White Glove Foodservice — New Approaches Treat Patients as Customers
Today's Dietitian
By Suzanne Caithamer, RD
Vol. 6 No. 6 p. 22

As a student in food and nutrition at Purdue University, I had a part-time job working in the diet office of St. Elizabeth Medical Center in Lafayette, Ind. One of my responsibilities was to visit newly admitted patients to see what they preferred to eat (within their diet parameters, of course). “Are there any vegetables you don’t like?” I would ask them. “Would you prefer hot or cold cereal? Tea or coffee? Is there anything you would especially like that we could try to get for you?”

Patients were amazed once they realized I was not there to take their blood or temperature or deliver bad test result news. They were so appreciative that someone wanted to make their stay in the hospital a little more personalized. The patients felt better cared for, the kitchen had less plate waste—why serve green beans to somebody who hates them?—and I had a great deal of job satisfaction. I felt I was really providing a service that mattered, and the patient, the foodservice department, and ultimately the hospital benefited in the end.

According to a recent Healthcare Foodservice Management study, the current top challenge to hospital foodservice is improving patient satisfaction.1 Patients are customers, after all, and keeping them happy with good customer service is just as important in a healthcare setting as it is in any other. John Lawn, editor of Food Management, notes that foodservice personnel have a unique role in their institution’s public relations as the “face” of hospitality. “Foodservice is a defining component of every hospital stay,” he states. “And the passing of meal trays is a primary contact point between the patient and the hospital’s institutional ‘self.’”2 Hospitals around the country are responding to the challenge by implementing patient-focused systems such as spoken menu, cart delivery systems, and room service.

Room Service
Hospital treatments, particularly for cancer patients, can cause unpleasant side effects such as lack of appetite, mouth sores, and nausea. Meal trays delivered at preset times compound the problem if a patient is not ready or able to eat. Food waste climbs, resulting in increased costs, and patients are not receiving the nutrition they need to heal and gain strength.

To counteract some of these issues, Memorial Sloan-Kettering Cancer Center (MSKCC) in New York introduced a pilot room service program in May 2001. In August 2002, the program was successfully introduced hospitalwide.

According to Sharon Cox, MA, RD, CDN, director of food and nutrition services at MSKCC, the room service program was begun to let patients eat according to their schedules. Patients can order food from an extensive menu (25 hot and cold entrees daily) by calling a nutrition associate in the diet office and placing their order whenever they feel like eating between 7 am and 9 pm. The goal is to have the meal delivered within 40 minutes. “The primary feedback [from patients] is that they feel like celebrities, that they are VIPs,” Cox says. “The variety is close to what they would have in a restaurant. The variety is the one thing they praise [above all else].”

Some examples of menu items that have been offered include farm-raised salmon with honey-mustard glaze, vegetable egg roll with gingered soy sauce, Caesar salad with grilled chicken, and vanilla pound cake.

The room service program initiative stemmed from a plate waste study undertaken in the first quarter of 1998 to determine how many patients were eating less than 50% of their main entree. Dietetic interns conducted bedside interviews during meal rounds and discovered that 60% of patients were eating one-half or less of their main entree. Thirty-two percent were not eating their entree at all, primarily because they were either not in their room or they were sleeping when the tray was delivered.

At the conclusion of the pilot program, plate waste studies showed that the number of patients eating more than one-half of their entree had increased to 88%.

While it is the face-to-face interaction between patients and the hospital’s room service associates that is a unique key to improving patient satisfaction, the program would not be feasible without the telephone, radio, and computer network involved. Room service associates carry a Nextel radio that enables them to quickly and efficiently communicate with the diet office and kitchen expeditor, whose role is to coordinate the items on the tray and check for accuracy. The diet office has a computer system that enables them to keep track of each patient and his or her prescribed diet and alert personnel when a patient does not order a tray or orders an item that is not advisable on his or her diet. Tray tickets are printed simultaneously for the cooks, the cold line, and the expeditor—similar to the system used in many restaurants.

The implementation of the room service program dramatically improved MSKCC’s Press Ganey rating for the Department of Food and Nutrition Services. (This rating is a measurement of patient satisfaction by independent healthcare surveyor Press Ganey). For MSKCC, “Quality of Food” improved from the 30th percentile in the first quarter of 2001 to the 99th percentile in the fourth quarter of 2002; “Courtesy of Staff” also improved from the 10th percentile to the 99th percentile. This was achieved in part by recruiting individuals for the program with direct culinary or hospitality experience. Cox says a large percentage of their cooks are professionally trained, and many of those hired as room service associates are from the hotel industry.

Preselect Menu
A preselect menu system, in which the patient receives meals without having chosen from a menu, may not seem to some to be patient-friendly. But Baptist Health in Little Rock, Ark., implemented a preselect menu in 1995 that has enabled them to save money while still increasing patient satisfaction. Glenyce Feeney, MS, RD, LD, DHCFA, FADA, system director for nutrition and food services at Baptist Health, notes that room service-type systems are very labor-intensive and a preselect menu can be a viable alternative. “Why are people continuing to develop systems to deliver patient foodservices that are labor-intense?” Feeney asked a seminar audience at the 2002 American Dietetic Association (ADA) Food & Nutrition Conference & Exhibition in Philadelphia. She cited a 2000 survey of foodservice directors that indicated that 73% expect they will employ fewer people in the future.3 “We believe that it is important to respond to the patient rather than have so many choices. It is the patient care and service, not the number of selections, that is important.”4

Thanks to streamlining and eliminating tasks such as menu distribution and pick-up, 22 full-time employee positions were reduced systemwide, which saves $268,000 per year, according to Lorie Hale, Baptist Health system nutrition clinical manager.
The seven-day cycle menu includes regional specialties such as turnip greens, fried catfish, and pot roast. Desserts such as cakes, pies, and cobblers, which are on every regular lunch and dinner tray, are very popular. “We really get good comments about our desserts,” Hale says.

Hale notes that since the hospital’s regular diet trays provide 3,000 calories per day, patients do have a degree of selection since they can eat what they like from what is offered. Patients who miss a scheduled meal are served an “express meal,” frozen entrees heated by the nursing staff on the unit. According to Hale, this has eliminated 130 late trays systemwide. Other advantages to this system are faster service (patients do not have to wait for the meal to be brought up from the kitchen), fewer dirty trays on the unit, and availability of the trays at all times.

For Baptist Health, patient satisfaction doesn’t have to stem from giving a lot of choices. “We developed our system to directly respond to patients in the most expedient manner but also with overall cost savings and attention to the fact that labor was and is hard to find and keep,” says Feeney, noting that they constantly evaluate their system to ensure it is the best method for their needs. “We have been doing this [preselect menu] for eight years with great success.”

Long-term Care
Long-term care facilities can face unique challenges at mealtime. Many residents may need assistance at every meal, due to lack of interest in food, poor motor skills, or other physical or mental hurdles such as dementia. Inadequate food intake can result in weight loss, inability to heal, and nutritional deficiencies—problems that can be detrimental to the health of this special population. The ADA recognizes that being able to enjoy food is an integral component of quality of life for older adults and challenges dietetics professionals to “engage out-of-the-box thinking to identify new and different approaches [for food and nutrition services within the continuum of care for older adults].”5

Sodexho Senior Services, headquartered in Gaithersburg, Md., has developed a unique meal delivery system for their long-term care facilities. The program, called To the Table, stemmed from studies showing that senior residents want to continue to have control and make their own decisions about what and how much to eat at mealtime.

During a meal, residents choose what foods they would like from hot (entree) and cold (salad) rolling buffet carts that stop at their tables in the dining room. Foods are attractively displayed family-style, on platters and in dishes that enable a resident to be served as much or as little of any or all choices.

Cindy Lauer, MA, RD, LDN, national director of nutrition services for Sodexho Senior Services, says facility menus do not have to be changed to implement the program. The core cycle menu offers two to three entrees and two starch and vegetables for a meal. The cold cart resembles a salad bar, with individual dishes of ingredients and toppings from which a resident can choose. The cold cart is changed to a dessert cart for a final trip through the dining room.

Lauer says having satisfied residents results in positive feedback not only from residents and their families, but also from nursing and dietary staff. Staff training is key to the success of the program, which is much more a restaurant style of service than is typically found in facilities. “We have found that the employees are much more motivated and have much more ownership in this type of service because of the close contact with the residents,” she notes.

Spoken Menu/Cart System
Saint John’s Medical Center, a 300-bed acute/primary care hospital in Anderson, Ind., utilizes a spoken menu system for lunch and dinner. According to Clinical Dietetics Manager Tina Ricafort, MA, RD, CD, the patient satisfaction and cost savings have been significant.

Like Baptist Health, Saint John’s utilizes a preselect menu. One to two hours prior to lunch or dinner, a diet clerk visits patients to assist with item selections. The clerks, familiar with patient diet restrictions and able to make modifications if necessary, carry preprinted paper menus to each room.

“We implemented this [system] to eliminate too many wasted trays due to patients not wanting what they selected the day before,” notes Ricafort.

Much like my experience working at St. Elizabeth, a spoken menu system involves direct dietary employee-to-patient contact, which has been shown to improve tray accuracy and patient satisfaction.6 Ricafort agrees: “Patients love to see dietary staff.”

Saint John’s also uses a cart system for their Breakfast@Bedside program, which has been in place since fall 1998. Patients choose from three hot and two cold items that are served directly from a mobile Camcruiser that stops outside their room. “We serve a full breakfast, including eggs, toast, bacon, milk, orange juice, and cereal,” says Ricafort. “Patients seem to love sausage gravy on biscuits best.”

Ricafort says the cost savings in implementing these programs have been extensive. By eliminating the traditional breakfast trayline, the dietary department was able to reduce staff by 4.7 full-time equivalents, a savings of more than $100,000 per year. Using a preselect menu eliminated two positions from the lunch and dinner traylines and also lowered food costs. Instead of purchasing menu software through a supplier, the department utilized the hospital’s information resources department to develop the technology for the spoken menu system, thereby avoiding thousands of dollars in start-up costs and annual maintenance fees.

While Ricafort notes that long-term or frequent patients at Saint John’s miss the variety of a full menu selection, they try to accommodate those patients by offering them a longer list of selections, such as cafeteria items. Overall, patient satisfaction is high. “This is still a new concept to many healthcare facilities,” she notes. “We are proud to pioneer this and see it successful. The greatest impact is the cost savings without compromising quality and patient satisfaction.”

— Suzanne Caithamer, RD, is part of the sales division for education and healthcare accounts at the Hubert Company, Harrison, Ohio.

References for this article are available upon request by e-mailing TDeditor@gvpub.com.

The Pros and Cons of Hospital Room Service Programs

Pros
• Increased patient satisfaction in food and foodservice
• Reduced food and supply costs
• Improved food presentation and freshness
• Reduced use of floor stock
• Improved food intake by patients
• Improvement in employee morale through positive feedback from patients

Cons
• Cost of changing employee/production schedules
• Cost of equipment
• Need to liberalize diets
• Patient complaints about repetitiveness of menus
• Timeliness of meal service expectations increase due to increased patient interaction
• Need to continue regular tray assembly for some units (such as mental health)

— Adapted from: Norton, Charnette. Implementing New Concepts in Patient Meal Delivery. Business Briefing: Hospital Engineering & Facilities Management.

Even Small Changes Make a Big Difference
Teri Kopp, healthcare account manager at the Hubert Company in Harrison, Ohio, has plenty of ideas for facilities looking for ways to make their foodservice more personal for the patient. While a full-scale room service program might be out of reach for hospitals with a limited budget, adding a special touch here or there will make a difference in patient perception and ultimately their satisfaction. “Room service is ideal for any hospital with 200 beds or more,” says Kopp. “Smaller hospitals can [implement room service] on a smaller scale.”

Kopp offers the following creative suggestions to make patient meals more appealing:
• Add a small vase of flowers to the tray.
• Offer stainless flatware instead of plastic.
• Use real china instead of plastic.
• Have employees who deliver trays wear nice uniforms, such as tuxedo-style aprons (these can be customized with embroidered logos), white gloves, and upscale name badges.
• Have menus presented in a customized folder, perhaps with your logo on the cover.
• Write the menu in the style of a restaurant. A descriptive menu makes patients hungry, says Kopp.
• For children, deliver meals in kid-oriented theme packaging.
• Have fun by coordinating a theme, such as picnic food, movie night, or Chinese “take out,” in your menu rotation and have the necessary packaging and accessories for the meal to carry out the theme.

Kopp, who gives presentations on room service and healthcare merchandising across the country, recognizes that healthcare facilities have to cater to the patient to a greater degree than in the past to stay competitive. “Patient satisfaction is really No. 1 right now,” says Kopp. “We’re used to being pampered with foods; it can’t stop just because there’s a hospital stay.”

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