Hospital foodservice directors often say offering healthy choices in their cafeterias is a key department mission. But many operators are quick to add that they still offer the so-called unhealthy options to prevent a drop in participation and revenue. Raquel Frazier, foodservice manager at 49-bed La Rabida Children’s Hospital in Chicago, doesn’t have that luxury. In 2007 she was mandated by the hospital’s administration to make the cafeteria 100% healthy.
“The administration wanted the employees to be healthy and to be good role models,” Frazier says. “So we made the change to healthy all at once in the cafeteria. It was like getting a shot over and done with.” In May 2007, the cafeteria made the switch to offering only healthy food options.
To meet the new nutritional guidelines, food items cannot exceed 450 calories, 10 grams of fat or three grams of saturated fat and have to contain at least three grams of fiber. In addition, portion sizes were decreased; vegetables are now offered in one-half-cup sizes; starches are one-half cup; meat is three to four ounces; gravies are two fluid ounces; and soup is eight fluid ounces.
Nutritional information for all menu items is posted on the menu and at the point of service. Calories and fat are listed for every item, and many items have their fiber and cholesterol content posted as well.
All items are available for à la carte sale. “We do have a combo option if people want to have an entrée and a side,” Frazier says. “Our thoughts for selling everything à la carte were that we didn’t want to tie folks into have an entrée, a starch and a vegetable by comboing everything. This way, if someone wants to purchase two vegetables they can do that.”
Daily cafeteria lunch options include a soup of the day, deli sandwiches, vegetarian fare and options from the Cooking Leaner menu, which has the meat and potatoes offerings—all healthy, of course. Choices on the Cooking Leaner menu include spicy fish kabobs, ginger chili fish cutlets with cilantro rice and Cuban steaks with a Creole sauce.
In the first year of the program, most hospital employees reported losing weight and keeping it off, according to an informal hospital survey. Some employees reported losing as many as 70 pounds by pairing the hospital’s healthy food initiative with exercise. Frazier says the employees have been so successful in their weight loss and overall health in part because “the no-temptation option the hospital provides has kept a healthier lifestyle in the forefront of our staff’s minds, which has added to the weight loss of those who are actively trying to do so.”
Frazier says there are still some customers who aren’t completely satisfied with the new cafeteria program. She says some people don’t like having the option to select unhealthy foods removed and that some still crave the old cafeteria fare. To accommodate these concerns, Frazier has taken some of the old comfort foods and re-engineered them to fit the new nutritional guidelines. “We [lured] people back to the cafeteria with healthy, new, in-house made desserts,” Frazier says. For example, the department made a healthier version of banana pudding by using non-fat yogurt. “We’ve been pretty creative by adapting some of the unhealthy items that we used to carry,” Frazier adds. “It was hard to swallow at first, but the overall response has been positive.”
In the first year of the healthy program, cafeteria sales dropped 3%, but since then sales have increased and are now up 15% since the program began.
Frazier says the biggest thing she learned during the transition to healthy was that you have to know your customer base. “You have to serve things that are appealing to your customers and you have to be creative. There are so many avenues of healthy, so you have to be able to come up with a clear definition of what healthy is. If you are too restrictive, you are going to have a hard time finding something to serve.”
Beyond the café: In addition to changing the cafeteria’s menu, the department changed other retail and patient foodservice menus. “You have to make the change to healthy in all areas,” Frazier says. “If you don’t, then people will go to the vending machines and buy unhealthy items and they won’t come into the cafeteria where the healthy items are being sold, and that doesn’t help anyone.”
All catering and special event menus now follow the same nutritional guidelines as those in the cafeteria. The transition to healthy in the vending machines was significant. Frazier estimates that only 30% of the vending machines’ previous offerings fit the new healthy nutritional guidelines. So along with her vending company, Frazier phased out all of the unhealthy items and replaced them with healthier versions. Frazier says when the switch was made, sales from the vending machines dropped significantly at first. But she says after switching to more kid-friendly vending options, sales have begun to increase.
For patient menus, Frazier says only minor changes had to be made because most of the offerings on the patient menu already fit the guidelines. “Because we are a children’s hospital, a lot of the items that we use are grab-and-go, such as pizza, chicken fingers and hamburgers,” she says. “What I was able to do was to keep similar products but look for the healthier version. So with the pizza, we do items with whole-grain crust. We do an oat bran chicken finger. With our burgers we are able to incorporate turkey and chicken burgers. We still do french fries, but they are baked. If we do have an application where we have to fry something, we have a non-trans fat oil.”
Marketing: Frazier knew that some customers would be upset with the change to all-healthy offerings in the hospital, so she tried to pre-empt any ill feelings with a marketing campaign. The biggest part of that campaign was the Healthy Taste of La Rabida. For the event, Frazier invited her food vendors to showcase healthy products at the hospital, “so that my customers could see that although we were going 100% healthy, these items still taste good,” Frazier says. The event lasted all day and all hospital employees, patients and guests were invited to participate. There was a VIP showing one hour before the event began to allow patients to enjoy the samples.
Frazier also put up posters, banners and bulletin board displays throughout the hospital during the healthy initiative’s kick-off week to let customers know about the change and to laud the health benefits of the program.
During National Nutrition Month, educational programs are run in the cafeteria. “We showcase items so that people can see the healthy implications of food items,” Frazier says. “We pick an item, like iron, and when people buy an item with a high iron content they get a punch on their punch card. If people turn in their cards at the end of the week with all the food items punched they are entered into a contest to win a prize.” This year, the hospital selected calcium to showcase, and the food items that customers needed to purchase to complete their punch cards included yogurt, flax seeds and nuts.
Patient satisfaction: This year, the foodservice department was named the most improved department, following six consecutive months of 100% patient satisfaction scores. “Or goal in the department is to have 95% or higher in patient satisfaction,” Frazier says. “To have 100% for six months in a row is just unheard of in this industry. Without our patients we wouldn’t be here.”
Mark Renfree, the hospital’s CFO and vice president of administration, says that Frazier is deserving of the award. “Under Raquel’s leadership, a lot of innovative programs have been incorporated into the foodservice operation. Raquel is passionate about foodservice and she demonstrates that day in and day out. That passion is incorporated in special events, training her employees and being creative with the menu to offer a variety of healthy entrées that people have responded well to.”
One of the ways Frazier and her team of 16 FTEs have increased patient satisfaction is by implementing a test tray audit committee. The committee consists of Frazier, the risk manager, the infection control nurse, a nursing team leader and a clinical dietitian. Every month, the team audits a tray from two different diets. A fictitious patient is created and the trays are delivered as if to a real patient. The team tests the trays for temperature, quality and delivery service; i.e., was the server polite and did she follow proper sanitation procedures.
Another change Frazier made that increased patient satisfaction was tweaking the daily patient satisfaction survey. “I developed a survey that has incorporated smiley faces,” Frazier says. “So if I wanted to do a question on the temperature of the food, the faces would go from being hot to a face with earmuffs on and shivering. This way if a child is younger and they can’t read, they can show you what their food tasted like.”