MICHIGAN STATE UNIVERSITY
COLLEGE OF HOME ECONOMICS
EAST LANSING, MICHIGAN

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I 6/01 animus-p.34

ABSTRACT

FOOD DISTRIBUTION SYSTEMS IN
MICHIGAN EXTENDED CARE FACILITIES

BY

Sister Nancy Raley, C.PP.S.

This study was concerned with developing an over-
view of food service to patients in Michigan extended care
facilities by a) determining the present on-premise patient
food distribution practices, b) examining the vieWpoints of
persons directly responsible for the management of the food
service with respect to the adequacy of their food distribu-
tion practices for their current and developing facility
needs, and c) identifying the current and developing prob—
lems of on-premise patient food distribution systems associ-
ated with organization change and facility expansion.

For this investigation, a sample of 79 Michigan
extended care facilities responded to a twelve-page mail
questionnaire which, in order to characterize the facilities,
was directed toward eliciting organizational data about the
total facility and the essential elements concerned with the
Operation of the food service. Personal interviews in a
selected sub-sample of 18 of the extended care facilities

were used to gain more Specific information concerning the

Sister Nancy Raley, C.PP.S.

food service and the Opinions of the food service manager.
In both cases, data were sought from persons responsible for
the management of the food services for the facilities.

Results of the study indicate that patient food
service in the extended health care units surveyed varies
greatly among facilities. In many cases, the systems of
patient meal distribution are neither adequate nor efficient
for the needs of the patients and the resources of the
facility. Efficiency could be markedly improved in many of
the existing food services by procedural modifications at
relatively nominal cost. Opinions expressed by managers of
the 18 food services reveal only a limited awareness of
problem areas in their resPective food services but express
willingness to utilize practical counsel from food service
specialists in order to improve their Operations.

Despite the limited scope of this fact-finding study
there is evidence that non-metrOpOlitan Michigan extended
care facility food services need assistance in organization
and management. Related investigations with a larger number
of metrOpOlitan facilities are needed to supplement these
data and to further identify the basic problem areas in this

important segment of the health care institutional complex.

FOOD DISTRIBUTION SYSTEMS IN

MICHIGAN EXTENDED CARE FACILITIES

BY

Sister Nancy Raley, C.PP.S.

A PROBLEM

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

MASTER OF SCIENCE

Department of Institution Administration

1970

ACKNOWLEDGEMENTS

The author wishes to express gratitude to
Dr. Grace A. Miller for her patience, support, and invalu-
able assistance during the author's period of graduate
work and during this study.

The author gratefully acknowledges the contribution
made by the extended care facilities which participated in
this study.

Special gratitude is extended to the Sisters of the
Precious Blood of Dayton, Ohio, who granted the author a
two-year sabbatical to pursue graduate study and to the
Department of Institution-Administration which provided

financial assistance.

ii

TABLE OF CONTENTS

CHAPTER

I. INTRODUCTION. . . . . . . . . .

II. REVIEW OF LITERATURE. . . . . .

Nursing Care and Related Homes

Number of facilities. . .
Beds available. . . . . .
Facility ownership. . . .
Patient characteristics .

Extended Care Services Under Medicare. . .

Medicare program. . . . .
Extended care services
Extended care facility
Facility participation
Patient benefits . . .

Participating institutions.

Units vs. facility type and ownership.

Beds vs. facility type and
Conditions of participation .

Dietary services . . .

Methods of food distribution.
Fact-finding Research Methods.

Survey sampling . . . . .
Survey techniques . . . .
Mail questionnaire . .
Personal interview . .
Survey instrument design

III. METHOD OF INVESTIGATION . . . .

The Mail Survey. . . . . . .
The sample. . . . . . . .
The mail questionnaire. .
The pre—test. . . . . . .

Questionnaire distribution.

The Personal Interview . . .
The sub-sample. . . . . .
The interview guide . . .
The interview . . . . . .

iii

ownership

Page

10
12
14
15
15
16
17
19
19

20
22
24
24
27

29
5O
5O
51
52

56

56
56
57
58
58
59
59
59
4O

TABLE OF CONTENTS-~continued

CHAPTER

Analysis of Data . . . . . .
The mail survey data. . .

The personal interview data

IV. ANALYSIS OF THE SURVEY DATA . .

Mail-questionnaire Findings.
Facility characteristics.

Food service department characteristics
Control of food service Operation.

Food service manager .

Responsibilities of the manager.

Department staff . . .

Contribution of volunteers

Meal service policies.

Resident patient meal service.

Meal distribution. . .
Menu policies. . . . .
Food service volume .
Personal Interviews. . . . .

Characteristics of the sub-sample
Characteristics of the food service
Opinions of the food service manager.

V. SUMMARY, CONCLUSIONS AND IMPLICATIONS

Mail-questionnaire Findings.
Facility characteristics.

Food service characteristics.

Personal Interview Findings.

Characteristics of the sub-sample
Characteristics of the food service
Opinions of food service managers
Conclusions and Implications of the Study.

BIBLIOGRAPHY . . . . . . . . . . . . .

Literature Cited . . . . . .
Additional References. . . .

APPENDIX . . . . . . . . . . . . . . .

iv

Page

40
4O
41

42

42
45

52
55
55
57
58
59
61
61
65
65
66
67
68
72

76

77
77
79
84
84
84
86
87

9O

9O
94

97

TABLE

1.

LIST OF TABLES

Page
United States Nursing Care and Related Homes:
1965 and 1967. . . . . . . . . . . . . . . . . . 9
Extended Care Facilities Participating in Medi-
care for the United States and for Michigan:
numbers of units and beds in 1967 classified by
type of facility and type of ownership . . . . . 21
Responses to Mail Questionnaire. . . . . . . . . 45
Responsibilities of the Food Service Manager . . 56

CHAPTER I

INTRODUCTION

The nursing care home, a relatively new phenomenon
in the American medical scene, has grown out of social,
medical, and economic changes in today's society. In the
five year period from 1965 to 1967, the number of nursing
care and personal care with nursing facilities in the United
States increased by 7 per cent and the number of beds by 85
per cent; for a total of 14,500 facilities with 775,200 beds
(55). In 1967 the national average for number of beds per
unit was 54 beds per facility and the trend is toward larger
unit capacities.

In Spite of this growth, both in the number and size
of nursing care and personal care wi£h_nursing care facilities,
many food service departments have continued to operate with-
out modifications consistent with the SCOpe and complexity
of the meal services required by the facility. As the number
Of beds per facility increases the on-premise patient food
distribution system necessarily grows more complex.

In January 1967, Federal insurance coverage for care
in skilled nursing facilities, termed extended care facili-

ties, became available to persons 65 years and over through

the Medicare program of the 1965 amendments to the United
States Social Security Act. This new legislation has pro-
vided additional impetus for the construction of new as
well as the renovation and/Or expansion of existing nursing
care facilities. Extended care represents a new level of
care designed to provide skilled nursing services in a high
quality extended care facility at less cost than in a
hospital.

Services of a dietitian are required for certifica-
tion under Medicare. This service can be provided on a
full-time, part-time, or consulting basis. The need is for
excellent food service departments which incorporate imagina-
tive solutions to nutritional and managerial problems. Good
food service can be an important asset to an extended care
facility. The quality of the food service may be more evident
to the patient, his family, and visitors than any other aSpect
of the facility. There is need for facility administrators
to a) recognize the importance of food service as an essen-
tial supportive health care service, b) examine the contribu-
tions which the food service department can, and indeed
should, make to the total patient care program, and c) ensure
that these concepts are translated into a workable, efficient
and productive program of action.

Although the demand for more and larger nursing care
and related facilities has generated considerable concern

for and serious study of general nursing care facility needs,

few studies have reflected parallel concern for developing
new or improving existing on-premise patient food distribu-
tion systems as essential components of these facilities.
Furthermore, little is known about the patient food distribu-
tion practices and problems which existing facilities are now
experiencing or will be facing in the near future as

licensed bed expansion takes place.

According to a recent report (55), in 1967 Michigan
ranked ninth in the United States in terms of numbers Of
nursing care and personal care wi£h_nursing care facilities
with totals of 567 and 85 facilities in these respective
categories. Of this 1967 total of 452 facilities, 108 or
24 per cent were certified as extended care facilities under
the Medicare program (1).

Consequently, this survey of current on-premise
patient food distribution systems of a sample of these Michigan
extended care facilities was undertaken in order to provide
descriptive data relative to the efficiency of systems cur-
rently in use and the actual or anticipated problems associ-
ated with facility eXpansion.

In planning the investigation, three basic assump-
tions were made:

a) Extended care facilities will continue to expand.
This expansion to optimum size will demand more efficient
on-premise patient food service systems than are currently

in use.

b) The number of nursing care and personal care with_
nursing care facilities eligible to participate as providers
of extended care services under'Medicare will increase.

Many facilities which are currently ineligible for Medicare
certification will modify their organizational structures,
policies, procedures, and physical plants to meet the certi-
fication requirements.

c) The availability of descriptive data concerning the
food service characteristics of extended care facilities
would be useful to persons responsible for planning and im-
proving the operational efficiency of patient food distribu—
tion systems in Michigan nursing care and personal care with
nursing care facilities.

The primary objective of this exploratory study was
to gain an overview of selected extended care facility
characteristics in terms of patient meal service a) by
determining the present on-premise patient food distribution
practices, b) by examining the viewpoints of persons
directly responsible for the operation of the food service
with respect to the adequacy of their food distribution prac-
tices for their current and developing facility needs, and
c) by identifying the current and developing problems of
on—premise patient food distribution systems associated with
organization change and facility expansion.

Following these introductory statements concerning

the rationale for and the stated purposes of the study, the

literature related to nursing care and related facilities,
the Medicare program and fact-finding research methods are
summarized in Chapter II. The’survey procedures used in

the study are described in Chapter III and the study findings
are reported and discussed in detail in Chapter IV. The
concluding chapter, Chapter V, includes a summary of the

findings and general conclusions drawn from the study.

CHAPTER II

REVIEW OF LITERATURE

The early history of nursing care facilities is
Obscure but their rapid growth in the past thirty years has
brought them into the medical scene today. The earliest
compilation of data on nursing, convalescent and rest homes
by the United States Bureau of the Census showed that in
1959 there were 1,200 facilities with a total capacity of
25,000 beds (7); by 1967 there were 19,200 nursing care and
related facilities with a total capacity of 846,000 beds
(55).

The expansion of nursing care and related facilities
can be attributed to a variety of social and economic
factors: the increased lifespan and resultant larger aged
population, the residential shift of the elderly from normal
family surroundings to institutional settings for required
health care services, changes in the patterns of illness
resulting from advances in medical technology, and the in-
creasing prevalence Of chronic disease. The effect of these
factors was further precipitated by the decline of the public
almshouse and the emergence of a new phiIOSOphy in public
welfare in the Social Security Act of 1955 and its 1965

amendments (27,54,55).

According to Baumgarten (5), nursing care and related
facilities are the least understood of all the health care
facilities in America. The goals, objectives, standards and
criteria for these facilities have not been clearly defined.
Because of the vagueness about the identity of the nursing
care facility, legal definitions of the term "nursing home"
vary among licensing bodies as well as among licensing laws.
In the State of Michigan a nursing home is defined as

an establishment or institution other than a hospital
having as one of its functions the rendering of healing,
curing, or nursing care for periods of more than twenty-
four hours to individuals afflicted with illness, injury,
infirmity, or abnormality.1
The existing information concerning the availability of
nursing home services, including age and health needs of
patients, costs of care, and sources of financing, is very
general and not uniformly reported (54).

According to the United States Bureau of the Census
Population Reports (50,51), between 1965 and 1967 the total
United States pOpulation for persons 65 years and over
increased 7 per cent while the total population for all ages
increased only 5 per cent. Bureau of the Census estimates
indicate that by 1970 both the total population and the popu-

lation for the group 65 years and over will have increased

an additional 4 per cent from the 1967 level.

 

1Michigan. Compiled Laws, Annotated (1967), Public
Act 1956, Number 159, Section 551.652.

8

Although, according to the latest Bureau of the Census
POpulation Report (52) the annual growth rate of the age
group 65 years and over has declined during the past 20 years
this age group remains the one that has grown most rapidly.
For about the first half of this century, the effects of
long-term declining fertility and mortality as well as the
higher rates of immigration in the early decades of this
century favored the higher annual rates of increase at the
older ages. In the fiscal year 1967-1968, the rate of growth
for the 65 and over age group was still higher than that for

the pOpulation of all ages.
Nursing Care and Related Homes

The National Center for Health Statistics (55) has
divided nursing care and related homes into four sub-classes
according to the predominate service provided: nursing care
homes, personal care wi£h_nursing care homes, personal care
without nursing care homes and domiciliary care homes. Totals
for the number of units in the United States, the number of
units in each of the sub-classes, and the number of beds
among and within sub-classes for 1965 and for 1967 are pre-

sented in Table 1.

Number of facilities
Of the 16,700 nursing care and related homes reported
in 1965, 49 per cent were classified as nursing care units,

50 per cent as personal care with nursing care units, 17 per

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cent as personal care without nursing care and 4 per cent as
domiciliary care units. By 1967 the total number of nursing
care and related homes had increased to 19,200 with corre-
sponding sub-class percentages of 55, 20, 25, and 2,
reSpectively. Although between 1965 and 1967 the total of all
sub-classes of nursing care and related homes in the United
States increased only 15 per cent, the number of units within
sub-classes changed considerably. During this 5-year period
the number of homes classified as nursing care units increased
51 per cent, personal care wg£h_nursing care decreased 22 per
cent, personal care without nursing care increased 52 per cent
and domiciliary care units decreased 57 per cent. These
changes in numbers of units within sub-classifications reflect
not only the previously mentioned social and economic factors
of this time period but also the impact of Medicare legisla—
tion and its specific requirement for skilled nursing service

in addition to personal care service.

Beds available

As shown in Table 1, in 1965 the total number of beds
available in nursing care and related homes in the United
States was 568,600. Of these, 56 per cent were in nursing
care units, 55 per cent in personal care wlhh nursing care
units, 9 per cent in personal care without nursing care units
and 2 per cent in domiciliary care units. In 1967 the total
number of available beds for all service classes was 846,000

with 69 per cent in nursing care units, 22 per cent in

11

personal care wi£h_nursing care units, 8 per cent in personal
care without nursing care units and 1 per cent in domiciliary
care units. Although between 1965 and 1967 the total beds
available in nursing care and related homes in the United
States increased 49 per cent, this expansion in the number of
beds available is reflected in only three of the four facility
sub-classes with by far the greatest percentage increase
occurring in the nursing care facility sub—classification.
The data reported in Table 1 also suggest that of the
two facility sub-classes which between 1965 and 1967 evidenced
growth in the number of units established, nursing care
facilities have tended to increase in unit size whereas
personal care without nursing care facilities have not.
Reports from the United States Public Health Service
(54,55) indicate that over the fourteen year period of 1954
to 1967 the national average for number of beds per unit has
doubled from 26.5 beds per facility in 1954 to 55.8 beds per
facility in 1967. This increase in establishment size is in
part the result of economic pressures; it is no longer feasi-
ble to Operate a small facility. Other associated changes
are the decrease in the number of conversions which are being
made from existing structures and the increase in new facili-
ties which are being built Specifically for nursing care.
According to Smith (27), the trend in newly constructed nurs-
ing care and related facilities is toward a unit capacity of

at least 60 to 75 beds. In the opinions of Baumgarten (5)

12

and Harshman (11), as medical knowledge expands, demands

for comprehensive skilled nursing care will continue to grow
in nursing care and related facilities and will result in
higher costs for facilities and personnel. Only facilities

with an adequate income base will be able to survive.

Fagility ownership

According to the Public Health Service (55), owner-
ship of nursing care and related homes is of three types:
government, proprietary, and non-profit. Of the 19,200
nursing care and related homes in 1967, 8 per cent were
government owned, 77 per cent were pr0prietary, and 15 per
cent were non-profit. Seventy-six per cent of the total
number of nursing care and related homes were classified as
providing some degree of nursing care, whereas, 24 per cent
were classified as providing only personal or domiciliary
care.

Within government-owned nursing care and related
homes, as reported by the Public Health Service (55), 58 per
cent of the facilities provide nursing care while 42 per
cent do not. In proprietary-owned nursing care and related
homes, 76 per cent of the facilities provide nursing care
while 24 per cent do not. -Eighty-three per cent of the
facilities provide nursing care in the non-profit segment of
the nursing care and related homes, whereas, 17 per cent

provide only personal or domiciliary care.

15

Reports from the Public Health Service (55) in 1967
indicate that when based on degree of nursing care provided,
ownership within facility types was predominately proprie-
tary. For those nursing care and related homes withnursing
care, government ownership represented 6 per cent, prOprie-
tary 78 per cent, and non-profit 16 per cent. Nursing care
and related homes without nursing care were 15 per cent
government owned, 76 per cent proprietary, and 11 per cent
non-profit.

Nursing care and personal care wlhh nursing care
facilities operated by governmental agencies were generally
large with an average bed capacity of 125 beds reported in
1965 (54). Since this is the smallest segment in the nursing
care field, Baumgarten (5) believes that the various levels
of government will enter the nursing care field only when a
vacuum exists and when pressure is sufficient to activate
legislators. The current trend is away from the public sector
entering the nursing care field.

The proprietary nursing care and personal care wihh
nursing care facilities tended in 1965 to be small with an
average of 52 beds. The owners generally served as adminis—
trators. The regulation of these facilities was through
various State licensing laws (54). In general, the proprie-
tary nursing care or personal care wihh nursing care home was
conceived and built by its owner-operators as a business

investment (5). The current trend in the proprietary nursing

14

care and personal care wi£h_nursing care facilities is toward
multiple-facility organization in which linkage is achieved
through a common investor and/Or management (4,8).

Non-profit nursing care and personal care wihh nurs-
ing care facilities in 1965 had an average Of 78 beds per
home. These facilities can be of two types: a) the hospital-
based facility, an adjunct to a general hOSpital usually
located on the hospital grounds so that it can utilize many
of the services of the hospital; or b) independent facilities
which tend to Specialize in areas of medical care such as
rehabilitative, custodial, psychiatric, or limit their services

to men or to women (1).

Patient characteristics

A major characteristic of patients in facilities
wg£h_nursing care is age, for 80 per cent are 65 years of age
and over, and 25 per cent are 85 years and over. The larger
the facility, the more likely that it will have a higher
prOportion of younger patients. Because of their greater
longevity and the fact that many more women than men in the
later years are widowed, nearly three-fourths of the patients
in nursing care facilities are women. This means that the
problems of the aged are increasingly the problems of aged
women (54).

About 40 per cent of the patients were admitted to
nursing care facilities from their own homes and another 40

per cent from hospitals. Thirty-three per cent of the

15

patients who left the facility did so due to death, 55 per
cent returned home, 25 per cent were transferred to a
hOSpital, and the remaining 8 per cent went to other nursing
homes (54).

Based on a 1966 report on the characteristics of
prOprietary nursing care facility patients in Massachusetts
(54), the three leading diagnoses for 59 per cent of patients
were cardiovascular conditions, chronic brain syndrome, and
arthritis. The two next most frequent diagnoses which account
for 15 per cent of the patients were diabetes, and fractures
and amputations. In a 1955-1954 study in thirteen states (7),
cardiovascular diseases were reported for two-thirds of the
patients while "senility" was diagnosed for one-fourth of
the patients at that time.

Data collected in a 1966 study of Missouri nursing
homes indicated that 78 per cent of the patients had an
appetite rating of good or excellent, about 16 per cent had
special diets, and 14 per cent were not able to feed them-
selves. Less than half of the patients were ambulatory to

the extent that they needed no assistance in walking (54).

Extended Care Services Under Medicare

Medicare_program
Health benefits for extended care services following
hospitalization became available on January 1, 1967, to per-

sons 65 years of age and over enrolled in the hospital

16

insurance program under Title XVIII of the Social Security
Act of 1965. Extended care represents a new level of care
designed to provide skilled nursing services in a high-
quality nursing care facility over a relatively short period
of time at less cost than in a hospital (58).

The program is intended as an extension of hOSpital
benefits for aged persons who have reached a stage in their
recovery that does not demand the intensive care and costly
services of a hospital but who do need skilled nursing
services which can be provided equally well by a high-quality
extended care facility. The program is not intended to
provide governmental subsidy for custodial or long-term

nursing care costs for the aged (40).

Extended ggre services. The term "extended care services,"
as defined in Title XVIII of the Social Security Act,2 means
the following items and services furnished to and/Or by an
extended care facility:

1) nursing care provided by or under the supervision
or a registered professional nurse;

2) bed and board in connection with the furnishing
of such nursing care;

5) physical, occupational, or Speech therapy furnished
by the extended care facility or by others under
arrangements with them made by the facility;

 

2U. S. Department of Health, Education, and.Welfare,
Title XVIILwof the Social Security Act, P. L. 89-97 as
Amended (Washington, D. C.: Government Printing Office,
41968), Section 1861(h), p. 55.

4)
5)

6)

7)

17

medical social services;

such drugs, biologicals, supplies, appliances, and
equipment, furnished for use in the extended care
facility, as are ordinarily furnished by such
facility for the care and treatment of inpatients;

medical services provided by an intern or resident-
in-training of a hospital with which the facility

has in effect a transfer agreement and other diagnos-
tic or therapeutic services provided by a hospital
with which the facility has such an agreement in
effect; and

such other services necessary to the health of the
patients as are generally provided by extended

care facilities; excluding, however, any item or
service if it would not be included if furnished to
an inpatient of a hOSpital.

Extended care facility. .To qualify for certification as an

"extended care facility"3 an institution (or a distinct part

of an institution) must be one which has in effect a transfer

agreement with one or more hOSpitals participating in Medicare

and must be one which--

1)

2)

5).

is primarily engaged in providing to inpatients
skilled nursing care and related services for
patients who require medical or nursing care, or
rehabilitation services for injured, disabled, or
sick persons;

has policies which are developed with the advice of
(and with provision of review of such policies from
time to time by) a group of professional personnel,
including one or more physicians and one or more
registered professional nurses, to govern the skilled
nursing care and related medical or other services

it provides;

has a physician, a registered professional nurse,
or a medical syaff responsible for the execution
of such policies;

 

3Ibid., Section 1861(j), p. 56.

18

4) has a requirement that the health care of every
patient must be under the supervision of a physi-
cian, and provides for having a physician available
to furnish necessary medical care in case of emer-
gency;

5) maintains clinical records on all patients;
6) provides 24-hour nursing service which is sufficient

to meet nursing needs and has at least one regis-
tered professional nurse employed full time;

7) provides appropriate methods and procedures for the
dispensing and administering of drugs and biologi-
cals;

8) has in effect a utilization review plan as required
by law;

9) in the case of an institution in any State in which
State or applicable local law provides for the
licensing of institutions of this nature, a) is
licensed pursuant to such law, or b) is approved,
by the agency of such State or locality responsible
for licensing institutions Of this nature, as meet-
ing the standards established for such licensing;
and
10) meets such other conditions relating to the health
and safety of individuals who are furnished services
in such institution or relating to the physical
facilities thereof.
In addition to the above requirements, each facility must
also comply with Title VI of the Civil Rights Act of 1964
which prohibits discrimination based on race, color, or

national origin (58).

Facility participation. Participation in the Medicare program‘
is optional and only nursing care and personal care ZIEB.

nursing care facilities that wish to participate need apply
for certification. .According to Somers and Somers (29) in

1967 there were two basic reasons why many of the prOprietary

19

and non-profit nursing care and personal care w1£h_nursing
care facilities in several states, of which Michigan was one,
were not participating in the Medicare program: either they
could not or were not willing to meet the conditions of
participation or they were dissatisfied with the method and

formula for reimbursement.

Patient benefits. Benefits provided by the Health Insurance
Program for the Aged (Medicare) include up to 100 days of
extended care services in a certified extended care facility
during a single benefit period (originally termed a "spell

of illness"). The program pays the full cost of covered
services for the first 20 days and the cost less a deductible
for the remaining 80 days. In general, the extended care
services for which Medicare insurance pays are the following:
a) bed in a semiprivate room and all meals, including Special
diets, b) regular nursing services, c) drugs furnished by

the extended care facility, d) physical, occupational and
speech therapy, e) medical supplies such as splints and casts,
f) use of appliances and equipment furnished by the facility
such as wheelchairs, crutches, and braces, and 9) medical
social services.\ In order to qualify for reimbursement under
Medicare for services provided by a certified extended care
facility a patient must meet the following requirements:

a minimum of three consecutive days of hospital confinement,
admittance on a doctor's order to the extended care facility

within 14 days of hOSpital discharge, and admittance to the

20

extended care facility for treatment of the conditions for

which the patient was hospitalized (40).

Participating_institutions

Of the 14,000 nursing care and personal care wihh
nursing care facilities in the United States in 1967,
approximately 5,700 (26%) were certified as providers of
extended care services under Medicare. Of these, approxi-
mately 100 (nearly 5%) were located in the State of Michigan.
Statistics reported by Allen (1) concerning the numbers of
units and available beds of extended care facilities partici—
pating in the Medicare program for the United States and for
the State of Michigan are Shown in Table 2. Two different
bases are presented for comparison: a) classification by
type of extended care facility and b) classification accord-

ing to type of facility ownership.

Units vs.4§acility type and ownership, AS shown in Table 2,
of the nearly 5,700 participating extended care units in the
United States in 1967, 77 per cent were classified as skilled
nursing care facilities, 14 per cent as extended care units
of hOSpitals, 6 per cent as units of domiciliary care insti-
tutions, and 5 per cent as units of rehabilitation centers.
Comparable figures for the State of Michigan indicate that
there were 108 facilities of which 77 per cent were Skilled
nursing care facilities, 12 per cent were extended care units

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22

and 5 per cent were units of rehabilitation centers.
Percentage comparisons between Michigan units and United
States units indicate a similar percentage distribution
among facility classes.

When classified according to type of ownership,
however, slightly more than two-thirds of the extended care
facilities in the United States in 1967 were privately owned
(proprietary). Churches and other non-profit organizations
owned about 25 per cent of the facilities with the remaining
9 per cent owned by Federal, State, and Local governments.
Corresponding figures for Michigan Show that 49 per cent of
the Michigan extended care facilities were under proprietary
control, 19 per cent were owned by non-profit organizations
and 52 per cent were government units. Percentage comparisons
of ownership data for Michigan and the United States as a
whole indicate that in 1967 the percentage of Michigan units
under governmental ownership (Federal, State, Local) was

considerably higher (25%) than for the nation as a whole.

Beds vs._fggilitv type and ownership. In terms of beds avail-
able in extended care units in the United States in 1967, 81
per cent were in skilled nursing care facilities, 11 per cent
were in units in hOSpitals, 6 per cent in units of domiciliary
institutions and 2 per cent in units of rehabilitation centers.
In the same year the distribution of available beds in
Michigan extended care facilities differed somewhat from the

national distribution with percentages of 77, 10, 10 and 5

25

for skilled nursing care facilities, units in hospitals,
units in domiciliary institutions and units in rehabilitation
centers, respectively.

As shown in Table 2, the nearly 5,700 extended care
facilities in the United States provided nearly 262,000 beds
in 1967; an overall national average of 71 beds per facility.
Similar comparison for the State of Michigan indicated that
in 108 facilities (5% of the U. S. total) there were 10,500
beds (4% of the U. S. total); an overall state average Of 95
beds per facility. With respect to type of extended care
facility, the Michigan averages for all types were consider—
ably higher than the national averages with the largest dif-
ferences occurring in the extended care units located in
domiciliary institutions and rehabilitation centers.

When tabulated according to facility ownership,
nationally 68 per cent of the available extended care beds
were in privately owned establishments, 20 per cent were in
non-profit facilities and 12 per cent were in government
owned installations. In the State of Michigan percentages
of beds among ownership classifications differed markedly
from the national percentages; 47 per cent were in private
facilities, 16 per cent were in non-profit units, and 57 per
cent were in government units. In all classifications of
ownership in 1967 Michigan facilities averaged more beds per
unit than comparable averages for the United States as a

whole.

24

In comparing government versus non-government ex-
tended care facilities for the nation as a whole, Allen (1)
indicates that the average number of beds in participating
government extended care facilities was one and one-half
times as many as the average number of non-government beds
for prOprietary and non-profit extended care beds combined
for each of the following categories: skilled nursing care,
extended care unit of a hospital, extended care unit of a
domiciliary institution, and extended care unit of a rehabili-

tation center.

Conditions of participation

All regulations pertaining to the conditions of
participation for extended care facilities are given in Sub-
part K of the Social Security Administration's Regulations
No. 5, Federal Health Insurance for the Aged, Part 405, and
cover twenty-eight areas relating to the health and safety
of Medicare beneficiaries (58). Of these, only two sections
(405.1125--Dietary Services and 405,1154--Physical Environ—
ment, subsections h_and i) Specifically describe the statutory

requirements for the dietary service component of the facility.

rDietary services. The eleven standards established for dietary
services-and for the physical environment of the kitchen and
dining areas and the factors explaining each of these standards
are included in the Appendix, pages 97 to 102. In general,

these standards relate to departmental staffing, sanitation,

25

nutrition, food quality, and the physical aspects of the
kitchen and food service areas. In capsule form, the
standards indicate that the dietary service, under the
direction of a qualified person appointed by the administra-
tor, has food service personnel sufficient to meet the needs
of the patients and the objectives of the operation.
Sanitary conditions must be evident both in the personal
hygiene of the workers as well as in the storage, preparation
and distribution of food. Insofar as medically possible,
diets (general.and therapeutic) must be provided to meet the
food and nutritional needs of patients in accordance with
the orders of attending physicians. Quality food is required
in terms of frequency and adequacy of meals, nutritional con-
tent, and acceptable methods of preparation and service.
The physical layout of the food service areas must be adequate
to meet the operational needs for refrigeration, storage,
preparation, and service of food, dishwashing, and refuse
storage and removal. .Since table service is encouraged for
all patients who can eat at a table, an attractive room of
sufficient size for this purpose must be available (58).

The major impact of the Conditions Of Participapion
for Extended CarepFacilities on the food service Operation
in many nursing care facilities was felt in the standard
requiring that a professional dietitian or other person with
suitable training be hired on a full- or part-time or con-

sulting basis. In the food service field, as in most health

26

care professions, there is a shortage Of trained professional
personnel. The lack of qualified dietitians was a serious
problem even before the Medicare program. To meet the needs
for professional direction, nursing care facilities, rather
than having a full-time dietitian on the staff, often share
the services of a dietitian with other institutions or receive
guidance from a dietary consultant who works a minimum of
eight hours a month (2,27).

Prior to the implementation of the Medicare program
a booklet was published by the United States Public Health
Service (56) which gave practical guidance on details of food
service operation in nursing care facilities for administra-
tors, food-service supervisors, and cook-managers. This
guide was developed by many of the individuals who were work-
ing on the dietary service requirements for Medicare certifi-
cation. During this Medicare pre-implementation period work-
shops were held to acquaint dietitians with the concept of
dietary consultation and to encourage inactive dietitians to
return to the food service field. .Much of the literature at
this time was concerned with getting the dietitian into the
nursing home and in defining her role once she got there (17,
22,26). A few articles authored by public health nutrition-
ists appeared in the literature which helped interpret the
objectives of the Conditions of Participation for Extended
Care Facilities (5,25,28). In general these articles were

normative; they presented what was eXpected of the dietary

27

department as an essential supporting service of the extended
care facility. With the exception of the Public Health Ser-
vice booklet (56), there is little published material avail-
able to provide dietary directors of extended care facilities
with practical assistance for improving the efficiency of
their operational procedures. Basic resource books on food
service management each contain sections which are valuable
for the food service Operator but leave the sorting of perti-
nent material to the reader's discretion (2,42). Some edi-
torials and opinions can be found but, more Often than not,
they are written by generalists in the health care field or
are directed to audiences other than dietary specialists in

the extended care service field.

Methods of food distribution

 

Food distribution in a health care facility is one
of the interfaces between food production and the patient.
The layout of the facility to a large extent determines the
characteristics of the distribution plan. Two general pat-
terns of food distribution predominate: centralized and
decentralized. In centralized service the individual trays
are set up in one location, transported to the patient area
by tray cart or mechanical conveyor, and delivered directly
to the patients. In decentralized service, the prepared food
is sent in bulk to the serving pantries on the various patient
floors or wards where it is arranged on trays and carried to

the patients (2,16,42).

28

Most nursing care facilities utilize the centralized
method of tray service but in as far as possible serve the
patients in a dining room rather than at their bedside.

This is done in an effort to assist the patients socially

and psychologically through provision of group contact. Such
group food service has distinct therapeutic value in that it
can help to minimize physical weakness or insecurity and
enable the patient to become more self-reliant (6,24).

Regardless of the type of food distribution system
used or the place in which the meal is eaten, an organized
assembly and delivery method is necessary with the primary
object being speed in getting hot, attractive and palatable

food to the patient (42).

Fact-finding Research Methods

General description is characteristic of the early
stage of investigative work in an area where the significant
factors have not been isolated, and where perhaps one would
not have means for measuring them if they were identified.

It is, therefore, a method of eXploration. .Descriptive-
survey approaches to investigation include induction, analysis,
classification, enumeration, measurement, evaluation, and
gathering data regarding current conditions. The typical
descriptive survey does not delve deeply into relationships

or causal factors; rather it discloses factors and suggests

relatively prominent possible connections between these

29

factors and apparent causes which present avenues for future
research (9).

<An important disadvantage of the survey technique is
the lesser degree of control over the data collection situa-
tion and the greater possibility for factors unknown to the
investigator to interfere with the results than occurs in

the experimental method of investigation (21).

Survey sampling

The elements of a population are the units for which
information is sought. The population of a survey is defined
jointly with the elements; since the population is the aggre-
gate of the elements, and the elements are the basic units
that comprise and define the population. The elements consist
Of a) content, b) units, c) extent, and d) time (14). For
example, in this study the elements are a) food service
operations, b) in extended care facilities, c) located in the
lower peninsula of Michigan, d) as of fall, 1969.

The survey pOpulation that is actually achieved may
differ somewhat from the desired target pOpulation due to
non-responses and non-coverage. Strictly speaking, only the
survey population is represented in the sample, however,
Often it is easier to write about the target population.

The sample is that portion of the target population which is
considered representative of the target population (15).
Parten (20) says an ideal sampling plan should yield

an unbiased picture of the population of which it purports to

50

be a sample, should be the most efficient way of securing
the desired information with the funds available, should be
well-defined prior to drawing the sample, Should be satis-
factory for the questions under consideration, and should be
set up to avoid biases from careless or illogical procedures

and should include techniques for handling non-responses.

Surveyptechnigues

Mai; questionnaire. This technique consists of a list of
questions sent by mail to persons selected for sampling.
The form is supposed to be completed by the recipient and
mailed back to the investigator. -While the mail question-
naire is the most widely used survey technique, it is also
the most criticized.

The primary advantage of using a mail questionnaire
is that it is possible to reach a wider geographical area
with a given amount of funds than could be accomplished by
personal interviews. Mailing costs are relatively low com-
pared with travel costs and time for interviews. An addi-
tional value is the directionality of the mail questionnaire
in reaching a Specific class of people (15,20).

»The mail questionnaire technique of gathering data
is not a quick or facile method of investigation according
to Good and Scates (9). It is slow, requires a large invest-
ment of time on the part of the investigator, and often gives

results that are highly disappointing because of their

51

incompleteness, indefiniteness, and the general indifference
of respondents.

The chief drawback in the use of mail questionnaires
is that the peOple who return them are not necessarily repre-
sentative of the group to whom the questionnaires were sent.
The direction of this bias tends to be toward those who are
interested in the subject matter, who are higher in socio-
economic status, and who have had more education (10). The
rate of return from mailed questionnaires sent to the general
public can be as low as 10 to 20 per cent (20). When the
questionnaire is sent to a special interest group and appro-
priate follow-ups are made, the rate of return can still be
as low as 50 or 60 per cent; higher percentages are rare (15).
AS a result of these low returns, valid generalizations are
difficult to make. To facilitate interpretation of the data,
Kerlinger (15) suggests that every effort should be made to
obtain mail questionnaire returns of at least 80 per cent,
and lacking such returns, to learn something of the character-

istics of the non-reSpondents.

Personal interyigw. Of the several ways of carrying out a
survey, the personal interview is considered the most power-
ful and useful tool (9,15). The personal interview is the
method of direct investigation in which skilled interviewers
call upon and solicit information from selected individuals
(20). This method of securing information has the advantage

of obtaining a high percentage of acceptable returns.

52

Parten (20) states that almost any survey using the personal
interview can expect cooperation from 80 per cent of the
cases, with 95 per cent Often attained. The information
secured is often more correct and complete than with other
techniques Since the interviewer can explain the questions
to the respondent and collect supplementary information
through observation.

There are two basic types of personal interviews:
unstandardized and standardized. In the unstandardized
interview, the interviewer is free to develOp the situation
and eXplore ideas within the confines Of the tOpic guide.

In a standardized interview, the interviewer is held to a
specific wording in the interview schedule and is not free

to adapt his questions to the situation. The unstandardized
interview seems to have a definite advantage within the
"context of discovery" by enabling the interviewer to explore
new ideas and thus go beyond the original fOrmulation of the

problem (21).

Survey instrument design

Both mail questionnaires and interview schedules are
frequently used tools in gathering a variety of data. They
have been used for collection of personal preferences, social
attitudes, beliefs, opinions, behavior patterns, group prac-
tices and habits, and factual data. The increasing use of

questionnaires and schedules is probably due to increased

55

emphasis on quantitative measurement of uniformly accumu-
lated data (45).

The real difference between the mail questionnaire
and the interview schedule or guide is the way in which the
inquiry is administered. The questionnaire is generally
mailed to informants to be answered as specified in a cover
letter without further assistance from the sender. The
personal interview is conducted by the interviewer who fills
out the interview schedule or guide and who can interpret the
questions for the respondent when necessary. Interview
schedules or guides are valuable as SUpplementary and extend—
ing devices in observation and interviews, and in evaluating
personal behavior and social situations. They aid in
standardizing and objectifying observations and interviews
as well as being useful devices for isolating one element at
a time and thus intensifying observation of it (45).

Questionnaires can be classified in various ways but
basically are of two general types: structured or unstruc-
tured. Structured questionnaires are those which pose
definite, concrete, and pre-ordained questions. Included
in this type are closed-form questions or check-lists which
are used when categorized data is required and open-ended
questions which elicit responses that are free and Spontaneous
expressions on the part of the respondent. Closed reSponse
items are quicker and easier to answer since they require

little writing; consequently, more questions can be asked

54

within a given length of time and more can be accomplished
with a given sum of money. Structured questionnaires are
generally used in mail surveys (19).

Unstructured questionnaires, frequently referred to
as interview guides, also aim at precision and contain
definite subject matter areas; however, the interviewer is
free within limits to arrange the form, order and timing of
the inquiries. Unstructured questionnaires are designed to
obtain viewpoints, opinions, and attitudes and to show rela-
tionships between data which might escape notice under more
impersonal types of investigation. The main disadvantage of
the unstructured questionnaire is that the data collected
may not be additive and comparable.

The information included or requested on the ques-
tionnaire is of three kinds:

a) Identifying information which includes sample
number, name of the survey, title of the question-
naire, name of agency Sponsoring the survey, name
Of the respondent, and often the name of the
interviewer.

b) Census-type factual data about the respondent which
provides the variable whereby the survey data can
be classified and also form the basis for evaluating
the sample. This information should conform, inso-
far as possible, to census and other previously
collected data so that comparisons can be made.

c) Questions concerning the subject of the survey which
are directed toward obtaining facts and/Or revealing
attitudes. These may be direct or indirect but in
all cases should be selected and worded with care.
If check-lists are used, allowance must be made for
all possible responses. Alternatives in multiple-
choice questions should be realistic and mutually
exclusive. Apparently unreasonable questions should
be introduced with a brief explanation justifying
the question (20).

55

Attractiveness often contributes to the respondent's
willingness to complete and return the mail questionnaire.
The format of the questionnaire should make the form readable
and appear as short as possible, and should facilitate com-
pletion. Layout, color and quality of paper, individuality
of address, and return envelope are all important considera—
tions. The layout of the mail questionnaire should be large
enough to provide adequate space for comments if such are
desired; since there is a definite relation between the write-
in Space provided and the amount of comments. Questionnaires
should be printed on relatively heavy paper in order to with-
stand handling. If possible, they should be printed on only
one Side of the paper. Light colors eSpecially yellow and
pink have been found to have the highest percentage of returns.
Distinctive colors also serve to call the reSpondent's atten-
tion to the questionnaire once it is on his desk awaiting
completion (20). Studies show that when stamped, self-
addressed return envelopes are provided a higher response
rate is attained (19).

Irrespective of survey technique (mail qUestionnaire
or personal interview) the design of the survey instrument
must take into consideration the audience to whom it is
directed. The questionnaire should be concrete and definite,
the questions simple and objectively phrased, and care should
be taken to avoid forcing replies. The everyday language of

practical affairs has proved to be the most useful (45).

CHAPTER III

METHOD OF INVESTIGATION

Two types of study techniques were used to investi-
gate on-premise food distribution systems currently being
used in Michigan Extended Health Care facilities: a) the
direct mail-questionnaire to gather descriptive information
about the facilities and their respective food distribution
policies and procedures and b) personal interviews with the
food service managers of a few of the facilities participat-
ing in the study to solicit their Opinions regarding the

effectiveness of their respective food distribution systems.

The Mail Survey

The sample

The sample of 145 extended health care facilities
located in the Lower Peninsula of Michigan was drawn from
two sources: the United States Social Security Administra-
tion's October 1968 list Of Medicare providers of services
(59) and the January 1969 list for accredited long—term
care facilities of the Joint Commission on Accreditation of
Hospitals (12). Since the conditions for Medicare certifi-

cation and for accreditation by the Joint Commission are

56

57

very similar, it was felt that most of the accredited long-
term care facilities would also be eligible to proVide

nursing care under Medicare. It was anticipated that response
data from this group would provide a descriptive overview of
the current on-premise food distribution policies and pro-
cedures of Michigan nursing care facilities other than
hospitals which are eligible for participation under Medi-

care.

The mail questionnaire

The mail questionnaire was designed to elicit informa-
tion concerning the general facility characteristics of size,
ownership, predominate health care and community health care
services provided, and extent of eligibility and participa-
tion in Medicare. Requested information pertaining to the
Specific food service policies and procedures of the extended
health care unit included identification of how the food
service of the facility is managed, number and classification
Of food service personnel, specific duties of the food service
manager, meal patterns and service systems used, types of
clientele served, menu planning and service policies, and
estimates of average weekday meal service volume detailed
with respect to clientele class for each type of meal served.
The twelve-page questionnaire was constructed to involve a
minimum of the respondent‘s time through the use of check

lists and simple completion items. In order to minimize

58

postal expense, the questionnaire was printed on both sides

of heavy weight yellow paper.

The pre-test

The survey instrument was pre-tested by ten food
service supervisors and dietitians in three inpatient health
care facilities not included in the sample selected for study.
Each person was sent a COpy of the proposed cover-letter
and questionnaire as well as a questionnaire-evaluation form.
In addition, suggestions were solicited from four consulting
dietitians and university educators who frequently work with
food service personnel associated with extended health care
facilities. The questionnaire was evaluated for format,
clarity, adequacy of content and required time for comple-

tion.

Questionnaire distribution

The revised questionnaire was mailed in November 1969
to the administrators of the 145 facilities selected for
study. .Enclosed was a cover-letter identifying the survey
and its purposes and requesting the administrators' OOOpera-
tion in having the persons directly responsible for the
management of the food services complete the questionnaire.
(A stamped, self-addressed envelOpe was included to encourage
participation. Facilities which preferred not to partici-
pate in the study were requested to return the blank question-

naire.

59

Three weeks were allowed for reply to the question-
naire. A follow-up post card was sent to the administrators
of those facilities which had not reSponded to urge their
participation and to provide a ready means of contact with
the researcher should they require an additional COpy of the
questionnaire. A thank you letter was sent to each adminis-
trator whose facility returned the completed questionnaire.
Copies of these mail survey forms can be found in the

Appendix, pages 105 to 121.
The Personal Interview

The sub—sample

A sub-sample of twenty-one food service managers of
extended care facilities who responded to the mail question-
naire was selected for personal interview. These managers,
all located within a sixty-mile radius of Lansing, Michigan,
were contacted by telephone for an appointment and eighteen
of the twenty-one were willing to have the researcher visit
their respective food services. A letter of confirmation was
sent to each food service manager stating the time of the
appointment, the purpose of the visit, and means of contact-

ing the researcher.

The interview guide
For the personal interview, an interview guide was
developed SO that similar information would be recorded for

each extended care facility food service. Information sought

40

during the interview included a) the physical layout of the
facility and of the food service in terms of food distribu—
tion to patients and types of equipment used for meal

service, and b) attitudes of the food service manager con-
cerning the food distribution system(s) currently in use as

well as their suggestions and projections for improvement.

The interview

 

All personal interviews were conducted between
February 25 and March 11, 1970, at times mutually convenient
to the food service manager and the researcher. No attempt
was made to visit each food service at the same time of the
day or to Observe food distribution, since this would have
limited accessibility and the number of facilities that could
be visited in time available to the researcher. In order to
facilitate discussion, no attempt was made to record answers
during the interview, rather information gathered was re-
corded by the investigator in the car immediately after the
visit. COpies of the letter of confirmation and the personal
interview guide are included in the Appendix, pages 122 and

125 to 125.

Analysis of Data

The mail survey_data
The questionnaire returns were hand coded and key
punched on cards for computer processing. For most of the

data, frequency counts and per cents of total response for

41

each questionnaire item were calculated using the Michigan
State University CISSR series ONEWAY routine (18) for fre-
quency analysis and Control Data Corporation 5600 Computer
at Michigan State University. Totals and means for certain
items were calculated using the Michigan Agricultural
Experiment Station STAT series MDSTAT routine (25) for

calculating basic statistics when missing data are involved.

The personal interview dghg

The interview guide data were hand tabulated, sum-
marized and examined by the investigator with particular
attention to the operational similarities and differences
among the facilities visited and the attitudes and Opinions
of the managers with respect to their food distribution

system(s).

CHAPTER IV

ANALYSIS OF THE SURVEY DATA

Two fact-finding techniques were used to gather data
relative to food distribution systems in selected Michigan
extended health care facilities: a mail-questionnaire sent
to a sample of 145 facilities located in the lower peninsula
of Michigan, and follow-up interviews with the persons in
charge of the food service departments of 18 of the respond-
ing facilities located within a sixtydmile radius of Lansing,
Michigan. In both phases of the study a concerted effort
was made to secure the data directly from individuals who
were actively involved in the management of food service for

the facility.

Mail-questionnaire Findings

The information sought included both descriptive
organizational data about the total facility and the essential
elements concerned with the Operation of the food service
component. The percentage of participation obtained from the
sample selected for study is detailed in Table 5.

As shown in Table 5, usable returns were received from

79 facilities or 55 per cent of the group contacted. Although

42

45

Table 5. Responses to Mail Questionnaire

 

——‘v

 

 

 

Initial Returns _ No
Michigan Mailing Usable Not-usable Response
Area No. ZL NO.a %b No. % No.

MetrOpolitan Detroit

and vicinityC 64 45 22 15 9 6 55 25
Outstate--lower

peninsula 79 55 57 40 4 5 18 15
TOTAL 145 100 79 55 15 9 51 56

 

 

 

 

 

aNumber of questionnaires

Per cent of initial mailing

Includes facilities within 50-mile radius of center of
Detroit

the initial sample selected for study included a high prOpor-
tion of facilities located in or near Metropolitan Detroit

(45%), the relatively low usable response from this Michigan
area (15% of initial mailing) was disappointing. As a result
the findings herein reported may be more descriptive of food
distribution systems in extended care facilities serving less
pOpulated areas than might be true of MetrOpolitan Detroit

and vicinity.

Facility chapgpteristics

Characteristics of the extended care facility deter-
mine the parameters within which the food service operation
develOps and functions. The following facility characteris-
tics are reported and discussed in terms of percentages of the

79 respondents: facility names, administrators, size in

44

terms of bed capacity and occupancy, expansion plans for
beds and ancillary services, ownership, type of nursing care
facility, kinds of health care services provided, and
Medicare eligibility and participation.

Facilities responding to the survey have a variety
of names: medical care facilities (27%), nursing homes (22%),
convalescent centers (11%), and units of hosPitals (11%).

The remaining 29 Per cent are called either homes for the
aged, lodges, manors, terraces, villas, or health centers.

In general, facility names are not descriptive of the type(s)
Of care provided by the facility. Although all of the report-
ing facilities are eligible to participate in Medicare and
can, therefore, be described as eXtended care facilities,

this terminology has not become part of the facility names.
Reluctance of many nursing care and personal care with nursing
care facilities to be predominantly identified as medical

care units, the diversity of services which they provide in
addition to extended care under Medicare, and the lack of
uniform terminology for this segment of the health care field,
all contribute to the variety of facility names reported.

The position titles of administrator or owner-admin-
istrator were reported for 89 per cent of the facility admin—
istrators, director or executive director were reported for
5 per cent, and four other position titles for the remaining
6 per cent: supervisor, commandant, superintendent, and cor-

porate representative. Although historically most of the

45

chief administrators of general and specialized hosPitals
have been male medical doctors, this is not necessarily true
of the chief administrators of Michigan nursing care and
personal care with nursing care homes classified as extended
care facilities. The findings from this study indicate that
among the 79 Michigan extended care facilities surveyed two-
thirds of the chief administrators are male and one-third
are female. Furthermore, of the entire group only 5 (4%) of
these persons have medical degrees.

The total number of available licensed patient beds
represented by the participants was 10,587. However, among
the units reporting, facility size, as expressed in terms of
bed capacity, ranged from 15 to 859 beds per facility.
Facility sizes of 50 beds or less were reported by 15 per
cent of the respondents, of 51 to 150 beds by 62 per cent, Of
151 to 250 beds by 19 per cent, and of 250 beds or more by 6
per cent. Of the latter, 5 facilities have between 500 and
400 beds and 2 have over 800 beds. At the time of the survey
two-thirds of the facilities reported occupancy averages of
85 per cent or more, 17 per cent reported occupancy levels
between 50 and 75 per cent, while 1 large government facility
(1%) was Operating at less than 50 per cent capacity.
Seventeen per cent of the reporting group chose not to com-
plete this item on the questionnaire.

According to the data received, outpatient services
are not offered at the majority (80%) of the extended care

facilities surveyed. However, outpatient services are

46

available at 15 per cent of the reporting facilities with

15 per cent averaging 50 or less patients/day and 2 per cent
averaging 75 or more patients/day. Four of the survey
participants (5%) failed to reSpond to this questionnaire
item.

Information relative to two aspects of facility
expansion was requested: a) planned increases in the number
of licensed beds and b) planned expansion of existing ancil-
lary services and/Or the addition of new ones. Group response
percentages for these questionnaire items were 95 and 84,
respectively. With respect to bed capacity expansion, only
12 (15%) of the responding facilities are planning to in-
crease their number of licensed beds. With the exception of
one very small unit (51 beds) which is planning a major
addition of 500 beds (an increase of 968%), the majority (10)
of these facilities with present bed capacities ranging from
50 to 157 beds will have expanded capacities ranging from 100
to 175 beds. One unit, with a present capacity Of 216 beds,
did not indicate the number of beds involved in their expansion
planning.

Planned expansion of one or more ancillary services
was reported by only 14 (18%) of the facilities surveyed.
Types of services to be added or enlarged include physical
therapy at 11 units, occupational and inhalation therapy at
4 units, Speech therapy at 5 units, and radiology (x—ray

services) at 4 units.

47

Three ownership classifications are commonly recog-
nized: private or corporate proprietary ownership, non-
profit philanthropic (fraternal, religious, or other), and
governmental (Federal, State or Local). Each type of owner-
ship was represented among the responding facilities:
proprietary 49 per cent, non-profit 17 per cent, and govern-
mental 54 per cent. These percentages for each ownership
classification are similar to those given in Table 2 (page 21)
for all extended care facilities in the State of Michigan;
consequently, the mail survey participants are considered
fairly representative of Michigan extended care facilities
in terms of ownership.

Of the 79 facilities surveyed, 52 facilities were
under either prOprietary or non-profit ownership. -Membership
in multiunit organizations in which there are other extended
ggie faciiities was indicated by 18 of the facilities in
these two ownership classifications. The number of other
units range from 1 to 5 for 6 respondents, 6 to 20 for 9
respondents, and 51 to 50 for 2 respondents, while 1 respondent
did not complete this part of the question. Thirty-four of
the proprietary and non-profit facilities indicated there were
no other extended care facilities under the same ownership.

Proprietary and non-profit facilities which are part
of multiunit chains in which there are other types of health
care facilities are represented by 12 of the respondents.

These other health care facilities include hOSpitals

48

(5 respondents), retirement homes (2 respondents), day care
centers for children (5 respondents), and an associated
general hOSpital(1 respondent); 5 respondents did not com-
plete this part of the questionnaire item. Forty facilities
indicated there were no other types of health care facilities
under the same ownership.

Percentage comparisons among facility sizes and types
of ownership indicate that for each of the three ownership
types, the concentration of number of facilities is at the
51 to 150 bed Size. Proprietary facilities cluster most
closely in this range with 28 of 59 facilities in this Size
range; 8 proprietary facilities are in the range of 151 to
250 beds, 2 in the range of 50 beds or less, and 1 is over
250 beds. The non-profit facilities are spread throughout
the Size range: 4 of the 15 facilities are in the range of
50 beds or less, 6 facilities have between 51 and 150 beds,

2 facilities have between 151 and 250 beds, and 1 facility
has over 250 beds. Government-owned facilities also cluster
at the 51 to 150 bed Size with 15 of the 27 facilities in
this size range, 5 facilities have between 151 and 250 beds,
4 facilities have 50 beds or less, and 5 facilities have over
250 beds and 2 of these have over 800 beds each.

Facilities other than hOSpitals providing some form
Of nursing care are classified by the Division of Health
Resources Statistics of the National Center for Health Statis-

tics, United States Public Health Service (55), as either a

49

nursing care home or a personal care with nursing home accord-
ing to the predominate service provided. The majority (95%)
of the survey participants indicated their facility is a
nursing care home in which 50 per cent or more of the resi-
dents received one or more nursing services and the facility
has at least one registered nurse or licensed practical nurse
employed 55 or more hours per week. .NurSing services include
nasal feeding, catheterization, irrigation, oxygen therapy,
full bed bath, enema, hypodermic injection, intravenous in-
jection, temperature-pulse-respiration, blood pressure,
application of dressing or bandage, or bowel and bladder re-
training.

Five (6%) Of those surveyed indicated they are a
personal care with nursing home which is defined as either
a) one in which some but less than half of the residents
receive nursing care or b) one in which more than half of the
residents receive nursing care, but no registered nurses
or licensed practical nurses are employed full time on the
staff. In both types of facilities personal services are
provided: rub or massage service, assistance with bathing,
dressing, correspondence or ShOpping, walking or ambulation,
or eating. One facility (1%) did not respond to this ques-
tionnaire item.

Health services provided by the responding extended
.care facilities are primarily convalescent and rehabilitative.

Long-term convalescent care (95%), rehabilitation including

50

physical therapy, occupational therapy, and/Or Speech therapy
(92%), and short-term and geriatric convalescent care (86%
each) were most frequently mentioned by the survey partici-
pants. Half indicated they provide geriatric custodial care,
while only 15 per cent offer psychiatric custodial care which
is a highly Specialized type of service.

Outpatient services include one or more of the follow—
ing: rehabilitation, clinical laboratories for diagnoses-and
evaluation of Specimens, and radiology departments. Out-
patient services are offered by only 18 per cent of the survey
participants. Moreover, those that do provide such services
are primarily county (governmental) medical care facilities
or extended care units which Share outpatient services with
a hospital.

Other health services offered by the survey partici-
pants include tuberculosis isolation/Sanitarium (5%),
physical therapy training'(1%), and skilled or acute nursing
care (1%).

All but one of the survey respondents reported they
were eligible to participate in the Medicare program: for
80 per cent the §Q£§i_facility was eligible, and for 19 per
cent p§£h_of the facility. One (1%) facility indicated it
was restricted from eligibility because its primary source
of funds was a Federal program which antedated the Medicare
legislation. Of the 15 facilities which reported only partial

eligibility 5 failed to indicate the percentage of their total

51

bed capacity which could be used for patients under the
Medicare program. Among the 10 facilities which did divulge
this information the percentages varied from less than 40
per cent for 1 facility, between 40 and 59 per cent for 6
facilities and between 60 and 71 per cent for 5 facilities.
At the time of the survey only 70 (90%) Of the 78
eligible facilities were actually participating in the Medi—
care program. Of these, 57 were total facility participators
and 15 were partial facility participators. Of the 8 eligible
facilities (10%) which were not participating in the Medicare
program 6 had total facility eligibility and 2 had only par-

tial facility eligibility.

Food service department characteristics

An extended care facility primarily provides medical
care, nursing care, and rehabilitative services for patients
no longer in an acute phase of illness. Since patients
generally remain longer in an extended care facility, food
assumes an important role for the patient. As an essential
supportive service, the dietary department should be committed
to the preparation of nutritious and attractive meals in
accordance with the needs of the patient population and within
the limitations of the facility. Data herein reported re-
flect underlying limiting factors and patient needs in the
responding extended care facilities' food services. The
areas reported include the following: control of the food

service organization, food service manager, responsibilities

52

of the manager, department staff, contribution of volunteers,
meal service policies, resident patient meal service, meal

distribution, menu policies, and food service volume.

Control of food service gperation. Management of the food
service operation in the responding extended care facilities
is of three types: independent, satellite, and contract.
The majority (79%) of the reSpondents independently operate
the food service, while in twelve (15%) of the facilities it
is satellite to a larger food service within the health care
complex. Four (5%) of the food services are operated by a
food management company under contract with either the
extended care facility or a larger food service unit within
the health care complex. One facility declined to divulge
this point of information.

Operational responsibilities assumed by a food manage-
ment company vary with the contract. All four respondents
reported the following responsibilities as included in the
contract: a) meal planning with the sub-reSponSibilities of
planning general and modified diets, and estimating and pro-
curing food and related supply needs; b) food preparation,
distribution, and control with the sub-responsibilities of
estimating daily production needs, controlling food quality
standards and food cost levels, maintaining on-premise food
and supply inventories, and establishing a satisfactory
finished food distribution system; and c) staffing with sub-

responsibilities of hiring, assigning, supervising, and

55

dismissing of employed food production and service workers
and supervisors, and of volunteer workers.

Certain other operational reSponSibilities, however,
vary with respect to individual contract agreements. ~Employee
training of food production and service supervisors, and food
production workers are the food management company's responsi-
bility for all four respondents, but only two are reSponSible
for training service workers, and only one is reSponSible for
training the maintenance workers and volunteers involved in
the food service operation. Two Of the respondents indicated
that the food management company assumes reSponSibility for
food service maintenance insofar as area housekeeping, equip-
ment, cleaning and repair, and departmental safety and sani—
tation. In all four contracted food services, the extended
care facilities retain reSponSibility for providing employee
uniforms and laundry. Three of the four reSpondents indi-
cated that the food management company assumes responsibility
for financial and transaction records as well as other in-
ternal Operating records, while only one company is responsi-
ble for food service employee benefits. None Of the food
management companies are contractually reSponSible for employee

payroll preparation and disbursement.

Afiood service manager. Persons responsible for the management
of food service departments in these Michigan extended care
facilities have a variety of titles and serve their respec-

tive institutions in varying capacities. When classified

54

according to the range of assigned managerial responsibili-
ties, the respondents appear to fall into three basic pro-
fessional employment categories: a) those for whom the
management of the food service is only one part of a larger
administrative assignment, b) those who manage only the food
service department, and 0) those who manage the food service
department as well as engage in food production for the
department. The majority of respondents (85%) were individ-
uals, with position titles of dietitian, food service
supervisor, kitchen supervisor, dietary manager, and manager
or director of food service, who manage only the food service
operation. Nine per cent of the respondents both manage

the food service and engage in food production with the posi—
tion title of cook; 5 per cent of the reSpondents were
individuals for whom the management of the food service
Operation was only one of a variety of reSponSibilities with
position titles of assistant administrator, dietary consult-
ant, and domestic service supervisor. One respondent did not
complete this questionnaire item.

Professional eXperience of the respondents as shown
by their previous work eXperience, indicates that about half
(48%) had had food service management experience as dietitians,
food service supervisors, and restaurant managers. Twenty-
five per cent had had non-managerial positions in food ser-
vices as kitchen assistants and production workers, and 5

per cent had previous work eXperience in management positions

55

unrelated to food service. Twenty-four per cent did not

respond to this questionnaire item.

Regponsibilities of the manager. Management of a food ser-
vice Operation involves many tasks which are necessary for
its successful functioning. Thirty-two of the most common
of these tasks are listed in Table 4. The degree to which
each task is a part of the food service manager's work in
the 79 facilities participating in the study is detailed in
terms of per cent of group reSponse.

Ninety per cent or more of the respondents reported
they estimate food, supply and equipment needs, purchase
foods, provide employee in-service training, determine daily
food production schedules, supervise workers in food produc-
tion and patient tray assembly, and have food production as
a regular assignment. Between 80 to 89 per cent indicated
they plan general diets, purchase supplies, hire employees,
determine portion size of food items, supervise workers in
patient and dining room service, and participate in patient
tray assembly as their regular work assignment. Planning of
modified diets and purchasing of equipment were mentioned by
76 and 72 per cent, respectively. Between 50 and 69 per cent
of the respondents reported supervising workers in equipment
repair, compiling internal records, giving inpatient diet
instructions and, as a regular assignment, work as a counter
server. Less than 50 per cent indicated responsibility for

assigning and training volunteers, determining the selling

56

Table 4. Responsibilities of the Food Service Manager

 

m

 

 

 

 

 

 

 

 

 

 

'Always
or Some- NO
Task times Never Response
I. Menu Planning
- general diets 84 15 5
- modified diets 75 14 10
II. Estimating Needs
- foods 97 0 5
- supplies 95 1 4
- equipment 90 4 6
III. Purchasing
- foods 95 5 2
- supplies 87 8 5
- equipment 72 18 10
IV. Staffing
- hiring employees 88 9 5
- assigning volunteers 19 29 52
- employee in- service training 90 6 4
- volunteer in- service training 17 50 55
V. Determinihg
- daily production schedule 95 5 2
- portion Size of food items 86 4 10
- selling price of food items 59 52 29
- per diem inpatient rate 16 48 56
IV. Supervising Workers in:
- food production 95 0 5
- patient tray assembly 94 0 6
- patient service 89 5 8
- dining room service 82 4 14
- equipment repair 52 52 16
- maintenance 49 52 19
VII. Departmental Accounting_
- financial accounting 21‘ 61 18
- payroll 20 61 18
- other internal records 52 57 11
VIII. Dietary Instruction
- inpatient 65 22 15
- outpatient 24 41 55
IX. Regular Work Assignment
food production 90 4 6
- patient tray assembly 86 1 15
- counter server 55 15 52
- dining room host/hostess 45 25 52
- cashier 18 44 58
X. Others not included above:
- executive planning committee 2 0 98

- patient review meeting 5 O 97

 

57

price of food items and the per diem inpatient rate, super-
vising maintenance workers, financial and payroll accounting,
instructing outpatients in diets, and regular work assign-
ments of dining room hosting and cashiering. Two additional
management responsibilities were added by some respondents:
participation on executive planning committees (2%) and in-
patient review meetings (5%).

In general, food service managers in extended care
facilities usually have regular work assignments in addition
to managerial responsibilities but less frequently are con-
cerned with the financial accounting and payroll functions,
volunteer workers, cashiering, and policy decisions concern-
ing inpatient food rates. These tasks can be and more often
are the responsibility of other organizational units within

the extended care facility.

Department staff. The size of the food service staff includ-
ing both administrative/supervisory staff and regular
employees depends on the physical layout for production and
distributive meal service, the extent of assigned managerial
responsibility, patient load, operational objectives, and

the level(s) of patient care provided by the facility. For
56 per cent of the survey participants the number of EEll'
Eihg_administrative/supervisory staff in the food service is

one staff member, while 15 per cent report no fpll-time

 

administrative/SUpervisory personnel. Group response per-

centages of 14 and 15 report 2 and 5 or more full-time staff

58

members, respectively. One part—time supervisory staff

 

member is reported by 54 per cent of the facilities and 2

part-time staff are reported by 8 per cent; however, the

 

majority (54%) report no part-time supervisory staff.

The number of regular full-time employees averaged 1
to 5 persons for 22 per cent of the respondents, 6 to 10
for 57 per cent, 11 to 20 for 25 per cent, and 21 or more
for only 15 per cent. Regular part-time employees averaged
5 or less for 70 per cent of the respondents, 6 to 10 for 15
per cent, 11 to 20 for 6 per cent, and 21 or more for only 4
per cent.

Respondents were asked to indicate the average number
of hours worked per week for each category of administrative/
supervisory and regular personnel. Full-time administrative/
supervisory staff averaged 45 hours/week and part-time staff
16 hours/week. Regular full-time employees averaged 40 hours/
week, while part-time regular employees work 21 hours/week.
Although administrative/supervisory personnel still work more
than the 40-hour work week typical in other segments of the

labor force, regular employees have achieved this goal.

Contribution of volunteers. Volunteer workers can and do
supplement the activities of many departments in the extended
care facility, but only 4 (5%) of the responding facilities
indicated that their food service departments have regular
daily assistance from volunteer workers. In three of these

facilities volunteers assist bed patients with eating, in 2

59

they collect and return patient trays, in 2 others they
assist with dining room hostessing, in 1 facility they
occasionally assist with food production and in another

facility they tranSport trays to patients.

Meal service policies. Meal service policies involve meal
patterns, clienteles served, areas of service and means of
distributing food to these areas--all of which evolve from
the needs of the patients and the goals of the extended care
facility.

Basic meal patterns for inpatients vary among the
reporting facilities. About two-thirds of the facilities
provide breakfast, dinner, and supper plus supplements, while
22 per cent provide breakfast, lunch and dinner plus supple-
ments. The daily meal pattern of 5-meals per day with no
routine supplements is offered by 7 per cent of the respond-
ents. Five facilities (6%) do not use the traditional 5—
meals per day: 4 provide breakfast and dinner plus 2 or 5
generous supplements, and 1 uses "four meals per day."

In addition to providing meals for inpatients, meals
for outpatients are provided in 15 (17%) Of the facilities
surveyed, either regularly or occasionally. Among these 15
facilities a variety Of procedures are used: either service
in the main dining room along with inpatients, or service in
the main dining room when inpatients are not being served,
or a separate area of the main dining room, or a separate
dining room, or snack bar, coffee shop, or vending areas, or

lounges on patient floors.

60

Meals for visitors are provided by 84 per cent of
the facilities: 28 per cent on a regular basis and 56 per
cent only occasionally. These meals are served chiefly in
the main dining room and in patient rooms for 44 and 45
per cent of the facilities, respectively. Other areas in
which visitor meals are served include the main dining room
along with patients (18%), separate dining room (17%),
employee cafeteria (11%), separate area of main dining room
(8%), snack bar or coffee Shop (6%), vending machine areas
(5%), and patient floor lounges (1%).

Thirteen per cent of the facilities do not serve
meals to employees; however, among those that do have
employee meals available, the facility personnel served
varies. About 80 to 87 per cent of the respondents serve
meals to administrative, nursing service and food service
personnel. About 72 per cent serve housekeeping and main-
tenance personnel. Smaller percentages Of the survey
participants serve the following groups: physicians and
medical service personnel (57%), non-food service volunteers
(55%), personnel in residence (28%), and food service volun-
teers (22%). Five per cent of the respondents provide meal
service to beauticians, physical therapy aides, recreation
directors, laundry personnel, librarians, and board members.

Facility personnel are provided separate or Special
dining areas in 82 per cent of the facilities. These are

generally personnel dining rooms (70%); lounge areas (4%)

61

and patient dining rooms (8%) are used in a small percentage
of the facilities. Eighteen per cent of the facilities do

not provide special dining rooms for personnel.

Residentipatient meal service. Of the average number of

 

resident meals for the 79 facilities as a whole, slightly less
than half are served in main dining rooms and Slightly more
than half are transported to patient rooms and nursing unit
day rooms.

Within the total number of facilities surveyed, 51
per cent of the resident patients are on general diets and
49 per cent on modified diets. Seven types of modified diets
were indicated: mechanical soft diets (17%), diabetic diets
(15%), sodium restricted diets (7%), bland or ulcer diets
(5%), reduction diets (5%), low fat diets (1%), and liquid

tube feedings (1%).

Meal distribution. The system of distribution of meals to

 

patients indicated most frequently by the survey respondents
involves main kitchen tray assembly before delivery to
patients for 90 per cent of the respondents. Decentralized
service in which bulk food is transported to a floor pantry
for tray assembly before delivery to patients was reported by
14 per cent of the facilities. Dining room table service

with waitresses is used in 55 per cent of the facilities.

Nine per cent or less of the respondents indicated the follow-

ing service systems: .family style dining room table service,

62

self-service cafeteria, self-service buffet, coffee Shop or
snack bar service, and vending service.

Various types of service equipment were reported for
tranSporting main kitchen pre-assembled trays to patients
and bulk foods to floor pantries. Closed carts were indi-
cated by 51 per cent of the respondents while 58 per cent
use some form of Open cart to transport patient trays.
Seventeen per cent of the facilities reported heated carts,
and another 17 per cent use combination hot and cold carts.
Refrigerated carts were mentioned by only 5 per cent of the
respondents. One respondent indicated use of heated bulk
carts and another reported use of a portable steam table to
transport foods. Insulated bulk containers were used by 4
per cent of the facilities. When unheated carts are used, 19
per cent indicated use of preheated/chilled plate assemblies,
5 per cent use insulated sectional trays, and 24 per cent
use insulated individual beverage servers.

Transportation between levels in facilities with more
than one floor was performed by service or passenger ele-
vators in 18 per cent of the facilities, by dumbwaiters in
8 per cent, and by continuous vertical tray belt in 5 per
cent. Continuous horizOntal belts were used in 6 per cent
of the facilities either to distribute trays or to collect
soiled trays.

The chief types of facility personnel who assist with

the actual distribution of patient trays are nursing service

65

personnel for 99 per cent of the facilities, while food
service personnel assist in 67 per cent, volunteer workers

in 19 per cent, and housekeeping personnel in 4 per cent.
After the patient receives his tray, assistance with his
meal is provided by nursing service in all (100%) facilities.
Volunteers also assist patients in 25 per cent of the
facilities, food service personnel provide assistance in

15 per cent, family or relatives in 5 per cent, and house-
keeping personnel in 4 per cent.

The findings from this study strongly support the
conclusions of West, Wood and Harger (42) and MacEachern (16)
that centralized tray assembly is the most common method used
in facilities providing some form of nursing care. Since
half of the reporting facilities do use table service for
patients who are sufficiently ambulatory, this finding tends
to add support to the suggestions of Savitsky and Zetterstrom
(24) concerning the psycho-social needs of convalescents.
Patient self-service, whether at meal time or for supplements,
is very limited and is perhaps primarily due to the limited

physical capabilities of the clientele.

Menu policies. Policies related to the type(s) of menu(s)
available are administrative decisions based on the goals

of the extended care unit and the capabilities of the food
service department. .Two types of menus are commonly used in
inpatient health care facilities: non-selective menus in

which the patient is given very little or no choice and

64

Semi-selective menus in which the patient may choose some of
the food items from a pre-determined list and/Or select the
size meal he prefers. ‘When patients remain for a fairly
long period of time, as in an extended care facility, actual
food intake needs to be checked frequently to ensure a diet
that is nutritionally adequate.

Respondents were asked to indicate from the following
four daily menu options which one(s) were offered for general
gie£_clientele: a) non-selective menu with preferences
honored occasionally, b) choice of main meal at noon or
evening, c) choice of breakfast items, and d) semi-selective
menu choices for luncheon, dinner or SUpper food items within
one or more of the following categories: appetizers, main
dishes, vegetables, salads, breads, desserts, and beverages.
More than two-thirds (68%) of the respondents indicated that
patients have no formal choice of menu items but preferences
are honored occasionally. Among the 25 (51%) Of the reporting
facilities which do permit some patient selection in one or
more menu categories, 22 permit choice Of breakfast items
and beverages, 17 of bread items, 15 of vegetables, 14 of
main dishes, 14 of desserts, 12 of salads, and 11 of ap-
petizers.

Similar patterns are observed within the daily menu
options for modified diets with Slightly less than two-thirds
(61%) of the respondents indicating that patients have no

formal choice of menu items but preferences are honored

65

occasionally. Among the daily menu Options for both general
and modified diets there is very little difference with
respect to clientele category: inpatients, outpatients,
food service workers, other facility employees, and guests.
Where patient selection is permitted, facility personnel and
guests are offered the same menu options.

Policies concerning menu planning and menu approval
for general and for modified diets differ somewhat among the
survey participants but, in many cases, are a team responsi-
bility shared by food service department personnel of differ—
ent management levels and associated facility personnel
outside the food service department. In addition, the degree
of involvement for planning the menus and the responsibility
for final approval of the planned menus may differ consider-
ably among team members. In the majority of the reporting
facilities the menus for both general and modified diets are
planned by administrative and production staff within the food
service department. However, in about half of the facilities
surveyed the menus which are planned for both general and
modified diets by the dietary personnel must also have the
approval of one or more persons outside of the dietary depart-

ment; facility administrators, physicians, and/Or nurses.

Food service volume. .Meal count estimates for an average

 

weekday for each type of meal and supplement served were pro-
vided by only 71 (90%) of the 79 respondents. When totalled,

these 71 extended care facilities provide, on the average, a

66

grand total of 52,100 meals per day and 7,250 meal supple-
ments per day. Of the total number of meals served for all
clientele types, 50 per cent are served at breakfast, 58 per
cent at noon lunch or dinner, and 52 per cent at evening
dinner or supper. More than half (59%) of the meal supple—
ments are served in the evening, 25 per cent in the afternoon
and 16 per cent in the morning.

Percentage distribution of total meals served among
clientele categories for all facilities reporting indicate
that the meal production and service patterns are purposely
tailored to accommodate the needs of the patients who account
for 88 per cent of all meals served: inpatients 84 per cent
and outpatients 4 per cent. Of the total number of patient
meals served, 49 per cent are general diet meals and 59 per
cent are modified diet meals. Meals served to accommodate
facility personnel and guests account for only 12 per cent
of the total and, in most of the reporting facilities, are
subject to the prevailing production and service patterns

established for patients.
Personal Interviews

The sub-sample selected for interview consisted of
21 facilities within a sixty-mile radius of Lansing, Michigan,
which had responded to the mail questionnaire. Of the 21
facilities contacted, 18 administrators were willing to have
the investigator visit their food service department and

talk with the person in charge.

67

Information sought during the interviews included
the position title and number of years in the present posi-
tion of the person in charge of the food service; physical
layout of the extended care facility in relation to the food
production area; flow of prepared food to patients; method
of tray assembly and equipment and serviceware used in tray
assembly and distribution; and Opinions Of the food service
manager concerning problems involved in distributing patient
trays, control of food items on patients trays, plans for
modifying procedural or physical aspects of the food service
system, and the feasibility of other styles of meal service

for patients.

Characteristics of the sub-sampie

The sub-sample was representative of the mail survey
response sample in terms of licensed bed capacity and owner-
ship of the extended care facilities. The majority (12) of
the 18 facilities visited have between 51 and 150 beds each,
1 facility has less than 50 beds, and 5 facilities have be-
tween 151 to 250 beds. Of the 18 facilities 8 are under
proprietary ownership, 5 are non-profit, and 5 are government
owned. Only 5 of the 18 facilities indicated provision for
outpatient services and each of these has less than 50 out-
patients per day. Only 2 of the 18 facilities were planning
expansion of licensed beds, and only 1 was planning expansion
of ancillary services (physical therapy). Of the 10 facili-

ties that were totally eligible for Medicare certification

68

all were participating in the program, while only 4 of the

7 facilities that were partially eligible had chosen to
participate. One government-owned facility Was restricted
from Medicare certification because its source of Federal
funds antedated the Medicare program; however, the required
facility standards parallel those for Medicare certification.

All of the interviewees are food service professionals
with position titles of dietitian in 6 of the facilities and
of food service supervisor/manager in the remaining 12
facilities. Seven of the managers have been in their present
positions for less than 5 years, while 11 have been in their
present positions from 5 to 15 years.

Twelve of the facilities visited by the investigator
are one-story structures and 6 are multi-story structures
with 2 to 4 patient floors. Vertical transportation of food
and supplies in all facilities with more than one patient

floor was either by elevator, ramp or stairway.

Characteristics of the food service

 

The food production areas of these extended care
facilities are located centrally on the first floor in 15
facilities and at the end of one wing in 5 facilities.
Horizontal distances traveled in patient food delivery ranged
all the way from the total length of the facility to group
dining areas located adjacent to the food production area.

Flows of prepared patient trays to bed patients were

of three types: a) centralized service-—kitchen assembly on

69

trays, delivery via cart to nursing unit, passing of trays
to patients by nursing service personnel (15 facilities);

b) decentralized service--kitchen preparation of food, bulk
portioning of food for delivery by carts to service kitchens
located on patient floors near the nursing units, assembly
of trays, and direct delivery to patients by nursing service
personnel (2 facilities); and c) kitchen preparation and
assembly on trays, followed by nursing service personnel
pick-up for direct delivery to patients (1 facility).

In all of the facilities visited, some form of dining
room or congregate dining service is available for patients
who are sufficiently ambulatory. For these patients, the
flows of prepared food from the kitchen are similar to those
used for the bed patients. In 9 of the facilities, trays
are assembled in the kitchen as in the centralized service
method, loaded into carts and taken into the dining area
where they are distributed to the patients. Seven facilities
do not use carts as an intermediary; the trays are assembled
in the kitchen and delivered directly to the patients. In
2 facilities patient trays are assembled at the cafeteria
steamtable and then carried to the seated patient.

Assembly-line methods of putting together the food
items for a patient tray requires a means of introducing a
consistent sequence Of operations so that at the end, the
tray is complete; horizontal tracks or conveyor belts serve

this function. In all of the facilities the trays were

70

manually moved along a track or surface; none of them
utilized a motorized conveyor belt. The surface or track
used included roller tracks in 5 facilities, tray slides in
6 facilities, and counter tops in 7 facilities. Another 7
facilities used the assembly-line technique for hot foods
only; cold food items were placed on the trays prior to meal
service time.

The assembled tray was put into some form of cart
or truck in the 17 facilities in which the tray was not
carried directly to the patients. The most frequently used
cart is the open-Shelf type in 9 facilities, with the closed-
Shelf, unheated carts used in 8 facilities. Only 5 of the
facilities used a closed, heated/chilled cart and 1 used a
bulk hot food cart. Two facilities that use heated/chilled
carts also use a closed, unheated cart to supplement their
service needs.

Service equipment used for maintaining the temperature
of the food varied both within and among the facilities
visited. Four of the units use heated/chilled carts to main—
tain food temperature, 2 use an insulated cover and base
assembly for the main plate, 5 use a heated pellet placed in
a special insulated plate assembly unit for the main plate,
while 9 facilities only pre-heat the main plate and use a
plate cover.

Serviceware for patient trays consists of china or

pyrex dinnerware in 12 facilities and plastic dinnerware in

71

6 facilities. However, plastic dinnerware is available in
all facilities to meet special patient needs. Drinking
glasses used on trays are reusable plastic in 11 facilities,
glass in 6, and disposable plastic in 1 facility. In all
facilities, stainless steel or Silverplate flatware is used
rather than disposable plastic.

Disposable tray items are used only to a limited
extent. Nine facilities use none, while 4 facilities use
paper or plastic souffle cups for portioning some foods, 1
facility uses all disposable items except flatware and trays
for the Sunday evening meal, and 1 facility has disposable
dinnerware available for patients in isolation. »All facili—
ties indicated they have disposable tray items available
for emergency use. One facility uses disposable cups and
dishes to pre-portion meal supplements before sending them to
the nursing unit. Another facility uses di5posable quart
containers to send meal supplements in bulk to the nursing
unit for refrigerated storage until portioned by nursing
personnel. D15posable dishes and containers are considered
too expensive for extensive routine use by most of the
facilities.

Purchased pre-portioned items are not used to any
extent in the facilities visited. Of those who do use them,
8 facilities use salt, pepper and sugar packets, 2 use
individual catsup, mustard, and salad dressings, and 2 use

individual jellies and jams. Seven of the food services do

72

not purchase pre-portioned items due to their cost and the
difficulties patients encounter in opening them. Many Of
the facilities pre-portion their own food items during Slack

production periods.

Qpinions of the food service manager

In an attempt to delineate current and potential
problem areas in extended care facility food services, the
Opinions of the food service managers were sought concerning
the five following areas: transportation of food to patients,
control of food items on patient trays, ideas for remodeling
the food service or modifying procedures for more efficient
service, satisfaction with their present tray assembly and
tray distribution procedures, and alternate styles of patient
meal service. Differences in the interviewees' educational
and experiential backgrounds, rather than the food service
itself, could account for the reSponseS.

Food service managers in 10 of the facilities indi-
cated that very few problems are encountered in getting
finished food from the preparation area to patients, but they
do have some problems in the food preparation and tray
assembly areas. In the opinions Of 6 food service managers,
the arrangement of the tray assembly-lines causes difficul-
ties; in these particular cases they felt that the tray line
is awkward in height or lacks adequate Space or they do not
have sufficient back-up refrigeration. One manager experi-

ences frequent problems in controlling the serving of meal

75

supplements to patients via nursing service personnel.

-And in another, the physical layout of the facility necessi-
tates a relatively steep ramp between floor levels which makes
it difficult to wheel loaded heated/chilled carts from one
part of the building to another.

In all facilities visited therapeutic diets and
patient preferences are systematically recorded for each
patient on a dietary record. In addition, some type of tray
card which lists patient name, diet, major food preferences
and dislikes, and room number is used in all facilities.
Individual modified diets are handled in two ways: unusual
or very restricted diet modifications are written individually
for each patient concerned, but commonly used modified diets
are served as posted for that meal. When the food service
manager or consulting dietitian is not available, last minute
food item changes for modified diets are usually handled by
the cook on duty. All of the interviewees permit a limited
amount of catering to patient preferences but agree that it
can get out of their control. One food service manager felt
that the longer a patient stays in the facility, the more
likes and dislikes he or She develOpS.

Ideas for remodeling the food service centered
chiefly around needs for certain additional equipment, re—
placement of obsolete equipment, and provision for increased
refrigeration and storage Space. One manager, who was new to

the facility, feels that there are many physical limitations

74

in the layout of the food service, but is concentrating her
efforts on developing and improving standardized procedures.
Desired equipment mentioned by the interviewees includes
mobile cooking and serving equipment, heated/Chilled tray
carts, closed carts to replace Open carts, tray slides or
conveyors to use for tray assembly, and larger dishwasher
capacity. Many of the interviewees are aware of the material
limitations of their respective food services, but feel that
any type of major renovation is too eXpensive to be con-
sidered at this time.

The majority (15) of the food service managers
interviewed are satisfied with their procedures for tray
assembly and tray distribution to patients. The three that
are not satisfied cited these problem areas: inadequate
space in the kitchen for tray assembly and loading of carts,
inadequate corridor Space for transporting carts, lack of
efficient means to keep food items at optimum temperatures,
and a built-in tray line which requires too many workers to
assemble trays. None of the managers indicated that they
regularly personally check the quality of the food as it
is received by the patient.

Although the majority of these extended care facili-
ties routinely serve Some of their patients by tray in some
type of dining room, the investigator endeavored to discover
what, if any, other styles of meal service have been tried

with ambulatory patients or are used for special occasions.

75

Generally the facilities do not deviate from their routine
manner of serving meals, however, at one time three facili-
ties did regularly serve patients from the cafeteria line

or serve them family-style in the dining room. The cafeteria
service was discontinued due to the changing physical capa-
bilities of patients who are now less ambulatory than at one
time, while the family-style service was discontinued for
reasons of sanitation and economy. Only one facility regu-
larly has picnics or buffets for the patients who are able to
participate. Waitress-style dining room service is not used
in any of the extended care facilities visited, although 1
facility had used it previously but discontinued it for
reasons of economy. In summary, most of the interviewees are
satisfied with the method of serving patients from trays

either in a dining room or patient room.

-CHAPTER V

SUMMARY, CONCLUSIONS, AND IMPLICATIONS

This study was concerned with developing an overview
of food service to patients in 79 Michigan extended care
facilities. Survey instruments were directed toward obtain-
ing organizational data about the total facility and the
essential elements concerned with the Operation of the food
service. Data used to characterize the extended care facil-
ity were gathered by mail questionnaire, while personal
interviews in a selected sub-sample of 18 of the extended
care facilities were used to gain more Specific information
concerning the food service and Opinions of the food service
manager. In both cases, data were sought from the person
responsible for the management of the food service for the
facility.

This chapter summarizes the data discussed in Chapter
IV. Conclusions are drawn, the implications for food distri-
bution systems associated with organizational change and

facility expansion are suggested.

76

77

Mail-questionnaire Findings

Facility characteristics

Facilities responding to the survey have a variety
of names with those mentioned most frequently being medical
care facilities, nursing homes, convalescent centers, and
units of hOSpitals. In general, the facility names are not
descriptive of the type(s) of care provided by the facility.

The administrators of these extended care facilities
generally have the position title of administrator or
director.

Facility size as exPressed in terms of number of
licensed beds ranged from 15 to 859 beds per facility with
the majority of the facilities in the range of 51 to 150 beds.
At the time of the survey, occupancy of the majority averaged
85 per cent or more.

Outpatient services are not offered in the majority
of the extended care facilities surveyed; moreover, most of
those facilities which do offer these services only do so to
a limited extent.

Facility expansion by increasing the number of
licensed patient beds is planned by only a few facilities.
This expansion can involve physical enlargement of the
facility and/Or conversion of surplus Space to patient bed-
rooms. The current size of most of the facilities which are
planning expansion is in the range of 50 to 157 beds, while

the expanded size would range from 100 to 175 beds. Planned

78

expansion of ancillary services is likewise limited with
rehabilitation services being the most frequently mentioned
in contrast to supportive services, such as dietary, house-
keeping, maintenance, and business office.

The ownership classifications are fairly representa-
tive of Michigan extended care facilities with almost half
of the facilities under proprietary ownership, about a third
under government ownership, and the remaining under non-
profit ownership. .Membership in multiunit organizations by
the facilities of proprietary and non-profit ownership was
indicated by about a third of those respondents. In some
cases those reporting were members of the same multiunit
organization.

Percentage comparisons among facility Sizes and types
of ownership indicate that, for each Of the three ownership
types, the concentration of numbers of facilities is at the
51 to 150 bed Size. However, government-owned facilities
within each size range tend to be larger than corresponding
proprietary and non-profit facilities.

The majority of the facilities indicated they are a

nursing care home as classified by the United States Public

 

Health Service. In addition to nursing and personal services,
convalescent and rehabilitative health care services are
provided.

All but 1 of the 79 survey respondents reported they

were eligible to participate in the Medicare program either

79

totally or partially; however, only 70 facilities were
participating. A decision on the part of the facility not to
participate in the Medicare program could be due to three
reasons: the facility already has an adequate number of
private patients without participating in the Federal program,
the initial expense of establishing records and bookkeeping
procedures is more than the facility can afford at this time,
and Medicare reimbursement is perceived as inadequate to

cover increased Operational and financing costs.

Food service characteristics

 

Management of the food service operations in the 79
responding extended care facilities is primarily independent
and operated by the respective facility; however, a few
(facilities are satellite to a larger health care facility
or have a contract with a food management company. Opera-
tional responsibilities assumed by the food management com-
pany vary with the type of contract but in general include
reSponSibilities for meal planning, food preparation,
distribution and control, staffing and employee training.
Utilization of the services of an outside food management com-
pany to a certain extent is dependent on the size Of the
extended care facility. All of the facilities contracting
this service were either larger than the average or part of
a multiunit organization.

Persons responsible for the management of the food

service departments in these Michigan extended care facilities

80

generally have the position titles of dietitian, food
service supervisor, kitchen supervisor, dietary manager, or
director of food service. >About half of the respondents
have had previous work experience in the management of a
food service operation, while a fourth have had non-manageri-
al food service responsibilities. >Another fourth did not
respond to this questionnaire item; this could be due to an
oversight when completing the questionnaire, lack of any
previous work experience, or a reluctance to indicate that
the previous experience was unrelated to either food service
or management.

The size of the food service staff depends on many
factors which may be unique to a particular facility.
However, on the average a facility usually has 1
administrative/supervisory staff member who is responsible
for the management of the food service; this person may work
on a full—time basis for about 45 hours/week or on a part-
time basis for about 16 hours/week. The majority of the
facilities are staffed with regular, full-time employees who
average 40 hours/week; part-time employees who average 21
hours/week are used only to a limited extent.

Only 4 of the 79 respondents indicated that their
food service received regular daily assistance from volun-
teer workers. In these facilities the volunteers generally
assist patients with eating, collect and return patient

trays, and serve as dining room hostesses. VOlunteer workers

81

can supplement the activities of many departments within the
extended care facility but gain their greatest satisfaction
from activities in which they have direct contact with
patients.

The meal service policies of a facility tend to be
individualized to fit its specific goals and needs; however,
all of the extended care facilities surveyed seem to have
certain elements in common. The basic meal pattern for
patients in about two-thirds of the facilities consists of
breakfast, lunch, evening dinner, and meal supplements;
while about one-third provide breakfast, noon dinner, supper,
and meal supplements. A few facilities use variations of
the four- or five-meal-a-day plan. .Those facilities with
outpatients generally provide meals for them; in addition,
meals for visitors and employees are available at the
majority of extended care units surveyed.

Of the average number of meals served in the 79
responding facilities, half are served in the main dining
room and about half are transported throughout the facility
to patient rooms and nursing unit day rooms. Within the
total number of facilities surveyed, about half of the
patients are on general diets and about half are on modi-
fied diets.

The centralized system of distribution of meals to
patients was indicated by 90 per cent of the respondents,

whereas, decentralized service was indicated by only 14 per

82

cent. Half of the facilities also provide dining room

table service with either waitresses or aides. Meal service
to patients involving self-service is infrequently offered;
this is most likely due to the physical limitations of the
patients.

Various types of service equipment were reported for
tranSporting the main kitchen pre-assembled trays to patients
and bulk food to floor pantries. Closed carts were mentioned
by about half of the respondents while about one-third use
some form of Open cart. Various forms of heated carts are
used but by less than a fourth of the respondents. When un-
heated carts are used, less than a fourth use some form of
insulated or heated plate assemblies to maintain the tempera-
ture of the food.

For extended care facilities of more than one floor,
transportation between floors was by elevators for the most
part, with a few facilities using dumbwaiters and continuous
vertical belts.

The actual distribution of trays from the cart to
patients is done by nursing service personnel in almost all
facilities, with some fOod service personnel assistance in
about two-thirds of the facilities. Smaller percentages of
volunteer workers and housekeeping personnel also assist.
After the patient receives his tray, assistance with eating
is provided by nursing service personnel in all facilities;

however, in a fourth or less of the facilities, volunteer

85

workers, food service personnel, family members or relatives,
or housekeeping personnel provide assistance to the patient.

The types of menus for both general and modified
diets commonly used in two-thirds of these extended care
facilities are non-selective in which the patient has no
formal choice of menu items but in which his preferences are
honored occasionally. Some patient selection is permitted
in a third of the facilities with the greatest flexibility
in the choice of breakfast items and beverages. In most
cases facility personnel and guests are offered the same menu
options as patients.

Policies concerning menu planning and menu approval
for general and for modified diets differ somewhat among the
survey participants, but in most facilities, are a team
reSponSibility shared by food service department personnel of
different management levels and personnel outside the food
service department. In many cases, menus planned by food
service professionals must also be approved by persons out-
side of the food service department.

Of the total number of meals served for all clientele,
approximately a third are served at breakfast, a third at
lunch, and a third at dinner. Of the total number of meal
supplements, more than half are served in the evening with
somewhat more of the remaining served in the afternoon than
in the morning. Percentage distribution of total meals

served indicated that the primary production and service

84

patterns accommodate patient needs rather than personnel

or guests.

Personal Interview Findings

Chappcteristics onphe sub-sample

The 18 extended care facilities in the sub-sample
selected for personal interviews were representative of
the mail survey reSpondents in terms of licensed bed capa-
city and ownership of the facilities. Of the 18 facilities
visited, 17 are eligible for Medicare certification; however,
of the 17 eligible, only 14 are participating with the
Federal program. (The 5 non-participating facilities are
each under proprietary ownership and are located in the
same urban area of the state.

The majority Of the extended care facilities are
one-story structures and require only horizontal transport
of food and supplies. Vertical tranSportation is provided

primarily by elevators in the multi-story structures.

thiacteristics of the food service

The persons interviewed were dietitians or food
service managers. Their experience in this position ranged
from a few months to 15 years. Generally those managers
with more education and/Or experience were very hospitable
and talked freely with the investigator.

The food production areas in the 18 facilities

visited are, for the most part, centrally located on the

85

ground floor, although in five facilities they are located
at the end of one wing of the facility.* The horizontal
distance traveled in patient food distribution ranged from
the total length of the facility to group dining areas
adjacent to the food production area.

The majority of the facilities use centralized
methods of food distribution to patients, and Offer some
form of congregate dining service for those patients who
are sufficiently ambulatory. Patients generally eat from
trays either in the patient's room or in the dining room.

Tray assembly-lines utilize roller tracks, tray
slides, and counter tOps; but none of the facilities use
motorized conveyor belts which are common in many hOSpitals.
The assembled trays are generally loaded onto Open carts,
with closed, unheated carts used in almost as many cases.
Only a few of the facilities use closed, heated/chilled
carts. Often one facility has several tray assembly methods
and also uses several different kinds of carts to deliver
patient meals. Service equipment used for maintaining
temperature of the food varies both within and among the
facilities visited. The types of service equipment used by
about half of the facilities are the insulated cover and
base assembly for the main plate, and heated pellet-
insulated base assembly; however, half Of the facilities
use only a pre-heated main plate and cover to maintain food

temperatures. Serviceware for patient trays is generally

86

china or pyrex with about a third of the facilities using
plastic dishes. Drinking glasses are reusable plastic in
most of the facilities. -DiSposable tray items and purchased
pre—portioned food items are used only to a limited extent
in any of the facilities due to their cost and the difficul-

ties patients encounter in handling them.

Qpinions of food service managers

The majority of food service managers interviewed did
not feel that their problems centered around delivery of food
to patients but, rather, their problems were associated with
food preparation and tray assembly. Many food production and
service areas evidenced lack of integrated planning in terms
Of the many functions performed within the area.

Patient preferences do receive consideration in all
facilities and all of the managers feel that they have ade-
quate control over the items that go on the patient trays.

Ideas for improving the efficiency of the food service
centered to a great extent on remodeling or acquiring new
equipment rather than procedural innovations utilizing the
existing physical resources. Many of the interviewees are
aware of limitations in their food service but were not
actively engaged in improvement programs at the time of the
interviews.

Although the majority of the extended care facilities
visited routinely serve some of their patients by tray in the

dining room, generally other styles of meal service have not

87

been tried with ambulatory patients even for Special occa-
sions. Reasons for this center around the limited physical
capabilities of the patients, the added employee cost of
other methods, and limited equipment for other styles of meal
service. .Most of the interviewees are satisfied with their
method of serving patients from trays and feel that this is
the best method within their resources. ~All acknowledged
that meal time is an important time of the day for the
patient but indicated that it is not meant to be the only

diversional activity of the day.
Conclusions and Implications of the Study

These data suggest that the service of food to
patients in the extended health care units surveyed varies
greatly among facilities. In many cases the system of
patient meal distribution is archaic and neither adequate nor
efficient for the physical resources of the food service
department. This is not to say that the physical facilities
are Old; on the contrary, many are relatively new but were
not designed with built-in flexibility. AS the meal service
demands of the facility have increased, the food service
itself has remained static so that its internal Operational
systems have become strained.

HOSpital standards can not be applied indiscrimi—
nately to these food services. Evidence suggests that there

is need to evaluate the Operational goals of non-hOSpital

88

health care facilities as Well as the functions of their
food service and develOp integrated, flexible systems
specifically geared toward nursing care facilities.
Efficiency could be markedly improved in most of the exist-
ing food services by procedural modifications at relatively
nominal cost.

Physical expansion of extended care facilities does
not seem to be as extensive among the facilities studied as
originally assumed. EXpansion Of existing facilities is a
reflection of the demand for additional patient accommoda-
tions and is generally considered the least expensive way
to add such facilities. However, changes in the licensure
codes at the State level are demanding costly renovations
in existing facilities, and, thus, diverting money from
expansion as well as making new construction of nursing care
facilities a better choice. As clean, safe, and modern
buildings become the rule rather than the exception, the
emphasis on construction will change to an emphasis on qual-
ity management. Perhaps the demand for licensed nursing
care beds is being sufficiently met in many areas of Michigan
so that the existing facilities are now faced with the chal-
lenge of improving the efficiency and quality of their
patient care in order to remain in a competitive position.

Despite the limited scope of this fact-finding study
there is evidence that non-metrOpOlitan Michigan extended

care facility food services need assistance in organization

89

and management. Related inVestigationS with a larger number
of metropolitan facilities are needed to supplement these
data and to further identify the basic problem areas in this

important segment of the health care institutional complex.

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10.

11.

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Smith, Charlotte E. "Dietary Consultation Services in
Nursing Homes: Highlights of Two WOrkshops."
Journal of the American Dietetic Association, XLVI
(September, 1965), 502-505.

Smith, Charlotte E. "Dietary Services in Extended Care
Facilities." Journal of the American Dietetic Associ-
ation, L (January, 1967), 21-25.

Smith, Charlotte E. "How to Translate Policies into
Procedures." Hoppital and Nursing Home Food Manage—
ment, III (September, 1967).

Somers, Herman M. and Somers, Ann Ramsay. Medicare and
the Hospitals: Issues and PrOSpects. Washington,
D. C.: The Brookings Institutions, 1967.

 

U. S. Bureau of the Census. "Estimates of the POpulation
of the United States, by Age, Color, and Sex: July
1, 1960 to 1965." Current Population Reports.
Series P-25, Number 521. Washington, D. C.: Govern-
ment Printing Office, 1965.

U. S. Bureau of the Census. "Estimates of the Popula-
tion of the United States, by Age, Race, and Sex:
July 1, 1964 to 1967." Current Pppulation Reports.
Series P—25, Number 585. Washington, D. C.: Govern—
ment Printing Office, 1968.

U. S. Bureau of the Census. "Estimates of the Population
Of the United States, by Age, Race and Sex: July 1,
1968." Current ngulation Reports. Series P-25,
Number 416. Washington, D. C.: Government Printing
Office, 1969.

 

U. S. Department of Commerce. Statistical Abstract of
the United States, 1968. washington, D.C.: Govern-
ment Printing Office, 1968.

U. S. Department of Health, Education, and Welfare.
Division of Medical Care Administration. Nursing
Home Utilization and Costs in Seiected States.

Health Economics Series Number 8. Publication Number
947-8. Washington, D. C.: Government Printing
Office, 1968.

U. S. Department of Health, Education, and Welfare.
National Center for Health Statistics. Health
Resources Statistics: Health Mappower and Health
Facilitiesi_1968. Publication Number 1509. Washing-
ton, D. C.: Government Printing Office, 19680

56.

57.

58.

59.

40.

41.

42.

45.

95

S. Department of Health, Education, and Welfare.
Public Health Service. A Guide to Nutrition and
Food Service for Nursing_Homes and Homes for the
Age . Publication Number 1509. Washington, D. C.:
Government Printing Office, 1965.

S. Department of Health, Education, and Welfare. Pub-
lic Health Service. Nursing Homes and Related
Facilities Fact Book. Publication Number 950-P-4.
Washington, D. C.: Government Printing Office,
1965.

 

S. Department of Health, Education, and Welfare.
Public Health Service. Health Insurance for the
Aged: Conditions of Participation for Extended Care
Facilities. Publication Number HIR-11 (2/68).
Washington, D. C.: Government Printing Office, 1966.

 

S. Department CHE Health, Education and Welfare.
Social Security Administration. Directopy of Medi-

care Providers of Services: Extenged Care Facilities,

Title XVIII. Washington, D. C.: Government Printing
Office, October 1968.

 

S. Department of Health, Education, and Welfare.
Social Security Administration. Health Insurance
Under Social Security: Your Medicape Handbook.
Washington, D. C.: Government Printing Office,
1969.

S. Department of Health, Education, and Welfare.
Social Security Administration. Title XVIII of the
Social Security Act: Health Insurance for thepAged.
Washington, D. C.: Government Printing Office, 1968.

West, Bessie Brooks; WOod, Levelle; and Harger, Virginia.

Food Service in Institutions. New York: John Wiley
and Sons, 1966.

 

Young, Pauline V. Scientific Social Surveys and Research.

Englewood Cliffs, New Jersey: Prentice-Hall, Inc.,
1966.

94
ADDITIONAL REFERENCES

Aimone, Virginia Roget. "Characteristics of the Employment
in Food Service Departments in Nursing Homes in Iowa."
Unpublished M. S. Thesis, Iowa State University, Ames,
Iowa, 1967. .

American Association Of Homes for the Aging. The Social
Components of Care. New York: American Association of
Homes for the Aging, 1966.

 

Binder, Gertrude. "What an Extended Care Facility is Not."
HOSpitals, XL (September 1,1966), 65-68.

Cashman, John W. "Nutritionists, Dietitians, and Medicare."
Journal of the American Dietetic Association, L
(January, 1967), 17-18.

Chappelle, Mary L. "Nutrition for the Aging." HOSpital
Progress, XLIV (July, 1965), 106-108.

Damazo, Paul S. "Design the Dietary Department to Save
Dollars." Modern Hospitals, CI (August, 1965), 114, 116,
118.

Donavan, Anne Claire, and Meyer, Burton. "How to Plan Pro-
gressive Patient Food Service." Modern Hospital, XCV
(December, 1960), 116, 118, 120.

 

Gee, David A., and Axelrod, Boris. "Study Analyzes Food Dis—
tribution Methods." Mpdern HQSpital, XCVIII (May, 1962),
154, 156-159; (June, 1962), 120, 124—126, 150, 152.

Gerletti, John Dominic. Nursing Home Administration.
Downey California: Attending Staff Association, 1961.

Graning, Harold M. "The Institution Needs of the Health
Industry." Public Health Reports, LXXXIV (April, 1969),
505-510.

Hankin, Jean, and Antonmattei, Jean C. “Survey of Food
Service Practices in Nursing Homes." Americpn Journal of
Public Health, L (August, 1960), 1157-1144.

 

Henderson, Pat, and Cook, Lucy. "Twelve-point Service Pro-
gram for Nursing Homes." Hospitals, XLI (September 1,
1967), 128, 150-152.

Horwitz, Julius. "The Nursing Home Industry Tools Up."
New York Times Magpzine. .May 1, 1966, PP. 26-27.

95

Howell, Sandra C., and Loeb, Martin B. "Nutrition and
Aging: A Monograph for Practitioners." The Gepontolo-
gist, IX (Autumn, 1969), 1—122.

Jacobs, H. Lee, and Morris, W. W., eds. Nursing_and Retire-
ment Home Administration. Ames, Iowa: Iowa State
University Press, 1966.

Jernigan, Anna Katherine. "Guide to Kitchen Equipment for
Small HOSpitals." HOSpitals, XXXVIII (October 16, 1964),
110, 117-118, 120.

Jernigan, Anna K., and Strucker, H. W. "Space Needs for
Kitchens in Smaller HOSpitals." HOSpitals, XXXIV (July
1! 1965) I 72’76.

 

Kahn, Robert L., and Cannell, Charles F. The Dynamics Of
Interviewing. New York: John Wiley and Sons, Inc.,
1957.

 

Knapp, Marjorie A. "Planning for Dining and Serving Areas
in Nursing Homes." HOSpitals, XL (November 16, 1966),
140-142.

Knoll, Anne Powell. "A Dietary Consulting Firm?--Experiences
of Two Dietitians." Journal of the American Dietetic
Association, LIII (September, 1968), 245-246.

Leeds, Morton, and Shore, Herbert, eds. Geriatric Institu-
tional Management. New York: G. P. Putnam's Sons,.1964.

McQuillan, Florence L. Fundamentals of Nursing Home Adminis-
tration. Philadelphia, Pennsylvania: Saunders, 1967.

Miller, Dulcy B. The Extended Care Facilipy: A Guide to
Organization and Qperation. New York: McGraw-Hill Book
Company, 1969.

Obert, Jessie, and Burr, Marjorie. "How Can We Improve Food
Service in Nursing Homes?" American Journal Of Public
Health, LIV (June, 1964), 952-959.

Feed, Ruddell. "How to Staff an Efficient Tray Line System."
Modern Hoppital, XCIV (May, 1960), 158, 140—142.

 

Rose Genevieve and Agnes Cecile, Sisters. "Food Prefer-
ences of the Aging." HOSpital Progress, XLVIII (April,
1967), 19.

Savitsky, Elias. “Psychological Factors in Nutrition for
the Aged." Social Casework, XXXIV (1955), 455.

96

Smigel, Joseph 0., and Rerter, Wilma H. Nursipquome Admin-
istration. Springfield, Illinois: Charles C. Thomas,
Publisher, 1962.

Smith, Charlotte E. "Working Toward Food Service Goals for
Nursing Homes." Hospitals, XXXVI (January 16, 1962),
91-92, 95-96, 98, 105.

Smith, Mary Catherine. "A Survey of Nursing and Custodial
Homes in the Vicinity of Waco, Texas." Unpublished
M. S. Thesis, Texas WOmen's University, Denton, Texas,

 

1967.

Solon, Jerry. "Proprietary Nursing Homes: Patients and
Their Care." Public Health Reports, LXXI (July, 1956),
646-651.

Solon, Jerry, and Baney, Anna Mae. "Ownership and Size of
Nursing Homes." Public Health Reports, LXX (May, 1955),
457-444.

Terrell, Margaret E. "Analyses of Food Trends and Policies:
Prelude to Dietary Department Design." Hospitals, XL
(October 1, 1966), 92-97; (October 16, 1966), 142-146.

U. S. Department of Health, Education, and Welfare. Social
Security Administration. The Evolution of Medicare from
Idea to Law, by Peter A. Corning. Office of Research and
Statistics Report Number 29. Washington, D. C.: Govern-
ment Printing Office, 1969.

 

 

U. S. Department of Health, Education, and Welfare. Public
Health Service. A Comparative Study of 40 Nursing Homes:
Their Design and Use. Publication Number 950-D-17.
Washington, D. C.: Government Printing Office, 1965.

Viguers, Richard T., and Connaugton, Carol. "Food Service
Standards Determine Food Service Functions." HOSpitals,
XL (May 1, 1966), 115-118.

Walsh, Maurice J., and Corning, Joyce M. “Aging: The
Challenges in Institutional Care." Hospital Progress,
XLVI (May, 1965), 120—125.

Williams, Ralph C. Nursing Home Management. New York:
F. W. Dodge Corporation, 1959.

Zetterstrom, M. A. "The Dietitian in the Modern Home for
the Aged." Journal of Gerontology, VI (1951), 45.

 

APPENDIX

Page

1. Excerpts from Conditions of Participation;
Extended Care Facilities. . . . . . . . . . . . . . 98

2. Survey Forms and Related Materials. . . . . . . . . 105

Cover leter for pre-test . . . . . . . . . . . . 105
Pre-test questionnaire evaluation form . . . . . 104
Cover letter for questionnaire . . . . . . . . . 106
Mail questionnaire . . . . . . . . . . . . . . . 107
Follow-up post card for non-respondents. . . . . 120
Thank-you letter to respondents. . . . . . . . . 121
Letter of confirmation for personal interview. . 122
Personal interview guide . . . . . . . . . . . . 125

97

EXCERPTS FROM CONDITIONS OF PARTICIPATION?

EXTENDED CARE FACILITIES4

Section 405.1125 Condition Of Participation--Dietapy Services.

The dietary service is directed by a qualified individual and
meets the daily dietary needs of patients. An extended care
facility which has a contract with an outside food management
company may be found to meet this condition of participation
provided the company has a dietitian who serves, as required
by the scope and complexity of the service, on a full-time,
part-time or consultant basis to the extended care facility,
and provided the company maintains standards as listed herein
and provides for continuing liaison with the medical and nurs-
ing staff of the extended care facility for recommendations on
dietetic policies affecting patient care.

a. Standard: Dietary Supervision. A person designated by the
administrator is reSponSible for the total food service of the
facility. If this person is not a professional dietitian,
regularly scheduled consultation from a professional dietitian
or other person with suitable training is obtained. The factors
explaining the standard are as follows:

1. A professional dietitian meets the American Dietetic
Association's qualification standards.

2. Other persons with suitable training are graduates
of baccalaurate degree programs with major studies
in food and nutrition.

5. The person in charge of the dietary service partici-
pates in regular conferences with the administrator
and other supervisors of patient services.

4. This person makes recommendations concerning the
quantity, quality and variety of food purchased.

5. This person is responsible for the orientation,
training and supervision of food service employees,
and participates in their selection and in the
formulation of pertinent personnel policies.

6. Consultation obtained from self-employed dietitians
or dietitians employed in voluntary or Official
agencies as acceptable if provided on a frequent
and regularly scheduled basis.

 

4U. S. Dept. of HEW, Social Security Admin., Health
Insurance Regulations for the Aged, Part 405, Sub-part K,
Document HIR-11.

98

99

b. Standard: Adeqpacy of Diet Staff, A sufficient number
of food service personnel are employed and their working

hours are scheduled to meet the dietary needs of the patients.
The factors explaining the standard are as follows:

1. There are food service employees on duty over a
period of 12 or more hours.

2. Food service employees are trained to perform
assigned duties and participate in selected in—
service education programs.

5. In the event food service employees are assigned
duties outside the dietary department, these duties
do not interfere with the sanitation, safety, or
time required for dietary work assignments.

4. Work assignments and duty schedules are posted.

c. Standard: Hygiene owaiet Staff. Food service personnel
are in good health and practice hygienic food handling tech-
niques. The factors explaining the standards are as follows:

1. Food service personnel wear clean washable garments,
hairnets, or clean caps, and keep their hands and
fingernails clean at all times.

2. Routine health examinations at least meet local,
State, or Federal codes for food service personnel.
Where food handlers' permits are required, they are
current.

5. Personnel having symptoms of communicable diseases
or Open infected wounds are not permitted to work.

d. Standard: Adequacy_of Diet. The food and nutritional
needs of patients are met in accordance with physicians'
orders, and, to the extent medically possible, meet the
dietary allowances of the Food and Nutrition Board of the
National Research Council adjusted for age, sex and activity.
A daily food guide for adults may be based on the following
allowances:

1. Milk: Two or more cups.

2. Meat group: Two or more servings of beef, veal,
pork, lamb, poultry, fish, eggs. Occasionally dry
beans, nuts, or dry peas may be served as alterna-
tives.

5. Vegetable and fruit group: Four or more servings
of a citrus fruit or other fruit and vegetable
important for Vitamin C; a dark green or deep
yellow vegetable for Vitamin A, at least every other
day; other vegetables and fruits including potatoes.

4. Bread and cereal group: Four or more servings of
whole grain, enriched or restored.

5. Other foods to round out meals and snacks, to satisfy
individual appetites and provide additional calories.

100

e. Standard: Therepeutic Diets. Therapeutic diets are pre-
pared and served as prescribed by the attending physician.
The factors explaining the standard are as follows:

 

1. Therapeutic diet orders are planned, prepared, and
served with supervision or consultation from a
qualified dietitian.

2. A current diet manual recommended by the State
licensure agency is readily available to food service
personnel and supervisors of nursing service.

5. Persons reSponSible for therapeutic diets have suf-
ficient knowledge of food values to make appropriate
substitutions when necessary.

f. Standard: Quality of Food. At least three meals or their
equivalent are served daily, at regular times, with not more
than a 14-hour span between a substantial evening meal and
breakfast. Betweenemeal or bedtime snacks of nourishing qual—
ity are offered. If the "four or five meal a day" plan is in
effect, meals and snacks provide nutritional value equivalent
to the daily food guide previously described.

9. Standard: Planning of Menus. .Menus are planned in ad-
vance and food sufficient to meet the nutrition needs of
patients is prepared as planned for each meal. When changes
in the menus are necessary, substitutions provide equal nu-
tritional value. The factors eXplaining the standard are as
follows:

1. Menus are written at least 1 week in advance. The
current week's menu is in one or more accessible
places in the dietary department for easy use by
workers purchasing, preparing, and serving foods.

2. Menus provide a sufficient variety of foods served
in adequate amounts at each meal. Menus are differ-
ent for the same days of each week and are adjusted
for seasonal changes.

5. Records of menus as served are filed and maintained
for 50 days.

4. Supplies of staple foods for a minimum of a 1-week
period and of perishable foods for a minimum of a
2—day period are maintained on the premises.

5. Records of food purchased for preparation are on
file.

h. Standard: Preparation of Food. Foods are prepared by
methods that conserve nutritive value, flavor, and appearance,
and are attractively served at the prOper temperatures and in
a form to meet individual needs. The factors explaining the
standard are as follows:

101

1. A file of tested recipes, adjusted to appropriate
yield, is maintained.

2. Food is cut, chOpped or ground to meet individual
needs.

5. If a patient refuses foods served, substitutes are
offered.

4. Effective equipment is provided and procedures.
established to maintain food at prOper temperature
during serving.

5. Table service is provided for all who can and will
eat at a table including wheelchair patients.

6. Trays provided bedfast patients rest on firm sup—
ports such as overbed tables. Sturdy tray stands
of prOper height are provided patients able to be
out of bed.

i. Standard: Maintenance of Sanitapy Conditions. Sanitary
conditions are maintained in the storage, preparation and
distribution of food. The factors explaining the standard
are as follows:

1. Effective procedures for cleaning all equipment
and work areas are followed consistently.

2. Dishwashing procedures and techniques are well
developed, understood and carried out in compliance
with the State and local health codes.

5. Written reports of inspection by State or local
health authorities are on file at the facility
with notation made of action taken by the facility
to comply with any recommendations.

4. Waste which is not diSposed of by mechanical means
is kept in leak-proof nonabsorbent containers with
close-fitting covers and is disposed of daily in
a manner that will prevent transmission of disease,
a nuisance, a breeding place for flies, or a feeding
place for rodents. Containers are thoroughly cleaned
inside and out each time emptied.

5. Dry or staple food items are stored off the floor in
a ventilated room not subject to sewage or waste
water backflow, or contamination by condensation,
leakage, rodents, or vermin.

6. Handwashing facilities including hot and cold water,
soap, and individual towels, preferably paper
towels, are provided in kitchen areas.

Section 405.1154 Condition of Participetion--Physical
Environment.

h. Stangepd: Dayroom and Dining_Area. The extended care
facility provides one or more attractively furnished multi-
purpose areas of adequate size for patient dining, diver-
sional‘and social activities. The factors eXplaining the
standard are as follows:

102

1. At least one dayroom or lounge, centrally located,
is provided to accommodate the diversional and
social activities of the patients. In addition,
several smaller dayrooms, convenient to patient
bedroom, are desirable.

2. Dining areas are large enough to accommodate all
patients able to eat out of their room. These
areas are well-lighted and well-ventilated.

5. If a multipurpose room is used for dining and
diversional and social activities, there is suf-
ficient space to accommodate all activities and
prevent their interference with each other.

i. Standard: Kitchen or Dietary Area. The extended care
facility has a kitchen or dietary area adequate to meet food
service needs and arranged and equipped for the refrigeration,
storage, preparation, and serving of food as well as for dish
and utensil cleaning and refuse storage and removal. Dietary
areas comply with the local health or food handling codes.
Food preparation Space is arranged for the separation of func-
tions and is located to permit efficient service to patients
and is not used for nondietary functions.

105

MICHIGAN STATE UNIVERSITY EAST LANSING - MICHIGAN 48323

 

COLLEGE OF HOME ECONOMICS - DEPARTMENT OF INSTITUTION ADMINISTRATION 0 HOME ECONOMICS BUILDING

October 24, 1969

To:

 

From: Sister Nancy Raley, C.PP.S.

Re: Request for assistance in pre-testing the survey
instrument for a study of on-premise patient food
distribution systems in selected Extended Care
Facilities in Michigan.

Enclosed are (_) COpies of the cover letter and
questionnaire develOped for the Michigan survey. The cover
letter attempts to describe the purpose of the survey and,
hopefully, the questionnaire will be completed by persons
directly reSponSible for the management of the food services
in extended care facilities (as Opposed to administrators,
general institutional managers, etc.).

Before final printing I am anxious to pre-test the question-
naire for format, clarity, comprehension by respondent, and
ease of completion by persons who carry such responsibility
in their respective operations. The responses from the
"trial-run" questionnaires will not in any way be used in

my study. My only purpose in requesting your cooperation is
to test the quality of the survey questionnaire and, there-
fore, I am eSpecially interested in your comments, criticisms,
and recommendations for improvement of the survey form.

A questionnaire evaluation form is enclosed to facilitate
your evaluation.

Enclosed is a addressed, stamped envelope for return of
completed questionaires and evaluation forms. YOur coopera-
tion in returning the completed forms to me by November 7
will be sincerely appreciated. Thank you for your time and
assistance.

‘NN‘ITIINNNNII|INININ{Nlllr1" ll

 

104

Facility

 

PRE-TEST QUESTIONNAIRE EVALUATION

1. Format

a. Did you find the format difficult to follow?
Please indicate any areas which were confusing.

b. In an effort to reduce mailing costs, we have used
both sides of the paper in printing this trial copy
of the questionnaire. Do you find this practice
Objectionable?

Yes No

— ~

c. Other comments on format?

2. Qpestionnaire Content

a. Are there questions you can not readily answer
because you do not have access to the information
requested? If so, please indicate by gpestion
number.

b. Are there questions which request information which
you are not at liberty to release? If so, please
indicate by guestion number.

c. Are there some important areas of inquiry which
have been omitted? Please indicate the types Of
additional data which you feel would improve the
questionnaire.

105

5. Questionnaire Claripy
a. Are there questions which lack clarity and/Or need

further editing for consistency? Please identify
by guestion number and indicate the ambiguities.

4. Completion Time

a. Approximately how long did it take to complete the
questionnaire?

 

(total time)

5. Additionel Comments and Suggestions

106

MICHIGAN STATE UNIVERSITY EAST LANSING - MICHIGAN 48323

 

COLLEGE OF HOME ECONOMICS - DEPARTMENT OF INSTITUTION ADMINISTRATION - HOME ECONOMICS BUILDING

November 21, 1969

Dear Administrator,

The enclosed questionnaire is a request for information
about your food service organization. The survey responses
will be used in assembling descriptive data which will indi-
cate the patient food distribution practices currently in
use in selected Michigan extended care facilities. By shar-
ing with us information about practices and needs of your
food service operation, you will enable us to get a clearer
picture of this important ancillary service in the health care
field.

I hOpe you will be willing to assist me in gathering this
information for it is very important that we have comparable
information from each of the chosen facilities. .YOur Operation
has been chosen to participate because we believe it is repre-
sentative of food service establishments of its kind. If in
your health care organization a selected member of your staff is
directly responsible for the management of your food service
department, your referral of our request to this person for
completion will be appreciated.

Your COOperation in returning the completed form to me on
or before December 15 will be sincerely appreciated. If you
do not wish to participate, please return the unanswered form.
An addressed, stamped envelope is enclosed for your conveni-
ence.

Sincerely yours,

Sister Nancy Raley, C.PP.S.
Graduate Assistant, Research

l‘fl‘llllla'n‘l'l‘llll‘llll!
IIIIIINIIII.IIIIIIIIIIIIIIIIII

(ll...

 

107

FOOD DISTRIBUTION SYSTEMS IN MICHIGAN EXTENDED CARE FACILITIES

Michigan State University, East Lansing

Institution Administration Dept. College of Home Economics

1.

2.

5.

I - ORGANIZATION

FACILITY NAME:

 

NO. & STREET

 

 

 

ZIP
CITY: MICH. CODE COUNTY:
TELEPHONE:
(Area Code) TNumber)

FACILITY ADMINISTRATOR

(Miss, Mrs., Mr., Dr.)

 

POSITION TITLE:

 

PERSON IN CHARGE OF FOOD SERVICE FOR THE FACILITY:

(Miss, Mrs . , Mr .)

 

POSITION TITLE:

 

POSITION HELD PRIOR TO THIS ONE:

 

 

II - GENERAL FACILITY CHARACTERISTICS
FACILITY SIZE
a. Number of licensed inpatient beds:

b. Average number of inpatient beds filled as of October
1969:

c. Average number of outpatients pergey (check one)
_____hone _____26 to 50 _____76 to 100
_____25 or less _____51 to 75 _____pver 100

d. Is your facility planning eXpansion of:

1. number of licensed beds No Yes

 

(how many?)

5.

108

 

2. ancillary services? No Yes
(what kind(s)

 

OWNERSHIP

a. Which type of ownership best describes your facility?
(check one)

prOprietary: private or corporate ownership
public: federal, state or county agency
philanthropic: fraternal, religious, or other

b. If your facility is under proprietary or philanthropic
ownership, are there other Extended Cere Facilities
under the same ownership? .

Yes No

IhOW'many?)

c. If your facility is under proprietary or philanthropic
ownership are there other types of Health Care Facili—
ties under the same ownership?

NO Yes

* *

 

(what types? how many each type?)

 

 

 

HEALTH CARE FACILITIES WITH NURSING CARE

Facilities providing some form of nursing care are classi-
fied by the U. S. Public Health Service according to the
predominant service provided, which ppe_of the following
definitions most accurately describes YOUR facility?

a. one in which 50% or more of the residents receive
one or more nursing services and the facility has
at least one RN or LPN employed 55 hours or more
per week.

—-—

b. one in which some, but less than 50%, of the
residents receive nursing care.

109

c. one in which more than 50% of the residents receive
nursing care, but no RN‘S or LPN'S are employed
fuii time on the staff.

d. none of the above:
(please describe your facility)

 

 

 

COMMUNITY HEALTH SERVICES
How many of the following kinds of health care services

are available at YOUR facility? (check as many as applic-
able)

a. convalescent care, short—term

b. convalescent care, long-term
c. geriatric convalescent care
d. psychiatric custodial care

e. geriatric custodial care (primarily personal care)

f. rehabilitation

 

 

 

 

 

 

 

 

(type(s)
___ g. sanitarium
(type(s)
h. outpatient
(type(s)
i. other
(describe)
MEDICARE

a. IS your facility eligible to participate in MEDICARE?

Yes (total facility Partially

 

(what part(s)
NO

 

b.

110

Is your facility currently participating in MEDICARE?

Yes (total facility) Partially

 

(what part(s)

NO

 

III - FOOD SERVICE CHARACTERISTICS OF THE FACILITY

9. MANAGEMENT RESPONSIBILITY

a.

How is the food service of YOUR facility managed?

independently operated by the Extended Care
Facility

satellite to a larger food service department with-
in a health care complex

Operated by a food management company under contract
with the Extended Care Facility or larger unit
within the health care complex

If your facility ie under contract with a good manage-
ment company, which Of the following operational
responsibilities are included in the contract? (Check
as many as applicable.) If your facility is not under
such an outside contract, omit this section and proceed
to question 10.

Meal Planning

____Menu planning - general diets
Menu planning - modified (therapeutic) diets
Estimating food and related supply needs
Procurement of food and related supply needs

Food Preparation, Distribution, and Contpgi
___ Estimation Of daily production needs

Food quality standards

Food cost level(s) ~

On-premise food and supply inventory

Finished food distribution system

Staffingy(hiring, assigning, supervieingy dismissing)
.___ Food production workers

Employed service workers

Food production and service supervisors

Volunteer workers

‘il it! I‘liiiilliluit (II I l![ ([1 I

10.

111

Employee Training
___ Food production and service supervisors
Food production workers
Employed service workers
Maintenance workers
Volunteer workers

Maintenance

Area housekeeping

Equipment cleaning and repair
Departmental safety and sanitation
Employee uniforms and laundry

Business and Accounting

Financial and transaction records
Other internal Operating records
Payroll preparation and disbursement
Employee benefits

FOOD SERVICE DEPARTMENT STAFF

a. How many workers are there in your food service depart-
ment? Please indicate according to classification and
extent of participation.

Full- Part- TOTAL
time time

Classification (no.2 (no.2 (NO.)

Administrative/Supervisory Staff
Regular Employees
Volunteer WOrkers

TOTALS

b. What is the average number of wogk hours/week for each
of these food service personnel classifications?

Full- Part-
time time
Claseification (hréwk) (hrzwk)

 

Administrative/Supervisory Staff
Regular Employees

Volunteer WOrkers

11. VOLUNTEERS

112

a. Does your food service department have peguier daily
assistance from volunteer workers?

NO (omit part b.)

Yes (please complete part b.)

b. What type(s) of duties/tasks do these volunteers
perform? (Check as many as applicable.)

food preparation (daily)
food preparation

(ocasionally)
patient tray assembly

transport tray to patients
collect & return patient

assist dining room

dining room hostessing

patients with eating
assist with counter
serving

.__ assist with buffet

 

trays service
__ assist bed patients with ,___work in snack bar/coffee
eating Shop
_ OTHER
(describe)

 

 

12. RESPONSIBILITIES OF THE FOOD SERVICE MANAGER

Many of the operational tasks which are necessary for the
successful functioning of a food service department in an
Extended Care Facility are listed below. Check (X) the
column which denotes the degree to which each item is a
part of the manager's work in YOUR facility.

 

Task

Some-

Always times Never

 

I. Menu Planning - general diets
- modified diets

II. Estimating Neede

III. Purchasing

foods
supplies
equipment

foods
supplies
equipment

115

 

Some-
Task Always times Never

 

IV. Staffing
- Hiring employees
- assigning volunteers
- employee in-service
training
- volunteer in-service
training
V. Determining
- daily production schedule
- portion size of food items
- selling price of food items
- per diem inpatient rate
VI. Supervising WOrkers in:
- food production
- patient tray assembly
- patient service
- dining room service
- equipment repair
- maintenance '
VII. Departmental Accounting
- financial accounting
- payroll
- compilation other internal
records
VIII. Dietary_;nstruction
- inpatient
- outpatient
IX. Regular Work Assignment
- food production
- patient tray assembly
- counter server
- dining room host/hostess
— cashier
X. Others not included above:

 

 

15. MEAL SERVICE POLICIES

a. Of the meal service patterns commonly used which one
best describes YOUR basic pattern for INPATIENTS?

‘1 I‘NIIIIIIIIIIITI IIINTIIIIIIIII

 

. i l
i'l I'll-ll": ([(II
I

114

breakfast, lunch, dinner

breakfast, lunch, supper

none of these

breakfast, lunch, dinner pius supplements

breakfast, dinner, supper plus supplements
breakfast, dinner plus 2 or 5 supplements

 

(describe pattern used)

 

Do you provide meal service for OUTPATIENTS?

Yes Occasionally

If ‘YES‘, where may they be served?

missible areas.)

main dining room along with inpatients

separate dining room

other

snack bar/coffee Shop/vending area

NO

(Check all per-

main dining room.when inpatients are not being fed
separate area of main dining room

 

Tidentify)

Which of the following meal service styles orpeystems
do you use for PATIENTS? (Check as many as apply for

each type of patient clientele.)

Service Styles'Or Systems

Main kitchen tray assembly before
delivery to patient

Bulk food to floor pantry for tray
assembly before delivery to
patient

D.R. table service (waitress)
D.R. table service (family style)

Self-service: Cafeteria
Self-service: Buffet

Coffee Shop/Snack bar
Vending service (central location)
Vending service (floor locations)

Other

 

(specify)

In-
patients

Out-
patients

d.

other(s)

115

What is your avepage weekday PATIENT main meal census
(noon or night) in each of the following dining areas?
(Inpatients and outpatients)
Main dining room

Day room in nursing unit

Patient rooms

Other

 

(describe)

On the average, how many PATIENTS are currently on each
Of the following types of diets? (Inpatients and out-
patients.) '

 

 

 

 

general sodium restricted
diabetic bland or ulcer
reduction mechanical soft
other

(Specify (how many?)
other

(Specify (how many?)

Which of the following types of Extended Care Facility
personnel assist with the on-premise distribution of
PATIENT meals? (Check as many as apply.)

 

food service personnel housekeeping personnel
nursing service personnel volunteer workers
other(s)

(identify)

If the patient needs assistance with his meal who per—
forms this type of service? (Check as many as apply.)

food service personnel housekeeping personnel

nursing service personnel volunteer workers

 

(identify)

 

116

Which of the following types of service equipment do
you use for transporting bulk foods to the floor
pantries or main kitchen pre-assembled trays to the
patients?

 

____Open cart ____Continuous tray
____Closed cart belt (vertical)
___ Refrigerated cart ____Continuous_tray
___ Heated cart belt (horizontal)
.___ Combination hot & cold cart ____Service elevator
____Insulated bulk container (passenger)
___ Insulated sectional tray ___ Dumbwaiter
____Preheated/Chilled plate

assembly ____Other
___ Insulated beverage server

(individual) ____Other

 

Do you provide meal service for VISITORS?

Yes Occasionally NO

If 'YES', where may they be served? (Check all permis-
sible areas)

main dining room along with patients

main dining room.when patients are not being fed
separate area of main dining room

separate Special dining room

in patient's room (special tray)

snack bar/Coffee shop

vending machine areas

 

other
' (identify)

Do you provide (whether individual purchase and/Or
facility furnished) meal service for the following
types of FACILITY PERSONNEL?

I-<
(D
U)
2
O

Pereonnel Types

Administrative personnel

Physicians & medical service personnel
Nursing service personnel

Food service personnel

Housekeeping personnel

Maintenance personnel

Personnel in residence

Volunteers (food service)

Volunteers (other than food service)

Other

 

(identify)

117

k. Do you provide separate or Special dining areas for
FACILITY PERSONNEL?

Yes No

If 'YES' please list the Special dining areas and indi-
cate who may use them.

1.

 

(area) (USEd by)

 

 

 

2.
5.
4.
5.

 

14. MENU POLICIES

a. What are the daily menu options for each type of general
diet clientele?

 

Food Other
Options Patients Service facility
In- Out- workers employees Guests

 

Non—selective menu only
No formal choice:
preferences honored
occasionally

Choice of most breakfast
items

Choice lunch ye, nOon
dinner

Choice light supper ye,
heavier dinner

Semi-selective menu choice:
- appetizer
— main dish
- vegetable(s)
- salad
- bread item
- dessert
- beverage

IIIIIII
|II||II
IIIIIII
IIIIIII
IIIIIII

May order substitute items
as desired

Other

 

(specify)

118

b. What are the daily menu Options for each type of modified
diet clientele?

 

Food Other
Options In Out Service facility
patients patients workers employees

 

Non-selective menu
only

No formal choice:
preferences honored
occasionally

Choice of most breakfast
items
Choice of lunch ye.
noon dinner
Choice of light supper
ye, heavier dinner

Semi-selective menu choice:
- appetizer
- main dish
- vegetable(s)
- salad
- bread item
- beverage

May order substitute
items as desired

Other

 

(specify)

c. What is the policy at YOUR facility for menu planning and
menu approval? Please complete the chart below according
to your policy for general diets and for modified diets.

 

Genepal Diets : Modified Diets

 

 

Person Responsible Planned ApprovedEPlanned App}oved
by by, g by by
Facility Administrator
Physician(s)
Nurse(s)

Dietitian--Consulting
Dietitian--Staff

Food Production Manager
Other

00 00 00 00 on no 00 00“

 

TSpecify)

119

15. FOOD SERVICE VOLUME

On an average weekday, approximately how many meals are
served by your food service department? In the chart
below please record your mea; count estimates for each
type of meal you serve for the clientele categories indi-
cated.

 

-TYPE OF MEAL SERVED

:Lunch/EDinner: Supplements
Break-:Dinner: or :Morn-:After-:Even-
faet (noon):Supper:inq :noon

CLIENTELE CATEGORY

IP-
5
n

Inpatient

General diets

Modified diets
Outpatient

General diets

Modified diets

Personnel

Food Service

Other employees

Volunteer workers

 

Guests

Patients' visitors

0. O. O. O. O. O. O. .0 O. O. O. O. O. O. p. O. O.

 

Others

 

TOTALS

.0 O. .0 O. O. O. O. O. .0 .0 O. .0 O. O. O. O. O. O. O. O. O. O. O. O. .0 O. O. I. O. O. O. I. O. O. O. O.

 

120

 

 

MICHIGAN STATE UNIVERSITY East Lansing
College of Home Economics--Dept. of Institution Administration

December 16, 1969
Dear Administrator,

If you have not completed and returned my questionnaire
concerning the food distribution system of your extended care
facility, may I encourage you to dO‘BO as soon as possible.

By c00perating in gathering this information, you will
enable us to present a clearer picture of how this important
ancillary service is managed in selected types of extended
care facilities in Michigan.

Should you have mislaid your questionnaire and need
another, please contact me at the following address:

5-B Home Economics Building
Michigan State University
East Lansing, Michigan 48825

Sister Nancy Raley, C.PP.S.
Graduate Assistant, Research

 

 

121

MICHIGAN STATE UNIVERSITY EAST LANSING . MICHIGAN 48823

 

COLLEGE OF HOME ECONOMICS 0 DEPARTMENT OF INSTITUTION ADMINISTRATION - HOME ECONOMICS BUILDING

December 18, 1969

 

 

 

 

 

Dear :

Thank you for your cooperation in completing my
questionnaire concerning the food distribution system of
your extended care facility. By sharing this descriptive
information, you are enabling us to get a clearer picture
of how this important ancillary service is managed in
selected types of extended care facilities in Michigan.

Your assistance is deeply appreciated.

Sincerely yours,

Sister Nancy.Ra1ey, C.PP.S.
Graduate Assistant, Research

122

MICHIGAN STATE UNIVERSITY EAST LANSING . MICHIGAN 48823

 

COLLEGE OF HOME ECONOMICS - DEPARTMENT OF INSTITUTION ADMINISTRATION - HOME ECONOMICS BUILDWG

February 12, 1970

 

 

 

 

Dear :

This letter is to confirm our telephone conversation
of (date) , in which I requested an appointment with
you. I plan to be at (name of extended caregfacilitv)

on (date , at (time) .

By visiting your facility's food service, I hope to
learn more about your methods of food distribution to
patients and share in your ideas and Opinions concerning them.
Perhaps you have ideas for the future which you believe could
improve your food service and food services of facilities
serving similar types of patients.

In reporting data which I have and will gather,
anonymity for all respondents and their respective facilities
is assured. Should you wish to contact me for any reason,

I can be reached at 517-551-4717 (home, East Lansing) or
517e555-4586 (Institution Administration Department).

Sincerely yours,

Sister Nancy Raley, C.PP.S.
Graduate Assistant, Research

 

125

ON SITE VISIT INFORMATION GUIDE

NAME OF FACILITY: CODE NO.

NAME OF PERSON INTERVIEWED:
POSITION:
YEARS IN PRESENT POSITION WITH THIS E.C.F.:

BRIEF OUTLINE OF VISIT (indicate interviewers' activi-
ties during visit, areas visited or viewed)

PHYSICAL LAYOUT OF FACILITY

a. No. of floors including basement/ground level:

b. Location of kitchen in relation to rest of facility:
c. Available means of transport between floors:

d. Food service areas in other buildings; service
performed for e.c.f.:

124

PHYSICAL LAYOUT OF FOOD SERVICE/TRAY SERVICE:

a.

Relation of tray service/food distribution areas to
preparation kitchen:

Flow of prepared food from preparation kitchen to
a representative bed patient:

Flow of prepared food from preparation kitchen to
dining room(s):

Type of tray service or method of tray set—up (use
brand names, give characteristics, etc.)

Type of food carts for tray service and/or bulk
food:

SMALL EQUIPMENT

a.

Kind of dinner ware used:
for tray service

for cafeteria/dining room

Use of disposable tray/Service utensils and
service-ware

Use of commercially pre-portioned items:

Reasons for choice of above items if within realm
of food service manager now in charge:

125

7. ATTITUDES OF FOOD SERVICE MANAGER

a.

Most frequent problems and/or difficulties encountered
in getting food from preparation area to patients:

Do therapeutic diets or patient likes/dislikes present
any special difficulties in controling what goes on
patient trays?

Do you have ideas for remodeling your food service
or modifying your meal service pattern so that you
can function more efficiently?

Are you satisfied with the relation between food
service tray assembly and tray distribution to
patients (indicate method in use and other depts.
involved)?

Have you considered using these styles of service
for patients:

cafeteria

buffet

dining room with waitress
dining room, family style

other

8. ADDITIONAL COMMENTS:

MICHIGAN STATE UI‘IIVERSITY
COLLEGE OF HOME [IAIIOL'IICS
EAST LANSING, MICHIGAN

 

MICHIGAN STATE UNIVERSITY
COLLEGE OF HOME ECONOMICS
EAST LANSING, MICHIGAN

‘ . Thésis M.S. 1970
RALEY, Sister Nancy, C. PP. 5.

Food Distribution Systems In
Michigan Extended Care Facilities

 

IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII

 

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