Redesigning mid-meal safety, nutritional accuracy and compliance, knowledge and satisfaction (SNACKS)

Published 2 December 2019. Last updated 12 December 2019.

This project looks at how the tea-run to adult patients at Westmead Hospital in the following wards can be improved to meet the nutritional and individual dietary needs of patients:

  • A4C – infectious diseases
  • B5A – respiratory
  • D5C – neurosurgery.

View a poster from the Centre for Healthcare Redesign graduation, December 2019.

Mid-meal SNACKS [poster]


To increase patients’ safety and satisfaction within the provision of mid-meals to adult inpatients at A4C, B5A, & D5C in Westmead Hospital by 30 August, 2020 by:

  • increasing the proportion of patients being:
    • correctly given prescribed items from 85% to 100%
    • offered the complete range of items in the correct order (i.e. high energy items first at morning tea and fruit first at afternoon tea, before standard items) from 27% to 75%
  • reducing the number of food items requiring refrigeration, known as potentially hazardous items to not remain with the patient after the four hour safe time limit from 22% (morning and afternoon tea) and 36% (supper) to 0%
  • reducing the waste due to mid-meals not being consumed by patients from 58% of total mid-meal food cost to 25%.


  • Delivery of the project goal and objectives may also result in the following additional benefits:
  • Increased nutritional intake for patients and subsequent improvements in nutritional outcomes.
  • A reduction in food waste due to increased patient consumption and improved management of potentially hazardous items.
  • Reduced costs due to reduced food waste and improved efficiencies.
  • Increased food service staff satisfaction.
  • Improved patient satisfaction.
  • Improved communication and collaboration across HealthShare NSW and Western Sydney Local Health District (WSLHD).
  • Increased awareness of the contribution of mid-meals to patients’ intake.
  • Contribution of evidence to support the review of the ACI Nutrition Standards for Adult Inpatients in NSW Hospitals.
  • Increased WSLHD customer satisfaction with HealthShare NSW services.


A hot cup of tea and a biscuit in between main meals can be a creature comfort for patients when they are feeling poorly. However, with the introduction of the nutrition standards and the ever increasing complexity of patients' dietary needs, what was previously a simple tea run has now become a more complicated mid-meal service.

As part of food service in NSW Health hospitals, mid-meals (morning tea, afternoon tea and supper) have traditionally been a small uniform snack and hot or cold beverage. As nutritional requirements and policies have evolved, mid-meals now form an essential part of nutrition services. Dietitians use them to meet a patient's energy, protein and fluid requirements, by including required high calorie supplements, additional fluids (thickened or other) and various fruits, cakes and snacks.

Despite the significance of the mid-meal, the processes and controls for their delivery have not adequately evolved. During a recent review of diet management services commissioned by HealthShare NSW, recommendations to improve the mid-meal service delivery model were generated following observation of the service across 26 sites, including Westmead Hospital. These recommendations were supported by similar observations within previous Food Service Nutrition and Dietetic Student projects across various sites. Recommended improvements were required across the scope of mid-meal provision, including clarity of ordering, detailed labelling, safe practices surrounding potentially hazardous items and the associated IT functionality.

Undertaking this redesign for the mid-meal service has begun, and will continue to, address the identified risks and ensure that the right patient receives the right food and drink items at the right time. Therefore, improving patient outcomes, reducing waste and improving the overall patient experience.


To achieve the project goal and objectives, there are a large number of actions and activities to be implemented.

The following have already been undertaken and completed.

  • Development and circulation of a national online survey to members of the Institute of Hospitality in Healthcare Committee (predominantly dietitians and food service managers) and Queensland Health to collect a current state assessment and develop benchmarking for the project around what currently occurs for mid-meal provision.
  • Completion of a literature review to identify current mid-meal delivery models and assess the supporting evidence.

The following activities and initiatives are currently being implemented, with target completion date of August 2020.

  • Introduction of real time data throughout the mid-meal service delivery to ensure food service staff have up to date information regarding patient dietary requirements and locations.
  • Take patients' mid-meal orders in advance to enable patients to select their preferred items from the complete mid-meal menu and provide ordering assistance and encouragement to those with complex dietary requirements.
  • Development of a standardised process for food service staff to capture patient feedback regarding mid-meal preferences and for the dietetics and nutrition department to receive and action the feedback.
  • Scheduling of a collection service for potentially hazardous items within the four hour window and include the time and date on the sticker to ensure all staff and patients know when the item is no longer safe for consumption and must be disposed of.
  • Identification of shelf-stable alternatives to replace potentially hazardous items within the supper service due to no availability of food service staff to collect and dispose of items four hours after supper.
  • Development of flavour schedules by dietitians, dietitian assistants and diet supervisors with individual patients upon assignment of nutritional supplements and/or thickened fluids, rather than rely on the use of 'any flavour' items.
  • Development of ready reckoners for “any flavour” options for flavoured milks to ensure the patients are receiving correct flavours.


Implementation – The initiative is ready for implementation, is currently being implemented, piloted or tested.


February 2019 to August 2020

Implementation sites

Westmead Hospital in wards A4C – infectious diseases, B5A - respiratory and D5C - neurosurgery



Upon implementation of each of the solutions, an evaluation will be conducted. Evaluation activities will include the following.

  • Develop and use an audit tool to review compliance of food service staff with the 'ready reckoner' for flavoured milks to patients assigned an 'any flavour' item.
  • Generate a report to identify the use of 'any flavour' nutritional supplements and thickened fluids to assess dietitian, dietitian assistant and diet supervisor compliance with assigning individual flavour schedules for patients.
  • Complete an observational audit to ensure food service staff are able to use the real time data correctly.
  • Conduct patient interviews and surveys to determine their preference for placing mid meal orders from a wider range of options in advance of the service, or from a limited range when the tea and coffee trolley comes.
  • Generate feedback from food service staff, dietitian assistants and diet supervisors through surveys and focus groups to assess how the new mid-meal ordering in advance is working.
  • Develop and use an audit tool to assess whether the tea and coffee trolley is being stocked correctly.
  • Develop and use audit tools to assess whether potentially hazardous items are being collected at morning tea, afternoon tea and supper by the allocated departments.
  • Conduct an audit to assess compliance with placement of the sticker with correct time and date on all necessary potentially hazardous items.
  • Generate food items lists for the supper service to assess dietitian compliance with using shelf-stable alternatives.

Lessons learnt

  • The benefits of working across organisations – the coming together of clinical and operational staff resulted in really holistic and thorough assessments and outcomes throughout the project.
  • The importance and weight of the patient voice – the needs and wants of patients may be different from what staff assume or expect and this can be highly influential in directing the path of the project.
  • Engage the experts – when you want to know how to improve a service, the best people to ask are those who work within the service because they live and breathe the challenges and often already know how it can be improved.
  • Preparation is paramount – taking the time to plan what outcomes are needed from a meeting or discussion, particularly when senior leaders are involved, is a much more efficient use of everyone’s time.
  • Good sponsorship and stakeholder engagement is key – the sponsors and stakeholders really help drive the project and if you don’t have them on board and engaged early it can delay your project.


Nicola Brownlee
Nutrition Services Manager, Clinical Support Services
HealthShare NSW
Phone: 0438 571 082

Dominique Takats
Diet Supervisor, Dietetics and Nutrition Department
Westmead Hospital
Western Sydney Local Health District
Phone: 0434 944 125


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NutritionPatient safetyWestern SydneyInpatientMetropolitanCentre for Healthcare Redesign
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