Extreme Makeover

John Lawn

When it comes to foodservice project management, healthcare operators often face difficulties obtaining both multi-year funding and administrative support for complex undertakings. Competition with "core" hospital departments for capital dollars, frequent transitions of senior administrators and a culture that's often focused more on cost cutting than ROI project evaluation all contribute to an environment that can sideline even the most promising foodservice upgrades.

That's one reason it's so impressive to see an administration get behind a modernization plan the way it has at Stony Brook University Hospital (Long Island, NY). There, a just-completed $6.8 million makeover of the kitchen, servery and foodservice operations is paying significant dividends. And the foodservice department is determined to leverage the new facilities to make sure the payoff continues to grow.

When it comes to foodservice project management, healthcare operators often face difficulties obtaining both multi-year funding and administrative support for complex undertakings. Competition with "core" hospital departments for capital dollars, frequent transitions of senior administrators and a culture that's often focused more on cost cutting than ROI project evaluation all contribute to an environment that can sideline even the most promising foodservice upgrades.

That's one reason it's so impressive to see an administration get behind a modernization plan the way it has at Stony Brook University Hospital (Long Island, NY). There, a just-completed $6.8 million makeover of the kitchen, servery and foodservice operations is paying significant dividends. And the foodservice department is determined to leverage the new facilities to make sure the payoff continues to grow.

Overall foodservice revenue—now over $5 million—is more than double what it was four years ago. It grew 16.5 percent last year and is on track to grow 18 percent more in 2005, says Suzette Smookler, R.D., administrator of food and nutrition services.

On the patient side, satisfaction levels and Press-Ganey scores have significantly increased over the same period and a recently-approved room service program should boost them further next year. Technology is improving efficiency in the front and back of the house. The addition of a new executive chef represents a commitment to making sure that food, too, will also get the attention it deserves.

Not to be overlooked: Stony Brook's foodservice has undergone a major management change over the past five years, converting to self-operation after nearly two decades with various contract management companies.

From the executive leadership's point of view, the changes have only been positive.

"We are in a rebuilding stage and have some very aggressive targets," says Amir Rubin, the hospital's COO. "Our goal is to be the leading academic medical center in the region, recognized nationally for excellence. To achieve that we have to improve the performance of every facet of the organization.

"One of the most visible signs of this to employees and visitors is the food, decor and patient services of the organization. The improvements Diane Carillo (Stony Brook's vice president for hospital operations) and Suzette have achieved in the overall experience of our patients and employees are a major contribution to what we have set out to do."

Then and there to here and now
First opened in 1980, Stony Brook Hospital's original foodservice had been designed around the so-called "convenience kitchen" model popular at the time. A much smaller facility then, meals were prepared using limited cook-chill capabilities, then rethermalized on the patient floors. Cooking, refrigerated storage and ware-washing facilities were limited. As the facility grew in the following two decades, production adapted, but mostly in a patchwork fashion.

Meanwhile, the retail operation was a whitewalled cafeteria with a straight-line steam table. "We liked to say it was designed in 1960, but built 20 years later," says Paul Hubbard, the department's associate director. "Over the years, 'sprucing it up' meant changing the color of the tiles and countertops. At the time of the renovation, they were aqua blue."

It was in 1997 that the hospital took a hard look at the rapidly changing healthcare environment and to how Stony Brook needed to position itself relative to competing facilities for the longer term.

"The model at the time was 'patientfocused care,' and the administration decided it wanted to return to one with a dedicated division-for support services," says Carillo, who was hired to drive that change at the time.

"Our goal was to take advantage of our strengths, address our weaknesses and improve the service we could provide to internal and external customers. Our strategies focused on the idea that there is an intimate connection between employee and patient satisfaction."

Carillo's background was in food and hospitality services and she brought that perspective to her role at Stony Brook. Her top goals were improving staff morale and providing continuity and a sense of ownership to management team members as the hospital embarked on a period of reinvestment and change.

"We are in the early stages of a $260 million strategic initiative and an extensive modernization of the facility," says Carillo. A new lobby that will define the sense our visitors and patients have of the hospital and a new ambulatory care building are part of those plans. Both will require foodservice. We see it as one way we can communicate that we are quality-driven."

It was Carillo who recommended that Stony Brook convert the foodservice to self operation and who hired Smookler to oversee that transition in March of 2000.

A move to self operation
Smookler began her career as a dietitian at a community hospital and later worked as a healthcare foodservice inspector for the New York State Department of Health. "I had the chance to see and evaluate hospital kitchens all over Nassau, Suffolk and lower Westchester counties," she says. "It was a real eye-opener—I formed a lot of opinions about what constitutes a well-run operation."

In 1991, she moved into management as a contract administrator for The Long Island State Veteran's Home, also located on the Stony Brook campus. It was there that she fine-tuned her operational skills after converting the facility to self operation in 1993.

Because The Veteran's Home is part of the Stony Brook campus and the State University of New York (SUNY) system, Smookler was able to work with its faculty-student association to create an auxiliary services department. That provides a variety of internal services on a self-supporting basis, centralizing payroll, purchasing and other support functions. Operating costs all must be offset by revenues, with any excess going to the institution's operating fund.

"Diane knew what I had accomplished over at The Veteran's Home and also had known me from my days with the Department of Health," says Smookler. "She recruited me to manage both the foodservice renovations she envisioned and the conversion to self-operation."

Initially, emphasis was placed on upgrading the physical kitchen facilities with a goal of improving the quality of food that could be offered to patients. Press Ganey scores at the time put patient satisfaction in the single digit percentile in the UHC peer group, and the administration was looking to change that situation via every means at its disposal.

"Our hospital mission statement focuses on our service to patients and that was the place to put our attention first," says Smookler. "And our Press Ganey score improvements show the results—today we are in the 62nd percentile of the same peer group, and are looking for an even more significant boost when we add patient room service next year."

Rebuilding from the ground up
The hospital's decision to fund a groundup re-design of the kitchen has contributed significantly to this goal, Smookler says. So has the new heat-on-demand system and a restructuring of the meal delivery system. The production manager's position was recently re-defined to include direct responsibility for food quality. And last December, the department added a new position— executive chef— with a goal of raising the bar in terms of what it is able to offer customers.

"We always had a bakery on premise, and always produced good product from it," says Smookler. "On the other hand, we are looking to Eric (Ingoglia, the new executive chef) to take the program to the next level. He will also oversee recipe development and culinary execution and coach our kitchen staff."

As part of a hospital-wide quality improvement program, every meal is measured against standards for taste, temperature and presentation. A HACCP program tracks temperatures throughout the production process and to the delivery, "and provides another way to provide quality assurance all the way to the patient's tray delivery," she says.

The department contracted with The Hysen-Group to act as the principal consultant on the project, helping it develop a master plan, economic pro formas and justifications for the renovations and to design and oversee the mechanical and construction work.

The renovation began in February of 2002 with a remodel of the dishroom, replacing the aged warewashing equipment and freeing up floor space for an expanded tray line. During renovation, a temporary tray line was set up in a nearby conference room. Once the tray line and delivery system was re-opened in September, construction moved to the bakery, main kitchen and storeroom areas.

Among other additions: two new commercial convection ovens, four combi ovens, and a new grill and griddle. "As we moved from cook-chill to cook-serve, we knew we could do a lot more custom prepared food for the tray line with better presentation value with the right equipment," says Hubbard. "It has changed our whole culture.

"When you listen to floor conversation today in the kitchen it is a lot more like what you hear in a hotel banquet production environment, with employees constantly keeping each other up to speed on how the production is moving along."

The fifth floor build-out
By March of 2003, the department was ready to move its attention from the first floor production area to the main cafè area on the fifth floor. Plans called for a complete gutting and redesign of the existing servery, a build-out onto an existing patio to double the size of the seating area, and a variety of other major construction changes.

To provide service during the cafè renovation, the department opened the Skyline Deli, a retail operation located near the cafè entrance. It combines retail grab-andgo options with sales of custom and premade deli sandwiches as well as sliced meats and other items that offer take-home convenience to employees. Soon after, the main cafè and its seating area were shut down.

"We not only continued to serve every customer, we also grew our business eight percent in the two years we were under construction," Hubbard says. "That was partly due to the retail style offerings and also to the fact that we began bundling more meals and offering more custom-prepared items that could be purchased right from the cooler.

"The customers saw the construction going on, but they also saw the menu changing right before their eyes. The value and ambience were improving, and it gave them a taste of what we had in mind for the future."

When the Marketplace Cafè opened for service last November, the new ambience exceeded all expectations. Signage and dècor gave made various stations—Field of Greens, Fierenza Nova Brick Oven, Brook Bakery, Fired Up and a Chef's Display island—a truly contemporary dining experience.

Although FTE counts have increased about eight percent with the opening, those costs are much more than offset by the additional revenue the space is now generating, Smookler says, noting that new POS technology has significantly helped the department improve its ability to manage traffic flows.

A nuts and bolts guy
Associate Director Paul Hubbard has a lot to do with that; he oversees operations for the department, everything from vendor selection and procurement to IT systems, security, retail operations and catering. He also acted as the construction liaison for the renovation.

A "nut-and-bolts" guy who is also a professionallytrained chef, Hubbard formerly worked as a contract services manager in both healthcare and other segments, and has wide ranging interests, including a fascination with the role technology can play in upgrading the hospital's operations.

Much of Hubbard's attention recently has been turned to the technology side of the Stony Brook operations.

Because the hospital regularly attracts a certain percentage of university students to its side of the campus, it has offered a mag strip debit card program for some years that is compatible with the cash balance program many of the students use for their school dining needs.

The opening of the new servery provided an opportunity to completely review the point of sale technology used by the department, and Hubbard was key in making the decision to adopt both new software and new register systems to manage retail sales and data. Among other changes: barcode readers at every register (see sidebar on p.32).

Patient Services
Kathy Werther, Stony Brook's director of nutritional services, is a 20-year veteran of the department and is as rooted in clinical nutrition and patient services as one can be.

"Our main focus these days is to align the mission of our patient feeding initiatives as we move to a room service model," she says.

Werther has only favorable comments to make about the move away from cook chill the way it was practiced at Stony Brook previously. "Because everything was prepared chilled, and plated in advance, it really limited our menu options and presentation style," she says.

Werther also notes that the earlier system wasn't as efficient as might be assumed—" supporting it meant maintaining an eight-hour a day tray line operation here."

In the last three years, that's been replaced by a just-in-time approach in which the department-plates meals at the time of service, uses a heat on-demand system to maintain temperatures, and then delivers trays directly to patient floors. Assembly operations are integrated with other production activities. And as a team culture, all employees are cross trained so they can both pass trays and perform other patient services functions.

In another effort to upgrade patient service, Werther implemented a scripting program last fall for all those who pass trays. "We call it 'Words that Work,'" she says. "It's an approach used by some of the highest-scoring Press-Ganey hospitals, and emphasizes key phrases and messages we want our people to use in dealings with patients. We were the first department here to roll it out and some other departments are now looking at how it can help them improve patient relationships."

The diet office computerized three years ago, but the software employed there is under review, particularly in light of an expected move to offer room service to many categories of patients next year. Also, the DOS-based system in place now, while reliable, needs to be replaced with a Windows-based package in order to make it consistent with software used throughout the rest of the hospital.

"This is a fast-paced operation," Werther says. "We are evaluating software choices knowing that our future model will require us to offer meals on demand that match patient schedules, admissions, therapy appointments and other needs that were not typical in years past."

Werther is also enthusiastic about the department's decision to add an executive chef to staff. "A more sophisticated approach on the culinary side will let us enhance patient meals to make them a better experience for our core customers," she says.

"That's especially important on the therapeutic side, where the diets are restricted. Even though patient meals have become more liberal in recent years, we are a teaching hospital and tend to have a patient population that has more specialized dietary requirements."

Meanwhile, the Skyline Deli proved so popular that employees don't want to see it go, says Smookler. "We've also found that it provides us with a limited service option for the third shift and on weekends, when traffic won't support the costs of keeping the cafè open."

There are also new projects on the drawing board: a physician's dining room that was not part of the original renovation but which Smookler has obtained space for in a former meeting room that adjoins the cafè. The room service initiative. And eventually, foodservice in the hospital's new lobby and ambulatory care center.

Smookler also believes there are important benefits to be gained from the influence the department's new executive chef, Eric Ingoglia, will bring to its operations. One of his current projects is the development of a monthly in-service training program for staff, to coach those who are interested in obtaining ACF certification.

Ingoglia also makes the rounds to patient floors on a regular basis to obtain feedback on meals, a practice Smookler says "helps to support our efforts at raising patient satisfaction. It is important for them to know that we are interested in satisfying their meal expectations and that we've hired the kind of people who can do that."