You’ve Tossed Your Trayline—Now What?

Mike Buzalka

Room service dining for patients is all the rage in hospital foodservice. Figures from the National Society for Healthcare Foodservice Management (HFM) show that 37 percent of respondents to an HFM survey earlier this year indicated they have implemented room service dining in some way, a quarter of them within the past year. Many more say they plan to do so in the near future.

But those broad numbers obscure a very important caveat, which is that there is little uniformity to how room service is deployed in different hospitals. Some provide it almost universally, while others limit it to select units. Some use staffers as order takers while others leave it to patients to call in menu requests by phone. Some deploy a single common menu, while others let patients see only their diet-specific selections. Some adapt basic, traditional dishes to the new ordering model, while others design elaborate menus, sometimes in multiple languages.

One thing is certain, though. Room service is a sea change for healthcare patient dining, putting the customer in charge.

That can be disconcerting for dining services departments used to controlling meal delivery schedules, but it also has major impact on other departments. Nursing, for example, can no longer depend on regular mealtimes to administer medicines that must be taken with food, and labs have to account for meals taken at odd times when scheduling procedures that require a period of fasting.

Sizing Up the Cost

Operationally, converting a hospital kitchen to room service means going from mass production to customization, from steam kettles and convection ovens to charbroilers and griddles, and from traylines to hotel style cook stations and tray assembly areas.

“Real estate is a key factor,” says Ellyn Luros-Elson, president of Computrition, Inc., a major vendor of nutrition software for healthcare applications. “How is the kitchen is laid out and how far do you have to take the food? Traditional hospital kitchens often don't have space where you can do grilling, for example.”

That was the situation facing Patricia Ours, director of food & nutrition services at Reid Hospital in Richmond, IN, when room service debuted there in 2005. “The cooks prepared the hot items and then we had to cart it to the other side of the kitchen for assembly,” she says.

However, that is no longer an issue, since Reid opened a brand new hospital in September with a kitchen designed for room service. Now, the hot and cold areas face each other so trays can be prepared quickly.

Other key issues: orders have to be double-checked to make sure the guy with the triple-bypass isn't trying to sneak a cheeseburger, and then transmitted quickly to production so that components can be prepared and the tray assembled.

“You have a window of about seven minutes to plate an item,” says Gary Conley, president of the Room Service Technologies consulting firm. “Much above that and you won't get it to the patient in the promised 45 minutes.”

Consequently, many departments use automation that quickly cross-checks orders with dietary restrictions and kicks order tickets to hot and cold prep areas simultaneously, helping to meet the short time window.

Implementing room service also means a significant labor commitment, as it almost always requires not just adding FTEs but a different kind of labor — more customer-friendly, flexible and multi-skilled — from what the closed-environment, clockwork routine of traditional hospital traylines demanded. In union shops, job descriptions have to be rewritten and posted (for an expert take on how room service changes the employee culture and how to deal with that, see the column at right).

Increased labor, new equipment and infrastructure changes are costly but, unlike hotels, where guests pay for room service up front, hospital room service doesn't charge, at least not directly. Furthermore, with no menu prices, each meal is in effect reimbursed at the same rate, despite varying food costs.

Fortunately, most hospitals have found that patients don't regularly order the most expensive selections. Still, the issue underlines the importance of designing a room service menu balanced between premium selections and attractive options that have lower food costs.

Given all these challenges, the natural question is, why do it?

Can Get Some Satisfaction

Patient satisfaction is the answer most directors cite, and it's a hard point to argue. Room service dining is to patient satisfaction scores what triple espresso is to heart rates.

“Our patient satisfaction jumped from the lower teens to 75 in the first 30 days,” reports Larry Fluke, director of nutrition & environmental services at Providence St. Peter Hospital in Olympia, WA, in a typical reaction.

Operators also cite decreases in food waste and, as a consequence, overall food cost, a not-inconsequential consideration in an age of rising food prices. Some also note that the new room service culture fosters greater employee satisfaction that translates to lower turnover, less absenteeism and greater productivity.

“Perhaps what surprised us most is how much our employees embraced this change,” says Fluke, whose union shop was kept involved through the conversion process.

“In a traditional system, when you ask a staffer, ‘Who are you working on?’ they would reply, ‘Two North,’” offers Conley. “With room service, the answer is ‘It's a tray for Mr. Smith in Two North.’ It's is much more personalized.”

The most significant factor driving the growth of room service, though, is competition. Just as colleges upgrade their campus dining programs as a “tiebreaker” factor to sway undecided students where academics are a wash, hospitals with comparable clinical reputations have turned to amenities like dining to get a competitive edge.

But as more institutions implement the service, it becomes harder for the rest to hold out, if only because the rise in patient satisfaction scores at one institution bumps the percentiles down for everyone else.

Also driving the trend are the major contract management companies (a segment of the industry not reflected in HFM's survey). Major healthcare contractors Aramark, Sodexo and Morrison Healthcare Services all now offer room service dining modules for their clients, with significant numbers of them taking that option. This puts additional pressure on self-operated foodservices to follow suit.

So it's not surprising that the impetus for putting in room service often comes from the top down. “Foodservice directors are interested in it,” says Conley, “but it is administrators talking to their peers and seeing the rave reviews in the press who say, ‘We have to look into this.’”

That's the story at Mid-Michigan Medical Center in Midland. “Our conversion was driven by the hospital president, who felt we needed to do this for patient satisfaction,” says Mary Jane Hoshaw, MS, RD, manager of food & nutrition services. “There were other hospitals in the area competing with us who already had it, and he really drove the project. My reply to him was ‘Yes, sir!’”

The top-down mandate had its advantages, easing the way to the capital commitments needed to completely revamp the kitchen, hire and train new staff and even change utilities.

“We converted to gas equipment to let us produce more quickly,” Hoshaw says. Mid-Michigan's antique circular trayline actually had to be cut into pieces to be removed just before the new system went live on June 19, 2008.

Differences in Deployment

Mid-Michigan went cold turkey with its conversion, putting all compatible units on room service (the psychiatric and rehab wards retain set mealtimes for clinical reasons, though the patients select from the room service menu). That is somewhat unusual, says Luros-Elson.

“While HFM's survey may show 37 percent of hospitals having room service, I doubt that more than 15 percent have it fully,” she says “Many offer it only to some areas, with the rest getting the traditional meal service.”

“Converting to room service is not as difficult as you might think as long as you get the resources to do it,” offers Tony Almeida, director of food & nutrition at Robert Wood Johnson University Hospital in New Brunswick, NJ, where room service is offered to every patient capable of using it — some 500 trays per meal period.

Almeida says a common mistake is overestimating the resources required. He cites as example one large hospital whose director toured RW Johnson's facilities in preparation for its own conversion.

“He had brought along his blueprints, which showed pure overkill,” says Almeida. “They had three times the equipment we have here, and were planning for three times as many FTEs. We do 400 meals on a four burner stove while they were looking at 18 burners. We showed him how we combine lines and share equipment to reduce duplication.”

The anecdote illustrates Almeida's key piece of advice: “visit as many programs as possible. The more you see the more you learn.”

One thing they learned at the pioneering room service program at Memorial Sloan Kettering Cancer Center in New York was to keep adapting, says Director Veronica McLymont. “If you don't keep reinventing, the staff gets bored, the chef gets bored and even some patients get bored,” she says.

To fight “boredom,” Sloan Kettering has several new initiatives: a tea cart serving gourmet teas, coffee and pastries in the mid-afternoon; a special Sunday brunch menu; a gift program that lets visitors and patients order gift baskets for staff, family or the patients themselves; and a guest menu to allow visitors to order room service meals for a cost ($6 breakfast, $10 lunch/dinner).

The Hours

Evening serving hour cutoffs are another challenge. Most programs begin serving around 6:30-7 am and go into the early evening, usually cutting off orders around 6:30-7 pm. However, this can get a kitchen slammed just before closing time.

That's what happened at UCLA Medical Center, where the original schedule was 7 am to 7 pm.

“We found that a significant number of patients prefer eating dinner later than seven and we want to be as accommodating as we can,” says Assistant Director Patricia Oliver. UCLA now takes orders until 8 pm.

At the University of Wisconsin Hospitals & Clinics in Madison, the order window is open until 9:30 at night. “The time was designed around our admission pattern,” says Foodservice Director John Hofman. “A lot of patients come in through ER or our clinics and they may not get to a bed until 8:30 or so after not having eaten since lunchtime. It also accommodates patients who want to eat dinner later, as well as those who ate earlier but might want a snack.”

Hofman deals with the expanded hours by staggering the 10-hour shifts of his four full-time cooks. Two start the day at 6:30 am, with the other two coming on at 11 am so that there are four to handle the busy lunch rush, when up to 300 orders can come down in a small time window. The two late-starters, augmented by some part timers, deal with dinnertime.

“That's one of the hidden benefits of room service,” says McLymont. “It helps keep us aware of service, that we're doing this not to please us but to please the patients.