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Creating Healthy Menus within Budget Constraints
from the association
ETHICS IN ACTION
Creating Healthy Menus within Budget Constraints Michelle A. Fratianne, RD, LD
T
he dietetics practitioner involved with menu planning in hospitals, nursing homes, schools, prisons, and other settings where the focus on health and quality is balanced with budget restraints has always been challenged with providing the best product for the money. Today, dietetics practitioners confront even greater difficulty as the demand for food and energy across the globe has resulted in rapid price increases, food shortages, and increased transportation and delivery costs. While these costs are rising, the funds allocated to meet them are shrinking, making the task challenging and rife with many potential ethical issues. Are food costs, at the very least, indexed to the inflation rate set by industry standards, or are practitioners expected to adhere to unrealistic price control? It is paramount that registered dietitians (RDs) and dietetic technicians, registered (DTRs), network with other practitioners in similar facilities and institutions to benchmark industry standards. RDs and DTRs may be asked to make choices, changes, or substitutions in some settings that are not in accordance with the accepted standards of practice and/or dietary guidelines. For example, decisions might include lower-cost meat items resulting in less protein or higher saturated fat or poor quality, limiting use of fresh fruits and vegetables, and/or filling menus with more lessnutrient-dense, carbohydrate-containing foods. In many settings, the practitioners are not involved in contract negotiations; this may result in products that are promoted by salesperM. A. Fratianne is owner of Nutricon of Maine and Bring It Home Fitness Retreat, and lives in Norway, ME. 0002-8223/$36.00 doi: 10.1016/j.jada.2011.02.019
sons that use an illegal “kickback” system, a limited ability to obtain specialized products needed by clients, or encouragement to select products based on incentives for individual gain. CASE STUDY #1 Principle #18: The dietetic practitioner does not invite, accept, or offer gifts, monetary incentives, or other considerations that affect or reasonably give an appearance of his/her professional judgment (1).
Ethical Dilemma: Can N.R. authorize giving a nutritionally inadequate substitute to control costs?
CASE STUDY #3 Principle #4: The dietetics practitioner complies with all laws and regulations applicable or related to the profession or the practitioner’s ethical obligations as described in this Code (1).
Ethical Dilemma: Can L.H. accept travel rewards, even though it is not cash, for items that she would already be purchasing and would be saving the facility money?
© 2011 by the American Dietetic Association
N. R. is an RD employee of a company that manages long-term care facilities in several states. In an attempt to trim expenditures, the Corporate Purchasing Agent made the decision to substitute nonfortified fruit drinks for fruit juices.
N. R. developed a proposal that included why this was inappropriate, using referenced information. In addition, she presented other cost-cutting suggestions that would not affect the nutritional quality of the food served. She included some suggestions regarding reduction of the use of convenience foods, use of paper products by staff, and more efficient use of cleaning chemicals.
L. H., a new Director of Food Service in a medium-sized hospital in the Midwest, was approached by the Director of Healthcare Sales for the Prime Vendor for the facility. The contract was coming up for renewal in 4 months. After discussing the current terms, L.H. inquired about the possibility of further reduction in costs of paper products and chemicals. She stated that she was considering a new bidding process for those items. The Vendor representative then told her about an incentive program that not only saved money for the hospital, but earned her “points” toward travel and vacation rewards. The representative stated that her predecessor had been part of the program and that this special offer was saved only for “preferred customers.”
L. H. thanked him for the information and ended the meeting. She proceeded to alert the Purchasing Director. The Vendor was not asked to bid on the contract because of the clear violation of principle 18. Even if the employer benefits from the agreed terms, gifts to employees are not acceptable.
CASE STUDY #2 Principle #12: The dietetics practitioner practices dietetics based on evidence-based principles and current information (1).
J. T. is a consultant to a facility that provides residential services to mentally challenged adults. The owners, in an effort to cut costs, ask that the menus include milk only at breakfast and that iced tea or fruit drinks be served at other meals. The dairy vendor has used a hidden clause in the contract to pass on increased costs to the customer. The RD knows that this does not meet the nutritional requirements nor the regulatory requirements of the jurisdiction.
Ethical Dilemma: Can J.T. provide menus that are not nutritionally adequate and do not follow regulatory expectations?
Journal of the AMERICAN DIETETIC ASSOCIATION
605
ETHICS IN ACTION J. T. discussed the issues with the owners and stated he would not provide inadequate menus, but would assist in any way to address the cost issue. He asked to review the contract and noted there was no apparent provision for exclusivity; ie, the owners were not bound to purchase milk ONLY from this vendor. J.T. then recommended that the owners have their lawyers review the contract to verify this item. When it was determined that the facility could purchase milk from other sources, J.T. was able to obtain milk at a more reasonable price from the grocery vendor and provide the required amount to the clients. The owners were most grateful for the advice and asked J.T. to be part of all negotiations for food contracts in the future.
Other sources to assist RDs and DTRs in standardizing ethical purchasing guidelines within our organizations can be found through the work of Group Purchasing Organizations (GPOs), which have become a significant partner in the buying process. Many of them have come together to form the HGPII, The Healthcare Group Purchasing Industry Initiative: “The goal of the Initiative is to assure ongoing adherence to ethical conduct and business practices, and to hold the confidence of the public and the Government in the integrity of the industry.” Each GPO has committed to the Initiative at the highest level. The governing body of the Initiative is comprised of the nine founding GPO Chief Executive Officers, who serve as a Steering Committee to set the Initiative’s policies and programs (2). Member organizations agree to follow a set of core ethical principles in their practice and to provide members with the best practices that lead to the development of these standards. Individual organizations have also formulated their own guidelines in this arena: Johns Hopkins Health System has a “Corporate Purchasing Code of Ethics” that is accessible online (3). At this time, due to the pressures of the economy, RDs and DTRs are challenged to create healthy menus. RDs and DTRs must remain confident in securing the highest quality of food for clients while demanding adequate funding to do the job. In addition, RDs and DTRs must illustrate that their
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April 2011 Volume 111 Number 4
use of food budget dollars has been at an optimum return on the investment. References 1. American Dietetic Association/Commission on Dietetic Registration Code of Ethics for the profession of dietetics and process for consideration of ethics issues. J Am Diet Assoc. 2009;109:1461-1467. 2. Bednar R. About HGPII. Healthcare Group Purchasing Industry Initiative Web site. http://www.healthcaregpoii.com. Accessed October 26, 2010. 3. Johns Hopkins Health System Purchasing Department. Johns Hopkins Medicine Web site. www.hopkinsmedicine.org/purchasing/. Accessed October 25, 2010.
ETHICS IN ACTION
Creating Healthy Menus within Budget Constraints Michelle A. Fratianne, RD, LD
T
he dietetics practitioner involved with menu planning in hospitals, nursing homes, schools, prisons, and other settings where the focus on health and quality is balanced with budget restraints has always been challenged with providing the best product for the money. Today, dietetics practitioners confront even greater difficulty as the demand for food and energy across the globe has resulted in rapid price increases, food shortages, and increased transportation and delivery costs. While these costs are rising, the funds allocated to meet them are shrinking, making the task challenging and rife with many potential ethical issues. Are food costs, at the very least, indexed to the inflation rate set by industry standards, or are practitioners expected to adhere to unrealistic price control? It is paramount that registered dietitians (RDs) and dietetic technicians, registered (DTRs), network with other practitioners in similar facilities and institutions to benchmark industry standards. RDs and DTRs may be asked to make choices, changes, or substitutions in some settings that are not in accordance with the accepted standards of practice and/or dietary guidelines. For example, decisions might include lower-cost meat items resulting in less protein or higher saturated fat or poor quality, limiting use of fresh fruits and vegetables, and/or filling menus with more lessnutrient-dense, carbohydrate-containing foods. In many settings, the practitioners are not involved in contract negotiations; this may result in products that are promoted by salesperM. A. Fratianne is owner of Nutricon of Maine and Bring It Home Fitness Retreat, and lives in Norway, ME. 0002-8223/$36.00 doi: 10.1016/j.jada.2011.02.019
sons that use an illegal “kickback” system, a limited ability to obtain specialized products needed by clients, or encouragement to select products based on incentives for individual gain. CASE STUDY #1 Principle #18: The dietetic practitioner does not invite, accept, or offer gifts, monetary incentives, or other considerations that affect or reasonably give an appearance of his/her professional judgment (1).
Ethical Dilemma: Can N.R. authorize giving a nutritionally inadequate substitute to control costs?
CASE STUDY #3 Principle #4: The dietetics practitioner complies with all laws and regulations applicable or related to the profession or the practitioner’s ethical obligations as described in this Code (1).
Ethical Dilemma: Can L.H. accept travel rewards, even though it is not cash, for items that she would already be purchasing and would be saving the facility money?
© 2011 by the American Dietetic Association
N. R. is an RD employee of a company that manages long-term care facilities in several states. In an attempt to trim expenditures, the Corporate Purchasing Agent made the decision to substitute nonfortified fruit drinks for fruit juices.
N. R. developed a proposal that included why this was inappropriate, using referenced information. In addition, she presented other cost-cutting suggestions that would not affect the nutritional quality of the food served. She included some suggestions regarding reduction of the use of convenience foods, use of paper products by staff, and more efficient use of cleaning chemicals.
L. H., a new Director of Food Service in a medium-sized hospital in the Midwest, was approached by the Director of Healthcare Sales for the Prime Vendor for the facility. The contract was coming up for renewal in 4 months. After discussing the current terms, L.H. inquired about the possibility of further reduction in costs of paper products and chemicals. She stated that she was considering a new bidding process for those items. The Vendor representative then told her about an incentive program that not only saved money for the hospital, but earned her “points” toward travel and vacation rewards. The representative stated that her predecessor had been part of the program and that this special offer was saved only for “preferred customers.”
L. H. thanked him for the information and ended the meeting. She proceeded to alert the Purchasing Director. The Vendor was not asked to bid on the contract because of the clear violation of principle 18. Even if the employer benefits from the agreed terms, gifts to employees are not acceptable.
CASE STUDY #2 Principle #12: The dietetics practitioner practices dietetics based on evidence-based principles and current information (1).
J. T. is a consultant to a facility that provides residential services to mentally challenged adults. The owners, in an effort to cut costs, ask that the menus include milk only at breakfast and that iced tea or fruit drinks be served at other meals. The dairy vendor has used a hidden clause in the contract to pass on increased costs to the customer. The RD knows that this does not meet the nutritional requirements nor the regulatory requirements of the jurisdiction.
Ethical Dilemma: Can J.T. provide menus that are not nutritionally adequate and do not follow regulatory expectations?
Journal of the AMERICAN DIETETIC ASSOCIATION
605
ETHICS IN ACTION J. T. discussed the issues with the owners and stated he would not provide inadequate menus, but would assist in any way to address the cost issue. He asked to review the contract and noted there was no apparent provision for exclusivity; ie, the owners were not bound to purchase milk ONLY from this vendor. J.T. then recommended that the owners have their lawyers review the contract to verify this item. When it was determined that the facility could purchase milk from other sources, J.T. was able to obtain milk at a more reasonable price from the grocery vendor and provide the required amount to the clients. The owners were most grateful for the advice and asked J.T. to be part of all negotiations for food contracts in the future.
Other sources to assist RDs and DTRs in standardizing ethical purchasing guidelines within our organizations can be found through the work of Group Purchasing Organizations (GPOs), which have become a significant partner in the buying process. Many of them have come together to form the HGPII, The Healthcare Group Purchasing Industry Initiative: “The goal of the Initiative is to assure ongoing adherence to ethical conduct and business practices, and to hold the confidence of the public and the Government in the integrity of the industry.” Each GPO has committed to the Initiative at the highest level. The governing body of the Initiative is comprised of the nine founding GPO Chief Executive Officers, who serve as a Steering Committee to set the Initiative’s policies and programs (2). Member organizations agree to follow a set of core ethical principles in their practice and to provide members with the best practices that lead to the development of these standards. Individual organizations have also formulated their own guidelines in this arena: Johns Hopkins Health System has a “Corporate Purchasing Code of Ethics” that is accessible online (3). At this time, due to the pressures of the economy, RDs and DTRs are challenged to create healthy menus. RDs and DTRs must remain confident in securing the highest quality of food for clients while demanding adequate funding to do the job. In addition, RDs and DTRs must illustrate that their
606
April 2011 Volume 111 Number 4
use of food budget dollars has been at an optimum return on the investment. References 1. American Dietetic Association/Commission on Dietetic Registration Code of Ethics for the profession of dietetics and process for consideration of ethics issues. J Am Diet Assoc. 2009;109:1461-1467. 2. Bednar R. About HGPII. Healthcare Group Purchasing Industry Initiative Web site. http://www.healthcaregpoii.com. Accessed October 26, 2010. 3. Johns Hopkins Health System Purchasing Department. Johns Hopkins Medicine Web site. www.hopkinsmedicine.org/purchasing/. Accessed October 25, 2010.