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Running head: CQI PROJECT 1

CQI Project: Late Tray Delivery

Alyssa Collins

University of Southern Mississippi


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Table of Contents

Introduction 3
Literature Review 4
Current Process 6
Data Collection Methods 8
Data Analysis 10
Results 11
Discussion and Recommendations 13
References 16
Appendix A 17
Appendix B 18
Appendix C 19
Appendix D 20
Appendix E 25
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Introduction

St. Marys Hospital in Grand Junction, Colorado is a 350 bed facility that generally

serves anywhere from 100 to 200 patients at a time. Food and Nutrition Services is a major

department in the hospital and a large number of employees are vital in the proper functioning of

the food service department. Food and nutrition are essential not only for improving health status

of a patient, but also for providing comfort. Therefore, it is important that the food served

through the patient services kitchen be nutritious and tasty for each patient admitted.

Increased meal consumption and patient satisfaction has been shown with room service

delivery over other types of food service (Kim, Kim, & Lee, 2010). St Marys utilizes a room

service style of food service; meaning patients call down to order their meals when they desire.

The goal of the food and nutrition services department is to deliver a meal 45 minutes or less

following the patients order. This time limit was set to maintain proper food temperatures,

increase patient satisfaction with the food service department, and subsequently improve patient

perception of healthcare overall. However, the department has yet to see 100% compliance with

this goal.

The purpose of this study is to examine the reasoning for late tray delivery and develop a

plan for improving the process and decreasing the overall amount of trays delivered late. The

overall goal of the study is to create a more efficient tray assembly and delivery process in order

to increase patient satisfaction with the meals provided. In order to develop and implement this

new process, this study examined each section of the tray assembly and delivery process and the

correlations between the number of employees working each day and late tray deliveries.
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Literature Review

Patient satisfaction with inpatient hospital foodservice is a major component of

satisfaction with overall healthcare experience (Wright, Capra, & Aliakbari, 2003). In fact, a

study published in the American Journal of Medicine and Medical Sciences observed that 52.8%

of patients dissatisfied with overall health care were dissatisfied because of food service

(Abdelhafez, et al., 2012). Due to this reason, many hospitals have implemented a patient

satisfaction survey to continuously improve the quality of the food service for patients.

Generally, patient satisfaction surveys include information on taste, texture, temperature and

appearance of meals. In a Press Ganey satisfaction survey, it was found that majority of negative

comments regarding the food were related to inappropriate temperatures (Troutner, et al., 2012).

Oftentimes, food temperatures are altered when trays are delivered late to patients

rooms. Trays are unintentionally delivered late for a number of reasons including network failure

for printing orders, accidental duplicate trays, and increased number of calls during a specific

meal (Mclymont, Cox, & Stell, 2003). Increased calls are often during conventional mealtimes

and can cause delayed ordering times, delayed assembly on the tray line, and a slower delivery

time as more trays need to be delivered.

When trays are delivered late and temperatures are found to be improper, this decreases

the percentage of meal consumption (Kim, Kim, & Lee, 2010). Since eating a well-balanced

meal aids in the healing process, late tray delivery is important to correct. In order to see which

part of the process of tray assembly and delivery caused the greatest loss of temperature, one

study monitored temperatures and time for assembly, time to reach the unit, and total time for the

entire process. This study found that the largest temperature loss was observed during the tray
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assembly process, not during delivery (Troutner, et al., 2012). Once the reason for late tray

delivery is discovered, new processes can be developed to correct the problem.

Late tray delivery causes improper food temperatures which influences patient

satisfaction with foodservice and perception of overall healthcare. Additionally, improper food

temperatures results in possible contamination of food, which can cause foodborne illnesses. In

fact, it was found that the most common reason for foodborne illness outbreaks in public school

systems were improper food storage and holding temperatures and food contaminated by a food

handler (Daniels, et al., 2002). When the trays are placed on a cart at room temperature and left

for more than ten minutes, this increases the risk for bacteria to grow with improper temperatures

of the food. Therefore, it is imperative that St. Marys decrease the amount of late trays

delivered in order to maintain correct food temperatures to increase patient satisfaction.


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Current Process

As previously stated, St. Marys Hospital uses a room service style of food delivery. The

process for hospital room service delivery is similar to ordering food at a restaurant. The patient

is placed on a certain diet by the attending physician. Once the patient is placed on a diet, they

are given a menu. The patient, the patients nurse, or a family member will call down to the diet

office to place an order. The diet office staff then places the order into Health Touch, the

computer system.

Once in the computer system, tickets are printed on the tray line. One ticket is printed at

the start of the tray line. The tray line starter will place silverware and beverages on the tray.

Another ticket will print for the hot food items. The cooks will prepare each hot item and plate

them once fully cooked. The hot and cold items are then placed on the tray and checked for

accuracy by the expo position. Once ensured that the ticket items match the items on the tray,

the tray is placed on a cart for delivery. The placement of the tray on a specific cart depends on

the floor the tray is being delivered to. There is one cart for the third, sixth and seventh floor, one

cart for the ninth, eleventh and twelfth floor and one cart for the eighth and tenth floor. However,

trays are occasionally shifted around to different carts based on the number of trays being

delivered to each floor. When a tray has been placed on an empty cart, a timer is started for ten

minutes. Ideally, when the timer goes off or the cart is full, whichever happens first, the trays on

the cart should be delivered to the patients. However, this does not happen as often as it should

when the patient services kitchen gets busy.

The trays are delivered to patient rooms by the hosts. The number of hosts generally

changes depending on patient census. When patient census is low, around 100-150 people, there
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are three hosts. When patient census is high, or higher than 150 patients, there are four hosts that

are available to deliver trays.

Just recently, a new scanning system has been put in effect at St. Marys. The meal tickets

are scanned when the order is placed, when the tray is ready, and when the tray is delivered.

When the tickets are scanned, they are automatically uploaded to Health Touch. This scanning

system ensures that trays are being delivered in a timely manner. Before this system, these times

were tracked by pen and paper by each employee. The scanning system increases reliability since

employees cannot alter the tray times. Appendix A includes a flow chart of the current process.

Appendix B displays the fishbone diagram.


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Data Collection Methods

The purpose of the study was to examine the possible causes of late tray deliveries and

identify how to decrease patient tray delivery times in order to improve patient satisfaction with

St. Marys food service and the hospital in general. In order to find the possible causes of late

tray delivery times, data was collected from March 1, 2017 to March 29, 2017. Only week days

were included in the study as more trays are generally delivered during the week, and the intern

collecting data did not work weekends. Data collected in the study on employees included the

number of hosts each day. Additionally, specific data was collected for three late trays were

collected each day. This data included the floor each late tray was being delivered to, the time the

call was made, the time the tray was ready in the kitchen, the time the tray left the kitchen, and

the time the tray was delivered.

Collecting the data came from observation as well as from Health Touch, the online

computer system. Data for employee numbers each day came from observation of the patient

services kitchen. Data for late tray times was conducted by observation and from Health Touch.

Some trays were followed through the process each day to collect the tray times. When trays

were followed, data was written on the sheet displayed in Appendix C. Unfortunately; many of

the trays that were followed were delivered in a timely manner, less than 45 minutes, and

therefore were not included in the final data report. If a tray was delivered late, these times were

included in the data collection. The other late tray delivery times, and the total number of late

trays each day were pulled from Health Touch. The data was compiled in an excel sheet, which is

displayed in Appendix D.

At the beginning of the study implementation, it was hypothesized that the tray delivery

process would take the longest, especially those going to the higher floors, as this would take the
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longest delivery time. Additionally, it was hypothesized that as the number of hosts increased,

the number of late tray deliveries would decrease since there were more people delivering the

trays.

Certain variations from the original project plan to the final methods described were

implemented as data collection began. Originally, the variables for collection included the times

the hot and cold foods were plated. However, these were combined into one category, tray

ready, as tracking each specific time was too difficult as multiple trays were being assembled at

once. The original plan was to also track the diet type for each late tray, to determine if diet types

influenced tray delivery times. This data was excluded from the final collection. More data was

also to be collected on the employees each day; including the number of diet office and tray line

employees. Once data collection began, tray line employees became too difficult to collect as the

employees were scheduled at different times each day and the number would change throughout

each day. Therefore, only information on the number of hosts each day remained in the study.

The number of diet office employees is always two, so this is a constant throughout the study.

These changes in data collection were made to make the study more concise and easier to

analyze.
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Data Analysis

After the data collection period was over, the data was analyzed to determine the cause of

late tray delivery and ways to decrease the number of overall late trays. In order to accomplish

this, the mean late tray delivery time was calculated. This shows the average number of late trays

over the 21 day period, which will help when measuring improvement over the months.

The next piece of data analyzed were the times for each section of tray assembly and

delivery. For each late tray, the time the call was made was subtracted from the time the tray was

ready, the time the tray was ready was subtracted from the time the tray left the kitchen, and the

time the tray left the kitchen was subtracted from the tray delivery time. From these numbers, an

average time for each section of tray assembly and delivery was calculated. The average times

were used to determine which area of the tray process takes the longest and therefore needs

improvement.

Lastly, correlations between numbers of staff members were analyzed. For each day, the

numbers of hosts were compared to total late trays to see if the number of employees that

delivered the trays influenced tray delivery times. Additionally, the average late number of late

trays delivered was calculated for the days with three hosts and also the days with four hosts to

determine if more trays were delivered late with three or four hosts.

The averages calculated were included in the excel sheet in Appendix D; time tray

waiting indicates the time on which the tray was on the cart waiting to be delivered.
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Results

During the 21 day period, the lowest number of trays delivered late in one day was two

trays, and the largest number of trays delivered late in one was 100 trays. The calculated average

number of trays delivered late in the study period was about 36 trays. This number will serve as a

starting point for measuring improvement over the following months.

In order to determine which portion of tray assembly and delivery took the longest on

average, mean times were calculated. The mean time between the patients call to the diet office

and the finished tray assembly was calculated to be about 15 minutes. The mean time of the tray

being scanned as ready and actually leaving the kitchen was found to be around 25 minutes. The

mean time for tray delivery was calculated to be about 16 minutes. Therefore, the longest time of

the tray assembly and delivery process at St. Marys is in fact the time where the tray is

assembled and is on the cart ready to be delivered. Graph 1 below shows a visual representation

of the average times for each section of the tray assembly and delivery process.

Graph 1.

30

25

20

15

10
Average Time (minutes)
5

0
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As the delivery portion of the tray process did not take the longest, there is no correlation

found between the number of late tray deliveries and the floor each tray was delivered to.

When examining the correlation between the number of hosts and the number of trays

delivered late each day, the hypothesis was that fewer trays would be delivered late when there

were a larger number of hosts. The results from data collection showed the opposite to be true.

There were nine total days with three hosts and 12 days with four hosts during the study period.

Graph 2 below shows a visual representation of the number of late trays delivered compared to

the number of hosts for each day. The average number of trays delivered late when there were

four hosts delivering trays was found to be approximately 38 trays. When there were three hosts

working, the average number of trays delivered late was around 33 trays.

Graph 2.

120

100

80

60
Total Number of Late Trays Delivered Three Hosts
Four Hosts
40

20

0
1 2 3 4 5 6 7 8 9

Day of the Month


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Discussion and Recommendations

The original hypothesis was that the longest time during the tray assembly and delivery

process would be the tray delivery time. This was proven untrue; the results analyzed from the

study showed that the longest section of the tray process is when the tray is placed on the cart

and is waiting to be delivered. Therefore, this is the main area for improvement on decreasing

late tray deliveries at St. Marys Hospital.

Interestingly, the number of hosts delivering trays and the number of late trays did not

correlate, which disproved the hypothesis as well. Likely this is due to the fact that more hosts

work when there is a higher patient census, meaning there are more trays to be delivered during

the day. In order to study this thoroughly, the patient census for each day should be compared to

the number of hosts and the number of late trays delivered.

In order to fully see if decreased late tray deliveries with the new process influences

patient satisfaction, especially as it pertains to the temperatures of food, patient satisfaction

surveys should be conducted to determine if there was an improvement. However, the study

period occurred during a transition time from Aramark to Sodexo, and therefore patient

satisfaction surveys were not conducted as no new policy on this had been implemented yet.

After analyzing the results of the study, it is clear that the improvements on the tray

assembly and delivery process are necessary after tray assembly and before tray delivery. The

current process is not effective on days where patient census is high, even if there are more hosts

delivering the trays.

One way to improve this process would be to hire a new host and increase the number of

hosts each day. Meaning, there would be four hosts for each day when patient census is low and

five hosts on days when patient census is high. The current process would not change, yet there
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would be more employees available to deliver trays and help with the assembly process as

needed. With the addition of a new host, there would need to be an addition of a new cart. There

are three carts with assigned floors for the current process. The fourth cart could be considered a

floating cart. When there are a small amount of trays on each cart for differing floors and the ten

minute timer goes off, the trays could be moved to the floater cart and delivered together by the

additional host. An additional employee would help lessen the workload on the other hosts and

the additional cart would help make more deliveries in a smaller amount of time.

Another strategy to decrease the amount of late trays delivered would be to assign one

host as a runner. The runner would be in charge of watching the timers to ensure that trays are

not sitting too long on the carts. The other hosts would function as they normally do. When there

are many trays for one floor, but only one or two trays for different floors, the runner would take

the trays that needed to be delivered to the floor with the least amount of trays. Essentially, the

runner would deliver smaller number of trays at a time to the floors with smaller amounts of

meals ordered. This would allow the other hosts to focus on delivering larger amounts of trays to

the same floors, instead of visiting a floor out of their way for one tray. This would also decrease

the time a tray waits on a cart, because the runner would watch the timers and run the trays when

needed. Appendix E contains a revised flow chart with the runner position included.

Late tray delivery is a problem that many hospitals face every day. Not only is ensuring

correct tray delivery times important for meeting hospital standards, it is also important for

controlling food temperatures and increasing patient satisfaction. Therefore, it is essential that

these institutions, including St. Marys Hospital, continue to improve on their processes to ensure

their patients are receiving the highest quality of care. From the results concluded by this study, it

is clear that the tray assembly and delivery process can be improved at St. Marys, especially
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when it pertains to the time when a tray is waiting to be delivered to a patients room. More

research should be conducted on the food temperatures and patient satisfaction when decreasing

the amount of late trays delivered in order to determine if the new processes implemented

improve these. However, this study can serve as a starting point for St. Marys food and nutrition

services department to improve their current tray assembly and delivery process and continue to

provide high quality nutritious food to patients.


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References

Abdelhafez, A. M., Qurashi, L. A., Ziyadi, R. A., Kuwair, A., Shobki, M., & Mograbi, H.

(2012). Analysis of Factors Affecting the Satisfaction Levels of Patients Toward Food

Services at General Hospitals in Makkah, Saudi Arabia. American Journal of Medicine

and Medical Sciences, 2(6), 123-130. doi:10.5923/j.ajmms.20120206.03

Daniels, N. A., Mackinnon, L., Rowe, S. M., Bean, N. H., Griffin, P. M., & Mead, P. S. (2002).

Foodborne disease outbreaks in United States schools. The Pediatric Infectious Disease

Journal, 21(7), 623-628. doi:10.1097/00006454-200207000-00004

Kim, K., Kim, M., & Lee, K. (2010). Assessment of foodservice quality and identification of

improvement strategies using hospital foodservice quality model. Nutrition Research and

Practice, 4(2), 163-172. doi:10.4162/nrp.2010.4.2.163

Mclymont, V., Cox, S., & Stell, F. (2003). Improving Patient Meal Satisfaction with Room

Service Meal Delivery. Journal of Nursing Care Quality, 18(1), 27-37.

doi:10.1097/00001786-200301000-00005

Troutner, M., Gregoire, M., Lafferty, L., & Stone, M. (2012). Analysis of Temperature of Patient

Meals. Journal of Foodservice Management & Education, 6(2), 1-5.

Wright, O., Capra, S., & Aliakbari, J. (2003). A comparison of two measures of hospital

foodservice satisfaction. Australian Health Review, 26(1), 70-75. doi:10.1071/ah030070


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Appendix A. Current Process Flow Chart

Patient
calls diet
office to
order meal

Diet clerk inputs


order into
computer system

Order sent
to tray line

Cold items,
drinks, and
condiments
plated

Hot items
cooked and
plated

Tray checked Hosts take


for accuracy, Tray
cart to floors
placed on cart delivered to
patient room
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Appendix B. Fish Bone Diagram

Diet Office Tray Line Transportation

Order received Trays placed on


Patient calls diet office from diet office cart

Patient understands diet Items plated quickly


Delivered to floor
and orders correctly and correctly
patient where is
Trays assessed located
Order inputted for accuracy
Patient
tray
Efficiency with plating delivery
Patient ordering
Efficiency with delivery
Cooking and plating
Following food safety rules

Delivery Number of diet clerks, hosts, tray


line employees

Time Employees
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Appendix C. Written Data Collection Tool

Data Collection Tool


Day:____________________________________________
Number of diet office clerks: ________________________
Number of tray line employees: ______________________
Number of hosts: _________________________________
Total number of late trays:__________________

Tray 1:
Diet type:______________________
Time call was made:__________________
Time tray assembly started:______________
Time cold food plated:____________________
Time hot food plated:_____________________
Time tray placed on cart:___________________
Time tray left kitchen:_____________________
Time tray arrived at patient room:___________
Total time for tray 1 delivery:_______________

Tray 2:
Diet type:___________________________
Time call was made:_____________________
Time tray assembly started:_______________
Time cold food plated:____________________
Time hot food plated:____________________
Time tray placed on cart:__________________
Time tray left kitchen:____________________
Time tray arrived at patient room:___________
Total time for tray 2 delivery:______________

Tray 3:
Diet type:____________________
Time call was made:____________________
Time tray assembly started:_______________
Time cold food plated:____________________
Time hot food plated:_____________________
Time tray placed on cart:__________________
Time tray left kitchen:____________________
Time tray arrived at patient room:__________
Total time for tray 3 delivery:______________
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Appendix D. Compiled Data in Excel Sheet

Day (in Total Trays Number of


March) Delivered Late Hosts
1 83 3
2 100 4
3 63 4
6 74 4
7 43 4
8 34 3
9 29 4
10 45 3
13 12 4
14 39 4
15 11 4
16 60 4
17 2 4
20 18 3
21 8 4
22 11 3
23 16 4
24 26 3
27 28 3
28 17 3
29 36 3

Tray 1 Tray 1 Call Time for tray Tray 1 Tray Time tray Tray 1 Left Time
Floor time assembly ready waiting kitchen d
9 7:11 18 minutes 7:29 28 minutes 7:57 16
11 9:28 31 minutes 9:59 11 minutes 10:10 13
12 6:15 42 minutes 6:57 5 minutes 7:02 4
9 6:40 18 minutes 6:58 21 minutes 7:19 22
10 7:30 18 minutes 7:48 32 minutes 8:20 17
8 7:00 19 minutes 7:19 18 minutes 7:37 16
3 8:00 10 minutes 8:10 29 minutes 8:39 19
8 7:15 14 minutes 7:29 14 minutes 7:43 23
7 8:12 10 minutes 8:22 20 minutes 8:42 24
3 6:49 8 minutes 6:57 29 minutes 7:26 19
6 12:27 19 minutes 12:46 24 minutes 1:10 16
7 7:26 8 minutes 7:34 26 minutes 8:00 18
10 3:45 26 minutes 4:11 18 minutes 4:29 16
11 9:21 27 minutes 9:48 23 minutes 10:11 8
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9 9:40 13 minutes 9:53 27 minutes 10:20 7


10 8:54 12 minutes 9:06 19 minutes 9:25 18
3 9:49 24 minutes 10:13 38 minutes 10:51 2
9 7:00 10 minutes 7:10 10 minutes 7:20 57
11 8:55 17 minutes 9:12 21 minutes 9:33 12
8 12:58 19 minutes 1:17 11 minutes 1:28 29
9 7:52 21 minutes 8:13 27 minutes 8:40 16
Tray 2 Tray 2 Call Time for tray Tray 2 Tray Time tray Tray Left Tim
Floor time assembly ready waiting kitchen d
3 8:45 13 minutes 8:58 28 minutes 9:26 1
12 11:15 12 minutes 11:27 28 minutes 11:55 8
9 7:20 35 minutes 7:55 12 minutes 8:07 1
3 8:10 9 minutes 8:19 41 minutes 9:00 1
10 1:09 9 minutes 1:18 27 minutes 1:45 1
10 7:56 30 minutes 8:26 14 minutes 8:40 7
3 8:04 11 minutes 8:15 24 minutes 8:39 1
3 8:36 11 minutes 8:47 29 minutes 9:16 1
11 12:13 12 minutes 12:25 25 minutes 12:50 1
11 7:25 11 minutes 7:36 20 minutes 7:56 2
10 1:53 18 minutes 2:11 28 minutes 2:39 2
6 9:43 8 minutes 9:51 48 minutes 10:39 7
10 4:00 18 minutes 4:18 11 minutes 4:29 1
6 9:36 13 minutes 9:49 29 minutes 10:18 1
3 2:38 3 minutes 2:41 35 minutes 3:16 2
12 12:03 12 minutes 12:15 26 minutes 12:41 1
7 11:15 19 minutes 11:34 32 minutes 12:06 1
11 9:26 24 minutes 9:50 35 minutes 10:25 6
8 12:24 8 minutes 12:32 30 minutes 1:02 1
3 1:19 6 minutes 1:25 41 minutes 2:06 7
8 11:55 10 minutes 12:05 25 minutes 12:30 1

Tray 3 Tray 3 Time for tray Tray 3 Tray Time tray Tray 3 Left Tim
Floor Call time assembly ready waiting Kitchen
11 11:45 28 minutes 12:13 21 minutes 12:34 1
9 12:29 13 minutes 12:42 30 minutes 1:12 2
3 12:17 23 minutes 12:40 14 minutes 12:54 1
6 1:54 11 minutes 2:05 26 minutes 2:31 2
6 1:13 8 minutes 1:21 24 minutes 1:45 2
7 12:18 16 minutes 12:34 21 minutes 12:55 1
3 1:05 6 minutes 1:11 42 minutes 1:53
7 12:13 18 minutes 12:31 30 minutes 1:01 1
8 12:30 8 minutes 12:38 29 minutes 1:07 2
Running head: CQI PROJECT 20

7 1:02 4 minutes 1:06 27 minutes 1:33 2


11 1:56 7 minutes 2:03 35 minutes 2:38 1
8 12:23 9 minutes 12:32 44 minutes 1:16
N/A N/A N/A N/A N/A N/A
3 3:25 17 minutes 3:42 40 minutes 4:22
10 4:50 13 minutes 5:03 14 minutes 5:17 2
8 5:05 10 minutes 5:15 32 minutes 5:47 1
9 11:15 22 minutes 11:37 29 minutes 12:06 1
10 4:30 10 minutes 4:40 23 minutes 5:03 2
10 5:41 15 minutes 5:56 20 minutes 6:16 1
9 4:55 12 minutes 5:07 13 minutes 5:20 2
7 5:26 16 minutes 5:42 24 minutes 6:06 2
Mean number of trays delivered late (total late
trays/21): 35.952 trays

Mean time for tray assembly (total minutes/62):


15.194 minutes

Mean time for tray waiting (total minutes/62):


25.436 minutes

Mean time for tray delivery (total minutes/62):


16.177 minutes

Average number of trays delivered late with 3 hosts


(total trays/9): 33.111 trays

Average number of trays delivered late with 4 hosts


(total trays/12): 38.083 trays
Running head: CQI PROJECT 25

Appendix E. Revised Flow Chart

Patient
calls diet
office to
order meal

Diet clerk inputs


order into
computer system

Order sent
to tray line

Cold items,
drinks, and
condiments
plated

Runner takes
single trays
Hot items
cooked and
plated
Tray
No
delivered
patient room

Tray checked After 10


for accuracy, minutes is
placed on cart
the cart
full? Host takes
Yes
cart

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