Standardization of the nutrition and diet division of the University Hospital in Santa Maria

Compu~rs ind. Engng VoL 31, No. 1/2, pp. 439 -44.2,1996 Copyright O 1996 EINvier Seienc~Lid Printed in Great Britai~ All ~lgh~ tern'red

Pergamon S0360.8352(96) 00170-2

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STANDARDIZATION OF THE NUTRITION AND DIET DIVISION OF THE UNIVERSITY HOSPITAL IN SANTA MARIA R. Radharamanan and L. P. Godoy Department of Industrial Engineering, Center of Technology Federal University of Santa Maria, Santa Maria (RS), 97119-900, Brazil

ABSTRACT This paper presents a proposal of standardization of the Nutrition and Diet Division, (NDD) of a University Hospital based on the quality philosophy in services and standardization of enterprises. The objective is to identify and document the routines of some of the existing categories through a routine manual. The procedures used to standardize the NDD show that more participation of the management in solving divisional problems, and adequate training of the employees are required.

KEYWORDS Standardization, nutrition and diet division, quality manuals, hospital services.

INTRODUCTION In Brazil, major health care services are provided to the public through the University Hospitals funded by the Federal Gove~-ament. The health care s~'vices provided by these hospitals are often criticized for lack of quality in services provided to the customers due to: 1. a b s e ~ of routines and procedures in providing the services; 2. lack of commitment from the hospital administration, 3. unqualified workers; 4. absence of appropriate training to the employees; and 5. reduction in budget as and when the government policy changes. As part of the solution to the above problems, this paper aims to standardize the procedures used in the nutrition and diet division of the University Hospital in Santa Maria (UHSM), Brazil. The standardization becomes appropriate as it contribotes for the evolution of quality that consists tn systematizing the standards and requisites for the food production and distribution process at UHSM (Vieira, 1995). The standardization procedures are the means of carrying out the process that is under control, after eliminating the problems (Sioan, 1991). Following the ~ r e s eliminates the variation in service qualtty when workers are substituted. Over time, the standardization confers with the reliability of the processes and guarantees suitability of the s~vices provided together with the clients (Toledo, 1987). The setting of standards and procedures avoids waste of time, person, and material that will reflect in the service qualtty provided by increasing the productivity of the division. The standardization process is the first step to obtain quality, and a weapon against wastes and h~w productivity (Nogueira, 1994). The standardilati~m of NDD, besides indicating certain existing deficiencies, must show I~)w to provide the services and stimulate the workers to engage in the campaign against waste.

PREPARATION OF MANUALS In order to facilitate the understanding of the standardization proposal of the NDD, a manual consisting of the following seven parts has been prepared: presentation manual, exuding manual, preparation manual, 439

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implementation manual, routine manual, auditing manual, and administrative manual. The system of procedures presented in a compact form obey a standard and systematic scheme and facilitate their consulting and reading. In preparing the standards, the existing conditions at the NDD have been analyzed in a broader sense considering the technical as well as economic aspects. As an example, the summary of the "Routine Implementation Manual" is presented and discussed below: Routine Implementation Manual 1. Objective: This manual determines the conditions for the implementation of the routines in the NDD division. 2. Complementary Documents: Consists of routine preparation manual, routine presentation manual, and routine coding manual. 3. Definitions: a) Implementation Pha~ - is the period between the approval and the distribution of routines, to the routine s~tions, and the confirmation of the same by auditing, b) Responsible for Implementation - the person responsible for standardization guides and follows the implementation of routin~ at the NDD. c) Follow-up of Implementation - a member of the routine commission responsible for the standardization program at the NDD does the follow-up. 4. General Conditions: a) The persons responsible for implementation are indicated by the routine commission, b) If no adequate performance is presented, the person responsible is evaluated by the routine commission, c) The person responsible can he substituted depending on the evaluation. 5. Implementation activities: The routine commission sends a copy of the approved routines to the person responsible for implementation. He/she receives and verifies whether there is a need for training the employees before impleJnenting the routines. If training is needed, he/she should conduct classes and/or meetings; and provide training in the NDD area. He/she also must fill up the control form with the probable date of implementation and send it to the routine commission. The implementation phase must he concluded on the emission date of the auditing report confirming the perfect application of the routine. The routine commission, having verified the routine implementation, must distribute copies of the same to the routine stations.

PRESENT SITUATION OF THE NDD Because of too much movement of persons in the hospital, there is a need to plan and prepare standardization activity for the NDD services of UHSM. The NDD is one of the divisions that presents serious problenx~ in the produetiou and distribution of meals. As this division is also responsible for tile recovery of the patients, together with the doctors, nurses and residents, there is a need for st~dards and procedures in this division. To emphasis the imp~ance of NDD in the general services of the University Hospital, the number of meals served in 1994 was registered as 414,858 meals. The divisions in which the procedures are not well defined, the quality was the responsibility of every employee. The cause and effect diagram, (Fig. 1) shows that Ihe distribution of meals in the hospitalization units of University Hospital. There have been absence of thermal carts that contribute for the arrival of cold meals to the patients. In other cases, there have been absence of salt, fat, etc. These occur due to the absence of procedures for the ~xecution of tasks. EQUIPMENT AbsenceXN of thermal ~ carts ~

NDD ENVIRONMENT METHOD \ ~ N o ventilation Absence of ~ Unpleasant~ quality , - " X , envtromnent ~ Intense noise " N43old meals, "Ni:hambers

~'~ Gold meals "~without salt "

MealSim~t / / ' ~

"~t¢-----

~ E R V I C E WITHOUT QUALITY D

team spirit Persons w i t h/ o u t / , I

Absence standardsofa flxlr~ nd/7

for recoverY" 7" procedures//Influence on / ~ , Patients in recovery/'Absence of / service quality / ~ommunication / ~ in the division PATIENTS NDD PERSONS REPORT Fig. 1. Cause and Effect Diagram - Nutrition and Diet Division of UHSM

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RE.SULTS AND DISCUSSIONS

The planning of menu is executed by the professional nutritimist, taking into consideration the nutrition required, food habits, available equipment, number of employees and their e~tpeflent~. The nutrition assistant picks up the prescription written by the medical group and there are no standards for carrying out this activity. The nutrition assistant, goes several times to different floors until he/she obtains the prescriptions for all the patients. The picking up of the medical and meals presertptic~ needs to he standardized to facilitate the work of the nutrition assistant. The meals are distributed by the waiters, who take the meals to the serving units, and later distribute the meals to the patients. This task is also very important for the recovery of the patients, om~ldering that he/she is weak, away from his residence and many times away from his town, and expects a quality meal. This also depends on the type of distribution. The meals are necessary to patients considering that he/she is weak. It is important to control the quality of the service before, since the sampling, inspection and control are nmde directly by the client. The clients have no means of testing the service before obtaining it (Feigenbaum, 1986). The following principal problems have been Identified when employees were asked to respond to a questionnaire: no adequate and appropriate training of the employees: no management participation in the divisional problems; lack of responsibility from ~ of the employees; no setting of standard procedures; no response from the employees; absence of nutrittonist, no motivation from the mana~t. Table 1 summarizes the data obtained from the questionnaire. The Pareto chart is used to analyze the problems by placing the data in the order of importance (Fig. 2). Table I Data obtained from the questionnaire Types of complaints % 1. Lack of responsibility 2. No manasement participation 3. No adequate trainins 4. No setting of standards 5. No motivation from the manasement 6. No response from the employees 7. Absence of nutritionist TOTAL

Frequency 13 11 8 7 3 2 1 45

45.

28.89 24.44 17.78 15.56 6.67 4.44 2.22 100.00

,IOO % ,90

80 30

6o

o

5o 4o

15

3O

'20 .10 2

3 4 5 6 Type of Complaints

Fig. 2. Pareto chart

7

Percentage

Cumulative 28.89 53.33 71.11 86.67 93.34 97.78 100.00

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CONCLUSION Considering the complexity of the nutrition and diet division which is c(m3parable to an enterprise, the objective of producing quality meals within the given conditions, imposes establishing a routine, with techniques capable of solutioning the problems in attaining the specific objectives. Major problems exist because of the system and processes compared to that of employees. However, a reevaluation of managing the services is need to solve the problems of the NDD. It can be concluded that the standardization by setting the procedures, avoids waste of time, person, and material. It is recommended that major participation of employees in training, and management assistance in solving the divisional problems are essential before implementing these standards and procedures.

ACKNOWLEDGMENT The authors thank CNPq (Brazilian R ~ r c h Radharamanan for the period 1995-96.

Council) for providing research fellowship to Prof. R.

REFERENCES Feigenbaum, A. V. (1986). Total Quality Control. McGraw-Hill Book Company. Nogueira, R. P. (1994). Perspectivas do Qualidade em SafMe. Edilora Qualitymark, Rio de Janeim. Sloan, D. M. and M. Chmel. (1991). The Quality Revolution and Health Care - A Primer for Purchasers and Providers. ASQC Quality Press. Milwaukee, Wisconsin. Toledo, J. C. (1987). Qualidade Industrial. Editora Arias S. A. S•o Paulo. Vietra, M. C. (1995). Proposta de Normalizaftto do Servifo de Nutrifao e Diet~tica do Hospital Universitdrio de Santa Maria (HUSM). DissertagAo de Mestrado. UFSM, Brastl.