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CH A PT E R

Meal Service and Menu Style Overview and Objectives

How do you provide meals to your clients? The decision depends upon the dining venues, equipment available and needs of the clientele. This chapter will take you through the steps of accessing your options and recognizing that no one style is always best for the clientele. After completing this chapter, you should be able to: 3 Describe different Styles of Service commonly used in the industry 3 Discuss the changing culture of meal delivery services 3 Relate how the Style of Service impacts the Style of Menu

ertified Dietary Managers (CDM) are working in an increasing number of service venues. The days of the traditional “nursing home” manager have been replaced with opportunities in School Foodservice, Corrections Food Managers, and Business Restaurant Manager. Healthcare now includes the Continuous Care Retirement Communities (CCRC) with country club style dining rooms and steakhouse concepts. The population or audience served by a CDM may include patients, students, toddlers, prisoners, seniors, tenants, restaurant patrons and catering attendees. Given the broad spectrum of the term, clients will be used for the purposes of this textbook. Dining services in the senior living communities range from the traditional large dining room to the smaller neighborhood concept with room-service meals offered to the Transitional Care Unit “patients.” Hospitals are recognizing the value of trained CDMs as part of their supervisory and management team. Meal services can span from the typical trayline and cart delivery to high-end room service and specialty dining options. Today’s food technology and equipment development have allowed for centralized production centers such as cook-chill and satelliting of meals in bulk or as pre-plated trays. Meals services are planned and managed for congregate dining, home delivered meals and remote meal service where there are limited food production facilities. There is no one definition for today’s dining services.

Glossary CCRC Continuous Care Retirement Communities

Foodservice Management—By Design

Meal Service and Menu Style Style of Service

Glossary Centralized Production Center A kitchen designed to produce large quantities of food items to be satellited out to multiple finishing kitchens or serving locations

Main or Centralized Kitchen Typically the single or primary food production kitchen for a facility

Decentralized Kitchen A small or satellite kitchen used for finishing or reheating of prepared items

Centralized (Delivery) Meal Service Foods are prepared and portioned onto trays or plates at a central location in or adjacent to the main kitchen

Decentralized (Delivery) Meal Service Bulk quantities of prepared foods are sent hot or cold to other locations for finishing and service

Rethermalize Reheat

Cook-Chill Items are prepared in advance to be reheated for service at a later time

Cook-Serve Food items prepared for immediate service

How you provide food in your facility is considered your Style of Service. There are many different methods for delivering meals to your clientele. A Certified Dietary Manager needs to use judgment to design and/or revise systems. In addition to the needs of clients, the manager must consider: • • • • • • •

The physical design of the kitchen Locations of dining rooms or service areas Requirements for off-site service (if any) Mission and goals of the organization Staffing resources Budget and operating costs Timing requirements for service

Centralized Versus Decentralized Meal Service Prior to considering the point of service or Style of Service, it is important to consider the preparation of the meal to be served. In a Centralized Production Center, food is prepared in large quantities for service either satellited to multiple locations or time delayed through a cook-chill process. More commonly seen is one kitchen for the building that produces the meals to be served on-site; a Main or Centralized Kitchen. The Decentralized Kitchen receives much of its food from a Production Center or Main Kitchen and provides finishing or reheating (rethermalizing) prior to service, often supplementing food items from a pantry or short order grill. (Production systems are further explored in Chapter 5.) Similarly, Centralized Meal Service means that food is portioned onto trays in a central location, such as the dining services department. An alternative is Decentralized Meal Service, in which food is distributed to other locations for plating at the point of service, such as Table-Side service in senior living. Cook-Chill is a production system that has been available for over 20 years. The food is prepared in advance, often in a Production Center, and either “blast chilled” or frozen and held for service at a later time. Food items may be distributed for reheating in bulk and served in a satellite dining room such as congregate meals or a remote facility. Individual meals may be pre-plated COLD on a trayline system and reheated in specialty equipment prior to service. Meals are shipped to other buildings, or transported by carts to nursing units for rethermalizing “on the unit floor”. Often, cook-chill is a model used by school systems, where food production is centralized and food is transported to individual school cafeterias for plating at the time of service. In both centralized and decentralized systems, the equipment used must support the service and delivery model. Temperature control from the time of assembly to actual delivery is of paramount concern. To help ensure food safety, as well as quality, food must be kept out of the danger zone (41° - 135°F). For a Cook-Serve tray service, when meals will be produced and served immediately, some of the most basic temperature control systems are: • Insulated trays > Each compartment is separated and insulated. > Keeps hot food hot and cold food cold. > Tray lid may cover all or part of the tray.

Foodservice Management—By Design

Meal Service and Menu Style

> The tray on the left in Figure 1.1 illustrates a typical insulated tray. • Heated base systems > Wax filled bases are pre-heated prior to meal plating > The tray on the right in Figure 1.1 illustrates a heated base tray • An instant heating system is also available from a number of manufacturers > Transfer heat into a base plate while keeping the edges cool > Figure 1.2 illustrates a Heat-On-Demand base heater • Insulated transportation carts > The cart is insulated and may even be heated to help maintain hot food temperatures > Figure 1.3 illustrates an insulated cart for transportation of completed trays Figure 1.1 Insulated Tray and Dinnerware Insulated Tray

Insulated Dinnerware

Aladdin-Temprite® Reprinted with permission.

Figure 1.2 Heat-On-Demand

Putting It Into Practice

Aladdin-Temprite® Reprinted with permission.

1. When working in a large hospital, you decide that food will be prepared in a central kitchen and then shipped in bulk to the other wings/ floors to reheat and serve. What type of meal delivery system is this?

Foodservice Management—By Design

Meal Service and Menu Style Figure 1.3 Insulated Carts for Transporting Completed Trays

Carter-Hoffmann Reprinted with permission.

Not all meals are served from pre-plated meal trays. In today’s marketplace, “Table-Side” meal selection is fairly common in senior dining where the client is served a meal from a hot-cart located within the dining room. Typically heated bases, transport carts and insulated trays are not viewed by CMS (Centers for Medicare & Medicaid Services) as part of the home-like dining experience.

Service Options—The Traditional Trayline and Beyond Trayline Service A Trayline, or the modified version POD system, is still the most common meal assembly process in acute care and many senior living communities. Trayline systems are also common in correctional facilities. A trayline system moves trays through an assembly line where employees place items on trays. During this process, trays may move along a straight line or a circular platform, often with the help of a conveyor belt. Some conveyor belt systems are powered by electric motors with speeds that can be regulated. Other facilities operate skate wheel systems where trays are manually slid along the wheels. In a POD system, all of the serving stations are compressed into a small wrap-around space so everything is within easy reach of the server. The individual trays are typically transported by carts and delivered to clients. Serving meals through a trayline system involves a number of steps that are tightly integrated with the diet order system and a menu management process. How these steps are implemented varies from one operation to another. Figure 1.4 provides a sample flow for a traditional trayline service.

Glossary POD System A small serving station with all items within reach of the server

Foodservice Management—By Design

Meal Service and Menu Style

Figure 1.4 Trayline Service—The Steps Prior to the meal service time, either an individual Meal Ticket or Tray Identification Card is prepared for each client.

The Meal Tickets are grouped by unit or dining room location.

Staff send the Meal Tickets or Tray Identification Cards down the trayline for assembly.

Food items and supplies are organized by stations on the trayline.

Items seleted or appropriate for the diet are added to the tray.

Staff place the tray on a cart or traveyor (an elevator belt with platforms for transporting trays to higher floors).

Nursing or Dining Services staff deliver trays to the client.

Tray Delivery Options Typically meal trays are transported throughout the facility in enclosed “food only” carts. Tray transport carts are designed to securely hold the trays while going up ramps, over bumps in the flooring, etc. Some carts are designed to provide thermostatically maintained heat, while others include a refrigeration section. For temperature controlled cart systems, Figure 1.5, during assembly, employees place hot foods on the “hot” side of the tray and cold foods on the “cold” side. A dividing seal helps maintain temperature control. Some units can plug into a controller unit to rethermalize hot foods on trays immediately prior to service. Although this system can be very successful in maintaining temperatures, the “high tech” appearance of the tray becomes visually institutional looking.

Foodservice Management—By Design

Meal Service and Menu Style Figure 1.5 Temperature Controlled Cart System

Aladdin-Temprite® Reprinted with permission.

Figure 1.6 Rethermalization Systems Bulk Rethermalization System

Tray Rethermalization System

Dinex. Reprinted with permission.

If an operation is using a cook-chill pre-plated tray system, in which foods are delivered cold and rethermalized just before service, trays are pre-assembled and delivered in carts. The carts and related technologies are designed to heat the food quickly using induction or convection heat. Figure 1.6 illustrates some rethermalization systems. Note that tray rethermalization can occur in a centralized location (in the dining services department just before tray distribution), or in a decentralized location (on the nursing units). Also, specialized rethermalization systems generally require specialized dinnerware to integrate with the systems. In selecting equipment, it is important to review related needs and costs for dinnerware. Many are available in a range of colors and designs.

Foodservice Management—By Design

Meal Service and Menu Style

With today’s service equipment, a manager can use software support for meal delivery systems to track temperature data, program rethermalization features, control and monitor remote delivery systems and generate reports through a desktop computer. Each style of service has its benefits and its compromises.

Pantry Service—Made to Order In an effort to better meet client expectations, some facilities have implemented a Pantry mini service on the unit. Typically food is prepared in a central kitchen and supplied to kitchenettes or pantries on the unit for plating and service to the clients. The pantry servery can support any menu format, from non-select to room service meal on demand, with what is expected to be hotter and fresher meal service.

Room Service Many definitions of Room Service have been brought forward over the past 10-15 years. Originally conceived as a hotel style of room service, the process has evolved to reflect the needs of the healthcare setting and delivery of meals in a business account. Menus are often altered to provide options that are known to function better on a room service format. In hotels and commercial dining locations, a service or delivery charge is typically added to the bill to cover the cost of labor related to special delivery of the meal. In healthcare, although the added cost of labor is a factor, implementing a service charge is not an option. Room Service, or some variation of the concept, is now a common element in healthcare from the large metropolitan acute care hospital to the Transitional Care Unit services in a community health center. Typically the room service concept is one of several styles of service within a given facility from: • a non-select meal served at a defined time for clients unable or unwilling to select their meal; to • menus selected by the client served from a traditional trayline at defined meal times in some units; to • a meals on demand room service concept.

Glossary

Table-Side In-Dining Room Service In an effort to provide a more “homelike” atmosphere in the senior living and congregate dining setting, many communities have turned to a Table-Side service using a hot well service station in the dining room. Plating and delivery of the meal to the client is completed in front of the clients. The meal served is often a select menu with two or more choices for the entrées and side-dishes. A number of communities have established the “neighborhood” concept for the senior living environment. Typically, in this setting, the clients live within a small group and share their meals around a family style dining table. Meals supplied from dining services are plated and served to the clients from a home or residential looking kitchen. Often special services, such as eggs made to order or sandwiches prepared upon request, are offered in the neighborhood dining room.

Pantry A small serving station or kitchenette

Room Service Meals selected and served upon request

Table-Side Service Serving clients from a hot well cart present in the dining venue

Buffet Style Meals selected to the client from buffet style serving line

Foodservice Management—By Design

Meal Service and Menu Style Buffet Style Service Buffet Style service is offered in some long-term care facilities as a way to create an atmosphere of choice. Facilities offer the same number of choices as with restaurant style service (further discussed below), only clients can serve themselves. Be prepared to offer extra help for those clients who may not be able to manage walking a buffet line, handle their tray/plate, serve themselves and carry the meal to the table. The buffet style of service is commonly used in a catered function whether in healthcare or the business setting. Catered events can be anything from coffee and donuts for a staff meeting of six to a full holiday meal for the board of directors.

Restaurant Style Service Restaurant Style is another way of implementing a new culture in residential dining. Your regular menu cycle entrée can be the daily special with an option of sandwiches, grilled items, vegetables and salads. Restaurant style dining might include the following: • Dining Service staff waiting on tables • Food ordered and delivered in courses • Food plated in the dining room • Specials such as sandwiches, salads or desserts offered tableside from a cart In many CCRC and corporate dining rooms, a high-end or white linen dining service is the norm. Meal options are more extensive and also upscaled with an emphasis on presentation. Training of staff on the correct service techniques in formal dining is essential to completing the fine dining experience.

Cafeteria Service School or dormitory foodservice, employee dining rooms, commercial feeding, and correctional facilities all use a variation of the Cafeteria model. Whether the straightline tray slides or the more popular scramble concept, the cafeteria is designed to move a large number of customers through the meal selection process quickly. Typically the actual plating of the food is provided by a cafeteria server with some self-serve or “grab-n-go” items available. Often the cafeteria includes a grill and some made-to-order items like sandwiches and specialty salads. Other than the correctional or dormitory setting, cafeterias are a cash based operation.

C-Store—Sandwich Counters and Kiosks

Glossary Restaurant Style A set menu of multiple options that does not change from day to day

Cafeteria Model Straight-line or scramble system offers cafeteria style options

Many of the CCRC and independent senior living communities offer a C-Store (Convenience Store) with frequently needed staples and supplies. Often a sandwich counter is an added service for a simple lunch meal when the main dining room is not available. A coffee kiosk or sandwich counter may be available in the lobby of an office complex, hospital out-patient surgery unit or campus walk-way.

Multiple Venues Dining services are being offered in more locations and with different “personalities” all within a single facility. Senior living communities may have a traditional dining room seating 50-100 residents, plus a wellness smoothie bar, a coffee kiosk with fresh bakery items and sandwiches, a white linen steakhouse, and a lounge with a full-service bar and appetizers–all on the same campus.

Foodservice Management—By Design

Meal Service and Menu Style

Satelliting Foodservice Equipping and staffing a food production kitchen is expensive and requires a lot of space and utilities support. Sometimes organizations decide to obtain their food items from a production center. Whether the food is delivered in bulk for reheating and serviced in a dining room, such as congregate dining, or pre-plated meals for individual clients in a school or care center, satelliting of meals is becoming more common. One type of satellited meal that has been employed across the country is Home Delivered Meals for the homebound and the elderly. Beyond equipment, there are additional service considerations related to the trayline system, particularly in healthcare. We will examine delivery to clients in a trayline system.

Service Concerns and Issues Even with well-designed equipment and well-planned systems, foodservice departments sometimes face delivery challenges with trayline systems. For example, in a healthcare facility, if trays reach their destinations through a cart service, staff then need to distribute trays to clients. This task may be the responsibility of either nursing or dining services staff. Staff who deliver trays need to accomplish several things: • Be available as trays arrive and distribute trays promptly • Verify that each tray is reaching the right client > Two “patient identifiers” is a guideline by The Joint Commission (TJC) and recommended by World Health Organization (WHO) and Centers for Medicare & Medicaid Services (CMS) > Verify a Client Name and Medical Record Number, or Date of Birth against the name on the menu or ticket on the tray. Some tray tickets include client photos for easier verification • Be alert to any diet changes that have just occurred • Help the client set up the tray and open any packaging • Help the client with feeding, as needed and approved by nursing • Obtain substitutes or make adjustments if a client has any difficulties with the meal • Make sure food is arriving to the client at the appropriate temperature and accurate to the menu ticket These tasks require training. In addition, they can take a lot of time. When nursing staff are required to assist, there can be time conflicts. A nurse may be involved in another clinical task at the time that trays arrive and this can cause delays. Furthermore, the Certified Dietary Manager needs to review schedules carefully to assure that they are reasonable and feasible with respect to client schedules. An effective staffing plan takes into account the skills and timing requirements of the job. In addition, it involves coordination between nursing, rehab and dining services departments. Delays in the distribution process are a common reason for complaints about food temperature and/or quality. In addition, there is a food safety concern with trays that sit at room temperature too long. How can a Certified Dietary Manager tackle this challenge? There is no single best answer. Some healthcare organizations have begun using additional auxiliary staff to assist with tray distribution and client feeding. Some have begun switching tray distribution from nursing to dining services staff to avoid timing conflicts. In addition, some of the rethermalization systems described allow staff to Foodservice Management—By Design

Meal Service and Menu Style control temperature much closer to the time of service. A temperature control cart that holds food temps may help provide a longer window of time in which to accomplish the job without sacrificing safety and quality. Also, to facilitate delivery, sequence the menus or tray tickets to ensure that trays are assembled and grouped in a meaningful order. Meal delivery schedules must also comply with additional regulations to assure that frequency and timing fit prescribed needs. For example, in healthcare, the time frame between supper and breakfast cannot be more than 14 hours (i.e., 5:30 supper and 7:30 breakfast). If delivery problems arise, it is up to the Certified Dietary Manager to review them with a nursing supervisor or administrator to help ensure that the entire meal delivery system functions effectively.

Culture Change in Healthcare Dining Services IThe choices for healthcare communities for older Americans are expanding and the type of food and nutrition care will need to expand as well. With 2010 CMS regulations, F242, “your facility has to demonstrate that it’s allowing residents’ choice and self-determination in dining.” At the same time, it is important to tailor a menu to the dietary requirements of the client. How do we accomplish this? This section will describe the culture change movement around the dining experience and the menu options to support the change.

Culture Change in Language Culture change begins with the language we use. Karen Schoeneman wrote about this in an editorial for the Pioneer Network Culture Change project. She asked people to come up with alternative words for bibs, feeder, elderly, etc. Figure 1.8 lists samples of dining terms that were suggested to help older adults maintain their dignity and healthcare facilities to become more person-centered. Figure 1.8 Terminology of Culture Change OLD TERMINOLOGY

SUGGESTED TERMINOLOGY

Elderly

Elder, older adult, individual

Wing, unit

Household, neighborhood, street

Institutional care

Individual care

Feeder table

Dining table

Feeder

Person who needs help eating

Facility, institution, nursing home

Home life center, living center

Foodservice worker, Hey You

The person’s name

Dietary service, food service

Dining services

Tray line

Fine dining

Nourishment

Snack

Bib

Napkin, clothing protector

Diabetic

Person who has diabetes

Mechanical soft food

Chopped food

Trays are here

It’s dinner time; dinner is served

Source: http://www.pioneernetwork.net Used with permission.

Foodservice Management—By Design

Meal Service and Menu Style

Culture Change in Dining The culture change movement in dining is driven, in part, by the large numbers of Americans who are aging and who will be entering the various healthcare communities as they age. It is also being driven by the change in regulations to implement more person-centered, resident-driven dining programs. This is indeed an opportune time to showcase dining services and your ability to enhance the quality of life through food and dining choices. One service option change is to offer restaurant or in-dining room tableside service instead of the traditional trayline. As with any change, there is resistance based on concerns about cost, staffing, and coordinating the changes with regulations. As you begin to adopt a new culture, there are many questions that need to be answered. Start with questioning clients to help decide what they want for dining services. You might ask questions such as: • What time of day do you like to eat your meals? • Do you snack regularly? • How frequently during the day do you want coffee, tea, or water? • Where do you prefer to eat your meals? • What foods do you usually eat at breakfast, lunch, and dinner? • Where should you begin with the culture change? (expanded snack program, restaurant services, selective menu) Next, you will want to choose appropriate resources for changing your dining and/or menu options. You could survey other facilities in your area to determine how/if they have begun to implement a culture change in their dining services. The Association of Nutrition & Foodservice Professionals (ANFP) published a position paper in 2011: The Role of Certified Dietary Manager in Person-Directed Dining. This position paper is available in the online Supplemental Textbook Material—Foodservice. Remember, the changes you make need to reflect your clients' food and dining preferences. Once you have data for what you want to do and why, the next step is to work with all departments in your facility. This will be a change for them as well, and you want them to support your efforts. Other departments that are likely to be affected are maintenance and nursing. You will want to develop a policy and procedure that outlines every department’s responsibility for each type of change you initiate. Communication and training will be key steps. It is important to note that a culture change is a process that takes some time to implement. While the changes outlined in Person-Directed Dining are directed at the healthcare field, they apply to any dining service. Dignity in dining is a concern in all marketplaces. Providing customer choice, quality products and trained staff are hallmarks of good management. Your menu and the style of the menu are major components in developing a new dining culture. The equipment available defines many of the meal delivery options available to you. Decisions to transition away from a set trayline/ no choice meal system to a more accommodating meal service and options take planning and forethought.

Putting It Into Practice 2. List at least three steps you would take to implement a culture change in your facility.

Foodservice Management—By Design

Meal Service and Menu Style Menu Options Two of the most common options are selective and nonselective. Whether you have a select or non-select format, you need to have a defined number of days over which the menu is used. This is referred to as the menu cycle—how fast you return to day 1 of the cycle. You do not want to write a new menu every week and end up with a cycle 365 days long. In the acute care setting, the average length of stay is now around 4 days. Many hospitals have gone to a cycle of 5-8 days so that the same items do not always fall on a Tuesday. In the residential segment of business (senior living, rehab and group homes) the cycle is more likely going to be 3–6 weeks. Often using an odd number of weeks works better for these communities and employee cafeterias. Typically staff work every other weekend and when the menu is set to a 2 or 4 week cycle the staff see the same thing every weekend. By using a 5 week cycle a nurse will work 10 weeks before they see the Oven Roasted Turkey and Dressing on Sunday again. Business and Industry dining rooms and school foodservice also benefit from a longer menu cycle of 3-5 weeks just to avoid the repetition of items on the serving line. The presence of the daily standard items in the grill, sandwich service and salad bars allows for an ever present and popular set of alternatives.

Selective Menus A selective menu is the way to implement current federal regulations, and more importantly, enhance the quality of life and quality of care for your clients. A selective menu is one in which clients have the opportunity to make choices or selections in advance of meal service. For example, it usually offers at least two choices for an entrée and multiple choices for most items.

Glossary Menu Cycle The number of days over which a menu is used

Selective Menu A menu designed with multiple choices

Putting It Into Practice 3. You have a long-term patient (16 days) complaining about their meals. You have a non-select seven day menu cycle. What can you offer the patient?

Computer-based selective menu systems may use handheld computers and/or telephone systems for entry of choices into an automated system. Typically, a selective menu is distributed to clients in advance of the meal. Select menus generally fit one of the following types: Pre-Select • Typically a printed menu with choices for Breakfast, Lunch and Dinner. • Often distributed to the client the morning of or the day before service for selection and return to the meal preparation area. • The selection maybe limited to two entrées with the same side dishes or, more commonly, offers two to three entrées, two to three starches and vegetables . • Family members may pre-select the meals for a week in advance knowing the client’s preferences. • No matter how many options are offered, a defined menu is set for each day as the nonselect meal for those who choose not to make their selections. > The defined menu ensures nutritional adequacy of the default meal being provided.

Foodservice Management—By Design

Meal Service and Menu Style

Table-Side Select • This may be the same base menu designed for the Pre-Select with a selection made in the dining room at the time of service. • The menu is typically posted in and around the dining room so clients can see in advance what the choices will be for the meal. • There is also a non-select menu for those who choose not to make their selections. Spoken • This may be the same base menu designed for the Pre-Select. • The menu is presented to the client by a Dining Services staff member by speaking. For example: “Good morning Mrs. Jones, today for lunch we have a garden salad, spaghetti with meat sauce, green beans and lemon sorbet for dessert. How does that sound to you?”… “I did not realize that you don’t like green beans, would you prefer broccoli or chopped spinach?” • By placing the first or non-select default item as “today for lunch we have…” leads the client to the preferred choice but leaves them with the option to request an alternative. • The printed version of the menu may be available to clients to see in advance what the choices will be for the meal. • There is also a non-select option for those who choose not to select their menu. Restaurant Variation • Typically this menu format is set up with a list of items that are always available as standard choices. • Additionally a daily feature or chef’s choice is presented as the preferred or default option for the meal. • Standard items tend to be a short order type that can be finished quickly, such as baked fish or chicken stir-fry. • The featured selection is often one that takes more time to prepare and would not be available every day, such as pot roast or pork chops. • The printed version of the restaurant menu is available to clients to see in advance what the choices will be for the meal and the daily features may be printed for the day or the week for client review. • There is also a non-select meal (typically the daily feature item) for those who choose not to make their selection. Cafeteria • Typically this menu format is set up with a list of items that are always available as a set or standard choices. • Additionally a daily feature or chef’s choice is also presented. • Standard items tend to be a short order type that can be finished quickly, such as baked fish or chicken stir-fry. • Featured menu selections are often ones that take more time to prepare and would not be available every day, such as pot roast or pork chops. Buffet • Generally a buffet menu is planned for a self-serve line. • This style is often centered around single-serve or portion-controlled items like baked chicken breast or lower-cost products where over portioning does not negatively impact financial performance. Foodservice Management—By Design

Meal Service and Menu Style Menus can be printed in a number of formats but typically start out as a Week-At-AGlance (WAG) layout with Breakfast, Lunch and Dinner (or Supper) planned for the week. This allows the manager and coordinator of the meal services to see in one place all of the meals planned for several days. Problems with repeating food items are easier to spot when looking at the WAG version. The WAG meets the needs of the “back of the house” production team but does not market well to your customers. For the “front of the house” or customer facing menu, most organizations prefer to jazz up the appearance and highlight the specials. The following 2 examples demonstrate the typical WAG for a healthcare facility, Figure 1.9, and a sample select menu for the day, Figure 1.10.

B R E A K FA S T

Figure 1.9 Sample Week-At-A-Glance Menu Layout SUN

MON

TUES

WED

THUR

FRI

SAT

Choice of Juice

Choice of Cold Cereal

Oatmeal

Malt-O-Meal

Cream of Wheat

Oatmeal

Malt-O-Meal

Cream of Wheat

Malt-O-Meal

Scrambled Eggs Ham Patty

Poached Egg

Fried Egg

Hard Cooked Egg

Scrambled Egg

Omelet

Scrambled Egg

Caramel Roll

Wheat Toast

Pancake & Syrup

Muffin

Wheat Toast

Waffle

Milk

Coffee

Tomato Soup

Wild Rice Soup

Pork Roast

Shepherd’s Pie

Grilled Cheese

Beef Lasagna

Chicken Tacos

Baked Pork Chop

Spanish Rice

Oven Brown Potatoes

Shredded Lettuce Diced Tomatoes

Winter Blend

LUNCH

Mashed Potatoes with Gravy

Bratwurst Potato Salad

Nantucket Vegetables

Vegetable Medley

Mixed Vegetable Salad

Baked Beans

Bread/Dinner Roll

Crackers

Bread/Bun

Garlic Bread

Fruit Pie

Fresh Fruit

Bananas or Fruit co*cktail Topped with Pudding

Mandarin Oranges

Diced Peaches and Pears

Homemade Bars

Pumpkin Crunch

Baked Fish with Rice Pilaf

Chicken (Strip or Salad) Wrap

Turkey Burger on a Bun

Roast Beef Sandwich

Chef Salad

Egg Salad Sandwich

Tuna Salad Wrap

Iced Tea/Coffee

Tuna Rice Bake with Peas

Beef Stroganoff

Grilled Chicken Breast

Breakfast Ham

Breaded Fish Fillet

Goulash

Noodles

Scalloped Potatoes

French Toast

Potato Wedges

Fresh Fruit

Hearty Vegetable Soup

SUPPER

Turkey Sandwich

French Style Green Beans

Bread/Dinner Roll

Three Bean Salad

Garden Salad

Dilled Carrots

Asparagus

Crackers

Bread/Dinner Roll

Cheesy Broccoli

Cut Corn

Dinner Roll/Muffin

Bread/Dinner Roll

Diced Pears

Brownie

Cobbler

Better Than Anything Cake

Sherbet

Fruited Red Gelatin

Custard

Pizza

Scrambled Eggs and English Muffin

Chicken Salad Stuffed Tomato

Cube Steak and Gravy

Grilled Cheese Sandwich

Hot Dog on Bun

Soup and Deli Sandwich

Milk

Coffee

Foodservice Management—By Design

Meal Service and Menu Style

Figure 1.10 Sample Select Menu for a Day BREAKFAST

LUNCH

SUPPER

Assorted Juice Hot or Cold Cereal Egg of Choice Breakfast Ham Slice

Fried Chicken Mashed Potatoes Chicken Gravy Green Beans

BBQ Riblette Mixed Vegetables Pasta Salad

English Muffin Jelly or Honey Margarine, Salt & Pepper Milk Coffee or Hot Tea

Fruit Cobbler Dinner Roll Margarine, Salt & Pepper Milk Coffee or Iced Tea

Brownie Cornbread Muffin Margarine, Salt & Pepper Milk Coffee or Iced Tea

Other Menu Selections Breakfast Fruit of the Day Toast Mini Danish

Other Menu Selections Cheeseburger on Bun Chef’s Salad Loaded Baked Potato

Other Menu Selections Grilled Chicken Breast Tuna Salad Stuffed Tomato Lemon Baked Fish

Room: _______________

Diet Order: ___________

Name: _______________

In healthcare facilities, or in any environment where the dining services department is responsible for honoring therapeutic diets, it is standard practice to review meal choices before they are served. If clients make choices on a selective menu, a member of the dining services team then reviews these choices against the medical diet of record and the nutrition guidelines for the diet. Common adjustments that may need to be made are: • Portion sizes of products that count as fluid, for a fluid-restricted diet. • Portion sizes of high-carbohydrate foods, for a carbohydrate counting diet. • Consistency of foods and liquids for specific dysphagia diets. • Special adjustments for diets with multiple restrictions. • Adjustments to incorporate a standing order, such as the addition of a liquid nutritional supplement to meals. What happens if the client does not request enough food on a selective menu? What if the client selects food that is not on his/her diet? Dining Services staff should be trained to address a client’s diet when they drop off the menu, for example: • “Good morning Mrs. Smith. I know that you are on a sodium restricted diet and here are your menu selections for today.” This helps remind the client of their diet and sets the stage for their choices. • If they see that the client has not selected very much food, the Dining Services staff might say, “Oh, Mrs. Smith, our roast chicken is very tender and moist today. May I add that to your selection?” • If the client insists on selecting something that is not on their menu, such as bacon on a salt restricted diet, gently remind the client that their diet does not allow them to have bacon.

Foodservice Management—By Design

Meal Service and Menu Style Always treat clients with respect and respond in such a way that they don’t become defensive. Keep in mind that you need to educate clients on the limits of their medically ordered diet, however, their resident/patient rights may overrule the dietary restrictions. Refer diet conflicts like these to the clinical nutrition staff for intervention and documentation in the medical record.

Figure 1.11 Examples of Food Substitutions* VITAMIN A CONTENT

VITAMIN C CONTENT

FOOD ITEM

FOOD CHOICES

(per 1/2 cup serving)

Dark Green Vegetables

Asparagus, boiled

905 IU

7 mg

Broccoli, frozen, boiled

1,208 IU

50 mg

Brussels sprouts, frozen, boiled

1435 IU

70 mg

Green beans, canned

54 IU

8 mg

Green peppers, boiled

194 IU

28 mg

Kale (use in soups)

8853 IU

265 mg

Mixed vegetables, frozen

1944 IU

1.5 mg

Pea pods, boiled

532 IU

17 mg

Peas, frozen and boiled

824 IU

38 mg

Romaine lettuce, 1 cup

2098 IU

1 mg

Bright Orange Vegetables

Carrots, frozen

9094 IU

1.6 mg

Sweet potatoes, boiled and mashed

1444 IU

8 mg

Winter squash, baked

793 IU

7 mg

White Vegetables

Cabbage, boiled

60 IU

28 mg

7 IU

27 mg

226 IU

1.5 mg

Cauliflower Celery Rutabaga

1.5 IU

16 mg

Turnips

0 IU

10 mg

Source: U.S. Department of Agriculture—National Nutrient Database for Standard Reference Vegetables are often the foods that clients will have an aversion to. Remember that substitutions have to be equivalent in nutritional value, so choose another vegetable(s) that is roughly equivalent to the content of the leader nutrients, vitamin A and vitamin C.

On a selective menu, there may also be items a client writes in as a special request. How this is handled depends on the facility policy. In general, health facilities attempt to honor write-in requests when practical. Many facilities develop a standardized list of write-in options to provide greater choice for clients.

Glossary Non-Selective Menu A menu with no defined alternatives—a predefined menu plan

Non-Selective Menus A non-selective menu is one in which clients do not have the opportunity to make choices. Instead, they receive a standard, predefined menu. This is more common in a group dining experience such as a nursing home or assisted living. Even with a non-select format, you can focus on the clients by following their individualized food preferences with appropriate substitutions.

Foodservice Management—By Design

Meal Service and Menu Style

In a non-selective menu system, it is also important to review and modify standard choices to accommodate specific diet orders. You still want to follow individual food preferences, which may mean changing a food item. Substitutions must be of equal nutritional value. For instance, if someone doesn’t like cabbage, the replacement should be a food that has similar Vitamin C, such as tomatoes. Since menus are planned to incorporate color, try to replace a food with a similar or a complementary color. Your facility should have a list of approved substitutes for your menu cycle. When making adjustments, always document the change and keep a record. This helps to prove during surveys that you are meeting client needs and preferences. See Figure 1.11 for food substitution choices.

Late Trays In a healthcare setting, it is essential to have a system for providing meals to clients who have just been admitted, whose diet orders have changed, or who have missed a meal due to testing or special procedures. Trays delivered between meal times are called late trays. Particularly in an acute care environment, diet-related information can change quickly. In many situations, late trays are cumbersome and expensive to produce and deliver. Obtaining required adjustments just before tray assembly can sometimes reduce the volume of added trays. Many healthcare operations strive to reduce out of sequence requests through their meal system design. Room service is an example of a service model that can virtually eliminate late trays, because all meals are provided on demand.

Summary Whatever menu or service style you use in your foodservice process, make sure there are adequate policies, staff training, and oversight to be able to provide the quality of service expected. You also need to establish policies for working with clients who choose foods that are contrary to the therapeutic diet that was ordered for them. In addition, a facility needs to devise procedures and provide adequate staffing to assist with person-centered dining. Now that you know what Style of Meal Delivery Service you have and what Style of Menu you provide to your clients, you can consider your options for a culture change in your dining services.

Glossary Late Trays Trays delivered between meal times

Foodservice Management—By Design

2 CH A PT E R

Menus—The Foundation of the Department Overview and Objectives

The menu is the starting point for many decisions involving purchasing, production, and service of food. You will examine the basics of menu planning and utilize techniques to provide satisfying meals for your clients. You will identify standard food weights and measures related to the meal service and portioning. You will also review both your legal and moral responsibilities for providing nutritious food to your clients. After completing this chapter, you should be able to: 3 Identify how the menu impacts the dining services department 3 List resources available for menu planning and development 3 Identify how cultures can impact the menu 3 Define how the menu affects the department budget 3 Describe how management decisions affect the menu 3 Evaluate the quality and accuracy of each meal service

y now, it is clear that a menu is a strong force in achieving client satisfaction. It has been said that the menu drives everything in the kitchen. It is also a means of communicating with clients—and even marketing your fare to future clientele. However, it’s more than that; a menu governs the series of events that define the department’s overall workflow. Figure 2.1 identifies this process in a simplified format. As you can see, recipe specifications, the products you need to carry in inventory, production information for the prep staff, and the final food presentation all hinge on the menu plan. In addition, the menu may define the requirements for staffing, equipment, physical layout and design of the department. Figure 2.1 displays the basic steps in the workflow, starting with menu planning through to meal delivery. Ultimately, the financial performance of your operation rests heavily on your menu. What it costs to produce and serve meals impacts your expenses. What you sell in cafeterias and retail venues impacts your revenues. In short, the menu is a critical and dominant force in your operation. As such, it merits special attention and careful planning. As you learned in Chapter 1 there are several styles and types of menus used in Dining Services. Each one is designed to meet the needs of the individual facility. In this chapter, the process of writing and revising menus will be covered. This will include the steps to track and monitor the quality and approval of your dining service to the clients.

Foodservice Management—By Design

Menus—The Foundation of the Department Figure 2.1 Simple Flow of Work in a Foodservice Operation Plan a meal

STEP

Create recipes Specify, purchase, and store food

STEP

Create production documents Prepare food

STEP

Deliver and serve food to clients

Menu Planning Considerations Whether a menu is written in the facility or purchased from a third party, several points need to be considered to ensure a quality menu is offered to the clients.

Key Points Customer/Client Satisfaction The most important consideration in menu planning is satisfying your customers/ clients. Chapter 7 will address the many ways to monitor and track customer satisfaction. Audits to evaluate “Plate Waste,” client surveys or “Menu Score-Cards” help identify opportunities for menu edits. In an effort to improve client satisfaction and meal consumption, many senior living facilities have moved to a more liberalized menu, allowing more options for all modified diets. However, it is still important to include special needs such as cultural factors, food habits, and especially food preferences and diets when planning your menus. Facilities often use a menu developed by their corporate office or a third party. It is essential to adapt this menu to the needs, wants, and regional preferences of your clients.

Foodservice Management—By Design

Menus—The Foundation of the Department

Nutrition and Other Resources Nutrition considerations should also be a primary goal of menu planning. It is important to maintain adequate nutritional status, to the highest extent possible. There are a number of resources to help; some of those include the Dietary Guidelines for Americans, (refer to the most updated at www.DietaryGuidelines.gov as these guidelines are updated every five years) the USDA DRI (Daily Reference Intakes), MyPlate (www.ChooseMyPlate. gov), facility diet manual, and Recommended Dietary Allowances (RDAs). Note that these resources are updated on a regular basis and the dietary manager should look periodically for the most current resources. Figure 2.2 on page 32 lists a number of standards that might be used to evaluate the nutritional content of your menus.

Modified or Restricted Diet Menus Often in healthcare settings, menus need to be adjusted to meet the dietary restrictions ordered by medical staff. While many menu items will not need to be altered to meet the dietary restrictions, some items may require ingredient changes or elimination from the menu as planned. Some managers have gone to a “one pot cooking” method for dealing with dietary restrictions. In essence, whatever the identified ingredient is that requires restriction is eliminated from all or most recipes making the recipe work across all diets. Many dining services have adopted a salt-free, fat-free and even sugar-free menu to allow for a single gravy, vegetable and entrée to be served to all clients. While this is a quick and simple answer to the problem it effectively penalizes all clients to the most restrictive of diets. Most clients do not need to follow all of these restrictions and find the limited palate of meal options unsatisfactory. Keep in mind that client satisfaction may be related to reimbursem*nts and clientele retention. Often the access to liberalized diets in senior living facilitates allows for the use of a more acceptable variety of foods on the menu. When the nutrient analysis of a menu dictates an alternate is required for some clients, the use of a modified recipe or totally different item is in order. Planning a menu with alternate items that mix well with the primary base menu (sides or entrées as appropriate) helps control the number of different items that need to be prepared. Specific information on Nutrition Therapy and food restrictions are covered in the Nutrition Fundamentals and Medical Nutrition Therapy textbook which accompanies this textbook in many Dietary Managers’ Training programs.

Glossary

Cultural, Regional, and Religious Considerations Cultural heritage should be a consideration when planning menus. To understand this aspect of menu planning, try asking yourself some questions. What does turkey and dressing with cranberry sauce mean to you? Many people will answer: Thanksgiving. This food has become part of a cultural tradition. Now, think about a wedding celebration. What food will always be served? Most people will answer: a wedding cake. Or, in China, the answer may be: roasted pig. Now, try another question. What food has become a symbol of American heritage and pride? Many people will answer: apple pie. From these examples, you can see that we regard food choices as cultural symbols. The meaning of these foods is much deeper than a sum of protein, carbohydrate, fat, vitamins, and minerals—the sheer nutritional values. Many food choices arise from what we learn through our own cultural experiences. Holidays, festivals, and important events each have associated foods. In addition, daily

Dietary Guidelines for Americans Dietary guidelines that encourage Americans to focus on eating a healthful diet that focuses on foods and beverages that contribute to achieving and maintaining a healthy weight, promote health, and prevent disease

Foodservice Management—By Design

Menus—The Foundation of the Department

Figure 2.2 Nutritional Guides or Standards for Menu Planning Name of Guide

Source

Dietary Guidelines for Americans

http://health.gov/DietaryGuidelines/

MyPlate

Department of Health and Human Services and U.S. Department of Agriculture: U.S. Department of Agriculture: www.choosemyplate.gov

Recommended Dietary Allowances

http://fnic.nal.usda.gov/dietary-guidance/dietary-reference-intake?

Exchange Lists for Diabetes or Renal Disease

Academy of Nutrition and Dietetics or American Diabetes Association

Nutrition.gov:

www.americandiabetes.com/using-exchange-lists-diabetes- meal-planning/

National Kidney Foundation: www.kidney.org/atoz/atozTopic_Nutrition-Diet.cfm

Centers for Medicare & Medicaid Services

www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/SOM107ap_pp_Guidelines_ltcf.pdf

National Dysphagia Diet

American Speech-Language Hearing Association:

CMS:

www.asha.org/SLP/clinical/dysphagia/Dysphagia-Diets

Nutrition411.com: www.nutrition411.com/?s=National+Dysphagia+Diet

National School Lunch

USDA Food and Nutrition Service: www.fns.usda.gov/nslp/national-school-lunch-program-nslp

School Nutrition Association: www.schoolnutrition.org

Facility Diet Manual

Check with facility dietitian or state regulations for a current diet manual or complete an online search for “healthcare diet manual” for additional resources

Corrections Food Guidelines

http://www.acfsa.org/fedRegs.php

food choices vary by culture. Traditional German cuisine, for example, is likely to include sausage, schnitzel, spätzle, beer, and other specialties. Japanese cuisine includes sushi, tempura, and rice. Swedish cuisine may include pancakes, even at meals other than breakfast. Mexican meals include staples such as tortillas, rice, and refried beans. Creole cooking, popular in New Orleans, represents a fusion of French cooking using locally available foods such as shrimp and intense spices, mixed with influences from local Caribbean and Spanish cultures. As a land of immigrants, the U.S. enjoys a multi-faceted cultural diversity. Our menu choices are as rich and complex as our population itself. It is important to look at the populations in the facility to determine what menu items should be added to meet the cultural diversity. Below are some of the more commonly seen ethnic regions that have migrated into the United States. Please note that this is not the full list but a sampling. Hispanic/Latinos. The United States Census Bureau defines Hispanics as those who indicate their origin to be Mexican, Puerto Rican, Cuban, Central or South American (e.g., Dominican, Nicaraguan, and Colombian) or other Hispanic origin. The largest of these is the Mexican-American population, which represents at least two-thirds of all Hispanics/ Latinos. According to a national survey conducted by the U.S. Department of Agriculture, 22

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“Hispanics tend to eat more rice but less pasta and ready-to-eat cereals than their nonHispanic white counterparts. Hispanics are also likely to consume vegetables, especially tomatoes, although they have a slightly higher consumption of fruits. Compared to nonHispanic whites, Hispanics are more than twice as likely to drink whole milk, but much less likely to drink low-fat or skim milk. Hispanics are also more likely to eat beef but less likely to eat processed meats such as hot dogs, sausage, and luncheon meats.” Legumes and corn in combination are good and common sources of protein and, along with cheese, are frequent ingredients in Hispanic ethnic meals. East Indian Americans. Staples of the Indian diet include rice, beans, lentils, and bread. Rice is usually served steamed and mixed with flavorings. Indian breads include chapattis, round flatbread made of whole wheat flour; and naan, a bread that uses yeast. India’s religious beliefs have also influenced the diet of Indians (e.g., Hindus believe that cows are sacred so they do not eat beef.) Chicken or lamb, in moderation, is augmented with vegetables, dried beans, lentils and split peas. Curry powder, a mixture of spices, is often used to flavor Indian foods. The heart of Indian cooking is the combination of spices that gives each dish its unique flavor. Indian cuisine has become increasingly popular during the first decade of the 21st Century with over 1200 Indian food products now available in the U.S. Chinese Americans. Vegetables, rice, noodles, fruits, and foods made from soybeans (such as tofu and soy milk) are very important foods in the Chinese-American diet. Plain rice is served at all meals. Sometimes fried rice is served. Pork, poultry, and fish are popular and used in small amounts to flavor the rice. Foods are often seasoned with soy sauce, which is high in sodium. (Low-sodium versions can be purchased). Corn oil, sesame oil, and peanut oil are used. Tea is the main beverage and it is almost always enjoyed black—without sugar, cream, or milk. Fruits are important and few sweets are eaten. Cow’s milk and dairy products are not used often (lactose intolerance is comparatively common in the Asian population). Japanese Americans. Some people are surprised to learn that Japanese food is quite different in appearance and taste from Chinese food. While Chinese food is often stirfried, Japanese food is often simmered, boiled, steamed, or broiled. Also, Japanese foods are not as highly seasoned as Chinese dishes. Sushi, a rice wrapped in seaweed has become a popular food choice in the U.S. in the past decade. Rice is the staple of many Japanese-American diets, along with a variety of noodles. As in Chinese cooking, soybean products, such as soy sauce, are important. Seafood is generally more popular than meat and poultry. Vegetables, such as watercress and carrots, are an important part of most meals. Tea is the most popular beverage, especially green tea, an excellent source of antioxidants. Middle Eastern Americans. Foods of choice in a traditional Middle Eastern diet include yogurt, cheeses (such as feta and goat cheese), lamb, poultry, chick peas, lentils, lemons, eggplant, pine nuts, olives, and olive oil. A Greek specialty is baklava, a baked dessert made with nuts, honey, and filo dough. Common cooking styles are grilling, frying, and stewing. See Figure 2.3 for cultural food influences. Here are more examples of cultural and ethnic food influences.

Foodservice Management—By Design

Menus—The Foundation of the Department Figure 2.3 Cultural Influences on Food Intake in the U.S. ASIAN FOOD GROUP

HISPANIC/ LATINO

Grains

Tortillas (some made with lard) and rice

Vegetables

(China, Japan, Korea, Southwest Asia)

MIDDLE EASTERN

EAST INDIAN

Rice noodles

Couscous, tahini, pita bread, and filo dough

Rice and whole wheat flatbread (naan)

Cactus, cassava, chayote, jicama, peppers, pinto beans, and tomatoes (salsa)

Garlic, ginger, mung beans, sprouts, bamboo shoots, bok choy, cabbage, and carrots

Tomatoes, olives, lentils, hummus, grape leaves, and eggplant

Red lentils, pigeon peas, legumes, and curries

Fruits

Avocado, bananas, guava, mango, papaya, plantain, and citrus fruits

Mango, banana, citrus fruit, coconut, and pineapple

Dates, figs, and citrus fruits

Coconut, watermelon, and mango

Meat

Chorizo (sausage and other processed meat), goat, meat, tongue, and pork

Small amounts of meat especially fish, eggs, and tofu

Small amounts of lamb, fish, and chicken

Mostly vegetarian— some mutton chicken and fish

Dairy

Goat cheese, goat milk, and whole milk

Soy milk

Yogurt and feta cheese

Milk, butter, and yogurt

Note: This is not a complete list of foods. All of these cultures have diets that vary from one region/country to another.

Regional Trends Part of the cultural heritage unique to the U.S. is the development of regional culinary trends. Often, these trends reflect a mix of native cultures, foods that are grown and harvested in the area, and ethnic traditions contributed by settlers and immigrants over time. For example, New England is known for maple syrup, Boston beans, brown bread, and cranberry muffins. Maine is recognized for lobster. Blueberries are important in New Jersey and in the Midwest, where many are grown. In Pennsylvania and parts of Ohio, the Pennsylvania Dutch heritage gives rise to scrapple (a loaf made from meat scraps, broth, and flour), homemade noodles, and shoofly (molasses) pie. Vidalia onions are a hallmark of Georgia’s cuisine and are the official state vegetable. Peanuts and peaches are also key crops in Georgia. Florida is known for key limes and key lime pie, coquina soup, and other specialties. Kuchen is the official state dessert in 24

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South Dakota. Most people associate Idaho with potatoes and New Orleans with Creole cuisine, such as jambalaya, dirty rice, and gumbo. Barbecued meats and pickled okra have special significance in Texas. In the Southwest (Arizona, New Mexico, Oklahoma, Texas), Mexican-style foods such as burritos and tacos are popular. Garlic is so important in California that the town of Gilroy celebrates an annual garlic festival. In fact, food celebrations, such as strawberry harvest festivals, maple syrup festivals, and many others, are key events in all parts of the country.

Religious Practices Religious beliefs, along with religious customs and rituals, can exert a strong influence on menu planning. Fasting is one practice that many religions observe. The length of time one fasts varies with his/her religion and can range from one day to a month. Some Muslims observe Ramadan, which lasts for one month and fasting occurs from sun up to sun down. Religious laws will also affect menu planning. For example, the Jewish faith has their own religious beliefs including building kosher kitchens which separate the meat from dairy when cooking. The Islamic faith has guidelines for the sourcing and cooking of halal foods. Some religious beliefs are specific to the time of child birth and the 6-8 weeks following birth. Many religions and cultures have specific food requirements for their dying loved ones. Developing a menu has now become more complicated for the Certified Dietary Manager as they must think about how to include these practices into the process for the facility. Identification of the presence and cultures of various ethnic and religious groups in your local population may require additional research into the food preferences and dietary restriction of those groups. Ethnic populations may influence large areas of the country, state or local community. For example, one-third of all Somalis living in the United States live in Minneapolis, Minnesota. Just 10 miles away in St Paul, you will find the largest single community of Hmong residents in the United States. Both of these cities also share a unique blend of Norwegian, Swedish and Danish heritage along with the significant presence of Native American tribal history. The Certified Dietary Manager is well-advised to verify the multiple cultures and religions present in their local community and to incorporate the dietary restrictions and food preferences into their menu planning.

Government Regulations Government regulation is another type of resource that plays a major part in menu planning. These regulations govern the type and quantity of food served at a meal. The Centers for Medicare & Medicaid Services (CMS) is a branch of the U.S. Department of Health and Human Services. CMS is the federal agency that administers the Medicare system and monitors the Medicaid programs offered by each state. All healthcare facilities have mandatory state licensing requirements. The facility is held to the strictest regulatory requirements, either state or federal. It is important to know and follow local and state regulations. These guidelines are dynamic, meaning they change constantly. Work with your facility administrator to make sure you have the most recent CMS guidelines that impact menu planning. If you work in a federal or state funded school system, you will be expected to follow the USDA National School Lunch Program. Critical upgrades were made through the Healthy,

Putting It Into Practice 1. As a new Certified Dietary Manager, you want your menu to address the cultural differences of your customers. What is the first step to implementing a cultural change movement in your facility?

Foodservice Management—By Design

Menus—The Foundation of the Department Hunger-Free Kids Act championed by the First Lady, Michelle Obama. More details on the Nutrition Standards for the National School Lunch Program can be found at http://www.fns.usda.gov/school-meals/nutrition-standards-school-meals. Also work with your school administrator to make sure you have the latest guidelines.

Color, Texture, and Shape Think about this menu, unbreaded baked cod, cauliflower, scalloped potatoes and vanilla pudding. Everything is white, round and the meal has strong competing flavors in the fish and cauliflower. This meal is often seen on menus and not widely accepted by clients. While there are times when the flavors and traditions, such as Thanksgiving Dinner, warrant a meal of competing flavors, it should not be seen on a regular basis. Well written menus not only look at the nutritional balance but also look at the color, texture, mix of strong and mild flavors and the shape of food on the plate. When the meal looks and tastes good, clients will be more apt to enjoy their food. One tip would be to prepare the planned menu and take a photo of the plate. This will tell the story around the appearance of the plate and what adjustments may need to be made. Look for all of these characteristics: • Color—Is there a variety and balance? • Shape—Is everything round, linear, wedged? • Texture—Is it diced, chopped, formed or mushy? • Plate Coverage—Is there a good balance across the plate (too crowded or empty)? • Seasoning—Is there a mix of mild and spicy? • Flavor—Is there bland or mild foods to complement the stronger meats or vegetables? • Food Group Balance—Is there a mix of protein, vegetables, and starches? • Consistency—Is everything in a sauce or gravy? • Overall—Look at the whole meal as served, not just the main plate. > The grilled chicken breast with herbed rice and mixed vegetables may look fine until you see the rest of the meal with coleslaw and fruited (fruit co*cktail) lemon gelatin, and sugar cookie. > Suddenly the whole meal is one color of mostly chopped up food items. Photos of the plates and meals assist you in identifying some simple-to-make menu errors. It also helps the staff to maintain a consistent plate presentation for the client.

Sanitation regulations can also play a part in menu planning as they dictate the temperature to which foods must be cooked or reheated prior to service. A beautifully prepared roast beef may have perfect plate presentation when cooked for the time of service. However, the same roast in a cook-chill operation needs to be reheated to a rather 26

Foodservice Management—By Design

Menus—The Foundation of the Department

well done 160° prior to service. How quickly food needs to be cooled, the appropriate storage time of cooked and raw foods and reheating guidelines all affect the safety and often the serving quality of foods. More will be discussed related to sanitation in chapter 19. More details on the regulations can be obtained from federal, state, and local agencies.

Special or Single Use Beyond the regular cycle menu that is planned for the clients of the facility, separate menus are often prepared to use for special events, theme meals or holidays. Many times these meals are designed to help break the monotony of a cycle menu. These menus may evolve out of a client food committee designed to incorporate their input into the meal planning process. Retail cafeterias are typically located in schools, hospitals and other institutions that provide meal services that may be offered to the customer/student. This type of menu may provide a complete meal at a fixed price or al a carte pricing. A complete meal might include an appetizer, a salad, an entrée, a starch, a vegetable or fruit, a beverage, and possibly dessert. For example, a school lunch menu may offer a pre-defined list of foods that constitute a meal. Typically, these are planned in conjunction with USDA guidelines. See Figure 2.4 for an example. Figure 2.4 Sample Special Menu 1 (St. Patrick’s Day) for a Hospital Cafe Appetizers • Baked Spinach Artichoke Dip with Pita Chips • Bruschetta with Edamame Pesto Entrées • Corned Beef • Irish Stew Accompaniments • Baked Cabbage with Bacon • Boiled Potatoes and Carrots Bread • Irish Soda Bread with Raisins Desserts • Crème de Menthe Pie • Chocolate Zucchini Cake Reviewed 2015.

A la Carte An a la carte menu allows clients to select each item they desire for a meal. In a retail setting, each menu item is priced individually. This may be used in campus dining or in schools. It is also common in many employee and visitor dining cafeterias.

Foodservice Management—By Design

Menus—The Foundation of the Department Standard Weights and Measures An essential part of menu planning is using standard food weights, measures, and recipes correctly. Within the menu planning process, consideration has to be given to the food being served in terms of quantity on the plate, nutritional value of the foods and cost controls. Serving sizes are specified in the menu design itself. If a cup of soup is planned as an appetizer, the quantity is significantly less than a bowl of the same soup served as the entrée of the meal. The Purchasing Supervisor needs to know the serving sizes and number of servings so they order the appropriate amount of raw ingredients. The Production Team needs to know the serving sizes of items so they prepare the correct amount of food. The Serving Staff need to know the serving size of each menu item so they can plate the meal correctly. Registered Dietitian Nutritionist, Dietetic Technician, Registered/Nutrition and Dietetics Technician, Registered and /or Certified Dietary Manager need to know the serving sizes to evaluate the client meal intake for dietary intake tracking. To plan a menu, you and your staff need to know how many servings in a full-size steam table pan, how many servings from a quart when using a disher/portion scoop, how many tablespoons in a cup, how many servings you can expect from a case of fresh broccoli, etc. One very helpful book that provides these charts for standard weights and measures is Food for Fifty by Mary Molt. This reference also contains many quantity recipes that may help you in revising menus to meet your facility/client needs. The need for accurate weights and measures in the recipe and production process are addressed in Chapters 3 and 4 of this textbook.

Menu Substitutions and Alternates/Standard Write-in Menu Even with liberalization, another issue often arises—the need for substitutions on the menu. A substitution is a product that replaces a planned menu item when requested by a client or family member because he/she does not like or refuses to eat the food being served. Centers for Medicare & Medicaid Services (CMS) regulations specify that requests for substitutions should be permitted and honored, as long as they are reasonable and achievable. A substitution must be of similar nutritive value. On a selective menu, some Certified Dietary Managers use the term menu write-in to describe the same idea. A client may write an item on the menu that was not part of the planned cycle. Providing substitutions upon request is part of the concept of giving clients control over their care; meal choice is considered a client right. Adjusting offerings to a client’s requests helps to ensure optimal nutritional intake. In all, honoring substitution requests contributes to quality of life, especially for nursing facility clients. What should a Certified Dietary Manager do with a substitution request? The answer is, honor it or provide an alternate choice. While some choices are not feasible, many options may exist. For a long-term client, a Certified Dietary Manager may be able to accommodate a special request. Sound management and practical realities dictate that the substitution process be planned and organized as part of the menu. One way to provide substitutions is simply to offer alternate choices on a menu or in the service setting itself. This eliminates many of the challenges of providing substitutions at the last minute. It is one reason that some long-term care facilities have changed to selective menus. On a selective menu, clients can choose their substitutions or alternates in advance of service, and dining services staff can tally requirements in time for production. 28

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Menus—The Foundation of the Department

With the goal of honoring client requests, a Certified Dietary Manager may also develop a list of “Always Available” write-in requests that can be accommodated in the kitchen. The manager can plan production of these items in conjunction with routine meal service or is at least prepared to honor these requests efficiently. Some write-in list offerings may cross over with items prepared daily for another service area, such as a cafeteria. Essentially, this write-in list becomes its own supplementary menu. Designated staff may refer to this menu to guide clients towards practical substitutions.

Management Considerations Since the menu drives what you do in food production, it also drives your labor and food costs. Other management considerations are: delivery methods, timing, labor, equipment, and food availability. • Production, Service and Delivery Methods. Your menu needs to coordinate with your type of service. For instance, if you are doing display cooking, a stir-fry would be a great menu item. However, for cafeteria service where food may be held on a steam table, stir-fried items may lose quality and prove a poor choice. If you use cook-chill rethermalization methods for trays that are pre-assembled and chilled, it’s important to examine what products stand up well to this process. Sometimes food thickness and the presence of liquids, gravies, sauces, and other aspects of the menu items you specify can influence quality achieved through various systems. Before adding items to a menu, test recipes through your own equipment and systems to find out how well they work. • Budget and Cost. Next to labor, food cost is the second largest expense for your department and maybe even for the facility. This means managing food cost is a very important part of your job. Many facilities determine their food cost per client, per day and your budget is allocated accordingly. Whether your menu uses foods from raw ingredients or pre-prepared foods items, both will impact your budget and your menu planning process. Further discussion of this and other budget controls is in Chapter 26. • Timing and Labor. How long it takes to prepare each menu item is an important consideration. Some menu items are more time-intensive than others. If you include a product that requires intensive preparation, you may need to pair it with a convenience or low-prep item to balance resources. The production schedule dictated by the menu must be realistic. In addition, you must match your menu to the skills of employees responsible for producing the menu items. Culinary challenges presented to minimally trained employees can lead to increased costs through the loss of food or time. On the other hand, a facility that has a trained chef can use this resource to incorporate sophisticated techniques and preparation while holding food costs down. Through focused training, a Certified Dietary Manager can broaden the skills of food production employees so as to incorporate specific menu items that require specialized techniques. Your foodservice department management team can help with menu planning by using their respective skills. For instance, the Certified Dietary Manager may provide input into the menu from the perspective of managing production. An Executive Chef can provide expertise on food items and preparation techniques. The Registered Dietitian Nutritionist can provide specific nutrition and therapeutic diet guidelines. The Diet Office Clerk or Serving Line Checker can identify the items that have frequent call backs for a second choice. The Dishroom Attendant can tell you what is returning on the plates uneaten. Each area of the department can contribute to the development of a better menu for the clients. Foodservice Management—By Design

Menus—The Foundation of the Department • Equipment. Menu items may require a broad variety of equipment. Consider each proposed menu item in terms of physical layout and equipment. You also have to consider what equipment will be in use at each time throughout the day. You may not have enough oven space if every menu item for a given meal requires the use of the oven. Storage equipment and transport/delivery requirements can be related concerns. • Availability of Food. What ingredients are available for your menu may be impacted by where your facility is located. Consider a rural facility that is 100 miles from a metropolitan center. You won’t be able to get an immediate delivery of a special menu item. With the current emphasis on purchasing locally, your menu may reflect the ingredients that are available in your geographic region, such as Idaho potatoes, Washington apples, or Wisconsin cranberries. Weather may also impact what menu items are available. If there is a freeze in Florida, oranges or orange juice might be available but at a price too high for your department budget. The availability of many of your produce items may be affected by weather and you may have to adjust your menu accordingly.

Monitoring the Menu and Meal Service The best meal service starts with a well-planned menu and finishes with a well trained staff. No matter how well designed the menu is, staff competencies and performance determine the final presentation of the meal to the client. During the meal service there are several steps that require monitoring. • Testing of the recipes for product performance and palatability is only the beginning. • Training of the Production Team on the techniques required to make the menu items and the use of standardized recipes (discussed in detail in Chapter 3) starts the meal service. • In addition to the standardized recipes, the use of Ingredient Pull Lists and Production Sheets with appropriate panning charts ensures the right items come to the serving line in the correct serving pans. • Specification of portion sizes and serving utensils helps standardize the portion control. • Pre-line meetings to taste the food and sample plate demonstrated the correct plating of the meal for consistency and presentation; and allows for any corrections to be made prior to the time of service. • Documented pre-line temperature logs ensure that food is reaching the serving line at the appropriate temperature. It allows for any corrections to be made prior to the time of service; this is for both HOT and COLD food (milk sitting at room temperature during a one hour serving line will be close to room temp by the end of the line—yuck).

Putting It Into Practice 2. How would you adjust the following menu so it doesn’t overload the same equipment? • Baked Chicken • Scalloped Potatoes • Green Bean Casserole • Baked Apples

• Monitoring the start and stop times of the meal service, and the time needed to deliver the meals (longer delays cause greater temperature loss). > If the serving line is stopping for re-supply of items, either: • your production numbers were not correct—or they didn’t make the amount specified; • the serving size on the line is over-portioned and they are running out; • the Production Team is not keeping up with the batch cooking; or • the Production Team is not focused on their primary task—Serving the Clients. • Check random trays for accuracy to the items specified on the menu and compliance with all diet restrictions and allergies. • Assess the trays for plate presentation, attractiveness and placement of the items on the tray or table setting.

Foodservice Management—By Design

Menus—The Foundation of the Department

• The mid-line temperature of the food being served—are appropriate temperatures being maintained. • Monitor the number and frequency of call-backs for a second meal selection. • Record the Over Production and Run-Out/Shorts for the line. > Why were the production numbers wrong (over or short)? > What did you substitute for the products you were short? • Observe the dishroom after the meal for what is coming back on the plate • Conduct Meal Rounds in the dining rooms talking with the clients or in the patient/ resident rooms during the meal service times • Conduct Test Trays/Meals > Sample the food as a complete meal at the point of service in the dining room or in a patient/resident room • Take temperatures • Taste the food • Ask nursing and support staff to participate in the Test Trays Information is your friend. Know what you expect and verify that it is the level of service you are providing.

Menu Revision In the foodservice industry, most experts agree that a menu should not become static. For both ongoing and occasional clients, periodic revisions are a necessity. Here are some events that might signal a need for menu revision: • Client Feedback. Client suggestions, along with information gathered through surveys, often begin to show patterns. A suggestion that arises repeatedly—or a complaint about a particular menu—can be triggers for revision. • Seasonal Change. People choose different foods at different times of the year. Summer foods may include salads, chilled entrées, and produce in peak season. Winter foods (where winters are cold) may include more soups, stews, and seasonally available produce. • Trends and Fashions. Ever-changing, the world of food experiences culinary innovations as well as trends. Keeping pace with these helps a facility compete in the industry. For instance: edamame was not well known 20 years ago; today it is a common restaurant menu option. • Special Requests. A Certified Dietary Manager may monitor items that clients request or add to their own menus. If a request appears repeatedly, it may be time to add the item to the menu or increase its frequency. • Sales Records. If you are monitoring sales records or selection data for the menu, you may discover that certain items are proving unpopular. One of the jobs of a Certified Dietary Manager is to identify menu “duds” and replace them with products clients prefer. • Quality Issues. Similarly, a Certified Dietary Manager conducting routine quality checks may determine that a certain item is not holding up well on the menu. There may be a solution. Changing the procedure or the recipe, using different techniques or equipment, or training staff may make a difference. If not, the item may need to be replaced.

Foodservice Management—By Design

Menus—The Foundation of the Department • Changes in the Physical Facility. Remodeling, renovations, or reallocation of space in a facility may impose changes on the foodservice department. Perhaps the opportunity exists to build an expanded cafeteria. A Certified Dietary Manager may explore a food court concept and its related menu implications. Or a facility may have an opportunity to build a group dining area, where buffet service is an option. The menu needs to change accordingly. • Service Revisions. Sometimes a Certified Dietary Manager faces the need to develop new services or serve new clients. In addition, mergers and acquisitions may present new requirements to serve remote facilities. Integrating service changes with existing schemes may provide cause for re-evaluation of the menu as a whole and all related coordination issues. A proposed menu revision should undergo evaluation for any nutrient standards that apply, as well as for costs. In addition, any menu revision creates ripple effects through the operational flow. To implement a change, systematically examine and plan related revisions required in staffing, service, delivery, inventory, purchasing, and food production. In all, you can see that a menu has great impact on every aspect of the foodservice operation. Designing a menu that meets your clients’ needs and expectations and uses your resources effectively is an enormous amount of work. However, the rewards are well worth the effort.

Tailoring Individual Menus—Honoring Legal and Moral Responsibiltiies Every healthcare menu system must have a method for ensuring that every client receives a meal, even if selections have not been made. Clients who do not complete a selective menu receive a house diet or default selection. For a client whose preferences are known, a member of the clinical staff may complete a menu based on care plan or client preference record. This information may be tracked in a diet office software system. Furthermore, every menu communications system must include control steps to ensure that foods planned for the individual menu meet the current diet order prescribed by the physician. Whether menus are selective or non-selective, spoken or paper-based, or implemented through trayline or buffet service, trained foodservice staff must assist with individual menu review before a client consumes the meal. Figure 2.5 on page 46 lists some of the criteria for menu review. Reviewing menus can be time consuming. Certified Dietary Managers can structure menu systems to minimize this. For example, there are computer programs to review menu choices in order to check for compliance, calculate totals for restricted nutrients (such as sodium, protein, or fluid), eliminate allergenic foods, or automate routine food additions. This process requires that staff maintain a computerized set of care plans or client preference records.

Putting It Into Practice 3. You decide to update your menu. What are three indicators of where to make changes?

When a foodservice staff member makes adjustments to a menu, communicating this with the client is important: • If the client does not know the menu has been adjusted intentionally, the revisions may be perceived as an error. • Menu review provides an opportunity for a dining services staff member to explain a meal pattern or other adjustment. • Discussing adjustments opens a dialogue with the client about diet-related needs and preferences.

Foodservice Management—By Design

Menus—The Foundation of the Department

Figure 2.5 Criteria for Individual Menu Review (Healthcare) Before a client receives a tray and consumes a meal, trained foodservice staff must review individual menus and answer the following questions:

Q Do the selections provide a well-balanced meal, or has the client selected choices from nearly all categories (e.g., entrée, vegetable, starch, beverage, etc.)?

Q If the client’s diet order specifies combined modifications, such as sodiumrestricted and carbohydrate-controlled, are selections compliant with these restrictions?

Q If the client has a meal pattern or a carbohydrate count, how do the totals compare to the plan?

Q If the client has a fluid restriction, how do the figures add up?

Q If the diet order or kardex lists specific foods to avoid, (e.g., allergies or food intolerances) have these items been removed from the menu?

Q Are appropriate condiments included (e.g., margarine for bread, dressing for salad, etc.)?

Q Q If texture modifications (e.g.,

mechanical soft diet or National Dysphagia Diet levels) are part of the diet order, does each menu selection comply with the order?

Q Are portion sizes indicated on the menu appropriate for this particular diet order?

Q If the client has requested a

substitution, is the request honored?

Q If the diet order or kardex lists specific additions for meals (e.g., nutrition supplements), are these items included?

It is the responsibility of the department director, dining services staff and Certified Dietary Manager to provide nutritionally adequate meals to clients. Sometimes there are specific requirements for patients, residents and school foodservice or one of customer choice. Planning a menu that meets the needs of both groups in a cost effective and efficient manner is the goal of every manager.

Putting It Into Practice 4. A client requests a menu item that is not allowed on their diet. What do you do?

Foodservice Management—By Design

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