INCREASING PATIENT SAFETY & SATISFACTION BY IMPROVING TRAY LINE ACCURACY

Sally Reed, Dietetic Intern

The Sage Colleges

Richmond, VA

INTRODUCTION
Facility provides:
Post-surgery rehabilitation, cardiac and stroke recovery, joint and fracture recovery, pneumonia and COPD recovery and more.

120 beds:
60 long term care: residents usually stay >2 years 60 rehab/skilled nursing: average 30-60 day stay

Patient demographics:
70% female, 30% male (on average) Oldest resident 103 years old Youngest resident 46 years old Patients mostly from surrounding cities and southern states (VA and NC)

INTRODUCTION

Food service is an integral component in the success of a long term care facility, often becoming the highlight of the day for many residents. 1

Process Improvement= Tray line accuracy

Chosen due to numerous complaints from:
Cooperate Dietitian Speech Therapist Dietary Staff

WHY IS TRAY LINE ACCURACY IMPORTANT?

Insures patient satisfaction and patient safety
Doctors and/or dietitians assume that prescribed diets are served as ordered
Errors in such diets can affect the treatment of the patients medical condition and can negatively affect the medical outcome Tray errors on patients with texture modifications can result in aspiration, pneumonia and/or death.

Quality nutritional practice in long -term care requires: 5

Assessment of nutritional barriers Reduction of risk factors Attention to specialized diets Appealing food presentation A positive eating environment.

HOW ARE MEALS SERVED AT BEAUFONT?

Trays move through an assembly line where workers place items on a tray so that individual trays can be delivered to customers. 1
Requires 3 dietary staff in kitchen, plus 1 for west wing, 1 for east wing, and 3- 4 CNAs per wing Centralized meal service: food is prepared and portioned in a centralized kitchen.
Trays are built for West hall in kitchen .

Decentralized: bulk quantities of food are distributed to other locations for portioning and service. 1
Smaller portions of food are carted to the East dining room for service from a hot line

MEAL TRACKER
Patients are of fered either the regular or alternative meal depending on their diet order. Nursing or dietary staf f enters the residents meal preferences into an computer program called Meal Tracker used for meal planning, ordering, nutritional evaluation, and managing tray tickets. Tray tickets are printed before each meal so that the most updated diet order and preferences will be listed for each meal. Tray tickets are stacked and put in numerical order for tray line service/dining room service.

Meal Tracker

PURPOSE/OBJECTIVES
Evaluate tray line accuracy and determine areas that need improvement so that patients are delivered the correct items at each meal. Goals & Objectives:
Reducing errors during tray line production Decreasing time spent on tray line production Decreasing risk for adverse clinical outcomes Maintaining customer service

METHODS
A PERT timeline was created to estimate the time required for each task, which helped the project stay on schedule.

Several department materials were reviewed including the Dining Services Policies and Procedures, diet guides and actual meal times in order to gain a better understanding of the tray line process as well as rules and regulations.
Literature review was conducted to further demonstrate the need for tray line accuracy and gather supporting evidence for the projects objectives. Goals were outlined in order to provide direction and further define project objectives. An observational spreadsheet was developed to measurably document errors during the tray building process

METHODS/ MATERIALS
PERT timeline

METHODS CONT
The tray building process was obser ved at lunch 3 times a week for 5 weeks for a total of 15 sur veys in both the main kitchen as well as the east dining room. Evaluation sheet included 7 categories: preferences, condiments, beverages, main plate items, bread/salad/desser t, por tions and adaptive equipment. If the diet order and tray ticket matched what was put on the tray, then the columns were checked. If an item was incorrect , then the column was given an x, and specific comments were recorded. Por tion sizes were evaluated by obser ving which utensils were used and how many scoops of each item were given while building the trays. Since ser vings spoons have cup measurements on the handle, this was compared to the ser ving size listed on the tray.

METHODS/ MATERIALS
Tr ay L i n e O b s e r va t i o n al To o l

RESULTS
Out of 15 total meal times observed, or 187 total trays, the average accuracy score was 92%, ranging from 80% to 96%. The baseline data, which consisted of 8 tray line audits, had an average score of 90.25% Post-intervention data, consisting of 7 tray line audits, had an average score of 94.2%.

Percent Accuracy
100 96 93 90 93 94 94 91 89 88 96 93.6 96 96

95

95

Percent Accuracy for Tray Line Audit

Preinter vention: 2/3/14 3/1 2/14 Postinter vention: 3/13/14 3/21/14

87

85 Percent Accuracy 80 80

75

70

Number of Tray Line Errors

5 6 6 5 5 Preferences Condiments Beverages 25 Main Plate Items Bread/Salad/Dessert

Portion Size
Adaptive Equipment

Most Common Mistakes

43

COST OUTCOMES

Save time (time=money)

Easier forecasting for food ordering

Reduce food waste

IN SERVICE
Complaints from kitchen staf f:
Tray tickets were too wordy Procedure for carrying out meal service had changed too many times

Reviewed standard long-term care diet order descriptions Emphasis was placed on food as an essential component of quality of life; an unacceptable or unpalatable diet can result in:
Poor intake Weight loss Under-nutrition A spiral of negative health effects. 6

TRAY TICKETS
B e fo r e i n - s e r v i c e A f te r i n - s e r v i c e

DISCUSSION
Mistakes made by staf f members occurred due to lack of knowledge, lack of perceived time and lack of desire or ef fort to carry out required tasks Post intervention tray accuracy was improved by printing a census report with textures, diet order, likes, dislikes and allergies was printed for each meal. CNAs served the dining room in a more organized manner Goal to provide patients with nutritious meals that aid in their recovery and are tailored to their specific health conditions. 8

RECOMMENDATIONS/CONCLUSION
Continue to perform a tray line accuracy audit once a month Use the same food service method and only make minimal changes if absolutely necessary Clearing the food items from the tray tickets to minimize unnecessary verbiage The changes implemented and recommendations given will meet the goals of reducing errors during tray line production, decreasing time spent on tray line production, decreasing risk for adverse clinical outcomes and maintaining customer service.

REFERENCES
http://www.beaufonthealthrehab.com/center /

1. J Collins. Person-Centered Dining: Innovations in Dietary Services. Dietary Manager. (ASK JEAN THE JOURNAL NAME) 2008: 14 -18.
2. S. Grossbauer. Managing Food Service Operations: A Systems Approach for Healthcare and I n s t i t u t i o n s . 4 th E d . D i e t a r y M a n g e r s A s s o c i a t i o n . 3. E Myers, S Knoz, M Greoire. Individualized Menu Slips Improve the Accuracy of Patient Trays. Journal of American Dietetic Association. 1991. 1425 -1428. 4. National Health Services. Managing food waste in the NHS. National Caterers Association. Report available at: http://www.hospitalcaterers.org /documents/ foodwst.pdf. Published 2003. Accessed March 18, 2014. 5. P Sloane, J Ivey, M Helton, A Barrick, A Cerna. Nutritional Issues in Long -Term Care. Journal of the American Medical Directors Association. Volume 9, Issue 7. 2008: 476 -485. 6. Position of the American Dietetic Association: Liberalization of the diet prescription improves quality of life for older adults in long -term care. Journal of the American Dietetic Association [2005, 105(12):1955-1965] 7. M Ferguson-Wolf. Preventing Weight Loss & Dehydration in Long Term Care. Dietary Manager. (ASK JEAN THE JOURNAL NAME) 2008 2007: 12 -19. 8. K Kim, M Kim, K Lee. Assessment of Foodservice Quality and Identification of Improvement Strategies Using Hospital Foodservice Quality Model. Nutrition Research and Practice. 2010. 163 172.