By Mike Buzalka
Administrative Director Shawn Noseworthy of the Florida Hospital Medical Center with some of the team at Florida Hospital-Orlando: (l. to r.) Process Improvement Specialist Kiden Koegel, Retail Manager Chuck Farnholtz, Noseworthy and FSD Frank Sadowski.
Florida Hospital admits more patients annually than any other hospital in the U.S. It is also the largest provider of Medicare services in the country. But its Nutritional Services team is overhauling itself into one lean machine.
By that we do not mean the standard "lean and mean" business seminar euphemism for slashing costs to the bone. Rather, "Lean" in this case refers to a specific operating approach that has proved highly successful in manufacturing and other industrial environments, but is almost unknown in foodservice.
The Florida Hospital Nutritional Services team, led by Administrative Director Shawn Noseworthy, has adapted a Lean Process approach to food preparation and production, with highly impressive results in the early going.
So far, the initiative has allowed Noseworthy's department to avoid more than $9 million in capital costs that might otherwise have been spent to add new capacity, as well as saving nearly $350,000 in annual labor costs. In its most recent fiscal year, the department came in 4.2 percent under budget, all while increasing efficiency and customer satisfaction.
We found that in some of our processes as little as five percent of the activities added value. Everything else was essentially wasted effort."–Shawn Noseworthy
Certainly, if any hospital foodservice operation is suited to try something originally intended for industrial mass production environments, Florida Hospital is it. The facility, a member of Adventist Health System sponsored by the Seventh Day Adventist Church, serves as a community hospital for Greater Orlando and as a major tertiary referral hospital for Central Florida and much of the Southeast, the Caribbean, and Latin America. The Nutritional Services department has nearly 223 FTEs, cranks out nearly 975,000 patient meals a year and generates over $7.3 million in annual sales in its retail operations.
That's just the Orlando campus. The entire Florida Hospital Medical Center (FHMC) system, whose Nutritional Services Noseworthy also oversees, encompasses seven hospitals with 1,785 beds, almost 500 nutrition department FTEs, and annually produces over 1.8 million patient meals and nearly $12 million in retail sales. With more than 4,000 residents moving into Central Florida each month, FHMC projects it will have to add 630 beds to the system by 2011 just to maintain its current market share.
In other words, food production at FHMC is already the culinary equivalent of a major Toyota assembly plant. So why not use a process that has worked so well in actual Toyota assembly plants?
Noseworthy is making the Lean conversion at Florida Hospital in stages. The first three stages, involving the Food Processing Center (the central cook-chill production kitchen), the patient meal assembly area and the cafeteria and catering operations, were completed last year.
How did Florida Hospital happen to "Go Lean"? The major drivers were desperation and inspiration in fairly equal measure, as Noseworthy relates it. Here's the story of how it came about.
The Leaning of Life
Three years ago, Noseworthy was facing a major challenge. Three of the hospital system's campuses were looking at significant expansion projects that would also mean increasing the demands put on her department.
So Noseworthy did the conventional thing. With the help of foodservice consultant Paul Hysen of the Hysen Group, she and her team drew up an expansion strategy based on estimated future patient and retail meal demand. The plan called for a new 28,812-sq.ft. kitchen in Orlando and an expanded Food Production Center that could service the entire system.
Unfortunately, "when we actually got them designed, the costs came out higher than what was budgeted," Noseworthy recalls.
The main problem was the new kitchen. Because of space limitations in the existing building, the plan called for extending it into space occupied by an adjacent parking lot (the kitchen is on the basement floor). Ordinarily, this would have been a simple basement excavation and construction project.
However, because the hospital planned eventually to add additional stories to the extension, Nutritional Services was forced to incorporate more elements— a stronger foundation and load-bearing walls, expandable utility lines and so forth—that would ready the structure for this projected future expansion.
The result, once the design of the building was completed, was a cost overrun of around $3 million, or 25 percent over the building's $12 million budget. The project was not approved due to lack of capital.
Noseworthy couldn't get any additional funds, so she had to find an alternative that would stay within the dollars allocated. "I had to come within budget with a smaller, more efficient kitchen, even though we had already designed a reasonable kitchen in the first place," she recalls.
As she explored her options, it was suggested that she might want to speak with the outside consultants who were working with the medical center on various other projects, particularly Michael Hogan of Ortho-Clinical Diagnostics, Inc., ValuMetrix Services, a consulting organization specializing in the Lean approach.
"My back was against the wall, so we agreed to conduct a two-week value stream map (VSM—more on this later) of our main service line processes in the Food Production Center, patient service area and retail kitchen," Noseworthy recalls.
Tale of the Tape
It was not an easy commitment. The Lean Process is basically a combination of techniques like motion analysis developed decades ago by industrial engineers to streamline factory production with more modern and highly sophisticated process flow analysis. As a consequence, the VSM required the Nutritional Services management team to get down to the production floor with stopwatches and video cameras to record each step in the production process ("If you are not using a stopwatch and video, you're not doing Lean," Noseworthy notes).
The effort charted the Product Process Flow by videotaping workers as they performed their tasks, isolating each step in the production process so it could be analyzed in terms of how much value (or lack thereof) it contributed to the final product.
To ensure that nothing was missed (and to help promote employee buy-in), the line workers were brought in to watch the video-tape and explain exactly what they were doing at each step of the production process, and why.
The analysis was sobering.
"We found that in some of our processes as little as five percent of the activities added value," Noseworthy says. "Everything else was essentially wasted effort—searching for tools, collecting ingredients, retrieving needed items and storing excess finished product."
It was at this point that Noseworthy made the strategic decision to commit to adopting a Lean approach to Florida Hospital's meal production processes. The decision was a daring one even if there was little other choice, given the situation. While Lean Processes have been tested extensively in industrial environments, the Florida Hospital NS Lean Team would basically have to invent a version for healthcare foodservice from the ground up.
"You bet," Noseworthy admits. "I was— and am—very conscious of the fact that if this fails, the repercussions will remain with this department for decades—and I'm young enough to have to live with it!"
Turning Theory Into Practice
The protocol for adopting, implementing and maintaining a Lean Process approach is well established. It involves a rigid series of steps that begin with developing a Value Stream Map (i.e., how raw materials flow through a process to become value-bearing products for customers at the end), charting the Product Process Flow and Full Work Analysis and then analyzing this to isolate all the value-and nonvalueadded steps.
The same steps were repeated for the Food Production Center, which is where the Lean Team decided to concentrate its initial efforts. It was the logical place to begin since it would require the most additional space according to the original projections. Also, it most resembled the sorts of manufacturing processes to which Lean Process principles had already been successfully applied in other industries.
The process was "unrelenting, eyeopening and ego-busting," and Noseworthy shudders when she recalls those days.
"Keep in mind that the NS Lean Team has people on it who are not from your department—people from finance, from process improvement, outside consultants," she says. "They are looking for ROI, and you have to be careful to keep the expectations and enthusiasm in check, because it can easily degenerate into an FTE witchhunt. The consultants want to look good, the finance people want to see dollars saved. Meanwhile, you want to see that things can be done better so that you will know what you are going through is worth it. I had to constantly remind them that foodservice is a personal service industry, not an auto plant."
The project involved not just the NS and the Lean Team but vendors (who had to commit to making changes in the supply chain) and Hysen, who had to adapt Lean approaches to the new kitchens and processing facilities he was designing for Florida-Hospital. Everyone worked long hours, flopping between enthusiasm and frustration in seemingly equal measure.
"It's like the Incredible Hulk ride at Universal Studios," Noseworthy says. "You start out slowly and methodically, but then you hit a certain spot where suddenly you are propelled forward uncontrollably at such a speed that you're literally hanging on by the skin of your teeth!"
Overhauling the FPC
One of the results of a Product Process Flow study is the development of "spaghetti diagrams" that map the movements employees must make in order to complete their assigned tasks in a particular process. The spaghetti diagram for Florida Hospital's Food Production Center dramatized the excessive walking and searching that was taking place and provided guidance on how to redesign the layout so that a constant flow of raw to finished product could be achieved with minimal extra motion.
Among the solutions the Lean team implemented after analyzing this study was reallocating existing labor to a so-called " water spider" position. A "water spider" is a worker who is responsible for supplying and replenishing production personnel with ingredients and tools as needed, leaving them free to produce. It also frees up space since the constant replenishments reduce the need to have excess amounts of ingredients staged at the assembly area.
Another solution: producing smaller batches, which lends itself to Lean's maketo-order philosophy. The approach eliminates some storage requirements and efforts wasted on making excess portions. Florida Hospital's cook-chill operation produces 810 bags of food a day, much of it stored for future use. After a proposed Lean renovation is effected, it would produce only 350, meeting daily demand but eliminating extended storage requirements.
In the vegetable prep area, a Full Work Analysis showed that the time and labor required to prep vegetables exceeded the cost of simply outsourcing the process—that is, purchasing value-added, fresh-cut product. Moving to fresh not only improved sanitation and freed up 351 sq.ft. in the production area (as well as space in the dry and cooler storage areas), but reduced labor from five FTEs to one. The net savings—$87,241 a year, even after accounting for the increased cost of the pre-cut product.
"You have to be careful to keep the expectations and enthusiasm in check, because it can easily degenerate into an FTE witch-hunt."
In the sandwich and salad lines, the major innovation that resulted from implementing Lean Processes was the conversion to a one-piece flow model, a counterintuitive approach that is the antithesis of the batch production mindset at the heart of many central production kitchen operations.
Yet, after seeing the evidence, Noseworthy is convinced that one-piece production is significantly more efficient and effective than batch production, and she has the data prove it. Time studies showed that a worker can prepare sandwiches faster by making each one individually (one-piece production) than via a batch approach in which many pieces of bread are laid out and batchassembled one ingredient at a time.
In addition to realizing the efficiencies of one-piece flow, the sandwich and salad production operations also benefited from the fact that they use a number of common ingredients. By consolidating the two into a single production area, the kitchen was able to leverage those synergies more effectively.
The result: from a situation with two production areas requiring eight total employees and 748 sq.ft., the Lean Team designed a single production area of 375 sq.ft. staffed by three employees producing 220 more sandwiches per employee in the same amount of time as before.
From Trayline to "Traycells"
Before Lean, Florida Hospital had a very impressive-looking 34-ft. trayline.
"Looking at the photos we took during our initial Product Process Flow analysis, it seemed nice and orderly, given typical healthcare segment standards," Noseworthy says.
"However, in retrospect, it was very inefficient and ineffective. In fact, once you know Lean, you can't stand to even look at the old video anymore because the inefficiencies just pop out at you."
The major problem on the "nice and orderly" trayline was that different tasks along the line required differing amounts of time to complete, so that some workers struggled to keep up while those in other positions often stood about with extra time, waiting for trays to come down the conveyor.
There turned out to be no way to iron this out while retaining the conveyor model, so the Lean Team took a whole different approach utilizing "tray cells." These are two three-person workstations in which each worker is assigned tasks that take an equal amount of time to complete. Again using the one-piece flow model, trays are assembled one at a time, moving from one worker to the next, each adding specific elements. A water spider keeps the stations replenished, so the tray assemblers can produce continually with minimal interruption.
The result: tray assembly run time per meal period was reduced from 3.5 hours to 2.75 hours and space requirements from 552 sq.ft. to 340 sq.ft.
Meanwhile, the Lean Team also found that the retail cafeteria and Special Functions ( catering) operations were doing similar or identical tasks and using like ingredients in their daily routines. Hence, it made sense to consolidate them into a single work area.
"Previously, there were 'invisible lines' separating areas that were dedicated to cafeteria and catering," Noseworthy explains. "We combined all the like functions so that there is one high-volume hot cell area and one high-volume cold prep cell. These two areas produce all the food for almost $10 million in cafeteria and catering operations. Also, the labor is shared. The dry storage has been consolidated to a central area where it can more efficiently support cafeteria and catering. With the closing of a separate pot room, even warewashing has been consolidated to one location."
Some more results: space requirements for the two operations have been cut from 1,770 sq.ft. to 1,000, prep time per item from 289 seconds to 161 and—most astonishingly—the average distance traveled by workers (to retrieve ingredients, supplies, etc.) was slashed from 413 feet to 18 feet by utilizing a water spider.
"Cooks should cook and the water spider should do the walking," says Noseworthy.
The changes allowed so much space to be saved that Nutritional Services was able to abandon the over-budget production kitchen extension project and have confidence that a redesign will stay within budget. Though it will still require additional square feet to meet anticipated future demand, this is almost 6,500 sq.ft. less than the original 28,812-sq.ft. expansion plan. The difference is enough that the current facility is able to accommodate it without embarking on new excavation and construction.
Meanwhile, the Food Production Center—originally proposed to almost double in size (because it supports all seven system campuses)—will now actually be able to handle future capacity increases in its present space, at a renovation cost that is a third of the original expansion budget.
"Administration and the finance people were very happy when they heard that," Noseworthy deadpans.
Florida Hospital Nutritional Services is hardly finished with its use of Lean analysis. Noseworthy points to a slew of projects that still have to be realized, from the full renovation of the FPC, patient meal assembly and retail production areas to the bringing of Lean principles to inventory control, retail front-of-the-house and the other campuses.
For example, the FPC's cook-chill area's current layout means production equipment must be fed from the outside, resulting in clogged aisles and cart pathways. Also, food is constantly backtracked through the production area and processing is inhibited by the layout of the equipment.
In Noseworthy's proposed renovation, ingredients would be brought in from one location and cellular production stations would allow work sharing. Product would move smoothly from one end of the production space as raw ingredients, to the other end, where the blast chillers, refrigerated storage and loading docks await at the other.
Hence, no aisle blockage and no backtracking product. In addition, the new design would allow more efficient make-toorder production, ending the mass-production paradigm that is the basis for the cook-chill approach. That in turn would allow greater flexibility in terms of menu variety as well as space savings because of reduced product inventory of up to 50 percent.
She also wants to improve the delivery service system for late trays and special orders to patients. A pilot project using Lean design and principles has already shown what might be possible: hot meals delivered without the need for microwaving in most cases, late trays/special orders delivered in 30 minutes or less (versus up to an hour currently) and late tray and cart assembly up to 79 percent faster than before.
Ultimately, Noseworthy emphasizes, the Lean approach is two things. One is simple process improvement ("Lean is process improvement on steroids," she quips), but the other is a permanent culture change that employees have to buy into. "In fact, experts estimate that about 80 percent of becoming a Lean enterprise is culture-related," she notes. To that end, the Lean project dovetailed with another Nutritional Services initiative based on the well-known "Who Moved My Cheese" program of employee change management and empowerment.
Lean operations encourage employee initiative, but within the context of the established process routine referred to in Lean terms as "Standard Work." An employee cannot simply stop doing something the way it was designed to be done and do it another way, even if she thinks her way is more efficient, says Noseworthy. That's because even though it may be more efficient for the particular individual, a change may cause inefficiencies or disruptions elsewhere.
Instead, employees in Lean environments are encouraged to bring their ideas for process improvement to management, which is obligated to analyze them. If they represent an improvement over established procedures, the change will be implemented . In this way, a Lean environment is dynamic, always ready to adapt better ideas suggested by workers if they are found to add to the value stream, but also disciplined in its systems.
Without this crucial culture change component, Noseworthy stresses, the Lean project becomes just another process improvement spasm.
"We've always done process improvement, looking for the maximum bang for the buck, but nothing this radical," she says. "My privilege is to be the leader of a fantastic, engaged and willing group of NS employees. Their extraordinary Lean PI efforts are positioning NS to move confidently into the future. The Lean approach puts everything to the test. Either it adds value or it doesn't. Nothing is sacred."
Annual Patient Meals
Retail FS Sales
The Lean Life
"Lean Production" was a term that came out of a five-year, $5 million study of the future of the automobile by the Massachusetts Institute of Technology in the late 1980s. It described a highly successful manufacturing methodology pioneered by Toyota after World War II that centers on understanding value from the customer's perspective and then focusing the production process on providing it. It does this by systematically identifying processes that do not add customer value (that is, do not increase the worth of the end product in the customer's eyes) and then eliminating, simplifying or combining them.
Lean Production has been highly successful in the auto manufacturing industry and has been adapted to various other production industries and more recently to service industries like banking and healthcare.
What Can Lean Deliver? In the manufacturing industries where it had its genesis, Lean has delivered...
30-80% increases in productivity
(Source: 1997-2005 Progressive Business Solutions & Business Improvement Group, LLC)
What Is the Lean Healthcare System?
Phase One: The Food Production Center (FPC)
ACTIONS TO DATE
Cold Prep (Sandwich and Salad Production)
RESULTS TO DATE
VIEW FLORIDA HOSPITAL'S PRODUCTION VIDEOS:
You can view sample before and after videos of the changes made to Florida Hospital's production lines at: www.food-management.com/FloridaHospital
Phase Two: Patient Meal Assembly Area
Previous System: 34-ft. conveyor trayline
ACTIONS TO DATE
RESULTS TO DATE
THE "LEAN TEAM"