Hospital Dietary Service Management Manual PDF

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HOSPITAL DIETARY SERVICE
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MANAGEMENT MANUAL .
DEPARTMENT OF HEALTH
REPUBLIC OF THE PHILIPPINES
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IjPSPITAL DIETARY SERVICE
MANAGEMENT MANUAL
Department of Health
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Second Edition
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Republic of the Philippines
The second edition ofthe Hospital Dietary Service
Management Manual is a publication of the
Health Finance Development Project of the
Department of Health.
This publication was made possible through
support provided by the U.S. Agency for
International Development (A.LD.), under the
terms of Contract No. 49Z-Q446-GOQ-ZIl4-00. The
opinions expressed herein are those of the
author(s) and do not necessarily reflect the views
ofthe U.S. Agencyfor International Development.
TABLE OF CONTENTS
AUTHORIZATION
MESSAGE
FOREWORD
PREFACE
ACKNOWLEDGMENTS
LIST OF FORMS
LIST OF ILLUSTRATIONS
LISTOF TABLES
LISTOF ABBREVIATIONS
Chapter
L
II.
DIETARY SERVICE IN
THE DEPARTMENT OF HEALTH
Introduction
Historical Background
HOSPITAL DIETARY SERVICE
Philosophy
Objectives
Functions
Standards
Page No.
1
1
2
5
5
5
6
6
III. DIETARY HUMAN RESOURCE MANAGEMENT 19
Hospital Employment Practices 19
Recruitment 19
Hiring 20
Termination 21
Functions and Management Skill of
the Nutritionist-Dietitian 23
Training and Development
of Dietary Personnel 25
Organization and Staffing Pattern of
the Different Health Care Levels 28
Guidelines in the Staffing Pattern 29
Job Descriptions of Staff and Personnel 32
Nutritionist-Dietitian N 32
Nutritionist-Dietitian III (Administrative) 33
Nutritionist-Dietitian II (Clinical) 35
Nutritionist-Dietitian II (Teaching-Training) 37
Nutritionist-Dietitian II (Education and Research) 38
Nutritionist-Dietitian I 39
Food Service Supervisor 40
Cook II 41
Food Service Worker/Utility Worker 42
Clerk I (Dietary Clerk-Typist) 43
Dietary Store Aide 44
,}
Chapter Page No.
N. ADMINISTRATION AND MANAGEMENT 45
Budgeting 46
Cost Control 46
Menu Planning 51
Purchasing , 52
Receiving 54
Storing 55
Issuing 58
Food Production 58
Meal Service 62
Sanitation, Safety, and Maintenance 66
Pest/Vermin Control 71
Energy Conservation 72
Effective Communication 72
Facility and Equipment for the
Dietary Service Health Care Level 74
Requirement for Kitchen Planning 74
V. CLINICAL, EDUCATIONAL, RESEARCH,
AND SPECIALIZED FUNCTIONS OF
THE DIETARY SERVICE 81
Clinical and Educational Functions 81
Charting and Ward Rounds 81
Diet Counselling 85
Nutrition Clinic 87
Malward or Nutreward 88
Research Function
88
Research Unit 90
Metabolic Balance Studies 95
Planning the Metabolic Kitchen Unit 95
Specialized Function 97
Disaster Feeding 97
VI. QUALITY ASSURANCE FOR
THE DIETARY SERVICE
99
Quality Assurance
99
The Importance of Quality Assurance
for Dietary Service
100
Components of the Quality Assurance Program 108
Stages in Program Development
110
Monitoring and Evaluation
119
Process for Writing Indicators
122
Data Collection Frames
129
Sampling Techniques
129
Computing Results
130
Quality Assurance Reviewers
133
Data Analysis and Summary
133
r
APPENDICES
Code of Ethics for Dietetic Profession
General Conditions on Bidding of Foodstuff
Specifications of Common Foodstuff Purchased
Food Sanitation Checklist
Presidential Decreee 856, Sanitaria in Food Service
Commended Classification by Weight of Filipino Children
Equipment Guide for a Conventional Hospital Dietetic Service
Nutrition Clinic Forms
DIETARYSERVICE FORi'vlS
REFERENCES
Republic of the Philippines .
OFFICE OFTHE SECRETARY
$ANLAZARO OOMPOUND
RIZAL AVENUE, $TA.CRUZ
MANIlA, PHIUPPINES
TEL NO. 711-6ll-8O
AUTHORIZATION
January 6, 1994
In accordance with the authority vested on the Secretary of Health, I hereby declare the policies,
regulations, and instructions in this Hospital Dietary Service Management Manual shall govern the
organization, management, and activities of the Dietary Service in government hospitals until modified
by order of the Department of Health or by law.
Republic of thePhllipplnee
DEPARTMENTOFHEALTH
OFFICE FOR HEALTH FACILITIES,
STANDARDS AND REGULATION
Sentszare Cmpd., Sta. Cruz Manila
Tol No. 71195-72, FaxNo. 711-95-09
MESSAGE
January 6, 1994
The Hospital Operations and Management Service of the Department of Health has been
tasked to develop operations manuals specifically for DOH hospitals that may be of use to other
public and private hospitals.
These manuals would serve as standard reference materials for DOH hospitals to aid
administrators and practitioners in. following standard operating procedures in the management and
practice of the different hospital services or units. Likewise, it may also serve as a reference guide for
other public and private hospitals-.
These manuals provide guidelines in the performance of duties and 'responsibilities of hospital
personnel as well as outline steps necessary in the effective and efficient operation of each unit or
service. The procedures in these manuals will assist them in the process necessary to operate an
effective and efficient hospital.
This is an attempt to develop standards and achieve uniformity of procedures in different
hospitals.
JU ~ N G S M.D.
Under ecretary on Health
Facilities, Standards
and Regulations
OFFICE OFTHE SECRETARY
SANLAZARO COMPOUND
RIZALAVENUE, STA. CRUZ
MANILA, PHIUPPINES
TEL NO. 711-6().8()
I'
FOREWORD
Total Health care delivery for all is the major thrust of the Department of Health. Being a
principal component and an important factor in the attainment of health care, the Dietary Service
have sought to find new and better ways to improve the nutritional well-being of its patients.
This manual was developed to set the directions needed for the effective management of the
Dietary Service. It is an invaluable reference for Nutritionists/Dietitians and all those involved in the
Dietary Service. Although not all the guidelines stated in this manual may be suitable for use in all
types of Dietary Service set-ups, Dietitians could derive useful guidelines and specific directions
which would aid them in evaluating existing operations and bring about constructive changes and
improvements.

MA. MARGARITA M GALON, MD., MHA
Director III
Hospital Operations and
Management Service
PREFACE
Communication is vital in all.human undertakings, but it is especially so in
areas concerned with the restoration and maintenance of well-being such as health
services. Because human life is the center of all activities in hospitals and other
health institutions, the problems in the communication channels within such
institutions must, at all costs, be resolved. One of the most effective means of
expediting communication is, undoubtedly, to establish policies that cover both
routine operations andtheirfrequent fluctuations, andtomake such policies available
to those concerned. Thismanual is expected to serve asa means of educating and
informing the hospital community about the Dietary Service and therefore, open
avenues of communications among the dietary service staff, physicians, nurses,
patients, aswell asother hospital staff.
Over and above such goals, this manual aims to improve the dietary care of
hospital patients for the attainment of quality patient care through effective
management and administration And since communication is a principal tool
towards thisgoal, thismanual was prepared with theobjective of giving guidance to
the Dietary personnel in improving theirdaily performance.
Theguidelines in thismanual should not beregarded asrigid standards. Their
application may vary throughout the country, and it is the prerogative of each
Dietary Department to either accept or modifythe guidelines according to their
specific needs. However, the ideas presented shouldhelp promote theexamination
of existing routines with thehopethat constructive changes and improvements will
beput intoeffect
The purpose of this manual is to provide a definition of requirements for the
various health care facilities and services. Whenthedevelopment of a unit isunder
consideration, the guidelines assist planners and government health authorities in
determining theneed forsuch a unit,and in assessing thepotential impact of a new
unitonexistingandprojectedservices, bothatthelocal andregionallevds. Deficiencies
in existing services can be identified, and in some cases, these can be corrected
without theneed todevelop a newunit Whenaunit already exists in a hospital, the
guidelines will help in identifying problemareas matedtoadministration, personnel,
equipment, and physical facilities. They will help determine necessary remedial
actions and set priorities for corrective measures on the basis of clinical needs,
budget realities, and thedegree to which a deficiency in physical facilities impedes
the function of the unit
Every health institution, therefore, is enjoined to avail of this manual
for their reference and guidance.
T. FELICIANO
etary Adviser
Hospital Operations and
Management Service
ACKNOWLEDGMENTS
The Committee on Revision of the Department of Health Hospital
Dietary Service Management Manual is deeply grateful to all those who
have contributed in the completion of this task, and acknowledges, with
sincere thanks, the wholehearted assistance. of the following:
To Dr. Margarita M. Galon, Director III, Hospital Operations and
Management Service, for her support and encouragement in the
preparation of this manual;
To Dr. Melchor R. Lucas, Jr., Medical Officer VII, Chief of the
Division and all other Advisers of the Support Division, Hospital
Operations and Management Service, for their constructive
criticisms and suggestions;
To the Chiefs-of-Hospital, for allowing the Nutritionist- Dietitian
to attend the Consultative Meetings held during the preparation of
this manual;
To the following persons who have contributed to the preparation
of the original Hospital DietaryService Management Manual(1986):
Ms. Rose C. Cavinoformer Dietetic Management Adviser, Bureau
of Medical Services, Ministry of Health, and chairman of the
Committee on manual preparation, together with Committee
members, namely, Ms. Josefina U. Ramos, Dietitian III, and Ms.
Erlinda Cordero, Dietitian, both of Rizal Medical Center; Ms. Leyte
Madamba, Dietitian Iv, Dr. Jose N. Rodriguez Memorial Hospital;
Ms. Cristina N. Josef, Dietitian II, Eulogio Rodriguez Sr. Memorial
Hospital; and myself, Chief Dietitian, Hospital ng Maynila; and
To Ms. Fenelia Mylene M. Hamo and Ms. Alma Q Sorra, Hospital
Operations and Management Service, for printing the text of this
manual.
Finally, no expression of appreciation would adequately suffice in
acknowledging the unstinted support of everyone who had contributed in
one way or another in the completion of this manual.
LIST OF FORMS
Statement of Daily Market Purchases
Supplies Ledger Card
Dietary Service Forms
NO.TITLE
lA.
lB.
2.
3.
4A.
4B.
5.
6.
7.
8.
9.
10.
1lA.
IlB.
1lC.
IlD.
12.
13.
14A.
14B.
15.
16A.
16B.
17.
Performance Targets Worksheet
Civil Service Commission Performance Appraisal Report
Employees Schedule for the Month
Dietary Order Slip for Bidder Items
Open Market Purchase Slip
Dietary Service Daily Admissions - Discharges Sheet
Daily Delivery Record Book
Supplies Requisition and Issue Form
Dietary Service Perpetual Inventory
Regular Weekly Menu
Therapeutic Weekly Menu
Standardized Recipes
Production Record Sheet - Regular Meals
Production Record Sheet - Therapeutic Diets
Cook's Copy - Patient Service
Cook's Copy - Cafeteria Service
Daily Patient Meal Census
Diet List
Special Meal Request Form
Special Meal Record Form
Dietary Service Admission Sheet
Problem List
Problem Oriented Progress Notes
Diet History Form
UST OF ILLUSTRATIONS
NO. ILLUSTRATIONS PAGE NO.
I. Quality Assurance Related to
Departmental Functions and Activities 101
2. Stages in Developing a Quality Assurance Program 111
3. Sample Dietary Policy and Procedures
for Quality Assurance 112
4(a). Annual Schedule for Quality Assurance Activities
in Dietetic Service (In-patient) 113
4(b). Annual Schedule for Quality Assurance Activities
in Dietetic Service (Out-patient) Il5
5. Sample Data Collection Form 116
6. Checklist for Quality Assurance Documentation 117
7. Worksheet for Writing Quality Assurance Indicators 122
8. Development of Indicators from
Department Goals and Functions 123
9. Checklist for Monitoring and Evaluation Methods 128
10. Checklist for Judging Criteria and Method 131
LIST OF TABLES
NO. TABLE PAGE NO.
I. Hospital Standard Requirements for Personnel 31
2. Dietary Service Staffing Pattern 31
3. Percentage Allowance for Kitchen Areas 76
LIST OF ABBREVIATIONS
AO
BF
COH
DOH
FIFO
FNRI
FSW
FTE
HMTDS
HOMS
]CAH
MBO
MF
NPO
PD
PGH
POMR
PRC
QAP
RA
RIV
SOAP
TB
Administrative Officer
Breast Feeding
Chief of Hospital
First-In-First-Out
Food and Nutrition Research Institute
Food Service Warker
Full Time Equivalent
Health Management Training Development Service
Hospital Operations and Management Services
Joint Commission on Accreditation of Hospitals
Management by Objective
Milk Formula
Nil Per Orem
Presidential Decree
Philippine General Hospital
Problem Oriented Medical Record
Professional Regulatory Commission
Quality Assurance Program
Republic Act
Requisition Issue Voucher
Subjective, Objective, Assessment, Plan Statement
,
Tuberculosis
DIETARY SERVICE IN THE
DEPARTMENT OF HEALTH
INTRODUCTION
All modes of health care have lately been a major concern of the
Philippine government. Recent initiatives aim at more effective means of
maintaining good health, its restoration and rehabilitation where it has
deteriorated or has been neglected.
Dietetics is a principal component of health care and an important
factor in the attainment of this ultimate goal. While efficiency is of utmost
importance in attaining this end, the provision for individual needs is of
even greater concern. Dietetics is a sensitive aspect of health care, it is a
branch of hygiene which deals with diet and dieting among individuals and
groups who are either healthy or ill. The proper application of its principles
is crucial to the success of health care delivery and the maintenance of good
health.
According to the Hospital Licensure Act (RA 4226) of the Bureau of
Medical Service (1971), the Dietary Service ranks as one of the six major
services of the hospital and is an integral part of the total patient care. It is
headed by a professionally qualified Nutritionist-Dietitian who serves as the
administrator of the service. In as much as food service involves
approximately 10-14% of the total hospital expenditures, this is a critical
area, and a hospital which cannot afford to employ a dietitian is under a
distinct handicap.
Based on the survey conducted by the committee involved in the
preparation of the Hospital Dietary Service Management Manual, ninety-
five percent (95%) of the hospital Dietary Service under the Department of
Health (DOH), both in Metro Manila and in the provinces, does not have
a formal manual as a guide in the management of the said service. A
greater percentage has informal written policies and procedures that are,
however, not up-to-date, Results of the survey further indicates that most-of
these Dietary Services are not properly equipped and/or managed. In 'view
of this existing situation, the committee was prompted to developthis manual.
1
Hospital Dietary Service Management Manual
This manual was developed to set the directions needed for the effective
management of the Dietary Service in a general hospital including Secondary
District, Tertiary Provincial, Tertiary Regional and Tertiary Medical Center.
All dietetic services need an operational guide or manual containing written
information on the efficient and effective management of the units and to,
provide ready reference in dealing with future problems. This manual also
serves as a communication tool within the service and with other
departments.
Not all of the guidelines stated in this manual will be suitable for use in
all types of dietary service set-ups. However, the ideas presented should help
the Nutritionist- Dietitian to evaluate existing operations with the hope
that constructive changes and improvements will be made.
HISTORICAL BACKGROUND
Dietetics is the combined science and art of planning, preparing, and
serving meals to individuals or groups according to the principles of nutrition
and management, taking into consideration economic and psychological
factors, But dietetics has not always been a science and an art in itself.
Despite its early practice as a vital part of patient care, it was not recognized
as a separate discipline. Thus, in the caring and feeding of the sick, the
nurse was also a dietitian.
Filipino nurses in the early 1900's underwent rigid training in the varied
aspects ofdietetics with Ainerican mentors. But soon, dietetics became closely
associated with food preparation, particularly cooking, that it earned a
misconception which took a long time to correct.
Shortly after World War II, both nursing and dietetics grewmore complex.
Recent knowledge on nutrition and the development of modern methods of
food service management soon required that dietetics be considered as a
new area of specialization. The limited dietetics training of nurses was no
longer adequate to meet the increasing demands in the field. In 1946, the
University of the Philippines accepted its first five students for a degree of
Bachelor of Science in Home Economics, major in Food and Nutrition.
Nurses. who were in responsible positions in the Dietary Service of the
hospitals were also given opportunities for specialized training.
In 1950, the first nutrition clinic was established by the Institute of
Nutrition (now Foods and Nutrition Research Institute) with the first Filipino
professionally trained in dietetics as the dietitian.
In 1952, when the Philippine General Hospital (PGH) was reorganized,
the Dietary Service became a separate department and other hospitals
followed. That same year, the DOH established under its Bureau of Medical
Services, the Office of the Dietetic Management Adviser. Its principal role
is to set, monitor, evaluate, and recommend dietary service standards, policies,
and guidelines for implementation in hospitals and medical centers licensed
by the Department all over the country. Its other advisory duties include
consultative services to hospital heads and dietitians.on training needs,
programming services for training requirements and consultation needs for
kitchen layout and equipment and personnel selection.
2
By 1955, it became necessary to regulate the practice of dietetics in the
Philippines. Moves were initiated by the newly formed Dietetic Association
of the Philippines to have a law enacted for this purpose. However, it was
not until 1960 that the' Dietetics Lawotherwise known as RA 2674 was passed
by. Congress. Briefly, among other things, law requires every government or
private hospital, with more than seventy-five (75) but less than one hundred
fifty (150) bed capacity shall employ at least one dietitian; those with more
than one hundred fifty (150) but less than three hundred (300) bed capacify
shall employ at least one dietitian and two assistant dietitians; and those
with more than three hundred (300) bed capacity shall employ two dietitians
and not less than four assistant dietitians.
This Lawwas superseded by Presidential Decree 1286in 1978, specifically
Section 27, which states that: "All hospitals whether government or private
with twenty five(25)to seventy five (75) bed capacity shall employ a minimum
of one Nutritionist-Dietitian; above seventy five (75) to one hundred fifty
(150) bed capacity, a minimum of two Nutritionist-Dietitians; above one
hundred fifty (150) to two hundred fifty (250) bed capacity, a minimum of
three Nurririonisr-Dieririans; above two hundred fifty (250) bed capacity to
five hundred (500) bed capacity, a minimum of four Nutritionist-Dietitian;
and above five hundred (500) to one thousand (1,000) bed capacity, a
minimum of five Nutritionist-Dietitians. Nutrition agencies, whether
government or private, shall employ at least one (I) Nutritionist-Dietitian
for each province, city, municipality, and rural health units." This decree
was a recognition of the expanded role of Nutritionist-Dietitians not only in
hospitals but also in community and/or public health nutrition, but the
essence of regulating the practice of the profession was retained.
3
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TIfEHOSPITAL DIETARY SERVICE
PHILOSOPHY
Each hospital has a guiding philosophy which should be articulated
and communicated to the staff of the various services. Each service, in
turn, must formulate its own philosophy which shall provide the anchor
for its goals, objectives and program of service.
The following can serve as a guide in the formulation of a philosophy
for the Dietary Service:
1. The Dietary Service is organized to promote optimal nutrition for
patients and hospital personnel regardless of race, creed, color, social
status, and political belief through the administration of a high quality
food service:
2. Diet is one of the most critical attributes in human growth and
development directly related to good health. It provides the most
appropriate means of maintaining vitality, developing resistance to
infections and organic deterioration, the control of many disease
processes, and recovery of health and function following illness and
iruury:
3. Dietary personnel must be prepared, guided and given direction in
their work within the context of prevailing local conditions in order
ro attain efficient output; and
4. Hospital and Dietary Service goals can be best attained through the
cooperation, coordination, mutual understanding, and dedication of
all those concerned with quality patient care.
OBJECTIVES
General
To maintain or enhance the health of the patients and personnel by
providing them with high quality and nutritious food through an efficient
Dietary Service.
5
Specific
,1. To provide or to serve safe, nutritious and attractive food through
careful planning, wise procurement, and proper preparation of
balanced and satisfying meals within budgetary limits;
2. To implement diet prescriptions in coordination with the physician
and the nurse-in-charge;
3. To provide nutrition consultations and education servicesto patients
as well as in-service training to both dietary personnel and other related
fields;
4. To undertake investigation, analysis, and research along the field of
Nutrition and Dietetics; and
5. To promote and maintain cooperation with other departments in the
hospital towards total patient care.
FUNCTIONS
As a major aspect of total health care and an integral part of the hospital
organization, the Dietary Service is committed to functions of
administration, clinical services, education and research as they relate to
the science of food service management and nutrition.
1. Administrativefunction is aimed at the effective utilization of resources
in the attainment of the goals set by the service. It includes the
establishment of policies and standards, and the implementation of
procedures concerned with budget and financial control; development
of menus; purchasing and receipt of foods; production and service of
safe, sanitary, nutritious, and palatable food; effective utilization of
personnel, layout, and equipment; and maintenance of records and
reports.
2.. Clinical function is aimed at providing and promoting a high quality
nutritional care which includes within its scope, diet prescription,
interpretation, implementation of diet orders, and the provision of
individual and group counselling of patients in normal and clinical
nutrition. Specialized services may include prescription of diets in
nutrition clinics, malnutrition ward (malward), disaster feeding,
outreach, and home care programs.
3. Education and research functions are aimed at the fulfillment of the
Dietary Service's commitment to the nutrition education of the
patients as well as hospital personnel and paramedic groups and to
the continued researchand development in food service management
and nutrition. It also includes the training of dietary personnel and
personnel of other allied fields to improve the quality and efficiency
of food serviceoperation, and the development of a research program
to upgrade knowledge in food service management and nutrition.
STANDARDS
Principle
Thereshall be an organized Dietetic Service which shall promote optimal
nutrition for patients and personnel through the efficient administration
of high quality food service.
6
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Standard I
Organization, Staffing and Manpower Development
The Dietetic Service shall be organized with clearly stated philosophy,
goals, and objectives. It shall be directed by a qualified person and staffed
by an adequate number of Nutritionist-Dietitians, technical, and clerical
personnel. It shall be integrated with the other units and departments of the
hospital in a manner designed to ensure the provision ofoptimal nutritional
care and quality food service. Likewise, it should establish linkages with the
nutrition component of field health services.
Interpretation
There shall be clearly stated goals, objectives, and procedures for the
Dietetic Service developed by the dietetic personnel and consonant with the
framework of the hospital. The Dietetic Service should have a written
organizational plan that indicates the routes of intra-departmental
communication. Integrated planning on dietetics with other divisions/
departments in the hospital shall be encouraged. Job descriptions should be
adopted for all classifications of personnel. The organizational plan, job
description, and the procedure manual should be reviewed periodically,
revised as necessary, and dated to indicate the time of the last review.
The Dietetic Service must have the required number of qualified
Nutritionist- Dietitians duly registered with the Professional Regulation
Commission (PRC) based on PO 1286, Sec. 27 (see p. 3). The service must
also have an adequate number of appropriately qualified personnel based
on the staffing pattern approved by the DOH. The Chief Nutritionist-
Dietitian shall have the authority and responsibility of ensuring that the
established policies are carried out; that overall coordination and integration
of the therapeutic and administrative dietetic services are maintained; and
that a review and evaluation of the quality, safety, and appropriateness of
the dietetic function is performed.
A qualified Nutritionist-Dietitian shall assure that the provision of high-
quality nutritional care to patients is maintained.
Educational programs offered to dietetic employees should include
orientation, on-the-job training, and continuing education programs. These
programs must include instructions on personal hygiene, proper inspection,
handling, preparation and serving of food, and proper cleaning and safe
operation of equipment.
Administrative and supervisory staff should be encouraged to take
advantage of available courses which will acquaint them with modern
concepts on preventive and therapeutic nutrition, and dietary management.
A hospital that has a contract with an outside food management company
for dietetic services must require, as a part of the contract, that the company
maintain at least the standards outlined herein for such services. (This is
also true to all private hospitals that have contracted the services of food
concessionaires.)
7
Ih..
Standard II
Facilities and Operations
The Dietetic Service shall have adequate space, equipment, and supplies to
facilitate the efficient, safe, and sanitary operations ofall functions assigned to it
Interpretation
Facilities must be provided to fulfill the food service and dietetic needs
of the patients and staff. The layout of the service, in accordance with the
type, size, and location ofequipment, should make efficient food preparation,
distribution, effective sanitation, and safety possible. The food service should
be appropriately located and equipped. '
The following precautions shall be taken in the handling and preparation
of food:
1. Protection of food from contamination and spoilage;
2. Storage of perishable foods at proper temperatures;
3. Convenient location of adequate toilet and handwashing facilities
throughout the service;
4. Thorough cleaning and sanitizing of all work surfaces, utensils, and
equipment after each period of use;
5. Provision of separate cutting boards for meat, poultry, fish (both cooked
and uncooked), raw fruits and vegetables;
6. Discardingof plasticware and china that is chipped, cracked, or has lost its
glaze, as well as disposable containers and utensilsafter one use;
7. Control of lighting, ventilation, and humidity, in order to prevent
the condensation of moisture and the growth of molds;
8. Use of efficient equipment and methods for washing and sanitizing
dishes. A good example is the installation of a hot water system;
9. Use of methods for making, storing, and dispensing ice that 'does not
allowcontamination to occur. For example, ice should not be scooped
by hand, nor should food items be stored directly on ice being stored
for dispensing; and '
10, Restriction of unauthorized individuals in the food preparation and
service areas to minimize the risk of contamination and improve
operational efficiency.
Safety shall be ensured by providing at least the following precautions:
1. Walk-in refrigerators that can be opened from the inside;
2. Insulationofhot and coldwaterpipes,waterheaters, refrigerator compressors,
condensingunits, and uncontrolled heat-producing equipment;
3. Clear labelling of supplies;
4. Separate storage of all food and non-food supplies;
5. Documentation of the activities of an active, preventive, and corrective
maintenance, and safety program;
6. Procurement ofall food suppliesfrom sources that provideassurance that the
food is processed under regulated qualityand sanitation controls; and
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r
7.
Proper holding, transfer, and disposal of garbage to prevent the
proliferation of insects and rodents, or otherwise permit the
transmission of disease. Containers must be leakproof and non-
absorbent with tight-fitting covers and it is recommended that
impervious plastic liners be used.
There should be adequate work space for supervisory and clerical
personnel. The office of the Nutritionist-Dietitian should be properly located
so that he/she is easily accessible for consultation to all who require his/her
service. Current reference materials should also be conveniently located in
the office.
Standard III
Policies and Procedures
There should be written policies and nutritional procedures to govern
all dietary activities.
Interpretation
Written policies and procedures for the Dietetic Serviceshall be developed
to guide all dietetic personnel in the performance of their duties. The chief
of the Dietetics Department , in cooperation with the dietetic staff,
representatives from the nursing and medical staff, shall develop policies
and procedures concerning food procurement, preparation, and service .as
well as nutritional care. These policies and procedures shall be reviewed
periodically, revised as necessary and dated to indicate the time of the last
review.
There shall bepolicies and procedures relating to at least the following:
1. Department goals and objectives, relationships, organizationand staffing;
2. Responsibilityand authorityassigned to the chief,dutiesofdietarypersonnel
with jobdescriptions, hours, and functions for the variousclassifications;
3. Personnel policies, including those related to health and grooming,
such as the use of aprons/gowns, dietary caps and indoor shoes in
the food preparation and service areas;
4. Administrative policies and procedures covering budget, patient arid
staff education, menu planning, specification for purchases of food
and equipment, ordering and control of food supplies, storage,
preparation, safety, and fire prevention, sanitation procedures, and
waste disposal. Procedures should also mention in detail, how the
physicians' orders, with regards to treatment and diet, will be carried
out to ensure that each patient receives the right diet served as
nutritiously and attractively as possible;
5. Provision of standardized recipes for economy and efficiency in food
preparation;
6. Proper housekeeping, sanitation, safety, and maintenance in the dietary
area;
7. Monthly Reports - statistics and cost accounting procedures
8. Methods of evaluating the Dietetic Service arid personnel to assess howwell
goals and objectives are beingmet and the qualityof service being rendered;
9. The proper use of and adherence to the standards for nutritional care,
as specified in the diet manual/handbook;
9
10. Nutritional assessment and .counselling, and diet instruction;
11. Disaster Plans the role of the Dietetic Service in the hospital's intemal and
extemal disaster plans shall be clearly defined. The Dietetic Service shall be
able to meet the nutritional needs of patients and staff duringthe disaster,
consistent withthe capabilities of the hospital and the communityserved;
12. DietManual/Handbook- Aqualified dietitian shall develop or adopt a diet
manual/handbookin cooperation with representatives of the medical staff
and withother appropriate dietetic staff. The diet manual/handbook shall
serve asa guide in ordering diets, and theserved menus should beconsistent
with the requirements in the diet manual/handbook. The diet manual/
handbook shall be reviewed annually and revised as necessary bya qualified
dietitian, dated to identify the review andanyrevision made, in consultation
with themedical staffthrough itsdesignated mechanism. Acopy of thediet
manual/handbook shall be placed in each patient care unit All master
menus and modified diets shall beapproved bya qualified dietitian; and
13. A nutrition clinic that will take care of nutrition referrals at the out-
patient department shall be organized adopting the nutrition clinic
guidelines of the DOH and/or the enclosed guidelines in the manual.
Standard IV
Nutritional Aspects of Patient Care
the administration of high quality nutritional care of patients shall be
under the direction of a qualified Nutritionist-Dietitian.
Interpretation
The nutritional aspects of patient care shall be directed by a qualified
Nutritionist-Dietitian, whose duties shall include:
1. Supervision of nutritional intake of all patients
a. Planning and evaluating all menus for nutritional adequacy;
b. Providing maximum effort to ensure the appetizing
appearance, palatability, proper serving temperature, and
retention of nutrient values of food;
c. Keeping records of nutritional intake when necessary;
d. Periodic assessment of the patient's nutrient intake and tolerance to
theprescribed diet modifications, including theeffect ofthe patient's
appetite and food habits on tood intake, andanysubstitutions made;
e. Conferring with other members of the treatment team about
dietary management and problems of patients. Initiating orders
for dietary modifications, when necessary; .
f. Recording dietary progress of patients in their records in
collaboration with the nursing service; and
g. Developing projects or studies to improve nutritional care.
2. Nutrition Educar.on
a. Patient Education - includes teaching of normal nutrition as well as
specific diets, and involves discussing with patients and/or their
families their food habits, diet f,lOors associated with their socio-
economic background, dietary intake, andother aspects of nutrition
which will affect the patient's health after discharge;
10
b. Education of other members of the therapeutic team;
c. Education of other Dietary Service personnel;
d. Education of community groups through referral to the
nutrition clinics;
e. Supervision of dietetic affiliates when applicable;
f. Collaboration in the-preparation or selection of suitable
booklets and instruction sheets for patients, and audio-visual
aid for teaching; and .'
g. Responsible for the preparation or selection of a suitable diet
manual for use as reference by medical and dietary personnel
when ordering diets.
3. Attendance at appropriate rounds and conferences, and representation
on appropriate committees.
a. A representative of the dietary staff should attend team
conferences or committee meetings whenever dietary
considerations are vital to the diagnostic or therapeutic
regimen of the patient or whenever matters pertaining to the
efficient delivery of the service are under discussion.
In 1982, the United StatesJoint Commission on Accreditation of Hospitals
OCAH) has revised the standards- which took effect on 1 July 1983. These
revised standards which can be adopted for our hospitals are as follows:
Principle
Dietetic services shall meet the nutritional needs of patients.
Standard I
The dietetic department/service shall be organized, directed and staffed,
and integrated with other units and departments ofthe hospital in a manner
designed to ensure the provision of optimal nutritional care and the quality
of food service.
Interpretation
The relationship of the dietetic department/service to other units and
departments of the hospital shall be specified within the overall hospital
organizational plan or described in writing elsewhere. The scope of the
dietetic services provided to in-patients, as appropriate to ambulatory care
patients and patients in a hospital-administered home care program, shall
be defined in writing.
Direction
The dietetic department/service shall be directed on a full-time basis by
an individual who, by education or specialized training and experience, is
knowledgeablein food service management. The director shall be responsible
to the chief executive officer or his designate. The director shall have the
authority and responsibility of ensuring that established policies are carried
out; that overall coordination and integration of the therapeutic and
administrative dietetic services are maintained; and that a review and
evaluation of the quality, safety, and appropriateness of the dietetic
department/ service functions are performed.
I I
Staffing
Dietetic Services shall be provided by a sufficient number of qualified
personnel under competent supervision. The nutritional aspects ofa patient's
needs shall be supervised by a qualified dietitian duly registered with the
Professional Regulation Commission (PRe).
Outside Sources
When dietetic services are provided for by an outside food management
company, the company shall comply with all applicable requirements of the
manual, and the contract shall specify the compliance requirements.
Standard II
Personnel shall be prepared for their responsibilities in the provision of
dietetic services through appropriate training and education programs.
Interpretation
The education, training, and experience of the personnel who provides the
dieteticservices shall be documented and shall be related to eachindividual's level of
participation in the provision ofdietetic services. A formal training program may
be required as a prerequisite. Newpersonnel shall receive an orientation ofsufficient
duration and substanceprior to providingdieteticservices without directsupervision
and this orientationshallbedocumented. As appropriatetotheir level ofresponsibility,
such individuals shall receive instructions and should demonstrate competence in:
1. Personal hygiene and infection control;
2. Proper inspection, handling, preparation, serving, and storing of food;
3. Proper care and safe operation of equipment;
4. General food service sanitation and safety;
.5. Proper methods of waste disposal;
6. Portion control;
7. Writing of modified diets using the diet manual! handbook;
8. Diet instruction; and
9. Recording of pertinent dietetic information in the patient's medical
record
Personnel providing dietetic service shall participate in relevant in-service
education programs. There shall be a provision for participation of personnel
from all work shifts. The director of the dietetic department/service or the
director's qualified designates shall participate in planning and conducting
in-service education for dietetic personnel and, as appropriate, for other
hospital personnel. In-service education shall include safety and infection
control requirements described elsewhere in this manual. Outside educational
opportunities shall be provided, as feasible, to supervisory dietetic personnel.
The extent of the dietetic personnel's participation in continuing
education shall be documented, and shall be realistically related to the size
of the staff and the scope and complexity of the dietetic services provided.
Education programs for dietetic services personnel shall be based, at least in
part, on the results of dietetic department/service evaluations.
12
,
J
Standard III
Dietetic services shall be guided by written policies and procedures.
Interpretation
There shall be written policies and procedures concerning the scope and
conduct of dietetic services. Administrative policies and procedures
concerning food procurement, preparation, and service shall be developed
by the director of the dietetic department/service. Nutritional care policies
and procedures shall be developed by a qualified Nutritionist-Dietitian when
appropriate consent or approval have been obtained from the medical staff
through its designated mechanism and from the nursing department/service.
The policies and procedures shall be subjected to timely review, revised as
necessary, dated to indicate the time of the last review, and enforced. The
policies and procedures shall relate to at least the following: .
1. The responsibilities and authority of the director of the dietetic
department/service and, when the director is not a qualified dietitian,
of the qualified dietitian;
2. Food purchasing, storage, inventory, preparation, and service;
3. Diet orders should be recorded in the patient's medical record by an
authorized individual before the diet is served to the patient;
4. The proper use of and adherence to the standards for nutritional care,
as specified in the diet manual! handbook;
5. Nutritional assessment, counselling, and diet instruction;
6. Menus;
7. The role, as appropriate, of the dietetic department/service in the
preparation, storage, distribution, and administration of enteric tube
feedings and total parenteral nutrition programs;
8. Alterations in diets or diet schedules, including provision of food
service to persons not receiving regular meal service;
9. An identification systemfor patient trays, and methods used to assure
that each patient receives the appropriate diet as ordered;
10. Personal hygiene and health of dietetic personnel;
11. Infection control measures to minimize the possibility of
contamination and transfer of infection. This shall include the
establishment of a monitoring procedure (to ensure that dietetic
personnel are free from infections and open skin lesions), and the
establishment of sanitation procedures (for the cleaning and
maintenance of equipment and work areas, and the washing and
storage of utensils and dishes); and
12. Pertinent safety practices, including the control ofelectrical, flammable,
mechanical, and, as appropriate, radiation hazards.
Disaster Plans
The role of the dietetic department/service in the hospital's internal
and external disaster plans should be clearly defined. The dietetic
department/service should be able to meet the nutritional needs of patients
and staff during a disaster, consistent with the capabilities of the hospital
and the community served.
Hospital DietaryService Management Manual
Diet Manual/Handbook
A qualified dietitian, in cooperation with other dietetic staff and the
representatives of the medical staff, should develop or adopt a diet manual/
handbook and the standards for nutritional care specified therein should be
in accordance with those of the Recommended Dietary Allowances of the
Food and Nutrition Research Institute (FNRI). The nutritional deficiencies
of any diet not in compliance with the recommended dietary allowances
should be specified. The diet manual/handbook should serve as a guide in
ordering diets, and the menus served should be consistent with the
requirements specified. The diet manual/handbook should be reviewed
annually and revised as necessary by a qualified dietitian, dated to indicate
the time of the last review and any revisions made, and approved by the
medical staff through its designated mechanism. A copy of the diet manual/
handbook should be placed in each patient care unit. All master menus
and modified diets should be approved by a qualified dietitian.
Standard IV
The dietetic department/service shall be designed and equipped to
facilitate the safe, sanitary, and timely provision of food service to meet the
nutritional needs of patients.
Interpretation
Sufficient space and equipment shall be provided for the dietetic
department/service to store food separatelyfrom nonfood supplies; to prepare
and distribute food, including modified diets; and to clean and sanitize
utensils and dishes apart from food preparation areas. When storage facilities
are limited, paper products may be stored with food supplies. Sufficient
space shall be provided for supportive personnel to perform their duties.
Current reference materials shall be made available to dietetic personnel and
must be conveniently located in the dietary department/service.
fuod and non-food supplies shall be stored under sanitary, safe, and secure
conditions. The dietetic department/service facilities and equipmentshould comply
with federal, state, and local sanitation and safetylaws and regulations. .
The following precautions should be taken in the handling and
preparation of food:
1. Food is protected from contamination and spoilage;
2. Food is stored at proper temperatures, utilizing appropriate
thermometers, and maintaining temperature records;
3. Lighting, ventilation, and humidity are controlled in order to prevent
the condensation of moisture and the growth of molds;
4. Methods that minimize the opportunity for contamination are used
for making, storing, and dispensing ice. For example, ice should not
be scooped by hand, nor should food items or scoops be stored directly
on ice that is being stored for dispensing;
5. Separate cutting boards are provided for meat, poultry, fish, and rawfruits
and vegetables. Cooked foods should not be'cut on the sameboards usedfor
raw food preparation. Separate cutting boards may not be required when
thereare boards in use that are non-absorbent and capable of being cleaned
and sanitized adequately, and when the cleaning and sanitizing procedures'
areperformedproperlybetween usage for different food categories;
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6. All working surfaces, particularly food contact surfaces, utensils, and
equipment, arethoroughlycleansed and sanitized between periods of use;
7. Adequate toilet, handwashing, and hand-drying facilities are
conveniently located throughout the department;
8. Dish-washing and utensil-washing equipment and techniques that assure
sanitized serviceware and prevent recontamination, including monitoring of
proper temperature maintenanceduring cleaning cycles, areused;
9. Plastic ware, china, and glassware that has lost its glaze or is chipped
or cracked, is discarded;
10. Disposable containers and utensils are discarded after usage; and
11. Movement of unauthorized individuals through food preparation and
service areas is controlled in order to decreasethe risk of contamination
and improve operational efficiency.
Safety shall be ensured by providing at least the following precautions:
1. All walk-in refrigerators and freezers on the premises, whether they
are in use or not, can be opened from the inside;
2. There is insulation of, or protection from, hot and cold water pipes,
water heaters, refrigerator compressors, condensing units, and heat-
producing equipment;
3. Food and non-food supplies are clearly labeled;
4. A review is conducted on the hospital preventive and corrective
maintenance and safety programs as these relate to the dietetic
department/service, and actions are taken based on the findings of
the review. The review and actions taken shall be documented; and
5. All food is procured from sources that process the food under regulated
quality and sanitation controls. This does not preclude the use of
local produce.
The holding, transfer, and disposal ofgarbage shall be done in a manner
that will prevent the proliferation of insects, rodents, and vermin, and will
not otherwise permit the transmission of diseases. Containers must be
leakproof and non-absorbent with tight-fitting covers, and it is recommended
that impervious liners be used.
Standard V
Dietetic servicesshall be provided to patients in accordance with a written
order of the responsible practitioner. All appropriate dietetic information
shall be recorded in the patient's medical record.
Interpretation
The qualified dietitian or authorized designate shall enter dietetic
information into the medical record as specified, and in the location
determined, by those performing the medical record review function. These
determinationsshall be made by the medical record committee if and when
one exists. The qualified dietitian or authorized designate is responsible for
documenting appropriate nutritional information in the medical record.
on the request of the appropriate medical staff member. Such documentation
may include:
15
1. Confirmation of the diet order by the responsible practitioner within
24 hours ofadmission for those patients receiving oral alimentation,
and within 24 hours for all subsequent orders for a diet modification;
2. Summary of the dietary history and/or nutrition assessment, when
the past dietary pattern is known to have a bearing on the patient's
condition or treatment;
3. Timely and periodic assessment of the patient's nutrient intake and
tolerance to the prescribed diet modification, including the effect of
the patient's appetite and food habits on food intake and any
substitution made;
4. Description ofthe diet instructions given to the patient or family and
assessment of their diet knowledge; and
5. Description or copy of the diet information forwarded to another
institution upon patient discharge. Ifnutritional care follow-up reverts
to the practitioner's office or a health care agency, this should be
noted in the patient's record.
Standard VI
The quality and appropriateness of nutritional care provided by the
Dietetic Service should be reviewed and evaluated regularly.
Interpretation
The director of the dietetic department/service, in consultation with a
qualified dietitian (when the director is not a qualified dietitian), shall be
responsible for ensuring that a reviewand evaluation of the appropriateness
and effectiveness of nutritional care is accomplished in a timely manner.
The reviewand evaluation program should also include the nutritional care
provided to in-patients and, when applicable, to ambulatory care patients
and patients in a hospital-administered home care program. The review
and evaluation shall be performed at least annually and shall involve the use
of the medical record and the pre-established criteria. The review and
evaluation shall include data gathered from the medical, nursing, and dietetic
staff and should be performed within the overall hospital quality assurance
program. The quality and appropriateness of dietetic services provided to
the hospital by outside sources shall be included in the review and evaluation
on the same regular basis.
The following quality control mechanisms shall be implemented:
I. All menus are evaluated for nutritional adequacy;
2. There is a means of identifying patients who are receiving oral intake;
3. Tray identification is monitored;
4. Not more than 15 hours elapse between the serving of the evening
meal and the next substantial meal for patients who are on oral intake
and do not have specific dietary requirements;
5. As appropriate, the nutrient intake of patients is assessed and recorded;
6. As appropriate, patients with special dietary needs receive instructions
relative to their diets, and an indication of the patient's (or family's)
understanding of these instructions is recorded in the medical record;
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7. As appropriate, patients who are discharged from the hospital on
modified diets should receive written instructions and individualized
counselling prior to their discharge;
8. Qualified dietitians participate in committee activities concerned with
nutritional care;
9. A maximum effort is made to ensure the <appetizing appearance,
palatability, proper serving temperature, and retention of the nutritional
value of food. Whenever possible, patient preferences shall be respected
and appropriate dietary substitutions shall be made available; and
10. Surveys to determine patient acceptance of food are encouraged,
particularly in the case of long-staying patients.
17
18
DIETARY HUMAN
RESOURCE MANAGEMENT
HOSPITAL EMPLOYMENT PRACTICES
RECRUITMENT
Opportunities for government employment shall be open to all qualified
individuals and positive efforts shall be exerted to attract the best qualified
applicant to enter the service.
Employees shall beselected on the basisoffitness, determinedbythe appointing
authority, to perform the duties and assume the responsibilities of the positions,
whether in the competitive or in noncompetitive service, as well as on the basis of
merit as provided for in the Civil Service lawand rules.
Qualifications and an appropriate examination shall be required from
the applicant for appointment to positions in the competitive service in
accordance with the Civil Service Rules and as embodied in PO 1286. Only
the registered Nutritionist-Dietitian who successfully passed the Nutritionist-
Dietitians' Board Examinations; given once a year by the PRC, shall be
considered for appointment to the classified/professional positions in the
Dietary Service, and are therefore legally authorized to practice dietetics in
government or private hospitals, with a bed capacity of 25 or more.
No written examinations shall be required for positions such as cooks
and food service workers. Some points to consider in the recruitment for
these positions include: age, experience, basic education and knowledge,
aptitude, capacity, skills, character, physical fitness, and potential for growth
and development. In recruitment, there should be a wide selection and
careful placement of applicants for the present job. The procedure in the
recruitment process includes:
I. Surveying the source of labor supply (personal contact, newspaper
advertisements, employment agencies, schools, etc.);
2. Filling-up of an application form by the applicant;
3. Giving a series of tests to gauge the aptitude and ability of the applicant;
4. Checking the applicant's work experience, school records, and personal
references;
19
5. Interviewing the applicant to evaluatethe factors not revealed by tests
.and to determine their ability in relation to the job opening;
6. Selecting the person most qualified for the particular opening; and
7. Undergoing a physical and medical checkup
HIRING
When the applicant has passed the requirements and is chosen for the
position, his/her application papers are finally processed by the Personnel
Department.
Medical Examination
All employees must undergo a complete medical checkup annually, and must
secure a health certificate issued by the respective government health office.
Chest X-ray, blood test, stool culture, and throat culture must be done
for each employee every year. In cases where an employee has a positive
finding, he/she will be allowed to rest for a period of time deductible from
his/her sick-vacation leave credits, as the case may be.
Number of Working Hours
The normal number of working hours is 40 per week (excluding meal
hours). Each employee must render a total of eight hours of work a day.
Shift schedules should be rotated in order to be fair to all employees. In
some cases, employees are scheduled on a broken shift duty when there is a
lack of personnel. As much as possible, such schedules should be avoided.
The Nutritionist-Dietitian-in-charge prepares the monthly time schedule
at least 15 days in advance to enable the employees to know their tour of
duty ahead of time. (See DSFormNo.2, Employees Schedule for the Month).
He/she also has the authority to make changes in the schedule whenever
necessary.
Leave of Absence
The following are the leave privileges enjoyed by employees:
1. Vacation Leave -granted to employees and allowed for personal reasons.
The.grant of a vacation leave is contingent upon the necessities of the
service.
2. Sick Leave - taken by an employee for reasons of his/her own sickness
or that of any member of his/her immediate family.
3. Maternity Leave - granted to married women employees in case of
pregnancy or by reasons of confinement, abortion, or miscarriage, in
addition to the vacation and sick leave to which they may be entitled.
Personnel Entitled to a Leave of Absence
After six months of full-time employment, each employee is entitled to
a 15-day vacation leave and a 15-day sick leave for each calendar year of
service with full pay, exclusive of Saturdays, Sundays and holidays. Any
absence within the first six months shall be without pay. The total vacation
and sick leave that can be accumulated to the credit of any employee shall,
in no case, exceed ten months.
20
In case of pregnancy, married women employees are entitled to a
maternity leave of not more than 60 days in addition to the vacation and
sick leave allowable, under the following conditions:
I. Married women employees who have rendered two or more years of
coritinuous service under regular and permanent appointment are
entitled to 60 days maternity leave with full pay;
2. Those who have rendered less than two years of continuous service
under regular and permanent appointment are entitled to 60 days
maternity leave with half pay;
3. Those who have rendered two or more years of continuous service
under provisional/temporary appointment are entitled to 60 days
maternity leave with half pay;
4. Those who are under provision/temporary appointment and have
rendered less than two years of continuous service are entitled to a
number of days of maternity leave with pay based on the ratio of 30
days of maternity leave to two years of continuous service; and
5. Those who have passed the Civil Service examination given before the date
of application for maternity leave, but the results of such examination were
released after the dateof application,areentitled to maternity leave grantedto
regular employees as of the date when said examination were given.
Granting of Leave of Absence
Granting of vacation leave depends upon the needs or demands of the
service and the discretion of the Nutritionist-Dietitian-in-charge.
Sick leave shall be granted only on account of sickness on the part of
the employee concerned or of any member of his immediate family. A
medical certificate from a government physician must be presented by the
employee before returning to work if the sick leave is five days or more.
TERMINATION
Termination of employment could be a voluntary resignation on the
part of the employee. In this case, resignation papers must be filled out and
submitted by the employee one month before the date of his resignation
takes effect. Clearance from any obligation should be checked prior to the
termination of employment.
Employment may be terminated due to failure to perform assigned duties,
incompetency, dishonesty, laziness, and insubordination. Unpleasant
personality, undesirable traits, stubbornness, and habitual absenteeism are
also grounds for dismissal. ~
The termination procedure is as follows:
I. The employee is notified about his termination;
2. The employee is given a chance to express himself/herself with regards
to his/her termination;
3. A final interview is given and the reasons for his termination are
reviewed; and
4. In some cases, the employee may be recommended for a lower position.
-
Depa-rtme,nt of Health
\ ~ ~ ""11\ ~
D330
H108.45 H79d
2 I
Employee Discipline
The following are declared to be grounds for disciplinary action in
accordance with the provision of the Civil Service laws and rules (PD No.
807, dated 6 October 1975):
1 Dishonesty
2. Oppression
3. Misconduct
4. Neglect of duty
5. Disgraceful and immoral conduct
6. Beingnotoriously undesirable, which is of common knowledge
7. Discourtesy in the course of official duties
8. Inefficiency and incompetence in the performance of official duties
9. Receiving for personal use a fee, gift, or othervaluable things in thecourse of
official duties or in connection therewith when such fee, giftor othervaluable
things are given byanyperson in thehopeor expectation of receiving a favor
or better treatment than that accorded to other persons, or committing acts
punishable under the anti-graft laws
10. Conviction of a crime involving moral turpitude
11. Improper or unauthorized solicitation of contributions from subordinate
employees and byteachers or school officials fromschool children
12. Violationof existingCivil Service laws and rules, and reasonable office
regulation
13. Falsification of official documents
14. Frequent unauthorized absences or tardiness inreponing forduty, loafing, or
frequent unauthorized absences from duty duringregular office hours
15. Habitual drunkenness
16. Gambling prohibited by law
17. Refusal to perform official duty or to render overtime service
18. Disgraceful, immoral, or dishonest conduct prior to enteringthe service
19. Physical or mental incapacity or disability due to immoral or vicious habits
20. Lending money at unreasonable interest rates
21. Borrowing money by superior officers from subordinates or lending
by subordinates to superior officers
22. Willful failure to pay debts or willful failure to pay taxes due to the
government
23. Contracting loans of money or other property from persons with
whom the office of the employee concerned has a business relation
24. Pursuit of private business, vocation, or profession without the
permission required by these rules or existing regulations
25. Insubordination
26. Engaging directly or indirectly in partisan political activities
27. Conduct prejudiced against the best interest of the service
28. Lobbying for personal interests or gain in the legislative halls and
offices without authority
22
I
29. Promoting the sale oftickets inbehalf ofprivate enterprises that are
not intendedfor charitableor publicwelfarepurposes andeveninthe
latter cases ifthere is no prior authority
30. Nepotismas definedin section 49 ofthis decree
Thecodeofethics shouldbeobservedbytheprofessional staff (SeeAppendix,
Code ofEthics)
EmployeeEvaluation
The New Performance Appraisal System, which is basically oriented
towards performance resultsandwhichis expectedto effectlinkagebetween
Management by Objective (MBO) and performance evaluation, has been
prescribedfor adoptioninthe career serviceeffective1January 1979.
There shallbe two rating periods during the year, one from January to
June and the other, fromJulyto December.
The supeIVisor should rate the employee's performance at the end of every
rating period Therating that is given to the employee should be discussed with
bimlher. Points of disagreement about therating should be settled at this stage so
that satisfactory supeIVisor-subordinate relationship maybe maintained.
The superior shall rate the employeeusing the Performance Appraisal
Report Form. Only one form is adopted for rating both supervisory and
non-supervisory personnel. (See DS Form No. lA, Performance Targets
Worksheet andDSFormNo. lB, Civil ServicePerformance Appraisal Report)
Five adjective ratings which are given corresponding point scores are
provided in the system. They are: Outstanding, Very -Satisfactory,
Satisfactory, Fair, andUnsatisfactory.
Importance ofthe Ratings
An employee needsarating ofsatisfactoryorhigher tobeeligiblefurpromotion
as well as fur grade increase. An employee with an"Outstanding" rating shall be
recommendedfor anincentive award Theefficiencyrating shall be oneofthebasis
indetenniningtheretention ofanemployeeincase ofareductionintheworkfurce.
Anemployee\\<hocontinuouslyreceives anefficiencyratingof''Unsatisfilctory''\Wl
be separated from the service, or reassigned to a position inwhich helshe could
expectedtodo satisfactorywork
FUNCTIONS ANDMANAGEMENT SKILLS OF
THENUTRITIONIST-DIETITIAN
A Functions:
1. Chief Nutritionist-Dietitian - One who plans, organizes, and
directs all activities ofthe department including educational
and research programs. Major functions are to plan diets,
provide nutrition informationfor patients and the health care
tools, and to counsel patients about diet and nutrition.
2. Administrative Nutritionist-Dietitian - One who plans,
organizes, develops, anddirectsfood serviceprograms within
budgetary limitations and in accordance to the principles of
nutrition andmanagement; developsstandardsofprocurement,
production, and services; maintains sanitary standards and
safetymethods inthe department; analyzes and keeps up-to-
date job descriptions and specifications for all positions;
23
standardizes recipes and supervises their use; supervises
selection and training of nonprofessional food service
personnel; assists in the maintenance of records for
department planning and financial management; and
evaluates work procedures, employees utilization,
physical layout and equipment.
3. Therapeutic Nutritionist-Dietitian - Onewho plansanddirects the
preparation andserviceofmodifieddietsprescribedbythephysician.
4. Teaching Nutritionist-Dietitian - One who plans, organizes,
andteaches courses or conducts educational programs related
to normal and therapeutic nutrition.
R Management Skills:
The management skillsneeded for the Chiefand/or Administrative
Nutritionist-Dietitian are as follows:
l Organizational Skills
a Plansandorganizesthe servicebasedon the objectives;
b. Establishes priorities and allocate resources; and
c. Encourages and participates in research
2 Financial Skills
a Interprets financial statements;
b. Preparesbudgets;
c. Plans the utilization of resources in department;
d. Forecasts manpower requirements; and
e. Continuallyupdatesmanagerial andtechnical knowledge
3. Educational Skills
a Creates, conducts, and evaluates orientations and in-
service training programs
4. Communication Skills
a Motivates andleads employees;
b. Maintains close 1iaison with the hospital administration;
c. Maintains records; and
d. Publishes results ofthe department's research
5. Political-NegotiationSkills
a Understands politicalprocesses inthe work place; and
b. Uses lobbyingto achieve objectives
6. TechnicalFood ServiceManagement Skills
a Designs menus and evaluates acceptance;
b. Standardizesrecipes;
c. Develops specifications for procurement offood and
equipment;
d. Establishes and maintains standards of
Production and service
Sanitation
Safety
24

e Plans kitchen layout designs; and
f Determines equipment requirements
7 Personnel Management Skills
a Appoints, appraises, and dismisses the staff;
b. Develops job descriptions and specifications;
c. Educates and trains the staff; and
d. Directs the staff
C. Skills needed for Therapeutic or Clinical Nutritionist- Dietitians
and/or Teaching Nutritionist-Dietitians
1 Communication Skills
a Knows and understands the needs of the target
audience; and ,<
b. Recognizes the most effective use of audio-visual
techniques and the media
2. Education Skills
a Methodology;
b. Planningand use ofavailable resources;
c. Report-writing skills;and
d. Research and work evaluation skills
3. Skills ofBehavioral Change
a Recognizes the relationship between' knowledge,
attitude, and behavior change; and
b. Acquires group therapy and behavior modification
techniques
4. TeamWork
a Has group dynamic skills;
b. Recognizes the skills of other professionals in
education and behavior change; and
c Acquires the ability to work as a team with people
other than medical professionals
TRAININGAND DEVELOPMENT
OFDIETARYPERSONNEL
Trainingand development ofpersonnel inthe Dietary Service is essential
for efficient andeffective food serviceoperation. Through training, employees
gain effectiveness in their present or future work by the development of
appropriate habits of thought and action, skills, knowledge and attitudes
towards his job. Training of personnel is one of the best ways to increase
overall efficiencyofthe Dietary Service: It is the responsibility ofthe head
ofthe service to see to it that the training ofemployees is done periodically
and conducted in the proper manner. '., .
Continuing education ~ h l i l be one of the main concerns in the
management of food service. This includes training programs' for new
employees, on-the-job training or in-service training for both old and new
employees, and training employees for supervisory and other management
positions.
25
Nutritionist-Dietitian student affiliation program can also be conducted
in the hospital's Dietary Service, provided the service is recommended for
accreditation by the Health Manpower Training and Development Service
(HMTDS) of the DOH. This training is for graduating students majoring
in Nutrition and Dietetics. The main objective of the program is to provide
actual experience and training in the clinical, administrative, educational,
and research phases of dietetics.
The following is an example of a training program for Dietary Service
employees focused on Food Service Awareness Program:
"The function of the Dietary Service is to provide the best food for
all groups in the hospital, the patients and personnel as well. Well-
oriented and trained employees can be expected to render service
effectively and will be better equipped to give the needed performance
in accordance with the organization's goals and objectives. Hence,
workers should be constantly reminded of the important role they play
in the total organizational set-up. If the food offered has variety, is well-
prepared and attractively served by trained employees, the patient leaves
the hospital with an agreeable impression of his care during
hospitalization."
Objectives:
I. To increase the food service employee's awareness of the relationship
of nutrition to health as well as the role of quality food service in
the maintenance of health;
2. To develop, among the food service personnel, a greater knowledge
of their duties, responsibilities, and rights; with the view towards
improving their attitude and work habits;
3. To be familiar with the organization and roles of the hospital: and
4. To be aware of and apply good human relations.
Participants
Cooks and Food Service Workers
Methodology
I. Lectures with visual aids;
2. Actual demonstration;
3. Film strips; and
4. Evaluation
Operating Details
I. Time Schedule
a. Duration of the course
b. Daily Schedule: Monday to Friday
c. Time: 2:00 to 3:00 PM
2. Place - To be determined by the coordinator
3. Records - Attendance sheets
26
Syllabus
The following are suggested seminar packages, each consisting of
several sessions on basic information and skills requirements needed
for cooks and food service workers..These seminar packages are to be
conducted on separate occasions, depending on the availability of the
participants and other factors that have to be considered.
Seminar I . Basic Foods and Nutrition
1. What food means to people
2. Nutrition and its relation to health
3. How the body uses food
4. Major Food Nutrients - function and sources
5. Food groupings
6. Nutrition needs related to the life cycle
a. Maternal food needs
b. Food needs of infants
c. Food needs of pre-schoolers
d. Food needs of school age children and adolescents
e. Food needs of the elderly
7. Food fads and fallacies
Seminar II - Basic Principles of Food Preparation and Sanitation
1. Understanding food buying and proper storage
2. Menu planning
3. Portion control and measurement
4. Canned foods label reading and comparative food buying.
5. Food preparation principles and basic terminologies
6. Sanitation and safety
7. Work simplification
8. Nutrition conservation in food preparation
9. Communicable, food, ana water borne diseases
10. Specific food handling procedures
11. Personal Hygiene
Seminar III . On the lob Orientation
1. Organization and management of the Hospital and Dietary Services
2. Policies and procedures of the Hospital and Dietary Services
3. Duties and responsibilities of dietary personnel
4. Developing proper attitude toward:
a. Patients
b. Co-workers
c. Supervisor
d. Agency
5. Self-analysis of the role of the Food Service Worker and/or Cooks
in the Dietary Service and the. hospital as a whole
27
Seminar N - Basic Diet Therapy
1. Fundamentals of Diet Therapy
2. Regular or Full Diet
3. Soft Diet
4. Liquid Diet
5. LowSalt or Sodium-restricted Diet
6. LowFat and Low Cholesterol Diet
7. Low Purine Diet
8. Low Residue Diet
9. Diabetic Diet
10. Low Calorie Diet
11. Tube Feeding
12. Hypo-allergenic Diets
I3. Other Modified Diets
.,
ORGANIZATION AND STAFFING PATTERN
OF THE DIFFERENT HEALTH CARE LEVELS
IN THE DIETARY SERVICE
Organization
The Dietary Service constitutes 4-5% of the total number of hospital
employees. The Chief Nutritionist-Dietitian who heads the Dietary Service
is directly responsible, either to the Chief of Hospital (COH) or to the
Hospital Administrative Officer (depending on the category level of the
hospital) for the organization and administration of its patient care program
of activities.
The Chief Nutritionist-Dietitian performs a dual role or responsibility.
Thi, .ncludes administrative responsibility to the COH and coordination
of the professional activities of the dietary staff in relation to those of the
medical, administrative staff, and the community. In carrying out these
responsibilities, the Chief Nutritionist-Dietitian is assisted by either the
Assistant Chief or Senior Nutritionist-Dietitian (if there is any), or by the
members of the Dietary Staff (again, depending on the category level of the
hospital) who share in the administrative and supervisory functions for the
coordination of both the administrative and clinical activities.
In addition to the administrative responsibility, the Chief Nutritionist-
Dietitian exercises direct supervision over the clinical, education, research,
teaching, and training activities of the service. He/she coordinates the
professional activities of the Dietary Service with the nursing, medical, and
administrative units. He/She shares these administrative and supervisory
responsibilities with the Assistant Chief Nutritionist-Dietitian or the latter's
designate. The staff Nutritionist-Dietitians in-charge of each phase assists
the Chief and the Assistant Chief in the coordination of the different
activities of the Dietary Service.
28
In a Secondary District Hospital (25 to 50 bed capacity), the cooks and
food service workers are directly responsible to the Nutritionist-Dietitian.
In a Tertiary Provincial (100-199 beds) and in a Tertiary Regional Hospital,
(200 to 249 beds) these workers are directly responsible to a food service
supervisor for both food production and food service activities, while in a
Tertiary Regional (250-299 beds) and Tertiary Medical Center, (300 beds-
above), the direct responsibility for these two activities is vested on the
Nutritionist-Dietitian and the Food Service Supervisor.
Organizational Chart
The organizational chart is the most valuable means of presenting
authority, responsibility, and relationships among the dietary personnel and
with other service units of the hospital. It is a graphic form of delineating
all of the above, showing how the parts relate to the whole. Through it,
existing relationships can be checked and clarified. An organizational chart
must be clear, simple, and illustrative.
The DietaryService organizationcan be visualized as a triangle, with the base,
resting on the shoulder of the workers, supporting the apex which represents the
Nutritionist-Dietitian, who, as head of the service, is responsible to the COHo All
policies, rules, and guidelines towards the effective realization of the nutrition goals
of the hospital shall emanate from the Nutritionist-Dietitian.
GUIDELINES IN THE STAFFING PATTERN
The staffing needs for the Dietary Service can be determined by studying
the specific tasks performed. The study should identify:
1. What tasks are needed to be completed and at what specific times
daily?
2. What must be accomplished daily, but not necessarily at a specific
time?
3. What needs to be done at other intervals such as semi- weekly, weekly,
and semi-monthly?
The number and skill level of employees needed at a critical period is
identified for a full day operation. Other duties are then divided between
these workers. Considering each eight hours of employee time as a Full
Time Equivalent (FTE), it takes at least 1-2/5 full-time equivalents, working
five-days a week, to fill each position. To allow for fringe benefits, 1-3/5 full-
time equivalents may be allowed for each position. A department requiring
6-1/2 full time equivalents would need a 10-2/5full time equivalents, working
five days each, to staff a seven-day week (6.5 FTE x 1.6 = 10.4 FTE).
Another method for planning the staff uses the number of minutes of labor
required to serve one meal to one personas its base. This example uses 14 minutes
for each meal served. The standard variable is 9-15 minutes per meal.
1. (Number of Patients) x (21 meals/week) + (Guests/Employee Meal/
Week) = (Total Meals/Week)
2. (Total Meals/Week) x (14 Minutes) = (Labor/Week in Minutes)
3. (Labor/Week) +(60) = (Labor/Week in Hours)
4. (Hours/Week) - (No. of Hours Full-time Employee Works) =
(Approximate Number of Full-time Employees Needed, including
Supervisor and Relief Workers)
29
A third formula, based on the average number of dietary employees in
hospitals of varying sizes and locations, is to divide the total bed capacity
of the facility by eight to find rough estimates of the total number of dietetic
service employees needed, including the relief personne1.'
The scope of service and functions of the Dietary Service also serves as
the primary guidelines for determining the staffing pattern for the
organization. Efficient dietary care depends on the number and quality of
dietary personnel on duty at all times.
PD No. 1286, as promulgated on 20January 1978 states that all hospitals,
whether government 0: private with a 25 to 75 bed capacity shall employ a
minimum of one Nutritionist-Dietitian; above 75 to 150 bed capacity, a
minimum of two Nutritionist- Dietitians; above 150 to 250 bed capacity, a
minimum of three Nutritionist-Dietitians; above 250 to 500 bed capacity, a
minimum offour Nutritionist-Dietitians, and above 500to 1,000 bed capacity,
a minimum of five Nutritionist-Dietitians, provided that no person shall be
employed as a Nutritionist-Dietitian in any hospital without having been
registered in accordance with the provisions of the decree.
Various graphing forms may be used for evaluating the effectiveness of
a dietary staffing pattern. The analysis should show such concerns as:
1. Labor distribution throughout the day
2. Labor distribution at peak periods
3. Unscheduled employee time
4. Time devoted to specific tasks
5. Tasks done at inappropriate times
6. Employees doing tasks above or below their skill level
Z Lunch or break times scheduled inappropriately
The analysis information will assist in making recommendations for
changes such as:
1. Increase/decrease in labor hours
2. Changes in scheduled work hours
3. Changes in task distribution
4. Changes in lunch or break times assigned
5. Job descriptions and job schedule preparation
Table 1 on page 31 shows the hospital's standard requirements of
personnel for the Dietary Service in the DOH. It indicates the total number
of personnel, which varies according to the bed capacity. The higher the
bed capacity of the hospital, the more employees are needed.
Table 2 on page 31 shows the proposed Dietary Service Staffing Pattern for
hospitals with a capacityof 10400 beds. This proposed staffingpattern was based
on the data gathered from the survey conducted from different health care levels
underthe DOH With theuseofthistable, theCOHand! or Hospital Administrative
Officer will be guided on the required number of personnel in the Dietary Service
based on the hospital'sbed capacity. At the sametime, this could be usedas a guide
in checking and evaluating whether the service is over or under staffed on each of
the various positions of personnel in the service.
'Cuidelines for Consultant Dietitian's In Long-Term Care Facilities. The
American Dietetic Association, August, 1977
30
Table 1
Ministry of Health
Bureau of Medical Services
., Manila
HOSPITAL STANDARD REQUIREMENTS
FOR PERSONNEL
AUTHORIZED BED CAPACITY
DIETARY
SERVICE
PERSONNEL -25 25 50 100 150 200 250 300 350 400 450
DIETITIAN 1 1 1 2 2 3 5 5 7 7 8
FOOD SERVICE 1 1 1 1 1 1 1 I
SUPERVISOR
COOK 1 1 1 2 3 5 5 5 7 8 11
FOOD SERVICE 1 2 4 5 9 10 12 14 14 18 19
WORKER
Table 2
DIETARY SERVICE STAF.FING PATTERN
(10TO 400 BEDS), 1990
POSITION BED CAPACITY
,25
25 50 100 200 300 400
Nutritionist-Dietitian IV 1 1
Nutritionist-Dietitian III . 1 1 1
Nutritionist-Dietitian II I 1 1 2 2 2
Nutritionist-Dietitian I 1 1 2 2 2 2
Food Service Supervisor II 1
Food Service Sunervisor I 1 1 1 1
look II 1 1 z. z z
Cook I 2 2 2 3 3 4 4
Food Service Worker (FSW) 2 3 4 8 12 15 16
GRAND TOTAL PERSONNEL 4 7 9 16 23 28 30
Career Path: ND IVin Medical Center can be promoted to Administrative Officer.
Position, providedtheyhave the necessary experience, educational attainment (MPA,
MHA, or MBA). Similarly, all ND Ill, II & I can riseto the rank of AOin Provincial/
District hospital, .
31
,.
JOB DESCRIPTIONS OF STAFF
AND PERSONNEL
A job description is a written summary which details the duties and
responsibilities of a particular job. It explains to the staff or personnel, his
authority (i.e., his right to make decisions) and his responsibility (i.e., the
degree to which he is expected to achieve something); The purpose of a job
description is to define exactly, for a worker, fellow-workers, and supervisors,
what the worker is expected to do, what standard he is expected to reach, to
whom he is responsible, and whose work he supervises.
The following are the job descriptions of the hospital staff and personnel
under the DOH.
A. Nutritionist-Dietitian IV
Under the direction of the COH, the Nutritionist-Dietitian N
supervises all activities of the Dietary Service in a Tertiary Medical
Center or hospital with an authorized bed capacity of 350 and above.
General Functions, Duties, and Responsibilities
1. Shall plan, organize, direct, supervise, and evaluate all activities of the
Dietary Service
a. Shall establish long and short range objectives for the Dietary
Service consistent with the goals of the institution
b. Shall interpret and recommend Dietary Service objectives,
policies, and standards to the administration
c. Shall plan an effective budget and proper human resources
management
d. Shall plan, organize, direct, and evaluate the total food service to the
patients and personnel: purchasing specifications for facilities and
materials, food production, sanitation, and safety standards
e. Shall develop and maintain an organization chart of the
Dietary Service showing the responsibilities and authorities
of all personnel
f. Shall delegate responsibilities and dutiesto competent subordinates
g. Shall supervise the maintenance of cost control, personnel
records, and reports
h. Shall participate in conferences of department heads, and
professional and community activities
I. Shall coordinate the activities of the Dietary Servicewith those
of other services
J. Shall establish and maintain effective .intra- and inter-
departmental communication systems
2. Shall plan, organize, direct, and evaluate the educational program of
the Dietary Service
a. Shall develop and maintain an active and effective staff
development program
b. Shall. participate in the formulation and maintenance of an
effective and continuous program for the orientation, training
and supervision of personnel
32
Hospital Dietaryservice saanagememtvtartua:
c. Shall plan and participate in the development and execution
ofeducational programs for Nutritionist- Dietitians, nursing,
medical and other students of allied professions
3. Shall plan/organize, direct, and evaluate the research program of the
Dietary Service
a. Shall develop and implement research programs in
administration, food production, normal and therapeutic
nutrition and education
b. Shall cooperate with and assist in medical research related in
nutrition and dietetics
Qualifications:
1. Must have passed the examination for Nutritionist-Dietitians and is
qualified in accordance with the provision of PD 1286
2. Mustbea Master ofScience graduate or must havegained at least twenty-four
(24) units of graduate studies or isa holderofa certificate of fellowship for at
least one (1) year in the field of nutrition and dietetics
3. Must have at least six (6) years of experience in the Dietary Serviceof
the hospital, three (3) years of which should be of supervisory level in
food service work
Procedures for Filling Yacancy
In case of a vacancy, the Nutritionist-Dietitian IVshall be selected from
among the Nutritionist-Dietitian III, provided they posses the above-
mentioned qualifications.
Should there be more than one qualified applicant to the said position,
the Individual Assessment Form shall be used and the following factors
taken into consideration:
1. Performance
2. Education and training
3. Experience
4. Physical characteristics and personality traits
5. Potential
B. Nutritionist-Dietitian III (Administrative)
Under the direction of the CQH, the Nutritionist-Dietitian
III is responsible for the administrative, therapeutic, and
educational aspects of food preparation and service in a Tertiary
Regional Hospital with an authorized 200 to 300 bed capacity.
However, in a Tertiary Medical Center or in a 350-bed
capacity and above, the Nutritionist-Dietitian III serves as an
assistant to the Nutritionist-Dietitian IV and acts as
Administrative Nutritionist-Dietitian. He/she assists in the
supervision of all the Dietary Service activities, particularly in
the management of the food service system.
33
...
General Functions. Duties and Responsibilities
1. Procurement
a. Shall plan, develop, implement, and evaluate food supply
requirementsof patients and personnel within the set budgetary
limitations
b. Shall inspect and accept all deliveries of foodstuffs for accurate
quantity and proper quality in accordance with specifications
set by the service
c. Shall maintain high standards of food refrigeration and
storage;
d. Shall maintain complete and accurate records of daily
purchases, issues, payments, and inventories offood supplies
e. Shall assist in the establishment ofspecifications, requisitions,
and purchases offood supplies and small equipment according
to established specifications to meet menu and census needs
f. Shall participate in facility planrting and selectionofequipment
2. Food Production
a. Shall plan, develop, implement, and evaluate preparation,
cooking, and apportiorting offood for patients and personnel
within the set budget limitations. It should be in accordance
with nutritional principles in order to maintain and improve
the nutritional status of patients and personnel
b. Shall plan, with the Nutritionist-Dietitian in-charge of the
patient's food service,the regular and modified patient menus
according to established patterns.
c. Shall direct the preparation of food within an established'
production system followingstandardized recipes, preparation,
service methods, and food handling techniques to ensure
quality standards
d. Shall develop menu patterns and evaluate client's acceptance
e. Shall assist in the maintenance of records for planning and
control of service
f. Shall maintain and improve high standards of sanitation,
safety, and accuracy
g. Shall analyze, develop, and update job description/
specifications and work schedules
h. Shall plan the master schedule of personnel
I. Shall recommend improvements for facilities and equipment
J. Shall participate in budget development and implementation
of a system of cost control procedures
k. Shall identify problems in food service and/or III the
production system
3. Food Service
a. Shall mortitorfood service for conformity withquality standards
b. Shall check food issued to the wards and the dining room
c. Shall supervise food distribution
d. Shall keep organized records of meal census
34
4. Education Program
a. Shall assist in seIeaing, scheduling andconduaingorientations, in-
service training andeducational programs for personnel
b. Shall maintain a routine personnel evaluation program
c. Shall develop standard professional and ethical practice
involving professional advancement andcontinuingeducation,
particularly in administrative management .
5. Shall participate in professional meetings and conferences
6. Shall perform additional duties incooperation with other hospital services
7. Shall assume the duties of the Nutritionist-Dietitian N if and-when
actingas the head of the service .
Qyalifications:
qualified in accordance with the provision of PO 1286
2. Must be a holder of a Bachelor's Degree conferred by a respectable
and legally constituted school, college or university, with nutrition
and dietetics as the major study .
3. Musthave at least four (4) years of experience in thedietarydepartment,
two (2) years of whichshould be of supervisorylevel
Proceaures for Filling Vacancies
In case of vacancy, selection for the Nutritionist- Dietitian III shall be
made from among the Nutritionist-Dietitian II, provided they possess the
above-mentioned qualifications.
Should there be more than one applicant to the said position, the
Individual Assessment Form shall be used and the following factors taken
into consideration: .
1. Performance
3. Experience
5. Potential
C. Nutritionist-Dietitian II (Clinical).
Under the direction of the COH, the Nutritionist-Dietitian II
directs and supervises the administrative, therapeutic, and educational
aspects of food preparation and service in a Secondary District or
Tertiary Provincial Hospital withan authorized 75 to 150 bedcapacity.
However, the Nutritionist-Dietitian II serves as an assistant to the
Nutritionist-DietitianIII inaTertiaryRegional Hospital with a200bed capacity
andacts as Clinical Nutritionist-Dietitian in a hospital with an authorized
bed capacityof250 andabove oracts as regular staffNutritionist- Dietitian in
aTertiaryMedical hospital with anauthorized bedcapacityof300andabove.
As such, he/she isresponsible for thenutritional care of individual orgroups
for health maintenance.
35
1. Shall plan nutritional care of patients and formulate improved
techniques and procedures in the preparation and servicing of regular
and modified diets to patients
2. Shall adapt and modify menus in accordance with the needs of patients for
the maintenance or improvement of nutritional status, as well as evaluate
food consumed, and provides counselling in principles of nutrition
3. Shall supervise the preparation of special diet food to ensure proper
quantity, quality, and accuracy of ingredients
4. Shall verify accuracy of diets served to patients
5. Shall observe patient's acceptance of diets and make notations in
appropriate forms
6. Shallmonitor the system for transmissionofpatient'sdiet orderand changes
Z Shall communicate appropriate dietary history and nutritional care
data through the record system;
8. Shall consult physicians concerning dietary prescriptions and
implement these through meals that are adapted to the needs of
individual patients
9. Shall participate in health team rounds and serve as a consultant on
nutritional care
lQ. Shall assist in the establishment of an efficient food delivery system
to the patients;
11. Shall instruct patients and family on normal nutrition and routine
diet modifications using effectiveteaching techniques
12. Shall analyze, develop, and update job descriptions and specifications
for diet therapy section personnel
13. Shall maintain high standards of sanitation and housekeeping in all
areas and units involved in diet therapy
14. Shall maintain effectivewritten and verbal communications and public
relations in the intra- and inter-departmentallevels
16. Shall participate in the in-service education for dietaryemployees and staff
lZ Shall perform additional duties, as assigned, in cooperation with other
hospital services
18. Shall.carry out established policies
19. Shall take charge of the malward if necessary
20. Shall assume the duties of the Nutritionist-Dietitian III or N if and
when acting as the head of the service
Qualifications
qualified in accordance with the provision of PD 1286
2. Must be a holder of a Bachelor's degree conferred by a respectable and
legally constituted school, college, or university, with nutrition and
dietetics as the major study
3. Must have at least two (2) years ofexperience in the dietary department
of the hospital, one (1) year of which should be of supervisory level
36
Procedure for Filling Vacancy
In case of vacancy, selection for the Dietitian II shall be made from
among the Nutritionist-Dietitian I, provided they possess the above
mentioned qualifications.
the Individual Assessment Form shall be used and the following factors
1. Performance
3. Experience
5. Potential
D. Nutritionist-Dietitian II (Teaching-Training)
Tertiary Provincial Hospital with an authorized 75 to 150 bed capacity.
However, the Nutritionist-Dietitian serves as an assistant to the
Nutritionist-Dietitian III or as teaching-training Nutritionist-Dietitian
in a Tertiary Medical Center with an authorized bed capacity of 300
or more, and is responsible for planning, conducting, 'and evaluating
educational programs of the service. .
1. Shall develop, conduct, and evaluate training and other educational
programs to meet the needs of the dietetic, medical, nursing, and
other allied health programs
2. Shall plan and conduct orientation and in-service educational
programs for the organization personnel
3. Shall prepare, evaluate, and utilize current educational methodology and
instructional medical methods to enhancelearningexperience ofstudents
4. Shall maintain accurately detailed data records related to the unit
5. Shall participate in the nutrition education of dietetic apprentice,
nursing, and medical students
6, Shall contribute expertise as a member of the organization's team for
planning and evaluation, and participate in committees and other
organizational activities "
7. Shall analyze, develop, and update job descriptions and specifications
for teaching-training unit personnel
8. Shall maintain high standards of sanitation and housekeeping in all
areas and units involved in teaching and training
10. Shall perform additional dutiesin cooperationwith other hospital services
11. Shall carry out established policies on education and training
12. Shall assume the duties of the Nutritionist-Dietitian III or N if and
when acting as the head of the service
37
Qualifications
qualified in accordance with the provision of the PD 1286
2. Must be a holder 'of a Bachelor's Degree conferred by a respectable
and legally constituted school, college, or university, with nutrition
and dietetics as the major study
3. Must have at least two (2) years ofexperience in thedietary departmentofthe
hospital, one (1) year ofwhich should have been ofsupervisory level; must
have at least one (1) year experience in teaching
In case of vacancy, selection for the Nutritionist-Dietitian II shall be
made from among the Nutritionist-Dietitian I, provided they possess the
above-mentioned qualifications.
the Individual Assessment Form shall be used and the following factors .
1. Performance
3. Experience
5. Potential
E. Nutritionist-Dietitian II (Education and Research)
Tertiary Provincial Hospital with an authorized 75 to 150 bed capacity.
However, the Nutritionist-Dietitian II serves as an assistant to the
Nutritionist-Dietitian III and acts as Education and Research
Nutritionist-Dietitian in a Tertiary Medical Center with an authorized
bed capacity of 300 and above, and is responsible for the overall food
service system researches.
1. Shall plan, organize, and conduct or participate in nutrition care
studies, food and food serviceresearchprograms, as well as innovative
programs, technological advances, and implementation of new
nutrition care programs
2. Shall evaluate and utilize appropriate methodology and tools to carry
out programs
3. . Shall evaluate.and communicate findings
4. Shall maintain accurate and detailed records related to the unit
5. Shall interpret, evaluate, and utilize pertinent and current researches
related to the program's needs
6. Shallplanor participate in thedevelopment of project proposals for funding
7. Shall plan, conduct and evaluate dietary studies and participate in
epidemiologic studies with a nutritional component
38
8. Shall study and analyze recent scientific findings in dietetics for
application in current research and for interpretation to the public
9. Shall utilize human and material resources efficiently and effectively
10. Shall analyze, develop, and update job descriptions/ specifications
for education and research unit personnel
11. Shall maintain the high standards of sanitation and house-keeping in
all areas and units involved in education and research
13. Shall perform additional duties, as assigned in cooperation with other
hospital services
14. Shall assume the duties of Nutritionist-Dietitian III or N if and when
acting as the head of the service
Qualifications
3. Must haveat least two (2) yearsof experience in the dietary department
of the hospital, one (1) year of which should be of supervisory level
Procedure is the same as the process enumerated in filling the vacancy.
for the Nutritionist-Dietitian II (Teaching-Training).
F. Nutritionist-Dietitian I
Under the direction of the CQH, the Nutritionist-Dietitian I directs
and supervises the total food service in a Secondary District hospital
with less than the authorized 75-bed capacity.
However, he/she servesas an assistant to.the Nutritionist- Dietitian
II in a hospital with an authorized 75 to 150 bed capacity, and as such,
he/she functions either as the administrative or clinical Nutritionist-
Dietitian.
For Tertiary Regional and Tertiary Medical Center or a hospital
with an authorized bed capacity of 200 and above, the Nutritionist-
Dietitian I assumes the role of clinical, education, or research
Nutritionist-Dietitian.
For a teaching-training hospital, the Nutritionist-Dietitian I acts
as a Teaching-Training Nutritionist-Dietitian.
The general functions of the Nutritionist-Dietitian I would greatlydepend
upon the authorized bed capacity of the hospital. For a hospital with less
than 75 authorized bed capacity, the Nutritionist-Dietitian I acts as the head
of the service and therefore, assumes the functions and responsibilities of
the Nutritionist-Dietitian IV
39
For a hospital with an authorized bed capacity of 100-150, the Nutritionist-
Dietitian assumes the duties of an assistant to the Nutritionist-Dietitian II,
and thus, performs the functions and responsibilities of the Nutritionist-
Dietitian II (clinical) or the Nutritionist-Dietitian III (administrative).
For a hospital with an authorized bed capacity of 200 and above, the
Nutritionist-Dietitian I acts as an assistant to the Nutritionist-Dietitian II
and performs the duties and responsibilities of the Nutritionist-Dietitian II
(teaching- training).
Qualifications
3. If acting as Teaching-TrainingNutritionist-Dietitian, he/she must have
at least one (I) year of experience in teaching
Procedure in Filling Vacancy
In case of vacancy, selection for the Nutritionist- Dietitian I shall be
made from among the Food Service Supervisor II (or I in other hospitals),
provided they possess the above- mentioned qualifications.
G. Food Service Supervisor
Under the direction of the COH, the Food Service Supervisor
assists in supervising and directing the activities of a food service
group in a Tertiary Provincial, Tertiary Regional Medical Center or
hospital with an authorized bed capacity of 100 and above.
1. Shall assist in the supervision of food production and serving of
meals to patients and personnel
2. Shall assist in the supervision and maintenance of cleanliness in all
working areas
3. Shall assist in the maintenance of safety standards
4. Shall assist in the maintenance and improvement offood service standards
5. Shall cater to specialized service functions in the hospital
6. Shall conduct daily inventories of all dietary equipment and utensils
7. Shall assist in instructing employees in the maintenance and care of
equipment in food service
8. Shall record meals census
9. Shall prepare patient's tray diet card or tags
10. Shall attend the regular meetings of the food service or other
departments
11. Shall perform additional related tasks as may be assigned by the
immediate supervisor or head of service
12. Shall assume the duties of the Nutritionist-Dietitian I in the latter's absence
40
Qualifications
1. Must have completed at least two (2) years of study in Bachelor of
Science in Nutrition and Dietetics
2. Must have one (1) year of supervisory level experience in food service
institutions
Preference would be given to those who are from the service, provided
that the above mentioned qualifications are met at the time of the
appointment.
Should there be more than one qualified suitable applicant to the said
position, the Individual Assessment Form shall be used and the following
factors taken into consideration:
1. Performance
? Education and training
3. Experience
5. Potential
H. Cook II
Under general supervision, the Cook II prepares and cooks menu
items for hospital in-patients and guests, if any, and supervises assistant
cooks in the preparation and cooking of food in a hospital with an
authorized bed capacity of 50 and above.
1. Shall provide overall supervision of the preparation and cooking of
meals
2. Shall prepare and cook meals according to planned menus for in-
patients and for special functions in the hospital
3. Shall coordinate work assignments of assistant cooks and food service
workers assigned as cook's helpers in maintaining quality standards
in the preparation and cooking of meals
4. Shall check and reviewwork of food serv.ce workers
5. Shall prepare daily storeroom requisitions needed for the preparation
of meals
6. Shallkeep records ofsupplies received and consumedfor inventorypurposes
7. Shall report to the immediate supervisor any leftovers for proper usage
and storage
8. Shall assist in the instruction and training of new cooks and food
service workers
9. Shall assist or givesuggestions on menu planning and the preparation
of the duty schedules of subordinates .
10. Shall assist in the standardization of recipes and portion control
11. Shall maintain sanitary standards in the preparation, apportioning,
and storage of food
41
12. Shall be responsible for the proper care and maintenance of equipment
in the unit
13. Shall perform other related tasks as may be assigned by the immediate
supervisor, when the need arises
14. Shall assume the duties of the Food Supervisor 1in the latter's absence
Qualifications
1. Must be a high school graduate
2. Must have atleast five (5) years of experience in cooking native and
foreign meals in any food service institution
3. Must have a Testimonial Civil Service eligibility
I. Cook I
Under general supervision, the Cook I prepares and cooks menu
items for hospital in-patients, especially those with modified diets,
and supervises food service workers in the preparation and cooking
of food in all hospital categories.
The general functions, duties, and responsibilities of the Cook I depends upon
the authorizedbedcapacity of the hospital For hospitals withless than 50beds, the
Cook I shall performthe functions as described in Cook II.
For hospitals with 50 beds and above, the Cook I acts as an overall
assistant to the Cook II, and shall perform the functions of the Cook II in
the latter's absence.
Qualifications
1. Must be a high school graduate
2. Must have at least three years of experience in the general preparation
and cooking of meals in any food service institution
3. Must have a Testimonial Civil Service eligibility
J. Food Service Worker (FSW)j Utility Workers
Under immediate supervision, the FSW performs a variety of
unskilled manual duties in the kitchen in the preparation and service
of food to hospital in-patients and personnel.
(Note: Depending on the type and bed capacity of the hospital, the
following may be assigned to one or more Food Service Worker).
1. Shall assist in food preparation work such as:
a. Peeling, washing, trimming, and cutting of fruits and vegetables
b. Weighing, washing, cleaning, and cutting meat and poultry
c. Washing, scaling, and cutting of fish and shellfish
2. Shall unload purchases from the delivery vehicles to the proper storage
areas. and carry these food supplies from the storeroom to the food
preparation area, as needed
42
3. Shall collect the diet lists from the different wards
4. Shall apportion food for distribution; both in patient's tray services,
as well as in the cafeteria counter, if there is any
5. Shall prepare spices, condiments, and mixed flavoring materials for
ingredients, according to instructions, as needed in the day's menu
6. Shall clean the kitchen and other premises; dispose of garbage; and
keep the kitchen and the dining room free from insects and vermin
7. Shall collect, clean, and return used trays, plates, and silverware to the
kitchen storage area after every use
8. Shall assist in cookingrice, and the preparationofdailymidnight snacks, if
any
9. Shall distribute food to the patients, in the different wards, or in self-
service cafeteria counter to the hospital personnel (if there is any
cafeteria), or on special occasions/functions in the hospital
10. Shall, during catering services for special functions; set the tables
.with linen, plates, and silverware; shall serve the food prepared
accordingly; and shall likewise collect dietary supplies after the catering
service for cleaning and storage of the same
11. Shall clean counter tables, dining room tables, and chairs (if cafeteria
service exists) after every mealtime
12. Shall defrost refrigerators and freezers
13. Shall maintain the orderliness and cleanliness of the storeroom area
14. Shall assume the duties of the cook in the latter's absence, from time
to time as may be assigned by the Nutritionist-Dietitian
15. Shall performotherrelated tasks asperinstructionofthe immediate supervisor
Qualification
1. Must have a high school diploma or at least have taken a high school course
K. Clerk I (Dietary Clerk-Typist)
Under the direction of the head ofthe Dietary Service! department,
[he dietary Clerk-Typist is responsible for general office routine work
in a hospital with an authorized bed capacity of 200 and above.
1. Shall perform general office clerical routines
2. Shall receive and transmit telephone messages ,
3. Shall type menus, schedules of personnel, requisitions, purchase orders,
payment vouchers, receipts, etc.
4. Shall cut stencils, mimeographs, duplicate menus ana other forms
5. Shall post bulletin board memoranda and announcements
6. Shall keep time records and/or attendance cards
7. Shall keep records of "applications for leave"
8. Shall prepare accident reports
9. Shall prepare requests for therepair of equipment
10. Shall type and keep minutes of the regular dietary staff and personnel
meetings/conferences
43
11. Shall request office supplies for dietary service use
12. Shall maintain cleanliness and sanitation in the office
13. Shall perform other related functions as may be assigned to him/her
by the head of the service
Qll;ilifications
I. Must have taken at least a college level education
2. Must be at least second grade eligible or must have passed the Civil
Service Subprofessional examination
3. Must be knowledgeable in typing and other office management
procedures
4. Must have good command of the English language
5. Must have at least one (1) year of clerical experience
Procedure in Filling Vacancy
In case of vacancy, those from within the Dietary Service should be
given priority, provided that there is a deserving FSW who can meet the
qualifications .needed at the time of vacancy.
L. Dietary Store Aide
Under general supervision, the Dietary StoreAidereceives, records, and
issues all dry goods needed for the preparation of meals for hospital in-
patients and personnel in a hospital with a capacityof 300beds and above.
I. Shall keep accurate records and perpetual inventory ot all stocks in
the Dietary Service
2. Shall collect daily requisitions needed for next day's use, as approved
by the Nutritionist-Dietitian in-charge
3. Shall receive and post on stock cards, accurate quantities of dry good
items delivered
4. Shall issue correct ingredients as requisitioned by the cooks
5. Shallsubmit a list of standing storeroomstocks that needs to be replenished
6. Shall maintain proper cleanliness and sanitation in the storeroomarea
7. Shall maintain proper storage procedures such as "FIFO" (First-In-
First-Out) system of issuance, as well as proper labelling
8. Shall perform other related functions as assigned to him/her by the
Nutritionist-Dietitian in charge
Oualifications
1. Must have at least two (2) years of college education
2. Must be knowledgeable in typing and preparation of written reports
44
ADMINISTRATION AND
MANAGEMENT
The Head of the Dietary Service must think and act like a manager if
the objectives of the department, as well as the overall objectives of the
hospital, are to be met. This means accepting and carrying out certain basic
responsibilities. In any operation, regardless of type or size, the manager is
the person responsible for getting things done by planning, organizing,
directing, and controlling the use of resources. These are the basic
management responsibilities.'
The resources of the Dietary Service are food supplies, facilities and
equipment, personnel, time, and money. In carrying out management
responsibilities, the Chief Dietitian uses these resources to meet the objectives
of the service and the hospital as a whole.
One of the most important areas of human activity is managing. It is
the task of the Chief Dietitian to establish and maintain an internal
environment wherepeople working together in groups can perform effectively
and efficiently towards the attainment of the group's objectives. It rests
upon the shoulders of the Chief Dietitian the responsibility of undertaking
those actions to ensure their best contribution towards group objectives.
Since management emphasis is on the internal environment of the
organization, no Chief Dietitian can perform these tasks well unless he/she
has a clear understanding of and is responsive to the many elements of the
ethical, social, economic, political, and technical environment which affect
his/her area of operation.'
Although the number of managerial levels varies with the size and
complexity of the institution, any person with management responsibilities
must have the appropriate skills and the necessary knowledge to meet the
job requirements. Likewise, although the titles and the scope of supervisory
responsibilities differ among various health organizations, the skills and
knowledge needed to be effective are common to all.
'M. Mahafey, M. Mennes and B. Miller, Food Service Manual for Health
Care Institutions, (American Hospital Association, 1981).
'E. R. Velasco, Practice Management. (FLC Press, Oct. 1984)
45
In the administration and management of the Dietary Service, the
following aspects must be considered:
BUDGETING
Budgeting is a method ofestimating future needs and their concomitant
cost in terms of personnel, logistics, or time frame of an organization. It
covers all activities for a specified period and contains details of expected
needs. It is an essential management tool which serves as the basis for
comparison and control, especially for expenditures.
The following are guidelines for the preparation of the Dietary Service
budget:
1. The dietary budget must be divided into three categories: food,
personnel, and operating expenses.
2. The Chief Nutritionist-Dietitian is responsible for the economical
and efficient financial management of the service. He/she must
establish priorities planned for the period covered by the budget.
3. New'leeds for both personnel and materials should be included with
the supporting data and justifications.
-,
4. The Budget Office should allocate the food budget based on per capita
per day. The per capita allowance per patient per day is determined
by the COH. This is based on the recommendation of the Chief
Nutritionist-Dietitian after due consideration of the current cost of
food and standards of food service to be maintained.
COST CONTROL
Cost control is a management tool used for determining and evaluating
performance. With cost control, the efficiencyor inefficiencyofthe operation
can be determined, thus, unfavorable trends can be traced, hit and miss
practices prevented, and corrective measures applied to ensure satisfactory
completion of a task as planned. .
Cost control is the responsibility of the whole Dietary Service as it
affects all its aspects. Where policies and procedures in cost fail, the aim of
the service remains unsatisfactorily fulfilled. It is therefore imperative that
the varied aspects of cost control be considered.
I. Types of Costs
Cost varies according to service. In dietetics, these are classified as
food cost, labor cost and operating costs.
A. Food Cost - This embraces the cost of all food items bought by the
Dietary Service. Ideally, these are controlled through a careful
consideration of the following factors:
I. Menus
2. Type of service
3. Purchasing methods
4. Receiving controls
5. Storage and storeroom control
6. Preparation, cooking, and leftover controls
46 I
7. Standardized portions
8. Waste materials
9. Method of pricing
10. Employee's meal cost
High food cost often results from a faulty implementation of
procedures. The following are recommended cost containment
measures that can be used in the major areas of the Dietary Service:
1. Menu Planning
a. Take into account time, day, weather, and temperature
b. Avoid monotonous menus
c. Utilize correct menu patterns
d. Maintain proper balance between high and low cost
items
e. Consider food supplies available in the market
f. Consider the appearance of the food on the plate
g. Price menu items correctly
h. Consider the type and amount of labor required for
various menu items
J. Consider the type and amount of equipment needed
in the preparation of the menu items
2. Purchasing
a. Purchase sufficient supplies
b. Obtain foodstuffs at reasonable cost
c. Avail of the detailed set of specifications governing
quality, weight, type, etc.
d. Make use of competitive purchasing policies
e. Centralize purchasing power and responsibility
f. Establish good relationships with purveyors
g. Maintain proper cost budgets for purchasing
h. Audit invoices and payments
I. Use fixed instead of flexible orders
J. Avoid graft between purchasing agent and purveyors
k. Avoid speculative purchasing
3. Receiving
a. Avoid theft among receiving personnel
b. Have an updated record of price trends
c. Check prices, quality and quantity properly
d. Maintain a proper system for obtaining credit
e. Check receiving methods and procedures properly
f. Use adequate facilities (such as weighing scales)
g. Use proper receiving equipment
h. Record and check goods received diligently
47
4. Sorting
a. Store perishable foods immediately upon delivery;
b. Place foods properly in storage areas
c. Maintain proper storage temperature and humidity
d. Practice daily inspection of foods stored
e. Observe proper sanitation in dry and refrigerated
storage areas
f. Avoid theft in the storeroom
g. Have periodic reports on dead stock or record of
inventory turnover
h. Conduct regular physical or perpetual inventories
1. Have a written policy of personnel's responsibility for
food storage
5. Issuing
a. Observe proper control in recording foods issued from
the storeroom .
b. Have proper authority or responsibility for requisition
and issues
c. Properly priced foodstuffs and supplies issued
6. Preparing
a. Provideadequate mechanical equipment, for deboning,
slicing, cutting, curving, trimming, and peeling
b. Avoid excessive trimming of vegetables and meats
c. Check rawyields properly
d. Use leftover foodstuff properly
7. Cooking
a. Avoid overproduction
b. Use proper methods of cooking
c. Cook at proper temperature
d. Avoid long cooking time
e. Use proper scheduling
f. Use standardized recipes
g. Clean and maintain equipment properly
h. Cook in small batches, if possible
8. Serving
a. Use standard portion sizes
b. Use standard size utensils for serving
c. Consider leftovers for a recycled menu
d. Record food served before it leaves the kitchen
e. Bring or serve food to consumers on time
f. Avoid spillage, waste, etc.
48
9. Controls
a. Forecast cost budget
b. Record price trends and determine the best time to
buy food supplies
c. Check on authority and responsibility of personnel
d. Use forms for control purposes

e. Use systematic procedures and policies for control
purposes
f. Account for employees' and visitors' meal properly
B. Labor Cost This refers to cost of services rendered in the Dietary
Service. The following factors affecting labor cost are:
L Type ofservice
2. Hours of service
3. Menu patterns and the form in which the food was purchased
4. The physical plant
5. Equipment and its arrangement
6. Personnel policy and its productivity
7. Efficiency of the supervisor
8. Rate of employees turnover and standards to be maintained
9. Wage scale and fringe benefits
Ways of Reducing Labor Cost are:
L Use reasonable cost machines to replace or assist manual work
2. Rearrange kitchenand dining room layouts to save time and steps
3. Apply work simplification in all tasks
4. Schedule employees to fit work flow
5: Develop interest and cooperation among employees to increase
productivity
C. Operating Cost and Other Expenses- Control should not end with
the control of food and labor cost. It should extend to operating and
other expenses which are either fixed or variable.
L Fixed expenses such as depreciation, etc.
2. Variable expenses such as supplies (office, papers, cleaning
utensils, equipment, etc.), utilities (fuel, light, telephone, water),
and services (laundry, pest extermination, repair and
maintenance, etc.)
II. Records
Records are basic tools in cost control. They contain the data
needed to determine how the Dietary Service functions. Records vary
with the type and size of the service, the policies set, the data desired,
and how these can be obtained efficiently and with the least cost.
Records likewisediffer with the type of the service where they will
be used. For the Dietary Service, the following records are used:
49
A. Procurement and Receiving Records
1. PurchaseOrder-A written record of items ordered by telephone
or by personal delivery. It lists the items, quantities desired,
and specifications.
It is usedbythe managementas a check againstdeliveries, to be
surethat whatwas ordered was received. (See DS FormNo.3, Dietary
Order Slip for Bidder Items and DS Form No. 4A,Open Market
Purchase Slip)
2. Invoice - The official receipt that accompanies the delivery of
goods. This is checked against the items received and against
the purchase order for correctness. Pricesand totals are checked.
For open market purchases, a statement of daily market
purchases should be used.
3. Delivery Record - A permanent record of the date of purchase,
vendor, quantity received, and the price of each individual
item. The primary purpose of this record is to have
information on prices for costing recipes and for storeroom
issues and inventories. (See DS Form No.5, Daily Delivery
Record Book)
B. Storeroom Records
1. Storeroom Requisition and Issue Record- Awrittenrecord of items
to be issued from the storeroom. (See DS Form No.6, Supplies
Requisition and Issue Form)
2. Perpetual Inventory - a "running" record of the balance on
hand for each item of goods in the storeroom. The items
received are posted from the invoices and added to the previous
balance on hand. As 'items are taken out, they are deducted
from the total. A physical count of each item should be made
regularly to ensure that the total on record reconcile with the
total on hand. (See DS Form No. 7, Dietary Service Perpetual
Inventory)
3. Physical Inventory - An actual count of the quantities of food
supplies on hand at the end of the accounting period, which
can either be daily, weekly, or monthly.
C. Production Records
1. Menu - A list of food items to be included in each meal. (See
DS Form No.8, Regular Weekly Menu and DS Form No.9,
Therapeutic Weekly Menu)
2. Standardized Recipe- a recipe which has been tested in a given
situation and has repeatedly produced good results. (See DS
Form No. 10, Standardized Recipes)
3. Production Record - A record of the amount of food to be
prepared, the resulting quantities of cooked food available to
be served, the total number of servings obtained from a given
amount of food and the quantities of leftovers. This record
helps in forecasting the said information. (See DS Form No.
llA; Production Record Sheet Regular Meals; DS Form No.
llB, Production Record Sheet Therapeutic Diets; DS Form
No. 11 C, Cook's Copy Patient Service; and DS Form No. llD,
Cook's Copy Cafeteria Service)
50
r -
D. Dining Room Service and Patient Meal Census Records
1. Daily Meal Census - A form for recording the meal count.
(See DS Form No. 12, Daily Patient's Meal Census)
2. Diet List - A list of patients to receive a tray for the day. This
information is needed to determine the type and amount of
food to be prepared. (See DS Form No. 13, Diet. List)
3. Special Meal Record - A record of meals catered to hospital
visitors. (See DS Form No. 14A, Special Meal Request Form
and DS Form No. 14B, Special Menu Record Form)
MENU PLANNING
Menu planning is a basic and essential activity in the Dietary Service.
It is therefore important that policies and procedures, as well as guidelines,
should carefully be considered.
Menus must be planned to ensure that patients receivenourishing meals,
that a variety of food is provided, and that efficient and economic use is
made of supplies, labor, and equipment.
The following tools are needed in menu planning:
1. A set of standardized recipes arranged according to categories (soups,
entrees, vegetables, salads, and desserts)
2. A copy of the Food Order Guide (FNRI Publication No. 112)
3. A copy of the Guide to Good Nutrition (FNRI Publication No. 19)
4. Market quotation sheets showing current prices of meat, fish, fruits,
and vegetables available in season.
The following menu planning procedures can likewise serve as guides:
1. The Dietary Service should use a 15 to 30 day cycle menu for patients
and personnel. The factors to be considered are: budget available,
supplies, manpower, and equipment.
2. As much as possible, planned menus should include foods that are in
season and are available locally and should be within the skill and
capabilities of the dietary personnel. They should also be within the
capacity, condition, and scope of the available kitchen equipment.
3. A cycle menu should meet the nutritional requirements of the personto be
served. It must please and satisfy Differences in ethnic, religious, and cultural
background should be considered. The season of the year should also be
taken into account No matter hO)V well a meal is planned, prepared, and
cooked, it will not be appreciated if it is not served at the appropriate
temperature. Hot food should be served hot, and cold food should be
served cold.
4. Acycle menu should be used for the guidance of all production areas.
5. As much as possible, full diet menus should be adopted for modified diets.
6. A menu form should be used and it should be large enough to record
all menu items for the period for which menus are planned.
7. All recipes should be standardized. The sizes of the serving portions
should be established. Portions of 50 and 100 gm. are recommended.
51
8. Planned menus should give variety through the use of:
a. Color - A combination of colors makes the meal attractive
and appetizing besides providing the needed nutrients
b. Flavor- Usea mixtureof bland and strongly flavored food in meals
c. Texture - Include soft, crunchy, and chewy food in each of
the menus
d. Shape - Planfor a variety of shapes in preparing and serving food
9. The planned menus should be flexible
10. Leftovers, if any, should be made use of as much as possible.
11. Monthly menu conferences should be held among the Dietary Staff,
Nutritionist-Dietitian, Food Service Supervisor and SeniorCook or whoever
is acting as Chief Cook, to coordinate changes, suggestions, and newideas.
PURCHASING
Purchasing is an operational procedure through which food items and
other goods needed in the service are acquired.
Policies in purchasing vary among institutions, but the following
guidelines should be useful for all dietary services:
1. The Administrative Dietitian should be responsible for ordering the
needed foodstuffs based on the daily menu and patient census, with
the approval of the Chief Nutritionist-Dietitian and the COH.
2. Purchasing decisions should be determined by the following:
a. Type of people to be served
b. Size and location of the facility
c. Availability and prices of various items
d. Area available for storage of staples, refrigerated, and frozen
foods
e. Capabilities of the dietetic staff
f. Available equipment
g. Budget allocation
3. The person in charge of purchasing should strive to obtain the right
product at the right time, in the right quantity, and at the right cost.
a. Quality should be the first consideration. Foodstuffs ordered
or bought should be according to specifications. There should
be a written description of each item to be purchased.
b. These description should be simple but detailed enough to
ensure that the product bought is the right one. The
information can be listed on a filing card and should include
the name of the item, quality (grade, trade name), size (weight,
number of units per carton or case, or minimum-maximum
weight, quantity (cases, kilograms, pieces, cartons, etc.), and
the unit of pricing (per piece, per kilogram, per dozen, etc.).
4. Foodstuffs for use in the Dietary Service should be purchased either
by open market or competitive bidding.
a. The open market method is an informal way of buying and it
involves the following procedures:
52
(1) The buyer requests quotations on the specific food items
he/she needs, and for specific amounts and qualities from
one or more sources of supply. Requests for quotations
should be made at leasta day beforean order is given.
(2) The orderis placed afterconsiderationofthe priceinrelation
to quality, delivery, and other services offeredwiththeapproval
of the head of the service. Contact betweenthe buyer and
vendor ismadebytelephone, avisitto the market,or through
a salesmanwho callson the buyer.
It is recommended that an arrangement should be made
immediately, with the purveyor, to deliver daily or depending
upon the storage facilities available.
In an open market purchase, either the dietary staff goes
to the market, or foodstuffs are delivered by the purveyor.
There are advantages and disadvantages in either case:
(I) Advantages of actual purchase in the market
(a) Variety of choices available
(b) Price survey is current
(2) Disadvantages of actual purchase in the market:
(a) Lesser time spent in the supervision of the
Dietary Service when the Nutritionist-Dietitian
goes to the market
(b) Risk of losing cash and valuables
(c) There is time pressure (i.e., there is less time
spent for the selection of the best quality food)
(d) Possibility ofdelay in food preparation because
of unavoidable circumstances
(3) Advantages of a delivery by a purveyor:
(a) Manpower availability is maximized
(b) Less expenditure of time, energy and resources
like transportation, gasoline. manpower, etc.
(c) The food delivered willbe on time becausethe dealer
would like to maintain his/her businesscredibitity
(d) Food is prepared on time
(e) More time spent in the supervision of the
Dietary Service.
(f) No time pressure in terms of selecting the right
qualitysincethereis an option to reject any delivery
not within the specifications called for.
(4) Disadvantages of a delivery by purveyor:
(a) Price survey is not as current compared to
actually going to the market
(b) Possibility of patronizing only one supplier
For open market purchase, it is advisable that an arrangement be
made with purveyors to deliver foodstuffs in the dietary office.
53
b. Competitive bidding is a more formal way of purchasing
supplies. The procedure involves the following:
(1) Submission of written specifications and quantity
needed to vendors with an invitation for them to
submit prices for the items listed
(2) Request for bids are advertised in newspapers. They
are printed or mimeographed and distributed to
interested bidders at least a month before the bidding
is conducted. Bidding should be conducted quarterly
(3) For the DOH, policies and guidelines on deliveries of
foodstuffs to hospitals and sanitaria are embodied in
Administrative Order No. 90,s. 1%8 and in the General
Conditions of Bidding and Awards (See Appendix);
The following should be prepared when purchase is
done through bidding:
(a) Market orders prepared one week in advance
should be based on these items:
a!. Prepared menu (regular and therapeutic)
aZ. Food order guide
a3. Price list
a4. List of standing orders
a5. Average daily patient census
(b) Food items listed according to food groups
(c) Orders indicating the item, quantity, vendor,
and time and date of delivery written on the
purchase order sheet
(d) Written orders verified by approving officers
(e) Approved ordersto be presented to vendorsor dealers
5. Specifications of Food Items Commonly Purchased by the Dietary
Service. (see Appendix)
RECENING
Receiving is a management responsibility which involves making certain that
the items orderedare satisfactorily received in terms ofquantity and quality. Losses
will result when food of poor quality is delivered or items are under weighed. Extra
careshould be exercised in checking orders and weighingfood being received. The
following are suggested guidelines in receiving foodstuffs:
1. The receiving officer should be a staff Nutritionist- Dietitian or a
well-trained competent Dietary personnel. The agency inspector should
also be present.
2. There should be adequate facilities and equipment for receiving such as an
accurateweighingscale(large or small capacity), inspector's table, etc.
3. There should be an established delivery time based on the needs of
the hospital. .Pood items that need precooking should be ordered and
delivered in advance.
4. Purchase order slip must always be on hand to check all deliveries
against specifications and quantity called for.
54
Hospital Dietary Service Management n u ~ l
5. The following suggested procedures should be helpful:
a. Upon receipt of goods, they should be inspected for signs of
spoilage, infestations, mishandling, etc. Verify quantity with
the order as to size, count and weight.
b. The purchase order should be checked against the invoice.
c. When it is necessary to reject goods, the supplier should be
informed immediately. Rejected goods should be returned to
the dealer right away.
d. All delivery receipts should be signed bythe designated receiver and
countersigned bythe Chief Dietitianand the agency inspector.
e. All deliveries for the day should be listed in the daily Delivery
Record Book. (See DS Form No.5, Daily Delivery Record Book)
f. All food itemsreceived should be properlylabelled according to the
menu or preparation unit where it will be used. Deliveries not for
immediate use should be stored in the appropriate storage area to
control loss from pilferage, deterioration or infestation.
STORING
Storing is a responsibility supplementary to receiving. The proper storage.
of food immediately after it has been received and checked, is an important
factor in the prevention and control of loss or waste. Adequate space for
storage should be provided in a location accessible to the receiving and
preparation area. The following are suggested guidelines in storing foodstuffs:
1. AStoreAideor a trainedreliable Dietarypersonnelshould be in chargeofthe
storeroom, under the supervisionof a Nutritionist-Dietitian.
2. Upon delivery, foodstuffs should be properly stored. Perishable items
should be placed in a refrigerated storage and nonperishable items in
a dry storage.
3. All storage areas should be kept locked for adequate control against
loss and pilferage.
4. Dry storage areas should be clean and well ventilated. Windows should
be screened, walls and floors should be rat-proofed.
5. Refrigerators and freezers should be equipped with thermostats which
should be checked regularly and properly maintained. Overcrowding
of foodstuffs should be avoided, to aid the circulation of cold air.
6. The storeroom should be cleaned and sprayed regularly. Special care
should be given to the cleaning and spraying of dark corners and
spaces under the shelves.
7. Always maintain the recommended storage temperature for foodstuff.
8. Other guidelines for storage of specific foods are the following:
A. Staples and Canned Goods
(1) Groceries and canned goods should be stored in shelves
and grouped as follows:
(a) Coffee, Tea, etc.
Condiments
Cereals
Crackers
Nuts
55
(b) Pastas
PastryItems
Syrups and Preserves
Vinegar
Fats, Oils, Shortening
Sugar, Salt, Flour
Dried Vegetables
(c) Canned Vegetables
Canned Soups
Canned Juices
Canned/Dried Fruit
Canned Meat
Canned Fish
(2) Items should bestoredin alphabetical sequence in their
respective groups.
(3) Cereals, cereal products, anddryvegetables should beplaced
in metal containers with tight-fitting lids. Galvanized cans
mounted onrollers may beused furthis purpose. Containers
should beproperlylabelled. Theproduct should be inspected
frequently for insect infestations.
(4) Cereals, cereal products, dryvegetables, spices, condiments,
and canned goods should bekept in dry storage.
(5) Shelves or platforms should be raised at least sixinches
(6") above the floor.
(6) For stores placed against the walls, a two-inch (2")
leeway should be allowed.
(7) Canned goods should be marked with the date of delivery
and should beused according to a first-in-first-out basis. It
should beinspected frequently for swells and leaks.
(8) Evaporated milk should be placed in the coolest part
of the storeroom.
(9) Food packed inglass should bekept inclosed boxes as light
tends to injure the color and flavor of these items.
(10) Rice and flour sacks should be crossed stacked on a raised
platfurm(2-3 ft from thefloor) tofacilitate proper ventilation
B. Fruits and Vegetables
(I) Fruits andvegetables should be examined carefully before
storage. Items which are overripe and about to wilt or rot
should bestored separately for immediate use.
(2) Crates of fruits and vegetables should not be stacked
on the "bulge" sides. These should be cross-stacked
whenever possible to allow the circulation of air.
(3) Crates of fruits and vegetables should be placed in
accessible positions so that they may be used on
rotation basis, in the order of delivery or ripeness.
(4) Thoroughly ripened fruits and vegetables should be
used as soon as they are delivered.
56 j
(5) Ripe fruits and vegetables such as avocado, melon,
mangoes, bananas, and tomatoes should be kept in
the coolest part of the storeroom.
(6) During storage, fruits should be frequently sorted and
decaying pieces removed.
(7) Bananas should be kept in dry storage, never in the
refrigerator.
(8) Sweet potatoes should be stored away from the light,
in a moderately well-ventilated room (if possible with
a temperature of 40 - 60F). Potatoes are susceptible
to freezing and therefore should not be placed in a
refrigerator or where they may be frozen.
(9) Sweet potatoes,squash, and dry onions should bestored in
a well-ventilated area. Theydo not need refrigeration.
C. Dairy Products
(1) Milkand creamcontainers shouldalways betightlycovered.
(2) Egg crates should always be set in an upright position
and cross-stacked whenever possible to allow for good
air circulation.
(3) Eggs should not be stored for more than 3 days at
room temperature from the time of delivery, if they
are to be stored for more than three days, temperature
should be at 41 o - 43F.
(4) Butter should always be refrigerated.
(5) Cheese shouldbewrapped tightly to prevent drying. Freezing
cheese should be avoided to prevent breaks of grain which
causes crumbling. Storage temperature is 4l
0_'45F.
D. Meat and Meat Products
(1) The proper temperature of a meat freezer is 31- 42F
or 0- 20F.
(2) Fresh meat should be stored on the shelves, fat side up
except for large pieces of beef or hog carcasses which
should be hung on hooks.
(3) Meat should be stored awayfrom other foods. Foreign
flavors in meats may be traced to fresh fruits and
vegetables stored in the same refrigerator.
(4) As oftenaspracticallypossible, themeatshouldbesegregated,
beefnext to beef, etc., with space in between for circulation.
(5) Lightly-cured meat must be stored under refrigeration
and wrapped or covered to prevent odor from spreading
throughout the refrigerator.
(6) Ground meat should be used within 24 hours,
otherwise, it should be precooked or frozen.
(7) Processed meats should be placed on shelves with visible
labels. Issue should be on a first- in-first-out basis.
(8) Frozen meat which has been thawed should not be
refrozen but cooked at once.
(9) Cooked meat should be well-covered when stored.
57
E. Fish and Seafood
(I) Fish should be kept refrigerated at all times at a
temperature below 40
a
F.
(2) Fish should be orderly arranged when stored in order
to hold their natural shape better and longer.
(3) Fish which has been thawed should not be refrozen.
(4) Maximum storage life can be obtained by maintaining
a temperature of oaFor below.
ISSUING
Dietary supplies may be issued from the Dietary Service storeroom or
from the Property Section storeroom. The process of issuing foodstuffs
from the Dietary Service storeroom should follow the following steps:
I. Food should be issued only upon presentation of a properly prepared
and signed requisition slip.
2. The requisition slip must contain a list of all items and quantities
requested and must include the signature of the requesting personnel.
3. Prepared and duly signed requisition slips should be presented to the
storekeeper.
4. The storekeeper should dispense the food items requested and then
record them on the stock card.
5. The storeroom keeper shall be responsible for all food items issued out
,
Guidelines in Issuing of Supplies from the Property Section Storeroom:
I. Supplies like rice, soap, detergents, insecticides, office supplies, and other
food supplies for stocks should be requested from the PropertySection.
2. Requests should be written in the RN form (General Form No. 4S(A),
Requisition and Issue Voucher). Supplies requested should be based
on a weekly consumption.
3. The RN should be properly signed by the Chief Nutritionist- Dietitian
and approved by the COH.
4. The RN should be given to the Property Section storekeeper and the
Nutritionist-Dietitian or his/her designate should receivethe supplies
and endorse them to the dietary storekeeper.
5. The Dietary Service storekeeper issues the supplies to be used for the
day following the procedures mentioned earlier. The storekeepershould
record the supplies received and issued on the stock card or Supplies
Ledger Card. (General Form No. 48 (A))
FOOD PRODUCTION
Food production covers all phases in the processing and preparation of
food for patients and hospital personnel. Systems in food production vary
in accordance with supply, size of serving portions, number of patients and
personnel, and time of service. Use of standardized recipes and proper
cooking methods should be followed in order to attain a quality product
served in the Dietary Service.
58
In food production, standardized recipes are an important tool that
could be made available to all types of Dietary Service operations for
maintaining quality and cost control. A standardized recipe includes the
ingredients, quantities by weight or measure, procedure, the portions size,
and yield (DS Form No. 10, Standardized Recipes). It should be especially
adapted to the available equipment and capabilities of the food production
staff. Standardized recipes have the following advantages:
I. They ensure high quality products due to established standards of
quantity and quality of ingredients, as well as methods and techniques.
2. They ensure production of accurate quantities required tor the service.
3. They reduce confusion, tension, and product failure.
4. They provide the ~ s s for requisitioning and cost control.
5. They simplify employee training, and free the supervisor from
dependence on the whims and/or changes in production personnel.
The steps in standardizing recipes are:
I. Prepare the original recipe.
2. Evaluate the product for acceptability using a small selected panel.
3. If there are changes to be made, make one change at a time and record
all adjustments made. Run two or three trials to be sure a uniform
product can be produced.
4. Expand the recipe to yield 50 to 100 portions, whichever is desired.
Make sure that calculations are correct.
5. Prepare the expanded recipe at least three times or more until the
desired product is achieved. Use the same personnel for preparation
and the same panel for testing.
Cooking procedure is a very important process in food preparation.
The reasons for cooking food are:
I. To make food appetizing in appearance, nature and flavor
2. To make food more digestible
3. To destroy harmful bacteria
4. To make meals more interesting using variations in cooking methods
The general methods of cooking are:
I. Roasting and baking with air as the cooking medium.
2. Boiling, simmering, poaching, andstewingwithwater asthecooking medium.
3. Steam as the cooking medium.
4. Frying with the use of oil.
5. Direct transferenceor conduction and radiation through the container
as in baking waffles, griddle-cakes and parboiling.
6. Combination of the above mentioned methods as in braising and
fricasseeing.
59
Listed herein are suggestions in the preparation of specific food items:
A. Meat and Meat Products
1. The methods of cooking meat and meat products should depend
upon the quality and the cut of meat, facilities available for its
preparation and service, and the quantity that should be prepared.
2. Dry heat is recommended for tender cuts of meat and moist
heat cookery for less tender cuts.
3. It isrecommended for frozen meat to bethawed before cooking to
reduce timeand heavy drip losses duringpreparation.
4. Mechanical treatments such as pounding, scoring, cubing,
grinding, and the addition of meat tenderizersshould be used
for less tender cuts of meat to shorten cooking time.
B. Vegetables .
1. Cooking time for vegetables should be as short as possible to yield
thedesired tenderness, shape, andtexture andtoretain itsmaximum
nutritional values. Overcooking of vegetables should be avoided.
2. Vegetables should be cooked at one time in small quantities as
is feasible for the type of service.
3. Fresh, green, and strong-flavored vegetables should be cooked
in boiling water in an open kettle.
4. Ifvegetables are cooked inwater, asmall amount ofwater ispractical
and should be at boiling point before the vegetables are added.
5. Vegetables should be handled carefully and mashing should
be avoided at all times.
6. Legumes should be hydrated, if possible, by soaking them in
water to shorten cooking time.
7. Waterin which vegetables are cooked should be used in gravies
or soups to conserve soluble vitamins and minerals.
8. Cooking time of vegetables should be controlled so they will
be ready just at serving time.
C. Fish and Shellfish
1. Fish should be'cooked at lowto moderate temperature.
2. Fish should be cooked only until the flesh is easily separated from
thebones. Overcooking, especiallywiththedry heat methodshould
beavoided, otherwise, the fish would tum out very dry.
3. The method of cooking fish should depend on its fat content;
Fat fish are best baked and broiled as their high fat content
will keep them from becoming dry. Lean fish are best cooked
by boiling or steaming. All types of fish are suitablefor frying.
4. Frozenfish should be completely thawed before cooking. Fish,
once thawed, should be cooked immediatelyand not refrozen.
5. In the preparation of oysters and other 'shell fish, high
temperatures and long cooking should be avoided'to prevent
toughening and shrinkage.
6. Shrimps, crabs and lobsters should be veryfresh or if possible
alive at the time of cooking to get the best product.
.60
D. Poultry and Poultry Products
I. Poultry should be cooked at moderate heat so that the meat
will be tender; juicy, and evenly done.
2. Poultry products should be evenly cooked, fairly well- done,
but not overcooked.
3. Cooking methods should be suited to the age and condition
of the bird. Young, tender, and well-fatted birds are suitable
for broiling, frying, and roasting. Mature or lean ones should
be braised in moist heat and the old ones should be stewed or
boiled in water or cooked in steam to tenderize them.
4. Frozen poultry should be thawed first before cooking. Frozen
poultry, which has not been thawed, requires longer cooking
time than defrosted or freshly dressed ones.
5. Cooked poultry should be frozen if it is to be kept for more
than a day.
E. Eggs and Egg Products
The accepted standards for some commonly cooked egg products
are as follows:
I. A soft cooked egg should have white set but jelly like and
opaque; should haveyolk slightly set on outside but not firm.
2. A hard cooked eggshould have white which is firm but tender
and yolk that is firm but not rubbery. It should not have any
discoloration at juncture of yolk and white.
3. Apoached egg should have whitethat is setbut jellylike and opaque,
and yolkslightly set aswell veiled with light albumin covering.
_4. A scrambled egg should be moist but not watery, tender and fluffy
and should be free from traces of whiteor evidence of browning.
5. Omelet should be light, delicately brown and tender.
6. Fried egg should have white that is firm but not rubbery, free
from browning, crisping, or bubble, and the yolk should be
set but not firm.
7. Custard should be smooth, homogenous, firm but tender,
fine in texture and free from porosity or evidence of curdling.
Soft custards should pour evenly.
8. Cooked salad dressing should be homogenous, smooth, free
from curdling or separation, pours evenly and it should have
a glossy surface.
F. Milk and Milk Products
I. In dishes that use milk such as creampufffillings, milk should
not be heated in a pan directly in contact with the flame
unless the heat is regulated at a low temperature. To avoid
scorching, use a double broiler or a pan.
2. To avoid scum formation, milk should be stirred constantly
while cooking.
3. If cheeseis used in cooking, the right cheese should be chosen
for the purpose. Quick melt cheese is best for dishes that have
to be baked or grilled because it melts fast before shrinkage
'and toughening occur.
61
4. In blendingcheese with liquids, the temperatureofthe liquid should
be hot enough to melt the fat but not so hot as to toughen the
protein in cheese. Grating or grinding, beforecombining the cheese
with other ingredients, facilitates meltingwithout over heating.
G. Cereal and Cereal Products
I. Correct proportions of waterto cerea1s should be used to retain the
shapeand to preventdisintegration For rice, heat should be reduced
and the cooking pan covered tightly once all the water has been
absorbed. No stirring should be done at this point
2. Pasta (macaroni, spaghetti, etc.) should be cooked firm enough
for one to be able to bite into it, but not too soft to become
mushy. After cooking, pasta should be poured into a colander
or strainer and cooled with tap water.
3. Dry "bijon" should be soaked in water just enough to make
the pieces limp. It should be drained well before adding to the
other ingredients. The amount of liquid necessary depends
on the size of the "bijon."
4. "Sotanghon" should be washed and soaked in water, drained
well and cut with kitchen shears or scissors before adding the
other ingredients.
5. "Miswa" should be added directly to boiling broth or soup
stock. It should be stirred gently to distribute "miswa" and
cooked until done.
6. Fresh "rniki" should be added to the other ingredients with
just enough stock to complete the cooking of the noodles, as
it has a high moisture content.
7. "Canton" should be cooked with less liquid and for a shorter
time because it has been precooked.
H. Starches
I. Topreventlumping, other ingredients in the recipe should be mixed
with the starch to separate the granules. W-lter should be added
gradually with constant stirring to make a smooth paste.
2. Starches must be cooked five minutes longer after reaching
maximum gelatinization point which occurs at 90Cto ensure
complete swelling and gelatinization.
3. Scorching should be avoided by thorough dispersion of starch
particles, by adding enough water, control of temperature,
and adequate stirring with occasional scraping of the sides of
the pan.
4. For a softer and more tender gel, starches should be cooked in
slow and indirect heat.
MEAL SERVICE
Excellent food service includes, not only the quality of the menu, but
also that of the food, its preparation and service. Service refers not only to
patients but to personnel as well.
Since patient care is the primary purpose of hospitals, quality meal
service should be rendered to all patients, whether paying or not. Most of
the hospitals under the DOH commute the subsistence allowanceof personnel
62
to cash and hence, they are not provided with meals. When this is not
practiced, the personnel should be given adequate meals and quality service.
A centralized type of service for both patient and personnel is the most
commonly used type ofservice in hospitals under the DOH, although there
are still a few who are using the decentralized type of service.
Whatever type of meal service is used, the following guidelines are followed:
I. Meal Service for the Patient
A. Diet List
1. Diet lists are received daily from wards. Theseshould be in
the dietarydepartment not laterthan 5:30 a.m. for breakfast,
10:30 a.m. for lunch, and 4:00 p.m. for supper.
2. The diet list should clearly include the full name of
the patient, his diet, ward, bed number, and other
pertinent information.
3. The diet list and all subsequent changes should be
signed by the person who prepared it and should always
be countersigned by the nurse on duty.
4. Acheckby the Nutritionist-Dietitians should be madewith
the wards for erroneous and/or incompletediet lists.
B. Admissions, Change of Diet, Discharges
1. The diet of new admissions, after the diet list has been
submitted to the Dietary Service, takes effect
immediately upon receipt of notice as reflected in the
DietaryService AdmissionSheet (See DS Form No. 15)
2. The Dietary Service should be notified by the nurse
on duty, of the discharge, change of room, and bed of
their patients before meal houfs to facilitate effective
food distribution.
3. Any notice of admission, discharge, or change of diet
received by telephone should be followed by a written
notice. It should be duly noted down the diet list
upon return of the diet list to the ward.
4. Changes of diets received between:
6:00 - 11 :00 a.m. will take effect at lunch
11 :00 - 3:00 p.m. will take effect at supper
5:00 - 7:00 p.m. will take effect at breakfast
However, changes will take effect immediately if
there is still food available for the specific order.
5. Check with the ward nurses for any discrepancy in
the changes or admissions sent by written notice or
called to the Dietary Service.
C. Patients' Meals and Nourishment
1. Patients' diets follow the prescription of the doctors.
The diet, as prescribed, appear in the diet list.
2. No trays are served to the patients on NPO (nil per orern),
MF (milk formula), or BF(breastfeeding) patients.
63
3. Meal hours for patients:
Breakfast - 6:30 - 7:30 a.m.
Lunch - 11:30 - 12:30 p.m.
Supper - 5:30- 6:30 p.m,
An hour's allowance is given for each meal, after
which all trays are collected and are brought back to
the Dietary Service.
4. "Hold Trays" (trayswithheld in the dietary) for patients
undergoing diagnostic procedure during meal time may
be brought to the ward only when called by the nurse
on duty after the procedure is accomplished and if
the tray is still necessary.
5. Nourishment is given to the following:
a. Patients on High Calorie, High Protein Diet
b. Patients on computed diets like Diabetic, Low
Protein, 2,500-calorie, 3,000-calorie, 1,800-
calorie, and 2,00O-Calorie diets.
6. Mid-morning nourishments may be included in the
breakfast tray, mid-afternoon snacks in the lunch tray,
and bedtime snacks in the supper tray. In such cases,
the patient must be informed accordingly.
D. Diet Orders/Prescriptions
1. Diet orders requiring computation should be
calculated by the Nutritionist-Dietitian after referring
to the chart and interviewing the patients. The
computation is transferred to the index card and
should be accessible to the dishing area for reference
in the preparation of computed trays. The date of
computation and/or revision should also be indicated.
2. All diet orders should be referred to existing hospital
diet guide or Nutritionist-Dietitians Associations of
the PhilippinzDier Guide.
3. Doubtful diet prescriptions should be clarified with
the attending physician.
E. Dishing-out and Food Distribution
1. Color coded tray cards or tags should be provided for
patients on therapeutic diets, pay and Medicare
patients as follows:
White - for regular or full diet
Orange - for liquid diet
Yellow - for soft bland and low residue diet
Red - for sodium restricted diet
Light Pink - for calculated diets such as diabetic, .
tube-feeding, etc.
Lighr Blue - for fat restricted diet
Light Green - for specified diets such as lowpurine,
low calcium, etc.
64
2. Food should be tasted before dishing-out particularly
the low salt diet.
3. All diets should be dished-out in individual trays in
the main kitchen.
4. Thefollowing approximate size ofservingshouldbeobserved;
30 gm. (1 exchange) - 1 small serving
45 gm (1 1/2 exchanges) - average serving
60 gm. (2 exchanges) 1 big serving
5. The proper tray arrangements that should be observed
are as follows:
Breakfast
Jam or
I
Protein Dish

Butter
I Fruit I
I
Bread/Cereal
I
I Diet I
Tag
Lunch or Supper
I Diet I
Tag
Rice
Protein Dish
EJI__lu
EJ I I
F. Recording of Daily Meal Census
1. Adailycensus of all full, soft, liquid, and therapeuticdiets
must be recorded in a logbookprovided for the purpose.
2. The census should be taken for each meal. The
Medicare patients should be indicated with an asterisk.
11. Meal Service for Personnel
A. The employees entitled to meal service are as follows:
1. All employees of the hospital who are not receiving
subsistence allowance.
2. Hospital trainees or internsas recommended by the COH
B. Policies in personnel meal service are:
1. Regular meal hours should be observed as follows:
Breakfast - 6:30 a.m. - 7:30 a.m.
Lunch - 11:30 a.m. - 1:00 p.m.
Supper - 5:30 p.m. - 6:30 p.m.
65
Hospital DietaryService ManagementManual
2. The dining room is closed after each meal. In case of
emergency, the Nutritionist-Dietitian on duty should
be notified for the opening of the dining room.
3. Authorized diners should present their meal tickets
before the issuance of food.
4. Meal hoursshouldbestrialy followed in the dining room.
5. Taking out meal shares and dining room utensils is
strictly prohibited.
6. Newlyauthorized diners should be checked by the
Nutritionist-Dietitian on duty for identification,
recording, and briefing on rules and regulations of
meal service in the dietary.
7. Medical trainees, observers, medical interns, and
medical technology interns on makeup duty are not
allowed to eat unless given permission by the COHo
8. Regular inventory of dining room equi pment and
utensils should be done at the end of each day.
SANITATION. SAFETY AND MAINTENANCE
To safeguard the health of patients and personnel, the Dietary Service
should maintain high standards of sanitation in the receipt, storage,
preparation, and service of food. An understanding of sanitation standards
among dietary personnel, therefore, is a must. This can be attained through
a well-structured training program with emphasis on sanitary practices.
Routine inspection of all dietary areas and personnel will likewise stress the
importance of sanitation.
The following aspects of sanitation and safety should be considered:
l. Food
The primary goal ofa food servicesanitation program is to protect
the customer from food-borne illnesses. Food is the natural habitat
of many microorganisms. Precaution should be taken to make sure
that the food served is free from contamination and spoilage, and
therefore, safe to eat.
To ensure safety in food, the following rules must be kept in mind:
A. All food and food supplies should come from reliable and
approved sources.
B. All food and food supplies should be inspected thoroughly
for spoilage, adulteration; and misbranding, thus, ensuring
cleanliness and making it safe for consumption.
C. All meat and meat products should be inspected for freshness
under an official state or local regulatory program.
D. Food should be protected from contamination while being
stored, prepared, displayed, served, and moved from the kitchen
or diet kitchen to the patient's room. Some suggestedmethods
for safe storage are as follows:
1. Only food items which need refrigeration should be
refrigerated. Overloading of the refrigerator must be
avoided to allowfree circulation of air.
66
2. All perishable food items should be stored at regulated
temperatures to protect them from spoilage.
3. All potentially hazardous food should be kept at 40F
or below except during preparation and serving.
4. Hot food should be kept at 140F or above until they
are served.
5. Leftovers should be refrigerated immediately in covered
containers and should be consumed as soon as possible.
6. Opened canned goods should be removed immediately
from the can and stored in the refrigerator in stable
containers made of glass and stainless steel. Bottled
food, like mayonnaise and salad dressing, should be
refrigerated once opened.
7. Food and food containers should be properly labelled
when stored.
8. All the food on shelves, tables, racks, or other clean
surfaces should be stored in such a way as to allow free
circulation of air and to protect them from
contamination, insects, and vermin.
E. Meat, fish, vegetables; and fruits should be washed in sinks
intended only for food preparation.
F. Raw fruits and vegetables should be washed thoroughly before use.
G. Insecticides and rodenticide should be properly marked and
stored away from food and food preparation areas.
II. Personnel
Only healthy people make suitable food handlers because disease
transmitted through food frequently originates from infected food
handlers or food service employees with poor personal habits. Thus,
the following rules must be followed:
A. Each member of the Dietary Service should be subjected to
physical and medical examinations upon acceptance, and at
least once a year thereafter.
B. Dietary Service personnel should observe desirable personal
hygiene, habits, safe food handling;. and serving practices.
The following should be practiced for personal hygiene:
I. A daily bath
2. Hair should be kept clean and neat, and should be
kept under control on the job with a hair net, bandette
or scarf for women, and cap for men.
3. Male employeesshould be clean shaven (no mustaches)
and must have short hair; female employees should
adopt a simple well-combed hair style.
4. Hands should bewashed withsoapand waterin hand sinks
conveniently located in the unit, before startingwork, after
handling unclean objects, after going to the toilet, after
keeping hair in place, after coughingor sneezing, and after
handling objects that have comein contact withthe mouth,
such as lipsticks, toothpicks and cigarettes.
67
5. Fingernails should be kept clean; colored nail polish
should be avoided.
6. Clean and washable aprons and uniforms should be
worn at all times.
7. Heavy ~ y earrings, bracelets, curlers, and expensive
rings should not be worn when on duty; wedding rings
and wrist watches are permissible.
8. Handkerchiefs should be used to wipe face and arms.
9. Smoking is prohibited in any part of the kitchen;
employees are allowed to smoke in designated areas
only.
10. Unless specialprecautions are taken, a dietary personnel
should not be allowed to work when he has a cold or
has an open sore, infected cut, or boil.
Guidelines on Safe Food Handling and Serving Practices
1. Only clean utensils should be used in preparing,
cooking, and serving food.
2. Food should never be handled with bare hands.
Spoons, forks, tongs, or other appropriate utensils
should be used, (e.g., ice scoop, to handle ice; spoon)
each time food is tasted.
3. Cups, knives, forks, spoons, spatulas, and tongs should
always be picked up by the handle.
4. Glasses must always be handled by the base, and plates by
the ream, to avoid contamination of the serving surface,
5. Clean dishes, glasses, and cups should be stored in
enclosed cabinets with glasses and cups bottoms-up,
preferably in baskets or trays.
6. Broken, cracked, or chipped dishes or other utensils
should be discarded.
7. Glasses should not be tacked when carried.
8. Cups and glasses should not be filled to the brim.
9. A fallen piece of silverware should always be replaced
with a clean one while serving.
10. Milk should be poured at the table from the original
container or an approved dispenser.
11. Dish-outtrays with food should not bestocked one on top
ofanother.
12. Refrigerated storage areas must be closed after using.
C. Dietary personnel must be trained on good personal hygiene
practices and proper handling, storing, and serving of food
through a continuous in-service educational program.
Ill. Utensils and Equipment
A. Equipment and utensils must be made of non-toxic, smooth,
durable, non-corrosive, and easily cleaned materials.
68
B. Proper instructions should be given to employees on how to
use available equipment.
C. Equipment should be frequently checked for needed repairs
which should be made as quickly as possible.
D. All equipment and utensils in food preparation, service and
storage must be cleaned and sanitized regularly. The following
are suggested cleaning schedules:
1. Daily or after use - counter tops, dining tables, chopping
boards and tables, ranges, can openers, "kawas", pots and
,pans, garbage cans, kitchenutensils, floors.
2. Weekly - refrigerators, storage shelves chairs, table legs.
3. Monthly- freezers, hoods, walls, ceilings, lighting fixtures.
E. Equipment and utensils should be thoroughly cleaned after
each use. The following are suggested cleaning procedures for
some common kitchen equipment and utensils:
1. Open-top gas range
a. After top grills are entirely cooled, soak in water
with a good grease solvent.
b. Remove encrusted material by scraping with a
blunt scraper.
c. Burners should be boiled in a solution ofsoda
or other grease solvent.
d. Clean clogged burner parts with a stiff wire.
2. Electric Range
a. To remove grease fibers, use warm water and
mild soap or detergent.
b. Rinse with clean water and dry.
c. Avoid getting water into the electrical
components.
d. Wipe surfaces made of iron with an oiled cloth
to prevent rusting.
3. Ovens
a. Do not clean oven until it is cool.
b. If racks and shelves are removable, take these
out and cleanthem. Use a blunt knife to scrape
off burnt particles. Use a brush, hot water,
and soap for the final cleaning.
c. Clean the inside of the oven by scraping any
burnt particles with a blunt knife. Brush out
scrapings with a wire brush.
d. Clean heat controls, but do not loosen or
remove dials.
e. Clean the outside of the oven with a clean
damp cloth.
4. Big "Kawas"
a. Use a stiff brush to clean the "kawas" after each
use. Rinse it with hot water and dry thoroughly.
69
b. Wipe the "kawas" with oil to prevent rusting
which is dangerous and detrimental to health
and sanitation.
c. Clean theoutside surface with soap and hot water.
5. Refrigerators and Freezers
a. Defrost refrigerators and freezers every two
weeks or as often as needed.
b. Turn control to the "off" position. When all
the frost in the freezer has melted, wipewater
from interior of freezing' compartment. Rinse
witha weak solutionof bakingsodaor "borax".
Dry thoroughly.
c. 'Turn control back to the proper setting and
replace food as quickly as possible.
6. Counters and Tables
a. Wash with clean cloth soaked in water.
b. Rinse with clean cloth and cleanwater.
c. Sanitize with cloth soaked in any available
sanitizing agent.
7. Hoods and Filters
Unclean filters and hoods are fire hazards so they
must be regularly cleaned.
a. Remove the filters.
b. Soak in a hot detergent solution or in a
degreasing agent. Brush, if necessary, to remove
all grease. Rinse and dry.
c. Hoods should be cleaned with detergent suds,
rinsed and dried.
8. Pots, Pans, Strainers, Skillets, and Kettles
a. A three-compartment sinkisrecommended. If it is
not available, use a two-compartment sink plus a
panorone-sinkplus two pans. Surfacestains should
be removed by scraping and soaking in one
compartment of thesinkfilled with hot water and
washed in a hot detergent solution.
b. Rinse well in the second compartment.
c. Sanitize in the third compartment.
d. Air drythepots, pans, strainers, skillets, andkettles.
e. Hangor stack upside down on racks for storage.
9. Dishes
a. Scrape dishes. Pre-rinse if heavily soiled.
b. Wash dishes in hot detergent water (110
0
- mOF).
c.. Rinse dishes in clear hot water.
d. Sanitizeby soaking in hot water (170F) for at
least two minutes or in cleanboiling water for
half a minuteo
70
e. Place dishes on racks and allow to air dry. Do
not use towels to dry.
f. Stack dishes in a clean and protected place.
10. Glasses and Silverwares
(Follow the procedures for dishes.)
a. Stack cups and glasses bottoms-up.
11. Floors, Walls, and Shelves
a. Usetwobuckets incleaning floors, walls and shelves.
b. Put detergent and disinfect in hot water in
bucket number one.
c. Put clean hot water in bucket number two.
d. Mop floor, always soaking the mophead in
bucket number one.
e. Rinse floor, always soaking the mophead in
bucket number two.
rv Garbage Disposal
Negligent disposal of garbage refuse and waste watermay bea sourceof
contamination and mayattract pests. In orderto ensure sanitary premises in
the dietaryunits, the following precautions aresuggested:
A. Store filled garbage containers in cool areas near the exit and
keep these away from food.
B. Collect garbage regularly.
C. Procure garbage cans that are non-absorbent, washable, easily
emptied, and tightly covered. Clean these with hot detergent
water and treat them with disinfectant, if and when necessary.
V. Food Sanitation Checklist (See Appendix)
Checklist on Presidential Decree No. 856 (See Appendix)
PESTjVERMIN CONTROL
Food not properly protected from contamination by pest and rodents
is a public health hazard. Flies and roaches may contaminate the food with
germs which can cause outbreaks ofintestinal diseases like diarrhea, dysentery,
gastroenteritis, and cholera. The premises should always be kept clean and
free from flies, vermins, and rodents. To render effective pest/vermin control
in the Dietary Service, the following should be observed:
I. No animals (ex., dogs, cats, etc.) should be allowed where food is
prepared and served.
2. Doors and windows shoq,J,d be properly screened.
3. An organized program of pest control should be maintained. This
includes regular spraying with insecticides and the use of the services
of an exterminator to prevent the appearance of bugs and rodents.
4. Insect sprays, fly baits androdenticides should be used as a part of the
rodent control program. Breeding places for these pests should be
eliminated by covering garbage cans, closing cracks and crevices in
walls and equipment. Cleanliness of the whole area should always be
maintained.
71
ENERGYCONSERVATION
The proper maintenance ofequipment and facilities with the aimof reducing
energy consumption must be a primary concern of the service. As the cost of
energy continues to increase, it is possible to reduce utilitybills from 20%to 3QO/o
through energy conservation. However, energy conservation is not the sole
responsibility of the head of the Dierary Service or the designated conservation
office, but of every worker in the DieraryService.
The following are some suggestions that will minimize waste of energy
and develop ideas on energy conservation:
1. The employees should be given lectures and training sessions on how
to minimize energy losses and take proper corrective measures.
2. Incentive programs and recognitions for outstanding achievements
on energy conservation should be set up to encourage employees to
look for ways to reduce energy usage.
3. Signs and posters to remind the staff about energyconservation should
be posted in appropriate places.
4. Lighting
a. Lights should be turned-off when not in use and natural light
should be utilized whenever possible.
b. Decorative lighting should be avoided.
c. Dirty bulbs and fixtures reduce light output. They should be
cleaned periodically.
EFFECTIVE COMMUNICATION
Lack of effective communication among dietary staff members often
brings about unhappy patients. Such a situation exists with the following
manifestations:
1. Spoiled food
2. Damaged equipment
.r. Problem employees.
4. Frustrated Nutritionist-Dietitian/Supervisors
The following are signs of communication problems in the operation
of the Dietary Service:
1. Spoiled foodstuff results when directions are not followed.
2. Difficulty in operating equipment eventhough complete instructions
have been given.
3. Failure to understand what people are saying even though the words
are commonly used.
4. Failure of people to do what is expected of them even though they
have been told what was to be done.
5. Emotionless faces of people when there should be expressions of
understanding.
6. Partial carrying out of instructions.
72
- - T
Factors that affect effective communication are as follows:
I. Different ethnic backgrounds among the employees
2. Language difficulties due to diverse customs and regional dialects
3. Educational backgrounds
4. Absence of an effective communication channel
k Dietary Service Supervisor must be able to know and determine
communication problems, analyze situations contributing to
miscommunication, and develop a .program to improve communication,
Asupervisor must strive to learn everything about communication, whether
it is to improve the effectiveness of his own communication, provide training
to employeesthat would improve their communication skills, or to identify
and solve communication difficulties in the food service operation.
The following are the basis for better communication:
I. An understanding of what the communication process is, how it
functions, and what keeps it from functioning effectively
2. A critical analysis of communication within the operation
3. A recognition and definition of the communication deficiencies that
the analysis reveals
4. The determination to take actions regarding the situation
S. The acquisition of neededknowledge and information so that necessary
improvements may be made
6. A plan of action to make the needed changes
7. Action to put into effect what is necessaryto improve communication
performance in all aspects of the operation
The following are ten guides to improve food service operation through
effective communication:
I. Know what you want to say and be sure of what it means to you. If
you are not sure of what you mean, you cannot expect other people to
know what you want them to know or to do.
2. Know as much as you can about your employees, their educational
level, interests, attitudes, skills, and abilities. Information of this
kind can help you be more readily understood by those with whom
you are commumcanng.
3. .Try to put yourself in the place of the person with whom you are
communicating, and consider what you have to sayasyou think he would.
4. Give attention to the people who are communicating with you. Being
a good' listener can mean a great difference in the effectiveness of
communication.
S. Make communication a two-way street and not two one-way streets.
Communication will bemuch more effective if people have an
opportunity to ask questions and a chance to clarify what they heard.
6. Recognize the limitations of the various communication methods.
7. Keep in mind that many factors affect other people in understanding
what you say and write.
73
8. Do not try to impress people with big complicated words. Research
shows that even people of high intellectual levels pay better attention
and react more effectively to messages that use shorter and simpler
words. Many people do not have time to try to determine the meaning
ofdifficult words. Thus, choose your words carefully, since some words
have general meanings.
9. People's opinions are not always based on reason and logic. Often,
logical statement of facts do not result in correcting their views and
opinions. Instead, they strengthen their determination to continue
holding on to views that they have, and they make a greater effort to
find new reasons to support those views.
10. Above all, recognize your needto improvecommunication, know what you
have to improvein your communication skills, and workhard at it
FACILITY AND EQUIPMENT FOR THE
DIFFERENT DIETARY SERVICE HEALTH CARE LEVEL
A centralized hospital kitchen is the recommended type of food service
system. This best suits the conditions and operational standards of the
different health care levels.
A centralized food distribution system is where food trays are prepared
at one central point, and then dispatched to the patient's room. The food
production area is usually adjacent or close to the tray set-up area. Trays are
placed in conveyor carts or conveyor belts horizontally or vertically, and are
then sent to the wards for distribution by the food service workers.
The following advantages arethe basisfor the choiceofa centralized service :
1. The proximity of the production area to the tray set-up station provides
for better quality meals.
2. Closer supervision and control can be made of the trays regarding
quality and quantity of meals.
3. Better food cost control can be implemented in this type of service.
4. Double handling of food is eliminated.
5. Food is not overcooked because it spent less time in transit.
6. Considerable labor is saved, both for professionals as well as non-
skilled aides..
7. Service kitchens in wards are eliminated.
8. It minimize pilferage of food.
REQUIREMENTS FOR KITCHEN PLANNING
Kitchen Planning necessitates the knowledge of answering the five"Ws"
- WHO, WHAT WHEN, WHERE, and WHY - to come up with a
functional hospital kitchen. Good facility planning and layout is a must in
hospital food service operation. Listed here are some factors which will
affect hospital kitchen planning. This list was prepared specifically for
hospital food service kitchens. Most of this information is common to all
kitchens and is essentially the same for all food services. Food and supplies
are received and stored. Food is prepared, cooked, and served. Space and
facility planning must be provided for these functions.
74
Factors to Consider Before Planning Hospital Kitchens
A Administrative Considerations
1. Type of Ownership
2. Type of Food Service Management
a. Concessionaire
b. In-House Management
c. - Management Contract
B. Operational Considerations
1. Type of Service
a. Centralized
b. Decentralized
c. Cafeteria Service
2. Proposed Menus
3. Availability of Raw Materials
4. Delivery Schedule
5. Hours of Service.
6. . Standards of Production
7. Number of people to be served
8. Skills and training of workers
C. Engineering and Architectural Considerations
1. Utilities available
2. Environmental restrictions
3. Health and Business Ordinances affecting Buildings
4. Architectural Restrictions - building characteristics
5. Structural restrictions
D. Monetary Considerations
1. Building Budget
2. Equipment Budget
3. Payroll - Employees' Wages
4. Operating Expenses
Space Allocation
Each square meter of space in a food service operation area can be
considered a fixed expense,whether it is doing more than its share or nothing
at all. Once space has been allocated, it cannot be easily changed. For this
reason, space should be carefully considered in designing hospital kitchens.
Hospital dietary operations, more than any other food service facility,
reflects the needs of the community it serves, aside from the fact that the
patient must be served at least 3 times a day. The level of therapeutic care
for each individual, as well as the ethnic origin and environmental
background, provides a unique challenge in menu and recipe formulation.
The food-service objectives, quality and therapeutic value must be included
in the planning of the hospital Dietary Service.
75
Equipment Selection
Based on theanalysis of kitchen requirements, consideration for the need for
various types of equipment should include the general and specialized equipment
for the different work centers in the kitchen. One of the most difficult problems
confronting the entire food service industry today is the selection of the right
equipment Thefollowing are factors involved in choosing the right equipment
1. Needs of the department
2. Budget allowance
3. Usefulness of the equipment to the department
4. Utility and adaptability
5. Safety
6. Mobility
7. Capacity-It must have thecapacity fortheparticular jobandcanhandle the
peak loads. Itcanalso beadjusted tooperateeconomically duringION periods.
8. Durability
9. Repair, maintenance, and service - It should be easily serviced. Be sure that
the equipment selected hasavailable spare parts for replacement
Different Work Centers and Suggested Equipment
1. Receiving Area
.The area should be large enough for examining all food supplies
with sanitation features to prevent contamination of foodstuff, must
be accessible from the main roads, provided with a parking space for
trucks and shall have equipment such as: weighing scale, counter-
table, garbage can, handwashing sink and food trolley.
2. Storage Area
The area should be near the receiving area and should provide a
dry storage section for staples and refrigeration for perishables.
a. Dry Storage area - should be dry, must have good lighting and
ventilation, located near or in front of the Nutritionist-Dietitian's
office andequipped with aladder, shelves, locked and opencabinets.
b. Cold Storage Area - should be equipped with a freezer and a
refrigerator, with suggested provision of 1.5 to 2 cubic feet per
meal served per day.
3. Pre-Preparation Area
It should have an efficient arrangement of space with a minimum of
cross traffic, permitting thebest possiblework flow. Thesize ofthepreparation
room should be carefully estimated to accommodate meat, vegetable, fish,
andpoultryunits with thecorresponding equipment needed. Itshall preferably \)
belocated as a separate room, oftenat theside or back of the cooking units.
It shall be equipped with a sink (standard sink size 20"x20"x14"), two
compartments or single with drainboard), acounter table, achopping board
or meat block, and a garbage canwith cover. .
4. Cooking Area
The area derives its supplies from thestorerooms and preparation areas.
Itshould benear or adjacent tothepotsandpansarea. Anisland arrangement
of thecooking equipment near thecenter of the roomin large kitchens is
77
usuallyfavored overa wall setup,because ofitsrelationship to the preparation
units, sanitation,aswell asthe shorteneddistanceto the servingunits. It shall
be equippedwith ranges with an oven, steamunit, broilers, hot plate, cook's
table, a sink near the cook's table, rackfor cleanpots and pans, pot and pans
sink, one large hood, ventilating fan, and portable garbage can with
cover and casters.
5. Therapeutic Diet Preparation Area
.This is an integral part of the main kitchen where modified diets and
tube feedings are prepared. It should be equippedwith workingtables with
shelves, dieteticscales, stove with oven, a washingsink, and a refrigerator.
6. Pots and Pans Area
Washing of pots and pans and other utensils is a noisy and dirty
task and should be done in a separate area equipped with deep sinks
(sink size 24"x24"xI4"), abundance of hot and cold water, and drying
racks. The location of the area should be near the cooking unit but
out of any main traffic lines.
7. Dishwashing Area
It should be compact, well-lighted, and dry. It shall be located'
directly adjacent to the dining room and, if needed, sound proofing is
recommended. If the handwashing method is used, a 3-compartment
sink shall be utilized. If a dishwashing machine is used, it shall be
away from the dining room. Dishes used by patients shall not be
washed in the same sink used for those of the personnel. There should
be separate doors for entrance and exit and they must be of sufficient
width to permit free entry of various types of carts. It should be near
the tray assembly area.
8. Serving Area
a. Personnel Dining Room - shall be sanitary, well-lighted,
ventilated, and shall be away from contagious pavilions,
morgue or any unsightly surrounding. It shall be equipped
with dining tables, chairs, electric fans and blowers, facilities
for drinking water, and a handwashing sink.
b. Patient's Food Service Area - shall have either a centralized or
decentralized food service. Where food service is centralized,
it shall be equipped with tray assembly, serving counter, and
an area for storing enclosed tray carts, dishes, and supply
storage area. Where food service is decentralized, it shall be
equipped with a floor pantry with adequate space to contain
sinks (3 compartment) and a drainboard, counter tables,
garbage cans with covers and casters, open and closed cabinets,
outlets for electric stoves and a refrigerator.
9. Employee Facilities
It should include separate washrooms and toilets for male and
female employees, lavatories and toilets should be provided at the
ratio of 1 is to 15 workers. These rooms should open into a corridor
rather than directly into the kitchen or dining room.
78
10. Food Wastes and Trash Storage
Garbage cans should not be too large to make handling difficult,
or to favor accumulation ofgarbage. They should be emptied at least
twice a day, preferably after lunch and before closing time. The trash
can shouldbe washed with hot water, and the storage area for garbage
should be located adjacent to the receiving area.
11 Dietitian's Office
It should be near specific areas of responsibility to provide the
Nutritionist-Dietitian as much eye control as possible over' all areas
and should be equipped with office desks, chairs, filing cabinets, a
telephone, a typewriter, an electric fan and a wall built-in book case.
A panel Vision ofglass wall may be used as part ofthe interior wall.
12 Parking Area for Mobile Equipment
Space should be allocated for parking mobile equipment such as
trolleys, food conveyors, and carts.
(For ready reference on the Equipment Guide for a Conventional
Hospital Dietetics Service, please see Appendix.)
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HospitalDietary Service Management Manual
80
CLINICAL, EDUCATIONAL,
RESEARCH AND SPECIALIZED
FUNCTIONS OF THE
DIETARY SERVICE
CLINICAL AND EDUCATIONAL FUNCTIONS
Charting and Ward Rounds
As a member of the health care team, charting and ward rounds are two
responsibilities of the Nutritionist-Dietitian. Through these, she fulfills her
part in bringing a patient back to health and/or maintaining good health.
A clinical Nutritionist-Dietitian should go with the medical team during
ward rounds, after which, she should do -her own charting. Like other
members of the health team, the Nutritionist-Dietitian, cooperates in carrying
out the written orders of the physician by promptly recording in the patient's
medical records, pertinent, meaningful observations and information on
food habits, food acceptance and dietary treatment. The dietary staff uses
reliable means of documenting regular communication with the physician
and other professionals participating in the patient's total care.
Where and How to Record
Regardless of the format used, entries in the patient's medical record should
contain sufficient information to support the dietary assessment, to justify the
dieteticcare and to document the results accurately. Peerreview is facilitated by the
centralization of information in the patient's record. The progress note section of
the medical record is recommended as the most suitable location for recording
dieteticcare information and nutritional care plans.
Brevity without sacrificing essential facts is the essence of effective recording.
Dietary progress notes and summaries should be brief and consistent with good
communication, and should be readily understood byall the members ofthe health
care team. When professional opinion is expressed, proper identification of the
person recordingthe notes should be done.
8 I
Who is to Record
Entries in patient's medical records may be made only by individuals
authorized by the institution's policies, which are usually developed in
cooperation with the medical staff. When the services of a qualified
Nutritionist-Dietitian is not available on a regular full-time basis, dietetic
assistants or technicians may be designated as authorized alternates to record
current and pertinent nutritional care information commensurate with the
responsibility delegated to their position within the institution. All entries
should be dated and signed with the name and title of the person making
the entry.
What to Record
The qualifiedNutritionist-Dietitian or authorized alternate is responsible
for recording the following subject items for patients on modified diets:
1 Confirmation on Diet Order
a Within 24 hours of admission, a notation that the prescribed
modified diet order is being fulfilled (except for those patients
not being fed orally)
b. All subsequent orders by the physician for a modified diet
2. Summary of Dietary History
a Evaluation ofpatient's diet pattern, nutrient deficit, life style,
food allergies, and socio-economic resources essential for
nutritional care planning
b. Assessment of patient's awareness of the relationship of the
diet to disease, has a direct bearing on plans for individual
nutritional care
3. Nutritional Care Therapy
a Type ofdiet and, if indicated, the number of calories or other
nutrients (e.g., sodium, cholesterol of saturated fat)
b. Daily record of patient's nutrient intake during a period of
quantitative or qualitative control of food and fluid intake,
medication, or other pertinent therapy
c Report of the patient's tolerance to the prescribed diet
modification (including the effects of the patient's appetite
and food habits on food intake) and any pubstitution made
d. Notation of any changes in diet orders and diet instruction plans
e. Briefwritten communications between dietetic staff, physician,
and/or nursing service personnel pertinent to the patient's
nutritional care
f Request, if indicated, for referral of patient to appropriate
community agency for assistance in following the diet at home
4. Nutritional Care Discharge Plan
a. Description of diet instructions 'given to the patient and/or family.
If preprinted instructions are given to the patient or family, a copy
should be placed eitherin the patient's medical record or on filein
themedical recorddepartment's reference file
b. Description or copy of diet pattern should be forwarded to
the referral agency or nursing home facility for subsequent
patient care
82
c. Plan for patient's continued nutritional care (including any
date for return visits)
5. Dietetic Consultation
a The physician's written request for dietetic consultation should
be acknowledged
b. Consultation reports containing a written opinion by the
dietitian that reflects an assessment of the patient's dietary
history, examination of the patient's medical record for any
previous dietetic care and any recommendation for normal
or modified diet. Subsequent counselling of the patient or
family should be recorded in the patient's medical record.
Metbod ofRecording
The method selected for recording dietary data in the patient's medical
record should be compatible with the institution's method for arranging
clinical data which is usually the problem-oriented medical record (POMR)
(See OS FormNo. 16A, ProblemList andOS Forni No. 16B, Problem Oriented
progress Notes). The POMRis an integrated recording system focusing on
the patient's problem and profile, plans for patient care, and education and
assessment ofprogress and results. In the POMR, the medical record is no
longer a private sanction ofthe physician but a shared one that insures the
recognition ofall the patient's problems all the time. It serves to coordinate
the activities of all members of the health team, acting as a medium by
which they can communicate, relate, and bring their expertise to bear on
the patient's discomforts.
The advantages ofthe POMR are the following:
1 Motivates the Nutritionist-Dietitian to write the nutritional problems
ofthe patients in the physician's progress notes
2. Helps bring the work ofthe Nutritionist-Dietitian into the area ofthe
total care, its importance dictates where it belongs
3. Develops discipline among members of the health care team
4. Serves as a common vehicle ofcommunication and expression among
the members of the health team, making them more effective
The Nutritionist-Dietitian acts as an implementor, evaluator, and educator
in the POMR. She undertakes the following:
I. As an implementor, she carries out the diet order.
Example:
Apatientwas admittedto thehospitalwiththe symptoms ofa congestive
heart failure, Hewas prescribed alow-sodium(Na) diet- I gm. Indiscussing
the prescnbed dietary treatment with the patient, the Nutritionist-Dietitian
found out that he had previouslyseena physician and had alreadybeen told
to followthistypeofdiet. However,the patientfailed to adhereto thisdietary
regimen. Awareoftheproblem,the Nutritionist-Dietitian could, at thispoint,
employ the POMR system to communicate her observations. Her notes
might read:
Problem:
Lack ofadherence to the dietary regimen (I gm. Na diet) prior to
admission.
83
Explain rationale oflowsodium diet in relation to congestive
heart failure.
Provide information on the sodium contents of food and
review major sources of sodium in the diet.
Design meal plan with the patient.
Encourage the patient to consume the hospital menu served.
2.
3.
4.
Subjective:
Patient says his previous instruction on the diet was 'just don't
add any salt to your food". Repeatedly states that he does not add
any salt to his food. Admits eating canned pork and beans, luncheon
meat, and frozen dinners. The patient was quite surprised to learn
that the food he usually ate were high in sodium content.
Objective:
Review ofan average daily food intake at home revealed patient's
intake was approximately 4.5 - 5.5 gm. ofsodium per day.
Reason for admission - edema.
Assessment:
Patient does not understand the principles or rationale ofhis low
sodium diet. Seems willing to follow dietary regimen if given
appropriate instructions.
Plan:
I.
In this example, the Nutritionist-Dietitian assumed the role of
one who implementsthe prescribed dietary order. However, the system
offers the Nutritionist-Dietitian to become further involved in the
patient's total care.
2 As an evaluator, the Nutritionist-Dietitian evaluates the dietary
management. Ifthe prescribed dietary treatment is inappropriate for
the patient, or is incomplete, then her role is to identify the problem
for the physician. To propose that the Nutritionist-Dietitian be the
evaluator is to place the responsibilityon the person who has acquired
the expertise to assume it.
It has been a tradition that the Nutritionist-Dietitian dare not
question the physician's order. However, more often than not, dietary
prescriptiondeals onlywithone ofthe patient' s symptoms, overlooking
other problems which may also require dietary care.
Example No.1:
Upon interview of the patient, the Nutritionist-Dietitian finds
out that the patient has false teeth or dentures that do not fit very
well, making it hard for the patient to chew his food properly. The
Nutritionist-Dietitian then modifies the 1gm. Na diet order by making
it soft, or chopped or mechanically soft.
Example No.2:
A patient who was prescribed a lowsodium diet was observed by
the Nutritionist-Dietitian to be underweight. She should note this
observation on the chart, discuss it with the attending physician and
recommend a high calorie diet. .
'84
3. As an educator, the Nutritionist-Dietitian takes the responsibility of
teaching the patient and ensure that the diet principles are well
understood by the patient before he goes home.
The policies and procedures in charting and ward rounds are:
l Twice or thrice a week, the clinical Nutritionist-Dietitian goes
on ward rounds to evaluate the patient's nutritional condition,
problems, and needs regarding his dietary intake.
2 After the ward rounds, the Nutritionist-Dietitian records on
the patient's chart, her observations regarding the patient's
nutritional needs and problems.
3. The members ofthe medical. team (e.g., doctors, nurses, and
Nutritionist-Dietitian) should discuss these needs and problems
of the patient and recommend possible solutions and then
implement them.
Diet Counselling
Diet counselling is the act of providing individualized professional
guidance to assist a person in adjusting his daily food consumption to meet
his health needs. Proficiency in diet counselling should be a basic skill of
the Nutritionist-Dietitian concerned with patient care. A requirement in
developing skills in diet counselling is that the Nutritionist-Dietitian, as a
counsellor, should have a well-organized idea ofwhat counselling entails.
Dietetic counsellors should have knowledge in food composition,
cooking, availability offoods, food combination for meals, economic, social,
ethnic, and physical factors affecting food consumption and the role of
food in the maintenance ofhealth. It is the counsellor's task to impart this
knowledge to her patients.
The process of diet counselling actually involves three activities:
Interviewing, counselling, and consulting.
l Interviewing is the gathering of information and/or data. Expert
interviewing requires training and experience since accurate, selective
information is basic to effective counselling.
2. Counselling is listening, accepting, clarifying, and helping the patient
form his own conclusions and develop his own plan of action. The
focus is on the patient. An effective diet counsellor must be able to
guide the patient's thinking, focus on objectives, interpret and evaluate
information accurately and effectively. The counsellor translates for
the patient, the regimen prescribed by the physician.
3. Consultinginvolves developing plans or proposals for a patient based on
observations and evaluations. The consultant's purpose is to addto and
enhancethe knowledge and understandingofthe person seekinghelp. By
keepingin mind these important factors in the process ofdiet counselling,
effective methodsmay bereadilydeveloped based on:
a The reason for the session (i.e., therapeutic treatment, general
nutritional assessment, nutrition education, etc.);
b. The skills and resources ofthe counsellor; and
c. The motivation, needs, and interest of the patient.
85
,
I
Procedural Guide for Diet Counselling
A Preparation
1. Read the patient's medical record.
2. Obtain information from referring source.
3. Make a tentative plan for the nutritional care program.
4. Have equipment on hand.
5. Plan ahead to avoid interruptions.
6. Designate a flexible time element for the interview.
B. Interview
1. Introduce yourself Be friendly. Talk to the patient about the
purpose of the visit. Include family members whenever
possible during the initial and follow-up visits.
2. Find out what the physicianhas discussed with him regarding
his prescribed diet.
3. Discuss the reasons for giving the diet.
4. Check the patient for the usual statistics, suchas height, weight,
and age, even though this information is available in the
medical record. Find out what the patient's occupation is
and where he eats his meals. This provides the. patient an
opportunity to become accustomed to the situation and to
establish rapport.
5. Obtain a typical day's (24 hrs.) intake to gain an idea of the
patient's food patterns, habits, and the amount consumed.
This information is used in evaluating and interpreting the
diet, as well as for reviewinfollow-upvisits. It is alsoimportant
in correlating other medical or social information and for
writing meaningful notes in medical records and reports.
6. Give the patient diet literature to read while you calculate and
evaluate the information on food intake.
7. Discuss the results ofthe evaluation with the patient.
8. Re-check in reference to your information on intake with:
a Medical problem/reason for referral
b. Laboratory results
c. Morbidity record
d. Energybalance(height, weight, activityvs. intake, etc.)
e. Social history, education, and/orintellectual capabilities
9. Discusswiththe clientany relevant conclusionssuch as activity
patterns, time of eating, meal patterns, blood sugar level, and
obvious problems related to intake.
10. Make use of appropriate visual and instructional materials.
It Prepare an individualized diet plan with the patient. Always
give him a written plan. Be certain that the information from
the interview and the diet plan are entered in the patient's
record inkeepingwith the hospital or clinicprocedures. Retain
copies, as needed, for reference and for communication.
86
C. The Follow-up
1. Establish the date or time schedule for reaching goals.
2. Develop alternative ways to remainin touchwiththe patientand his
progress through returnappointments, telephone or maiL
3. Establish a "reminder" system.
4. Besurethe plans are stated clearly to the patient, arewritten in the
medical record, and arereported on the diet historyform.
Nutrition Clinic
A Nutrition Clinic is an independent out-patient and in-patient clinic
which functions as the coordinating center for all diet therapy and nutrition
education activities in the hospital. It should be located near the patient's
therapy, consultation services for professional staff and communication
between the clinic Nutritionist-Dietitian with the dietetic staff and other
personnel. Since the Nutritionist-Dietitian must discuss with the patient
his usual eating habits and prescribed diet within the framework of his
social, economic, physiologic, and psychologic needs, the atmosphere and
physical setting of the clinic must insure privacy during patient's interview.
Teaching equipment and furnishings should be adequate for group or
individual diet instructions.
Objectives of the Nutrition Clinic
General Objective:
To help the patient carry out the diet prescriptions according to the
principles of nutrition and therapeutic diet management.
Specific Objectives:
1. To give diet instructions to in-patients and out-patients with doctor's
referral.
2. To effectively make patients understand the prescribed diets.
3. To guide the patient well with the assurance that when they go home,
they can follow the diets accurately with satisfaction and with
minimum inconvenience to themselves and theirfamilies.
4. To serve as a training center for student nurses, doctors and
Nutritionist-Dietitians.
Policies in Operating a Nutrition Clinic
1. The nutrition clinic should set the time and specific days of the week
for its operation.
2. Patients should be referred to the clinic for dietary instructions by a
physician by filling out the hospital referral slip. It should state the
diet prescription and the diagnosis of the patient. The Nutritionist-
Dietitian should give the diet instructions after a thorough interview
with the patient. .
3. Request for diet instructions of patients for discharge should be made
at least one day before the actual discharge.
87
Procedures in Operating a Nutrition Clinic
l A patient with a referral slip should go to the nutrition clinic and
hand the referral slipto the Nutritionist-Dietitian. Referral slips should
indicate the diet prescription and diagnosis of the patient.(See NC
Form No. I, Nutrition Clinic Referral Slip)
2 The Nutritionist-Dietitian should interview the patient, take his
nutritional history, food likes and dislikes, meal pattern, and other
pertinent information needed (See DS Form No. 17, Diet History
Form and NC Form No.2, Nutrition History and NC Form No. 3A,
Usual Daily Food Intake). The patient's chart should be referred for
laboratory findings and other information needed or matters relevant
to the diet prescription.
1 The Nutritionist-Dietitian should compute the diet and give the dietary
instructions depending upon the patient's needs and conditions. (See
NC Form No. 3B, Diet Distribution Plan)
4. The patient should be asked to come back a week after the follow-up,
ifneeded.
Malwanl or Nutreward
A Malnutrition Ward (Malward) or Nutrition Ward (Nutreward) is a
special area in the hospital for patients suffering from third degree
malnutrition with complications. The ward can be set up as part of the
Pediatric ward or it can be a separate ward in itself. The demonstration
kitchen is a must in every Nutreward, because it is here where the nutrition
education is carried out.
Objectives ofa Malward
General Objective:
To treat and rehabilitate severely malnourished children through proper
nutrition and health education of the parents.
Specific Objectives:
l To rehabilitate severely malnourished children through special medical
and dietary care;
2 To educate the parents, especially mothers, in the fields of proper
nutrition, family planning, environmental sanitation, food production,
handicraft, and other income-generating skills;
1 To providetrainingfor medicalandparamedical personneland students on
the identification and management of malnourished children;
4. To provide follow-up services for all discharged cases; and
5. To coordinate/collaborate with government, social service, and religious
organizations to help improve the socio-economic conditions of
selectedwelfare cases.
Policies and Procedures ofthe Malward are as foUows:
A Admission ofPatients
Childrenwho arethird-degree malnourished or thosewhose weightare
belowsixty percent (60%) of the ideal body weight, and children who are
seconddegreemalnourishedwith complicationsareadmittedtotheNutreward.
Theweightofthe childisbasedonthe Weight Tableforpre-sehoolers
88
Marasmic and Kwashiorkor children with complications like
broncho-pneumonia, pulmonary TB, chronic diarrhea, and others
are transferred from the Nutreward to the Pediatric ward as soon as
their conditions improved.
R DietaryManagement
1 ThePediatriciangivesthe diet prescription andthe Nutritionist-
Dietitian computesandtranslatesthe dietprescription interms
offood. The basis of computation is as follows:
a Tota1wergyrequirement iscomputedfollowinganallowance
of!00-200caloriesperkilogramofdesirablebodyweigbt.
b. Protein allowance - two to four grams ofprotein per
kilogramofdesirablebody weight per day.
c. Fluidallowance- 120to 150milliliter per kilogramof
body weight.
This initial prescription is changed whenever the patient
develops diarrhea, dyspnea, and other conditions because of
complicationsaccompanying malnutrition. A changeis also
made if the childis on the road to recovery such that calorie
andproteinlevelshave increasedastolerated.
2 Since the dietis computed, the food servedto the malnourished
children are measured using household standards. Nutrient
levels, especially calorieandproteinlevelsoffood served, are
computedupon admission andweeklythereafter, or whenever
there is a notable increaseinweight.
C. Other A$Jlects of Management During Confinement
1 lntheNutreward, each childisweighed everyday or every otherday
to check forweight changes. Weight isrecordedinthechart.
2 Mothers or watchers take turns in the meal planning and
budgeting, food preparation, and cooking for malnourished
patients through the supervision ofthe Nutritionist-Dietitian.
3. Healthandnutritionactivities consistsofinformalinstructions
regarding proper child feeding, personal hygiene,
environmental sanitation, family planning, food production,
handicraft, and other income generating activities.
4. Ifthere is a spacefor gardening, mothers or watchers may do
some gardening, and may utilize their harvest in food
preparation for the malnourished children.
5. Sincemothers andwatchers actually do the food preparation
for their children, they are also givenfree meals.
6. Some form ofmental stimulation for children helps inpromoting
growth in language ability by encouraging parents to adopt aew
techniques andattitudes, to be actively involved in andconcerned
with the development needs of children andthe consequences of
child rearingpracticesthrough artwork, games, songs, dances, etc.
D. Discharge ofPatients
A child should be dischargedafter an increase of 10-20%ofhis!
her body weight. A child is considered to have improved ifhe/she
attainedthe saidweight increase.
89
E Follow-up ofPatients
1 A discharged patient is asked to return after one month
for follow-up.
2 A follow-up team is composed of a Pediatrician, a Nurse, a
Nutritionist-Dietitian, and a Social Worker. Periodic home
visits are done to ensure that the rehabilitation ofthe child is
sustained at home.
1 The childmaybereferredto thelocalhealthunit for follow-up.
F. Rules on the Use ofthe Kitchenette
1 The Nutritionist-Dietitian shall be solely responsible and
accountable for the kitchenette facilities and supplies.
2 Two or three mothers should be allowed to stay in the
kitchenette for the cooking demonstrations, and only those
who are scheduled for that day should be allowed to enter the
kitchenette. The patient should stay in the ward.
1 Hospital personnel not involved intheMalwardkitchenette should
be slrictly prohibited fromloitering in the area, and shouldrefrain
fromusingitsfilcilities and supplies for otherpwposes.
4. Participating mothers in the food preparation area should
wash their hands with soap and water, wear aprons, put on
headbands or hairnets, and observe all sanitary procedures.
5. Participating mothers may be entitled to food after dishing
out patient meals as an incentive for participating.
6. Participating mothers assigned in the food preparation for
the day shall be responsible for the maintenance ofcleanliness
and sanitation ofthe kitchenette.
G. DutiesandResponsibilitiesofaNutritionist-DietitianassilJIledintheMalward
1 Plans the menu;
2 Interprets the diet prescription;
1 Makes dietary calculations for all Malward patients;
4. Makes market orders and supervises food preparation;
5. Prepares special diets such as tube or blenderized feeding;
6. Gives diet instructions and diet counselling;
7, Organizes mothercraft activities and coordinates with the
nurses, social workers, and other ancillary services;
8. Conducts lectures and demonstrations to mothers on the topics
of nutrition, food, and low cost menus; and
9. Participates in the follow-up team.
RESEARCH FUNCTIONS
Research Unit
Advances in clinical nutrition, food service administration, and other
allied health sciences emphasize the need for expanding current efforts in
the area ofresearch. Because ofthe need to improve and enhance an effective
Dietary Service, the Nutritionist-Dietitian should keep abreast with current
trends by actively participating in research studies.
90
To achieve this, the head ofthe Dietary Service should strive to develop
the research capabilities ofthe staff, to cooperate and participate in research
activities of the Dietary Service involving all areas. These areas include
basic nutrition, clinical nutrition, community nutrition, food science, and
institutional food service.
Studies show that priority research needs in these areas are enormons.
The Nutritionist-Dietitian should try to find time and conduct studies in
the said areas, to benefit not only the institution where he/she is connected,
but also for continuing education purposes.
The following are some suggested topics inthe different areas ofresearch:
ResearchAreas
L Basic Nutrition'
Activities
a)Distribution of
Food in the
Family
Research Needs
1 The cost of an
adequate meal for
the family in rural
areas compared with
the urban areas.
2.The contributions
made by the green
revolution to the
improvement of the
family diet.
c)Food
Fortification
b)Analysis of
Nutrient
Composition
3. Nutritional
improvement of the
vulnerable groups
through
supplementary
feeding programs.
1 Nutrient content in
food as affected by
genetic improvement,
soil, fertility, light,
storage, and milling.
2.Thorough evaluation
of food mixture
intended as a
weaning food.
1 Effective food
fortification as a
solution to anemia
problems.
2 Supplementation
versus fortification as
a new approach to
solve nutritional
problems.
'Carmen L. Intengan, "Priority Research Needs: Basic Nutrition," Philippine
Journal ofDietitians, 31:2 (April-June 1978)
9 I
ResearchAreas Activities ResearchNeeds
II. Clinical Nutrition" a) Breast-feeding. I. Socio-cuhural
benefits of
breastfeeding.
2 Biochemical and
nutritional
composition and
output ofhuman milk.
3. Improvement of
breastmilk
substitutes.
4.Modification of
currentlyused
infant foods to make
them nutritionally
suitable for infant
feeding.
b) Nutritional I. Simplifyingassess-
Assessment ment of nutritional
status by use of
health workers and
the lay public.
2Evaluation of
nutrient content of
the diet served to
patients and
personnel.
3. Evaluation of
patient's acceptance
and rejection on
diets served.
c)Food Formulation I. The use oflocally
available and
inexpensive food,
and formulation in
certain disease
conditions such as
"Buko Water" and
"guava leaftea. "
d)Nutritional I. Evaluation ofthe
Education and effectiveness of
Diet Counselling diet instruction to
patients.
"Perla Santos Ocampo, ''Priority Research Needs: Clinical Nutrition",
Philippine JoumalofDietitians, 31:2 (April-June 1978).
92
HospitalDietaryService Management Manual
Research Areas
III. Community
Nutrition'"
IV. Food Science....
Activities
a)Barangay
Nutrition
b) Identification of
the Malnourished
c)Operation
''Tunbang''
d)Food Assistance
a)Nutritional
Research Needs
1. Effectiveness ofthe
barangay nutrition
network.
2 Monitoring the
barangay scholars.
1 Cut-off points in
the use ofthe
weight-height standard
in the rehabilitation
ofthe malnourished.
1 Evaluation ofOPTin
terms ofefficiency,
accuracy, and cost.
2 The degreeofaccuracy
oftheresuhsofOP'r.
1 Effectiveness of
NutqJakandNutqJak-
type products in the
rehabilitation of the
malnourished.
2 Comparative study-
center feeding and
distribution ofhome
assistance.
1 Levels ofnutrients
and components of
foodthat have direct
bearing on nutrition
in health and disease
such as cholesterol,
aflatoxin, salt,
pesticide residues,
anti-metabolites and
others.
2 Effects ofprocessing
on losses and
improvements in the
nutrient level offood.
"'Rodolfo E. Florentino, ''Priority Research Needs: Community Edition",
Philippine Journal ofNutrition, 31:2 (April-June 1978).
....Josefa S. Eusebio, "PriorityResearch Needs: Food Science", Philippine
Journal ofNutrition, 31:2 (April-June 1978).
93
ResearchAreas
V Institutional
Food Service"?"
Activities
b)Food
Fortification
and Enrichment
c)Substitution of
Vegetablesfor
Animal Proteins
d)NewlyProcessed
Food
a)Menu Planning
b)Purchasing
c)Storage
Research Needs
LResearch on the most
appropriate vehicle
for fortification of
food with Vitamin A,
Iron, or Iodine.
l.Protein from
indigenous beans
and nuts
2Development of
nutritious low cost
food for infant
feeding and their
acceptance.
LSearch for new
products from
sources like yeast,
fungi, and bacteria.
2 Use ofconvenience
food.
LDistribution of food
groups, peso and
nutrient values in
cycle menus.
2 Classification of
menu items
according to the food
value ofthe food
exchanges.
LStandardization of
food specialization
practical for use by
local suppliers.
LStorage life ofsome
convenience food.
2 Study of the
bacterial
contamination on
food upon delivery
and after storage
and cooking.
l
....Rachel Chipeco Fajardo, "Priority Research Needs: Clinical
Nutrition", Philippine Journal ofNutrition, 31:2 (April-June 1978).
94
Research Areas Activities
d)Preparation
e) Employment
f)Equipment and
Layout
g)Dish and Pot
Washing
Research Needs
I.Standardization of
recipe using
vegetable proteins
and meat extenders.
1. Methods of
recruitment and its
effectiveness.
2.Development of
teaching-training
modules foremployees
3. Development of
instructional aids.
1. Standardization of
specifications for
locallymanufactured
equipment.
2. Development of a
usable catalogue of
equipment locally
availablewith prevailing
market prices.
3. Layout for varying
space available, floor
plan, budget, and needs
of Filipino workers.
4.Work simplification
studies.
1. Bacterial a:unt ci dishes
used in the operation.
2.Work simplification
studiesonw.rrehand1ing.
METABOLIC BALANCE STUDIES
The MetabolicBalance Study is a method of investigatingthe metabolism
of chemical elements or food constituents in a patient by determining the
loss or retention of these substances in his/her body. Each patient included
in the study is interviewed and oriented. The diet is planned according to
individual preferences and the calculated level ofspecificnutrients as ordered
bythe physician. Thesediets are preparedand served at the metabolic balance
study kitchen unit. The types of patients selected are:
1. Those who have some metabolic disturbances;
2. Patients used as controls; and
3. Patients who have specific conditions and are used to test a drug or
medical procedures.
95
Planning the Metabolic Kitchen Unit
A Management
The metabolic balance study kitchen unit is under the
administrative management ofthe Chief ofthe Dietary Service.
R Number ofPatients
The number ofmetabolic balance study patientsto be fed at one time
from a metabolickitchenunit and the procedures employedwill determine
the number ofstaH; the floor space, and the equipmentneeded.
Because ofthe detailed, tedious, and time-consuming procedures
necessary, and the accuracy with which they must be accomplished, it
is recommended that not more than ten patients be served metabolic
balance study diets from one kitchen unit at the same time.
C. Staff
The metabolic kitchen staff should consist of one Nutritionist-
Dietitian, and enough non-professional staff to accomplish the work
ofthe unit efficiently. They should work seven days a weekwithout
pressure and with a minimum of errors.
The functions of the Nutritionist-Dietitian in this unit includes
the following:
I. Planning and calculating the complicated and precise constant
diet required in the study ofmetabolism ofa specific nutrient;
2 Orderingand properlystoringthe food necessaryfor the research;
3. Training and supervising the non-professional staffin accurate
weighing, preparing, and serving of meals to avoid any loss
of nutrients;
4. Orientingthe patientswith the principles ofthe diet and adapting
it to the patient's preferenceswithin requiredrestrictions;
5. Giving the patients encouragement, understanding and
motivation to consume the food served;
6. Informing the nurse, nursing attendants and others concerned
about the necessary procedures to be used in measuring intake
and output and preserving any food left;
7 Arrangingfor periodiclaboratory analysis ofdiet whennecessary;
8. Keeping accurate records of intake, output and pertinent
observations that might effect results ofthe research; and
9. Compiling and evaluating findings ofthe nutritional researches
as a part ofthe entire research project compilation.
The non-professional staffis composed ofthe cook, assistant cook
and food service workers. Their functions include the following:
I. Preparation, weighing, cooking, and servingoffood in accordance
with specific, standardizedmetabolicbalancestudytechniques;
2. Accuracy in using calibrated measuring devices; and
3. Proper methods of storing foods.
The number ofnon-professional staffto be employed dependsupon the tasks
to be performed and the number ofhours or days when they must be completed.
90
D. Facilities, Location and Space
A metabolic kitchen unit consists oftwo major areas:
L Nutritionist-Dietitian's Office - it should be close to the
patient's rooms, the kitchen and offices ofthe other members
ofthe research team. It should be designed to provide privacy
and it should be free from noise for detailed work. It should
have enough space for office equipment.
2 Kitchen - it should be located within one hundred feet from
the patient's rooms. Locatingthe kitchen at a greater distance
or on another floor of the hospital is an unsatisfactory
arrangement. Transporting patient's trays on elevators or
through lengthy corridors would result in the contamination
of food, cold meals for the patient, insufficient supervision
ofpatient's intake, less control with regard to food refusals or
spillage, and cooperative patients.
The kitchen should be large enough to include the following:
l Handwashing sink
2. Storage cabin space
3. Pre-preparation work space (counter space and tables for
weighing foods)
4. Cooking equipment
5. Tray set-up space
6. Floor space for tray carts, freezer, refrigerators and waste cans
7. Dishwashing and clean-up area
8. Storeroom for storing canned or other unrefrigerated food
SPECIALIZED FUNCTIONS
Protein (gm)
25
35
63
56
53
Calories
970
1740
2590
2000
1500
Disaster Feeding
Whenever a disaster occurs, feeding the victims is.a responsibility of
both private and government organizations. The objective is not only to
allay hunger but also to sustain morale.' It is a difficult task especially for
those who are burdened with the said responsibility for the first time,
therefore the following guidelines for its operation should be followed:
l Meals should be limited to simple foods which are easily available
and require minimum preparation;
2. Meals should meet the daily allowances, at least for calories and protein
only, even for short-term feeding. Recommended daily nutrient
allowance by age groups:
Age Groups
Infant 6-12 months
Children 1-12years
Males 13-39years
Females 13-39 years
Adults 40 years or over
Ma. Patrocino E. de Guzman, "Disaster Feeding", Philippine Journal of
Nutrition, 33 (January-March 1977).
97
For pregnant and lactating women, additional milkis given while
adults involved in rescue operations should receive additional sources
ofenergy. The victims are provided with at least 2 quarts ofwater.
1 Meals that should be served willdepend upon the stage ofemergency:
a. For the early emergency period, characterized by stress and
anxiety, serve stimulatingwarmdrinks and light snacks. Avoid
very hot or iced beverages. Milkisbest for infants and children;
coffee, fruit juice or soft drinksfor adults. Easy to serve snacks
which are high in carbohydrates are preferred;
b. For the intermediate period, when cooking facilities are
available, a full meal may be served, usually a nourishing one-
dish hot meal which is easy to prepare, transport, and serve.
Otherwise, meals from packaged or canned foods and fresh
fruits which do not require heating may be planned; and
c. For extended operations, when cooking facilities are already
set up, one-dish-meals with fruit and rice or bread may be
served. Two or three meals a day can also be served.
Principles in Planning and
Organizing an Emergency Feeding Program
1 Qualified individuals must do the planning and orgarnzmg.
2 Delegation ofline authorities and responsibilities must be clear
to all involved.
1 The development ofa good plan requires the following information:
a. Probable location ofmass feeding centers
b. Estimated number ofvictims
c. Available feeding personnel
d. Existing physical resources
4. Plans must be practical and manageable.
5. Plans must be fully coordinated with civic, religious, and other
agencies involved.
Role of Nutritionist-Dietitian
1 Develops a written emergency feeding plan based on the above
mentioned principles.
2 Establishes lines of succession to operationalize the plan at any time.
1 Compiles a set ofemergency feedingmenus and listingoffood supplies
and equipment needed.
4. During the disaster, the Nutritionist-Dietitian decides on the location
ofthe center, know the existing facilities, determine the food supplies
and equipment necessary, devise a system whereby food suppliescould
always be ready, and assign specific duties to stafffor the feeding.
5. Maintains food stocks for emergencies, especially in emergency prone
areas (e.g. typhoon belts, earthquake belts, etc.).
98
QUALITYASSURANCEFOR
DIETETICSERVICE
QUALITYASSURANCE DEFINED*
Quality Assurance is a planned systematic process that objectively
monitors and evaluates the quality and appropriateness of all important
aspects ofcarethrough ongoing reviews, correctionofidentifiedproblems,
follow-up on opportunities to enhance patient care, andlastingimprovement
in the care provided to patients or residents.
The following information is providedto helpdefinethe terms included
inthisdescription ofQualityAssurance aswell asthose commonly associated
with this topic.
Aplanned process is a method that identifies, in advance, the major
clinical activities that have great impact onthe qualityofpatient or resident
care. It prioritizesthese activities, andhas pre-determined indicators with
related criteriaandmethodsfor determining the extent to which standards
for these activities are beingmet.
A systematic process is a method which enables the collection and
analysis of data, regarding the success of the department's major clinical
activities, on a frequent basis and routinelyacts to improve care.
Objectivemonitoringand evaluation should be doneonan continuous basis
using non-judgmental methods that arevalid, reliable, andpractical. Monitoring
entails the continual collection andscreening of data to identifYthe levels ofcare
that areactually provided Evaluation requires the examination andreviewofthis
datatoseeifappropriate levels ofcare have beenprovided, and to identifYpattems
ortrends aswell asproblems inthe service,
Quality andAppropriateness ofcare refers to the adherence to proper
standards ofpractice, outcomes, and timeliness ofthe service provided by
competent persons. Aspects of cost and efficiency are not commonly
included in the QualityAssurance Program(QAP) but they maybe used to
interpret resuhs or resolveproblems.
'Rita Jackson, "QualityAssurance tor Dietetic Service," Kingland, Georgia.
19l1J .
99
Important Aspects of Patient Care are the major clinical activities or
functions that have the greatest impact on patient care.
Ongoing Reviews are done to systematically screen and collect data
according to pre-determined methods and objectively match the existing
situation with the standards set for professional practice and outcomes. It
is recommended that they be done daily or weekly, and that they be frequently
summarized and analyzed to identify problems and trends in patient care
delivery.
Correction of Identified Problems must be an automatic reaction to
any situation which might indicate that the standards of appropriateness
and quality are not being followed, or that a downward trend exists. A plan
of correction is developed to involve the proper designated individuals and/
or mechanisms which can, as much as possible, eliminate the problems and
correct unacceptable patterns.
Improvement in patient careshould be the documented result of a QAP. The
surfacing of negative trends, suggestive results, or problems must be used as an
opportunity to gainsupport for planning corrections that will enhancepatient care.
Thegoverning body ofthe facility isultimately responsible for makingsurethat the
mechanism identified for corrective action is effective in implementingsuch plans
and promoting high qualitycare.
Indicators of Quality Care are those events and outcomes that are
monitored and evaluated to learn the extent to which routine activities
conform to the standards set for them.
Criteria are the specific professional standards against which a situation
is compared to learn the extent to which appropriate care is offered to
patients or residents.
THE IMPORTANCE OF QUALITY ASSURANCE
FOR DIETETIC SERVICE
The major advantage of a QAP. is that it acts as a valuable management
tool to assist health care professionals in achieving and maintaining the
highest possible level ofquality care for all patients or residents of the facility.
Some managers and dietitians simply give up when they find themselves
in a limited environment that presents an overwhelming number of problems
or barriers to their efforts in improving patient care. They comment on the
lack of support from the administration, poorly trained or unmotivated
employees, inferior sources of food, a limited budget, and the like. With
this kind of thinking, it is easy to divorce oneself from the patient- related
problems that appear to be inherent in the system, those which are not a
direct remit of their efforts on the job. When patients complaint or incidents
occur, or when code violations are received, it is therefore easy to blame the
system for the lack of support and resources.
Illustration 1 shows the Q!'\P reflecting the level of patient care provided
and the many departmental activities that are influenced by the outcome of
the program. The QAP monitors and evaluates the quality and
appropriateness of patient care and the results are used as inputs for the
activities listed, as well as for many others.
100
r
Illustration I
QUALITY ASSURANCE RELATED TO
DEPARTMENTAL FUNCTIONS AND ACTMTIES
PATIENT/RESIDENT
I
QUALITY AND APPROPRIATENESS OF CARE
1. DEPARTMENTAL -----,
EVALUATION
r----7. STAFFING
REQUIREMENTS
2. UNIT EVALUATION =:l Ir=8. FINANCIAL
ALLOCATIONS
3. INDIVIDUAL I I 9. SCHEDULING
PERFORMANCE QUALITY AND W ~
APPRAISAL ASSURACE ASSIGNMENTS
PROGRAMME
4. EMPLOYEE I Il-IO.PROBLEM SOLVING!
TRAINING ~ ~ DECISION MAKING
5. PERIODIC 11. RISKMANAGEMENT
REPORTING
6. MANAGEMENT ..J
OBJECTIVES
L----12.HEALTH SURVEY
PREPARATION
13.SETTING AND INTEGRATING
DEPARTMENTAL PRIORITIES
1 DEPARTMENTAL EVALUATION
The overall level of patient or resident care is reflected in the
outcome of the QbP. If the program uses methods that are valid and
reliable for measuring quality and appropriateness of care, then
acceptable results are obtained. The director of dietetic services can
be objective in answering the question "How well are we doing?".
This can be done in qualitative terms. For example, instead of saying
"the patients seem to accept the meal service because we get few
complaints," one can more clearly evaluate this acceptance and say
" ninety-two percent (92%) of the patients report that the meal services
are acceptable and major problems appear to be in the areas.of hot
food temperature (75%) and menu variety (80%)." Such a statement
is more valuable in identifying the processes that need improvement
and learning the extent to which overall standards for meal acceptability
are being made. Instead of saying "the dietitians do a good job in
assessing the nutritional status of patients" one can state "eighty-five
percent (85%) of the patients in the facility are receiving a nutritional
assessment within seventy-two (72) hours of admission and ninety
percent (90%) of these assessments meet all the criteria for quality
nutritional care." A good QbP has indicators/criteria and methods
which are commonly accepted by the Administration, the Quality
Assurance Committee, a panel of experts, and the department.
101
Therefore, arbitrary connnents on personal opinionsbased on isolated
mcidents are excludedsincean agree on the way quality nutritional care is
measured and evaluated. Asa result, there are no questionsas to what the
department shouldbe evaluatedfor itsoverall effortsto providegood care.
UNITEVALUATION
When a QAP is designed, accountability should be built into the
plan. Dietetic service is normally divided into several separate units
or functions which interact to provide food and nutrition services to
patients, residents, employees, and guests. The major functions of
typical department are shown below:
In-Patient
Nutrition Intervention (screening, assessment, care planning, etc.)
DietaryTherapy(nutritiousfoodservedto coroplywshdiet prescription,
foodpreferences, sanitation standards, safetystandards, etc.)
Nutrition Education (information for patient and/or family)
Out-Patient
Nutrition Intervention (screening, assessment, care planning, etc.)
Nutrition Education (information for patient and/or family)
Non-Patient
Employee Cafeteria Services
Catering Services
VendingServices
One can encourage accountability in the design of a QAP for
dietetic services by having the Clinical Nutrition Unit for in-patients
responsible for reacting to the results found for "nutrition intervention"
and "nutrition education". In turn, the Food Service Unit would
respond to results for "diet therapy," and the Clinical Nutrition Unit
for out-patients would react to results for the two functions their unit
provides. Results ofthe reviews of cafeteria food service, catering,
and vending would be responded to by the Non-Patient Food Service
Unit. The success which each unit has, in increasing scores after they
react to solve problems, is used for their periodic evaluation.
By integrating accountability into the QAP, the director of the
department is able to identify specific dietary units which need
improvement and support. Without such accountability, it becomes
difficult to identify the source of problems and, of course, ways to
correct them. Accountabilityalso enablesthe director ofdietetic services
to objectively analyze results in terms of the success of each
departmental function and to quickly delegate the job of problem
solving to the person(s) in charge of each function.
I. INDIVIDUALPERFORMANCE APPRAISALS
If accountability for each dietary unit is built into the QAP, so
can accountability ofindividuals withineach unit. Ifthe ChiefClinical
Dietitian is able to significantly improve the quality ofnutrition care
by increasing scores in "nutrition intervention" and "nutrition
education", it can be assumed that this individual is effectively
managing his or her unit. .
102
I
Annual performance appraisalsnormally require input regarding
the employee's major accomplishments during the past year, and
Quality Assurance results provide qualitative and quantitative data
which can be incorporated directly in the appraisal. Performance
appraisals also often require comments for ways the individual can
improve performance for the coming year. Again, this information
is readily available in the Qua1ity Assurance documentation from
annual trends, plans for corrective action, and detailed reports of
specific standards in need of improvement. Since the Quality
Assurance datahasbeencollectedand analyzed inanobjective manner,
the performance appraisalwill, therefore, be freeofsubjective opinions.
An added benefit for the employee is that he or she is f.miliar with
the exact basisfor evaluationscores, andthere are no surprises at the
end of the year because input on the same basic criteria has been
receivedon a continuingbasis throughout the year via the QAP. The
individual canalso clearlyseethe QualityAssurance scores that are in
need ofcorrection andhowhe/she can improvehis/her performance.
QualityAssurance includesspecificstandards and criteria for quality
care, and the individual has all the information necessary to achieve
better appraisalsin the future..
4. EMPLOYEE TRAINING
Since theresuhs of awell planned QualityAssurance Programindicate
areas that need improvement, and one method of improving employee
pedilnnanceisthroughtraining, theoutput oftheQo\Pprovidesaframework
for planning the department's training schedule. Not an corrective action
inchuies theneedfortraining, but quite often criteria for qualitypatient care
areriot metbecause employees donot knowor donot follow departmental
standards \Wileperformingtheirjobs. Toreinforce thesestandards, training
isveryuseful aslong asappropriate follow-up isprovidedto ensure thatthe
badWOlXhabits arediscontinued andacceptable onesareimplemented ona
continuing basis.
When an effective QAP is used, the results are easily utilized in
the creation of a meaningful and more successful employee training
program. Individuals or groups of employees in a particular
department receive information about the results ofQualityAssurance
reviews, and they proceed to learn how they can directly influence
patient care by improvingtheir knowledge and work habits.
An employeetrainingprogram is effective only ifit :
Addresses specific patient needs, according to priority, and
relatesthe results ofQualityAssurance Program;
Changes employee work behavior immediately and
continuouslyafter the training is given;
Is followed byon-the-job observation andcorrection, ifneeded,
for specific employees;
Covers all employeesin the group for which it was intended,
not just those who happen to attend the class or are on duty;
Motivates employeesto do a better job;
Accurately covers needed informationin short time intervals
for optimal retention;
Is presented at the employees' level ofunderstanding;
103
Provides individualized instruction for those in need of it
rather than repetitive classes for the majority of employees
that have already incorporated the principles in their work;
Includes the immediate supervisor for the group ofemployees
as the trainer, or at least as an active participant;
Promotes accountability in all persons trained;'
Is scheduled at the most convenient time around employees'
tasks to avoid stress-on-the-job during training; and
Results in higher quality care and is followed by an increase
in evaluation scores on the topic that was presented,
It may be necessary to train and re-train in a specific topic until
favorable results are found, It is possible that the trainor may have to
get advance training so he or she can be more capable of
communicating in an effective way,
A final recommendation for training comes from the ability of
the Quality Assurance Program to specifically identify the persons
that are weak in a certain skill Ifthis is the case, those found to be
proficient at this skill need not be re- trained and they can even be
used to do the training themselves. Ifan employee lacks many basic
skills which are essential to his/her jobs, he/she can be sent to a local
educational institution or seminar to gain a broad base ofinformation
which the Departmental Manager have the time to provide.
PERIODICREPORTINGOF DEPARTMENTALACTIVITIES
Most department directors and unit managers are required to
submit monthly reports of activities and progress reports to
administration. It is quite easy to assemble, analyze, and report
financial data because the objective formulas for this aspect of the
service are understood and commonly accepted by all. It is also very
easy to present a listing ofactivities during a specified period oftime,
so this is frequently included in periodic reports as well. But have the
financial resources and activities resulted in high quality patient care?
Has the department meet its overall goals and did it contribute to
facility-wide objectives during the period? These are the real questions
that need to be included in such reports but are not always addressed.
One is not able to document the programs in the level ofquality care
unless an effective QAP is inplace. The output ofthis programprovides
clear and undisputable evidence ofthe progress that has been made.
Professionals in Dietetic Services have little free time on their
hands, and seem to be constantly involved in a multitude ofprojects
and activities. Just howthese activities contribute to patient care is of
utmost importance to the Administration so' justification of
departmental costs can be made. Quality Assurance allows managers
and dietitians to chart or graph past and present results in quantitative
terms, ina manner similar to the way departmental costs are presented.
6. MANAGEMENTOBJECTIVES
Many health care facilities employ techniques of Management-
by-Objectives. The Administration calls for specific departmental
objectives each year with time-tables for attaining these objectives.
104
The objectives set by each department head should conformto
the facility-wide objectives. Methods for achieving these goals are
normally outlined with descriptions of resources to be utilized and
measurable outcomesto be expected.
Sincetheprimarygoal ofdieteticservice isto providehighquality
nutrition care and most management objectives fall into this realm,
the QAP is convenient mechanism for identifying objectives that
should be included and for determining the present status of the
department withregardto eachspecificmanagement objective selected.
High priority issues revealedin the QAP should be addressed. The
methods used to collect and analyze data in the QAP can be used to
objectively measurethe outcomeandprogress ofdepartmentalefforts
as the time-tableis implemented. Ids difficult to identifywhether or
not the objectiveshave really been met without acceptable methods
for quantifying results.
1 STAFFINGREOUIREMENTS
Thejob ofthe dieteticservicesdirector is to allocate appropriate
resourcesto the departmental function sopositiveoutcomeswill result.
People arethe primaryresource inthe department andthere aretimes
when staffing patterns, tables of organization, and job descriptions
are found to be insufficient to meet the goals of the department.
Often, problems occur in areas that are not properly staffed or
organized. For example, it may be found, from Quality Assurance
results, that few patient's receive timely nutrition screening and
assessments. Further investigation into the matter may reveal thar
dietitians areproperlytrainedandproficient at the carethat ispresently
being given, but theyaretoo fewinnumbersto coverthe entirepatient
population in need of their care.
To require increased productivity in a staff that is performing
sufficiently may decrease the qualityoftheir work so another action
maybe warranted. The allocation ofpersonal resources couldthen be
reviewed.: One might have to change the organizational table and
staffing pattern, or even create a new job description, such as the
dietetic assistantor dietetictechnician, to alleviate theproblem After
this is done, one shouldexpect QualityAssurancescores intimeliness
ofnutrition screening and assessmentto increase.
8.
Just as theallocation of personnel needs to be planned and modified to
ensure enhancement inthe quality of care given to patients; so dofinancial
allocations. Thedirector ofdietetic seIVices makes budgetrequests on an
annualbasisandneedstohavejm
rificationford1angesinco!t-eenteraDotnmts
orbudgetaryincreases. QualityAssuranceprovidesthejustificationbased on
reviews that were conducted. The results help to showthe departmental
fimctionsandco!t-centersthatareinneedofreaDocationoffimdsorincreased
financing, andhowthequalityofcare canbeimprovedupontheapproval of
proposed budgets. Bydoing this, thepurchases of food, equipment, and
supplies canbejustifiedinterms ofhow allocationwill enhancepatient care.
It will beupto the department staffto ensure thatthereisindeed a positive
outcome after theinvestment ismade.
105
.1i. SCHEDULINGANDWORKASSIGNMENTS
The director of Dietetic Service is responsible for scheduling
employees on days and shifts that best contribute to optimal patient
care and that each employee on duty performs a series oftasks that
are replanned and carried out in the proper manner. When statistics
for manhours-per-meal-served are compared, a variation is seen from
facility to facility. Dietetic Service in some settings lack the number
of manhours to perform effectively, while others have adequate
manpower but fail to organize and direct themproperly. In the latter
case, unsatisfactory scores on Quality Assurance reviews can be
corrected by reorganizing schedules and work assignments, and
justification for the changes made, in terms of "patient care," can be
made to administrators and employees alike. Even in a department
withaworkers union present, management retains the right to schedule
and assign employee to the needs ofthe facility, and it is beneficial for
managers to exercise this right because they are responsible for
enhancing the level ofpatient care.
10. PROBLEM SOLVING AND DECISION MAKING
The primary function of QAP is to identify problems and
opportunities for improvement in patient care. During the course of
a day's work, managers and dietitians see or hear reports of many
problems, and it is sometimes difficult to discern if they are just
isolated incidents or common problem which require in depth
attention. Their perceptions and those received though others may
not truly represent the actual situations, as they really happen because
subjective opinions often enter into the picture in very subtle way.
Quality Assurance assists managers and dietitians in identifying the
problems inan objective manner without leavingproblemidentification
up to chance, such as randomor chance observation. It also provides
a framework for learning the scope ofthe problem and the extent to
which standard are being met in patient care.
Most directors of dietetic services can immediately list all the
problems related to their department and identify several potential
solutions for each. Ifan effective QAP is inplace, the extent ofnon-
compliance is known for each problem and priorities are easily
identified. Decisions can be made solely on the basis of severity of
problems and the resources available.
Il RISKMANAGEMENT
The focus ofRisk Management is to protect the financial assets of
the health care facility, its human .resources, and prevent injury to
patients andproperty. Like QualityAssurance, it isbased on improving
the quality ofcare through ongoing efforts in monitoring the facility
to prevent incidents and losses. Therefore, many activities ofthe Risk
Management Program overlapthose ofthe QualityAssurance Program
The major difference between these two programs is that risk
managers deal more with legal and insurance activities, in that they
report on the incidents while QualityAssurance searches for problems,
trends or patterns ofnon-conformance and opportunities in increasing
the level ofpatient care.
106
The dietetic services director maybe required to submit to the Risk
Management staH; specific incidents that occurinthe mcility. It would also
be helpful ifthe director of dietetics is first briefed on the high risk cases
befure theyare investigated bytheRisk Management staff
A good procedurewhich is implemented in manyfacilities is the
"Patient Incident Report". This report can be filled in by health
related professionalswhen an incident is observed. Dietetic Service
can have its own internal reporting systemthat is stored by a QAP.
When an incident is observed, the formis filled out accordingto
the following steps:
L Duplicate Copies ofthe Patient Incident Report include:
Name and location ofpatient or resident
Date and time of incident or complaint
Exact description of the problem and how the staff
memberbecameaware ofit
Other persons witnessingthe problem
What was immediately done by the staff member to
alleviate the problem
2 Patient Incident Report is further completedby Departmental
Manager in-chargeto include:
Further action taken in the case
Specific precautions taken so that the incident would
not occur again with this or other patients
Posting ofcompletecopy so all employeeswho come
incontactthepatientinvolved are awareoftheincident
andwhat was done
Automatic increase in the frequency of monitoring
the patient involved
3. Original copyto Director ofDietetic Servicewho:
Follows up the problemand its correction
Classifies the incident for inclusion in the QAP
Such a procedure insures that everyone is aware ofthe incident,
its potential risks, and the follow-up action that was taken.
12 PREPARATIONFORHEAL1HSURVEYS
The purpose ofQualityAssurance is to monitor and identify the
extentto whichhighstandardsofcare are followed for patient service.
Thisis the samepurpose ofa health care survey.
If the dietetics manager or dietitian has a Quality Assurance
Programwhich reflects the criteria and standards specifiedin health
codes, the areas of non-compliance will surface on a regular basis,
andplans for correction ofthe problems identifiedwill continuously
be in place. One will know, at anypoint in time, potential violations
that might be citedifa survey should occur, and the focus becomes
. less on the "last minute" preparationfor a health surveyandmore on
continual improvements to the systemso all criteria for proper care
are met at all times.
107
ToiacoiporatecoderegaletionsinQJa1ityAs!mancereviewswould !meIy
increasetheamount oftime andenergyrequired to develop theprogramfor
Dietetic Service, But,oncethisisdone, thebenefitsaregreat. Insteadofthe
"Iali minutepreparation,"the departmental sta1f1S"alwaysready" fora!lIIVey.
Patients andstaffalike, benefit fromthis change inattitude.
13. SETTINGDEPAR'IMEN'D\LPRIORITIES
Anyonethat1ulSwotkedinthedietetic serviceshas, atonetimeoranother,
found it easyto fall into the situation where it seems as iftheir timeand
attention arebeing pulled in ahundred diffurent directions. Iftheydelegate
many activities andproblem solving tasks, the time of their staffmembers
maybe found tobe segmmted into asmany directions. At theendoftheday
theysay, "wewere busyanday, but what didwe reallyaccomplish?"
Administrators have their priorities for the department, andnewones
seem to be conmnmicated, at least on a weekly basis. The department
managernentbyobjectivesplanprovidesanother setofdirectionsandactivities
with a time-table for implementation which IIDISt be met. Daily incidents
thatoccurmustbe checkedandproblemsresolved immediately Labor, food
and supply budgets provide for certain activities which also have to be
accomplished or else fimds will run short. Thetraining programprovides
additional andoften diffaent sections of focused.
Aneffective QAPoffers theDietetic Service director avaluable tool by
which to prioritize an problems and activities from the patient of resident
pointofview. It doesthis inanobjective manner sothatthepriorities setare
difficuh to dispute. Most frequently documented problems and critical
patient relatedissuesareon thetopofthelist. Theyprovideaframeworkfor
activityin an the management fimctions discussed inthis section. There is
a also valid rationale for not being able to devote much time andenergy in
activities whichdonot solvepatient relatedproblems orenhancepatient care.
Some things mayjusthave to sit onthebackburner for a while until more
critical issues areresolved. This rationale helps thedietitian andmanager to
screen out unimportant activities andconcentrate onthedepartmental goals
andobjectives setforhigh qualitypatient care.
COMPONENTS OF THE
QUALITYASSURANCEPROGRAM
The essentialcomponents ofthe QAPare the following:
1 Identification ofimportant or potential problems, or related concerns,
in patient care.
2 Objective assessment ofthecauseandscopeoftheproblem(s)orconcem(s),
including determining priorities for both investigating and resolving the
problem(s). Ordinarily, priorities shaD berelated to thedegree ofimpact on
patient care that canbe expected iftheproblemremains unresolved.
3. Implementing decisions, or actions that are designed to eliminate
identified problems.
4. Monitoring activities designed to ensure that the desired result has
been achievedand sustained.
5. Documentationthatsubstantiatesthe effectiveness oftheoverall programto
enhance patient care andto ensure sound clinical performance.
108

Component 1
"Identification ojimportant orpotentialproblems, or relatedconcerns,
inpotient care. "
The QAP describedcan assist in identifying important problems by:
1 Including all important aspects ofpatient careinthe listing offunetions and
indicators andhave these aspects scheduled fur continuous monitoring.
2 .Observing times whenthese aspects receive inappropriate scores on
the data collection and summary forms indicating that a problem
exists.
3. Observing and analyzing downwardtrends over time and the annual
spreadsheetof'annualresults.
Component 2
"Objective assessment ofthe course andscope ojproblems or concerns,
including determining the priorities jor both investigating and resolving
problems. -Ordinarily, priorities shall be related to the degree ojimpact on
patient care that can be expectedifthe problem remains unresolved"
Thisessential component ofthe QualityAssurance Program can be
demonstratedbythe following:
1 Objective assessment ofthe cause and scope ofa problemor concern
is possibleifthe indicators, criteria, and methods for data collection
and analyses are developed in a valid and reliablemanner andifthey
are evaluated and ratified bya group of experts who confirm and
document their objectivity.
2 Prioritiesfor investigating andresolving problems are set becausethe
most important aspects of patient care are included in the program.
Lower or decreasing scores onthe annualspreadsheetofresults show
that a problemis evolving andthat proper attention is needed. Areas
withlower or decreasing scores becomequalityassurancepriorities.
3. Priorities fur investigation andresolution are also identified by reviewing
resuhsofthe"critical indicators,"thosemnchareusedtomonitorpotentially
high risk situations such astube-tedpatients, NPOcases, etc. When these
scores arelowor declining, the director ofDietetic Service is immediately
alerted ofpotential high risk situations.
Component 3
"Implementing, through appropriate individuals or designated
mechanism, decisions, or actions that are designed to eliminate identified
problems. "
This component can be demonstrated by showingpolicy and actual
decisions or actions made in the QAP by using the following:
1 Thetable of organization furthefilcility-wide QAPinthemanual showsthe
designated mechanismfurproblemsolving. Accordingtothedepartmental
policy, the unit managers write their plan of correction and if this plan
requires support for cooperation from persons outside the department, the
director of Dietetic Service, administrators, andthe members of Quality
Assurance Committee workto implement the solution.
Policy, therefore, specifically indicatesthe mechanismto be used
for successful correction ofallproblems.
109
2. Examples ofactual reviews and how problems have been solved in the
past can further provide documentation of the mechanism used for
solving problems.
3. Improved scores on follow-up reviews can demonstrate that the
mechanism used for problem solving has worked and is effective.
Since the program is on-going, all reviews are continuous and follow-
up scores can be identified for all functions included.
Component 4
"Monitoring activities designed to ensure that the desired result has
been achieved and sustained."
Documentation in the Quality Assurance Manual that can
demonstrate this component of the program can include the following:
1. Again, since the annual spreadsheet of results shows the Quality
Assurance reviews being done on an "on-going" basis, one can see if
an improvement in scores, showing greater compliance, has occurred
after the implementation of the plan of correction.
2. When a desired result has been sustained, the annual spreadsheet for
future periods will show maintenance of the improved scores or an
upward trend in results.
ComponentS
"Documentation that reasonably substantiates the effectiveness of the
overall program to enhance patient care and ensure sound clinical
performance. "
This component can be demonstrated by the following information
in the QualityAssurance Manual:
1. The indicators, criteria, and data collection methods are found valid and
reliable by a teamofexperts. Theprogram,therefore, adequately measures the
qualityofcaregivento patients or residents, and sound clinical performance.
2. All scores on the annual spreadsheets of results will gradually increase
over time so it can be easily demonstrated that the program is
enhancing patient care. The standards ofsound clinical performance
are being met with greater frequency over time because of the successful
implementation of the plans of correction. All of this information is
included in the manual.
By correctly documenting and organizing records, one can see how
the Joint Commission standards for the essential components of the QAP
can be demonstrated. If the Quality Assurance results are haphazardly
filed, not analyzed, or not related to past and future outcomes, the Quality
Assurance Program will lose its meaning and cannot be considered as a
well-defined, well-organized program that enhances patient care through
ongoing monitoring and evaluation, and correction of important
problems.
STAGES IN PROGRAM DEVELOPMENT
Illustration 2 outlines the stages in the development of a QAP: Not only
must one cover all phases in this planning process, but it is recommended that they
be completed following theordershownfor a fully integrated and cohesive program.
110
-
HospitalDietaryService Management Manual,
ILLUSTRATION 2
STAGES IN DEVELOPING AQUALITY ASSURANCE PROGRAM
(A) WRITE PROGRAM OBJECTIVES
(B) IDENTIFHROGRAM'ORGANIZATION
(C) DETERMINE SCOPE OF THE PROGRAM
(D) DEVELOP MECHANISMS FOR MONITORING
AND EVALUATION
(1) Identify Major Departmental Functions
(2) Select Indicators to Monitor Important Functions
(3) vc.Tite Criteria to Evaluate Indicators of Quality Care
\4) Develop Methodology for Monitoring and Evaluation
. (5) Ratify Criteria and Method
(6) Collect Data and Analyze Outcome
(E) CONTINUOUSLY MONITOR AND EVALUATE
(F) APPRAISE AND REVISE PROGRAM
The first phase of program development involves writing program
objectives. Objectives should. be closelyaligned with those from the facility-
wide QAP. One objective is to be able to identify important or potential
problems, related patient concerns, and opportunities to improve the level
of care at the facility. A second objective of the program should be to
accuratelyand objectivelyassess the cause and scope of problems and' correct
conclusions should be drawn from the data collected. A third objective of
the program should be to resolve problems and act on opportunities to
improve patient or resident care on an on-going basis. Short-term corrective
action can be made as soon as a problem is identified, while long term
preventive action can be planned to keep the problem from occurring
again. A fourth objective should be the inclusion of all important aspects
of patient or resident care. A fifth objective should refer to the overall
effectiveness of all efforts in the program and its documentation.
The second phase in the planning process is identification of the
organization of the Qb.P
The third phase of the quality assurance planning process is the
determination of the scope of the program, including all important aspects
of patient or resident care needs to be addressed. The best wayto identify
these aspects is to review the goals and objectives of Dietetic Service, the
scope of services, the patient-related functions of the department, and to
give a special focus on potentially high risk cases that are most likely to
exhibit signs of poor nutritional status in the facility.
111
Thefourth' phase of the planning process is the development of mechanisms
for monitoring and evaluating selected departmental functions. It involves the
analysis of major departmental functions andselection oftheones tobereviewed in
an ongoingbasis. Indicators of"quality care" are thenwritten with the criteria to
evaluate theextent towhich standards are being followed. Finally, as apartof this
phase, onedevelops methodology forthereview process, modifies the procedures,
and proceeds to collect data and analyze it to learn how the department complies
with thestandards set.
Thefifth phaseentails continuous or on-going monitoringand evaluation
activities for all the important functions of the dietetics service included in
the program. An annual schedule for these reviews is normally set, and
individuals are assigned to the datacollection, analysis and reporting activities.
.The last phaseof the planning process is done on an annual basis and It
involves an appraisal and revision design to ensure that it is continuous
overtime,to address all important health careissues in the facility in a valid
and reliable manner.
TheQAP needs to bewell-defined and organized, and its development should
stress proper documentation to assist in demonstrating this by using schedules,
policies, procedures, methods for continuous monitoring and evaluation, and
descriptive statements and summaries of results. Theprogram should contain all
the essential components of a sucoessful program which have been discussed to
assist managers and dietitians in designing the program.
Illustration 3
SAMPLE DIETARY POLICY AND PROCEDURES
FOR QUALITY ASSURANCE
POLICY
DIETETIC SERVICEHAS A QUALITYASSURANCE PROGRAM
WHICH MONITORS THE FOLLOWING ON A CONTINUAL BASIS:
1) THE EXTENT TO WHICH STANDARDS ARE
FOLLOWED, AND
2) PROBLEMS RELATED TO NUTRITIONAL CARE OF
PATIENTS
DATA IS ANALYZED AND REPORTED; AND PLANS ARE
IMPLEMENTED TO ENHANCE CARE ON A CONTINUAL BASIS
AND TO PURSUE OPPORTUNITIES TO INCREASE THE QUALITY
OF PATIENT CARE
PROCEDURES
1. Assess thequality ofnutritional care andpatient care activities. Outcomes are
monitored on a regular basis an annual schedule is followed.
2. Standards are based on the facility-wide program, code requirements,
departmental policies, and/or professional standards for criteria design.
3. The purpose of the program is to define the present status of the
department on certain pre-defined standards or criteria which reflect
quality and appropriateness of care.
4, All majordepartmental functions are monitoredwith special emphasis
on indicators for the important and critical aspects of patient care.
112
5. Criteria andscheduling are reviewed andrevised annually bythedietary staff
incooperationwith theadministration andtheQualityAssurance Committee.
6. After results are summarized, a planof correction is designed and followed
bytheunit manager. Ifa mechanism outside the department isneeded for
problem solving, the dietary staffmembers work with the administration
andtheQualityAssurance Committee toimplement thesolution Oncethe
planof correction isin effect, thetopicismonitored on an ongoing basis to
ensure that thesolution worked appropriately.
7. All results are reported to the administration, the Quality Assurance
Committee, and to the dietaryemployees on a monthly basis according
to the annual schedule. When applicable, results are also reported to
the Nutrition Committee, Safety Committee, Infection Control
Committee and/or other committees.
8. All procedures, results, corrective actions, and outcomes are
documented and entered in the Quality Assurance Manual.
9. The procedures in selecting an indicator of quality careand developing
a monitorng method are the following:
a. Identify important functions;
b. Select indicators to monitor these functions;
c. Write criteria to evaluate indicators of quality care;
d. Develop methodology for .reviews;
e. Ratify criteria and methods; and
f. Collect data and analyze outcomes.
ILLUSTRATION 4(a)
ANNUAL SCHEDULE FOR QUALITY ASSURANCE ACTMTIES
IN DIETETIC SERVICE
FUNCTION INDICATORS REVIEWED BY REPORTED
A. Nutrition Interven- I. Timeliness of nutrition Weekly Monthly
tion for In-patients intervention
2. Accurate identification Weekly Monthly
of patients in need of
nutrition intervention
3. Proper evaluation, Weekly Monthly
assessment, care plans
and goals
4.Appropriate follow-up on Weekly Monthly
changes in nutritional status
5.Appropriateness of diet Weekly Monthly
order for diagnosis
6. Appropriateness of enteral/ Weekly Monthly
parenteral nutrition
7. Intervention of NPO or Daily Monthly
inadequate intake for
three days or more
113
FUNCTION INDICAlORS REVIEWEDBY REPORTED
B.DietTherapy for 1. Nutritional adequacy
(When menu is revised
In-patients of menus
or food products change)
2.Accuracy of diet order Daily Monthly
implementation (meals
and nourishments)
3. Patient food Weekly Monthly
acceptability
4.Patient food Daily Monthly
consumption
5. Food sanitation!safety Monthly Monthly
C.Nutrition 1. Timeliness of education Weekly Monthly
Education for
hi-patients 2. Patient/family Weekly Monthly
comprehension
3. Patient training on Weekly Monthly
potential drug/food
interaction
4.Nutritional status Weekly Monthly
after education
5. Patient re-admission Weekly Monthly
after education
Illustrations 4(a) and 4(b) illustrate to an outsider of the department
exactly what quality assurance activities are undertaken, when reviews are
completed, when data is analyzed, and the frequency' of reporting.
The departmental activities are separated into three units: 1) in-
patient, 2) out-patient. 3) non-patient. These units are further
delineated into functions and are monitored according to the annual
schedule. Indicators to identify the level of quality for each function
should be determined. Indicators are the "patient care activities,
events, occurrences, and outcomes that are monitored and evaluated"
on an ongoing basis during the year. Data collected is analyzed and
reported on a monthly basis after which a plan of correction is set
and implemented. After the problems are corrected, a follow-up review
should reveal improved scores if the plan of correction was appropriate
and effective in resolving the problems identified in the past months.
114
1 _
ILLUSTRATION 4(b) .
ANNUAL SCHEDULE FOR OUALITY ASSURANCE ACTIVITIES
IN DIETETIC SERVICES
FUNCTION INDICATORS REVIEWED BY REPORTED
A Nutrition Jnterven. 1. Timeliness of nutrition Weekly Monthly
tim fOr Out-patients intervention
2. Accurate identification Weekly Monthly
of patients in need of
3. Proper evaluation, Weekly Monthly
assessment, care plans
and goals
4.Appropriateness of the Weekly Monthly
order for diseases
5. Appropriateness of enteral/ Weekly Monthly
parenteral nutrition
6.Appropriateness of followup Weekly Monthly
or changes in nutritional status
B. Nutrition 1. Timeliness of education Weekly Monthly
Education for
Out-patients 2.Patient/family Weekly Monthly
comprehension
3. Nutritional status after Weekly Monthly
education
4.Patient readmission for Weekly Monthly
same nutritional problems
A Cafeteria Food 1. Client acceptability Monthly Monthly
Services
2.Timeliness of food services Monthly Monthly
3. Food safety andsanitation Monthly Monthly
B.Catering Ser:vices 1. Client acceptability Monthly Monthly
2.Tuneliness offood services Monthly Monthly
3. Food safety andsanitation Monthly Monthly
C.Vending Services 1. Client acceptability Monthly Monthly
2.Timeliness of food services Monthly Monthly
3. Food Safety andsanitation Monthly Monthly
',' '
115
ILLUSTRATION 5
SAMPLE DATA COLLECTION FORM
DATA COLLECTION FORM CONDUCTED BY:
OUALITY ASSURANCE INDICATOR:
Appropriateness for Tube Fed Residents
DATE:
OBJECTIVE:
To determine the extent to which highstandards of care are followed for
residents on tube-teedings,
CRITERIA METHOD FINDING COMMENT
1. A physician's List all residents
order is made on Tube Feeding and
and renewed compute the percentage
monthly for in compliance with both
all tube-fed standards. %
patients
2. The physician's Compute the percentage
order should of residents' orders
specify exact containing:
feeding para- Type of Feeding _%
meters Amount of
Feeding _%
Strength
-
%
Time of Feeding
-
%
Feeding Method
-
%
(Average 5 items for
overall score.) %
3. Residents Compute the percentage
receive a of residents that have been
complete evaluated bythe MD, nurse,
evaluation and Dietitian within 30 days
within 30 of admission (Exclude those
days of whose length of stay is
admission less than 30 days) %
4. Each resident Compute percentage of
has an indivi- all the residents that
dualized plan havedocumented care %
of care plans by the MD, Nurse,
and the Dietitian.
5. The care plan Observe each case
is being and compute the
carried out percentage that have
as developed their orders and care
plans in effect.
(Refer to the notes
ofall staff to
determine rhis.)
%
I 16
D
--_%
6. There is a
regular
evaluation
of resident's
progress and
revision of
care plans
as indicated.
7. For residents
that have
experienced
undesirable
side effects
during the
last six
months, the
physician was
made aware of
the problems.
8. For residents
expenencmg
side effects
during the past
six months, the
muti-disciplinary
team has reacted
Refer to the follo-
wing records to
determine if progress
is being made and compute
the percentage of
charts that demonstrate
intervention if and
when a problem occurs:
-lab values
- weight loss
- tube size
- tolerance
- bowel movement
- administration
- other documentation
in the chart %
Identify residents
that have experienced
side effects that are
undesirable from lab
test, urine records,
chart notes, etc.
Compute the percentage
of cases that have
documentation of
proper notification
of the MD. _.
For the same group of
residents, compute the percent-
age of cases that have input from
the multi-disciplinaryteam (MD,
nurse, and Dietitian) who have
evaluated the side effects to
determine cause and adjustment
which the plan needed. __%
OVERALL SCORE TOTAL THE 8 SCORES
ANDDMDEBY8 %
ILLUSTRATION 6
CHECKLIST FOR QUALITY ASSURANCE DOCUMENTATION
WHO is responsible for ...
__Reviewing and responding to quality assurance results for Dietetic
Service and assisting the department in eliciting outside support
and actions when needed.
__Planning the annual schedule of quality assurance reviews.
Data collection for the schedule of review.
___ Writing plans of correction and timetables for implementation.
117
Following plans ofcorrectionas set.
-- .
__Ongoingmonitoring and evaluation of results.
Communicating resu1ts to the Quality Assurance Committee,
-- administration, and others.
Ratifying indicators, criteria, and methods.
__Annual revision ofthe program
WHAT shouldbe includedas ...
__Theimportant aspectofpatientcareto be monitored andevaluated
in the program
__The indicators for the important aspect of patient care to judge
qualityofcare.
The criteriafor measuring the extent to whichstandards ofquality
-- .
.aremet.
Thebest methodsfor data collectionandanalysis andthe elements
-- ofeachreviewconducted.
__The best plan of correction, the one with the most potential for
enhancing patient care.
WHENwill ...
Each reviewbe conducted andthe data be collected.
--
__Results be analyzed and summarized,
__Results be reported to the administration, the Quality Assurance
Committee, employees, andothers.
__The programbe revisedandupdated.
HOWwill ...
Eachreviewbe conducted and data be collected.
__. _ Results be analyzed and summarized.
__ Results communicated to the administration, the Quality
AssuranceCommittee,employees, andothers.
__The program be revised and updated annually.
__Problems or patient concernsbe identified.
__Priorities, investigations, and resolutions bechosen
__The panel ofexperts for ratification be selected.
__The panel ofexperts assessthe objectivity, validity, reliability, and
practicalityofthe program
__Theprogramensurethat patientcareis enhanced overtimethrough
the programactivities.
__Theprogramfor Dietetic Service fit intothe facility-wide program
and conformto its standards.
__ Assistance be elicited from the administration, the Quality
AssuranceCommittee, or other outsideunitswhenit isneeded to
resolvea nutrition relatedproblem
118
One determineifthe plan ofcorrection actuallyworks to resolve
-- and sustainpositiveresults. -
_'_ Thequality assurance plandemonstrate that it systematically reviews
patient care.
__Thequalityassurance plandemonstrate that thisis a Comprehensive
approachto patient care.
__Thequalityassurance plandemonstratethat thisis a comprehensive
approachto patient care.
WHEREis the location of ...
Data which is to be efficiently and effectively collected during
-- eachreview.
__All qualityassurancedocuments, policies andprocedures, and are
they found in a organized state.
WHY...
__Does the QAPhave a valueto the facility?
Does the QAPhave a valueto patients or residents?
--
__Does the QAPhave avalueto employees andguests ofthe facility?
__Canwe saythatthe Quality Assurance isactivelyworkingto enhance
patient care and sound clinical performance?
MONITORINGANDEVALUATION
STEl'ONE:
IDENTIFYlNGMAJORDEPARTMENTALFUNCDONS
FORREVIEW
,Most departments that offer dietetic services inthehealth care industry have
similar overall goals andobjectives fur theservices they provide. These goals and
objectives arenormaDywrittenatthebeginningofthePolicyandProcedureManual
andshould beused to setpriorities for managing the department. Thefollowing
statement of goals, or somethingverysimilar to it, is often used:
"Thegoal ofthe DietaryDepartment is to providehighqualitynutritional
careby:
(1) serving patients appetizing and nutritious meals which are prepared
in a safe and sanitarymanner and adhere to the diet prescription of
eachpatient;
(2) providingnutritionintervention bya qualified dietitian for in-patients
and out-patients; and
(3) servinghigh quality food servicestothe employees andguestsofthefacility."
This statement not only defines the department's goals but also indicates the
scope of services that are offered It describes the recipients ofthe services and
indicates some "qualityattributes"aswell Mostdepartmentsintheacute andlong
termcare settings offer their services to in-patients (or residents), out-patients, and
others to include employees and guestsofthefacility. Since theQAPisto include
theinmortant ~ t s ofpatient care, soshouldthedepartment's goalstatement It
islogical tobasetheprogramontheprimarygoalsandobjectives oftheservice,
119
High Ouality Nutrition Care For In-Patients
Nutritioncareinvolvesthreemajor fimctions: nutrition interventionbyaqualified
dietitian, diet therapy, and nutrition education. Inorderto be ofhigh quality, each
of thesefimctionsneedstoreflect certainprofessionalstandards andspecial attention
should be given to high risk cases, those patients or residents that have greater
potential for poor nutritional statusthan others.
Nutrition Intervention for in-patients or residents should be provided
on a timelybasis by qualifiedindividuals who properly evaluate and assess
the patient's nutritional needs and develop appropriate nutrition care plans
and goals which are monitored and modified on an ongoing basis according
to the individual needs of each patient.
Diet Therapy for in-patients or residents entails the implementation of a
nutritionallyadequatemenu which conforms tothediet prescription, food preferences
andhigh standards of sanitation andsafetyfor proper patient care.
Nutrition Education needs to be timely and appropriate to the
individualized needs of each patient and includes consultation with the
family when necessary.
High Ouality Nutrition Care For Out-Patients
Facilities thatprovide out-patient nutrition services normallyhaveprofessional
standardsthatguidethiscare. In theclinical setting, dietitians provide bothnutrition
intervention and education and/or consultation for patients.
Nutrition Intervention for out-patients need to be provided on a timely
basis by qualifiedindividuals who properly evaluate and assess the patient's
nutritional needs and develop an appropriate and individualized nutrition
care plan with goals which are monitored and modified on an ongoing
basis with periodic assessment ofthe effects of nutrition therapy given and
followed by the patient at home.
Nutrition Education should be timely and appropriate to the needs of
the patient and should include consultation with the familywhen necessary.
HighOuality Food Services For Non-Patients
Although thisserviceisnot directly relatedto patient care, thismaybeincluded
asaseparate partofthe QAPto monitor thesuccesstowhich thisdepartmental goal
isreached. High qualityfood services fornon-patients isachieved byimplementing
anacceptable menu with sufficient andtimely services to meet the individual needs
of employees andguests ofthe facility. If professional standards for food service
acceptability andefficiency ofservices areset, onecan measure theextent to which
thisdepartmental goalis achieved.
STEPTWO:
SELECTING INDiCATORS TO MONITOR
IMPORTANT FUNCTIONS
In order to monitor and evaluate the important aspects of patient care, one
must further expand the "quality attributes" so that theyare not ambiguous and
can bemeasured objectively. Thedevelopment of specific indicatorsa/quality care
for each important departmental function aidsin thisprocess.
120
Indicators for High OualityNutrition Care for In-Patients
For hospital in-patients or residents at a long term care facility,
this goal normally entails three basic activities or functions as
previously discussed. These are: I) nutrition intervention, 2) nutrition
therapy, and 3) nutrition education and/or consultation. For each
of the three functions, several indicators of quality can be selected
for measuring how well the activities are being carried out in the
facility. For example, for nutrition intervention, one aspect that can
be used to test appropriateness is the timeliness of this intervention.
Other indicators are shown below.
Function:
SomeSample
Indicators
Nutrition Interventionfor In-Patients (or Residents)
1. TImeliness ofnutrition screening .
2 Accurate identification ofpatients requiring
3. Timeliness of Nutrition intervention
4. Appropriate evaluationand assessment ofthe
patient's nutritional status
As can be seen, the indicators relate to professional standards of
quality for each aspect of the function. During the monitoring
process, if one finds failure to practice the standards, patients can
be considered to be at risk. For another departmental function,
nutrition therapy, sample indicators are illustrated below:
Function:
SomeSample
Indicators
Diet Therapyfor In-Patients(or Residents)
1. Nutritional adequacy ofmenus
2 Accuracy ofdiet order implementation
3. Patient food acceptability
4. Adequacy ofpatient food consumption
Other indicators can be added to this listing for a complete
representation of professional standards of quality for nutrition
therapy. Sample indicators on the function of nutrition education
and/or consultation are shown below:
Function:
.SomeSample
Indicators
Nutrition Education (or Residents)
1. TImeliness of education
2. Patient or family's comprehension of the
materialpresented
3. Patient's nutritional status after the education.
is complete
The second major goal of the dietary department is to provide high
qualitynutritional care for out-patients by functioningto provide nutrition
interventions and nutrition education and/or consultation.
121
-,
PROCESS FOR WRITING INDICATORS
The process of writing quality assurance indicators begins by writing a
statement of the department's goals and objectives. This statement should
clearly identify the scope of services offered and the specific activities or
functions the department is expected to engage in and be successful at.
Departmental goals, functions, and indicators should be reviewed with a
supervisor/administrator in charge of the department to insure that the
goals stated match everyone's expectation of the service and conform to the
organizational goals for the department. This helps to avoid the common
conflict often caused when two or more persons use different standards to
evaluate the department, and, therefore, have different opinions of howwell
it is managed. An agreement should be reached by all parties involved at
this stage in the development of the program.
Then, the specific functions can be listed with indicators that can be
used to help monitor and evaluate howwell the department completes each
activity.
ILLUSTRATION 7
WORKSHEET FOR WRITING
QUALITY ASSURANCE INDICATORS
STATEMENT OF DEPARTMENTAL GOALS AND OBJECTIVES:
122
GOAL FUNCTION SAMPLE INDICATORS
ILLUSTRATION 8
DEVELOPMENT OF INDICATORS FROM
DEPARTMENTAL GOALS AND FUNCTIONS
GOAL
I. HIGH QUAIJTY
NUTRITION
CARE FOR
IN-PATIENTS
OR RESIDENTS
FUNC;nON
A.Nutrition
Intervention
B. Diet Therapy
SAMPLE INDICATORS
1. Timeliness of nutrition
intervention
2. Accurate identification of
patients requiring intervention
3. Proper evaluation, assessment
care plans and goals
4. Appropriateness of diet
order for diagnosis
5. Appropriateness of enteral
or parenteral nutritional care
6. Intervention of NPO or
inadequate intake for more
than three days
7.Appropriate follow-up on
1. Nutritional adequacy of menus
2. Accuracy of diet order
implementation (meals and
nourishments)
3. Patient food acceptability
4. Patient food consumption
. 5. Infection control compliance
6. Appropriateness offood served
C. Nutrition Education 1. Timeliness of education
2. Patient/funily comprehension
3. Patient training on potential
drug/food interaction
4. Nutritional status after
. education
5. Patient readmission after
education
123
GOAL
II.HIGH QUAUfY
NUTRITION
CAREFOR
OUT-PATIENTS
OR RESIDENTS
FUNCTION
A.Nutrition
Intervention
SAMPLE INDICATORS
1. Timeliness of nutrition
intervention
2. Accurate identification of
patients requiring intervention
3. Proper evaluation, assessment
care plans and goals
4. Appropriateness of diet
order for diagnosis
5. Appropriateness of enteral
or parenteral nutritional care
6.Appropriate follow-up on
B. Nutrition Education 1. Timeliness of education
2. Patient/family comprehension
3. Nutritional status after
education
4. Patient readmission for
some nutritional problems
5. Patient training on potential
drug/food interaction
III.HIGH QUALITY
FOODSERVICES
FOR EMPLOYEES
AND GUESTS
124
A.Cafeteria
Food Services
B. Catering Services
C.Yending Services
1. Client acceptability
2. Timeliness of food services
3.Food safety/infection control
2. Timeliness of food services
3. Foodsafety/infectio!l control
2.Timeliness of food services
3. Food safcty/infeaion control
S'IEPTHREE:
TOEVALUA'IEINDICATORS
OFQUALITYCARE
Criteria are the standards against which a situation is compared to learn
the extent to which appropriate care is offered for each element of the
indicator to be evaluated.
Theyare used to evaluatethe indicatorsand should be objective, explicit, and
generallyacceptedmeasures of quality. Before anydata iscollectedand reviewed,
criteria nmstbe written, ratified, and accepted for use bythe clinical staffand those
persons who are goingto do the work that isto be reviewed.
The development of the criteria often begins with a "brain-storming"
session conducted by the person in charge of quality assurance for the
department and includes the managers and practitioners involved in the
function at hand. In order to write the criteria for a specific indicator, one
asks the question: "What is the acceptable standard or practice at the facility
against which the existing situation should be measured in order to determine
its compliance with the Departmental goals?" For example, one of the
functions/activities discussed is Nutrition Intervention for In-Patients and
one ofits indicators is Timeliness of Nutrition Screening. To develop the
criteria for this indicator, one must ask: "What are our standards for
timeliness ofnutrition screening?". Perhaps the Policy and Procedures Manual
states that "all newly admitted patients are screened within 24 hours to
indicate the level of nutrition intervention required, and that patients who
exhibit a change of condition during their stay are also to be re-evaluated
within 24 hours of this change." If this 24 hour criteria is acceptable to the
facility and complies with acceptable clinical standards of practice, then it
can be used as shown in the example below.
Function: Nutrition Intervention for In-Patients (or Residents)
Indicator: Timeliness of Nutrition Screening
Criteria: I. All new admissions are screened within 24
hours to indicate the level of nutrition
intervention required
2. All in-patients with changed conditions are
screened within 24 hours of the change to
indicate a revision ofthe nutrition assessment
and care plan
Another example is the function ofDiet 11lerapy. One ofthe indicators
previously stated for this function is Accuracy ofDiet Order Implementation.
Our health codes set the criteria for this indicator by stating that all patients
or residents must receive the diet according to the diet prescription written
by their physician. An example ofthe criteria statement for this indicator is
shown below. To measure the criterion, one could match the patient's diet
prescription with the tray received to be sure the diet order is properly
implemented by the dietetic service personnel.
Function: Diet Therapy for In-Patients (or Residents)
Indicator: Accuracy of Diet Order Implementation
Criteria: All in-patients (or residents) receive the diet 'according
to the current diet prescription as documented in their
medical record.
125
When writing thecriteria, it isimportant to make themunderstandable to all,
relevant, practical, and measmable. Whenever possible, the criteria should be
"outcome based" (ie., theyshould measure the outcome ofpatient careactivities
ratherthantheir stmctureortheprocess). Forexample, furAccuracyofDietOrder
Implementation, onecouldwrite avariety ofcriteria such as:
1 Employees have been trained to provide diets as ordered. ( Training
recordswouldbe reviewed.)
2 The diet listed in the cardex matches the diet card on the patient's
tray. (A comparisonofthe two would occur.)
1 Enoughworkersareemployedto provide dietsas ordered. (Thestaffing
pattern would be matched with the daily minimum standard for
employee staffing.)
4. The patients claimthat they receivedthe diet ordered for them (An
interviewor questionnaire wouldhelp to collect the datafrompatients)
5. The diet manual contains all of the diets ordered for the patients.
(The manualwould be comparedto the cardex or diet census.)
6. The department has a policy for diet order implementation. (The
policyandprocedures manualwouldbe reviewed.)
Someofthesecriteria are structure-based, while othersareprocess-based.
Some are not valid, relevant, or realistic. The acronym "RUMBA" is
commonlyused to checkthe important characteristicsofcriteria. It stands
forRelevant, Understandable, Measurable, Behavioral, andAchievable. One
last example will begivento demonstrate the choicesonemakeswhentrying
to write the criteria. Suppose the indicator is patient food acceptability.
Which criterionshouldbe selected?
1 All foods are judged for their quality by the dietetic staff prior to
service to the patients. (A scoring sheet would be devisedto have
dietitians and supervisorsevaluate food quality.)
2 Patients consume 75% or more of the foods served to them (An
intakestudywould servefor data collectiou.)
3. Patientsreport the food to be ofacceptablequality. (A questionnaire
would be circulated and patients' responses averaged for an overall
scoreof acceptability.)
4. Patientsverballyreport that their meals are acceptable(An interview
wouldserveto collect responsesthat are averagedfor anoverallscore
ofacceptability.)
5. Nursing supervisors report overall patient food acceptability to be
good. (Someone questions the nursing staff at eachmeal period.)
6. Patientsshowsignsofhaving optimalnutrient status, (Achart review
would determine the percentage of patients exhibiting appropriate
nutrient status.)
7 Number of patient complaints. (The actual number of complaints
voicedby patients each month is compared.)
None of these criteria and methods are perfect. One frequently has to
select the best possible method and stay aware, at all times. of its
shortcomings. The sixthcriteria listedis outcome-based, but the data for
measuring it is not always available nor are standards of nutrient status
currentlyagreedupon by allprofessionals. So, eventhough it is perhaps the
126
best criterion, it is not realistic in most settings. The third choice would be
appropriate in the acute care setting, but difficult to administer in long
term care where the second or fourth .criteria would apply. The first lind
fifthcriteria are difficult, ifnot impossible, to administer objectively because
theyuse persons other thanpatientsthemselves to evaluate food acceptability.
Rather than measuring "patient food acceptability." they m ~ s u r other
people's perceptions of "patient 'food acceptability.'" When we measure
something other than what is stated to be an indicator, the criteria is not
valid and should not be used. The seventh criteria relates the number of
negative incidents and is outcome- based. As long as the number of
complaints is put into perspective and objectively related to other months,
it is appropriate. With such an important indicator as food acceptability,
perhaps it would be best to use a minimum of two criteria and correlate
them on an ongoing basis.
In the development of a QAP, some individuals divide each indicator
into component parts; or "elements," and then write a criterion for each
part. They find this process to be helpful in organizing their thoughts and
plans. An example of this method can be shown for the indicator
"appropriateness ofenteral nutrition." The elements that need to be evaluated
for this indicator may include: type offeeding, amount offeeding, strength,
feeding times, administration methods, and the calorie/nutritional needs
ofeach patient receiving it.
Also, while writing indicators and developing criteria, it is important
to realize that alI ofthe departmental functions need not be completed at
once. In fact, it is perhaps better to first outline the departmental functions,
then list the indicators for one of them only. This one criterion can be
determined and Steps 4, 5 and 6 can be taken to its completion through
data collection and analysis. In this manner, a person new to program
development can avoid the potential problem of making a common error
for alI criteria written, and one can leam more quickly from any errors
made when alI steps are finished for one single" criterion. This helps to "
avoid a mistake being repeated throughout the program, and minimizes the
need for major revisions in the program to correct this common error. .
STEPFOUR:
DEVELOPINGA METHODOLOGYFOR
MONITORINGAND EVALUATION
After the criteria are listed for the indicators, each one will have a
corresponding methoddescribing ''how'' it would be measured. Remember
that there are many ways to measure anyone criteria, just as there could be
many alternative criteria for any given indicator.
Selection of the method to be used depends upon the setting and
resources available. To take the last example, Patient Food Acct:j!tabiIity, a
method which uses a patient questionnaire for data collection isnot normalIy
practical in the long term care setting due to a low response rate from
elderly patients. But this method often works well in acute care hospitals
where a good return rate isexpected.
A CHECKLISTFORMETHODDEVELOPMENT
The following checklist can be used to identify the best method
for monitoring important aspects of patient care
127
ILLUSTRATION 9
CHECKLIST FOR MONITORING AND EVALUATION METHODS
() PRACTICALITY - The method is the best for the setting and uses a
minimal amount of resources for a maximum amount of data to be
collected. The method can be followed by any individual assigned
with minimal training because it is at a sufficient level of understanding
and the process does not rely solely on one or two individuals to be
completed as planned.
() SIMPLICITY - Always ask the question: "Is there an easier way to
collect the data?" For example, if information is located in the
dietitian's cardex, the method should not require a review of the
patients' medical records. Or if the information that is needed is
collected elsewhere in the facility, do not duplicate their efforts by
repeating this process.
() CLEAR INSTRUCTIONS - The method gives clear identification of the
exact source of the data with the location of the source of the documents
providedalongwiththeinstructions tor sampling and analysis whenapplicable.
All those that read the instructions should interpret them the same wayand
should be able to carry them out in exactly the same manner.
() VALIDITY - The method truly measures what is intended to be
measured. When one follows the method, the result definitely reveals
the standard or criterion which it was supposed to reflect.
() RELIABILITY- The methods for data collection and analysis can be
applied by several reviewers at the same time and yield the same
results. This shows that the methods that are selected are free of
ambiguities and unclear instructions. If sampling is used, the sample
should be large enough and properly selected so that it is indicative of
the entire population because it is not biased in any way.
( ) OUANTITATIVE - The methods for monitoring and evaluation
provide a guide, with documentation, as to how the reviewers compute
a numerical score to represent the extent to which the standard or
standards are upheld at the facility. Worksheets may be recommended
because they often help a person in the computation of the final
score and they also give data for future references regarding the nature
of the problem when needed. It is helpful, if all quantitative scores
were based in the positive or in the negative. When they are not,
confusion occurs as to the meaning of the score.
() OUALITATIVE - The method provides documentation of specific
characteristics with the inclusion ofdetailed notes, written comments,
or worksheets to organize the data so the nature of the problems are
easily indicated along with the possible cause and potential plan for
correction. A numerical score is .not enough. One needs to know
why the score is low, which particular aspect of the activity did not
comply with the standard set, and therefore, would require correction.
() ONGOING EVALUATIONAND MONITORING - The method of
implementing the entire Quality Assurance Program should be ongoing
and a schedule should be set for the administration of each segment
of the problem. This schedule needs to identify the frequency of
summarizing and reporting results. It should reflect a systematic,
ongoing collection of data which are analyzed frequently enough to
identify trends of quality patient care.
128
DATACOLLECTIONTIME FRAMES
Problemsregarding quality care ofpatientsor residentsmaybe reviewed
prospectively, concurrently. or retrospectively. Choosingamongthese three
methods depends-upon the nature of the problem, availability of data,
volume of data, and time frame within which the results are needed.
Concurrent reviews forproblemidentification and assessment have themajor
advantage because the resuhs provide an accurate "picture" of the real, current
situation andthis affords theopportunity forimmediate correction of problems for
thepatients whoexhibit them, aswell as forlong termcorrection which focuses on
theprevention oftheproblem(s) in the future.
Yet, there are times when prospective or retrospective reviews are
appropriate and evenbeneficial. Potential problems with a newlyproposed
systemofbealthcaredelivery cansuccessfully be addressed withaprospective
review. Andcurrent problemscanoftenbe addressedbycollecting historical
data, retrospectively, to increasethe numberofcases ina sampleandprovide
more accurateresults.
The time one selectsfor data collection needs to be carefullyconsidered
for it certainly affectsthe accuracy, timeliness, meaning, andimplementation
of correct action for the results found.
SAMPLINGTECHNIQUES
Sampling techniques areuseful when thesample drawn and/or thedayor days
thatthedata iscollectedtruly represent theentire population ofthepatients overall
hours of their stay at the facility, with only a small degree of error. The goal in
designing methodology for frequency of data collection isto attempt to cover as
many cases as possible, in anunbiased manner overtime, in aneffort to reflect the
actual truthabout caregiven to all patients.
Samples of patients, their charts, meal trays, or the like should be done at
random (i.e., selected without bias). Every individual unitin thepopulation should
have anequal chance ofbeing selectedforthegreatest possiblesignificanceofresuhs.
Itisthereforeimportantto select fromall floors, all agegroups, alltypes ofdiagnoses,
andall kinds ofdiets. Data though, can beanalyzed byseparating the samples into
these separategroupsbecause nutritional problems may begreater inonegroup than
in another. Onefinal concern regarding random sampling isthe appropriateness of
thesample size. The larger thesamplestaken fiomanypopulation, themore significant
arethe resuhs. But since the resources arelimited, the question becomes: 'What
percentage can be reviewed to still attain accurate resuhs?" In general, without
dealing with complicated statistical methods," data from at least one-third of the
population should be reviewed to have significance at .05. If the population of
patients islarge (over 500beds), alower percentage canbeused, and ifthepopulation
issmall (under 200beds), a higher percentage should beused, since the difference
between each individual case isgreater in a small population.
Probability sampling techniques allowthe use of results from a sample
to be used to describe or to infer conclusions on the entire population. The
reason why this can be done is that an adequate sample size is used and
because each unit in the population has an equal and independent chance
ofbeing selected to'be a part ofthe sampleused. Equal means that at each
stage of the sampling process, all remaining units in the population have
the samechance of beingselected. Independent means that no selectionhas
I
anyeffect on anyother selection. Inorder to do this, the sampleneeds to be
selected in a random fashion.
129
Thethreebasicways ofselecting randomsamples are:
l Simple random sampling
2 .Stratified sampling
3. Systematic sampling .
Non-probability sampling techniques do not enable precise statistical
inferences to be made about a population because too few units in the
population are selected, or because a "conveniently" available sub-set is
used instead of selecting the subjects randomly. This technique is often
usedwhenthe extent ofthe probabilityusedis knownor whenits prevalence
at a certainpoint intimehas to be monitored. It is a useful technique since
it requiresless timethan random sampling, but it is limited sinceresults do
not necessarily represent the entire population. Three basic types of
probability sampling are:
l Purposiveor Judgemental Sampling
2 Quota Sampling
3. Convenience Sampling
COMPUTINGRESULTS
Thetoolusedtocollect datawill determinethetype of computationneeded. A
checklist mayprovidetwoanswers, "yes" and "no", andthereviewer might beasked
tocomputethepercentage ofthe"yes"answers furthe overall scoreofthereview. A
scale such as a patient questionnaire giving three or more choices such as "very
good,""good,""tim," and"poor"mayalso beprovided. Thepercentageofpatients
respondingineachcategorycanbecomputedandreport resaltsrecordedaccordingly.
Thetwohighest categoriesmightbeconsideredacceptableandtheothernot acceptable,
andtheresu1ts canbereported asthepercentage ofpatientswhorespondedthatthe
seviceis "acceptable". Ifmanyquestionsarelisted,theoverallpercentageofacceptable
responses can then beusedto quantify resuhs, andthedetails found for each item
can beusedto qualify theresults.
It isnormally easyfor thepersoncollecting datato do simple calculations,
andspacecanbe providedonthe data collection formitselffor thispurpose.
A quantitative score should be computed for each criteria indicating the
percentageof cases that complywith the standarddescribed. Sinceseveral
criterianormallyreflect one indicator, the percentages from each criteria
canbe averaged for the overall score.
If clear instructionswere givenon the data collection foim, the person
who does the reviewcan easilydo the computations, write the summary
statement, and even supply commentswhich contribute to a good plan of
correction. Some facilities evenhavethisindividual bringthe resultsdirectly
. to the person in charge of the unit reviewed and they meet to discuss the
findings andlaythe groundworkfor a successful plan ofcorrectiontogether.
The department director and QualityAssuranceCoordinator then receives
a copyofthe total reviewandintervenesonlyif the planofcorrection does
not appear to be appropriate or feasible. This adds accountability to the
program, and eliminates an excess of "paper handling" steps before the
plan for correction is developed and administered. .
130.
STEP FIVE:
RATIFYING CRITERIA AND MElHODS
The criteria and methods are now fully developed by dietary staff
members with some assistance from other professionals in the facility. So
tar, only 'a few individuals have been involved and their work needs to be
ratified by a group of selected experts. The same individuals need not be
used for all departmental functions, in tact, this might present problems
with limited expertise of the sub-committee if this were done. Instead, a
group of five to seven individuals, always including a departmental
representativeand the Quality Assurance Coordinator (or hisjher designate),
should be identified to act as members of the sub-committees for each
departmental function.
This sub-committee of medical and clinical professionals has several
functions. First, it determines if the criteria and methods are acceptable
and functional for monitoring compliance with standards for quality and
appropriateness in the health care field. They do a reviewofthe work done
so tar to ensure that valid and reliablesources have been set for the important
aspects of nutrition care of quality care. Once the criteria and methods are
ratified, and the reviews are conducted, this sub committee can assist in
analyzing results, communicating information, and revising the program.
After the individuals are selected, they can be invited to serve on the
subcommittee on an ongoing basis. They may require some training from
the Quality Assurance Coordinator as to their role in objectively judging
criteria and methods for use by the department. This judgement should be
based on practicality, simplicity, clarity of instructions, validity, reliability,
provision ofqualitative and quantitative results, and use as a tool for ongoing
monitoring and evaluation ofthe selected departmental function. The quality
assurance review form, which contains information on the function, criteria,
and method, can first be presented to the group. They should be encouraged
to study it, test the method, and note any problems for discussion and
resolution at a follow-up meeting. After the committee formally approves
the criteria and methods, they can be used again in the future to review
results on a periodic basis and when revision of the program is warranted.
ILLUSTRATION 10
CHECKLIST FORJUDGING CRITERIA AND METHOD
Instructions: Subcommittee members individually assess and work
with other members to correct problems identified
with the tool.
DEPARTMENTAL FUNCTION:
CRITERIA:
DATA COLLECTION FREQUENCY__--'- _
REPORTING FREQUENCY:
YES NO
Us the function an important component
of patient care?
2.Is the function included in the scope and goals
of Dietetic Service?
131
YES NO
3.Do the indicators represent the essential component
parts of this function?
4.Arethe indicators clearlystated andrelatedto
thefilcility's policy and/or professional standard?
5.Are the criteriaclearlystated andrelatedto the
. facility's policy and/or professional standards?
6.Arethe criteria "outcome-based"whenever possible?
7.Arethe criteriavalidas accuratemeasuresofthe
indicator they fall under?
8.Is themethod practical and isit using minimal resources?
9. Is the method simple or is there an easier method
that will accomplish the same thing?
IO.Are the instructionsclear in showing data sources
andhowto acquiresamples, calculate, etc.?
II. Doesthe methodtruly measurewhat is intended?
12.1s the method reliable and free of ambiguities;
andis the samplesize adequate?
13.Doesthe methodyielda quantifiable result? or
14.1s the method qualitative providingdescriptionor
results andpotential correctiveaction?
15. Is the frequency ofdata collection sufficient?
16.Isthe frequency ofreportingtimelyand does
it provide the ongoing systemof monitoring
the criteria?
17. Note other comments below.
18.Please list waysyou might streamline and/or
simplify tl.e method. _
132
Name:
_______________Date: _
STEPSIX:
COLLECTINGDATA AND ANALYZINGRESULTS
Prior to this last step, the criteria and method for collecting data would
. have been tested and ratified by the subcommittee ofmedical and clinical
professionals in the facility. A schedule for implementation has also been
set, as a part ofthe method, to reflect the frequency at which data will be
collected and analyzed.
QUALITYASSURANCEREVIEWERS
The quality assurance policy should identify the responsibilities of
reviewers. They should be well-trained and familiar with all aspects ofthe
program The process identified below shows how the logistics on data
collection and analysis can be assigned in a typical Dietary Service.
1 The assigned reviewer conducts the review by collecting required data
as instructed on the review forms.
2. All calculations are done and comments regarding pertinent
observations are noted.
3. The reviewer meets with the manager in charge ofthe unit assigned to
him/her to observed and they write a summary statement together
reflecting the results.
4. The reviewer andmanager discuss the results and suggestions are made
for corrective action.
5. The manager in charge ofthe unit writes a corrective action and follows
through on this plan. A copy ofthe review, the summary ofresults,
and plan for correction are forwarded to the director ofthe department
who intervenes ifthis is warranted.
6. The manager in charge disseminates the results and plan for corrective
action to all employees ofthe unit.
7 Thedepartment director disseminatestheresults andplanfurcorrectiveaction
to the administration, the Quality Assurance Committee, and the
subcommittee assigned to do the ongoingmonitoring ofthe program
DATAANALYSIS ANDSUMMARY
There are normally several criteria listed for an indicator. For each
criteria, a method stipulates how the data will be collected and how they
will be computed. A quantitative score can be easily obtained for any
criteriaby simply computingthe percentage ofacceptable units. For example,
suppose a hospital dietary staffthat uses the S.O.A.P. Note format, selects
five criteria to reflect one indicator of the Nutrition Intervention, Proper
Evaluation, Assessment, Care Plan, and Goals. The method developed for
this facility involved peer review hy many dietitians over the course of a
month.
In summary,the mechanisms or methods used to collect data and analyze
results are critical in the establishment of a selective Quality Assurance
Program Such methods must be practical, efficiently valid, and reliable;
and they must yield results that are qualitative and quantitative in nature.
133
..
APPENDICES
CODE OF ElHICS FOR
DIETETIC PROFESSION
The Code of Ethics for Members of the Nutritionist-Dietitians' Association of the Philippines
The organization aims to raise the standard of the dietetic service, to protect the status of the
profession, and to foster cooperation among allied professions.
I. Each member should continue to enrich their knowledge of the principles and most recent
advances in the field of Nutrition and allied subjects in order that he may do his part efficiently
in the maintenance and improvement of human nutrition.
2. Each member should support all the activities of the association aimed towards the achievement
of the goals set by the organization to attain the highest standards of service in the interest of
the welfare of the nation as a whole. .
3. Each member should strive to create harmonious relations with allied professions and other
organizations established to improve the nutritional status of the Filipino people.
4. Each member should possess the qualities vital to efficiencyand good human relations - integrity,
loyalty, courtesy, understanding and respect, high standards of cleanliness and professional
skill, accuracy, pride in good workmanship, wholehearted interest in one's work, courage to
accept criticism and to profit from mistakes - in order to uphold the status of the profession
and of the association.
Code of Ethics for the Government Service*
Any person in the service of the Republic of the Philippines should:
I. Respect and uphold the constitution of the Republic of the Philippines.
2. Observe the highest standard of morality, integrity, honesty, loyalty and devotion to public
health.
3. Perform his task thoroughly, faithfully and efficiently.
4. Be physically and mentally fit for public safety and live within his income.
5. Expose corrupt practices in the public service without fear or favor.
6. Serve the public courteously, justly and impartially regardless of kinship, friendship, social
standing and religious or political differences.
Z Discharge duties promptly without thought of gifts, benefits or any remuneration which may
influence the proper performance of official functions.
8. Engage in no business with government or with any private party, either directly or indirectly,
which will be inconsistent with his position as a public servant.
9. Divulge no confidential information coming to him by the nature of his office or duties.
10. Uphold, respect and observe these principles ever conscious that public office is a public trust
which he should neither violate, nor should he allowsuspicion to arise that such trust has been
abused or betrayed.
*Prepared by the Civil Service Commission, Philippines
Journal of Public Administration, October 1960, p. 362.
Ministry of Health
Office of the Minister
COMMITTEE ON BIDDING AND AWARDS
Manila
GENERAL CONDITIONS ON BIDDING OF FOODSTUFF
OUALIFICATION OF BIDDERS
1. Only responsible and duly accredited as certified by the Accreditation Committee of the Ministry
of Health are allowed to participate in the bidding for foodstuffs.
BIDDER'S BOND
2. Each bidder shall post together with the bid a BIDDER'S BOND preferably in MANAGERS
CHECK. BIDDER'S BOND shall be fixed at 5% of the total amount of the offer for specific
quantity bidded, but in no case shall it exceed PlO,OOO.OO per bidding, pursuant to Rule No. 34
of Department Order No. 13 of the Department of General Services dated September 6, 1971.
The government reserves the right to confiscate the bond if the winning bidder refuses to accept
the award. If the winning bidders, the bidder's bond shall be returned after the award has been
released and the bidder has posted the required performance bond. For the losing bidders, said
bond shall be returned after the award has been released.
BID PROPOSALS
3. Bidders shall receive only one (I) set of proposals consisting of two (2) copies. The duly
accomplished ORIGINAL COpy has to be submitted to the Committee during the actual
bidding together with two (2) PHOTOCOPIES thereof.
4. No bids shall be accepted after 9:30 A.M. on at the Malaria
Eradication Conference Hall (3rd Floor MES Building). Bidders or their representatives, duly
authorized with a Power of Attorney, showing their business addresses and numbers and dates
of their business licences are required to be present during the bidding, otherwise their bid
proposals will not be considered.
5. ALL QUOTATIONS MUST BE TYPEWRITTEN. Any correction made should likewise be
typewritten and must be properly initialed before the same is deposited in the box provided
therefor. Non-compliance of these requirements shall subject the bid(s) to be rejected.
6. Withdrawal of the bid shall not be allowed after the same has been submitted or dropped in the
box. Withdrawal after opening the bids shall be a ground for the confiscation of the bidder's
bond.
CONFORME:
NAME OF COMPANY
DATE
SIGNATURE OF BIDDER
Z The signature of the bidder on all the pages shall constitute acceptance of and assent to, all the
conditions embodied in this Bid Proposal. Unsigned bid/pageisj/copies of the bid proposal
shall be rejected outright. Bids should be submitted under oath.
8. The items subject of this bid .are only the estimated quantities required by hospitals for three (3)
months and the government reserves the right to increase or decrease the quantities depending
upon the actual needs of the hospitals, subject to the availability of funds.
9. Quotations submitted shall be for the items called for and must be on the unit specified. In
case the unit specified is no longer available, the committee will entertain what" is currently
available in the market in a manner advantageous to the government. Items/products with
brand names are open to all brands provided they are registered with the Food and Drug
Administration (FDA) prior to public bidding. A photocopy of the registration of new brands
should be submitted together with the bid tender. Bidders are enjoined to specify their proposed
brands IN WRITING opposite each item being bidded otherwise the bid proposal will not be
considered. Bidders shall quote only on items that have estimates from end-using agencies.
10. Tampering of any portion of the bid documents, e.g. erasures or changing of units specified for,
is a ground for disqualification of bid proposal for that item.
11. Any price quotation indicated in the Bid Proposal shall be considered as FINAL.
12. Bids must be supported by samples when specified in the Bid Proposal as SS(SUBMIT SAMPLE);
and only the sample of each item called for must be submitted during the deliberation. Said
sample should be placed in a clean container, properly sealed, identified and signed by the
bidder, The end-user or his authorized representative may be invited by the Committee on
Bidding and Awards to attend the deliberation if his/her presence, in the opinion of the
Committee, necessary in the evaluation of the bids.
13. These general conditions of the bid proposals and pertinent provisions of Administrative Order
No. 90, series of 1%8, hereto attached, shall become part of the contract.
AWARD
14. The Committee on Bidding and Awards for foodstuffsthrough its representative may conduct a canvass
in the open market ofcurrent prices of the itemsto bebidded beforethe public bidding.
15. The bidder or bidders who offer the most advantageous tenders to the government shall be
notified in writing of the acceptance by the Ministry of Health of his or their tenders.
16. The winning bidderts) upon receipt of advise of award from the Committee for any or all of the items
called for inthe bid, shall post a PERFORMANCEBOND in tileamount equivalent to ten percent(100/0)
of the total valueof the itemsawarded to him with the Government Service Insurance System (GSIS) to
guarantee for the faithful performance of his obligationunder this contract.
17. In awarding the contract, the provisions ofCommonwealth Act No. 138, known as the Philippine
Flag Law, and all other pertinent laws shall be applied.
CONFORME:
NAME OF COMPANY
,DATE
SIGNATURE OF BIDDER
PURCHASE ORDERS/DELIVERIES
18. EveryFriday,all winning bidders are required to pick up purchase orders from the Chief Dietitian
or receiving Dietitian as an advance order for the following week. Pandesal and Cream Bread
must be delivered to the end-users not later than 5:00 AM.; Meat and Fish not later than 7:00
AM., while all other items not later than 10:00 AM. for the day.
19. All deliveries shall be subject to all provisions of Administrative Order No. 90, series of 1968,
hereto attached.
20. All deliveries must be made in the presence of an Acceptance Committee of the respective
hospitals who must acknowledge the receipt thereof with proper notation on the invoices in
triplicate and the dietary order slips or requisitions as the case may be.
21. All deliveries of beef, forequarter and hindquarter in the bid proposal shall, in addition to the
specification thereat, be complete with toes, nails, and skin portions attached, which shall be
removed only after inspection and immediately after weighing and shall not be part of the total
weight to be accepted of the end-users.
22. For every ten (10) kilos oflivechicken, one (1) kilo corresponding to the crops (buchi) and water
should be deducted from the total quantity delivered. In case of "dressed" and "drawn" chicken,
deliveries should not include intestines, legs, heads, feathers, and water. The Committee will
not entertain any request for reconsideration to this effect.
23. Bidders for meat or pork items should comply with the existing pertinent regulation of the
National Meat Inspection Committee of the locality.
PENALTIES
24. Bidders who fail to comply with the terms and conditions of their Contract as reported by end-
users shall be a cause for suspension after due hearing. Three (3) suspensions shall be the
ground for debarment of the erring supplier. For less serious infractions, such as three (3) non-
deliveries, five (5) belowspecification/substitution, five (5) late deliveries, five (5) short deliveries,
and five (5) frozen deliveries, the dealer shall be warned in writing. Five (5) warnings shall be a
ground of cancellation of the current contract and/or suspension from participating in subsequent
biddings. The government reserves the right to suspend/debar the participation of suppliers in
the succeeding biddings evenbefore the five (5)warnings are attained when the supplier's behavior
duly jeopardizes the hospital/patient interest.
25. Bidders properly identified as previously suspended/debarred for failure to comply with the
terms of their contracts shall not be allowed to re-enter or participate in future biddings of the
Ministry of Health directly or indirectly through the use of other names or persons.
26. All bidders are enjoined to observe strictly the above conditions. Any violation of the General
Conditions shall be sufficient ground for the cancellation of the contract and/or suspension in
accordance with item no. 24 of these general conditions.
CONFORME:
NAME OF COMPANY
DATE
SIGNATURE OF BIDDER
27. THE GOVERNMENT RESERVES THE RIGHTTOREJECT ANY OR ALL BIDS, TOWAIVE
ANY DEFECT ANDTOACCEPTSUCH BIDOR BIDS, AS MAY BE CONSIDEREDMOST
ADVANTAGEOUS TO THE GOVERNMENT AI-m THAT IT RESERVES THE RIGHT TO
RESCIND THE CONTRACT AND DEBARTHE DEALER FROM ENTERING IN FUTURE
BIDS INCLUDING THE CONFISCATION OF HIS/HER BIDDER'S OR PERFORMANCE
BOND.
Revised as of December, 1983
CONFORME:
NAME OF COMPANY
DATE
SIGNATURE OF BIDDER
SPECIFICATIONS OF
COMMON FOODSTUFFS RURCHASED
A. VeJ:etables
1. Should be fresh upon delivery.
2. Should be free from bruises, decay, and other damages caused by insect manifestation
and discoloration.
3. For root vegetables and tubers, should be of right maturity, firm, not badly misshapen,
free from black spots, bruises, cuts, scars, and other blemishes.
4. Those with stems should not be more than 6 inches long.
5. Head vegetables should be without waste leaves.
6. Leafy greens should be fresh, young, crisp, and free from mold and decay.
7. Should be in accordance with the detailed or itemized specifications.
B. Fruits
1. Should be firm and ripe but not overripe and free from decay, bruises, and other
imperfections or other indications of insect infestations.
2. Citrus fruits should be heavy for their size, firm and mature for maximum juiciness.
C. Pork
1.
2.
3.
4.
5.
6.
D. Beef
1.
2.
3.
4.
Delivery must be accompanied with a Meat Inspection Permit in which date, weight,
name of owner or vendor, the point of origin and destination is indicated.
The skin must bear the stamp of the Bureau of Animal Industry to indicate that it was
inspected and passed.
It must be fresh, young, and of good quality.
It must be free from discoloration and disagreeable odor.
Lean should be well-marbled with tat.
It must be placed in sanitary containers or delivery vans to prevent contamination
Delivery must be accoinpanied with a Meat Inspection Permit in which date, weight, a
name of owner or vendor, the point of origin and destination is indicated.
The meat must bear the stamp of the Bureau of Animal Industry to indicate that it was
inspected and passed.
It must be fresh or frozen as indicated in the specification.
It must be free from discoloration and disagreeable odor.
5. Lean part must be of fine grain and not stringy.
6. The color of the lean must be typical of beef, from pale red to deep blood red.
7. Must have a generous amount of bt around the edge of meat and marbled through it.
8. It must be placed in sanitary containers or delivery vans to prevent access of dirt or any
contaminant.
9. Beef carcass, hindquarter or forequarter should have naturally attached skin, 3. 1/2 by 2".
10. Must be free from water injection.
E. Fish
I. Whole Fresh Fish
a. Must have firm flesh, shiny and tight skin, bright red gills and clear full eyes.
b. Scales should be shiny and not easily removed.
c. Must have natural slimy covering.
d. Must have intact abdomen .md belly walls.
e. Must have mild, fishy flavor.
f. Sizes should be in accordance to specifications called for.
g. Headless fish, if specified. must have head removed after inspection and before
weighing.
2. Fish Meat
a. Fish meat must have naturally attached skin, 2" x 2" to show that it was taken
from the kind of fish ordered.
b. Must be firm and show no sign ofdeterioration, discoloration or decomposition.
c. Must be clean.
d. Must be in accordance with the detailed specifications.
3. Smoked and Dried Fish
a. Must be free from molds and dirt.
b. Must be free from any signs of deterioration and decomposition.
c. Flesh should be finn and .ntached to the bones.
d. Must not cause itchiness to the tongue when eaten.
F. Shellfish
I. Must have closed shells.
2. Must have a clear and creamy melt color.
3. Must not show signs of deterioration or discoloration and decomposition.
4. For crabs, it must be heavy fi,r their sizes and must have firm joints.
5. For shrimps, it must have a mild odor, firm meat shells that fits tightly.
G. Poultry
1. Live
a. Must be in accordance with the specified breeds and weights called for in the
specifications.
b. Must posses a healthy full-bright red comb, clean nostrils, no discharge from the
mouth, clear eyes, smooth legs.
c. Flesh must be plump and well distributed.
2. Dressed and Drawn
a. If fresh, must be clean and freshly dressed and drawn.
b. Feet must be cut up to the knee.
c. Liver and giblets must be very clean and well-drained.
d. Must not have any greenish-blue discoloration.
e. Must be free from disagreeable odor.
f. Must be in accordance with the specifications called for.
g. Must not have water injected in the flesh
h. Must be placed in sanitary containers to prevent contamination.
H. Eus
1. Fresh
a. Sizes must be in accordance with the specifications called for.
b. Shells must be clean and free from cracks.
c. When candled, it should have a clear, stable yolk at the center ot the white.
d. When placed in a pan of water, must sink and lie on its side.
2. Salted
a. It must be well salted.
b. Deliveries must be subjected to random sampling to check on quality.
c. Discovery of rotten or spoiled eggs after receipt must be replaced without extra
charge on cost to the buyer. .
I. Canned Goods
1. Must have no bulges, swelling or one that gives evidence of leak.
2. Must have not evidence of rust that extends deeper than the surface of the can.
3. Brands which are available and has been found satisfactory must be selected.
4. Must be properly labelled.
EQUIPMENT GUIDE
FOR ACONVENTIONAL
HOSPITAL DIETETIC SERVICE
EQUIPMENT GUIDE FORA CONVENTIONAL HOSPITAL DIETETIC SERVICE"
Capacity
WORK AREA EQUIPMENT No. of Meals 100(}1500 E (Essential)
AREA 75 - 200 200 - 400 400 - 600 800 & Above N (Necessary)
D (Desirable)
NU rfBER OF BEDS
25 - 75 75 - 150 150 - 250 300 500
RECEMNG SCALE maybe floor mounted or in Weights up 75 kg. 75 kg. 250 kg. 500 kg. E
AREA platform; Fixed or Mobile; dial or beam to 50 kg.
plus tare, properly calibrated (minimum)
PREPARATION MOBILE UNIT FOR CARRYING dolley (1) dolley (1) Utility Cart (1) Utility Cart(1) Utility Cart(1) N
AREA FOOD, beverages and wares byhand dolley (1) dolley (1) dolley (1)
for short distances, furnished with
handles or push carts.
Could be carts or dolleys.
Dolley - solid platform or open frame-
work mounted on a set ofcasters maybe
equipped With handle or push bars.
em-of varying structure usually
with open shelves
Utility tabletop with sound flat surface 1 1 1 1 1 N
preferably a non-corrosive metal;
stationary or mobile with under
shelves or over shelves and two drawers
Refuse receptacle 1 1 1 1 2 E
Hand sink 1 1 1 1 1 N
Mixer with attachments for grinding, 1 1 . 1 1 1 0
vegetables slicing, chopping. and dicing;
bench model, motor driven;
20 quart capacity
'Grace Perdigon, Food Service Management in the Philippines, 1989
- 1 -
Meat chopper/gnnder; Table or 1 1 1 1 1 N
Floor mounted, and/or motor driven
Portion Scale 1 1 1 1 2 N
. Meat Saw 1 1 1 1 1 0
Meat Slicer 1 1 1 1 1 0
Garbage receptacles with cover 1 1 1 1 2 N
Hand Sink 1 1 1 1 1 N
Vertical Cutter, mixer - floor type (25 qr.) (25-40 qt.) (40-60 qt.) (60 qt. 0
machine with a vertical tilting mixing capacity
bowl having 25 to 80 quart capacity; minimum)
a 'strainer basket may be included
PREPARATION Vegetable slicer, 1 1 0
AREA hand or motor driven,
(Vegetable) table mounted
Potato peeler, floor or benchmounted 1 1 0
Coconutgrater, table or floor mounted, 1 1 1 1 1 N
manual or motor driven
Storage, Cold Refrigerator upright, reach-in refrigerator 70 cu. ft. 110 cu. ft. with 110 cu. ft. with 160 cu. ft. with atleastlw.J&.in E
walk-in, (individual temperature ranges total storage adjustable adjustable adjustable fOr meat&fish
fur meat, fish, vegetable, dairy, etc.) capacity shelving that shelvings shelvings in addition to
2 days storage will stand th re-storage for
Freezer, upright, reach-in or walk-in. haN1& left-over vege-
atmosphere ir tables, dairies
cold rooms butter, salads
.
and deserts
Storage, Dry Small scale for store room issues; 1 1 1 1 1 E
a scalewith a dial or portable
platform type (weighs up to 20 kg.)
Shdving(slatted, open wire, embossed, eII:.) E
Bins
- 2 -
Capacity
WORK AREA EQUIPMENT No. of Meals 1000-1500 E (Essential)
AREA 75 - 200 200 - 400 400- 600 800 & Above N (Necessary)
-
D (Desirable)
NUMBER OF BEDS
25 - 75 75 - 150 150 - 250 300 500
PREPARATION Ladder
AREA Pallets
(Meat & Fish) Means of communication with their N
departments (telephone, intercon, etc.)
Calculators, computers (very desirable)
Board (roctangular or round) or meat block, 1 1 1 1 1 E
Sink, Zcompartmenr type, with drain- 1 1 1 2 (1 meat, 1fish) 2 (1 meat, 1fish) N
boards (average 24" square, 14" deep)
Work tables, top non-corrosive metal 1 each for 1 each for 1 each for 1 each for 1 each for N
such as stainless steel guage meat & fish meat & fish meat & fish meat & fish meat & fish
Chopping Board, (roctangular or round) 1 1 1 2 2 E
portable
Sink, Zcompartment type, with drain- 1 single 1 double 1double 1 double 1 double E
boards (14" deep) compartment compartment compartment compartment compartment
PREPARATION Work table topwithsound flat surface 1 1 1 2 2 or more E
AREA preferably a non-corrosive metal, suchas
(Vegetable) stainless steel (guage 14 ) or an
aluminum (guage 20)
Garbage receptacle with a:JIU, heavy duty 1/2 sized drum 1/2 sized drum one full size 2full size 2or more E
(30' diameter)
COOKING KAWA made of cast iron or heavy
AREA aluminumwith thefuIbving dimensions:
30" diameter size 2 3
38" diameter size 1 1 3 4 E
40" diameter size 2 2 4 E
48" diameter size 4
- 3 -
Soup Boiler or Stock Pots 1 (15-20 gal.) 1 ( 20 gal.) 1 ( 20 gal.) 1 ( 20 gal.)
10 gal. 2 6 6 8 10 E
20 gal. 2 4 8 E
Top burners 6 10 12 12 18 E
(Incre se burner size s needed)
Griddle, size 18x18=344 in' 1 1 1 2 2 or more N
HJod with filter,deodorizer exhaust & lights numb r and size dep rnding on the r eaurement of cpoking area E
Electric Fan numb and size dep rnding on the r eaurement of cpoking area E
Wall type exhaust fans numb r and size dep nding on the 1 eaurement of ccoking area N
Pressure cooker (12 qt.) 1 1 1 2 2 N
Oven (stationary type), numb r and size dep nding on the r enu and type c service D
conventional oven type
Deep Fat Fryers numb r and size deprnding on the r enu and type cc service D
Storage racks and shelves numb r and size deprnding on the r enu and type cc service E
Mobile work table 1 1 1 D
Institutional can opener, mobile or 1 1 1 1 1 E
stationary; nonnal or electrically operated
Work tables, stainless steel 1 1 1 1 1 N
Sink, 2-compartments 1 1 1 1 1 N
Shelves 1 1 1 1 1 N
Ingredient Bins: unit 3 1 1
unit 4 1 1 (d:jxnding upon
the nxnu seMi)
Portable chopping boards 1 1 1 1 1 N
Ice Maker 1 1 1 1 1 D
Soiled dish table 1 1 1 1 1 E
Scrape block 1 1 1 1 1 N
Garbage can with cover 1 1 1 or as nerled
DISHWASHING Prerinse cornpmnxnt with hx and <DId water 1 1 1 1 1 E
AREA Dishwasher or wash and rinse
- compartments
- single tank type
- double to triple tank type capac y varies with I eak load
- 4 -
Capacity
,
WORK AREAEQUIPMENT No. of Meals 1000-1500 E (Essential)
AREA 75 -200 200- 400 400 - 600 800 & Above N (Necessary)
D (Desirable)
NUMBER OF BEDS
25 - 75 75 - 150 150 - 250 300 500
Clean dish table 1 1 1 1 1 N
Utility carts (shelf type) 1 1 1 1 2 D
Dish storage size epends upon he number of atients
'Glass washing unit Size epends upon t he number of atients
Refuse receptacle with cover size epends upon t he number of atients
POT & PAN Sinkdeep, stainless steel, 3<ompnunent E
WASHING with drainboard strainer 24" deepwith
running hot and cold water
Adjustable shelves and racks 1 1 1 1 1 E
Platform truck 1 1 1 1 1 N
Refuse receptacle with cover 2 2 2 2 2 E
SERVING Trayassembly line, complete unit 1 1 1 1 1 N
AREA Food carts depe nding upon th number ofpa ients per ward
(Patients) Utility carts 1 1 2 2 2 E
Hand sink 1 1 1 1 1 N
Griddle, Toaster, Coffee
Urn Water cooler'
r'
n
- 5 .
PRESIDENTIAL DECREE 856

A sample Checklist based on PD 856, Sanitation in Food Service, is shown below:
I. Establishment
1. Is the site at the reasonable distance from noise, odor, and other disturbing activities?
2. Have safety requirements been provided (i.e. fire exits, fire extinguisher, etc.)?
3. Does the topography contribute to giving proper drainage, prevention of standing or
stagnant water?
II. Food Handlers
1. Are they provided with up-to-date health certificates? Are they subjected to regular
. physical examination, stool, blood and urine examinations?
2. Havedaily examinations been made of the food handlers as to the fitness to work, by the
supervisors (Note: boils, open wounds, sore throat)?
3. Is the person-in-eharge trained in the principles of good sanitation?
4. Arethey in proper uniform - with caps, hairnets, aprons, trimmed fingernails, and neat
looking?
III. Toilet Facilities
1. Are toilet facilities accessible and conveniently located (distant from the kitchen)?
2. Is the toilet served with sewer lines or a septic tank?
3. Are the plumbing appurtenances in proper condition? (With stored water enough for
flashing, washing and cleaning.)
Iv. Garbage. Refuse Collection and Disposal
1. Is the establishment adequately provided with garbage receptacles or containers?
2. Are containers placed in proper locations?
3. Is there frequent!regular collection of garbage?
V. Water Supply
1. Is the source of water supply SAFE and POTABLE?
2. Is the amount of water supply adequate to meet requirements?
3. Is there enough water.stored in case of failure?
4. Is the water supply protected from cross-contamination with non-potable water?
5. Is the water supply obtained from a well? If so, how deep or shallow is the well?
VI. EquipmentjUtensils
1. Are the equipment/utensils adequate in number?
2. Are equipment/utensils made ofnon-toxic, smooth, durable, non-corrosive, easily-cleaned
materials?
3. Are all these equipment and utensils used for food preparation cleaned and sanitized
after use?
4. Are all equipment/utensils kept in good condition and free from cracks?
VII. Food Storage
1. Are refrigerator facilities adequate to store perishable food without overcrowding?
2. Are there separate storage facilities for perishable food (cooked/raw)?
3. Are all perishables such as milk, milk products, meat, fish and shellfish, poultry,
vegetables, salads, cream- filled pastries kept at proper temperatures (45
0P/ZZoq?
4. Areall foods kept clean,wholesome, free from spoilage, and insect and vermin infestation?
5. Is there proper maintenance of all refrigeration and storage facilities?
VIII. Kitchen
1. Is it clean and orderly (floor, walls, ceiling)?
2. Is it provided with screened, self-closing door, and adequate lighting and ventilation?
3. Is it equipped with good washing facilities?
4. Are surfaces in contact with food impervious, clean and resistant to chipping?
5. Are all equipment and kitchenware, including shelves, tables, meat blocks, refrigerators,
sinks, kept clean from dust; insects, and other contaminating materials?
IX. Insects and Vermin Control
1. Is there any evidence of insect and vermin infestation?
2. . Are there possible insect and vermin breeding areas?
3. Is there an organized program for vermin and insect control?
4. Are there any chemical and mechanical measures used for insect and vermin control?
5. Are animals found in the premises (cats, dogs, etc.)?
FOOD SANITATION CHECKUST
The following are some of the Food Sanitation Check List which can be used as a guide in the
Dietary Service:
SATISFACTORY POOR
I. GENERAL KITCHEN SANITATION
1. Floor and Walls
a. Tile
b. Cracks and holes are repaired
immediately
c. Cleaned and disinfected
daily while other areas are
disinfected weekly
d. All areas with drainage outlets
e. Standing water is
eliminated or drained
2. Work Areas
a. Well-ventilated
b. No damp areas
c. Wood surfaces are carefully
scraped after use.
d. Lighting is adequate at all times
e. Kitchen doors and windows are
properly screened and cleaned
f. Dishwashing area is adequately
supplied with hot water
g. Exhaust hood, fans, and ducts
are cleaned at least once a week
h. Sink for hand washing is
provided with hand towel and
soap within the kitchen
I. No overhead pipes that might
leak into food and equipment
FAIR EXCELLENT
SATISFACTORY POOR
j. Comfort Rooms
(1) Clean and away from
the work area
(2) Adequately supplied
with necessities
3. Equipment and Kitchenware
a. Chillers and refrigerators are
cleaned and defrosted weekly
b. Condition of equipment used
c. Cleanliness of equipment
immediately after use
d. Separate refrigerators/freezers
for seafood and meat products
e. Type of plastic food
containers utilized
f. Food containers are
off clean floors
g. Stainless steel table tops
and shelves
h. Storage of utensils, kitchenware,
and equipment in clean and dry
places at sufficient height from
the floor, protected from flies,
dust, and other contamination
i. Manual dishwashing procedure
j. Wiping cloths
k. Cleanliness of unused equipment
L Sinks are clean and unclogged
4. Garbage and Pig Swill
a. Covered containers
b. Daily disposal
c. Kept in isolated and wel1-
ventilated areas
FAIR EXCELLENT
SATISFACTORY POOR
5. Pest Control
a. Regular schedule for pest
control application
b. Adequate measures to eliminate
rodents, insects and vermin
c. Protection of food and food
equipment on application
of pesticides
II. STAFF HYGIENE
1. Regular physical check-up
of kitchen staff
2.: Daily shower requirement
3. Fingernails are well-trimmed
4. No jewelries worn during
working hours
5. Caps and hairnets are worn
at all times
6. Hands are washed after using
comfort room and before
commencing work
7. Uniforms are changed daily
8. Towels and aprons are changed daily _
9. No personnel with skin ailments,
infections and intestinal diseases,
decayed teeth and open wounds are
permitted to work in the kitchen
10. Locker rooms are properly cleaned
III. FOOD HANDLING AND HYGIENE
1. Defrosting of frozen food
2. Vegetables and fruits stored
below 15C
3. Canned goods stored below 15C'
4. Badly dented and inflated
'cans are rejected
FAIR EXCELLENT
5. Canned goods opened are
immediately removed from
the can and stored in stable
containers such as glass or
stainless steel
6. Raw and chopped meat is stored
for not more than two days
in the refrigerator
7. Unwrapped cakes, pies and
breadstuffs are kept in a clean
area or a covered tray protected
from dusts, flies and handling
SATISFACTORY POOR FAIR EXCELLENT
rv WATER AND ICE SUPPLY
1. Water supply is safe
2. Adequate and sanitary hot
and cold water supply
3. W,ter is accessible in all areas
where food is prepared or utensils
are washed
4. Ice received from an
approved source
5. Ice and ice-handling utensils
are properly stored
V. STOREROOMS
1. Clean
2. Temperature is satisfactory
----
3. Free from mustiness and odor
4. Properly ventilated
NUTRITION CLINIC FORMS
NCFORMNO.l
NUTRITION CLINIC REFERAL SLIP
DATE: _
Blood Sugar: _
Diagnosis: ~ _
Occupation: Relation: _
Name of Patient: _
Address: _
No. of Households/Children: _
Family Head: __-;:-::__-;-----
(Name)
.. Classification of Patient-,- ---------
Kind of Service Given: _
Laboratory Exam: _
Diet Prescription: _
Referred by:
Physician/Nurse
Department
(To be detached and referred to Source of Referal)
NUTRITION CLINIC ACKNOWLEDGMENT SLIP
DATE: _
(Physician/Nurse)
Name of Patient _
Address: _
Referred by: ; : ~ : ~ ~
Department: _
Diet Advise Given:
Date of Follow-up:
(Nutritionist-Dietitian)
NCFORM NO.2
NUTRITION HISTORY
I. Personal Data:
Date _
HI. __Wt. (Ibs.) _
Age __Ideal WI. _
_ Relation: _
Occupation:
Name of Patient: _
Address: _
Occupation: _
Religion:
Referal: _
Diagnosis: _
Diet Order: _
No. of HouseholdsjChildren: _
Family Head: _
(Name)
Recreation, Physical Activity: _
Educational Attainment: Primary, Elementary, High School, College, Vocational
II. Household Inquiry:
A. Facilities: (Encircle the answer)
Cooking: electricity, natural gas, kerosene, wood charcoal, others
Storage: refrogeration, ice box, cupboard, others _
B. Meals:
Regular: always, often, sometimes, never
Hurried: always, often, sometimes, never
C. Where usually taken?
At home Boarding House _ Restaurant _
D. Has patient ever been on diet before?
Never, once, twice, more than once
If so, was it prescribed by a Physician? Yeas No
III Follow-up
_.
-
Date Weight Lab Exam Remarks
VSUAL DAILY FOOD INTAKE
Analysis of Food Intake
(Computation)
NCFORM NO. 3A
Food Item Household Measures Cal. CHO P F
Breakfast
AM. Snack
Lunch
P.M. Snack
Supper
. ... .0
Extra Meals
Total
NC FORM NO. 3B
DIET DISTRIBUTION PLAN
Diet Prescription Cal. Prot. CHO Fat _
Food List No. of CHO Prot Fats Cal. B L S A.M. P.M.
Exchange gm. GM gm. GM. Snack Snack
I. Vegetable A
Vegetable B
II. Fruit
III. Milk
rv Rice
V. Meat
VI. Fat
Nutritionist-Dietitian
NCFORM NO. 4
Kasalukuyang Timbang _
Pangalan =:- -::-:-----:--:-_---==:--:- _
Edad _=--:- Taas _
Tamang Timbang _
Karamdaman _
Manggagamot __
1. Gulay A
Gulay B
11. Prutas
III. Gatas
Iv. Kanin 0
Tinapay
. V. Karne 0 lsda 0
Manok o Pamalit
VI. Taba
Agahan Snack Tanghalian Snack Hapunan Midnight
AM. P.M. Snack
.
RECOMMENDED CLASSIFICATION
BY WEIGHT OF
FILIPINO CHILDRENl
A. One to Eleven Months
Age Height Nonna! First Degree Second Degree Third Degree
m (Cm} Range Malnuttitioo Malnuttitioo Malnuttitioo
months

I 53.65 3.90- 4.;1\ 325- 3.89 2.60 - 3.24 25J
2
56.;1\ 4.52 - 5.50 3.77- 4.51 3.02 3.76 3.01
3 .il.83 5.17 - 6.29 4.31- 5.16 3.45 - 4.30 3.44
4 62.19 5.68 - 6.92 4.73 5.01 3.79 - 4.72
'-
3.78
5 64.ll 6.08 - 7.40 5.07 6.07 4.05 - 5.06 4.04
6 65.91 6.45 - 7.85 5.37 - 6.44 4.30 - 5.36 4.29
7 67.01 6.72 8.20 5.61 - 6.71 4.49 - 5.60 4.48
8 68.69 6.99 - 8.51 5.82 - 6.98 4.66- 5.81 4.65
9 69.80 7.09- 8.65
. 5.91 -
7.08 4.73 - 5.90 4.72
10 71.42 7.30- 8.90 6.09 - 7.29 4.87 - 6.08 4.86
11 73.13 7.62 - 9.30 6.11 7.61 5.09 - 6.34 5.08
B. One to Eight Years
Age Height Norma! First Degree Second Degree Third Degree
in (Cm.) Range Malnutrition Malnutrition Malnutritioo
years

1 74.69 7.95 . 9.69 6.63 - 7.94 5.30 6.62 5.29
2 86.37 10.66 . 13. 00 8.88 - 10.65 7.11 . 8.87 7.10
3 93.55 12.25 . 14.95 10.21 - 12.24 8.71 . 10.20 8.16
4 100.16 13.92-17.00 11.61 . 13.91 9.29 - 11.60 9.28
5 106.18 15.00 - 18.32 12.5] 14.99 10.01 - 12.50 10.00
6 112.21 16.42 - 20.04 13. 68 - 16.41 10.95 . 13.67 10.91
7 117.87 18.35 . 22.41 15.19 - 18.34 12.24 . 15.28 12.23
8 123.70 20.94 - 24.94 17.02 20.41 13.62 - 17. OJ 13.61
1 Taken from NFRI Publication Nos. 137 and 138, Revised January 1974.
DIETARY SERVICE FORMS
DS FORM NO. IA
PERFORMANCE TARGElS WORKSHEET
EMPLOYEE: _
POSITION: _
DMSION/SECTION:
BUREAU/MINISTRY/D;:;;IRE=Cro=RJ\:-;:::rn:;;-:------
FUNCTIONS AND ACTUAL DUTIES KEY RESULT PERFORMANCE TARGETS
AREAS
RESULTS MEASURES OF RESULTS
QUANTITY QUALITY TIME
Please SIgn commitment on the reverse SIde of this page. This form WIll be attached to the Performance AppraISal Report
1-
I agree to achieve these targets for the
rating period _
to .,..- _
(Signature of Employee)
(Date)
-2-
I agree to assist the employee achieve his/her
targets for the rating period _
to _
(Signature ofSupervisor)
(Date)
DS FORM NO. IB
CMLSERVICE COMMISSION
PERFORMANCE APPRAISAL REPORT
______TO .199
EMPLOYEE: _
POSITION: _
PART I OFFICE/AGENCY:

PERFORMANCE TARGETS
PT IT RESULTS QUANTITY QUALITY TIME REMARKS RATING
PLANNED ACTUAL PLANNED ACTUAL PLANNED ACTUAL
QN Q!. T
.
Average Point Score: _
Equivalent Point Score: _
PT = PLANNED TARGETS
IT= INTERVENING TARGETS
. I -
TOTAL =
GRAND TOTAL = _
PART II CRITICAL FACTORS AFFECTING JOB PERFORMANCE
FACTORS POINT SCORE REMARKS
1. PUBLIC RELATIONS --'- _
2.PUNCTUALlTY/ATTENDANCE _
3. POTENTIAL _-'- -'-- _
TOTAL
AVERAGE POINT SCORE
EQUIVALENT
SIGNATURES OF AGREEING PERSONNEL
PART III PERFORMANCE RATING Ratee;
Overall Point Score
Equivalent Numerical Rating
Additional Point Score (If any)
Total Numerical Rating
Adjectival Rating
Supervisor's Recommendation(s)
2
(Name inPrint)
Position:
DISCUSSED WffiI
Rater:
(Name in Print)
Position:
REVISED BY
Rater's
Supervisor:
(Name inPrint)
Position:
Head ofOffice (Regional Director, etc.)
(Signature)
(Date)
(Signature)
(Date)
(Signature)
(Date)
(Signature)
(Name in Print)
(Date)
OS FORM NO.2
EMPLOYEES SCHEDULE FOR TIfE MONTIf OF 19
--
NAME TIME I 2 l 4 I 1 I 1 1 I 1 I 2 21 2J 2 2 2 26 27 28 29 30 31 REMARKS
-/DUTY CODE XOFF-DUTY
DS FORM NO.3
DIETARY ORDER SLIP
FOR BIDDER ITEMS
DATE
Please deliver the following foodstuff needed by the hospital on _
Quantity Unit Particulars Unit Amount
Price
ORDERED BY:
CHIEF NUTRITIONIST-DIETITIAN
APPROVED:
CHIEF OF HOSPITAL
DS FORM NO. 4A
OPEN MARKET PURCHASE SLIP
DATE
Please deliver the following foodstuff needed by on _
,
,
Quantity Food Items Unit Amount
Price
ORDERED BY:
ADM. NUTRITIONISTDlETITIAN .
APPROVED:
CHIEF OF HOSPITAL
DATE
NAME OF HOSPITAL
DIETETIC SERVICE
Daily Admissions - Discharges Sheet
DS FORM NO. 4B
ADMISSIONS DISCHARGES
.
Ward Name ofPatient Diet Ward Name ofPatient Diet
.
DS FORM NO.5
DAILY DELIVERY RECORD BOOK
DATE NAME OF INY. QfY. PARTICULARS UNIT TOTAL RECEIVER AGENCY INTERNAL
SUPPLIER NO. PRICE PRICE INSPECTOR CONTROL
UNIT
OS FORM NO.6
SUPPLIES REQUISITION AND
ISSUE FORM
DATE __
QUANTITY ARTICLES' DESCRIPTION QUANTITY PURPOSE
ORDERED
RECENED
(Name)
RECENED BY: __---;:-::-----,-__
(Name)
REQUESTED BY: _
(Position) (Position)
APPROVED BY: .
(Name)
(Position)
DS FORM NO.7
(Name ofHospital)
DIETARY SERVICE
PERPETUAL INVENTORY
ITEM SPECIFICATION
DATE ON HAND USED BALANCE UNIT COST TOTAL COST
DS FORM NO.8
REGULAR WEEKLY MENU
FROM TO ,199_
MONDAY nJESDAY WEDNESDAY THURSDAY FRIDAY SAnJRDAY SUNDAY
1;;

0
<E
Cl
c::

cc
Cl
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,
,

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u
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><
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:r::
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:::> :::E
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PREPARED BY:
OS FORM NO.9
THERAPEUTIC WEEKLY MENU
FROM TO .199_
MONDAY -TIJESDAY WEDNESDAY THURSDAY FRIDAY SATIJRDAY SUNDAY

I

l>'I
co
\
;r::
U
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:3
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PREPARED BY:
DS FORM NO. 10
STANDARDIZED RECIPES
Name of Recipe:
INGREDIENTS AND
. WT.
MEASURE PROCEDURE
DESCRIPTION
PORTION SIZE:
YIELD: .
DS FORM NO. IlA
PRODUCTION RECORD SHEET
DATE:
REGULAR MEALS:
MENU INGREDIENTS OUANTITY TOTAL
CHARITY PAY OR MEDICARE PERSONNEL
B
R
E
A
K
F
A
S
T
L
U
N
C
H
S
U
p
P
E
R
DS FORM NO. liB
PRODUCTION RECORD SHEET
DATE:
THERAPEUTIC DIETS:
MENU INGREDIENTS QUANTITY roTAL
LS LSLF LS LChol LChol 5Bland Db TF OTHERS
F 5 F S F S
B
R
E
A
K
F
A
S
T
L
U
N
C
H
S
U
P
P
E
R
OS FORM NO. lIC
COOK'S COpy
DATE:
PATIENT SERVICE
MENU INGREDIENTS/ MODIFIED orsrs
QUANTITY DIET MENU NO. OF INGREDIENTS/
NEEDED PATIENTS QrY. NEEDED
B
R
E
A
K
F
A
S
T
L
U
N
C
H
S
U
P
P
E
R
DS FORM NO. liD
COOK'S COPY
DATE:
CAFETERIA SERVICE
MENU FOR INGREDIENTS/ SPECIAL FUNCTION I INGREDIENTS/
THE DAY QUANTITY NEEDED . (IF ANY) QUANTITY NEEDED
(FOR SPECIAL FUNCTIONS)
B
R
E
A
K
F.
A
S
T
L
U
N
C
H
S
U
P
P
E
R
M
I
D S
N N
I A
G C
H K
T
DAILY PATIENT'S MEAL CENSUS
OS FORM NO. 12
DATE: _
PAY MEDICARE CHARITY GRAND TOTAL
SURGICAL PED O.B. EENT MED
-DIET B L S B L S B L S B L S B L S B L S
IB
L S P M CH
FULL
SOFT -
UQUID
CLEAR/FULL
TUBE FEEDING
BLAND I
BLAND II
BLAND III
SOFT BLAND
FULL BLAND
WWRESIDUE
SOFT WW RESIDUE
HIGH CAWRIEj
HIGH PROTEIN
SOFT HIGH CAWRIE
I
HIGH PROTEIN
WW PROTEIN
SOFT WW PROTEIN
WWFAT
SOFTWWFAT
LOW SALT
SOFTWWSOFT
WW SALT WW FAT
WW CHOLESTEROL
DIABETIC
SOFT DIABETIC
WW PURINE
HYPOALLERGENIC
OTHER
TEST MEALS
HGB FREE
BRAT
--
GLUCOSE WATER
NOTHING BY MOUTH
MILK FORMULA
BREAST FEEDING
LEGEND:B-BREAKFAST L- LUNCH S-SUPPER P- PAY CH -CHARITY M- MEDICARE
MEDICARE IN WARDS OTHER THAN PAY
DS FORM NO. 13
DIET LIST
WARD: _ DATE: _
ROOM & NAME OF PATIENT
BED NO.
FULL SOFT LIQUID OTHER
DIETS
DIET
CHANGES
NOTE:
PREPARED BY: _
I. Diet list ofthe day should be forwarded to the Dietary Service befor,'_._ A.M. daily.
2. New admission takes effect immediately upon receipt.
3. Orders for diet changes and new admissions should be sent to the Dietary Service before __A.M. for
breakfast; __A.M. for lunch; P.M. for supper. Diet changes made after these hours will take
effect on the next meal.
l
DS FORM NO.14A
SPECIAL MEAL REQUEST FORM
DATE:
REQUEST FOR: [I BREAKFAST
. [J LUNCH [I SUPPER
OTHERS:
(Please specify)
Number of Persons:
Suggested Menu:
Requested by:
(Name)
(Department)

DATE:
Respectfully forwarded to the Hospital Director (or Administrator) for comments and recommendations.
THE COST OF THE SUGGESTED MENU:
OTHER SUGGESTIONS (if any):
Name
Chief Dietitian

DATE:
Said request is hereby Approved/Disapproved.
Other comments (if any):
Name
Hospital Director
OS FORM NO. 14B
SPECIAL MEAL RECORD FORM
DATES MEAL MENU COST REQUESTED APPROVED
REQUESTED BY: BY:
\
OS FORM NO. 15
NAME OF HOSPITAL
DIETARY SERVICE
ADMISSION SHEET
WARD NO. ROOM NO. NAME OF PATIENT DIET ORDERS CALLED BY: TIME RECEIVED BY:
,
;
DS FORM NO. 16A

NAME OF HOSPITAL
PROBLEM LIST
PROBLEM APPROX. ACTIVE PROBLF1S DATE DATE INACTIVE PROBLEMS
NO. DATE OF RECORDED RESOLVED
ONSET
PATIENT'S IDENTIFICATION: (NAME, AGE, SEX, WARD NO.) PAGE NO.
PROBLEM
ORIENTED
MEDICAL
RECORD
I
I
--
DS FORM NO. 16B
MEDICAL RECORD PROBLEM ORIENTED PROGRESS NOTES
PROBLEM Format Problem title (Do not abbreviate)
DATE NO. S. Subjective o.Objective . A. Assessment p. Plans
(All note must have signature and title ofperson making entry.)
PROBLEM
ORIENTED
PROGRESS
NOTES
DS FORM NO, 17
DIET HISTORY FORM
NAME: DIETARY PRESCRIPTION: DATE:
ADDRESS: DR,: SOCIAL HISTORY
MEDICAL HISTORY: AGE: FOOD PREPARED BY:
HEIGHT:
WEIGHT:
NUMBER IN FAMILY:
OCCUPATION:
FOOD HISTORY:
BREAKFAST LUNCH SUPPER BETWEEN ESSENTIAL SURVEY OF DIE
MEALS FACTORS APPETITE
HOSPITAL FORM NO.1
NAME OF HOSPITAL
STATEMENT OF DAILY MARKET PURCHASES
By 19 ,
.IJlJlQ.E UNIT TOfAL RECEIVED WITNF.I'S TO DISTRIBUTION OF PATIENTS
PRICE PRICE PAYMENT PAYMENT QJAIIGES
Sfm PERSONNEL CHARITY PRIVATE PAY
'0
I hereby certify that I have purchased the above-named articles in the
quantity and at the prices set above and that I paid therefore the total sum
of P out of the funds advanced to me for that purpose.
Nutritionist-Dietitian-Buyer
===================================================================--====
Noted and Approved:
Chief ofHospital
Received from the Cashier the above amount
ofP this day
of ~ ___
Nutritionist-Dietitian-Buyer, Hospital
Purchases inspected and found ~ _
Date Property Inspector
Property Audit Department
General Auditing Office
GENERAL FORM NO. 48 (A)
Stock No. _
SUPPLIES LEDGER CARD.-
Unit _
Unit ssu prce, p_-:-_.,--
(lnduding [ltil!t\ "0) (Name and deciption must conform with me invoia:)
NAME: =".- _
DfSCRlPfION:,_--,.c----,.-,---,---__-:---,.--,---c--,---_
WARRANT DATI: OF FROM WHOM RECEIVED DEBITS CREDITS BALANCfS
OR JOURNAL WARRANT OR TO WHOM
VOUCHER OR JOURNAL
QTy. VAlUE QTY. VAlUE QTY. VAlUE
NUMBER VOUCHER
I
Organizational Chart: 25-Bed Hospital
Chief
. of
Hospital
I
STAFFING:
Nutritionist-Dietitian II
-
Administrative Nutritionist-Dietitian I -
Officer Cook I
-
Food ServiceWorkers
-
I
NO II
(Chief)
I
NO I
(Administrative)
I I I
I
Cook I
FSW (I) - am FSW (2) - pm
Cook I (Production & (Production &
(Assistant/Reliever)
Service) Service)
I
I
2
3
7
, !
9
I
I
I
2
4
TAFFING:
Nutritionist-Dietitian I
Cook II
Cook I
ood ServiceWorkers
Chief
of
Hospital
I
Administrative
Officer S
I
ND II
(Chief) F
I
ND I
(Administrative)
I
I
Food Production
Food Service
I
T
FSW (2) - am
Cook II
(Patient Service)
(Dishwashingl
Housekeeping)
FSW (2) - pm
Cook 1(2)
(Patient Service)
(Dishwashingl
Housekeeping)
Organizational Chart: lOO-Bed Hospital
Chief
of
Hospital
I
Administrative
Officer
STAFFING:
- 1
I Nutritionist-Dietitian 1 - 2
Food Service Supervisor
- 1
ND II
Cook II 1 -
(Chief)
Cook I 3 -
Food Service Workers
- 8
I
I I . -----.-
16
ND 1
ND I
(Clinical. teaching-
(Administrative)
training, research)
I
Food Service
Supervisor
(General Reliever)
Food Production Food Service
I I
I I I I I
Cook II Cook 1(3) FSW (4)
FSW (2) FSW (2)
(Patient Service) (Dishwashingl
Housekeeping)
Chief
of
Hospital
I
STAFFING:
Administrative Nutritionist-Dietitian III - I
Officer Nutritionist-Dietitian II
- 2
Nutritionist-Dietitian I - 2
I
Food Service Supervisor - I
Cook II - 2
ND III
Cook I - 3
(Chief)
Food-ServiceWorkers
- 12
-------
I
23
I
ND II ND II
(Clinical - a.m.) (Administrative)
I
ND I
ND I
Food Service
(Clinical - p.m.)
(Food Productionl Supervisor
Clinical-Reliever)
(Food Service I
Reliever-Admin)
I I
_. I I I
Cook II (2) Cook I (3) FSW (3)
FSW (5) FSW (2) FSW (2)
(Patient Service) (DiShwashing) (Housekeeping)
Organizational Chart : 300-Bed Hospital
Chief
of
Hospital
I
Administrative
Officer STAFFING:
Nutritionist-Dietitian IV - I
I
Nutritionist-Dietitian III - I
Nutritionist-Dietitian II - 2
ND IV Nutritionist-Dietitian I - 2
(Chief)
Food Service Supervisor - I-
Cook II - 2
I
Cook I
- 4
Food ServiceWorkers - 15
ND III
-------
(Senior
28
Administrative)
I
ND II
ND II
(Clinical. teaching-
(Assistant
training. research)
Administrative)
I I
ND I
ND I Food Service
(Clinical
(Food Production)
Supervisor
Reliever)
I I
I I I
Cook II (2) Cook 1(4) FSW (4)
FSW (5) FSW(4) FSW (2)
(Patient Service) (Dishwashing) (Housekeeping)
Chief
of
Hospital
I
Administrative
Officer STAFFING:
Nutritionist-Dietitian IV
- I
I
Nutritionist-Dietitian III - I
Nutritionist-Dietitian II - 2
ND IV Nutritionist-Dietitian I
- 2
(Chief)
Food Service Supervisor - 2
Cook II
- 2
I
Cook I 4
.
-
Food ServiceWorkers
- 16
ND III
-------
(Senior
30
Administrative)
I
ND II ND II
(Clinical, teaching- (Assistant
training, research) Administrative)
I
ND I
ND I Food Service
(Clinical
(Food Production)
Supervisor (2)
Reliever)
I i
I I I I
.
Cook II (2) Cook 1(4) FSW(5)
FSW (5) FSW (4) FSW (2)
(Patient Service) (Dishwashing) (Housekeeping)
REFERENCES
BOOKS
American Dietetic Association, Guidelines for Consultant Dietitians.
In Long Term Care Facilities. May 1978.
Canadian Council in Hospital Accreditation, Guide in Hospital
Accreditation. Toronto, Ontario Canada 1977.
Durbin, Richard L. and Herbert Springall, Organization and
Administration of Health Care. Second Edition 1974.
Downs, Sister Rose Genevieve, Dietary Policy and Procedure Manual.
The Catholic Health Association, USA 1979.
Hospital Planning, Ontario Ministry of Health, Institutional Planning
Branch, A Guide to Programming and Planning Construction
Project, Ontario Canada, 1978.
Jackson, Rita, Quality Assurance for Dietetic Service, Kingland,
Georgia, 1988
Kotschevar, Lendal H. and Margaret E. Terrel, Food Service Planning,
Layout and Equipment, 2nd Edition, 1977.
Mahaffey, M., M. Mennesand B. Miller, Food Service Manual for Health
Care Institution. American Hospital Association, 1981.
McGibony, John R., Principles of Hospital Administration, Second
Edition, 1969.
Ministry of Health, Policy and Procedure Manual for Hospital of the
Ministry of Health, Ministry of Health, Manila, Philippines, March
1979.
Ministry of National Health and Weifare, Dietetic Department
Guidelines in Smaller Health Care Facilities. Canada 1979.
National Nutrition Service, Manual on Management of Malnourished
Children. NNS Department of Health, Manila, May 1976.
Nutritionist-Dietitian's Association of the Philippines, Fundamentals of
Nutrition and Dietetics, Manila 1982.
Perdigon, Grace P., Food Service Management in the Philippines.
Diliman, Quezon City, Philippines, 1989
State of Utah, Food Service Sanitation Manual, Department of Health,
1962.
The Dietary Staff, DietaryService Policies and Procedure, Rizal Medical
Center, Pasig, Metro-Manila, Jan. 1982.
Velasco, Antonio, E.R., Practice Management, First Edition, 1982
West and Wood, Food Service in Institution, John Willy & Sons, Inc.
1977.
i
I
I
l
REFERENCES
JOURNALS AND HANDOUTS
Eusebio, Josefa S., Priority Research Needs: Food Service. Philippine
Journal of Nutrition 21:2, April-June, 1978.
Fajardo, Rachel C., Priority Research Needs: Institution Management,
Philippine Journal of Nutrition, 31:2, April-June, 1978.
Florentino, Rodolfo E., friority Research Needs: Community Nutrition,
Philippine Journal of Nutrition, 31:2, April-June, 1978. .
Guzman de, Patrocinio, Disaster Feeding, Philippine Journal of Nutrition,
33: 1, January-March, 1977.
lntengan, Carmen L., Priority Research Needs: Basic Nutrition, 31:2,
April-June, 1978.
Joint Accreditation Commission, U ~ A 1983, 1988.
McMasters, Virginia, Administrative Dietetic Internship Handbook,
University of California, USA, 1979.
Ocampo, Perla S., Priorit1! Research Needs: Basic Nutrition, 31:2, April-
June, 1978.
Presidential DecreeNo. 807, Providing for the Org;oniution ofthe Civil
Service Commission in Accordance with the Provisiol1s of the
Constitution, Prescribing its Powers and Functions and other
Purposes, Malacanang, Manila, October 6, 1975.
Review Committee, Guidelines for Evaluating Dietetic Practice, A
Report ofthe Professional Standards. Journal of American Dietetic
Association, April, 1976.
Silayan, Imelda and Associates, Food Facilities Consultants and
Designer. 1983.
Social Service Staff, Annual Report, NEDA-MOH-MPW-PMCC Inter-
agency Coordinating Committee for the Development of A National
Hospital Program, 1980, August 1981.
Van-Lane, Diedre, Feeding Disabled Persons. Resource Kit on Food.
Nutrition and the Disabled. Canada Information Service, 1981.
. ~
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H108.45 H79d I Hospital dietary service management manual
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