Healthcare foodservice providers must dig deep into their creative wells as the wild healthcare ride becomes more tumultuous with demands for cost containment and quality improvements.

An organized assembly area assists staff to provide efficient room service at Southern Maine Health Care in Biddeford.Healthcare foodservice providers hoped this year would be less tumultuous as everyone became more accustomed to the implementation of the Patient Protection and Affordable Care Act. Unfortunately, this expectation seems to be a mere pipe dream as the healthcare industry continues to evolve. And these changes continue to impact the foodservice operators that serve the healthcare community. Change continues to be the only constant.

For example, as healthcare systems continue to consolidate, they look to vigorously compete with other operators. This puts pressure on all departments to contain costs and focus on high quality products. And foodservice is no exception.

"The merger of more hospitals and systems will continue," says Char Norton, MS, RDN, LD, FADA, FFCSI, industry consultant. "Foodservice is impacted by the increased requirement for departments to be part of systems that use the same vendors to increase purchasing power, coupled with standardized products and operating systems."

As the systems grow, so too does the scope of services foodservice needs to provide. "This industry consolidation and system growth and integration will result in foodservice directors taking on multiple departments and system activities," says Paul Hysen, principal at the Hysen Group in Northville, Mich.

Bruce Thomas, MBA, vice president, Guest Services, explains that the Geisinger Health System Center in Pennsylvania was involved in more than a half dozen acquisitions in the last three years and several more are on the horizon. "Integration of support services across the various platforms have been challenging," he says. "We have removed contract managers in several instances, but I am stretching my management team."

A snapshot of healthcare foodservice in this environment reveals a cornucopia of ventures and accomplishments as featured in this month's issue. "I am surprised by the number of feasibility studies that call for capital projects and the actual decrease in the number of the projects receiving funding," says Christine Guyott, FCSI, RD, principal at Robert Rippe & Associates, a Minnetonka, Minn.-based foodservice design firm. "Many of us thought the wait-and-see period would be over, but as healthcare administrators watch their spending so closely, they are reticent to commit to major projects such as new towers and major foodservice operations. Also, more hospitals are part of big systems so foodservice is competing against more departments and initiatives for funding. Many healthcare systems put off building the larger health kitchens and instead install smaller kitchens in remote areas even though this may not be labor efficient in the big picture."

In this tug-of-war environment foodservice teams must dig deep into their creative wells to find innovative solutions that make the most of available resources for projects large and small. "Increasing revenues for both retail and malnutrition diagnoses will become more important to move the department to less of a cost center and more of a revenue producing
department," Norton says.

ROI an Absolute

For today's foodservice operators, showing a positive return on investment is an absolute imperative. "As funding tightens up in both patient and retail areas, foodservices must show immediate return on investment for whatever they're doing," Hysen says.

While looking to find economies of scale, many healthcare foodservice directors echo the necessity to show return on investment for expenditures. "We must do more with less and create efficiencies and reduce labor costs," says Laura Watson, MS, RDN, CD, system director, Patient Support Services, Intermountain Healthcare, Salt Lake City. "But we must also creatively improve the patient experience by delivering caring, quality and culinary excellence with every meal we serve."

For example, Angelo Mojica, director of Nutrition and Food Services at UNC Health Care in Chapel Hill, N.C., moved to restaurant delivery-style programs for the efficiencies but had to make sure that this system resulted in improved customer satisfaction.

This need to quantify return on investment rings true for retail operations ranging in size from robust cafés to smaller coffee shops. Proving ROI is another reason benchmarking ranks high on directors' priorities.

For patient services, showing ROI becomes even more challenging than for retail services. Some patient satisfaction surveys still include direct questions about food and foodservice, but no questions about food or foodservice appear on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys, which measure patients' perspectives of hospital care and are used in part to determine if a hospital or medical center receives Medicare reimbursement.

"Another criteria for Medicare reimbursement is recidivism," Hysen says. "If a patient comes back to a hospital within 30 days with the same problem, the hospital doesn't get reimbursed. So how do malnutrition and good nutrition play a part in this? And how is this going to be determined?"

Room Service Variations

"With the competition for high customer satisfaction scores, room service will continue to be implemented but with a more efficient model that is less labor intensive," Norton says. "Foodservice departments already operating a room service model are investigating ways to operate more efficiently and altering their menus to include more healthy options. But at the same time, the menus are lower in cost and less labor intensive to produce while meeting the changing ethnic population of their patients and residents."

Intermountain Healthcare is one of many systems creating system wide room service menus. "We standardized our food products last year with the knowledge that was the first step in standardizing menus," Watson says. "Once our product guide was standard, we began to create a room service menu that will be used systemwide. We have 16 of 22 hospitals doing some form of room service. This has taken a while, primarily because we don't have dedicated resources. Our hospital chefs and others have done this in addition to their other work."

At Southern Maine Health Care in Biddeford the patient dining model transitioned from a traditional trayline service to a room service model nearly three years ago. Southern Maine Health Care is an acute care medical center licensed for 150 beds with an average daily inpatient census of between 75 and 100. The In Room Dining call center accepts calls from patients between the hours of 6:45 a.m. to 6:45 p.m.

The staffing matrix was built to manage a census of 75 patients. Foodservice utilizes one room service cook with a back-up at peak lunchtime service. The service line consists of one starter, one expeditor and two host/hostess delivery staff. A ratio of 30 to 35 patients per delivery person is best. When the census reaches higher levels, the starter is called on to deliver trays as needed. Department leadership staff routinely step in to assist wherever needed.

Hybrid systems also fit the bill at many hospitals. For example, pod tray assembly works well at Baystate Medical Center in Springfield, Mass., which increased its patient satisfaction scores with the launch of a spoken menu concept combined with guest service ambassadors and a pod tray assembly area with two air-curtain refrigerators, a five-well steam table, a stainless steel worktable, as well as a plate heating system and delivery carts.

Equipment and Technology Support Department Goals

Improving food quality at all points of healthcare foodservice continues to top the healthcare foodservice providers' priorities. Proponents of large-scale operations say the right combination of equipment, choice of food, handling and packaging is essential to produce high quality menu items.

Operations with display and point-of-service kitchens take advantage of small yet high-powered grills, ventless ovens, induction cookers, countertop combi ovens and rapid-speed ovens.

Other technology finding success in healthcare environments are kiosks for customers to order and research nutritional information as well as sophisticated bedside ordering technology featuring flat screen TVs and tablets. Robots also allow efficient deliveries.

A Boom in Senior Services

As Baby Boomers age, senior services continue to grow exponentially. For an aging population with sophisticated tastes and expectations, foodservice is far from an afterthought at hospitals and retirement communities catering to this segment of the population. In fact, the quality of the food and dining environment significantly influences residents' choice of facilities.

"In senior living, we're all seeing a generational shift with new residents who are younger and want restaurant-style experiences with upscale food served in beautiful dining rooms," says Mary Cooley, LDN, director of Dining Services at Pennswood Village in Newtown, Penn.

Answering residents' requests for memorable dining experiences, Cooley and her staff introduced action stations during lunch service in the main dining room. Staff use a flat top grill, Panini grill and food warming chafers to produce a main menu item and toppings so residents can customize their selections. Themes include Thai soups, Thai rolls, Reuben sandwiches, burgers and many more.

Simultaneously, Pennswood focuses on a culture change to resident-directed care and dining. "We were centralized and now we're moving toward decentralization so we can do more in satellite settings," Cooley says. At these sites, kitchens contain induction cookers that staff use to make omelets and grilled sandwiches a la minute. Equipment also includes cold rails for deli ingredients and a hot steam table for baked chicken breast, baked salmon filets and other entrées. "Instead of slicing a leg of lamb in the kitchen and sending it over, we're sending the entire leg of lamb and a skilled employee carves it to order. The dining experience is better for quality of the food and service."

Cooley and her staff also bring mobile serving carts with special breakfast items, sandwiches and salads to patients in the skilled nursing areas. The cart includes three hot wells on top and a cold and dry unit beneath to hold supplies.

"With an older population, we still have to address diet concerns," Cooley says. "For example, residents want tender meat or other foods that must be pureed. They're also asking for gluten-free and lactose-free menu items."

The Labor Challenge

No matter the size, shape or system affiliation, every healthcare foodservice provider faces labor challenges that affect decisions about services they offer.

Recruiting new employees is a challenge for many establishments. "We do not hire tobacco users, essentially cutting our potential labor pool by at least a third. Once we get them, we need to find ways to retain them," says Geisinger's Thomas.

At ProHealth Care, Inc. in Waukesha, Wis., attracting new talent to the industry has been a major focus for Randy Sparrow, system director, Food, Nutrition and Environmental Services. "At some point, almost everyone is going to eat in a hospital as a patient or a visitor and we need the next generation of innovative healthcare foodservice leaders. As a future AHF president, one of my initiatives will be to increase participation in college fairs and to continue to work with community skill enhancement programs like the Easter Seals project."

Cross-training is another focus for Sparrow and ProHealth. "We are also in the process of developing a ProHealth care standard so that the same protocols are followed throughout our system for food and nutrition services and environmental services.

At Robert Wood Johnson University Hospital in New Brunswick, N.J., Tony Almeida, DHCFA, director of Food & Nutrition, emphasizes various training opportunities, including those in the culinary arena. "This training helps us to keep raising the level of our foodservice and helps staff members improve professional skills they will use for a lifetime."

Intergenerational and multi-ethnic workforces require substantial and on-going training. "Finding a way to engage employees so they want to provide superior service is a challenge," Norton adds. "Without dedicated employees an organization cannot be successful."

Norton adds that reduction of management staff coupled with retirements has created a vacuum for training new supervisory staff.

Synergizing Health and Wellness

As the cost of healthcare insurance increases, many healthcare organizations require their employees to adopt a healthy lifestyle. Programs supporting employees to maintain a healthy weight, exercise and quit smoking are gaining acceptance. Some offer incentives such as reduced insurance premiums. The jury is out whether these programs are, in fact, cost effective.

Pennswood's Synergy program, for example, addresses health and wellness for residents. This collaborative effort among fitness, activities and nutrition departments emphasizes seven dimensions of wellness: emotional, intellectual, physical, vocational, social, spiritual and environmental. "This holistic approach is receiving favorable response," Cooley says.

Scheduled for opening in late summer, a $70 million, 116,000-square-foot Pewaukee Cancer Center in Waukesha, Wis. will feature a café with healthy food choices and outdoor dining. "This will be a challenge for our department because 80 percent of the food offerings will provide a health benefit," says Sparrow.

Yet retail units in hospitals are in business to make money and also offer concepts — their own and those of fast food companies — that appeal to customers who like high-calorie, high-salt indulgences. Educating and incentivizing customers to eat in moderation seems to be the most effective means to attain a healthy employee population.

"Developing community programming to teach patients how to make healthy food choices at home is also important," Sparrow says.

Preparing for Long-Term Sustainability

"Sustainability is the right thing to do for the community and the environment and our departments need to find cost-neutral or money-saving ways to support sustainability as a goal," Watson says. "Simplifying ways to reduce and dispose of waste will continue to be an emphasis no matter whether you're in California with mandates to save water or in the east with mandates to minimize waste sent to landfills," Hysen says.