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DEPARTMENT OF HEALTH REPUBLIC OF THE PHILIPPINES

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IjPSPITAL DIETARY SERVICE MANAGEMENT MANUAL

Department of Health

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Department of Health Republic of the Philippines

The second edition ofthe Hospital Dietary Service Management Manual is a publication of the Health Finance Development Project of the Department of Health. This publication was made possible through support provided by the U.S. Agency for International Development (A.LD.), under the terms of Contract No. 49Z-Q446-GOQ-ZIl4-00. The opinions expressed herein are those of the author(s) and do not necessarily reflect the views ofthe U.S. Agency for International Development.

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TABLE OF CONTENTS AUTHORIZATION MESSAGE FOREWORD PREFACE ACKNOWLEDGMENTS LIST OF FORMS LIST OF ILLUSTRATIONS LIST OF TABLES LIST OF ABBREVIATIONS Page No.

Chapter L

II.

III.

DIETARY SERVICE IN THE DEPARTMENT OF HEALTH Introduction Historical Background

1 1 2

HOSPITAL DIETARY SERVICE Philosophy Objectives Functions Standards

5 5 5 6 6

DIETARY HUMAN RESOURCE MANAGEMENT Hospital Employment Practices Recruitment Hiring Termination Functions and Management Skill of the Nutritionist-Dietitian Training and Development of Dietary Personnel Organization and Staffing Pattern of the Different Health Care Levels Guidelines in the Staffing Pattern Job Descriptions of Staff and Personnel Nutritionist-Dietitian N Nutritionist-Dietitian III (Administrative) Nutritionist-Dietitian II (Clinical) Nutritionist-Dietitian II (Teaching-Training) Nutritionist-Dietitian II (Education and Research) Nutritionist-Dietitian I Food Service Supervisor Cook II Food Service Worker/Utility Worker Clerk I (Dietary Clerk-Typist) Dietary Store Aide

19 19 19 20 21 23 25 28 29 32 32 33 35 37 38 39 40 41 42 43 44

Page No.

Chapter N.

V.

VI.

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ADMINISTRATION AND MANAGEMENT Budgeting Cost Control Menu Planning Purchasing , Receiving Storing Issuing Food Production Meal Service Sanitation, Safety, and Maintenance Pest/Vermin Control Energy Conservation Effective Communication Facility and Equipment for the Dietary Service Health Care Level Requirement for Kitchen Planning CLINICAL, EDUCATIONAL, RESEARCH, AND SPECIALIZED FUNCTIONS OF THE DIETARY SERVICE Clinical and Educational Functions Charting and Ward Rounds Diet Counselling Nutrition Clinic Malward or Nutreward Research Function Research Unit Metabolic Balance Studies Planning the Metabolic Kitchen Unit Specialized Function Disaster Feeding QUALITY ASSURANCE FOR THE DIETARY SERVICE Quality Assurance The Importance of Quality Assurance for Dietary Service Components of the Quality Assurance Program Stages in Program Development Monitoring and Evaluation Process for Writing Indicators Data Collection Frames Sampling Techniques Computing Results Quality Assurance Reviewers Data Analysis and Summary

45 46 46 51 52 54 55 58 58 62 66 71 72 72

74 74

81 81 81 85 87 88 88 90 95 95 97 97 99 99 100 108 110 119 122 129 129 130 133 133

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APPENDICES Code of Ethics for Dietetic Profession General Conditions on Bidding of Foodstuff Specifications of Common Foodstuff Purchased Food Sanitation Checklist Presidential Decreee 856, Sanitaria in Food Service Commended Classification by Weight of Filipino Children Equipment Guide for a Conventional Hospital Dietetic Service Nutrition Clinic Forms DIETARY SERVICE FORi'vlS REFERENCES

Republic of the Philippines . Department of Health OFFICE OF THE SECRETARY

$AN LAZARO OOMPOUND RIZAL AVENUE, $TA.CRUZ MANIlA, PHIUPPINES

TEL NO. 711-6ll-8O

AUTHORIZATION January 6, 1994

In accordance with the authority vested on the Secretary of Health, I hereby declare the policies, regulations, and instructions in this Hospital Dietary Service Management Manual shall govern the organization, management, and activities of the Dietary Service in government hospitals until modified by order of the Department of Health or by law.

Republic of the Phllipplnee

DEPARTMENT OFHEALTH

OFFICE FOR HEALTH FACILITIES, STANDARDS AND REGULATION Sen tszare Cmpd., Sta.Cruz Manila Tol No. 711·95-72, FaxNo. 711-95-09

MESSAGE

January 6, 1994

The Hospital Operations and Management Service of the Department of Health has been tasked to develop operations manuals specifically for DOH hospitals that may be of use to other public and private hospitals. These manuals would serve as standard reference materials for DOH hospitals to aid administrators and practitioners in.following standard operating procedures in the management and practice of the different hospital services or units. Likewise, it may also serve as a reference guide for other public and private hospitals-. These manuals provide guidelines in the performance of duties and 'responsibilities of hospital personnel as well as outline steps necessary in the effective and efficient operation of each unit or service. The procedures in these manuals will assist them in the process necessary to operate an effective and efficient hospital. This is an attempt to develop standards and achieve uniformity of procedures in different hospitals.

~ANAGAS,

JU M.D. Under ecretary on Health Facilities, Standards and Regulations

Republic of the Philippines Department of Health OFFICE OF THE SECRETARY

SANLAZARO COMPOUND RIZALAVENUE, STA. CRUZ MANILA, PHIUPPINES TEL NO. 711-6().8()

FOREWORD Total Health care delivery for all is the major thrust of the Department of Health. Being a principal component and an important factor in the attainment of health care, the Dietary Service have sought to find new and better ways to improve the nutritional well-being of its patients. This manual was developed to set the directions needed for the effective management of the Dietary Service. It is an invaluable reference for Nutritionists/Dietitians and all those involved in the Dietary Service. Although not all the guidelines stated in this manual may be suitable for use in all types of Dietary Service set-ups, Dietitians could derive useful guidelines and specific directions which would aid them in evaluating existing operations and bring about constructive changes and improvements.

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MA. MARGARITA M GALON, MD., MHA Director III Hospital Operations and Management Service

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• PREFACE Communication is vital in all.human undertakings, but it is especially so in areas concerned with the restoration and maintenance of well-being such as health services. Because human life is the center of all activities in hospitals and other health institutions, the problems in the communication channels within such institutions must, at all costs, be resolved. One of the most effective means of expediting communication is, undoubtedly, to establish policies that cover both routine operations andtheirfrequent fluctuations, and to make such policies available to those concerned. This manual is expected to serve as a means of educating and informing the hospital community about the Dietary Service and therefore, open avenues of communications among the dietary service staff, physicians, nurses, patients, aswell as other hospital staff. Over and above such goals, this manual aims to improve the dietary care of hospital patients for the attainment of quality patient care through effective management and administration And since communication is a principal tool towards thisgoal, thismanual was prepared with the objective of giving guidance to the Dietary personnel in improving theirdaily performance. Theguidelines in thismanual should not be regarded as rigid standards. Their application may vary throughout the country, and it is the prerogative of each Dietary Department to either accept or modify the guidelines according to their specific needs. However, the ideas presented shouldhelp promote the examination of existing routines with the hopethat constructive changes and improvements will be put into effect The purpose of this manual is to provide a definition of requirements for the various health care facilities and services. When the development of a unit isunder consideration, the guidelines assist planners and government health authorities in determining theneed forsuch a unit,and in assessing the potential impact of a new unitonexistingandprojected services, bothatthelocal andregionallevds. Deficiencies in existing services can be identified, and in some cases, these can be corrected without the need to develop a new unit Whena unit already exists in a hospital, the guidelines will help in identifying problem areas matedto administration, personnel, equipment, and physical facilities. They will help determine necessary remedial actions and set priorities for corrective measures on the basis of clinical needs, budget realities, and the degree to which a deficiency in physical facilities impedes the function of the unit Every health institution, therefore, is enjoined to avail of this manual for their reference and guidance.

T. FELICIANO etary Adviser Hospital Operations and Management Service

ACKNOWLEDGMENTS The Committee on Revision of the Department of Health Hospital Dietary Service Management Manual is deeply grateful to all those who have contributed in the completion of this task, and acknowledges, with sincere thanks, the wholehearted assistance. of the following: To Dr. Margarita M. Galon, Director III, Hospital Operations and Management Service, for her support and encouragement in the preparation of this manual; To Dr. Melchor R. Lucas, Jr., Medical Officer VII, Chief of the Division and all other Advisers of the Support Division, Hospital Operations and Management Service, for their constructive criticisms and suggestions; To the Chiefs-of-Hospital, for allowing the Nutritionist- Dietitian to attend the Consultative Meetings held during the preparation of this manual; To the following persons who have contributed to the preparation of the original Hospital DietaryService Management Manual(1986): Ms. Rose C. Cavinoformer Dietetic Management Adviser, Bureau of Medical Services, Ministry of Health, and chairman of the Committee on manual preparation, together with Committee members, namely, Ms. Josefina U. Ramos, Dietitian III, and Ms. Erlinda Cordero, Dietitian, both of Rizal Medical Center; Ms. Leyte Madamba, Dietitian Iv, Dr. Jose N. Rodriguez Memorial Hospital; Ms. Cristina N. Josef, Dietitian II, Eulogio Rodriguez Sr. Memorial Hospital; and myself, Chief Dietitian, Hospital ng Maynila; and To Ms. Fenelia Mylene M. Hamo and Ms. Alma Q Sorra, Hospital Operations and Management Service, for printing the text of this manual. Finally, no expression of appreciation would adequately suffice in acknowledging the unstinted support of everyone who had contributed in one way or another in the completion of this manual.

LIST OF FORMS Statement of Daily Market Purchases Supplies Ledger Card Dietary Service Forms NO.TITLE

lA. lB.

Performance Targets Worksheet Civil Service Commission Performance Appraisal Report

2.

Employees Schedule for the Month

3. 4A. 4B. 5.

Dietary Order Slip for Bidder Items Open Market Purchase Slip Dietary Service Daily Admissions - Discharges Sheet Daily Delivery Record Book

6.

Supplies Requisition and Issue Form

7.

Dietary Service Perpetual Inventory

8.

Regular Weekly Menu

9.

Therapeutic Weekly Menu

10. 1lA.

Standardized Recipes Production Record Sheet - Regular Meals

IlB.

Production Record Sheet - Therapeutic Diets

1lC.

Cook's Copy - Patient Service Cook's Copy - Cafeteria Service

IlD.

12. 13. 14A. 14B. 15. 16A. 16B. 17.

Daily Patient Meal Census Diet List Special Meal Request Form Special Meal Record Form Dietary Service Admission Sheet Problem List Problem Oriented Progress Notes Diet History Form

UST OF ILLUSTRATIONS NO.

ILLUSTRATIONS

PAGE NO.

Quality Assurance Related to Departmental Functions and Activities

101

2.

Stages in Developing a Quality Assurance Program

111

3.

Sample Dietary Policy and Procedures for Quality Assurance

112

Annual Schedule for Quality Assurance Activities in Dietetic Service (In-patient)

113

Annual Schedule for Quality Assurance Activities in Dietetic Service (Out-patient)

Il5

5.

Sample Data Collection Form

116

6. 7. 8.

Checklist for Quality Assurance Documentation

117

I.

4(a). 4(b).

9.

10.

Worksheet for Writing Quality Assurance Indicators 122 Development of Indicators from Department Goals and Functions

123

Checklist for Monitoring and Evaluation Methods

128

Checklist for Judging Criteria and Method

131

LIST OF TABLES NO.

TABLE

PAGE NO.

I.

Hospital Standard Requirements for Personnel

31

2.

Dietary Service Staffing Pattern

31

3.

Percentage Allowance for Kitchen Areas

76

LIST OF ABBREVIATIONS AO BF COH DOH FIFO

FNRI FSW FTE HMTDS HOMS ]CAH

MBO MF NPO

PD PGH POMR PRC QAP RA RIV

SOAP TB

Administrative Officer Breast Feeding Chief of Hospital Department of Health First-In-First-Out Food and Nutrition Research Institute Food Service Warker Full Time Equivalent Health Management Training Development Service Hospital Operations and Management Services Joint Commission on Accreditation of Hospitals Management by Objective Milk Formula Nil Per Orem Presidential Decree Philippine General Hospital Problem Oriented Medical Record Professional Regulatory Commission Quality Assurance Program Republic Act Requisition Issue Voucher Subjective, Objective, Assessment, Plan Statement , Tuberculosis

DIETARY SERVICE IN THE DEPARTMENT OF HEALTH INTRODUCTION All modes of health care have lately been a major concern of the Philippine government. Recent initiatives aim at more effective means of maintaining good health, its restoration and rehabilitation where it has deteriorated or has been neglected. Dietetics is a principal component of health care and an important factor in the attainment ·of this ultimate goal. While efficiency is of utmost importance in attaining this end, the provision for individual needs is of even greater concern. Dietetics is a sensitive aspect of health care, it is a branch of hygiene which deals with diet and dieting among individuals and groups who are either healthy or ill. The proper application of its principles is crucial to the success of health care delivery and the maintenance of good health. According to the Hospital Licensure Act (RA 4226) of the Bureau of Medical Service (1971), the Dietary Service ranks as one of the six major services of the hospital and is an integral part of the total patient care. It is headed by a professionally qualified Nutritionist-Dietitian who serves as the administrator of the service. In as much as food service involves approximately 10-14% of the total hospital expenditures, this is a critical area, and a hospital which cannot afford to employ a dietitian is under a distinct handicap. Based on the survey conducted by the committee involved in the preparation of the Hospital Dietary Service Management Manual, ninetyfive percent (95%) of the hospital Dietary Service under the Department of Health (DOH), both in Metro Manila and in the provinces, does not have a formal manual as a guide in the management of the said service. A greater percentage has informal written policies and procedures that are, however, not up-to-date, Results of the survey further indicates that most-of these Dietary Services are not properly equipped and/or managed. In 'view of this existing situation, the committee was prompted to develop this manual.

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Hospital Dietary Service Management Manual

This manual was developed to set the directions needed for the effective management of the Dietary Service in a general hospital including Secondary District, Tertiary Provincial, Tertiary Regional and Tertiary Medical Center. All dietetic services need an operational guide or manual containing written information on the efficient and effective management of the units and to, provide ready reference in dealing with future problems. This manual also serves as a communication tool within the service and with other departments. Not all of the guidelines stated in this manual will be suitable for use in all types of dietary service set-ups. However, the ideas presented should help the Nutritionist- Dietitian to evaluate existing operations with the hope that constructive changes and improvements will be made.

HISTORICAL BACKGROUND Dietetics is the combined science and art of planning, preparing, and serving meals to individuals or groups according to the principles of nutrition and management, taking into consideration economic and psychological factors, But dietetics has not always been a science and an art in itself. Despite its early practice as a vital part of patient care, it was not recognized as a separate discipline. Thus, in the caring and feeding of the sick, the nurse was also a dietitian. Filipino nurses in the early 1900's underwent rigid training in the varied aspects of dietetics with Ainerican mentors. But soon, dietetics became closely associated with food preparation, particularly cooking, that it earned a misconception which took a long time to correct. Shortly after World War II, both nursing and dietetics grew more complex. Recent knowledge on nutrition and the development of modern methods of food service management soon required that dietetics be considered as a new area of specialization. The limited dietetics training of nurses was no longer adequate to meet the increasing demands in the field. In 1946, the University of the Philippines accepted its first five students for a degree of Bachelor of Science in Home Economics, major in Food and Nutrition. Nurses. who were in responsible positions in the Dietary Service of the hospitals were also given opportunities for specialized training. In 1950, the first nutrition clinic was established by the Institute of Nutrition (now Foods and Nutrition Research Institute) with the first Filipino professionally trained in dietetics as the dietitian. In 1952, when the Philippine General Hospital (PGH) was reorganized, the Dietary Service became a separate department and other hospitals followed. That same year, the DOH established under its Bureau of Medical Services, the Office of the Dietetic Management Adviser. Its principal role is to set, monitor, evaluate, and recommend dietary service standards, policies, and guidelines for implementation in hospitals and medical centers licensed by the Department all over the country. Its other advisory duties include consultative services to hospital heads and dietitians.on training needs, programming services for training requirements and consultation needs for kitchen layout and equipment and personnel selection.

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Hospital Dietary Service Management Manual

By 1955, it became necessary to regulate the practice of dietetics in the Philippines. Moves were initiated by the newly formed Dietetic Association of the Philippines to have a law enacted for this purpose. However, it was not until 1960 that the' Dietetics Law otherwise known as RA 2674 was passed by. Congress. Briefly, among other things, law requires every government or private hospital, with more than seventy-five (75) but less than one hundred fifty (150) bed capacity shall employ at least one dietitian; those with more than one hundred fifty (150) but less than three hundred (300) bed capacify shall employ at least one dietitian and two assistant dietitians; and those with more than three hundred (300) bed capacity shall employ two dietitians and not less than four assistant dietitians. This Law was superseded by Presidential Decree 1286 in 1978, specifically Section 27, which states that: "All hospitals whether government or private with twenty five (25)to seventy five (75) bed capacity shall employ a minimum of one Nutritionist-Dietitian; above seventy five (75) to one hundred fifty (150) bed capacity, a minimum of two Nutritionist-Dietitians; above one hundred fifty (150) to two hundred fifty (250) bed capacity, a minimum of three Nurririonisr-Dieririans; above two hundred fifty (250) bed capacity to five hundred (500) bed capacity, a minimum of four Nutritionist-Dietitian; and above five hundred (500) to one thousand (1,000) bed capacity, a minimum of five Nutritionist-Dietitians. Nutrition agencies, whether government or private, shall employ at least one (I) Nutritionist-Dietitian for each province, city, municipality, and rural health units." This decree was a recognition of the expanded role of Nutritionist-Dietitians not only in hospitals but also in community and/or public health nutrition, but the essence of regulating the practice of the profession was retained.

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Hospital Dietary Service Management Manual

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TIfEHOSPITAL DIETARY SERVICE PHILOSOPHY Each hospital has a guiding philosophy which should be articulated and communicated to the staff of the various services. Each service, in turn, must formulate its own philosophy which shall provide the anchor for its goals, objectives and program of service. The following can serve as a guide in the formulation of a philosophy for the Dietary Service: 1. The Dietary Service is organized to promote optimal nutrition for patients and hospital personnel regardless of race, creed, color, social status, and political belief through the administration of a high quality food service: 2. Diet is one of the most critical attributes in human growth and development directly related to good health. It provides the most appropriate means of maintaining vitality, developing resistance to infections and organic deterioration, the control of many disease processes, and recovery of health and function following illness and iruury: 3. Dietary personnel must be prepared, guided and given direction in their work within the context of prevailing local conditions in order ro attain efficient output; and 4. Hospital and Dietary Service goals can be best attained through the cooperation, coordination, mutual understanding, and dedication of all those concerned with quality patient care.

OBJECTIVES General To maintain or enhance the health of the patients and personnel by providing them with high quality and nutritious food through an efficient Dietary Service.

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HospitalDietary Service Management Manual Specific ,1. To provide or to serve safe, nutritious and attractive food through careful planning, wise procurement, and proper preparation of balanced and satisfying meals within budgetary limits; 2. To implement diet prescriptions in coordination with the physician and the nurse-in-charge; 3. To provide nutrition consultations and education services to patients as well as in-service training to both dietary personnel and other related fields; 4. To undertake investigation, analysis, and research along the field of Nutrition and Dietetics; and 5. To promote and maintain cooperation with other departments in the hospital towards total patient care.

FUNCTIONS As a major aspect of total health care and an integral part of the hospital organization, the Dietary Service is committed to functions of administration, clinical services, education and research as they relate to the science of food service management and nutrition. 1. Administrative function is aimed at the effective utilization of resources in the attainment of the goals set by the service. It includes the establishment of policies and standards, and the implementation of procedures concerned with budget and financial control; development of menus; purchasing and receipt of foods; production and service of safe, sanitary, nutritious, and palatable food; effective utilization of personnel, layout, and equipment; and maintenance of records and reports. 2.. Clinical function is aimed at providing and promoting a high quality nutritional care which includes within its scope, diet prescription, interpretation, implementation of diet orders, and the provision of individual and group counselling of patients in normal and clinical nutrition. Specialized services may include prescription of diets in nutrition clinics, malnutrition ward (malward), disaster feeding, outreach, and home care programs. 3. Education and research functions are aimed at the fulfillment of the Dietary Service's commitment to the nutrition education of the patients as well as hospital personnel and paramedic groups and to the continued research and development in food service management and nutrition. It also includes the training of dietary personnel and personnel of other allied fields to improve the quality and efficiency of food service operation, and the development of a research program to upgrade knowledge in food service management and nutrition.

STANDARDS Principle There shall be an organized Dietetic Service which shall promote optimal nutrition for patients and personnel through the efficient administration of high quality food service.

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Hospital Dietary Service Management Manual

Standard I Organization, Staffing and Manpower Development The Dietetic Service shall be organized with clearly stated philosophy, goals, and objectives. It shall be directed by a qualified person and staffed by an adequate number of Nutritionist-Dietitians, technical, and clerical personnel. It shall be integrated with the other units and departments of the hospital in a manner designed to ensure the provision of optimal nutritional care and quality food service. Likewise, it should establish linkages with the nutrition component of field health services. Interpretation

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There shall be clearly stated goals, objectives, and procedures for the Dietetic Service developed by the dietetic personnel and consonant with the framework of the hospital. The Dietetic Service should have a written organizational plan that indicates the routes of intra-departmental communication. Integrated planning on dietetics with other divisions/ departments in the hospital shall be encouraged. Job descriptions should be adopted for all classifications of personnel. The organizational plan, job description, and the procedure manual should be reviewed periodically, revised as necessary, and dated to indicate the time of the last review. The Dietetic Service must have the required number of qualified Nutritionist- Dietitians duly registered with the Professional Regulation Commission (PRC) based on PO 1286, Sec. 27 (see p. 3). The service must also have an adequate number of appropriately qualified personnel based on the staffing pattern approved by the DOH. The Chief NutritionistDietitian shall have the authority and responsibility of ensuring that the established policies are carried out; that overall coordination and integration of the therapeutic and administrative dietetic services are maintained; and that a review and evaluation of the quality, safety, and appropriateness of the dietetic function is performed. A qualified Nutritionist-Dietitian shall assure that the provision of highquality nutritional care to patients is maintained. Educational programs offered to dietetic employees should include orientation, on-the-job training, and continuing education programs. These programs must include instructions on personal hygiene, proper inspection, handling, preparation and serving of food, and proper cleaning and safe operation of equipment. Administrative and supervisory staff should be encouraged to take advantage of available courses which will acquaint them with modern concepts on preventive and therapeutic nutrition, and dietary management. A hospital that has a contract with an outside food management company for dietetic services must require, as a part of the contract, that the company maintain at least the standards outlined herein for such services. (This is also true to all private hospitals that have contracted the services of food concessionaires.)

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Hospital Dietary Service Management Manual

Standard II Facilities and Operations The Dietetic Service shall have adequate space, equipment, and supplies to facilitate the efficient, safe, and sanitary operations of all functions assigned to it Interpretation Facilities must be provided to fulfill the food service and dietetic needs of the patients and staff. The layout of the service, in accordance with the type, size, and location ofequipment, should make efficient food preparation, distribution, effective sanitation, and safety possible. The food service should be appropriately located and equipped. ' The following precautions shall be taken in the handling and preparation of food: 1. Protection of food from contamination and spoilage; 2. Storage of perishable foods at proper temperatures; 3. Convenient location of adequate toilet and handwashing facilities throughout the service; 4. Thorough cleaning and sanitizing of all work surfaces, utensils, and equipment after each period of use; 5. Provision of separate cutting boards for meat, poultry, fish (both cooked and uncooked), raw fruits and vegetables; 6. Discarding of plasticware and china that is chipped, cracked, or has lost its glaze, as well as disposable containers and utensilsafter one use; 7. Control of lighting, ventilation, and humidity, in order to prevent the condensation of moisture and the growth of molds; 8. Use of efficient equipment and methods for washing and sanitizing dishes. A good example is the installation of a hot water system; 9. Use of methods for making, storing, and dispensing ice that 'does not allow contamination to occur. For example, ice should not be scooped by hand, nor should food items be stored directly on ice being stored for dispensing; and ' 10, Restriction of unauthorized individuals in the food preparation and service areas to minimize the risk of contamination and improve operational efficiency. Safety shall be ensured by providing at least the following precautions: 1. Walk-in refrigerators that can be opened from the inside; 2. Insulationofhot and coldwaterpipes,waterheaters, refrigerator compressors, condensing units, and uncontrolled heat-producing equipment; 3. Clear labelling of supplies; 4. Separate storage of all food and non-food supplies; 5. Documentation of the activities of an active, preventive, and corrective maintenance, and safety program; 6. Procurement ofallfood suppliesfrom sources that provideassurance that the food is processed under regulated quality and sanitation controls; and

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Hospital Dietary Service Management Manual

7.

Proper holding, transfer, and disposal of garbage to prevent the proliferation of insects and rodents, or otherwise permit the transmission of disease. Containers must be leakproof and nonabsorbent with tight-fitting covers and it is recommended that impervious plastic liners be used.

There should be adequate work space for supervisory and clerical personnel. The office of the Nutritionist-Dietitian should be properly located so that he/she is easily accessible for consultation to all who require his/her service. Current reference materials should also be conveniently located in the office.

Standard III Policies and Procedures There should be written policies and nutritional procedures to govern all dietary activities. Interpretation Written policies and procedures for the Dietetic Service shall be developed to guide all dietetic personnel in the performance of their duties. The chief of the Dietetics Department , in cooperation with the dietetic staff, representatives from the nursing and medical staff, shall develop policies and procedures concerning food procurement, preparation, and service .as well as nutritional care. These policies and procedures shall be reviewed periodically, revised as necessary and dated to indicate the time of the last review. There shall bepolicies and procedures relating to at least the following: 1. Department goals and objectives, relationships, organization and staffing; 2. Responsibility and authority assigned to the chief,dutiesofdietarypersonnel with job descriptions, hours, and functions for the various classifications; 3. Personnel policies, including those related to health and grooming, such as the use of aprons/gowns, dietary caps and indoor shoes in the food preparation and service areas; 4. Administrative policies and procedures covering budget, patient arid staff education, menu planning, specification for purchases of food and equipment, ordering and control of food supplies, storage, preparation, safety, and fire prevention, sanitation procedures, and waste disposal. Procedures should also mention in detail, how the physicians' orders, with regards to treatment and diet, will be carried out to ensure that each patient receives the right diet served as nutritiously and attractively as possible; 5. Provision of standardized recipes for economy and efficiency in food preparation; 6. Proper housekeeping, sanitation, safety, and maintenance in the dietary area; 7. Monthly Reports - statistics and cost accounting procedures 8. Methods of evaluating the Dietetic Service arid personnel to assess how well goals and objectives are being met and the quality of service being rendered; 9. The proper use of and adherence to the standards for nutritional care, as specified in the diet manual/handbook;

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Hospital Dietary Service Management Manual

10. Nutritional assessment and .counselling, and diet instruction; 11. Disaster Plans • the role of the Dietetic Service in the hospital's intemal and extemal disaster plans shall be clearly defined. The Dietetic Service shall be able to meet the nutritional needs of patients and staff during the disaster, consistent with the capabilities of the hospital and the communityserved; 12. DietManual/Handbook- A qualified dietitian shall develop or adopt a diet manual/handbook in cooperation with representatives of the medical staff and with other appropriate dietetic staff. The diet manual/handbook shall serve asa guide in ordering diets, and theserved menus should beconsistent with the requirements in the diet manual/handbook. The diet manual/ handbook shall be reviewed annually and revised as necessary bya qualified dietitian, dated to identify the review and any revision made, in consultation with the medical staffthrough itsdesignated mechanism. A copy of the diet manual/handbook shall be placed in each patient care unit All master menus and modified diets shall be approved by a qualified dietitian; and 13. A nutrition clinic that will take care of nutrition referrals at the outpatient department shall be organized adopting the nutrition clinic guidelines of the DOH and/or the enclosed guidelines in the manual.

Standard IV Nutritional Aspects of Patient Care the administration of high quality nutritional care of patients shall be under the direction of a qualified Nutritionist-Dietitian. Interpretation The nutritional aspects of patient care shall be directed by a qualified Nutritionist-Dietitian, whose duties shall include: 1. Supervision of nutritional intake of all patients a. Planning and evaluating all menus for nutritional adequacy; b. Providing maximum effort to ensure the appetizing appearance, palatability, proper serving temperature, and retention of nutrient values of food; c. Keeping records of nutritional intake when necessary; d. Periodic assessment of the patient's nutrient intake and tolerance to theprescribed diet modifications, including theeffect ofthe patient's appetite and food habits on tood intake, and anysubstitutions made; e. Conferring with other members of the treatment team about dietary management and problems of patients. Initiating orders for dietary modifications, when necessary; . f. Recording dietary progress of patients in their records in collaboration with the nursing service; and g. Developing projects or studies to improve nutritional care. 2. Nutrition Educar.on a. Patient Education - includes teaching of normal nutrition as well as specific diets, and involves discussing with patients and/or their families their food habits, diet f,lOors associated with their socioeconomic background, dietary intake, and other aspects of nutrition which will affect the patient's health after discharge;

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Hospital Dietary Service Management Manual

b.

Education of other members of the therapeutic team; c. Education of other Dietary Service personnel; d. Education of community groups through referral to the nutrition clinics; e. Supervision of dietetic affiliates when applicable; f. Collaboration in the-preparation or selection of suitable booklets and instruction sheets for patients, and audio-visual aid for teaching; and .' g. Responsible for the preparation or selection of a suitable diet manual for use as reference by medical and dietary personnel when ordering diets. 3. Attendance at appropriate rounds and conferences, and representation on appropriate committees. a. A representative of the dietary staff should attend team conferences or committee meetings whenever dietary considerations are vital to the diagnostic or therapeutic regimen of the patient or whenever matters pertaining to the efficient delivery of the service are under discussion. In 1982, the United StatesJoint Commission on Accreditation of Hospitals OCAH) has revised the standards- which took effect on 1 July 1983. These revised standards which can be adopted for our hospitals are as follows:

Principle Dietetic services shall meet the nutritional needs of patients.

Standard I The dietetic department/service shall be organized, directed and staffed, and integrated with other units and departments of the hospital in a manner designed to ensure the provision of optimal nutritional care and the quality of food service. Interpretation The relationship of the dietetic department/service to other units and departments of the hospital shall be specified within the overall hospital organizational plan or described in writing elsewhere. The scope of the dietetic services provided to in-patients, as appropriate to ambulatory care patients and patients in a hospital-administered home care program, shall be defined in writing. Direction The dietetic department/service shall be directed on a full-time basis by an individual who, by education or specialized training and experience, is knowledgeable in food service management. The director shall be responsible to the chief executive officer or his designate. The director shall have the authority and responsibility of ensuring that established policies are carried out; that overall coordination and integration of the therapeutic and administrative dietetic services are maintained; and that a review and evaluation of the quality, safety, and appropriateness of the dietetic department/ service functions are performed.

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Hospital Dietary Service Management Manual

Staffing Dietetic Services shall be provided by a sufficient number of qualified personnel under competent supervision. The nutritional aspects of a patient's needs shall be supervised by a qualified dietitian duly registered with the Professional Regulation Commission (PRe). Outside Sources When dietetic services are provided for by an outside food management company, the company shall comply with all applicable requirements of the manual, and the contract shall specify the compliance requirements.

Standard II Personnel shall be prepared for their responsibilities in the provision of dietetic services through appropriate training and education programs. Interpretation The education, training, and experience of the personnel who provides the dieteticservices shall be documented and shall be related to each individual's level of participation in the provision of dietetic services. A formal training program may be required as a prerequisite. New personnel shall receive an orientation ofsufficient duration and substanceprior to providing dieteticservices without directsupervision and this orientationshallbe documented. As appropriateto their level ofresponsibility, such individuals shall receive instructions and should demonstrate competence in: 1. Personal hygiene and infection control; 2. Proper inspection, handling, preparation, serving, and storing of food;

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Proper care and safe operation of equipment; 4. General food service sanitation and safety; .5. Proper methods of waste disposal; 6. Portion control;

7. Writing of modified diets using the diet manual! handbook; 8. Diet instruction; and 9.

Recording of pertinent dietetic information in the patient's medical record

Personnel providing dietetic service shall participate in relevant in-service education programs. There shall be a provision for participation of personnel from all work shifts. The director of the dietetic department/service or the director's qualified designates shall participate in planning and conducting in-service education for dietetic personnel and, as appropriate, for other hospital personnel. In-service education shall include safety and infection control requirements described elsewhere in this manual. Outside educational opportunities shall be provided, as feasible, to supervisory dietetic personnel. The extent of the dietetic personnel's participation in continuing education shall be documented, and shall be realistically related to the size of the staff and the scope and complexity of the dietetic services provided. Education programs for dietetic services personnel shall be based, at least in part, on the results of dietetic department/service evaluations.

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Hospital Dietary Service Management Manual

Standard III Dietetic services shall be guided by written policies and procedures. Interpretation There shall be written policies and procedures concerning the scope and conduct of dietetic services. Administrative policies and procedures concerning food procurement, preparation, and service shall be developed by the director of the dietetic department/service. Nutritional care policies and procedures shall be developed by a qualified Nutritionist-Dietitian when appropriate consent or approval have been obtained from the medical staff through its designated mechanism and from the nursing department/service. The policies and procedures shall be subjected to timely review, revised as necessary, dated to indicate the time of the last review, and enforced. The policies and procedures shall relate to at least the following: . 1. The responsibilities and authority of the director of the dietetic department/service and, when the director is not a qualified dietitian, of the qualified dietitian; 2. Food purchasing, storage, inventory, preparation, and service; 3. Diet orders should be recorded in the patient's medical record by an authorized individual before the diet is served to the patient; 4. The proper use of and adherence to the standards for nutritional care, as specified in the diet manual! handbook; 5. Nutritional assessment, counselling, and diet instruction; 6. Menus; 7. The role, as appropriate, of the dietetic department/service in the preparation, storage, distribution, and administration of enteric tube feedings and total parenteral nutrition programs; 8. Alterations in diets or diet schedules, including provision of food service to persons not receiving regular meal service; 9.· An identification system for patient trays, and methods used to assure that each patient receives the appropriate diet as ordered; 10. Personal hygiene and health of dietetic personnel; 11. Infection control measures to minimize the possibility of contamination and transfer of infection. This shall include the establishment of a monitoring procedure (to ensure that dietetic personnel are free from infections and open skin lesions), and the establishment of sanitation procedures (for the cleaning and maintenance of equipment and work areas, and the washing and storage of utensils and dishes); and 12. Pertinent safety practices, including the control ofelectrical,flammable, mechanical, and, as appropriate, radiation hazards. Disaster Plans The role of the dietetic department/service in the hospital's internal and external disaster plans should be clearly defined. The dietetic department/service should be able to meet the nutritional needs of patients and staff during a disaster, consistent with the capabilities of the hospital and the community served.

Hospital Dietary Service Management Manual

Diet Manual/Handbook A qualified dietitian, in cooperation with other dietetic staff and the representatives of the medical staff, should develop or adopt a diet manual/ handbook and the standards for nutritional care specified therein should be in accordance with those of the Recommended Dietary Allowances of the Food and Nutrition Research Institute (FNRI). The nutritional deficiencies of any diet not in compliance with the recommended dietary allowances should be specified. The diet manual/handbook should serve as a guide in ordering diets, and the menus served should be consistent with the requirements specified. The diet manual/handbook should be reviewed annually and revised as necessary by a qualified dietitian, dated to indicate the time of the last review and any revisions made, and approved by the medical staff through its designated mechanism. A copy of the diet manual/ handbook should be placed in each patient care unit. All master menus and modified diets should be approved by a qualified dietitian.

Standard IV The dietetic department/service shall be designed and equipped to facilitate the safe, sanitary, and timely provision of food service to meet the nutritional needs of patients. Interpretation Sufficient space and equipment shall be provided for the dietetic department/service to store food separately from nonfood supplies; to prepare and distribute food, including modified diets; and to clean and sanitize utensils and dishes apart from food preparation areas. When storage facilities are limited, paper products may be stored with food supplies. Sufficient space shall be provided for supportive personnel to perform their duties. Current reference materials shall be made available to dietetic personnel and must be conveniently located in the dietary department/service. fuod and non-food supplies shall be stored under sanitary, safe, and secure conditions. The dietetic department/service facilities and equipmentshould comply with federal, state, and local sanitation and safetylaws and regulations. . The following precautions should be taken in the handling and preparation of food: 1. Food is protected from contamination and spoilage; 2. Food is stored at proper temperatures, utilizing appropriate thermometers, and maintaining temperature records; 3. Lighting, ventilation, and humidity are controlled in order to prevent the condensation of moisture and the growth of molds; 4. Methods that minimize the opportunity for contamination are used for making, storing, and dispensing ice. For example, ice should not be scooped by hand, nor should food items or scoops be stored directly on ice that is being stored for dispensing; 5. Separate cutting boards are provided for meat, poultry, fish, and raw fruits and vegetables. Cooked foods should not be'cut on the sameboards used for raw food preparation. Separate cutting boards may not be required when there are boards in use that are non-absorbent and capable of being cleaned and sanitized adequately, and when the cleaning and sanitizing procedures' are performed properlybetween usage for different food categories;

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Hospital Dietary Service Management Manual

6. All working surfaces, particularly food contact surfaces, utensils, and equipment, are thoroughlycleansed and sanitized between periods of use; 7. Adequate toilet, handwashing, and hand-drying facilities are conveniently located throughout the department; 8. Dish-washing and utensil-washing equipment and techniques that assure sanitized serviceware and prevent recontamination,including monitoring of proper temperature maintenance during cleaning cycles, are used; 9. Plastic ware, china, and glassware that has lost its glaze or is chipped or cracked, is discarded; 10. Disposable containers and utensils are discarded after usage; and 11. Movement of unauthorized individuals through food preparation and service areas is controlled in order to decreasethe risk of contamination and improve operational efficiency. Safety shall be ensured by providing at least the following precautions: 1. All walk-in refrigerators and freezers on the premises, whether they are in use or not, can be opened from the inside; 2. There is insulation of, or protection from, hot and cold water pipes, water heaters, refrigerator compressors, condensing units, and heatproducing equipment; 3. Food and non-food supplies are clearly labeled; 4. A review is conducted on the hospital preventive and corrective maintenance and safety programs as these relate to the dietetic department/service, and actions are taken based on the findings of the review. The review and actions taken shall be documented; and 5. All food is procured from sources that process the food under regulated quality and sanitation controls. This does not preclude the use of local produce. The holding, transfer, and disposal ofgarbage shall be done in a manner that will prevent the proliferation of insects, rodents, and vermin, and will not otherwise permit the transmission of diseases. Containers must be leakproof and non-absorbent with tight-fitting covers, and it is recommended that impervious liners be used.

Standard V Dietetic services shall be provided to patients in accordance with a written order of the responsible practitioner. All appropriate dietetic information shall be recorded in the patient's medical record. Interpretation The qualified dietitian or authorized designate shall enter dietetic information into the medical record as specified, and in the location determined, by those performing the medical record review function. These determinations shall be made by the medical record committee if and when one exists. The qualified dietitian or authorized designate is responsible for documenting appropriate nutritional information in the medical record. on the request of the appropriate medical staff member. Such documentation may include:

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Hospital Dietary Service Management Manual

1. Confirmation of the diet order by the responsible practitioner within 24 hours ofadmission for those patients receiving oral alimentation, and within 24 hours for all subsequent orders for a diet modification; 2. Summary of the dietary history and/or nutrition assessment, when the past dietary pattern is known to have a bearing on the patient's condition or treatment; 3. Timely and periodic assessment of the patient's nutrient intake and tolerance to the prescribed diet modification, including the effect of the patient's appetite and food habits on food intake and any substitution made; 4. Description of the diet instructions given to the patient or family and assessment of their diet knowledge; and 5. Description or copy of the diet information forwarded to another institution upon patient discharge. Ifnutritional care follow-up reverts to the practitioner's office or a health care agency, this should be noted in the patient's record.

Standard VI The quality and appropriateness of nutritional care provided by the Dietetic Service should be reviewed and evaluated regularly. Interpretation The director of the dietetic department/service, in consultation with a qualified dietitian (when the director is not a qualified dietitian), shall be responsible for ensuring that a review and evaluation of the appropriateness and effectiveness of nutritional care is accomplished in a timely manner. The review and evaluation program should also include the nutritional care provided to in-patients and, when applicable, to ambulatory care patients and patients in a hospital-administered home care program. The review and evaluation shall be performed at least annually and shall involve the use of the medical record and the pre-established criteria. The review and evaluation shall include data gathered from the medical, nursing, and dietetic staff and should be performed within the overall hospital quality assurance program. The quality and appropriateness of dietetic services provided to the hospital by outside sources shall be included in the review and evaluation on the same regular basis. The following quality control mechanisms shall be implemented: I. All menus are evaluated for nutritional adequacy; 2. There is a means of identifying patients who are receiving oral intake; 3. Tray identification is monitored; 4. Not more than 15 hours elapse between the serving of the evening meal and the next substantial meal for patients who are on oral intake and do not have specific dietary requirements; 5. As appropriate, the nutrient intake of patients is assessed and recorded; 6. As appropriate, patients with special dietary needs receive instructions relative to their diets, and an indication of the patient's (or family's) understanding of these instructions is recorded in the medical record;

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Hospital Dietary Service Management Manual

7.

As appropriate, patients who are discharged from the hospital on modified diets should receive written instructions and individualized counselling prior to their discharge;

8. Qualified dietitians participate in committee activities concerned with nutritional care; 9. A maximum effort is made to ensure the