The healing power of food comes to the hospital
Chefs mingle with dietitians in Seattle program
To scan the menu for patients in Seattle’s 500-bed Swedish Hospital is like checking out the menus of some of the best restaurants in the city.
A patient could start the day with country-fried potatoes and cinnamon French toast, have a mid-morning fruit plate snack, lunch on a club sandwich, and have a stir-fry dinner (for a more complete listing of the menu offered, see boxes on pp. 40-41). If that patient were a little peckish later on, perhaps a slice of cheesecake and a decaf nonfat almond latte would hit the spot.
Much of the menu is available 24 hours a day, simply by picking up the phone, says Kris Schroeder, RD, CD, director of nutrition services at the hospital. And aside from vastly improved patient satisfaction surveys, the new program costs no more to run than the old food service regime, and entices many patients to eat who otherwise wouldn’t.
The first idea for the change to an on-demand, restaurant-style food service program was borne of a union between Swedish’s main campus and the Fred Hutchison Cancer Research Center, which in 1996 was moving its 20 beds within the walls of Swedish, says Schroeder. "They were a customer of ours, and had on-demand food service. We didn’t want to decrease the level of service they had for their patients."
Coinciding was a desire by the department to improve patient satisfaction scores. "I don’t want to admit how low they were," says Schroeder. "But our goal was for 90% to rate us excellent or good, and we weren’t even close."
The old-style service — where patients got a menu today for tomorrow’s choices and staff put meals together on an assembly line for delivery three times a day when it was convenient for the hospital — obviously was not working.
"You know, appetites are affected in the hospital, and predetermined meal times don’t always match the patients’ wants and needs."
Why not like a hotel?
For her model, Schroeder looked at food service outside health care. "I looked at hotels," she says. "Why couldn’t we be more like them? Certainly, patient satisfaction demands more now. And health care is getting less prescriptive. We are partnering more with the patient now. And, we have to operate more like a business than we used to. Why not the hotel business?"
The next step, once Schroeder decided to proceed, was to put together a team of people to work on the project. "We are a large department that provides a lot of different services in many ways. We have patients we care for with food, we have five cafeterias, a physicians’ dining room, catering functions, and nutrition functions."
As a result, every manager and supervisor was included on the team, along with someone from Fred Hutchison, clinical dietitians, and diet technicians. The group held a retreat with a chef consultant from Learn Associates, a Seattle company.
Consulting with the best
In early 1996, the team leaders visited the Dana Farber Cancer Institute in Boston to view its on-demand program. At about the same time, changes were made in the Swedish kitchens. There were renovations to make and a computer-system upgrade to complete (provided free by the software vendor, CBORD of Ithaca, NY). Swedish also had to bring natural gas into the kitchen, purchase new china, sauté pans and glassware, and set up deli stations.
The cost, including the consultant fees, was about $500,000. "Most of it was from the capital budget," says Schroeder. "The rest we absorbed in our labor and supply budget."
The upper administration had to support the program for it to work, Schroeder notes. And they did. "The strongest opposition came not from a person or group, but from people just amazed that we would think of doing this. There was some internal resistance, which is why we had the retreat."
The other group that had to be sold on the program was the nursing staff. Each nursing unit received an in-service on the program, and there were pamphlets available with frequently asked questions about the program. "As part of the phase in, to push the system, we provided the food to the nursing units, so they could see the new presentation and taste all the items, Schroeder says. "That was the biggest piece of PR we did."
By the fall of 1996, the program was ready to go live. Initially, it was going to be limited to oncology patients, and the first 60 beds to benefit from the new service in November were from the cancer unit. "We figured they had the most appetite difficulties," Schroeder recalls. "But the HIV population meets those criteria, too. And maternity patients might be hungry after giving birth at 2 a.m. So it became an issue of, why not do it for everyone." By spring of 1997, the whole hospital was on the program.
The goals of the program were largely easy to measure. "First, we wanted there to be cost neutrality in the program," Schroeder says. "Second, we wanted to give five-star service, which is a patient satisfaction issue. Third, we wanted to be leaders in our field. We knew we were taking a big risk, [and] that no one had done this on such a large scale in health care before. We figured we would be cutting edge, or the laughing stock. Even our consultant said he wouldn’t want to be in our shoes."
Cost neutrality would be helped along by the decrease in food waste. "If a patient doesn’t want a full meal, just soup, that’s what he or she gets. Before, if they didn’t fill out a menu, they’d still get a whole meal."
Schroeder and her team also figured the better food — and better variety — would result in increased revenues. Staff and visitors have a separate menu of items they can purchase.
"That will be used to defray the costs of additional labor," explains Schroeder. "This is not a labor-saving program and isn’t billed as such. But we felt if we decreased waste and increased revenue, it wouldn’t be too hard to swallow."
So far, the expense per patient day is down by 5.3%. (Schroeder wouldn’t divulge actual costs.) Revenues are also up, and food costs are down. "That was a tricky thing, since we upscaled the menu so much."
As for patient satisfaction, the department did a benchmarking survey before the start — an internal one, although it uses a major independent survey vendor, too. The first set of scores just came back, and Schroeder says that while Swedish isn’t yet at 90%, it is much closer to that goal.
"We have, over time, been at 89% on some specific items," she reports. "We do very well on the service sections because of the personalized attention people get. Our food quality scores have also jumped a tremendous amount."
Although largely a success, there were lessons Schroeder learned the hard way. For instance, when the program first began, there was an option for leaving voice mail messages with kitchen staff.
"That was a disaster for patients and a nightmare for us," she says. "They would leave a message with incomplete information, and we’d have to call them back. Or they would call back to talk to a real person and get two orders. If it was really busy, the voice mail stacked up."
That service was ended, and while there is still an issue of patients being on hold, the hospital is looking at staffing levels and working with the telecommunications department to try to decrease the average wait time for patients ordering.
The food service program also pointed out to Schroeder that patients don’t like to eat dinner at 5 p.m.
"The dinner hour is really stretched out. We are busy until eight, and then we get the dessert rush. Big TV nights are also an issue — we get a Thursday night rush, and on game nights, the same thing."
Schroeder also learned that food service really does have an impact on virtually every area of the hospital. "We had to think about physical therapists, who often structure things around meal times. But now there aren’t any meal times. And if there are issues about medications, then you have to make sure that nursing staff knows when the patient orders meals."
The new system is also more management intensive than a traditional tray line, says Schroeder. "There is more ownership of this among staff. And that’s a good thing. We have a real sense of pride about what we do."
Lastly, Schroeder had to change how she recruited staff. She no longer advertises in the health care section of the local papers’ want ads, but in the restaurant section.
"We want culinary-trained staff from local hotels and restaurants. That can also help with our board lunches."
That came home to Schroeder recently, when a board member called. Unbeknownst to the staff, he had been recently hospitalized and so enjoyed the on-demand program that he wanted to order from the patient menu, rather than have what the rest of the board was eating.
"It was a real compliment," she says.
The program is being expanded to the 150-bed Ballard Swedish campus in the fall, says Schroeder.
"From the standpoint of focusing on the patient, there are obvious reasons to do this. This is a true patient focus. And if we can do something better at the same cost, why not?"
Source
• Kris Schroeder, RD, CD, Director, Nutrition Services, Swedish Medical Center, 747 Broadway, Seattle, WA 98114-0999. Telephone: (206) 386-6000.
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