Wednesday, April 7, 2010

From Meal Trays to Dining Room…

Sunnybrook Health Sciences Centre houses Canada’s largest veteran population, providing long term and complex continuing care to approximately 500 elderly veterans. In June of 2007, six Nursing Home units, representing 204 beds in the Veterans Centre, were converted from tray meal service to a bulk meal service dining room to align with the Ontario Ministry of Health and Long Term Care Dietary standards. The project presented a unique opportunity, not only because of the size of the population involved, but because most other long term care facilities offering bulk meal service have done so from the time of opening and rarely undergo a change in service model.

As dietitians working in food services our priorities are meeting nutrition standards, menu planning, meeting fiscal responsibilities, and patient/resident satisfaction. To evaluate that we met our objectives fo r this project, we retrospectively collected data pre – and post-implementation looking at nutritional parameters (e .g., weight, nutritional risk level , diet), financials, and food satisfaction. Converting to a bulk meal service did not appear to impact the residents’ nutritional status parameters, we were able to operate within our financial objectives, and our third party food satisfaction survey showed that changing the meal service model had no sustained impact on residents’ satisfaction with food. Despite achieving our food service objectives, the food serv ice team spent the majority of time addressing the unforeseen social outcomes of this change.

Adjusting to anything new takes time. The bulk meal service model had many benefits for residents, however, asking anyone to change their daily routine, especially around meals, inevitably results in some resistance. The new daily social interaction among residents at meal times allowed many relationships to flourish but also opened the door for conflict among others. Who sits with whom in the dining room was not an easy puzzle to put together. Waiting for tables to be served exposed residents to wait times that were previously less obvious when they ate in their rooms. Dietary restrictions were more visible to tablemates, and suddenly, residents started asking for specific food items of which they had not previously been aware. This phenomenon stimulated discussion among the care team about liberalizing the resident menu.

Despite the fact that forecasting, preparation, and production were done separately for each seating, having a ‘second seating’ at meals gave some residents the perception that ‘first seating’ received preferential treatment, and that those seated second were getting leftovers. Education with staff, residents and family members was necessary to dispel this myth.

The bulk meal service was implemented in phases bringing on one nursing unit per week over four weeks so that we could focus on the particular needs of each unit. Unique challenges surfaced when the implementation took place on the Cognitive Unit. Continuity is important for these residents; they may not be able to recall yesterday’s events but adapt well to routines. One resident, when offered a choice of two entrées replied, “I don’t want either, I just want my lunch tray”. Where family members previously made menu selections for residents with the tray service, some residents appeared overwhelmed having to shift to making seemingly simple food choices three times a day. Over time, the bulk meal service became routine and these challenges now seem to be non-issues. All of our experiences during the implementation prompted good discussion between our department and the care team about dining room philosophy and creating a home-like environment. Dining ‘ground rules’ for processes and conduct for both staff and residents continues to be a work in progress to improve the quality of the dining room experience.

Resident satisfaction with the bulk meal service was of high importance for both our department and for the organization in evaluating the success of the project. Despite the fact that there does not appear to be a difference in resident satisfaction over the long term, it is important to note that the satisfaction survey primarily assessed operations and food services para meters (e.g., quality, timeliness, temperature ). The potential impact of a dining environment and mealtimes on other factors related to quality of life cannot be discounted.

Lessons learned from this project:

1. Get to know the population and consider the social impact of the change for the residents and families;

2. Consider a broader survey tool to evaluate the impact of changing the meal service model on residents’ quality of life;

3. Recognize the value of ongoing communication with the residents and families; and,

4. Be patient!


Alexa Edmonstone, RD
Clinical Dietitian

Ann Robertson, RD
Director, Food Services

Sunnybrook Healthcare Food Services



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