Hospital Nutrition and Dietetics Service Management Manual, Third Edition

Front Cover

Title Page

HOSPITAL NUTRITION AND DIETETICS SERVICE MANAGEMENT MANUAL

Copyright 2019 by the Department of Health. All rights reserved. Subject to the acknowledgement of the Health Facility Development Bureau (HFDB), Department of Health, the Manual may be freely abstracted, reproduced or translated in part or in whole for non-commercial purposes only. If the entire Manual or substantial portions will be translated or reproduced, permission should be requested from the HFDB. Printed in the Republic of the Philippines.

National Library Cataloging-in-Publication Data

ISBN

Published by

Department of Health San Lazaro Compound Rizal Avenue, Sta. Cruz, Manila 1003 PHILIPPINES

PRODUCTION CREDITS Project Leader:
Josephine L. Guiao, RND, DCN, MSc Copy Editor:
Glenn A. Cruz Technical Editors: Adela Jamorabo-Ruiz, RND, MSN, DPA, PhD Celeste C. Tanchoco, RND, MPH, DrPH

Cover Design: Ar. Jean Paolo L. Policarpio

Development of this Manual was initiated, completed and subsequently published through the HFDB. For inquiries, contact the Bureau: Phone: +63 2 8651 7800 locals 1401, 1403, 1408 Email Address: doh.hfdb.od@doh.gov.ph

Republic of the Philippines Department of Health OFFICE OF THE SECRETARY

MESSAGE

The Department of Health (DOH) steers the health sector towards developing a Productive, Resilient, Equitable, People-Centered health sector to realize its vision of making Filipinos among Southeast Asia’s healthiest people in 2022. This is outlined in the strategy map of the DOH’s FOURmula One Plus (F1 Plus) for Health.

The Universal Health Care Act aims for better health outcomes, more responsive health systems, and more equitable health care financing. Hence, DOH is working to ensure high quality and affordable health services for every Filipino, including nutrition care of patients in hospitals. This manual endeavors to provide evidence-based nutrition-care standards for patients admitted in hospitals and health facilities. It is a call for action towards an interdisciplinary and coordinated delivery of high quality and affordable nutrition care for all.

I commend the Health Facility Development Bureau (HFDB) for their initiative and commitment in harmonizing and streamlining the standards and processes in health facility operations through updating the Manual of Standards for Hospital Nutrition and Dietetics Service Management. The Nutrition and Dietetics Service is a fundamental facet of hospital operations, with the Nutritionist-Dietitians as its agents and ambassadors.

We are confident that this manual shall be instrumental in fulfilling the DOH’s aspiration of genuine Universal Health Care that is focused on people’s needs and well-being, while recognizing the Filipino people’s varying cultures, beliefs, and values.

Republic of the Philippines Department of Health OFFICE OF THE SECRETARY

MESSAGE

With the implementation of the Universal Health Care (UHC) Law, the whole health sector shall endeavor to ensure that all Filipinos have better access to appropriate health care services without experiencing financial hardship and a more responsive health system that makes them feel respected, valued, and empowered.

This entails improving the quality of services in health facilities, since this is where patients experience health care and treatment first hand. Health facilities must then be venues of clinical quality, operational efficiency and people-centered processes.

The updated Hospital Nutrition and Dietetics Service Management Manual aims to better respond to patient needs by reflecting the latest developments in evidence-based nutrition care and food service administrative management. It accounts for the necessary care across health care settings, while keeping true to the fundamental principle of efficient and effective delivery across the continuum. It includes comprehensive updates on the organization and management standards of the Nutrition and Dietetics Service, as well as detailed discussions on clinical nutrition therapy, as guided by DOH Administrative Order No. 2019-0033, “Guidelines for the Implementation of Nutrition Care Process in Hospitals”. This Manual also encourages the strengthening of the nutrition and dietetics profession through conduct of research, learning and development, and other specialized programs in the facilities.

We enjoin every stakeholder to promote health through continuous learning, peer support, and mentorship, and to implement the standards in this Manual as most appropriate in their respective settings.

Thank you very much and best wishes to all!

Republic of the Philippines Department of Health OFFICE OF THE SECRETARY

FOREWORD

The Health Facility Development Bureau (HFDB) of the Department of Health is charged with leading in the continuous development of quality health facilities that are efficient and responsive to the needs of the Filipinos. Towards this end, the Bureau is entrusted to develop policies, programs and standards, as well as provide technical assistance and advisory services in the development, planning, operations and maintenance of health facilities.

For the DOH's flagship program to boost Universal Health Care, FOURmula One Plus for Health, the HFDB is committed to the development of the Philippine Health Facility Development Plan, policies and recognition mechanisms on People-Centered Health Care Services, Patient Safety and Infection Prevention and Control, and manuals on health facility operations for quality services and integration. All these strategic functions serve to implement the DOH's mandates under Republic Act No. 11223, or the Universal Health Care Act.

The target health facility manuals include this updated edition of the Hospital Nutrition and Dietetics Service Management Manual. The HFDB is extremely grateful for the generosity of the Technical Working Group members, the invited resource persons, and other stakeholders, who dedicated their time, expertise and effort to ensure that this latest edition of the manual shall be of sufficient content and convenient form to address the hospitals' needs for continuous quality improvement especially among the Nutritionist-Dietitians and foodservice staff.

The health facility is the people's primary interface with the health system. It is at this juncture, where Filipinos' expectations and the genuine changes brought by Universal Health Care intersect. The Bureau hopes that this and our other initiatives, as well as your sustained enthusiastic cooperation will strengthen the DOH's goals of financial risk protection, a more responsive health service delivery, and better health outcomes for all.

PREFACE

Republic Act (R.A.) No. 10862, the “Nutrition and Dietetics Law of 2016’’ recognizes the important role of Registered Nutritionist-Dietitians (RNDs) in nation-building and human development through adequate nutrition. The law updated and upgraded the practice of Nutrition and Dietetics in the Philippines.

The country then received its biggest boost for universal health care when R.A. No. 11223, or the ‘’Universal Health Care Act’’ was enacted in 2019. The law ensures universal coverage in terms of financing, reach and access to health care services – that every Filipino shall gain automatic membership to the National Health Insurance Program, access to a continuum of health care in the life-span, and guaranteed zero co-payments for basic ward admissions in the government hospitals. Particular to nutrition, the law provides for the strengthening of national health promotion efforts, including the ‘’effective promotion of healthy lifestyle, physical activity, proper nutrition…’’ as well as the use of administrative and research data for evidence-informed sector policy and planning for universal health care.

The Hospital Nutrition and Dietetics Service Management Manual is in consonance with the provisions of R.A. Nos. 10862 and 11223, and this manual is one of the targeted milestones of the Health Facility Development Bureau of the Department of Health. The manual intends to serve as a tool to guide nutritionist-dietitians, physicians, nurses, pharmacists, and other health care professionals in addressing nutrition and dietetics concerns in public and private hospitals, as well as other health care facilities.

This third edition of the manual contains eight chapters. Each chapter offers comprehensive, updated, expanded content pertinent to the operationalization of standards in human resources, facilities, total quality management, and policies in the nutrition aspects of patient care.

It is hoped that this Manual will be most appropriate and indispensable as a provider of hospital nutrition and dietetics guidance, sufficient to meet the professional needs of RNDs all over the Philippines.

        JOSEPHINE L. GUIAO, RND, DCN, MSc

Development Management Officer IV (Dietary Adviser) Health Facility Development Bureau

ACKNOWLEDGEMENTS

The Third Edition of the Hospital Nutrition and Dietetics Service Management Manual was made possible by exemplary commitment and dedication of Dr. Adela Jamorabo-Ruiz, former Director of Quality Assurance Center of the Polytechnic University of the Philippines, and Dr. Celeste Tanchoco, Country Director of the International Life Sciences Institute.

Our profound gratitude to the following Technical Working Group and Resource Persons for their contribution and unselfish cooperation on the development of this manual:

Technical Working Group

Ms. Milagrina Jacinto

Quirino Memorial Medical Center Ms. Guillerma Apigo

Southern Philippines Medical Center Ms. Editha Callao

Zamboanga City Medical Center Ms. Noemi Clement

Western Visayas Medical Center Ms. Nydia Bandaeril

Jose Reyes Memorial Medical Center Ms. Socorro Balderamos

National Kidney and Transplant Institute Mr. Daniel Tagulao

San Lazaro Hospital Ms. Vilma Amil

Philippine Heart Center

Resource Persons

Dr. Adela Jamorabo-Ruiz

Polytechnic University of the Philippines Dr. Celeste Tanchoco

International Life Sciences Institute Dr. Divina Cristy Redondo

Philippine Women’s University Dr. Imelda Agdeppa

Food and Nutrition Research Institute Dr. Jesus Fernando Inciong

St. Luke’s Medical Center Dr. Jose Rodolfo Dimaano Jr

Abbott Nutrition International Hon. Virgith Buena

Professional Regulation Commission Ms. Eloisa Villaraza

Our Lady of Lourdes Hospital Ms. Esther Feliciano

Manila Tytana College Ms. Josephine Jamon

Veterans Memorial Medical Center Ms. Juvy Martillos-Sy

Asian Hospital and Medical Center Ms. Nieves Serra

NDAP Foundation Inc. Ms. Perla Esguerra

Philippine Heart Center Ms. Zenaida Velasco

Nutritionist-Dietitians’ Assoc. of the Philippines Ms. Luz Tagunicar

Disease Prevention & Control Bureau-DOH Ms. Rosemarie Holandes

Disease Prevention & Control Bureau-DOH Ms. Florinda Panlilio

Health Emergency Management Bureau-DOH Prof. Luz Felicidad Callanta

University of the Philippines-Diliman

We are grateful for the support and encouragement from Dr. Ma. Theresa G. Vera, Director IV of the Health Facility Development Bureau (HFDB), Ms. Madeliene Gabrielle Doromal, Division Chief of the Policy, Planning and Program Development Division – HFDB and Dr. Criselda G. Abesamis former Director IV of HFDB in the completion of the manual.

We extend our sincere gratitude to all the Chiefs of Hospitals and Medical Centers and Bureau Directors, who generously allowed the following Nutritionist-Dietitians to participate in the consultative meetings and workshops:

Mr. Francis Cyril de Guzman

Philippine Heart Center Mr. Aldie Fajardo

Philippine Children’s Medical Center Ms. Blandina Guilalas

Dr. Jose N. Rodriguez Memorial Hospital Ms. Catherine Bautista

San Lorenzo Ruiz Women’s Hospital Ms. Concepcion Valencia

East Avenue Medical Center Ms. Consuelo Sabio

San Lazaro Hospital Ms. Eva Valdez

Amang Rodriguez Memorial Medical Center Ms. Felina Tolentino

Philippine Orthopedic Center Ms. Jocelyn Parungao

Rizal Medical Center Ms. Katherine Ortega

Philippine Heart Center Ms. Ma. Aurora dela Cruz

National Center for Mental Health Ms. Ma. Lourdes Abellera

East Avenue Medical Center Ms. Macaria Aseoche

National Kidney and Transplant Institute Ms. Minviluz Crispina Vera Cruz

Bicutan Treatment and Rehabilitation Center Ms. Myra Ibong

Rizal Medical Center Ms. Pacita Estrella

Tondo Medical Center Ms. Ramonida del Rosario

Las Piñas General Hospital and STC Ms. Sheryl Ann Mabolo

Lung Center of the Philippines Ms. Susan Hernandez

Valenzuela Medical Center Ms. Susana Sagad

National Children’s Hospital Ms. Betty Grospe

Dr. Jose Fabella Memorial Hospital Ms. Agnes Sabana

Region I Medical Center Ms. Alicia Pazziuagan

Cagayan Valley Medical Center Ms. Angelita Pascual

Jose B. Lingad Memorial Regional Hospital Ms. Imelda Lotivio

Bicol Regional Training & Teaching Hospital Ms. Juliet Calpatura

Baguio General Hospital Ms. Julieta Valenzuela

Dr. Paulino J. Garcia Memorial Research and

Medical Center Ms. Ma. Christine Dumlao

Mariano Marcos Memorial Hospital and

Medical Center Ms. Melanie Gacott

Ospital ng Palawan Ms. Norma Geonzon

Vicente Sotto Memorial Medical Center Ms. Bai Nish Candao

Cotabato Sanitarium Ms. Darlene Joy Caligdog

Davao Regional Medical Center Ms. Florence Galamgam

Cotabato Regional and Medical Center

Ms. Grace Javier

Mayor Hilarion A. Ramiro Sr. Medical Center Ms. Marilyn Peralta

Northern Mindanao Medical Center Ms. Percybell Rosales

Margosatubig Regional Hospital

We appreciate the involvement of the following health facilities, agencies and institutions that participated in the stakeholders’ conferences concerning the manual:

Hospitals and Medical Centers

Adela Serra Ty Memorial Hospital Amai Pakpak Medical Center Amang Rodriguez Memorial Medical Center Asian Hospital and Medical Center Baguio General Hospital and Medical Center Basilan General Hospital Bataan General Hospital and Medical Center Batanes General Hospital Batangas Medical Center Bicol Medical Center Bicol Region General Hospital and Geriatric Medical Center Bicol Regional Training and Teaching Hospital Cagayan Valley Medical Center Caraga Regional Hospital Conner District Hospital Corazon Locsin Montelibano Memorial Regional Hospital Cotabato Regional and Medical Center Cotabato Sanitarium Culion Sanitarium and General Hospital Davao Regional Medical Center Don Emilio del Valle Memorial Hospital Don Jose Monfort Medical Center Extension Hospital Dr. Jose Fabella Memorial Hospital Dr. Jose N. Rodriguez Memorial Hospital and Sanitarium Dr. Jose Rizal Memorial Hospital Dr. Paulino J. Garcia Memorial Research and Medical Center East Avenue Medical Center Eastern Visayas Regional Medical Center Eversley Child’s Sanitarium and General Hospital Far North Luzon General Hospital and Training Center Gov. Celestino Gallares Memorial Hospital Ilocos Training and Regional Medical Center Jose B. Lingad Memorial Regional Hospital Labuan General Hospital Las Piñas Gen. Hospital and Satellite Trauma Center Luis Hora Memorial Regional Hospital Lung Center of the Philippines Margosatubig Regional Hospital Mariano Marcos Memorial Hospital and Medical Center Mariveles Mental Wellness and General Hospital Mayor Hilarion A. Ramiro Sr. Medical Center Mindanao Central Sanitarium National Center for Mental Health National Children’s Hospital Northern Mindanao Medical Center Ospital ng Palawan Our Lady of Lourdes Hospital Philippine Children’s Medical Center Philippine Orthopedic Center Quirino Memorial Medical Center Region I Medical Center Region II Trauma Medical Center

Research Institute for Tropical Medicine Rizal Medical Center San Lorenzo Ruiz General Hospital Schistosomiasis Control and Research Hospital Southern Isabela Medical Center Southern Philippines Medical Center St. Anthony Mother and Child Hospital St. Luke’s Medical Center Sulu Sanitarium Talavera General Hospital Talisay District Hospital Tondo Medical Center Valenzuela Medical Center Vicente Sotto Memorial Medical Center

Centers for Health Development BARMM Ministry of Health Cordillera CHD Ilocos CHD Cagayan Valley CHD Central Luzon CHD CaLaBaRZon CHD MIMAROPA CHD Bicol Region CHD Western Visayas CHD Central Visayas CHD Eastern Visayas CHD Zamboanga Peninsula CHD Northern Mindanao CHD Davao CHD SOCCSKSARGEN CHD Caraga CHD

Treatment and Rehabilitation Centers TRC Dagupan City TRC Bicutan TRC Bataan TRC Tagaytay City TRC San Fernando, Camarines Sur TRC Dulag, Leyte TRC Caraga

Other Agencies and Organizations Board of Nutrition and Dietetics, Professional Regulation Commission DOH League of Registered Nutritionist- Dietitians Inc. Food and Nutrition Research Institute Nutritionist-Dietitians’ Association of the Philippines Our profound thanks to the following Nutritionist-Dietitians who acted as support staff during the development of the manual:

Mr. Arvie Briones

Quirino Memorial Medical Center Ms. Catherine Adviento

DOH League of Registered
Nutritionist-Dietitians Inc. Ms. Cristina Riza Dayao

DOH League of Registered
Nutritionist-Dietitians Inc. Ms. Klarizza Marie Quiambao

Philippine Orthopedic Center Ms. Mary Leilani Mayola

National Kidney and Transplant Institute Ms. Renz Anneka Daquioag

East Avenue Medical Center

Likewise, we express our appreciation to Ms. Caitlyn Mae Tomas, Ms. Trisha May Sarabia, Ms. Sarah Sacdalan-Levy, Ms. Rhod-Ann A. Lebrino and Ms. Joan Guevarra, whose administrative and clerical work facilitated the manual development activities, and our special thanks to Mr. Glenn Cruz, Development Management Officer III, HFDB for editing and lay out, and Ms. Chrys Abigail Paita, Development Management Officer III, and Mr. James Bryan de Guzman, Development Management Officer IV, HFDB for providing additional materials and technical inputs.

Special acknowledgement too for the DOH League of Registered Nutritionist-Dietitians Incorporated for the additional technical and financial assistance they accorded to the development of the manual.

And lastly, we give thanks and praise to the Lord, our God, for giving us strength and wisdom to bring and engage the right persons and institutions, all of whom contributed significantly to the production of this new edition of the Hospital Nutrition and Dietetics Service Management Manual.

LIST OF ACRONYMS AND ABBREVIATIONS

AO Administrative Order APP Annual Procurement Plan BFAD Bureau of Food and Drugs BLHSD Bureau of Local Health Systems Development BSFP Blanket Supplementary Feeding Program CAM Complementary and Alternative Medicine CED Chronic Energy Deficiency CGS Child growth standards CPD Continuing Professional Development CQI Continuous Quality Improvement DA Department of Agriculture DOH Department of Health DOLE Department of Labor and Employment DOST Department of Science and Technology DPCB Disease Prevention and Control Bureau DSWD Department of Social Welfare and Development EN Enteral Nutrition ENNS Expanded National Nutrition Survey EO Executive Order EPI Expanded Program of Immunization F1 Plus Fourmula One Plus for Health FBF Fortified blended food FDA Food and Drug Administration FEFO First expiry, first out FFQ Food frequency questionnaire FIFO First in, first out FNRI Food and Nutrition Research Institute GIDA Geographically isolated and disadvantaged area HACCP Hazard Analysis Critical Control Point HACT HIV and AIDS Core Team HEMB Health Emergency Management Bureau HFDB Health Facility Development Bureau HFSRB

Health Facilities and Services Regulatory Bureau

HHRDB Health Human Resource Development Bureau HPCS Health Promotion and Communication Service IAR Inspection Acknowledgement Report IDD Iodine deficiency disorders IHOMIS Integrated Hospital Operation and Management Information System IMAM Integrated Management of Acute Malnutrition IMCI Integrated Management of Childhood Illnesses
IPCR Individual Performance Commitment and Review ISO International Organization for Standardization ITC In-Patient Therapeutic Care IYCF LDI Infant and young child feeding Learning and Development Intervention LGU Local government unit MAM Moderate acute malnutrition MNP Micro-nutrient powder MSP Micronutrient Supplementation Program MUAC Mid-upper arm circumference NCD Non-communicable disease NCP NcP Nutrition Care Process Nutrition Care Plan NDS Nutrition and Dietetics Service NDSA Nutrition and Dietetics Service Administration NEDA National Economic and Development Authority NFAC National Food and Agriculture Council NNC National Nutrition Council OEL Occupational exposure limit ONS Oral nutrition supplements OPCR Office Performance Commitment and Review OSHS Occupational Safety and Health Standards OTC Out-Patient Therapeutic Care PBB Performance-based Bonus PBIS Performance-based Incentive System PD Presidential Decree PDCA Plan-Do-Check-Act

PDRI

PEI Philippine Dietary Reference Intakes
Productivity Enhancement Incentive PGS Performance Governance System PN Parenteral Nutrition PPMP Project Procurement Management Plan PRC Professional Regulation Commission PWUD Persons who use drugs QMS Quality Management System RA Republic Act RER Reimbursement Expense Receipt RIS Requisition Issuance Slip RND Registered Nutritionist-Dietitian RUSF Ready-to-use supplementary food RUTF Ready-to-use therapeutic food SAM Severe acute malnutrition SFC Supplementary Feeding Center SFP Supplementary Feeding Program SPMS Strategic Performance Management System

SPS Stock Position Sheet SPSP Sangkap Pinoy Seal Program SWOT Strengths-Weaknesses- Opportunities-Threats TCS Temperature Control Safety TDZ Temperature danger zone TQM Total Quality Management TSFP Targeted Supplementary Feeding Program UHC Universal Health Care UIE UNICEF Urinary iodine excretion United Nations International Children’s Fund VADAG Vitamin A deficiency, anemia and goiter WASH Water, sanitation and hygiene WC Waist circumference WFH Weight for height WFL Weight for length WHO World Health Organization WHR Waist-to-hip ratio YFAS Yale Food Addiction Scale

TABLE OF CONTENTS

Page No. Chapter 1 Nutrition and Dietetics in the Philippines 1

I. Situation of Nutrition in the Philippines II. The Nutrition and Dietetics Profession III. Nutrition and Dietetics in Health Care Delivery

Chapter 2 The Hospital Nutrition and Dietetics Service
39

I. Philosophy II. Vision III. Mission IV. Core Values V. Objectives VI. Strategic Goals VII. Standards

Chapter 3 Human Resource Management
51

I. Personnel Administration II. Standard Staffing Patterns III. Job Titles and Descriptions IV. Management Skills of Nutritionist-Dietitians

Chapter 4 Foodservice Administration and Management 69

I. Functions of NDS Foodservice Systems II. Main Work Flow: Menu Planning to Food Service III. Sanitation, Safety and Maintenance IV. Budgeting and Cost Control V. Facilities and Equipment in the NDS

Chapter 5 Clinical Nutrition Therapy 121

I. Nutrition Care Process in Hospitalized Patients II. Nutrition Care Process in the Outpatient Department
III. Operating a Nutrition Clinic

Chapter 6 Research, Learning and Development
139

I. Nutrition and Dietetics Research II. Learning and Development III. Hospital Dietetics Practicum
IV. Strategic Planning of the NDS

Chapter 7 Other Specialized Programs
159

I. Medical Related Programs II. Public Health Related Programs III. Other Special Projects

Chapter 8 Continuous Quality Improvement
199

I. Total Quality Management II. Quality Management System III. Performance Management IV. Risk Management

APPENDICES

Set A Nutrition and Dietetics Service Administrative Forms 213 Set B Nutrition and Dietetics Service Clinical Forms 279 Set C Other Supplemental Content 293 Set D DOH Issuances 325

LIST OF TABLES

No. Title Page 1 List of government agencies, local non-government organizations and international organizations supporting nutrition and dietetics in the country 31 2 Clinical, administrative, and learning and development records maintained in the NDS 48 3 Administrative, clinical, research, learning and development monitoring and quality control mechanisms in the NDS 50 4 Nutrition and dietetics staffing pattern for 25- to 500-bed capacity hospitals per DBM-DOH Joint Circular No. 2013-01 52 5 Proposed nutrition and dietetics staffing pattern for 200- to 1,500-bed capacity hospitals 53 6 Desirable management skills of ND V, IV and III 66 7 Desirable management skills of ND II 67 8 Guidelines for storage of specific foods: recommended temperature and maximum period of storage 77 9 Minimum internal temperature chart 93 10 Factors to consider before planning hospital kitchens 113 11 Subsequent steps in the nutrition care algorithm 129 12 The parts of a research report and their contents 145 13 Examples of action researches 149 14 Competency and Training Needs of NDS Personnel 150 15 Subject matter relevant to the competency areas 150 16 Recommended Philippine Dietary Reference Intakes (PDRI) by age groups 163 17 Sample menu for various situations (Sample Survival Kit) 164 18 Foods to be stockpiled for an emergency feeding for a family with 6 members 165 19 Sample menu of stock foods for an emergency and disaster feeding 165 20 Identification of acute malnutrition in infants <6 months of age 171 21 Identification of acute malnutrition in children 6-59 months of age 171 22 Summary of suggested criteria for admission for SAM used in children five years or older, adolescents and adults 171 23 Flow of activities in in-patient therapeutic care 172 24 F100 formulations for infants <6 months per phase 177 25 The activities in out-patient therapeutic care (OTC) 179 26 MUAC Interpretation 180 27 Admission criteria for MAM cases 180 28 Sample timeline for routine health services for a year 186 29 Calendar of Health Events 192 30 Main clauses and requirements under ISO 9001:2015 203 31 SPMS five-point rating scale 206

LIST OF FIGURES

No. Title Page 1 Trends in the prevalence of malnutrition among Filipino children <2 years old 2 2 Prevalence of anemia among Filipino children <2 years old by age group

2 3 Exclusively breastfeeding among Filipino infants 0-5.9 months

2 4 Mean duration of breastfeeding among Filipino infants 0-23 mos.

3 5 Trends in the proportion of Filipino children 6-23 month meeting the Minimum Acceptable Diet 3 6 Trends in the prevalence of malnutrition among children, under-five years old (0-59 months): Philippines, 2003-2018 3 7 Trends in the prevalence of anemia among children 6 months to 5 years old: Philippines, 2003-2018 4 8 Trends in the prevalence of malnutrition among school children, (6 to 10 years old): Philippines, 2003-2018 4 9 Prevalence of anemia among school children, (6 to 10 years old): Philippines, 2003 vs 2018 5 10 Prevalence of IDD among school children(6 to 10 years old): by single age, Philippines, 2003 vs 2018 5 11 Trends in the prevalence of stunting and wasting among adolescents, >10- 19 years old: Philippines 2003-2018 6 12 Trends in the prevalence of overweight and obesity among adolescents,

10-19 years old: Philippines 2003-2018 6 13 Proportion of insufficiently physically active adolescents >10-17 years old by sex and age group: Philippines, 2018 6 14 Proportion of current smokers among adolescents >10-19 years old by age group: Philippines, 2015 and 2018 7 15 Prevalence of anemia among children, 13-19 years old by sex: Philippines, 2013 and 2018 7 16 Percent distribution of UIE levels among adolescents, >10-12 years old: Philippines 2018 7 17 Prevalence of chronic energy deficiency among non-pregnant/non-lactating women of reproductive age, 15-49 years old: Philippines, 2015 and 2018 8 18 Prevalence of overweight and obesity among non-pregnant/non-lactating women of reproductive age, 15-49 years old: Philippines, 2015 and 2018 8 19 Trends in the prevalence of nutritionally at-risk pregnant women: Philippines, 1998-2018 9 20 Trends in the prevalence of chronic energy deficient and overweight/obese among lactating mothers: Philippines, 2011 to 2018 9

No. Title Page 21 Trends in the prevalence of anemia among pregnant and lactating women: Philippines, 1993 to 2018 9 22 Prevalence of iodine deficiency disorder among women of reproductive age, 15-49 years old: Philippines, 2013 and 2018 10 23 Trends in the prevalence of chronic energy deficiency and overweight & obesity among adults 20 years old and above: Philippines, 1993 to 2018 10 24 Nutritional status of adults 20-59 years old: Philippines, 2018 11 25 Trends in the prevalence of high waist circumference (WC) among adults 20 years old and above: Philippines, 2003 to 2018 11 26 Trends in the prevalence of high waist-hip ratio (WHR) among adults 20 years old and above: Philippines, 2003 to 2018 11 27 Anemia among adults 20-59 years old by sex, place of residence and wealth quintile: Philippines, 2018 12 28 Trends in the prevalence of elevated blood pressure among adults 20 years old and above: Philippines, 1993 to 2018 12 29 Trends in the prevalence of fasting blood sugar among adults 20 years old and above: Philippines, 2003 to 2018 12 30 Current smoking among adults 20 years old and above: Philippines, 1998 to 2018 13 31 Binge drinking among currently drinking adults 20-59 years old, by age group and sex: Philippines, 2018 13 32 Physical inactivity among adults 20-59 years old, by age group, sex place of residence: Philippines, 2015 vs 2018 13 33 Nutritional status of the elderly 60 years old and above: Philippines, 2018 14 34 High waist circumference among elderly males 60 years old and above, by age group and place of residence: Philippines, 2015 vs 2018 14 35 High waist circumference among elderly females 60 years old and above, by age group and place of residence: Philippines, 2015 vs 2018 15 36 High waist-hip ratio among elderly males 60 years old and above, by age group and place of residence: Philippines, 2015 vs 2018 15 37 High waist-hip ratio among elderly females 60 years old and above, by age group and place of residence: Philippines, 2015 vs 2018 15 38 Anemia among the elderly, 60 years old and above, by sex, place of residence and wealth quintile: Philippines, 2013 vs 2018 16 39 Iodine deficiency disorder among the elderly, 60 years old and above, by sex, place of residence and wealth quintile: Philippines, 2013 vs 2018 16 40 Elevated blood pressure among the elderly, 60 years old and above, by age group and sex: Philippines, 2015 vs 2018 17 41 High fasting blood sugar among the elderly, 60 years old and above, by age group and sex: Philippines, 2013 vs 2018 17 42 Current smoking among the elderly, 60 years old and above, by age group and sex: Philippines, 2015 vs 2018 18 43 Binge drinking among currently drinking elderly, 60 years old and above, by age group and sex: Philippines, 2018 18

No. Title Page 44 Physical inactivity among the elderly, 60 years old and above, by age group and sex: Philippines, 2015 vs 2018 18 45 Nutrition Interventions Framework adopted from the Lancet Maternal and Child Nutrition Series, “Framework for actions to achieve optimum fetal and child nutrition development,” 2013 34 46 Nutrition interventions for mothers and children across the lifecycle, adopted from the Lancet Maternal and Child Nutrition Series, “Conceptual framework,” 2013 35 47 DOH Nutrition 2014-2024 Framework 36 48 Organogram of the hospital including the Nutrition and Dietetics Service under the Allied Health Professional Service 43 49 Organizational chart of the Hospital Nutrition and Dietetics Service 44 50 Recruitment or hiring process for the NDS personnel 51 51 Work flow of administrative functions of the foodservice system of the NDS 70 52 Temperature danger zone 76 53 Examples of color-coded tray cards or tags 89 54 Tray arrangements for breakfast, and for lunch or supper 90 55 Flow of food to illustrate food safety 91 56 Proper hand washing procedure 100 57 Three-compartment sink (gold standard) 115 58 Nutrition care algorithm (adapted) 128 59 Procedural flow in conducting ward rounds 132 60 Procedural guide for diet counseling (In-patient) 133 61 Procedural guide for diet counseling (Out-patient) 136 62 Action research cycle 148 63 Strategic planning framework 153 64 Strengths-Weaknesses-Opportunities-Threats, or SWOT Analysis tool 155 65 Sample results from SWOT analysis 156 66 Sample strategy formulation from TOWS 156 67 Procedures of admission to MAM program 181 68 Interventions for management of SAM 182 69 Procedures for monitoring and recording data for the management of MAM 186 70 Repetitive four-stage PDCA cycle model for continuous improvement 202 71 Relationships between the risk management principles, framework, and processes based on ISO 31000:2009 209

Hospital Nutrition and Dietetics Service Management Manual | 1

CHAPTER 1 NUTRITION AND DIETETICS IN THE PHILIPPINES

Factors providing the context for the Nutritionist-Dietitian’s commitment and leadership in the delivery of quality nutrition care include the nature and magnitude of nutrition problems in the country, the policy environment governing nutrition and the nutrition and dietetics profession, and the related national structures, programs and implementers.

I. Situation of Nutrition in the Philippines

A. Magnitude of Nutrition Problems in the Country

This report on the nutritional status of Filipinos is derived from the results of the 2018 Expanded National Nutrition Survey (ENNS), and organized across the human life span, i.e. infants and young children (zero to 23 months), pre-school children (two to five years old), school children (six to 10 years old), adolescents (above 10 to 19 years old), women of reproductive age (non-pregnant/non-lactating, pregnant and lactating women, 15 to 49 years old), adults (20 to 59 years old), and the elderly (60 years old and above).

Nutritional status of Filipino infants and young children (0 to 23 months)

Stunting prevalence remains high and doubles at one year of age, coinciding with the transition to complementary feeding period. Anemia prevalence is high, specifically among infants six to 11 months old. Exclusive breastfeeding among zero to five months old significantly improved in a span of seven years, but the rate of breastfeeding exclusively until 59 months’ duration remains low. Young children meeting the minimum acceptable diet is very low, particularly among infants six to 11 months, thus complementary feeding remains suboptimal. (See Figures 1 to 5.)

Nutritional status of Filipino pre-school children (2 to 5 years old)

Stunting remains to be of high magnitude among under-five children. Overweight is becoming a problem as the child grows older. A decreasing trend in anemia prevalence was observed with a slight increase from 2013 to 2018; anemia was considered a “mild” public health problem for this age group in 2018. (See Figures 6 to 7.)

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2 | Hospital Nutrition and Dietetics Service Management Manual

Figure 1.
Source: ENNS 2018, DOST-FNRI

Figure 2.

Source: ENNS 2018, DOST-FNRI

Figure 3.

Source: ENNS 2018, DOST-FNRI

Chapter 1 | Nutrition and Dietetics in the Philippines

Hospital Nutrition and Dietetics Service Management Manual | 3

Figure 4.

Source: ENNS 2018, DOST-FNRI

Figure 5.

Source: ENNS 2018, DOST-FNRI

Figure 6.

Source: ENNS 2018, DOST-FNRI

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4 | Hospital Nutrition and Dietetics Service Management Manual

Figure 7.

Source: ENNS 2018, DOST-FNRI

Nutritional status of Filipino school children (6 to 10 years old)

Stunting and underweight among school children is still a public health problem of high severity. Overweight is a growing problem for this age group. Anemia prevalence increased in 2018 for school children affecting most of the 6 years old with moderate severity. (See Figures 8 to 10.)

Figure 8.

Source: ENNS 2018, DOST-FNRI

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Hospital Nutrition and Dietetics Service Management Manual | 5

Figure 9.

Source: ENNS 2018, DOST-FNRI

Figure 10.

Source: ENNS 2018, DOST-FNRI

Nutritional status of Filipino adolescents (above 10 to 19 years old)

Among adolescents, stunting has decreased significantly from 31.9% to 26.3%. Wasting has decreased but not significant at 5% level. Overweight is a growing problem. Majority have insufficiently physical activity particularly among females, 10-17 years old. Current smokers decreased among all age groups but there were still smokers <18 years of age. Anemia remains a problem of mild public health significance especially among females, 13-19 years old. Pockets of Iodine Deficiency Disorder still exist among 10-12 years old. (See Figure Nos. 11 to 16.)

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6 | Hospital Nutrition and Dietetics Service Management Manual

Figure 11.

Source: ENNS 2018, DOST-FNRI

Figure 12.

Source: ENNS 2018, DOST-FNRI

Figure 13.

Source: ENNS 2018, DOST-FNRI

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Figure 14.

Source: ENNS 2018, DOST-FNRI

Figure 15.

Source: ENNS 2018, DOST-FNRI

Figure 16.

Source: ENNS 2018, DOST-FNRI

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Nutrition situation of women of reproductive age in the Philippines

Among non-pregnant and lactating women and lactating mothers of reproductive age, chronic energy deficient has decreased significantly. Overweight and obese is also growing problem. Anemia has decreased but remains a problem of mild public health significance. Iodine deficiency disorder has decreased significantly. Nutritionally-at-risk pregnant women have decreased, especially among adults but not significant at 5% level. Anemia remains a problem of moderate public health significance. (See Figures 17 to 22.)

Figure 17.

Source: ENNS 2018, DOST-FNRI

Figure 18.

Source: ENNS 2018, DOST-FNRI

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Figure 19.

Source: ENNS 2018, DOST-FNRI

Figure 20.

Source: ENNS 2018, DOST-FNRI

Figure 21.

Source: ENNS 2018, DOST-FNRI

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Figure 22.

Source: ENNS 2018, DOST-FNRI

Nutritional status of Filipino adults, 20 to 59 years old

Among adults, chronic energy deficiency significantly declined, while overweight and obesity are increasing. Android obesity (WC and WHR) also increased. Anemia is of “mild” public health significance. Elevated blood pressure significantly declined, while high fasting blood sugar increased. Smoking further declines, more than half of current drinkers are engaged in binge drinking while physical inactivity of adults did not change. (See Figures 23 to 32.)

Figure 23.

Source: ENNS 2018, DOST-FNRI

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Figure 24.

Source: ENNS 2018, DOST-FNRI

Figure 25.

Source: ENNS 2018, DOST-FNRI

Figure 26.

Source: ENNS 2018, DOST-FNRI

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Figure 27.

Source: ENNS 2018, DOST-FNRI

Figure 28.

Source: ENNS 2018, DOST-FNRI

Figure 29.

Source: ENNS 2018, DOST-FNRI

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Figure 30.

Source: ENNS 2018, DOST-FNRI

Figure 31.

Source: ENNS 2018, DOST-FNRI

Figure 32.

Source: ENNS 2018, DOST-FNRI

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Nutritional status of Filipino elderly, 60 years old and above

Nutritional status of the elderly - CED significantly declined but overweight and obesity is increasing, android obesity (WC and WHR) also increased. Anemia is of “moderate” public health significance. Iodine Deficiency Disorder (based on UIE) decreased, but excessive intake (300 mcg/dL or more) increased. Elevated blood pressure significantly declined but high fasting blood sugar increased. Smoking further declined, but 4 in every 10 (44.9%) elderly are engaged in binge drinking. About half (50.6%) are physically inactive. (See Figures 33 to 44.)

Figure 33.

Source: ENNS 2018, DOST-FNRI

Figure 34.

Source: ENNS 2018, DOST-FNRI

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Figure 35.

Source: ENNS 2018, DOST-FNRI

Figure 36.

Source: ENNS 2018, DOST-FNRI

Figure 37.

Source: ENNS 2018, DOST-FNRI

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Figure 38.

Source: ENNS 2018, DOST-FNRI

Figure 39.

Source: ENNS 2018, DOST-FNRI

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Figure 40.

Source: ENNS 2018, DOST-FNRI

Figure 41.

Source: ENNS 2018, DOST-FNRI

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Figure 42.

Source: ENNS 2018, DOST-FNRI

Figure 43.

Source: ENNS 2018, DOST-FNRI

Figure 44.

Source: ENNS 2018, DOST-FNRI

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B. The Policy Environment to Address Nutrition Problems

Republic Acts

Republic Act (R.A.) No. 11233, or “Universal Health Care Act,” dated February 19, 2019 provides for automatic enrolment of Filipino citizens to the National Health Insurance Program and expand PhilHealth coverage to include free medical consultations and laboratory tests.
R.A. No. 11148, or “Kalusugan at Nutrisyon ng Mag-Nanay Act,” dated November 29, 2018, provides for the scaling up of national and local health and nutrition programs through a strengthened integrated strategy for maternal, neonatal, child health and nutrition in the first 1,000 days of life.
R.A. No. 11037, or “Masustansyang Pagkain para sa Batang Pilipino Act,” dated June 20, 2018, provides for institutionalizing a national feeding program for undernourished children in public day care, kindergarten and elementary schools to combat hunger and under-nutrition among Filipino children. Components include supplemental feeding day-care children, school-based feeding, milk feeding program, micronutrient supplements, health examination, vaccination and deworming, Gulayan sa Paaralan, water, sanitation and hygiene (WASH), and integrated nutrition education, behavioral transformation and social mobilization.
R.A. No. 10862, or “Nutrition and Dietetics Law of 2016,” signed on May 25, 2016, provides for regulation on the practice of nutrition and dietetics in the Philippines, repealing for the purpose Presidential Decree (P.D.) No. 1286.
R.A. No. 10611, or “Food Safety Act of 2013,” signed on August 23, 2013, provides for the strengthening of the food safety regulatory system in order to protect the public from food- and water-borne illnesses, as well as unsanitary, unwholesome, misbranded or adulterated foods; enforces the P.D. No. 856, “Code on Sanitation of the Philippines.”
R.A. No. 10028, or “Expanded Breastfeeding Promotion Act of 2009,” which builds on R.A. No. 7600 (“Rooming-in and Breastfeeding Act of 1992”), mandates all health facilities and non-health facilities, establishments or institution to establish milk banks, lactation stations and grant lactation breaks in addition to the regular time-off for meals to breastfeed or express breast milk. The law orders the agencies concerned to integrate in relevant subjects in the elementary, high school and college levels especially in the medical and allied medical courses and in technical vocational education the importance, benefits, methods or techniques of breastfeeding and change of social attitudes towards breastfeeding. It also provides incentives to all government and private health institutions with rooming in and breastfeeding practices.
R.A. No. 9711, or “Food and Drugs Administration Act of 2009,” renamed the Bureau of Food and Drugs to Food and Drug Administration.

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R.A. No. 8976, or “Food Fortification Law of 2000,” addresses the micronutrient deficiency problem. The programs aim to increase the dietary intake of Vitamin A, iron, and iodine, equivalent to 50% of the Recommended Dietary Allowance (RDA) contributed by fortified foods.
R.A. No. 8423, or “Traditional and Alternative Medicine Act (TAMA),” created the Philippine Institute of Traditional and Alternative Health Care (PITAHC) to provide better health through the provision of safe, beneficial, and culturally-acceptable traditional and alternative health care products, services, and techniques.
R.A. No. 8191, or “National Diabetes Act,” created the National Commission on Diabetes Education, which is tasked to develop a national program for the primary prevention of diabetes. The Commission has drafted “The National Diabetes Prevention and Control Program, 1999-2010”, with the mission “to establish diabetes awareness, information, education, medical and allied services within the reach of every Filipino family.”
R.A. No. 8172, or “An Act on Salt Iodization Nationwide”, dated July 1995, popularly known as ASIN Law, is designed to prevent/control iodine deficiency disorders (IDD) through salt iodization.
R.A. No. 7600, or “Rooming-in and Breastfeeding Act of 1992,” dated February 5, 1992, is designed to promote breastfeeding by requiring hospitals to provide rooming-in facilities.
R.A. No. 2674, “Dietetic Law,” enacted in 1960 required the employment of dietitians in hospitals and regulated the practice of Dietetics in the Philippines. This law was superseded by PD 1286 “
R.A. No. 2067 (1958), “Science Act of the Philippines”, reorganizing the Philippine Institute of Nutrition into the Food and Nutrition Research Center (FNRC), renamed Food and Nutrition Research Institute (FNRI) under the National Science Development Board (NSDB) now Department of Science and Technology (DOST).
R.A. No. 832 (1947), Rice Enrichment Law provides that all milled rice must be enriched with Premix Rice. Although the law has never been repealed, it is no longer being enforced.

Presidential Decrees, Executive and Administrative Orders 16. Executive Orders (E.O.) No. 472 (2005) – DOH named as the chair of the NNC, with the DA and DILG as vice-chairs. In addition to its policy and coordinating functions, NNC was also tasked to focus on hunger-mitigation and authorized to generate and mobilize resources for nutrition and hunger- mitigation programs.

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E.O. No. 352 (1996), designating certain statistical activities that will generate data for decision-making and including the Food and Nutrition Research Institute (FNRI) national nutrition surveys and provincial updating of the nutritional status of Filipino children.
Administrative Order (A.O.) No. 88 (1988) transferring NNC from DSWD to DA.
E.O. No. 234 (1987), an Act reorganizing the National Nutrition Council (NNC), expanding membership of the NNC to include the Department of Labor and Employment (DOLE), Department of Trade and Industry (DTI), Department of Budget and Management (DBM) and the National Economic Development Authority (NEDA) and transferring NNC from the Department of Agriculture (DA) to the Department of Social Welfare and Development (DSWD)
E.O. No. 128 (1987), created the Department of Science and Technology (DOST) and mandating the Food and Nutrition Institute (FNRI) to define the nutritional status of the Filipino citizenry periodically.
E.O. No. 51 dated October 20, 1986 – “Philippine Code of Marketing of Breast Milk Substitutes”, otherwise known as “Milk Code of the Philippines”- protects and promotes breastfeeding by ensuring the proper use of breast milk substitutes and supplements when necessary and regulates the marketing of breastmilk substitutes.
Presidential Decree (P.D.) No. 1569, Barangay Nutrition Scholar Decree (1978), providing one scholar for every barangay who will be responsible for delivering nutrition services and related activities.
P.D. No. 1286, promulgated on January 20 1978, “Nutrition and Dietetics Decree of 1977” integrated Nutrition and Dietetics into one profession.
P.D. No. 1211 signed on October 12, 1977 regulates the Milling of Rice, consistent with the government’s nutrition programs, e.g. rice mill owners/operators must mill a minimum of 10% all the palay milled by them into brown rice (rice with only hull removed) and prohibits over milling of rice.
P.D. No. 491, dated June 1974 “Nutrition Act of the Philippines” – declared nutrition as a priority program of the government, created the National Nutrition Council as the highest policy-making and coordinating body of nutrition and designated July as Nutrition Month for the purpose of creating awareness on the importance of nutrition.
E.O. No. 285 (1971) promulgated the creation of the National Food & Agriculture Council (NFAC) to coordinate nutrition programs in addition to national food programs.

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E.O. No. 94 (1947) created the Institute of Nutrition as a first attempt to institutionalize a national nutrition program, with a mandate to be the clearing house of data and information concerning nutrition.

DOH Administrative Issuances 28. A.O. No. 2019-0033, “Guidelines for the Implementation of Nutrition Care Process in Hospitals,” provides the mandate and directs public and private hospitals to operationalize and institutionalize the nutrition care process in their respective facilities. 29. A.O. No. 2016-0020, Standardization of per capita budget per meal provision of patient, which is strictly 1800 kcal as prescribed by physicians for a normal and regular diet of an adult person using actual number of inpatients or an equivalent of at least 150 pesos’/ day meal allowance of inpatient. 30. A.O. No. 2015-0055, National Guidelines on the Management of Acute Malnutrition for Children under 5 years, thus to improve the survival of children under 5 years by ensuring access to evidence-based effective, and life-saving interventions to prevent and treat acute malnutrition. 31. A.O. No. 2011-0003 “Healthy Lifestyle Policy” – National policy on strengthening the prevention and control of control of chronic lifestyle related non-communicable diseases. 32. A.O. No. 2010-00015 – Revised Policy on Child Growth Standards that adopts the Child Growth Standards for the Assessments of the nutritional status of children and in the conduct of activities related to growth monitoring and promotion and Operational Timbang Plus, 33. A.O. No. 2010-0010, Revised Policy on Micronutrient Supplementation to Support Achievement of 2015 MDG Targets to Reduce Under-five and Maternal Deaths and Address Micronutrient Needs of Other Population Groups. 34. A.O. No. 2009-0025, Adopting New Policies and Protocol on Essential Newborn Care, includes delayed cord clamping, skin to skin contact and early initiation of breastfeeding. 35. A.O. No. 2008-0029, Implementing Health reforms for the Rapid Reduction of Maternal and Neonatal Mortality defines the Maternal, Newborn and Child Health and Nutrition (MNCHN) Strategy which includes antenatal services, including those related to nutrition as well as the promotion of optimum IYCF practices. 36. A.O. No. 2007-0045, Zinc Supplementation and Reformulated Oral Rehydration Salts in the Management of Diarrhea among Children. 37. A.O. No. 2007-0026, Revitalization of the Mother-Baby Friendly Hospital Initiative in Health Facilities with Maternity and Newborn Care Services. 38. A.O. No. 2005-0014, National Policies on Infant and Young Child Feeding.

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Department Memorandum No. 2012-0113, Using Fortified Food Products and other Food Service Institutions.

Other Government Issuances 40. NNC Governing Board Resolution No. 2 s. 2009, adopting the National Policy on Nutrition Management in Emergencies and Disasters 41. NNC Governing Board Resolution No. 4 s. 2018, adopting the NNC Policy Statement on Fad Diets. 42. NNC Governing Board Resolution 2000 adopting the Nutritional Guidelines for Filipinos (NGF). The NGF is a set of 10 behaviors that should guide nutrition education efforts. 43. Letter of Instruction 441 (1976) directed to the Departments of Social Welfare, Agriculture, Education and Culture, Health, and Local Government and Community Development; the National Science Development Board. The Budget Commission and the National Nutrition Council for the implementation of the Philippine Nutrition Program (PNP). The Department of Local Government (now DILG) was mandated to establish nutrition committees in every region, province, city, municipality and barangay.

C. The National Response to Address Nutrition Problems

The National Nutrition Program office was established in 1967 under the DOH, and was later named National Nutrition Service (NNS). It implemented a series of significant programs including Prevention and Control of VADAG (Vitamin A Deficiency, Anemia and Goiter), Food Supplementation Program with CARE, Mothercraft Project, Nutrihut with the Nutrition Center of the Philippines, and hiring and deployment of nutritionists to the provinces. The NNS developed the Comprehensive Nutrition Program 1992-1996. In 2000, the Service was subsumed under the National Center for Disease Prevention and Control (now called Disease Prevention and Control Bureau).

Global Nutrition Frameworks and Actions

Figure 45 (at the end of this Chapter) illustrates a global nutrition interventions framework, which guides the country’s strategic nutrition framework, and which shows the means to optimum fetal and child growth and development. This framework outlines the dietary, behavioral, and health determinants of optimum nutrition, growth and development, and how they are affected by underlying food security, caregiving resources, and environmental conditions, which are in turn shaped by economic and social conditions, national and global contexts, capacity, resources and governance.

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The left panel of the framework shows different nutrition specific interventions and programs – oral health and healthy lifestyle already exist in the Philippine context. On the right panel, nutrition-sensitive programs and approaches, though not necessarily related to health, are shown as having potential effects in addressing the underlying determinants of malnutrition, and incorporate specific nutrition goals and actions. It also shows how an enabling environment can be built to support interventions and programs to enhance growth and development. The framework shows the benefits of all these interventions and approaches.

As published in Lancet in 2013 (Figure 46), many nutrition interventions have been successfully implemented at scale, the evidence base for effective interventions and delivery strategies have grown. Ten nutrition-specific interventions across the life cycle were modeled to assess the effects and cost of scaling up. The following interventions will address under-nutrition and micronutrient deficiencies among women of reproductive age (WRA), pregnant women, neonates, infants, and children:

Peri-conceptual folic acid supplementation;
Maternal balanced energy protein supplementation;
Maternal calcium supplementation;
Multiple micronutrient supplementation in pregnancy;
Promotion of breastfeeding;
Appropriate complementary feeding;
Vitamin A supplementation;
Preventive zinc supplementation in children aged six to 59 months;
Management of severe acute malnutrition (SAM); and
Management of moderate acute malnutrition (MAM).

National Nutrition Framework and Action

The Philippines’ adaptation of the global framework published in the Lancet – illustrates the packages of health and nutrition services at each life stage in the continuum of care, from preventive/promotive interventions in the public health facilities and communities to the curative/clinical interventions in hospital settings. See Figures 45 and 46.

The Strategic Framework for Comprehensive Nutrition Implementation (Figure 47) shall set the direction and critical approaches to achieve the targets. This implementation design, which introduces the vision, mission, goals, objectives and targets for nutrition strategic management, adopts three guiding principles:

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Integration and life-based approach;
Evidenced-based interventions translated into essential health and nutrition packages for each life stage; and
Partnerships and shared responsibility.

Nutrition is everybody’s business, and the strategic framework will be the instrument of the DOH’s dynamic and challenging discipline of nutrition management. The approach involves intra-collaborative nutrition interventions, integrating nutrition-related programs from the DPCB and other DOH offices such as Health Facility Development Bureau, Health Emergency Management Bureau, Health Promotion and Communication Service, Health Human Resource Development Bureau, and Bureau of Local Health Systems Development.

Current Nutrition Programs and Interventions

Infant and Young Child Feeding Program: The DOH implemented this program to contribute to the achievement of the Millennium Development Goals, mainly to reduce child mortality and morbidity through optimal feeding of infants and young children. Its main objective is to ensure and accelerate the promotion, protection and support of good infant and young child feeding practices.

Breastfeeding TSEk Campaign: TSEk, meaning Tama, Sapat at Eksklusibo, introduces complementary food at six months’ age. World Health Organization explains that at the age of six months, the infant’s need for energy starts to exceed what is provided by breastmilk, and complementary foods are essential to meet the gaps for vitamin A and iron.

Micronutrient Supplementation Program: The government adopted micronutrient supplementation (MS) in response to micronutrient malnutrition in the country. The overall MS policy is contained in DOH’s A.O. No. 2010-0010, “Revised Policy on Micronutrient Supplementation to Support Achievement of 2015 MDG Targets to Reduce Under-Five and Maternal Deaths and Address Micronutrient Needs of Other Population Groups.” MS is an intervention intended to prevent and/or correct high levels of micronutrient deficiencies by providing large doses of micronutrients immediately until more sustainable food-based approaches (e.g. food fortification and diet diversification) are put in place and become effective.

Healthy Lifestyle Program – Conduct of “Belly Gud for Health – Keeping Fit, Moving Forward”: This is an effort of the DOH to promote and protect the health of its employees and officials from non-communicable diseases. It consists of conduct of baseline and quarterly NCD risk assessment and screening; enhancement of the DOH Cooperative Canteen as a Healthy Canteen; sessions on nutrition,

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physical activity and specific diseases; Fitness camp, Hataw exercises and daily “Ala Stress”. Recognition awards are given to employees who attained desirable waist circumference as well as to the office with the greatest percentage of staff with the desirable waist circumference. DOH held a series of orientation and technical assistance to promote and advocate Belly Gud to other national government agencies.

Growth Monitoring and Promotion: A health facility-based and child-focused program which basically involves accurate assessment and recording of child’s weight and height from birth to 71 months on a Growth Monitoring chart (GMC).

The GMP Guidelines are issued to strengthen the growth monitoring and promotion activities and to fast track the implementation, mainstreaming and integration of the WHO-CGS in various health delivery systems particularly at the local level.

GMP is one of the three major activities being implemented in the assessment of 0- 71 month’s old children. Other two assessment of physical growth include the National Nutrition Survey and Operation Timbang Plus.

Garantisadong Pambata or Child Health Day: A comprehensive and integrated package of services and communication on health, nutrition and environment for children available every day at various settings such as home, school, health facilities and communities by government and non-government organizations, private sectors and civic groups. This has been expanded to cover 0-14 yrs. old children and to be done year-round rather than a specific day in the year as part of the effort of moving from a campaign mode to institutional mode. This includes administration of high dose vitamin A supplements twice a year for 6 to 59 months children, the promotion of IYCF practices, deworming, immunization, environmental sanitation and also aim to change behavior toward the adoption of key health and nutrition behaviors.

Integrated Management of Acute Malnutrition in the Philippines (IMAM): IMAM was first implemented in Maguindanao and North Cotabato in 2009. In collaboration with the Department of Health, UNICEF supported partners such as the Save the Children, Accion Contra El Hambre (ACF-E), and Medecins Sans Frontiers (MSF) to bring in their global expertise and experience in IMAM. IMAM is now in more than 21 municipalities, with more than 30 out-patient treatment sites in RHUs or BHS. Four community hospitals have also been capacitated to give appropriate management of complicated cases using the updated treatment protocol (UNICEF briefing paper on IMAM).

Development of the Integrated NCD Prevention and Control Program Framework: The framework includes the provision of comprehensive services along the continuum of care, evidenced-based program management, partnerships

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and advocacy, primary health care approach and community-based implementation. It addresses equity concerns and ensures sustainability.

Hospital Nutrition and Dietetics: The current office that handles the Hospital Nutrition and Dietetics is the Health Facility Development Bureau. The office developed Hospital Nutrition and Dietetics Service Management Manual to serve as a guide and standard reference for nutrition hospital management, service providers and support staff to inject quality in their day-to-day operation at various aspects of work with service delivery point at the nutrition and dietetics service in the hospital.

Nutrition in Emergencies: This refers to key nutrition services that are components of emergency preparedness, response and recovery phases aimed at preventing death and worsening of malnutrition in the affected population, particularly in the most nutritionally vulnerable groups: infants, children, pregnant women and breastfeeding mothers and older persons.

The Health Emergency Management Bureau (HEMB) in the Department of Health was tasked to prevent or minimize the loss of lives and illnesses during emergencies and disasters in collaboration with government, business and civil society groups. EO 102 (1999) is the legal basis for creating the Health Emergency Management Staff (HEMS) as the lead agency for formulating the health sector response to emergencies and disasters.

Food Fortification (Sangkap Pinoy): The Sangkap Pinoy Seal Program (SPSP) is a strategy to encourage food manufacturers to fortify processed foods or food products with essential nutrients at levels approved by the DOH. The DOH through the BFAD is the lead agency responsible for the implementation and monitoring of the law.

Nutrition to Boost Universal Health Care

In its continuing stewardship of health sector reform, the DOH launched FOURmula One Plus (F1 Plus) for Health as the framework to boost the country towards universal health care, where Filipinos are ensured of “equitable access to quality and affordable health care goods and services, and protected against financial risk.”

F1 Plus is aligned to the Philippines long-term vision embodied by AmBisyon Natin 2040, where every Filipino aspires for “matatag, maginhawa at panatag na buhay.” The F1 Plus strategy map is anchored to the vision that Filipinos are among the healthiest people in Southeast Asia by 2022, and Asia by 2040, focused on the strategic goals for better health outcomes, more responsive health system, and more equitable healthcare financing, and contains four-plus-one pillars, which contain

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medium-term packages of health reforms: Governance, Financing, Regulations, Service Delivery, and a cross-cutting pillar, Performance Accountability.

The F1 Plus targets are embodied in the National Objectives for Health 2017-2022 (NOH), which contains among others sentinel impact indicators; one of the ten impact indicators has relevance in childhood nutrition. It was noted that the prevalence of stunting among under-five children remained almost unchanged between 2005 and 2015. With a baseline of 33.4 in 2015, the F1 Plus target to reduce prevalence of stunting among under-five children was set at 21.4 by 2022. Also of interest to workers in health care facilities, two impact indicators related to responsive health systems are client satisfaction rates and provider responsiveness scores.

Under the F1 Plus Service Delivery Pillar – or the general objective of “accessibility of essential quality health products and services ensured at appropriate levels of care – two of 23 coverage indicators have relevance to delivery of nutrition care programs and services: indicator 22, incidence of low birth weight among newborns, and indicator 24, prevalence of raised blood pressure. As background, it was noted that a quarter of pregnant women were consistently “nutritionally at-risk of delivering low birth weights (LBW) babies.” FNRI-DOST studies between 2008 and 2015 indicated a rebound increase of LBW proportions among children 0 to 3.9 years old. LBW incidence is targeted to decrease from 21.4 percent to 15 percent by 2022. Meanwhile, high blood pressure is a common risk factor associated with lifestyle-related non-communicable diseases, which accounts for over 80 percent of the leading causes of mortality. Raised blood pressure prevalence among 18 years old and above is targeted to decrease from 22.6 percent to 18.1 percent by 2022 (to be sourced from the National Nutrition Survey).

Early in 2019, the country received its biggest boost for universal health care to date when Republic Act (R.A.) No. 11223, or the “Universal Health Care Act” came into effect. R.A. No. 11223 ensures universal coverage in terms of population, health care services and financing: All Filipinos gain automatic membership to the National Health Insurance Program; access to a continuum of health care in the life- span; and guaranteed zero co-payments for basic or ward admissions in government hospitals. Particular to nutrition, the law provides for the strengthening of national health promotion efforts, including the “effective promotion of healthy lifestyle, physical activity, proper nutrition…” as well as use of administrative and research data for evidence-informed sector policy and planning for universal health care.

For the implementation of F1 Plus, the DOH was reorganized into seven functional teams, and the Health Facility Development Bureau (HFDB) was teamed up with the Health Facilities and Infrastructure Development Team (HFIDT). The HFIDT specifically contributes the following for the F1 Plus:

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Availability of adequate health services across the country
Developing health facilities through management of health sector resources
Health care assured through efficient and effective health facility operations
Use of technology to facilitate patient experience during health care and empower patients through adequate information

In health facilities, nutrition education is being provided to patients/clients as part of the Clinical Nutrition Therapy included in Chapter 5 of the manual, for advocacy and promotion of nutrition through nutrition counselling and dissemination of nutrition information education and communication (IEC) materials such as diet handouts/diet slips for different diseases developed by the Health Facility Development Bureau (HFDB) and National Center for Health Promotion. For community nutrition practice, nutrition services such as micronutrient supplementation, support for the First 1000 days, healthy lifestyle and wellness for the prevention of non-communicable diseases and treating severe and acute malnutrition (SAM) through food supplementation are available. However, the manual is intended only for the Nutrition and Dietetics Service Department in the hospital. Matters pertaining to the promotion of nutrition in health facility networks, i.e. outside the hospital, is beyond the scope and coverage of the manual.

Strategies for Strengthening Nutrition and Dietetics Efforts in the Health Facilities during Universal Health Care (UHC) Implementation The NDS in health facilities shall support the implementation of UHC through people-centered approach and primary care provider focused in healthcare delivery system. The promotion of the role of RNDs as independent clinicians in hospital settings through collaboration with other health professionals regarding proper diet prescriptions, compliance monitoring, and evaluation of medical nutrition therapy provided are enhanced. For the continuity of care, patients being discharged must have access to a comprehensive set of quality and cost-effective nutrition service through a strengthened referral system to a primary care provider. Clear delineation of roles of key agencies and stakeholders must be identified towards better nutrition outcomes in the healthcare process. The DOH-Health Facility Development Bureau (HFDB), the Field Implementation and Coordination Team (FICT) and the Professional Regulation Commission (PRC) shall conduct monitoring to ensure effective implementation of patient quality care outcomes.

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The release of an updated edition for the Hospital Nutrition and Dietetics Service Management Manual is one of the targeted milestones for the HFDB’s work program for F1 Plus and initial implementation of the R.A. No. 11223.

II. The Nutrition and Dietetics Profession

R.A. No. 10862, or the “Nutrition and Dietetics Law of 2016,” recognizes the important role of Registered Nutritionist-Dietitians (RNDs) in nation building and in human development through adequate nutrition. This Act governs on the following:

The standardization and regulation of nutrition and dietetics education;
The examination, registration and licensure of nutritionist-dietitians;
The standardization, supervision, control, and regulation of the practice of nutrition and dietetics;
The development of professional competence of nutritionist-dietitians through continuing professional development (CPD); and
The integration of the nutrition-dietetics profession.

A person is deemed to be in the practice of nutrition and dietetics through the performance of the following:

Providing medical nutrition therapy through the application of the Nutrition Care Process for purposes of disease prevention, treatment and management;
Optimizing the health and well-being of patients through the delivery of quality products, programs and services;
Promoting nutritional health and well-being of individuals, groups, communities and populations;
Setting standards, guidelines and policies that create and encourage an environment that supports nutritional health;
Managing food and nutrition systems, including programs, projects and services;
Facilitating and conducting food, nutrition and related research across a variety of practice settings; and
Educating and training others about food and nutrition in a variety of practice settings.

Different organizations and institutions in and outside the country support the continuing development of the nutrition and dietetics, including but not limited to the following listed in Table 1.

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Table 1. List of government agencies, local non-government organizations and international organizations supporting nutrition and dietetics in the country Government Agencies Local Non-Government Organizations International Organizations  Commission on Higher Education (CHED)  Dept. of Education (DepEd)  Dept. of Health (DOH)  Dept. of the Interior and Local Government (DILG)  Dept. of Labor and Employment (DOLE)  Dept. of Social Welfare and Development (DSWD)  Dept. of Trade and Industry (DTI)  Food and Drug Administration (FDA)  Food and Nutrition Research Institute – Dept. of Science and Technology (FNRI-DOST)  Local Government Units  National Economic Development Authority (NEDA)  National Nutrition Council (NNC)  Philippine Information Agency (PIA)  Professional Regulation Commission (PRC)  Senate and House of Representatives  Association of Diabetes Nurse Educators of the Philippines (ADNEP)  DOH-League of Registered Nutritionist- Dietitians Inc. (DOH– LRNDI)  Nutrition Center of the Philippines (NCP)  Nutrition Foundation of the Philippines (NFP)  Nutritionist-Dietitians’ Association of the Philippines (NDAP)  Philippine Association for the Study of Overweight and Obesity (PASOO)  Philippine Association of Diabetes Educators (PADE)  Philippine Association of Nutrition(PAN)  Philippine Society of Endocrinology, Diabetes and Metabolism (PSEM)  Philippine Society of Nutritionist-Dietitians (PSND)  Academy of Nutrition and Dietetics (AND), by virtue of its reciprocity program with the PRC  Helen Keller International (HKI)  International Life Sciences Institute - Southeast Asia Region Philippine Committee (ILSI-SEAR)  United Nations International Children’s Fund (UNICEF)  United States Agency for International Development (USAID)  World Food Programme (WFP)  World Health Organization (WHO)

III. Nutrition and Dietetics in Health Care Delivery

Nutrition and Dietetics Work in the Communities: The Nutritionist-Dietitian (ND) promotes good nutrition for the public through conduct of various nutrition programs such as food and micronutrient supplementation, nutrition education, monitoring of nutritional status of the target population and necessary referral.

Nutrition and Dietetics Work in the Hospitals: According to the Hospital Licensure Act, or R.A. No. 4226, the Dietary Service ranks as one of the six (6) major services of a hospital and is an integral part of total patient care.

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32 | Hospital Nutrition and Dietetics Service Management Manual

In as much as food service involves approximately 10-14% of the total hospital expenditures, this is a critical area that needs to be managed by a Registered Nutritionist-Dietitian (RND). The role of RND is critical in providing quality nutritional care, although it is a concerted effort and a shared responsibility primarily of the physicians, nurses and dietitians.

With the existing seventy (73) DOH retained hospitals nationwide, each has its own nutrition and dietetics service that needs to be upgraded in terms of standards for manpower, facilities, process, systems and nutritional aspect of patient care to provide optimal nutrition for patients and personnel through efficient and effective administration of high quality food service.

The DOH-Health Facility Development Bureau developed the Hospital Nutrition and Dietetics Service Management Manual to serve as a guide and standard reference for nutrition hospital management, service providers and support staff to inject quality in their day-to-day operation at various aspects of work with service delivery point at the nutrition and dietetics service in the hospital. Diet handouts for different disease were developed with National Center for Health Promotion (NCHP) to serve as guide to the nutritionist-dietitians and other allied health professionals in giving therapeutic and regular diet counselling services. These will also serve as reference materials to groups and individuals who are promoting healthy eating habits.

In summary, the RNDs’ work in the hospital are as follows:

Set highest standard of excellence and integrity in the practice of hospital nutrition and dietetics;
Provide quality and optimal nutritional care and quality food service to patients, hospital personnel and other stakeholders;
Provide diet counseling and nutrition education services to patients as well as in-service training to both nutrition and dietetic personnel and other related field;
Conduct research and development along the field of Nutrition and Dietetics;
Update knowledge and skills of personnel in food service management and nutrition and dietetics;
Develop and implement standard operating procedures concerned with nutrition and dietetics.

Multidisciplinary Role of RNDs in the Hospital: The RNDs promote and maintain coordination with other DOH agencies and other departments in the hospital towards total patient care with approval of management, and establish and implement policies and standards related to Nutrition and Dietetics.

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As part of the medical team in the hospital, the primary role of RNDs is to provide and implement the nutritional care process to patients with various disease conditions to improve health, promote faster recovery, and prevent malnutrition by serving appropriate meals and giving expert nutrition guidance and counselling. Hospital foodservice quality is defined as “foodservice that meets nutritional requirements of in-patients”. The hospital foodservice RNDs goals are to provide in-patients with nutritious meals for their recovery and health; and to present them with a nutritional model with meals tailored to their specific health conditions.
Meal consumption of in-patients is a good indicator of dietary status and satisfaction with meal service. When meals are carefully planned and served and when patients consume what they are served, the goal to meet the nutritional requirements of in-patients can be achieved.

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34 | Hospital Nutrition and Dietetics Service Management Manual

Figure 45. Nutrition Interventions Framework adopted from the Lancet Maternal and Child Nutrition Series, “Framework for actions to achieve optimum fetal and child nutrition development,” 2013 (To view, please quarter-turn counter-clockwise once)

NOTE: *Oral Health and Healthy Lifestyle are existing interventions in the Philippines.

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Figure 46. Nutrition Interventions for Mothers and Children Across the Lifecycle, adopted from the Lancet Maternal and Child Nutrition Series, “Conceptual framework,” 2013 (To view, please quarter-turn clockwise once)

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Figure 47. DOH Nutrition 2014-2024 Framework (To view, please quarter-turn counter-clockwise once)

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REFERENCES Food and Nutrition Research Institute-Department of Science and Technology. Expanded National Nutrition Survey 2018. Jamorabo-Ruiz A, Lagua RT and Claudio VS. 2012. Nutrition and Diet Therapy Reference Dictionary Philippine Edition. Manila, RP: Merriam & Webster Bookstore Inc. National Economic and Development Authority, “About AmBisyon Natin 2040,” http://2040.neda.gov.ph/about-ambisyon-natin-2040/, Accessed: May 15, 2019. Republic Act No. 10862, “An Act Regulating the Practice of Nutrition and Dietetics in the Philippines, Repealing for the Purpose Presidential Decree No. 1286, known as the “Nutrition and Dietetics Decree of 1977”, Appropriating Funds Therefor and For Other Related Purposes. Republic Act No. 11223, “An Act Instituting Universal Health Care for All Filipinos, Prescribing Reforms in the Health Care System, and Appropriating Funds Therefor,” Section 3 (b).

SUGGESTED READINGS Food and Nutrition Research Institute, “2018 Expanded National Nutrition Survey” The Lancet, Executive Summary of The Lancet Maternal and Child Nutrition Series

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38 | Hospital Nutrition and Dietetics Service Management Manual

Hospital Nutrition and Dietetics Service Management Manual | 39 CHAPTER 2 THE HOSPITAL NUTRITION AND DIETETICS SERVICE

Each hospital has a guiding philosophy, which should be articulated and embedded to the staff of the various services. The Nutrition and Dietetics Service (NDS) must formulate its own philosophy that shall anchor its goals, objectives and programs of service.

I.
Philosophy

The following can serve as a guide in the formulation of a philosophy for the NDS:

The NDS is organized to promote optimal nutrition and other related services for patients and hospital personnel and other stakeholders regardless of race, religion, social status, and political belief through the provision of a high quality food service;
The NDS considers that diet is one of the most critical attributes in human growth and development directly related to good health. It provides the most appropriate means of maintaining vitality, developing resistance to infections and organic deterioration, the control of many disease processes, and recovery of health and function following illness and injury;
The NDS personnel must be oriented, guided and regularly evaluated in their work within the context of prevailing local conditions in order to attain efficient output; and
The NDS goals can be best attained through the cooperation, coordination, mutual understanding, and dedication of all those concerned with quality patient care.

The Nutrition and Dietetics Service supports the mission and philosophy of the hospital in promoting the health and nutritional status of the patients through quality nutrition service and care towards optimum health.

II.
Vision

Excellent service in the practice of hospital nutrition and dietetics towards the well- being of patients and other stakeholders.

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40 | Hospital Nutrition and Dietetics Service Management Manual III.
Mission

Comprehensive nutrition care through efficient and effective food service delivery, nutrition education, continuing research, learning and development

IV.
Core Values

C Commitment to Quality Service The NDS pledges to provide comprehensive nutrition care towards the well- being of clients. Excellence in all endeavors describes its professional statements and actions. To be truly science-based, it constantly interfaces with national and international experts.

A Accountability and Integrity Trustworthiness is paramount to the NDS. To be always trusted, honesty rules its thoughts, words and conduct. Candor and openness hallmark its responsibility towards the welfare of its clients.

R Resource Maximization Efficiency in the delivery of nutrition services through conscientious utilization of resources, it always zealously tries to maintain and restore. To further the limited resources, it innovates and exercises creativity.

E Empowered Leadership and Management NDS leads initiatives towards promoting health and wellness through nutrition. An advocate of health, the NDS leads the advocacies for varied and balanced food selection. It partners with patients, their families, physicians, other healthcare professionals and the general public. It collaborates and shares knowledge with them, as it believes that it is through this that it empowers people towards successful management of nutrition- related health concerns. It opens opportunities for the professional growth of the staff, thereby raising the quality in the delivery of services of the nutrition and dietetics department.

V.
Objectives

A. General Objective

To maintain and improve the health of patients and stakeholders by providing high quality, safe, and nutritious foods at minimum cost.

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Specific Objectives

To prepare and to serve safe, nutritious, palatable and appetizing food through good planning and procurement within budget allocation.
To provide appropriate clinical and medical nutrition therapy to clients and stake- holders.
To provide continuous in-service learning and development to both nutrition and dietetic staff, student affiliates and other allied health professionals.
To conduct evidence-based researches in the field of Nutrition and Dietetics practice in the hospital.
To promote and maintain multi-disciplinary collaboration with highest ethical standards with other allied, support services in the hospital and in the community.
To equip the Nutrition and Dietetics Service with adequate and responsive information system through Integrated Hospital Operation and Management Information System (IHOMIS).
To sustain compliance to quality standards with International Organization for Standardization (ISO).

VI.
Strategic Goals

A. Clinical

Medical Nutrition Therapy is provided to support the physician with the nutritional care of patients to maintain and improve nutritional status.

Nutrition Care Process

Nutritional Care is an organized group of activities allowing the identification of nutritional needs and provision of care to meet these needs. The Nutrition Care Process is an organized approach to nutrition intervention that consists of assessing, planning, implementing, and evaluating. It parallels the nursing care process, but focuses on nutrition concerns.

Nutrition Assessment is a systematic process of obtaining, verifying, and interpreting data in order to make decisions about the nature and cause of nutrition- related problems. It is an on-going dynamic process involving not only initial data collection, but also continual reassessment and analysis of patient/client/group needs.

Nutrition Diagnosis is the identification and labelling of an actual occurrence, risk of, or potential for developing a nutritional problem that dietetics professionals are

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42 | Hospital Nutrition and Dietetics Service Management Manual responsible for treating independently. At the end of the assessment step, data are clustered, analyzed, and synthesized. This will reveal a nutrition diagnostic category from which to formulate a specific nutrition diagnostic statement. Nutrition diagnosis has 3 components namely (a) problem (diagnostic label), (b) etiology (cause/contributing risk factors), and (3) signs/symptoms (defining characteristics).

Nutrition Intervention are purposely-planned actions designed with the intent of changing a nutrition-related behavior, risk factor, environmental condition, or aspect of health status for an individual, a target group, or population at large. This step involves 1) selecting, 2) planning, and 3) implementing appropriate actions to meet patient/ client/groups’ nutrition needs. It is directed at the etiology or effects of a diagnosis. The selection of nutrition interventions is driven by the nutrition diagnosis and provides the basis upon which outcomes are measured and evaluated.

Nutrition Monitoring and Evaluation use selected outcome indicators (markers) that are relevant to the patient’s defined needs, nutrition diagnosis, nutrition goals, and disease state. The purpose of monitoring and evaluation is to determine the degree to which progress is being made and goals or desired outcomes of nutrition care are being met.

B. Administrative functions in support of strategic goals include:

Establishment of policies and standards
Implementation of procedures concerned with budget and financial control
Development and planning of menus
Procurement, receiving and proper storage of foods
Production and provision of safe, sanitary, nutritious, and palatable food
Utilization of available manpower and other resources
Maintenance of accurate and updated records and reports.

C. Education and research functions in support of strategic goals include:

Nutrition education of the patients, hospital personnel and other stakeholders
Research and development in nutrition and dietetics.
Updated knowledge and skills of personnel in food service management and nutrition and dietetics
Training of student affiliates on nutrition and dietetics.

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Hospital Nutrition and Dietetics Service Management Manual | 43 VII. Standards

Standards are tools to monitor and evaluate the performance of Hospital Nutrition and Dietetics Service (NDS)

A. Organization and Staffing Development

Standard 1: The Nutrition and Dietetics Service (NDS) is managed by a full-time Registered Nutritionist-Dietitian (RND) with adequate number of staff as approved by the Department of Budget and Management.

Figure 48. Organogram of the hospital including the Nutrition and Dietetics Service under the Allied Health Professional Service

Interpretation: There shall be clearly stated goals, objectives, mission, vision and procedures for the Nutrition and Dietetics Service developed by the Nutrition and Dietetics personnel and in consonance with the framework of the hospital. The NDS shall post organizational chart with the updated PRC license of all RND staff. It shall indicate the routes of intra-departmental communication. Integrated planning on nutrition dietetics with other divisions/departments in the hospital shall be encouraged. Job descriptions should be adopted for all classifications of personnel. The organizational chart, job description, and the procedure manual should be reviewed periodically, revised as necessary, and dated to indicate the time of last review. There shall be regular rotation of RNDs in all units.

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44 | Hospital Nutrition and Dietetics Service Management Manual

Figure 49. Organizational chart of the Hospital Nutrition and Dietetics Service

The Nutrition and Dietetics Service must have the required number of qualified Nutritionist-Dietitians duly registered with the Professional Regulation Commission (PRC) based on Section 29 of R.A. No. 10862.

Similarly, the NDS must have adequate number of appropriately qualified personnel based on the staffing pattern approved by the DOH. The Chief Dietitian shall have the authority and responsibility of ensuring that the established policies are carried out; that overall coordination and integration of the therapeutic and administrative nutrition and dietetics services are maintained; and that a review and evaluation of the quality, safety, and appropriateness of the nutrition and dietetics functions are performed.

However, a hospital that has a contract with outside Food Service Company for nutrition and dietetic services must require that the company maintains the standards, outlined herein on such services. (This is also true to all private hospitals that have contracted the services of food concessionaires.)

B. Human Resource Learning and Development

Standard 2: The members of the staff are provided with appropriate orientation, continuous learning and development for competency.

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Interpretation: The education, learning and development intervention, and experiences of the personnel who provide the nutrition and dietetics services shall be documented and shall be related to each individual’s level of participation in the provision of the services.

Newly hired personnel shall undergo orientation and on-the job training. A continuous learning and development intervention program is required. All personnel should demonstrate competence as appropriate in:  Personal hygiene and infection control;  Proper inspection, handling, preparation, serving, and storing of food;  Proper care and safe operation of equipment;  General food service sanitation and safety;  Occupational health and safety;  Proper methods of waste disposal;  Portion control;  Preparation of Diet Tags;  Basic Diets;  Nutrition screening and assessment;
 Recording of pertinent nutrition and dietetics information;  Disaster and Health Emergency Preparedness.

The personnel providing nutrition and dietetics service shall participate in relevant in-service education programs. There shall be a provision for participation of personnel from all work shifts. The head of the NDS or qualified designates shall participate in planning and conducting in-service training and education for nutrition and dietetics personnel and other stakeholders.

Outside educational opportunities shall also be provided that is feasible to nutrition and dietetics personnel.

The extent of the nutrition and dietetics personnel’s participation in continuing education shall be documented and related to the size of the staff, scope and complexity of the services provided. Education and LDI programs for personnel shall be based on the results of NDS evaluation.

C. Policies and Procedures

Standard 3: The Chief ND in collaboration with the other services shall develop policies and procedures on the management of NDS and total patient care which

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46 | Hospital Nutrition and Dietetics Service Management Manual should be reviewed and revised periodically/ as needed with date and time of last review.

Interpretation: Written policies and procedures for the NDS should be developed to guide all nutrition and dietetics personnel in the performance of their duties. The Head of the NDS, in collaboration with the other units concerned shall develop policies and procedures concerning total patient care. These policies and procedures shall be reviewed, enforced and revised periodically as necessary and dated to indicate the time of last review.

There shall be policies and procedures relating to the following:  Department goals and objectives, organization and staffing;  Duties and responsibilities of nutrition and dietetics personnel with job descriptions, functions and working hours;  Personnel policies, including those related to health, personal hygiene and sanitation;  Administrative policies and procedures;  Total Quality Management (TQM) policies;  Nutritional screening, assessment and Nutrition Care Plan management;  Administration and management of enteral and parenteral nutrition therapy;  Measures on Infection control;  Management of Disaster and Health Emergency procedures;  Development and adoption of Diet. It should be reviewed annually, revised as necessary and dated in consultation with the medical staff through its designated mechanism. A copy of the diet manual should be placed in each patient care unit;
 Maintenance of functional nutrition clinic;
 Safety measures and practices (control of electrical, flammable, mechanical, chemical and radiation hazards).

D. Facilities and Operations

Standard 4: The Nutrition and Dietetics Service shall have adequate space, equipment and supplies to facilitate the efficient, safe, and sanitary operations and timely provision of food service to meet the nutritional needs of the patients.

Interpretation: The facilities must be provided to fulfill the food service and nutrition and dietetics needs of the patients and staff. The layout shall be in accordance with the type, size, and location of equipment, to make efficient food

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Hospital Nutrition and Dietetics Service Management Manual | 47 preparation, distribution, effective sanitation and safety. The food service should be strategically located and completely equipped. Necessary permits such as heath certificate of staff and sanitary permit of the NDS must be secured.

There should be an adequate workspace for supervisory and clerical personnel. The office of the Nutritionist-Dietitians should be properly located so that he/she is easily accessible for consultation to all who require his/her service. Current reference materials should also be conveniently located in the office.

The following precautions shall be taken in the handling and preparation of food:
 Protection of food from contamination and spoilage;  Storage of perishable foods at proper temperature and maintenance of temperature records;  Location of adequate and convenient comfort room and hand washing facilities throughout the service. Provision of separate male and female comfort rooms.  Cleaning and sanitizing of all work surfaces, utensils, and equipment after each period of use;  Provision of separate cutting boards for meat, poultry, fish (both cooked and uncooked), raw fruits and vegetables;  Replacement of unserviceable wares, utensils and equipment;  Control of lighting, ventilation, and humidity, in order to prevent the condensation of moisture and the growth of molds;  Use of efficient equipment and methods for washing and sanitizing dishes, such as, installation of a hot water system;  Use of methods for making, storing, and dispensing ice that does not allow contamination to occur. Ice should not be scooped by hand, nor should food items be stored directly on ice being stored for dispensing; and  Restriction of unauthorized individuals in the food preparation and service to minimize the risk of contamination and improve operation efficiency.

Safety shall be ensured by providing at least the following precautions:  Walk-in refrigerators that can be opened from the inside;  Installation of hot and cold water pipes, water heaters, refrigerator compressor, condensing units, and uncontrolled heat-producing equipment;  Labeling of supplies on a first-in first-out (FIFO) policy;  Separation and proper storage of all food and non-food supplies;

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48 | Hospital Nutrition and Dietetics Service Management Manual  Documentation of the activities of an active, preventive, and corrective maintenance, and safety program;  Procurement of all food supplies from sources that provide assurance that the food is processed under regulated quality and sanitation controls;
 Observance of proper waste management and disposal to prevent the proliferation of insects, rodents and transmission of diseases. Containers must be leak proofed and non-absorbent with tight-fitting covers preferably with impervious plastic liners to be used.

E. Recording and Documentation

Standard 5: The NDS shall maintain relevant records and documents for filing as reference materials. All pertinent nutrition and dietetics information shall be recorded in the medical chart.

Interpretation: The RND shall write nutrition and dietetics information into the nutrition forms to be inserted into medical chart (refer to medical records adviser regarding the medical chart) as specified, and in the location determined by those performing the medical record review function. Such documentation may include:  Verification of the diet order of the attending physician as needed within 24 hours upon admission;  Summary of the dietary history and/ or nutrition assessment, when the past dietary pattern is known to have a bearing on the patient’s condition or treatment;  Assessment of the patient’s nutrient intake and tolerance of the prescribed diet modification;  Recommend the diet appropriate for the disease condition of the patient; and  Provide a copy of their diet prescription prior to discharge.

All documents shall be signed over a stamped name and license number

Table 2. Clinical, administrative, and learning and development records maintained in the NDS CLINICAL ADMINISTRATIVE LEARNING AND DEVELOPMENT

Nutrition Care Process Form (ADIME)
SAM and MAM Data Report Form
Patient Conformé
Meal Census (B, L, S, AMS, PMS)
Diet Census (Routine, Therapeutic)
Cycle Menu
Issuances of Supplies
Consumption report
Project Procurement Management Plan (PPMP)
List of personnel attendance to LDIs/ seminars and convention
Certificates of LDIs

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Hospital Nutrition and Dietetics Service Management Manual | 49 CLINICAL ADMINISTRATIVE LEARNING AND DEVELOPMENT 6. Purchase request 7. Daily Market Order 8. Daily Market Purchase 9. Daily Expense 10. Disbursement Voucher 11. Replenishment of Cash Advance 12. Liquidation of Cash Advance 13. Dealers/Suppliers Performance Report 14. Inventory Report 15. Diet Tags 16. Diet List 17. Annual Accomplishment Reports 18. Meal Request Form 19. Statistical Report for Records Section 20. Stock cards (Receiving) 21. Project Procurement Management Plan (PPMP) 22. Monthly Schedule of NDS Personnel 23. Waste Management Record (Recyclable materials) 24. Daily Monitoring Safety Checklist (Gas pipe, electricity, water, doors, windows, garbage) 25. Daily Monitoring of Temperature (Room Temperature, Dry Storage, Chiller and Freezer) 26. Time of Food Delivery
27. Job Order Request Form 28. Customer Satisfaction Survey Form 4. Strategic Performance Management System

F. Monitoring and Evaluation

Standard 6: The quality and appropriateness of nutritional care provided by the NDS shall be monitored, reviewed, and evaluated regularly.

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50 | Hospital Nutrition and Dietetics Service Management Manual Interpretation: The head of the Nutrition and Dietetics Service (NDS) shall be responsible for ensuring that a review and an evaluation of the appropriateness and effectiveness of nutritional care are accomplished in a timely manner. The review and evaluation program should also include the nutritional care provided to in- patients and, when applicable, to ambulatory care patients and patients in a hospital- administered home care program. The review and evaluation shall be performed at least annually and shall involve the use of the medical record and the pre-established criteria. The review and evaluation shall include data gathered from the medical, nursing and nutrition and dietetics staff and should be performed within the overall hospital continuing quality improvement (CQI) program. The quality and appropriateness of nutrition and dietetics services provided to the hospital by outside sources shall be included in the review and evaluation on the same regular basis.

The quality and appropriateness of nutritional care provided by the nutrition and dietetics should be monitored, reviewed, and evaluated regularly. The following monitoring and quality control mechanisms shall be implemented:

Table 3. Administrative, clinical, research, learning and development monitoring and quality control mechanisms in the NDS ADMINISTRATIVE CLINICAL RESEARCH, LEARNING AND DEVELOPMENT

Nutritional adequacy of all meals served
Patient’s diet list should identify all patients who are admitted
Tray identification through color-coded tag
Compliance to submission of reports
Ensure the appetizing appearance, palatability proper serving, temperature, and retention of the nutritional value of food
Reports of Surveys to determine patient satisfaction of food service.
(See Customer Satisfaction Survey Form in Appendices A)
Special and therapeutic diets are identified
The nutritional care provided to all patients
Patients receiving therapeutic diets are given diet counselling according to their medical conditions as recorded in the medical chart
Critically-ill patients must be prioritized
Nutritionist Dietitians actively participates in committee activities concerned with health and Nutrition care, such as Breastfeeding and Lactation Management Committee, Inpatient Therapeutic Care, SAM Management, Infection Prevention and Control Committee and others
Human Resource Capability (KAS)
Research Facilities
Budget / Funding
Institutionalization (Initiatives & Partnership)
Soft Skills Development
Career Progression / Pathing / Plotting (refer to definition)
Affiliation and Practicum

Hospital Nutrition and Dietetics Service Management Manual | 51 CHAPTER 3 HUMAN RESOURCE MANAGEMENT

Human resource is one class of resources crucial for the Nutrition and Dietetics Service (NDS) to meet the objectives of the service and of the hospital. The NDS administrative management is responsible for proper planning, organizing, directing, coordinating and controlling human resources.

I. NDS Personnel Administration

In carrying out effective management responsibilities, it is relevant to put the proper number of staff with right qualifications suited for the achievement of the desired objectives. While some functions may be assumed by the management of the NDS, personnel administration is mainly governed by Civil Service rules and regulations, as well as other policies enforced by the hospital. Figure 50 shows recruitment or hiring related processes relevant to the NDS.

Figure 50. Recruitment or hiring process for the NDS personnel

The NDS must be aware of statutory and regulatory requirements for individual employees as well as for the agency/institution. For example, food service employees are required to have health certificates, and RNDs should have updated PRC licenses. The NDS must have sanitary permit, and the hospital must comply with PhilHealth accreditation requirements, in addition to licensing requirements of the DOH Health Facilities and Services Regulatory Bureau (HFSRB).

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52 | Hospital Nutrition and Dietetics Service Management Manual II. Standard Staffing Patterns

The standard staffing pattern for the NDS is included in the DBM-DOH Joint Circular No. 2013-01, “Revised Standards and Organizational Structure and Staffing Pattern of Government Hospitals, CY 2013 Edition” dated September 23, 2013. This policy covers hospitals with 25 to 500 bed capacities, the NDS staffing summarized on Table 4.

Table 4.
Nutrition and dietetics staffing pattern for 25- to 500-bed capacity hospitals per DBM-DOH Joint Circular No. 2013-01 Position Salary
Grade Bed Capacity 25 50 75 100 150 200 LVL 2 200 LVL 3 300 400 500 Nutritionist-Dietitian V 22

1 1 1 1 Nutritionist-Dietitian IV 20

1 1 1 1 Nutritionist-Dietitian III 18

1 1 1

Nutritionist-Dietitian II 15 1 1 1

2 3 5 6 Nutritionist-Dietitian I 11

1 2 2

Cook II 5 2 2 2 3 4 5 6 8 10 12 Administrative Aide III (Food Server) 3 1 2 3 4 6 7 12 12 16 16 Administrative Assistant II 8

1 1 1 1 TOTAL

4 5 6 9 13 15 23 26 34 37

Table 5 summarizes nutrition and dietetics staffing pattern based on the HFDB’s 2019 proposal for 200- to 1,500-bed capacity hospitals, included here for reference.

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Hospital Nutrition and Dietetics Service Management Manual | 53 Table 5.
Proposed nutrition and dietetics staffing pattern for 200- to 1,500-bed capacity hospitals POSITION TITLE SG BED CAPACITY STAFFING ACTION 200 300 400 500 600
to 700 800 to 900 1000 to 1100 1200 to 1300 1400 to 1500 III. ALLIED HEALTH PROFESSIONAL SERVICE Nutrition and Dietetics Department Nutritionist-Dietitian V 22 1 1 1 1 1 1 1 1 1 E Nutritionist-Dietitian IV 20 1 1 1 1 1 1 1 1 2 E+A Nutritionist-Dietitian III 18 3 3 3 3 3 3 4 6 9 C Nutritionist-Dietitian II 15 3 4 7 9 11 11 14 16 18 E+A Food Service Supervisor II 11 3 3 4 6 6 6 7 7 7 E+A Chef 11 1 1 1 1 1 1 1 1 1 C Assistant Chef 8 1 1 1 1 2 2 3 3 3 C Cook II 5 11 13 15 17 21 21 23 23 23 E+A Administrative Assistant II 8 1 1 1 1 2 2 2 2 2 E+A Administrative Aide IV
(Food Service Worker) 4 22 22 26 26 30 34 38 42 46 E+A TOTAL 47 50 60 66 78 82 94 102 112

LEGEND – STAFFING ACTION: E = Existing Position; C = Position for Creation; R = Position for Reclassification (with Incumbent); X = Position for Abolition/Collapse; V = Position for Conversion (Unfilled Position); A = Additional

III.

Job Titles and Descriptions

A. Nutritionist-Dietitian VI or V, or Chief Nutritionist-Dietitian

Under the direction of the Chief of Medical Professional Staff, the Nutritionist-Dietitian V supervises all activities of the NDS in a Level III Hospital or Medical Center or Hospital with an authorized bed capacity of 200 and above.

General Functions, Duties and Responsibilities

Plans, organizes, directs and evaluates clinical and administrative service of the Nutrition and Dietetics Services. a. Establishes long and short range objectives of the NDS consistent with the vision of the institution. b. Recommends and implements NDS policies and standards to the administration. c. Plans an effective budget and supervises maintenance of cost control and personnel records and reports.
d. Plans an effective purchasing methods, specifications for facilities, equipment, food supplies, enteral nutrition products, and materials needed in the NDS. e. Plans proper sanitation and safety standards and implements them adhering to strict compliance of national laws, regulations, and administrative orders.

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54 | Hospital Nutrition and Dietetics Service Management Manual f. Develops and maintains an organizational and flow chart of the NDS showing the responsibilities of all personnel. g. Delegates responsibilities to all professional staff members and supervises their work. h. Plans and maintain effective human resource management. i. Conducts regular meetings with the Nutrition and Dietetics staff and personnel. j. Participates in meetings, conferences, to different committees, departments, and other professional and community activities. k. Coordinates and integrates the activities of the Nutrition and Dietetics Service with those of other services. l. Establishes and maintains effective intra- and inter-departmental communication systems. Acts as the Chairman of the Nutrition Committee to maintain effective communication and oversight with food safety concerns, nutrition care quality outcomes. m. Establishes quality indicators of performance evaluation of Nutrition and Dietetics.

Plans, organizes, directs and evaluates education programs of the Nutrition and Dietetics Services. a. Develops and formulates an effective and continuous staff training and development programs. b. Plans, advices and/or participates in the development and execution of education programs for patients, student affiliates and other stakeholders. c. Participates in the formulation and maintenance of an effective and continuous program for the orientation, training and supervision of staff and personnel.
Plans, organizes, directs and evaluates research programs of the Nutrition and Dietetics Services. a. Develops and implements research programs of the administrative, clinical and education and LDI section of the Nutrition and Dietetics Service. b. Collaborates and participates in Nutrition research activities.

Qualifications

Registered Nutritionist-Dietitian in accordance with the provision of RA 10862.
Must have a Master’s Degree in Nutrition and Dietetics or Management and administration-related degree programs.
Must have an updated RND license.
Must have at least four (4) years of experience in the Nutrition and Dietetics Service of the hospital, two (2) years of which should be of supervisory level (This

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Hospital Nutrition and Dietetics Service Management Manual | 55 qualification can be revised if new qualification standards are issued by the Civil Service Commission.) 5. Preferably computer literate.

B. Nutritionist-Dietitian IV

In a Level III or Regional Hospital with an authorized 200 to 1,500 bed capacity, the Nutritionist-Dietitian IV is under the direction of the Nutritionist-Dietitian V. He/she assists in the supervision of all Nutrition & Dietetics Service activities, particularly in the management of the food service system.

General Functions, Duties and Responsibilities

Assists the Nutritionist-Dietitian V
Serves as Officer-in-Charge in the absence of Nutritionist-Dietitian V.
Assists in the establishment of long and short range objectives of the Nutrition and Dietetics Service consistent with the vision of the institution.
Assists in the recommendation and implementation of Nutrition and Dietetics Service policies and standards to the administration.
Plans an effective budget and supervises maintenance of cost control and personnel records and reports.
Plans effective procurement methods and specifications for facilities, equipment, food supplies and other supplies and materials needed in the service.
Implements and evaluates proper sanitation and safety standards.
Delegates responsibilities to all professional staff members and supervises their work.
Monitors, reviews and evaluates the efficiency of the education and research programs.
Plans, organizes, directs and evaluates education programs of the Nutrition and Dietetics Services.
Oversees the implementation of plan and policies of the clinical Nutrition and Dietetics.
Establishes and maintains effective intra- and interdepartmental communication systems.
Monitors quality indicators of performance evaluation of Nutrition and Dietetics.
Reports the efficiency of the Administrative, Clinical, Education and Research function of the Nutrition and Dietetics Service to the Nutritionist-Dietitian V.

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56 | Hospital Nutrition and Dietetics Service Management Manual Qualifications

Registered Nutritionist-Dietitian in accordance with the provision of RA 10862
Must have a Master’s Degree in Nutrition and Dietetics or management and administration-related degree programs or its proposed equivalent.
Must have at least three (3) years of experience in the Nutrition and Dietetics Service of the hospital, one (1) year of which should be of supervisory level (refer to CSC policy).
Preferably computer literate.

C. Nutritionist-Dietitian III

The Nutritionist-Dietitian III supervises all activities of the Nutrition & Dietetics Service in a Level II Hospital with an authorized 101-200 bed capacity. In a Level III or Regional Hospital with an authorized 200-1,500 bed capacity, the Nutritionist- Dietitian III is under the direction of the Nutritionist-Dietitian IV. He or she exercises supervision of all Nutrition & Dietetics Service activities in the administrative, clinical, education and research sections.

General Functions, Duties and Responsibilities

Administrative Dietitian a. Implements supply requirements for patients and personnel within the set budget allocations. b. Inspects and accepts all deliveries of foodstuffs for accurate quantity and proper quality in accordance with the specifications set by the service. c. Maintains high standards of food storage. d. Maintains complete and accurate records of daily purchases, issuances, payments and inventory of food supplies; e. Assists in the establishment of specifications, requisitions, and purchases of food supplies, utensils and equipment required in the menu. f. Participates in the facility planning and selection of equipment. g. Assists or prepares and submits Project Procurement Management Plan. h. Plans, implements and evaluates proper sanitation and safety standards. i. Implements infection control precautions and practices. j. Utilizes human and material resources efficiently and effectively. k. Assists the Chief Dietitian to analyze, develop and update job descriptions or specifications for educational and research unit personnel. l. Maintains the high standards of sanitation and housekeeping in their respective area of assignment.

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Hospital Nutrition and Dietetics Service Management Manual | 57 m. Participates in professional meetings and conferences. n. Handles multi-task responsibilities, as assigned by immediate supervisor.

Food Production and Food Service a. Develops and revises menu cycle based on budget, client’s acceptance, availability of resources and prevailing situations. b. Implements food preparation and service for patients and personnel within the budget allocations. c. Directs the food production within standards. d. Analyzes and updates job description/specifications and work schedules. e. Prepares the duties of production area personnel. f. Supervises and ensures high standards of sanitation and safety. g. Implements infection control precautions and practices. h. Identifies problems in food service and/or in the production system. i. Monitors food service for conformity with quality standards. j. Supervises the food in dishing out and distribution to the different wards and dining room. k. Supervises the maintenance of organized filing of records.
Clinical a. Plans and implements nutrition care process of patients and formulates improved techniques and procedures in the preparation and servicing of regular and modified diets to patients. i. Consults the attending physician concerning dietary prescriptions that needs verification.
ii. Adapts and modifies menus in accordance with the needs of patients for the maintenance or improvement of nutritional status.
iii. Conducts nutritional assessment and counseling to inpatients and outpatients. iv. Monitors the progress of patient’s diet orders. v. Monitors and evaluates patient’s actual caloric and nutrient intake.
vi. Monitors and evaluate patient’s tolerance to prescribed diets and make necessary documentation using the Dietitian’s progress notes in the medical chart. vii. Instructs patient and family on proper nutrition and routine diet modifications including food and nutrient interaction. viii. Documents dietary history and nutritional care data through the record system.

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58 | Hospital Nutrition and Dietetics Service Management Manual b. Verifies accuracy of therapeutic diets to patients as endorsed by Food Production Unit/Administrative Dietitian. c. Participates in nutrition support team and serve as consultant on nutrition care. d. Supervises the tray line distribution of all diets and specifically therapeutic diets including tube feeding to ensure that physician’s prescribed diet are properly implemented. e. Implements infection control precautions and practices. f. Maintains high standards of sanitation and safety practices and housekeeping in all areas and units involved in nutrition therapy. g. Analyzes, develops, and updates job descriptions and specifications for clinical nutrition section personnel. h. Maintains effective written and verbal communication and public relations in the intra- and inter-departmental levels. i. Conducts and provides statistical report.

Research, Education, Learning and Development a. Conducts research and continuing education program for dietary staff and personnel. b. Assists in selecting, scheduling and conducting orientations, in-service LDIs and educational programs for personnel, residents, interns and student-affiliates. c. Implements and monitors standards professional and ethical practice involving professional advancement and continuing education, particularly in administrative and clinical management. d. Evaluates and communicates research findings to departments concerned. e. Performs additional duties in cooperation with other hospital services. f. Plans, organizes, and conducts in nutritional care studies and food service research programs, as well as innovative programs, technological advances, and implementation of new nutrition care programs. g. Evaluates, updates and utilizes appropriate methodology, tools and IEC materials to carry out programs. h. Studies and analyzes recent scientific finding in nutrition and dietetics for application in current research and for dissemination to the public. i. Interprets, evaluates, and utilizes pertinent and current researches related to the program’s needs. j. Maintains accurate and detailed documentation.

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Hospital Nutrition and Dietetics Service Management Manual | 59 k. Participates in professional meetings and conferences i.e., research case conferences, ward rounds, orientation seminars for incoming interns and medical staff and other affiliates.

Qualifications

Licensed Nutritionist-Dietitian in accordance with the provision of RA 10862
Candidate for a master’s degree in Nutrition and Dietetics or related fields and has earned at least 30 units.
At least two (2) years of relevant experience and training
Computer literate (Microsoft Excel, Word and PowerPoint)

D. Nutritionist-Dietitian II

The Nutritionist-Dietitian II is under the direction of the Nutritionist-Dietitian III. He or she participates in the administrative, clinical, education and research of the NDS.
However, in a Level I - 75 bed capacity and below, the Nutritionist-Dietitian II assumes responsibility in the management of the NDS.

General Functions, Duties and Responsibilities

Administrative - Food Production a. Plans, develops, implements, and evaluates supply requirements for patients and personnel within the set budget allocations. b. Inspects and accepts all deliveries of foodstuffs for accurate quantity and proper quality in accordance with the specifications set by the service. c. Maintains high standards of food storage. d. Maintains complete and accurate records of daily purchases, issuances, payments and inventory of food supplies. e. Assists in the establishment of specifications, requisitions, and purchases of food supplies, utensils and equipment required in the menu. f. Participates in the facility planning and selection of equipment. g. Prepares and submits Annual Procurement Plan. h. Modifies the regular to therapeutic diet to meet the specific nutritional needs of the patients.
i. Directs the food production within standards.
j. Develops and revises menu cycle based on client's acceptance, availability of resources and prevailing situations.
k. Identifies problems in in the production system.

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60 | Hospital Nutrition and Dietetics Service Management Manual l. Supervises the maintenance of records for planning and control. m. Supervises and ensures high standards of sanitation and safety. n. Implements infection control precautions and practices. o. Analyzes and updates job descriptions or specifications and work schedules. p. Prepares the master schedule of duties of nutrition and dietetics personnel.

Administrative - Food Service a. Monitors food service for conformity with quality standards. b. Supervises the food in dishing out and distribution to the different wards and dining room.
c. Supervises the maintenance of organized filing of records.
d. Prepares the master schedule of duties of nutrition and dietetics personnel.
Clinical a. Plans and implements nutrition care of patients and formulate improved techniques and procedures in the preparation and servicing of regular and modified diets to patients. i.
Consults the attending physician concerning dietary prescriptions that needs verification.
ii.
Adapts and modifies menus in accordance with the needs of patients for the maintenance or improvement of nutritional status.
iii. Conducts nutritional assessment and counseling to inpatients and outpatients. iv. Monitors the progress of patient’s diet orders. v.
Monitors and evaluates patient’s actual caloric i.e., per oral, on tube feeding or parenteral feeding and nutrient intake.
vi. Monitors and evaluate patient’s tolerance to prescribed diets and make necessary documentation using the Dietitian’s progress notes in the medical chart. vii. Instructs patient and family on proper nutrition and routine diet modifications including food and nutrient interaction. viii. Documents dietary history and nutritional care data through the record system. b. Verifies accuracy of therapeutic diets to patients as endorsed by Food Production Unit/Administrative Dietitian. c. Participates in nutrition support team and serve as consultant on nutrition care. d. Supervises the tray line distribution of all diets and specifically therapeutic diets including tube feeding to ensure that physician’s prescribed diet are properly implemented.

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Hospital Nutrition and Dietetics Service Management Manual | 61 e. Implements infection control precautions and practices. f. Maintains high standards of sanitation and safety practices and housekeeping in all areas and units involved in nutrition therapy. g. Analyzes, develops, and updates job descriptions and specifications for clinical nutrition section personnel. h. Maintains effective written and verbal communication and public relations in the intra- and inter-departmental levels. i. Conduct continuing education program for dietary staff and personnel. j. Conducts and provides statistical report.

Education, Learning, Development and Research a. Develops standard professional and ethical practice involving professional advancement and continuing education. b. Plans and conducts LDI and education program for nutrition and dietetics trainees in food service management and conducts lecture or orientation to student affiliates and trainees.
c. Prepares, evaluates, and utilizes current educational methodology and institutional medical methods to enhance learning experience of student affiliates. d. Develops, conducts, and evaluates LDI and other educational programs to meet the needs of the dietetic, medical, nursing and other allied health profession. e. Supervises the compliance of the routine personnel evaluation system. f. Plans, organizes, and conducts nutritional care studies and food service research programs, as well as innovative programs, technological advances, and implementation of new nutrition care programs. g. Evaluates, updates and utilizes appropriate methodology, tools and IEC materials to carry out programs. h. Handles multi-task responsibilities as assigned by immediate supervisor. i. Contributes expertise as a member of the organization's team for planning and evaluation, and participate in committees and other organizational activities. j. Accomplishes complete and accurate documentations in Education, LDI and Research.

Qualifications

Licensed Nutritionist-Dietitian in accordance with the provision of RA 10862
Candidate for a master’s degree in Nutrition and Dietetics or related fields and has earned at least 30 units.

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62 | Hospital Nutrition and Dietetics Service Management Manual 3. Must have at least two (2) years of relevant experience and training 4. Computer literate (Microsoft Excel, Word, PowerPoint)

E. Food Service Supervisor

Under general supervision, the Food Service Supervisor assists in food production and ensures quality control in food service activities in a Level III or Provincial Hospital and a Level III or a Regional Hospital and Medical Center.

General Functions, Duties and Responsibilities

Assists in the supervision of food production and serving of meals to patients and personnel
Shall supervise the maintenance of cleanliness in all working areas
Assists in the maintenance and improvement of sanitation and safety standards
Prepares daily storeroom requisitions needed for the preparation of meals
Assists in the maintenance and improvement of food service standards
Supervises the catering to specialized service functions in the hospital
Conducts daily inventories of all dietary equipment, utensils and food supplies
Shall assist in instructing employees in the maintenance and care of equipment in food service
Receives and posts on stock cards accurate quantities of all food items delivered
Submits a list of standing storeroom stocks that needs to be replenished
Maintains proper storage procedures such as "FIFO" (First In, First Out) or “FEFO” (First Expiry, First Out) system of issuance, as well as proper labeling
Collects daily requisitions needed for next day's use, as approved by the Nutritionist-Dietitian in-charge
Handles multi-task responsibilities, as may be assigned by the immediate supervisor

Qualifications

Graduate of Bachelor’s degree in Food- and Nutrition-related programs
Civil Service eligibility
Preferably with at least one (1) year supervisory experience in food service institutions or health facilities.

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Hospital Nutrition and Dietetics Service Management Manual | 63 F. Cook II

Under general supervision, the Cook II participates in meal planning and recipe development. Performs preparation of therapeutic and full diet meals according to planned menus for in-patients and for special functions in the hospital.

General Functions, Duties and Responsibilities

Maintains and ensures food palatability to achieve quality standards.
Coordinates work assignments of assistant cooks and food service workers assigned as cook’s assistant.
Reports equipment status to the dietitian-on-duty.
Reports to the immediate supervisor any leftovers for proper usage and storage.
Assists in the instruction and LDI of new cooks and food service workers.
Assists in the standardization of recipes and portion control.
Supervise the cleanliness and upkeep of the working area and utensils.
Maintains sanitary standards in the preparation, apportioning and storage of food.
Ensures hygienic practices in the preparation and distribution of food.
Handles multi-task responsibilities as may be assigned by the immediate supervisor.
Participates in skills development/upgrading related to functions performed.

Qualifications

TESDA NC II (National Certificate of Competency in Cookery) or equivalent
At least graduate of Senior High School
Preferably at least one (1) year work experience from a food service institution

G. Administrative Aide (Food Service Worker)

Under the immediate supervision, the Food Server performs a variety of unskilled manual duties in the dietary in the preparation and service of food to hospital in-patients and personnel. Depending on the type and bed capacity of the hospital, the following may be assigned to one or more Food Server:

General Functions, Duties and Responsibilities

Portions food in patient's tray as well as in cafeteria counter, if there is any.
Distributes food to the patients in the different wards, or in self- service cafeteria counter to the hospital personnel (if there is any cafeteria) or on special occasions/functions in the hospital.

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64 | Hospital Nutrition and Dietetics Service Management Manual 3. Collects, cleans and returns used trays, plates and silverware to the dietary storage area after every use. 4. Assists in food preparation work such as peeling, washing, trimming, and cutting of fruits and vegetables. 5. Cleans the dietary and other premises. 6. Assists in cooking rice and the preparation of daily diabetic nourishment and other supplemental feedings. 7. Assists in the catering services for special functions: set the tables with linen, plates, and silverware; serves the food prepared accordingly; and shall likewise collect all wares, utensils and linen after the catering service for cleaning and storage of the same. 8. Cleans and sanitizes counter tables, dining room tables, and chairs after every mealtime. 9. Defrosts, cleans and sanitizes refrigerators and freezers. 10. Maintains the orderliness and cleanliness of the working area. 11. Assumes the duties of the cook in the latter's absence, as may be assigned by the Nutritionist-Dietitian with direct supervision. 12. Assists the Food Service Supervisor in store keeping. 13. Handles multi-task responsibilities, as may be assigned by the immediate supervisor.

Qualifications

TESDA NC II (National Certificate of Competency in Food Service) or equivalent
At least graduate of Senior High School
Preferably at least one (1) year work experience from a food service institution

H. Chef

Chefs can improve hospital food by bringing with them expertise in menu planning, fresh food sourcing and making healthy food delicious.

General Functions, Duties and Responsibilities

The Chef is the over-all supervisor of the cooks.
Designs and improves the menu including creation and standardization of new recipe and review food and beverage purchases.
Assists in training cooks and other food service workers.

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Hospital Nutrition and Dietetics Service Management Manual | 65 4. Involved in staffing in the kitchen, developing menu offering, forecasting supply needs and estimating cost together with the RND. 5. Prepares and cooks patients’ meals. 6. Assists in the dishing out of patient’s meals trays for all meals. 7. Responsible for menu planning and preparation of food and beverages for catering services and special events.
Qualifications:

TESDA NC III (Hot and Cold Kitchen)
Civil Service Eligibility
Diploma in Culinary Arts preferably but not required
Senior High School graduate
At least 3 years work experience

I. Assistant Chef

The justification of the position of the Asst. Chef is very important because they are accountable for the success and failure of the Nutrition and Dietetics Department.

General Functions, Duties and Responsibilities

Assistant Chef provides support to Chefs and have duties such as maintaining supplies, handling leftovers, preparing foods, testing new recipes, cleaning the hospital kitchen, keeping cooking organized and plating dishes.
Asst. Chef assists to modify menus or create new ones that meet quality standards as well as estimate for ingredient requirements and food labor costs. Qualifications:
TESDA NC III (Hot and Cold Kitchen)
Senior High School graduate
At least 2 years work experience

IV. Management Skills of Registered Nutritionist-Dietitians

The desirable management skills of ND VI, ND V, IV and III are shown in Table 6. Specific skills are listed under each of the skills identified namely, organizational, financial, educational, communication, technical foodservice management, people management, teamwork and skills of behavioral change. In Table 7 the specific skills for ND II are listed under organizational, analytical, research, communication, administration, clinical nutrition, teamwork and supervisory skills.

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66 | Hospital Nutrition and Dietetics Service Management Manual

Table 6. Desirable management skills of ND VI, V, IV and III Organizational Skills Financial Skills Educational Skills Communication Skills  Plans and organizes the service based on the objectives  Establishes priorities and allocate resources  Encourages and participates in research activities  Visionary  Interprets financial statements  Prepares budgets and effective cost control  Efficient utilization of resources
 Forecasts manpower requirements  Effective procurement system  Develops, conducts and evaluates orientation and in- service training programs  Technical Report writing skills  Research skills  Information Education Communication (IEC) development skills  Motivates and leads employees  Maintains good public relations  Competent in preparing oral and written communication
 Knows and understands the needs of the target audience  Recognizes the most effective use of audio- visual techniques and media Technical Food Service Management Skills People Management Skills Skills of Behavioral Change Team Work  Designs menus and evaluates its acceptability  Develops and standardizes new recipes  Develops specifications for procurement of food and equipment requirement  Establishes and maintains quality standards
 Plans and designs kitchen layout

 Possesses strong leadership  Appoints, recognizes and appraises staff  Develops job descriptions and specifications  Educates and trains the staff  Observes proper delegation of work  Applies diplomatic approach
 Acts as good mediator between staff and supervisors
 Demonstrates flexibility  Recognizes the relationship between knowledge, attitude, and behavioral change  Acquires techniques in group therapy and behavior modification  Good counsellor and adviser

 Has group dynamic skills  Recognizes the skills of other professionals in education and behavioral change.  Acquires the ability to work as a team with people other than the medical professionals
 Able to handle multi- task responsibilities

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Hospital Nutrition and Dietetics Service Management Manual | 67

Table 7.
Desirable management skills of ND II Organizational Skills Analyzing Skills Research Skills Communication Skills  Organizes the service based on the objectives  Establishes priorities and allocate resources  Participates in research activities  Prepares and analyzes reports (Statistical reports, Consumption reports, etc.)  Prepares research proposal  Systematic review of Literature  Collection of data  Analyzing of data  Prepares research reports  Motivates and leads employees  Maintains good public relations  Competent in preparing oral and written communication
 Recognizes the most effective use of multi- media Administrative Skills Clinical Nutrition Skills Supervisory Skills Team Work  Develops and standardizes new recipes  Develops specifications for procurement of food and equipment requirements  Establishes and maintains quality records  Assesses and classifies the Nutritional Status of patients  Computes the dietary requirement on specific disease  Conducts diet counseling
 Conducts out-patient lectures  Possesses strong leadership  Appoints, recognizes and appraises staff  Educates and trains the staff  Observes proper delegation of work  Has group dynamic skills  Recognizes the skills of other professionals in education and behavioral change.  Acquires the ability to work as a team with people other than the medical professionals
 Able to handle multi- task responsibilities

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68 | Hospital Nutrition and Dietetics Service Management Manual

REFERENCES

Department of Health (2004). Hospital Nutrition and Dietetics Service Management Manual Second edition.

DBM-DOH Joint Circular No. 2013-01, Revised Standards and Organizational Structure and Staffing Pattern of Government Hospitals CY 2013 Edition.

Hospital Nutrition and Dietetics Service Management Manual | 69 CHAPTER 4 FOODSERVICE ADMINISTRATION AND MANAGEMENT

The administration and management of the foodservice system of the Nutrition and Dietetics Service include the different functions to attain the goal of serving quality meals.

I. Functions of NDS Foodservice Systems

The foodservice systems of the Nutrition and Dietetic Service consist of the following functions as shown in Figure 51.

Menu Planning refers to the process of determining the specific food and beverage items to be offered by the NDS that will satisfy patients, employees and guests as well as the institution’s goals for revenues. The menu is an important working document that influence every facet of the food service operation.
Food Purchasing refers to the procurement of goods and services with due consideration to right quality, right quantity, right time and right service.
Storing and Receiving refers to functions that aim to maintain an adequate supply of food, ensure its safety for consumption and to minimize losses at all stages, from receiving to production, through spoilage and pilferage.
Food Preparation - the objectives of food preparation are to conserve the nutritive value of the food, improve the digestibility of food, develop and enhance the flavor and attractiveness, and destroy injurious organisms and substances
Food Distribution - the Nutrition and Dietetic Service usually follow the centralized food service. This service requires that trays be assembled at the dietary and then sent for dispensing into the wards or directly to the patients’ room.
Sanitation and Safety - The primary goal of the Nutrition and Dietetic Service is to provide quality food to clients. Quality food is safe food. It should be free of microorganisms, chemicals and foreign substances. To have safe food, the resources, processes and environment of the Nutrition and Dietetic Service should integrate sanitation.
Budgeting refers to forecasting activities and income or revenue, expenses and other disposition of funds and estimates an overall financial- position at the end of a specific period. Aimed to achieve goals, it provides information on what must be done to meet predetermined profit and cost objective.

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70 | Hospital Nutrition and Dietetics Service Management Manual 8. Cost Control refers to the process by which managers attempt to regulate costs based on the cost standards set by the Nutrition and Dietetic Service. It is an on- going process involving every step in the food service operation, from menu planning to service and sales, and is concerned with all cost categories; food, labor and overhead. The end objective of cost control is to eliminate excessive costs to ensure that the operation meets its pre- determined cost objectives. 9. Continuous Quality Improvement pertains to the process designed to evaluate the different functions of the food service, identify and analyze any deficiency and plan/implement corrective measure for improvement. It is an effective method for monitoring the administrative function of the Nutrition and Dietetic Service.

Figure 51.
Work flow of administrative functions of the foodservice system of the NDS

The first section of this chapter discusses the mainstream functions in the work flow, i.e. menu planning, purchasing, receiving, storage and issuance, food production, and food distribution (or service). The second section discusses sanitation, safety and maintenance, and the third, budgeting and cost control. A fourth section concludes the chapter with the facility and equipment necessary for a centralized food distribution system.

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Hospital Nutrition and Dietetics Service Management Manual | 71 II. Main Work Flow: From Menu Planning to Food Service

A. Menu Planning

The Nutrition and Dietetics Service should use a 14- to 28-day cycle menu for patients and personnel. The factors to be considered are: budget availability, supplies, manpower, and equipment. A cycle menu should be used for the guidance of all production areas. Planned menus should include foods that are in season, available locally, and should be within the skill and capabilities of the dietary personnel. They should also be within the capacity, condition, and scope of the available kitchen equipment.

A cycle menu should meet the nutritional requirements of the person to be served. It must please and satisfy the patients. Differences in ethnic, religious, and cultural background should be considered. The season of the year should also be taken into account. No matter how well it is planned, prepared, and cooked, it will not be appreciated if it is not served at the appropriate temperature. Hot food should be served hot, and cold food should be served cold.

Full diet menus should be adopted for modified diets. A menu form should be used large enough to record all menu items for the period for which menus are planned. All recipes should be standardized. The sizes of the serving portions should be established according to yield.

Planned menus should give variety through the use of:

Color. A combination of colors makes the meal attractive and appetizing besides providing the needed nutrients.
Flavor. Use a mixture of bland and strongly flavored food in meals
Shape. Plan for a variety of shapes in preparing and serving food
Texture. Include soft, crunchy and chewy food in each of the menus

The planned menus should be flexible and revised as necessary. Leftovers, if any, should be made use of as much as possible. Monthly menu conferences should be held among the Dietary Staff, Nutritionist-Dietitian, Food Service Supervisor, Chef and Senior Cook or whoever is acting as Chief Cook, to coordinate and implement changes, suggestions, and new ideas.

B. Procurement (conforms with R.A. No. 9184)

Purchasing is an operational procedure through which food items and other goods needed in the service are acquired. Policies and practices in purchasing and

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72 | Hospital Nutrition and Dietetics Service Management Manual receiving foodstuff deliveries vary among institutions. The following guidelines should be useful for all dietary services:

The Administrative Dietitian should be responsible for ordering the needed foodstuffs based on the daily menu and patient census, with the approval of the Chief Nutritionist-Dietitian and the Chief of Hospital (COH).

Purchasing decisions should be determined by the following:

Type of the people to be served
Size and location of the facility
Area available for storage of staples, refrigerated, and frozen foods
Capabilities of the dietetic staff
Available equipment
Budget allocation
Availability of the supplies/foodstuffs

The person in charge of purchasing should strive to obtain the right product at the right time, in the right quantity, and at the right cost. Quality should be the first consideration. Foodstuffs ordered or bought should be according to specifications. There should be a written description of each item to be purchased. These descriptions should be simple but detailed enough to ensure that the product is the right one. The information can be listed on the filing card and should include the name of the item, quality (grade, trade name), size (weight, number of units per carton or case, or minimum-maximum weight, quantity (cases, kilograms, pieces, cartons, etc.) and the unit of pricing (per piece, per kilogram, per dozen, etc.). Foodstuffs should be purchased either by open market or competitive bidding.

Two methods of food sourcing:

Open Market Method - this is applicable only during emergency situation based on cash advance allocation.

Situations where open market method can be applied: ● Failure of public bidding ● Negotiated procurement ● Emergency and contingency during disasters and calamities ● As much as possible, ingredients should be locally sourced and in season

Competitive Bidding – based on RA 9184, mandate of government to undergo public bidding

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Hospital Nutrition and Dietetics Service Management Manual | 73 The Open Market Method is an informal way of buying and involves the following procedures:

The buyer requests quotations on the specific food items he/she needs, and for specific amounts and qualities from one or more sources of supply. Requests for quotations should be made at least two days before an order is given.
The order is placed after consideration of the price in relation to quality, delivery, and other services offered with the approval of the head of the service.
Contact between the buyer and vendor is made by telephone, a visit to the market, or through a salesman who calls on the buyer.
It is recommended that an arrangement should be made immediately, with the purveyor, to deliver daily or depending upon the storage facilities available.
In an open market purchase, either the Nutrition and Dietetics Service staff goes to the market or foodstuffs are delivered by the purveyor.

Competitive Bidding is a more formal way of purchasing supplies. The procedures involve the following:

Submission to the Chairman, Bids and Awards Committee of the hospital, a list of the quantity and specifications of food items needed by the hospital quarterly or semi-annually.
Request for bids are advertised in newspapers or through the Government Electronic Procurement System (G-EPS) at least a month before the bidding is conducted (Refer to Republic Act (RA) 9184, Article 111, Section 8).
The bidding is conducted by the Hospital Bids and Awards Committee (HBAC). General conditions in bidding have been set to guide bidders. After the bidding, an official price list is forwarded to the Nutrition and Dietetics Service, which serve as a basis and guide in ordering foodstuffs needed by the hospital.

The following documents should be prepared when purchasing is done through bidding. Market orders prepared one week in advance should be based on these items:

Prepared menu (regular and therapeutic)
Order Slip
Price List
List of Standing orders
Average daily patient census
Inventory stock level
Annual Procurement Plan (APP)

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74 | Hospital Nutrition and Dietetics Service Management Manual Food items should be listed according to food groups. Orders indicating the item, quantity, vendor, and time and date of delivery are written on the purchase order sheet. Written orders will be verified by approving officers. Approved orders are to be presented to vendors or dealers.

For the specifications of Food Items Commonly Purchased by the Nutrition and Dietetic Service, refer to Appendices C.

C. Receiving, Storing and Issuance

Receiving is a management responsibility which ensures that the items ordered are satisfactorily received in terms of quantity and quality. Losses will result when food of poor quality is delivered or items are underweighed. Extra care should be exercised in checking orders and weighing food being received.

Suggested Guidelines in Receiving Foodstuffs

The receiving officer should be a staff Nutritionist-Dietitian or well-trained competent Nutrition and Dietetics Service personnel. The agency inspector should be present (Internal Control Service)
There should be adequate facilities and equipment for receiving such as an accurate weighing scale (large or small capacity), inspector’s table, etc.
There should be an established delivery time based on the needs of the hospital.
Food items that need precooking should be ordered and delivered in advance.
Purchase order slip must always be on hand to check all delivered against specifications and quantity called for.
The following procedures could be helpful:
a. Upon receipt of goods, they should be inspected for signs of spoilage, infestations, mishandling, etc. Verify quantity with the order as to size, count and weight.
b. When it is necessary to reject goods, the supplier should be informed immediately. Rejected goods should be returned to the dealer right away and should be properly documented. c. All delivery receipts should be signed by the designated receiver and countersigned by the agency inspector.
d. All deliveries for the day should be listed in the Daily Delivery Book e. All food items should be properly labeled according to the menu or preparation unit where it will be used. Deliveries not for immediate use should be stored in the appropriate storage area to control loss from pilferage, deterioration or infestation. f. All discrepancies must be noted for corresponding penalties.

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Food items received must be stored immediately and properly. The assigned staff is the Storeroom Keeper and Production Dietitian. The documents needed are Requisition of Supplies and Stock Bin.

General Guidelines in Food Storage

Eligible administrative aide should be in-charge of the store room under the supervision of a Nutritionist-Dietitian.
Upon delivery, food items should be properly stored. Perishable items should be placed in a cold storage and non-perishable items in a dry storage.
All storage areas should be kept locked for adequate control against loss and pilferage.
All openings to the outside environment must be secured against rodent, pests and insect invasion.
Lighting, ventilation must be controlled to prevent condensation, growth of microorganisms and molds.
Floor drains in food preparation and storage areas that might permit contamination by sewage back flow should be avoided.
Dry storage areas should be clean and well ventilated. Windows should be screened; walls and floors should be rat-proofed.
Cold storage should be equipped with thermostats or thermometers, checked and recorded daily on a Refrigerator or Freezer Temperature Chart and properly maintained. Actions taken if the temperature exceeds allowable limits (0˚F or ˗18˚C for freezers, and 44˚F or 5˚C for refrigerators) must be documented.
Overstocking of food items should be avoided, to aid the circulation of cold air.
The storeroom should be cleaned and sprayed with FDA-approved chemical spray. Special care should be given to the cleaning and spraying of dark corners and spaces under the shelves. Shelves for storing containers of food should be at least 6 inches above the floor or on wheels to permit proper cleaning of floors and to protect containers from splash and other contamination.
To prevent cross-contamination, wrap or cover food and store raw meat, poultry, and seafood separately from ready-to-eat food. If this is not possible, store ready-to-eat food above raw meat, poultry, and seafood. This will prevent juices from raw food from dripping onto ready-to-eat food.
Store food items in the following top-to-bottom order: (A) Ready-to-eat food, (B) Seafood, (C) Whole cuts of beef and pork, (D) Ground meat and ground fish, and (E) Whole and ground poultry. This storage order is based on the minimum internal cooking temperature of each food.

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76 | Hospital Nutrition and Dietetics Service Management Manual 12. Always maintain the suggested maximum storage temperature and time; refer to Table 8.

Guidelines on Temperatures in Food Storage

Store TCS food (foods that need time and temperature control for safety) at an internal temperature of 41˚F (5˚C) or lower or 135˚F (57˚C) or higher.
Store frozen food at temperatures that keep it frozen.
Make sure storage units have at least one air temperature measuring device. It must be accurate to +/- 3˚F or +/- 1.5˚C.
Place the device in the warmest part of refrigerated units, and the coldest part of hot-holding units.
Do not overload coolers or freezers. This prevents airflow and makes unit work harder.
Frequent opening of the cooler lets warm air inside, which can affect food safety.
Use open shelving. Lining shelving restricts circulation.
Monitor food temperatures regularly by randomly sampling food temperatures.

Figure 52. Temperature danger zone To keep food safe, only remove as much food from the cooler as you can prepare in a short period of time. This limits time- temperature abuse. Return prepared food to the cooler or cook it as quickly as possible. Make sure workstations, cutting boards, and utensils are clean and sanitized.

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Hospital Nutrition and Dietetics Service Management Manual | 77 Table 8.
Guidelines for Storage of Specific Foods: Recommended Temperature and Maximum Period of Storage Food Temperature (°F) Temperature (°C) Maximum Storage Canned Products
70 21 12 months Cooked dishes with eggs, meat, milk, fish poultry 36 3 Served on day prepared Cream filled pastries 36 3 Served on day prepared Dairy products

Milk (fluid)

40 5 3 days, in original container tightly covered Milk (dried) 70 21 3 months in original container Butter 40 5 2 weeks in waxed carton Cheese (hard) 40 5 6 months tightly wrapped Cheese (soft) 40 5 7 days, in tightly covered container Ice cream and Ices
10 -12 3 months, in original container, covered Eggs
45 7 7 days unwashed, not in cardboard Fish (fresh), 36 2 2 days loosely wrapped Shellfish (fresh) 36 2 5 days in covered container Frozen Products 0 (to -20) -17 (to -29)
Fruits*

Apples, Pears, Citrus

50 (to 70) 10 (to 20) 2 weeks, in original container Berries, Grapes 40-45 4.4-7.2 3 to 5 days; do not wash before refrigerating Pineapples (ripen first) 40-45 4.4-7.2 3 to 5 days; refrigerate after ripening Leftovers 36 2 2 days, in covered containers Poultry 36 2 7 days properly wrapped Meat

Ground

38 3 2 days properly wrapped Fresh meat cuts 38 3 6 days properly wrapped Liver and variety meats 38 3 2 days properly wrapped Cured Bacon, Ham 38 3 1-4 weeks, wrapped Dried beef 38 3 6 weeks, wrapped Leafy vegetables
45 7 7 days unwashed Potatoes, onions, squash, root vegetables 70 21 7-30 days dry in ventilated container or bags *Fruits that need ripening should not be refrigerated. Leave at room temperature until ripe; then refrigerate as above. The peels of ripened bananas and avocados get dark in refrigeration, but the flesh or pulp is not affected, as long as they are not bruised or the skin is intact. Sources: Perdigon, Claudio & Chavez (2006) and NRAEF (2012) ServSafe® Coursebook

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78 | Hospital Nutrition and Dietetics Service Management Manual

Guidelines for Storage of Specific Foods

Staples and Canned Goods a. Groceries and canned goods should be stored in shelves and by groups. b. Item should be stored in alphabetical sequence in their respective groups. c. Cereals / cereal products and dry vegetables should be placed in containers with tight-fitting lids. Containers should be properly labeled. The product should be inspected frequently for insect infestations. d. Cereals and cereal products, dry vegetables, spices, condiments, and canned goods should be kept in dry storage. e. Shelves or platforms should be raised at least six inches (6”) above the floor. f. For shelves placed against the walls, a two-inch (2”) leeway should be allowed. g. Canned goods should be marked with the date of delivery and should be used according to a first-in-first-out (FIFO) and first-expired-first-out (FEFO) policy. It should be inspected frequently for swells and leaks. h. Evaporated milk should be placed in the coolest part of the storeroom. i. Food packed in glass containers should be kept in closed boxes as light tends to injure the color and flavor of these items. j. Items in big boxes should be unpacked. k. Rice and flour sacks should be crossed stacked on a raised platform (6 inches [6”] from the floor) to facilitate proper ventilation and cleaning. l. Maintain standard temperature and humidity at maximum of 20º-25ºC for dry storage.

Fruits and Vegetables a. Fruits and vegetables should be examined carefully before storage. Items that are overripe and are about to wilt or rot should be stored separately for immediate use. b. Green crates of fruits and vegetables should not be stacked on the “bulge” sides. These should be cross-stacked whenever possible to allow the circulation of air. c. Thoroughly ripened fruits and vegetables should be used as soon as they are delivered. d. Ripe fruits and vegetables such as avocado, melon, mangoes, bananas, and tomatoes should be kept in the coolest part of the storeroom.

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Hospital Nutrition and Dietetics Service Management Manual | 79 e. During storage, fruits should be frequently sorted and decaying pieces removed. f. Bananas should be kept in dry storage, never in the refrigerator. g. Root crops should be stored away from the light in a moderately well ventilated room with a temperature of 40º - 60ºF).

Dairy Products a. Milk and cream containers should always be tightly covered. b. Butter should always be refrigerated. c. Cheese should be wrapped tightly to prevent drying. Freezing cheese should be avoided to prevent breaks of grain that causes crumbling. Storage temperature is 41º - 45ºF.

Eggs a. Egg crates should always be set in an upright position and cross-stacked whenever possible to allow for good air circulation. b. Eggs should not be stored for more than 3 days at room temperature from the time of delivery, if they are to be stored for more than three days, temperature should be at 41º - 43ºF.

Meat and Meat Products a. The proper temperature of a meat freezer is 31º - 42ºF or 0º - 20ºC. b. Fresh meat should be stored on the shelves, fat side up except for large pieces of beef or hog carcasses that should be hung on hooks. c. Meat should be stored separately from other foods. d. The meat should be segregated, beef next to beef, etc. with enough space in between for better circulation. e. Cured meat must be stored under refrigeration and wrapped or covered to prevent odor from spreading throughout the refrigerator. f. Ground meat should be used within 24 hours; otherwise, it should be precooked or frozen. g. Processed meats should be placed on shelves with visible labels. Issue should be on a first-in-first-out basis. h. Frozen foods must be thawed at refrigeration temperatures of 4ºC (40ºF) or below or quick thawed as part of the cooking process. Frozen foods, such as meat that had been thawed should not be re-frozen but should be used immediately afterwards. Microorganisms can multiply very quickly if food is stored at room temperature.

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80 | Hospital Nutrition and Dietetics Service Management Manual i. Cooked meat should be well covered when stored.

Fish and Seafood a. Fish should be kept refrigerated at all times at a temperature below 40ºF. b. Fish should be properly arranged when stored to hold their natural shape better and longer. c. Fish that has been thawed should not be refrozen. d. Maximum storage life can be obtained by maintaining a temperature of 0ºF or below.

Guidelines in Storing Chemicals and Cleaning Supplies

Chemicals and cleaning supplies must be stored in the designated storage area to prevent food contamination. Dirty cleaning tools, such as a mop, can also be a hazard to food. Mind these guidelines:

Always store chemicals and cleaning supplies in the designated storage area.
Ask your manager where these items should be stored.
Store chemicals in their original containers. If chemicals are transferred to a new container, the label on the container must list the common name of the chemical.
NEVER store chemicals and cleaning supplies near food. The chemicals might get on the food.
NEVER store cleaning equipment near food. Dirty equipment might contaminate the food.
Dispose of chemicals according to their labels.
Always dump mop water and other dirty liquids into a designated service sink with a floor drain.
NEVER dump mop water or dirty liquids into a toilet or urinal. It might contaminate the cleaning equipment and spread pathogens.

Guidelines in the Issuance of Foodstuffs

Dietary supplies may be issued from the Nutrition and Dietetics Service storeroom or from the Materials Management Department. The process of issuing foodstuffs from the Nutrition and Dietetics Service storeroom should be guided by the following steps:

Food should be issued only upon presentation of a properly prepared and signed requisition slip.

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Hospital Nutrition and Dietetics Service Management Manual | 81 2. The requisition slip must contain a list of all items and quantities requested and must include the signature of the authorized requesting staff or Chief Dietitian. 3. Prepared and duly signed requisition slips should be presented to the storekeeper. 4. The storekeeper should dispense the food items requested and then record them on the stock card. 5. The storeroom keeper shall be responsible for all food items issued out.

The process of issuing foodstuffs from the hospital’s Materials Management Division should be guided by the following steps:

Supplies like rice, soap, detergents, insecticides, office supplies, and other food supplies for stocks should be requested from the Property Section.
Requests should be written in the Requisition Issuance Slip form (RIS) (General Form No. 1). Supplies requested should be based on a weekly consumption or as needed.
The RIS should be properly signed by the Chief Nutritionist-Dietitian, approved by the Chief Medical Professional Staff (CMPS) or Chief Administrative Officer (CAO)
The approved RIS should be given to the Materials Management Department storekeeper for issuance of request. The RND or his/her designate should receive the supplies and endorse them to the dietary storekeeper.

The NDS storekeeper issues the supplies to be used for the day following the procedures mentioned earlier. The storekeeper should record the supplies received and issued on the stock card or bin card. (Accounting Form No. 84, revised September 2002).

D. Food Production

Food production covers all phases in the processing and preparation of food for patients and hospital staff. Systems in food production vary in accordance with supply, size of serving portions, number of patients and staff, and time of service. Use of standardized recipes and proper cooking methods should be followed in order to attain a quality product served in the NDS.

In food production, standardized recipes are important tools that could be made available to all types of NDS operations for maintaining quality and cost control. A standardized recipe includes the ingredients, quantities by weight or measure, procedure, the portion size, and yield. It should be especially adapted to the available equipment and capabilities of the food production staff.

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82 | Hospital Nutrition and Dietetics Service Management Manual Standardized recipes result in the following advantages:

Ensure high quality products due to established standards of quantity and quality of ingredients, as well as methods and techniques.
Ensure production of accurate quantities required for the service.
Reduce confusion, tension, and product failure.
Provide the basis for requisitioning and cost control.
Simplify employee training, and free the supervisor from dependence on any one cook or chef and/or changes in production staff.

Steps in Standardizing Recipes

Prepare the original recipe.
Evaluate the product for acceptability using a small selected panel.
If there are changes to be made, make one change at a time and record all adjustments made. Run two or three trials to be sure a uniform product can be produced.
Expand the recipe to yield 50 to 100 portions, whichever is desired. Make sure that calculations are correct.
Prepare the expanded recipe at least three times or more until the desired product is achieved. Use the same staff for preparation and the same panel for testing.

General Methods of Cooking

Roasting and baking with air as the cooking medium.
Boiling, simmering, poaching, and stewing with water as the cooking medium.
Steam as the cooking medium.
Frying, stir frying, sautéing with the use of oil.
Direct transference or conduction and radiation through the container as in baking waffles, griddlecakes and parboiling.
Combination of the above mentioned methods as in braising and fricasseeing.

Suggestions in the Preparation of Specific Food Items

Meat and Meat Products The methods of cooking meat and products should depend upon the quality and the cut of meat, facilities available for its preparation and service, and the quantity that should be prepared. a. Dry heat is recommended for tender cuts of meat and moist heat cookery such as braising for less tender cuts.

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Hospital Nutrition and Dietetics Service Management Manual | 83 b. It is recommended for frozen meat to be thawed before cooking to reduce time and heavy drip losses during preparation. c. Mechanical treatments such as pounding, cutting, etc., and the addition of meat tenderizers should be used for less tender cuts of meat to shorten cooking time. d. Low temperature for meat cookery is required to ensure fewer cooking losses and to obtain most palatable product. 2. Vegetables a. Cooking time for vegetables should be as short as possible to yield the desired tenderness, shape, and texture and to retain its maximum nutritional values. Overcooking of vegetables should be avoided. b. Fresh, green, and strong-flavored vegetables should be cooked in boiling water in an open kettle. c. If vegetables are cooked in water, a small amount of water is practical and should be at boiling point before the vegetables are added. d. Vegetables should be handled carefully. e. Legumes such as beans should be hydrated, by soaking them in water for at least 3 hours to shorten cooking time. f. Water in which vegetables are cooked should be used in gravies or soups to conserve soluble vitamins and minerals. g. Cooking time of vegetables should be controlled so they will be ready just at serving time.

Fish and Seafood a. Fish should be cooked at low to moderate temperature. b. Fish should be cooked within 10-15 minutes only or until the flesh is easily separated from the bones. Overcooking, especially with the dry heat method as in baking or roasting should be avoided; otherwise, the fish would turn out very dry. c. The method of cooking fish should depend on its fat content. Fat fish are best baked and broiled, as their high fat content will keep them from becoming dry. Lean fish are best cooked by boiling or steaming. All types of fish are suitable for frying. d. Frozen fish should be completely thawed before cooking. Fish, once thawed, should be cooked immediately and not refrozen. e. In the preparation of oysters and other shellfish, high temperatures and long cooking should be avoided to prevent toughening and shrinkage.

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84 | Hospital Nutrition and Dietetics Service Management Manual f. Shrimps, crabs and lobsters should be very fresh or if possible alive at the time of cooking to get the best product.

Poultry and Poultry Products a. Poultry should be cooked at moderate heat so that the meat will be tender, juicy, and evenly done. b. Poultry products should be evenly cooked, fairly well done, but not overcooked. c. Cooking methods should be suited to the age and condition of the bird.
Young, tender, and well-fatted birds are suitable for broiling, frying, and roasting. Mature or lean ones should be braised in moist heat and the old ones should be stewed or boiled in water or cooked in steam to tenderize them. d. Frozen poultry should be thawed first before cooking. Frozen poultry, which has not been thawed, requires longer cooking time than defrosted or freshly dressed ones. e. Cooked poultry should be frozen if it is to be kept for more than a day.

Eggs and Egg Products a. A soft cooked egg should have white set but jelly like and opaque; should have yolk slightly set on outside but not firm. b. A hard cooked egg should have a firm white but tender and yolk that is firm but not rubbery. It should not have any discoloration at juncture of yolk and white. c. A poached egg should have white that is set but jellylike and opaque, and yolk slightly set as well, veiled with light albumin covering. d. A scrambled egg should be moist but not watery, tender and fluffy and should be free from traces of white or evidence of browning. Omelet should be light, fluffy, delicately brown and tender. e. Fried egg should have white that is firm but not rubbery, not browned, crisping, or bubbled, and the yolk should be set but not firm. f. Omelet should be light, fluffy, delicately brown and tender. g. Custard should be smooth, homogenous, firm but tender, fine in texture and free from porosity or evidence of curdling. Soft custards should pour evenly. h. Cooked salad dressing should be homogenous, smooth, and free from curdling or separation, pours evenly and should have a glossy surface.

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Hospital Nutrition and Dietetics Service Management Manual | 85 6. Milk and Milk Products a. In dishes that use milk such as cream puff fillings; milk should not be heated in a pan directly in contact with the flame unless the heat is regulated at a low temperature. To avoid scorching, use a double boiler or a pan with water under it. b. To avoid scum formation, milk should be stirred constantly while cooking under low heat. c. Choose the right kind of cheese for cooking. Quick melt cheese is best for dishes that have to be baked or grilled because it melts fast before shrinkage and toughening occur. d. In blending cheese with liquids, the temperature of the liquid should be hot enough to melt the fat but not so hot as to toughen the protein in cheese. Grating or grinding before combining the cheese with other ingredients facilitates melting without overheating.

Cereals and Cereal Products a. Correct proportions of water to cereals should be used to retain the shape and to prevent disintegration. For rice, heat should be reduced and the cooking pan covered tightly once the boiling starts. No stirring should be done at this point. b. Pasta (macaroni, spaghetti, etc.) should be cooked firm enough, but not too soft to become mushy. After cooking, pasta should be poured into a colander or strainer and cooled with tap water. c. Dry “bihon” should be washed in water enough to make it limp but not mushy. It should be drained well before adding to the other ingredients. The amount of liquid necessary depends on the size and kind of “bihon”. d. “Sotanghon” should be washed and soaked in water, drained well and cut with kitchen shears or scissors before adding to the other ingredients. e. “Miswa” should be added directly to boiling broth or soup stock. It should be stirred gently to distribute “miswa” and cooked until done. f. Fresh “miki” should be added to the other ingredients with just enough stock to complete the cooking of the noodles, as it has high moisture content. g. “Canton” should be cooked with less liquid and for a shorter time because it has been precooked.

Starches a. To prevent lumping, other ingredients in the recipe should be mixed with the starch to separate the granules. Water should be added gradually with constant stirring to make a smooth paste.

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86 | Hospital Nutrition and Dietetics Service Management Manual b. Starches must be cooked five minutes longer after reaching maximum gelatinization point, which occurs at 90ºC to ensure complete swelling and gelatinization. c. Scorching should be avoided by thorough dispersion of starch particles by adding enough water, control of temperature, and adequate stirring with occasional scraping of the sides of the pan. d. For softer and tender gel, starches should be cooked in slow and indirect heat.

E. Food Service

Excellent food service to clients includes the quality of the menu, food preparation and service. Clients refer to patients, hospital staff and guests as well. Since patient care is the primary purpose of hospitals, quality meal service should be rendered to all patients, whether in a private room, suite room or ward. Most of the hospitals under the DOH commute the subsistence allowance of staff to cash and hence, they are no longer provided with free meals. When this is not practiced, the staff should be given adequate meals and quality service. A centralized type of service for both patient and staff is the most commonly used type of service in hospitals under the DOH, although there are still a few that are using the decentralized type of service. Whatever type of menu service is used, the following guidelines are followed:

Meal Service for the Patient

Diet List

The Diet List must be generated by the use of IHOMIS. Diet Lists should be received daily from the Nursing Unit not later than 5:00 a.m. for breakfast, 10:30 a.m. for lunch, and 3:00 p.m. for supper. It should be legibly prepared by the Nursing Service. Original copy should be submitted to the NDS for reference and filing. The Diet List should clearly include the patient’s full name, diet prescription, room number or bed number, weight in kilogram (kg), height in meter (m), BMI, age, sex, diagnosis and patient’s classification, religion, allergies, and nationality. Subsequent changes should be prepared, submitted duly signed by the nurse on duty.

The RND should verify from the nurse on duty for erroneous and/or incomplete diet lists. For certain diet that needs computation, the Nutrition and Dietetics Service will compute the dietary requirements.

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Hospital Nutrition and Dietetics Service Management Manual | 87

Admissions, Change of Diet, Discharges

Upon receipt of the Diet List, the NDS should implement the diet immediately. The Nutrition and Dietetics Service should be notified by the nurse on duty of the discharges, change of diet, patients transfer from one unit to another, room and bed number before meal hours to facilitate effective food distribution. Any notice of admission, discharge, or change of diet received by telephone should be followed by a written notice from the Nursing Unit. Suggested changes of diets received between: 6:00 a.m. – 11:00 a.m. will take effect at Lunch 11:01 a.m. – 5:00 p.m. will take effect at Supper After 5:00 p.m.
will take effect at Breakfast

Changes in diet prescription especially those in NPO and liquid diets will take effect immediately. For other diets, implementation will take effect on the next meal. Check with the ward nurses for any discrepancy in the changes or admissions sent by written notice or called to the Nutrition and Dietetics Service. Clearance for diet counseling from the Nutrition and Dietetics Service is needed prior to discharge of the patient.

Patient’s Meals and Nourishment

Patients’ diet follows the prescription of the doctors. The prescribed diet appears in the diet list. No meal trays are served to watchers of patients on NPO (nothing per oral) and those patients on tube feeding. Breastfeeding mothers are provided with meals. Suggested meal hours for patients: Breakfast 6:30 a.m. – 7:30 a.m.
Lunch
11:00 a.m. – 12:00 noon Supper
5:30 p.m. – 6:30 p.m.

An hour’s allowance is given for each meal time, after which all trays are collected and brought back to the Nutrition and Dietetics Service. “Hold Trays” (trays withheld in the NDS) for patients undergoing diagnostic procedure during meal time may be brought to the ward only when called by the nurse on duty after the procedure is done and if the tray is still necessary. Nourishment is given on computed diets.

Mid-morning nourishments may be included in the breakfast tray, mid- afternoon snacks in the lunch tray, and bedtime snacks in the supper tray or delivered separately at 10:00 a.m., 3:00 p.m. and 7:30 p.m., respectively. In such cases, the patient must be informed accordingly.

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88 | Hospital Nutrition and Dietetics Service Management Manual

Diet Orders or Prescriptions

Nutritionist-Dietitian on-duty should calculate diet orders requiring computation after referring to the chart and interviewing the patients. The computation is transferred to the index card and should be accessible to the tray line area for reference in the preparation of computed trays. The date of computation and/or revision should also be indicated. Clarification regarding the diet prescription should be verified with the attending physician or nurse on duty. The NDAP Diet Manual may serve as a reference.

Patients on tube feeding must be identified with the use of a label (Refer to Appendices A). Tube feedings must be endorsed to the nurse on-duty and properly acknowledges in the Dietary logbook. Nurse on-duty is responsible for the storage and safe handling of the formula. Nurse on-duty must also be responsible for administering the tube feeding to patients.

Dishing-out and Food Distribution

As suggested, color-coded tray cards or tags should be provided for service and pay patients. See Figure 53 for tray card samples using the following color coding:

ORANGE for all patients with modified and restricted sodium level, CKD patients GREEN for all patients with modified or therapeutic diets, diabetic, low cholesterol, low fat, hypoallergenic diet, low microbial and sterile diets BLUE for all patients on general and or clear liquid diet YELLOW for all patients on soft diet PINK for all patients with regular diet or full Diet. RED for all patients in isolation precaution

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Hospital Nutrition and Dietetics Service Management Manual | 89

Figure 53. Examples of color-coded tray cards or tags

Food should be tasted before dishing-out particularly the low salt diet. All diets should be dished out in individual trays in the main kitchen. Infection Prevention Control such as the use of disposable biodegradable containers should be practiced. The following approximate size of serving for fish, meat and poultry should be observed: 30 gm. (1 exchange)
1 small serving 45 gm. (1 ½ exchanges) 1 average serving 60 gm. (2 exchanges)
1 big serving

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90 | Hospital Nutrition and Dietetics Service Management Manual The proper tray arrangements that should be observed are provided in Figure 54.

Figure 54. Tray arrangements for breakfast, and for lunch or supper

Recording of Daily Meal Census

A daily census of all full, soft, liquid, and therapeutic diets must be recorded in a logbook provided for the purpose. The census should be taken every meal time.

B. Meal Service for Staff

The employees entitled to meal service are as follows:

All employees of the hospital who are not receiving subsistence allowance.
Hospital trainees or interns as recommended by the COH.

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Hospital Nutrition and Dietetics Service Management Manual | 91 Included as policy in staff meal service, regular meal hours should be observed as follows: Breakfast
6:30 a.m. to 7:30 a.m. Lunch
11:30 a.m. to 1:00 p.m. Supper
5:30 p.m. to 6:30 p.m.

The dining room is closed after each meal. In case of emergency, the Nutritionist- Dietitian on duty should be notified for the opening of the dining room. Authorized diners should present their meal tickets before the issuance of food. Meal hours should be strictly followed in the dining room. Taking out of meal shares and dining room utensils is strictly prohibited. Newly authorized diners should be checked by the Nutritionist-Dietitian on duty for identification, recording, and briefing on rules and regulations of meal service in the dietary. Medical trainees, observers, medical interns, and medical technology interns on makeup duty are not allowed to eat unless given permission by the COH. Regular inventory of dining room equipment and utensils should be done at the end of each day.

III. Sanitation, Safety and Maintenance

Keep food safe throughout the flow of food as illustrated in Figure 55.

A sanitation plan is important in any food service preparation area.
It ensures that all surfaces are cleaned on a regular basis and reduces the risks of transferring bacteria or other pathogens from an unclean surface to clean equipment such as cutting boards or tools.

Five risk factors for foodborne illness includes purchasing food from unsafe sources, failing to cook food correctly, holding food at incorrect temperatures, using contaminated equipment and practicing poor personal hygiene.

Time-temperature abuse happens when food has stayed too long at temperatures good for pathogen growth. Food has been time- temperature abused when it has not been held or stored at correct temperatures, not cooked or reheated enough to kill pathogens, or not cooled correctly.

Cross-contamination occurs when pathogens are transferred from one surface or food to another. It can cause a foodborne illness when contaminated ingredients are added to food that receives no further cooking, ready- Figure 55. Flow of food to illustrate food safety

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92 | Hospital Nutrition and Dietetics Service Management Manual to-eat food touches contaminated surfaces, a food handler touches contaminated food and then touches ready-to-eat food, or contaminated cleaning cloths touch food-contact surfaces.

Poor personal hygiene can cause a foodborne illness when food handlers fail to wash their hands correctly after using the restroom, cough or sneeze on food, touch or scratch wounds and then touch food, or work while sick.

Poor cleaning and sanitizing practices includes equipment and utensils not washed, rinsed, and sanitized between uses, food contact surfaces wiped clean instead of being washed rinsed, and sanitized, wiping cloths not stored in a sanitizer solution between uses, and sanitizer solution not prepared correctly.

To safeguard the health of patients and staff, the Nutrition and Dietetics Service should maintain the highest standards of sanitation and safety in all areas of food service. The standards for maintaining a safe food service environment shall include the following:

Keeping food safe from food-borne illness
Time and temperature controls
Proper hygiene techniques
Cross-contamination, sanitation and cleaning
Proper work flow of the food flow (HACCP)
Pest control and other hazards of the operation

A. Food

Foodborne illness (also called food poisoning) is an illness caused by eating foods that have harmful organisms such as bacteria, parasites, and viruses. They are mostly found in raw meat, chicken, fish, and eggs, but they can spread to any type of food. They can also grow on food that is left out on counters or outdoors or is stored too long before you eat it. Sometimes foodborne illness happens when people do not wash their hands before they touch food.

Food-borne illness may be reduced by utilizing safe food storage, handling and preparation methods by complying with government and local health standards.
Intrinsic contamination may be present in the food product when purchased. It may result from contamination introduced during food preparation, from one food to another, or from staff with silent or active infections.

A leading cause of foodborne illness is time and temperature abuse of Temperature Control Safety (TCS). The temperature danger zone is 41 to 140ºF (5 to 60ºC).
This occurs when food is not cooked to the recommended minimum internal

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Hospital Nutrition and Dietetics Service Management Manual | 93 temperature, not held at the proper temperature and not cooled or reheated properly. Keep Hot Foods Hot (must be maintained at 140ºF or above) and Cold foods cold (must be maintained at 41ºF or less).

Foods that need time and temperature control for safety - known as TCS foods, include milk and dairy products, eggs, meat (beef, pork, poultry), fish, shellfish and crustaceans, baked potatoes, tofu or other soy protein, sprouts and sprout seeds, sliced melons, cut tomatoes, cut leafy greens, untreated garlic and more.

Refer to minimum internal temperature chart for meat, fish, poultry and seafood. (Table 9)

Table 9.
Minimum internal temperature chart Food

Temperature Poultry (includes ground poultry)

165 °F* 74 °C* Stuffing, sauces, gravies, soups

165 °F 74 °C Reheated or microwaved foods,
leftovers, casseroles, hot dogs

165 °F 74 °C Ground meats: beef, pork, veal, lamb USDA: 160 °F 71 °C FDA: 155 °F 68 °C Precooked ham USDA-inspected: 140 °F 60 °C All others: 165 °F 63 °C Eggs USDA: 160 °F 71 °C FDA: 145 °F 63 °C Beef, veal, lamb, pork, fish

145 °F**

3 minute rest 63 °C**
3 minute rest Vegetable and fruits

135 °F 57 °C Commercially processed ready-to-eat foods

135 °F 57 °C NOTES: *In 2006, the USDA selected 165 F (74 C) to be the single safe minimum end-point temperature. However, consumers can choose to cook poultry to higher temperatures. It is recommended to check the temperature in whole birds at three locations – thigh (deep crevice), wing joint, and breast. **145 F (63 C) for medium rare, 160 F (71 C) for medium, and 170 F (78 C) for well done.

Along with training, provide your staff with thermometers and temperature logs for successful monitoring. The only way to be sure about a food’s temperature—and whether or not it is in the temperature danger zone. Employees should be given their own thermometers, times to check certain foods or equipment (refrigerators, freezers, fryers, serving areas), methods to log the temperature and time, and an established set of corrective action procedures. This information should then be filed in the organization’s records. An active monitoring program is essential for the prevention of foodborne illnesses.

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94 | Hospital Nutrition and Dietetics Service Management Manual When using thermometers, wash, rinse, sanitize, and air-dry thermometers before and after using them. Calibrate them before each shift to ensure accuracy. Make sure thermometers used to measure the temperature of food are accurate to +/-2˚F or +/-1˚C. Only use glass thermometers if they are enclosed in a shatterproof casing. Insert the thermometer stem or probe into thickest part of the product (usually the center). Take more than one reading in different spots and wait for the thermometer reading to steady before recording the temperature.

Holding Foods

Hot foods FDA: at least 140°F (60°C) Cold foods FDA: under 40°F (4°C)

Hold TCS food at the correct temperature; Hot food: 135˚F (57˚C) or higher; and Cold food: 41˚F (5˚C) or lower. Check temperatures at least every four hours. Throw out food not at 41˚F (5˚C) or lower. Check temperatures every two hours to leave time for corrective action. Never use hot-holding equipment to reheat food unless it’s designed for it. Reheat food correctly, and then move it into a holding unit.

Cold food can be held without temperature control for up to six hours if: it was held at 41˚F (5˚C) or lower before removing it from refrigeration; it does not exceed 70˚F (21˚C) during service. Throw out food that exceeds this temperature; it has a label specifying the time it was removed from refrigeration and time it must be thrown out; and if it is sold, served, or thrown out within six hours.

Hot food can be held without temperature control for up to four hours if: it was held at 135˚F (57˚C) or higher before removing it from temperature control; it has a label specifying when the item must be thrown out; and if it is sold, served, or thrown out within four hours.

It is recommended that after 2 hours, the food has to be discarded if it falls outside these minimal internal temperatures.

Cooling Foods

According to the USDA, foods should be cooled to below 40°F (4°C) within 4 hours of removal from cooking or they pose a danger to consumers. The FDA Food Code suggests that the cooling of hot foods occur in two stages: 135 to 70°F (57 to 21°C) in the first 2 hours, and then 135 to 41°F (57 to 5°C) within 6 hours or less. Food not reaching these temperatures within 6 hours should be discarded.

Before cooling food, start by reducing its size by cutting larger items into smaller pieces and dividing large containers of food into smaller containers or shallow pans.

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Hospital Nutrition and Dietetics Service Management Manual | 95 To cool food safely and quickly, place food in an ice-water bath, stir it with an ice paddle and place it in a blast chiller.

When storing food for further cooling, loosely cover food containers before storing them. Food can be left uncovered if protected from contamination. Storing uncovered containers above other food, especially raw seafood, meat, and poultry, will help prevent cross-contamination.

Reheating Foods

Within 2 hours before being served, all hot foods must be reheated to at least 165°F (74°C) for 15 seconds. Reheat commercially processed and packaged ready-to-eat food to an internal temperature of at least 135˚F (57˚C).

Serving Foods

When serving, the USDA recommends that the 140°F (60°C) and 40°F (4°C) boundaries continue to be observed, while the FDA Food Code suggests ≤41°F (5°C) and ≥135°F (57°C) for retailers.

Contamination may occur through improper cooking, service, storage or inadequate environmental sanitation. The Temperature Danger Zone is 41-140ºF (5-60ºC), which is the temperature range for rapid growth of most bacteria. Factors which promote growth of microorganisms once food is contaminated include:

Failure to use food within appropriate time interval after preparation
Failure to cook food within the required internal and or external temperatures
Failure to maintain or store food at appropriate temperatures
Unsanitary methods of displaying and or serving of food

Precautions should be taken to make sure that the food served is free from contamination and spoilage, and therefore, safe to eat. The following aspects of sanitation and safety should be considered:

All supplies should come from reliable and reputable sources and should be inspected thoroughly for expiration, spoilage, misbranding and adulteration.
All meat products should be inspected by the national or local regulatory authority, i.e., the National Meat Inspection Service (NMIS).
Certain foods may be contaminated at the time of purchase such as: a. Eggs and their by-products to include dry and frozen egg products. Whole eggs should be fresh and free from cracks and fecal matter. Because of the possibility of salmonella contamination. Eggs should not be eaten raw.

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96 | Hospital Nutrition and Dietetics Service Management Manual b. Dairy products c. Cream-filled pastries and poultry d. Fresh meats, fish and poultry.
4. Food should be protected from contamination while being stored, prepared, displayed, served and moved from the receiving area up to the cooking area until it reaches the patient’s room.
5. Food must be thrown out in the following situations: when it is handled by staff who have been restricted or excluded from the operation due to illness; when it is contaminated by hands or bodily fluids from the nose or mouth; and when it has exceeded the time and temperature requirements designed to keep food safe.

Safe Storage Methods

Only food items that need refrigeration should be refrigerated. Overloading of the refrigerator must be avoided to allow free circulation of air. All perishable food items should be stored at regulated temperatures to protect them from spoilage. Hot food should be kept at 140ºF or above until they are served. Hot foods must be chilled in shallow containers and must reach an internal temperature of 5ºC or less within 2 to 4 hours of preparation.

Leftovers should be refrigerated immediately in covered containers, labeled properly and should be consumed as soon as possible. Contents of opened canned goods should be transferred in stable containers made of glass or stainless steel then stored in the refrigerator and must be covered. Bottled food, like mayonnaise and salad dressing, should be refrigerated once opened. Food and food containers should be properly labeled when stored.

All the food on shelves, tables, racks or other clean surfaces should be stored in such a way as to allow free circulation of air and to protect them from contamination, insects and vermin. Fruits, vegetables, dairy products, meat, fish and poultry must be stored at refrigerated temperatures of less than or equal to 5ºC (44ºF). A temperature of less than or equal to 7ºC (45ºF) is allowed for old refrigerated equipment, if equipment is capable of maintaining temperature and will be replaced or upgraded within 5 years, per Regulatory Authority. Meat, fish, vegetables, and fruits should be washed in sinks intended only for food preparation. Raw fruits and vegetables should be washed thoroughly before use. Insecticides and pesticide should be properly marked and stored away from food and food preparation areas.

Water analysis should be regularly sampled (preferably monthly) and analyzed by a reputable company to determine bacterial contamination. Water tanks should be regularly cleaned.

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Hospital Nutrition and Dietetics Service Management Manual | 97

Handling Left-Overs

Wrap Leftovers Well. Cover leftovers, wrap them in airtight packaging, or seal them in storage containers. These practices help keep bacteria out, retain moisture, and prevent leftovers from picking up odors from other food in the refrigerator. Immediately refrigerate or freeze the wrapped leftovers for rapid cooling.

Store Leftovers Safely. Leftovers can be kept in the refrigerator for 3 to 4 days or frozen for 3 to 4 months. Although safe indefinitely, frozen leftovers can lose moisture and flavor when stored for longer times in the freezer.

Thaw Frozen Leftovers Safely. Safe ways to thaw leftovers include the refrigerator, cold water and the microwave oven. Refrigerator thawing takes the longest but the leftovers stay safe the entire time. After thawing, the food should be used within 3 to 4 days or can be refrozen.

Cold water thawing is faster than refrigerator thawing but requires more attention. The frozen leftovers must be in a leak-proof package or plastic bag. If the bag leaks, water can get into the food and bacteria from the air or surrounding environment could enter it. Foods thawed by the cold water method should be cooked before refreezing.

Microwave thawing is the fastest method. When thawing leftovers in a microwave, continue to heat it until it reaches 165°F as measured with a food thermometer. Foods thawed in the microwave can be refrozen after heating it to this safe temperature.

Reheating Leftovers without Thawing. It is safe to reheat frozen leftovers without thawing, either in a saucepan or microwave (in the case of a soup or stew) or in the oven or microwave (for example, casseroles and combination meals). Reheating will take longer than if the food is thawed first, but it is safe to do when time is short.

Reheat Leftovers Safely. When reheating leftovers, be sure they reach 165°F as measured with a food thermometer. Reheat sauces, soups and gravies by bringing them to a rolling boil. Cover leftovers to reheat. This retains moisture and ensures that food will heat all the way through.

When reheating in the microwave, cover and rotate the food for even heating. Arrange food items evenly in a covered microwave safe glass or ceramic dish, and add some liquid if needed. Be sure the covering is microwave safe, and vent the lid or wrap to let the steam escape. The moist heat that is created will help destroy harmful bacteria and will ensure uniform cooking. Also, because microwaves have

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98 | Hospital Nutrition and Dietetics Service Management Manual cold spots, check the temperature of the food in several places with a food thermometer and allow a resting time before checking the internal temperature of the food with a food thermometer. Cooking continues for a longer time in dense foods such as a whole turkey or beef roast than in less dense foods like breads, small vegetables and fruits.

Refreezing Previously Frozen Leftovers. Sometimes there are leftover "leftovers." It is safe to refreeze any food remaining after reheating previously frozen leftovers to the safe temperature of 165°F as measured with a food thermometer.

If a large container of leftovers was frozen and only a portion of it is needed, it is safe to thaw the leftovers in the refrigerator, remove the needed portion and refreeze the remainder of the thawed leftovers without reheating it.

B. Personnel

Only healthy people are suitable food handlers because disease is transmitted by an infected food handler and food service employees with poor personal habits. Thus, the following rules must be followed:

Each member of the Nutrition and Dietetics Service should be subjected to physical and medical examinations upon acceptance and at least once a year thereafter.
Nutrition and Dietetics Service personnel should observe good personal hygiene, proper habits, safe food handling and serving practices. The following should be practiced for personal hygiene: a. A daily bath b. Hair should be kept clean and neat with the use of hair net and cap.
c. Practice proper hand washing (Refer to Figure 56.) d. Food handlers must wash their hands before they start work and after using the restroom, handling raw meat, poultry, and seafood (before and after), touching the hair, face, or body, sneezing, coughing, or using a tissue, eating, drinking, smoking, or chewing gum or tobacco, and handling chemicals that might affect food safety.
e. Food handlers must wash their hands after taking out garbage, clearing tables or bussing dirty dishes, touching clothing or aprons, handling money, leaving and returning to the kitchen/prep area, handling service animals or aquatic animals and touching anything else that may contaminate hands.
Male employees should be properly shaved and must have short hair; female employees should adopt a simple well-combed hairstyle.

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Hospital Nutrition and Dietetics Service Management Manual | 99 4. Hands should be washed with soap and water for 20 seconds in hand sinks conveniently located in the unit, before and after handling food. An infection- control approved waterless hand rinse (alcohol-based hand sanitizer) as a hand- washing agent can be used.
5. Fingernails should be kept clean and cut short without nail polish. 6. Clean and washable aprons and uniforms should be worn at all times. 7. Pieces of jewelry and curlers should not be worn when on duty. 8. Clean face towel and handkerchiefs should be used to wipe face and arms. 9. Smoking is strictly prohibited. 10. Should wear proper Personnel Protection Equipment. 11. Cover wounds on: a. the hand or wrist with an impermeable cover, (e.g. bandage or finger cot) and then a single-use glove;
b. the arm with an impermeable cover, such as a bandage; and
c. on other parts of the body with a dry, tight-fitting bandage.

Unless special precautions are taken, Nutrition and Dietetics Service personnel should not be allowed to work when he has a cold or has an open sore, infected cuts or boil. NDS personnel must be trained on good personal hygiene practices and proper handling, storing, and serving of food through a continuous in-service educational program.

The Nutrition and Dietetics Service personnel must have a yearly Health Certificate issued by the City/Municipal Health Office.

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100 | Hospital Nutrition and Dietetics Service Management Manual Figure 56.
Proper hand washing procedure

Guidelines on Safe Food Handling and Serving Practices

Only clean utensils should be used in preparing, cooking, and serving food.
Food should never be handled with bare hands. Use disposable plastic hand gloves. Spoons, forks, tongs or other appropriate utensils should be used each time food is tasted.
Cups, knives, forks, spoons, spatulas and tongs should always be picked up by the handle.

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Hospital Nutrition and Dietetics Service Management Manual | 101 4. Glasses must always be handled by the base and plates by the rim, to avoid contamination of the serving surface. 5. Clean dishes, glasses and cups should be stored in enclosed cabinets with glasses and cups bottoms-up, preferably in baskets or trays 6. Broken, cracked or chipped dishes or other utensils should be discarded. 7. Glasses should not be tacked when carried. 8. Cups and glasses should not be filled to the brim. 9. A fallen piece of silverware should always be replaced with a clean one while serving. 10. Milk should be poured at the table from the original container or an approved dispenser. 11. Dish-out trays with food should not be stocked one on top of another. 12. Refrigerated storage areas must be closed after using. 13. Minimize manual food handling. 14. Leftover foods from patient’s tray should be discarded appropriately.

C. Utensils and Equipment

Equipment and utensils must be made of non-toxic, smooth, durable, non- corrosive and easily cleaned materials. Proper instructions should be given to employees on how to use and care available equipment and utensils. Equipment should be frequently checked for needed repairs that should be made as soon as possible. All equipment and utensils in food preparation, service and storage must be cleaned and sanitized regularly. The following are suggested cleaning schedules:

Daily or after use – counter tops, dining tables, chopping boards and tables, ranges, can openers, “kawas” (vats), pots and pans, garbage cans, kitchen utensils, floors.
Weekly – refrigerators, storage shelves chairs, table’s legs and fans.
Monthly – freezers, hoods, walls, ceiling, lighting fixtures, window screen, industrial exhaust fans, air conditioners and grease trap.

Equipment and utensils should be thoroughly cleaned after each use. Use disposable wares and utensils for patients with infectious and communicable disease. Cleaning schedule of areas and equipment should be posted in the board.

In order to kill pathogens, dishwashing temperatures should be between 140°F and 160°F (60°C and 71°C), and rinse temperatures must be at least 180°F (82°C) for 10 seconds or 170°F (77°C) for 30 seconds. Despite concerns that dishwashing

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102 | Hospital Nutrition and Dietetics Service Management Manual failures result in foodborne illness, only 5% of sanitation failures can be traced to faulty equipment; the remaining 95% are a result of human error.

D. Washing, Sanitizing and Disposal of Garbage

Illness-causing bacteria can survive and spread across your kitchen, so it is important to clean properly to prevent bacteria from spreading to food. Here are the right ways to wash up:

Wash hands for at least 20 seconds with soap and running water. Wash hands before preparing or eating food.
Wash surfaces, cutting boards, dishes and cooking utensils with hot soapy water after each use to prevent bacteria from spreading throughout the kitchen.
Rinse produce under running tap water, no soap required. Avoid washing seafood, meat, poultry or eggs as this can actually cause more bacteria to spread.
Sanitize sponges daily and replace frequently. Don't forget to wash dishcloths and towels on a regular basis, too.
Use appropriate washing detergents. Emphasize to NDS staff that chemicals and detergents must be used properly and correctly.

Handling of Food Waste and Garbage

Food waste and garbage disposal shall follow the policies/guidelines set by the Department of Environment and Natural Resources (DENR). The steps based on Healthcare Waste Management are as follows:

Segregation of Food Waste ● Bio-degradable (Green) ● Non-biodegradable, including Recyclable –(Black) ● Infectious (Yellow) ● Radioactive-Isotope (Orange)

Collection a. Daily routine collection b. Establishment of accredited garbage collector

Disposal

Observing proper waste disposal avoids contamination and attraction of pests. In order to further ensure sanitary practices in the NDS, the following precautions are suggested:

Segregate dietary waste according to its kind prior to disposal and use the following color-coded plastic containers or plastic garbage bags:

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Hospital Nutrition and Dietetics Service Management Manual | 103 BLACK for non- infectious dry waste like paper, carton, carbon papers, cans, bottles, plastics, straws and other biodegradable materials GREEN for non-infectious wet waste like leftover and spoiled foods, fruits and vegetable peelings and other perishable foods YELLOW for infectious waste like tissue, sanitary napkin, used cotton, gauze, etc. 2. Store garbage containers in cool areas near the exit and keep these away from food. 3. Collect and dispose garbage daily.
4. Procure garbage containers that are non-absorbent, washable, easily emptied, and tightly covered. Clean these with hot water and detergent. Use of disinfectant is encouraged.

E. Food Sanitation Checklist

Included in the Appendices are checklists on Food Sanitation in compliance with P.D. No. 856, or the Code on Sanitation, as well as Applied Food Service Sanitation. (See Appendices C)

F. Pest Control

Food naturally draws living creatures; even the cleanest facility can be put at risk of transmitting foodborne illness by the presence of insects, rodents, birds, turtles, or other animals. Rodents such as mice and rats can carry Salmonella, typhus, and the bubonic plague. Insects such as cockroaches transfer microorganisms by landing, walking, and regurgitating their stomach contents on foods when feeding. To discourage pests from taking up residence, it’s best to: (1) block pests from entering the establishment, (2) block pests from all food, and (3) maintain a pest- control program.

G. Accident Prevention

The following suggestions are to be observed to prevent accident among Nutrition and Dietetics personnel:

Floors should be cleaned and dried daily. Drippings of oil grease and water should be removed, spills of food should be cleaned immediately to prevent accident.
Preparation, cooking, serving area and corridors should be adequately lighted and ventilated.
Broken, cracked, chipped dishes or utensils and worn out equipment should be discarded.

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104 | Hospital Nutrition and Dietetics Service Management Manual 4. Remove immediately broken dishes or glasswares that have dropped on the floor. Place a chair over broken dishes on the floor if they cannot be removed immediately. 5. Equipment should be checked and inspected regularly. 6. Do not use the top of refrigerators or other equipment as storage place of supplies. 7. Unplug electrical equipment before cleaning. 8. Electrical wiring must be checked regularly by the maintenance section and must secure a safety service report.
9. Availability of functional and not expired fire extinguisher and should be placed in accessible areas for emergency use. 10. Cleaning tools and materials should be properly stored in place to avoid accidents or fall. Use proper warning device while cleaning the floor. 11. Orientation and training of kitchen personnel on the use, handling and operation of kitchen equipment, utensils and other gadgets is a must. 12. First aid kit should be made available in the Nutrition and Dietetics Service at all times. (It must include burn ointment, cotton, gauze, bandage, micropore tape, alcohol, povidone iodine, distilled water)

IV.
Budgeting and Cost Control

Budgeting is a method of estimating future needs and their concomitant cost in terms of staff, logistics, or time frame of an organization. It covers all activities for specified period and contains details of expected needs. Where management is concerned with planning, organizing, directing and controlling the use of resources, the budget becomes an essential management tool.

As the manager, the Chief ND derives the NDS budget from an analysis of the balanced and optimal use of resources to meet the objectives of the service and the hospital. These resources may be categorized into five M’s: manpower, machinery, materials, minutes, and money. The budget serves as the Chief ND’s basis for comparison and control, especially for expenditures.

Considerations in the Preparation of the Budget

The NDS budget is concerned with three categories: food, personnel, and operating expenses. The Chief ND, being responsible for the efficient and economical financial management of the service, must plan and establish the priorities of the service for the period covered by the budget.
The budget cycle in national government is a synchronized schedule, begins with the budget call from the DBM, and ends with the passage and approval of the

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Hospital Nutrition and Dietetics Service Management Manual | 105 General Appropriations Act. The DOH appropriately advises all its units and health facilities in keeping with this synchronized schedule.
3. In accordance to schedule, the Chief ND prepares and submits the Project Procurement Management Plan (PPMP) to the Finance Service, and for the approval of the hospital chief.
4. Setting the food budget is currently guided by DOH A.O. No. 2016-0020, or “Standardization of Per Capita Budget for Meal Provision of Patients of the Department of Health (DOH) and Local Government Unit (LGU) Hospitals in the Country,” dated June 13, 2016. 5. Additional needs for personnel and other operating expenses should be included in the proposed PPMP with supporting data and justifications.

Cost control is likewise a management tool used for determining and evaluating performance. With cost control, the efficiency or inefficiency of the operation can be determined, thus, unfavorable trends can be traced, hit and miss practices prevented, and corrective measures applied to ensure satisfactory completion of a task as planned.

Cost control is the responsibility of the whole Nutrition and Dietetics Service as it affects all aspects of operation. When policies and procedures in cost fail, the aim of the service remains unsatisfactory fulfilled. It is therefore imperative that the varied aspects of cost control be considered.

Cost varies according to service. In nutrition and dietetics, these are classified as food cost, labor cost and operating costs.

A. Food Cost

This includes the cost of all food items bought by the Nutrition and Dietetics Service. Ideally, these are controlled through a careful consideration of the following factors:

Menus
Type of service
Purchasing methods
Receiving controls
Storage control
Preparation, cooking, and leftover controls
Standardized portions
Waste materials
Method of pricing

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106 | Hospital Nutrition and Dietetics Service Management Manual 10. Employee’s meal cost

High food cost often results from a faulty implementation of procedures. The following are recommended containment measures with regard to food cost.

Menu Planning a. Take into account the time, day, weather, and temperature b. Consider food supplies available in the market c. Avoid monotonous menus d. Consider the appearance of the food on the plate e. Utilize correct menu patterns f. Price menu items correctly g. Maintain proper balance between high and low cost items h. Consider the type and amount of labor required for various menu items i. Consider the type and amount of equipment needed in the preparation of the menu items j. Acceptability of the menu to the clientele

Purchasing a. Purchase sufficient supplies b. Obtain foodstuffs at reasonable cost for open marketing c. Provide detailed set of specifications governing quality, weight, type, etc. d. Make use of competitive purchasing policies
e. Centralize purchasing power and responsibility f. Maintain proper cost budgets for purchasing g. Audit invoices and payments h. Use fixed orders instead of flexible orders i. Avoid bribery between purchasing agent and purveyors j. Avoid speculative purchasing

Receiving a. Avoid theft among receiving personnel b. Have an updated record of price trends c. Receive items according to the specification called for d. Observe proper receiving methods and procedures

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Hospital Nutrition and Dietetics Service Management Manual | 107 e. Use adequate facilities and proper receiving equipment such as weighing scales f. Record and check goods received diligently

Storing a. Store foods in their proper storage areas upon delivery b. Maintain proper storage temperature and humidity c. Practice daily inspection of foods stored d. Observe proper sanitation in dry and refrigerated storage areas e. Avoid pilferage in the storeroom f. Have periodic reports on dead stock or record of inventory turnover g. Conduct regular physical or perpetual inventories h. Have a written policy of personnel’s responsibility for food storage i. First-in-first-out policy in the storeroom j. Proper labelling of stocks

Issuing a. Observe proper control in recording foods issued from the storeroom b. Have proper authority or responsibility for requisition and issues c. Properly priced foodstuffs and supplies issued d. Update stock cards

Preparing a. Provide adequate mechanical equipment, for deboning, slicing, cutting, curving, trimming, and peeling b. Avoid excessive trimming of vegetables and meats c. Check raw yields properly d. Utilize leftover foodstuff properly

Cooking a. Use standardized recipes to avoid over production b. Use proper methods of cooking c. Use of proper cooking equipment and utensils d. Use proper scheduling e. Clean and maintain equipment properly

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108 | Hospital Nutrition and Dietetics Service Management Manual f. Cook in small batches, if possible g. Cook at proper temperature h. Avoid long cooking time

Serving a. Use standard portion sizes b. Use standard size utensils for serving c. Consider leftovers for recycled menu d. Record food served before it leaves the kitchen e. Bring or serve food to consumers on time f. Avoid spillage, waste, etc. g. Maintain desirable temperature of food before serving

Controlling a. Forecast cost budget b. Record price trends and determine the best time to buy food supplies c. Check on authority and responsibility of personnel d. Use forms for control purposes e. Use systematic procedures and policies for control purposes f. Account for employees’ and visitors’ meal properly

B. Labor Cost

This refers to cost of services rendered in the Nutrition and Dietetics Service. The following factors affect labor cost:

Type of service
Hours of service
Menu patterns and the form in which the food was purchased
The physical plant
Equipment and its arrangement
Personnel policy and its productivity
Efficiency of the supervisor
Rate of employees turnover and standards to be maintained
Wage scale and fringe benefits

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Hospital Nutrition and Dietetics Service Management Manual | 109 Recommended ways of reducing labor cost include the following:

Use reasonable cost machines to replace or assist manual work
Rearrange kitchen and dining room layouts to save time and steps
Apply work simplification in all tasks
Schedule employees to fit work flow
Develop interest and cooperation among employees to increase productivity

C. Operating Cost and Other Expenses

Control should not end with the control of food and labor cost. It should extend to operating and other expenses, which are either fixed or variable. Fixed expenses include depreciation cost, etc., while variable expenses include supplies (office, papers, cleaning utensils, equipment, etc.), utilities (fuel, light, telephone, water), and services (laundry, pest extermination, repair and maintenance, etc.).

D. Records in Cost Control

Records are basic tools in cost control. They contain the data needed to determine how the Nutrition and Dietetics Service functions. Records vary with the type and size of the service, the policies set, the data desired, and how these can be obtained efficiently and with the least cost. Records likewise differ with the type of the service where they will be used for the Nutrition and Dietetics Service, the following records are used:

Procurement and Receiving Records a. Purchase Request. A written record of items ordered by telephone or by personal delivery. It lists the items, quantities desired, and specifications. It is used by the management as a check against deliveries, to be sure that what was ordered was received
b. Invoice. The official receipt that accompanies the delivery of goods. This is checked against the items received and against the purchase order for correctness. Prices, quantities and totals are checked. For open market purchases, a statement of daily market purchases should be used. c. Reimbursement Expense Receipt (RER). This form is used to support claims for reimbursement of expenses where payee’s printed receipt is not available. d. Requisition Issuance Slip (RIS). This form is used for requests of supplies and materials duly approved by authorized officials. e. Stock Position Sheet (SPS). This is being maintained for each class of article. All receipts and issues of supplies and the balance on hand are recorded

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110 | Hospital Nutrition and Dietetics Service Management Manual currently on this card. This form serves as guide in preparing the estimates of the quantity and description of articles needed and in guarding against overstocking of supplies and materials. f. Inspection Acknowledgement Report (IAR). This form is used to acknowledge the receipt of supplies and equipment purchased and inspection made thereof. g. Canvass Form. This form is used to solicit prices from different suppliers for specific supplies and equipment. h. Delivery Record. A permanent record of the date of purchase, vendor, quantity received, and the price of each individual item. The primary purpose of this record is to have information on prices for costing recipes and for storeroom issues and inventories. i. Reimbursement Voucher. This form is used to reimburse expenses incurred.

Storeroom Records a. Storeroom Requisition and Issue Record. A written record of items to be issued from the storeroom. b. Perpetual Inventory is a “running” record of the balance on hand for each item of goods in the storeroom. The items received are posted from the invoices and added to the previous balance on hand. As items are taken out, they are deducted from the total. A physical count of each item should be made regularly to ensure that the total on record reconcile with the total on hand. c. Physical Inventory is an actual count of the quantities of food supplies on hand at the end of the accounting period, which can either be daily, weekly, or monthly.
d. On the other hand, there should also be an inventory of kitchen utensils and equipment. e. Stock Cards/Bin cards are records of food and non- food items received and issued on a daily basis which reflects the balance on hand.

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Hospital Nutrition and Dietetics Service Management Manual | 111

Production Records a. Menu is a list of food items to be included in each meal. Examples: one-week cycle menu; 28-day cycle menu.
b. Standardized Recipe is a recipe that has been tested in a given situation and has repeatedly produced good results. c. Production Record. A record of the amount of food to be prepared, the actual yield or quantities of cooked food available to be served, the total number of servings obtained from a given amount of food and the quantities of leftovers. This record helps in forecasting the said information.
Dining Room Service and Patient Meal Census Records a. Daily Meal Census. A form for recording the meal count. b. Diet List is a list of patients’ names who will receive a meal tray for the day. This information is needed to determine the type and amount of food to be prepared. c. Special Function Meal Request Form is a record of meals catered to hospital visitors.

Efficient and systematic way of recording and documentation is integral to the NDS to keep and maintain evidences of information about the activities of the service. Further improvements in recording and documentation systems include the following:

Proper Documentation and Recording
Computerization of Communications and other Documents.
Guidelines and Work Instructions
Guidelines in Proper Disposal of Documents

With the proper utilization of tools such as the budget and cost controls (as supported by efficient recording and documentation), the Chief ND fulfils her/his accountability to top management, and contributes to ensuring the hospital’s sound finances. Finance as referred here means the proper utilization of funds with effective cost control measures that lead to operational efficiency of the NDS to ensure the satisfactory completion of its activities and tasks as planned.

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V.
Facility and Equipment

A centralized food distribution system is the recommended type of food service. This best suits the conditions and operational standards of the different health care levels. A centralized food distribution system is where food trays are prepared at one central point, and then dispatched to the patient’s room. The food production area is usually adjacent or close to the tray set-up area. Trays are placed in conveyor carts or conveyor belts horizontally or vertically, and are then sent to the wards for distribution by the food service workers. The system has its advantages:

The proximity of the production area to the tray set-up station provides for better quality meals.
Closer supervision and control can be made of the trays regarding quality and quantity of meals.
Better food cost control can be implemented in this type of service.
Double handling of food is eliminated.
Overcooking is avoided, less time in transit.
Considerable labor is saved, both for professionals as well as non-skilled aides.
Service kitchens in wards are eliminated.
It minimizes pilferage of food.

A. Hospital Kitchen Planning

Kitchen planning necessitates the answering of the “Five W’s and One H”– WHO, WHAT, WHEN, WHERE, WHY and HOW – to come up with a functional hospital kitchen. There are factors to consider before beginning kitchen planning as summarized on Table 10.

Good facility planning and layout is a must in hospital kitchen planning. This list was prepared specifically for hospital food service kitchens. Most of this information is common to all kitchens and is essentially the same for all food services. Food and supplies are received and stored. Food is prepared, cooked, and served. Space and facility planning must be provided for these functions.

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Table 10.
Factors to consider before planning hospital kitchens General Considerations Specific Factors to Consider Administrative

▪ Type of Ownership ▪ Type of Food Service Management – Concessionaire – In-House Management ▪ Management Contract Operational ▪ Type of Service – Centralized – Decentralized – Cafeteria Service ▪ Proposed Menus ▪ Availability of Raw Materials ▪ Delivery Schedule ▪ Hours of Service ▪ Standards of Production ▪ Number of People to be Served
▪ Skills and Training of Workers Engineering and Architectural ▪ Location and Accessibility to the Wards ▪ Utilities Available ▪ Environmental Restrictions ▪ Health and Business Ordinances that Affect Buildings ▪ Architectural Restrictions (Building Characteristics) ▪ Structural Restrictions Monetary ▪ Building Budget ▪ Equipment Budget ▪ Payroll – Employees’ Wages ▪ Operating Expenses

Space Allocation

Each square meter of space in a food service operation area can be considered a fixed expense, whether it is doing more than its share or nothing at all. Once space has been allocated, it cannot be easily changed. For this reason, space should be carefully considered in designing hospital kitchens. Refer to Appendices C for sample kitchen layouts for 100- and 250-bed capacity hospitals.

Equipment Selection

Based on the analysis of kitchen requirements, consideration for the need for various types of equipment should include the general and specialized equipment for the different work areas in the kitchen. One of the most difficult problems confronting the entire food service industry today is the selection of the appropriate equipment.

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The following are factors involved in choosing the appropriate equipment: a. Needs of the Unit b. Budget allowance c. Usefulness of the equipment d. Utility and adaptability e. Safety f. Mobility g. Capability – it must have the capability to do a particular job and can handle the peak loads. It can also be adjusted to operate economically during low periods. h. Durability i. Repair, maintenance, and service - it should be easily serviced. Be sure that the equipment selected has available spare parts for replacement.

Different Work Areas and Suggested Equipment

Receiving Area: The area should be large enough for examining all food supplies with sanitation features to prevent contamination of foodstuff, must be accessible from the main roads, provided with a parking space for trucks and shall have equipment such as: weighing scale, counter table, garbage can, hand washing sink and food trolley.

Storage Area: The area should be near the receiving area and should provide a dry
storage section for staples and cold storage for perishables. ▪ Dry Storage area – should be dry, must have good lighting and ventilation, located near and in front of the nutritionist dietitian’s office and equipped with a weighing scale, bin with covers, ladder, shelves, locked and open cabinets. ▪ Cold Storage area – should be equipped with freezer, chiller and refrigerator.

Pre-Preparation Area: It should have an efficient arrangement of space with a minimum traffic, permitting the best possible workflow. The size of the preparation room should be carefully estimated to accommodate meat, vegetable, fish, and poultry with the corresponding equipment needed. It shall preferably be located as separate area, often at the side or back of the cooking units. It shall be equipped with a sink (standard sink size 20”x20”x14”), two compartments or single with drain board, a counter table, a chopping board or meat block, and garbage can with cover.

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Hospital Nutrition and Dietetics Service Management Manual | 115 Cooking Area (regular and therapeutic preparation area): The area derives its supplies from the storerooms and preparation areas. It should be near or adjacent to the pots and pans area. An island arrangement of the cooking equipment at the center of the room in large kitchens is usually favored over a wall setup to shorten the distance from the preparation area to the serving area. It shall be equipped with ranges, oven, broilers, hot plate, fryers, cook’s table, a sink near the cook’s table, rack for clean pots and pans, pot and pans sink, one large hood, ventilating fan, and portable garbage can with cover and casters.

Enteral Formulary Room: This is an integral part of the main kitchen where blenderized / commercial feedings are prepared. Preferably, the area must be air conditioned to maintain its sterility. It should be equipped with stainless working tables with shelves, blender, bottles, stainless measuring cup and spoon, sterilizer, dietetic scales, stainless washing sink, refrigerator and stove (optional).

Pots and Pans Area: Pots and pans washing area should be in a separate area equipped with deep sinks (sink 24”×24”×14”), abundance of hot and cold water, and drying racks. The location of the area should be near the cooking area but out of any main traffic lines.

Dishwashing Area: The dishwashing area should be near the tray assembly area. It should be well lighted and ventilated. It shall be located directly adjacent to the dining room and soundproofing is recommended to avoid undesirable sound. If the hand washing method is used, a 3-compartment sink shall be utilized (see Figure 57). If a dishwashing machine is used, it shall not be washed in the same sink used for those of the personnel. There should be separate doors for entrance and exit and these must be of sufficient width to permit free entry of various types of carts.

Figure 57.
Three-compartment sink (gold standard)

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Personnel Dining Room shall be sanitary, well lighted, ventilated, and located away from contagious pavilions, morgue or any unsightly surrounding. It shall be equipped with dining tables, chairs, electric fans and blowers, facilities for drinking water, and a hand-washing sink. Additional amenities can be provided such as:
audio-video system for relaxation.

Patient’s Food Service shall have either a centralized or decentralized food service. In a centralized food service, it shall be equipped with tray assembly, serving counter, bainmarie, storage cart, wares, trays and food conveyors.

In a decentralized food service, it shall be equipped with a floor pantry with adequate space for 3-compartment stainless sink, drain board, counter tables, garbage cans with covers and casters, open and closed cabinets, electric stove, refrigerator and food conveyors.

Employee Facilities: It should include separate washrooms and toilets for male and female employees. Lockers should be provided. Hand washing sinks should also be available. On Call Room as sleeping quarters must be provided as needed by the operational needs.

Food Wastes and Trash Storage: Garbage containers should not be too large to make handling difficult, or to favor accumulation of garbage. Use color-coded plastic garbage bags. It should be emptied at least twice a day, preferably after lunch and before closing time. The garbage can should be washed with detergents and hot water, and the storage area for garbage should be located adjacent to the receiving area.

Nutritionist-Dietitian’s Office: It should be strategically located to oversee all areas of operation. It should be equipped with office desks, chairs, filing cabinets with vaults, telephone, a computer with printer and internet, fax machine, photocopier, electric typewriter, an air conditioning unit or electric fan and a built-in shelves. A panel vision of glass wall may be used as part of the interior wall.

Parking Area for Mobile Equipment: Space should be allocated for parking mobile equipment such as trolleys, food conveyors and carts. (See Appendices C.)

B. Inventory and Disposal of Equipment

Inventory taking refers to the conduct of physical count of equipment and utensils. It verifies its presence, accuracy and value, disclose possibility of fraud theft or loss and reveals any weaknesses in the inventory control system. On the other hand, disposal proceedings should be immediately initiated to avoid continuing inventory

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Hospital Nutrition and Dietetics Service Management Manual | 117 cost, prevent further deterioration thereby obtaining the fair return in case of sale, and relieves employees of unnecessary accountability.

Guidelines for conducting an inventory

Identify equipment according to the following categories: ▪ heavy equipment ▪ office equipment ▪ utensils and wares
Set frequency of inventory for serviceable equipment ▪ Internal inventory – or within the NDS, monthly or quarterly ▪ External inventory – or the Inventory Committee, semi-annual or annual
Serviceable Equipment – are equipment that are still functioning or in good working condition a. Establish/require Preventive Maintenance on the following:
▪ Air- conditioning unit – monthly cleaning ▪ exhaust fan – monthly or quarterly cleaning ▪ centrifugal hoods – annual (job–out) b. Request for repair ▪ In-house ▪ Job out c. Prepare job order
Unserviceable Equipment – are equipment which can no longer be repaired or reconditioned. This also refers to equipment whose maintenance cost of repair more than outweighs the benefits and services that will be derived from its continued use.

Inventory of Unserviceable Equipment
● Prepare report of unserviceable equipment ● Evaluated by maintenance ● Condemn equipment ● Bidding process

Steps for Disposal

Request for evaluation of condemned items from Hospital Facilities Management Department.
Require pre-inspection report
Prepare and sign condemned report
Submit Condemned equipment report and Pre-inspection report and the condemned items to Supply Office

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118 | Hospital Nutrition and Dietetics Service Management Manual 5. Require acknowledgment of condemned equipment report i.e. credit slip

C. Energy and Water Conservation

Energy and water conservation must be the primary concern of the service. As the cost of energy and water continues to increase, it is possible to reduce utility bills from 20 to 30 % through energy and water conservation. The proper maintenance of equipment and facilities will help reduce energy and water consumption. However, energy and water conservation is not the sole responsibility of the head of the Nutrition and Dietetics Service or the designated conservation office, but of every worker in the NDS.

Suggestions to establish energy and water efficiency consciousness

The employees should be given lectures and training sessions on how to conserve and minimize energy losses and take proper corrective measures.
Incentive programs and recognitions for outstanding achievements on energy conservation should be set up to encourage employees to look for ways to reduce energy usage.
Signs and posters to remind the staff about energy conservation should be posted in appropriate places.

Suggestions on energy-efficient use of lighting

Lights should be turned-off when not in use and natural light should be utilized whenever possible.
Decorative lighting should be avoided.
Dirty bulbs and fixtures reduce light output. They should be cleaned regularly.
Report immediately all defective electrical fixtures to the maintenance section for appropriate action

Suggestions on energy-efficient use of air-conditioning

Delay operation of air-conditioned units when morning breeze is cool.
Shut-off air conditioner during lunch breaks.
Request regular cleaning and maintenance.

Suggestions on efficient use of water

Close the faucet when not in use.
Report defective water faucets, pipes and fittings immediately.
Regulate the usage of water

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REFERENCES

Atif W & Dela Cruz GH (2015). FoodSHAP Basic Food Safety for Food Handlers. EduSafe Publishing.

Department of Health Hospital (2004). Nutrition and Dietetics Service Management Manual Second Edition.

Jamorabo-Ruiz A, Perdigon GP, Claudio VS and the Nutritionist-Dietitians’ Association of the Philippines. (2006). Quantity Food Production in the Philippines. Merriam & Webster Bookstore Inc. Manila.

Perdigon GP, Claudio VS & Chavez LL. (2006). Food, Water and Environmental Sanitation and Safety for the Hospitality Industry and Institutions. Merriam & Webster Bookstore Inc. Manila.

National Restaurant Association Educational Foundation (2012). ServSafe® 6th Edition Manager book. Chicago, NRAEF.

SUGGESTED READING

Program to Institutionalize Meritocracy and excellence in human resource management (Prime-HRM), Civil Service Commission

Hospital Nutrition and Dietetics Service Management Manual | 159 CHAPTER 7 OTHER SPECIALIZED PROGRAMS

The responsibilities of the Nutritionist-Dietitians (NDs) are not limited to counseling patients on nutrition and healthy eating; and in developing nutrition plans and preparing and serving meals in the hospital. As a health professional, the ND has a stronger commitment and larger responsibility in addressing public and social issues especially in augmentation to the health work force in emergencies and disasters.

In this chapter, the specialized programs for the Nutrition and Dietetics Service (NDS) include medical-related programs such as targeted feeding in emergencies and disasters, nutrition management in the context of substance abuse, and the healthy lifestyle program. In addition, NDs contribute to public health programs designed to address the country’s commitments to Sustainable Development Goals that relate to proper nutrition and alleviation of hunger and eradication of malnutrition, namely: goals 1 (No Poverty), 2 (Zero Hunger), and 3 (Good Health and Well-being).

Other emerging projects related to Nutrition and Dietetics are covered in the gender and development, with particular emphasis on reproductive health, maternal and child care programs.

I.
Medical-Related Programs

A. Nutrition in Emergencies refers to essential nutrition services that are components of emergency preparedness, response, and recovery phases aimed at preventing death and worsening of malnutrition in the affected population, particularly in the most nutritionally vulnerable groups: infants, children, pregnant women and breastfeeding mothers, and older persons. Nutrition is important in each phase of the emergency response because of the following objectives: Early Phase
 To mitigate hunger, help counteract shock, and provide comfort and improve morale
 To initiate the implementation of appropriate nutrition interventions

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Intermediate and Extended Phase
 To re-establish body reserves for micronutrients leading to the improvement of the nutritional status of the malnourished
 To prevent deterioration in the nutritional status of the affected population

Priority groups include: Pregnant women; Lactating women; Infants; Children below 6 years old; Young children, 1-2 years old; Children with low weight- for-height or MUAC; Older persons; Sick and injured; Rescue workers; Cases of HIV-AIDS.

Role of the NDS in Emergencies and Disasters  Include in the Continuing Professional Education (CPE), competency building on Nutrition in Emergencies and Disasters.  Develop the nutrition part of the Hospital Disaster Risk Reduction and Management in Health Plan in accordance to the principles in planning, organizing and implementing essential health services in emergency and disaster.  Establish authority of succession to operate the plan at any time anchored on the Hospital Emergency Incident Command System (HEICS).  The NDS must support the establishment or enhancement of the hospital capacity for the management of Severe Acute Malnutrition with complications along with the Integrated Management of Child Illnesses in the light of the Universal Health Care. The NDs must be a member of the Philippine Integrated Management of Acute Malnutrition (PIMAM) Management Team supported by policy to ensure that referral pathways within and outside the hospital are clear.  Compile a set of emergencies feeding menus and listing of food supplies and equipment needed to support hospital surge capacity. The NDS must be included in the HEICS particularly in the Planning and Operations Sections when the Alert Code is raised to blue or red.  Check inventory of food supplies for expirations every three months for its freshness. Utilize and replace food stocks near expiry. Stocks and supplies for emergency management should be replaced every 3 months.  Coordinate with the Health Emergency Management Bureau (HEMB) for the location of deployment, as needed. Map out for priority Nutrition in Emergencies service package that must be implemented such as assessment of the nutritional and health needs of affected populations, protection, promotion and support of Infant and Young Child Feeding;

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Hospital Nutrition and Dietetics Service Management Manual | 161 provision of essential micronutrients; community-based management of acute malnutrition, and other cross-cutting issues.  The NDS must support the management of human milk banks, including ensuring its functionality, mobilization of volunteer mothers, and assist in the distribution in the evacuation centers.

Principles in Planning, Organizing and Implementing Emergency and Feeding Program  Multi-Disciplinary Team must do the planning, organizing and implementing the program.  Delegation of line authorities and responsibilities must be clear to all involved.  The development of a good plan requires the following information: – Probable location of mass feeding centers – Estimated number of victims and emergency response team – Existing alternative resources in terms of facilities and equipment
 Plans must be manageable.  Plans must be fully coordinated with civic and social organization, religious, and other private and government agencies involved.
The NDS as represented in the Nutrition Cluster must promote and adhere to the following principles:
 Availability and accessibility of Nutrition in Emergencies (NiE) Plan in the Nutrition and Dietetics Service.
 Dissemination of the NiE Plan among NDS personnel.
 Promotion of the following in-hospital and out-hospital, in case selected NDS Staff will be deployed to augment hospital or public health NDs:
a) Food should be limited to simple, easily available and does not require cooking as much as possible ideal food types during disasters: – Carbohydrate sources: rice, root crops, bread, noodles
– Protein sources: eggs, canned meat and fish, fresh meat and fish, dried meat and fish, milk
– Fat sources: cooking oil, margarine
– Vitamin and mineral sources: fruits and vegetables
– Others: coffee and other beverages b) To the greatest extent possible, the food provided (either in cooked or dry-ration form) should contain 100% of the PDRI for calories and protein, and at least 80 percent of vitamins A, B1, B2, niacin, iron, and

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calcium. If this is not possible, food served should meet at least 85% of the daily allowances for calories and protein even on a short-term feeding. Refer to Table 16. c) Estimating Energy Requirements: Average daily energy requirement is 2,100 kcal/person/day broken down into:
– 10 per cent of total energy provided by protein (53g)
– 17 per cent of total energy provided by fat (40g)
– adequate micronutrient intake Special needs of pregnant women:
– Need an additional 300 kcal/day
– If malnourished, need another 500 kcal/day – Should receive iron and folate supplements Special needs of lactating women:
– Need an additional 500 kcal/day
– If malnourished, need another 500 kcal/day
– Should receive sufficient fluids, taking into account activity. At least 2 liters of water are provided per victim
For HIV or HIV-AIDS cases: – Energy allowance increased as appropriate
d) Meals to be given are easy to prepare, practical, can satisfy hunger and nutritious that commonly include boiled rice, cooked sardines, boiled root crops, or one-dish meals (sinigang, nilaga, munggo). Food supplies in storage must last for 2-3 days’ consumption.
e) Meals should be served depending on the stages of emergency: – For early emergency periods characterized by stress and anxiety, serve stimulating warm drinks and light snacks. Avoid very hot or iced beverages. Milk is best for children; coffee, tea or fruit juices for adults. Easy to prepare food preferably those high in carbohydrates. – For the intermediate period, when cooking facilities are available, a full meal may be served, usually a nourishing one- dish hot meal, which is easy to prepare, transport and serve.
Meals from packaged or canned foods which do not require heating and fresh fruits may be planned; – For extended operations when cooking facilities are already set- up, one-dish meals with fruits and rice or bread may be served. Two or three meals a day may be served.

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Hospital Nutrition and Dietetics Service Management Manual | 163 f) Back-up Food Service equipment and supplies should be available: Hot beverage containers, cups, bowls; Food preparation/serving equipment; Food storage; Stove; Refrigerator/freezer; Dishwashing supplies; Pitchers, glasses or paper cups; Garbage bins; and Water dispensers.

Table 16. Recommended Philippine Dietary Reference Intakes (PDRI) by age groups Age Groups Energy (kcalories) Protein (grams)

Male Female Male Female Infants (6-12 months) 720 630 17 15 Preschool Children (1-2 years) 1000 920 18 17 Preschool Children (3-5 years) 1350 1260 22 21 Children (6-9 years) 1600 1470 30 29 Children (10-12 years) 2060 1980 43 46 Adolescents (13-15 years) 2700 2170 62 57 Adolescents (16-18 years) 3010 2280 73 61 Adults (19-29 years) 2530 1930 71 62 Adults (30-49 years) 2420 1870 71

Adults (50-59 years) 2420 1870 71 62 Older Adults (60-69 years 2140 1610 71 62 Older Adults (70 years & over) 1960 1540 71 62

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Table 17. Sample menu for various situations (Sample Survival Kit) NOTE: Menu variations may vary depending on the availability of food supplies in one’s area.

Breakfast Lunch Supper Snack NO FUEL,
NO WATER Canned/tetra pack/bottled fruit juice/water Crackers/Biscuits

Canned /tetra pack/ bottled fruit juice Canned pork & beans Crackers Canned vegetables Sardines Crackers/buns Canned/tetra pack/ bottled fruit juice Biscuits Canned/tetra pack/bottled fruit juice FUEL AVAILABLE,
NO WATER

Canned/tetra pack/bottled fruit juice/water Bread, if available or crackers/biscuits Canned vegetables Sautéed corned beef Buns Canned/tetra pack/ bottled fruit juice Sautéed tuna Bread with margarine Canned/tetra pack/ bottled fruit juice Biscuits Canned/tetra pack/ bottled fruit juice WATER AVAILABLE,
NO FUEL

Canned /tetra pack/bottled fruit juice/milk/chocolat e Drink Biscuits Canned soup Luncheon meat Bread Candies Canned vegetables Canned tuna Bread Canned/tetra pack/ bottled fruit juice Bread if available with liver spread or Biscuits Canned/tetra pack/ bottled fruit juice WATER AND FUEL AVAILABLE Champorado Fried fish Coffee/tea/milk/ Chocolate drink Noodle Soup Chicken Adobo Rice Fruit cocktail Pork Nilaga Rice Banana or canned fruit Bread/ margarine Fruit juice

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Hospital Nutrition and Dietetics Service Management Manual | 165 Table 18. Foods to be stockpiled for an emergency feeding for a family with 6 members Food Items One week Two weeks Milk/Milk products Milk, powder Powdered, Chocolate drink

3 packs - 200 grams 2 packs - 200 grams

6 packs - 200 grams 4 packs - 200 grams Rice/Substitute Rice Biscuit/Crackers Bihon Misua Macaroni Fortified Instant Noodles

7 kilos 24 pieces - 25 grams ½ kilo ¼ kilo ½ kilo 3 pack - 55 grams

14 kilos 48 pieces - 25 grams 1 kilo ¼ kilo 1 kilo 6 pack - 55 grams Fruits and Vegetables Powdered Fruit Juice Canned Mushroom Canned Green peas Canned Garbanzos Canned Sweet Corn Kernel

2 packs - 200 grams 1 can - 420 gram 1 can - 360 grams 1 can - 420grams 1 can - 420 grams

4 packs - 200 grams 2 cans - 420 grams 2 cans - 360 grams 2 cans - 420g 2 cans - 420grams Sugar ¼ kilo ½ kilo Protein Sources (canned/ dried) Luncheon Meat Corned Beef Vienna sausage Pork & Beans Canned Pusit Sardines in Tomato Sauce Dried Fish, Tuyo/Dilis Daing Mongo Beans

2 cans - 350grams 5 cans -160 grams 4 cans - 160 grams 2 cans - 420 grams 4 cans - 420grams 3 cans - 420grams ¼ kilo ½ kilo ½ kilo

4 cans - 350 grams 10 cans - 160grams 8 cans - 160 grams 4 cans - 420 grams 8 cans - 420grams 6 cans - 420grams ½ kilo 1 kilo 1 kilo

Table 19. Sample menu of stock foods for an emergency and disaster feeding

MEALS Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Breakfast Hot Milk Biscuits Hot Choco Bihon w/ Sardines Juice Biscuits

Macaroni Soup w/ Corned beef Juice
Biscuits Hot Milk Instant Canton Hot Choco Biscuits Lunch Vienna Sausage
Rice Canned Pusit Rice Corned beef w/ peas Rice Luncheon Meat w/ Sweet Corn Rice Pork & Beans Rice Tuyo Rice Luncheon Meat w/ Mushroom Rice Supper Sardines Rice Pork & Beans Rice Canned Pusit Rice

Mongo w/ Daing Rice Vienna Sausage Rice Canned Pusit Rice Corned
beef w/ Garbanzos Rice

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B. Nutrition Management for Substance Abuse or Persons Who Use Drugs (PWUDs) – Nutrition therapy should address the most serious medical and nutritional conditions first and then target the psychological and behavioral aspects of eating. Adoption of the Yale Food Addiction Scale (YFAS) which is a valid diagnostic instrument for food addiction and has been used widely in clinical research. Foods most notably identified by YFAS to cause food addiction were those high in fat and high in sugar.

Drugs impact nutrition in different ways:

Opiates (including codeine, oxycodone, heroin, and morphine) slow the way the body functions, making people who take them feel sleepy and less able to efficiently process nutrients from food. The most recognizable side effect of disrupted digestion is constipation. Symptoms that are common during withdrawal include diarrhea, nausea and vomiting that may lead to a lack of enough nutrients and an imbalance of electrolytes (such as sodium, potassium, and chloride). Eating balanced meals may make these symptoms less severe (however, eating can be difficult, due to nausea). A high-fiber diet with plenty of complex carbohydrates (such as whole grains, root crops, vegetables, peas, and beans) is recommended.

Marijuana can increase appetite. Some long-term users may be overweight and need to cut back on fat, sugar, and total calories.

Stimulants such as cocaine, methamphetamine and prescription ADHD medications reduces appetite, and leads to weight loss and poor nutrition. Users of these drugs may stay up for days at a time resulting in dehydration and electrolyte imbalances during these episodes. Returning to a normal diet can be hard if a person has lost a lot of weight. Stimulant users are also more likely to develop eating disorders, such as anorexia. Memory problems, which may be permanent, are a complication of long-term stimulant use.

Nutritional Guidelines and Policies on the Management of Substance Abuse/ Persons Who Use Drugs (PWUDs)

 The brain mechanisms in people with food addiction are similar to those in people with substance dependence, such as persons who use drugs (PWUD). Proper nutrition can help the healing process. Nutrients supply the body with energy and provide substances to build and maintain healthy organs and fight off infection to help improve the odds of a lasting and healthy recovery.

 Prioritize efforts to improve eating habits and overall health in recovery programs. Promote regular mealtimes. Provide foods that are low in fat, more protein, complex carbohydrates and dietary fiber. Vitamin and mineral

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Hospital Nutrition and Dietetics Service Management Manual | 167 supplements may be helpful during recovery (these may include B-complex, zinc, and vitamins A and C).

 During recovery from substance use, dehydration is common. Provide enough fluids during and in between meals. Appetite usually returns during recovery. A person in recovery is often more likely to overeat, particularly if they were taking stimulants. Emphasize to patients the importance of eating healthy meals and snacks and avoidance of high-calorie foods with low nutrient-density, such as sweets.

Recommended Menu for PWUDs

Foods identified likely to trigger dependence symptoms are avoided. These foods correlate with the high-fat, high-sugar foods. The YFAS questionnaire lists the following foods to restrict or avoid in planning and serving meals for the PWUDs:  Sweets like ice cream, chocolate, doughnuts, cookies, cake, candy  Starches like white bread, rolls, pasta, crackers and biscuits  Salty snacks like chips, pretzels  Fatty foods like steak, bacon, hamburgers, cheeseburgers, pizza, and French fries  Sugary drinks like soda or soft drinks.  Coffee or drinks high in caffeine

C. Healthy Lifestyle Program is designed to prevent the incidence of non- communicable diseases and other health-related disorders. It is a combination of physical activity and proper nutrition in achieving desirable body weight, reducing risk of chronic diseases, promoting overall well-being and improving quality of life. The National Nutrition Council (NNC) recommends the adherence to a holistic, sustainable, adequate, and nutritionally-balanced diet, complemented by an active lifestyle and lifelong behavioral modifications.

Examples of programs that can be offered in the hospital are health risk assessment, biometric screening, disease prevention and management, weight loss program, stress management, smoking cessation, healthy food options (e.g., in cafeteria, vending machines), classes in nutrition or healthy living, mental health services, and safety program (e.g., ergonomics, workplace violence education).

The NDS must discourage the poor dietary practices such as the popular Fad Diets. These refer to dietary practices that promise weight loss or other health advantages characterized by highly restrictive or unusual food choices. Teenagers

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following fad diets are at risk of permanently stunted growth. Most fad diets fall into five general groups:

Low-carbohydrate high fat diets, such as the Atkins diet, The Zone Diet, Sugar Busters, Ketogenic diet;
High-fiber, low-calorie diets, which often prescribe double the normal amount of dietary fiber;
Food-specific diets, which encourage eating large amounts of a single food, such as the grapefruit diet or the cabbage soup diet;
Liquid diets such as meal replacement drinks (Cambridge diet, SlimFast), or Master Cleanse. Liquid diets do not provide enough nutritional value to sustain the human body consistently and should only be used for short periods of time for example in these cases: after heart attacks, after certain kinds of surgery, with patients who have digestive problems, with patients who have acute infections, and before certain X-rays of the digestive tract.
Fasting, e.g., the lunar diet which is simply fasting according to the lunar calendar, allowing only water and juice during a full or new moon to lose weight in a single day. Intermittent fasting (IF) has become an increasingly popular way to lose weight fast. The approach involves extended periods of not eating; e.g., fasting for two days out of the week (called 5:2, which involves eating very little on fast days), or setting a specific eating window (like 16 hours fasting, 8 hours feeding).

The NDS must use the National Nutrition Council Governing Board Policy Statement on Fad Diets which emphasized that fad diets are nutritionally- imbalanced, challenging to comply with in the long-run, induce stress, trigger disease to certain organs, lack focus on physical activity, and may have psychological implications in educating the patients and the general public. Recommendations for a safe, healthy, and holistic dietary, exercise, and behavioral plan as key to long-term weight loss and improvement of overall health must be advocated by the NDS in particular and all NDs in general, both in private and public practice.

D. Complementary and Alternative Medicine (CAM) refer to medical products and practices that are not part of standard medical care and are not fully integrated into the dominant health-care system. They are used interchangeably with traditional medicine.

As defined in RA 8423, traditional and alternative health care is “the sum total of knowledge, skills, and practices on health care, other than those embodied in biomedicine, used in the prevention, diagnosis, and elimination of physical or mental disorder,” while traditional medicine is “the sum total of knowledge, skills, and practice on health care, not necessarily explicable in the context of modern,

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Hospital Nutrition and Dietetics Service Management Manual | 169 scientific philosophical framework, but recognized by the people to help maintain and improve their health towards the wholeness of their being, the community and society, and their interrelations based on culture, history, heritage, and consciousness.” Complementary medicine is when alternative medicine (e.g., acupuncture, homeopathy, Chinese or Oriental medicine) is used with mainstream medical treatment and care in the belief that the combination of the two would enhance the efficacy of the treatment.

E. Celebration of Nutrition Month is observed every July of the year, led by the National Nutrition Council in all private and government hospitals pursuant to Presidential Decree 491 also known as “The Nutrition Act of the Philippines”. It aims to promote and raise awareness among Filipino people about healthy diet that protects against under- and over-nutrition, as well as non-communicable diseases (NCDs) such as hypertension, diabetes mellitus, cardiovascular diseases and certain types of cancer. Planning of activities related hereto are established and carried out throughout the year through which the NDS anchors month-long activities within the hospital.

II.
Public Health Related Programs

The NDS must support the Philippine Integrated Management of Acute Malnutrition Program through initially enhancing capacities in collaboration with the other health professionals. Assessment, classification, and case management of the following can happen in the public health or hospital setting based on the presentation of signs and symptoms.

Specifically, the NDS must play an active role in the management of Severe Acute Malnutrition (SAM) following the In-patient Therapeutic Care Protocol. The NDS must also establish its capacity to manage cases enrolled in the Out-patient Therapeutic Care for possible referral and admission.

In addition, considering a worst scenario, the support of NDS will be required in the public health setting for the appropriate management of moderate acute malnutrition.

In all of the above cases, the concepts and principles are discussed below in details:

A. Severe Acute Malnutrition (SAM) is characterized by a very low weight-for-height below -3 z-scores of the median WHO Growth Standards, visible severe wasting and presence of bilateral pitting edema.

Identification of Severe Acute Malnutrition
a. Infants less than 6 months of age - presence of any of the following: – W/L < -3 SD

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– MUAC <115 mm or <11.5 cm – Presence of bilateral pitting edema b. Children 6-59 months of age - presence of any of the following: – MUAC <115 mm or <11.5 cm – Presence of bilateral pitting edema – Weight-for-Height (W/H) or Weight-for-Length (W/L) < -3 SD c. Children more than 5 years old, adolescent, and adults - There is no international agreement on the MUAC cut-off for adolescents and adults. (UNICEF 2015). – Available published data for adults suggests <160mm, but this is currently considered too low in non-famine contexts (including in the context of HIV/AIDS) – MUAC cut-offs of <180 or <185mm are most widely used by agencies.

Refer to Tables 20, Table 21, and Table 22, respectively.

Table 20. Identification of acute malnutrition in infants <6 months of age Infants <6 mos. Criteria Severe Acute Malnutrition WFL < -3 z-scores

MUAC < 115mm or 11.5cm or Presence of bilateral pitting edema Moderate Acute Malnutrition WFL < -2 z-scores and  -3 z-scores MUAC 11.5 cm to <12.5 cm SOURCE:
Adapted from UNICEF Programme Guidance Document (2015). Management of Severe Acute Malnutrition in children: Working towards results at scale.

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Table 21. Identification of acute malnutrition in children 6-59 months of age Children 6-59 mos. Criteria Severe Acute Malnutrition MUAC < 115mm (11.5cm) OR Presence of bilateral pitting edema OR Weight-for- Height (WFH) or Weight-for- Length (WFL)
< -3 Z-scores Moderate Acute Malnutrition MUAC < 125mm (12.5cm) AND  115mm (11.5cm) WFH or WFL < -2 z- scores AND  -3 z-scores SOURCE:
Adapted from UNICEF Programme Guidance Document (2015). Management of Severe Acute Malnutrition in children: Working towards results at scale.

Table 22. Summary of suggested criteria for admission for SAM used in children five years or older, adolescents and adults Age group Criteria for therapeutic admission Children 5 – 9 years MUAC < 129mm AND / OR BMI for age
< -3 z-score AND / OR Bilateral pitting edema Adolescents 10 – 18 years MUAC <160mm
AND / OR BMI for age
< -3 z-score AND / OR Bilateral pitting edema Adults > 18 years BMI < 16 (kg/m) AND / OR MUAC < 185mm AND / OR Bilateral pitting edema SOURCE:
Adapted from UNICEF Programme Guidance Document (2015). Management of Severe Acute Malnutrition in children: Working towards results at scale.

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2. In-Patient Therapeutic Care (ITC)

ITC for children with SAM is provided in order to:  Stabilize children with SAM aged 6-59 months who also have medical complications or a lack of demonstrated appetite sufficiently to allow them to continue their nutritional rehabilitation with Out-Patient Therapeutic Care (OTC).
 Recover infants < 6 months with SAM who require intensive treatment.  Provide complete nutritional rehabilitation in inpatient care for children with SAM where there is no access to OTC.
 Children in outpatient care may also be referred to inpatient care for a period of more intensive treatment/monitoring when they are not responding appropriately to treatment as an outpatient.

Table 23. Flow of activities in in-patient therapeutic care (ITC)

ITC for children with SAM aged 6-59 months focuses primarily on the nutritional and medical stabilization of the child and appropriate management of medical complications. It occurs in three distinct phases: Phase 1 or Stabilization, Transition, and Phase 2. See Table 23.

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Hospital Nutrition and Dietetics Service Management Manual | 173 a. Assessment and Admission
Assess the mid-upper arm circumference or the weight-for- height/weight-for-length status of infants and children who are 6–59 months of age and also examine them for bilateral edema. Infants and children who are 6–59 months of age and have a mid-upper arm circumference <115 mm or a weight-for-height/length <–3 Z-score of the WHO growth standards, or have bilateral edema, should be immediately admitted to a program for the management of severe acute malnutrition. Children identified as having SAM should first be assessed with a full clinical examination to confirm whether they have medical complications and whether they have an appetite. Children who have medical complications, severe edema (+++), or poor appetite (fail the appetite test), or present with one or more Integrated Management of Childhood Illness (IMCI) danger signs should be treated as in-patients. Children with severe acute malnutrition who have severe bilateral edema (+++), even if they present with no medical complications and have appetite, should be admitted for inpatient care. Children with SAM who are admitted to hospital can be transferred to outpatient care when their medical complications, including edema, are resolving and they have a good appetite, and are clinically well and alert. The decision to transfer children from inpatient to outpatient care should be determined by their clinical condition and not on the basis of specific anthropometric outcomes such as a specific mid-upper arm circumference or weight-for-height/length.

b. Nutritional Management of children 6-59 months
For new admissions to ITC, use F75 for Phase 1 nutritional management. For admissions coming from OTC who are already demonstrating appetite, RUTF can be used and Phase 2 entered directly. Children with severe acute malnutrition who present with either acute or persistent diarrhea, can be given ready-to-use therapeutic food in the same way as children without diarrhea, whether they are being managed as inpatients or outpatients.

c. Phase 1 / Stabilization Step 1:
Calculate the quantity of F75 therapeutic milk (a low protein formulation containing the right balance of macro- and micronutrients) to be administered. The energy requirement of the child in Phase 1 is 100 kcal/kg/day. This translates to 130mL of F75 milk/kg/day. The F75 is given according to

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the weight of the child (in Appendices C). Check manual calculations of milk requirement against the tables for accuracy.
Step 2:
Prepare F75, alternate F75 recipe, or F100 diluted as a temporary measure (administering the same volumes as given for F75, refer to related tables in Appendices C). Step 3:
The milk should be given in divided feeds ideally every two (2) to three (3) hours in Phase 1 depending on the condition of the child (8-12 feeds per day, see Appendices C for volumes of milk to be administered according to number of feeds per day). Step 4:
Pre-prepared feeds may be used overnight, but only where functional refrigeration units are available for storage following preparation. The milk should be warmed before use by placing the milk in a bowl of hand-hot water for 5-10 minutes. Milk should not be reheated by direct heat or microwave. Unused refrigerated milk should be disposed of after 12 hours. Step 5: If clinical assessment is delayed for any reason, give 10% sugar-water (10g or 1 tablespoon of sugar in 100mL of water) if the child is able to take oral fluids in order to prevent hypoglycemia. Fruit juice may be given if no sugar-water is available.

d. Transition Phase - takes one to three days but may take longer.
It signals a change in the nutritional management of the child. The amount of energy provided in Transition Phase is increased by 30% (to 130 kcal/kg/day) and the amount of protein is increased.
Transition Phase is entered once: 1) medical complications are resolving; 2) appetite returns; and 3) edema is reducing. Transition may be divided into two distinct management approaches: (1) Transition to outpatient care for SAM where it is available (2) Transition to Phase 2 inpatient care where outpatient care for SAM is not available

Transition to RUTF in Preparation for Outpatient Care – normally takes one to three days but may take longer. The aim is to prepare the SAM child for nutritional rehabilitation in outpatient care (i.e. to eat sufficient RUTF to gain weight and recover) while ensuring they get all the nutritional requirements they currently

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Hospital Nutrition and Dietetics Service Management Manual | 175 need. This is done by gradually introducing and increasing the proportion of the daily feeding provided by RUTF. Step 1:
Prepare indicated dose of RUTF, the appropriate quantity of F75 for the child and a glass of drinking water. Step 2:
The caregiver should be instructed to wash their hands and the child’s hands and face. Step 3:
Ask the caregiver to offer the child the RUTF. Step 4: Observe the child eating the RUTF. Step 5: After each mouthful, breast milk or a sip of water should be offered to the child. Note: RUTF is a thick paste and plenty of clean drinking water should be available for the child to drink. Older children can ask for water when they are thirsty but young children must be offered the water regularly when taking RUTF. A thirsty child may refuse RUTF which may be mistaken for poor appetite. Step 6: If the child fails to eat the required amount of RUTF at each feed, the child should finish the feed by being offered the ration of F75 to drink in addition to any RUTF that has been eaten. The time taken to eat the RUTF and F75 (if necessary) should be no more than 1 hour. Step 7: Record the amount of both F75 and RUTF taken on the patient’s treatment chart. Step 8: After each feed, the RUTF should be placed in a cool dry place, safe from insects and re-used at the next scheduled feeding time. Step 9: The process of offering both RUTF and F75 continues until the child is able to take the required amount for 24 hours.

When at least 75% of the full OTC daily amount of RUTF (see Annex 4) is eaten within 24 hours and there are no other issues identified during monitoring, the child is considered to be ready to continue their rehabilitation at home through the OTC. The child may then be discharged from the hospital and referred to the OTC nearest to their home.

Children with SAM who present with some dehydration or severe dehydration but who are not shocked should be rehydrated slowly, either orally or by nasogastric tube, using oral rehydration solution for malnourished children (5–10 mL/kg/h up to a maximum of 12 h).

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Transition to Phase 2 Using F100 When there is no outpatient treatment available, the child must be treated and cured of SAM entirely within the inpatient care setting. For children remaining in inpatient care, the energy requirement of 130 kcal/kg/day is given in the form of F100 therapeutic milk. F100 contains 100 kcal/100mL of milk. This means that when the milk is changed from F75 to F100 in Transition Phase, the volume of milk the child has been receiving in Phase 1 remains the same; only the type of milk changes.
The child should continue to be breastfed on demand.
The amount of F100 milk to be given in Transition Phase is indicated in Annex 5. This transition onto a higher calorie diet can take one to three days. The child should be monitored closely during this time. When at least 90% of the prescribed F100 ration is being taken orally and no other issues are identified during monitoring, the child is considered ready to continue their rehabilitation in Phase 2.

e. Phase 2 – average duration is 2 – 3 weeks In Phase 2, the energy and protein intake of the child is increased to 200 kcal/kg/day, giving F100 therapeutic milk. During Phase 2, iron is added to the therapeutic milk. The amount of iron to be added is as follows:  200mg Ferrous Sulfate (1 tablet) in 2 liters therapeutic milk
 100mg Ferrous Sulfate (1/2 tablet) in 1 liter therapeutic milk
 If smaller quantities of milk are being given, crush 100mg (1/2 iron tablet) and mix thoroughly in 10mL of water (ensure the tablet is well crushed and leaves no sediment).
 Add 10mg Ferrous Sulfate (1mL of 10mL Iron solution) in each 100mL of therapeutic milk Table 24 gives the volume of F100 therapeutic milk to be given in Phase 2. Feeds should be given at least five (5) times per day. The table gives milk volumes depending on whether 5 or 6 feeds per day are given.

Nutritional Management of infants less than 6 months

Feeding approaches for infants who are less than 6 months of age with severe acute malnutrition should prioritize establishing, or re-establishing, effective exclusive breastfeeding by the mother or other caregiver.

Infants who are less than 6 months of age with SAM and who are admitted:

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Hospital Nutrition and Dietetics Service Management Manual | 177  Should be breastfed where possible and the mothers or female caregivers should be supported to breastfeed the infants. If an infant is not breastfed, support should be given to the mother or female caregiver to re-lactate. If this is not possible, wet nursing should be encouraged;
 Should also be provided a supplementary feed:
– supplementary suckling approaches should, where feasible, be prioritized;
– For infants with severe acute malnutrition but no edema, expressed breast milk should be given, and, where this is not possible, commercial (generic) infant formula or F75 or diluted F100 may be given, either alone or as the supplementary feed together with breast milk;
– For infants with severe acute malnutrition and edema, infant formula or F75 should be given as a supplement to breast milk;
 Should not be given undiluted F100 at any time (owing to the high renal solute load and risk of hypernatremic dehydration);
 If there is no realistic prospect of being breastfed, should be given appropriate and adequate replacement feeds such as commercial (generic) infant formula, with relevant support to enable safe preparation and use, including at home when discharged.

Table 24. F100 formulations for infants <6 months per phase Phase F100 formulations for infants <6 mos. Phase 1 Diluted F100 at 100kcal/kg/day (8 feeds per day) Transition Phase Diluted F100 at 130kcal/kg/day (8 feeds per day) Phase 2 Diluted F100 at 200kcal/kg/day (6 feeds per day)

Individual Monitoring, Follow-up and Referral

Where a child has a complication or is undergoing fluid rehydration, the monitoring needs to be much closer and should be indicated by the clinical staff on an individual patient basis. Unless there are signs of Refeeding Syndrome, acute watery diarrhea, or osmotic diarrhea, there is no need for the child to pass back into Phase 1. There is also no need to treat the diarrhea unless the child loses weight. The child should continue RUTF (or F100 if transitioning to Phase 2 inpatient care) and be observed closely. The diarrhea should NOT be treated with Zinc.

Switch from RUTF to F100 for Transition if the child is stable but appetite is not improving after three days in Transition (the required amount of each feed is not being taken). In this case, switch to F100 and transition the child

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to Phase 2. Transition onto RUTF can be attempted again after a couple of days.

Discharge - Criteria for discharging children from treatment
a. Children with severe acute malnutrition should only be discharged from treatment when their:
 weight-for-height/length is ≥–2 Z-score and they have had no edema for at least 2 weeks, or
 mid-upper arm circumference is ≥125 mm and they have had no edema for at least 2 weeks.
b. The anthropometric indicator that is used to confirm severe acute malnutrition should also be used to assess whether a child has reached nutritional recovery, i.e. if MUAC is used to identify that a child has severe acute malnutrition, then MUAC should be used to assess and confirm nutritional recovery. Similarly, if weight-for-height is used to identify that a child has severe acute malnutrition, then weight-for- height should be used to assess and confirm nutritional recovery.
c. Children admitted with only bilateral pitting edema should be discharged from treatment based on whichever anthropometric indicator, mid-upper arm circumference or weight-for-height is routinely used in programs.
d. Percentage weight gain should not be used as a discharge criterion. e. Infants who are less than 6 months of age can be discharged from all care when they are breastfeeding effectively or feeding well with replacement feeds, and 1) have adequate weight gain, and 2) have a weight-for-length ≥–2 Z-score.
Out-Patient Therapeutic Care (OTC)

The activities in Out-Patient Therapeutic Care (OTC) are shown in Table 25.

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Hospital Nutrition and Dietetics Service Management Manual | 179 Table 25. The activities in out-patient therapeutic care (OTC)

a. Assessment Admission

Children who have appetite (pass the appetite test) and are clinically well and alert should be treated as outpatients.

b. Nutritional Management

Nutritional rehabilitation in outpatient care is through the use of Ready-to- Use Therapeutic Food (RUTF). Determine the amount of RUTF required by the child based on their current weight at an intake of 200 kcal/kg/day. The amount given to each patient must be adjusted as weight increases during treatment.

c. Individual Monitoring, Follow-up and Referral

Children with severe acute malnutrition who are discharged from treatment programs should be periodically monitored to avoid a relapse. In some cases where children are not responding to treatment (loss or static weight for two weeks), chronic conditions may be suspected and in this case, children should be referred for further investigations in the hospital.
This can include:

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 Referral for TB testing, counseling and treatment  Referral for screening and assessment of congenital abnormalities (e.g. congenital heart defects, cerebral palsy, etc.)
 Referral for HIV counseling and testing
 Referral for assessment of family functioning and capacity for care (refer to the Municipal Social Welfare Worker/ Officer)

Follow-up through home visit should be triggered for children with medical complications who have refused transfer to inpatient care and are being treated on an outpatient basis.

B. Moderate Acute Malnutrition (MAM) is defined as moderate wasting indicated by a low weight-for-height between -3 and -2 Z-scores of the WHO Growth Standards median, or by a mid-upper arm circumference (MUAC) between 11.5 cm and 12.5 cm.

Assessment

Nutritional status in acute malnutrition can be classified as moderate (MAM), severe (SAM) or no malnutrition (normal) based on the measure of MUAC in a child 6 up to 59 months old; the measure of WFL/H according to the Child Growth Standards; and/or the presence or absence of bilateral pitting edema.

Mid-upper arm circumference of the left arm is a quick way of identifying acute malnutrition in children under five. It has a color-coded indicator of nutritional status. Table 26 provides the MUAC interpretation.

Table 26. MUAC Interpretation Classification MUAC Color SAM <11.5 cm RED MAM 11.5 cm to <12.5 cm YELLOW Normal 12.5 cm GREEN

Table 27. Admission criteria for MAM cases Age Group Admission Criteria Infants and young children 6–59 months ƒ WFL/H Z-score -3 to < -2 (WHO CGS), OR ƒ MUAC 11.5 cm to < 12.5 cm, AND ƒ Absence of bilateral pitting edema* NOTE: *Edema is a clinical sign of SAM even if MUAC and WFL/H criteria are not met, thus referral to SAM program

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Hospital Nutrition and Dietetics Service Management Manual | 181 2. Admission to MAM program

All children 6 months to 59 months of age who fulfill any of the admission criteria in Table 27 or classified as having MAM should be admitted to the MAM treatment program. The procedures of admission is shown in Figure 66.

Figure 67. Procedures of admission

Nutritional Management / Intervention

Figure 68 shows the various interventions in the TSFP for the management of MAM. It includes addressing the nutritional status of the child and providing routine child health services to ensure better management of the health and nutrition of the child. The nutrition intervention for the management of MAM is through targeted supplementary feeding program (TSFP), while the blanket

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supplementary feeding program (BSFP) is the nutrition intervention for the prevention of MAM, provided with wet rations or dry rations.

Figure 68. Interventions for management of SAM

Three Forms of Supplementary food:
 RUSF – ready-to-use supplementary food or ready to eat
 Locally Prepared Foods with MNP
 Blended cereals – as wet or dry ration (preparation needed)

a. Ready-to-use Supplementary Food (RUSF)
This supplementary food is a commercially produced food preparation made of peanuts, sugar, milk powder, vegetable oils, and vitamins and minerals, though they may be made with chickpeas, almond or other commodities.
 It comes in individual packages and used for the management of moderate acute malnutrition in infants and children 6-59 months.
 Provides 513-550 kcal per day with 12.6-15.4 grams of protein and 30- 38.6 grams of fat and 42.7 g carbohydrate  It is fortified with 23 micronutrients (vitamins A, D, E, C, B1, B2, B6, B12 and K; biotin, folic acid, pantothenic acid, niacin, calcium, phosphorus, potassium, magnesium, zinc, copper, iron, iodine, sodium and selenium) and contains essential fatty acids and quality protein to ensure that the child’s nutritional needs are met.
 It can be consumed directly from the package with no dilution, mixing or cooking necessary.

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b. Locally Prepared Foods
In the absence of RUSF, supplementary foods for 6-59 month children can be prepared from local food sources. Micronutrient Powder (MNP) should be added to the prepared food. When planned properly, the energy and macronutrient (protein, fat and carbohydrate) contents of the locally prepared food are comparable to the RUSF. For ease of computation, the Food Exchange list can be used to calculate the energy and macronutrient content.
The ND may modify the calculation depending upon the availability of local foods but making sure that the energy and macronutrient contents are close to that of RUSF.
 Locally prepared foods can be given in between the regular meals/feeding of breakfast, lunch and supper.
– The food shall have an energy content of 510-560 kcal, protein of 11-16 grams and fat of 26-36 grams (the rest from carbohydrates: 30.5-70.5 g carbohydrates*), equivalent to a sachet of RUSF.
– One sachet of MNP should be given every other day. MNP is distributed only to 623 month old children by DOH and the LGUs. Make sure that MNP is made available to 24-59 month old children with MAM.
– The food should contain all essential nutrients in adequate amounts. The extra nutritional requirements will enable young children to have accelerated weight and height gain and full physiological recovery.
– The nutrients should be biologically available to children with altered intestinal function that is associated with MAM.
– Locally prepared foods can be stored at home up to 4 hours at a time at room temperature.
 In areas where infants and children can be gathered in a community, the BNS and the mothers can prepare the supplementary foods such as ginataang bilo-bilo, arroz caldo, squash congee, and fried rice in the community center. This may also be an opportunity for the BNS to conduct

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nutrition education, food safety, and WASH in the community. Cooking demonstrations of complementary/supplementary foods and gardening may also be done.
 The Barangay Nutrition Committee may also opt to identify local food vendors who can provide and/or prepare the complementary/ supplementary food given that the local food vendors have the necessary business and sanitary permits, and health certification.

Continued breastfeeding for infants 6 to 24 months and beyond and giving of appropriate complementary foods is necessary in addition to the locally prepared food comparable with RUSF given to the child.

c. Blended Cereals
Blended cereals are milled supplementary food from whole grains and beans such as wheat, oats, soybeans and mung beans. The blended food is modified in its energy density, protein, fat or micronutrient composition to help meet the nutritional requirements of specific formulations. This food is not intended to be the only source of nutrients but should complement the regular diet of the child. The blended cereals can be given to children as wet feeding or as dry take home rations where preparation can be done at home.

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Hospital Nutrition and Dietetics Service Management Manual | 185 Wet Supplementary Feeding (on-site rations)
 Food is prepared once or twice daily in the kitchen of the supplementary feeding center (SFC) and is consumed by the child in the center for a duration of the treatment program.
 The child is then brought to the center daily to consume the supplementary food.
 Usually implemented in emergency settings when people have limited access to fuel and water, security conditions put people at risk while taking rations home, or for those who need additional food but cannot cook for themselves.
 This option is only used in exceptional circumstances.  Two meals are needed to provide the right amount of energy and protein given the small stomach size of children.
 Can also be given in the SFC while the participant waits for his/her dry ration.

Dry Supplementary Feeding (take-home rations)
 The ingredients are mixed in the SFC prior to distribution; the mixture is taken home to be prepared and consumed by the child at home, or in temporary settlements for special circumstances such as emergencies.
 The ration is a fortified blended food (FBF) with sugar and oil (pre-mixed or distributed separately), or may include high-energy biscuits, beans, lentils and wheat.
 Distribution is every 1-2 weeks depending on the resources, access to distribution sites, security and other conditions.
 One-week distribution is preferred for hygienic purposes, storing less food in the household
 Experience also shows that the ration is shared and consumed within a short time after distribution; biweekly distribution is preferred when the beneficiaries have a long way to travel to reach the SFC.
 The distribution days are usually timed with market days, while there are MAM days or SFP days in some areas, and usually once a month distributions in GIDAs (geographically isolated and disadvantaged areas).
 A take-home or dry ration is usually more than the amount required in order to compensate for family sharing. Sharing of ration among family members will lessen the energy and nutrients that are intended for the child.

All children 6 to 59 months of age, whether registered or not to the SFP shall also receive their regular health services as scheduled (See Table 28). These services are available in BHSs and RHUs.

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Table 28. Sample timeline for routine health services for a year Month Breastfeeding Oral Health Immunization Vitamin A Deworming MNP/Iron 1st

MNP 2nd

MNP 3rd

Measles

Iron 4th

GP GP Iron + Folate 5th

6th

Iron 7th

8th

9th

Iron 10th

GP GP

11th

12th

DPT

d. Monitoring, follow up and referral

Figure 69 illustrates the procedures for monitoring and recording data for the management of MAM.

Figure 69. Procedures for monitoring and recording data for the management of MAM

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e. Procedures of Discharge

As soon as the child reaches the criteria for discharge (WFL/H > -2 Z-score and/or MUAC >125 mm) for two consecutive weeks, s/he can be discharged from the program. The procedures of discharge are as follows:  Inform caregiver the reason for discharge
 Record anthropometric measurements
 Check immunization & IYCF
 Link to other services
 Follow up for 3 months

f. Forming Linkages

The management of MAM is closely linked with existing health, nutrition, early child development, WASH and social services. Strategies for the management of MAM merge with public health interventions that promote optimal child development. These strategies include the promotion of age-appropriate breastfeeding and complementary feeding practices (IYCF), access to appropriate health care for the prevention and treatment of disease, and improved water, sanitation and hygiene practices (WASH).

Linkages could be formed with the following and considered by the health and nutrition workers as well as hospital staff.
 SAM treatment
 Health and nutrition programs through the Municipal/City Health Offices, District or Provincial Hospitals: IYCF, Operation Timbang Plus, EPI, MNP Supplementation
 Integrated Management of Childhood Illness (IMCI)
 Mother support groups and activities in line with nutrition
 Social welfare programs through the DSWD: Conditional Cash Transfer (4Ps), Sustainable Livelihood Program, KALAHI-CIDSS, Self- Employment Assistance-Kaunlaran (SEA-K)
 Food security, agriculture and livelihood programs by LGUs, NGOs or private sectors
 WASH promotion
 PhilHealth enrolment and coverage

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III.
Other Special Projects

A. Gender Equality and Development is to achieve “Health for All” as well as promote gender equity in the health service delivery. It is necessary for the policy- maker, program planner, the government and public health workers to sensitize with aspects of gender in the public health system and how it works in the social system.

Gender mainstreaming is a strategy for developing policies, legislations, programs, projects, society and nutrition and dietetics development plans for gender equality perspective in order to benefit for the women and men.

Magna Carta of Women

RA 9710 contends that women are active agents of development and not just passive recipients of development assistance; and stresses the need of women to organize themselves and participate in political processes to strengthen their legal rights. In order to eliminate discrimination against women, a comprehensive national strategy consisting of health programs, services and information for promoting women’s right to health throughout their lifespan shall be developed and implemented.

Reproductive Health Program – access to programs and services shall be ensured for responsible, ethical, legal, safe, and effective methods of family planning; prevention of abortion and management of pregnancy-related complications; prevention and management of infertility and sexual dysfunction pursuant to ethical norms and medical standards; prevention and management of reproductive tract cancers such as breast and cervical cancers, and other gynecological conditions and disorders.
Maternal and Child Care Program – to include pre-natal services, delivery and post-natal services to address pregnancy and infant health and nutrition; promotion of breastfeeding and proper nutrition for lactating mothers; management, treatment, and intervention of mental health problems of women and girls.

B. Occupational Safety and Health deals with all aspects of safety and health in the workplace which primarily focuses on the reduction of occupational health and safety risk and prevention of work-related incidents. It is mandatory to educate the workforce on basic requirements for workplace health protection.

RA 11058 or “An Act Strengthening Compliance with Occupational Safety and Health Standards (OSHS) and Providing Penalties for Violations Thereof” requires employers to provide complete safe work procedures; inform workers of hazards associated with their specific jobs; provide appropriate and personal protective equipment which have passed the Department of Labor and Employment’s required tests; and provide access to mandatory OSH trainings as prescribed by the DOLE.

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There shall be health and safety policies and practices for identifying distress, harmful use of psychoactive substances and illness and for providing resources and support to manage them, involvement of employees in decision-making, organizational practices supporting a healthy work-life balance, programs for employee career development and recognition of employee contribution.

These may include policies for smoke-free workplaces, ergonomic workplace design, work equipment and tools; ergonomic risk assessment; administrative controls: adequate staffing levels, job enlargement and rotation, working hours and breaks, worker education and training; personal protective equipment, healthy food options at low prices in food service facilities and vending machines; physical activity programs with inclusion of workers in planning and implementation, and protection from violence, harassment and bullying.

Occupational Safety and Health Standards Compliance Simple technical guidance for employers and workers should be made available on the following topics:
 Assessing and managing exposure to hazardous substances, and the use of Occupational Exposure Limits (OELs);
 Controlling exposure to biological agents;
 Noise assessment and control (including simple control methods for controlling noise at source);
 Controlling exposure to non-ionizing radiation including exposure to the sun  Preventing work-related musculoskeletal disorders  Managing psychosocial risk factors including violence, bullying and harassment leading to work-related stress  Provision of a safe work environment, including protection from exposure to second hand tobacco smoke, and adequate welfare facilities  Management of health and safety in the NDS in general. A healthy and safe workplace is essential to the wellbeing of employees and employers. This requires an ongoing understanding that efforts must be managed and sustained. Any tools, strategies or programs that can help a company to improve its health and safety is worthy of consideration.
Universal Precautions are the basic standard of infection control. The underlying principle is to assume that all patients and staff are potentially infected with blood-borne pathogens such as HIV and hepatitis B virus.

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Universal Precautions is intended to prevent transmission of infection from patient to staff, staff to patient, staff to staff, and patient to patient. The procedures for Universal Precautions shall include: a. Standard hygienic procedures, especially handwashing, should be followed at all times. b. Hospital or medical center guidelines for disinfection and sterilization should be consulted and followed faithfully. c. Any skin disease or injury should be adequately protected with gloves or impermeable dressing to avoid contamination with a patient's body fluids. d. Any spills of blood or other potentially contaminated material should be liberally covered with household bleach (dilution of 1 to 10), left for 30 minutes then carefully wiped off by personnel wearing gloves. e. Gown, gloves, mask and protective eyewear should be worn, if possible, during surgery, childbirth and other procedures where contact with blood or body fluids are likely. f. Needles and sharp objects should be discarded immediately after use in puncture-proof containers marked BIOHAZARD. Do not bend or break needles by hand. Do not recap used disposable needles. g. Reusable needles and syringes should be handled with extreme care and safely stored prior to cleaning and sterilization or disinfection h. Linen soiled with blood or other body fluids should be handled as little as possible. Gloves and a protective apron should be worn while handling soiled linen. i. Specimens of blood and body substances should be handled as potentially infectious.

The HIV and AIDS Core Team (HACT) is the primary group tasked to provide treatment, care, and support services to PLHIV, as well as to implement policies and guidelines on matters relating to HIV and AIDS in a hospital setting. HACT is multi-disciplinary group of health workers with policy-making, implementing, coordinating, assessing, training, research and other project development functions on matters related to the diagnosis, management and care of HIV/AIDS patients and the prevention and control of HIV/AIDS infection in the hospital. Its primary objectives are to facilitate the provision of safe, comprehensive and compassionate care to HIV/AIDS patients by properly trained personnel; to mobilize hospital and community resources towards minimizing the impact of HIV/ AIDS infection on the patient and his family; and to coordinate all efforts to prevent and control the transmission of HIV/AIDS infection.

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Hospital Nutrition and Dietetics Service Management Manual | 191 The duties and functions of ND as member of the team include:
 Educating clients on the need for proper nutrition and healthy living;  Preparation of dietary guidelines for clients upon discharge.

C. Other Opportunities in Coordination with the DOH

The DOH releases a calendar of activities related to health events and celebrations (Table 69). The NDS can lead and actively participate by supporting these activities in various ways like conducting free nutrition counseling, exhibitions and demonstrations, cook fests and awareness campaigns.

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Table 29. Calendar of Health Events in the Philippines MONTH DAY/S NAME OF OBSERVANCE JANUARY All Month National Deworming Month

All Month Schistosomiasis Awareness and Mass Drug Administration Month

All Month Liver Cancer and Viral Hepatitis Awareness and Prevention Month

3rd Week Autism Consciousness Week

4th Week Goiter Awareness Week

Last Sunday World Leprosy Day FEBRUARY All Month National Cancer Awareness Month

All Month Philippine Heart Month

All Month Oral Health Month

All Month National Health Insurance Month

All Month National Down Syndrome Consciousness Month

2nd Week National Awareness Week for the Prevention of Sexual Abuse and Exploitation

Last Week Leprosy Control Week

Last Week National Rare Disease Week

14th to 20th Mental Retardation Week - Feb 14-20

4th World Cancer Day

15th International Childhood Cancer Day MARCH All Month Colorectal Cancer Awareness Month

All Month Rabies Awareness Month

1st Week Women's Week

3rd
International Ear Care Day

8th
National Women's Day

24th
World TB Day APRIL All Month National Hemophilia Awareness Month

1st Week World Health Worker's Week

Last Week World Immunization Week

Last Week Head and Neck Consciousness Week

7th
World Health Day

25th
World Malaria Day MAY All Month Cervical Cancer Awareness Month

All Month Hypertension Awareness Month

All month Road Safety Month

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Hospital Nutrition and Dietetics Service Management Manual | 193 MONTH DAY/S NAME OF OBSERVANCE MAY 2nd Week Safe Motherhood Week

Last Week International Thyroid Awareness Week

3rd Sunday AIDS Candlelight Memorial Day

7th
Health Worker's Day

25th
World Thyroid Day JUNE All Month Prostate Cancer Awareness Month

All Month Cancer Survivor's Day

All Month Scoliosis Awareness Month

All Month Dengue Awareness Month

All Month National Kidney Month

All Month National No Smoking Month

3rd Week National Safe Kids Week

4th Week National Poison Prevention Week

14th World Blood Donor Day

15th ASEAN Dengue Day

23rd
DOH Anniversary

26th
International Day Against Drug Abuse and Illicit Trafficking JULY All Month National Deworming Month

All Month National Blood Donors Month

All Month Nutrition Month

All Month National Disaster Resilience Month

All Month Filariasis Mass Drug Administration Month

3rd Week National Disability Prevention and Rehabilitation Week

8th
National Allergy Day

11th
World Population Day

17th
National Cardiopulmonary Resuscitation (CPR) Day

30th
World Day Against Trafficking in Persons AUGUST All Month Blood Cancer Awareness Month

All Month Family Planning Month

All Month ASEAN Month

All Month Sight Saving Month

All Month National Lung Month

All Month National Adolescent Immunization Month

All Month National Breastfeeding Awareness Month

1st Week Mother-Baby Friendly Hospital Initiative Week

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MONTH DAY/S NAME OF OBSERVANCE AUGUST 2nd Week Philippine National Research System Week

2nd Week Asthma Week

1st to 7th
World Breastfeeding Week

6th to 12th
National Hospital Week

1st Family Planning Day

1st
White Cane Day

12th
International Youth Day

19th
National TB Day SEPTEMBER All Month International Childhood Cancer Month

All Month World Leukemia Awareness Month

All Month Generics Awareness Month

All Month Blood Diseases Month

All Month National Thyroid Cancer Awareness Month

1st Week National Epilepsy Awareness Week

1st Week Obesity Prevention Awareness Week

3rd Week Alzheimer's Disease Awareness Week

16th to 22nd
Cerebral Palsy Awareness Week

10th
World Suicide Prevention Day

17th
World Patient Safety Day

26th
World Environment Health Day

28th
World Rabies Day OCTOBER All Month Breast Cancer Awareness Month

All Month National Hospice and Palliative Care Awareness Month

1st Week National Newborn Screening Week

1st Week Filipino Elderly Week

2nd Week National Mental Health Week

3rd Week Bone and Joint Awareness Week

3rd Week National Attention Deficit / Hyperactivity Disorder Awareness Week

3rd Week Health Education Week

Last Week Food Safety Awareness Week

2nd Thursday World Sight Day

10th
World Mental Health Day

15th
Global Handwashing Day

29th
World Psoriasis Day

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Hospital Nutrition and Dietetics Service Management Manual | 195 MONTH DAY/S NAME OF OBSERVANCE NOVEMBER All Month Lung Cancer Awareness Month

All Month National Children's Month

All Month Filariasis Awareness Month

All Month Traditional and Alternative Health Care Month

All Month Malaria Awareness Month

2nd Week National Skin Disease Detection and Prevention Week

3rd Week National Consciousness Week Against Counterfeit Medicine

Last Week National Biotechnology Week

23rd to 29th
Population and Development Week

3rd Wednesday Chronic Obstructive Pulmonary Disease Awareness Day

7th
National Food Fortification Day

14th
World Diabetes Day

17th
World Prematurity Day

19th
World Toilet Day

25th
National Consciousness Day for the Elimination of VAWC

Nov 25th to
Dec 2nd
18-Day Campaign to End Violence Against Women DECEMBER All Month Firecrackers Injury Prevention Month

2nd Week Linggo ng Kabataan

3rd to 9th Ear, Nose and Throat Consciousness Week

1st
World AIDS Day

3rd
International Day of Persons with Disabilities

6th
National Health Emergency Preparedness Day

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REFERENCES

Development Initiatives (2018). 2018 Global Nutrition Report: Shining a light to spur action on nutrition. Bristol, UK: Development Initiatives.

DOH Administrative Order No. 2015-0055: National Guidelines on the Management of Acute Malnutrition for Children under 5 Years.

DOH Administrative Order No. 2010-0008: Policies and Guidelines in the Conduct of HIV counseling and testing (HCT) at community and health facility settings.

DOH HIV & AIDS Core Team Operating Guidelines. Feb 23, 2016.

DOH-UNICEF Philippines Manual of Operations. First Edition (2015). National Guidelines on the Management of Severe Acute Malnutrition under 5 years.

DOH-WFP Manual of Operations. First Edition (2016). National Guidelines on the Management of Moderate Acute Malnutrition for Children Under 5 Years.

DOLE Occupational Safety and Health Standards (As Amended). Occupational Safety and Health Center, Manila. Reprinted 2017.

Health Research & Educational Trust. (2016, October). Health and wellness programs for hospital employees: Results from a 2015 American Hospital Association survey. Chicago, IL: Health Research & Educational Trust.

Khawandanah, J.A. & Tewfik, I. (2016). Fad Diets: Lifestyle Promises and Health Challenges. Journal of Food Research. 5(6): 80.

Local Government Unit Disaster Preparedness Manual for City and Municipal LGUS (2018). Local Government Academy (LGA) Department of the Interior and Local Government.

NEDA-PCW (2016). Harmonized Gender and Development Guidelines for Project Development, Implementation, Management, Monitoring and Evaluation. Third Edition. National Economic and Development Authority, Philippine Commission on Women Official Development Assistance Gender and Development Network.

NNC Governing Board Resolution No. 4, Series of 2018 Adopting the NNC Policy Statement on Fad Diets

Pocket Emergency Tool. 4th Edition (2012). Philippine Department of Health – Health Emergency Management Staff (DOH-HEMS), with support from the Emergency and

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Hospital Nutrition and Dietetics Service Management Manual | 197 Humanitarian Action, Regional Office for the Western Pacific, World Health Organization (WHO-WPRO).

Presidential Decree 491 s. 1974. Creating A National Nutrition Council and For Other Purposes

PSA Board Resolution No. 09, Series of 2017 “Approving and Adopting the Initial List of Sustainable Development Goals for Monitoring in the Philippines”. Initial list as of May 16, 2017.

Republic Act 9710 Magna Carta of Women. Implementing Rules and Regulations.

Republic Act 8423, traditional and alternative health care.

Salz, A. (2014, December). CPE Monthly: Substance Abuse and Nutrition. Retrieved from http://www.todaysdietitian.com/newarchives/120914p44.shtml

UNICEF Programme Guidance Document (2015). Management of Severe Acute Malnutrition in children: Working towards results at scale.

World Health Organization (2018). HEARTS Technical package for cardiovascular disease management in primary health care: healthy-lifestyle counselling; Geneva: WHO.

World Health Organization (2017). International minimum requirements for health protection in the workplace. Geneva: WHO.

World Health Organization (2016). Healthy Workers, Healthy Future Why investing in healthy workers is fundamental to national development. WPR/2016/DNH/016.

World Health Organization (2013). Pocket book of hospital care for children: guidelines for the management of common childhood illnesses – 2nd edition. Geneva: WHO.

World Health Organization, Wolf J, Prüss-Ustün A, Ivanov I, Mugdal S, et al. (2018) . Preventing disease through a healthier and safer workplace. World Health Organization. https://apps.who.int/iris/handle/10665/272980.

WHO and DOH (2009). Training Manual for Health Workers on Healthy Lifestyle: An Approach for the Prevention and Control of Non - communicable Diseases.

World Health Organization (2013). Guideline: Updates on the management of severe acute malnutrition in infants and children. Geneva: WHO.

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Hospital Nutrition and Dietetics Service Management Manual | 199 CHAPTER 8 CONTINUOUS QUALITY IMPROVEMENT

The standards of the Hospital Nutrition and Dietetics Service are geared towards Continuous Quality Improvement (CQI), a cyclical process of assessing performance, implementing improvement plans, and reassessing results. CQI is founded on a total quality management philosophy, established in a quality management system compliant with ISO 9001:2015 standards, and strategically managed on platforms such as the Performance Governance System and the Strategic Performance Management System.

CQI in the NDS intends to evaluate patient care, identify and analyze deficiencies, and plan and implement corrective measures to improve patient care. It is an effective system of monitoring nutrition assessment and care. The ten (10) steps of the CQI process are:

Development of criteria for optimum care;
Assignment of responsibilities;
Delineation of the scope and care;
Identification of indicators;
Establishment of thresholds for evaluation;
Collection and organization of data;
Evaluation of data related to quality of care;
Taking action to improve care;
Assessing action and documentation of improvements; and
Communication of findings or outcomes.

CQI is the responsibility of every employee, and a committee or department is organized to monitor CQI activities in a facility with a Chairperson and Department Head as members. Components of CQI include client satisfaction, scientific approach and team approach.

I.
Total Quality Management

As a holistic, organization-wide approach in maintaining and improving quality service, total quality management (TQM) requires a highly proactive, highly participative style of management. It is a philosophy that gives major emphasis on the continuous process of quality improvement with the effective use of resources and sustained patients and clients satisfaction as ultimate goals.

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Hospital Nutrition and Dietetics Service Management Manual | 200 The very purpose of managing quality is to establish a system that measures and manages care in a way to provide the best care for all clients/patients. To achieve this would require a deliberate effort for managers at every level of the organization to initiate and maintain quality.

TQM acts as a valuable management tool that assist health care professionals in achieving and maintaining the highest possible level of quality care for all patients of the facility. The common guiding principles in TQM practice can be summarized by the ACCEPT acrostic: A – Aim for patient satisfaction C – Communicate and coordinate all activities C – Cooperate towards continuous improvement E – Empower the employees P – Promote usage of problem-solving tools T – Train for quality

The above principles can only take root if there is a well-uniformed quality leadership that sustains the continuous improvement process.

II.
Quality Management System

Quality per International Organization for Standardization (ISO) is the “totality of features and characteristics of a product or service that bear on its ability to satisfy stated or implied needs.” A federation of national standards bodies, the ISO’s aims to promote the development of standardization to facilitate international exchange of goods and services.

The ISO 9000 series of standards define what is required of a quality-oriented system. Principles involved in quality management include:

Customer Focus
Leadership
Engagement of people
Process approach
Improvement
Evidenced-based decision making
Relationship management

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Hospital Nutrition and Dietetics Service Management Manual | 201 ISO 9001:2015 provides the requirements for a quality management system (QMS). The adoption of an ISO 9001:2015 compliant QMS is a strategic decision for an organization such as a health facility to improve its overall performance and provide a sound basis for sustainable development initiatives. The potential benefits to an organization of implementing an ISO 9001:2015 QMS are:

The ability to consistently provide products and services that meet customer and applicable statutory and regulatory requirements;
Facilitating opportunities to enhance customer satisfaction;
Addressing risks and opportunities associated with its context and objectives;
The ability to demonstrate conformity to specified quality management system requirements.

A. The Process Approach

The ISO 9001:2015 employs the process approach, which incorporates the Plan-Do- Check-Act (PDCA) cycle. The process approach enables an organization to plan its processes and their interactions to enhance customer satisfaction by meeting customer requirements.

Understanding and managing interrelated processes as a system contributes to the organization’s effectiveness and efficiency in achieving its intended results. This approach enables the organization to control the interrelationships and interdependencies among processes of the system, so that the overall performance of the organization can be enhanced.

The PDCA Cycle enables an organization to ensure that its processes are adequately resourced and managed, and that opportunities for improvement are determined and acted on. The cycle can be briefly described as follows:

Plan: establish the objectives of the system and its processes, and the resources needed to deliver results in accordance with customers’ requirements and the organization’s policies, and identify and address risks and opportunities;
Do: implement what was planned;
Check: monitor and (where applicable) measure processes and the resulting products and services against policies, objectives, requirements and planned activities, and report the results;
Act: take actions to improve performance, as necessary.

Figure 70 shows the ISO 9001:2015 requirement clauses incorporated into the PDCA cycle.

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Hospital Nutrition and Dietetics Service Management Manual | 202 Figure 70. Repetitive four-stage PDCA cycle model for continuous improvement

B. Risk-Based Thinking

ISO in its guide on risk management defines risk as the “effect of uncertainty of objectives.” Further, it clarifies that effect is “[a] deviation from the expected” whether positive and/or negative, and that risk is “often characterized by reference to potential events and consequences, or a combination of these.” Uncertainty surrounding objectives may be due to lack of information, understanding or knowledge on the likelihood of these potential events and consequence.

ISO 9001:2015 employs a risk-based thinking approach because a QMS is established as a tool to prevent risks. The standard requires that in establishing the organization’s context, it shall determine risks (and opportunities) as basis for planning, implementing and documenting the QMS. The organization is required to apply risk-based thinking, to formulate actions to address risks, and may keep documents as evidence how it determined risks.

C. ISO 9001:2015 QMS Requirements

Table 30 summarizes the requirements in establishing a QMS as defined by ISO 9001:2015.

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Hospital Nutrition and Dietetics Service Management Manual | 203 Table 30. Main clauses and requirements under ISO 9001:2015 Main Clauses Titles of Clauses Specific Clauses Requirements 4.0 Context of the Organization 4.1 Understanding the organization and its context 4.2 Understanding the needs and expectations of interested parties 4.3 Determining the scope of the QMS 4.4 QMS and its processes 5.0 Leadership 5.1 Leadership and commitment
(includes 5.1.2, “Customer Focus”)

5.2 Policy (i.e. “Quality Policy”)

5.3 Organizational roles, responsibilities and authorities 6.0 Planning 6.1 Actions to address risks and opportunities

6.2 Quality objectives and planning to achieve them

6.3. Planning of changes 7.0 Support 7.1 Resources
(includes 7.1.2, “People”; 7.1.3, “Infrastructure”; 7.1.4, “Environment”; 7.1.5, “Monitoring and measuring resources”; 7.1.6, “Organizational knowledge”)

7.2 Competence

7.3

7.4 Communication

7.5 Documented information 8.0 Operation 8.1 Operational planning and control 8.2 Requirements for products and services
(includes 8.2.1, “Customer communication”, 8.2.2, “Determining the requirements”, 8.2.3, “Review of the requirements”, 8.2.4, “Changes to requirements”) 8.3 Design and development of products and services
(includes 8.3.2, “Planning”; 8.3.3, “Inputs”; 8.3.4, “Controls”; 8.3.5, “Outputs”; 8.3.6, “Changes”)
8.4 Control of externally provided processes, products and services 8.5 Production and service provision 8.6 Release of products and services 8.7 Control of nonconforming outputs 9.0 Performance Evaluation 9.1 Monitoring, measurement, analysis and evaluation (includes 9.1.2, “Customer satisfaction”)

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Hospital Nutrition and Dietetics Service Management Manual | 204 Main Clauses Titles of Clauses Specific Clauses Requirements 9.2 Internal audit 9.3 Management review 10.0 Improvement 10.2 Nonconformity and corrective action 10.3 Continual improvement

III.
Performance Management

A. Performance Governance System (PGS)

The PGS is based on the performance management system that uses the “balanced scorecard” technology. Through the PGS, the organization gets closer to attaining its vision through the efficient execution of its strategies that leads to results. Instead of measuring and monitoring only the organizational output, the PGS, will more importantly measure the impact of the programs, projects, and activities of the health facility to its employees, customers, stakeholders, the Philippine government, and the country.

The PGS consists of four stages - Initiation, Compliance, Proficiency, and Institutionalization – described as follows:
 Initiation Stage focuses on the setting of the overall direction of the organization including its strategies, outcomes, and key success indicators. In this stage, the organization goes through defining its value chain, performs environmental scanning, identifies its inefficiencies and vulnerabilities to corruption, and think of ways to improve the facility’s governance system to give breakthrough results to its stakeholders.  Compliance Stage focuses on the alignment of the facility’s resources to its strategies. The facility’s enterprise scorecard will be cascaded to the different levels of the organization. In addition, the facility shall create a multi-sector governance body composed of internal and external stakeholders who will be part of the governance process, formally integrate the roles and responsibilities of offices on strategy management and policy and planning management, and craft a communication plan.  Proficiency and Institutionalization Stages focus on assessing the readiness of the facility to undergo the Proficiency Evaluation Process, which involves a third party audit and impact assessment. Here, the facility’s systems and processes, which were established, refined, and streamlined during the first two stages of the PGS will be assessed if these correspond to the PGS elements. An assessment of the results of the enterprise scorecard will also be conducted as well as the impact of the facility’s programs, projects, and activities to the different levels of society.

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The facility shall undergo a “revalida” at the end of each stage. The revalida is a public presentation to a chosen panel group where it will be determined whether the facility has complied with the PGS elements and passed the stage.

B. Strategic Performance Management System (SPMS)

According to the Civil Service Commission’s “Guidebook on the Strategic Performance Management System”, the SPMS is a mechanism that links employee performance with organizational performance to enhance the performance orientation of the compensation system. It ensures that the employee achieves the objectives set by the organization and the organization, on the other hand, achieves the objectives that it has set as its strategic plan. It has the following basic elements: a. Goals that are aligned to agency mandate and organizational priorities; b. System that is outputs/outcomes-oriented; c. A team approach to performance management; d. Forms that are user-friendly and shows alignment of individual and organizational goals; e. Information systems that support monitoring and evaluation; and f. A communication plan.

More importantly, the SPMS complements the Results-Based Performance Management System that is implemented by the Office of the President and that links organizational performance to societal goals. It is also linked to the Performance-Based Incentive System (PBIS) that consists of the Productivity Enhancement Incentive (PEI) and the Performance-Based Bonus (PBB).

The SPMS Process - follows a four-stage cycle, consisting of the following: a. Performance planning and commitment: During this stage, success indicators are determined. Success indicators are performance level yardsticks consisting of performance measures and performance targets. These shall serve as bases in the office’s and individual employee’s preparation of their performance contract and rating form. b. Performance monitoring and coaching: The performance of the office and every individual shall be regularly monitored at various levels. Monitoring and evaluation mechanisms ensure that timely and appropriate steps can be taken to keep a program on track, and that its objectives or goals are met in the most effective manner. Managers and supervisors act as coaches and mentors to provide an enabling environment/intervention to improve team performance, and to manage and develop individual potentials.

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Hospital Nutrition and Dietetics Service Management Manual | 206 c. Performance review and evaluation: This phase aims to assess both office’s and individual employee’s performance level based on performance targets and measures as approved in the office and individual performance commitment contracts. Part of the individual employee’s evaluation is the competency assessment vis-à-vis the competency requirements of the job. The assessment shall focus on the strengths, competency-related performance gaps and the opportunities to address these gaps, career paths, and alternatives. d. Performance rewarding and development planning: The results of the performance evaluation/assessment shall serve as inputs for the agency’s HR Plan, which includes identification and provision of developmental interventions, and conferment of rewards and incentives.

The SPMS Rating Scale uses a five-point rating scale, described in Table 31.

Table 31. SPMS five-point rating scale Numerical Rating Adjectival Equivalent Description 5 Outstanding Performance represents an extraordinary level of achievement and commitment in terms of quality and time, technical skills and knowledge, ingenuity, creativity, and initiative. Employees at this performance level should have demonstrated exceptional job mastery in all major areas of responsibility. Employee achievement and contributions to the organization are of marked excellence. 4 Very Satisfactory Performance exceeded expectations. All goals, objectives, and targets were achieved above the established standards. 3 Satisfactory Performance met expectations in terms of quality of work, efficiency, and timeliness. The most critical annual goals were met. 2 Unsatisfactory Performance failed to meet expectations, and/or one or more of the most critical goals were not met. 1 Poor Performance was consistently below expectations, and/or reasonable progress toward critical goals was not made. Significant improvement is needed in one or more important

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Hospital Nutrition and Dietetics Service Management Manual | 207

Performance Commitment and Review

Office Performance Commitment and Review (OPCR) Form is accomplished by Agency Directors. The OPCR consists of seven (7) columns:  Column 1: Major Final Outputs  Column 2: Success Indicators  Column 3: Allotted Budget  Column 4: Divisions Accountable
 Column 5: Actual Accomplishments  Column 6, further divided into four (4) sub-columns: Rating for Quality (Q), Efficiency (E) and Timeliness (T), and the Average (Ave)  Column 7: Remarks

Division Performance Commitment and Review (DPCR) Form is accomplished by Division Chiefs. The DPCR consists of 7 columns:
 Column 1: Major Final Outputs  Column 2: Success Indicators  Column 3: Allotted Budget  Column 4: Individuals Accountable  Column 5: Actual Accomplishments  Column 6, further divided into 4 sub-columns: Rating for Quality (Q), Efficiency (E) and Timeliness (T), and the Average (Ave)  Column 7: Remarks

Individual Performance Commitment and Review (IPCR) Form is accomplished by individual staff in all the units of the organization. The IPCR consists of five (5) columns:
 Column 1: Major Final Outputs  Column 2: Success Indicators  Column 3: Actual Accomplishments  Column 4, further divided into 4 sub-columns: Rating for Quality (Q), Efficiency (E) and Timeliness (T), and the Average (Ave)  Column 5: Remarks

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Hospital Nutrition and Dietetics Service Management Manual | 208 The lower portion of the forms is signed by the Supervisor and/or Rater at the beginning and the ending of the rating period.

IV.
Risk Management

Risk Management is the coordination of activities that direct and control an organization with regard to risk. It focuses on protecting the financial assets of the health care facility, its human resources, and preventing injury to patients and property. The rationale behind establishing risk management includes the following:  To improve the chances of realizing objectives of the Service;  To understand the risks involved in pursuing the objectives of the Service;  To know when and how to address these risks; and,
 To put measures to quantify the uncertainties represented by the risks.

In different types and sizes of organizations, there are already general types of risks commonly identified:
 Living too long  Illness  Injury/Accident  Disability  Death  Global  Environmental  Natural Disaster  Fire  Terrorism  Political  Technological  Intellectual Property  Investment  Regulatory  Liability  E-commerce

A. Risk Management Principles  Creates and protects value;  Integral part of all organizational processes;  Part of decision making;  Explicitly addresses uncertainty;  Systematic, structures, and timely;  Based on best available information;  Tailored;  Takes human and cultural factors into account;  Transparent and inclusive;  Dynamic, iterative, and responsive to change; and  Facilitates continual improvement.

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Hospital Nutrition and Dietetics Service Management Manual | 209

B. Risk Management Framework and Processes

In order to increase the likelihood of achieving objectives, the organization needs to identify and treat risks, then subsequently improve identification of opportunities and threats, controls, reliable basis for decision making and planning, operational effectiveness and efficiency. Based on ISO 31000, standards related to risk management, Figure 71 shows the relationships between the principles, framework design, and the process related to risk management.

Figure 71.
Relationships between the risk management principles, framework, and processes based on ISO 31000:2009

C. Levels of Risk Exposure  High – likely to cause significant increase in cost, disruption in schedule, or degradation of performance;  Moderate – may cause some increase in cost, disruption in schedule, or degradation of performance;  Low – has little or no potential for increase in cost, disruption in schedule, or degradation of performance.

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D. Getting Started in Risk Management

Per ISO 31000, getting started in risk management entails risk assessment as the overall process of risk identification, risk analysis and risk evaluation, as follows.

Risk Identification: The organization should identify sources of risk, areas of impacts, events (including changes in circumstances) and their causes as well as their potential consequences. The aim of this step is to generate a comprehensive list of risks based on those events that might create, enhance, prevent, degrade, accelerate or delay the achievement of objectives. Risk identification tools and techniques suited to the objectives and capabilities, and to the risks faced by the organization should be applied.

Risk Analysis: This involves provides and input to risk evaluation and to decisions on whether risks need to be treated, and on the most appropriate risk treatment strategies and methods. It can also provide an input into making decisions where choices must be made and the options involve different types and levels of risk. The consideration of the causes and sources of risk, their positive and negative consequences, and the likelihood of their occurrence are also involved in Risk Analysis.

The confidence in determination of the level of risk and its sensitivity to preconditions and assumptions should be considered in the analysis, communicated effectively to decision makers and, as appropriate, other stakeholders.

Risk Evaluation: Its purpose is to assist in making decisions, based on the outcomes of Risk Analysis, about which risks need treatment and the priority for treatment implementation. It involves comparing the risk found during the analysis process with risk criteria established when the context was considered. Based on this comparison, the need for the treatment can be considered.

E. Food Safety Risk Management

Risk management is vital to ensure food safety. In calamities such as flooding, earthquakes or other natural disasters, for example, risk management is important to ensure food safety during emergency responses – it becomes an effective and efficient tool for information exchange, its implementation helps focus on saving lives, preventing the undesirable complications as foodborne illnesses. Such illnesses include listeriosis from frozen vegetables, as well as the outbreak of salmonellosis from infant formula. The Food and Agriculture Organization and the World Health Organization came out with a guide that applied risk analysis, risk management principles and procedures to ensure food safety in emergencies.

Chapter 8 | Continuous Quality Improvement of the NDS

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General Principles

Principle 1: Risk management should follow a structured approach. Such approach includes the following elements:  Risk Evaluation;  Risk Management Option Assessment;  Implementation of Management Decision; and
 Monitoring and Review.

Principle 2: Protection of human health should be the primary consideration in risk management Decisions.

Principle 3: Risk management decisions and practices should be transparent.

Principle 4: Determination of risk assessment policy should be included as a specific component of risk management.

Principle 5: Risk management should ensure the scientific integrity of the risk assessment process by maintaining the functional separation of risk management and risk assessment.

Principle 6: Risk management decisions should take into account the uncertainty in the output of the risk assessment.

Principle 7: Risk management should include clear, interactive communication with consumers and other interested parties in all aspects of the process.

Principle 8: Risk management should be a continuing process that takes into account all newly generated data in the evaluation and review of risk management decisions.

Chapter 8 | Continuous Quality Improvement of the NDS

Hospital Nutrition and Dietetics Service Management Manual | 212 REFERENCES

Customer Satisfaction Definition taken from the New England Journal of Medicine Website. Accessed from https://catalyst.nejm.org/patient-satisfaction-surveys/, November 29, 2018.

SPMS Description taken from the Civil Service Commission website. Accessed from http://csc.gov.ph/2014-02-21-08-16-56/2014-02-21-08-17-24/2014-02-28-06-36-47.html, November 29, 2018.

PGS Description taken from the Intellectual Property Office of the Philippines website. Accessed from https://www.ipophil.gov.ph/transparency/performance-governance-system- pgs2, November 29, 2018.

Balance Scorecard Description taken from the Balance Scorecard Institute website. Accessed from https://www.balancedscorecard.org/BSC-Basics/About-the-Balanced-Scorecard, December 10, 2018.

David F. (2009). Strategic Management: Concepts and Cases, 12th Edition. Pearson Education Inc. p. 178.

OPCR/IPCR taken from the Guidebook on the Strategic Performance System by the CSC. pp. 68-69. Accessed from http://hrdo.upd.edu.ph/spms.pdf, December 12, 2018.

General Principles of Food Safety Risk Management taken from Risk Management and Food Safety Report of a Joint FAO/WHO Consultation, Rome, Italy, 27 to 31 January 1997. Accessed fromhttp://www.fao.org/3/a-w4982e.pdf, December 14, 2018.

ADDITIONAL READINGS

DOH Hospital Nutrition and Dietetics Service Management Manual, Second Edition.

ISO 9001:2015 Requirements

Performance Governance System

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214 | Hospital Nutrition and Dietetics Service Management Manual LIST OF APPENDICES Appendix A.01 Comment Card Appendix A.02 Monthly Hospital Statistical Report Appendix A.03 Quarterly Hospital Statistical Report Appendix A.04 Year-End Hospital Statistical Report Appendix A.05 Supplies Ledger Form Appendix A.06 Request for Nourishment Appendix A.07 Temperature Monitoring Sheet (Freezer) Appendix A.08 Temperature Monitoring Sheet (Refrigerator) Appendix A.09 Monthly Dealer Performance Report Appendix A.10 Market Order Appendix A.11 Open Market Purchase Appendix A.12 Supplies Issuance Form (Lunch and Supper) Appendix A.13 Monthly Main Kitchen Inventory Report Appendix A.14 Daily Food Consumption and Calorie Count Appendix A.15 Monthly Cycle Menu - Charity (Service) Patients Appendix A.16 Monthly Cycle Menu - Suite / PhilHealth Patients Appendix A.17
Tray Inventory (Breakfast) Appendix A.18
Tray Inventory (Lunch) Appendix A.19
Tray Inventory (Supper) Appendix A.20
Cleanliness Monitoring Check Sheet Appendix A.21 Monthly Cycle Menu (Therapeutic Patients) Appendix A.22 Monthly Therapeutic Inventory Appendix A.23 Daily Therapeutic Meals and Census Appendix A.24 Tubefeeding (3 Feedings) Appendix A.25 Tubefeeding (4 Feedings) Appendix A.26 Tubefeeding (5 Feedings) Appendix A.27 Tubefeeding (6 Feedings) Appendix A.28 Tag for Therapeutic Diets Appendix A.29 Tag for Routine Diets Appendix A.30
Tag for Tubefeeding
Appendix A.31 Monthly Therapeutic Consumption Appendix A.32
Specifications of Common Foodstuff Purchased Appendix A.33
Checklist on Sanitation in Food Service Appendix A.34
Applied Food Service Sanitation

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Hospital Nutrition and Dietetics Service Management Manual |215 APPENDIX A.01 Comment Card

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216 | Hospital Nutrition and Dietetics Service Management Manual APPENDIX A.02 Monthly Hospital Statistical Report

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APPENDIX A.02 | MONTHLY HOSPITAL STATISTICAL REPORT (Page 2)

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218 | Hospital Nutrition and Dietetics Service Management Manual

APPENDIX A.02 | MONTHLY HOSPITAL STATISTICAL REPORT (Page 3)

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Hospital Nutrition and Dietetics Service Management Manual |219 APPENDIX A.03 Quarterly Hospital Statistical Report

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220 | Hospital Nutrition and Dietetics Service Management Manual APPENDIX A.04 Year-End Hospital Statistical Report

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APPENDIX A.04 | YEAR-END HOSPITAL STATISTICAL REPORT (Page 2)

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222 | Hospital Nutrition and Dietetics Service Management Manual

APPENDIX A.04 | YEAR-END HOSPITAL STATISTICAL REPORT (Page 3)

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Hospital Nutrition and Dietetics Service Management Manual |223 APPENDIX A.05 Supplies Ledger Form

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224 | Hospital Nutrition and Dietetics Service Management Manual APPENDIX A.06 Request for Nourishment

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Hospital Nutrition and Dietetics Service Management Manual |225 APPENDIX A.07 Temperature Monitoring Sheet (FREEZER)

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226 | Hospital Nutrition and Dietetics Service Management Manual APPENDIX A.08 Temperature Monitoring Sheet (REFRIGERATOR)

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Hospital Nutrition and Dietetics Service Management Manual |227 APPENDIX A.09 Monthly Dealer Performance Report

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228 | Hospital Nutrition and Dietetics Service Management Manual APPENDIX A.10 Market Order

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Hospital Nutrition and Dietetics Service Management Manual |229 APPENDIX A.11 Open Market Purchase

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230 | Hospital Nutrition and Dietetics Service Management Manual APPENDIX A.12 Supplies Issuance Form (LUNCH & SUPPER)

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Hospital Nutrition and Dietetics Service Management Manual |231 APPENDIX A.13 Monthly Main Kitchen Inventory Report

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232 | Hospital Nutrition and Dietetics Service Management Manual

APPENDIX A.13 | MONTHLY MAIN KITCHEN INVENTORY REPORT (Page 2)

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APPENDIX A.13 | MONTHLY MAIN KITCHEN INVENTORY REPORT (Page 3)

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234 | Hospital Nutrition and Dietetics Service Management Manual

APPENDIX A.13 | MONTHLY MAIN KITCHEN INVENTORY REPORT (Page 4)

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APPENDIX A.13 | MONTHLY MAIN KITCHEN INVENTORY REPORT (Page 5)

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236 | Hospital Nutrition and Dietetics Service Management Manual APPENDIX A.14 Daily Food Consumption & Calorie Count

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APPENDIX A.14 | DAILY FOOD CONSUMPTION & CALORIE COUNT (Page 2)

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238 | Hospital Nutrition and Dietetics Service Management Manual

APPENDIX A.14 | DAILY FOOD CONSUMPTION & CALORIE COUNT (Page 3)

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APPENDIX A.14 | DAILY FOOD CONSUMPTION & CALORIE COUNT (Page 4)

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240 | Hospital Nutrition and Dietetics Service Management Manual APPENDIX A.15 Monthly Cycle Menu – CHARITY (SERVICE) PATIENTS

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APPENDIX A.15 | MONTHLY CYCLE MENU – CHARITY (SERVICE) PATIENTS (Page 2)

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242 | Hospital Nutrition and Dietetics Service Management Manual

APPENDIX A.15 | MONTHLY CYCLE MENU – CHARITY (SERVICE) PATIENTS (Page 3)

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APPENDIX A.15 | MONTHLY CYCLE MENU – CHARITY (SERVICE) PATIENTS (Page 4)

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244 | Hospital Nutrition and Dietetics Service Management Manual APPENDIX A.16 Monthly Cycle Menu – SUITE / PHILHEALTH PATIENTS

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APPENDIX A.16 | MONTHLY CYCLE MENU – SUITE / PHILHEALTH PATIENTS (Page 2)

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246 | Hospital Nutrition and Dietetics Service Management Manual

APPENDIX A.16 | MONTHLY CYCLE MENU – SUITE / PHILHEALTH PATIENTS (Page 3)

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APPENDIX A.16 | MONTHLY CYCLE MENU – SUITE / PHILHEALTH PATIENTS (Page 4)

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248 | Hospital Nutrition and Dietetics Service Management Manual APPENDIX A.17 Tray Inventory (BREAKFAST)

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Hospital Nutrition and Dietetics Service Management Manual |249 APPENDIX A.18 Tray Inventory (LUNCH)

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250 | Hospital Nutrition and Dietetics Service Management Manual APPENDIX A.19 Tray Inventory (SUPPER)

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Hospital Nutrition and Dietetics Service Management Manual |251 APPENDIX A.20 Cleanliness Monitoring Check Sheet

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252 | Hospital Nutrition and Dietetics Service Management Manual APPENDIX A.21 Monthly Cycle Menu (THERAPEUTIC PATIENTS)

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APPENDIX A.21 | MONTHLY CYCLE MENU - THERAPEUTIC PATIENTS (Page 2)

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254 | Hospital Nutrition and Dietetics Service Management Manual

APPENDIX A.21 | MONTHLY CYCLE MENU - THERAPEUTIC PATIENTS (Page 3)

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APPENDIX A.21 | MONTHLY CYCLE MENU - THERAPEUTIC PATIENTS (Page 4)

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256 | Hospital Nutrition and Dietetics Service Management Manual APPENDIX A.22 Monthly Therapeutic Inventory

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Hospital Nutrition and Dietetics Service Management Manual |257 APPENDIX A.23 Daily Therapeutic Meals & Census

NOTE: The hypoallergenic diet should be specified, e.g., shellfish (crabs, shrimps), wheat, peanuts, etc.

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APPENDIX A.23 | DAILY THERAPEUTIC MEALS & CENSUS (Page 2)

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APPENDIX A.23 | DAILY THERAPEUTIC MEALS & CENSUS (Page 3)

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260 | Hospital Nutrition and Dietetics Service Management Manual

APPENDIX A.23 | DAILY THERAPEUTIC MEALS & CENSUS (Page 4)

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Hospital Nutrition and Dietetics Service Management Manual |261 APPENDIX A.24 Tubefeeding (3 FEEDINGS)

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262 | Hospital Nutrition and Dietetics Service Management Manual APPENDIX A.25 Tubefeeding (4 FEEDINGS)

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Hospital Nutrition and Dietetics Service Management Manual |263 APPENDIX A.26 Tubefeeding (5 FEEDINGS)

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264 | Hospital Nutrition and Dietetics Service Management Manual APPENDIX A.27 Tubefeeding (6 FEEDINGS)

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Hospital Nutrition and Dietetics Service Management Manual |265 APPENDIX A.28 Tag for Therapeutic Diets

NOTE: For definition of therapeutic diets, refer to pages 124-126.

Hypoallergenic diets should be specified as to the allergen or cause of food sensitivity.

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266 | Hospital Nutrition and Dietetics Service Management Manual APPENDIX A.29 Tag for Routine Diets

NOTE: BRAT diet (banana, rice (or lugaw), apple, tea is no longer used; a low fat-low residue diet is prescribed instead.

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Hospital Nutrition and Dietetics Service Management Manual |267 APPENDIX A.30 Tag for Tubefeeding

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268 | Hospital Nutrition and Dietetics Service Management Manual APPENDIX A.31 Monthly Therapeutic Consumption

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APPENDIX A.31 | MONTHLY THERAPEUTIC CONSUMPTION (Page 2)

NOTE: See notes on pages 265 and 266 for BRAT and Hypoallergenic diets.

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APPENDIX A.32

Specifications of Common Foodstuff Purchased

VEGETABLES  Should be fresh upon delivery  Should be free from bruises, decay, and other damages caused by insect infestation and discoloration  For root vegetables and tubers, it should be of right maturity, firm not badly misshapen, free from black spots, bruises, cuts, scars and other blemishes  Those with stems should not be more than 6 inches long  Head vegetables should be without wilted leaves  Leafy greens should be fresh, young, crisp, and free from molds and decay  Should be in accordance with the detailed or itemized specifications

FRUITS  Should be firm and ripe but not overripe and free from decay, bruises, and other imperfections or other indications of insect infestations  Citrus fruits should be heavy for their size, firm and mature for maximum juiciness

PORK  Delivery must be accompanied with a Meat Inspection Permit in which date, weight, name of owner or vendor, the point of origin and destination is indicated  The skin must bear the stamp of the Bureau of Animal Industry to indicated it was inspected and passed  It must be fresh, young, and of good quality  It must be free from discoloration and disagreeable odor  Lean meat should be well-marbled with fat  It must be placed in sanitary containers or delivery vans to prevent contamination

BEEF  Delivery must be accompanied with a Meat Inspection Permit in which date, weight, name of owner or vendor, the point of origin and destination is indicated  The meat must bear the stamp of the Bureau of Animal Industry to indicate that it was inspected and passed  It must be fresh or frozen as indicated in the specification  It must be free from discoloration and disagreeable odor  Lean meat must be of fine grain and not stingy  The color of the lean meat must be pale red  Lean meat should well-marbled with fat  It must be placed in sanitary containers or delivery vans to prevent access of dirt or any contaminant

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Hospital Nutrition and Dietetics Service Management Manual |271  Beef carcass, hindquarter or forequarter should have naturally attached skin,
3 ½” by 2”  Must be free from water injection

FISH

Whole Fresh Fish  Must have firm flesh, shiny skin, bright red gills, and clear full eyes  Scales should be shiny and not easily removed  Must have natural slimy covering  Must have intact abdomen and belly walls
 Must have mild, fishy flavor
 Sizes should be in accordance to specifications  Headless fish, if specified, must have head removed after inspection and before weighing

Fish Fillet Cut  Fish fillet must have naturally attached skin, 2” x 2” to show that it was taken from the kind of fish ordered  Must be clean, firm, and show no signs of deterioration, discoloration or decomposition  Must be in accordance with the detailed specifications

Smoked and Dried Fish  Must be free from molds, dirt and be free from any signs of deterioration and decomposition  Flesh should be firm and attached to the bones  Must not cause itchiness to the tongue when eaten

SHELLFISH  Must have clean closed shells and fresh odor  Must have a clear and creamy meat color  Must not show any signs of deterioration, discoloration and decomposition  For crabs, it must be fresh, heavy for their sizes and must have firm joints  For shrimps, it must be fresh, with firm meat shells that fits tightly

POULTRY

Live  Must be in accordance with the specified breeds and weights called for in the specification  Must possess in a healthy full-bright red comb, clean nostrils, no discharge from the mouth, clear eyes, smooth legs  Flesh must be plump and well distributed

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Dressed and Drawn  If fresh, must be clean and freshly dressed and drawn  Feet must be cut up to the knee  Liver and giblets must be very clean and well-drained  Must not have any greenish-blue discoloration  Must be free from disagreeable color  Must be in accordance with the specifications  Must be free from water injection  Must be placed in sanitary containers to prevent contamination

EGGS

Fresh  Sizes must be in accordance with the specifications  Shells must be clean and free from cracks  When subjected under the light, it should have a clear, stable yolk at the center of the white  When placed in a pan of water, must sink and lie on its side

Salted  It must be well salted  Deliveries must be subjected to random sampling to check on the quality  Discovery of rotten or spoiled eggs after receipt must be replaced without extra charge on cost of buyer

CANNED GOODS  Must have no bulges, swelling or one that gives evidence of leak  Must have no evidence of rust that extends deeper than the surface of the can  Brands which are available and has been found satisfactory must be selected  Must be properly labelled (nutrition facts, date of expiration)

RICE  White, dry and whole-grained  Good quality (specify desired variety)  Must be free from weevils, palay, stones, grass, seeds, dirt and other foreign materials

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Hospital Nutrition and Dietetics Service Management Manual |273 APPENDIX A.33 Checklist on Sanitation in Food Service

Below is a sample checklist-questionnaire on Sanitation in Food Service based on Presidential Decree No. 856, “Code on Sanitation in the Philippines”.

I. ESTABLISHMENT  Is the site at the reasonable distance from noise, odor, and other disturbing activities?  Have safety requirements been provided (i.e. fire exits, fire extinguisher, etc.)?  Does the topography contribute to giving proper drainage, prevention of standing or stagnant water?

II. FOOD HANDLERS  Are they provided with up-to-date health certificates? Are they subjected to regular physical examination, stool, blood and urine examinations?  Have daily examinations been made of the food handlers as to the fitness to work, by the supervisors (Note: boils, open wounds, sore throat)?  Is the person- in-charge trained in the principles of good sanitation?  Are they in proper uniform – with caps, hairnets, aprons, trimmed fingernails, and neat looking?

III. TOILET FACILITIES  Are toilet facilities accessible and conveniently located (distant from the kitchen)?  Is the toilet served with sewer lines or a septic tank?  Are the plumbing appurtenances in proper condition? (With stored water enough for flashing, washing and cleaning.)

IV. GARBAGE, REFUSE, COLLECTION AND DISPOSAL  Is the establishment adequately provided with garbage receptacles or containers?  Are containers placed in proper locations?  Is there frequent/regular collection of garbage?

WATER SUPPLY  Is the source of water supply SAFE and POTABLE?  Is the amount of water supply adequate to meet requirements?  Is there enough water stored in case of failure?  Is the water supply protected from cross-contamination with non-potable water?  Is the water supply obtained from a well? If so, how deep or shallow is the well?

VI. EQUIPMENT AND UTENSILS  Are the equipment/utensils adequate in number?  Are equipment/utensils made of non-toxic, smooth durable, non-corrosive, easily cleaned materials?  Are all these equipment and utensils used for food preparation cleaned and sanitized after use?

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274 | Hospital Nutrition and Dietetics Service Management Manual  Are all equipment/utensils kept in good condition and free from cracks?

VII.
FOOD STORAGE  Are refrigerator facilities adequate to store perishable food without overcrowding?  Are there separate storage facilities for perishable food (cooked/raw)?  Are all perishables such as milk, milk products, meat, fish and shellfish, poultry, vegetables, salads, cream-filled pastries kept at proper temperatures (45 degrees Fahrenheit/ 7.2 degrees Celsius)?  Are all foods kept clean, wholesome, free from spoilage, and insect and vermin infestation?  Is there proper maintenance of all refrigeration and storage facilities?

VIII. KITCHEN  Is it clean and orderly (floor, walls, ceiling)?  Is it provided with screened, self-closing door, and adequate lighting and ventilation?  Is it equipped with good washing facilities?  Are surfaces in contact with food impervious, clean and resistant to chipping?  Are all equipment and kitchenware, including shelves, tables, meat blocks, refrigerators, sinks, kept clean from dust, insects, and other contaminating materials?

IX. INSECTS AND VERMIN CONTROL  Is there any evidence of insect and vermin infestation?  Are there possible insect and vermin breeding areas?  Is there an organized program for vermin and insect control?  Are there any chemical and mechanical measures used for insect and vermin control?  Are animals found in the premises (cats, dogs, etc.)?

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Hospital Nutrition and Dietetics Service Management Manual |275 APPENDIX A.34 Applied Food Service Sanitation

Safe and sanitary handling practices should be observed in the entire food service operation to prevent serving of contaminated food. The following are standard operations that must be observed in the different work areas:

RECEIVING AREA  Food is inspected immediately upon receipt for spoilage or insect infestation.  Perishable food is immediately put inside refrigerators and freezers.  Empty containers and packages are promptly discarded at disposal area.  The receiving area should be kept clean and free of food particles and debris.

DRY AND COLD STORAGE AREAS  All food should be stored at least six (6) inches off the floor.  The floor must be clean and free from spilled food.  Shelves are high enough off the floor, away from the wall to permit cleaning and ventilation.  Food supplies are stored in a manner to insure “first-in-first-out” rule and to avoid overcrowding.  Empty cartons and trash are removed regularly.  There should be no evidence of insects or rodents.  Refrigerators and freezers are equipped with thermometers and should be clean and free from objectionable odor.

Some measures to follow for proper storage of refrigerated items:  Pack food loosely to allow air to circulate.  Store in shallow pans to cool interior and exterior areas.  Cover food to protect from odor, drippings and drying out.  Discard food that is not going to be used to prevent overcrowding and to increase air circulation.  Defrost refrigerator frequently to keep clean and prevent dirt and bacteria from accumulating.  Defrost before it reaches ¼ inch frost because the frost on pipes cuts down the cooling process.  Open the door, only when necessary because frequent opening raises temperature.

VEGETABLE PREPARATION AREA  The area is clean and free from objectionable odor, empty containers, insects or rodents.  Vegetable sink is used only for food preparation.  Vegetable peelers, slicers, choppers are cleaned every after use.  Cutting boards are in good condition – free from splits or cuts. They must be cleaned and sanitized before and after use.

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276 | Hospital Nutrition and Dietetics Service Management Manual  Must adopt a color coded scheme for cutting board of raw and cooked food.

MEAT CUTTING AREA  The area is clean and free from objectionable odor, free from accumulation of empty cartons and wrappers.  Cutting boards are in good condition- free from splits, holes, or cuts, cleaned and sanitized before and after use.  All tables, grinders, slicers, meat saws, boning knives and other meat cutting equipment are cleaned and sanitize, if not in use.  Frozen meat, poultry and fish are thawed inside the refrigerator.  Meat sinks are used for food and not for hand washing or mop washing.

FOOD PREPARATION AND COOKING AREAS  The area is clean and free from accumulated debris; floor is dry and free from cracks with no evidence of insects and rodents.  Thermostats are properly operating for ovens, ranges and fryers.  Hot holding equipment are available to maintain hot foods at above 140 degrees Fahrenheit; cold foods are held at 45 degrees Fahrenheit or lower.  Utensils not in use are cleaned, sanitized and properly stored.  Cook’s sinks are used solely for food preparation.  Cleaning supplies and pesticides should not be found in this area.

DINING ROOM AND SERVING AREA
 The area including, floor, tables and chairs are kept clean and dry.  Silverware and serving utensils are stored to prevent contamination.  A separate clean towel must be used for wiping dining tables and chairs.  Chinaware and silverware are picked up by the rims and handles respectively.  Insect spraying must be done before closing time.

DISH WASHING AND STORAGE AREA  There should be sufficient hot water supply to meet the requirements of the food service operation; rinse temperature for at least 170 degrees Fahrenheit should be maintained for tableware and utensils.  The detergent concentration is maintained at the necessary level for effective washing.  Personnel are made to wash hands between handling soiled table ware and sanitized ware.  Dishwashing equipment is cleaned after each day’s use to remove chemicals, food particles, soil and debris.  Washed wares should be stored in a clean, dry area free from insects and rodents

GARBAGE DISPOSAL AREA  Area is generally clean and orderly, floor platform or ground surface should be without traces or spilled particles of food.  Area has no objectionable odor.  Trash and garbage are confined in color plastic lined and covered containers.

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Hospital Nutrition and Dietetics Service Management Manual |277  Observe proper waste segregation and color coding i.e. black for dry and green for wet.  Empty garbage and refuse containers are properly washed and sanitized after every use.  There is no evidence of flies, cockroaches, rats, rat holes or nests in the vicinity of the disposal area

EMPLOYEES FACILITIES INCLUDING REST ROOMS  The area is clean, dry and free from odor.  There is an adequate hot and cold water supply.  There is sufficient supply of hand washing soap and tissue paper for employees’ needs.  All sanitary facilities are operating efficiently and in good condition.  Proper receptacles are made available for disposal of waste materials.  There should be no evidence of rodents or insects in the facilities.

SOURCE: Perdigon, Grace P. (1998). Food Service Management in the Philippines.

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Hospital Nutrition and Dietetics Service Management Manual | 279

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280 | Hospital Nutrition and Dietetics Service Management Manual LIST OF APPENDICES Appendix B.01 Nutrition-Focused Physical Examination (NFPE) Appendix B.02 Clinical and Physical Findings related to Micronutrient Deficiencies Appendix B.03 Academy/ASPENs Adult Malnutrition Characteristics
Appendix B.04
Fluid Intake and Actual Intake Balance Sheet Appendix B.05 Nutrition Screening and Referral Tool (Adult) Appendix B.06 Nutrition Screening and Referral Tool (Pediatric) Appendix B.07 Medical Nutrition Therapy (Nutrition Care Plan) Appendix B.08 Nutrition Care Process Bi-Annual Report Appendix B.09 WHO and Asian BMI Classification Appendix B.10
Fad Diets

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Hospital Nutrition and Dietetics Service Management Manual | 281 APPENDIX B.01 Nutrition-Focused Physical Examination (NFPE)

Physical Examination: Parameters Useful in the Assessment of Nutritional Status Examination Area Tips Severe Malnutrition Mild-Moderate Malnutrition Well Nourished Subcutaneous Fat Loss Orbital Region View patient when standing directly in front of them; touch above cheekbone Hollow look, depressions, dark circles, loose skin Slightly dark circles, somewhat hollow look
Slightly bulged fat pads, Fluid retention may mask loss Upper Arm Region Triceps/Biceps Arm bent, roll skin between fingers, do not include muscle in pinch Very little space between folds, fingers touch Some depth pinch, but no ample Ample fat tissue, obvious between folds of skin Thoracic and Lumbar Region – Ribs, Lower Back, Midaxillary Line Have patient press hands hard against a solid object Depression between ribs very apparent lliac crest very prominent Ribs apparent, depressions between them less pronounced
Iliac crest somewhat prominent Chest is full; ribs do not show Slight to no protrusion of the iliac crest Loss of Muscles Mass Temple - Temporalis Muscle View patient when standing directly in front of them, ask patient to turn head side to side Hollowing, scooping, depression
Slight depression
Can see/ feel well defined muscle Clavicle Bone Region – Pectoralis Major, Deltoid, Trapezius Muscles Look for prominent bone Make sure patient is not hunched forward Protruding, prominent bone Visible in male, some protrusion in female Not visible in male, visible but not prominent in female Clavicle and Acromion Process – Deltoid Muscle Patient arms at side; observe shape Shoulder to arm joint looks square. Bones prominent. Acromion protrusion very prominent Acromion process may slightly protrude Rounded, curves at arm/ shoulder/ neck Scapular Bone Region – Trapezius, Suspraspinus, Infraspinus Muscles Ask patient to extend hands straight out, push against solid object Prominent, visible bones, depression between ribs/scapula or shoulder/spine Mild depression or bone may show slightly
Bones not prominent, no significant depressions Dorsal Hand – Interosseous Muscle Look at thumb side of hand; look at pads of thumb when tip of forefinger touching tip of thumb Depressed area between thumb-forefinger Slightly depressed Muscle bulges, could be flat in some well-nourished people Lower Body Less Sensitive to Change Patellar Region – Quadricep Muscle Ask patient to sit with leg propped up bent at knee Bones prominent, little sign of muscle around knee Knee cap less prominent, more rounded Muscles protrude, bones not prominent Anterior Thigh Region – Quadriceps Muscles Ask patient to sit, prop leg up on low furniture. Grasp quads to differentiate muscle tissue from fat tissue Depression/line on thigh, obviously thin Mild depression on inner thigh Well rounded, well developed Posterior Calf Region – Gastrocnemius Muscle Grasp the call muscle to determine amount of tissue Thin, minimal to no muscle definition Not well developed Well-developed bulb of muscle Edema Rule out other causes of edema, patient at dry weight View scrotum/vulva in activity restricted patient; ankles in mobile patient Deep to very deep pitting; depression last a short to moderate time (31-60 seconds), extremely looks swollen (3 - 4 +) Mild to moderate pitting, slight welling of the extremity, indentation subsides quickly (0-30 seconds)
No sign of fluid accumulation

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282 | Hospital Nutrition and Dietetics Service Management Manual APPENDIX B.02 Clinical and Physical Findings Related to Micronutrient Deficiencies

Region of Body Assessment/ Examination Abnormal Findings Possible Vitamin/Mineral Deficiencies Comments Skin Inspect and palpate for color, moisture, texture, temperature and lesions. Pallor, cyanosis

Yellowing coloring

Dermatitis, red scaly rash or hyperkeratosis

Bruising, petechiae, unhealed cuts/wounds Iron, folate or B12, biotin, copper carotene or bilirubin (excess related)

B-complex vitamins (riboflavin, niacin, vitamin B6), vitamin A, and zinc

Vitamins K, C, and zinc Skin should be smooth, uniform in color and appearance. Iron is involved in the transport and storage of oxygen; copper is involved in iron metabolism and melanin pigment formation.

Vitamin A regulates epithelium cell integrity.

Vitamin K is vital in blood clotting; vitamin C is necessary for collagen synthesis.

Nails Inspect and palpate for color, shape and texture. Pallor or white coloring. Clubbing, spoon-shape, or transverse ridging/ banding; excessive dryness, darkness nails, curved nail ends Iron Protein Vitamin B12 Nail bed should be free of splints, uniform in shape, rounded and smooth. Color and shape changes can reflect other medical conditions. The nail is made from the protein keratin. Low protein intake can affect nail growth and texture.

Head/ Hair Inspect and palpate the scalp/hair for quantity, distribution and texture. Dull/ lackluster; banding/sparse; alopecia; depigmentation of hair; scaly/flaky scalp
Protein and energy, biotin; and copper; Essential Fatty Acid Deficiency (EFAD) Scalp should appear normal in color and texture with no diffused hair patches. Hair color and texture should appear uniform, thick, firm and not easily plucked. Protein and biotin are needed to maintain hair growth.

Eyes Inspect for changes in vision; color of the conjunctiva and sclera.

Palpate the eye for dryness; and cracks. Vision changes, particularly at nighttime; dryness, foamy spots on eyes (Bitot’s spots). Itching, burning, corneal inflammation

Pallor conjunctiva; yellowish icterus

Vitamin A, riboflavin, niacin

Iron, folate, B12; excessive carotenoids The eyes should appear bright with smooth cornea; along with pink and moist membranes. Rhodopsin, the eye pigment responsible for vision in dim light, along with tear production and debris removal are all vitamin A dependent.

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Hospital Nutrition and Dietetics Service Management Manual | 283 Region of Body Assessment/ Examination Abnormal Findings Possible Vitamin/Mineral Deficiencies Comments Mouth Extra-Intraoral Cavity Inspect the lips and corners of the mouth, and inside the oral cavity: tongue, gums, and papillae
Corners of the mouth are swollen (angular stomatitis) and vertical cracks of the lips (cheilosis)

Magenta color, beefy red tongue (glossitis) and atrophied papillae

Pallor and generalized inflamed mucosa

Bleeding gums and poor dentition

Distorted or diminished taste (hypogeusia)

B-complex vitamins (riboflavin, niacin, vitamin, B6)

Riboflavin, niacin, folate, B12, iron

Iron, B12 or folate, B- complex

Vitamin C

Zinc The extra-oral cavity should be without cracks and sores, appearing smooth in color. The intraoral cavity should appear free of swelling around the gum and tongue. B-complex vitamins and vitamin C aid in cellular synthesis, function and integrity; deficiencies of these micronutrients can affect cellular turnover and collagen synthesis in the oral cavity.

Anemia can cause low hemoglobin levels, resulting in pallor coloring within the mucous membrane.

Neck/ Chest Inspect and palpate the neck and chest Distended neck veins

Enlarged thyroid

Muscle and fat wasting with prominent bony chest region

Fluid overload

Iodine

Calorie and protein depletion Not necessarily part of micronutrient deficiencies assessment; however, this region of the body can provide information regarding muscle and fluid status. Musculoskeletal/ Lower Extremities Inspect and palpate arm, finger, wrist, shoulder, legs for range of motion, swelling and ankles for fluid accumulation Poor muscle control (ataxia)

Swollen and painful joints; epiphyses at wrist

Rickets, knock knees, bowleg

Thiamin, copper

Vitamin C and D

Vitamin D, calcium Generalized muscle mass, strength, stability, movement, and balance can be assessed via various functional tests (e.g., hand grip, gait speed, and bioelectric-impedance analysis).

Edema rating scale can be used to assess fluid accumulation along with skin turgor test.

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284 | Hospital Nutrition and Dietetics Service Management Manual APPENDIX B.03 Academy/ASPEN Adult Malnutrition Characteristics

Other Unspecified Severe Protein-Calorie Malnutrition ICD-10 E43 Severe Malnutrition in the Context of Acute Illness/ Injury Severe Malnutrition in the Context of Chronic Illness Severe Malnutrition in the Context of Social/ Behavioral Environmental Circumstances Weight Loss Weight change over time is reported as a percentage of weight lost from baseline Weight Loss Weight Loss Weight Loss

2% in 1 week 5% in 1 month 7.5% in 3 months 5% in 1 month 7.5% in 3 months 10% in 6 months 20% in 12 months 5% in 1 month 7.5% in 3 months 10% in 6 months 20% in 12 months Intake Suboptimal intake is determined as a percentage of estimated needs over time Energy Intake Energy Intake Energy Intake ≤ 50% energy intake compared to estimated energy needs ≥ 5 days ≤ 75% energy intake compared to estimated energy needs ≥ 1 month ≤ 50% energy intake compared to estimated energy needs ≥ 1 month Physical Assessment Loss of subcutaneous fat Body Fat Body Fat Body Fat Moderate depletion Severe depletion Severe depletion Physical Assessment Loss of subcutaneous muscle Muscle Mass Muscle Mass Muscle Mass Moderate depletion Severe depletion Severe depletion Physical Assessment General or local fluid accumulation Fluid Accumulation Fluid Accumulation Fluid Accumulation Moderate to severe Severe Severe Hand Grip Strength Based on standards supplied by dynamometer manufacturer Hand Grip Strength Hand Grip Strength Hand Grip Strength Measurably reduced Measurably reduced Measurably reduced Moderate Protein-Calorie Malnutrition ICD-10 E44.0 Non-Severe (Moderate) Malnutrition in the Context of Acute Illness/ Injury Non-Severe (Moderate) Malnutrition in the Context of Chronic Illness Non-Severe Malnutrition in the Context of Social/ Behavioral/ Environmental Circumstances
Weight Loss Weight change over time is reported as a percentage of weight lost from baseline Weight Loss Weight Loss Weight Loss 1% - 2% in 1 week 5% in 1 month 7.5% in 3 months 5% in 1 month 7.5% in 3 months 10% in 6 months 20% in 12 months 5% in 1 month 7.5% in 3 months 10% in 6 months 20% in 12 months Intake Suboptimal intake is determined as a percentage of estimated needs over time Energy Intake Energy Intake Energy Intake < 75% energy intake Compared to estimated energy needs > 7 days < 75% energy intake compared to estimated energy needs > 1 month < 75% energy intake compared to estimated energy needs ≥ 3 months Physical Assessment Loss of subcutaneous fat Body Fat Body Fat Body Fat Mild depletion Mild depletion Mild depletion Physical Assessment Loss of subcutaneous muscle Muscle Mass Muscle Mass Muscle Mass Mild depletion Mild depletion Mild depletion Physical Assessment General or local fluid accumulation Fluid Accumulation Fluid Accumulation Fluid Accumulation Mild Mild Severe Hand Grip Strength Based on standards supplied by dynamometer manufacturer Hand Grip Strength Hand Grip Strength Hand Grip Strength Not applicable Not applicable Not applicable

White JV, Guenter P, Jensen G, Malone A, and Schofield M. Consensus Statement: Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition: Characteristics recommended for the identification and documentation of adult malnutrition (undernutrition). JPEN J Parenter Ent Nutr. 2012:36(3):275-283.

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Hospital Nutrition and Dietetics Service Management Manual | 285 APPENDIX B.04 FLUID INTAKE & ACTUAL INTAKE BALANCE

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APPENDIX B.04 | FLUID INTAKE AND ACTUAL INTAKE BALANCE (Page 2)

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Hospital Nutrition and Dietetics Service Management Manual | 287 APPENDIX B.05 NUTRITION SCREENING & REFERRAL (ADULT)

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288 | Hospital Nutrition and Dietetics Service Management Manual APPENDIX B.06 NUTRITION SCREENING & REFERRAL (PEDIATRIC)

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Hospital Nutrition and Dietetics Service Management Manual | 289 APPENDIX B.07 MEDICAL NUTRITION THERAPY (NUTRITION CARE PLAN)

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290 | Hospital Nutrition and Dietetics Service Management Manual APPENDIX B.08 NUTRITION CARE PROCESS BI-ANNUAL REPORT

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Hospital Nutrition and Dietetics Service Management Manual | 291 APPENDIX B.09 WHO & Asian BMI Classification

The World Health Organization (WHO) classifies obesity by body mass index (BMI), which is closely related to both percentage body fat and total body fat.

BMI Classification < 18.5 Underweight 18.5 – 24.9 Normal Weight 25.0 – 29.9 Overweight 30.0 – 34.9 Class I Obesity (Obese) 35.0 – 39.9 Class II Obesity (Severely Obese)  40.0 Class III Obesity (Morbidly Obese)

The Asia-Pacific Guidelines on BMI classification use different cut-off points for normal and overweight individuals from the WHO classification and provides risk of co-morbidities in adult Asians.

Classification BMI (kg/m2) Risk of Co-Morbidities Waist Circumference

< 90 cm (men) < 80 cm (women)  90 cm (men)  80 cm (women) Underweight < 18.5 Low
(but increased risk of other clinical problems) Average Normal Range 18.5 – 22.9 Average Increased Overweight  23.0

At Risk 23.0 – 24.9 Increased Moderate Obese I 25.0 – 29.9 Moderate Severe Obese II  30.0 Severe Very Severe

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292 | Hospital Nutrition and Dietetics Service Management Manual APPENDIX B.10 FAD DIETS

TYPES OF FAD DIETS (Reference: British Dietetic Association, or BDA, 2014)

DIET TYPE KNOWN EXAMPLES Low Carbohydrates (< 100 g / day)  Atkins Diet Revolution  South Beach Diet Extremely Low Fat (< 20% kcal from fat / day)  Pritikin Diet  Pasta Diet Combination  Fit for Life  Zone Diet Very Low Calorie (<800 kcal / day)  Cambridge Diet  Rotation Diet Novelty (Certain nutrients or foods)  Beverly Hills Diet  Junk Food Diet Formula  Slim Fast  Last Chance Diet Pre-measured  Jenny Craig  Nutri-System Detox  The Master Cleanse High Fat  Ketogenic Diet High Protein  Dukan  Bodybuilder Diet

MAIN CATEGORIES OF FAD DIETS (As suggested by the BDA)

Low Protein Low Carbohydrate Moderate Fat Low Carbohydrate Low Fat Very High Carbohydrate Very Low Calorie  Atkins  Dukan  South Beach  Zone  Jenny Craig  Nutri-System  Weight Watchers  Ornish  New Pritikin Program  LEARN  Bernstein  Lighter Life  Slim Fast

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Appendices – C | Other Supplemental Content

294 | Hospital Nutrition and Dietetics Service Management Manual LIST OF APPENDICES Appendix C.01
Nutrition and Dietetics Law of 2016 Appendix C.02
Rooms, Space Demands and Total Area of Nutrition and Dietetics (100- Bed, Level 2 Hospital) Appendix C.03 Layout of Nutrition and Dietetics Department Showing Rooms and Space Components (100-Bed, Level 2 Hospital) Appendix C.04
Rooms, Space Demands and Total Area of Nutrition and Dietetics (250- Bed, Level 3 Hospital) Appendix C.05
Layout of Nutrition and Dietetics Department Showing Rooms and Space Components (250-Bed, Level 3 Hospital) Appendix C.06
Strengthening the No-Balance Billing Policy Appendix C.07
Research Topics in Nutrition and Dietetics Appendix C.08
Amount and Preparation of F75 Milk to be Given to Children Aged 6 - 59 Months in Phase 1 Appendix C.09
Alternate F75 Recipes Appendix C.10
Amount of F100 Milk to be Given to Children Aged 6 - 59 Months in Transition Phase Appendix C.11
Amount of RUTF to be Given to the Child on Transfer to Outpatient Care Appendix C.12 Amount of F100 to be Given in Phase 2

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Hospital Nutrition and Dietetics Service Management Manual | 295 APPENDIX C.01 Nutrition and Dietetics Law of 2016

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306 | Hospital Nutrition and Dietetics Service Management Manual APPENDIX C.02 Rooms, Space Demands & Total Area Nutrition and Dietetics Service in a 100-Bed Level 2 Hospital

SOURCE: Manual on Technical Guidelines for Hospital Planning and Design, 100-Bed Hospital (Level 2)

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Hospital Nutrition and Dietetics Service Management Manual | 307 APPENDIX C.03 Layout Showing Rooms & Space Components Nutrition and Dietetics Service in a 100-Bed Level 2 Hospital

SOURCE: Manual on Technical Guidelines for Hospital Planning and Design, 100-Bed Hospital (Level 2)

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308 | Hospital Nutrition and Dietetics Service Management Manual APPENDIX C.04 Rooms, Space Demands & Total Area Nutrition and Dietetics Service in a 250-Bed Level 3 Hospital

SOURCE: Manual on Technical Guidelines for Hospital Planning and Design, 250-Bed Hospital (Level 3)

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Hospital Nutrition and Dietetics Service Management Manual | 309 APPENDIX C.05 Layout Showing Rooms & Space Components Nutrition and Dietetics Service in a 250-Bed Level 3 Hospital

SOURCE: Manual on Technical Guidelines for Hospital Planning and Design, 250-Bed Hospital (Level 3)

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310 | Hospital Nutrition and Dietetics Service Management Manual APPENDIX C.06 Strengthening the No Balance Billing Policy

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318 | Hospital Nutrition and Dietetics Service Management Manual APPENDIX C.07 Research Topics in Nutrition & Dietetics

These are examples of research topics done, or participated in by RNDs.

Food Service, Meal Management, Menu Planning and Recipe Testing  Recipe development of nutritious snacks for feeding programs  Comparative review of food prices for open market items  Planning and costing different therapeutic menus (including tube feedings)

Food and Nutrition Education, Instructional Materials and Programs  Study of patient education handouts provided by pharmaceutical companies: basis for a localized version  Development of different patient handouts for therapeutic diets

Nutrition Practices and Benchmarking  Performance indicators of clinical dietitians in nutritional assessment and dietary counseling  Time and motion study in performing dietary instructions and nutritional assessment  Monitoring the frequency of how often ABC diet is prescribed by physicians, what medical conditions were prescribed by this diet  Comparison of blenderized and commercial tube feedings on patients based on length of hospital stay  Bacterial count study of enteral formulas (commercially prepared formulas and blenderized feeding), the tube feeding room and enteral feeding tubes  Microbial evaluation of neutropenic or low bacterial diet and food safety procedures intended for bone marrow transplant patients  Case studies of cardiovascular, diabetic and renal disease patients

Clinical: Assessment Tools  Use of the knee height caliper among hospitalized Filipino patients  Bio-impedance analysis of Filipino geriatric patients assessed by mini-nutritional assessment (MNA)  The value of the mid-arm circumference in the nutritional screening for malnutrition in geriatric patients  Validation of modified SGA tool for nutrition assessment

Source: Jamorabo-Ruiz, A. (2016). The Research Engagement of Nutritionist-Dietitians in Philippine Hospitals: An Assessment. JNDAP 30 (1&2): 37-42.

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Hospital Nutrition and Dietetics Service Management Manual | 319 APPENDIX C.08
Amount and Preparation of F75 Milk in Phase 1 To be Given to Children Aged 6 - 59 Months

Weight of the Child Amount of Milk per Feed 8 Feeds per Day Amount of Milk per Feed 6 Feeds per Day

2.0 – 2.1 kg 40 mL 50 mL 2.2 – 2.4 kg 45 mL 60 mL 2.5 – 2.7 kg 50 mL 65 mL 2.8 – 2.9 kg 55 mL 70 mL 3.0 – 3.4 kg 60 mL 75 mL 3.5 – 3.9 kg 65 mL 80 mL 4.0 – 4.4 kg 70 mL 85 mL 4.5 – 4.9 kg 80 mL 95 mL 5.0 – 5.4 kg 90 mL 110 mL 5.5 – 5.9 kg 100 mL 120 mL 6.0 – 6.9 kg 110 mL 140 mL 7.0 – 7.9 kg 125 mL 160 mL 8.0 – 8.9 kg 140 mL 180 mL 9.0 – 9.9 kg 155 mL 190 mL 10.0 – 10.9 kg 170 mL 200 mL 11.0 – 11.9 kg 190 mL 230 mL 12.0 – 12.9 kg 205 mL 250 mL 13.0 – 13.9 kg 230 mL 275 mL 14.0 – 14.9 kg 250 mL 290 mL 15.0 – 19.9 kg 260 mL 300 mL

PREPARATION OF F75 MILK

Mix one small packet (102.5 g) with 500 mL of water.
Water should be boiled then cooled and preferably filtered.
Therapeutic milk should then be made within 30 minutes of boiling the water. The use of hot water from dispensers while convenient is not recommended as there is a risk of cross infection and contamination if the dispensing nozzle is not meticulously cleaned between every use.

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320 | Hospital Nutrition and Dietetics Service Management Manual APPENDIX C.09 Alternate F75 Recipes

Type of Milk Milk
(g) Sugar
(g) Oil
(g) Cereal Powder* (g) CMV
Red Scoop (6.35 g) Water
(mL)

Dry skim milk 50 140 54 70 1 Add cooled boiled water up to
2,000 mL Dry whole milk 70 140 40 70 1 Fresh cow milk 560 130 40 70 1 Fresh goat milk 560 130 40 80 1 *Cereal powder is cooked for about 10 minutes before the other ingredients are added

TO PREPARE F75

Add the milk, sugar, pre-boiled cereal powder and oil to one liter (L) water and mix. Boil for 5 to 7 minutes. Allow to cool, add the combined mineral and vitamin mix (CMV) and mix again. Make up the volume to 2,000 milliliters (mL) with cooled boiled water.

Note: Other local recipes for the preparation of F75 have been developed but require the addition of micronutrient supplementation to the child in place of the CMV in the above.

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Hospital Nutrition and Dietetics Service Management Manual | 321 APPENDIX C.10 Amount of F100 Milk in Transition Phase To be Given to Children Aged 6 - 59 Months

Weight of the Child 6 FEEDS PER DAY 5 FEEDS PER DAY

Less than 3.0 kg F100 full strength should not be used 3.0 – 3.4 kg 75 mL per feed 85 mL per feed 3.5 – 3.9 kg 80 95 4.0 – 4.4 kg 85 110 4.5 – 4.9 kg 95 120 5.0 – 5.4 kg 110 130 5.5 – 5.9 kg 120 150 6.0 – 6.9 kg 140 175 7.0 – 7.9 kg 160 200 8.0 – 8.9 kg 180 225 9.0 – 9.9 kg 190 250 10.0 – 10.9 kg 200 275 11.0 – 11.9 kg 230 275 12.0 – 12.9 kg 250 300 13.0 – 13.9 kg 275 350 14.0 – 14.9 kg 290 375 15.0 – 19.9 kg 300 400

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322 | Hospital Nutrition and Dietetics Service Management Manual APPENDIX C.11 Amount of Ready-to-Use Therapeutic Food (RUTF) To be Given to the Child on Transfer to Outpatient Care

Weight of the Child Packets per Week Packets per Day

3.5 – 3.9 kg 11 1.5 4.0 – 4.9 kg 14 2 5.0 – 6.9 kg 18 2.5 7.0 – 8.4 kg 21 3 8.5 – 9.4 kg 25 3.5 9.5 – 10.4 kg 28 4 10.5 – 11.9 kg 32 4.5  12 kg 35 5

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Hospital Nutrition and Dietetics Service Management Manual | 323 APPENDIX C.12 Amount of F100 to be Given in Phase 2

Weight of the Child F100 (6 Feeds per Day)
in mL F100 (5 Feeds per Day) in mL

Less than 3.0 kg Do not use full strength F100; use diluted F100 3.0 – 3.4 kg 110 130 3.5 – 3.9 kg 125 150 4.0 – 4.9 kg 135 160 5.0 – 5.9 kg 160 190 6.0 – 6.9 kg 180 215 7.0 – 7.9 kg 200 240 8.0 – 8.9 kg 215 260 9.0 – 9.9 kg 225 270 10.0 – 11.9 kg 230 280 12.0 – 14.9 kg 260 310

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326 | Hospital Nutrition and Dietetics Service Management Manual LIST OF APPENDICES Appendix D.01
Administrative Order No. 2016-0020
“Standardization of Per Capita Budget for Meal Provision of Patients of the Department of Health (DOH) and Local Government Unit (LGU) Hospitals in the Country” Appendix D.02
Department Memorandum No. 2020-0165
“Interim Guidelines for Registered Nutritionist-Dietitians in Hospitals on the Nutritional and Dietary Management of Suspected, Probable, and Confirmed Coronavirus Disease 2019 (COVID-19) Patients and on the Provision of Healthy Diet to Hospital Workforce” Appendix D.03 Department Memorandum No. 2020-0166
“Interim Guidelines on Food Preparation and Food Handling for Converted Temporary Treatment and Monitoring Facilities for COVID- 19 Patients”

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Hospital Nutrition and Dietetics Service Management Manual, Third Edition

Document Info

Food and Nutrition Research Institute Dr. Jesus Fernando Inciong

St. Luke’s Medical Center Dr. Jose Rodolfo Dimaano Jr

Health Emergency Management Bureau-DOH Prof. Luz Felicidad Callanta

Mr. Francis Cyril de Guzman

National Kidney and Transplant Institute Ms. Minviluz Crispina Vera Cruz

DOH League of Registered Nutritionist-Dietitians Inc. Ms. Klarizza Marie Quiambao

National Kidney and Transplant Institute Ms. Renz Anneka Daquioag

DOH League of Registered
Nutritionist-Dietitians Inc. Ms. Klarizza Marie Quiambao