Food Service Module VIII: Integration of Food Systems with

other Services
CRD 2.10 Establish collaborative relationships with other health professionals and support personnel to deliver
effective nutrition services
C4 Communicate and connect effectively with a variety of persons in the healthcare setting

1. Introduce yourself to and communicate with employees of the different areas or services.
2. Discuss with them their understanding of the relationship between the food service system
and their service.
3. Evaluate and document in narrative form (report) how the different services are integrated.
Make suggestions for improvements in communication and interaction among various services
in the facility.
DIETETIC TECHNICIAN
Went on rounds with a dietetic technician and learned how the process of feeding a patient begins. Diet techs usually do 2 or
more rounds on patient wards to make sure they have all new admissions, and patients that may have been out for testing or
surgery on their previous attempt to see them.
The diet tech first identifies the patient by asking for 2 patient identifiers (i.e., name and birthdate), then asks the patient a
series of routine questions that determine their nutritional risk status. These questions look for unintentional weight loss,
weight loss over 5% in 3 months or 10% in 6 months, or weight gain. They assess the functionality of the GI tract including if
the patient is having, or has had; nausea, vomiting, constipation, or diarrhea. They ask if the patient has any food allergies,
food intolerances, aversions, and if they take any multivitamins or herbal supplements. It is determined if the patient has
any difficulty swallowing or chewing and if they have adequate detention. If they wear dentures, did they bring them with
them to the hospital? These questions are then entered into the inpatient charting system by the diet tech along with their
current height, weight, usual weight, primary and secondary diagnoses and the system will assign a risk score. A nutrition
screen will print with the score on it and the diet tech will assign it to a dietitian if the score is over a zero.
The patients are given a phone number in which to reach the diet tech if they would like to make any changes to their menu
(if allowed by the MD). The diet tech will make these changes if allowed or will make recommendations if the patient is
unsure what they want.
After a dietitian has seen a patient who has screened out high risk, she will determine if the patient should be followed by a
dietitian or can be handed back to the diet techs to monitor.
In my opinion, diet techs are very important in providing efficient and effective nutrition care services. Not all patients will
see a RD because they are busy with those who screen out as high risk, but all patients will see a diet tech so they know that
the nutrition department has been tracking their admission and are concerned about their nutritional needs.
I noticed when I was with the diet tech she had to go and look at the nurses roster for the most updated patient list. She
was a little frustrated to see that it was not updated or current, which meant she would have to make another trip upstairs,
or if she ran out of time, she would have to put the screen off until the morning which she didnt want to do. I think
improved communication between nursing and the diet techs would be beneficial for both professions and for patient care.

INPATIENT TRAY LINE WORKER

During this food service rotation at Womack, I have had the opportunity to spend time observing and assisting on the
patient tray line. The tray line workers collect the meal tickets from the dietetic technicians (DT), who have received
them from the nurses on the wards. They read the tickets for specialized diets, modifications, allergies, etc. To identify
the different diets a color coding system is used. Here is a picture depicting how they use this system:

Sugar Substitute

Sodium Free Seasoning Blend

The first tray line worker sets up the tray with the diet packet that relates to the patients prescribed diet. As the tray
advances down the line the subsequent workers recognize the color and its meaning and will add or omit certain items
at their station. At the end of the line the loader will pick up the tray, check it for accuracy and then put it on a cart to
be taken up to the wards once all the trays for that ward are onboard.
Employees on the tray line all are aware of different allergens. They have a big responsibility to protect patients against
allergens in foods as they are often the last safety point before the patient receives the tray. I asked several patient tray
workers what they would do if they saw a salad with tomatoes on a patients tray that was allergic to tomatoes. They all
replied that they would remove and remake the salad using fresh lettuce. When I asked them why they would not just
pick the tomatoes off, they replied that the tomatoes could have contaminated the lettuce and even a very small
amount of an offending food can cause an allergic response in someone who has a food allergy. They understood that if

an allergy is entered into Computrition by a DT or a dietitian, it will appear on the meal ticket. However, they also
understood that mistakes can easily be made when many trays are being prepared at once, so they all must accept
responsibility for looking out for harmful foods and for knowing when to replace the product in its entirety.
When I first started at WAMC there were a few incidences where trays were allowed up to patient rooms with food
items that could have caused an allergic reaction. My first in-service addressed wheat and egg allergies, common food
items that contain these ingredients, pseudonyms, hidden sources, and what to do if you notice one of these items on a
patient tray.
After my in-service, when going through the lunch line that afternoon one of the cooks told me he had checked all of the
boxes in the freezer for hidden wheat ingredients! Also, later that afternoon a patient tray line worker came up and
showed me that he had found caramel color as an ingredient on the Ginger Ale. He was concerned because caramel
color was on the list of possible wheat containing ingredients. We reviewed the label together and I explained that it
was an excellent observation, but caramel color is usually not made of wheat or gluten in North America. I also
explained that under the Food Allergen Labeling and Consumer Protection Act, any packaged food sold in the United
States, must state on the label if it contains protein from wheat. This communication showed me that the in-service I
had given had alerted these employees to the danger of food allergens and they were taking their role seriously. It was
a very meaningful experience.
The worker who is assigned to do patient tray delivery, will help the loader prepare his/her cart and when complete, will
take the heated cart out to the cart elevators and up to the wards. This job is very important to do efficiently and
correctly. It is important for the patients to get the correct food and at the correct temperature. To ensure that the
food is correct for the patient, the food service worker will ask the patient to provide patient identifiers (PIDs). These
PIDs are their name and birthdate which are also printed on the meal ticket.
I assisted as the tray service workers prepared Jell-O for their refrigerators in front of the tray line. They were using 2
ounce plastic ramekins with plastic lids. The Jell-O mix came in a large silver pouch that could make 60 portions of Jell-O
using only hot water. The recipe was mixed and quickly poured into the ramekins. To see what they would say, I asked
them why they did not just buy the pre-made Jell-O already in the cup. One employee replied that it would be way too
expensive. Another employee told me she liked to make the Jell-O in many different colors because kids could be
picky about their Jell-O color, and she wanted sick kids to have whatever color they wanted. This worker was taking
responsibility for patient care in a small but important way. I think it was excellent that she realized that no matter what
your job is in a hospital, the most important thing is the patient and making them better.
A problem with communication I noticed was that the microphone on the patient tray line was broken and they had to
yell loudly for a diet tech if they needed to ask a question concerning a patient tray. It would be hard for them to leave
their position because that would cause the entire line to stop working. Several times during the lunch shift when the
loader yelled, the diet tech was on the phone, or couldnt hear the tray line worker due to other noise. A better means
of communication like a direct line phone, or even walkie talkies could help make that communication more efficient.
Also, when a late order comes down from the wards, the diet tech could quickly communicate with the tray workers to
put the order in, or make a last minute modification.

WORK LEADER - COOK

I got to assist the cook work leader as he prepared the main dishes for dinner. The menu had been printed so he knew
what he needed to make. The dry ingredients had been pulled from the storage area and put on a cart labeled for his
use earlier that morning. He prepared pepper steak in one of the large tilt skillets. This was prepared earlier and
allowed to cook on a low temperature for an extended time. This would make the meat very tender the cook told

me. He was going to wait to put the green peppers and onions in the skillet close to the start of dinner so they would
still have some texture to them. When the entrees are done, he will pan them out into large pans that fit on the buffet
table, and slide them into the warmer the line cooks can access from the line.
He also checked the leftovers from lunch to see if they were still viable for dinner. The lunch cooks store all the leftovers
in the big warmer covered in plastic and labeled with the date. If the dinner cook thinks that it still looks good, and it
has been held at the correct temperature they will put it out on the line first to prevent waste. It is important for the
different shifts to label and store food correctly if it will be used again at a later time to prevent food borne illness.
This cook is responsible for his immediate area. He must keep it clean and orderly. He must communicate with the line
cooks to make sure they have enough food in their warmers to access during peak times. If they run out and give him no
advanced warning, it could delay the product getting back out to the service line, which could negatively impact profits.
The cook communicated with the shift supervisor when he needed supplies from any of the locked coolers or freezers.
He also returned supplies no longer needed to the shift supervisor to put back in storage.
The workers who do this job are very efficient and know their job well. They are responsible for their own part of the
meal and make sure they have communicated with the shift supervisor to secure all the goods and equipment they need
to complete their work. A suggestion for improvement in communication may be for the dinner shift to communicate to
the lunch shift how much of their leftovers they actually use and how much is discarded. Since the menu is a cycle
menu, patterns of consumption may emerge that will alert the cooks to produce less of certain products and more of
others.

SHIFT SUPERVISOR
I spent a day with a shift supervisor to learn what he did. On this occasion he was the late-shift supervisor. He came
in at 1030 and would leave at 1900. The supervisor communicates with the other supervisors and with work leaders
through a daily staff journal. In this journal he can also see if staff members have called in sick or will be out of work for
some reason. They also record telephone calls, and other communications that require their action.
The first thing the supervisor did was review the daily menus and make sure the display board out front was correct. We
then found menu cards with calorie counts that corresponded to the items on the lunch menu and put them on display
for the customers to see. Next we went out into the service area and checked the refrigerator and freezer temperatures
and recorded them on their individual logs. As we were recording the temperatures we looked at the contents inside to
make sure it was properly covered and labeled with a date and name. We then checked all of the beverage and coffee
service equipment to see if it was clean, fully stocked and was producing product.
I used a food thermometer to check the food on the salad bar and found a pistachio salad to be at an incorrect
temperature. The supervisor checked with the person who made it and found out that it was fresh, so he put it in the
blast chiller to bring it quickly down to temp before it went back out on the salad bar. We also checked the food on the
pasta bar and found a pan of tomatoes at an incorrect temperature; upon investigation we found that they had no ice
underneath the pan. The supervisor contacted the person in charge of that area and had them add ice to all pans. We
checked the food on the service line, and the sandwich line, and found all of those temperatures were good. We also
looked at all the pre-packaged foods to make sure none were expired, and threw away some Jello that was set to expire
that day.
As the supervisor made his way around the kitchen, employees would stop him for various tasks. He told me that he
had an assistant that he delegated some responsibilities to in order to get everything done. For instance when he was
checking out the cleanliness of the dishwashing section he noticed that the garbage disposal was not working and he
was concerned that employees were putting food waste into trash cans instead of the other disposal. This concerned

him because as a result insects or rodents may enter the kitchen to get to the trash. His assistant told him that it had
been broken, it was getting replaced and the dish workers knew to scrape the plates into a large container that would be
taken to the other disposal to be gotten rid of correctly. While in the dishwashing area we also checked the water
temperature of the dishwasher and the 3 basin sink.
We also checked out the rolling trash carts used to collect bags from the various smaller cans around the kitchen. He
said that after that cart was emptied into the big dumpster, they worker should spray it out, sanitize it and leave it over
large drains in the dish area upside down to air dry.
Another interesting thing I learned was that the large walk in freezer was equipped with an alarm if the temperature got
too high. If he was there, he could shut it off and investigate, solve the issue or call maintenance. If it was in the middle
of the night, the alarm was set to alert Central Monitoring which monitors the whole hospital. They could then unlock
the freezer and move all items into another freezer until food service workers return the next morning.
While we were walking the supervisor was taking note on equipment that needed regular cleaning, and equipment that
needed to be deep cleaned. He then would assign these tasks to the worker in charge of that area currently. A piece of
equipment he was especially interested in that day was the ice machine. He wanted to check the log to make sure it had
recently been emptied and sterilized. He also wanted to see if the ice scoop was in good shape. When he found the ice
scoop he felt like it was on the verge of chipping in a few places, so he communicated with the supply supervisor and
ordered another one.
Here is a copy of the log used by supervisors to communicate with each other:

4. Develop and/or review organizational chart showing interrelationships of all services at

the facility. Discuss with preceptor. Develop summary of your findings
The organizational chart can be found on Module 1, Figure 4.
At the top of the organizational chart is the Chief of the Nutrition Care Division, Colonel C, MS, RD. Directly below her is
her non-commissioned officer in charge (Master Sergeant R), the Chief of Production and Service (First Lieutenant S, MS,
RD) and on the clinical side, the Chief of Clinical Nutrition Services (J.B, MS, RD).
The following chart (Figure 1) will concern the Production and Service Part of the organization and has been simplified
below. Following this chart will be a visual representation of the relationship with the patient tray workers and clinical
staff (Figure 2).

Production and Service Flow Chart

Division Chief

Chief, Production and

Service

NCOIC
Office of the Chief

NCOIC, Production
and Service

Subsistence and
Supply

Cook Forman (1)

Cook Supervisor (1)

Cook Supervisor (1)

Cook Supervisor (1)

Cooks (5)

Cooks (5)

Cooks (5)

Clinical Nutrition Services

Food Service Workers

(6)

Food Service Workers

(6)

Cashiers (7)

Figure 1

Food Service Workers

(6)

Division Chief

Chief Clinical
Nutrition Services

Chief, Inpatient

Chief Outpatient

Clinical Dietitians

NCOIC,
Inpatient
Diet Office
(DTs)

Figure 2

Patient Tray
Section