S22-Food-Jan 2013

Malaysian Hospital Accreditation Standards 4th Edition January 2013
SERVICE STANDARD 22 Food and Dietary Services
TOPIC 22.1: ORGANISATION AND MANAGEMENT
STANDARD 22.1.1
Food and Dietary Services shall be organised and administered to provide safe and optimal nutritional care for
patients, staff and public, in accordance with the overall objectives of the Facility. Components of such
services may be provided by one department or through separate entities:
1. Food and Dietary Services.
2. Cafeteria.
CRITERIA FOR COMPLIANCE:
22.1.1.1 There are documented purposes which may be termed Vision and Mission statements, goals,
objectives and values that suit the scope of the Food and Dietary Services. When compiling the
purposes, consideration shall be given to the following:
a) They are what the services want to achieve.
b) The goals of the service are achieved by the objectives as stated.
c) The goals and objectives are consistent with professional standards, guidelines and
relevant legislation.
d) Statements are monitored, reviewed and revised as required accordingly.
22.1.1.2 There is an organisation chart which:
a) provides a clear representation of the structure, function and reporting relationships

between the Head and the staff of the Food and Dietary Services;
b) is accessible to all staff;
c) includes off-site services if applicable;
d) is revised when there is a major change in any one of the following:
 organisation;
 functions;
 reporting relationships;
 goals and objectives;
 staffing patterns.
Service Standard 22: Food and Dietary Services Page 1

22.1.1.3 There are written and dated specific job descriptions for all categories of staff that include:
a) qualifications, training, experience and certification required for the position;
b) lines of authority;
c) accountability, functions, and responsibilities;
d) review when required and when there is a major change in any one of the following:
 nature and scope of work;

 duties and responsibilities;
 general and specific accountabilities;
 qualifications required;
 staffing patterns;
 Statutory Regulations.
22.1.1.4 Regular staff meetings are held to discuss issues and matters pertaining to the operations of the
Food and Dietary Services. Minutes are kept and accessible to relevant staff.
22.1.1.5 Personnel records on training, staff development, leave and others are maintained for every
staff.
22.1.1.6 The Head of the Food and Dietary Services shall be involved in the planning, management, and
justification of budget and resource utilisation of the services.
22.1.1.7 The Head of the Food and Dietary Services is involved in the appointment and/OR assignment of
staff.
22.1.1.8 Appropriate statistics and records shall be maintained in relation to the provision of Food and
Dietary Services. Information on the number of meals provided (differentiating special diets) and
unit costs is kept. The above statistics and information are to be used for managing the Food and
Dietary Services and patient care purposes.
22.1.1.9 The Head of the Food and Dietary Services shall ensure that the staff of Food and Dietary
Services complete incident reports which are discussed by the services with learning objectives
and forwarded to the Person In Charge (PIC) of the Facility.
22.1.1.10 Incidents reported have had Root Cause Analysis done and action taken to prevent recurrence.
22.1.1.11 The quantity, quality, and variety of food offered shall be acceptable to patients and staff and
also meet their nutritional requirements, religious and cultural preferences.
22.1.1.12 Dietitians shall be involved in the following aspects of nutritional services to patients:
a) nutritional assessment, nutritional care planning, and evaluation of nutrition or

interventions;
b) formulation of menus and recipes;

c) continuous training and education for food services staff.
22.1.1.13 Where Food and Dietary Services are provided by an external source, there is a written
agreement between the external service provider and the Facility stating the requirements for the
services that include the following:
a) valid license from the local authorities;
b) formal lines of communication and responsibilities between the external service provider
and the Facility;
c) personnel providing the services are supervised by a qualified dietitian or a person with
training and experience in food services;
d) participation, as appropriate, of the external service provider in committees of the Facility;
e) arrangements for after-hours and emergency services;
f) involvement of the external service provider in safety and quality improvement activities of
the Facility, as appropriate;
g) space, facilities and equipment are provided by the Facility.

TOPIC 22.2: HUMAN RESOURCE DEVELOPMENT AND MANAGEMENT
STANDARD 22.2.1
The Food and Dietary Services is directed and supervised by qualified and experienced dietitian to achieve its
aims and objectives and ensure skills in handling, preparing and serving of food and supervision and
management of food handlers.
22.2.1.1 The Head of Food and Dietary Services shall be a qualified and experienced dietitian who shall
be responsible for the direction and staffing of the services to achieve the objectives of the Food
and Dietary Services.
22.2.1.2 Where the Head of Food and Dietary Services is not a dietitian, the Person In Change (PIC) of
the Facility shall ensure that the availability of consulting a qualified dietitian on food service
procedures which include the storing, processing and serving of food, the planning of menus and
the management of therapeutic diets.
22.2.1.3 The authority, responsibilities and accountabilities of the Head of Food and Dietary Services are
clearly delineated and documented in a letter of appointment.
22.2.1.4 Sufficient numbers of personnel and support staff with appropriate qualifications are employed to
enable the services to meet its documented purposes. There shall be regular review of staffing
needs and staff utilisation.
22.2.1.5 There is a structured orientation programme where new staff are briefed on their services,
operational policies and relevant aspects to prepare them for their roles and responsibilities.
22.2.1.6 There is evidence of a staff development plan which provides the knowledge and skills required
for staff to maintain competency in their current positions as the demands of the positions evolve.
22.2.1.7 There are continuing education activities for staff to pursue professional interests and to prepare
them for current and future changes in practice. There is evidence that staff education and
development needs have been appraised and identified.
22.2.1.8 Staff receive written evaluation of their performance at the completion of the probationary period
and annually thereafter, or as defined by the Facility.
22.2.1.9 All food handling staff must undergo medical screening and immunisation as required by relevant
statutory requirements.

TOPIC 22.3: POLICIES AND PROCEDURES
STANDARD 22.3.1
Food and Dietary Services shall be provided in accordance to the policies set by the respective Facility and
statutory requirements where applicable. Documented policies and procedures appropriate to the provision of
quality and safe food services shall be made accessible to all staff.
22.3.1.1 There are written policies and procedures for Food and Dietary Services and they are consistent
with the overall policies of the Facility.
22.3.1.2 Policies and procedures are developed in collaboration with staff, medical practitioners,
Management and where required with other external service providers and with reference to
relevant sources involved.
22.3.1.3 Policies and procedures are dated, authorised, signed and reviewed at least once every three
years and revised as required.
22.3.1.4 New and revised policies and procedures are communicated to all staff.
22.3.1.5 There is evidence of compliance with policies and procedures.
22.3.1.6 Copies of policies and procedures, relevant Acts, Regulations, By-Laws and statutory
requirements are accessible to staff.
Notes/Explanations
Copy of guidelines on “Hospital Catering” by Food Quality Control Division, Ministry of Health or
other recognised bodies is available for references.
22.3.1.7 Fire precautions, disaster plans and safety procedures shall be documented and followed.
22.3.1.8 Stock control, ordering and stock taking arrangements shall be in place to promote effective
management of the Food and Dietary Services and deter pilfering and theft.
22.3.1.9 Documentation of policies for storage and handling of food shall be evident.
22.3.1.10 Food for consumption and food not yet cooked shall be stored and handled separately.
22.3.1.11 Bulk preparation of food for long term holding such as freezing shall be carried out only if
qualified staff are available to establish the standards and supervise the handling, preparation,
and processing of food stuff.
22.3.1.12 Menus shall be planned to provide meals that meet the needs of patients on unrestricted or
therapeutic diets. Menus shall also provide for the needs of staff and suit religious and cultural
practices.
22.3.1.13 There shall be designated staff to deliver and serve the food to the patients supervised and
monitored by the nursing staff.
22.3.1.14 There is an appropriate documented procedure to ensure safe provision of meals to infectious
patients.
22.3.1.15 Preventive and corrective maintenance programmes for equipment and records shall be in place.
22.3.1.16 Documented procedures shall be evident for the cleaning of all equipment.
22.3.1.17 Procedures for machine and hand dishwashing shall be documented and available.
22.3.1.18 Garbage shall be held in covered containers and removed from the Food and Dietary Services
area daily.
22.3.1.19 There is a proper procedure for the disposal of food refuse.
22.3.1.20 There is a continuing programme on pest and vermin control.
22.3.1.21 There is evidence of inspection and certification by the Health Authority at least annually and the
rating should be 75% and above.
22.3.1.22 Appropriate clean, protective clothing shall be worn by all staff and this clothing shall be changed
daily and as required.
22.3.1.23 All food services staff shall comply with good hygienic practices while on duty.
22.3.1.24 The Head of Food and Dietary Services shall ensure that no person:
a) infected with or who is a carrier of a communicable disease;
b) having boils;
c) with open or infected skin lesions;
d) with an acute respiratory infection.
shall work in any area of food preparation and services during the duration of the illness.

TOPIC 22.4: FACILITIES AND EQUIPMENT
STANDARD 22.4.1
Appropriate physical layout, mechanical and electrical facilities, and equipment shall be available for the
efficient operations of the Food and Dietary Services.
22.4.1.1 The layout of areas for Food and Dietary Services shall allow for the following:
a) receiving of food stocks;
b) storage of food ensuring adequate separation of dry ration from perishable and adequate
segregation of perishable by type;
c) food handling prior to cooking with separate process areas for meat, fish and vegetables
to prevent contamination;
d) separate areas for preparation of salad, pastries and confectionaries;
e) preparation of food including cooking or reconstitution;
f) holding of prepared food;
g) distribution of food or meals;
h) plating of food;
i) dishwashing and scullery activities;
j) storage for other items;
k) waste disposal;
l) adequate hand washing facilities for staff, separate from those utilised for food
preparation;
m) staff rest and changing areas should be outside any food preparation area.
22.4.1.2 Floors, walls, and ceilings finishes shall be easily cleaned, non-skid, impervious and kept in good
repair.
22.4.1.3 Lighting shall be adequate and appropriate to provide safe work environment.
22.4.1.4 Appropriate ventilation, temperature and humidity control shall be available to provide
comfortable working condition and promote cleanliness.

22.4.1.5 There is evidence of compliance with fire safety requirements.
22.4.1.6 Food storage in dry stores, refrigerated stores, and freezers shall comply with appropriate health
regulations and standards of good practice.
22.4.1.7 There is documented evidence that equipment complies with relevant standards, e.g. those set
by SIRIM Berhad (Standards and Industrial Research Institute of Malaysia) and current statutory
requirements.
22.4.1.8 There is evidence that the facility has a comprehensive maintenance programme such as
predictive maintenance, planned preventive maintenance and calibration activities, to ensure the
facilities and equipment are in good working order.
22.4.1.9 Where specialised equipment is used, there is evidence that only staff who are qualified and
privileged by the Facility operate such equipment.

TOPIC 22.5: SAFETY AND QUALITY IMPROVEMENT ACTIVITIES
STANDARD 22.5.1
The Head of Food and Dietary Services shall ensure the provision of quality performance with staff
involvement in the continuous safety and quality improvement activities of the Services.
22.5.1.1 There is evidence that the Head of the Service has in a written document assigned
responsibilities to appropriate individuals/committees for safety and quality improvement activities
within the services.
22.5.1.2 There are planned and systematic safety and quality improvement activities that monitor and
evaluate the performance of the services including a plan for action and follow up to ensure that
the action taken is effective in continually improving the quality of care. Innovation is advocated.
22.5.1.3 There are safety and quality improvement activities in place which support the Facility’s safety
and quality improvement activities including tracking and trending of specific performance
indicators not limited to but at least two (2) of the following:
a) number of samples of ready to serve food (cooked and freshly cut) tested positive for
pathogenic microorganism from 6-10 samples over a period of three (3) months done on
separate occasions
b) occurrence of physical contamination of food served to patients
Notes/Explanations
Reports are available on indicators include tracking and trending for specific performance
indicators carried out.
22.5.1.4 Feedback on results of safety and quality improvement activities are regularly communicated to
the staff.
22.5.1.5 Appropriate documentation of safety and quality improvement activities is kept and
confidentiality of staff and patients is preserved.
22.5.1.6 There are safety and quality improvement activities that address staff safety.

TOPIC 22.6: SPECIAL REQUIREMENTS – CAFETERIA SERVICES
STANDARD 22.6.1
Cafeteria Services shall be appropriately staffed, organised and managed to provide safe food for staff and
public, in accordance with the overall objectives of the Food and Dietary Services.
22.6.1.1 There shall be a formal contract agreement between the management and cafeteria operator (if
outsourced) stating the requirements of the services.
22.6.1.2 Service provider has a valid licence from the relevant local authority to operate the Cafeteria
Services.
22.6.1.3 Head of the Food and Dietary Services shall be involved in the supervision of the cafeteria.
22.6.1.4 Sufficient numbers of trained personnel and support staff are employed to allow for the services
to meet its documented purposes.
22.6.1.5 All food handling staff must undergo medical screening and immunisation as required by relevant
statutory requirements.
22.6.1.6 Trained personnel shall have proof of having attended training course for food handlers by
Ministry of Health or other recognised agency.
22.6.1.7 There is a structured orientation programme where new staff are briefed on their services,
operational policies and relevant aspects to prepare them for their roles and responsibilities.
22.6.1.8 There is clear evidence of appropriate quality assurance mechanism and adherence to
standards and regulations on Food Quality by local authority, including microbiological testing on
food samples.
22.6.1.9 The Head of Food and Dietary Services shall ensure that no person:
a) infected with or who is a carrier of a communicable disease;
b) having boils;
c) with open or infected skin lesions;
d) with an acute respiratory infection.
shall work in any area of food preparation and services during the duration of the illness.

STANDARD 22.6.2
The Cafeteria Services shall take cognisance to make available the delivery of quality and safe food services
for the staff and public.
22.6.2.1 There are written policies and procedures for Cafeteria Services (in outsourced services terms of
contract) that are consistent with the overall policies of the Facility.
22.6.2.2 New and revised policies and procedures are communicated to members of cafeteria
management.
22.6.2.3 There is evidence of compliance with policies and procedures.
22.6.2.4 Copies of relevant regulations and statutory requirements including guidelines on “Hospital
Catering” and “Garis Panduan Penilaian Pengiktirafan Kafeteria Sihat (2012)” by Ministry of
Health or any other recognised bodies are available for reference and are compliance with.
22.6.2.5 Fire precautions, disaster plans and safety procedures are documented and followed.
22.6.2.6 Planned preventive and corrective maintenance programs for equipment and records shall be in
place.
22.6.2.7 Documentation of policies for storage and handling of food shall be evident.
22.6.2.8 Cooked food and raw food shall be stored and handled separately.
22.6.2.9 Garbage shall be held in covered containers and removed from the cafeteria daily.
22.6.2.10 A clear procedure shall be established and documented in regard to the disposal of food refuse.
22.6.2.11 There shall be a continuing programme of pest and vermin control.
22.6.2.12 There is evidence of inspection and certification by the Health Authority at least annually and the
rating should be 75% and above.
22.6.2.13 Appropriate clean, protective clothing shall be worn by all staff and this clothing shall be changed
daily and as required.
22.6.2.14 All food services staff shall comply with good hygienic practices while on duty.

STANDARD 22.6.3
To meet its goals and objectives the physical facilities and equipment appropriate to the needs of the
Cafeteria Services shall be available.
22.6.3.1 The layout of areas for Cafeteria Services shall allow for the following:
a) storage of food ensuring adequate separation of dry ration from perishables and adequate
separation of perishables by type;
b) food handling prior to cooking with separate process areas for meat, fish and vegetables
to prevent contamination;
c) receiving of food stocks;
d) holding of prepared food;
e) preparation of food including cooking or reconstitution;
f) distribution of food or meals;
g) serving of meals;
h) dishwashing and scullery activities;
i) storage for other items;
j) waste disposal;
k) staff rest and changing areas should be outside any food preparation area;
l) there shall be separate areas for preparation of salads, pastries, confectionaries;
m) adequate hand washing facilities for staff, separate from those utilised for food preparation
in the main kitchen area.
22.6.3.2 Floors, walls, and ceilings finishes shall be easily cleaned, non-skid, impervious and kept in good
repair.
22.6.3.3 Appropriate lighting to allow safe work environment shall be available.
22.6.3.4 Appropriate ventilation, temperature and humidity to provide comfortable working conditions and
promote cleanliness.
22.6.3.5 There is evidence that the cafeteria is complied with the fire safety requirements.

22.6.3.6 Refrigeration and storage of food in dry storage, refrigerated storage and in freezers shall comply
with appropriate health regulations and standards of good practice. Where appropriate, Cold
Room shall be made available.
22.6.3.7 There is documented evidence that equipment complies with relevant standards, e.g. those set
by SIRIM Berhad (Standards and Industrial Research Institute of Malaysia) and current statutory
requirements.
22.6.3.8 There is evidence that the facilities and equipment are maintained in good working order and
subject to ongoing planned preventive maintenance and calibration.
22.6.3.9 Where specialised equipment is used, there is evidence that only qualified and privileged staff,
operate such equipment.
STANDARD 22.6.4
The hospital management ensures the provision of quality food services in the Cafeteria through ongoing
safety and quality improvement activities of the Facility.
22.6.4.1 The management through the Head of Food and Dietary Services shall be responsible for safety
and quality improvement activities within the Cafeteria Services.
22.6.4.2 Appropriate documentation of safety and quality improvement activities is kept, e.g. client
satisfaction survey.

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Malaysian Hospital Accreditation Standards 4th Edition January 2013

SERVICE STANDARD 22 Food and Dietary Services

TOPIC 22.1: ORGANISATION AND MANAGEMENT

1. Food and Dietary Services.

CRITERIA FOR COMPLIANCE:

a) They are what the services want to achieve.

b) The goals of the service are achieved by the objectives as stated.

d) Statements are monitored, reviewed and revised as required accordingly.

22.1.1.2 There is an organisation chart which:

a) provides a clear representation of the structure, function and reporting relationships

b) is accessible to all staff;

c) includes off-site services if applicable;

d) is revised when there is a major change in any one of the following:

Service Standard 22: Food and Dietary Services Page 1

a) qualifications, training, experience and certification required for the position;

c) accountability, functions, and responsibilities;

 nature and scope of work;

a) nutritional assessment, nutritional care planning, and evaluation of nutrition or

Service Standard 22: Food and Dietary Services Page 2

c) continuous training and education for food services staff.

a) valid license from the local authorities;

d) participation, as appropriate, of the external service provider in committees of the Facility;

e) arrangements for after-hours and emergency services;

g) space, facilities and equipment are provided by the Facility.

Service Standard 22: Food and Dietary Services Page 3

TOPIC 22.2: HUMAN RESOURCE DEVELOPMENT AND MANAGEMENT

CRITERIA FOR COMPLIANCE:

Service Standard 22: Food and Dietary Services Page 4

TOPIC 22.3: POLICIES AND PROCEDURES

CRITERIA FOR COMPLIANCE:

22.3.1.5 There is evidence of compliance with policies and procedures.

22.3.1.19 There is a proper procedure for the disposal of food refuse.

22.3.1.20 There is a continuing programme on pest and vermin control.

a) infected with or who is a carrier of a communicable disease;

c) with open or infected skin lesions;

d) with an acute respiratory infection.

Service Standard 22: Food and Dietary Services Page 6

TOPIC 22.4: FACILITIES AND EQUIPMENT

CRITERIA FOR COMPLIANCE:

a) receiving of food stocks;

d) separate areas for preparation of salad, pastries and confectionaries;

e) preparation of food including cooking or reconstitution;

f) holding of prepared food;

g) distribution of food or meals;

i) dishwashing and scullery activities;

j) storage for other items;

Service Standard 22: Food and Dietary Services Page 7

22.4.1.5 There is evidence of compliance with fire safety requirements.

Service Standard 22: Food and Dietary Services Page 8

TOPIC 22.5: SAFETY AND QUALITY IMPROVEMENT ACTIVITIES

CRITERIA FOR COMPLIANCE:

b) occurrence of physical contamination of food served to patients

Service Standard 22: Food and Dietary Services Page 9

TOPIC 22.6: SPECIAL REQUIREMENTS – CAFETERIA SERVICES

CRITERIA FOR COMPLIANCE:

a) infected with or who is a carrier of a communicable disease;

c) with open or infected skin lesions;

d) with an acute respiratory infection.