Aye, Robots at OSU

John Lawn

It's a little bit eerie here in the dimlylit ATS room on the ground floor of The Ohio State University Medical Center (OSUMC) building. Cavernous and mostly empty, but alive at the same time; populated by a silent fleet of robotic transport carts that travel back and forth, each with what appears to be a mind and mission of its own.

At the far wall, an elevator door opens and another cart wheels out, carrying containers of trash from another floor in the complex. As it moves into the ATS room, it slows to a stop at a crossing point, politely waits for another cart with patient trays (and apparently, the right of way) to drive by; then resumes its travel to a different elevator bank. It waits patiently until the doors open, enters, and a moment later, carries the trash to the disposal center by the loading dock.

I am at somewhat of a loss. How does one take still pictures that will adequately portray what I see before me in the pages of the magazine? You can view a video clip of the OSUMC robots here.

"Pretty impressive, isn't it?" The voice behind me is that of Mary Angela Miller, administrative director of the Nutrition and Dietetics department, who has returned after answering a page. We continue on a walking tour of the medical center's foodservice facilities and I make a mental note to return to capture a video clip of the robots later....

The new automated transport delivery system at OSUMC is only one of a series of technology applications and productivity enhancements that have helped the foodservice department there dramatically improve its operational performance over the past decade. In fact, technology investment has long been a tradition here. (Last year the Center was listed among the "100 Most Wired" facilities by Hospitals & Health Networks magazine in its annual IT benchmarking survey.)

"We have always sought to employ technology as an operating strategy," says Miller. "Our goal has not only been to leverage technology and become more efficient, but also to use it to enhance service to our customers."

In the hospital's main Seasons Cafè, you can see one early technology investment still at work—a 'Circle-Serve' carousel system that was installed when the medical center was first constructed in 1976.

While impressive to watch, offering retail customers an array of heated and cooled menu items on a slowly revolving display that is continuously replenished as the carousel passes through the kitchen, it is a dinosaur by today's standards.

And while Miller does not say so, the carousel illustrates the fact that technology investment alone does not automatically result in the most cost effective foodservice operations for the long term. Efficiency is as much a result of planning and programs as it is of capital investment.

Like many large university hospitals, OSUMC has grown dramatically in the past 20 years. Today it is comprised of University Hospitals, the James Cancer Center Hospital, OSU Harding Hospital, Dodd Rehabilitation, Ross Heart Hospital and OSU East, a satellite hospital on the east side of Columbus.

When Miller joined the medicalcenter as director of nutrition and dietetics in 1990, the department only scored in the bottom 75th percentile nationally in terms of its foodservice cost per patient day when compared to similar facilities.

These days it regularly scores in the 25th percentile and also boasts marked improvements in patient and customer satisfaction with its services. It achieved that improvement even as it serves significantly more meals and operates with about 40 percent fewer FTEs than in 1993.

A chronological look at the changes Miller has implemented over the last decade illustrates both the challenges and the sometimes difficult-to-attain solutions that have faced many large medical centers in a period characterized by rapid change, facility consolidations and intense cost-containment pressures.

Selective sub-contracting
Some of those changes were typical. For example, one of Miller's first moves was to adopt a prime vendor for food purchases, using a contract with the University Health Care Consortium (now Novation). Because foodservice costs are evaluated and benchmarked net of contributions from any cash operations, the department also looked for ways to increase cash sales. Still, "we had very little capital to work with, and major retail renovations just weren't possible," says Miller, so major renovation of the retail facilities to grow those revenues wasn't a real option.

"As an alternative way of expanding our retail income, we bid a quickservice restaurant contract that was won by a local Wendy's corporate store. Once the basic space finishing and utilities were brought to the site, Wendy's footed the cost for restaurant seating construction," she says. "Wendy's pays our cost center a lease fee for the space and a commission based on sales, presently in excess of $1.5 million annually. And while that revenue is not ours to spend, it does count in our budget as an offset to our costs in other ways. The contract also requires the operation to stay open until 1 AM, allowing us to to serve the needs of third shift employees."

Soon after, a similar arrangement was made for a local franchisee to install a gourmet coffee cart operation that now rings up over $400,000 a year in sales. While the department-operated Seasons Cafè continues to be the primary retail option for most employees, the Wendy's, a Cappucino Espress Oasis , three outdoor Skyward Concessions carts and a full range of vending services allow it to extend foodservice to other locations on the campus and to offer service during extended hours when the cafè is closed.

"Some people would argue that we just gave up that business," says Miller. "On the other hand, we have facility constraints that limited how much service we could effectively provide. Instead, we decided to focus our efforts on making improvements on the production side. That showed the most promise in terms of helping to cut our costs."

The end of the microwave
Miller also looked at what was then a decentralized production operation and made plans to centralize it. She closed two satellite kitchens that were operating in the center's adjoining Psychiatric and Rehabilitation hospitals, consolidating all tray production in the main facility. The hospital's system re-therming patient meals also was costly and problematic, and she initiated plans to change that.

"Meals were heated in small microwave units on the floor, one plate at a time," she recalls. "You started with the soup, moved to the entree, then the sides. When you had three trays ready, you delivered them, then started over. We had a patient foodservice staff of over 50 people who were mainly involved just in providing this floor meal service three times a day."

Over a two-year period, arrangements were made to install a new re-therm system so that full trays could be moved via refrigerated carts to individual floor stations for bulk re-therm on demand.

After the system was introduced in 1996, "we had promised a 25 percent reduction in staff devoted to tray delivery and we achieved a 30 percent reduction," says Miller. "The project represented a three-to-five year payback, but we had an immediate improvement in patient satisfaction relative to the temperature of served meals."

In November, 2001, the old double-sided tray line was completely replaced by a more compact and efficient (and mobile) circular tray line. That mobility has already paid dividends: the tray line has been relocated twice since its installation.

Automating floor stock orders
Better management of floor stock—both bulk nourishment products and the variety of portion-controlled beverages and other food items supplied to patients between meals—was another issue OSU tackled with a technology solution.

"Almost $25,000 in floor stock is charged off here every month, and we needed a much better way to manage and account for those orders," Miller says. The old system was paper-driven, inefficient, and did not provide managers with enough control over ordering practices. It was also highly fragmented: floor stock is maintained in 13 galleys and provided to 37 patient areas in six buildings.

"It also made pricing updates a nightmare," says Julie Jones, director of nutrition services. "There was a real opportunity for improvement and we believed that online ordering would help us address all of these problems."

The project was initiated in mid 2001 and fully implemented in 2002. Today, authorized floor personnel place all orders via an intranet-based interface that has constantly updated inventory and pricing. A nurse manage at each unit can customize the order guide used by nurses on that floor so that only items he or she wants to have available appear.

When orders are placed, the product is automatically charged to the floor account, a picking order printed, and a delivery initiated (beginning next year, these will be delivered via the new ATS system). Among other benefits, it has saved the department about 28 hours a month in related chargecapturing labor, dramatically increased the accuracy of floor stock accounting and reduced floor stock complaints by 75 percent.

More recently, nutrition services moved to eliminate another paper-based procedure at the floor level—the old pre-select menu system. In 2002, the hospital moved to a spoken menu approach, with floor personnel taking orders using personal digital assistants (PDAs) that tie directly into the department's CBORD management software. They not only offer staff the ability to provide more personalized menu choices, but also automate dietary information so that choices can be automatically limited for specific patients as required.

On the retail side, the hospital intranet posts the daily cafè menu, with a link from the first level of the hospital's home page. While monthly paper flyers remain popular with employees, and are still produced, "our online menu is one of the most popular sites for employees," says Jones. "We consolidated our system so that menu data input into one place is used both for the daily posting and for the monthly paper version."

The robots are coming
The hospital first began to consider investing in the new robotic delivery system six years ago, although that was not its first venture into automated transport. When the Columbus facility was first built back in 1976, its original design included a ceiling-mounted, chain driven transport system. While it had never been practical for moving food, it had moved loads of linen and trash for many years until increasingly high maintenance costs began to outweigh its benefits in the mid 90s.

"When the Medical Center investigated the cost of replacing it, they looked to expand its applications to help justify the investment," adds Jim Warner, the department's associate director. "

Analysis showed that the large number of drops and pickups associated with patient foodservice would be an important contributor to the savings needed to put the project over its ROI hurdle."

Miller notes that another analysis showed that over a quarter of the work time of the department's nutrition aides was spent pushing meal carts to or from the hospital's various units. "This is not rewarding work and it does not add to the patient experience or the worker experience. It also tends to have a high rate of injuries occupationally."

Instead, "the new ATS system allows our nutrition aides to spend more time at bedside with the patients, rather than pushing carts around." In fact, even when the system had only been partially implemented, the labor it freed up allowed the department to institute a new beverage service program for patients.

The first robotic transportation began with trash hauling this past February; foodservice use followed quickly, for the movement of soiled tray carts back from the units to the dish room. Pilot deliveries of hot trays began in late November, with the goal of reaching 100 percent ATS delivery in the main complex over the next several months.

Cashless transactions
Although implementation of the ATS system and the associated central re-therm facilities has consumed much of the department's time over the last two years, it embarked on another major technology implementation as well: a new POS system that will make possible cashless retail transactions, faster credit card processing and a payroll deduction option for employees. Miller says the department is looking ahead to improved cash management as well as increased check averages as a result of these changes.

"The last major capital investment envisioned for the near term will fund a total redo of the Seasons Cafè prep and service area," says Miller. "When the old carousel goes, I'll know we've finally gone full circule in our initial master plan.

"It does seem that the pace of change has increased considerably," she admits. "But we have also earned more credibility with our administration over time. When we obtained capital dollars in the past, we ensured that we returned what we said we would as a result of those investments. That track record helped us when it came time to petition for new projects.

"We've also demonstrated our ability to use technology to address customer satisfaction, food safety and operational issues that go beyond issues of efficiency. In the end, the stability and quality of our own management team over the past 14 years has made as much of this possible as the technology has."