Americans must hold on to their hats to weather the wild ride the country has been taking since the implementation of the Patient Protection and Affordable Care Act. Healthcare foodservice professionals are responding to the ever-changing environment with creative solutions for containing costs; generating revenue; providing responsive, high-quality, patient-centered care; introducing wellness-focused initiatives; and applying information and machine technology to enhance efficiency and improve the quality of food and service. Add to this finding ways to work within consolidated healthcare systems and this year promises to present unprecedented challenges. It would be easy to say that the implementation of the Affordable Care Act continues to have a profound impact on healthcare foodservice. While this is accurate, the fact remains that healthcare foodservice was poised for a change regardless of what happened on the political landscape: Facilities were aging. Baby boomers were entering a new stage of their lives. And consumers were becoming more engaged in their own health before the historic healthcare legislation passed into law.

While not a primary revenue generator for a healthcare facility, the importance of foodservice operations has never been greater. At the same time, the pressure to operate effectively and efficiently remains intense.

"Cost will drive healthcare systems as it has for a long time," says Paul Hysen, principal at the Hysen Group in Northville, Mich. "We'll need very sophisticated control systems to know what foodservice costs are and what the system is getting for the costs. Costs will justify services, renovations, room service, retail, staffing and everything in operations." In addition to managing costs, operators realize they must maintain quality of care across the board.

The pressure to better manage costs will make benchmarking ever more valuable, says Mary Keysor, a healthcare consultant in Portland, Maine, and the former foodservice director at Maine Medical Center.

Below, FE&S takes a look at ten trends impacting healthcare foodservice and the creative solutions operators are employing to meet them.

1. System Consolidation

Looking at the larger landscape, the bigger healthcare providers will continue to merge and that will lead to more systemization of healthcare, says Christine Guyott, principal at Robert Rippe & Associates, a Minneapolis-based foodservice consulting firm. “We’ll no longer have smaller, community stand-alone hospitals, because they’ll all be part of the bigger systems. This is certainly changing the way foodservice will be provided and managed.”

As more healthcare systems consolidate, foodservice professionals will participate on strategic teams to combine everything from operations to purchasing, customer service and cultures. For instance, Swedish Health Services, a system with 5 hospitals, more than 70 primary care and specialty clinics, 3 ambulatory care centers, a home-care division and 11,000 employees in greater Seattle, entered into an affiliation with Providence Health & Services, which has 27 hospitals, 214 physician clinics and nearly 53,000 employees across 5 states. The two organizations formed a new not-for-profit healthcare system to improve quality of care, access and affordability for the residents of western Washington. Each system keeps its name; and Swedish Health Services remains a nonreligious organization, while Providence retains its Catholic identity.

To help this new system evolve, Kris Schroeder, administrative director of support services for Swedish Health Services, serves on a team looking at the big picture and strategic plan. In addition, two of Schroeder’s associates — Candace Johnson, director of nutrition and environmental services, and Eric Eisenberg, corporate executive chef for nutrition, catering, retail and conference services — also serve on teams that will develop localized strategies for standardizing practices across the system.

“I’m a pragmatist and believe I can hold fast for keeping systems or procedures that I feel are sacred,” Eisenberg says. “But I know there will be compromises. I’m much better off being a leader in my organization and being part of a solution and embracing changes.” Meetings are in the initial stages.

2. Data Integration and Synthesis

As systems grow, healthcare foodservice departments will need to report their progress on meeting goals, achieving specific metrics, and keeping up with other performance indicators. And they will need to do this more quickly than before and integrate data from multiple systems.

"As University of North Carolina (UNC) Health Care continues to grow and mature, it is increasingly critical to have one integrated suite of clinical and financial products that provide coordinated, real-time data for our patients, providers and outside parties," says Angelo Mojica, director of food and nutrition services for UNC hospitals in Chapel Hill, N.C.

In April, the system went live for UNC Hospitals, UNC Faculty Physicians, Chatham Hospital and UNC Physicians Network West. In June the system will go live for Rex Healthcare, Rex LLC and UNC Physician Network East. "Eventually this will include foodservice, as well," Mojica says. "It will affect diet orders, recipes and all the information we use for foodservice."

3. Consolidation and Supply Management

In 2012, HCA West Florida took a consolidated approach to the management of food and nutrition services (FANS) for its hospitals. The 16 hospitals of WFD FANS represent $45 million in total operating expense, the equivalent of 550 full-time employees and $20 million in total supply costs. "The consolidation of FANS is designed to improve the overall operation via replication of best practices, reduction of costs via product standardization and automation," says Joyce Hagen-Flint, division director of food and nutrition services, HCA West Florida Division, Largo, Fla. "Savings have exceeded $2 million per year in addition to labor savings via improved productivity. With the consolidation, a fully integrated information system was implemented and redundant management activities reduced."

To track savings and compare outcomes, FANS uses a monthly dashboard, quarterly balanced scorecard analysis and Association for Healthcare Foodservice (AHF) Benchmark reports. "Prior to consolidation, each hospital had its own menu and procedures with little consistency in approach and systems," Hagen-Flint says. As a result, service-level variations and duplicated efforts from redundant activities led to waste.

Taking the operation in-house and standardizing the approach paid significant dividends. For example, in spite of inflation, total food cost per adjusted admission decreased each year since the consolidation began, Hagen-Flint says. Food cost net of retail revenue per adjusted patient day decreased nearly 15 percent and productivity improved by more than 4 percent. "The most significant food cost savings were generated by appropriate utilization of product, achieved by using software tools to forecast and track patient, retail and complimentary meals, amenities and services as well as effective policies to control their use," she says.

Patient Service Takes Many Forms

Whatever form patient foodservice takes, both food quality and customer service must be high to contribute to patients' positive experience. "There's more pressure on foodservice because expenditure of services must be directly linked to patient satisfaction," Hysen says.

Some hospitals, such as Rush University Medical Center in Chicago, continue to operate a more standard program. Patients receive restaurant-style menus and staff help them make selections. Foodservice galleys on patient floors, with combi ovens and high-speed ovens, allow staff to heat and customize food orders.

Room service, the most popular form, ranges from a classic program with call centers at Robert Wood Johnson University Hospital in New Jersey (see page 32) and University of Michigan Health System (see page 46) and Reading Health System (see page 53) to hybrid systems that feature attendant-based ordering. "We have room service that uses both dining service associates and a call center. Patients who can order through the call center do so and those requiring assistance at the bedside can get that assistance. It's the best of both worlds," says Lynne Ometer, MS, MHA, RD, LD, director of food and nutrition services at Emory Healthcare in Atlanta. "Whether it will be affordable going forward is the question.

Technology seems to play a prominent role in every type of patient delivery program today. At the University of California San Francisco Medical Center, for example, patients will soon have access to tablet computers that will give them information in English and Spanish about the menus as well as the foods they can't eat due to their physician-prescribed dietary restrictions and dietitians' recommendations, says Dan Henroid, director of nutrition and food services, and sustainability officer. "The information will be integrated with their health record so they have all the information they need to make choices," he adds.

5. Retail Services Multiply Exponentially

If run properly, retail services can generate much-needed revenue, which is why hospitals continue to tap into their potential. Trained chefs continue to enhance quality food production and contribute to the interactive eatertainment. Integrated retail-patient menus continue to gain popularity, as well as coffee and wellness kiosks, vending machines with healthful selections and convenience markets.

Last year ProHealth Care in Waukesha, Wis., opened a new foodservice facility that generated 250 more transactions per day in the beginning. The Grille’s stations include a deli counter where customers can order toasted subs, sauté, pizza, char grill, salad bar with fruit and a grab-and-go case, as well as an area for bakery items and a coffee shop. “All but one station is interactive with customers,” says Randy Sparrow, system director of food, nutrition and environmental services. “It’s a great opportunity for staff to meet customers and educate them if they have questions.” Staffing for the Grille gets a big boost thanks to the department’s partnership with area culinary schools.

6.Food Helps Wellness Initiatives Grow and Get Healthier

As many hospitals and healthcare clinics attempt to shift from being illness centers for patients to becoming wellness centers for patients, employees and community members, food is stepping into a more prominent role.

"In our recipes, we are obviously watching controlling the main nutrients such as sodium, fat, saturated fat, etcetera, but we are constantly trying to find ways to educate staff, employees and patients that low-sodium/low-fat foods don't have to be bland and that flavor can be achieved with other seasonings if the product is cooked and handled properly," says Drew Patterson, executive chef at Ohio State University Wexner Medical Center in Columbus.

Another wellness program, LiVe Well, takes center stage at Intermountain Healthcare's cafés in Utah. "Since the rollout a year ago, chefs at Intermountain Healthcare's major hospitals have developed 72 plates," says Julie Spelman, director of food and nutrition services at Primary Children's Hospital in Salt Lake. The seven chefs' LiVe Well plates each contain no more than 600 calories, a maximum of 700 mg of sodium and less than 30 percent fat.

The plates are part of Intermountain Healthcare's LiVe Well public service campaign to encourage adults, teens and children to adopt healthful behaviors, be physically active and make healthful food choices. Recipes and videos for LiVe Well dishes are posted online in the "Eat Well" section of the hospital system's website. "The next steps will most likely be a branding of our cafés in the system to show our support of good old-fashioned healthy eating," Spelman says.

Healthcare operators are moving in this direction by taking the Hospital Nutrition Environment Scan (HNES) survey, which grades facilities on the marketing and availability of healthy items in their cafés. Twenty of the 22 hospitals in the Intermountain system have taken the surveys and plan to publish the results in the coming year.

Under Spelman's direction, Primary Children's Hospital is tackling the research component with a local researcher/educator. "We are very excited about the progress, especially since this is a validated survey that first was published in the Journal of the Academy of

Nutrition and Dietetics," Spelman says. "Our scores were better than the 38 hospitals in California and much better than the contract hospitals in the original survey. And this was without instructions on how to better our scores."

Spelman hopes "to have a LiVe Well plate every day of the week in every Intermountain hospital, to have the very best HNES scores in the nation, and to demonstrate best practices in offering a healthy environment to our customers."
Another wellness initiative in retail operations is to cut back on sweetened beverages. For example, at Saint Francis Health System in Tulsa, Okla., staff give out an educational tool regarding portion size and the benefits of decreasing or eliminating soda; change the mix of healthier choices to 60 percent or 70 percent; decrease the number of 20-ounce sodas offered in retail and bring in 12-ounce canned soda; dedicate the first refrigerated door in all retail venues to water and canned soda; and offer 12-ounce fountain beverages and canned soda at a slightly discounted price.

7. Lean, Green and Sustainable

Waste and energy management programs continue to gain momentum as operators learn how to justify the costs.

Many trendsetting health and sustainability practices come from Fletcher Allen Health Care in Burlington, Vt. In 2006, Diane Imrie, director of nutrition services, signed the department on to Health Care Without Harm's Healthy Food in Health Care pledge, committing to promote the health of Fletcher Allen's patients, the community and the environment.
Imrie's department spends more than $1.5 million each year on food produced in Vermont. The hospital's comprehensive waste-reduction program, which includes foodservice, composts food from the kitchens. The department also purchases compostable paperware.

In addition, the hospital hosts classes about community gardening and nutrition on its rooftop. "We offer weekly classes with our gardener and dietitian, focusing on how to grow healthy food, what healthy food is and how to cook it," Imrie says.

Imrie also works with a physician to coordinate the Health Share project to increase access to healthy food for 24 low-to-moderate income families in Colchester, Vt., by providing a free farm share. "Participants were targeted for hypertension and income needs through biometric screening with their physicians," she says. "Farm shares came from Vermont Youth Conservation Corps once a week for 12 weeks. Each week we set up a tent, explained what was in each share and had a recipe tasting or two. We also gave out some essential gadgets like a salad spinner. We saw some significant improvement in health behaviors, although we had a small number of participants over a short period, but this gave us enough to tell us that we should continue with the program. We have funding from TD Bank to do one site this year and would like to expand to all four of our primary care sites if we can obtain more funding."

8. Resident-Directed Long-Term Care

Culture change is a national movement for the transformation of older adult services. "Culture change is based on person-directed values and practices where the voices of elders and those working with them are considered and respected. Core person-directed values are choice, dignity, respect, self-determination and purposeful living," according to Pioneer Network, which was formed in 1997 by a small group of prominent professionals in long-term care to advocate for person-directed care.

Making long-term care services more homelike and tailored to the individual rather than the daily routine takes top priority at Pennswood Village, a continuing care retirement community, in Bucks County, Pa. "Rather than providing meal service to residents in their rooms or providing a more formalized style of service in the dining room, this means creating a homelike environment for the residents to express their choices," says Mary Cooley, director of dining services. "Tracy Russell, dining services manager, leads the charge along with key members of the healthcare team by creating special theme days and activities for our residents."

For example, made-to-order breakfasts are served from Pennswood's country kitchen in the skilled care dining area. "We use pasteurized shell eggs, so residents can have poached and over-easy eggs," Cooley says.

"The culture change transformation is helping us make changes in our organizational practices and rethink how we provide care to our residents, whether it's a special themed meal, such as a Phillies picnic for the home opener, or making cookies with our residents for St. Patrick's Day," Cooley says. Residents thanked Pennwood Village's staff by making shamrock butter cookies and arranging for trays to be delivered to various departments.

"The best part is that when we involve the residents in these simple activities, they eat more and are more engaged with staff and each other during meal service," Cooley says. "It's helping to transform their dining experience in ways that are wonderfully unexpected and really don't add additional cost to the operation. We are just getting started and realize we still have much more to do to really integrate culture change into the organization."

9. Finding New Technologies

At Swedish Health, a new food-labeling system allows staff to enter all menu items into a database that contains information for a standardized label with expiration dates and the name of the employee who places the item into storage. “Vinyl labels don’t disintegrate with heat or change with cold,” Eisenberg says. “We’re also looking into a system that monitors food temperatures all day, not only in refrigerators but also in serving wells and on a serving line. The system generates a database for our reference.”

At UCSF Medical Center, Henroid’s team carries handheld devices to swipe credit cards for guest meals. At the new hospital opening next year, technology will include a robotic meal transport system and an interactive patient information center.

Other technology gaining favor includes high-speed ovens, combi ovens with smokers, soft-serve machines, hot/cold wells, blast chillers integrated into walk-in coolers, charbroilers and grills on room service lines, and utility distribution systems that allow change-out of equipment when needed.

10. Image Enhancement

Self-ops and contract companies continue to market their foodservice brand to convey a more contemporary, professional message about their products and employees. This year, Morrison Healthcare and Crothall Healthcare, both units of Compass Group North America, introduced new logos and word marks as part of a combined brand refresh. The streamlined looks are similar in design to show their close alignment and integrated approach to providing hospital and health system clients with specialized food, nutrition and support services. The refresh includes new chef coats and uniforms, marketing materials and signage in cafés.