Patient Experience Management in the Nutrition Sector as a Strategy to Elevate Csat

Adriana Zupo Domeneghetti; Tatiani Schmitt

DOI: 10.22167/2675-6528-202602603

Article derived from a Course Conclusion Work (TCC), with content based on the student’s original work and adapted to the editorial format of the E&S Magazine with the support of the ResumeAI tool, an artificial intelligence solution developed by Instituto Pecege for textual synthesis and organization.

Summary

The growing appreciation for the patient experience in a hospital setting has highlighted the relevance of the nutrition service as a component of care quality, especially concerning food acceptance, safety, and satisfaction. The study analyzed the experience of patients in the nutrition department of a private hospital in São Paulo, identifying critical points and proposing improvements to enhance satisfaction, measured by CSAT. A descriptive and exploratory case study with a mixed approach was adopted. Data were collected from an internal satisfaction survey with inpatients, occurrence records from the nutrition department, and CSAT data. Participants were patients on oral diets. The data were analyzed by tabulation in Excel spreadsheets, with the application of the GUT matrix for prioritization and the 5W2H tool for developing action plans. The results indicated that the taste of meals and delivery delays were the main factors of dissatisfaction, with recurring complaints about temperature and variety. The implemented interventions promoted operational improvements, resulting in a reduction of occurrences and a gradual increase in CSAT, which rose from 4.0 to 4.3. It was concluded that the integration of satisfaction metrics and management tools strengthened decision-making processes, highlighting the patient experience as a strategic indicator of care quality. Systematic adjustments in the preparation, presentation, and distribution of meals positively impacted user perception, reinforcing the need to improve communication channels for more precise interventions.

Keywords: Patient-centered care; Management tools in a nutrition service; Hospital nutrition service satisfaction; Hospital nutrition service.

1. Introduction

The growing appreciation for the patient experience in the hospital environment has highlighted the importance of the nutrition service as an essential component of care quality. Consumer expectations regarding hospitals have been increasing, and food provision, along with the dining experience, are becoming increasingly relevant in the medical and support services offered (Anderson et al., 2013). This experience ranges from dietary prescription to meal delivery at the bedside.

In this context, the competitiveness and success of healthcare institutions depend directly on the quality of services provided (Gronroos, 1990). To achieve this goal, organizations must be able to identify how to improve the quality of their services and how this improvement will be perceived by patients. Quality management in healthcare organizations, therefore, becomes central, requiring professionals to reflect, review their values, implement and follow protocols that ensure good practices in the work process (Labbadia et al., 2004).

In recent years, a more patient-centered and results-oriented approach has consolidated in the healthcare sector (Barry, 2012). This premise of Patient-Centered Care [PCC] presupposes a partnership between healthcare professionals, patients, and their families, configuring itself as a complex, collective, and essential strategy for quality healthcare (Bokhour et al., 2018). According to Donabedian (1990), healthcare quality is influenced by the interaction between structure, process, and outcome, and indicators are essential tools for measuring these dimensions. Such metrics allow for the identification of flaws, the promotion of continuous improvements, and the assurance of greater transparency in service delivery (Young and Williams, 2011).

Within the scope of care quality, malnutrition in the hospital environment represents a high-impact condition. It is characterized by changes in body composition, reduced functional capacity, and impaired mental status, resulting from insufficient nutrient intake, impaired absorption, or increased metabolic demands during the disease state (Cass and Charlton, 2022; Orlandi and González, 2022). The prevalence of malnutrition in hospitalized patients in Latin American countries can reach rates of up to 60% upon admission, being more frequent in the elderly, severely ill, or those undergoing certain surgical procedures (Correia and Waitzberg, 2017).

The Brazilian Survey of Hospital Nutritional Assessment [IBRANUTRI], a multicenter study, revealed that 48% of hospitalized patients were malnourished, with 12.6% presenting severe malnutrition and worsening associated with hospital stay duration (Correia et al., 1998). Factors such as advanced age, low food intake, and prolonged hospitalization are associated with a higher nutritional risk and worse clinical outcomes, including the need for ICU transfer and mortality (Regis Neto et al., 2025; Schindler et al., 2010). Causes of inadequate nutrition in hospitals include food quality and presentation, the meal environment, staff friendliness, meal delivery accuracy, and menu variety (Hartwell et al., 2016).

Given this scenario, systematically evaluating the patient’s perception of the nutrition service becomes complementary to clinical and operational indicators. In Brazil, studies focused on measuring patient satisfaction in private hospitals are still scarce, especially when it comes to applying standardized metrics such as the Customer Satisfaction Score [CSAT] to evaluate nutrition services. This gap limits the ability to identify critical points and implement evidence-based improvements, reinforcing the importance of research that explores the use of CSAT as a structured tool to measure and enhance patient perception of hospital nutrition services (Camargo, 2019).

This research is justified by the need to deepen the understanding of the patient experience in the hospital nutrition sector and, from this, develop effective strategies to increase satisfaction. This work aimed to analyze the patients’ experience in relation to the nutrition sector of a private hospital in the city of São Paulo, identifying critical points and, based on the findings, proposing improvements that could contribute to increased satisfaction, measured by CSAT.

2. Material and Methods

The research was designed as a case study, of a descriptive and exploratory nature, with a mixed methodological approach, combining qualitative and quantitative procedures. The case study allowed for the investigation of a contemporary phenomenon in its real context, enabling an in-depth analysis of the characteristics and particularities of the studied object (Yin, 2015). The descriptive character focused on identifying characteristics, while the exploratory aimed to broaden the understanding of the phenomenon (Gil, 2019).

The mixed approach was adopted to complement numerical and textual data, allowing for the measurement of quantitative information and the analysis of qualitative perceptions. This combination of approaches and data sources contributed to a comprehensive understanding of the phenomenon studied, especially when different data sources were used in a complementary manner (Creswell; Creswell, 2021).

The study was conducted in a large private hospital, located in the southern zone of the city of São Paulo. The institution’s food service is outsourced, responsible for the preparation and distribution of approximately 14,800 monthly meals to patients, covering breakfast, mid-morning snack, lunch, afternoon snack, dinner, and supper. Previously, a literature review was carried out to support the definition of satisfaction attributes and the selection of management tools.

The study population included patients admitted to the hospital’s inpatient units, with oral diet, excluding Intensive Care Units (ICUs). Patients on fasting, without meals, or with exclusive enteral or parenteral diet were not considered. Data collection occurred in specific periods for each instrument, aiming for information triangulation and reducing dependence on a single source (Yin, 2015).

Data collection involved three main sources. The Customer Satisfaction Score (CSAT) was obtained between March and November 2025, through a questionnaire sent by e-mail post-discharge, where customers rated the services from one to five, with one being “very dissatisfied” and five “very satisfied” (Camargo, 2019). The CSAT calculation consisted of the sum of scores 4 and 5, divided by the total number of responses received.

The internal satisfaction survey was applied monthly to hospitalized patients, from July to November 2025. The semi-structured questionnaire contained five multiple-choice questions, one scaled satisfaction question (using the five-point Likert scale, from 1- Poor to 5- Excellent) and a free comment field (Likert, 1932). The instrument was made available via Google Forms and applied in person by supervising nutritionists from the hospital and the outsourced company.

Internal incident records attributed to the nutrition sector, covering the period from January to November 2025, were analyzed documentarily. These records, formalized by the nursing staff and clinical body, were collected monthly and tabulated in Excel spreadsheets to identify the most frequent issues, aiming to identify, analyze, and prevent operational failures (Gil, 2019).

The analysis of qualitative data, from the three sources, used the content analysis technique proposed by Bardin (2016). This technique made it possible to organize and interpret communications through systematic categorization procedures, allowing the identification of recurring themes and patterns in the analyzed material, such as taste, temperature, meal delivery delay, and menu variety.

After identifying the main themes, the GUT matrix (Severity, Urgency, Tendency) was used as a support tool to prioritize actions (Gallegos, 2023). The GUT matrix, with a scale from one to five, allowed each problem to be classified and an index to be calculated by multiplying the scores for Severity, Urgency, and Tendency. For the development of action plans and detailing of prioritized actions, the 5W2H tool was used (Gallegos, 2023).

Regarding ethical considerations, the present study was not submitted to the Research Ethics Committee (CEP), as its methodological characteristics did not fit the institutional criteria that required such a procedure. However, measures were taken to ensure ethical standards, such as preserving patient anonymity and obtaining formal authorization from the institution through the signing of the consent form, guaranteeing the confidential treatment of information for academic purposes.

3. Results and Discussion

The analysis of patient experience in the nutrition sector revealed that, out of 1,745 responses registered in the internal Customer Satisfaction Score [CSAT] system, 39 manifestations were directed specifically to the nutrition service. It was noted that a portion of patients assigned low scores, one or two, but without providing detailed justifications that could elucidate the reasons for their dissatisfaction. This absence of additional information limited the depth of the qualitative analysis, an aspect that the literature points to as a methodological gap, suggesting the triangulation of qualitative and quantitative data for a more robust understanding of patient perception (Chatzipavlou et al., 2025).

The main factors of dissatisfaction identified, according to CSAT feedback, were meal flavor and delivery delays, both representing approximately 38% of complaints. Inadequate food temperature and limited menu variety were also pointed out, each accounting for about 10% of feedback. These initial data already indicated the need for interventions focused on operational and sensory aspects of the nutrition service, aligning with the objective of identifying critical points to improve patient satisfaction.

The analysis of internal occurrence records, from a notification system, complemented the CSAT data. Of the 139 records analyzed, 48.2% related to delays in meal delivery. This finding highlights punctuality as a significant critical point, negatively impacting the perception of the nursing staff and patients, and potentially compromising the quality of care. Other records, related to internal routines or employee meals, were not considered, maintaining the focus on hospitalized patients, according to the study’s scope.

In parallel, an internal satisfaction survey, applied monthly to inpatients on oral diets, surveyed 172 individuals and recorded 48 manifestations. Of these reports, 50% were directly related to the taste of the preparations, reinforcing the relevance of this attribute to the patient’s experience. Other aspects such as dish presentation, temperature, and variety were also mentioned, although less frequently. The survey used a semi-structured questionnaire with multiple-choice questions and a five-point Likert scale to measure the degree of satisfaction, in addition to a free-text field for comments, which allowed for the capture of additional qualitative perceptions (Likert, 1932; Gil, 2019).

The integration of data from the three sources – CSAT, satisfaction survey, and incident records – confirmed that meal flavor and delivery delays were the main factors of dissatisfaction. While flavor accounted for 50% of the mentions in the internal survey and approximately 38% in CSAT, delays predominated in incident records, with 48.2% of the points. Factors such as temperature and menu variety, although with lower percentages, showed high monthly recurrence, which justified their inclusion in the prioritization analysis.

To prioritize improvement actions, the GUT Matrix (Gravity, Urgency, Tendency) was applied. The inadequate temperature of the food obtained the highest score, with a GUT index of 100, indicating its high criticality. Meal delivery delays ranked second, with an index of 48. Menu variety and food flavor obtained indices of 36 and 27, respectively. Although flavor presented the lowest score in the GUT Matrix, its direct influence on food acceptance and patient experience justified the attention dedicated to this aspect, as also observed in studies such as Furness et al. (2023), who identified poor performance in flavor in other contexts.

The discussion about the taste of meals revealed that, despite its lower priority in the GUT Matrix, it directly impacts food acceptance. The study by Furness et al. (2023) corroborates the identification of low performance in taste, while other works, such as those by Verçoza et al. (2025) and Viana et al. (2022), presented more satisfactory results. In the context of the research, the renovation of the unit’s kitchen, which required the acquisition of meals from an external kitchen, may have negatively influenced the sensory quality of the food. To address this issue, the 5W2H tool was used to plan improvement actions, aiming to raise the sensory standard and acceptance of meals, with a focus on outsourced production and recipe adjustments.

The actions implemented for flavor included joint tasting of preparations by hospital and outsourced company nutritionists, replacement of the supplier responsible for meal preparation on two occasions, and technical visits by the unit’s cook to the supplier for recipe alignment and seasoning adjustments. Despite these efforts, no significant decrease in flavor-related dissatisfaction was observed in CSAT or the satisfaction survey, except during July and August, which coincided with the second supplier change. This result suggests that the complexity of flavor quality management in a scenario of outsourced production and structural reform posed considerable challenges.

Regarding delays in meal delivery, the analysis confirmed unsatisfactory performance, this being a recurring problem across the three data sources and classified as the second highest priority by the GUT Matrix. Literature, such as the study by Lalande et al. (2025), indicates that delays in meal distribution can impair adherence to the dietary plan and interfere with clinical routine, compromising nutritional care. In contrast, other research, such as that by Furness et al. (2023), Verçoza et al. (2025), and Viana et al. (2022), did not identify this problem with the same intensity.

The interventions planned with the 5W2H tool for delays aimed to reduce delivery time, ensure compliance with therapeutic schedules, and integrate the service into clinical routines. Actions included the adaptation of the pantry staff, optimization of the outsourced company’s hiring process, adjustments to the diet release process on the electronic panel, and improvement of internal communication between clerks and pantry staff. After implementing these measures, a reduction in internal incident reports and in CSAT delay complaints was observed.

However, the renovation of the unit’s kitchen, which kept the exclusive elevator for serving pantries closed for a period, was an intervening factor that may have influenced the results related to delays. This structural limitation, although temporary, added complexity to the distribution logistics and may have mitigated the full impact of the operational improvements implemented. The need to adapt to a compromised logistical flow required flexibility and continuous monitoring by the team.

Food temperature was identified as a critical factor, not only due to its high score in the GUT Matrix (100 points), but also because of its direct relationship with food safety, diet acceptance, and patient satisfaction. Brazilian sanitary regulations, such as RDC No. 216/2004 from the Brazilian Health Regulatory Agency (Anvisa), establish strict parameters for food conservation and distribution, aiming to minimize contamination risks. Dissatisfaction with temperature was recurrent, especially during winter months, suggesting a possible seasonal influence on the results.

Unlike some studies, such as those by Furness et al. (2023), Lopes et al. (2020), Verçoza et al. (2025), and Viana et al. (2022), which recorded satisfactory evaluations for temperature, the current research highlighted temperature as the attribute of greatest criticality. The actions proposed by the 5W2H tool for this problem included the maintenance and adjustment of thermal cars, the definition and monitoring of dish heating time, staff training for the proper use of thermal equipment, and the acquisition of milk and coffee machines for direct portioning in the cafeterias. These measures aimed to ensure the safe temperature of meals and stimulate diet acceptance.

Despite the interventions, it was not possible to identify a significant improvement in the formal temperature indicators, such as internal records and manifestations in communication channels. However, a reduction in requests for cold meal replacements was observed, which may indicate an indirect positive impact of the adopted measures on patient perception. The underreporting of complaints, with the nursing staff immediately replacing items, may have masked the real evolution of the formal indicators, making it difficult to accurately measure the effectiveness of the actions.

The low variety of the menu was another factor that negatively impacted food acceptance and patient satisfaction, making the experience less attractive (Leonhardt et al., 2019). Although the percentages of dissatisfaction manifestations related to variety were not the most expressive (12.8% in CSAT and 18.8% in the satisfaction survey), the recurrence of these reports and their direct relationship with food waste and the evolution of nutritional status justified their consideration. Studies by Furness et al. (2023) and Viana et al. (2022) also pointed to dissatisfaction with variety, while others, such as Lopes et al. (2020) and Verçoza et al. (2025), considered the results adequate.

The measures planned with the 5W2H tool to increase menu variety included menu evaluation and adaptation, with the replacement of preparations and introduction of new recipes, especially after the kitchen renovation was completed. A Menu Committee was implemented for weekly evaluation, aiming to replace repetitive, unharmonious preparations with a high rejection rate. However, even after the implementation of these actions, no significant improvement in results was observed. The kitchen renovation, which involved the supply of frozen preparations in sealed plastic packaging for regeneration, and the packaging of proteins with sauces, may have compromised the final quality and the perception of variety, as many patients preferred grilled preparations.

Based on the findings and identified improvement opportunities, managerial action proposals were developed to enhance processes and increase patient satisfaction. For the “temperature” attribute, suggested strategies included training, temperature control at all stages, and maintenance of thermal carts. For “flavor”, it was proposed to conduct periodic joint tastings, monitor the rejection of preparations, and review technical sheets. Regarding “delays”, strategies focused on reviewing the sizing of pantry staff, monitoring delivery time, and improving real-time interdepartmental communication.

From a practical point of view, the integration of satisfaction metrics, such as CSAT, with management tools like the GUT Matrix and 5W2H, strengthened decision-making processes in hospital nutrition services. This approach highlighted the patient experience as a strategic indicator of care quality. A gradual increase in CSAT was observed, rising from 4.0 at the beginning of the monitoring to 4.3 at the end of the study, indicating that interventions, even in the face of structural challenges, produced initial progress in service perception. Furthermore, there was a reduction in requests for cold meal replacements and in records of delays, pointing to indirect positive impacts.

In summary, the study demonstrated that systematic adjustments, even if simple, in the preparation, presentation, and distribution of meals can positively impact user perception. The kitchen renovation and the potential underreporting of complaints were limiting factors in measuring formal improvements, but the indirect results and the increase in CSAT suggest that the interventions were effective. The research reinforces the need to continuously improve communication channels to capture essential information and guide more precise and responsive interventions, consolidating the patient experience as a pillar of care quality.

4. Conclusion

This study analyzed the patient experience regarding the nutrition sector of a private hospital in São Paulo, seeking to identify critical points and propose improvements to increase satisfaction, measured by CSAT. It was found that the taste of meals and delivery delays were the main factors of dissatisfaction, with recurring complaints about the inadequate temperature of food and the limited menu variety. The application of the GUT Matrix prioritized temperature as the most critical aspect, followed by delays. To address these issues, the 5W2H tool was used to plan and implement actions. A gradual increase in CSAT was observed, rising from 4.0 to 4.3, and a reduction in requests for replacement of cold meals and in delay records, indicating initial progress in service perception.

The main contribution of this work lies in demonstrating how the integration of satisfaction metrics, such as CSAT, with management tools like the GUT Matrix and 5W2H, strengthens decision-making processes in hospital nutrition services, highlighting the patient experience as a strategic indicator of care quality. However, the unit’s kitchen renovation, which required outsourcing production and closing the service elevator, constituted a structural limitation that impacted sensory quality and distribution logistics. Furthermore, the underreporting of complaints by the nursing staff may have masked the real evolution of some formal indicators. It is recommended to continuously improve communication channels to capture essential information and guide more precise interventions, as well as to re-evaluate satisfaction indicators after the kitchen renovation is completed to monitor the effects of the implemented improvements.

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