Dietetic Internship Weeks 11 + 12: Management

What separates a good hospital meal from a mediocre one? It’s the cumulation of details: the temperature of the food, the quality of the ingredients, and the overall aesthetics of the dish. These two weeks in management involved making a lot of (seemingly small) changes in recipes to improve the patients’ food experiences.

One recipe we modified was the cheese sandwich. The old cheese sandwich recipe included 2 slices of processed cheese and a bit of mayo between 2 slices of whole wheat bread. The cheese sandwich we made has 2 slices of natural light cheddar, 2 slices of tomato, green leaf lettuce, and garlic-mustard mayo between 2 slices of flax bread. We dubbed it the gourmet cheese sandwich. Although it may sound like we haven’t changed much (where are the grilled veggies and olive tapenade?), I can tell you that the production and food costs of this new sandwich is about twice as much as the old one. Although the natural cheese was more expensive, the lettuce and tomatoes also added to the heftier price tag. “When adding a component to a dish”, our preceptor explained to us, “you’re adding to processes both horizontally and vertically. What that means is not only do you have to add lettuce and tomato to a large number of sandwiches at the assembly step, there are now more additional steps upstream too, like ordering and receiving, washing, and cutting.” Then, there are changes in therapeutic diets that need to be taken into account. For example, patients on minced and cut up diets cannot receive this sandwich as the lettuce and tomato are more difficult to chew –they would be getting the old sandwich. Diabetic patients can only receive half of the new sandwich due to the higher carbohydrate content of the new bread, whereas they could have a whole old sandwich previously. Ready for more details? The food service worker can fit 20 of the old sandwiches into each container, which makes it easy to tally up the number of sandwiches prepared. With the new bread, only 16 sandwiches can fit into a container. Thus previously routine calculations became harder, and most people don’t like change, especially when it involves doing mental math. Phew, I think those were all the details we ran into when making these sandwiches for a trial in the hospital.

Gourmet Cheese Sandwich: natural cheddar, lettuce, tomato, mustard-garlic mayo, and flax bread.
Lunch: Gourmet Cheese Sandwich (natural cheddar, lettuce, tomato, mustard-garlic mayo, and flax bread), served with tomato soup, coleslaw, and banana cake.

So after all the effort that went into the sandwich, it’s important to record if the patients liked it. We audited the consumption of the sandwich and sent out a survey, which we collected on the trays as they came back to the kitchen. Overall, the sandwich received a favourable reception, with over 80% of patients stating they liked it or liked it very much. So what’s the fate of the sandwich? Will it be kept on the menu or will the additional steps prevent it from ever being served again? Our preceptor discussed this with us, and broke it down simply: someone has to complete the extra work, but we will not get extra money for the completion of this work. Therefore, an existing procedure must be simplified, or eliminated to make time for the gourmet cheese sandwich. My intern partner thought of a possible option, which is to add additional vegetables to the soup to replace the salad. Then there would be more time to prepare sandwiches. Of course, the kitchen will need to test out that new idea and work out the details that come along with that change.

Another recipe we’re working on is a chicken potato bake. We’ve probably tried close to 10 different variations, and we’re going to get feedback from nurses and patients on Monday. This process of trial and error is new to me. I’m more accustomed to doing things once, and leaving it the way it is. It makes me feel frustrated when something that I’ve spent a lot of time doing is still not good enough. But I understand that it’s not a personal issue; continual improvement is the only way to achieve (and  maintain) a high level of performance as an institution, and as individuals.


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