Happy New Year!

Have a safe and joyous New Year!

Merry Christmas!

Have a very merry Christmas! Try to worry less about the preparations and enjoy the day more!

Holiday Ideas: Tray Favors

I have not seen this for some time, but that does not mean it is not happening somewhere or that it is not still a good idea.

When I first became a food service director many years ago, a local school make tray favors for the residents for the holidays. Other facilities in our company had similar relationships with local schools.

The residents really enjoyed the tray favors! It was something special for the holiday. It decorated the tray or place setting at the table. In addition, it gave the residents something to discuss.

If you have not done this, I encourage you to investigate it for 2011!

Holiday Ideas: Children’s Activity

This doesn't not relate to food, but it does relate to the holidays, and I am so thrilled with how well it worked that I want to share it!

Every few years I order Christmas cards from the American Humane Society. So, every year I receive samples of the the current cards. The samples are just the front of the card. I have been saving them and this year bought construction paper, glue sticks, markers, and peel and stick foam Christmas decorations. My husband and I had the grandchildren this weekend (ages nine and five). I suggested we make Christmas cards.

They loved it!!! It was so simple to take a piece of construction paper, fold it in half, glue a card sample to the front, and then decorate as desired inside and out. They were really proud of what they created!

I highly suggest this as a holiday activity for the young children in your life. If you do not have sample cards, cut the backs off last year's Chirstmas cards.

Holiday Ideas: Residents and Food Preparation

When residents are preparing food as part of an activity, it is important to be certain that they do not contaminate the food. Cross-contamination in an activity needs to be avoided just as much as in the kitchen.

This does not mean that food preparation activities should be avoided. Just be sure that the residents wash their hands properly, use utensils as much as possible when handling food, use gloves when utensils are not practical, and change gloves and wash hands whenever gloves become contaminated.

A simple activity that many residents enjoy is decorating cookies. If all the residents are doing is picking up cookies, frosting and decorating them, gloves work well. If someone in activities sets up their work area and gets them whatever they need, they will not be as likely to contaminate the food. Of course, the employees and volunteers assisting the residents must follow the same procedures for keeping food safe!

Holiday Ideas: Moderation!

There are so many great things to eat at the holidays! For anyone trying to eat healthy, it can be challenging.

Remember, though, that nothing in excess is good for us and nothing in moderation will hurt us. The tricky part is defining "moderation" and "excessive!" (A small brownie is moderate. Half a pan of brownies is excessive!)

Indulge in moderation!

Holiday Ideas: Ethnic Meals

Many residents' parents or grandparents immigrated to the United States. They brought with them traditional holiday foods from their home country.

Interviewing residents for these holiday foods and meals and then incorporating what you can into the menu during December is something that would be very special for the residents. As with last week's suggestion, let everyone know the resident and the country. And again, Activities/Life Enrichment can assist you!

Holiday Ideas: Resident Recipes

Many facilities do a resident-planned menu for Christmas and New Year's Day. Some also do resident-planned menus for Christmas Eve and New Year's Eve. These are great ways to involve residents and give them what they like. However, it is still a rather limited number of selections.

In addition to the holiday meals, you can do something along the "Twelve Days of Christmas" theme. Solicit favorite recipes from residents. For twelve days, feature one of the recipes for at least one meal. (If you can do it for noon and evening that doubles the recipes used.)

Work these recipes into the normal menu. It is not difficult to substitute dessert, salad, vegetable, and bread recipes into an existing menu. Even entree recipes can be substituted into the menu without too much effort.

Make copies of the recipes and include who submitted them. Distribute the recipes with the meal. It will give the residents something to discuss as well as provide additional variety for the meals!

Remember, you do not have to do this alone. Activities would probably enjoy helping to solicit and collect recipes. They can even copy and distribute the recipes that you use.

Holiday Ideas

This month's topic is a cornucopia of holiday ideas. Some are for your residents, some are for you. I hope you enjoy them!

Happy Day After Thanksgiving!

I hope that you did not eat too much yesterday and can still function today! Or if, like me, you have multiple days of giving thanks with extended families, enjoy all of them!

Happy Thanksgiving!

Tomorrow, take a few minutes out of your day and think about all the things for which you are thankful. Sometimes we are so stressed about the day-to-day activities that we forget how much we really do have.

And keep the food safe!! :)

LTC Regulations: Survey Preparedness

There are several things that a facility can do to improve its chances for a good survey. One is to be "survey ready every day." In other words, know the regulations and follow the regulations, every day.

I have worked with facilities that "geared up" for survey. I have had managers tell me, when I have pointed out violations during a mock survey, that the employees know what to do and will do it when the surveyors are there.

This defeats the whole purpose of regulations and surveys. We should all be doing the right things because they are the right things to do for the residents, not just to please the surveyors.

And following the regulations is the right thing to do for the residents. F371 is based on the FDA Food Code. This is what needs to be followed to be sure food is safe.

We should be following F371, not because we will be surveyed on it, but because it is the right thing to do for the residents, everyday.

LTC Regulations: F441, Infection Control

Any nursing employee preparing or serving food must follow F371, including the portion about no bare hand contact with food.

However, when nursing employees are assisting residents with meals, F441, Infection Control, comes into play. The important aspects of F441 related to meal service concern hand hygiene.

The SOM states: "Hand hygiene is a general term that applies to washing hands with water and either plain soap or soap/detergent containing an antiseptic agent; or thoroughly applying an alcohol-based hand rub (ABHR).

It also states: "Hand washing refers to washing hands with plain (i.e. nonantimicrobial) soap and water."

F441 specifies when hand hygiene must occur. It also specifies when hand hygiene must include hand washing.

For example, hand washing must occur when hands are visibly soiled. Hand washing must also occur before and after eating or handling food. Hand hygiene can include using an ABHR.

F441 defines when nursing employees must wash their hands and when they can use an ABHR.

According to F371, they still cannot touch food with bare hands. If they use gloves, the gloves become contaminated as soon as they touch anything else, just as if they were dining service employees.

Nursing employees using gloves in the dining room really is not practical. They would be changing gloves and washing hands almost constantly. A better approach is a combination of completing as much food handling as possible in the kitchen by dining service employees and using utensils in the dining room.

For example, if toast is buttered in the kitchen as it is being made, that saves a step in the dining room. A fork can then be used to hold the toast in place while a knife is used to spread the jelly in the dining room. Deli papers can also be used, but they are a single use item.

What are you doing to avoid bare hand contact with food while residents are being assisted?

LTC Regulations: Facility Tags

In the past, regulations were grouped by discipline. There were "dietary" tags and "nursing" tags and neither discipline paid much attention to the others. Some facilities still have this philosophy. A better approach is to consider all regulations as facility regulations.

Any employee, regardless of department, must follow F371 if she is handling food. This applies to dining service employees, of course. It also applies to employees in activities/life enrichment, social services, nursing, department managers and anyone else that prepares or serves food, even if it is just for special events.

It is necessary that the dining service manager take responsibility for seeing that all employees who work with food are properly trained. It is also necessary to monitor that they are actually using the knowledge they were given.

LTC Regulations: F371 and No Bare Hand Contact with Food, Serving Considerations

Remember, gloves are not magic. Anytime an employee touches the glove with anything that would contaminate his hands, the gloves have just been contaminated. This applies to service as well as production.

Often I see an employee wearing gloves on trayline to pick up food, rolls for example, and place them on the plate. However, the employee is also touching serving utensils, plates, rearranging the plate lowerator, putting trays in a cart, etc. Often, the employee is also opening the oven door, handling dirty potholders, taking food out of the oven, etc. Those gloves are no longer clean for handling food. Whatever contaminates were on the lowerator, carts, oven handles, potholders, etc., are now on the food and the residents will consume the contaminates when they eat the food. This is classic cross-contamination. And in this case, classic is not good!

A safer approach is to use utensils to handle food. (Be sure to use a different utensil for each food. If one food contains contaminates, such as bacteria, using the same utensil will contaminate all the food items.) Use tongs, spatulas, scoops, ladles, or whatever utensil is appropriate for the task.

If utensils are used for handling the food, gloves are not necessary for serving. Gloves create a barrier between hands and food. If the hands are not touching the food, gloves are not necessary. A major disadvantage of using gloves during service is that employees will touch food with contaminated gloves without thinking about it when they would not touch food with their bare hands.

Inappropriate use of gloves is often the cause of contaminating food during service.

LTC Regulations: F371 and No Bare Hand Contact with Food, Kitchen Considerations

A major emphasis with the revised F371 is no bare hand contact with food. The purpose of this is to help keep food safe.

Several items cans be used to create a barrier between hands and food including disposable gloves, utensils, and deli sheets.

A critical aspect to remember is that gloves are not magic. Anytime gloves touch something that would have contaminated the hands, the gloves have just been contaminated and must be changed.

For example, an employee's task is to make cold sandwiches. She washes her hands, puts on gloves properly, and opens up the cooler door to get the ingredients. STOP!!! She has just contaminated her gloves on the cooler door!

The proper way to do this is for her to wash her hands and set up her work area. She is not touching food so she does not need to wear gloves. She gets out the cutting board, knife, other utensils she may need, pans to put the sandwiches in, food wrap to cover the pans, labels and pen for labeling and dating the pans, the containers of food, etc. While she is doing this, she is careful not to touch the food or any surface that will come into contact with food. Then she washes her hands, properly puts on gloves, and can begin to make sandwiches.

When she has a pan of sandwiches made, or needs to get more food from the cooler, she needs to take off her gloves, wash her hands, cover and label the pans of sandwiches, put them in the cooler, get more containers of food, etc. Before she touches the food again, she needs to wash her hands and put on a new pair of gloves.

Employees must be monitored closely to be sure they understand and do this properly. Too often, they do believe that once they put on gloves they can touch anything they want and still touch food. This is not true! Gloves can cause cross-contamination just as easily as hands.

What success stories can you share in training employees on proper glove use?

LTC Regulations

At one time, it was said that the only industry that was more regulated than LTC was nuclear power plants! I'm not sure if that is still true, but we are very heavily regulated!

When it comes to food service, there are many sets of regulations that must be followed. The federal government, through CMS, has its set of regulations. These are in the State Operations Manual (SOM). The link for the latest version, October 2010, is http://www.cms.gov/transmittals/downloads/R66SOMA.pdf.

In addition, state long-term care regulations must also be followed. If there is a discrepancy, follow the most stringent.

Although not always enforced by state long-term care surveyors, another set of regulations that also need to be followed are state food service regulations, often call the state food code. Depending upon the city or county where a facility is located, there may be county and/or city regulations that must be followed. Again, follow whatever regulation is most stringent.

The FDA Food Code contains recommendations, not regulations. However, most regulations, including the SOM, are based on the FDA Food Code.

The FDA Food Code is an excellent reference. It can help greatly in developing your policies for those gray areas that the regulations do not address. If a surveyor questions what you are doing, and it is is not spelled out in detail in any regulation, if you can show in the FDA Food Code that what your are doing is acceptable, it is difficult for a surveyor to cite you.

If anyone wants o share survey stories, please do! Everyone is always interested in specifics!

Employee Management: Have Fun!

People like to have fun!

Adding some fun , some humor, to the work place makes it more enjoyable. This actually increases productivity and moral. People want to come to work more if they have fun while they are there.

Of course, all safety and sanitation policies still need to be followed. But there are many ways to add fun while still keeping the employees, residents, and food safe.

I was talking with a manager a few days ago who said someone she worked with had brought in a rubber rat and hid it in someone's desk drawer. That person put it in someone else's desk. Now the joke is who is going to get it next? It's silly, but it adds fun!

For Halloween, why not do something fun? It can be as simple as having a treat basket in your office.

Employee Management: Respect

Everyone wants to be treated with respect.

One of the best things you can do is to always treat your employees with the respect that they deserve, simply because they are fellow human beings.

Listen, and try to understand their point of view. It doesn't mean that you have to do what they want you to do, but listen, and then explain why or why not.

Simple courtesies such as "please" and "thank you" also go far.

Treat your employees with the same level of respect that you want to receive yourself.

Employee Management: Recognition

Everyone enjoys recognition! It can be simple, but as long as it is sincere, people will remember!

A company I used to work for had a program called "I was caught doing something right." Any facility, regional, or corporate employee could give a button with this phrase on it when they found someone doing something well.

I happened to give a button to a young dietary aide in a facility where I was consulting. I don't remember now what he did, but I gave him a button. A couple years later, I happened to be in the same facility. This young man in the kitchen runs up to me and said, "I remember you! You gave me this button!"

Not only did he still remember, he still had the button!

Never underestimate the importance of recognition!

Employee Management: Walk Your Talk

Those of you that have been in management for awhile probably remember the axiom "walk your talk." It is still good advice today!

It is not enough to merely talk about what you want your employees to do. It is also necessary to model proper behavior. If it is not important enough for you to look professional, why should your staff? If it is not important enough for you to wash your hands, why should your staff?

Setting the standard for your staff also means adopting that as the minimum standard for yourself.

A similar axiom is that actions speak louder than words. Your "walk" will motivate your employees much more than your "talk" ever will.

Employee Management: Train and Follow-up

Training is essential. It is necessary not only to train employees on what to do and how to do it, but also why. If employees understand why they are to do something, they are more likely to do it and do it well.

Follow-up is also important. Observe them at work to see if they truly understand what to do and how to do it.

For example, there is a restaurant my husband and I go to frequently. The food is good and generally so is the service. The last time we went there, however, the server could have done better.

Obviously, she had been told to talk about a new appetizer the restaurant was featuring. She started talking about it, but then didn’t really know what to say, and finished by saying it was “interesting” but she didn’t really like it! Needless to say, we didn’t order it!

After training on the new appetizer, the manager should have done some role-playing with each server to see how each would promote the new item.

Employee Management: Give Them the Tools They Need

Employees cannot do their jobs if they do not have the necessary tools. For example, employees serving meals cannot accurately portion the meals if there are 3 items that require a #8 scoop, and there is only 1 #8 scoop available in the department! Or, the department cannot be cleaned and sanitized if the chemicals and cleaning equipment are not available.

Not having the necessary tools to do the job is extremely frustrating for employees. This negatively effects moral and can bring the productivity of the entire department down.

The best way to determine if the employees have the right equipment to do their jobs is to ask them!

Employee Management: Setting and Communicating the Standard

One of the most important methods to get the results you want from your employees is to set the standard and communicate it to them! Too often we think everyone has the same standards as we do, and that is not always true. Everyone has different experiences. What was perfectly acceptable for a past employer may not be acceptable to you. But your employees will not know that if you don’t tell them.

And don’t just “tell” them what to do. Also “show” them. Tell them exactly what you expect from them. Show them what “clean” means to you. Show them what “attractive” plate appearance means.

It will be less frustrating for you and your employees if they know exactly what you expect!

Employee Management

Managing employees can be exceedingly challenging and extremely gratifying all at the same time! It is frustrating when they do not do what they are paid to do, but it is so rewarding to watch employees grow and develop professionally.

Some of my best memories are of seeing former employees years later and having them tell me that I made a difference in their careers!

This month’s blog is a variety of ideas and suggestions on managing employees.

As always, comments and your ideas are very welcome!

National Healthcare Foodservice Workers Week

Next week, the week of October 4-10, is recognized as National Healthcare Foodservice Workers Week. In 1985, the U.S. Congress declared the first week in October as a national time to recognize the important role that foodservice staff have in the health of residents, patients, and employees of healthcare facilities.

Without foodservice employees, our facilities would not function!

Next week is an excellent opportunity to recognize and thank your employees for their importance as part of your team.

Food Safety: Food Allergens

An aspect of food safety that is of a growing concern is food allergens. The most common food allergens include milk and dairy products, eggs and egg products, fish and shellfish, wheat, soy and soy products, peanuts, and tree nuts.

When people with allergies consume these products, reactions can include itching around the mouth; tightening in the throat; shortness of breath; hives; swelling; abdominal cramps, vomiting, or diarrhea; loss of consciousness; or even death.

When allergens are introduced into food prepared for people with allergies, this is called cross contact. This is not the same as cross contamination. Cross contamination refers contaminants that could be harmful to everyone (such as bacteria). Allergens are only harmful to those allergic to that specific allergen.

It is critical that cross contact not occur while preparing food for someone with allergies. Cross contact can occur the same way that cross contamination can—not washing utensil, not washing hands, not changing gloves, etc.

Food Safety: Resources

There are many great resources for food safety! A few are listed below. Most can be used for both professional and personal. And many include information beyond food safety.

• Centers for Disease Control (CDC) http://www.cdc.gov/, www.cdc.gov/outbreaknet, www.cdc.gov/foodborneoutbreaks (The last one is great for searching for outbreaks by state, location [hospital, restaurant, etc.] and by etiology.)
  
• Federal Food Safety Information http://www.foodsafety.gov/
  
• Food and Drug Administration (FDA) http://www.fda.gov/
  
• Food Safety and Inspection Service (FSIS) http://www.fsis.usda.gov/

And don’t forget your professional associations such as the American Dietetic Association (http://www.eatright.org/) and the Dietary Managers Association (http://www.dmaonline.org/)!

Food Safety: Setting the Standard

One of the most important things a manager can do to ensure safe food is to set the standard. If it is not important enough for the manager to do it, it will not be important enough for the employees to do it.

If the manager takes the time to wash his/her hands every time he/she enters the kitchen, it sends a very strong message to the employees that they are to do this as well. Plus, it is a great way to determine if there is actually soap and disposable towels at the hand wash sink!

Although the manager’s “uniform” may differ from the employees, it is still important that it be clean and neat. The manager’s hair needs to be restrained whenever he/she is in the kitchen. Even if not working with food, the message sent is that restraining hair is important.

Not only does setting the standard, or “walking the talk,” help ensure food safety, it also helps in developing a good relationship with employees.

Food Safety: Use Reputable Suppliers

Nothing will improve the quality or the safety of the food as it enters your department. If you accept unsafe food, you cannot make it safe later.

There are some things that can be done during receiving to help ensure safe food is accepted into the facility. These include rejecting the following: food at unsafe temperatures, frozen foods that show signs of thawing and refreezing, foods with compromised packaging, or foods past their use-by or expiration dates.

In addition, it is necessary that the supplier can be trusted to first buy safe food from the farmer, manufacturer, or processor and ensure that the food is transported safely to the supplier. The supplier must then store the food safely and deliver it safely.

Food Safety: Practice Good Personal Hygiene

Good personal hygiene, especially hand washing, is critical to food safety!

The first step is to not contaminate the food. Contaminants include biological, chemical, and physical hazards.

The food received may be safe and free from biological contaminants. But, if an employee does not wash his/her hands after using the restroom and then works with food, he/she has contaminated the food and it is no longer safe.

The food received may be free of physical contaminants. But, if an employee does not restrain his/her hair, wears jewelry, wears a bandage without a glove, etc. and any of those items get in the food, the food has a physical contaminant. Many of the personal hygiene polices are an attempt to keep physical contaminants out of the food. An addition concern is that these physical contaminants frequently carry biological contaminants as well.

As discussed previously, poor hand washing is also a frequent contributor to cross-contamination.

Food Safety: Prevent Cross-contamination

Cross-contamination occurs when bacteria, viruses, or other contaminants from one food get into another food without the two foods touching. This happens when contaminants from one food contaminate a surface such as a cutting board, utensil, hand, glove, etc. If that surface is not cleaned and sanitized before another food is touches that surface, the second food becomes contaminated.

For example, if an employee is cutting fresh chicken and then uses the same cutting board and knife to cut lettuce without first washing and sanitizing the cutting board and knife, the bacteria from the chicken will go onto the board and knife and from there to the lettuce. The chicken is cooked, killing the bacteria. But the lettuce is not cooked, so the bacteria grow and people become sick.

If the employee does not wash his/her hands before cutting the lettuce, cross-contamination will occur. Sometimes employees think it is enough to wear gloves. It is not. If the employee puts on gloves without washing his/her hands, the gloves become contaminated in the process of putting on the gloves and the gloves then contaminate the lettuce.

Cleaning, sanitizing, and proper personal hygiene are critical to prevent cross-contamination.

Food Safety: Prevent Time-temperature Abuse

Bacteria need the proper temperature to grow and they need time to grow. If food handlers allow food to remain in these temperatures for too long, bacteria will grow to levels high enough to make customers sick.

Bacteria survive and grow between the temperatures of 41° F. and 135° F. This is called the temperature danger zone. Bacteria grow very rapidly between the temperatures of 70° F. and 125° F.

Bacteria also require sufficient time to grow to dangerous levels. Four hours or more in the temperature danger zone is enough time for bacteria to grow to levels to make people sick.

Of course, it is necessary that food be in the temperature danger zone when it is prepared and pass through the temperature danger zone during cooking, cooling, and reheating. The key is to minimize the time food is in the temperature danger zone.

Key points include:

• Do not leave food at room temperature.
• Keep hot foods hot and cold foods cold.

Food Safety: Four Factors to Keep Food Safe

There are four primary factors that need to be practiced to keep food safe. These include:

• Prevent time-temperature abuse
• Prevent cross-contamination
• Practice good personal hygiene
• Buy food from reputable suppliers
  

Each of these will be discussed throughout the month.

Food Safety: September is National Food Safety Education Month

National Food Safety Education Month (NFSEM) was created by the National Restaurant Association in 1994. The purpose is to increase awareness about the importance of food safety education and training. A new theme is created each year. This year’s theme is “High-Risk Customers: Serve Your Fare with Extra Care.” Learning activities and posters are available free from the website, www.servsafe.com/nfsem.

The materials quickly communicate key concepts to employees. Since food safety is food safety, these would also make good in-service materials for healthcare food service workers. Also available on the website are the archived training materials from past years.

This month the blog topic is food safety. Please add your comments on what you have done in training your employees to prepare safe food!

Customer Satisfaction: Elderly

There was an experience on the flight home that made me think about how we may treat the elderly sometimes. People may not mean to, or even be aware that they are, but sometimes the elderly are treated as children.

The flight attendant asked if I wanted cookies or peanuts. I wasn’t interested in either because I wasn’t feeling well. I asked what she had to drink, hoping some sort of diet white soda was available. Rather than answering my question, she literally leaned into my face and very slowly said, “No! Cookies or peanuts?!”

I was aghast at her condescending and patronizing attitude! After I calmed down a bit, I started thinking about times when I had, unfortunately, witnessed similar incidents in long-term care facilities. Rather than addressing the residents’ needs and answering their questions, how many times have we redirected them as though they were children so that we could finish our tasks?

Culture change really is about treating residents as individual adults. How we respond to them is critical!

Are there any stories you would like to share related to customer service and customer satisfaction?

Customer Satisfaction: You Expect What You Pay For

There is the phase “You get what you pay for.” There is generally truth to that statement.

It is also true that you expect what you pay for. The more you pay, the higher the expectations.

Some of the service we had in the hotel dining room would have been acceptable at a family-style restaurant. Considering what we were paying for each meal, however, we expected much better service!

The same applied to the hotel room itself. In lower priced hotels I don’t like it if they don’t leave soap and shampoo, but I deal with it by calling down and requesting what I need. When this hotel let us run out of shampoo, it was an issue! For as much as we were paying, something as simple as that should not have happened.

The more you want to be paid for your services, the greater the services you have to provide.

Customer Satisfaction Employee Privacy

The manager’s office was in the same hallway as the pay phone. Another day, while I was on the pay phone, I couldn’t help but overhear the manager disciplining an employee. That, of course, is something that should be private between a manager and the employee.

Treating disciplinary action privately is fair and respectful to the employee. Also, if customers overhear disciplinary action, it can reflect badly on the reputation of the facility. It may bring problems to the attention of the customer that the customer did not notice before. Also, it cannot be determined how the customer will react to the information or what he or she will do with it.

Sometimes it is necessary to correct an employee in public. For example, if an employee is about to give a resident the wrong item. It is critical to correct the employee in a very professional manner and as quickly and quietly as possible. Further discipline, if warranted, can be done later, in private.

Customer Satisfaction: What You Can Do, Not What You Cannot Do

The hotel was in a very remote location. No cell phone service! (That was quite a culture shock.) The hotel, although remodeled, was very old. During remodeling, attempts were made to keep it as close to the original as possible. This included no phones in the rooms. The only option for calling out was two pay phones off the lobby.

While we were on vacation, my mother had minor surgery. Before we left, I said I would call my brother to see how she was doing. I was not expecting pay phones!

The last time I used a pay phone was almost 35 years ago. At that time you could call collect and the charges would go on the other person’s phone bill. I thought that would still work. It didn’t. When my brother answered the phone the operator wanted a credit card number. I knew he wouldn’t know what was going on, so I hung up and went to the front desk for help.

I explained the situation and the clerk said she could not let me use the desk phones or the office phones. I hadn’t asked to do so! When I started to say something she interrupted and said employees did not have codes to the phone and could not call out, only managers could. So I asked what she suggested. She said she could give me change for the pay phone!

If she had just told me in the first place what she could do, and not what she could not do, the problem would have been solved faster, I would have been much less frustrated, and customer service would have been positive.

Always tell the customer what you can do for him or her. Only say you cannot if the customer asks for something that you truly cannot do.

Customer Satisfaction: Truth and Consequences

I do not know if one server lied to us or not. But the possibility that he did tainted our impression of customer service at this location.

I enjoy peanut butter and jelly on toast or an English muffin for breakfast. The first breakfast I asked if I could have that. The server immediately answered that of course I could.

The second breakfast I asked for the same thing. The server stated that they did not have peanut butter. I said that I had had it the day before. Then his story changed slightly. He said they were out of it, that they were out of a lot of things. (The last part is more truth than the customer needs!)

The next day, I ordered it again and the waitress said she didn’t know if they had peanut butter or not, but thought they must, because what kitchen didn’t have it? (That was probably sharing more of her thought process with the customer than was truly professional.) She looked and found peanut butter.

Of course, it is possible that the second day the restaurant was truly out of it. But the way the server answered and his body language made me suspicious. If you don’t know, it is always better to say so and then find the answer. And if you don’t want to take the extra effort to satisfy the customers, then it is time to look for something else.

Customer Satisfaction: Accuracy and Timeliness First

It was obvious at this hotel that all dining room servers were instructed to be friendly and to chit-chat with the customers. All asked the same type of questions such as “Where are you from?” And they all followed up with some information about themselves. “I used to visit there.” “I hear that’s a great place.” They were good conversationalists.

When this was combined with accurate and timely service, it was very nice! But it did not work that way very often.

One young man was excellent with accuracy, efficiency, organization, professionalism, and friendliness. He had a very busy section, but he carried it off grandly! My husband and I left that meal feeling that we had experienced really great service.

One young woman, however, spent so much time conversing with the table next to ours that we were left waiting with empty plates for the dessert menu, then the dessert, and finally the check. The other table may have thought the service was great. We thought it was terrible. Conversing and timeliness must be balanced. It is possible to be warm and friendly without taking a great deal of time.

Another young woman was also great with the chit-chat. But there were three errors with our simple breakfast order. Friendliness turns into flightiness when the accuracy is not there. Again, there must be a balance.

Customer Satisfaction: The Importance of Variety

The location where we stayed had one dining room and a very simple, casual café with limited hours and a more limited menu. Although the dining room was very nice, the menu upscale with good variety, and the food fantastic in both flavor and presentation, after two days we desperately wanted something different!

There really was not anything wrong with what was offered. There was an emphasis placed on using fresh, local food. The chef was willing to make modifications to meet our needs and wants. But we were seeing the same items everyday with one or two “chef’s specials” added.

My husband also works in long-term care. This was an eye-opener for both of us. If we were getting bored with the food after two days, what do residents feel after weeks, months, even years? And this food was much higher quality than what the majority of long-term care facilities can afford.

This experience really emphasized the critical importance of variety and choice. How satisfied would you be if you ate all three meals in your facility for a week? A month? A year?

Customer Satisfaction: It’s Everywhere

Every business is dependent upon good, or even great, customer service to survive. Long-term care is no exception.

There are many examples of good, great, and phenomenal customer service in other industries that can be used in long-term care. There are also many examples of where customer service is lacking or absent.

Recently my husband and I went on vacation. We stayed at an historic hotel in a beautiful location. The dining room had fantastic views, the menu was upscale, the food was extremely good, but the service varied from very good to poor.

There were many good learning experiences at this location that can be applied to long-term care. These, along with other customer service ideas, are what I will share with you this month.

As we go along, please share your ideas and experiences!

Emergency: Advance Warning, Staff

If there is sufficient warning of an emergency, schedule and call in extra staff so that they will be available when needed.

Depending upon the emergency, it may be necessary for staff to spend the night, or several nights, at the facility. Plan in advance where they will sleep, what they need to bring with them, and how and what they will be fed.

Some facilities may have a policy that staff can bring family members to the facility with them. If this is the case, the dietary manager needs to be involved so he/she knows how her staff fit into the situation and how the family members in addition to the staff will be fed.

Emergency: Advance Warning, Kitchen

If there is advance warning, there is much that can be done in the kitchen to make the emergency easier to manage.

If there is time, some things to consider doing include:

• Order extra food, water, supplies, and ice
• Cook in advance meats that can be served cold (also slice), casseroles that can be heated and served, bakery items
• Select the coldest setting on refrigerators and freezers
• Store ice and water (freeze sandwich bags of water for easy distribution, freeze as much water as possible, fill as many containers with water as possible)
• Wash dishes and switch to disposable (if losing the dishroom is likely)
• Serve a substantial meal before the storm hits

Anything that can be done in advance will make handling the emergency easier.

Emergency Menu Development, Order Guide

Once the emergency menus and other food and supplies lists have been created, it is very beneficial to create order guides. Order guides tell not only what to order, but how much.

Not only does the food and supplies need to be ordered in advance of an emergency, if the emergency lasts long at all, it will be necessary to reorder. Depending upon the emergency, it may be worthwhile to place a new emergency order as soon as the emergency supplies start being used. For example, if the emergency supply is three days, it may take that long to get new supplies.

It is not difficult to develop an order guide in a spreadsheet with formulas to calculate the amount needed depending upon the customer count. Change the count and it will change the amount to order.

Suppliers may also be able to assist you in creating this as a supplement to your regular order guide or worksheet.

The middle of an emergency is not the time to try to determine what needs to be ordered and how much. The emergency order guide should be ready, available, and so easy to use that anyone in the department can use it.

Emergency Menu Development, Supplies to Keep on Hand

In addition to food to keep on hand for emergencies, it is also necessary to keep supplies on hand.

Of course, everyone has the emergency supply of disposable plates, bowls, cups, flatware and napkins. The amount depends upon the number of customers, the number of meals and snacks served, and the duration of the emergency. It will not be necessary to use these items in all emergencies. If the dishroom is operational; if there is sufficient safe, hot water; and if there is sufficient staff; then regular dishes can be used.

Other supplies to keep on hand include:

• Extra trash liners (all the used disposables have to go somewhere)
• Bleach/sanitizer in case hot water is not available
• Water purification kits (if your facility decides to use them)
• Hand antiseptics (although they are not intended to take the place of hand washing, they are better than nothing if hand washing is not possible)
• Sternos for holding hot food
• Foil pans for cooking and holding if washing pots and pans is problematic
• Batteries, batteries, batteries (and be sure they work)
• Paper towels (it may not be possible to launder cleaning towels)
• Moist towelettes to distribute to customers with meals and snacks
• Manual can openers
• Flashlights or lanterns (make sure they work and have batteries)
• Disposable gloves and other personal protection equipment

This is not a complete list, but it provides a good place to start.

It is important to rotate these items into general use just like food. Some items will deteriorate with time. Also, if these items are not moved, pests can easily hide and live in and behind the cases.

It is also beneficial to work closely with suppliers for emergency food and supplies. The representatives can make excellent suggestions on available products.

Emergency Menu Development, Food to Keep on Hand

In addition to food for the emergency menus, it may also be necessary to keep items on hand for snacks and other situations. Some ideas for food to keep available include convenience items, shelf-stable items, ready-to-use items, and individually wrapped items. These items may need to be beverages as well as food.

Nutritional products such as tube feedings and supplements will also need to be available. Food items for texture modified diets and thickened liquid diets will still be necessary if there are residents or patients needing these items. Therapeutic diet items may also be necessary for some residents or patients.

A consideration for these and other emergency items is that they may be used in a pinch or be consumed by staff. It is important to take inventory on the emergency supplies to ensure everything is available in the event of an emergency.

Emergency Menu Development, Potential for Multiple Menus

It is important to consider nutritional needs of customers in developing an emergency menu, as discussed previously. It is also important to consider what resources may or may not be available.

For example, if both electrical and gas equipment are available, a menu could be written using only gas equipment and one using only electrical equipment. It would also be necessary to have a menu if neither gas nor electrical equipment was available. Another option, of course, is to write and use just the third menu!

It may be that equipment is available, but water is not. This may not require a separate menu, but instead policies and procedures on how to either make the water safe or how to use bottled water.

Another consideration is lack of staff. In this case, food could be cooked, but the menu would need to be simplified for either convenience items or items that require little preparation.

The length of emergency menus is another consideration. A three day menu may be sufficient for most emergencies. For longer emergencies, seven days may be necessary.

There is no right or wrong to emergency menus. It just depends upon what the facility needs in any particular situation.

Emergency Menu Development Nutrition Considerations

There are many considerations in developing an emergency menu. A very basic consideration is realistically, what equipment and staff resources will be available and what can be prepared and served.

Another important consideration is the nutritional needs of the customers. Hydration and calories become the most important. Some residents or patients may have other requirements as well. This is especially true of those receiving texture modified diets and thickened liquids. There may be other therapeutic restrictions that cannot be lifted for even a day or two.

Customers may be more than just residents and patients. Customers may also include staff and possibly staff families or community members. If staff is working, they probably need more calories than the residents and patients.

Also consider allergic reactions. In the past, peanut butter has been a good emergency menu basic. If there are customers with peanut allergies, though, it might be best to avoid peanut butter completely. It can be difficult enough to avoid allergen cross-contact under normal circumstances; it becomes even more difficult in an emergency.

Allergens become a concern not only with the emergency menu, but also with snacks that may be provided.

Each establishment is different because it has different customers. A menu that works in one establishment may not work in another. Although it is possible to purchase emergency menus, and these can be a great starting point, it is still necessary to assess them and make changes as necessary.

Emergency Menu Considerations

The term “emergency menu” generally creates an image of a very simplified, easy to prepare, and easy to serve menu to use in an emergency. This is a necessary tool to have. There may be times when this type of menu is needed. Developing this type of menu will be discussed more in future postings.

However, in many emergencies, it is not necessary to immediately jump to the emergency menu. Depending upon the type, scope, and length of the emergency, it may be very feasible to modify the existing menu and use existing food stores before going to the emergency menu and emergency supply.

Some basic considerations in an emergency include using perishable foods first, frozen foods second, non-perishables third, and use emergency stock last. This is especially true if refrigerator and freezer storage may be lost.

Menus can be written for these types of emergencies. Or staff can be trained on what to do and how handle these emergencies. At the very least they need to be trained on when to start using the emergency menu and emergency supplies.

Emergency Menus and Advanced Planning

A key component in emergency planning is the menus. There are many considerations in developing emergency menus. When an emergency strikes, that is not the time to try to determine what to serve. It is necessary for any staff member to be able to pull the emergency menu and know what to prepare and serve. The manager may not be there!

Another consideration is what to do if you have advanced warning of an emergency. A typical example is a hurricane. There is usually quite a bit of advance warning about when a hurricane will strike and the possible extent of the damage. With advance warning, it is possible to prepare food in advance and be better able to meet the emergency effectively and efficiently.

These two topics will be discussed this month.

Menu System: Diet Spreadsheets and Tray Tickets

Diet spreadsheets tell the servers what items residents are to receive based upon diet orders and the amount of each item (portions). This affects cost control, customer satisfaction, and regulatory compliance.

Portion control is one of the most important aspects of cost control. If portions are too large, it results in waste. If residents receive items they cannot have, this also results in waste when a second tray is prepared.

Portion control also affects customer satisfaction. People can become upset when someone gets larger portions than they do.

Portion control can also affect nutritional status if residents do not receive the amounts necessary. It can also affect survey results because if portion control is not followed, then diet orders from physicians are not followed.

Tray tickets ensure that the correct tray goes to the correct resident. In a manual menu system, diet spreadsheets and tray tickets are separate tools. In an integrated system, if the tray ticket lists exactly what each resident is to receive, based on diet orders, preferences, and selections, then the need for a diet spreadsheet is eliminated.

The important result is that each resident receives the proper meal items, in the proper amounts, based upon his/her diet, food preferences, and selections.

Menu System: Recipes

Recipes are critical for cost control, customer satisfaction, and regulatory compliance.

Recipes tell the cooks how to make items. Recipes should be quantified for the amount necessary for the meal. If they are not, the cooks may not take the time to adjust the recipes for the amount actually needed but just double or triple the recipe. This leads to overproduction, waste, and increased costs.

If the recipes are not followed, the product will not be consistent from one time to the next. Customers like consistency. They like to receive what they expect.

If the recipes are not followed, the residents will not receive the nutrients in the amounts necessary for health. They may receive too little or too much. Both can be detrimental. Poor nutritional status can affect survey results.

In a manual menu system, recipes need to be quantified by hand. This is time consuming! Some menu systems will quantify the recipes for the amounts entered. This is better, but someone must still determine the amounts needed. A computerized integrated menu system will take into account diet orders, food preferences, and selections and determine the quantification level of the recipes for a particular meal.

Menu System: Production Sheet

The production sheet is a report telling the cooks and aides what items to prepare, the amount of each item, and the amount to portion. This greatly increases accuracy of production by limiting over- and under-production and omission of items.

Increased accuracy assists in controlling costs. Over-production generally results in waste, which is money down the garbage disposal.

Increased accuracy also assists with customer satisfaction. If residents have selected an item and then they cannot have it because of under-production, they will be dissatisfied.

Under-production can also negatively affect surveys if residents do not receive what was planned on the menu.

Pre-production sheets are useful to tell the cooks what to prepare in advance and what to pull from the freezer.

With a manual menu system, someone must count the number of each item to prepare based upon diet orders, food preferences, and selections. Integrated computer systems will count the items and give a total.

Menu System: Order Guide

The order guide provides information on the food items and amounts that you need for each week or each ordering period. This allows for accuracy in ordering. This is especially important if the person normally doing the order is not available and someone else needs to do it instead.

Both over-ordering and under-ordering can negatively affect the food budget. It can also negatively affect regulatory compliance and customer satisfaction.

Some menu systems will calculate order guides (or grocery lists) based upon your menu and diet census. With manual systems, it is necessary to calculate the information by hand. However, once it is done, unless there are major census changes, it is accurate enough for the remainder of the menu cycle.

In the long-run, it is more efficient to calculate the products and amounts needed once at the beginning of the cycle and write it down in a logical format than to start from scratch each week for six months or the length of the cycle.

Menu System: Cost Report

A cost report is critical to meet the food budget. If you do not know what the meals cost, you cannot make informed decisions on how to stay within budget.

The most accurate menu system is one that will update the cost every time the menu is changed and every time new food prices are downloaded. Check with your supplier on what menu systems will obtain your prices and update the cost of your menu whenever you request it.

Another important feature of a menu system is one that will calculate the cost of not just your regular menu, but all your therapeutic and texture modified menus and then calculate a total menu cost based upon your diet census.

This total menu cost will always be higher than just the cost of your regular diet. If you try to operate your department using just the cost of the regular diet, you will be operating with inaccurate information.

Menu System: Nutritional Analysis

The purpose of a nutritional analysis is to ensure that the menu meets the nutritional criteria in the diet manual for the regular, therapeutic, and texture modified diets. The most important aspect is that the average for the cycle meets the requirements.

Some menu systems can complete a nutritional analysis for each meal and each day for each diet. Some can complete a nutritional analysis for each week for each diet, which provides an average for the week. And some just provide an average for the cycle for each diet.

If the cycle average meets the criteria, in most cases this is good enough. It is normal to be higher some meals and days for certain nutrients and lower other meals and days. The advantage of having a more detailed nutritional analysis is that if something is too high or too low, it is easier to determine which food items are creating the effect and change them.

If menus are purchased, a nutritional analysis should be included. If menus are written and there is not a computer system to complete an analysis, completing one by hand is next to impossible. Instead, the diet manual should be followed and the completed menu checked manually to ensure that the proper number of servings from each food group is included, that items high in certain nutrients are included as indicated, and that inappropriate foods are avoided.

Menu System: Week-at-a-Glance

This component is simply an overview of the menu items for all meals for a particular diet for a week. It is an easy way for managers and cooks to see what will be served later in the week.

It can also be used to communicate upcoming meals to residents and families either through personal copies, posting on menu boards, in facility newsletters, or posting on the facility’s website. If used for posting on a menu board it may need to be enlarged so it can be read.

It is also a useful tool in planning holiday and special event meals. When a holiday meal is planned, compare it to the menu items the meals/days before and after. It may be necessary to adjust other meals/days to avoid repetition.

Menu System: Diet Manual

The diet manual has to be the basis for any menu system. A diet manual is based on the latest (within 5 years) scientific research. The menu must be based on scientific research for regular, therapeutic, and texture modified diets. The menu cannot be written on what someone “thinks” it should be or on what he/she learned 10 or more years ago in school. Things change. Science changes.

The first step in developing or revising a menu system is to choose a diet manual. There are several available, some of which are written specifically for long-term care. The diet manual must address the needs of your residents. For example, if you have the elderly-elderly in your facility, a diet manual with liberalized diets makes sense. If you also have the young-elderly for short-term rehab, you may need a diet manual that addresses diets that they may already be following, such as reduced fat, reduced salt, or diabetic.

If you are purchasing a menu system where the regular, therapeutic, and texture modified diets have been written for you, the first question to ask is on which diet manual is it based. If it is not based on a diet manual, you will need to review every recipe to see if it has been linked to the diets that are appropriate based on your diet manual. If it is based on a diet manual, determine which one and if it meets the needs of your residents. If it does not, look further or be prepared to review each recipe and make changes to reflect your diet manual. You need to receive at least one copy of the diet manual as part of the menu package if you will be using that diet manual.

If you are purchasing a menu system where you write the menus or enter your existing menus and then the system will create all the reports for you, check that you can link the recipes to the appropriate diets based upon your diet manual.

The diet manual can also help during surveys. If a surveyor questions something on the menu, and you can show that in the diet manual it states that the item is acceptable for that diet, then the surveyor has no reason to give a citation.

Remember that the menu is the basis for the management of the department and the diet manual is the basis of the menu.

Menu System: Importance

Technically, a menu is just a listing of food items to be served for one meal, day, or longer. A menu system has the components necessary to manage a food service department. Although the term menu will be used for this month’s topic, it really refers to a menu system.

The menu is the basis for everything that happens in the department. It determines food costs, the quantity and quality of labor necessary, equipment needs, storage requirements, customer satisfaction, and regulatory compliance.

Every facility has the choice of creating its own menu or purchasing a menu from another source, such as a consultant dietitian, food supplier, or menu software company. Whether developing, revising, or purchasing a menu, the menu must meet certain criteria including:

• Meet the nutritional needs of all residents;
• Meet federal and state regulations;
• Be attractive, appealing, and palatable to all customers;
• Meet department considerations; and
• Meet budget requirements, both for food costs and the cost of the menu itself and implementation.

Menu system components will be the focus for the remainder of this month

Making Meals Memorable: Staff Responsibilities

Each department has responsibilities to make meal service memorable. Here are examples of what some of these responsibilities might involve.

The environmental department needs to ensure that the kitchen equipment operates properly so that meals can be prepared. It also needs to make sure that dining room furniture is in good repair. The dining needs to be kept clean. Tablecloths and/or napkins need to be laundered (or sent out for laundering).

Activities (or life enrichment) can do many things to make meals special. Activities during meal time makes the wait time seem shorter and the meal more enjoyable. This can be music or other entertainment. Activities can also assist with decorating, centerpieces, menu selection, and escorting.

Social services can assist residents in adjusting to the dining environment and informing them of options they have. Assistance with menu selection and escorting is also possible.

Nursing services, of course, has an extremely important role to play with escorting, assistance with eating, serving, and following-up with residents after the meal.

Dining services prepares food, sets tables, takes menu selection, serves food and beverages, assists with follow-up, and clears tables.

All department managers should also play a role in meal service. Each one is responsible for ensuring that his/her staff is performing the required responsibilities during meal service. Many facilities also have managers take turns acting as a host or hostess for meals. In this role they greet residents, assist with serving food and beverages, and ensure smooth meal operation.

Each facility is different, and these are just examples. The important thing to remember is that everyone must work together to make meals memorable for the residents.

What suggestions do you have for department responsibilities?

Making Meals Memorable: Service

The technical aspects of service involve setting the table, escorting residents to the dining room, serving food and beverages, and clearing dining room after the residents have finished.

Properly setting the table will add to the atmosphere in the dining room. Each place setting should be the same and each table should be the same. The dishware needs to be clean and in good repair—no chipped or cracked dishes.

Beverage service can occur prior to the meal. This gives the residents something to do while waiting for the food. Beverage service can be from a beverage cart. This is a good way to offer choice to the residents.

The meals can be served using restaurant serving trays and stands. Or meals can be served using serving carts. Avoiding institutional hospital trays to serve food enhances the dining experience.

Serving carts can also be used to serve salads and desserts. This is also a great method to offer more choice to the residents.

After the meal is served, it is important to follow-up. Ask the residents how the food was and if they would like any additional food or beverage.

After meal service, the dining room must be cleared. If residents are still in the dining room, this should be done quietly and away from tables where residents are still eating. Bussing carts work well for this.

What service do you offer in your facility?

Making Meals Memorable: Service

Service contains two components, the employees providing the service and the technical aspects of how the food is served.

The employee aspects that will be discussed apply to all employees working in the dining room, regardless of their department.

All employees must have a clean and neat dress and appearance. Some facilities have uniforms for the dining service employees. Some also have aprons for anyone working in the dining room. This is not required, so long as all employees look professional.

All employees also need to be courteous, respectful, and hospitable. Smiling is important!

Employees must, of course, follow all food safety regulations.

For all of this to happen, employees must be well-trained. They need to know what the standards and expectations are, and why.

How do you train your staff for serving in the dining room?

Making Meals Memorable: Environment

The environment includes the dining room; the tables and chairs; the dishes, glassware, and flatware; and the serving equipment. The environment affects the perception of the meal service. It may have a positive or negative impact.

Have you ever eaten at a restaurant that was dirty, cluttered, and dark? Did you stay? If not, was it because you thought that if the dining room looked that bad, what would the kitchen look like and how could the food be safe and taste good? And if you did stay, did you have a negative perception of the food before you even saw it?

The residents and their families are not any different. If the dining room is clean, uncluttered, and attractive, it will create a positive impression which will be reflected upon the food as well.

The tables and chairs also need to be clean, attractive, and comfortable. Tablecloths, napkins, centerpieces, and attractive dinnerware all contribute to the impression of the food and service.

Serving equipment, such as trays, stands, serving carts, and bussing carts also need to be cleaned and well-maintained.

A good practice is to try to look at the dining room before each meal as though you were seeing it for the first time. What impression does it make? And then change what creates a negative impression.

What was the nicest dining room you ever saw? What made it special?

Making Meals Memorable: Food

Food starts with the menu. The menu must have a variety of food items. It must also have variety in color, flavor, texture, and shape. This is necessary each meal, each day, and each week. This also applies to therapeutic and texture modified diets.

The food must be attractive. This includes, of course, that the food itself must look good. Plate arrangement is also important. If the food is attractively arranged on the plate it will be more appealing. Appropriate dishes affect the attractiveness. Bread on a separate bread plate is more appealing than bread put on top of the potatoes and gravy. Garnishes also improve the appearance of the food as it is served.

The food must also be appetizing. Recipes must be followed for this to occur. The food must be properly cooked, flavorful, the appropriate texture for the product, and served at the appropriate temperatures.

All this applies to the cold food items as well. Sometimes we focus in on the hot food and do not pay as much attention as we should to the cold salads, desserts, fruits, and beverages.

What do you do to improve the quality and appearance of the food?

Making Meals Memorable: Key Concepts

There are some key concepts that must be remembered to achieve an improved dining program.

A fine dining program must be a facility philosophy, not a dietary program.
Every department, every staff member has responsibilities.
Everyone must work together to achieve goals.
A fine dining program must be individualized to the facility’s residents, staff, and physical plant.

If these concepts are not adopted and followed, the dining program will never be much more than getting the meals out.

Do you find it is difficult to get other departments involved in meal service? What have you done to overcome this?

Making Meals Memorable: Advantages

There are many advantages to achieving dining excellence. The more conducive meal time is to eating, the more the residents eat, thus the greater the nutritional and hydration status of the residents. This leads to less, if any, weight loss. This, of course, leads to greater survey results.

This also has a positive impact on the bottom line. If the residents enjoy meal time, and eat more, there is less food waste. There is also less need for supplements if the residents eat the meals. This helps food costs.

A fine dining program also means the residents enjoy meal time more. This leads to an increased quality of life. This, too, affects survey results. It also assists the marketing effort in that if the residents talk positive about a program, and the families see the benefits, word of this gets into the community.

In addition to all of this, and perhaps most important, it makes the lives of the residents in our facilities better.

What other advantages have you found in improving meal service?

Making Meals Memorable

May 9 -15 is National Nursing Home Week. The theme is “Enriching Every Day!” One of the best ways to enrich the lives of the residents is to enhance meal service.

Meals are extremely important to all of us. Meals not only nourish the body, they also nourish the mind and the spirit.

When assessing a dining program for improvement, the three areas to evaluate are the food, the environment, and the service. An important aspect to remember is that there is no reality, only perception. It is important to determine what the residents’ perceptions are of the current dining program and what improvements are necessary and desirable. And then take it several steps further to really “wow” the residents, who are your primary customers.

This month we will discuss how to enhance any dining program. Are there certain areas you would like to see addressed?

Emergency Preparedness: Kitchen and/or Serving Areas

Sometimes the emergency is that there is no longer a kitchen in which to prepare meals. It is necessary, of course, to have a plan in advance for such an emergency, especially if the plan is to use another kitchen.

It may be possible to temporarily use another area in the facility to prepare a simplified, cold menu. In investigating potential areas, check the electrical outlets and if they are connected to the emergency generator. In some cases, it might be possible to move portable refrigeration units to another area. Also check to see if it will be possible to keep this area secure.

For an emergency lasting longer, it might be possible to use the kitchen of other establishments. Another healthcare facility, restaurant, school, church, banquet hall, and mobile kitchens are all possibilities. Transportation needs to be planned as well. A contract in advance is also necessary.

Another option is to contract out to have someone in the community prepare and deliver meals to your facility. If it is not another healthcare facility doing this, keep in mind that you may have to educate on diets and healthcare standards for food safety and sanitation.

If the dining rooms are not available for service, consider other areas such as activity rooms, therapy rooms, lounges, and meeting rooms. Room service is also an option, provided there are enough trays and carts available for this type of service.

What other kitchen and/or serving areas are available to you?

Emergency Preparedness: Deliveries

Many disasters can create the emergency of not being able to have food and supplies delivered as scheduled.

A very simple procedure that can eliminate this during short-term emergencies is to use skip days. For example, if the delivery normally comes in on Wednesday, skip Thursday, and don’t start using the delivery until Friday. Frequently, if the delivery cannot be delivered on the normal delivery day, it can be delivered the next day. This simple procedure prevents an emergency from even occurring.

Other things to do include identifying the food normally available and how these items can be used in the menu or in a simplified menu. There is also the emergency menu that can be used when needed. Most states have regulations related to needing a three-day supply on hand.

It is also good to have contracts with back-up vendors. Perhaps a delivery cannot be made because of an emergency between your facility and the warehouse. A more local vendor may not have any difficulties. It may also be possible to obtain food and supplies from alternative sources and establishments in the community. It is necessary to have contracts in advance of an emergency, however.

What contracts do you have in place?

Emergency Preparedness: Staff

Many disasters can also cause an emergency related to lack of staff. Staff may not be able to come to work.

In these cases, it may be necessary to go to simplified diets and a simplified menu so that it does not take as much time to prepare and serve meals. It may also be necessary to use disposables if there is not adequate staff to operate the dishroom.

It may be possible to utilize staff from other departments and maybe even from other facilities if the scope of the emergency is small.

In the cases of advance warning, such as a hurricane or blizzard, staff may be able to come to work prior to the storm hitting. The reverse is also possible, in that staff may not be able to leave during a disaster. Both these scenarios may occur throughout the facility. In these cases, it is necessary to have a plan on how to feed these people.

What are your facility policies on ensuring adequate staff in an emergency?

Emergency Preparedness: Communication and Computers

Two other important considerations are communication and computers.

The most obvious form of communication is telephone. If the phone lines are down and/or the cell towers are down, it is important to be able to contact staff outside the facility. The facility plan will probably work for the dining services department as well as the rest of the facility, but the manager must know what the plan is.

Another consideration to is have all staff phone numbers, cell, home, and others as appropriate, easily accessible during an emergency. For example, it doesn’t help to have the numbers in your own phone if you cannot access your phone or in the computer if you cannot access the computer.

And if the cell phones are working, but the power is out, there needs to be a way to recharge the cell phone batteries. Check to be sure there are sufficient outlets connected to the emergency generator.

The computer stores a vast amount of data. If the computer is not accessible, it is important to determine in advance of an emergency how to access that data. In some cases keeping hard copies on file will work. Another option would be to have the files backed up so the information can be accessed through a laptop computer, provided there is a method to keep the batteries charged. Also check to see if the printer will be available.

Many facilities store information and communicate through an intranet. The manager must know what the facility plan is if that is to go down.

A great deal of communication occurs over the Internet, including order placement. If computers and/or the Internet are not available, there needs to be a back-up plan for placing orders and other types of communication.

As dependent as we are on computers and instant communication, this could be a difficult situation to handle in an emergency.

What comments do you have on addressing this issue?

Emergency Preparedness: Water

In a water emergency, it may be that there is no water coming into the facility, the water coming into the facility is unsafe and cannot be used, or the water coming into the facility is unsafe and can be made safe by boiling or purification. Each situation requires a slightly different plan.

In developing water emergency plans, first identify water needs under each situation. Some considerations include water for drinking for residents, staff, and others; food preparation and cooking; washing hands; and cleaning and sanitizing dishware, utensils, and equipment. Another consideration is whether dining services is to supply water just for the department’s needs or for the entire facility.

Possibilities for water include bottled water supply on hand, water delivery, or storing water if there is advance notice (collapsible containers). If purification kits are used, the appropriate amount needs to be kept on hand as part of emergency supplies.

A critical aspect of the water emergency plan is how to communicate to staff not to use the water at all or to use it after proper boiling or purifying, depending on the situation. Follow-up that staff is using proper procedures is critical.

Another often forgotten aspect is the ice machine. If the water is not safe, neither is the ice. The machine needs to be shut down and emptied as quickly as possible so no one uses contaminated ice accidentally. When the emergency is over, the machine needs to be cleaned and sanitized.

Are there other sources of water that you use?

Emergency Preparedness: Electricity and Gas

In planning for a loss of electricity, the first thing to do is to identify all equipment that is on electrical power. This may include lights in preparation, serving, and storage areas; refrigerators and freezers; cooking equipment; dishwasher; booster heaters; outlets; elevators or dumbwaiters; and water heaters.

Next, determine which of these items are connected to the emergency generator. What emergency lighting will you have? Which outlets (if any) will work? Will you have any cooking equipment? Holding equipment? Refrigeration? Hot water?

Then it is a matter of determining how to make due without the equipment that is not on the generator. Consider incorporating some of the following into your plan.

• Refrigerator/freezer units: use food, move to other establishments, borrow refrigerated truck, allow minimum access.
• Cooking equipment: gas equipment, switch to cold menu, outside grill.
• Holding equipment: chafing dishes and sternos for hot, ice in pans for cold.
• Dishwasher: switch to disposables, disposable foil pans for cooking.
• Booster heater: chemical sanitizers.
• Outlets: ready-to-serve texture modified meals, slice by hand, manual can openers.
• Elevators: system for manual transport.
• Water heaters: heat on gas stove, chemical sanitizers.
• Lighting: flashlights with extra batteries, crank flashlights.
  

Follow the same procedure for gas equipment. Equipment may include cooking equipment and water heaters. Plans could include using electrical equipment, switching to a cold menu, alternative methods for heating water, and/or chemical sanitizers.

Also plan what to do if you lose both electricity and gas!

What other items do you have in your plans?

Emergency Preparedness: Plan Development

In developing an emergency preparedness plan for dining services, one of the most important steps is to determine what the facility plan is and how dining services fits into it. And an important step in developing a facility plan is determining how it fits into the community plan.

For example, will the facility assist by providing meals to emergency workers in the community? Will families of staff members be allowed to stay at the facility during some disasters? If so, the dining services plan must include how to feed them. Is dining services responsible for ordering all water for consumption and use, or only the water that the department will use? There is not any right or wrong answers to these situations. The dining services manager just needs to know what is expected.

The department plan must:

• Include the staff’s role within the department.
• Include the department’s role within the facility.
• Be clear and easy to read and understand.
• Easily located by staff.
• Include staff information contact information.
• Include vendor contact information.
• Include contracts with vendors (water, food, supplies, equipment).
• Include contracts with other facilities and establishments.

What is your facility and department expected to do in an emergency?

Emergency Preparedness: Scope and Length of Emergency

When planning for emergencies, it is important to consider both the scope and the length of the emergency.

The scope relates to how wide-spread the emergency is. If it is only your facility that has loss power, for example, there are many nearby resources that you can call upon. If you have contracts developed in advance, you could call local grocery stores, schools, banquet halls, and even other facilities to see if they could store some of your food for you.

If the scope is wider and includes your community or city, then these resources will be in the same situation as you. You would need to reach out further for assistance. If the scope is county or state wide, you may not be able to receive assistance. So what are your plans if you can get help and what are your plans if you cannot?

The other major consideration is the length of the emergency. We can survive anything for a couple of days! But what happens if the length of the emergency stretches beyond that? What are your plans if you do not have electricity for a week or longer? What are your plans if you do not have a kitchen for a month? Short-term and long-term plans differ.

In developing emergency plans, consider both the scope and the length of the emergency.

Are there plans that you have that you would like to share?

Emergency Preparedness: Disasters and Emergencies

The terms disasters and emergencies are often used interchangeably. For the purposes of this month’s topic, however, we will define them separately.

Disasters can be natural disasters such as earthquakes, extreme heat, floods, hurricanes, landslides, thunderstorms, tornadoes, wild land fires, wind, and winter storms including blizzards, ice storms, and severe cold. Other external disasters include accidents, fires, explosions, pandemics, riots, and terrorist attacks. Internal disasters include bomb threats, explosions, fires, hazardous spills, strikes, and workplace violence.

These disasters can cause emergencies for us because they affect how we operate our business. Many of the above disasters could cause one or more of the following emergencies: loss of electricity, gas, water, phone, computer access, Internet access, shortage of staff, late or no deliveries, and even loss of kitchen or serving areas. Disasters can also create evacuations, either of our residents to another location or another facility’s residents evacuating into our facility.

This month we will discuss items to consider in how to plan for these potential emergencies.

Are there additional disasters or emergencies that you face?

Nutrition: Unintended Weight Loss

Unfortunately in long-term care, sometimes residents lose weight. The most important step is to determine why and address that issue.

If you go to the doctor because you are not feeling well, you want the doctor to diagnosis and treat the disease, not the symptoms. For example, if you have headaches, you want the doctor to determine why. If he/she just treats the headache, without determining that cancer is causing it, you won’t last long.

Determining why the resident is losing weight determines the actions to take. Usually it is because the resident is not eating enough. Determine why the resident is not eating enough. If the resident is depressed, address that issue. If the resident is in pain, address the pain. If the resident needs more assistance, provide the assistance. If the resident’s dentures don’t fit anymore, get new dentures. If medications are causing a lack of appetite, address that. And so on, and so on, and so on….

Maybe the resident eats, but cannot consume enough at meals to maintain weight. Provide food between meals. Provide more caloric dense foods at meals. And consider smaller portions at meals. If the resident is not going to eat it, too much food can be overwhelming and cause the resident not to want to eat at all.

Sometimes a resident eats well but because of metabolic issues needs more than what is provided with meals. Consider large or double portions as well as caloric dense foods.

Adding cream, sauces, butter, gravies, etc. to food increases the calories. Sugar, brown sugar, honey, syrup, and other sweeteners added to food add calories as well. And an old-fashioned standby that still works is non-fat dry milk. It adds calories and protein to foods like hot cereal, cream soups, potatoes, and others. These foods work well both for residents that cannot handle a normal volume of food and those that require more calories.

Commercial supplements are also an option. Too often, though, these are provided as an easy solution without first investigating why the resident is losing weight and using the above approaches to address the why. It’s usually good to try to address the problems with “real food first.”

Nutrition: Eating Out

It is much easier to eat out and eat healthy now than it was in the past. Many more restaurants offer healthier menu items and healthier options, such as low fat dressings and condiments.

Some things that you can do to eat healthier and/or consume fewer calories include:

• Share entrees. Order one meal, an extra salad or soup, and split the entrée. The food tastes just as good, and there is less of it for both of you.
  
• Share desserts. If you have to have something sweet (and we all do sometimes!) share it.
  
• Only eat half the meal and take the other half home for a second meal.
  
• Order items that are baked or grilled rather than fried.
  
• Order items without sauces and gravies or ask for them on the side.
  
• Order fat free or reduced fat dressings and condiments or ask for the regular ones on the side. If it is on the side, you control how much goes on.
  
• Ask for plain bread and olive oil on the side for dipping rather than buttered garlic bread.
  
• Ask for half the amount of cheese on your pizza and order vegetables instead of meat.
  
• Focus more on chicken and fish and less on meat. (But still watch the preparation method.)
  
• Order a plain baked potato with salsa or fat free dressing instead of butter and sour cream.
  
• Save the high fat, but really good, appetizers for when there is a group. You can have a bite or two, but are less likely to overindulge.
  
• Avoid sugared beverages.
  
• Ask for nutrition information if you are uncertain of an item. Many restaurants have this available.
  
• If you are old enough, order from the senior menu. The portion sizes are often smaller.

As I said in an earlier post, I look at this as being able to eat anything I want; just not as much as I may want, or as often as I may want! But there is nothing that I have forbidden myself to never have again. In my opinion, that would be setting myself up for failure.

Please share any ideas you have for eating healthier when you eat out!

Nutrition: Portion Control

Portion control is important in any food service establishment. It affects costs and customer satisfaction. In healthcare, it also affects nutritional status and regulatory compliance.

Portion control is also important in our everyday lives. The only way to know if we are consuming the right amount of nutrients, not too much and not too little, is to follow the portion sizes in recipes and on ingredient labels.

Much of the overweight and obesity problems in this country are related to overeating (obviously!) but much of the overeating is related to not watching portion sizes.

The only way to learn accurate portion sizes is to measure it, weigh it, or count it. If you are not used to doing this, it will be amazing!

For example, the label on a brand name of potato chips states that a serving size contains 160 calories and 10 grams of fat. The serving size is 1 ounce, or about 12 chips. Have you ever counted out and eaten just 12 chips? It’s not much. But that is a serving for this item.

If instead of one serving, you ate the entire 10 ounce bag (10 servings), it would be 1600 calories and 100 grams of fat! An average calorie level is considered 2000 calories (many people need to consume less than that to maintain weight and some more). So this bag of potato chips contains over 3/4 of the average caloric needs for one day.

For a 2000 calorie diet, recommended total fat (for a healthy person) is less than 65 grams. This one bag of chips provides all the fat for that day and a good portion for the next.

One of the best things you can do for your health and your weight is follow portions sizes.

Nutrition: Therapeutic Diets for Long-Term Care

In the early 1980’s when I finished my dietetic internship and started working as a food service director and dietitian, it was still common to see strict therapeutic diets in long-term care. There were some residents who probably benefited from this, but for many weight loss was a bigger issue.

As the residents in long-term care became older with more issues related to being able to consume adequate nutrition and maintain weight, it made sense to go with more liberalized diets. Often the goal was just to get the person to eat, so why make it more difficult by eliminating many foods she would eat.

Liberalized diets still make sense for most of the elderly-elderly from nutrition as well as quality of life and resident choice stands. However, many facilities now also have younger residents (50s and 60s) for rehab or other reasons.

Many of these residents follow a therapeutic diet with good results, often related to health conditions. It is usually in their best health interests to continue to follow their diets. Or, if they are not following a therapeutic diet, they are young enough to benefit from one.

Because of this, facilities need to reevaluate the diets they offer. Options include:

• Offering strict therapeutic diets again in addition to the liberalized diets.
  
• Using food preferences to meet individual needs, such as having fat free or reduced fat options available and seasonings other than salt.
  
• Modify the existing menu so it is more “heart healthy” and address individually those that may need more concentrated calories. Be sure to follow the diet manual for heart healthy, and do not just “make it up.”

A tool that will assist with the decision is an accurate nutritional analysis of the menu. This allows you to determine what changes you would need to make in the menu and in the recipes to achieve a heart healthy diet.

Happy Saint Patrick’s Day!

We are all familiar with traditional Irish foods—Irish stew, potatoes, cabbage, soda bread, potatoes and cabbage, corned beef, cabbage and potatoes, and green beer. (Well, green beer is really more of an Irish-American tradition. Or maybe it is more just an American tradition. There are probably many more people drinking green beer that are not of Irish descent than are.)

Other traditional staples in Ireland included grains (especially oats) and dairy products. The Irish have been accomplished cheese makers for centuries. Soups, seafood, and meats such as beef, lamb, and pork are also traditional staples.

It has only been in the last few decades that the Irish diet has changed much. This change related heavily to more Irish having the economic means to travel to mainland Europe and other parts of the world. There they ate new foods and wanted to continue to eat them when they returned home. Today the typical Irish diet is similar to that of Western cultures.

There is also a large slow food movement in Ireland. There is greater emphasis on using the freshest foods available and taking time with preparation.

If you were to travel to Ireland today, you would find many of the same foods there as you would here.

Nutrition: Cutting the Fat

Three years ago my husband almost had a heart attack. Luckily it was determined what was wrong and he had a stent put in prior to actually having a heart attack. We have both watched our diet and fat intake much better since then!

What is a little scary is that his cholesterol levels were not that bad. They are good now! Mine have always been pretty good, and now they are great! So diet does help and is worth it. A side benefit to cutting the fat was that we both lost weight. Dropping two clothing sizes was fun (and expensive). I got to buy two wardrobes in less than a year!

The following are just some things that have worked for us.

• Fat free salad dressings, condiments, mayonnaise, “butter” etc. we use wherever possible. The quality has improved greatly over the past several years!
  
• Naturally fat free condiments such as catsup, mustard, barbecue sauce, etc. are always an option. My husband really loves salsa on his baked potatoes now instead of butter and sour cream. Fat free ranch dressing is another option and many restaurants carry it.
  
• Fat free cheeses (hard, cottage, cream) work well in casseroles, pizza, etc. I prefer the low or reduced fat for sandwiches or bagels.
  
• Fat free sour cream works great in dip. We serve it routinely and no one knows the difference.
  
• Fat free yogurt is great to eat alone (there are so many flavors) or in fruit dips.
  
• There is an absolutely fabulous fat free brownie mix—No Pudge! Fudge Brownie Mix. It is mixed with fat free yogurt.
  
• Many dessert recipes and mixes can be altered to use fat free yogurt or applesauce.
  
• Eating less meat helps cut the fat. Both watching the portion size and eating it less frequently helps.
  
• There are healthier oils to use for cooking than butter or margarine. Dipping bread in olive oil is really very good! But you still need to watch the amounts.

The way I look at it, I can eat anything I want. I just can’t eat it whenever I want and as much as I want! But we do allow ourselves “diet holidays” for special occasions. And it has been worth it!

Nutrition: Using a Registered Dietitian

Since today is National Registered Dietitian Day, I wanted to talk a little about how beneficial working with a registered dietitian can be in meeting your health and weight goals.

To become a registered dietitian, a person must first complete a bachelor’s degree in nutrition or dietetics. The next step is to complete an internship (generally a year) or obtain a master’s degree. This enables the person to take the national registration exam through the American Dietetic Association. Once the exam is passed, it is necessary to obtain 75 continuing education credits every five years to maintain registration. In addition, many states also have licensure and certification requirements that must be met to operate in that state.

Be aware that “nutritionist” is a very vague term. Anyone can call themselves a nutritionist. Some dietitians do use that term because the public seems to respond well to it. But before you work with a nutritionist, ask for his or her credentials.

Registered dietitians (RD) that specialize in nutrition keep up on the latest scientific research. There are so many fads and trends out there, that it is hard to know what is true and what isn’t. RDs filter through all this and can help you understand it. They also educate you on healthy eating for your situation. Maybe you want to lose weight, maybe you have diabetes, maybe you have a heart condition, maybe you have several concerns—they can help you develop an eating plan that meets your needs.

Some RDs are also coaches. They go beyond just educating you; they also help you determine what you can do to make healthy changes. In many ways, they ask the questions, but you provide the answers on what you are willing to do!

To contact an RD you can ask your physician for a recommendation. You can also go to the American Dietetic Association’s website, www.eatright.org. In the upper right hand corner, click on “Find a Registered Dietitian.” From there, you can search by specialties and location.

Nutrition: Diet Manual

The diet manual is a critical component of nutrition care in any health care setting. The diet manual provides information for normal and therapeutic nutrition. The diet manual needs to be based on the latest scientific evidence.

The diet manual is the basis for writing the menus. It is the diet manual that states how many servings of the different food groups are necessary for optimal nutrition for different groups of people. It also states what changes are necessary in nutrients and textures to meet the needs of people with special dietetic needs such as diabetes, heart conditions, and dysphasia.

Menus cannot be written based on what the writer “thinks” a diet should contain. Menus need to be written based on the latest scientific research. The diet manual provides this.

If you are purchasing menus, ask for a copy of the diet manual upon which the menu was based. This is your foundation for ensuring good nutritional status of your residents! This is the first step in meeting the nutritional needs of the residents. It is also your first line of defense if surveyors question why you are providing residents with certain food items or withholding certain food items.

The diet manual is critical!

Nutrition: National Nutrition Month

March is National Nutrition Month! In honor of National Nutrition Month, this month’s blog will contain various nutrition information segments. Some of it will be aimed to help you help your residents, and some will be just to help you.

National Nutrition Month is an annual nutrition and education campaign by the American Dietetic Association. The focus is to help the public make informed food choices and develop good eating and physical activity habits.

This year’s theme is “Nutrition from the Ground Up.”

March 10 is also Registered Dietitian Day. This day is to increase the awareness of the important role registered dietitians play in providing nutrition information.

For more nutrition information, go to www.eatright.org (American Dietetic Association). Another good source for nutrition information, including an interactive site, is www.mypyramid.gov (USDA). Some of your Internet-savvy residents may enjoy this one. It is also a great place for nutrition information for you and your family.

Food Cost Control: Security Issues

No one wants to think that their employees could steal, but it happens. It may be as simple as occasionally taking home coffee packets from the breakroom or as serious as smuggling cases of meat out of the freezer.

Simple security measures include:

• Keep non-dietary employees out of the kitchen and storage areas.
• Lock the storage areas when not in use.
• Lock the kitchen when no one is in there.
• Keep any kitchen access areas separate from the main work areas locked.
• Carefully control access to keys.
• Monitor deliveries and do not allow delivery people to put away stock.
• Use a purchasing system with needed amounts compared to inventory.
• Monitor receiving practices and putting away stock.
• Monitor taking out garbage.

Another important aspect is to have policies and procedures in place on what constitutes theft and what will happen to employees caught stealing, educate all staff on these policies, and enforce them. Keep in mind that some people really do not see taking small items as stealing.

Food Cost Control: Tracking Expenses

It is not possible to control food costs if the manager does not know where the money is going. It is also not possible to make good decisions if the manager does not know how the money is being spent.

For example, perhaps food costs are increasing because of a new employee meal program. If a fee is charged, then the revenue is also increasing. If only expenses are reviewed, and not the revenue, an accurate picture cannot be obtained.

Perhaps food costs are increasing because of an increase in supplements. Why is there an increase in supplements? Are more acute residents who truly need supplements being admitted? If so, perhaps the food budget needs to be adjusted. Or are residents not getting the assistance they need at meal time and so more supplements are given?

Is there an increase in marketing events, special activities for employees, more resident activities requiring food? If so, it can be evaluated whether these areas are the best use of a limited resource—the food dollar.

Maybe there has been a large increase in the number of residents on thickened liquids. If these residents require thickened liquids, there may need to be an adjustment in the food budget to allow for this.

If the dietary manager is tracking where money is being spent, and there does not seem to be increases in non-resident meal areas, then it may be the meals. If the menu has not changed, then it is likely that the increased expenditures are related to waste, theft, or increased food costs from the supplier. The manager can then further investigate these areas to determine the root cause of the increase in food costs.