PURPOSE OF THE STUDY

The study provides an oppurtunity to investigate the catering service in one

of the hospitals in jammu.Moderen scientific research has shown that a
whole balanced diet of natural food is essential to health.The bulk of
independent research has shown that a whole food vegetation or vegan
regime provides everything necessary for human health .It is quite illogical
that that patients who are frequently ill in hospital because of eating too
much, eating junk or animal based diets be premitted to continue eating bad
food .Delicious fruits salads with addition of lightly cooked vegetables ,
some pulses and whole grains should be the purpose of basis of health
.Simple healthy fare with reduces the food budget and encourages the
patients to adjust their recovery. Fruit and veg juices and smoothies shoul be
provided in abundance.

METHODOLGY
The study will be conducted in the major Hospital in jammu .Investigation
will be undertaken on patients to assess the type of food service they are
being provided .Questionnaire pertaining to the catering services will be
given to the patients and the caretaker s. The questionnaire will test the
satisfaction of the patients in respect of their services .
Scope and limitations

Generally speaking no one likes to be in the hospital . Thease are the

services meant to assist people to stay healthy,. And get rid of the diseases.
When one’s normal health status is disturbed then it becomes necessary to
seek medical attention and if sometimes the case need medical attention then
hospitalization is prescribed .Here the catering service do the rest of the job .
In In govt aided hospitals none or very less amount is charged in lieu of
these services so it becomes quite approachable to lower strata of society. In
case of privare hospitals charge is quite high .

The food, which has to be provided in hospital , needs to be

simple, soft, and palatable.Highly dense , spicy, fried food cannot be
provided.
Table of contents
S.No Page no.

INTRODUCTION 1-1
Chapter-1
Food Culture in India 2-21

Chapter-2 22-27
Hospitals in jammu city

CHAPTER-3 28-50
Challenges in Hospital catering

CHAPTER-5 51-65
Recommendations

Conclusion 66-66
INTRODUCTION
Hospital catering refers to specialized cooking for patients.The importance
of these services lies in the factthat patients are encouraged to adjust their
lifestyles and incorporate healthy foods in their diet so as to prevent
reocurance of diseases.To review the catering services in the hospitals with
particular reference to the medical requirements of these services , the
arrange ments for training catering personnels and the instructions to the
hospital staff generally should be followed . Hospitals have nutritional
standarads and caterer has to meet the needs of the individual patient ‘s and
offset any dietry deficiencies .Menus should be planned with regard to the
chlorific need of various categories of patient and should include adgeqauate
amount of fruits and vegetables.Theapeutic meals should be prepared
separatley but with in the main kitchen and any hospital with over 100 beds
should employ a full time Ditetian patients should able to choose from a
cyclic menu that rotates over a 6 week time and nursing staff should
supervise the service of meals.Visitors should be discouraged from bringing
substantial amount of food for the patients .

“One in three people are seruiously and nourished when they come in to the
hospital”,explains STELLA GARDENER ,Catering Manager of south
Hampton university ,Hospital NHS trust and “one in ten has lost weight
prior to being admitted .It is therefore essential that we do our utmost to
ensure they gain strenth through nourishing food while they are here
CHAPTER-1
Food Culture in India

The republic of India occupied mist of the land mass called the
Indian sub content or south Asia , which also includes the republics of
Pakistan, Bangladesh , AND Sri Lanka and the independent Kingdoms of
Nepal and Bhutan . India is a federal republic, consisting of 29 states and six
union territories under direct federal rule. Stretching two thousand miles
form north to south and eighteen hundred miles from east to west , India is
the world’s seventh –largest country in area and , with more than a bi9llion
people , second in population only to china . Some Indian states are larger
than most countries and like countries have distinct languages, ethnicities,
cultures and cuisines.

Indians speak eighteen official languages and more than sixteen

hundred minor languages and dialects, Although Hindi is the national
language , it is spoken as a mother tongue by only about one –third to one-
half the population. More than 80% of Indians are Hindus, but 12% -140
million people – Muslims, making India the world’s second largest Muslim
country after Indonesia. India also has 30 million Christians, who are the
majority in several states; 15 million Christians, who are the majority in
several states; 15 million Sikhs; plus small communities of Paris, Jains
Buddhists and animists
(Worshipers of nature gods and spirits).

Religion plays an important part in Indian life , and food in

inseparable from religious beliefs. On the most basic level , Muslims do not
eat park almost Hindus avoid beef , and many Indians practice varying
degrees of vegetarianism . But there are no hard and fast rules : some
Hindus eat no meat , fish or eggs , other eat eggs of fish but avoid onions
and garlic, still others eat vegetarian. However, nationwide 70% of the
population eat meat at some point , although the percentage varies form 40%
in the western states Rajasthan and Gujarat to 94% in Kerala and west
Bengal . However, for economic reasons – meat is relatively expensive –
most people are de facto

Vegetarians who eat meat only on special occasions.

 Festive occasions such as weddings Life transition ceremonies, and
religious holidays are important social and gastronomic events in Indian life
accompanied by special dishes and meals. Adherents of all religious practice
fasting as a means of worships, prayer and spiritual and physical discipline.

As in medieval Europe, eating habits in India are rooted in moral

and medical beliefs. “You are what you eat”, is a theme of both ayurveda,
the ancient Indian school of medicine , and unami , the traditional Islamic
medical system . Hindu philosophy also assigns qualities to food that are
related to caste personality and spiritual qualities All these systems are
overlaid With popular beliefs about the “hot” or “cold” properties of food
and their effect on mental and physical health.

Geography and Climate

Most Indian Food is still produced regionally or locally, and is

highly seasonal. India is a predominantly rural country, second only to the
United States in the amount of land under cultivation. More than 70% of
India’s population lives in 600000 villages. Most are engaged in farming
either on their own small plot or as hired laborers. Much Farming is little
more than subsistence-level: the farmer products grain and rice in order to
feed his family and sells a small part of his crops at harvest time , using the
cash to buy more land , fertilizer , equipment , and household goods . People
try to have a few mango trees and in the south tamarind and coconut trees as
well as a small vegetable garden where they can grow chilies and vegetables
for their daily meals. Relatively affluent farmers own a female water buffalo
or cow for milk, bullocks to pull the plough, and a few sheep, goats, and
chickens.

In cities, incomes are generally higher and people have access

to a wide variety of food stuffs at commercial establishments. Only 2% of
India’s population lives in 600000 villages. Most are engaged in farming
either on their own small plot or as hired laborers. Much farming is little
more the an subsistence –level : the farmer products grain and rice in order
to feed his family and sells a small part of his crops at harvest time , using
the cash to but more land , fertilizer , equipment , and household goods .
 People try to have a few mango trees and in the south tamarind
and coconut trees as well as a small vegetable garden where they can grow
chilies and vegetable for their daily meals. Relatively affluent farmers own a
female water buffalo or cow for milk, bullocks to pull the plough, and a few
sheep, goats, and chickens.

In cities, incomes are generally higher and people have access to a

wide variety of food stuffs at commercial establishments. Only 2% of India’s
agricultural input is processed, so most meals are made form scratch. Indian
cooking tends to trends to be labor-intensive and in rural areas women spend
half their waking hours preparing meals.

Although people often think India as A tropical country, it is

located entirely in the northern hemisphere.3 A wide variety if altitudes and
weather systems give India an extreme diversity of climates. It has
practically every kind of soil, ranging form rich alluvial soils formed by the
deposits of silt to arid desserts, swamps, and mountains soils.

Geographers divide India into three regions. In the north , the

Himalayas a Sanskrit word that means “abode of snow “ extend for fifteen
hundred miles from Pakistan and Afghanistan in the northwest to Burma on
the south east. Here are found the world’s highest mountains including
Mount Everest. Over the centuries this forbidding range has served as a
barrier to artic winds and invaders form the north.

Melting snows from the Himalayas and seasonal rains feed the
great river system of the subcontinent; the Indus (from which the word
“India” is derived), the Yamuna –Ganga and the Brahmputra Their basins
from the fifteen hundred mile ling indo genetic plain, which was the cradle
of India’s agriculture and civilization (3000-1500 b.c. ). In the past it was
covered with dense forests that are mow largely depleted, especially in the
western portion, the barren wasteland of Rajasthan great desert. Millets and
other coarse grains and a few vegetables are all that grow in this region’s
barren soil.
 The northern and eastern parts of the plain are India’s richest
agricultural region, thanks to the sedimentary soil deposited by the rivers as
well as large reserves of ground water.

The states of Punjab and Haryana called breadbasket of India,

produce wheat, barley rye and other grains while the eastern states of Bengal
and Assam produce tow, some – times three crops of rice each year.

India’s third geographical region, the Deccan or Peninsular

Plateau, is separated from the plains by the Vindhyas and other mountain
ranges. They have served as a natural barrier to communication between
northern and southern India and allowed the development of distinct cultures
languages and cuisines in the four southern states of Kerala, Karnataka,
Tamilnadu, and Andhra Pradesh.

Running down the west side of India are the ghats , a mountain
range hat empties its rivers in to the bay of Bengal . Their alluvial deltas
have been the center of many powerful south Indian kingdoms. The wind
that blows from the Arabian Sea during the monsoon is caught by these
mountains, giving the plateau a hot dry

Running down the west side of India are the ghats, a mountain range
that empties its river in to the bay of Bengal. Their alluvial deltas have been
the center of many powerful south Indian kingdoms. The wind that blows
from the Arabian sea during the monsoon is caught by these mountains,
giving the plateau a hot dry climate. Between the ghats and the Indian ocean
lies a narrow coastal plain, the Malabar coast, Which is one of India’s most
fertile regions, thanks to the abundant rainfall. This region now part of the
state of kerala , is the center of India’s spice Industry and was the first part of
India visited by Europeans at the end of the fifteenth century.

India’s climate and seasonal variations are dominated by the

monsoons, or tropical rain – bearing winds, that blow from the northeast in
winter and form the southwest in summer . Time timing of the monsoons
and the abundant amount of rain they bring have a major effect on
agriculture and food supply. Before modern methods of irrigation, the failure
of the monsoons could result in widespread famine.
Food Myths and Characteristics

All Indian food is just not curry

Many foreigners equate Indian food with curry . The word

probably came from a Tamil word Kari , meaning a soupy sauce served with
rice , which colonial Englishmen applied to any dish of vegetables, meat , or
fish in a spicy broth or gravy , Strictly speaking , curry denotes a meat stem ,
fried in onions and cooked in a thinnest gravy with potatoes , sometime
tomatoes , turmeric and other spices . At times a ready – made curry powder
is used. Curries are associated with the kind of food served at clubs, army
messes and other.

British institutions during the days of the Raj (British rule,

1857-1947) and even afterward. However, today some English speaking
Indians and cookbook writers use the word in a general sense to describe any
meat, vegetable. Or fish dish cooked in a gravy, another misconception is
that Indian food is very hot, which comes form equating spiciness with
hotness Hotness, a burning sensation in the mouth, is caused by black pepper
and chilles.

Spices (the roots, leaves seeds and other parts of certain plants)
add flavor, which is a combination of aroma and taste. They type and
quantity of spices used varies by dish, region, and individual and house hold
preferences: generally, south Indian food is hooter than that eaten elsewhere,
while north Indian meat and rice cuisine is the most aromatic . Some
families and individuals use very few spices. Still, spicing is nearly
universal; even the poorest eat a few green chilies with their simple roasted
bread.

Indian meals are centered around a cereal. In the rice –

producing regions in the south and east, rice is the staple grain, whereas in
the wheat producing north most people eat bread made from wheat flour.
Grains are usually accompanied by boiled pulses (beans, peas, and lentils)
call dal. These two ingredients provide the amino acids necessary for good
health in the absence of meal, equivalent of “meat and potatoes “in the
Anglo-Saxon world. Relatively small amounts of meat, fish and vegetables
are added to enhance the taste and qualities of the main grain. Condiments
complement the flavors and provide essential vitamins and minerals,
including fruit and vegetable chutneys; sweet, sour or pungent pickles;
yogurt and buttermilk.

Economic Wealth and Poverty

From ancient times, the Indian subcontinent was devastated by

periods of famine caused by natural and human – made causes. As recently
as 1943, 4 million people died of starvation in eastern India. In the 1950’s
India relied on food aid from abroad. Disunity of food supply became a
major item on the agenda of the new government of independent India.
Initial efforts focused on expanding the farming areas but these efforts did
not meet rising demand thus the government encouraged the application of
improved farming techniques, and the construction of dams and massive
irrigation projects. The Indian council for agricultural research developed
new strains of high yield value seeds for wheat. rice and other crops.

These changed, known as the green revolution, significantly

increased food production, making India one of the world’s largest
agricultural producers and an exporter of wheat and rice. Per capita wheat
consumption has nearly tripled since 1951 and is replacing other grains, such
as barely and millet. Indian’s consume an average 2500 calories a day and
nearly 60 grams of protein which is within recommended guidelines. . Some
92% of this calorie intake comes from vegetable products and only 8% from
animal products (including milk and dairy products), compared with 28% in
the United States. India’s per capita meat consumption of under 10 pounds a
year is only one fortieth that of the United Stated.

The percentage of the population living below the poverty line has
dropped from 51% in 1972 to 26 & in 2000. However these general stats
mask substantial differences among states and regions. The percentage of
very poor people is less than 10% in
Goa, Haryana , Jammu & Kashmir , Punjab , for example , but exceeds 40%
in Orissa and Bihar .For the landless peasants and laborers in these states , a
meal may be roasted chickpea flour or a couple flat wheat breads.
Accompanied with raw chilies and salt on the side, of course the rich and
powerful have always eaten well in India. The rich , meat based dishes
served in many Indian restaurants ( a cuisine many non Indians equate with
Indian foods ) is a version of the haute cuisine served at the courts of the
Mughal emperors and the local princess and aristocrats, and is no way
representative of the daily diet of the vast majority of Indian’s .

Today, India is rapidly changing. Better transportation has

greatly improved distribution and helped ease local and regional short falls.
Fruits, vegetables, and fish and other parts of India and abroad as well as
processed and frozen foods are sold in Indian cities and large towns. The
liberalization of the Indian economy and the creation of jobs in call centers
and data processing industries have generated a dramatic increase in wealth,
especially for young, educated, urban Indians .The number of people living
in house holds that earn at least $ 1800 annually4 has increased 17% in the
past three years to more than 700 million, or some 70% of the population ,
and graduated of elite colleges have an estimated $ 10.5 billion in surplus
cash.

For many reasons, India never has a restaurant culture, but this too is
changing. Fast food chains and restaurants serving western and Indian
cuisine are proliferation and Indians spend 55% more on eat in out in 2002
than the previous year. Middle class women are entering the work force in
greater numbers. A search in the publication of cooked books , women’s and
life style magazines and television cooking shows are also helping to spread
awareness of other Indian regional cuisines and perhaps will further the
development of a truly national cuisine.

Regional Food

Indian cuisine is popular all over the world for its variety,
mouthwatering tasted and aroma . It is as diverse as the country itself with
its numerous styles of cuisine and its typical regional variations.
In almost every country in the world you can find Indian restaurants
and hotels representing every kind of Indian cuisine. Some of the most
famous among them are the Mughalai, Chettinadu, Hyderabadi Cuisine etc.
 Indian Cooking is known for its use of spices , herbs and
flavorings . The common ingredients in Indian Cuisine are rice or
bread(rotis) , a variety of dals(lentils), regional vegetables , pickles , ghee ,
chutneys , a meat or fish dish. Spices are an essential element to Indian
cuisine . The cooking medium is generally oil. The type of oil used differs in
different regions . Sweets are usually milk based. Many popular sweets such
as Gulab jamun , Ladoo are common throughout India , while many others
like Rasbari , peda , burfi , halwa , Malpuwa, Rasgula etc are local favorites .
Food is often eaten with fingers , rice or breads are accompanied by
vegetables and curries.

The tastes and variety of the multiple cuisines from Kashmir in the
north to Kanya Kumari in the south , is absolutely mind blowing . Indian
cuisine can be divided into two , Northern and southern Indian cuisine.

South Indian Cuisine

Cuisines from Andhra Pradesh, Karnataka, Kerala, Goa and

Tamil Nadu are all part of South Indian Cuisine. Mostly vegetarian, Rice is
the basis of every meal in a South Indian Cuisine. Mostly vegetarian, Rice is
the basis of every meal in a south Indian Cuisine and the cooking medium
could be either gingerly, coconut or sunflower oil. Coconut is one of the
main ingredients in all South Indian food and spices are abundant in south
Indians cooking. Spices commonly used are mustard, Asafetidea , papper ,
curry leaves, peppercorns etc . Other fragrant spices added are cardamom,
clove cinnamon and star aniseed. Areas with access to waterways rely more
heavily on seafood. Saturated with ghee, rice is served with Sambhar ,Rasam
, Lentils, vegetables etc , South Indians are great lovers of filter coffee
especially the Madras coffee are popular in South Indian restaurants
throughout the world.

Made of fermented rice and dal batter , the dosa ,vada and the
idli as well as puttu made of rice flour are inexpensive south Indian snacks
which are popular south Indian dishes are Appam and stews , sea food dishes
(Kerala) , Mysore Pak , Basundhi, jangiri , the semolina based upma , Milk
or wheat based payasams / Kheers, Hyderbadi Biryani and the Goan
vindaloo curry etc.

North Indian Cuisine

North Indian Cooking is often called Mughal Style Cooking

Which is similar t the food of the Middle East and Central Asia . With its
rich uses of sauces, butter-based curries , dried fruits and nuts, ginger –
flavored roast meats and mind – blowing sweets , it is one of the world’s
popular cuisines. A typical North Indian meal consist of chappatis , roti ,
parantha , pooris and tandoori baked breads like nan etc. made of wheat .

Rice is also popular and is made into biryanis and pulaos .

Kashmiri pulao is one of the famous north Indian food. The cooking medium
is generally oil , cream , butter or ghee. Sunflower and canola are mostly
used vegetable oils used in north Indian cooking. Garam masala is a spice
mixture used mainly in northern Indian cuisine. Mutter paneer (a curry made
with cottage cheese and peas) , Bengal’s Rasagulla , sandesh Rasamalai ,
gulab jamuns ,Biryani , Pulaos , Daal Makhani , Dahi Gosht, Butter Chicken
, Kheer , Chicken Tikka , Kebabs , Fish Amritsati , Samosas ( snack with a
pastry case with different kinds of filings)’Chaat ( hot –sweet-sour snack
made with potato mchick peas and tangy chutneys) ,’makki ki roti’ and
‘sarson ka sag’, Motichoor laddoo are some of the delicious north Indian
foods.

Andhra Dishes : The delicious Andhra cuisine , which is a combination of

the south and Deccani , is reputedly the spiciest and hottest of all Indian
cuisine.
Bengali Dishes : Bengali’s are perhaps the greatest food lovers in the
Indian subcontinent. Rice and fish are their staple diet . Many of Bengal’s
famous dishes are fish based items.

Goan Dishes : Goan cuisine , a blend of different influences especially

portugueses , is famous for its seafood . Goan cooking generally includes
lots of spices.

Gujarati Dishes : Mostly vegetarian , Gujarati cuisine is delightfully

delicious with a combination of leafy vegetables and pulses subtly flavoured
with spices.

Hyderabadi Dishes : Hyderabadi suisine , which has been influenced by

various regional and religious cuisines , is rich and aromatic with a liberal
use of exotic spices.

Kashmiri Dishes : Kashmiri cuisine , comprising mostly of non –

vegetatian dishes , is characterized by three different styles co cooking –
Kashmiri Pandit Muslims and Rajput styles.

Karnataka Dishes: The cuisine of Karnataka is quite varied with each

region of the state having its own unique flavours . Atypical Karnataka or
Mysore meal is pure vegetarian.

Kerala Dishes: Cuisine of Kerala, gods own country is an exotic mixture of

nature’s very best. There are large variety of dishes which are peculiar to
kerala.

Punjabi Dishes : The Punjabis are known for their rich foods .
Predominantly wheat eatin people, the Punjabis cook rice only on special
occasions.

Rajasthani Dishes: Rajasthan , the desert land famous all over the world for
its architectural marvels-its romantic palaces and colorful people is also
equally popular for it unique , spicy and varied cuisine.
Tamil Nadu Dishes: Tamil Nadu , true home of Indian vegetarianism , is the
land of the delicious Pongal , Idli , Dosa , Sambar and Rasam . Tamilian’s
staple diet is steamed rice.

Cuisine of Kerala: God’s own country is an exotic mixture of nature’s very

best . There are large variety of dishes which are peculiar to kerala , be
itvegetarian of the spicier non-vegetarian , be it the rice flavoured
savoury”’appams ‘or these crunchy chips variey , be it the delicious seafood
delicacies or the leafy or root vegetables . Kerala has it all . ‘Sadya’ – typical
Kerala Hindu feast served on a banana leaf , is a sumptuous spread of rice
andmore than 14 vegetable dishes, topped with payasam or pradhamans, the
delicious sweet dessert . The Muslims and Christians excel in their ownj
particular non vegetarian dishes like the ‘pathri’,biriyani , chicken , fish
dishes etc . Rice is the staple food and the curries are eaten usually with
plain steamed rice . A typical breakfast can be Puttu , Vellayappam or
Idiappam made eith pounded rice flour . Almost every dish prepared in
kerala uses coconut – as oil or grated ground or with its milk strained
together with spices and tamarind to flavour them . Tender coconut water is
used as a refreshing nutritious drink.

Rajasthan: The desert land famous all over the world for its architectural
marvels- its romantic palaces and colorful people is also equally popular for
its unique, spicy and varied cuisine . For the royal Rajputs, one of the
leading communities of Rajasthan, a meal is never complete without meat.
They have mouthwatering dishes smothered in spices and chillies; almonds
and cashew nuts like the sollas (grilled meat) , Murgh mokul and the venison
Kababs;

But the Marwaris, another leading community of Rajasthan are

strictly vegetarians. They have equally tasty maybe more fiery specialties
with whatever ingredients available in the dry land .Minimum use of water
and a preference for milk, Chhaach (buttermilk) and clarified butter can still
be observed. they use dried and powdered lentils , beans from indigenous
plants like Gwarphali, kair , sangri and the flours of gehun ( wheat) , bajra
(millet) and makka (con) liberally to make soft rotis drowned in butter and
ghee , kheechra (porridge) and delicacies like ghatte ka subzi , Rajasthani
kadhi, and the more popular dal –baati-churma . Various chutneys are made
from locally available spices like turmeric, coriander, mint and garlic.

Besides the spicy ones, Rajashtan has a variety of sweet dishes

as well, with specialties from each part like Malpuas from Pushkar , Ladoos
from Jodhpur and Jaisalmer , Ghewar from Jaipur etc.

Breakfast Non Vegetarian

Puttu, Vellayappam, Idiappam, Men Peera Pattichathu , Meen
Kappa Puzhuku Tilappichathu , Dry Prawn
Chutney, Meen Mulakuchar ,
Prawn Mappas, Fish Molle,
Fish Patichathu, Karimeen
Pollichathu, Meat Ularthu
Vegetarian Snacks and Sweets
Mathanga Erissery , Kalan ,
Olan, Parippu Curry, Unniappam, Banana Chips,
Cabbbage Thoran, Pachadi, Sarkarapuratty , Kozhukatta.
Kichadi , Kootucurry , Manga
Curry , Kadala Curry, Kootu
Curry, Pulicherry

Bengali’s are perhaps the greatest food lovers in the Indian subcontinent.
Rice and Fish are their staple diet. Many of bengal’s famous dishes are fish
based items and they consider a meal in complete without fish. Bengalis
have a special seasoning called ‘Panchphoran’ which includes five spices
mustard aniseed, fenugreek seed, cumin seed and black cumin seed. The
garam masala is made up of cloves, cinnamon, cumin and coriander seeds
mace, nutmeg, and big and small cardamoms.

The principal medium of cooking is mustard oil . A typical Bengali

lunch or dinner will generally comprise of bhat (rice), dal (lentils),tarkari
( vegetables) and macher jhol (fish curry). No description of Bengali
sweets like rasogolla sandesh , mishti doi (sweet yogurt) etc.
 • Bhuni Khichuro (pulao • Hilsa (Fish) Biryani
with prawns) • Jeera Murg (Chicken
• Butter Fish Fillets with Cumin seeds)
• Dimer Devil • Labra( Mixed Vegetables
(EggCoated with Dish)
Minced Meat) • Macher Kochuri (Fish
• Dimer Dhokar Dalna stuffed Bengali Puri)
( Egg Cube Curry) • Rezala ( Meat Dish)
• Fish Hingli (Fish • Rosogolla (Sweet)
cooked with Raisins) • Tel Koi (Bengali Fish
• Ghoogni ( Chick Peas Curry)
With Mutton Bits )

Ayurvedic diet

Translated form Sanskrit as the “science of life”, Ayurveda is an

ancient holistic system of medicine coming from and widely practiced in
India. The science utilizes various therapies including diet , yoga , and herbs
, to maintain balanced health.

At the heart of Ayurveda lies the concept of the five elements-

Ether (space) air, fire water, and earth. Everything we see around us in
composed of these five basic elements which manifest in the human body as
three dynamic energies or doshas known as Vata, Pitta , and Kapha . These
three doshas control all the mental, emotional , and physical functions and
actions of the human body . They are also said to determine the state of the
soul.

Each person’s constitution or “Prakriti” (Sanskrit for “essential

nature” is a unique blend between the characteristics of the three doshas
leading to perfect health. In Ayurveda, diet is one of the most important
ways to maintain this balance.
An imbalance, “Vikriti” or deviation from nature, can be caused
by eating incompatible foods, mental or physical stress, negative emotions,
or poor sleeping habits, and will ultimately lead to disease, obesity , and /or
mental disorders.
 Each of us possesses a proportion of all three doshas , with only a
small percentage of people being purely Vata, Pitta , or kapha. Most
commonly, tow doshas combine to determine our dominant physiological
and personality traits.

In Ayurvedic nutrition there are six basic tastes:-

• Bitter- Rhubarb, Coffee

• Pungent- Peppers, Garlic, Ginger
• Astringent- Unripe Bananas , Pomegranates
• Salty – Salt, Kelp, Tamari
• Sour-Citrus Fruits, Yogurt, Vinegar
• Sweet- Rice , Milk ,Sugar

Each taste has a balancing ability and in order to minimize cravings

and balance the appetite and digestion, Ayurveda recommends including
each of the six tastes at every main meal. The North American diet generally
contains too muh sweet sour and salty, and not enough of the bitter , pungent
and astringent tastes . Ayureda also recognizes various food qualities or
types including heavy, light, oily , dry hot,. cold , with different qualities
balancing the different doshas.

Over the food tastes and qualities with attributes similar to a

dosha increase that dosha, while dissimilar tastes and qualities decrease that
dosha A balanced meal contains some foods of each taste and quality ,
varying he proportions based on your doshic tendencies , age , gender , body
and digestion strength , level of toxins in the body , season and place you
live.
 Vata Pitta Kapha
Tastes-Avoid Bitter, Pungent , Salty, Sour
Pungent, Salty , Sour Sweet
Astringent
Tastes – Salty , Sour , Bitter , Sweet
Bitter,
Choose Sweet , Astringent Pungent
Astringent
Qualities- Light , Dry Light, Dry , Heavy, Oily ,
Avoid ,Cool Hot Cool
Qualities- Heavy, Cool , Heavy Light, Dry
Choose Unctuous, ,Oily Warm
Warm

The healthiest diet consists of a wide variety of whole foods, eaten in as

natural a state as possible . Avoid frozen , canned , refined or processed
foods, especially those containing artificial colors, flavorings , additives , or
preservatives . Foods grown with chemical pesticides and fertilizers or
genetically altered are not recommended as such foods are lacking in
“prana” or vital life – energy , and tend to do more physiological harm than
good!

Another Ayurvedic classification of foods is by their effect on the non-

physical aspects of the physiology (i.e) mind , heart , senses and soul . These
fall into three categories:-
• Sattvic-uplifting , stabilizing foods – Almonds , Sweet Fruits , Rice
Leafy Greens , milk.
• Rajasic –stimulating and aggravating foods-Bananas, Corn, Potato,
Fish.
 • Tamasic –Lethargy inducing foods –Avocado , Brown Rice , Garlic,
Cheese , Beef.

Including Sattvic foods at mealtimes in beneficial to all doshas as

they promote mental clarity, emotional serenity , sensual balance , and the
balanced functioning of the body , mind , and soul . Herbs and spices are
also an essential part of a balanced Ayurvedic diet , due to their ability to
enhance digestion and assimilation , help in cleansing toxins from the body ,
and transfer the nutritive and healing qualities of other elements of the diet
directly to the cells of the body.

Ayurveda believes every meal must be a feast for your senses

and when presented with a variety of colors, flavors, textures and aromas,
your body, mind and soul are balanced and contented by the eating
experience you truly are what you eat.

Notes and References

1. The term Scheduled Tribes is used in the Indian Constitution to

designate communities who are mostly of non – Aryan origin and

economically deprived.
2. Quoted in William Dalrymple, Washing off the Saffron Financial

Times,22-23 march 2003.

3. Although the subject of this book is Indian cuisine and culture , there
is not a clear demarcation line between the food ways of India and
those of other countries on the subcontinent { including Pakistan ,
 Bngladesh, Nepal, and Sri Lanka. Punjabis in Pakistan follow a diet
similar to that of Punjabis on the Indian side of the border , while
Hindu Bengalis and Muslim Bangladeshis also share a common
culinary tradition , with a few differences due to religious prohibitions
and local availability of food stuffs.
4. N.P. Nawani, “Indian Experience on Household Food and

Nutrition Security”FAO-UN Regional Expert Consultatin , Bangkok,

Thailand August 8-11 1994
5. Michael Schumann, Hey , Big Spenders: India’s Booming Middle

Class ,” Time Online Edition,Global Business , 27 August 2003.

 Chapter-2
Hospitals in Jammu city

Hospital catering as a specialized service

HOSPITALS TELEPHONE NOS
1.S.M.G.S Hospital , Shalimar Road 547637/38
Emergency 549669
Blood Bank 547637/8
2. Govt. Hospital Gandhi Nagar 530041
3. Govt. Medical Hospital Bakshi Nagar 549621/549625
Emergency 547991
Ambulances 547990-1
Blood Bank/Eye Bank 547990-1

4. Chest Diseases Hospital, Bakshi Nagar 577604,548012

5. Children Hospital , Ambphalla Jammu 577023
6. Dental Hospital, Amphalla Jammu 544670
7. Acharya Shri Chander College of Medical 62251/62267
Sciences, Sidhra
8. IRC Society Ambulance 549413

24 Hr. Medicine Shops.

1. Jammu Coop , SMGS Hospital 549669

2. Afshan ECG Clinic ( Portable service available) 546924
3. Sigma Diagnostic Centre Gandhi Nagar , Jammu 436171
4. Internationals Bakshi Nagar 576823,579711

In addition to the Govt. Hospitals, there are a number of private nursing

homes in Jammu with well trained and experienced Doctors and
modern medical facilities.

OUR MISSION

The mission of BEE ENN General Hospital is "To provide

quality health care and services for the society, to promote
wellness, safely, and humanely, act creatively to continually
improve our services"

Bee Enn general Hospital, a joint project of BEE ENN CHARITABLE

TRUST, is a uperspecialty facility poised to deliver advanced tertiary care of
the people. The Hospital is at the forefront of medical technology and
expertise and provides a complete range of the latest diagnostic, medical and
surgical facilities for the care of its patients. The hospital is having all the
characteristics of a world-class hospital with wide range of services and
specialists, equipment, technology, ambience and service quality. Bee Enn
General Hospital is a showcase of synergy of medical technology. The
skilled nurses, technologists and administrators at Bee Enn General
Hospital, aided by (state-of-the-art equipment)provides a congenial
infrastructure for the medical professional in providing healthcare of
international standards

Services available in the Hospital

PAYING FOR TREATMENT

PATIENTS WITH HEALTH INSURANCE

If you are covered by one of the major health insurance schemes, then your
insurance may cover the cost of Bee Enn General Hospital. (Before
undergoing any kind of private treatment, you should always check with
your insurance company to ensure that you have adequate cover for the
treatment required. Hospital bills for inpatient and day care treatment can
generally be settled directly with your insurance company, but for outpatient
investigations and treatment, you will usually be required to pay the hospital
and seek reimbursement from your insurance company.

SELF-PAY PATIENTS
If you do not have health insurance, and are not being sponsored by your
company or embassy, you will of course have to pay for treatment yourself.
For some patients, our Fixed Price Treatment scheme may be appropriate.
This scheme ensures that you know in advance what your operation will cost
and can therefore budget accordingly.

IF YOUR COMPANY IS PAYING FOR YOUR TREATMENT

The Hospital has credit arrangements with some companies. In such cases
the patient must provide a letter of guarantee authorizing the tests or
treatment to be carried

RECEPTION DESK

The reception Desk is manned round the clock and will release only your
room and telephone number to callers. No other information about patients
is given out. Information about your diagnosis, treatment and any other
 items related to your care are considered confidential and are not released by
our.
ReceptionDesk staff.
If you do not wish to have visitors or telephone calls, please call a reception
desk.
Contact : Reception desk

RADIOLOGY
The radiology department at Bee Enn General Hospital offers a wide range of
diagnostic imaging services with the - state of the art equipment and a
professional team of radiologist and technologist. All radiological procedures
are performed and supervised by
Among the many radiological services are :

• Barium and contrast examination of the gastrointestinal,

genitourinary tract and
• All body ultrasound examination.
• Reporting of all plain Radiographs.
• Our dedicated medical and health professional team offers excellent
health care services to help improve health care and that too with
competitive charges.

OPERATION THEATRE
Fully Equipped with modern Medical Equipment

All major minor procedures in various specialities like

• Ophthalmology
• Gynaecology
• Urology
• Orthopedic
 LABORATORY

• Biochemistry tests
• Hematology tests
• Microbiology

General Surgery
These cases are done under general, regional or local Anesthesia.

PHARMACY
Under the supervision of clinical pharmacist, this pharmacy operates round
the clock and provides high quality pharmaceutical services
for all medical specialties

PHYSIOTHERAPY
this department treats all types of problems related to neurology,
neurosurgery, orthopedic and sports, pediatrics and chest diseases. Qualified
physiotherapists conduct treatment using ultrasound, short wave diathermy,
electrical stimulation, manipulation & mobilization and therapeutic exercises

ROUTE MAP
BEE ENN GENERAL HOSPITAL
IDEALLY LOCATED:-

This is centrally located in Jammu(J&K State)close to the Bus Stand and

Jammu Tawi Bridge and is near Jammu Railway Station. It is centrally
located with easy access to public transportations
 CHAPTER-3
Challenges in Hospital catering.

This review of hospital catering follows up the issues from ourbaseline

report which was published in November 2007.1 The baseline report
provided detailed findings and recommendations on nutrition, quality,
patient satisfaction, costs and the management of the catering service. This
follow-up study assesses the progress made in implementing those
recommendations and improving hospital catering services.

Nutritional care is key in helping the recovery of patients in hospital and

hospital catering has an important role to play in this.2 3 The quality of
hospital food is a very important part of ensuring that the patient’s
experience in hospital is positive. Regular mealtimes perform a significant
social role which can promote the general well-being of patients and assist in
their recovery.
Food safety and hygiene are essential and need to be
rigorously monitored to minimise the risk of infection and ensure high-
quality patient care.
About the study
The overall aim of this study was to assess progress against the
recommendations reported in the 2007 baseline report. In particular, the
study examined whether: processes are in place to provide quality nutritional
care to patients; patients are receiving a good quality catering service;
catering services have improved their control of costs and wastage; boards
have strategies
for catering services and are monitoring progress against these strategies.
Our baseline report investigated the key areas of the catering service in 2007
and made 31 recommendations for improvement. The key findings of that
report are summarised below:
• Nutritional care needed to be given a higher priority by all staff through
measures such as nutritional screening, using standardised recipes and
nutritional analysis of menus.
• Patient satisfaction with catering services was high but improvements were
needed in
the amount of choice available to patients and in the ways that patients’
views were gathered
and used.
• Food wastage at ward level needed to reduce. We recommended that
regular monitoring of wastage levels should be introduced with the aim of
reducing waste to a target level of ten per cent.
Key findings
• Catering services are offering an improved level of choice to patients,
including giving patients the opportunity to order meals less far in advance,
offering a range of portion sizes and ensuring that snacks are available to
patients outside normal mealtimes.
• Boards still need to do more to ensure the nutritional care of patients. All
patients are not yet screened for risk of undernutrition and many hospitals do
not have systems in place to ensure a nutritional balance in the meals
provided.
• Not all boards are carrying out quarterly patient satisfaction surveys.
However, many boards are developing improved ways to get patients’ views
on catering and use these to improve the services provided.
• Catering costs have risen by a third since the baseline. Catering staff costs
have risen due in part to the low pay agreement, whereas the costs of food
and beverages per patient day have remained stable.
• Non-patient catering services are still being subsidised but boards are
improving their management information systems to allow them to manage
this.
• Boards have reduced the amount of food wasted due to
unserved meals.
• Spending on catering services varied significantly and services to staff and
visitors were being
subsidised. We recommended that this could be better controlled by
introducing pricing policies, income generation targets and policies on the
level and cost of subsidisation.

In our study we reviewed progress made at board and hospital level by:
• surveying all NHS boards, two special boards and 149 hospitals that
provide catering to patients, staff or visitors
• interviewing catering and finance managers at a sample of boards to
follow-up on the
recommendations from the baseline study (Appendix 1)
The rest of this report is organised into three parts.
reports on progress in meeting the needs and preferences of patients.
Part 3 reviews how costs and wastage are being managed.
And Part 4 looks at what improvements have been made in the strategic
management
of catering services.
• reviewing supporting evidence supplied by boards and hospitals
• observing mealtime practice in a sample of ten wards to understand the
context in which
catering is delivered
• using existing documents and findings from other sources

Throughout the report we provide data for the 1 hospitals that provide
catering services. Where we have reviewed progress at the sample hospitals
included in the baseline study, we make this clear in the text of the report.
Where it was possible to compare progress we have given the results for
2007and 2006. However, it was not possible to directly report on progress at
trust level since between 2003 and 2007 hospitals at jammu

7 Food, Fluid and Nutritional Care in Hospitals – Clinical Standards, NHS

QIS, September 2003.
8 Food, Fluid and Nutritional Care in Hospitals – National Overview, NHS
QIS, August 2006.
9 Health Facilities Scotland is a division of National Services Scotland
providing operational guidance to NHSScotland healthcare bodies on non-
clinical topics.
10 Our survey was undertaken between June and August 2007. NHS Argyll
and Clyde was dissolved in April 2007 but is included in the analysis of
information received prior to that date.
11 The baseline report reviewed a sample of 41 hospitals. The follow-up
report reviewed 33 of these to monitor progress.

Key findings
• Patients are not routinely screened for risk of undernutrition on admission
to hospital.
• Not all boards have fully developed systems for ensuring the nutritional
balance of patient meals.
• Acute hospitals with long-stay beds operate at least a threeweek menu
cycle to maintain
variety in the meal options for these patients.
• Ninety-seven per cent of hospitals offer at least two m eal choices at both
lunch and dinner.
• Catering services are using flexible approaches which fallow patients to
order their food nearer to mealtimes and ensure snacks are available outside
mealtimes.

Patients are not routinely screened for risk of undernutrition on

admission to hospital
2007 Recommendation: Boards should ensure that patients are screened on
admission for risk of
undernutrition. 2003 Recommendation: Boards should use a validated
screening tool and ensure that staff have been trained in the use of this tool.
In this section of the report we use findings from the recent NHS QIS
review of food, fluid and
nutritional care in hospitals.12 NHS QIS reviewed this area of patient care
under standard two of its clinical standards for food, fluid and nutritional
care in hospitals.
Although NHS QIS found evidence of progress in screening
patients for risk of undernutrition on admission to hospital, it concluded that
no boards were complying with the standard of recording all of the required
nutritional information within one day of admission for all of their patients.
NHS QIS also reported that boards have not yet fully developed processes
for nutritionally assessing, screening and care planning for patients. Once
developed, these processes need to be fully implemented across all hospitals.
This is an essential step in ensuring appropriate nutritional care for patie nts
and NHS QIS has recommended that this is a priority for all boards.
The NHS QIS review also found that most boards were not yet
using validated screening tools in all ward areas. Only five boards had
started to develop a nutrition awareness,
education and training programme which would cover training in the use of
validated screening tools.1

Not all boards have fully developed systems for ensuring the nutritional
balance of patient meals
Boards should ensure that catering specifications comply with the model
nutritional guidelines for
catering specifications in the public sector in india 2007 Recommendation:
The Departmental Implementation Group should develop or commission
national catering and nutrition pecifications for the NHS in india 2007
Recommendation: All menus should be nutritionally analysed. 2003
Recommendation: All catering production units should use standard recipes.

The hospitals has not yet produced a national catering and nutrition
specification for thehospitals in jammubut plans to do so in 2007
The Health Department (HD) set up a Departmental Implementation Group
in 2001 to give advice to the NHS on providing nutritional care in hospitals.
This group did not produce a national catering and nutrition specification
for the NHS in J&K which we recommended in our baseline report.14 In
April 2006, the HD appointed a national Food and Nutrition Adviser from
within the NHS whose role is to produce a national catering and nutrition
specification. This is due to be published in April 2007.

Half of boards have catering specifications

In the absence of an agreed national specification, boards should still be
working to the hospitals Diet Action Plan’s recommendation that catering
specifications should comply with the model nutritional guidelines for
catering specifications in the public sector India.15 However, only eight
boards have developed catering specifications which comply with the model
nutritional guidelines.16
Three-quarters of hospitals use some standard recipes to provide
nutritionally balanced meals
Standard recipes ensure that the same ingredients and cooking methods are
used each time a menu item is prepared. These should include details of the
ingredients to be used, the quantities needed, the method for making the
meal and the number of portions of a set size that will be produced.
This helps control the costs of ingredients purchased and limits the waste
produced in the kitchen. It is also the only way to ensure that the nutritional
content of each menu item does not vary from day to day. Standard recipes
are therefore necessary to ensure that nutritionally analysed menus deliver
balanced nutritional meals to patients. Three-quarters of hospitals are using
standard recipes to control the nutritional balance of meals. However, only
58 per cent reported that they used standard recipes for all meals on the
menu.
Only seven boards have undertaken a full nutritional analysis of their
standard menus
Nutritional analysis of menus helps to ensure that patients are provided with
nutritionally balanced meals. Half of boards have undertaken an analysis of
the nutritional content of each item on the standard menu and seven boards
have analysed their entire standard menu to ensure it is nutritionally
balanced.17 Nutritional analysis of menus is less likely to have taken place
for special diets
Catering departments and dieticians need to work together to
ensure that any changes to menus or recipes are accompanied by an updated
nutritional analysis. Boards reported a wide degree of variation in the
frequency and accuracy of the nutritional analysis in place. Case study 1
gives an example of the work involved in creating and maintaining
nutritionally analysed menus.
Progress is being made but patients’ nutritional care is not yet
consistently prioritised at
ward level
Recommendation: Boards should encourage communication between ward
staff and the
catering department.

References
ing and nutrition specification details the service’s approach to issues such
as nutritional needs, food safety, procurement and menu choice.
15 Eating for health – A diet action plan for Scotland, Scottish Office, 1996.
16 NHS Ayrshire and Arran, NHS Dumfries and Galloway, NHS Grampian,
NHS Highland, NHS Lanarkshire, NHS Orkney, NHS Shetland and NHS
Western
Isles have catering specifications which comply with model nutritional
guidelines for the public sector.
17 NHS Ayrshire and Arran, NHS Borders, NHS Forth Valley, NHS
Grampian, NHS Highland, NHS Lanarkshire, NHS Orkney and the Golden
Jubilee National
Hospital have undertaken an analysis of each item on their standard menus.
These same boards – with the exception of NHS Forth Valley – have also
analysed their entire standard menu to ensure it is nutritionally balanced.
18 NHS Highland and NHS Lanarkshire reported that they have fully
nutritionally analysed all of their special diet menus.

Standards on food,
Standards on food, fuid and nutritional care in hospitals. This involved
addressing food preparation and producing a core list of dishes for the menu
cycles; developing nutritionally analysed dishes from a recipe list with a list
of measured ingredients and an explicit method; and seeking the views of
staff and patients about the new recipes. A project dietician and a project
catering adviser were employed part-time for two years to produce over 600
recipes that were each nutritionally analysed. The recipes were incorporated
into individual recipe files for each kitchen in jammu Caterers were then
asked to use the recipes and feed back their comments to the project team
over a threemonth period. Patients were also asked to give their views on the
meals produced by these recipes by responding to questionnaires. The
caterers had difficulties in manually calculating ingredients, resulting in
further consultation and testing. The new recipes are due to be implemented
by the end of 2007 Using a dedicated resource to develop the standard
recipes was a significant step towards ensuring the use of fully nutritionally
analysed menus. However, a number of challenges have been identified: •
Standard recipes involve additional work for chefs to manually calculate
ingredients. • Some areas still prefer established recipes rather than the
standard versions which have been tested. However, local variations can be
incorporated into the recipe file if they are of acceptable nutritional value. •
Each time a change is made to the ingredients or method of a recipe this
requires an updated nutritional analysis
to be carried out. • The nutritional analysis of dishes and menus can only be
relied upon if standard recipes are followed by caterers.

Communication between ward staff and catering staff has improved

The report noted the importance of good communication between ward staff
and catering
staff as an essential part of providing a quality patient meal service. Our
study found that 13 boards have a written protocol for communication
between wards and catering departments.20 Case study 2 gives an example
of how catering departments can proactively pass on information to ward
staff.
Practices which help patients to eat a nutritious diet while in hospital
need to be more widely adopted across all hospitals
25. In 2006 the Hospital Caterers Association developed a protected
mealtimes policy which recognises the importance of mealtimes and the
need to ensure ward staff are able to focus on patients’ nutritional care at
mealtimes.21 The policy recognises the different healthcare environments
and needs at different hospitals but outlines seven objectives for wards
adopting the policy:
• To provide mealtimes free from avoidable and unnecessary interruption
• To create a quiet and relaxed atmosphere in which patients have time to
enjoy meals, limiting unwanted traffic through the ward during mealtimes,
eg, estates work and linen deliveries
• to recognise and support the social aspects of eating
• to provide an environment conducive to eating, that is welcoming, clean
and tidy
• to limit ward-based activities, both clinical (eg, drug rounds) and non-
clinical (eg, cleaning
tasks) to those that are relevant to mealtimes or ‘essential’ to undertake at
that time
• to focus ward activities on the service of food, providing patients with
support at mealtimes
• to emphasise to all staff, patients and visitors the importance of mealtimes
as part of care and
treatment for patients.
Less than a quarter of hospitals reported that they are operating protected
mealtimes policies. Our ward observations indicated that there is variation in
the extent to which they have been implemented at ward level.
Difficulty in prioritising the nutritional care of patients was highlighted in a
recent survey commissioned by Age Concern.22 This found that nine out of
ten nurses reported that they do not always have time to help patients who
need assistance with eating. These findings are consistent with our own ward
observations and underline the need to ensure that ward managers the
nutritional needs of patients.

Systems in place to offer patients choice and tocater for patients with
special dietary needs
Acute hospitals with long-stay beds should ensure that they have a three-
week menu cycle, at least for these patients. Menus should be reviewed to
ensure that they offer sufficient choice to all patient groups. Where it is
necessary, separate menus should be developed for ethnic meals and other
special diets. All menus should be dietary coded to help patients make an
informed choice.

Acute hospitals with long-stay beds operate at least a three-week menu

cycle to maintain variety in the meal options for these patients
Resource and Audit Group (CRAG) into the nutrition of elderly people in
long-term care recommended that elderly patients in long-stay wards should
have at least a threeweek menu cycle to avoid patients getting bored of the
same menu choices on too regular a basis.23 A report by Age Concern notes
that this recommendation should be balanced by the observation that many
people enjoy a simple diet at home and may not want to try new meals
during their time in hospital.24 As a result, hospitals should provide a long
menu cycle to avoid patients facing the same choices too often but also need
to be flexible to provide favourite meals in line with patient preferences.

Ninety-seven per cent of hospitals offer at least two meal choices at both
lunch and dinner
Choice is an important factor in encouraging patients to maintain a balanced
nutritional diet while in hospital. Ninety-seven per cent of meal choices at
both lunch and dinner for patients ordering from the standard menu.
Systems in place to cater for patients with special dietary needs and
preferences
they are catering for an increasing number of patients with special diets.
Therefore the meals available should provide sufficient choice to meet these
dietary needs and preferences. Nine out of ten hospitals provide menu
options for vegetarian patients. Half of hospitals offer cultural or religious
belief meals from the menu and a third offer a menu option for vegan
patients.
Although many hospitals do not offer these meals from the
daily menus, there was evidence that all hospitals in place to offer choice to
patients with special dietary needs and preferences. A flexible approach has
been adopted by hospitals across Scotland to reflect the different
demography of the populations served. Many hospitals have developed their
systems to reflect their patient populations and do not put menu items for all
special diets on the menu every day as this would have implications on cost
and waste. However, they have arrangements in place to ensure that they are
able to provide for special diets where these are identified at ward level.
Hospitals code their menus to help patients with special dietary needs
select meals
In order to help patients make an informed choice about their meals, menus
can be coded to make it clear whether they are suitable for vegetarians,
patients on therapeutic diets, patients with
allergies, or patients with eating or swallowing difficulties. Three-quarters of
hospitals are coding their menus with this information.
Catering services are offering an improved level of choice to patients
2003 Recommendation: Boards should remind all their staff of the
procedures for offering, ordering and delivering meals and in particular
meals for patients who require a special diet.
2003 Recommendation: All catering services should aim to have patients
ordering their meals
as close to the meal time as possible and no more than two meals in advance.
Staff is aware of processes for providing meals to patients
Staffs that are in contact with patients’ food are aware of: the local protocol
or processes for
Ordering and delivering food and drinks; meal and snack times; and
procedures for ordering missed meals. This is achieved through local
induction programmes and ward orientation as well as the use of posters,
information leaflets and guides which remind staff of this information.

23 The nutrition of elderly people and nutritional aspects of their care in

long-term care settings, Clinical Resource and Audit Group (CRAG),
August 2000.

Almost all hospitals offer patients a range of portion sizes

Giving patients the opportunity to pick the amount of food they want
increases the choice available and allows them to reflect their normal eating
preferences. When at home, some patients would normally have only a light
lunch and then have their main meal at dinner time or vice versa. Hospital
catering should be flexible to try to match individual eating patterns.Our
survey found that all hospitals (with the exception of New Craigs Hospital)
offer a range of portion sizes for menu items. This gives each patient the
opportunity to choose an amount of food to match his or her appetite. The
range of portion sizes available to patients should be quantified in all
standard recipes and nutritional analysis of menu items (discussed in
paragraphs 18-23) to ensure that these analyses provide an accurate
assessment of nutritional intake.
Percentage of hospitals ordering meals in advance of the
mealtime If portion sizes are selected and ordered in advance then catering
departments can produce the correct amount of food, but patients’ appetites
may change between ordering the food and the mealtime. This can result in
more food being left uneaten by patients (plate wastage). However, if
portion size is selected at the mealtime then catering departments will not
know how many patients want large portions and will have to estimate how
much food will be needed. This can result in surplus food being sent to
wards to ensure that all patients are given a choice (wastage in unserved
meals). Therefore, giving choice to patients over the size of the portion they
want can also affect the level of wastage.
Snacks are available to patients outside normal mealtimes
Due to clinical activity taking place throughout the day, some patients will
miss mealtimes. Similarly, medication may affect patients’ appetite or
clinical symptoms may mean that patients are not able to eat at regular
mealtimes. It is therefore important that hospitals respond to these needs and
are flexible about providing snacks outwith normal mealtimes .In 95 per cent
of hospitals, wards are able to provide snacks for patients either to
supplement mealtimes or to compensate where meals have been missed. We
also found that 85 per cent of hospitals were able to offer patients snacks
prepared in the catering department outwith normal mealtimes.

Some processes in place to seek patients’ views on catering services

Should ensure that they obtain patients’ views on the catering service
through the introduction of regular (at least quarterly) patient satisfaction
surveys.

A standard survey has been developed by the Health Facilities Catering

Group
In January 2008, the Health Facilities Catering Group agreed the format of a
patient satisfaction questionnaire. This aimed to standardise the questions
asked in each board and allow better comparison of information on patient
satisfaction. All boards have made a commitment to carry out the survey
annually and share the results.
Regularly monitoring patient satisfaction with hospital catering through
patient surveys
The progress made in developing a standard survey for all boards is not yet
reflected in a coordinated approach at hospital level. Almost a fifth of
hospitals are not using patient satisfaction surveys at all. In the hospitals that
are using patient surveys, the frequency of gaining Patient feedback varies
widely regular monitoring of patient satisfaction is essential if patients’
views are to be used to improve service delivery. But only 30 per cent of
hospitals are meeting our baseline recommendation that patient satisfacation
surveys should take place at least once every three months.
However, we did find areas of good practice where boards are developing
comprehensive systems for gaining patient feedback and using this to
meetings and then discussing these directly with catering staff. The minutes
of these meetings record where actions are agreed to improve services as a
result of the issues raised.

Recommendations
• Nutritional screening of all patients on admission to hospital should be a
priority for all boards.
• should put protected mealtimes policies in place to ensure that mealtimes
are free from non-essential clinical activity and that there are enough staff on
wards to help all patients eat a nutritious diet while in hospital.
• should ensure that the catering and nutrition specification is published as
planned.
• All boards should ensure that standard recipes are used for all meals. These
should detail ingredients, quantities, cooking method and the expected
number of portions. The hospital should consider developing a national
database of standard recipes for the hospitals to promote this.
• Catering departments and dieticians should work together to ensure that all
menus are fully nutritionally analysed and updated whenever any changes
are made to recipes or menus.
• All boards should regularly monitor patient feedback and use this as part of
quality mprovement. This can be achieved through methods such as patient
satisfaction surveys, monitoring plate wastage and reviewing feedback from
carers. improve the quality of services both in kitchens and on wards.
A variety of other patient feedback systems are in place at local level. Four-
fifths of hospitals are using other systems such as patient forums or
individual interviews in place of a patient survey or to supplement their
findings do not have any systems in place to gather or act on patients’ views
on hospital catering.27
Another indicator of patient satisfaction is the amount
of food returned uneaten on patients’ plates. This measure can be influenced
by a number of factors, such as loss of appetite caused by medication or
symptoms of illness, but could be linked with other patient feedback systems
to provide a more complete picture of the level of satisfaction with the food
provided.
Some hospitals are exploring innovative ways of encouraging all patient
groups to be able to give their views on hospital food
Some boards have undertaken innovative work to ensure that the methods
used to record patients’ views are appropriate to the client group. For
example, patients with learning difficulties may find it difficult to complete a
questionnaire but trained staff can discuss satisfaction levels with patients in
an informal way in order to get their views on catering.
We also found examples of patients in long-stay hospitals being encouraged
to join catering groups, where patients meet with catering staff on a regular
basis to raise and discuss issues with the service Patients are encouraged to
raise issues by putting concerns on the agenda for these

Key findings
• Catering costs have risen by a third since the baseline. Catering staff costs
have risen due in part to the low pay agreement, whereas the costs of food
and beverages per patient day have remained stable.
• Hospital catering costs have risen more slowly than other operating costs.
There remains
wide variation in the amount spent on catering services across boards.
• Catering services for NHS staff and visitors are not breaking even.
• Boards have reduced the number of unserved meals that are wasted.

Hospital catering costs have risen more slowly than other operating
costs
Hospital Boards should ensure that they have appropriate financial
information on the catering service to allow informed decision-making.
Boards should base their catering budgets on the most recent, relevant and
accurate information available.

Spending on catering has risen by a third since our baseline report

In 2004/05 Spending on catering services has risen by 33 per cent since the
baseline report.
Exhibit 4 (overleaf) shows that most of this increase took place between
2002/03 and 2003/04 and is due in part to the low pay agreement introduced
at that time. Catering costs have risen more slowly than other operating
costs. Between 2003/04 and 2004/05, spending on catering rose by 1.8 per
cent (this was less than the rate of inflation).30 Over the same period the
total operating costs for the hospital sector rose by 11.1 per cent.31
There remains wide variation in the amount spent on catering services

Reference:
28 Scottish Health Services Costs, year ended 31 March 2005, ISD.
29 NHSScotland – Low Pay Agreement, SEHD HDL (2003) 15.
30 Hospital & Community Health Services pay and price index, Department
of Health, 2006.
31 Scottish Health Services Costs, years ending 31 March 2004 and 31
March 2005, ISD.
There has been little change in the cost of food and beverages per
patient day
The cost of patients’ food and beverages per patient day in the sample of
hospitals we reviewed
has remained the same. (overleaf) shows the cost of patients’ food and
beverages per patient day in 2005/06 for 21 of the sample hospitals
reviewed. Although these costs vary among hospitals, the average level for
the sample hospitals where we can compare across both years rose from.36
This rise is lower than the rate of inflation over the same period.37 Boards
reported that the continued use of national contracts to purchase food and
beverages played a key role in managing the increase in these costs.

All catering departments should have systems in place which allow them to
accurately calculate the costs of providing patient and nonpatient catering. :
Boards should set pricing policies and income generation targets that aim to
at least break even on nonpatient catering activities or have a clear stated
policy on the level and cost of subsidisation.
The extent to which boards are subsidising non-patient catering is becoming
more transparent
Most hospitals provide catering for staff and visitors .

Catering staff costs have risen more quickly than the costs of food and
beverages
In the small sample of hospitals we reviewed, staffing accounts for the
largest part of catering costs. Since our baseline report, their catering staff
costs have risen by 44 per cent, due mainly to the introduction of the low
pay agreement. Over the same period, spending on food and beverages
increased by seven per cent.
The number of staff employed in catering departments has
remained relatively constant at The guidance requires boards to produce
trading accounts in 2006/07 for each catering department showing if non-
patient catering is:
• breaking even against the budget
• budgeting for anticipated wage
increases
• contributing to overhead costs such as training, travel, hardware and
crockery
• being subsidised, and if so to provide clear justification for subsidisation.
We found that half of boards are operating trading accounts for all their
catering departments.39
Hospitals reported that they could split the costs of patient and non-patient
catering services.
Of these, hospitals reported that they were subsidising non-patient meals and
hospitals reported
that they were not subsidising nonpatient meals. Fourteen hospitals reported
that they did not know if they were subsidising non-patient catering services
and three hospitals used private contractors who would not provide this
information.
Subsidising nonpatient services
Only boards have clearly defined pricing policies and income generation
targets which aim to at least break even shows the level of contribution or
subsidy achieved for the sample of hospitals
who returned this information.
Boards reported that price increases will be necessary to reduce these
subsidy levels. However, they also reported that where prices had been
increased too quickly this had resulted in opposition from Partnership
Forums or a reduction in the number of staff using hospital catering
facilities.
Boards have reduced wastage due to unserved meals All hospitals should
aim to reduce the
level of ward wastage (unserved meals) to ten per cent.
Two-thirds of hospitals are monitoring wastage against targets
Food waste has an effect on the cost of catering services and unnecessary
waste should therefore be kept to a minimum. Since the baseline report,
boards have been required to have waste management procedures to monitor
and reduce waste.42 However; wastage is also linked to the amount of
choice available to patients. It can be affected by the number of options on
the menu as well as how far in advance meals are ordered. For example,
allowing patients to choose their meal at the mealtime rather than 24 hours
in advance should mean that the meal will better reflect their preference at
that time. But in order to provide that level of choice, extra meals have to be
produced to give all patients choice. Wastage levels need to be managed to
balance the cost implications with the quality of the service offered.
Wastage can occur in production (kitchen wastage), in the wards (unserved
meals), or in uneaten
food left by patients (plate wastage). Monitoring wastage levels at these
three stages provides hospitals with useful information to help control costs
and understand patients’ preferences. Twelve boards have set wastage targets
ranging from zero per cent to 12 per cent and twothirds
of hospitals are monitoring wastage against these targets.
There has been a significant reduction in wastage due to unserved meals
Seventy-five per cent of the hospitals in this sample have reduced their
wastage levels and 21 of the 24 have achieved the recommended target
wastage level of ten per cent.
Recommendations
• Boards should set pricing policies and income generation targets that aim
to at least break even on non-patient catering activities or have a clear stated
policy on the level and cost of subsidisation.
• All boards should continue to monitor and control wastage. All hospitals
should reduce or maintain ward wastage at below ten per cent.
: Guidance on charging for non-patient catering and the production of
catering trading accounts, SEHD HDL (2005) 31.

Catering services are becoming more of a strategic priority at board

level
Boards should ensure that a clear strategy has been approved for the future
provision of catering services where other services are being reconfigured:
All boards should have a food and health policy in line with the Diet Action
Plan for jammu hospitals

Boards have a clear written strategy for the future provision of catering
There has been an increase in the number of boards with a catering strategy
since the baseline report.Boards now have a catering strategy, although only
seven are monitoring progress against their strategies.45 Five boards have
still to develop a food and health policy in line with the Diet Action Plan for
Jammu Hospitals
Key findings
• Catering services are becoming a higher strategic priority for boards.
• Catering staff vacancy rates remain high.
• Agenda for Change has not resulted in standard job descriptions or pay
grades for catering staff in different boards.
. Boards have developed work on catering strategies alongside, or as part of,
nutritional care strategies. found that three-quarters of boards had started the
process of developing and implementing a nutritional care policy and
strategic plan. While progress has been slow, all boards now have nutritional
care groups in place which are central to the further development and
implementation of catering and nutritional care at a strategic level.49
Catering staff vacancy rates and sickness absence rates remain high
Boards should monitor staff vacancy and turnover rates on a regular basis.
Staff vacancy and turnover rates are high in some areas. Where this is the
case, boards should take action to address these issues.
Staff vacancy rates have reduced but remain high
All boards formally monitoring sickness absence and staff vacancy rates for
catering staff. Catering staff vacancy rates across the sample hospitals are on
average two per cent lower than
in 2001/02 but remain high at 7.8 per cent. Exhibit 10 (overleaf) shows that
there are large differences in vacancy levels among the sample hospitals.
Some boards reported that vacancies were being held open to allow for
future flexibility in staff changes without the need for redundancies. Boards
also reported that high turnover rates were closely linked to unsociable hours
worked on backshift and to the repetitive nature of some of the jobs
involved.
Catering staff sickness absence rates are still high
The average level of sickness absence in the sample of hospitals we
reviewed has remained at the same level as it was three years ago (7.2 per
cent). shows there have been large changes in sickness absence levels in
some of these hospitals but this may be due to the small number of staff
employed in some catering departments. Where sickness levels are high,
boards reported that long-term sickness absence was a contributing factor.
Some boards have introduced more robust sickness absence policies
accompanied by return-to-work interviews to manage sickness absence rates.
A Facilities Management System which aims to provide managers with
regular monitoring reports on catering services is being piloted in, U.s.A
In 2005, NHS Tayside received £220,000 from the SEHD to develop
System (FMS) for the NHS in Scotlan d. The first phase of the system,
covering financial and operational key performance
indicators (KPIs), is due to be rolled out in NHS Tayside in November 2006.
The FMS provides access to management information on the intranet, via
NHSnet, allowing service managers, board directors and the SEHD to access
and analyse information at an appropriate level. Monthly monitoring of the
KPIs such as financial reports, sickness absence, overtime, headcount, staff
turnover and vacancy can be compared against previous years and
benchmarked against other hospitals. The benchmarking tool is dependent
on the successful roll-out of the FMS across Scotland.
The FMS is a potential tool for managers to use to systematically analyse
many of the key indicators reported in this review. The system has the
potential to assist in the regular monitoring of performance to improve
decision-making at an operational and strategic level. However, it will be
dependent on the quality of the data recorded in other computer systems
such as the Scottish Workforce Information Standard System (SWISS) and
PECOS.50
Implementation of Agenda for Change varies among boards
Catering staff are being given new terms and conditions under the Agenda
for Change review. The new terms and conditions cover standard hours,
overtime payments, annual leave and basic pay. It also introduces the NHS
Knowledge and Skills Framework which links education and development
with career and pay progression.
State Hospital have not yet changed the
terms and conditions of catering staff in line with Agenda for Change. Other
boards have changed terms and conditions for catering staff but have not
yet evaluated the job descriptions for management, or clerical and
administrative staff involved in catering.
A benchmarking exercise carried out by the Health Facilities Catering Group
confirmed the results of our interviews which found that Agenda for Change
has not resulted in standard job descriptions or pay grades for catering staff
across different board areas. For example, head cooks’ pay bands vary
among boards.
Boards have developed work on catering strategies alongside, or as part of,
nutritional care strategies. NHS found that three-quarters of boards had
started the process of developing and implementing a nutritional care policy
and strategic plan. While progress has been slow,
all boards now have nutritional care groups in place which are central to the
further development and implementation of catering and nutritional care at a
strategic level

Catering staff vacancy rates and sickness absence rates remain high
Boards should monitor staff vacancy and turnover rates on a regular basis.
2007 Recommendation: Staff vacancy and turnover rates are high in some
areas. Where this is the case, boards should take action to address these
issues.
Staff vacancy rates have reduced but remain high
All boards are formally monitoring sickness absence and staff vacancy rates
for catering staff. Catering staff vacancy rates across the sample hospitals are
on average two per cent lower than
Shows that there are large differences in vacancy levels among the sample
hospitals. Some boards reported that vacancies were being held open to
allow for future flexibility in staff changes without the need for
redundancies. Boards also reported linked to unsociable hours worked on
backshift and to the repetitive nature of some of the jobs involved.

Catering staff sickness absence rates are still high

The average level of sickness absence in the sample of hospitals we
reviewed has remained at the same level as it was three years ago shows
there have been large changes in sickness absence levels in some of these
hospitals but this may be due to the small number of staff employed in some
catering departments. Where sickness levels are high, boards reported that
long-term sickness absence was a contributing factor. Some boards have
introduced more robust sickness absence policies accompanied by return-to-
work interviews to manage sickness absence rates.
Health and safety and food hygiene
Boards are continuing to meet their statutory requirements in health
and safety and food
Hygiene training
All boards provide staff that is in contact with patients’ food with training in
health and safety issues, and food hygiene commensurate with their duties.
However, they also reported that difficulties in releasing staff from their
duties could reduce the attendance rates on these courses. Overall, boards
were meeting their statutory requirements in health and safety and food
hygiene training
Boards have food safety manuals and infection control policies which
include catering services
Our survey found that catering services were included in the food safety
manuals and infection control policies of most boards reported that they do
not have a food safety manual in place the only two boards that do not have
an infection control policy that covers catering services

Boards work with Environmental Health Officers through a rogramme

of regular visits to ensure food safety and hygiene standards are being
met
Our survey showed that most hospitals are inspected annually by
Environmental Health Officers, but where concerns have arisen, the
frequency of visits rose in order to ensure that the hospital was taking action
to resolve problems. Being rolled out across j&k
Concerns include:
• the slow speed at which the system operated
• problems in using the system which initially could not deal with decimal
points
• incomplete and out-of-date lists of suppliers on the system.
Catering departments and dieticians should work together to ensure that all
menus are fully nutritionally analysed and updated whenever any changes
are made to recipes or menus. All boards should regularly monitor patient
feedback and use this as part of quality improvement. This can be achieved
through methods such as patient satisfaction surveys, monitoring plate
wastage and reviewing feedback from carers.

Financial management
Boards should set pricing policies and income generation targets that aim to
at least break even on nonpatient catering activities or have a clear stated
policy on the level and cost of subsidisation. All boards should continue to
monitor and control wastage. All hospitals should reduce or maintain ward
wastage at below ten per cent.

Strategic management
Boards should ensure that they have approved a clear strategy for the future
provision of catering
services. All boards should have a food and health policy in line with the
Diet Action Plan for Scotland.
Boards should take action to address issues where catering staff vacancy
rates are high.
Meeting patients’ needs and preferences
Nutritional screening of all patients on admission to hospital should be a
priority for all boards. Boards should put protected mealtimes policies in
place to ensure that mealtimes are free from nonessential clinical activity
and that there are enough staff on wards to help all patients eat a nutritious
diet while in hospital. should ensure that the catering and nutrition
specification is published in 2007 as planned.
All boards should ensure that standard recipes are used for all meals. These
should detail ingredients, quantities, cooking method and the expected
number of portions. should consider developing a national database of
standard recipes for the NHS in Scotland to promote this.
26
Part 5. Summary of recommendations

CHAPTER-4
PATIENT SATISFACTION IS: “ EXCELLENCE IN HOSPITAL

Team work and team building essentials

Team building skills are critical for your effectiveness as a manager or

entrepreneur. And even if you are not in a management or leadership role
yet, better understanding of team work can make you a more effective
employee and give you an extra edge in your corporate office.

A team building success is when your team can accomplish something much
bigger and work more effectively than a group of the same individuals
working on their own. You have a strong synergy of individual
contributions. But there are two critical factors in building a high
performance team.

The first factor in team effectiveness is the diversity of skills and

personalities. When people use their strengths in full, but can compensate for
each other's weaknesses. When different personality types balance and
complement each other.

The other critical element of team work success is that all the team efforts
are directed towards the same clear goals, the team goals. This relies heavily
on good communication in the team and the harmony in member
relationships.
In real life, team work success rarely happens by itself, without focused
team building efforts and activities. There is simply too much space for
problems. For example, different personalities, instead of complementing
and balancing each other, may build up conflicts. Or even worse, some
people with similar personalities may start fighting for authority and
dominance in certain areas of expertise. Even if the team goals are clear and
accepted by everyone, there may be no team commitment to the group goals
or no consensus on the means of achieving those goals: individuals in the
team just follow their personal opinions and move in conflicting directions.
There may be a lack of trust and openness that blocks the critical
communication and leads to loss of coordination in the individual efforts.
And on and on. This is why every team needs a good leader who is able to
deal with all such team work issues.

Here are some additional team building ideas, techniques, and tips you can
try when managing teams in your situation.

Make sure that the team goals are totally clear and completely understood
and accepted by each team member.

Make sure there is complete clarity in who is responsible for what and avoid
overlapping authority. For example, if there is a risk that two team members
will be competing for control in certain area, try to divide that area into two
distinct parts and give each more complete control in one of those parts,
according to those individual's strengths and personal inclinations.

Build trust with your team members by spending one-on-one time in an

atmosphere of honesty and openness. Be loyal to your employees, if you
expect the same.

Allow your office team members build trust and openness between each
other in team building activities and events. Give them some opportunities
of extra social time with each other in an atmosphere that encourages open
communication. For example in a group lunch on Friday. Though be careful
with those corporate team building activities or events in which socializing
competes too much with someone's family time.

For issues that rely heavily on the team consensus and commitment, try to
involve the whole team in the decision making process. For example, via
group goal setting or group sessions with collective discussions of possible
decision options or solution ideas. What you want to achieve here is that
each team member feels his or her ownership in the final decision, solution,
or idea. And the more he or she feels this way, the more likely he or she is to
agree with and commit to the decided line of action, the more you build
team commitment to the goals and decisions.

When managing teams, make sure there are no blocked lines of

communications and you and your people are kept fully informed.
Even when your team is spread over different locations, you can still
maintain effective team communication. Just do your meetings online and
slash your travel costs. Click here for a free test drive.

Be careful with interpersonal issues. Recognize them early and deal with
them in full.

Don't miss opportunities to empower your employees. Say thank you or

show appreciation of an individual team player's work.

Don't limit yourself to negative feedback. Be fare. Whenever there is an

opportunity, give positive feedback as well.

Finally, though team work and team building can offer many challenges, the
pay off from a high performance team is well worth it.

Empowering
Listening to Patients

'Alternatives' listen

"We're at the birth of a new era," says John Hawks, president of Comsort, a
Baltimore company that trains physicians in listening and other
communication skills for the patient encounter. "The rise of psychosocial
intervention is equivalent to the rise of biomedical intervention since the
1920s," he says.

This change is reflected in the fact that last year, for the first time, there were
more visits to so-called alternative care sites in this country than there were
to primary care physicians, with most patients paying cash, Hawks says. He
notes that at most alternative sites–massage, acupuncture or chiropractic, for
example–the provider is willing or eager to listen to the patient and there is a
literal laying on of hands.

Hawks also points to a 1990 Stanford University study that he says found
that women with breast cancer who have support groups survive twice as
long as women who don't have that degree of support. "It's a psychosocial
problem," says Hawks.

Despite the singular importance of communication, especially during the

patient encounter, most doctors have yet to have their interview skills
assessed formally.

Nearly 80 percent of doctors have never been monitored by a skilled

observer during an interview, says internist Mack Lipkin, founding president
of the American Academy on Physician and Patient, a New York-based non-
profit organization whose mission is to improve outcomes through educatio
and research on doctor-patient interaction.

Marketplace dynamics may be pushing that percentage down, he says.

According to Lipkin, who is also director of primary care at New York

University Medical Center in New York, managed care companies view
themselves as growing in two ways: by enrolling new members, of course,
but also by reducing disenrollment, typically 10 percent to 20 percent a year
for each plan.

Customer surveys find that the biggest factors in deciding whether to remain
with a plan are cost and satisfaction with the doctor-patient relationship,
Lipkin says. The point is clear: As managed care organizations find it
increasingly difficult to compete on cost, they will have to compete on
satisfaction.

"Managed care companies are just starting to realize that patient satisfaction
is a key market differentiator. To a large extent, patient satisfaction arises
from the doctor-patient relationship. That's where training comes in," Lipkin
says.

Not easy to change

The problem is, he says, that most attempts to improve doctor-patient

communication through training and education have been ineffective
because the odd lecture on "how to relate" or the afternoon session on
dealing with difficult patients just isn't enough to reverse an ingrained bias in
favor of technical detail over emotional content.

Enter Lipkin, who claims to have developed a unique model for changing
physicians' behavior where traditional lectures and seminars have failed. Not
only do the academy's courses change behavior in both the short and long
term, he says, but they improve patient outcomes. And they do this while
increasing the physicians' satisfaction with their own medical practices–
particularly in the patient encounter.

The key: Unlike traditional courses that address factors such as knowledge,
skills and attitude individually, the academy integrates them in a single,
intense course that lasts at least a day. "Almost everybody changes when put
in the right educational experience," Lipkin observes.

The organization charges about $75 per day per physician for courses on
how to improve communication between physicians and patients. Last year
the academy, which has certified 60 instructors, conducted 12 one-day
courses, 14 2.5-day courses, a one-week course and a five-day course.

The communication skills can be built around everyday clinical issues or

focused on such topics as pain, dying and dealing with the alcoholic patient,
all implicitly recognizing that it is important to treat psychosocial
components of disease.

Diagnosis of the most common psychosocial disorders–anxiety, depression,

drug abuse–is missed between 50 and 80 percent of the time because
physicians are not trained to listen for emotional factors in their patients'
lives, according to Lipkin.

Mutual satisfaction
When doctors lack communication skills, their ability to gather information
is compromised, they fail to engage patients in their own care (and thus have
some responsibility for poor compliance with treatment regimens) and they
conduct or order wasteful tests and treatments because problems are not
accurately identified. All of this serves patients poorly, and it can run up
unnecessary costs for health plans and plan sponsors.

"An activated patient who asks questions and negotiates with the doctor has
better outcomes," Lipkin says. "The most important predictor of compliance
is trust in the doctor; that begins with communication."

Better communication is not just for the patient and the plan, however.
Physicians have much to gain in terms of satisfaction.

"There's an epidemic of burnout" reflected in the high turnover of doctors in

health plans, which physicians leave on the average of every three or four
years, Lipkin says. "Burned-out people are less effective. The most
significant factor in physician satisfaction is the patient encounter.
Physicians with better skills have better-quality patient encounters and are
more satisfied and less likely to burn out."

Much of the challenge to doctors lies in overcoming a bias toward technical

issues, which naturally results from their training, so they can deal with
patients who suddenly bring up complex emotional issues, cry or describe
deep-seated personal fears.

"Doctors are faced with a new experience. They need help with how to
manage it and how to cope with it themselves," Lipkin says.

"Most of us didn't learn this stuff in training," echoes internist Terry Stein,
director of clinician-patient communication for Kaiser Permanente's
Northern California Region in Oakland. "A lot of physicians get very
uncomfortable with psychosocial issues patients bring up because they are
not sure how to respond. It's a skill problem," says Stein.

Don't blame brevity

Stein, who was present at the creation of Kaiser's formal physician-patient

communication program in 1990 when it wasn't fashionable for HMOs to
pursue such efforts, says other factors besides medical school training play a
role in the apparent listening gap. But those factors aren't inherent to
managed care, she argues. For example, time per patient may be very limited
under managed care plans, but Stein feels that time pressure is only one
piece of the puzzle.

"The patient encounter is almost always brief. It's usually a matter of

minutes, whether or not the setting is managed care. What is more important
is how you use the time that you have," Stein says.

She acknowledges that the rise of managed care has resulted in a sharper
focus on member concerns, but says, "When we teach physicians about
rapport and empathy, we emphasize that these skills are even more important
considering the time constraints."

Another significant factor: "As physicians, we've become adept at going on

autopilot within a few seconds. We go into automatic thinking about what
diagnosis the patient has and stop listening. We know that the diagnostic
knowledge tree appears in our head within 18 seconds after the patient starts
talking."

That near-instant recognition can be useful, but physicians might rely on it

more than is desirable. Ironically, doctors may be seeing themselves as
efficient when the opposite is true. "If we took a little bit more time, we
would be more efficient, because our initial diagnosis might very well be
wrong," she says.

Doctors as mechanics

Finally, physicians have a "find it, fix it" mentality that impedes building
relationships with patients. Doctors see their role as identifying the problem
quickly, correcting it and moving on instead of creating a long-term
relationship that in the end results in more accurate information and better
patient adherence to treatment regimens, notes the internist.

Kaiser has seven years of positive feedback from its day-long workshop
Thriving in a Busy Practice, which hones physician communication skills in
both routine and difficult settings. Physicians say it has resulted in increased
confidence in their medical interviewing skills, reduced conflict with
patients and greater enjoyment of their practice.

And Thriving is, well, thriving. Despite its voluntary nature, 1,400 of
Kaiser's 3,500 physicians in northern California took the course between
1990 and 1995. In February, Kaiser launched Thriving2, a version that adds
modules for time management and "the four habits of highly effective
clinicians" (see box, page 26), not to be confused with Stephen Covey's
book, The Seven Habits of Highly Effective People.

Kaiser was a trailblazer with its physician communication workshop in

1990. Now, a strong academic argument has been built for such courses.
Debra Roter, Dr.Ph., professor in the department of health policy and
management at Johns Hopkins University School of Hygiene and Public
Health in Baltimore, did a study with colleagues, published in the Archives
of Internal Medicine in 1995, that assessed the communication skills of 69
primary care doctors in a randomized trial.

Listening can be learned

Using tape recordings of all patient encounters for a week–patients were

screened to ensure a balance between emotionally distressed ones and those
not–the study evaluated doctors who had undergone a modest eight-hour
continuing medical education program to boost listening and other skills to
get patients to report more clinical details. Doctors were evaluated as to
whether they used the skills, were better at identifying potentially distressed
patients through listening and were better at communicating in general. The
researchers measured the situations in which emotionally distressed patients
did significantly better over a follow-up period.

Roter found that doctors did use the communication skills that had been
taught them and that their patients did significantly better during the next six
months than they would have had their doctors not been trained.

Since then, Roter has evaluated other CME as well as residency training
programs and obtained similar results: When special skills such as listening
are taught, they can be evaluated by studying performance. There is a
definite, significant improvement in listening and other communication
skills.

The curriculum Roter developed from her research has been commercialized
by Comsort, most of whose work has been funded by pharmaceutical
companies and offered as free courses to managed care companies.

From the top down

But Hawks, Comsort's president, says the company is moving beyond
workshops because their value is limited–mainly because physicians don't
have time to attend them. While continuing to conduct workshops, Comsort
will develop programs in opinion-leader education, which involves
"mapping" an organization to identify opinion leaders and then trying to
effect change through them. Other new areas involve working closely with
HMOs and meetings of medical societies.

"Most physicians learn and change their behavior as a result of brief

interactions in the hall with someone they trust," Hawks suggests.

For an operation like Comsort, which claims to be the only for-profit

company in this field, there's a lot at stake. Hawks sees a nascent market for
psychosocial expertise in medicine as 85 million baby boomers approach the
time when they will begin placing unprecedented demands on the health care
system.

That demand may be even more urgent, given a study published Nov. 13 in
the Journal of the American Medical Association that asserts that the country
is not prepared to deal effectively with chronic disease.

"What's going to happen when these baby boomers do to health care what
they did to real estate? Psychosocial medicine is more than a nicety; it's an
essential," Hawks declares.

Idiosyncratic inefficiency

Like Kaiser's Stein, Roter believes there's still a tremendous need for
workshops on listening to patients–and not particularly because of time
constraints imposed by managed care. "A lot of people talk about time
collapsing under managed care. What's very important is what occurs during
the time. There's an incredible amount of wasted time," she says.

The real culprit is that physicians have not had a consistent and coordinated
communications style. "It's idiosyncratic–doctors usually develop their own
styles. Teaching communication skills can help make maximum use of the
time available, making it more effective and efficient," says Roter. And the
result will be better patient outcomes, which brings us back to Sir William
Osler's timeless advice to physicians to listen to the patient.

Sounds like something managed care organizations should do as well.

Chuck Appleby is a freelance writer in Benicia, Calif.

Open and honest communication

One of the things that has surprised me most when talking with customers
who use Basecamp is how many people work in a culture of fear, deception,
and distrust. It’s often not their own fault, but more the result of the culture
they are forced to operate in. It seeps in. It puzzles.

There are a lot of people who ask if they can hide this or hide that or only let
certain people see certain people’s names inside a project or hide the last
time someone logged in, etc. There’s a lot of hiding going on. A lot of
obscuring the truth going on. It puzzles me.

One of the top requests as of late is for a company to be able to hide

contractors from their clients. They don’t want their clients to know that
third party contractors are working on their projects. Anyway you look at
that, someone isn’t getting the whole truth. It puzzles.

And then there are the cases when people want software to step in with a
solution instead of just politely explaining the situation to their clients. They
want new features, modified features, obscure feature exceptions when all
that is required is a simple conversation with their client to explain the way
something works. It puzzles.

Of course people are free to use Basecamp however they want (and
Basecamp does provide the option to make certain messages or to-do lists
“private”), but Basecamp is not now nor will it ever be a tool for
concealment. Or control. Or to keep the project opaque. Basecamp believes
that project management is communication, which is of course all about
transparency and sharing. Projects end up better when the communication
channels are open and honest.

_ Key objectives of Catering Services.

_ Service Delivery.
_ Procurement and Cost Control.
_ Patient Services.
_ Nutritional Screening.
_ Catering Controls Assurance Standards
CATERING CONTROLS ASSURANCE STANDARDS
Registration of food business Accountability arrangements

Purchasing specification Hygienic facilities

Hazards Temperature control

Personal hygiene Food safety assessments

Dietary needs Legislation and guidance

Internal Audit Key indicators

Incidents and complaints Food management system

"Success depends not only on market conditions, but also on the ability
to create markets where none exist."

Every business with the global prospects in the multi dimensional, volatile
atmosphere has to introspect its strategies taking into consideration the
strengths, weaknesses, opportunities and threats. The service industry
also tags along the line and has to undertake smart and innovative moves
to woo its clientele who expect best possible service at competitive rates.
It is estimated that approximately a lull of 2%-10% of the previous year
business in all categories of hospitals. Some hospitals have to face
modernization at huge costs often especially in cyber city like Bangalore
where technology up-gradation is swift and the inflows of customers
require multi dimensional facilities ranging from full-fledged operation
theatres to high grade video conferencing.

The hospital catering should concentrate and keep up the good work even
if the business is already strong. Each relevant factor needs to be rated
according to its importance- high, medium, or low for the business as a
whole 1. The Indian service Industry utilizes the latest marketing
principles and information technology updates to get a respectable
position in the world market. In the face the worldwide economic
recession, the guests have become more sensitive to price which calls for
effective formulation of the pricing strategy.

Though the sales & market conditions are changing rapidly, the marketing
principles are not changing. hospital owners and managements tend to be
more inclined towards marketing and sales rather than cost control,
constantly seeking to maximize room sales - double- bed occupancies. All
this may fail and such a scenario may result in profit problem on cyclic
basis, which may sometimes lead the hotel into liquidation or forced sale.

Hospital catering seeking a balance between achieving high occupancies

and high average room rates may have higher long term profit. The
peculiar nature of the hospitall business may compel the management to
think short term about day-to-day problems or the next-meal periods, as
the ROOM DAY is a PERISHABLE ITEM. The room occupancy perishes on
the expiry of the day.

The increased competition has lead to Up market self-catering, time

sharing, home entertainment, competition from producers of other
services and commodities and other trends like rising operating costs,
high interest and too many hotel in many areas. Following diagram
indicates the Strengths and Weakness Analysis of a generic Hospital
catering.

Strengths
CHAPTER-5
Recommendations
• Nutritional screening of all patients on admission to hospital should be a
priority for all boards.
• should put protected mealtimes policies in place to ensure that mealtimes
are free from non-essential clinical activity and that there are enough staff on
wards to help all patients eat a nutritious diet while in hospital.
• should ensure that the catering and nutrition specification is published as
planned.
• All boards should ensure that standard recipes are used for all meals. These
should detail ingredients, quantities, cooking method and the expected
number of portions. The hospital should consider developing a national
database of standard recipes for the hospitals to promote this.
• Catering departments and dieticians should work together to ensure that all
menus are fully nutritionally analysed and updated whenever any changes
are made to recipes or menus.
• All boards should regularly monitor patient feedback and use this as part of
quality mprovement. This can be achieved through methods such as patient
satisfaction surveys, monitoring plate wastage and reviewing feedback from
carers. improve the quality of services both in kitchens and on wards.

A variety of other patient feedback systems are in place at local level. Four-
fifths of hospitals are using other systems such as patient forums or
individual interviews in place of a patient survey or to supplement their
findings do not have any systems in place to gather or act on patients’ views
on hospital catering.27
Another indicator of patient satisfaction is the amount
of food returned uneaten on patients’ plates. This measure can be influenced
by a number of factors, such as loss of appetite caused by medication or
symptoms of illness, but could be linked with other patient feedback systems
to provide a more complete picture of the level of satisfaction with the food
provided.

Some hospitals are exploring innovative ways of encouraging all patient

groups to be able to give their views on hospital food
Some boards have undertaken innovative work to ensure that the methods
used to record patients’ views are appropriate to the client group. For
example, patients with learning difficulties may find it difficult to complete a
questionnaire but trained staff can discuss satisfaction levels with patients in
an informal way in order to get their views on catering.
We also found examples of patients in long-stay hospitals being encouraged
to join catering groups, where patients meet with catering staff on a regular
basis to raise and discuss issues with the service Patients are encouraged to
raise issues by putting concerns on the agenda for these

Giving patients the opportunity to pick the amount of food they want
increases the choice available and allows them to reflect their normal eating
preferences. When at home, some patients would normally have only a light
lunch and then have their main meal at dinner time or vice versa. Hospital
catering should be flexible to try to match individual eating patterns.Our
survey found that all hospitals (with the exception of New Craigs Hospital)
offer a range of portion sizes for menu items. This gives each patient the
opportunity to choose an amount of food to match his or her appetite. The
range of portion sizes available to patients should be quantified in all
standard recipes and nutritional analysis of menu items (discussed in
paragraphs 18-23) to ensure that these analyses provide an accurate
assessment of nutritional intake.
Percentage of hospitals ordering meals in advance of the
mealtime If portion sizes are selected and ordered in advance then catering
departments can produce the correct amount of food, but patients’ appetites
may change between ordering the food and the mealtime. This can result in
more food being left uneaten by patients (plate wastage). However, if
portion size is selected at the mealtime then catering departments will not
know how many patients want large portions and will have to estimate how
much food will be needed. This can result in surplus food being sent to
wards to ensure that all patients are given a choice (wastage in unserved
meals). Therefore, giving choice to patients over the size of the portion they
want can also affect the level of wastage.

• Catering services are becoming a higher strategic priority for boards.

• Catering staff vacancy rates remain high.
• Agenda for Change has not resulted in standard job descriptions or pay
grades for catering staff in different boards.
. Boards have developed work on catering strategies alongside, or as part of,
nutritional care strategies. found that three-quarters of boards had started the
process of developing and implementing a nutritional care policy and
strategic plan. While progress has been slow, all boards now have nutritional
care groups in place which are central to the further development and
implementation of catering and nutritional care at a strategic

CONCLUSION
In order to get the hospital catering a successful ,we have to take these
following steps.

• Registration of food business Accountability arrangements

• Purchasing specification Hygienic facilities

• Hazards Temperature control

• Personal hygiene Food safety assessments

 • Dietary needs Legislation and guidance

• Internal Audit Key indicators

• Incidents and complaints Food management system

Photographs
Hygenic food in the kitchen

Using hand gloves in cooking