The Road to Room Service

Ten years later, "the next big thing" in hospital foodservice is finally moving past the roadblocks and into a growing number of healthcare facilities.

FoodService Director - room service - HFM - Robert Wood Johnson University HospitalA decade has gone by since hospitals began exploring the idea of implementing room service programs. Touted then as a landscape-altering trend in hospital foodservice, room service certainly has had its share of success stories. Nonetheless, the concept is only now starting to capture the fancy of the majority of hospital administrators in the United States.

In FoodService Director's Hospital Census (June 15, 2006, p. 28) just over one-quarter of healthcare foodservice directors surveyed, 27%, said they offer a version of the hotel-style program. According to the National Society for Healthcare Foodservice Management, which comprises only hospitals that manage their own foodservice programs (what HFM calls "on-staff foodservice"), 17% of its members provide room service, although half of those who don't, say they are planning to implement it in the next two years.

Those percentages may puzzle hospital room service proponents, who say there are many benefits to such a program, the most potent of which is a marked increase in patient satisfaction scores at hospitals that have switched. But it doesn't surprise them.

"Room service is so radically different from anything that anyone who's been in healthcare for a long time has ever experienced," says Mary Spicer, director of nutrition services at Presbyterian Hospital of Plano, Texas. "There is a whole culture shift that has to take place,"she says.

That, Spicer notes, can be frightening to employees whose entire professional lives have been spent in the assembly-line environs of institutional foodservice. "Room service is a very fast-paced environment. It is not methodical like traditional hospital foodservice," she adds.

Other stumbling blocks on the road to room service include a fear of the labor costs associated with switching to room service, a concern that is not totally without merit.

"You can't reduce FTEs with a room service program, or it won't work," notes Lorna Kirsch, director of nutrition and dietetics for the five-hospital Clarian Health System in Indianapolis. "The problem is, there is not enough data out there to support the fact that room service still can be as efficient as a cook-chill system."

Kirsch should know: In the past two-and-a-half years she has taken three hospitals in the Clarian system from cook-chill to the cook-to-order process of room service. Clarian's progress report? A 25% drop in raw food cost, balanced by a slight increase in labor costs, for a break-even program that "significantly enhances patient satisfaction scores."

At Robert Wood Johnson University Hospital, in New Brunswick, NJ, switching to room service required foodservice director Tony Almeida to add 15% to 20% more FTEs. "There is a food cost savings of maybe 3% to 5%," Almeida says. "So we added $300,000 in labor, and saved $150,000 in food cost. But there is also that intangible of higher patient satisfaction scores."

And operators are quick to point out that patient satisfaction is of no small import to administrators.

"Patient satisfaction has been the driver for us," says Karen Smith, vice president of the hospital division of Atlanta-based Morrison Management Specialists. Morrison offers its clients a room-service program called Dining On Call, as well as a complementary restaurant-style program called Catering To You. "Hospital administrators," she continues, "are so tied to patient satisfaction scores that even if it costs a hospital more to provide room service it's worth the trade-off."

FoodService Director - room service - HFM - Robert Wood Johnson University HospitalVanessa Robinson, director of nutritional services for Aramark at The Methodist Hospital in Houston, agrees. "The biggest benefit of our room service program definitely has been the increase in patient satisfaction," notes Robinson about her program, which was implemented in June 2005. "In December 2005, our Press-Ganey scores put us in the 99th percentile for hospitals [in the U.S. with] 600 beds or more. We were the first department in the hospital ever to be in the 99th percentile."

The reason for this, operators and foodservice executives note, is obvious. "Room service is based on one simple thing," says Paul Gizara, vice president of product development and program management for Aramark's healthcare division. "Give patients what they want when they want. Flexibility is the key, as we make foodservice one of the very few things the patient holds power over."

Control room: Giving patients control, operators say, does two things for their departments. It reduces food waste and allows foodservice to be viewed as an important cog in the mechanics of a patient's recovery.

"When we did a study in 1998, before we implemented room service, we found a large amount of plate waste," explains Sharon Cox, director of food and nutrition services for Memorial Sloan-Kettering Cancer Center in New York. "One-third of our patients did not even touch their trays, and another third ate less than 50% of the food on the tray."

"Now, 80% of our patients consume 50% or more of their trays, because they are ordering foods they want at times they actually feel like eating."

Clarian's Kirsch notes that room service can also be used for nutrition education. "Room service is nice for diabetic patients, who can be trained to work their insulin and nutrition balance before they leave the hospital, because we are working with them on their schedule," she says.

Well equipped: Despite the fears that have dissuaded many of their colleagues, operators say that from an operational standpoint, room service has been easier to execute than they imagined. "You don't need a lot of equipment to pull off room service," says Almeida. "We have a grill, a fryer, a char-broiler, stovetop, Turbo-Chef oven and a pasta cooker. That, plus the computer system, is all we need."

At Memorial Sloan-Kettering, Cox installed an island-like cooking suite in order to implement room service. The kitchen set-up, modeled after the kitchen at the Waldorf Astoria Hotel, "gives us quite a bit of firepower in a very small footprint," Cox explains. "It allows us to prepare 400 meals using only three people." The bottom line, according to adherents, is that at whatever cost or challenge to conceive and execute, room service is well worth the effort.

"At Presbyterian, room service has become a marketing tool," explains Spicer. "Our president doesn't talk about the hospital without talking about room service. He doesn't bring visitors into the hospital without asking me to make sure room service menu items are available for them to taste."

"Recently, a local sports announcer was in the hospital, and he was interviewed on one of the sports radio talk shows," she recalls. "They asked him about the food, and he said, 'I've gained four pounds since I've been here. If I stay much longer I'll have to go on a diet when I leave.' We were pretty tickled by that. It speaks well of the hospital and of room service."



Before the first meal is served, you need to make sure everyone's onboard, especially the nurses.

FoodService Director - room service - HFM - Robert Wood Johnson University HospitalThe key to implementing a room service program, and keeping it viable, is to make sure that everyone accepts the idea well before you kick it off. That, say veterans of the room service wars, includes not only your bosses but also employees of ancillary departments, and even members of your own staff.

"A room service program changes the way people think about how we serve patients and the experience they have," says Shelley Kalfas, senior vice president of food and nutrition brand management for Sodexho's healthcare division. "It has to be coordinated with medication, physical therapy, etc. It really takes a team effort."

Vanessa Robinson, foodservice director at The Methodist Hospital in Houston, an Aramark account, agrees. "The biggest challenge to selling room service is to make sure that everyone is on the same page," says Robinson. "Nursing, other department directors, diabetes educators, rehab therapists, every walk of business has to be brought to the table so you can get their input."

Take it from Tony: Tony Almeida, director of nutritional services at Robert Wood Johnson University Hospital in New Brunswick, NJ, says that nursing is the most important department to consider.

"The biggest impact of room service can be on nurses," Almeida explains. "Traditionally, they always knew when trays were being delivered, so they could set up things like injections for diabetics. So we instruct diabetic patients to alert their nurses when they order a meal. Also, the order ticket for a diabetic will say 'diabetic priority,' 'diabetic.' We can also alert nurses with the call button when we deliver a tray."

Equally important, says Mary Spicer, director of nutrition services for Presbyterian Hospital in Plano, Texas, is making sure your own staff can handle the change. "Most staff are not used to interacting with patients," notes Spicer. "You have to make sure you have the right players in the right roles, because room service can be a very fast-paced environment. You may have to shift positions around. And if you don't have a chef or a lead person in the production area who knows how to do restaurant-style cook to order, you're sunk."

Cox concurs: Sharon Cox, director of food and nutrition services at New York's Memorial Sloan-Kettering Cancer Center, agrees.

"It really is about having the right people and having them trained," she says. "We need a new type of foodservice associate, people who have hospitality experience or training."

Once the program is in place, training and communication must be ongoing. Methodist Hospital's Robinson treats her operation like a restaurant, holding pre-service meetings daily in the kitchen and the call center, and with the hostesses who deliver trays.

"You need that," she says. "You give them a pep talk and any necessary information, and it also serves as another time where they can share their issues and concerns."

Some operators caution that even with a room service program in place, you still may need to operate a traditional tray line.

"Running a dual system is the biggest challenge we have," says Lorna Kirsch, director of nutrition and dietetics for Indianapolis's Clarian Health Systems. "But room service is not quite appropriate for all patients. The elderly and the very ill sometimes can't or won't order by phone. If family members aren't there to order for them, we just default to a regular menu."



Room service allows hospitals to broaden the menu choices available to patients.

Because the value of room service hinges on giving patients what they want to eat when they want to eat it, the menu is a big part of a room service program. So room-service hospitals have broadened their menus in an attempt to offer patients as much variety as the departments' staffs and budgets can handle.

Paul Gizara, vice president of Aramark's healthcare division, says the key to menu success with a room service program is customization. "It is important to personalize the menu to the patient before they ever see it," he explains. "You don't want to be showing patients foods they don't want or, worse, can't have because of diet restrictions."

The right message: In pediatrics, for instance, Aramark has eight different menus, specific for various age groups, he adds, "because a four-year-old has different menu desires from a 16-year-old. And it is not just the menu items themselves. It's the messaging; the graphics are different. We have benefited from our relationship with our School Support Services division, which has helped us design appropriate menus."

Hospital room service menus often can be more extensive than some hotel room service menus, when all items are considered. For example, a typical menu for Morrison's Dining On Call program features 11 main entrees, ranging from marinated grilled chicken breast to pan-seared tilapia. There are also three entree salads, six soups, five side salads and 17 sides such as macaroni and cheese, pinto beans and bread sticks.

And if that isn't enough for a discerning palate, patients can build their own sandwiches, create a personal pan pizza, or order items from the grill. Thirteen different desserts round out the four-page menu.

The "wow" factor: Menus can become particularly challenging in certain units, such as surgical wards. "These are mostly clear liquid and full liquid diets," says Jim Behnke, director of nutritional services for the Gwinnett Hospital System in Lawrenceville, GA. Behnke recently implemented a full room-service program in a 37-bed surgery unit. "How do you 'wow' a patient with broth?"  Behnke explains that marketing skills, such as giving items appealing names, and customer service skills come into play.

"Our call center staff use scripts for taking orders," he notes. "One thing we say to the liquid-diet patients is, 'We can't wait until you get on to regular foods, because our food here is really good.'"

At Memorial Sloan-Kettering Cantcer Center in New York, director of food and nutrition services Sharon Cox makes the menu as upscale as possible to enhance the idea of room service. Crab cakes, veggie quesadillas, poached salmon and even New York strip steaks can be found on the menu, along with chef's specials like Southern pecan-crusted rainbow trout with rice pilaf and asparagus.

Sometimes, however, even the most extensive or upscale room service menu may not be enough for some patients. In the Clarian Health System in Indianapolis, for example, the room service menu features 80 items, 45 of which are entrees. "In addition, we just revamped the menu, to add some new items and some chef's specials," explains director of nutrition and dietetics Lorna Kirsch. "We did this because we often have people coming back into the system, and they've told us they think the menu is stale."

"Of course, whenever we ask them what they would like that's not on the menu, they can never think of anything."



Seattle's Swedish Medical Center was one of the first "room service"  hospitals. Fsd Kris Schroeder looks back on the process.

Ten years ago, Allen Caudle had an outlandish vision. The foodservice director at Swedish Medical Center in Seattle thought, "if a hotel can do room service for its guests, why can't a hospital? Why can't we give patients more choice over what, and when, to eat?"

Caudle appointed Kris Schroeder to oversee the implementation of room service at the hospital, and together they helped pioneer an idea that has withstood the scrutiny of skeptics and established itself as a philosophy for more than a quarter of our nation's hospitals.

Caudle is now vice president of supply chain management for the three-hospital system, and Schroeder is its foodservice director. She remembers the process with pride, and not a little humor.

Nurses go bonkers: "One of the classic surprises we encountered when we implemented room service was that patients or their families began setting their trays outside their rooms," Schroeder recalls. "That told us that we had marketed the idea of hotel-style room service very well, but the nurses went bonkers."

Another unforeseen aspect of the program was its impact on dinner. "What we discovered was that patients were ordering dinner much later than hospitals have traditionally served it," she says. "It really shifted our thinking about how early people wanted to eat."

As is true of all pioneers, Caudle and Schroeder forged their path without much help, in this case from the consultants and software programs operators have available now. They couldn't even redo the kitchen in the first, and largest, hospital they converted, instead having to retrofit a space that was ill-designed for room service.

"We did have a chef-consultant, who had experience in hotel room service, especially in opening new hotels, so that helped," Schroeder says. "But we didn't anticipate everything we needed as far as equipment, so we kept going back to administration saying, 'Just one more piece of equipment.' But overall we did remarkably well. It has been one of the most satisfying concepts I've ever been involved with."

Continued improvement: Over the years, Swedish has been able to revisit its process flow to make the operation more efficient and reduce delivery times. Now, the department is discussing building a commissary to make the process even more streamlined.

"What we need to consider is how we can centralize some production and still offer a high-quality product," she explains. "One of the beauties of room service is we don't prepare your food until you order it. So how can we get the cost-benefit of a commissary without reducing the quality or that made-to-order aspect?"

For the room service concept in general, she believes technology has the chance to have the biggest impact on making room service viable for more hospitals. "We now have several major software vendors out there with programs for room service," she notes. "So there is the potential for major impacts on the program."

Another area poised for major changes is the menu. "I believe that consumers are going to be asking healthcare providers to be more environmentally responsible," Schroeder suggests. "We've begun to do some things in retail with organic and sustainable foods that I think are going to spill over onto the patient side."

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