RESEARCH Research and Professional Briefs
Using a Visual Plate Waste Study to Monitor Menu Performance PRISCI PRISCILLA LLA L. CONNOR CONNORS, S, PhD, PhD, RD; SARAH SARAH B. ROZELL ROZELL,, RD
ABSTRACT Two visual plate waste studies were conducted in 1-week phas phases es over over a 1-ye 1-year ar peri period od in an acut acute e care care hosp hospit ital al.. A tota totall of 383 383 tray trayss were were eval evalua uate ted d in the the first first phas phase e and and 467 467 in the the seco second nd.. Food Food item itemss were were rank ranked ed for for cons consum umpt ptio ion n from from a low low (1) (1) to high high (6) (6) scor score, e, with with a scor score e of 4.0 4.0 set set as the the benc benchm hmar ark k denoting denoting a minimum minimum level of acceptable acceptable consumption. consumption. In the first phase two entrees, four starches, all of the vegetables, sliced white bread, and skim milk scored below the benchmark. As a result six menu items were replaced and one was modified. In the second phase all entrees scored at or above 4.0, as did seven vegetables, and a dinner roll that replaced sliced white bread. Skim milk continued to score below the benchmark. A visual plate waste study assists in benchmarking performance, planning menu changes, and assessing effectiveness.
J Am Diet Assoc. 2004;10 2004;104:9 4:94-9 4-96. 6.
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visual plate waste study provides valuable information tion that that can can be used used as a benc benchm hmar ark k of menu menu performance and to guide activities designed to improve menu response and efficiency. By minimizing waste an effective menu optimizes patient nutrition, sponsors positiv positive e percepti perceptions ons,, and establis establishes hes a foundati foundation on for meeting meeting financial financial objecti objectives ves (1). As delineat delineated ed in the Standard Standardss of Profess Professiona ionall Practic Practice e establi establishe shed d by the American Dietetic Association for dietetics professionals in management and foodservice, a routine function of the profession profession is evaluating evaluating services services and analyzing analyzing practices (2). A system systematic atic review review of the menu to determi determine ne its effectiveness falls within the scope of practice for dietetics professionals who have access to professional resources, such as journals, for guidance (3). A structured approach for menu menu review review avoids avoids overrel overrelianc iance e on anecdot anecdotal al evidence dence and supplie suppliess objecti objective ve informa information tion for decisio decision n making. One method for evaluating menu performance is a plate plate waste waste study. study. Previou Previously sly reported reported studies studies have
P. L. Connors is an assistant professor, Hospitality Management, University of North Texas, and S. B. Roz ell is chief clinical dietitian, Nutritional Services, Denton Community Hospital, Denton, TX. Address correspondence correspondence to: Priscilla L. Connors, PhD, RD, Hospitality Management, University of North Texas, PO Box 311100, Denton, TX 76203-1100. E-mail:
[email protected] [email protected] Copyright © 2004 by the American Dietetic Association. Association. 0002-8223/04/10401-0005$30.00/0 doi: 10.1016/j.jada.2003.10.012
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indicated that patients waste an average of 16% of calories served and 21% of foods served (4,5). Plate waste refers to the volume or percentage of food discarded discarded and can be used to measure measure menu effectiveness effectiveness (6). Three approach approaches es have have been been reported reported:: weighed weighed or physic physical al measur measureme ement, nt, 24-hour 24-hour recall, recall, and visual visual.. Although the weighed method optimizes accuracy, it is labor intensive, requires space for holding soiled trays and measuring waste, and becomes increasingly unmanageable able as sample sample size grows grows (6,7). (6,7). In additio addition n when when the objective is simply to compare meal consumption with a predetermined standard, the high level of accuracy pro vided by a physical measurement may not be necessary. The recall method asks patients to rate the amount of food they discarded discarded over the past past 24 hours hours (8,9). This method method is inexpen inexpensiv sive e and avoids avoids tray handling, handling, howhowever, it depends on retrospective self-reported data and may not provide provide enough enough informa information tion for specifi specificc foods. foods. The third method is a visual plate waste study. For the purpose purpose of taking taking a benchm benchmark ark measur measureme ement nt of food items wasted on a cycle menu, a visual plate waste study provides adequate detail yet does not significantly alter foodservice activities. Although Kirks and colleagues caution that for aggregated food groups a visual plate waste study may provide misleading results, if the purpose is to highlight those items generating the greatest amount of waste, this type of study provides useful information (10). In addition, it does not require additional space for holding soiled trays, adds little to labor costs, collects data on actual rather than intended behavior, does not require interaction interaction with patients, and, in keeping with the precepts of universal precautions, minimizes handling of soiled trays. The purpose of this article is to describe how a visual plate waste study can be used to take benchmark measurements of food items and guide menu modifications. METHODS Five nutrition professionals reviewed procedures, including a tick sheet with a six-point scale that was based on one designed by Comstock and colleagues (7). The tick sheet was preprinted with food items listed in a left-hand left-hand column adjacent to horizontal rows of circles designed to reflect reflect an ascendi ascending ng scale of none none consume consumed d (1) to all consumed (6) (Figure). Plate waste data were recorded directly on the tick sheet, with a separate form used for each tray. The same investigator was responsible for data collection in both phases of the study. Before collecting data the investigator investigator tested plate waste estimation estimation accuracy by scoring waste on 20 soiled lunch trays and comparing results to those obtained by using weighed plate waste. Scoring strategy was adjusted until an accuracy
© 2004 by the American Dietetic Association
Figure. Tick sheet for plate waste study.
level of 80% was achieved. For each meal in both phases of the study the investigator monitored tray assembly for 15 minutes to observe a minimum of 10 trays and establish an accurate image of a standard portion for eventual comparison with waste on soiled patient trays. Although portion sizes were standardized as 3 oz meat and one-half cup starch, fruit, or vegetable, the shape and texture of each food item in fluenced portion appearance. Familiarity with the plated portion enhanced accuracy of subsequent waste estimation. At the conclusion of each meal, soiled trays were indi vidually collected at bedside by nursing staff and placed on patient carts. Carts were transported for visual inspection in the dish washing room. The investigator used menu slips on returned trays as a reference to original contents and inspected each tray before removing it from the cart and placing it on a tray rack. Trays without menu slips were included only if the remaining foods clearly suggested the original contents. The extra step of transferring trays to a rack before washing did not change the hour and a half normally required to clean meal trays, and data collection was completed in this time. For each phase of the study, plate waste data were collected for all lunches and dinners over 7 consecutive days. Breakfast was excluded because of its uncomplicated menu and popularity with patients. Trays for patients receiving liquid or pureed diets as well as trays that were delivered but not served were excluded from the study. For each meal a mean score was tabulated for the entree, starch, vegetable, fruit, bread or roll, and milk that was served to the majority of patients. It was determined that any item with a mean score below a benchmark of 4.0 was producing excessive waste and would be scrutinized for possible replacement. RESULTS AND DISCUSSION A North Texas acute care hospital was the site for the study. A daily average of 66 inpatients were served meals
during the first phase (August 2001), and 68 were served during the second phase (August 2002). Average length of stay was 4.5 and 4.0 days, respectively. The population was evenly divided between male and female patients. Approximately 82% of patients were white, 10% were Hispanic, and 8% were Asian or African American. No single diagnostic related group or age range predominated. The nutritional services department operated a conventional food production system with a 7-day cycle menu. Although patients had the option to make menu choices, most received nonselect trays. A hazard analysis critical control point system was in place, and all foods met minimum temperature standards as outlined in the hospital policies and procedures manual. Fourteen entrees, seven starches, seven vegetables, and six fruits were observed during the first phase, conducted for 1 week in August 2001. A total of 383 trays were observed (190 lunch and 193 dinner), with an average of 27 trays per meal. All fruits served met or exceeded the benchmark value. Twelve entrees exceeded the benchmark value, including beef and macaroni (5.0), southwest chicken (4.7), and turkey with gravy (4.7). The only entrees to score below the benchmark value were pot roast (3.6) and Salisbury steak (2.8). Nursing staff reported that patients who had dif ficulty cutting disliked the large chunks in the pot roast, and patients with poor dentition found the Salisbury steak dif ficult to masticate. Three starches, mashed potatoes (4.5), baked potato chips (4.3), and dressing (4.3), scored above the benchmark value, although baked potato (3.8), noodles (3.7), rice (3.5), and au gratin potatoes (3.2) scored below. All vegetables, including mixed vegetables (3.6), peas (3.5), broccoli (3.4), carrots (3.4), green beans (3.4), corn (2.8), and spinach (2.8), scored below the benchmark, as did sliced whole wheat bread (3.6) and skim milk (3.6). The following changes were made based on the evidence of unpopularity that was shown by the first phase of the
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Table. Effect of changes on plate waste by menu category Phase 1
Phase 2 a
Category
Observations
Mean
SD
Entree Starch Vegetable Fruit Bread/roll Skim milk
328 229 357 210 262 295
4.3 3.9 3.5 4.5 3.4 3.6
1.8 1.9 2.2 2.0 2.3 2.3
a
Observations
Mean
SD
373 374 371 304 309 304
4.9 4.6 4.0 4.6 4.6 3.8
1.5 1.6 2.0 2.1 2.1 2.3
b
t
P
04.60 04.51 02.91 0.702 06.50 0.788
Ϫ
Ϫ
Ϫ
Ϫ
Ϫ
Ϫ
.000c .000c .004d .483 .000c .431
SD standard deviation. b Two-tailed significance. c Significant at .001. d Significant at .005. ϭ
plate waste study. Pot roast and Salisbury steak were replaced with steak fingers and chopped steak. Noodles, rice, and au gratin potatoes were replaced with red potatoes and macaroni and cheese. A dinner roll that was baked on site replaced sliced whole wheat bread. In August 2002 the second phase of the study was conducted. A total of 467 trays (231 lunch, 236 dinner) were observed, with an average of 33 trays per meal. Fourteen entrees, seven starches, eight vegetables, and six fruits were observed. All entrees, including steak fingers (5.4) and chopped steak (4.0), as well as all starches, including baked potato (4.4), macaroni and cheese (4.6), and red potatoes (4.1), cleared the benchmark value. Mixed vegetables (4.4), peas (4.3), broccoli (4.2), carrots (4.1), corn (4.1), and peas and carrots (4.0) met or exceeded the benchmark, although green beans (3.9) and tossed salad (3.8) scored below it. Dinner rolls (4.6) outperformed the previously offered sliced bread, but skim milk (3.8) continued to score low. The findings of this study are consistent with previous reports that sliced bread and milk are among the least popular food items for patient meals (4,5). To determine the impact of menu changes on plate waste, a series of t tests were conducted to compare phase one and two by meal category (Table). Plate waste scores for entree, starch, vegetable, and bread/roll were signi ficantly higher after the changes, although those for fruit and skim milk were not. This outcome is not surprising because menu changes (replacement of two entrees, three starches, two vegetables, and sliced bread) did not equally impact all categories. More importantly, results suggest that menu changes based on plate waste evidence are an effective way to decrease waste and improve patient consumption of meals. To better understand those factors that in fluenced food waste, a visual plate waste study was conducted to pro vide objective information for decision making. Action taken based on initial results improved menu appeal and made food production activities more effective. A follow-up study con firmed that patients were eating more of the foods provided. APPLICATIONS This article summarizes how the nutritional services in one hospital successfully carried out a two-phase plate waste study. Exploration of causative factors behind undesirable waste and poor patient consumption high-
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lighted correctable problems and provided justi fication for expenditures targeted at improving performance. Measuring menu performance is an important task. A visual plate waste study can provide valuable information for determining the desirability of each food item on the menu. A popular menu improves consumption and enhances the nutritional status of patients. References 1. Folio D, O’Sullivan-Maillet J, Touger-Decker R. The spoken menu concept of patient foodservice delivery systems increases overall patient satisfaction, therapeutic and tray accuracy, and is cost neutral for food and labor. J Am Diet Assoc. 2001;102:546-548. 2. Grif fin B, Dunn JM, Irvin J, Speranza IF. Standards of professional practice for dietetics professionals in management and foodservice settings. J Am Diet Assoc. 2001;101:944-946. 3. Glore S. Show me the science. J Am Diet Assoc. 2001; 101:186. 4. Frankes RM, Arjmandi BH, Halling JF. Plate waste in a hospital cook-freeze production system. J Am Diet Assoc. 1986;86:941-942. 5. Hirsch KM, Hassanein RS, Nelson SJ. Factors in fluencing plate waste by the hospitalized patient. J Am Diet Assoc. 1979;75:270-273. 6. Buzby JC, Guthrie JF. US Department of Agriculture, Economic Research Service. Plate waste in school nutrition programs: Final report to congress E-FAN-02.009. Washington, DC: US Government Printing Of fice; 2002. 7. Comstock EM, Pierre RG, Mackiernan YD. Measuring individual plate waste in school lunches. J Am Diet Assoc. 1981;79:290-296. 8. Weisberg K. A remedy for patient meals: Memorial Sloan-Kettering aims to increase meal intake. Foodservice Director. 2002;15:32. 9. O’Hara PA, Harper DW, Kangas M, Dubeau J, Borsutzky C, Lemire N. Taste, temperature, and presentation predict satisfaction with foodservices in a Canadian continuing-care hospital. J Am Diet Assoc. 1997;97:401-405. 10. Kirks B, Wolff H. A comparison of methods for plate waste determination. J Am Diet Assoc. 1985;85:328331.
