Managing results and costs is a delicate balance.
In June, when President Barack Obama kicked off his summer campaign to raise Americans' awareness of the need for healthcare reform, he chose in a speech in Green Bay Wisconsin to emphasize two top concerns this way:
“We have to ask why places like Geisinger Health System in rural Pennsylvania [and] Intermountain Health in Salt Lake City … can offer high-quality care at costs well below average, but other places in America can't.”
Coincidentally, Food Management was scheduled to visit Geisinger just a few days later. Obama's question provided an additional reason to look into the structure and culture of the system's approach to managing foodservices. Here's what we found…
Not your typical 400-bed hospital
When you exit from I-80 East and drive south into Danville, you notice right away that the town — and the Geisinger facility — are not what you expect.
You are in the heart of Pennsylvania's old anthracite coal region, 250 miles from Cleveland and 160 miles from New York City. Danville is classic, rural Pennsylvania, with a population of about 5,000. Geisinger, the largest employer in the region, employs about 13,000, more than 8,000 of them in Danville facilities.
The campus that spreads out before you doesn't look anything like a typical 400-bed acute care hospital. Its facilities dominate the town's northeast quadrant.
AT A GLANCE
Geisinger Health System: www.geisinger.org
There are large office and utility buildings, a high rise tower, administrative centers. From a distance, it looks more like a large corporate headquarters than anything else. And perhaps that's because in many ways it is — Geisinger is a fully integrated health system with about $2 billion in annual revenue from operations that range from acute care to health insurance to community practice operations. The health insurance plan alone has 212,000 members.
My first interview is with Bob Davies, vice president of system services. He likes to talk about the system's traditions, which have always focused on a closed group practice model and providing service to the communities it serves. Physician-managed, and founded in 1915 on a service model inspired by the Mayo Clinic, “we serve 43 counties in Pennsylvania,” he says.
“Our peer group would include the large academic medical centers in major cities. We have always focused on measuring and improving outcomes and controlling costs and have been pretty successful in these efforts, which is why we are often cited.”
How does foodservice fit in?
“Patient feeding is an integral part of care and recovery for our patients,” he responds. “We pay a lot of attention to ensuring that our dining and foodservices are integrated with physician care. Foodservice is also an important employee benefit, and while we do not subsidize it, we want to ensure that it is a great value for employees.”
In recent years, the system has had a lot of growth, but it has sought to manage that growth carefully, Davies adds.
“Thirty years ago, we had about the same number of beds we have today, but only 1200 employees. What is amazing is that our foodservice facility is almost the same size as it was 36 years ago, when I started here.”
In fact, while Geisinger's main employee cafeteria was upgraded a few years ago, its seating and serving areas are designed primarily for practicality, not for show. They are undersized given the traffic patterns the facility serves.
The situation will improve in a few years when Geisinger completes its Hospital for Advanced Medicine, a large project now under construction. Most of the ground floor is slated for retail and patient foodservice and will provide a much needed expansion.
A focus on wellness and systems
My next stop is down the hall, at the office of Bruce Thomas. A past board member and outgoing president of HFM (the National Society for Healthcare Foodservice Management), Thomas has become well-known in the foodservice community in recent years.
A graduate of Penn State's Hospitality School, he worked in the hotel and restaurant industry before joining Geisinger' in 1987. Although he acknowledges, “I never saw myself working for very long in healthcare,” Thomas eventually went on to become foodservice director, and then, after earning an MBA, moved on to his current, system-wide role in 2006.
In it, he has administrative responsibility for foodservices, the Henry Hood Conference Center, housekeeping, mail operations, a print shop, patient transport, the Pine Barn Inn (an on-campus hotel) and business travel and reimbursement.
I ask him if that isn't an awful lot to have on a single plate.
“A lot of people ask me that,” he says. “My role is not structured like that of a multi-department manager. I have administrative oversight, but hat is quite different than having operational responsibility for all those departments.”
What about another area that has long been cited as an opportunity to control healthcare costs while also improving quality — a move to electronic record-keeping?
“Geisinger made it a priority to embark on that transition more than ten years ago,” says Thomas. “Our patients can view their medical records and communicate with their physicians electronically and our physicians can share information the same way.
“Foodservice has also become a lot more technology driven in the past five years and we rely heavily on our information systems to drive efficiencies.” (see sidebar).As an example, he points to how a doctor at bedside in any of Geisinger's facilities can change a diet on his digital patient chart and have those changes immediately reflected in the foodservice production system. Hostesses on the floors who take menu orders can similarly send them to the system in real time.
“One of the things I am most proud of has been our effort to improve the nutritional quality of the food that we offer and the perception our customers have of it,” Thomas says.
Part of that effort has involved traditional approaches such as reducing the amount of butter and fat used in recipes. Still, Thomas says, “we chose not to take the approach some do in forcing more healthful choices on customers” by just eliminating all items viewed as less than healthful.
“Instead, our approach has been to emphasize making healthful choices look more attractive as options and to present them in ways that make customers want to buy them.” The emphasis has been on increasing awareness of the fact that customers have a health-related choice every time they purchase a meal, and to make it easier for them to make better choices on a regular basis, he says.
To facilitate such efforts, the department created a Healthy Selections Coordinator position, providing a liaison between foodservice and Geisinger's employee wellness department.
Christine Rice, who fills that job, reports directly to Thomas and ensures that nutritional information for all menu offerings is widely available at point of sale and that those choices which meet nutritional and portion size guidelines are clearly identified. She has also been instrumental in developing the department's Healthy Selections campaign and such efforts as its “No Fry Fridays,” which encourage awareness of choice options rather than eliminating choices outright.
I ask if there are conflicts between putting system-wide programs like this one in place and the need to allow flexibility at the operating level for departments like foodservice.
“It is always a delicate balance,” he says. “There are some areas that are highly centralized — our employment policies and procurement contracts, for example. In others, we need flexibility and find it helps us identify best practices we can share with each other.”
Logistics have also become a big issue for foodservice, Thomas says. “Our production facilities are on the western edge of campus, but all of our expansion and new construction has occurred on the east.
“We've chased our customers over the years as we've grown,” he adds, “trying to extend the cafeteria and its offerings to other locations. That is no longer a good solution and we're now focused on developing concept brands for the different parts of the campus.”
When the Hospital for Advanced Medicine is completed, the additional retail space it provides will let the department undertake a major review of its approach to cook-chill and other production systems, he says.
In the meantime, the main job of coping with such constraints falls to Steve Cerullo, director of foodservice for the Danville campus. It's a role that includes responsibility for eight retail outlets, catering services and patient foodservices at the main hospital as well as at Health South, an off campus rehabilitation facility. He also oversees foodservice vending and procurement contracts system-wide.
Another graduate of Penn State's hospitality school, Cerullo grew up in the region and had also spent a number of years working for a major hotel chain in locations across the country. He joined Geisinger as the system's production manager soon after returning to the Danville area to settle down and was promoted to the foodservice director's role in 2006.
Geisinger's largest café is on the second floor of the Medical Center. Campus retail locations range from Bistro 100, a trattoria concept on the hospital's first floor, to the Miracle Square Café in the Janet Weis Children's hospital, to office building cafés and an outlet in the Woodbine surgery center (about three miles away).
Over the past five years, “we have almost doubled our retail sales” in Danville, Cerullo says, mostly through an increase in transactions. The retail outlets do about 3500 transactions a day, at a check average of about $3.40.
Over the years, the department has moved its retail production away from what was a rigid, six-week cycle menu to a three-week cycle with seasonal rotations. It has also reduced the reliance of retail operations on bulk production and grill station items, moving toward more small batch cooking and grab-and-go selections. It has also added staff with culinary degrees and recently an executive chef position with responsibility for menu development.
Cerullo has been instrumental in the effort to move away from having “standard” menus and specials across the system. “Instead, we've worked to make each location a destination in its own right, to better meet the tastes of its customers,” he says.
As an example, the main café now offers daily fresh-rolled sushi (production is managed by a local provider) and specials via an interactive grill station. The Bistro 100 concept is new, replacing what formerly was a coffee shop, and offers a rotating menu of paninis, pizzas and pasta specials.
Cerullo views station flexibility as a key to increasing sales and satisfying different customer demands over the course of a day. Thus, the main café, which offers a salad bar throughout most of the day as part of the department's Healthy Selections program, converts that station in the mornings to a self-service breakfast station which offers yogurt, fresh fruit and cereal sold on a per-ounce basis.
On the patient side, Danville is a cook-chill facility and employs a traditional non-select menu, although Cerullo run a pilot program in the fall to test a cook-to-serve approach to providing real-time meal choices to patients in the 98-bed Janet Weis Children's Hospital. The menu will include pierogies, chicken fingers, mac and cheese and other kids' favorites.
“We'll use our regular carts to deliver meal components, and think there will be greater satisfaction if we handle this more like a catered function with choices made at the point of delivery.”
How does the drive for more efficiency affect the way he manages?
“It's a hospital-wide initiative,” Cerullo says. “We benchmark our numbers every month and do a lot of reporting to our administration. More important from an operations point of view is that we also share numbers with staff and encourage friendly intra-departmental competition to improve them. We want everyone focused on the same goals.”
“Separating the businesses”
As the Geisinger system has expanded its reach, a main area of growth has been in the Scranton/Wilkes-Barre area, what it refers to as its Northeast region, where there are two additional campuses associated with Geisinger Wyoming Valley Medical Center. One is an acute care facility licensed for 237 beds that recently was certified as a Level 2 trauma center. The other is a former hospital in Wilkes Barre that was acquired in 2005 and converted to an ambulatory clinic/urgent care center and hospice with housed rehabilitation.
Lynne Brown, the region's foodservice director, administers programs at both facilities. After nearly two decades in healthcare foodservice, a good part of it with contract management companies, she is an old hand at dealing with change and facility constraints, and at upgrading retail offerings in a healthcare environment.
“The changes in our acquired facility are illustrate how our system has sought to separate businesses in our region,” she says. “Patient stays are growing shorter. Even as an acute trauma, tertiary care hospital, we are still trying to grow ambulatory care, short stay visits. We have a very large outpatient business here.”
We asked what the transition was like.
“There was a significant reduction in our workforce at the Wilkes-Barre operation,” she says. “But many of the downsized employees were able to transfer to the GWV hospital. Those who remained operate in an entirely different environment than before.
“As patient feeding was eliminated and the size of the location workforce reduced, we closed the cafeteria and moved strictly to grab-and-go as the most effective way to service what is now a mostly retail customer base.”
At GWV, food is produced on a cook-to-serve model and Brown recently implemented a hostess program. In retail, she has sought to offer more choice and to improve the presentation and production quality of offerings.
Typical has been a series of “gourmet sandwich” menus in which a basic grill or deli sandwich is offered in five variations each day of the week. The department also invested in a high-speed oven to support a made-to-order toasted sandwich program. That replaced a labor-intensive action station and improved both variety and customer throughput.
While facilities at GWV are also space constrained, Brown points to improvements on both employee satisfaction surveys and on Press Ganey satisfaction scores from patients as the fruits of her efforts to do more with the facilities she operates in.
Bringing strengths to the table
My last interview is with Tami Almquist, manager of environmental and food services at Geisinger Marworth, an alcohol and chemical dependency center about 90 miles northeast of Danville. The center gets referrals from four states and operates both an outpatient clinic and residential day program.
The foodservice program is a modest one, with a staff of only seven FTEs, Almquist says. “We are able to manage with a small staff because we do not do tray service to the rooms. We serve in traditional cafeteria line fashion and have short windows for community meal times.”
At Marworth, foodservice is a part of treatment in that menus are often based on comfort foods that facilitate group socialization in structured meal time environments.
“The culture is very distinct here,” Almquist says. “You will find people from all walks of life eating together. Mealtime is something they look forward to after a day of what are often difficult group sessions. We are all here for a common good and our goal is to greet patients with a smile and accept them for who they are. Foodservice is part of the therapy here.”
Almquist also reports directly to Thomas and has another role as well, traveling regularly to the other foodservice locations in the system as an internal department auditor to ensure that foodservice policies and procedures are being followed.
“It is not a matter of checking temperatures in coolers,” she says. “It is about inspecting HR and other records to make sure that policies are implemented consistently, that training is being delivered effectively and that where best practices have been adopted they are working as intended.”
As the system grows, does achieving consistency become more difficult, I ask?
“We are all different entities,” she says. “Even though we are separated by distance, the challenge is to not become isolated. We work hard to maintain good communications and that makes the difference. Over the years, that is one of things Geisinger has done very well, and it has allowed all of our people to bring their best strengths to the table.”
Using Technology to Drive Efficiency
In keeping with Geisinger's commitment to making full use of digital technology, foodservice invested several years ago in a system to automate temperature tracking and logging for all of its coolers and freezers. That effort proved so successful that the system was subsequently adopted by other departments in the hospital that had similar needs, such as tracking the temperatures of pharmacy refrigerators, stores of warming blankets and even operating rooms. Altogether, foodservice deploys about 90 remote sensors across the system, and other departments deploy about 120 for their applications.
In retail, FSD Steve Cerullo says use of the department's cashless payroll deduction system is heavily promoted, including its use in hospital gift shops and at the hospital pharmacy.
In managing production, his department has sought to fully deploy the integrated capabilities offered by its food, nutrition and production management software.
Record-keeping for food production, patient feeding and forecasting, diet office functions, tray tickets and all retail outlet deliveries are managed centrally. Integrating the department's recipe database with its production forecasting lets the system automatically generate biweekly purchase orders for its distributors. The same system generates batch production orders on a daily and weekly basis for kitchen staff.
When combined with the department's benchmarking efforts “our goal is to make decision making both data-driven and more collaborative so that in areas like healthy meal selections and cost management we can learn from each other and share our best practices and ideas,” Cerullo says.
Giving Benchmarking a Context
The Geisinger system's reputation for efficiency has been earned over many years, and has long been associated with tracking and using data to drive its processes and decision-making. Foodservice here has long been a participant in the national benchmarking program managed by HFM, the Society for Healthcare Foodservice Management (now part of the Association for Healthcare Foodservice) and uses those numbers alongside hospital-wide Press Ganey score reports.
“Benchmarking is core to our culture,” says Bruce Thomas, associate vice president of guest services, “but benchmarking alone is not enough.
“The important thing is working to interpret what the numbers mean for your facility, and knowing how to use them to improve your performance,” he says. It also means educating a hospital administration over time about the subtleties and variations among benchmark results at different kinds of operations, he adds.
For example, “while it is typical for an administrator to look at food cost per patient day or labor cost per patient day as key metrics, we prefer to focus on net cost per patient day after taking retail revenue into account,” Thomas says.
“On a campus like ours, patient costs are not the driver. Food costs per patient day are high because the number of retail meals we serve is high. In that context, net cost per patient day is the core metric to look at regardless of the size of your hospital.”
Geisinger foodservice director Steve Cerullo offers another example of how context needs to accompany operational comparisons.
“In our case, floor stock numbers are a bit high relative to averages, but one reason for that is that our floor inventories also include supplies at several off site buildings, like surgery and outpatient centers, which need them for patients who are there for full days or nights even though they may not be admitted to the hospital.
Thomas emphasizes that such information should be presented to administrators not as an excuse, but as a basis for strategy to improve results.
“We use benchmark numbers and explanations like this in budget submissions, in selling business plans or in making recommendations for equipment purchases. Sometimes you have to present them and say — this is an area where we are not doing as well as we should. Here is why and here is how we want to address it.”