PURPOSE OF THE STUDYThe study provides an oppurtunity to investigate the catering service in one of the hospitals in jammu.Moderen scientific research has shown that a whole balanced diet of natural food is essential to health.The bulk of independent research has shown that a whole food vegetation or vegan regime provides everything necessary for human health .It is quite illogical that that patients who are frequently ill in hospital because of eating too much, eating junk or animal based diets be premitted to continue eating bad food .Delicious fruits salads with addition of lightly cooked vegetables , some pulses and whole grains should be the purpose of basis of health .Simple healthy fare with reduces the food budget and encourages the patients to adjust their recovery. Fruit and veg juices and smoothies shoul be provided in abundance.

METHODOLGY The study will be conducted in the major Hospital in jammu .Investigation will be undertaken on patients to assess the type of food service they are being provided .Questionnaire pertaining to the catering services will be given to the patients and the caretaker s. The questionnaire will test the satisfaction of the patients in respect of their services .

Scope and limitations

Generally speaking no one likes to be in the hospital . Thease are the services meant to assist people to stay healthy,. And get rid of the diseases. When one’s normal health status is disturbed then it becomes necessary to seek medical attention and if sometimes the case need medical attention then hospitalization is prescribed .Here the catering service do the rest of the job . In In govt aided hospitals none or very less amount is charged in lieu of these services so it becomes quite approachable to lower strata of society. In case of privare hospitals charge is quite high .

The food, which has to be provided in hospital , needs to be simple, soft, and palatable.Highly dense , spicy, fried food cannot be provided.

Table of contentsS.No Page no.

INTRODUCTION 1-1Chapter-1Food Culture in India 2-21

Chapter-2 22-27Hospitals in jammu city

CHAPTER-3 28-50 Challenges in Hospital catering

CHAPTER-5 51-65Recommendations

Conclusion 66-66

INTRODUCTIONHospital catering refers to specialized cooking for patients.The importance of these services lies in the factthat patients are encouraged to adjust their lifestyles and incorporate healthy foods in their diet so as to prevent reocurance of diseases.To review the catering services in the hospitals with particular reference to the medical requirements of these services , the arrange ments for training catering personnels and the instructions to the hospital staff generally should be followed . Hospitals have nutritional standarads and caterer has to meet the needs of the individual patient ‘s and offset any dietry deficiencies .Menus should be planned with regard to the chlorific need of various categories of patient and should include adgeqauate amount of fruits and vegetables.Theapeutic meals should be prepared separatley but with in the main kitchen and any hospital with over 100 beds should employ a full time Ditetian patients should able to choose from a cyclic menu that rotates over a 6 week time and nursing staff should supervise the service of meals.Visitors should be discouraged from bringing substantial amount of food for the patients .

“One in three people are seruiously and nourished when they come in to the hospital”,explains STELLA GARDENER ,Catering Manager of south Hampton university ,Hospital NHS trust and “one in ten has lost weight prior to being admitted .It is therefore essential that we do our utmost to ensure they gain strenth through nourishing food while they are here

CHAPTER-1Food Culture in India

The republic of India occupied mist of the land mass called the Indian sub content or south Asia , which also includes the republics of Pakistan, Bangladesh , AND Sri Lanka and the independent Kingdoms of Nepal and Bhutan . India is a federal republic, consisting of 29 states and six union territories under direct federal rule. Stretching two thousand miles form north to south and eighteen hundred miles from east to west , India is the world’s seventh –largest country in area and , with more than a bi9llion people , second in population only to china . Some Indian states are larger than most countries and like countries have distinct languages, ethnicities, cultures and cuisines.

Indians speak eighteen official languages and more than sixteen hundred minor languages and dialects, Although Hindi is the national language , it is spoken as a mother tongue by only about one –third to one- half the population. More than 80% of Indians are Hindus, but 12% -140 million people – Muslims, making India the world’s second largest Muslim country after Indonesia. India also has 30 million Christians, who are the majority in several states; 15 million Christians, who are the majority in several states; 15 million Sikhs; plus small communities of Paris, Jains Buddhists and animists

(Worshipers of nature gods and spirits).

Religion plays an important part in Indian life , and food in inseparable from religious beliefs. On the most basic level , Muslims do not eat park almost Hindus avoid beef , and many Indians practice varying degrees of vegetarianism . But there are no hard and fast rules : some Hindus eat no meat , fish or eggs , other eat eggs of fish but avoid onions and garlic, still others eat vegetarian. However, nationwide 70% of the population eat meat at some point , although the percentage varies form 40% in the western states Rajasthan and Gujarat to 94% in Kerala and west Bengal . However, for economic reasons – meat is relatively expensive – most people are de facto

Vegetarians who eat meat only on special occasions.

Festive occasions such as weddings Life transition ceremonies, and religious holidays are important social and gastronomic events in Indian life accompanied by special dishes and meals. Adherents of all religious practice fasting as a means of worships, prayer and spiritual and physical discipline.

As in medieval Europe, eating habits in India are rooted in moral and medical beliefs. “You are what you eat”, is a theme of both ayurveda, the ancient Indian school of medicine , and unami , the traditional Islamic medical system . Hindu philosophy also assigns qualities to food that are related to caste personality and spiritual qualities All these systems are overlaid With popular beliefs about the “hot” or “cold” properties of food and their effect on mental and physical health.

Geography and Climate

Most Indian Food is still produced regionally or locally, and is highly seasonal. India is a predominantly rural country, second only to the United States in the amount of land under cultivation. More than 70% of India’s population lives in 600000 villages. Most are engaged in farming either on their own small plot or as hired laborers. Much Farming is little more than subsistence-level: the farmer products grain and rice in order to feed his family and sells a small part of his crops at harvest time , using the cash to buy more land , fertilizer , equipment , and household goods . People try to have a few mango trees and in the south tamarind and coconut trees as well as a small vegetable garden where they can grow chilies and vegetables for their daily meals. Relatively affluent farmers own a female water buffalo or cow for milk, bullocks to pull the plough, and a few sheep, goats, and chickens.

In cities, incomes are generally higher and people have access to a wide variety of food stuffs at commercial establishments. Only 2% of India’s population lives in 600000 villages. Most are engaged in farming either on their own small plot or as hired laborers. Much farming is little more the an subsistence –level : the farmer products grain and rice in order to feed his family and sells a small part of his crops at harvest time , using the cash to but more land , fertilizer , equipment , and household goods .

People try to have a few mango trees and in the south tamarind and coconut trees as well as a small vegetable garden where they can grow chilies and vegetable for their daily meals. Relatively affluent farmers own a female water buffalo or cow for milk, bullocks to pull the plough, and a few sheep, goats, and chickens.

In cities, incomes are generally higher and people have access to a wide variety of food stuffs at commercial establishments. Only 2% of India’s agricultural input is processed, so most meals are made form scratch. Indian cooking tends to trends to be labor-intensive and in rural areas women spend half their waking hours preparing meals.

Although people often think India as A tropical country, it is located entirely in the northern hemisphere.3 A wide variety if altitudes and weather systems give India an extreme diversity of climates. It has practically every kind of soil, ranging form rich alluvial soils formed by the deposits of silt to arid desserts, swamps, and mountains soils.

Geographers divide India into three regions. In the north , the Himalayas a Sanskrit word that means “abode of snow “ extend for fifteen hundred miles from Pakistan and Afghanistan in the northwest to Burma on the south east. Here are found the world’s highest mountains including Mount Everest. Over the centuries this forbidding range has served as a barrier to artic winds and invaders form the north.

Melting snows from the Himalayas and seasonal rains feed the great river system of the subcontinent; the Indus (from which the word “India” is derived), the Yamuna –Ganga and the Brahmputra Their basins from the fifteen hundred mile ling indo genetic plain, which was the cradle of India’s agriculture and civilization (3000-1500 b.c. ). In the past it was covered with dense forests that are mow largely depleted, especially in the western portion, the barren wasteland of Rajasthan great desert. Millets and other coarse grains and a few vegetables are all that grow in this region’s barren soil.

The northern and eastern parts of the plain are India’s richest agricultural region, thanks to the sedimentary soil deposited by the rivers as well as large reserves of ground water.

The states of Punjab and Haryana called breadbasket of India, produce wheat, barley rye and other grains while the eastern states of Bengal and Assam produce tow, some – times three crops of rice each year.

India’s third geographical region, the Deccan or Peninsular Plateau, is separated from the plains by the Vindhyas and other mountain ranges. They have served as a natural barrier to communication between northern and southern India and allowed the development of distinct cultures languages and cuisines in the four southern states of Kerala, Karnataka, Tamilnadu, and Andhra Pradesh.

Running down the west side of India are the ghats , a mountain range hat empties its rivers in to the bay of Bengal . Their alluvial deltas have been the center of many powerful south Indian kingdoms. The wind that blows from the Arabian Sea during the monsoon is caught by these mountains, giving the plateau a hot dry

Running down the west side of India are the ghats, a mountain range that empties its river in to the bay of Bengal. Their alluvial deltas have been the center of many powerful south Indian kingdoms. The wind that blows from the Arabian sea during the monsoon is caught by these mountains, giving the plateau a hot dry climate. Between the ghats and the Indian ocean lies a narrow coastal plain, the Malabar coast, Which is one of India’s most fertile regions, thanks to the abundant rainfall. This region now part of the state of kerala , is the center of India’s spice Industry and was the first part of India visited by Europeans at the end of the fifteenth century.

India’s climate and seasonal variations are dominated by the monsoons, or tropical rain – bearing winds, that blow from the northeast in winter and form the southwest in summer . Time timing of the monsoons and the abundant amount of rain they bring have a major effect on agriculture and food supply. Before modern methods of irrigation, the failure of the monsoons could result in widespread famine.

Food Myths and Characteristics

All Indian food is just not curry

Many foreigners equate Indian food with curry . The word probably came from a Tamil word Kari , meaning a soupy sauce served with rice , which colonial Englishmen applied to any dish of vegetables, meat , or fish in a spicy broth or gravy , Strictly speaking , curry denotes a meat stem , fried in onions and cooked in a thinnest gravy with potatoes , sometime tomatoes , turmeric and other spices . At times a ready – made curry powder is used. Curries are associated with the kind of food served at clubs, army messes and other.

British institutions during the days of the Raj (British rule, 1857-1947) and even afterward. However, today some English speaking Indians and cookbook writers use the word in a general sense to describe any meat, vegetable. Or fish dish cooked in a gravy, another misconception is that Indian food is very hot, which comes form equating spiciness with hotness Hotness, a burning sensation in the mouth, is caused by black pepper and chilles.

Spices (the roots, leaves seeds and other parts of certain plants) add flavor, which is a combination of aroma and taste. They type and quantity of spices used varies by dish, region, and individual and house hold preferences: generally, south Indian food is hooter than that eaten elsewhere, while north Indian meat and rice cuisine is the most aromatic . Some families and individuals use very few spices. Still, spicing is nearly universal; even the poorest eat a few green chilies with their simple roasted bread.

Indian meals are centered around a cereal. In the rice –producing regions in the south and east, rice is the staple grain, whereas in the wheat producing north most people eat bread made from wheat flour.

Grains are usually accompanied by boiled pulses (beans, peas, and lentils) call dal. These two ingredients provide the amino acids necessary for good health in the absence of meal, equivalent of “meat and potatoes “in the Anglo-Saxon world. Relatively small amounts of meat, fish and vegetables are added to enhance the taste and qualities of the main grain. Condiments complement the flavors and provide essential vitamins and minerals, including fruit and vegetable chutneys; sweet, sour or pungent pickles; yogurt and buttermilk.

Economic Wealth and Poverty

From ancient times, the Indian subcontinent was devastated by periods of famine caused by natural and human – made causes. As recently as 1943, 4 million people died of starvation in eastern India. In the 1950’s India relied on food aid from abroad. Disunity of food supply became a major item on the agenda of the new government of independent India. Initial efforts focused on expanding the farming areas but these efforts did not meet rising demand thus the government encouraged the application of improved farming techniques, and the construction of dams and massive irrigation projects. The Indian council for agricultural research developed new strains of high yield value seeds for wheat. rice and other crops.

These changed, known as the green revolution, significantly increased food production, making India one of the world’s largest agricultural producers and an exporter of wheat and rice. Per capita wheat consumption has nearly tripled since 1951 and is replacing other grains, such as barely and millet. Indian’s consume an average 2500 calories a day and nearly 60 grams of protein which is within recommended guidelines. . Some 92% of this calorie intake comes from vegetable products and only 8% from animal products (including milk and dairy products), compared with 28% in the United States. India’s per capita meat consumption of under 10 pounds a year is only one fortieth that of the United Stated.

The percentage of the population living below the poverty line has dropped from 51% in 1972 to 26 & in 2000. However these general stats mask substantial differences among states and regions. The percentage of very poor people is less than 10% in

Goa, Haryana , Jammu & Kashmir , Punjab , for example , but exceeds 40% in Orissa and Bihar .For the landless peasants and laborers in these states , a meal may be roasted chickpea flour or a couple flat wheat breads. Accompanied with raw chilies and salt on the side, of course the rich and powerful have always eaten well in India. The rich , meat based dishes served in many Indian restaurants ( a cuisine many non Indians equate with Indian foods ) is a version of the haute cuisine served at the courts of the Mughal emperors and the local princess and aristocrats, and is no way representative of the daily diet of the vast majority of Indian’s .

Today, India is rapidly changing. Better transportation has greatly improved distribution and helped ease local and regional short falls. Fruits, vegetables, and fish and other parts of India and abroad as well as processed and frozen foods are sold in Indian cities and large towns. The liberalization of the Indian economy and the creation of jobs in call centers and data processing industries have generated a dramatic increase in wealth, especially for young, educated, urban Indians .The number of people living in house holds that earn at least $ 1800 annually4 has increased 17% in the past three years to more than 700 million, or some 70% of the population , and graduated of elite colleges have an estimated $ 10.5 billion in surplus cash.

For many reasons, India never has a restaurant culture, but this too is changing. Fast food chains and restaurants serving western and Indian cuisine are proliferation and Indians spend 55% more on eat in out in 2002 than the previous year. Middle class women are entering the work force in greater numbers. A search in the publication of cooked books , women’s and life style magazines and television cooking shows are also helping to spread awareness of other Indian regional cuisines and perhaps will further the development of a truly national cuisine.

Regional Food

Indian cuisine is popular all over the world for its variety, mouthwatering tasted and aroma . It is as diverse as the country itself with its numerous styles of cuisine and its typical regional variations.

In almost every country in the world you can find Indian restaurants and hotels representing every kind of Indian cuisine. Some of the most famous among them are the Mughalai, Chettinadu, Hyderabadi Cuisine etc.

Indian Cooking is known for its use of spices , herbs and flavorings . The common ingredients in Indian Cuisine are rice or bread(rotis) , a variety of dals(lentils), regional vegetables , pickles , ghee , chutneys , a meat or fish dish. Spices are an essential element to Indian cuisine . The cooking medium is generally oil. The type of oil used differs in different regions . Sweets are usually milk based. Many popular sweets such as Gulab jamun , Ladoo are common throughout India , while many others like Rasbari , peda , burfi , halwa , Malpuwa, Rasgula etc are local favorites . Food is often eaten with fingers , rice or breads are accompanied by vegetables and curries.

The tastes and variety of the multiple cuisines from Kashmir in the north to Kanya Kumari in the south , is absolutely mind blowing . Indian cuisine can be divided into two , Northern and southern Indian cuisine.

South Indian Cuisine

Cuisines from Andhra Pradesh, Karnataka, Kerala, Goa and Tamil Nadu are all part of South Indian Cuisine. Mostly vegetarian, Rice is the basis of every meal in a South Indian Cuisine. Mostly vegetarian, Rice is the basis of every meal in a south Indian Cuisine and the cooking medium could be either gingerly, coconut or sunflower oil. Coconut is one of the main ingredients in all South Indian food and spices are abundant in south Indians cooking. Spices commonly used are mustard, Asafetidea , papper , curry leaves, peppercorns etc . Other fragrant spices added are cardamom, clove cinnamon and star aniseed. Areas with access to waterways rely more heavily on seafood. Saturated with ghee, rice is served with Sambhar ,Rasam , Lentils, vegetables etc , South Indians are great lovers of filter coffee especially the Madras coffee are popular in South Indian restaurants throughout the world.

Made of fermented rice and dal batter , the dosa ,vada and the idli as well as puttu made of rice flour are inexpensive south Indian snacks

which are popular south Indian dishes are Appam and stews , sea food dishes (Kerala) , Mysore Pak , Basundhi, jangiri , the semolina based upma , Milk or wheat based payasams / Kheers, Hyderbadi Biryani and the Goan vindaloo curry etc.

North Indian Cuisine

North Indian Cooking is often called Mughal Style Cooking Which is similar t the food of the Middle East and Central Asia . With its rich uses of sauces, butter-based curries , dried fruits and nuts, ginger – flavored roast meats and mind – blowing sweets , it is one of the world’s popular cuisines. A typical North Indian meal consist of chappatis , roti , parantha , pooris and tandoori baked breads like nan etc. made of wheat .

Rice is also popular and is made into biryanis and pulaos . Kashmiri pulao is one of the famous north Indian food. The cooking medium is generally oil , cream , butter or ghee. Sunflower and canola are mostly used vegetable oils used in north Indian cooking. Garam masala is a spice mixture used mainly in northern Indian cuisine. Mutter paneer (a curry made with cottage cheese and peas) , Bengal’s Rasagulla , sandesh Rasamalai , gulab jamuns ,Biryani , Pulaos , Daal Makhani , Dahi Gosht, Butter Chicken , Kheer , Chicken Tikka , Kebabs , Fish Amritsati , Samosas ( snack with a pastry case with different kinds of filings)’Chaat ( hot –sweet-sour snack made with potato mchick peas and tangy chutneys) ,’makki ki roti’ and ‘sarson ka sag’, Motichoor laddoo are some of the delicious north Indian foods.

Andhra Dishes : The delicious Andhra cuisine , which is a combination of the south and Deccani , is reputedly the spiciest and hottest of all Indian cuisine.

Bengali Dishes : Bengali’s are perhaps the greatest food lovers in the Indian subcontinent. Rice and fish are their staple diet . Many of Bengal’s famous dishes are fish based items.

Goan Dishes : Goan cuisine , a blend of different influences especially portugueses , is famous for its seafood . Goan cooking generally includes lots of spices.

Gujarati Dishes : Mostly vegetarian , Gujarati cuisine is delightfully delicious with a combination of leafy vegetables and pulses subtly flavoured with spices.

Hyderabadi Dishes : Hyderabadi suisine , which has been influenced by various regional and religious cuisines , is rich and aromatic with a liberal use of exotic spices.

Kashmiri Dishes : Kashmiri cuisine , comprising mostly of non – vegetatian dishes , is characterized by three different styles co cooking – Kashmiri Pandit Muslims and Rajput styles.

Karnataka Dishes: The cuisine of Karnataka is quite varied with each region of the state having its own unique flavours . Atypical Karnataka or Mysore meal is pure vegetarian.

Kerala Dishes: Cuisine of Kerala, gods own country is an exotic mixture of nature’s very best. There are large variety of dishes which are peculiar to kerala.

Punjabi Dishes : The Punjabis are known for their rich foods . Predominantly wheat eatin people, the Punjabis cook rice only on special occasions.

Rajasthani Dishes: Rajasthan , the desert land famous all over the world for its architectural marvels-its romantic palaces and colorful people is also equally popular for it unique , spicy and varied cuisine.

Tamil Nadu Dishes: Tamil Nadu , true home of Indian vegetarianism , is the land of the delicious Pongal , Idli , Dosa , Sambar and Rasam . Tamilian’s staple diet is steamed rice.

Cuisine of Kerala: God’s own country is an exotic mixture of nature’s very best . There are large variety of dishes which are peculiar to kerala , be itvegetarian of the spicier non-vegetarian , be it the rice flavoured savoury”’appams ‘or these crunchy chips variey , be it the delicious seafood delicacies or the leafy or root vegetables . Kerala has it all . ‘Sadya’ – typical Kerala Hindu feast served on a banana leaf , is a sumptuous spread of rice andmore than 14 vegetable dishes, topped with payasam or pradhamans, the delicious sweet dessert . The Muslims and Christians excel in their ownj particular non vegetarian dishes like the ‘pathri’,biriyani , chicken , fish dishes etc . Rice is the staple food and the curries are eaten usually with plain steamed rice . A typical breakfast can be Puttu , Vellayappam or Idiappam made eith pounded rice flour . Almost every dish prepared in kerala uses coconut – as oil or grated ground or with its milk strained together with spices and tamarind to flavour them . Tender coconut water is used as a refreshing nutritious drink.

Rajasthan: The desert land famous all over the world for its architectural marvels- its romantic palaces and colorful people is also equally popular for its unique, spicy and varied cuisine . For the royal Rajputs, one of the leading communities of Rajasthan, a meal is never complete without meat. They have mouthwatering dishes smothered in spices and chillies; almonds and cashew nuts like the sollas (grilled meat) , Murgh mokul and the venison Kababs;

But the Marwaris, another leading community of Rajasthan are strictly vegetarians. They have equally tasty maybe more fiery specialties with whatever ingredients available in the dry land .Minimum use of water and a preference for milk, Chhaach (buttermilk) and clarified butter can still be observed. they use dried and powdered lentils , beans from indigenous plants like Gwarphali, kair , sangri and the flours of gehun ( wheat) , bajra (millet) and makka (con) liberally to make soft rotis drowned in butter and ghee , kheechra (porridge) and delicacies like ghatte ka subzi , Rajasthani

kadhi, and the more popular dal –baati-churma . Various chutneys are made from locally available spices like turmeric, coriander, mint and garlic.

Besides the spicy ones, Rajashtan has a variety of sweet dishes as well, with specialties from each part like Malpuas from Pushkar , Ladoos from Jodhpur and Jaisalmer , Ghewar from Jaipur etc.

Breakfast Non VegetarianPuttu, Vellayappam, Idiappam, Kappa Puzhuku

Men Peera Pattichathu , Meen Tilappichathu , Dry Prawn Chutney, Meen Mulakuchar , Prawn Mappas, Fish Molle, Fish Patichathu, Karimeen Pollichathu, Meat Ularthu

Vegetarian Snacks and SweetsMathanga Erissery , Kalan , Olan, Parippu Curry, Cabbbage Thoran, Pachadi, Kichadi , Kootucurry , Manga Curry , Kadala Curry, Kootu Curry, Pulicherry

Unniappam, Banana Chips, Sarkarapuratty , Kozhukatta.

Bengali’s are perhaps the greatest food lovers in the Indian subcontinent. Rice and Fish are their staple diet. Many of bengal’s famous dishes are fish based items and they consider a meal in complete without fish. Bengalis have a special seasoning called ‘Panchphoran’ which includes five spices mustard aniseed, fenugreek seed, cumin seed and black cumin seed. The garam masala is made up of cloves, cinnamon, cumin and coriander seeds mace, nutmeg, and big and small cardamoms.

The principal medium of cooking is mustard oil . A typical Bengali lunch or dinner will generally comprise of bhat (rice), dal (lentils),tarkari ( vegetables) and macher jhol (fish curry). No description of Bengali sweets like rasogolla sandesh , mishti doi (sweet yogurt) etc.

Bhuni Khichuro (pulao with prawns)

Butter Fish Fillets Dimer Devil

(EggCoated with Minced Meat)

Dimer Dhokar Dalna ( Egg Cube Curry)

Fish Hingli (Fish cooked with Raisins)

Ghoogni ( Chick Peas With Mutton Bits )

Hilsa (Fish) Biryani Jeera Murg (Chicken

with Cumin seeds) Labra( Mixed

Vegetables Dish) Macher Kochuri (Fish

stuffed Bengali Puri) Rezala ( Meat Dish) Rosogolla (Sweet) Tel Koi (Bengali Fish

Curry)

Ayurvedic diet

Translated form Sanskrit as the “science of life”, Ayurveda is an ancient holistic system of medicine coming from and widely practiced in India. The science utilizes various therapies including diet , yoga , and herbs , to maintain balanced health.

At the heart of Ayurveda lies the concept of the five elements-Ether (space) air, fire water, and earth. Everything we see around us in composed of these five basic elements which manifest in the human body as three dynamic energies or doshas known as Vata, Pitta , and Kapha . These three doshas control all the mental, emotional , and physical functions and actions of the human body . They are also said to determine the state of the soul.

Each person’s constitution or “Prakriti” (Sanskrit for “essential nature” is a unique blend between the characteristics of the three doshas leading to perfect health. In Ayurveda, diet is one of the most important ways to maintain this balance.

An imbalance, “Vikriti” or deviation from nature, can be caused by eating incompatible foods, mental or physical stress, negative emotions, or poor sleeping habits, and will ultimately lead to disease, obesity , and /or mental disorders.

Each of us possesses a proportion of all three doshas , with only a small percentage of people being purely Vata, Pitta , or kapha. Most commonly, tow doshas combine to determine our dominant physiological and personality traits.

In Ayurvedic nutrition there are six basic tastes:-

Bitter- Rhubarb, Coffee Pungent- Peppers, Garlic, Ginger Astringent- Unripe Bananas , Pomegranates Salty – Salt, Kelp, Tamari Sour-Citrus Fruits, Yogurt, Vinegar Sweet- Rice , Milk ,Sugar

Each taste has a balancing ability and in order to minimize cravings and balance the appetite and digestion, Ayurveda recommends including each of the six tastes at every main meal. The North American diet generally contains too muh sweet sour and salty, and not enough of the bitter , pungent and astringent tastes . Ayureda also recognizes various food qualities or types including heavy, light, oily , dry hot,. cold , with different qualities balancing the different doshas.

Over the food tastes and qualities with attributes similar to a dosha increase that dosha, while dissimilar tastes and qualities decrease that dosha A balanced meal contains some foods of each taste and quality , varying he proportions based on your doshic tendencies , age , gender , body and digestion strength , level of toxins in the body , season and place you live.

Vata Pitta KaphaTastes-Avoid Bitter,

Pungent, Astringent

Pungent , Salty , Sour

Salty, Sour Sweet

Tastes – Choose

Salty , Sour , Sweet

Bitter , Sweet , Astringent

Bitter, Pungent Astringent

Qualities- Avoid

Light , Dry ,Cool

Light, Dry , Hot

Heavy, Oily , Cool

Qualities-Choose

Heavy, Unctuous, Warm

Cool , Heavy ,Oily

Light, Dry Warm

The healthiest diet consists of a wide variety of whole foods, eaten in as natural a state as possible . Avoid frozen , canned , refined or processed foods, especially those containing artificial colors, flavorings , additives , or preservatives . Foods grown with chemical pesticides and fertilizers or genetically altered are not recommended as such foods are lacking in “prana” or vital life – energy , and tend to do more physiological harm than good!

Another Ayurvedic classification of foods is by their effect on the non-physical aspects of the physiology (i.e) mind , heart , senses and soul . These fall into three categories:-

Sattvic-uplifting , stabilizing foods – Almonds , Sweet Fruits , Rice Leafy Greens , milk.

Rajasic –stimulating and aggravating foods-Bananas, Corn, Potato, Fish.

Tamasic –Lethargy inducing foods –Avocado , Brown Rice , Garlic, Cheese , Beef.

Including Sattvic foods at mealtimes in beneficial to all doshas as they promote mental clarity, emotional serenity , sensual balance , and the balanced functioning of the body , mind , and soul . Herbs and spices are also an essential part of a balanced Ayurvedic diet , due to their ability to enhance digestion and assimilation , help in cleansing toxins from the body , and transfer the nutritive and healing qualities of other elements of the diet directly to the cells of the body.

Ayurveda believes every meal must be a feast for your senses and when presented with a variety of colors, flavors, textures and aromas, your body, mind and soul are balanced and contented by the eating experience you truly are what you eat.

Notes and References

1. The term Scheduled Tribes is used in the Indian Constitution to

designate communities who are mostly of non – Aryan origin and

economically deprived.

2. Quoted in William Dalrymple, Washing off the Saffron Financial

Times,22-23 march 2003.

3. Although the subject of this book is Indian cuisine and culture , there

is not a clear demarcation line between the food ways of India and

those of other countries on the subcontinent { including Pakistan ,

Bngladesh, Nepal, and Sri Lanka. Punjabis in Pakistan follow a diet

similar to that of Punjabis on the Indian side of the border , while

Hindu Bengalis and Muslim Bangladeshis also share a common

culinary tradition , with a few differences due to religious prohibitions

and local availability of food stuffs.

4. N.P. Nawani, “Indian Experience on Household Food and

Nutrition Security”FAO-UN Regional Expert Consultatin , Bangkok,

Thailand August 8-11 1994

5. Michael Schumann, Hey , Big Spenders: India’s Booming Middle

Class ,” Time Online Edition,Global Business , 27 August 2003.

Chapter-2Hospitals in Jammu city

Hospital catering as a specialized service

HOSPITALS TELEPHONE NOS

1.S.M.G.S Hospital , Shalimar RoadEmergencyBlood Bank

547637/38549669547637/8

2. Govt. Hospital Gandhi Nagar 530041

3. Govt. Medical Hospital Bakshi Nagar 549621/549625

EmergencyAmbulancesBlood Bank/Eye Bank

547991547990-1547990-1

4. Chest Diseases Hospital, Bakshi Nagar 577604,548012

5. Children Hospital , Ambphalla Jammu 577023

6. Dental Hospital, Amphalla  Jammu 544670

7. Acharya Shri Chander College of Medical Sciences, Sidhra

62251/62267

8. IRC Society Ambulance 549413

  24 Hr. Medicine Shops.

1. Jammu Coop , SMGS Hospital 549669

2. Afshan ECG Clinic ( Portable service available) 546924

3. Sigma Diagnostic Centre Gandhi Nagar , Jammu 436171

4. Internationals Bakshi Nagar 576823,579711

  In addition to the Govt. Hospitals, there are a number of private nursing homes in Jammu with well trained and experienced Doctors and modern medical facilities.

      

OUR MISSION

The mission of BEE ENN General Hospital is "To provide quality health care and services for the society, to promote wellness, safely, and humanely, act creatively to continually improve our services" 

Bee Enn general Hospital, a joint project of BEE ENN CHARITABLE TRUST, is a uperspecialty facility poised to deliver advanced tertiary care of the people. The Hospital is at the forefront of medical technology and expertise and provides a complete range of the latest diagnostic, medical and surgical facilities for the care of its patients. The hospital is having all the characteristics of a world-class hospital with wide range of services and specialists, equipment, technology, ambience and service quality. Bee Enn General Hospital is a showcase of synergy of medical technology. The skilled nurses, technologists and administrators at Bee Enn General Hospital, aided by (state-of-the-art equipment)provides a congenial infrastructure for the medical professional in providing healthcare of international standards

Services available in the Hospital

PAYING FOR TREATMENT

PATIENTS WITH HEALTH INSURANCEIf you are covered by one of the major health insurance schemes, then your insurance may cover the cost of Bee Enn General Hospital. (Before undergoing     any kind of private treatment, you should always check with your insurance     company to ensure that you have adequate cover for the treatment required. Hospital bills for inpatient and day care treatment can generally be settled directly with your insurance company, but for outpatient investigations and treatment, you will usually be required to pay the hospital and seek reimbursement from your insurance company.

SELF-PAY PATIENTS  If you do not have health insurance, and are not being sponsored by your company or embassy, you will of course have to pay for treatment yourself. For some patients, our Fixed Price Treatment scheme may be appropriate. This scheme ensures that you know in advance what your operation will cost and can therefore budget accordingly.

IF YOUR COMPANY IS PAYING FOR YOUR TREATMENTThe Hospital has credit arrangements with some companies. In such cases the patient must provide a letter of guarantee authorizing the tests or treatment to be carried

RECEPTION DESK

        The reception Desk is manned round the clock and will release only your room and telephone number to callers. No other information about patients is given out. Information about your diagnosis, treatment and any other items related to your care are considered confidential and are not released by our. ReceptionDesk staff. If you do not wish to have visitors or telephone calls, please call a reception desk. Contact : Reception desk   

RADIOLOGY The radiology department at Bee Enn General Hospital offers a wide range of diagnostic  imaging services with the - state of the art equipment and a

professional team of  radiologist and technologist. All radiological procedures are performed and supervised by Among the many radiological services are :

  Barium and contrast examination of the gastrointestinal, genitourinary tract and

  All body ultrasound examination.  Reporting of all plain Radiographs.  Our dedicated medical and health professional team offers excellent

health care services to help improve health care and that too with competitive charges.

             OPERATION THEATRE             Fully Equipped with modern Medical Equipment

             All major minor procedures in various specialities like Ophthalmology Gynaecology Urology Orthopedic

     LABORATORY Biochemistry tests Hematology tests Microbiology

General Surgery These cases are done under general, regional or local Anesthesia.

PHARMACYUnder the supervision of clinical pharmacist, this pharmacy operates round the clock and provides high quality pharmaceutical services for all medical specialties

 PHYSIOTHERAPYthis department treats all types of problems related to neurology, neurosurgery, orthopedic and sports, pediatrics and chest diseases. Qualified physiotherapists conduct treatment using ultrasound, short wave diathermy, electrical stimulation, manipulation & mobilization and therapeutic exercises

ROUTE MAPBEE ENN GENERAL HOSPITAL

IDEALLY LOCATED:-

This is centrally located in Jammu(J&K State)close to the Bus Stand and

Jammu Tawi Bridge and is near Jammu Railway Station. It is centrally located with easy access to public transportations

CHAPTER-3Challenges in Hospital catering.

This review of hospital catering follows up the issues from ourbaseline report which was published in November 2007.1 The baseline report provided detailed findings and recommendations on nutrition, quality, patient satisfaction, costs and the management of the catering service. This follow-up study assesses the progress made in implementing those recommendations and improving hospital catering services.

Nutritional care is key in helping the recovery of patients in hospital and hospital catering has an important role to play in this.2 3 The quality of hospital food is a very important part of ensuring that the patient’s experience in hospital is positive. Regular mealtimes perform a significant social role which can promote the general well-being of patients and assist in their recovery. Food safety and hygiene are essential and need to be rigorously monitored to minimise the risk of infection and ensure high-quality patient care.

About the study The overall aim of this study was to assess progress against the recommendations reported in the 2007 baseline report. In particular, the study examined whether: processes are in place to provide quality nutritional care to patients; patients are receiving a good quality catering service; catering services have improved their control of costs and wastage; boards have strategiesfor catering services and are monitoring progress against these strategies. Our baseline report investigated the key areas of the catering service in 2007 and made 31 recommendations for improvement. The key findings of that report are summarised below:• Nutritional care needed to be given a higher priority by all staff through measures such as nutritional screening, using standardised recipes and nutritional analysis of menus.• Patient satisfaction with catering services was high but improvements were needed inthe amount of choice available to patients and in the ways that patients’ views were gatheredand used.• Food wastage at ward level needed to reduce. We recommended that regular monitoring of wastage levels should be introduced with the aim of reducing waste to a target level of ten per cent.Key findings• Catering services are offering an improved level of choice to patients, including giving patients the opportunity to order meals less far in advance, offering a range of portion sizes and ensuring that snacks are available to patients outside normal mealtimes.• Boards still need to do more to ensure the nutritional care of patients. All patients are not yet screened for risk of undernutrition and many hospitals do not have systems in place to ensure a nutritional balance in the meals provided.• Not all boards are carrying out quarterly patient satisfaction surveys. However, many boards are developing improved ways to get patients’ views on catering and use these to improve the services provided.• Catering costs have risen by a third since the baseline. Catering staff costs have risen due in part to the low pay agreement, whereas the costs of food and beverages per patient day have remained stable.• Non-patient catering services are still being subsidised but boards are improving their management information systems to allow them to manage this.

• Boards have reduced the amount of food wasted due tounserved meals.• Spending on catering services varied significantly and services to staff and visitors were beingsubsidised. We recommended that this could be better controlled by introducing pricing policies, income generation targets and policies on the level and cost of subsidisation.

In our study we reviewed progress made at board and hospital level by:• surveying all NHS boards, two special boards and 149 hospitals that provide catering to patients, staff or visitors• interviewing catering and finance managers at a sample of boards to follow-up on therecommendations from the baseline study (Appendix 1) The rest of this report is organised into three parts. reports on progress in meeting the needs and preferences of patients.Part 3 reviews how costs and wastage are being managed. And Part 4 looks at what improvements have been made in the strategic managementof catering services.• reviewing supporting evidence supplied by boards and hospitals • observing mealtime practice in a sample of ten wards to understand the context in whichcatering is delivered• using existing documents and findings from other sources

Throughout the report we provide data for the 1 hospitals that provide catering services. Where we have reviewed progress at the sample hospitals included in the baseline study, we make this clear in the text of the report. Where it was possible to compare progress we have given the results for 2007and 2006. However, it was not possible to directly report on progress at trust level since between 2003 and 2007 hospitals at jammu

7 Food, Fluid and Nutritional Care in Hospitals – Clinical Standards, NHS QIS, September 2003.8 Food, Fluid and Nutritional Care in Hospitals – National Overview, NHS QIS, August 2006.

9 Health Facilities Scotland is a division of National Services Scotland providing operational guidance to NHSScotland healthcare bodies on non-clinical topics.10 Our survey was undertaken between June and August 2007. NHS Argyll and Clyde was dissolved in April 2007 but is included in the analysis ofinformation received prior to that date.11 The baseline report reviewed a sample of 41 hospitals. The follow-up report reviewed 33 of these to monitor progress.

Key findings• Patients are not routinely screened for risk of undernutrition on admission to hospital.• Not all boards have fully developed systems for ensuring the nutritional balance of patient meals.• Acute hospitals with long-stay beds operate at least a threeweek menu cycle to maintainvariety in the meal options for these patients.• Ninety-seven per cent of hospitals offer at least two m eal choices at both lunch and dinner.• Catering services are using flexible approaches which fallow patients to order their food nearer to mealtimes and ensure snacks are available outside mealtimes.

Patients are not routinely screened for risk of undernutrition on admission to hospital2007 Recommendation: Boards should ensure that patients are screened on admission for risk ofundernutrition. 2003 Recommendation: Boards should use a validated screening tool and ensure that staff have been trained in the use of this tool. In this section of the report we use findings from the recent NHS QIS review of food, fluid andnutritional care in hospitals.12 NHS QIS reviewed this area of patient care under standard two of its clinical standards for food, fluid and nutritional care in hospitals. Although NHS QIS found evidence of progress in screening patients for risk of undernutrition on admission to hospital, it concluded that

no boards were complying with the standard of recording all of the required nutritional information within one day of admission for all of their patients. NHS QIS also reported that boards have not yet fully developed processes for nutritionally assessing, screening and care planning for patients. Once developed, these processes need to be fully implemented across all hospitals. This is an essential step in ensuring appropriate nutritional care for patie nts and NHS QIS has recommended that this is a priority for all boards. The NHS QIS review also found that most boards were not yet using validated screening tools in all ward areas. Only five boards had started to develop a nutrition awareness,education and training programme which would cover training in the use of validated screening tools.1

Not all boards have fully developed systems for ensuring the nutritional balance of patient mealsBoards should ensure that catering specifications comply with the model nutritional guidelines forcatering specifications in the public sector in india 2007 Recommendation: The Departmental Implementation Group should develop or commission national catering and nutrition pecifications for the NHS in india 2007 Recommendation: All menus should be nutritionally analysed. 2003 Recommendation: All catering production units should use standard recipes.

The hospitals has not yet produced a national catering and nutrition specification for thehospitals in jammubut plans to do so in 2007The Health Department (HD) set up a Departmental Implementation Group in 2001 to give advice to the NHS on providing nutritional care in hospitals. This group did not produce a national catering and nutrition specification for the NHS in J&K which we recommended in our baseline report.14 In April 2006, the HD appointed a national Food and Nutrition Adviser from within the NHS whose role is to produce a national catering and nutrition specification. This is due to be published in April 2007.

Half of boards have catering specificationsIn the absence of an agreed national specification, boards should still be working to the hospitals Diet Action Plan’s recommendation that catering specifications should comply with the model nutritional guidelines for catering specifications in the public sector India.15 However, only eight

boards have developed catering specifications which comply with the model nutritional guidelines.16Three-quarters of hospitals use some standard recipes to provide nutritionally balanced mealsStandard recipes ensure that the same ingredients and cooking methods are used each time a menu item is prepared. These should include details of the ingredients to be used, the quantities needed, the method for making the meal and the number of portions of a set size that will be produced.This helps control the costs of ingredients purchased and limits the waste produced in the kitchen. It is also the only way to ensure that the nutritional content of each menu item does not vary from day to day. Standard recipes are therefore necessary to ensure that nutritionally analysed menus deliver balanced nutritional meals to patients. Three-quarters of hospitals are using standard recipes to control the nutritional balance of meals. However, only 58 per cent reported that they used standard recipes for all meals on the menu.

Only seven boards have undertaken a full nutritional analysis of their standard menusNutritional analysis of menus helps to ensure that patients are provided with nutritionally balanced meals. Half of boards have undertaken an analysis of the nutritional content of each item on the standard menu and seven boards have analysed their entire standard menu to ensure it is nutritionally balanced.17 Nutritional analysis of menus is less likely to have taken place for special diets Catering departments and dieticians need to work together to ensure that any changes to menus or recipes are accompanied by an updated nutritional analysis. Boards reported a wide degree of variation in the frequency and accuracy of the nutritional analysis in place. Case study 1 gives an example of the work involved in creating and maintaining nutritionally analysed menus.Progress is being made but patients’ nutritional care is not yet consistently prioritised atward levelRecommendation: Boards should encourage communication between ward staff and thecatering department.

Referencesing and nutrition specification details the service’s approach to issues such as nutritional needs, food safety, procurement and menu choice.15 Eating for health – A diet action plan for Scotland, Scottish Office, 1996.16 NHS Ayrshire and Arran, NHS Dumfries and Galloway, NHS Grampian, NHS Highland, NHS Lanarkshire, NHS Orkney, NHS Shetland and NHS WesternIsles have catering specifications which comply with model nutritional guidelines for the public sector.17 NHS Ayrshire and Arran, NHS Borders, NHS Forth Valley, NHS Grampian, NHS Highland, NHS Lanarkshire, NHS Orkney and the Golden Jubilee NationalHospital have undertaken an analysis of each item on their standard menus. These same boards – with the exception of NHS Forth Valley – have alsoanalysed their entire standard menu to ensure it is nutritionally balanced.18 NHS Highland and NHS Lanarkshire reported that they have fully nutritionally analysed all of their special diet menus.

Standards on food, Standards on food, fuid and nutritional care in hospitals. This involved addressing food preparation and producing a core list of dishes for the menu cycles; developing nutritionally analysed dishes from a recipe list with a list of measured ingredients and an explicit method; and seeking the views of staff and patients about the new recipes. A project dietician and a project catering adviser were employed part-time for two years to produce over 600 recipes that were each nutritionally analysed. The recipes were incorporated into individual recipe files for each kitchen in jammu Caterers were then asked to use the recipes and feed back their comments to the project team over a threemonth period. Patients were also asked to give their views on the meals produced by these recipes by responding to questionnaires. The caterers had difficulties in manually calculating ingredients, resulting in further consultation and testing. The new recipes are due to be implemented by the end of 2007 Using a dedicated resource to develop the standard recipes was a significant step towards ensuring the use of fully nutritionally analysed menus. However, a number of challenges have been identified: •

Standard recipes involve additional work for chefs to manually calculate ingredients. • Some areas still prefer established recipes rather than the standard versions which have been tested. However, local variations can be incorporated into the recipe file if they are of acceptable nutritional value. • Each time a change is made to the ingredients or method of a recipe this requires an updated nutritional analysisto be carried out. • The nutritional analysis of dishes and menus can only be relied upon if standard recipes are followed by caterers.

Communication between ward staff and catering staff has improvedThe report noted the importance of good communication between ward staff and cateringstaff as an essential part of providing a quality patient meal service. Our study found that 13 boards have a written protocol for communication between wards and catering departments.20 Case study 2 gives an example of how catering departments can proactively pass on information to ward staff.Practices which help patients to eat a nutritious diet while in hospital need to be more widely adopted across all hospitals25. In 2006 the Hospital Caterers Association developed a protected mealtimes policy which recognises the importance of mealtimes and the need to ensure ward staff are able to focus on patients’ nutritional care at mealtimes.21 The policy recognises the different healthcare environments and needs at different hospitals but outlines seven objectives for wards adopting the policy: • To provide mealtimes free from avoidable and unnecessary interruption• To create a quiet and relaxed atmosphere in which patients have time to enjoy meals, limiting unwanted traffic through the ward during mealtimes, eg, estates work and linen deliveries• to recognise and support the social aspects of eating• to provide an environment conducive to eating, that is welcoming, clean and tidy• to limit ward-based activities, both clinical (eg, drug rounds) and non-clinical (eg, cleaningtasks) to those that are relevant to mealtimes or ‘essential’ to undertake at that time• to focus ward activities on the service of food, providing patients with support at mealtimes• to emphasise to all staff, patients and visitors the importance of mealtimes as part of care and

treatment for patients.Less than a quarter of hospitals reported that they are operating protected mealtimes policies. Our ward observations indicated that there is variation in the extent to which they have been implemented at ward level.Difficulty in prioritising the nutritional care of patients was highlighted in a recent survey commissioned by Age Concern.22 This found that nine out of ten nurses reported that they do not always have time to help patients who need assistance with eating. These findings are consistent with our own ward observations and underline the need to ensure that ward managers the nutritional needs of patients.

Systems in place to offer patients choice and tocater for patients with special dietary needs Acute hospitals with long-stay beds should ensure that they have a three-week menu cycle, at least for these patients. Menus should be reviewed to ensure that they offer sufficient choice to all patient groups. Where it is necessary, separate menus should be developed for ethnic meals and other special diets. All menus should be dietary coded to help patients make an informed choice.

Acute hospitals with long-stay beds operate at least a three-week menu cycle to maintain variety in the meal options for these patientsResource and Audit Group (CRAG) into the nutrition of elderly people in long-term care recommended that elderly patients in long-stay wards should have at least a threeweek menu cycle to avoid patients getting bored of the same menu choices on too regular a basis.23 A report by Age Concern notes that this recommendation should be balanced by the observation that many people enjoy a simple diet at home and may not want to try new meals during their time in hospital.24 As a result, hospitals should provide a long menu cycle to avoid patients facing the same choices too often but also need to be flexible to provide favourite meals in line with patient preferences.

Ninety-seven per cent of hospitals offer at least two meal choices at both lunch and dinner Choice is an important factor in encouraging patients to maintain a balanced nutritional diet while in hospital. Ninety-seven per cent of meal choices at both lunch and dinner for patients ordering from the standard menu.

Systems in place to cater for patients with special dietary needs and preferences they are catering for an increasing number of patients with special diets. Therefore the meals available should provide sufficient choice to meet these dietary needs and preferences. Nine out of ten hospitals provide menu options for vegetarian patients. Half of hospitals offer cultural or religious belief meals from the menu and a third offer a menu option for vegan patients. Although many hospitals do not offer these meals from the daily menus, there was evidence that all hospitals in place to offer choice to patients with special dietary needs and preferences. A flexible approach has been adopted by hospitals across Scotland to reflect the different demography of the populations served. Many hospitals have developed their systems to reflect their patient populations and do not put menu items for all special diets on the menu every day as this would have implications on cost and waste. However, they have arrangements in place to ensure that they are able to provide for special diets where these are identified at ward level.Hospitals code their menus to help patients with special dietary needs select mealsIn order to help patients make an informed choice about their meals, menus can be coded to make it clear whether they are suitable for vegetarians, patients on therapeutic diets, patients withallergies, or patients with eating or swallowing difficulties. Three-quarters of hospitals are coding their menus with this information.Catering services are offering an improved level of choice to patients2003 Recommendation: Boards should remind all their staff of the procedures for offering, ordering and delivering meals and in particular meals for patients who require a special diet.2003 Recommendation: All catering services should aim to have patients ordering their mealsas close to the meal time as possible and no more than two meals in advance.Staff is aware of processes for providing meals to patientsStaffs that are in contact with patients’ food are aware of: the local protocol or processes forOrdering and delivering food and drinks; meal and snack times; and procedures for ordering missed meals. This is achieved through local induction programmes and ward orientation as well as the use of posters, information leaflets and guides which remind staff of this information.

23 The nutrition of elderly people and nutritional aspects of their care in long-term care settings, Clinical Resource and Audit Group (CRAG), August 2000.

Almost all hospitals offer patients a range of portion sizesGiving patients the opportunity to pick the amount of food they want increases the choice available and allows them to reflect their normal eating preferences. When at home, some patients would normally have only a light lunch and then have their main meal at dinner time or vice versa. Hospital catering should be flexible to try to match individual eating patterns.Our survey found that all hospitals (with the exception of New Craigs Hospital) offer a range of portion sizes for menu items. This gives each patient the opportunity to choose an amount of food to match his or her appetite. The range of portion sizes available to patients should be quantified in all standard recipes and nutritional analysis of menu items (discussed in paragraphs 18-23) to ensure that these analyses provide an accurate assessment of nutritional intake. Percentage of hospitals ordering meals in advance of the mealtime If portion sizes are selected and ordered in advance then catering departments can produce the correct amount of food, but patients’ appetites may change between ordering the food and the mealtime. This can result in more food being left uneaten by patients (plate wastage). However, if portion size is selected at the mealtime then catering departments will not know how many patients want large portions and will have to estimate how much food will be needed. This can result in surplus food being sent to wards to ensure that all patients are given a choice (wastage in unserved meals). Therefore, giving choice to patients over the size of the portion they want can also affect the level of wastage.Snacks are available to patients outside normal mealtimesDue to clinical activity taking place throughout the day, some patients will miss mealtimes. Similarly, medication may affect patients’ appetite or clinical symptoms may mean that patients are not able to eat at regular mealtimes. It is therefore important that hospitals respond to these needs and are flexible about providing snacks outwith normal mealtimes .In 95 per cent of hospitals, wards are able to provide snacks for patients either to supplement mealtimes or to compensate where meals have been missed. We

also found that 85 per cent of hospitals were able to offer patients snacks prepared in the catering department outwith normal mealtimes.

Some processes in place to seek patients’ views on catering servicesShould ensure that they obtain patients’ views on the catering service through the introduction of regular (at least quarterly) patient satisfaction surveys.

A standard survey has been developed by the Health Facilities Catering GroupIn January 2008, the Health Facilities Catering Group agreed the format of a patient satisfaction questionnaire. This aimed to standardise the questions asked in each board and allow better comparison of information on patient satisfaction. All boards have made a commitment to carry out the survey annually and share the results.

Regularly monitoring patient satisfaction with hospital catering through patient surveysThe progress made in developing a standard survey for all boards is not yet reflected in a coordinated approach at hospital level. Almost a fifth of hospitals are not using patient satisfaction surveys at all. In the hospitals that are using patient surveys, the frequency of gaining Patient feedback varies widely regular monitoring of patient satisfaction is essential if patients’ views are to be used to improve service delivery. But only 30 per cent of hospitals are meeting our baseline recommendation that patient satisfacation surveys should take place at least once every three months.However, we did find areas of good practice where boards are developing comprehensive systems for gaining patient feedback and using this to meetings and then discussing these directly with catering staff. The minutes of these meetings record where actions are agreed to improve services as a result of the issues raised.

Recommendations

• Nutritional screening of all patients on admission to hospital should be a priority for all boards.• should put protected mealtimes policies in place to ensure that mealtimes are free from non-essential clinical activity and that there are enough staff on wards to help all patients eat a nutritious diet while in hospital.• should ensure that the catering and nutrition specification is published as planned.• All boards should ensure that standard recipes are used for all meals. These should detail ingredients, quantities, cooking method and the expected number of portions. The hospital should consider developing a national database of standard recipes for the hospitals to promote this.• Catering departments and dieticians should work together to ensure that all menus are fully nutritionally analysed and updated whenever any changes are made to recipes or menus.• All boards should regularly monitor patient feedback and use this as part of quality mprovement. This can be achieved through methods such as patient satisfaction surveys, monitoring plate wastage and reviewing feedback from carers. improve the quality of services both in kitchens and on wards. A variety of other patient feedback systems are in place at local level. Four-fifths of hospitals are using other systems such as patient forums or individual interviews in place of a patient survey or to supplement their findings do not have any systems in place to gather or act on patients’ views on hospital catering.27 Another indicator of patient satisfaction is the amount of food returned uneaten on patients’ plates. This measure can be influenced by a number of factors, such as loss of appetite caused by medication or symptoms of illness, but could be linked with other patient feedback systems to provide a more complete picture of the level of satisfaction with the food provided.Some hospitals are exploring innovative ways of encouraging all patient groups to be able to give their views on hospital foodSome boards have undertaken innovative work to ensure that the methods used to record patients’ views are appropriate to the client group. For example, patients with learning difficulties may find it difficult to complete a questionnaire but trained staff can discuss satisfaction levels with patients in an informal way in order to get their views on catering.We also found examples of patients in long-stay hospitals being encouraged to join catering groups, where patients meet with catering staff on a regular

basis to raise and discuss issues with the service Patients are encouraged to raise issues by putting concerns on the agenda for these

Key findings• Catering costs have risen by a third since the baseline. Catering staff costs have risen due in part to the low pay agreement, whereas the costs of food and beverages per patient day have remained stable.• Hospital catering costs have risen more slowly than other operating costs. There remainswide variation in the amount spent on catering services across boards.• Catering services for NHS staff and visitors are not breaking even.• Boards have reduced the number of unserved meals that are wasted.

Hospital catering costs have risen more slowly than other operating costsHospital Boards should ensure that they have appropriate financial information on the catering service to allow informed decision-making. Boards should base their catering budgets on the most recent, relevant and accurate information available.

Spending on catering has risen by a third since our baseline reportIn 2004/05 Spending on catering services has risen by 33 per cent since the baseline report.Exhibit 4 (overleaf) shows that most of this increase took place between 2002/03 and 2003/04 and is due in part to the low pay agreement introduced at that time. Catering costs have risen more slowly than other operating costs. Between 2003/04 and 2004/05, spending on catering rose by 1.8 per cent (this was less than the rate of inflation).30 Over the same period thetotal operating costs for the hospital sector rose by 11.1 per cent.31There remains wide variation in the amount spent on catering services

Reference:28 Scottish Health Services Costs, year ended 31 March 2005, ISD.29 NHSScotland – Low Pay Agreement, SEHD HDL (2003) 15.30 Hospital & Community Health Services pay and price index, Department of Health, 2006.31 Scottish Health Services Costs, years ending 31 March 2004 and 31 March 2005, ISD.

There has been little change in the cost of food and beverages per patient dayThe cost of patients’ food and beverages per patient day in the sample of hospitals we reviewedhas remained the same. (overleaf) shows the cost of patients’ food and beverages per patient day in 2005/06 for 21 of the sample hospitals reviewed. Although these costs vary among hospitals, the average level for the sample hospitals where we can compare across both years rose from.36 This rise is lower than the rate of inflation over the same period.37 Boards

reported that the continued use of national contracts to purchase food and beverages played a key role in managing the increase in these costs.

All catering departments should have systems in place which allow them to accurately calculate the costs of providing patient and nonpatient catering. : Boards should set pricing policies and income generation targets that aim to at least break even on nonpatient catering activities or have a clear stated policy on the level and cost of subsidisation.The extent to which boards are subsidising non-patient catering is becoming more transparentMost hospitals provide catering for staff and visitors .

Catering staff costs have risen more quickly than the costs of food and beveragesIn the small sample of hospitals we reviewed, staffing accounts for the largest part of catering costs. Since our baseline report, their catering staff costs have risen by 44 per cent, due mainly to the introduction of the low pay agreement. Over the same period, spending on food and beverages increased by seven per cent. The number of staff employed in catering departments has remained relatively constant at The guidance requires boards to produce trading accounts in 2006/07 for each catering department showing if non-patient catering is:• breaking even against the budget• budgeting for anticipated wageincreases• contributing to overhead costs such as training, travel, hardware and crockery• being subsidised, and if so to provide clear justification for subsidisation.We found that half of boards are operating trading accounts for all their catering departments.39Hospitals reported that they could split the costs of patient and non-patient catering services.Of these, hospitals reported that they were subsidising non-patient meals and hospitals reportedthat they were not subsidising nonpatient meals. Fourteen hospitals reported that they did not know if they were subsidising non-patient catering services and three hospitals used private contractors who would not provide this information.

Subsidising nonpatient servicesOnly boards have clearly defined pricing policies and income generation targets which aim to at least break even shows the level of contribution or subsidy achieved for the sample of hospitalswho returned this information.Boards reported that price increases will be necessary to reduce these subsidy levels. However, they also reported that where prices had been increased too quickly this had resulted in opposition from Partnership Forums or a reduction in the number of staff using hospital catering facilities.Boards have reduced wastage due to unserved meals All hospitals should aim to reduce thelevel of ward wastage (unserved meals) to ten per cent.Two-thirds of hospitals are monitoring wastage against targetsFood waste has an effect on the cost of catering services and unnecessary waste should therefore be kept to a minimum. Since the baseline report, boards have been required to have waste management procedures to monitor and reduce waste.42 However; wastage is also linked to the amount of choice available to patients. It can be affected by the number of options on the menu as well as how far in advance meals are ordered. For example, allowing patients to choose their meal at the mealtime rather than 24 hours in advance should mean that the meal will better reflect their preference at that time. But in order to provide that level of choice, extra meals have to be produced to give all patients choice. Wastage levels need to be managed to balance the cost implications with the quality of the service offered.Wastage can occur in production (kitchen wastage), in the wards (unserved meals), or in uneatenfood left by patients (plate wastage). Monitoring wastage levels at these three stages provides hospitals with useful information to help control costs and understand patients’ preferences. Twelve boards have set wastage targets ranging from zero per cent to 12 per cent and twothirdsof hospitals are monitoring wastage against these targets.There has been a significant reduction in wastage due to unserved mealsSeventy-five per cent of the hospitals in this sample have reduced their wastage levels and 21 of the 24 have achieved the recommended target wastage level of ten per cent.Recommendations• Boards should set pricing policies and income generation targets that aim to at least break even on non-patient catering activities or have a clear stated policy on the level and cost of subsidisation.

• All boards should continue to monitor and control wastage. All hospitals should reduce or maintain ward wastage at below ten per cent.: Guidance on charging for non-patient catering and the production of catering trading accounts, SEHD HDL (2005) 31.

Catering services are becoming more of a strategic priority at board levelBoards should ensure that a clear strategy has been approved for the future provision of catering services where other services are being reconfigured: All boards should have a food and health policy in line with the Diet Action Plan for jammu hospitals

Boards have a clear written strategy for the future provision of cateringThere has been an increase in the number of boards with a catering strategy since the baseline report.Boards now have a catering strategy, although only seven are monitoring progress against their strategies.45 Five boards have still to develop a food and health policy in line with the Diet Action Plan for Jammu HospitalsKey findings• Catering services are becoming a higher strategic priority for boards.• Catering staff vacancy rates remain high.• Agenda for Change has not resulted in standard job descriptions or pay grades for catering staff in different boards.. Boards have developed work on catering strategies alongside, or as part of, nutritional care strategies. found that three-quarters of boards had started the process of developing and implementing a nutritional care policy and strategic plan. While progress has been slow, all boards now have nutritional care groups in place which are central to the further development and implementation of catering and nutritional care at a strategic level.49Catering staff vacancy rates and sickness absence rates remain highBoards should monitor staff vacancy and turnover rates on a regular basis. Staff vacancy and turnover rates are high in some areas. Where this is the case, boards should take action to address these issues.Staff vacancy rates have reduced but remain high

All boards formally monitoring sickness absence and staff vacancy rates for catering staff. Catering staff vacancy rates across the sample hospitals are on average two per cent lower thanin 2001/02 but remain high at 7.8 per cent. Exhibit 10 (overleaf) shows that there are large differences in vacancy levels among the sample hospitals. Some boards reported that vacancies were being held open to allow for future flexibility in staff changes without the need for redundancies. Boards also reported that high turnover rates were closely linked to unsociable hours worked on backshift and to the repetitive nature of some of the jobs involved.Catering staff sickness absence rates are still highThe average level of sickness absence in the sample of hospitals we reviewed has remained at the same level as it was three years ago (7.2 per cent). shows there have been large changes in sickness absence levels in some of these hospitals but this may be due to the small number of staff employed in some catering departments. Where sickness levels are high, boards reported that long-term sickness absence was a contributing factor. Some boards have introduced more robust sickness absence policies accompanied by return-to-work interviews to manage sickness absence rates.A Facilities Management System which aims to provide managers with regular monitoring reports on catering services is being piloted in, U.s.A In 2005, NHS Tayside received £220,000 from the SEHD to develop System (FMS) for the NHS in Scotlan d. The first phase of the system, covering financial and operational key performanceindicators (KPIs), is due to be rolled out in NHS Tayside in November 2006. The FMS provides access to management information on the intranet, via NHSnet, allowing service managers, board directors and the SEHD to access and analyse information at an appropriate level. Monthly monitoring of the KPIs such as financial reports, sickness absence, overtime, headcount, staff turnover and vacancy can be compared against previous years and benchmarked against other hospitals. The benchmarking tool is dependent on the successful roll-out of the FMS across Scotland.The FMS is a potential tool for managers to use to systematically analyse many of the key indicators reported in this review. The system has the potential to assist in the regular monitoring of performance to improve decision-making at an operational and strategic level. However, it will be dependent on the quality of the data recorded in other computer systems such as the Scottish Workforce Information Standard System (SWISS) and PECOS.50Implementation of Agenda for Change varies among boards

Catering staff are being given new terms and conditions under the Agenda for Change review. The new terms and conditions cover standard hours, overtime payments, annual leave and basic pay. It also introduces the NHS Knowledge and Skills Framework which links education and development with career and pay progression. State Hospital have not yet changed the terms and conditions of catering staff in line with Agenda for Change. Other boards have changed terms and conditions for catering staff but have not yet evaluated the job descriptions for management, or clerical and administrative staff involved in catering.A benchmarking exercise carried out by the Health Facilities Catering Group confirmed the results of our interviews which found that Agenda for Change has not resulted in standard job descriptions or pay grades for catering staff across different board areas. For example, head cooks’ pay bands vary among boards.Boards have developed work on catering strategies alongside, or as part of, nutritional care strategies. NHS found that three-quarters of boards had started the process of developing and implementing a nutritional care policy and strategic plan. While progress has been slow,all boards now have nutritional care groups in place which are central to the further development and implementation of catering and nutritional care at a strategic level

Catering staff vacancy rates and sickness absence rates remain highBoards should monitor staff vacancy and turnover rates on a regular basis. 2007 Recommendation: Staff vacancy and turnover rates are high in some areas. Where this is the case, boards should take action to address these issues.Staff vacancy rates have reduced but remain highAll boards are formally monitoring sickness absence and staff vacancy rates for catering staff. Catering staff vacancy rates across the sample hospitals are on average two per cent lower thanShows that there are large differences in vacancy levels among the sample hospitals. Some boards reported that vacancies were being held open to allow for future flexibility in staff changes without the need for redundancies. Boards also reported linked to unsociable hours worked onbackshift and to the repetitive nature of some of the jobs involved.

Catering staff sickness absence rates are still highThe average level of sickness absence in the sample of hospitals we reviewed has remained at the same level as it was three years ago shows there have been large changes in sickness absence levels in some of these hospitals but this may be due to the small number of staff employed in some catering departments. Where sickness levels are high, boards reported that long-term sickness absence was a contributing factor. Some boards have introduced more robust sickness absence policies accompanied by return-to-work interviews to manage sickness absence rates.

Health and safety and food hygiene Boards are continuing to meet their statutory requirements in health and safety and foodHygiene trainingAll boards provide staff that is in contact with patients’ food with training in health and safety issues, and food hygiene commensurate with their duties.

However, they also reported that difficulties in releasing staff from their duties could reduce the attendance rates on these courses. Overall, boards were meeting their statutory requirements in health and safety and food hygiene trainingBoards have food safety manuals and infection control policies which include catering servicesOur survey found that catering services were included in the food safety manuals and infection control policies of most boards reported that they do not have a food safety manual in place the only two boards that do not have an infection control policy that covers catering services

Boards work with Environmental Health Officers through a rogramme of regular visits to ensure food safety and hygiene standards are being metOur survey showed that most hospitals are inspected annually by Environmental Health Officers, but where concerns have arisen, the frequency of visits rose in order to ensure that the hospital was taking action to resolve problems. Being rolled out across j&kConcerns include:• the slow speed at which the system operated• problems in using the system which initially could not deal with decimal points• incomplete and out-of-date lists of suppliers on the system.Catering departments and dieticians should work together to ensure that all menus are fully nutritionally analysed and updated whenever any changes are made to recipes or menus. All boards should regularly monitor patient feedback and use this as part of quality improvement. This can be achieved through methods such as patient satisfaction surveys, monitoring plate wastage and reviewing feedback from carers.

Financial managementBoards should set pricing policies and income generation targets that aim to at least break even on nonpatient catering activities or have a clear stated policy on the level and cost of subsidisation. All boards should continue to monitor and control wastage. All hospitals should reduce or maintain ward wastage at below ten per cent.

Strategic managementBoards should ensure that they have approved a clear strategy for the future provision of cateringservices. All boards should have a food and health policy in line with the Diet Action Plan for Scotland. Boards should take action to address issues where catering staff vacancy rates are high. Meeting patients’ needs and preferences Nutritional screening of all patients on admission to hospital should be a priority for all boards. Boards should put protected mealtimes policies in place to ensure that mealtimes are free from nonessential clinical activity and that there are enough staff on wards to help all patients eat a nutritious diet while in hospital. should ensure that the catering and nutrition specification is published in 2007 as planned.All boards should ensure that standard recipes are used for all meals. These should detail ingredients, quantities, cooking method and the expected number of portions. should consider developing a national database of standard recipes for the NHS in Scotland to promote this.26Part 5. Summary of recommendations

CHAPTER-4PATIENT SATISFACTION IS: “ EXCELLENCE IN HOSPITAL

Team work and team building essentials

Team building skills are critical for your effectiveness as a manager or

entrepreneur. And even if you are not in a management or leadership role yet, better understanding of team work can make you a more effective employee and give you an extra edge in your corporate office.

A team building success is when your team can accomplish something much bigger and work more effectively than a group of the same individuals working on their own. You have a strong synergy of individual contributions. But there are two critical factors in building a high performance team.

The first factor in team effectiveness is the diversity of skills and personalities. When people use their strengths in full, but can compensate for each other's weaknesses. When different personality types balance and complement each other.

The other critical element of team work success is that all the team efforts are directed towards the same clear goals, the team goals. This relies heavily on good communication in the team and the harmony in member relationships.

In real life, team work success rarely happens by itself, without focused team building efforts and activities. There is simply too much space for problems. For example, different personalities, instead of complementing and balancing each other, may build up conflicts. Or even worse, some people with similar personalities may start fighting for authority and dominance in certain areas of expertise. Even if the team goals are clear and accepted by everyone, there may be no team commitment to the group goals or no consensus on the means of achieving those goals: individuals in the team just follow their personal opinions and move in conflicting directions. There may be a lack of trust and openness that blocks the critical communication and leads to loss of coordination in the individual efforts. And on and on. This is why every team needs a good leader who is able to deal with all such team work issues.

Here are some additional team building ideas, techniques, and tips you can try when managing teams in your situation.

Make sure that the team goals are totally clear and completely understood and accepted by each team member.

Make sure there is complete clarity in who is responsible for what and avoid overlapping authority. For example, if there is a risk that two team members will be competing for control in certain area, try to divide that area into two distinct parts and give each more complete control in one of those parts, according to those individual's strengths and personal inclinations.

Build trust with your team members by spending one-on-one time in an atmosphere of honesty and openness. Be loyal to your employees, if you expect the same.

Allow your office team members build trust and openness between each other in team building activities and events. Give them some opportunities of extra social time with each other in an atmosphere that encourages open communication. For example in a group lunch on Friday. Though be careful with those corporate team building activities or events in which socializing competes too much with someone's family time.

For issues that rely heavily on the team consensus and commitment, try to involve the whole team in the decision making process. For example, via group goal setting or group sessions with collective discussions of possible decision options or solution ideas. What you want to achieve here is that each team member feels his or her ownership in the final decision, solution, or idea. And the more he or she feels this way, the more likely he or she is to agree with and commit to the decided line of action, the more you build team commitment to the goals and decisions.

When managing teams, make sure there are no blocked lines of communications and you and your people are kept fully informed. Even when your team is spread over different locations, you can still maintain effective team communication. Just do your meetings online and slash your travel costs. Click here for a free test drive. 

Be careful with interpersonal issues. Recognize them early and deal with them in full.

Don't miss opportunities to empower your employees. Say thank you or show appreciation of an individual team player's work.

Don't limit yourself to negative feedback. Be fare. Whenever there is an opportunity, give positive feedback as well.

Finally, though team work and team building can offer many challenges, the pay off from a high performance team is well worth it.  

EmpoweringListening to Patients

'Alternatives' listen

"We're at the birth of a new era," says John Hawks, president of Comsort, a Baltimore company that trains physicians in listening and other communication skills for the patient encounter. "The rise of psychosocial intervention is equivalent to the rise of biomedical intervention since the 1920s," he says.

This change is reflected in the fact that last year, for the first time, there were more visits to so-called alternative care sites in this country than there were to primary care physicians, with most patients paying cash, Hawks says. He notes that at most alternative sites–massage, acupuncture or chiropractic, for example–the provider is willing or eager to listen to the patient and there is a literal laying on of hands.

Hawks also points to a 1990 Stanford University study that he says found that women with breast cancer who have support groups survive twice as long as women who don't have that degree of support. "It's a psychosocial problem," says Hawks.

Despite the singular importance of communication, especially during the patient encounter, most doctors have yet to have their interview skills assessed formally.

Nearly 80 percent of doctors have never been monitored by a skilled observer during an interview, says internist Mack Lipkin, founding president of the American Academy on Physician and Patient, a New York-based non-

profit organization whose mission is to improve outcomes through educatio and research on doctor-patient interaction.

Marketplace dynamics may be pushing that percentage down, he says.

According to Lipkin, who is also director of primary care at New York University Medical Center in New York, managed care companies view themselves as growing in two ways: by enrolling new members, of course, but also by reducing disenrollment, typically 10 percent to 20 percent a year for each plan.

Customer surveys find that the biggest factors in deciding whether to remain with a plan are cost and satisfaction with the doctor-patient relationship, Lipkin says. The point is clear: As managed care organizations find it increasingly difficult to compete on cost, they will have to compete on satisfaction.

"Managed care companies are just starting to realize that patient satisfaction is a key market differentiator. To a large extent, patient satisfaction arises from the doctor-patient relationship. That's where training comes in," Lipkin says.

Not easy to change

The problem is, he says, that most attempts to improve doctor-patient communication through training and education have been ineffective because the odd lecture on "how to relate" or the afternoon session on dealing with difficult patients just isn't enough to reverse an ingrained bias in favor of technical detail over emotional content.

Enter Lipkin, who claims to have developed a unique model for changing physicians' behavior where traditional lectures and seminars have failed. Not only do the academy's courses change behavior in both the short and long term, he says, but they improve patient outcomes. And they do this while increasing the physicians' satisfaction with their own medical practices–particularly in the patient encounter.

The key: Unlike traditional courses that address factors such as knowledge, skills and attitude individually, the academy integrates them in a single, intense course that lasts at least a day. "Almost everybody changes when put in the right educational experience," Lipkin observes.

The organization charges about $75 per day per physician for courses on how to improve communication between physicians and patients. Last year the academy, which has certified 60 instructors, conducted 12 one-day courses, 14 2.5-day courses, a one-week course and a five-day course.

The communication skills can be built around everyday clinical issues or focused on such topics as pain, dying and dealing with the alcoholic patient, all implicitly recognizing that it is important to treat psychosocial components of disease.

Diagnosis of the most common psychosocial disorders–anxiety, depression, drug abuse–is missed between 50 and 80 percent of the time because physicians are not trained to listen for emotional factors in their patients' lives, according to Lipkin.

Mutual satisfaction

When doctors lack communication skills, their ability to gather information is compromised, they fail to engage patients in their own care (and thus have some responsibility for poor compliance with treatment regimens) and they conduct or order wasteful tests and treatments because problems are not accurately identified. All of this serves patients poorly, and it can run up unnecessary costs for health plans and plan sponsors.

"An activated patient who asks questions and negotiates with the doctor has better outcomes," Lipkin says. "The most important predictor of compliance is trust in the doctor; that begins with communication."

Better communication is not just for the patient and the plan, however. Physicians have much to gain in terms of satisfaction.

"There's an epidemic of burnout" reflected in the high turnover of doctors in health plans, which physicians leave on the average of every three or four years, Lipkin says. "Burned-out people are less effective. The most significant factor in physician satisfaction is the patient encounter. Physicians with better skills have better-quality patient encounters and are more satisfied and less likely to burn out."

Much of the challenge to doctors lies in overcoming a bias toward technical issues, which naturally results from their training, so they can deal with

patients who suddenly bring up complex emotional issues, cry or describe deep-seated personal fears.

"Doctors are faced with a new experience. They need help with how to manage it and how to cope with it themselves," Lipkin says.

"Most of us didn't learn this stuff in training," echoes internist Terry Stein, director of clinician-patient communication for Kaiser Permanente's Northern California Region in Oakland. "A lot of physicians get very uncomfortable with psychosocial issues patients bring up because they are not sure how to respond. It's a skill problem," says Stein.

Don't blame brevity

Stein, who was present at the creation of Kaiser's formal physician-patient communication program in 1990 when it wasn't fashionable for HMOs to pursue such efforts, says other factors besides medical school training play a role in the apparent listening gap. But those factors aren't inherent to managed care, she argues. For example, time per patient may be very limited under managed care plans, but Stein feels that time pressure is only one piece of the puzzle.

"The patient encounter is almost always brief. It's usually a matter of minutes, whether or not the setting is managed care. What is more important is how you use the time that you have," Stein says.

She acknowledges that the rise of managed care has resulted in a sharper focus on member concerns, but says, "When we teach physicians about rapport and empathy, we emphasize that these skills are even more important considering the time constraints."

Another significant factor: "As physicians, we've become adept at going on autopilot within a few seconds. We go into automatic thinking about what diagnosis the patient has and stop listening. We know that the diagnostic knowledge tree appears in our head within 18 seconds after the patient starts talking."

That near-instant recognition can be useful, but physicians might rely on it more than is desirable. Ironically, doctors may be seeing themselves as efficient when the opposite is true. "If we took a little bit more time, we

would be more efficient, because our initial diagnosis might very well be wrong," she says.

Doctors as mechanics

Finally, physicians have a "find it, fix it" mentality that impedes building relationships with patients. Doctors see their role as identifying the problem quickly, correcting it and moving on instead of creating a long-term relationship that in the end results in more accurate information and better patient adherence to treatment regimens, notes the internist.

Kaiser has seven years of positive feedback from its day-long workshop Thriving in a Busy Practice, which hones physician communication skills in both routine and difficult settings. Physicians say it has resulted in increased confidence in their medical interviewing skills, reduced conflict with patients and greater enjoyment of their practice.

And Thriving is, well, thriving. Despite its voluntary nature, 1,400 of Kaiser's 3,500 physicians in northern California took the course between 1990 and 1995. In February, Kaiser launched Thriving2, a version that adds modules for time management and "the four habits of highly effective clinicians" (see box, page 26), not to be confused with Stephen Covey's book, The Seven Habits of Highly Effective People.

Kaiser was a trailblazer with its physician communication workshop in 1990. Now, a strong academic argument has been built for such courses. Debra Roter, Dr.Ph., professor in the department of health policy and management at Johns Hopkins University School of Hygiene and Public Health in Baltimore, did a study with colleagues, published in the Archives of Internal Medicine in 1995, that assessed the communication skills of 69 primary care doctors in a randomized trial.

Listening can be learned

Using tape recordings of all patient encounters for a week–patients were screened to ensure a balance between emotionally distressed ones and those not–the study evaluated doctors who had undergone a modest eight-hour continuing medical education program to boost listening and other skills to get patients to report more clinical details. Doctors were evaluated as to whether they used the skills, were better at identifying potentially distressed patients through listening and were better at communicating in general. The

researchers measured the situations in which emotionally distressed patients did significantly better over a follow-up period.

Roter found that doctors did use the communication skills that had been taught them and that their patients did significantly better during the next six months than they would have had their doctors not been trained.

Since then, Roter has evaluated other CME as well as residency training programs and obtained similar results: When special skills such as listening are taught, they can be evaluated by studying performance. There is a definite, significant improvement in listening and other communication skills.

The curriculum Roter developed from her research has been commercialized by Comsort, most of whose work has been funded by pharmaceutical companies and offered as free courses to managed care companies.

From the top down

But Hawks, Comsort's president, says the company is moving beyond workshops because their value is limited–mainly because physicians don't have time to attend them. While continuing to conduct workshops, Comsort will develop programs in opinion-leader education, which involves "mapping" an organization to identify opinion leaders and then trying to effect change through them. Other new areas involve working closely with HMOs and meetings of medical societies.

"Most physicians learn and change their behavior as a result of brief interactions in the hall with someone they trust," Hawks suggests.

For an operation like Comsort, which claims to be the only for-profit company in this field, there's a lot at stake. Hawks sees a nascent market for psychosocial expertise in medicine as 85 million baby boomers approach the time when they will begin placing unprecedented demands on the health care system.

That demand may be even more urgent, given a study published Nov. 13 in the Journal of the American Medical Association that asserts that the country is not prepared to deal effectively with chronic disease.

"What's going to happen when these baby boomers do to health care what they did to real estate? Psychosocial medicine is more than a nicety; it's an essential," Hawks declares.

Idiosyncratic inefficiency

Like Kaiser's Stein, Roter believes there's still a tremendous need for workshops on listening to patients–and not particularly because of time constraints imposed by managed care. "A lot of people talk about time collapsing under managed care. What's very important is what occurs during the time. There's an incredible amount of wasted time," she says.

The real culprit is that physicians have not had a consistent and coordinated communications style. "It's idiosyncratic–doctors usually develop their own styles. Teaching communication skills can help make maximum use of the time available, making it more effective and efficient," says Roter. And the result will be better patient outcomes, which brings us back to Sir William Osler's timeless advice to physicians to listen to the patient.

Sounds like something managed care organizations should do as well.

Chuck Appleby is a freelance writer in Benicia, Calif.

Open and honest communication

One of the things that has surprised me most when talking with customers who use Basecamp is how many people work in a culture of fear, deception, and distrust. It’s often not their own fault, but more the result of the culture they are forced to operate in. It seeps in. It puzzles.

There are a lot of people who ask if they can hide this or hide that or only let certain people see certain people’s names inside a project or hide the last time someone logged in, etc. There’s a lot of hiding going on. A lot of obscuring the truth going on. It puzzles me.

One of the top requests as of late is for a company to be able to hide contractors from their clients. They don’t want their clients to know that third party contractors are working on their projects. Anyway you look at that, someone isn’t getting the whole truth. It puzzles.

And then there are the cases when people want software to step in with a solution instead of just politely explaining the situation to their clients. They want new features, modified features, obscure feature exceptions when all that is required is a simple conversation with their client to explain the way something works. It puzzles.

Of course people are free to use Basecamp however they want (and Basecamp does provide the option to make certain messages or to-do lists “private”), but Basecamp is not now nor will it ever be a tool for concealment. Or control. Or to keep the project opaque. Basecamp believes that project management is communication, which is of course all about transparency and sharing. Projects end up better when the communication channels are open and honest.

_ Key objectives of Catering Services._ Service Delivery._ Procurement and Cost Control._ Patient Services._ Nutritional Screening._ Catering Controls Assurance Standards

CATERING CONTROLS ASSURANCE STANDARDSRegistration of food business Accountability arrangements

Purchasing specification Hygienic facilities

Hazards Temperature control

Personal hygiene Food safety assessments

Dietary needs Legislation and guidance

Internal Audit Key indicators

Incidents and complaints Food management system

"Success depends not only on market conditions, but also on the ability to create markets where none exist."

Every business with the global prospects in the multi dimensional, volatile atmosphere has to introspect its strategies taking into consideration the strengths, weaknesses, opportunities and threats. The service industry also tags along the line and has to undertake smart and innovative moves to woo its clientele who expect best possible service at competitive rates. It is estimated that approximately a lull of 2%-10% of the previous year business in all categories of hospitals. Some hospitals have to face modernization at huge costs often especially in cyber city like Bangalore where technology up-gradation is swift and the inflows of customers require multi dimensional facilities ranging from full-fledged operation theatres to high grade video conferencing.

The hospital catering should concentrate and keep up the good work even if the business is already strong. Each relevant factor needs to be rated according to its importance- high, medium, or low for the business as a whole 1. The Indian service Industry utilizes the latest marketing principles and information technology updates to get a respectable position in the world market. In the face the worldwide economic recession, the guests have become more sensitive to price which calls for effective formulation of the pricing strategy.

Though the sales & market conditions are changing rapidly, the marketing principles are not changing. hospital owners and managements tend to be more inclined towards marketing and sales rather than cost control, constantly seeking to maximize room sales - double- bed occupancies. All this may fail and such a scenario may result in profit problem on cyclic basis, which may sometimes lead the hotel into liquidation or forced sale.

Hospital catering seeking a balance between achieving high occupancies and high average room rates may have higher long term profit. The peculiar nature of the hospitall business may compel the management to think short term about day-to-day problems or the next-meal periods, as the ROOM DAY is a PERISHABLE ITEM. The room occupancy perishes on the expiry of the day.

The increased competition has lead to Up market self-catering, time

sharing, home entertainment, competition from producers of other services and commodities and other trends like rising operating costs, high interest and too many hotel in many areas. Following diagram indicates the Strengths and Weakness Analysis of a generic Hospital catering. 

Strengths¥ India's rich cultural  heritage¥ Second largest foreign exchange earner¥ Demand far exceeds Supply¥ Global economical turn-up¥ Inclusion in EPCG* scheme¥ New business opportunities

Weaknesses ¥  Capital intensive ¥  Lack of adequate Man power  ¥  Non-availability of land ¥  Regional imbalance of hotels ¥  Long gestation period ¥  Poor infrastructure and cleanliness¥  Huge labor turnover¥  Less  corporate ownership

Opportunities¥  Boom in tourism

¥  Privatization of airlines ¥  Tie ups with international hospital catering chains¥  Increase in disposable incomes

Threats¥ Sensitive to disturbances in the country¥ Competition from other Asian countries whose official currencies have fallen drastically¥  High service & luxury taxes may render India as an unviable destination.¥  Lack of trained entrepreneurs

¥  Boost in tax concessions

CHAPTER-5Recommendations• Nutritional screening of all patients on admission to hospital should be a priority for all boards.• should put protected mealtimes policies in place to ensure that mealtimes are free from non-essential clinical activity and that there are enough staff on wards to help all patients eat a nutritious diet while in hospital.• should ensure that the catering and nutrition specification is published as planned.• All boards should ensure that standard recipes are used for all meals. These should detail ingredients, quantities, cooking method and the expected

number of portions. The hospital should consider developing a national database of standard recipes for the hospitals to promote this.• Catering departments and dieticians should work together to ensure that all menus are fully nutritionally analysed and updated whenever any changes are made to recipes or menus.• All boards should regularly monitor patient feedback and use this as part of quality mprovement. This can be achieved through methods such as patient satisfaction surveys, monitoring plate wastage and reviewing feedback from carers. improve the quality of services both in kitchens and on wards. A variety of other patient feedback systems are in place at local level. Four-fifths of hospitals are using other systems such as patient forums or individual interviews in place of a patient survey or to supplement their findings do not have any systems in place to gather or act on patients’ views on hospital catering.27 Another indicator of patient satisfaction is the amount of food returned uneaten on patients’ plates. This measure can be influenced by a number of factors, such as loss of appetite caused by medication or symptoms of illness, but could be linked with other patient feedback systems to provide a more complete picture of the level of satisfaction with the food provided.

Some hospitals are exploring innovative ways of encouraging all patient groups to be able to give their views on hospital foodSome boards have undertaken innovative work to ensure that the methods used to record patients’ views are appropriate to the client group. For example, patients with learning difficulties may find it difficult to complete a questionnaire but trained staff can discuss satisfaction levels with patients in an informal way in order to get their views on catering.We also found examples of patients in long-stay hospitals being encouraged to join catering groups, where patients meet with catering staff on a regular basis to raise and discuss issues with the service Patients are encouraged to raise issues by putting concerns on the agenda for these

Giving patients the opportunity to pick the amount of food they want increases the choice available and allows them to reflect their normal eating preferences. When at home, some patients would normally have only a light lunch and then have their main meal at dinner time or vice versa. Hospital catering should be flexible to try to match individual eating patterns.Our

survey found that all hospitals (with the exception of New Craigs Hospital) offer a range of portion sizes for menu items. This gives each patient the opportunity to choose an amount of food to match his or her appetite. The range of portion sizes available to patients should be quantified in all standard recipes and nutritional analysis of menu items (discussed in paragraphs 18-23) to ensure that these analyses provide an accurate assessment of nutritional intake. Percentage of hospitals ordering meals in advance of the mealtime If portion sizes are selected and ordered in advance then catering departments can produce the correct amount of food, but patients’ appetites may change between ordering the food and the mealtime. This can result in more food being left uneaten by patients (plate wastage). However, if portion size is selected at the mealtime then catering departments will not know how many patients want large portions and will have to estimate how much food will be needed. This can result in surplus food being sent to wards to ensure that all patients are given a choice (wastage in unserved meals). Therefore, giving choice to patients over the size of the portion they want can also affect the level of wastage.

• Catering services are becoming a higher strategic priority for boards.• Catering staff vacancy rates remain high.• Agenda for Change has not resulted in standard job descriptions or pay grades for catering staff in different boards.. Boards have developed work on catering strategies alongside, or as part of, nutritional care strategies. found that three-quarters of boards had started the process of developing and implementing a nutritional care policy and strategic plan. While progress has been slow, all boards now have nutritional care groups in place which are central to the further development and implementation of catering and nutritional care at a strategic

CONCLUSION In order to get the hospital catering a successful ,we have to take these following steps.

Registration of food business Accountability arrangements

Purchasing specification Hygienic facilities

Hazards Temperature control

Personal hygiene Food safety assessments

Dietary needs Legislation and guidance

Internal Audit Key indicators

Incidents and complaints Food management system

Photographs

Hygenic food in the kitchen

Using hand gloves in cooking

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