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Factors influencing HACCP implementation in Taiwanese public hospital kitchens
Food Control 22 (2011) 496e500
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Factors influencing HACCP implementation in Taiwanese public hospital kitchens Kuei-Mei Shih a, Wei-Kang Wang b, * a b
Department of Nutrition, Tao-Yuan General Hospital, Department of Health, Executive Yuan, 1492 Chung-Shan Road, Tao-Yuan City 33004, Taiwan, ROC College of Management, Yuan Ze University, 135 Yuan-Tung Road, Chung-Li 32003, Taiwan, ROC
a r t i c l e i n f o
a b s t r a c t
Article history: Received 1 June 2009 Received in revised form 16 September 2010 Accepted 24 September 2010
This study investigated the potential factors which may influence implementation of the HACCP system in hospital catering operations in Taiwan. A total of 132 catering managers and operators at 23 hospitals affiliated with the Department of Health (DOH) participated in the study. Three structured questionnaires were used to collect data concerning employee satisfaction, difficulties, and benefits related to HACCP implementation. The results show that differences in gender, age, and job position are factors that may influence HACCP implementation in Taiwanese hospitals. Most of the catering staff in the observed hospitals agreed that HACCP was very beneficial for hospital catering. Crown Copyright Ó 2010 Published by Elsevier Ltd. All rights reserved.
Keywords: HACCP Food hygiene Hospital catering
1. Introduction According to the report by the Department of Health (DOH) (2009), a total of 1295 cases of food borne disease occurred from 2004 to 2008 in Taiwan. These involved 18,067 people who were ill and 3 who died as a result of consuming contaminated food. Among all of the cases, 7 took place in patient care settings and involved a total of 56 victims. Since the level of food hygiene is a very important issue for inpatients, personnel in all patient care settings need to pay close attention to preventing food contamination so as to ensure patient safety. Food safety has received an increasing amount of attention recently around the world. To prevent contamination of food supplies, various groups in public health, industry, regulatory agencies, and academia must play important roles. Measures are also needed to reduce or eliminate contamination between the farm and the table. Since end-product testing alone is unable to assure safe food production, the hazard analysis critical control point (HACCP) system has been adopted in order to eliminate identified hazards or reduce them to an acceptable level (Ehiri, Morris, & McEwen, 1995; Walker, Pritchard, & Forsythe, 2003). HACCP is a management system in which food safety is addressed through the analysis and control of biological, chemical, and physical hazards from raw material production, procurement and handling, to manufacturing, distribution and consumption of the
* Corresponding author. Tel.: þ886 3 4354605; fax: þ886 3 4633845 E-mail addresses: [email protected] (K.-M. Shih), [email protected]. edu.tw (W.-K. Wang).
product (NACMCF, 1997). It is based on a logical, structured exploration of potential hazard points in a food operation, and on the introduction of control and monitoring measures (Richards, Parr, & Riseborough, 1993). The HACCP system evolved from standards that were set up in the 1960s by Pillsbury in cooperation with the National Aeronautics and Space Administration (NASA), the U.S. Army, and the U.S. Air Force Space Laboratory with the goal of providing astronauts with safe foods (Goldmann & Kaushal, 2002; Ten Eyck, Thede, Bode, & Bourquin, 2006). The system provides a careful review of the entire food production process and identifies principal hazards and control points where contamination can be prevented, limited, or eliminated. HACCP safety principles have been applied in the food industry for over 30 years, and the system has been accepted universally as a powerful tool for evaluating the control of risk in foods and ensuring food quality and safety (Richards et al., 1993). The system is also an ideal tool for hospital infection control and food hygiene practices. Baird, Henry, Liddell, Mitchell, and Sneddon (2001) studied the application of HACCP principles to prevent infection following intraocular surgery. Their results showed that medical safety was improved following the implementation of HACCP in healthcare processes. Richards et al. (1993) also found that HACCP implementation in hospital kitchens enabled operators to produce guidelines for their catering departments which were applicable to other hospital kitchens as well. The HACCP system was introduced into Taiwan in 1998 and since then has been applied in the food industry to prevent largescale food borne illnesses. It was integrated into the Governing Food Sanitation Act in 2000. To promote food hygiene and hospital catering safety, Taiwan’s DOH has encouraged DOH-affiliated
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K.-M. Shih, W.-K. Wang / Food Control 22 (2011) 496e500
regarding satisfaction levels, 9 items regarding implementation difficulties, and 9 items regarding the benefits of implementing HACCP. (2) The second questionnaire was used to survey operators at the same 12 hospitals that had implemented HACCP. This questionnaire had 13 items regarding satisfaction levels. (3) The third questionnaire was used to survey managers at 11 hospitals which had not implemented HACCP. This questionnaire contained 9 items regarding expected difficulties with HACCP implementation and 9 items regarding the anticipated benefits of implementing HACCP. In total, 138 staff members (45 managers and 65 operators of hospitals which had implemented HACCP, and 28 managers of hospitals which had not implemented HACCP) participated in the study from November to December, 2007. A total of 132 staff members (44 managers and 61 operators of hospitals which had implemented HACCP, and 27 managers of hospitals which had not implemented HACCP) returned fully completed and valid questionnaires, representing a 95.7% response rate. Each item was scored on a 5-point Likert scale: 1 (strongly disagree), 2 (disagree), 3 (neutral), 4 (agree), 5 (strongly agree). The reliability of the instrument was substantiated with a Cronbach’s alpha coefficient higher than 0.70 for all variables. The data obtained from the survey form were evaluated using the package program SPSS 12.0 for Windows. The frequency distributions of the sample were determined with respect to gender, age (by class: &30 years; 31e50 years; S51 years), and position (manager; operator). Independent samples t-tests were conducted to determine whether or not there were significant differences in the perceived benefits and level of difficulty of implementing HACCP between managers of hospitals which had implemented HACCP and managers of hospitals which had not. A pair of independent samples t-tests was also conducted to determine whether or not there were significant differences in satisfaction levels between females and males, and between managers and operators after hospitals had implemented the HACCP system. A one-way ANOVA was conducted to determine whether or not there were significant differences in satisfaction levels among three age groups (i.e., &30 years, 31e50 years and S51 years) in hospitals which had implemented HACCP. In addition, Scheffé post hoc tests were used to perform multiple comparisons. For all the analyses performed in this study, a level of p < 0.05 was used to determine statistical significance (two-tailed).
Table 1 Sample characteristics (n ¼ 132). Characteristics
Gender Female Male Age &30 31e50 S51 Position Manager Operator
Hospitals which had implemented HACCP
Hospitals which had not implemented HACCP
Total
n
%
n
n
%
84 21
80.0 20.0
20 7
74.1 25.9
104 28
78.8 21.2
12 75 18
11.4 71.4 17.1
5 20 2
18.5 74.1 7.4
17 95 20
12.9 72.0 15.1
44 61
41.9 58.1
27 0
100.0 0.0
71 61
53.8 46.2
%
497
hospitals to implement HACCP and obtain DOH certification since 2001. Hospitals in Taiwan are classified into different categories according to their type of ownership (public, private, or corporate); the type of medical treatment they provide (general, chronic disease, or psychiatric), their instructional capability (teaching or non-teaching hospital); and their level of accreditation (medical center, regional hospital, or district hospital). DOH-affiliated hospitals belong to the category of public hospitals, so they are ahead of all other Taiwanese hospitals in implementing HACCP. Most DOH-affiliated hospitals are equipped with kitchens so that they can provide inpatient catering, which is designed and prepared under the supervision of registered dietitians in each hospital’s nutrition department. The purpose of this study was to investigate factors which may influence the implementation of HACCP in public hospital catering in Taiwan. Therefore, in this study, we surveyed catering personnel at DOH-affiliated hospitals to determine their level of satisfaction with HACCP implementation, the difficulties they encountered, and perceived benefits of HACCP. According to DOH records, 12 out of 29 DOH-affiliated hospitals implemented HACCP in 2007 and obtained HACCP certification from the DOH. Among the DOH-affiliated hospitals that did not implement HACCP, 6 were excluded from the study because they are not equipped with kitchens and, therefore, provide their inpatients with purchased meals. 2. Methods
3. Results
In order to obtain insights into the possible factors influencing HACCP implementation in the kitchens of DOH-affiliated hospitals, we developed three different structured questionnaires: (1) One questionnaire was used to survey managers of 12 hospitals which had implemented HACCP. This questionnaire contained 13 items
3.1. Characteristics of the sample As shown in Table 1, there were more females than males and more managers than operators in the study. The age group between 31 and 50 years old comprised the majority of the study sample in
Table 2 Analysis of the difficulty of HACCP implementation from the perspective of managers in hospitals which had implemented HACCP and in hospitals which had not. Items
Hospital Difficulty of getting support from the hospital Difficulty of getting funds from the hospital Difficulty of coordinating with related departments in the hospital Operation procedure and facility Difficulty of setting up standard operating procedures for HACCP Insufficient manpower allocation Difficulty of changing operating procedures Difficulty of filling in paperwork for HACCP Difficulty of running the kitchen during facility improvement Difficulty of allocating funds for facility improvement
HACCP-implemented
HACCP-unimplemented
(n ¼ 44) Mean (SD)
(n ¼ 27) Mean (SD)
2.68 (0.97) 3.14 (0.89) 2.92 (0.89)
3.74 (0.98) 4.30 (0.82) 3.85 (0.86)
4.30*** 5.33*** 4.18***
2.95 3.08 3.16 3.11 3.11 3.41
3.81 4.37 3.96 3.96 4.00 4.56
3.43*** 5.73*** 3.16** 3.36*** 3.79*** 5.69***
(0.91) (0.98) (1.01) (1.02) (0.94) (0.90)
(1.11) (0.74) (0.98) (0.98) (0.92) (0.64)
Items were scored on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree); SD: standard deviation; **P＜0.01, ***P＜0.001.
t
498
K.-M. Shih, W.-K. Wang / Food Control 22 (2011) 496e500
Table 3 Analysis of the benefits of HACCP implementation from the perspective of managers in hospitals which had implemented HACCP and in hospitals which had not. Items
Operation management Increasing the percentage of patients who order meals Improving coordination between catering managers and operators Improving work efficiency in the kitchen Keeping staff turnover low in the kitchen Increasing the frequency of educational training for staff in the kitchen Increasing the autonomous hygiene management ability of staff in the kitchen Achievement Increasing the patients’ satisfaction with catering Positive impact of HACCP implementation on hospital evaluation by DOH Improving food hygiene
HACCP-implemented
HACCP-unimplemented
(n ¼ 44) Mean (SD)
(n ¼ 27) Mean (SD)
3.27 3.84 3.78 3.49 4.00 4.03
3.07 3.41 3.70 3.26 3.89 4.04
(0.65) (0.50) (0.71) (0.69) (0.58) (0.55)
3.70 (0.70) 4.43 (0.60) 4.35 (0.59)
(0.68) (0.84) (0.72) (0.76) (0.70) (0.59)
t
1.17 2.36* 0.44 1.24 0.67 0.07 0.66 1.29 1.20
3.81 (0.62) 4.22 (0.70) 4.19 (0.48)
Items were scored on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree); SD: standard deviation; *P＜0.05.
both the hospitals which had implemented HACCP and those which had not.
management” and “Positive impact of HACCP implementation on hospital evaluation by DOH” and “Improving food hygiene” under “Achievement.”
3.2. Differences in mean responses to difficulty items Table 2 shows that managers at hospitals which had not implemented HACCP rated nine difficulty items significantly higher than managers at hospitals which had implemented HACCP. For managers at both groups of hospitals, the highest mean responses were given to “Difficulty of getting funds from the hospital” and “Difficulty of allocating funds for facility improvement.” 3.3. Differences in perceived benefits of implementing HACCP As seen in Table 3, there was a significant difference in the responses of managers in hospitals which had implemented HACCP and managers in those which has not for the item “Increasing the coordination between catering managers and operators.” Managers in hospitals which had implemented HACCP had a significant higher mean score than their counterparts for the above item. Managers in both groups of hospitals indicated that the items with the least benefit for their hospitals were “Increasing the percentage of patients who order meals” under “Operation management” and “Increasing the patient’s satisfaction with catering” under “Achievement”. There were three items with mean scores higher than 4.00 in both groups of hospitals. These items were “Increasing the autonomous hygiene management ability of staff in the kitchen” under “Operation
3.4. Differences in satisfaction levels between females and males, and between managers and operators The Table 4 shows that, among respondents in hospitals which had implemented HACCP, the satisfaction levels of female respondents were significantly lower than male’s on five items, i.e. “Control of work flow”, “Control of transportation of raw catering materials and finished meals”, “Improvement in sanitation in the operating environment,” “Improvement in the cleanliness of kitchen facilities” and “Improvement in the overall quality of the whole kitchen.” On the other hand, the satisfaction levels of managers were significantly higher than operators’ on the following five items: “Improvement in the operating flow process,” “Improvement in food hygiene,” “Improvement in the autonomous hygiene management ability of staff,” “Improvement in overall team coordination throughout the kitchen,” and “Overall implementation of the HACCP system.” 3.5. Differences in satisfaction levels among three age groups Table 5 shows the summary of variance in satisfaction level among three staff age groups (i.e. & 30 years, 31e50 years, and S 51 years) at hospitals which had implemented HACCP. The P levels
Table 4 Analysis of the effects of gender and job position differences on staff members’ level of satisfaction with HACCP implementation in hospitals which had implemented HACCP. Items
Environment and sanitation Improvement in kitchen facilities Control of work flow Control of transportation of raw catering materials and finished meals Improvement in sanitation in the operating environment Improvement in the cleanliness of kitchen facilities Effectiveness of pest control in the kitchen Flow and quality Improvement in the operating flow process Improvement in food hygiene Improvement in the autonomous hygiene management ability of staff Results of DOH evaluation The overall satisfaction indicator Improvement in the overall quality of the whole kitchen Improvement in overall team coordination throughout the kitchen Overall implementation of the HACCP system
Gender
Position
Female (n ¼ 84)
Male (n ¼ 21)
Mean (SD)
Mean (SD)
3.90 3.75 3.85 3.98 3.92 3.85
(0.75) (0.77) (0.75) (0.71) (0.71) (0.78)
4.00 4.14 4.19 4.33 4.33 4.10
(0.77) (0.47) (0.51) (0.57) (0.57) (0.70)
3.94 4.05 3.98 3.93
(0.70) (0.66) (0.73) (0.67)
4.19 4.29 4.19 4.19
(0.62) (0.72) (0.60) (0.68)
3.92 (0.77) 3.87 (0.80) 3.95 (0.79)
4.38 (0.59) 4.10 (0.63) 4.24 (0.54)
Manager (n ¼ 44)
Operator (n ¼ 61)
Mean (SD)
Mean (SD)
0.52 2.22* 1.99* 2.13* 2.47* 1.33
4.07 3.77 3.93 4.14 4.09 3.91
(0.76) (0.71) (0.66) (0.63) (0.68) (0.68)
3.82 3.87 3.90 3.98 3.93 3.90
(0.74) (0.76) (0.77) (0.74) (0.73) (0.84)
1.50 1.46 1.25 1.59
4.16 4.25 4.20 4.09
(0.65) (0.62) (0.63) (0.64)
3.87 3.98 3.89 3.90
(0.70) (0.70) (0.73) (0.70)
2.18* 2.03* 2.33* 1.42
2.55* 1.20 1.57
4.16 (0.65) 4.09 (0.64) 4.18 (0.62)
3.90 (0.83) 3.79 (0.84) 3.89 (0.82)
1.72 2.02* 2.02*
t
Items were scored on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree); SD: standard deviation; *P＜0.05.
t
1.68 0.66 0.21 1.11 1.12 0.16
K.-M. Shih, W.-K. Wang / Food Control 22 (2011) 496e500
499
Table 5 Summary of the variance in satisfaction level among three staff age groups at hospitals which had implemented HACCP. Items Environment and sanitation Improvement in kitchen facilities
Control of work flow
Control of transportation of raw catering materials and finished meals
Improvement in sanitation in the operating environment
Improvement in the cleanliness of kitchen facilities
Effectiveness of pest control in the kitchen
Flow and quality Improvement in the operating flow process
Improvement in food hygiene
Improvement in the autonomous hygiene management ability of staff
Results of DOH evaluation
Overall satisfaction indicator Improvement in the overall quality of the whole kitchen
Improvement in overall team coordination throughout the kitchen
Overall implementation of the HACCP system
Source of Variation
Sum of Squares
df
Mean Square
F
Significance
Between Groups Within Groups Total Between Groups Within Groups Total Between Groups Within Groups Total Between Groups Within Groups Total Between Groups Within Groups Total Between Groups Within Groups Total
0.90 58.49 59.39 1.86 55.05 56.91 2.15 52.07 54.23 2.32 48.44 50.76 3.39 48.61 52.00 2.97 58.87 61.85
2 102 104 2 102 104 2 102 104 2 102 104 2 102 104 2 102 104
0.45 0.57
0.78
0.46
0.93 0.54
1.72
0.18
1.08 0.51
2.11
0.13
1.16 0.48
2.44
0.09
1.69 0.48
3.55
0.03*
1.49 0.58
2.58
0.08
Between Groups Within Groups Total Between Groups Within Groups Total Between Groups Within Groups Total Between Groups Within Groups Total
2.29 46.70 48.99 1.96 45.09 47.05 4.98 46.98 51.96 4.03 43.93 47.96
2 102 104 2 102 104 2 102 104 2 102 104
1.14 0.46
2.50
0.09
0.98 0.44
2.22
0.11
2.49 0.46
5.41
0.01*
2.02 0.43
4.68
0.01*
Between Groups Within Groups Total Between Groups Within Groups Total Between Groups Within Groups Total
1.93 59.06 60.99 0.14 55.86 56.00 2.23 56.76 58.99
2 102 104 2 102 104 2 102 104
0.96 0.58
1.66
0.20
0.07 0.55
0.13
0.88
1.11 0.56
2.00
0.14
df: degrees of freedom; *P＜0.05.
of the items “Improvement in the cleanliness of kitchen facilities” (P ¼ 0.03), “Improvement in the autonomous hygiene management ability of staff” (P ¼ 0.01), and “Results of DOH evaluation” (P ¼ 0.01) were below the significant level of 0.05. Scheffé post hoc comparison tests were used to analyze means differences across the three groups. Table 6 shows that the satisfaction levels for three
Table 6 Analysis of variance in satisfaction level for items with significant differences among three staff age groups at hospitals which had implemented HACCP. Items
&30 (1) (n ¼ 12)
31e50 (2) (n ¼ 75)
S51 (3) (n ¼ 18)
Mean (SD)
Mean (SD)
Mean (SD)
Scheffé test
Environment and sanitation Improvement in the 4.33 (0.79) 4.03 (0.68) 3.67 (0.69) (1)＞(3)* cleanliness of kitchen facilities Flow and quality Improvement in the 4.42 (0.79) 4.05 (0.63) 3.61 (0.79) (1)＞(3)* autonomous hygiene management ability of staff Results of DOH evaluation 4.33 (0.79) 4.01 (0.65) 3.61 (0.61) (1)＞(3)* Items were scored on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree); SD: standard deviation; *P＜0.05.
items were significantly higher in the &30 age group than in the S51 age group. These items were “Improvement in the cleanliness of kitchen facilities”, “Improvement in the autonomous hygiene management ability of staff”, and “Results of DOH evaluation”. 4. Discussion This study examined the perceived difficulty and benefits of implementing HACCP among managers of both hospitals which had implemented HACCP and hospitals which had not. The study also investigated the satisfaction levels of staff, according to gender, age and position, in hospitals which had implemented HACCP. Managers of both groups of hospitals considered two items in the questionnaire the most difficult. One was “Getting funds from the hospital” under “Hospital” and the other was “Difficulty of allocating funds for facility improvement” under “Operation procedure and facility.” In addition, the results showed that there were statistically significant differences between managers of both groups of hospitals with regard to the difficulty of implementing HACCP. Among managers of hospitals which had not implemented HACCP, the expected difficulty level of implementation was between 3.74 and 4.56, which showed that the managers of these hospitals had no confidence in receiving support, funds, or human resources from their hospitals when implementing HACCP. On the
500
K.-M. Shih, W.-K. Wang / Food Control 22 (2011) 496e500
other hand, among managers of hospitals which had implemented HACCP, the perceived difficulty levels of obtaining support, funds, and human resources from their hospitals were between 2.68 and 3.41, which indicates that the actual difficulty level of implementing HACCP was lower than the difficulty level expected by managers of hospitals which had not implemented HACCP. According to the requirements of the Department of Health (DOH) in Taiwan, HACCP team members should receive professional training and advice from HACCP experts, and learn how to improve kitchen facilities and food production procedures before and during HACCP implementation. The catering staff at the hospitals in this study which had implemented HACCP had also received related training, experts’ advice, and support from their hospitals before and during implementation, and that this assistance had reduced the difficulty level. The standard operating procedures employed by staff also have practical effects on HACCP system implementation. The results of this study suggest that hospitals need to provide more funds, support, facility, HACCP training, and advice from experts and consultants in order to eliminate their staff’s fear of implementing the system. It is also necessary for hospitals to encourage their staff to coordinate with one another while implementing HACCP. Staff at both groups of hospitals regarded two items in the questionnaire on HACCP implementation to be of little benefit. One was “Increasing the percentage of patients who order meals” under “Operation management,” and the other was “Increasing the patients’ satisfaction with catering” under “Achievement.” This implies that patients’ understanding of the differences in catering hygiene and safety before and after implementation of the HACCP system was insufficient. To help patients feel more comfortable with hospital catering, hospitals need to make greater effort to enhance patients’ understanding of the advantages of implementing HACCP in their hospital kitchens. Once patients have more knowledge about the HACCP system, they are more likely to order meals, and their level of satisfaction with catering hygiene can be expected to increase. Meanwhile, hospitals which have not implemented HACCP can also be encouraged to support and invest funds in implementation. In food service, proper kitchen layout and flow charts of food production are the first two things that need to be considered before HACCP implementation. Kitchen designs and operations that are based on HACCP concepts will facilitate HACCP implementation and applications (Hopkins, 1991; Sun & Ockerman, 2005). In this study, we found that the satisfaction levels of female respondents were significantly lower than males’ on five items. Moir and Jessel (1991) stated that differences in the brain and hormones between males and females cause females to pay more attention to details and cleanliness. Females, moreover, are more sensitive to the nuances of expressions and gestures, and are more adept at judging character. Thus, these five items are probably related to the tendency among females to find fault and be more easily dissatisfied. The results also revealed that operators had lower satisfaction levels than managers, and that older staff members had lower satisfaction levels than younger staff. Operators are more highly engaged in daily catering processes, and older staff members might lack sufficient strength for the required physical activities. Therefore, kitchen layout and operation procedure planning should take the physical strength of older staff members into consideration.
This would help to increase operators’ level of satisfaction with HACCP implementation. Standard operating procedures can also facilitate work that involves both operators and managers. Conflicts between operators and managers that stem from different perceptions of work demands can be avoided or eliminated; thus, they can cooperate with one another better. 5. Conclusion The results of the study show that the possible factors influencing HACCP implementation in hospital kitchens in Taiwan include gender, age, and job position differences as well as differences in the confidence staff members feel in receiving support from staff in other departments and financial support from the hospital itself. Most of the staff members in the nutrition departments of both groups of hospitals agreed that HACCP could increase the autonomous hygiene management ability of kitchen staff, which in turn could raise the quality of food hygiene and have a positive effect on DOH evaluations. Realizing the great benefits of HACCP as demonstrated by the results of this study, we hope that hospitals which have not yet implemented HACCP will be inspired to do so. Acknowledgements The authors gratefully acknowledge the funding provided by Tao-Yuan General Hospital, Department of Health, Executive Yuan, Taiwan, R.O.C., and the assistance of the respondents in this study. References Baird, D. R., Henry, M., Liddell, K. G., Mitchell, C. M., & Sneddon, J. G. (2001). Postoperative endophthalmitis: the application of hazard analysis critical control points (HACCP) to an infection control problem. Journal of Hospital Infection, 49, 14e22. Ehiri, J. E., Morris, G. P., & McEwen, J. (1995). Implementation of HACCP in food businesses: the way ahead. Food Control, 6(6), 341e345. Goldmann, D., & Kaushal, R. (2002). Time to tackle the tough issues in patient safety. Pediatrics, 110, 823e826. Hopkins, R. E. (1991). HACCP by the numbers. Food Management, 26(9), 74. Moir, A., & Jessel, D. (1991). Brain sex: The real difference between men and women. London: Mandarin. National Advisory Committee on Microbiological Criteria for Foods (NACMCF). (1997). Hazard analysis and critical control point. Principles and application guidelines. Adopted August 14. 1997. Richards, J., Parr, E., & Riseborough, P. (1993). Hospital food hygiene: the application of hazard analysis critical control points to conventional hospital catering. Journal of Hospital Infection, 24, 273e282. Sun, Y. M., & Ockerman, H. W. (2005). A review of the needs and current applications of hazard analysis and critical control point (HACCP) system in foodservice areas. Food Control, 16(4), 325e332. Ten Eyck, T. A., Thede, D., Bode, G., & Bourquin, L. (2006). Is HACCP nothing? a disjoint constitution between inspectors, processors, and consumers and the cider industry in Michigan. Agriculture and Human Values, 23, 205e214. Walker, E., Pritchard, C., & Forsythe, S. (2003). Hazard analysis critical control point and prerequisite program implementation in small and medium size food businesses. Food Control, 14(3), 169e174.
Kuei-Mei Shih, MBA, RD, Director, Department of Nutrition, Tao-Yuan General Hospital, Department of Health, Taiwan, R.O.C.
Wei-Kang Wang, PhD, Associate Professor, Chair, College of Management, Yuan Ze University, Taiwan, R.O.C.
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Factors influencing HACCP implementation in Taiwanese public hospital kitchens Kuei-Mei Shih a, Wei-Kang Wang b, * a b
Department of Nutrition, Tao-Yuan General Hospital, Department of Health, Executive Yuan, 1492 Chung-Shan Road, Tao-Yuan City 33004, Taiwan, ROC College of Management, Yuan Ze University, 135 Yuan-Tung Road, Chung-Li 32003, Taiwan, ROC
a r t i c l e i n f o
a b s t r a c t
Article history: Received 1 June 2009 Received in revised form 16 September 2010 Accepted 24 September 2010
This study investigated the potential factors which may influence implementation of the HACCP system in hospital catering operations in Taiwan. A total of 132 catering managers and operators at 23 hospitals affiliated with the Department of Health (DOH) participated in the study. Three structured questionnaires were used to collect data concerning employee satisfaction, difficulties, and benefits related to HACCP implementation. The results show that differences in gender, age, and job position are factors that may influence HACCP implementation in Taiwanese hospitals. Most of the catering staff in the observed hospitals agreed that HACCP was very beneficial for hospital catering. Crown Copyright Ó 2010 Published by Elsevier Ltd. All rights reserved.
Keywords: HACCP Food hygiene Hospital catering
1. Introduction According to the report by the Department of Health (DOH) (2009), a total of 1295 cases of food borne disease occurred from 2004 to 2008 in Taiwan. These involved 18,067 people who were ill and 3 who died as a result of consuming contaminated food. Among all of the cases, 7 took place in patient care settings and involved a total of 56 victims. Since the level of food hygiene is a very important issue for inpatients, personnel in all patient care settings need to pay close attention to preventing food contamination so as to ensure patient safety. Food safety has received an increasing amount of attention recently around the world. To prevent contamination of food supplies, various groups in public health, industry, regulatory agencies, and academia must play important roles. Measures are also needed to reduce or eliminate contamination between the farm and the table. Since end-product testing alone is unable to assure safe food production, the hazard analysis critical control point (HACCP) system has been adopted in order to eliminate identified hazards or reduce them to an acceptable level (Ehiri, Morris, & McEwen, 1995; Walker, Pritchard, & Forsythe, 2003). HACCP is a management system in which food safety is addressed through the analysis and control of biological, chemical, and physical hazards from raw material production, procurement and handling, to manufacturing, distribution and consumption of the
* Corresponding author. Tel.: þ886 3 4354605; fax: þ886 3 4633845 E-mail addresses: [email protected] (K.-M. Shih), [email protected]. edu.tw (W.-K. Wang).
product (NACMCF, 1997). It is based on a logical, structured exploration of potential hazard points in a food operation, and on the introduction of control and monitoring measures (Richards, Parr, & Riseborough, 1993). The HACCP system evolved from standards that were set up in the 1960s by Pillsbury in cooperation with the National Aeronautics and Space Administration (NASA), the U.S. Army, and the U.S. Air Force Space Laboratory with the goal of providing astronauts with safe foods (Goldmann & Kaushal, 2002; Ten Eyck, Thede, Bode, & Bourquin, 2006). The system provides a careful review of the entire food production process and identifies principal hazards and control points where contamination can be prevented, limited, or eliminated. HACCP safety principles have been applied in the food industry for over 30 years, and the system has been accepted universally as a powerful tool for evaluating the control of risk in foods and ensuring food quality and safety (Richards et al., 1993). The system is also an ideal tool for hospital infection control and food hygiene practices. Baird, Henry, Liddell, Mitchell, and Sneddon (2001) studied the application of HACCP principles to prevent infection following intraocular surgery. Their results showed that medical safety was improved following the implementation of HACCP in healthcare processes. Richards et al. (1993) also found that HACCP implementation in hospital kitchens enabled operators to produce guidelines for their catering departments which were applicable to other hospital kitchens as well. The HACCP system was introduced into Taiwan in 1998 and since then has been applied in the food industry to prevent largescale food borne illnesses. It was integrated into the Governing Food Sanitation Act in 2000. To promote food hygiene and hospital catering safety, Taiwan’s DOH has encouraged DOH-affiliated
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K.-M. Shih, W.-K. Wang / Food Control 22 (2011) 496e500
regarding satisfaction levels, 9 items regarding implementation difficulties, and 9 items regarding the benefits of implementing HACCP. (2) The second questionnaire was used to survey operators at the same 12 hospitals that had implemented HACCP. This questionnaire had 13 items regarding satisfaction levels. (3) The third questionnaire was used to survey managers at 11 hospitals which had not implemented HACCP. This questionnaire contained 9 items regarding expected difficulties with HACCP implementation and 9 items regarding the anticipated benefits of implementing HACCP. In total, 138 staff members (45 managers and 65 operators of hospitals which had implemented HACCP, and 28 managers of hospitals which had not implemented HACCP) participated in the study from November to December, 2007. A total of 132 staff members (44 managers and 61 operators of hospitals which had implemented HACCP, and 27 managers of hospitals which had not implemented HACCP) returned fully completed and valid questionnaires, representing a 95.7% response rate. Each item was scored on a 5-point Likert scale: 1 (strongly disagree), 2 (disagree), 3 (neutral), 4 (agree), 5 (strongly agree). The reliability of the instrument was substantiated with a Cronbach’s alpha coefficient higher than 0.70 for all variables. The data obtained from the survey form were evaluated using the package program SPSS 12.0 for Windows. The frequency distributions of the sample were determined with respect to gender, age (by class: &30 years; 31e50 years; S51 years), and position (manager; operator). Independent samples t-tests were conducted to determine whether or not there were significant differences in the perceived benefits and level of difficulty of implementing HACCP between managers of hospitals which had implemented HACCP and managers of hospitals which had not. A pair of independent samples t-tests was also conducted to determine whether or not there were significant differences in satisfaction levels between females and males, and between managers and operators after hospitals had implemented the HACCP system. A one-way ANOVA was conducted to determine whether or not there were significant differences in satisfaction levels among three age groups (i.e., &30 years, 31e50 years and S51 years) in hospitals which had implemented HACCP. In addition, Scheffé post hoc tests were used to perform multiple comparisons. For all the analyses performed in this study, a level of p < 0.05 was used to determine statistical significance (two-tailed).
Table 1 Sample characteristics (n ¼ 132). Characteristics
Gender Female Male Age &30 31e50 S51 Position Manager Operator
Hospitals which had implemented HACCP
Hospitals which had not implemented HACCP
Total
n
%
n
n
%
84 21
80.0 20.0
20 7
74.1 25.9
104 28
78.8 21.2
12 75 18
11.4 71.4 17.1
5 20 2
18.5 74.1 7.4
17 95 20
12.9 72.0 15.1
44 61
41.9 58.1
27 0
100.0 0.0
71 61
53.8 46.2
%
497
hospitals to implement HACCP and obtain DOH certification since 2001. Hospitals in Taiwan are classified into different categories according to their type of ownership (public, private, or corporate); the type of medical treatment they provide (general, chronic disease, or psychiatric), their instructional capability (teaching or non-teaching hospital); and their level of accreditation (medical center, regional hospital, or district hospital). DOH-affiliated hospitals belong to the category of public hospitals, so they are ahead of all other Taiwanese hospitals in implementing HACCP. Most DOH-affiliated hospitals are equipped with kitchens so that they can provide inpatient catering, which is designed and prepared under the supervision of registered dietitians in each hospital’s nutrition department. The purpose of this study was to investigate factors which may influence the implementation of HACCP in public hospital catering in Taiwan. Therefore, in this study, we surveyed catering personnel at DOH-affiliated hospitals to determine their level of satisfaction with HACCP implementation, the difficulties they encountered, and perceived benefits of HACCP. According to DOH records, 12 out of 29 DOH-affiliated hospitals implemented HACCP in 2007 and obtained HACCP certification from the DOH. Among the DOH-affiliated hospitals that did not implement HACCP, 6 were excluded from the study because they are not equipped with kitchens and, therefore, provide their inpatients with purchased meals. 2. Methods
3. Results
In order to obtain insights into the possible factors influencing HACCP implementation in the kitchens of DOH-affiliated hospitals, we developed three different structured questionnaires: (1) One questionnaire was used to survey managers of 12 hospitals which had implemented HACCP. This questionnaire contained 13 items
3.1. Characteristics of the sample As shown in Table 1, there were more females than males and more managers than operators in the study. The age group between 31 and 50 years old comprised the majority of the study sample in
Table 2 Analysis of the difficulty of HACCP implementation from the perspective of managers in hospitals which had implemented HACCP and in hospitals which had not. Items
Hospital Difficulty of getting support from the hospital Difficulty of getting funds from the hospital Difficulty of coordinating with related departments in the hospital Operation procedure and facility Difficulty of setting up standard operating procedures for HACCP Insufficient manpower allocation Difficulty of changing operating procedures Difficulty of filling in paperwork for HACCP Difficulty of running the kitchen during facility improvement Difficulty of allocating funds for facility improvement
HACCP-implemented
HACCP-unimplemented
(n ¼ 44) Mean (SD)
(n ¼ 27) Mean (SD)
2.68 (0.97) 3.14 (0.89) 2.92 (0.89)
3.74 (0.98) 4.30 (0.82) 3.85 (0.86)
4.30*** 5.33*** 4.18***
2.95 3.08 3.16 3.11 3.11 3.41
3.81 4.37 3.96 3.96 4.00 4.56
3.43*** 5.73*** 3.16** 3.36*** 3.79*** 5.69***
(0.91) (0.98) (1.01) (1.02) (0.94) (0.90)
(1.11) (0.74) (0.98) (0.98) (0.92) (0.64)
Items were scored on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree); SD: standard deviation; **P＜0.01, ***P＜0.001.
t
498
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Table 3 Analysis of the benefits of HACCP implementation from the perspective of managers in hospitals which had implemented HACCP and in hospitals which had not. Items
Operation management Increasing the percentage of patients who order meals Improving coordination between catering managers and operators Improving work efficiency in the kitchen Keeping staff turnover low in the kitchen Increasing the frequency of educational training for staff in the kitchen Increasing the autonomous hygiene management ability of staff in the kitchen Achievement Increasing the patients’ satisfaction with catering Positive impact of HACCP implementation on hospital evaluation by DOH Improving food hygiene
HACCP-implemented
HACCP-unimplemented
(n ¼ 44) Mean (SD)
(n ¼ 27) Mean (SD)
3.27 3.84 3.78 3.49 4.00 4.03
3.07 3.41 3.70 3.26 3.89 4.04
(0.65) (0.50) (0.71) (0.69) (0.58) (0.55)
3.70 (0.70) 4.43 (0.60) 4.35 (0.59)
(0.68) (0.84) (0.72) (0.76) (0.70) (0.59)
t
1.17 2.36* 0.44 1.24 0.67 0.07 0.66 1.29 1.20
3.81 (0.62) 4.22 (0.70) 4.19 (0.48)
Items were scored on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree); SD: standard deviation; *P＜0.05.
both the hospitals which had implemented HACCP and those which had not.
management” and “Positive impact of HACCP implementation on hospital evaluation by DOH” and “Improving food hygiene” under “Achievement.”
3.2. Differences in mean responses to difficulty items Table 2 shows that managers at hospitals which had not implemented HACCP rated nine difficulty items significantly higher than managers at hospitals which had implemented HACCP. For managers at both groups of hospitals, the highest mean responses were given to “Difficulty of getting funds from the hospital” and “Difficulty of allocating funds for facility improvement.” 3.3. Differences in perceived benefits of implementing HACCP As seen in Table 3, there was a significant difference in the responses of managers in hospitals which had implemented HACCP and managers in those which has not for the item “Increasing the coordination between catering managers and operators.” Managers in hospitals which had implemented HACCP had a significant higher mean score than their counterparts for the above item. Managers in both groups of hospitals indicated that the items with the least benefit for their hospitals were “Increasing the percentage of patients who order meals” under “Operation management” and “Increasing the patient’s satisfaction with catering” under “Achievement”. There were three items with mean scores higher than 4.00 in both groups of hospitals. These items were “Increasing the autonomous hygiene management ability of staff in the kitchen” under “Operation
3.4. Differences in satisfaction levels between females and males, and between managers and operators The Table 4 shows that, among respondents in hospitals which had implemented HACCP, the satisfaction levels of female respondents were significantly lower than male’s on five items, i.e. “Control of work flow”, “Control of transportation of raw catering materials and finished meals”, “Improvement in sanitation in the operating environment,” “Improvement in the cleanliness of kitchen facilities” and “Improvement in the overall quality of the whole kitchen.” On the other hand, the satisfaction levels of managers were significantly higher than operators’ on the following five items: “Improvement in the operating flow process,” “Improvement in food hygiene,” “Improvement in the autonomous hygiene management ability of staff,” “Improvement in overall team coordination throughout the kitchen,” and “Overall implementation of the HACCP system.” 3.5. Differences in satisfaction levels among three age groups Table 5 shows the summary of variance in satisfaction level among three staff age groups (i.e. & 30 years, 31e50 years, and S 51 years) at hospitals which had implemented HACCP. The P levels
Table 4 Analysis of the effects of gender and job position differences on staff members’ level of satisfaction with HACCP implementation in hospitals which had implemented HACCP. Items
Environment and sanitation Improvement in kitchen facilities Control of work flow Control of transportation of raw catering materials and finished meals Improvement in sanitation in the operating environment Improvement in the cleanliness of kitchen facilities Effectiveness of pest control in the kitchen Flow and quality Improvement in the operating flow process Improvement in food hygiene Improvement in the autonomous hygiene management ability of staff Results of DOH evaluation The overall satisfaction indicator Improvement in the overall quality of the whole kitchen Improvement in overall team coordination throughout the kitchen Overall implementation of the HACCP system
Gender
Position
Female (n ¼ 84)
Male (n ¼ 21)
Mean (SD)
Mean (SD)
3.90 3.75 3.85 3.98 3.92 3.85
(0.75) (0.77) (0.75) (0.71) (0.71) (0.78)
4.00 4.14 4.19 4.33 4.33 4.10
(0.77) (0.47) (0.51) (0.57) (0.57) (0.70)
3.94 4.05 3.98 3.93
(0.70) (0.66) (0.73) (0.67)
4.19 4.29 4.19 4.19
(0.62) (0.72) (0.60) (0.68)
3.92 (0.77) 3.87 (0.80) 3.95 (0.79)
4.38 (0.59) 4.10 (0.63) 4.24 (0.54)
Manager (n ¼ 44)
Operator (n ¼ 61)
Mean (SD)
Mean (SD)
0.52 2.22* 1.99* 2.13* 2.47* 1.33
4.07 3.77 3.93 4.14 4.09 3.91
(0.76) (0.71) (0.66) (0.63) (0.68) (0.68)
3.82 3.87 3.90 3.98 3.93 3.90
(0.74) (0.76) (0.77) (0.74) (0.73) (0.84)
1.50 1.46 1.25 1.59
4.16 4.25 4.20 4.09
(0.65) (0.62) (0.63) (0.64)
3.87 3.98 3.89 3.90
(0.70) (0.70) (0.73) (0.70)
2.18* 2.03* 2.33* 1.42
2.55* 1.20 1.57
4.16 (0.65) 4.09 (0.64) 4.18 (0.62)
3.90 (0.83) 3.79 (0.84) 3.89 (0.82)
1.72 2.02* 2.02*
t
Items were scored on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree); SD: standard deviation; *P＜0.05.
t
1.68 0.66 0.21 1.11 1.12 0.16
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499
Table 5 Summary of the variance in satisfaction level among three staff age groups at hospitals which had implemented HACCP. Items Environment and sanitation Improvement in kitchen facilities
Control of work flow
Control of transportation of raw catering materials and finished meals
Improvement in sanitation in the operating environment
Improvement in the cleanliness of kitchen facilities
Effectiveness of pest control in the kitchen
Flow and quality Improvement in the operating flow process
Improvement in food hygiene
Improvement in the autonomous hygiene management ability of staff
Results of DOH evaluation
Overall satisfaction indicator Improvement in the overall quality of the whole kitchen
Improvement in overall team coordination throughout the kitchen
Overall implementation of the HACCP system
Source of Variation
Sum of Squares
df
Mean Square
F
Significance
Between Groups Within Groups Total Between Groups Within Groups Total Between Groups Within Groups Total Between Groups Within Groups Total Between Groups Within Groups Total Between Groups Within Groups Total
0.90 58.49 59.39 1.86 55.05 56.91 2.15 52.07 54.23 2.32 48.44 50.76 3.39 48.61 52.00 2.97 58.87 61.85
2 102 104 2 102 104 2 102 104 2 102 104 2 102 104 2 102 104
0.45 0.57
0.78
0.46
0.93 0.54
1.72
0.18
1.08 0.51
2.11
0.13
1.16 0.48
2.44
0.09
1.69 0.48
3.55
0.03*
1.49 0.58
2.58
0.08
Between Groups Within Groups Total Between Groups Within Groups Total Between Groups Within Groups Total Between Groups Within Groups Total
2.29 46.70 48.99 1.96 45.09 47.05 4.98 46.98 51.96 4.03 43.93 47.96
2 102 104 2 102 104 2 102 104 2 102 104
1.14 0.46
2.50
0.09
0.98 0.44
2.22
0.11
2.49 0.46
5.41
0.01*
2.02 0.43
4.68
0.01*
Between Groups Within Groups Total Between Groups Within Groups Total Between Groups Within Groups Total
1.93 59.06 60.99 0.14 55.86 56.00 2.23 56.76 58.99
2 102 104 2 102 104 2 102 104
0.96 0.58
1.66
0.20
0.07 0.55
0.13
0.88
1.11 0.56
2.00
0.14
df: degrees of freedom; *P＜0.05.
of the items “Improvement in the cleanliness of kitchen facilities” (P ¼ 0.03), “Improvement in the autonomous hygiene management ability of staff” (P ¼ 0.01), and “Results of DOH evaluation” (P ¼ 0.01) were below the significant level of 0.05. Scheffé post hoc comparison tests were used to analyze means differences across the three groups. Table 6 shows that the satisfaction levels for three
Table 6 Analysis of variance in satisfaction level for items with significant differences among three staff age groups at hospitals which had implemented HACCP. Items
&30 (1) (n ¼ 12)
31e50 (2) (n ¼ 75)
S51 (3) (n ¼ 18)
Mean (SD)
Mean (SD)
Mean (SD)
Scheffé test
Environment and sanitation Improvement in the 4.33 (0.79) 4.03 (0.68) 3.67 (0.69) (1)＞(3)* cleanliness of kitchen facilities Flow and quality Improvement in the 4.42 (0.79) 4.05 (0.63) 3.61 (0.79) (1)＞(3)* autonomous hygiene management ability of staff Results of DOH evaluation 4.33 (0.79) 4.01 (0.65) 3.61 (0.61) (1)＞(3)* Items were scored on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree); SD: standard deviation; *P＜0.05.
items were significantly higher in the &30 age group than in the S51 age group. These items were “Improvement in the cleanliness of kitchen facilities”, “Improvement in the autonomous hygiene management ability of staff”, and “Results of DOH evaluation”. 4. Discussion This study examined the perceived difficulty and benefits of implementing HACCP among managers of both hospitals which had implemented HACCP and hospitals which had not. The study also investigated the satisfaction levels of staff, according to gender, age and position, in hospitals which had implemented HACCP. Managers of both groups of hospitals considered two items in the questionnaire the most difficult. One was “Getting funds from the hospital” under “Hospital” and the other was “Difficulty of allocating funds for facility improvement” under “Operation procedure and facility.” In addition, the results showed that there were statistically significant differences between managers of both groups of hospitals with regard to the difficulty of implementing HACCP. Among managers of hospitals which had not implemented HACCP, the expected difficulty level of implementation was between 3.74 and 4.56, which showed that the managers of these hospitals had no confidence in receiving support, funds, or human resources from their hospitals when implementing HACCP. On the
500
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other hand, among managers of hospitals which had implemented HACCP, the perceived difficulty levels of obtaining support, funds, and human resources from their hospitals were between 2.68 and 3.41, which indicates that the actual difficulty level of implementing HACCP was lower than the difficulty level expected by managers of hospitals which had not implemented HACCP. According to the requirements of the Department of Health (DOH) in Taiwan, HACCP team members should receive professional training and advice from HACCP experts, and learn how to improve kitchen facilities and food production procedures before and during HACCP implementation. The catering staff at the hospitals in this study which had implemented HACCP had also received related training, experts’ advice, and support from their hospitals before and during implementation, and that this assistance had reduced the difficulty level. The standard operating procedures employed by staff also have practical effects on HACCP system implementation. The results of this study suggest that hospitals need to provide more funds, support, facility, HACCP training, and advice from experts and consultants in order to eliminate their staff’s fear of implementing the system. It is also necessary for hospitals to encourage their staff to coordinate with one another while implementing HACCP. Staff at both groups of hospitals regarded two items in the questionnaire on HACCP implementation to be of little benefit. One was “Increasing the percentage of patients who order meals” under “Operation management,” and the other was “Increasing the patients’ satisfaction with catering” under “Achievement.” This implies that patients’ understanding of the differences in catering hygiene and safety before and after implementation of the HACCP system was insufficient. To help patients feel more comfortable with hospital catering, hospitals need to make greater effort to enhance patients’ understanding of the advantages of implementing HACCP in their hospital kitchens. Once patients have more knowledge about the HACCP system, they are more likely to order meals, and their level of satisfaction with catering hygiene can be expected to increase. Meanwhile, hospitals which have not implemented HACCP can also be encouraged to support and invest funds in implementation. In food service, proper kitchen layout and flow charts of food production are the first two things that need to be considered before HACCP implementation. Kitchen designs and operations that are based on HACCP concepts will facilitate HACCP implementation and applications (Hopkins, 1991; Sun & Ockerman, 2005). In this study, we found that the satisfaction levels of female respondents were significantly lower than males’ on five items. Moir and Jessel (1991) stated that differences in the brain and hormones between males and females cause females to pay more attention to details and cleanliness. Females, moreover, are more sensitive to the nuances of expressions and gestures, and are more adept at judging character. Thus, these five items are probably related to the tendency among females to find fault and be more easily dissatisfied. The results also revealed that operators had lower satisfaction levels than managers, and that older staff members had lower satisfaction levels than younger staff. Operators are more highly engaged in daily catering processes, and older staff members might lack sufficient strength for the required physical activities. Therefore, kitchen layout and operation procedure planning should take the physical strength of older staff members into consideration.
This would help to increase operators’ level of satisfaction with HACCP implementation. Standard operating procedures can also facilitate work that involves both operators and managers. Conflicts between operators and managers that stem from different perceptions of work demands can be avoided or eliminated; thus, they can cooperate with one another better. 5. Conclusion The results of the study show that the possible factors influencing HACCP implementation in hospital kitchens in Taiwan include gender, age, and job position differences as well as differences in the confidence staff members feel in receiving support from staff in other departments and financial support from the hospital itself. Most of the staff members in the nutrition departments of both groups of hospitals agreed that HACCP could increase the autonomous hygiene management ability of kitchen staff, which in turn could raise the quality of food hygiene and have a positive effect on DOH evaluations. Realizing the great benefits of HACCP as demonstrated by the results of this study, we hope that hospitals which have not yet implemented HACCP will be inspired to do so. Acknowledgements The authors gratefully acknowledge the funding provided by Tao-Yuan General Hospital, Department of Health, Executive Yuan, Taiwan, R.O.C., and the assistance of the respondents in this study. References Baird, D. R., Henry, M., Liddell, K. G., Mitchell, C. M., & Sneddon, J. G. (2001). Postoperative endophthalmitis: the application of hazard analysis critical control points (HACCP) to an infection control problem. Journal of Hospital Infection, 49, 14e22. Ehiri, J. E., Morris, G. P., & McEwen, J. (1995). Implementation of HACCP in food businesses: the way ahead. Food Control, 6(6), 341e345. Goldmann, D., & Kaushal, R. (2002). Time to tackle the tough issues in patient safety. Pediatrics, 110, 823e826. Hopkins, R. E. (1991). HACCP by the numbers. Food Management, 26(9), 74. Moir, A., & Jessel, D. (1991). Brain sex: The real difference between men and women. London: Mandarin. National Advisory Committee on Microbiological Criteria for Foods (NACMCF). (1997). Hazard analysis and critical control point. Principles and application guidelines. Adopted August 14. 1997. Richards, J., Parr, E., & Riseborough, P. (1993). Hospital food hygiene: the application of hazard analysis critical control points to conventional hospital catering. Journal of Hospital Infection, 24, 273e282. Sun, Y. M., & Ockerman, H. W. (2005). A review of the needs and current applications of hazard analysis and critical control point (HACCP) system in foodservice areas. Food Control, 16(4), 325e332. Ten Eyck, T. A., Thede, D., Bode, G., & Bourquin, L. (2006). Is HACCP nothing? a disjoint constitution between inspectors, processors, and consumers and the cider industry in Michigan. Agriculture and Human Values, 23, 205e214. Walker, E., Pritchard, C., & Forsythe, S. (2003). Hazard analysis critical control point and prerequisite program implementation in small and medium size food businesses. Food Control, 14(3), 169e174.
Kuei-Mei Shih, MBA, RD, Director, Department of Nutrition, Tao-Yuan General Hospital, Department of Health, Taiwan, R.O.C.
Wei-Kang Wang, PhD, Associate Professor, Chair, College of Management, Yuan Ze University, Taiwan, R.O.C.