Article Text
PDF
Abstract
Introduction For medical students, food is rarely discussed from the clinical perspective. Yet, in hospitals reduced food intake poses the risk of malnutrition, along with increased morbidity and mortality. The issue of food waste, a cause of inadequate dietary intake and a common issue within the National Health Service, is rarely addressed. The implementation of protected mealtimes has done little to solve this. This quality improvement project aimed to reduce the average amount of inpatient food waste by 20% by May 2022.
Methods A standardised meal size intervention was tested. Meals were weighed before and after meal services to collect baseline and postintervention data. The percentage consumed and the percentage wasted were then calculated. Finally, the overall average of the percentage wasted across both meal services was determined.
Results Quantitative data showed a change in the average amount of food waste from 70.16% to 65.75%, a decrease of 4.41%. Survey results also found an increase of 3% in patient satisfaction with meal sizes.
Conclusion Standardising meal sizes is shown to improve inpatient food waste and may serve as a starting point for healthcare providers to devise further strategies to reduce wastage in hospitals.
- quality improvement
- waste management
- patient satisfaction
Data availability statement
Data are available on reasonable request.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
Statistics from Altmetric.com
WHAT IS ALREADY KNOWN ON THIS TOPIC
As stated in the available knowledge section, we know that poor nutrition can lead to worse outcomes for patients in the hospital.
Food waste is a global issue that contributes to inadequate dietary intake, particulary in hospitals.
WHAT THIS STUDY ADDS
Patients can be overwhelmed by large portion sizes in the hospital.
Using a measurement system to standarise portion sizes for hospital meals can help decrease the amount of food wasted.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
Hospitals may consider offering a variety of meal sizes to patients to potentially reduce the amount of food waste produced in the inpatient population.
Introduction
Problem description
In 2020–2021, an annual review found that 6500 tonnes of unserved meals were thrown away across all National Health Service (NHS) Trusts.1 Moreover, with catering services varying significantly across Trusts and a lack of nationwide data on inpatient plate waste, this figure is likely to be significantly higher.2 3 A multitude of factors influence why food is wasted. Food waste as defined by the Food and Agricultural Organization of the United Nations is the decline in the quantity or quality of food because of the decisions made by retailers, food service providers and consumers.4 The type of ward, catering service, the meal ordering system, quality of food, the menu choices and portion size all contribute to this decline in the quantity or quality of food.2
Available knowledge
Food is a basic human need, however, in the context of medicine, it becomes a critical part in the patient’s road to recovery. Reduced food intake poses the risk of malnutrition along with its associated adverse outcomes.5 These include an increase in length of stay in hospital, morbidity, mortality and decreased quality of life overall.6 Reasons for inadequate dietary intake vary greatly. Poor appetite, nil-by-mouth status, inadequate nutritional screening, missed meals for medical procedures, polypharmacy, limited dietary selection or nutritional inadequacy of hospital meals and food waste are all contributing factors.7 This project focuses on food waste.
The NHS has attempted to solve the problem of food waste with the protected mealtimes (PMs) national initiative created by NHS Estates in 2004, as part of the Better Hospital Food Programme.8 It encourages wards to stop all non-urgent clinical activity during mealtimes, allowing patients to eat their meals without interruptions and for those who need assistance with meals to be attended to by nursing staff. However, a wide array of evidence shows that PMs have little, if any benefit in improving patients’ overall food intake.
A meta-analysis of observational studies from across England, Australia and Canada found no statistically significant changes in nutritional intake with or without PMs.9 A randomised control trial across three different hospital sites in Melbourne, Australia, discovered no statistical difference in energy intake for patients receiving PMs compared with those who were interrupted (p=0.88).10 In addition, a cohort study in a teaching hospital in the UK found no difference in energy intake as well as no significant difference in the number of patients experiencing mealtime interruptions, although PMs had been well integrated into the Trust for several years.11 Contrastingly, two out of seven studies that used a PM programme in a global systematic review found food waste decreased among patients with the programme.12
Within the local context, a PM Policy exists in the ‘Policy for the Nutrition and Hydration Provision to Inpatients’ for East Lancashire Hospitals NHS Trust (ELHT). However, the effectiveness of the policy in decreasing food waste is yet to be proven.
Baseline data
This quality improvement (QI) project took place on Ward C2, a gastroenterology ward in Royal Blackburn Hospital (RBH). Baseline data were collected by weighing meals prior to and after mealtime, which is further explained in the methods section of this paper. Data were also collected by surveying both patients and staff (see online supplemental appendix A). Collection of data occurred from November to December 2021. There were no primary data on food waste or intake on this ward prior to this.
Supplemental material
Quantitative data showed an average of 70.16% of meals were wasted. Only main meals were included in the data. Sandwiches and snacks were excluded. Figure 1 displays the breakdown of food consumed versus food wasted during both meal services.
Mealtime consumption and wastage.
Data in the survey found poor appetite were a major reason for not finishing a meal. 57.14% of patients found that their meal size was appropriate (12 out of 21 surveyed patients). However, 42.86% felt meal sizes were too large (9 out of 21 surveyed patients). The survey also sought suggestions from staff to improve the amount of food wasted. Smaller portion sizes were the main recommendation.
Rationale
Initially, an observational quality mealtime audit was completed on the gastroenterology ward in May 2021 which prompted the initiation of this QI project. Through a patient survey, the audit found that patients did not finish most of their meals. Auditors felt that the next logical step was to measure the amount of food waste, to see whether there were areas where improvement in both waste and patient experience could be sought. Additionally, six nutrition incident reports were made on ward C2 following the changes made after the audit. These factors together prompted the initiation of the QI project.
Process mapping then helped identify prominent issues in the procedure of getting meals to patients. The process map tool was provided by the QI Team at ELHT. This can be seen in figure 2.
Process map.
The initial aim was to only analyse patients requiring assistance during mealtimes whose risk of malnutrition was significantly higher, identified by a red tray. Patients with no significant risk, needing no assistance, were identified using a white tray.
However, as this was the first time such data had been collected, stakeholders felt it would be more beneficial to analyse all inpatient food waste on the ward.
Aim
The SMART (Specific, Measurable, Achievable, Relevant, and Time-Based) aim of this QI project was to reduce the average amount of inpatient food waste on ward C2, by 20%, by May 2022.
Objectives
Understand the process of patient food delivery, from kitchen to ward-level.
Recognise the roles and responsibilities of respective staff members/stakeholders and acknowledge where their expertise is needed within the process.
Introduce an intervention that could potentially be used Trust-wide to decrease food waste at ward level.
Increase staff members’ awareness of food waste within the hospital.
Method
The test of change was completed on Thursday 17 March 2022. Members of the QI team aided in data collection through both the lunch and dinner service.
Intervention
Figure 3 demonstrates the driver diagram that was used to identify potential change ideas to decide on a specific intervention. An initial aim was set for 20% reduction of inpatient food waste by May 2022, a year from when the audit that triggered the start of this QI project was completed. Primary drivers for this QI project were split into education, communication and documentation. Secondary drivers for the project were to improve awareness of nutrition standards in hospital, have clearer communication between staff members about the expectation of nutrition by patients and reduce the risk of incident reports.
Driver diagram.
After determining drivers for the project, a number of ideas for change were generated over two meetings with stakeholders.
Next, as seen in figure 4, a resource/impact analysis chart was used to categorise each of these change ideas. The ideas were separated into ‘quick wins’—ideas that would be ‘easy’ to implement. ‘Long-term plans’—ideas that would ultimately help reach the aim but would take a considerable amount of time to complete. ‘Low hanging fruit’—ideas which were less likely to meet the aim. Finally, ‘thankless tasks’, which may cause more increased labour with potentially no influence on the aim.
Resource impact analysis.
After a course of meetings with stakeholders interested in the project, it was determined that decreasing the standard portion sizes and offering larger portion sizes, rather than smaller, would be an appropriate change idea. It was agreed that patients who wished for a larger meal size would be allowed to request this at any time if they found the standard meal size too small.
The facilities manager helped to change menus accordingly to reflect a larger and smaller portion size option for patients to select for each meal. This was simply an extra column added to paper menus for patients to tick a desired meal size.
The original ‘standard’ portions were not standardised using measurement tools, but rather by eye; this was commented on by the facilities manager in multiple meetings as a very subjective manner of serving meals. In addition, the original option for smaller portion sizes on the menu often resulted in the same ‘standard’ portion size. This was one of the ‘Quick Wins’ identified that all stakeholders were satisfied with.
For the intervention, the catering team used specific measurements for each component of a meal to create the standardised portion, and larger portion sizes. Prior to this change, regular meal services would typically use eyeball estimates (eg, one scoop of mash potatoes would vary in size on the assembly line, depending on the member of staff responsible for that component of the meal).
For this intervention, a standard portion contained 6 ounces (or 170 g) of a source of carbohydrates (eg, rice, mashed potatoes or baby potatoes) and 6 ounces of a protein-based source (eg, stew, curry or casserole). A larger portion contained 8 ounces of the two main meal components. Interestingly, fruit-based and vegetable-based meals were not offered regularly so no standard portion size could be created for these food groups.
The images in figure 5 display three example meals side by side.
Standard portion size versus larger portion size.
A method for weighing portion sizes was agreed on between stakeholders, partially based on a simple food weighing method used by researchers in Malaysia.13
Once portion sizes were decided, meals were weighed before and after mealtime in the same way baseline data were collected on the day of the test of change. Three types of dinner plates and plastic insulation covers were weighed. An average was taken, which was then subtracted from the total weight of each main meal. This gave us the weight of the plates before consumption (variable b).
After mealtime, the empty plates were weighed on the ward with the plastic insulation covers included. The average weight of the dinner plates with the plastic insulation covers was subtracted. This gave us the weight of the plates after consumption (variable a).
The percentage consumed of each main meal was calculated using the following equation:
The percentage wasted on each main meal was calculated with another equation:
Finally, to obtain the overall average of the percentage wasted across both meal services, the % wasted for each individual meal was totalled together and divided by the total number of meals served.
Surveys were conducted before and after the meal size intervention. The main goal of the survey was to determine staff and patients’ perception of food waste on the ward. Survey questions were printed and handed to participants face-to-face after lunchtime, between 15:00 and 16:00 hours. Verbal consent was taken from both staff an patients. All responses were anonymised. There was no limit on the length of response, however, a prompt was included to instruct responders to keep answers to one sentence or shorter.
Staff included in the survey had to be working on the ward for at least 1 month, have at least 5 min to themselves to fill in the survey completely, and consent to their job role being included in the survey.
Patients included in the survey had to have been an inpatient for at least 1 week and have at least 5 min to themselves to fill in the survey completely.
Surveys were collected 5 min after the last survey was handed out. Before the meal size intervention, 21 patients completed the survey and 7 staff members. After the meal size intervention, 10 patients responded and 8 staff members.
Stakeholders
Figure 6 highlights the key stakeholders involved in the project.
Stakeholder analysis.
Patients were important stakeholders as the problem identified triggering this project was the risk of malnutrition stemming from multiple factors, which included food waste in hospitals. Although patients themselves were not interested in the food waste generated on the ward, their participation was paramount.
This project was predominantly supported by the following staff members:
Facilities manager.
Improvement practice coach.
Ward C2 manager.
Ward staff, particularly healthcare assistants and ward-level nurses were also supportive of this project as they were responsible for delivering meals to patients and supporting them during mealtimes.
Catering staff made efforts to modify the meal sizes for the intervention. The dietetics team were actively involved in group meetings for the project and helped generate ideas.
Measures
Outcome measures: determine if the SMART aim of the project has been achieved.
Average percentage of waste during mealtimes.
Process measures: evidence of whether the new process (test of change) is working well.
Amount of time taken for catering staff to prepare the standardised meal portion.
Patient satisfaction with portion sizes.
Balancing measures identify potential unintended consequences as a result of the test of change.
Staff satisfaction—explaining new menu changes to patients may lead to shortage of time for other tasks/confusion.
Results
Outcome measures
An average of 65.75% of meals were wasted; this was an improvement of 4.41% from the baseline data. A breakdown of food consumed versus food wasted during both meal services is shown in figure 7.
Comparison of mealtime consumption and wastage after standardising meal sizes.
Process measures
60% of patients were happy with their meal size after the intervention. However, the 40% who were not satisfied with their meal size still found the quantity of food to be excessive. No patients had their meals being too small. Survey responses can be seen in online supplemental appendix A4.
Discussion
The overall aim to reduce the average amount of food waste of patients was achieved, although the goal of 20% was not reached. Waste decreased by 4.41% with the standardised meal size intervention. The underwhelming improvement was not completely unexpected; even with standard meal sizes patients may have been dissatisfied and put off by the portion sizes.14 Though the catering staff were vigilant in their approach to measuring each component of the meal, it is likely that smaller portion sizes were overestimated.15–17 This would explain why 40% of patients were still dissatisfied with meal sizes, even after standardisation. Nevertheless, the intervention did show some improvement and should continue to be implemented.
Strengths
This project did not have significant negative effects on the process and systems used to provide meals to patients. Overall, the project was well received by staff members, both on the ward and in the kitchens. There was an opportunity to provide greater awareness of the food waste issue to staff, particularly doctors who, from the results of the survey, had not taken notice of the significant amount of food wasted on the ward (see online supplemental appendix A). Qualitative studies show that staff can successfully identify major issues in nutrition and hydration, such as weight loss and malnutrition, but fail to acknowledge factors like sleep disturbance and mood changes.18 19 One suggestion to potentially bridge the gaps in staff knowledge would be to implement multidisciplinary team-based training on nutrition.20–22
Weaknesses
Weaknesses of this QI project include; lack of accuracy when measuring meals due to equipment, exclusion of snacks and foods eaten in-between meal services, and inadequate resources available to assess patient’s individual dietary intake against individual waste. Subsequent projects should aim to tackle these issues by obtaining more accurate scales for measurement and following up individual patients throughout their day of eating. There may also be potential to seek the help of a trained dietitian to evaluate intake via visual estimation and aid in analysis of nutrient composition of meals.23
Limitations
An important caveat to note in this project was that it was conducted in only one ward type, a gastroenterology ward. Patients also had varied dietary needs, comorbidities and length of stay in hospital.
The time restriction for this project largely affected the measures reported. Dietitians in particular would have been fundamental in helping collate and interpret data, however, due to scheduling conflicts their input could not be adequately included. This project also did not explore other aspects of meal service, such as flavour, temperature and texture which would have contributed to food waste.
Average percentage of waste during mealtimes was the only outcome measure. Further projects could consider observing direct patient outcomes, particularly the risk of malnutrition in relation to food waste. An additional limitation was the willingness from patients to participate in the survey after the intervention; 21 participated before the intervention, while only 10 participated afterwards.
Further recommendations
Sequential projects may want to attempt having the ward monitor the number of unserved food portions after each meal service and determine the ‘general number of portions’ necessary, which can be reported to kitchen staff to adjust the number of meals served accordingly. This strategy was used by The Children’s University Hospital in Dublin and saw the quantity of food waste decrease by 12.5%, with ward kitchens rarely needing to ring the catering department to ask for more food, showing that enough food was being provided.24
Conclusion
In summary, this QI project decreased inpatient food waste on ward C2 in RBH by 4.41% through a standardised meal size intervention. This was far below the target of a 20% reduction. Further projects may want to add additional changes to the process in place, such as ‘general number of portions’ for each ward where data are collected.
Data availability statement
Data are available on reasonable request.
Ethics statements
Patient consent for publication
Acknowledgments
This quality improvement project was made possible with the support of the Quality Improvement team at the East Lancashire Hospitals NHS Trust (ELHT) Improvement Hub. I also want to thank all the staff at the Estates and Facilities Division and Quality Improvement Team, for their cooperation, in particular Tim Radcliffe and Kim Reid.
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Correction notice This article has been corrected since it was first published. The author byline and acknowledgement section have been updated.
Contributors AJ: Guarantor, University Hospitals of Morecambe Bay NHS Trust.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.