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Position of the American dietetic association: Management of health care food and nutrition services
ADA REPORTS
Position TheAmerican Dietetic Association: Management of health care food and nutrition services
ffective management of resources is critical in the dynamic environment of the health care industry because the costs of medical technology, innovations, and sophisticated health care procedures consume an increasing portion of the gross national product. It is apparent that rising health care costs are affecting the competitiveness of American industry. Consumers, payers, legislators, and health care providers are focused on the need for health care reform. Judicious allocation of resources and maintenance of quality care are challenges that face administrators of health care facilities and managers of services within these facilities (1). The expense budget of the health care food and nutrition services department may be a small percentage of the total facility budget; however, the cost of resources necessary to support the customers of the department may equate to millions of dollars and cannot be considered insignificant. The products and services provided by the department include foodservice in the form of meals and nourishments, as well as nutrition services in the form of screening, assessment, counseling, and consults with members of the medical team. With few exceptions, the customers of the department include not only patients and visitors but also staff who provide patient medical services. The department emphasis is typically on medical nutrition care of patients. However, food is an integral part of patient nutrition care and the quality of foodservice affects not only patient satisfaction but also employee morale. In most health care food and nutrition services departments, the foodservice component comprises the largest percentage of the budget and may be as high as 85% of expenses allocated for patient care. The director of food and nutrition services has a significant role in the success of the health care facility through judicious decisions regarding resource allocation and use that allow for the provision of effective medical nutrition services and foodservices. These decisions are best made by a person who is competent in management, food science and safety, foodservice systems, and nutrition in health and disease. Although competence in all of these areas is essential, competency in management is primary to the director's ability to coordinate all facets of a successful system. A dietetics professional who has demonstrated competence in management may be the most cost-effective director of these departments because of his or her academic background in nutrition and food (2-6). 914 / AUGUST 1993 VOLUME 93 NUMBER 8
POSITION STATEMENT It is the position of TheAmerican DieteticAssociationthat the effective management of health care food and nutrition services is best accomplished by a dietetics professionalwith demonstrated competence in management in addition to knowledge and skills infood science and safety, foodservice systems, and nutrition in health and disease. MANAGER ROLE The fundamental role of the manager of any food and nutrition services department is to manage the manufacturing model effectively and efficiently (inputs: conversion: outputs) in order to provide required products and services at the level of quality expected by all customers. This must be accomplished within the financial goals of the organization, which may include generation of profit. To do this, the successful manager must be able to analyze the production and service processes quantitatively through the application of appropriate production/operations management techniques. Implementation of W. Edwards Deming's theories of continuous quality improvement enables the manager to focus both on customer satisfaction and process efficiency (7-10). In health care, the emphasis on customer satisfaction introduces an element of hospitality management, which has traditionally been found in hotel and restaurant facilities. However, in contemporary health care food and nutrition services departments, the manager must be able to please the patient by implementing patient services (such as room service) that have not previously been promoted in health care facilities. CURRENT MANAGEMENT ISSUES Human Resources The changing demographics of the labor pool increases the complexity of designing systems to deliver appropriate services. The traditional labor pool for foodservice workers is decreasing in size and increasing in diversity of cultural backgrounds. The decrease in the availability of foodservice employees is occurring at a time when the demand for quality services is increasing. Cultural diversity among employees can enrich a workplace. However, management of a culturally diverse work force is complicated because of differences in language; education levels; work ethics; and values and perceptions regarding sanitation,
supervision, and service quality. Also, societal issues such as substance abuse and the need for child and elder care have a large effect on the labor pool and the quality of effort produced in the workplace. Labor resources may compose 60% to 70% of the departmental budget; therefore, competence in human resource management is key to operational success. Food Science and Safety The process of producing and serving a wide variety of products - including nutrition-modified foods and meals - to patients, staff, and visitors is complicated. This complexity increases with the size and diversity of the facility. Knowledge of the principles of food science and food safety are basic to success. The growing number of patients and other customers with compromised immune systems because of disease, age, or treatment technologies heightens the importance of competence in food safety. Newer production and service technologies, such as cook-chill or sous-vide, may offer some operational advantages; however, successful application is dependent on thorough understanding of how these processes affect; the physical and chemical properties of foods as well as microbial growth through all stages of processing, storage, and service. Government Regulations Knowledge of governmental regulations is vital for the manager of the health care food and nutrition services department. Decisions pertaining to such things as the nutritional value of the menus, meal service times, qualifications of employees, safety of food supply and work environment, waste management, and patient length of stay are influenced or dictated by the myriad of local, state, and federal legislation as well as by regulatory and accreditation agencies. Legislation and regulations govern all aspects of the health care industry and establish the policies, procedures, standards, and guidelines by which health care food and nutrition services are managed. Regulations in other industries, such as food manufacturing, agriculture, and transportation, also directly affect all foodservice operations including health care. Medical Nutrition Care Changing demographics of the patient population, specifically criticality and the number of elderly, increases the demand for sophisticated and complex medical nutrition services. Very important functions of the manager of food and nutrition services are to define medical nutrition care services that are appropriate for the specific client population and to match skill level of employee to services required. For example, in a large tertiary care facility, the acuity level of patients is high. As a result, there is an increased need for sophisticated nutrition services for patients on alternative feeding modalities such as enteral and parenteral nutrition. Advanced level practice registered dietitians with specialized training and experience in nutrition support would be a vital and perhaps majority part of the clinical staffin this facility (11,12). In a health care facility where patient acuity is lower, the ratio of professional staff to patients, as well as the type of expertise required of the dietetics professional staff, would be quite different. The ability of the manager to ensure that appropriate clinical services are provided continues to be increasingly important. DIETETICS PRACTICE IN HEALTH CARE The practice of dietetics is evolving. The paradigm that dietitians should be all things to all people is not congruent with the reality of competitive and competent dietetics practice in complex health care facilities. The continuous evolution of concepts and theories in nutrition science, food science, management science, and foodservice systems makes it unlikely that a person can continue to build her or his competence in all areas of practice
beyond the entry level. The successful director of complex health care food and nutrition services departments must be the coordinator of a team of dietetics professionals, each of whom contributes expertise in a specific facet of dietetics practice that is relevant to the department mission. The director must be able to access this expertise and communicate effectively in order to contribute to both the facility health care and administrative teams. In smaller health care facilities, the medical nutrition services required for quality patient care may be less complex than the challenges of managing finite resources in a cost-containment environment. In these facilities, the director, who may be the only dietetics professional on staff, may need higher-level competence in managing the department systems rather than providing medical nutrition care. The management of health care food and nutrition services is best accomplished by a professional who is knowledgeable in identifying services required by patients and competent in managing resources and processes necessary to provide the services. A dietetics professional who has demonstrated competence in management may be the best director of these departments because of her or his academic background in nutrition and food. However, academic preparation in dietetics/food and nutrition without management competence is not sufficient for successful direction of health care food and nutrition services. References 1. The Evolving Health Care Enzironnwnet: Implicatiosfor Food Service Adranistrators.Chicago, Il: American Hospital Association; 1987. 2. Dowling RA, Lafferty LJ, McCurley MS. Credentials and skills required for hospital food and nutrition department directors. J A m DietAssoc. 1990; 90:1535-1540. 3. Dowling R, Lafferty LJ, Norton C.The management component of our profession. JAm Diet Assoc. 1990;90: 1065-1066. 4. Yates SC, Shanklin CW, Gorman MA. Competencies of foodservice directors/managers required in health care operations. Am Diet Assoc. 1987;87:]1636-1640. 1643. 5. Kane h, Estes C,Colton D,Eltoft C.Role )eliteotiooljbrRegistered DietitiansaidE.t y-Level Dietetic Technicil0s. Chicago, III: American Dietetic Association; 1990. 6. Boudreaux LJ, Shanklin CW, JohnsonJT. Factors infltuenciing success of dietitians employed in business and industry. JA m Diet Assoc. 1991; 91: 1227-1232. 7. Scholtes PR. Th.e Team Handbook: How to U.se T trzs to Improve Quality. Madison, Wis: Joiner Associates; 1988. 8. Schlesinger LA, Heskett JL. The service-driven service company. finla rrd Bus Rev. 1991;69(5): 71-81. 9. Roach SS. Services under siege: the restrulc(uringintperative. Ho rc/ard Bus Rev!. 1991;69(5): 82-91. 10. Deming WE. Out of the Crisis. Cambridge, Mass: Massachusetts Institute of Technology, Center for Advanced Engineering Study; 1986. 11. Maillet JO. Are clinical dietetic specialties in our future? Possible scenarios and health care trends. Top Clien Nutr. 1991:6(2): 24-:32. 12. Strasen L. Redesigning hospitals around patients and technology. NIrs Eccon. 1991;9(4): 233-238. * ADA Position adopted by the House of Delegates on October 18, 1992. * Recognition is given to the following for their contributions: Authors: Linda J. Lafferty, PhD, RD; Rebecca A. Dowling, PhD, RD Revi(ewers: James F. Hailing, MS, RD; Marilyn Laskowski-Sachnoff, MA, RD; Donna Smith Becker, MS, RD; Ann M. Messersmith, PhD, RD; ADA Members with Management Responsibilities in Health Care Delivery Systems dietetic practice group; Consultant Dietitians in Heallt h Care Facilities dietetic practice group .IO IRNAL OF THE AMERICAN DIETETIC ASSOCIATION / 915
Position TheAmerican Dietetic Association: Management of health care food and nutrition services
ffective management of resources is critical in the dynamic environment of the health care industry because the costs of medical technology, innovations, and sophisticated health care procedures consume an increasing portion of the gross national product. It is apparent that rising health care costs are affecting the competitiveness of American industry. Consumers, payers, legislators, and health care providers are focused on the need for health care reform. Judicious allocation of resources and maintenance of quality care are challenges that face administrators of health care facilities and managers of services within these facilities (1). The expense budget of the health care food and nutrition services department may be a small percentage of the total facility budget; however, the cost of resources necessary to support the customers of the department may equate to millions of dollars and cannot be considered insignificant. The products and services provided by the department include foodservice in the form of meals and nourishments, as well as nutrition services in the form of screening, assessment, counseling, and consults with members of the medical team. With few exceptions, the customers of the department include not only patients and visitors but also staff who provide patient medical services. The department emphasis is typically on medical nutrition care of patients. However, food is an integral part of patient nutrition care and the quality of foodservice affects not only patient satisfaction but also employee morale. In most health care food and nutrition services departments, the foodservice component comprises the largest percentage of the budget and may be as high as 85% of expenses allocated for patient care. The director of food and nutrition services has a significant role in the success of the health care facility through judicious decisions regarding resource allocation and use that allow for the provision of effective medical nutrition services and foodservices. These decisions are best made by a person who is competent in management, food science and safety, foodservice systems, and nutrition in health and disease. Although competence in all of these areas is essential, competency in management is primary to the director's ability to coordinate all facets of a successful system. A dietetics professional who has demonstrated competence in management may be the most cost-effective director of these departments because of his or her academic background in nutrition and food (2-6). 914 / AUGUST 1993 VOLUME 93 NUMBER 8
POSITION STATEMENT It is the position of TheAmerican DieteticAssociationthat the effective management of health care food and nutrition services is best accomplished by a dietetics professionalwith demonstrated competence in management in addition to knowledge and skills infood science and safety, foodservice systems, and nutrition in health and disease. MANAGER ROLE The fundamental role of the manager of any food and nutrition services department is to manage the manufacturing model effectively and efficiently (inputs: conversion: outputs) in order to provide required products and services at the level of quality expected by all customers. This must be accomplished within the financial goals of the organization, which may include generation of profit. To do this, the successful manager must be able to analyze the production and service processes quantitatively through the application of appropriate production/operations management techniques. Implementation of W. Edwards Deming's theories of continuous quality improvement enables the manager to focus both on customer satisfaction and process efficiency (7-10). In health care, the emphasis on customer satisfaction introduces an element of hospitality management, which has traditionally been found in hotel and restaurant facilities. However, in contemporary health care food and nutrition services departments, the manager must be able to please the patient by implementing patient services (such as room service) that have not previously been promoted in health care facilities. CURRENT MANAGEMENT ISSUES Human Resources The changing demographics of the labor pool increases the complexity of designing systems to deliver appropriate services. The traditional labor pool for foodservice workers is decreasing in size and increasing in diversity of cultural backgrounds. The decrease in the availability of foodservice employees is occurring at a time when the demand for quality services is increasing. Cultural diversity among employees can enrich a workplace. However, management of a culturally diverse work force is complicated because of differences in language; education levels; work ethics; and values and perceptions regarding sanitation,
supervision, and service quality. Also, societal issues such as substance abuse and the need for child and elder care have a large effect on the labor pool and the quality of effort produced in the workplace. Labor resources may compose 60% to 70% of the departmental budget; therefore, competence in human resource management is key to operational success. Food Science and Safety The process of producing and serving a wide variety of products - including nutrition-modified foods and meals - to patients, staff, and visitors is complicated. This complexity increases with the size and diversity of the facility. Knowledge of the principles of food science and food safety are basic to success. The growing number of patients and other customers with compromised immune systems because of disease, age, or treatment technologies heightens the importance of competence in food safety. Newer production and service technologies, such as cook-chill or sous-vide, may offer some operational advantages; however, successful application is dependent on thorough understanding of how these processes affect; the physical and chemical properties of foods as well as microbial growth through all stages of processing, storage, and service. Government Regulations Knowledge of governmental regulations is vital for the manager of the health care food and nutrition services department. Decisions pertaining to such things as the nutritional value of the menus, meal service times, qualifications of employees, safety of food supply and work environment, waste management, and patient length of stay are influenced or dictated by the myriad of local, state, and federal legislation as well as by regulatory and accreditation agencies. Legislation and regulations govern all aspects of the health care industry and establish the policies, procedures, standards, and guidelines by which health care food and nutrition services are managed. Regulations in other industries, such as food manufacturing, agriculture, and transportation, also directly affect all foodservice operations including health care. Medical Nutrition Care Changing demographics of the patient population, specifically criticality and the number of elderly, increases the demand for sophisticated and complex medical nutrition services. Very important functions of the manager of food and nutrition services are to define medical nutrition care services that are appropriate for the specific client population and to match skill level of employee to services required. For example, in a large tertiary care facility, the acuity level of patients is high. As a result, there is an increased need for sophisticated nutrition services for patients on alternative feeding modalities such as enteral and parenteral nutrition. Advanced level practice registered dietitians with specialized training and experience in nutrition support would be a vital and perhaps majority part of the clinical staffin this facility (11,12). In a health care facility where patient acuity is lower, the ratio of professional staff to patients, as well as the type of expertise required of the dietetics professional staff, would be quite different. The ability of the manager to ensure that appropriate clinical services are provided continues to be increasingly important. DIETETICS PRACTICE IN HEALTH CARE The practice of dietetics is evolving. The paradigm that dietitians should be all things to all people is not congruent with the reality of competitive and competent dietetics practice in complex health care facilities. The continuous evolution of concepts and theories in nutrition science, food science, management science, and foodservice systems makes it unlikely that a person can continue to build her or his competence in all areas of practice
beyond the entry level. The successful director of complex health care food and nutrition services departments must be the coordinator of a team of dietetics professionals, each of whom contributes expertise in a specific facet of dietetics practice that is relevant to the department mission. The director must be able to access this expertise and communicate effectively in order to contribute to both the facility health care and administrative teams. In smaller health care facilities, the medical nutrition services required for quality patient care may be less complex than the challenges of managing finite resources in a cost-containment environment. In these facilities, the director, who may be the only dietetics professional on staff, may need higher-level competence in managing the department systems rather than providing medical nutrition care. The management of health care food and nutrition services is best accomplished by a professional who is knowledgeable in identifying services required by patients and competent in managing resources and processes necessary to provide the services. A dietetics professional who has demonstrated competence in management may be the best director of these departments because of her or his academic background in nutrition and food. However, academic preparation in dietetics/food and nutrition without management competence is not sufficient for successful direction of health care food and nutrition services. References 1. The Evolving Health Care Enzironnwnet: Implicatiosfor Food Service Adranistrators.Chicago, Il: American Hospital Association; 1987. 2. Dowling RA, Lafferty LJ, McCurley MS. Credentials and skills required for hospital food and nutrition department directors. J A m DietAssoc. 1990; 90:1535-1540. 3. Dowling R, Lafferty LJ, Norton C.The management component of our profession. JAm Diet Assoc. 1990;90: 1065-1066. 4. Yates SC, Shanklin CW, Gorman MA. Competencies of foodservice directors/managers required in health care operations. Am Diet Assoc. 1987;87:]1636-1640. 1643. 5. Kane h, Estes C,Colton D,Eltoft C.Role )eliteotiooljbrRegistered DietitiansaidE.t y-Level Dietetic Technicil0s. Chicago, III: American Dietetic Association; 1990. 6. Boudreaux LJ, Shanklin CW, JohnsonJT. Factors infltuenciing success of dietitians employed in business and industry. JA m Diet Assoc. 1991; 91: 1227-1232. 7. Scholtes PR. Th.e Team Handbook: How to U.se T trzs to Improve Quality. Madison, Wis: Joiner Associates; 1988. 8. Schlesinger LA, Heskett JL. The service-driven service company. finla rrd Bus Rev. 1991;69(5): 71-81. 9. Roach SS. Services under siege: the restrulc(uringintperative. Ho rc/ard Bus Rev!. 1991;69(5): 82-91. 10. Deming WE. Out of the Crisis. Cambridge, Mass: Massachusetts Institute of Technology, Center for Advanced Engineering Study; 1986. 11. Maillet JO. Are clinical dietetic specialties in our future? Possible scenarios and health care trends. Top Clien Nutr. 1991:6(2): 24-:32. 12. Strasen L. Redesigning hospitals around patients and technology. NIrs Eccon. 1991;9(4): 233-238. * ADA Position adopted by the House of Delegates on October 18, 1992. * Recognition is given to the following for their contributions: Authors: Linda J. Lafferty, PhD, RD; Rebecca A. Dowling, PhD, RD Revi(ewers: James F. Hailing, MS, RD; Marilyn Laskowski-Sachnoff, MA, RD; Donna Smith Becker, MS, RD; Ann M. Messersmith, PhD, RD; ADA Members with Management Responsibilities in Health Care Delivery Systems dietetic practice group; Consultant Dietitians in Heallt h Care Facilities dietetic practice group .IO IRNAL OF THE AMERICAN DIETETIC ASSOCIATION / 915