a major economic problem. Waste control allows either
a longitudinal assessment of the eating behaviour of the
single subject, or the transversal one on the efficacy of the
Catering System. Waste control allows also the possibility to
carry out arrangements in general organization (e.g.
decreasing the portion size but increasing the nutrient
density) addressed to improve caloric and nutrient intake.21
In our case, the waste control, carried out by the dietician
and the nursing staff, has allowed, over time, to eliminate
dishes that were characterized by an excessive amount of
waste.
We also pointed out the ‘‘mistakes’’ made by the kitchen
staff in the preparation of meals in terms of discrepancies
between what was supplied and the orders placed by the
floor supervisor or the diet prescriptions. The mistakes made
for diets were nearly two-folds greater than for standard
diets. The corrective actions we adopted did not give
satisfactory results to this day. The diet preparation requires
a procedure that is mostly completely separated from those
for the common diet for a great part. To reduce this gap, it is
probably necessary to check the work processes in the
kitchen, the human resources involved in this job, and above
all to train more efficiently the operators working in those
preparations.
Subjective assessment of the catering system efficiency
European hospitals seem to have an image problem when it
comes to the quality of the food served. Before even tasting
it, patients often expect poor quality and after tasting it
their expectation is many times confirmed22–24; sometimes
 ARTICLE IN PRESS

patients do not eat all the food served because taste do not Our study has two important limits. It was carried out in a
suit them and there is no menu choice.7 rehabilitation care facility with a stay in hospital of 20–60
Different methods to assess patient satisfaction have days. The findings may not be relevant, for this reason, for
been developed and implemented in different settings.25–28 acute hospital with average length of stay of less than 1
These instruments may influence the quality of food service week. Even if the results are not applicable ipso facto to this
practice and can also have a benefit on food wastage. second type of facilities, still, the basic concepts remain, in
However, the provision of meals should be regarded as an our opinion, valid for every admission facility.
essential part of the treatment of patients, and not as a The second limit is that the selection of the patients and
hotel service. Therefore, it differs from the customer of the wards where the controls were carried out did not
satisfaction so sought-after by catering companies and that occur according to randomized procedures. This can justify
can often be achieved only meeting the patient’s bad some results that are difficult to interpret.
habits—that are partly the cause of admission.
In our hospital, we used a questionnaire to rate satisfac- Conclusion
tion and the results for these years were substantially good.
The data interpretation takes place though taking into
Constant research and quality verification path, where all
account the limits that the subjective judgment has for
member of the Catering Service team are involved, provides
what concerns the patients’ not excellent eating habits, the
a constant quality improvement.29,30 The consumer of the
fact that the diet is often experienced as an unforeseen
Catering Service in healthcare settings should receive a
imposition (the patient thinks he/she was hospitalized to
service he/she appreciates, but that—at the same time—is
follow a pharmacological or rehabilitation program; he/she
correct from a nutritional stand-point. Continuous media-
does not expect to go on a diet that he/she has avoided
tion between customer satisfaction and the work of
doing for such a long time) and the negative judgment on
nutritionists, dieticians and nursing staff is imperative.
the quality of the meals (our patients thought a menu with a
From this point of view, the educational approach and the
4 weeks rotation—that is difficult to realize even at
assistance given by dieticians and nursing staff at the
home—did not promote enough variability).
moment of choosing food become essential for ideal patient
For the latter point, the results we obtained are good
compliance to the dietetic treatment, even when the
(menu variability was judged as adequate by 4% of the
patient is sent home. The role of the nursing staff along
patients in 2002 and by almost 45–50% in 2003–2006) even if,
with that of nutritionists and dieticians becomes essential
more than half patients still think the menu is not varied
also to allow a correct collection of objective data and
enough and sustain that dishes are repeated too often during
the indication of solutions to the problems eventually
the week. The result was obtained in particular thanks to a
pointed out.
more attentive menu programming and to the introduction
of new foods (especially for what concerns vegetables) and
of gastronomic preparations (for pasta and second courses). Conflict of interest statement
This was possible thanks to the attentive analysis of
subjective and objective control data. No one of the authors has a conflict of interest, due to
But we must go on working on this point. Our organization financial or personal relationships, that might inappropri-
provides a single menu with dish rotation every 4 weeks. ately influence their actions and bias their work.
Thus, patients cannot choose what they can eat every single
day but the same meal is not repeated for 1 month. To Acknowledgement
obtain an improvement in this category, we should work on
the Catering Service (introducing a double choice menu) and This work was partially supported by funds from the Istituto
also on the patient who should acquire a realistic view of the Clinico Riabilitativo ‘‘Villa delle Querce’’ of Nemi (RM,
hospital catering (that is and remains different from home Italy).
cooking) and of the need of a nutritionally correct approach The contribution of each Author can be described as
to eating at least in a hospital environment. follows:
In some cases, the results obtained did not show as much
improvement over time as expected or had considerable
fluctuations from one year to the other. We believe it is due
 Donini L.M.: design of the study, data analysis and
manuscript preparation;
to fortuitous circumstances (changes in the management of
the Catering Service Company) and to the change of the
 Castellaneta E.: design of the study, data analysis and
practical performance;
population examined: in particular, during the 5-year
observation, the average age decreased significantly and
 De Guglielmi S., De Felice M.R., Savina C., Coletti C. and
Paolini M.: practical performance; and
probably (we do not have data to this purpose) also the
socio-cultural level of patients changed.
 Cannella C.: manuscript critical reviewer.
Thus, the hospital ought to adequate the hotel performances
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