Baptist Health: Selling the Big Picture

John Lawn, Photos: Willie Allen

Before the renovations at Baptist Health Medical Center in Little Rock, there was the kitchen at Emanuel Medical Center in Turlock, CA. Before Turlock, there was the new kitchen and deli at the Community Hospitals of Central California in Fresno. And before Fresno, there was the renovation at Riverside Hospital in Columbus, Ohio.

Indeed, if you were to look at the details in Charlotte Mosqueira’s resume, it might seem her career as a hospital foodservice director has taken her from one renovation to another. In fact, that’s probably not too far from the truth.

That experience in managing hospital foodservice operations while also overseeing major construction projects has paid real dividends at the Little Rock Medical Center, the largest facility in the Arkansas Baptist Health system. That’s where Mosqueira has spent the last five years overseeing a complex renovation that has entailed rebuilding virtually every part of the 800-bed hospital’s primary kitchen, even as the facility continued normal operations.

Aging infrastructures

Baptist Health is the state’s most comprehensive healthcare service provider, with more than 80 facilities that include medical centers, family clinics, therapy and wellness centers. Mosqueira’s department manages the foodservice for both the main Medical Center in Little Rock and its Rehabilitation Institute; it also provides bulk food to some satellite operations on and near its Little Rock campus.

The main campus buildings were built 30 years ago in the construction heyday of the healthcare industry. It was a time when hospitals were fully reimbursed for operational costs and there was relatively little concern about FTE counts or their relation to production facility design.

As is the case with many major hospitals, more than a decade of downsizing and department re-engineering austerity have taken their toll on Baptist Health’s foodservice facilities. Its aging infrastructure had reached a point where major reconstruction was required in many key areas both to meet code requirements and to enable it to achieve planned productivity increases in the future.

In terms of foodservice facilities, “it has been clear since the early 90’s that a major renovation was going to be required,” says Glenyce Feeney, a former IFMA Silver Plate winner and Baptist Health’s system director, nutrition and foodservices.

A RECONFIGURED TRAY LINE: The reconfigured tray line production area at Baptist Health now features 13 mobile temperature and humidity-controlled food holding units on the hot side and expanded refrigerated storage space on the cold side. Adjustments in office areas also made it possible to expand the staging area for mobile meal delivery carts. At right: Corporate Executive Chef Johnny Curet shows off his new combi ovens.

“It was also clear that much of the equipment that needed to be replaced would have to be selected in the context of an overall plan, rather than by ‘in kind’ specifications, which hospital policy had generally required in the past.”

With that objective in mind, Feeney is the one who hired Mosqueira five years ago to run foodservice operations at the medical center and to help in designing and overseeing the major reconstruction effort she saw ahead.

Getting in phase

Changing demand patterns and the facility’s growth as a major regional service provider had long since begun to overtax servery space that had originally been built to handle only half the number of customers the department now serves daily. In comparison to dining facilities available at newer facilities in the system, the servery at the main Baptist Health campus was typically so over-crowded and over taxed during peak meal periods that it had become a workplace quality issue.

And while the need to update front-ofthe- house facilities was obvious to staff and visitors, the foodservice department knew that the production facilities that were behind the scenes had even more immediate needs.

A FRESH BREEZE: Hospitality Manager Delbert Hagger, Operations Analyst Michael Firtik and Customer Service Leader Harold Woodbury evaluate food quality at the Breezes deli, a satellite operation on the Baptist Health campus.

There, major structural repairs were needed for the floors, walls and ceilings. Cooking equipment, fryers, kettles and refrigeration equipment all needed replacement. Three different brands of dish machines and a tray washer were in place, all of them old, and all demanding excessive maintenance.

Among other challenges, the kitchen’s central exhaust system required major asbestos abatement and needed to be completely rebuilt. Assuming that approval could be obtained to move forward with a major renovation, abatement requirements promised to complicate and extend every phase of the kitchen’s remodeling.

“While we agreed the serveries badly needed an upgrade, we made the case that we needed to increase our production capacity to adequately support them before we could undertake redesigns that would almost certainly increase production demand,” Mosqueira says.

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MANAGING THE MOVE: Reconstruction of the department’s office space meant that many people moved several times during the renovation. Above: Personnel Liaison Stanley Vault and Secretary to Nutrition and Foodservices Becky Mitchell discuss the new office layout.

With the beginnings of the project already sketched out, in 1999, Feeney and Mosqueira began working closely with The Hysen Group to develop a master plan that would address the physical renovation needs they had identified and which would meet the capital funding requirements of Baptist Health System’s administration.

“In our kind of environment, you can not replace equipment with a justification based on a return-on-investment in most cases,” notes Mosqueira. “New capital expenditures at this facility were frozen in 1997. If we hadn’t gotten our projects classed as a renovation, rather than a capital equipment allocation, we wouldn’t have gotten the project started.

“Instead, we justified it on the basis of intrastructure repair and modernization,” adds Feeney.

Still, convincing the administration that their plans deserved funding promised to be a major hurdle. They began laying the groundwork for their case by focusing on the department’s need to replace the aging equipment in its dishrooms, where maintenance and repairs had grown increasingly costly.

“That was also when we began to develop the phased approach to a master plan that we have followed since then,” says Mosqueira.

“Frankly, it is easier on an annual basis to ask an administration for money if they know in advance it is part of an overall plan, not just a wish list presented in a piecemeal fashion. You have to ensure they know what they will get after the final phase, and to build their confidence that you won’t be coming back for additional funding after the last phase is completed.”

In practice, Feeney acted as the primary liaison to the Baptist Health System administration while Mosqueira worked with the facilities design and engineering staff and oversaw project execution at the facility.

“Ninety-five percent of my job is to be an advocate for this department,” says Mosqueira. “Every time that Glenyce or I had an opportunity to speak to our administration, we would present our case for the modernization we knew we needed.”

Looking for a blank square

Renovation plans were also complicated because no new space was going to be made available to foodservice.

While production capabilities needed to be increased, they had to do so within the original footprint of the department. That meant existing production and operations would have to continue even as some parts of the kitchen were closed down (and in the case of the area requiring asbestos abatement, sealed off). To do that, the middle of the production room, where most cooking had been done previously, was sealed off after other cooking locations had been created in perimeter areas of the kitchen.

TARGETING PATIENT SATISFACTION: Patient Service Manager Stacy Opitz and Clinical Nutrition Coordinator Linda Means discuss patient menu requirements.

“In most renovations, you try to free up some space that acts as a “blank square” in the puzzle, letting you repeatedly move some production or other activities into the empty area while the original space is renovated,” says Mosqueira. “In our case, there was no blank square—we had to find a way to make one without using any additional space.”

While the hospital was willing to consider their proposals for additional renovation work, it made clear that approval to move forward would still come with major strings attached. One was that each phase of the proposed renovation had to be self contained so that, if additional funding were curtailed at some point, the remaining parts of the project could be terminated at any stage. The project also had to show some immediate results in terms of labor productivity.

Their plan was first presented to Baptist Health administration in late 1999, and with approval to move forward with its first phase, construction began in mid-1999.

Phase I: A dishroom demonstrates credibility

Where to begin? Maintenance costs for the hospital’s aging warewashing equipment had become a major problem and analysis showed that the three dish machines and tray washer could all be replaced with a single unit. That consolidation would reduce the total space requirement of the area by about 15 percent, freeing up a small amount of much needed space for subsequent renovation activities.

“It promised to be the best example of how the right kind of renovation could save FTEs and improve productivity—to demonstrate the savings you could have if you modernized with a plan rather than just doing ‘in-kind’ replacements,” remembers Mosqueira. “It was a clearly-defined project that would let us demonstrate the credibility of our plans to the administration.”

Those plans called for the location of incoming tray conveyors to be changed to provide a more efficient floor layout and for a single large dishwasher to replace the three older machines that had reached the end of their working life. The existing industrial pot washer was the only piece of equipment that was retained. Alongside it, they also added an agitated pot soaking sink and a pulper to help reduce waste, a change the department counts on to reduce long term disposal costs. Finally, when the project was completed, department staffing was reduced by five FTEs.

Phase II: Rebuilding refrigeration capabilities

With that part of their plan complete, in 2001 Feeney and Mosqueira began lobbying for approval to upgrade another key area. The kitchen’s freezer and coolers “had been shored up many time, and were really long beyond repair,” says Mosqueira. The insulation had become waterlogged and significantly reduced energy and cooling efficiency. Plus, “we simply didn’t have enough refrigerated space for the amount of production we manage,” she notes. “Like many operations, our menu mix requires far more refrigerated product today that was typical back in the 1970s.”

The project once again clearly fit the infrastructure retrofit requirements the administration was looking for and approval was reached to move forward. Four new walk in refrigerators were custom designed with higher ceilings, better lighting and plexiglass doors, giving staff a clear view of their contents ( a fifth is scheduled for installation next year). Also, the w alk in doors are oversized so that a full pallet of product can be moved directly into the cooler. A similar door design built into the back of the new freezer opens directly to the receiving dock, permitting immediate movement of frozen product from a distributor’s truck into frozen storage.

“Many operators do not appreciate the productivity improvement that comes with a see-through door design,” Mosqueira says. “It is much easier for staff to know what is in each cooler without opening the door. It also encourages more pride in keeping these areas clean and organized, because everyone can see at a glance how the last person accessing a unit has left it.”

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Another notable design feature suggested by the consultant was the use of dual compressor systems for both refrigeration and freezer systems, providing redundant capacity so that minimum levels of refrigeration can be maintained even if a major component fails. “Parts delivery can sometimes take several days, and this ensured we would not face an immediate crisis if a spare part has to be shipped in from out of state,” Mosqueira says.

A final key component added in Phase II was a blast chiller capable of chilling up to four mobile carts at a time. These can be rolled directly into it from a new bank of combi ovens that were added in Phase III.

“The blast chiller has revolutionized our production,” says Mosqueira. ‘We could not have envisioned how much we would use it once it became available, both for our daily production and for special applications.

“We have a conference center where we frequently cater sit down dinners for our foundation,” adds Corporate Executive Chef Johnny Curet. “Now we can preplate, blast chill and refrigerate our meals in advance. When it’s time to serve, they can be rolled into the combi ovens, 100 plates to a rack, and be re-thermed in six or seven minutes. Final plating only requires the addition of sauce and garnish. It becomes a simple matter to serve 450 people in 20 minutes.”

Phase III: Reconfiguring the trayline

By the time the refrigeration facilities were in place, Feeney and Mosqueira received provisional permission to move on to Phase Three. The expanded refrigeration facilities had allowed them to move to partial advance food production, easing production demands as they began moving and reconfiguring the tray line. At the same time, the foodservice office space was reconfigured and half of the kitchen cooking areas was replaced.

A key need in the tray line area was the addition of space for staging of the hospital’s mobile meal delivery carts, which up to then had been staged out in one of the building’s hallways, blocking traffic and seriously hampering productivity.

Where did the extra space come from? “Mostly from two areas,” says Mosqueira.

“By re-configuring our offices we made more efficient use of what designers call ‘circulation space,’ (the square footage of walk and hall space). And by replacing multiple reach-in refrigerators with a single walk-in cooler, we freed up floor space we could then dedicate to tray assembly use.”

Where the walk-in supports the cold side of the tray line, 13 new mobile temperature & humidity-controlled food holding units support the hot side. These allow much greater quality control during holding periods. Another productivity-enhancing tray line feature added was a built-in water line that can fill all the lines consecutively, employing only single valves for filling and draining.

Baking production, formerly handled in a separate area, was integrated into the general production flow, with an emphasis on moving most to bakeoff-type products. Typical of production changes: dinner rolls, which formerly were proofed on one cart, transferred to different carts in a revolving oven, are now proofed as part of a programmable cycle in the combi ovens, cycled through a resting period, and then baked off in a continuous cycle.

Phase IV: Now we’re cooking

Phase IV of the renovation began in early 2003. It called for replacement of the remaining half of the main production area, including cold prep, with special focus on the main cooking facilities.

The fryer bank was replaced with new, optionally-basketless units that can better accommodate the high volume catfish fries that have long been a traditional staple of Friday lunches at the facility. Also added: new grills, char-broilers and a bank of smaller mixer-kettles to be used in advanced food preparation.

Four state-of-the-art programmable combi ovens were installed in February that replace what had been separate steamers and convection ovens. (Another four will be installed in 2004). All are networked via Ethernet so they can be programmed remotely from the executive chef’s offices and so the manufacturer can run remote diagnostics if required.

The kitchen’s utility distribution system was streamlined and upgraded and its electrical panels, formerly in multiple closets throughout the department, were centralized in a single area.

Similarly, in preparation for tightened HACCP requirements now being implemented, more sophisticated temperature monitoring systems were also installed, with all readouts now monitored and recorded at a single site.

As Phase Four finishes up this fall, the renovation activity will move to the front of the house with a new quickservice café that will take some of the pressure off of the overtaxed main cafeteria and prepare the way for servery renovations that are coming next year.

Finally: moving into the front of the house

In Phases Five and Six, planned for 2004- 2006, there will be a complete redesign of the cafeteria servery and renovation of all dining areas. That work promises to finally give the medical center a servery comparable to those in some of the new facilities that exist elsewhere in Baptist Health system.

“We are looking at how we market our services and whether the model on the cash side needs to be more strategic,” notes Feeney, “both to bring in revenue and to enhance the marketability of our facility to future employees and to retain current ones. Our plans call for us to significantly increase our retail revenues once we complete our front of the house serving capacity.

“Our servery is the part of the hospital with the greatest amount of public exposure,” she adds. “We like to believe it is the ‘human face’ of the institution to its patients and their families.

“We want to be seen as a respite for them. We believe the dining areas should communicate a message about how we treat the people and patients who come to us.