In 2010, Manchester Manor Health Care Center, an independently owned and managed health care center located in Manchester, Conn., was presented with the American Health Care Association/National Center for Assisted Living Gold Excellence in Quality Award. Managing partner Paul Liistro and his team are known for their relentless pursuit of quality and person-centered care.

No More Trays

It was in this vein that the center took up its latest project, known as direct dining—a growing concept in long term care that eliminates institutional tray service, replacing it with fresh hot or cold meals served by a dietary aide in conjunction with nursing staff from a mobile food cart.
Resident choice and restaurant-like options are the most appealing aspects of this style of dining. Additionally, the point of service could be anywhere the resident chooses, whether it be in their room, main dining room, or in a lounge with the company of others.
This idea began at a department head meeting while discussing ways to enhance the resident dining experience. The team was able to tap into its dining services vendor for resources to accomplish this endeavor.
After the visit, a plan was developed by the dining services director, detailing the required equipment, changes in service to implement this program, and associated costs. The plan also included the process for phase-in of all three nursing units over a period of several days and was reviewed with the resident council. It was presented to the strategic planning committee and was approved and adopted as part of the facility’s 2012-2013 strategic plan.

A Launch Plan

In May, a launch date of June 18, 2013, was scheduled. Using the cycle of improvement known as Plan Do Study Act (PDSA), the team met several times prior to this date to ensure everything was on target. Topics included consulting with local health officials, preparing and positioning residents for breakfast, re-assignment of duties, and identification of potential fire safety hazards.
Frontline staff were invited to participate in roundtable discussions as the start date drew closer. During this time, meal services were expanded in the main and therapeutic dining rooms to incorporate their full use. In addition, a sample group of residents was surveyed to provide feedback before and after the transition as a means of tracking progress.
On June 18, the first meals without trays were served to the subacute residents. Additional staff members were scheduled to ease the burden of transition. Over the next several days, the team monitored trends, met daily, and made adjustments to improve the flow of service.
The original plan called for a four-day transition, but through PDSA, the team realized it required longer to achieve full implementation. In the third week, the final unit was transitioned.
After two months, the process came to realization. Continuous monitoring is still ongoing.
Upon implementation, residents began sharing feedback immediately about positive impacts on quality and satisfaction. Areas of improved satisfaction included the ability to make a choice, the wonderful aromas of food throughout hallways, hotter food temperatures, and more personalized service.
One resident commented about how he felt like he was “in a restaurant.” Feedback was not limited to residents, as family members shared their views as well. A family member of a resident known for not eating remarked, “My mother is eating real food.”

Survey Says: Success!

Survey results from the 18 residents polled revealed improvements across the board. Initially, only 12 residents felt they had a choice in their meals. Thirty days after implementation, 16 residents responded that they had choices available. This represented improvement of 12.2 percent.
Prior to the transition, more than half of the responses showed that lunch was by far the hottest meal. After implementation, the results were nearly identical at all meals, with breakfast and dinner scores at least twice the pre-implementation scores. Quality scores for food satisfaction have risen 6 percent, and overall satisfaction scores are up 12 percent.
These statistics can be attributed to the residents receiving their food in a more timely fashion because staff must serve it promptly on arrival to the dining site. Temperatures documented by the culinary team have shown foods to consistently be 10 to 30 degrees hotter than with the previous serving method.
With the system in place, certified nurse assistants have said that it is more efficient than tray service, allowing them more time to spend on patient care. The dining service employees are also happier since they now can interact with residents face to face.
Labor and food costs have remained neutral despite having to increase food production to combat the unknown element of choice.
Several factors played a role in keeping costs balanced. Most of the portion-control, individually packaged items, such as juice cups and canned soda, were replaced with bulk items like gallon orange juice and liters of soda. Some bulk items used in lesser quantities were replaced with portion-control items to reallocate labor to other tasks.
Supplement and nourishments cost declined 38 percent and 17 percent, respectively. Seeing drops in these two line items confirms that residents are eating actual prepared food.

Significant Savings Realized

The largest savings centered on capital equipment. The capital cost involved in this conversion totaled $11,901.83. The new equipment—two hot/cold food carts, four enclosed bussing carts, two hot holding units, and four freezer packs—replaced several assets that were coming to the end of their useful life (meal carts, tray-line refrigerator, a plate warmer, and an induction charger). The total cost of replacing these items was valued at $32,523.03, resulting in a savings of $20,621.20.
Small-wares such as coffee air pots, service carts, serving pan, and utensils totaling approximately $2,500 were purchased under the operating budget.
Other small savings included the use of dishwasher chemicals and paper. The number of racks run through the dishwasher declined by 21.6 percent because trays, dome lids, and induction bases no longer needed washing (each cycle costs $0.40). Based on the current usage, this translates into a savings of $15.20 per day.
However, some of these costs are being absorbed into purchasing other chemicals because there are now more pans to wash. Still, the reduction of racks saves a great deal of wear and tear on the dishwasher, but is difficult to quantify because it is a soft savings.
Also, under the old system, residents were given daily menus to select their meals. The paper and labels used to generate them have produced a cost savings of $3.02 a day, or $1,102.30 per year.
Overall, the investment and return have been met with great satisfaction. The team is currently collaborating with the fabricator of its food service carts and sharing feedback that will be used in future product designs.
Peter Ponticelli is the Sodexo general manager who manages the dining services department at Manchester Manor. Peter holds degrees in culinary arts and food service management. He can be reached at (860) 533-2545 or