Hospital takes innovative approach to food services
Hotel chains, management group provide data
People don’t choose a hospital for the food it serves, and no one expects the food to be great while he or she is stuck in a hospital bed. But poor scores on food service can impact overall patient satisfaction scores, and for many patients, getting proper nutrition is a matter of life and death.
Now, MD Anderson Cancer Center in Houston has jumped on the bandwagon to integrate restaurant-grade food and service into its facilities. And although the cost of such programs is generally higher than typical assembly-line hospital food, the impact on patient and staff satisfaction has been dramatic. There also seem to be positive clinical implications for MD Anderson’s patients.
John Crossley, RN, PhD, the vice president of operations and nursing, first broached the idea when MD Anderson was already looking at a capital outlay to refurbish its kitchen. "I asked that since we were a 450-bed hospital, why couldn’t we pretend we were a 450-bed hotel? We already act more like a restaurant in our cafeteria, so why not in the rest of the facility?"
At the same time, says Carol Frankmann, MS, RD, the director of clinical nutrition, patient satisfaction regarding food had plateaued, despite several menu changes. "We knew that with cancer patients and the impact their treatment has on appetite, a standard menu system wouldn’t meet their nutritional needs or their satisfaction," she explains. "But the idea of room service with a facility as large as ours was something to consider carefully."
At the time, Dana Farber Cancer Institute in Boston had some of its beds on a room service program — a program since terminated — and Swedish Hospital in Seattle was beginning a pilot program for oncology and obstetrical patients that eventually spread to the entire facility.
MD Anderson’s staff spent time at both facilities and talked to staff there to find out how they did what they did. In the future, Crossley says that MD Anderson will share data with Swedish to see how their programs fare against each other.
Frankmann says it also is important to continue to compare the facility to hospitals with traditional food service programs. "That way we can see if, as expected, we get higher satisfaction than facilities that don’t offer this kind of service," she says.
Crossley also brought in Culinaire International of Dallas, a management group that specializes in the hospitality industry, to determine if the plan was feasible. "The upshot was that we were going to put in new heating elements and trays or something else. And we decided on doing something else," he says.
The first phase involved two 32-bed units as a pilot project. "We had to take very therapeutic diets and modify them," Crossley explains. The pilot lasted a year before spreading to the rest of the hospital.
May I take your order?’
Food is available from 6:30 a.m. to 9:30 p.m. Patients have a menu and can order what and when they want, with breakfast offered until 10:30 a.m. Frankmann adds that patients who have special requests are accommodated as much as possible, and family and friends who come to visit also are welcome to order from visitor menus, which are priced in a la carte fashion.
Calls go through a call center, whose staff are trained to assist patients in making choices and provide as alternatives if a particular patient on a restricted diet orders something he or she is not supposed to eat.
Wait staff are instrumental in tracking what patients are eating. For those who are on a calorie count diet or are diabetic, staff often take it on themselves to visit with the patients and encourage them to eat. That means the skill set needed for food-service workers at MD Anderson is very different from that of the typical hospital food service staff, Frankmann says. They require more training and experience, and there have to be more of them to ensure the kind of prompt service MD Anderson wants to provide.
Room service manager Mohammad Tekrouri, whose experience comes from the Ritz Carlton hotel chain, was key in developing the program and training the staff in the ways of the hospitality industry that the hospital is trying to emulate.
For instance, the wait staff don’t simply deliver the tray to the patient’s room; instead, they take time to serve the patients, addressing them by name and asking where they want to eat. The staff members review the order, check to make sure nothing is missing or needed, and inform the patients when they will return to collect trays.
Staff are recruited from among hotel and restaurant workers in the Houston area. "Then we have to train them," Tekrouri says. "They are clinical waiters who do more than just serve [patients]. They collect data for calorie counts and find out how much food was eaten. For patients in isolation rooms, [staff] have to know what the procedures are before entering the room."
Cooks, too, are recruited from local hotels, not from area hospitals, he adds. The staff are "empowered" and paid better than they would be in similar situations at restaurants or other hotels. A fringe benefit is the satisfaction staff members get by doing something special to help care for some very ill patients, Tekrouri says.
Among the other Ritz Carlton traditions Tekrouri brought with him are daily staff meetings, where yesterday’s problems are discussed and potential problems for today are gone over. Comment cards from patients are shared and problems discussed.
Everyone encouraged to participate
Staff are encouraged to provide tips and ideas at the meetings, which can be implemented programwide. For example, one of the wait staff had trouble when nurses would remove trays from rooms and put them all together in one place. The staff member had no idea which plate came from which patient, which made tallying up what they ate difficult. "So she started writing a little room number on the slip of paper that accompanied the meal so she would know," says Duke Rohe, performance improvement specialist for the hospital. The idea has been copied throughout the facility.
Another idea that came out of the daily meetings was providing meal service to ambulatory patients who are being treated during meal times. "They are able to order from the same menu, with prices from our a la carte service," says Rohe. "The guests and patients both love it."
And if you smell toast wafting down the halls of every floor, know that the idea came from staff members, too, who were brainstorming about how to keep toast warm between the time it left the kitchen and got to the patient. The answer: Put a toaster on every floor, says Rohe.
Finding the few others that offer this kind of service will be increasingly important as time goes on and the service seeks to improve, says Rohe. He has been evaluating how well the new service is performing. He has studied the entire program and done time studies of its various parts. "They have a goal of getting all meals to patients within 25 minutes," Rohe explains. "Right now, we are achieving about 30 minutes. But it’s hard when there is no one to compare ourselves against to see where we can improve."
But so far, he is impressed with the effort he sees. "The entire staff are focused on getting food to the patients quickly," says Rohe. "They will look at the order twice to make sure it matches. They load it up and monitor how long the oldest tray has been sitting there so that it is not longer than 20 minutes. They hustle all the time."
Frankmann says satisfaction has gone from 11% of patients rating food services as excellent to 70% to 80% providing an excellent rating. "That was the main focus from the start," she says.
But the positive impact goes beyond just having better patient satisfaction. "We know patients are ordering fewer meals but consuming more food," Crossley says. "That means that nutritional intake is improving. Fewer trays are returned uneaten. And the use of anti-nausea drugs has dropped, which means that patients are consuming more food without getting sick."
Frankmann says that although the analyses are ongoing, it appears that data will show that there is an increase in how much patients are eating since the change. "But we have to remember that there are a lot of things that drive patient intake, and we don’t know if the difference will be statistically significant."
Good service — not just good economics
Tekrouri says the chefs tell him food costs are down due to an elimination of waste, too.
The decision to go this route has to be based on more than just economics, Crossley says. "The decision is, can we do it, can we do it economically, and if we can, should we do it for our patients? When you put it in terms of the last of those, it becomes a much easier decision. Your role is to provide care and deal with people at a point of crisis in their lives. You make every effort to make the experience as positive as you can if it is at all in your power. That can mean spending more money."
The decision has to move beyond simple economics, Crossley concludes. "You sometimes have to invest in what’s right, even if it is painful economically," he says. "The satisfaction you get is that it is a big hit with patients. People don’t choose a hospital for its food. They are in a powerless situation, and to have this much control helps them spiritually, emotionally, and although it is hard to measure, I am thoroughly convinced it is therapeutic for them, too."
[For more information, contact: Duke Rohe, Performance Improvement Specialist; Carol Frankmann, MS, RD, Director, Department of Clinical Nutrition; John Crossley, RN, PhD, Vice President of Operations and Nursing; and Mohammad Tekrouri, Room Service Manager, MD Anderson Cancer Center, Houston. Telephone: (713) 745-4433.]
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