THE OHIO STATE UNIVERSITY MEDICAL CENTER (FY 2004)
No. of Beds: Licensed: 1583 Staffed: 1066 (includes one satellite, 5 on-campus facilities)
THE OHIO STATE UNIVERSITY MEDICAL CENTER (FY 2004)
No. of Beds:
Avg. Daily Census: 867
Foodservice Staffing: 146 FTEs at main facility; 32 at satellite campus
No. of Meals Served Annually: 1.7 million
It's a little bit eerie here in the dimlylit ATS room on the ground floor of The Ohio State University Medical Center (OSUMC) building. Cavernous and mostly empty, but alive at the same time; populated by a silent fleet of robotic transport carts that travel back and forth, each with what appears to be a mind and mission of its own.
At the far wall, an elevator door opens and another cart wheels out, carrying containers of trash from another floor in the complex. As it moves into the ATS room, it slows to a stop at a crossing point, politely waits for another cart with patient trays (and apparently, the right of way) to drive by; then resumes its travel to a different elevator bank. It waits patiently until the doors open, enters, and a moment later, carries the trash to the disposal center by the loading dock.
I am at somewhat of a loss. How does one take still pictures that will adequately portray what I see before me in the pages of the magazine? You can view a video clip of the OSUMC robots here.
"Pretty impressive, isn't it?" The voice behind me is that of Mary Angela Miller, administrative director of the Nutrition and Dietetics department, who has returned after answering a page. We continue on a walking tour of the medical center's foodservice facilities and I make a mental note to return to capture a video clip of the robots later....
The new automated transport delivery system at OSUMC is only one of a series of technology applications and productivity enhancements that have helped the foodservice department there dramatically improve its operational performance over the past decade. In fact, technology investment has long been a tradition here. (Last year the Center was listed among the "100 Most Wired" facilities by Hospitals & Health Networks magazine in its annual IT benchmarking survey.)
"We have always sought to employ technology as an operating strategy," says Miller. "Our goal has not only been to leverage technology and become more efficient, but also to use it to enhance service to our customers."
Mary Angela Miller, Administrative Director, Nutrition and Dietetics, of The Ohio State University Medical Center, with team members from the department staff.
Above: the rotating carousel serving station in the main Seasons Cafè, as viewed from inside the main production kitchen. The unit was considered a state-of-the-art investment when the OSU Medical Center facility was built back in 1976.
An Atlanta Bread Co. kiosk serviced by Cuyahoga Vending Services is one of several programs OSUMC uses to enhance its retail foodservices. The vendor also provides boxed meals in the evening as a service to call residents. Above: tray line meal assembly for lunch.
Nathen Miller, Nutrition Services' business services officer, demonstrates the online system that OSU Medical Center floor units use to order bulk nourishment supplies.
Left: Julie Jones, Jim Warner and Mary Angela Miller near the entrance to OSUMC's Seasons Cafè.
In the hospital's main Seasons Cafè, you can see one early technology investment still at work—a 'Circle-Serve' carousel system that was installed when the medical center was first constructed in 1976.
While impressive to watch, offering retail customers an array of heated and cooled menu items on a slowly revolving display that is continuously replenished as the carousel passes through the kitchen, it is a dinosaur by today's standards.
And while Miller does not say so, the carousel illustrates the fact that technology investment alone does not automatically result in the most cost effective foodservice operations for the long term. Efficiency is as much a result of planning and programs as it is of capital investment.
Like many large university hospitals, OSUMC has grown dramatically in the past 20 years. Today it is comprised of University Hospitals, the James Cancer Center Hospital, OSU Harding Hospital, Dodd Rehabilitation, Ross Heart Hospital and OSU East, a satellite hospital on the east side of Columbus.
When Miller joined the medicalcenter as director of nutrition and dietetics in 1990, the department only scored in the bottom 75th percentile nationally in terms of its foodservice cost per patient day when compared to similar facilities.
These days it regularly scores in the 25th percentile and also boasts marked improvements in patient and customer satisfaction with its services. It achieved that improvement even as it serves significantly more meals and operates with about 40 percent fewer FTEs than in 1993.
A chronological look at the changes Miller has implemented over the last decade illustrates both the challenges and the sometimes difficult-to-attain solutions that have faced many large medical centers in a period characterized by rapid change, facility consolidations and intense cost-containment pressures.
Some of those changes were typical. For example, one of Miller's first moves was to adopt a prime vendor for food purchases, using a contract with the University Health Care Consortium (now Novation). Because foodservice costs are evaluated and benchmarked net of contributions from any cash operations, the department also looked for ways to increase cash sales. Still, "we had very little capital to work with, and major retail renovations just weren't possible," says Miller, so major renovation of the retail facilities to grow those revenues wasn't a real option.
"As an alternative way of expanding our retail income, we bid a quickservice restaurant contract that was won by a local Wendy's corporate store. Once the basic space finishing and utilities were brought to the site, Wendy's footed the cost for restaurant seating construction," she says. "Wendy's pays our cost center a lease fee for the space and a commission based on sales, presently in excess of $1.5 million annually. And while that revenue is not ours to spend, it does count in our budget as an offset to our costs in other ways. The contract also requires the operation to stay open until 1 AM, allowing us to to serve the needs of third shift employees."
Soon after, a similar arrangement was made for a local franchisee to install a gourmet coffee cart operation that now rings up over $400,000 a year in sales. While the department-operated Seasons Cafè continues to be the primary retail option for most employees, the Wendy's, a Cappucino Espress Oasis , three outdoor Skyward Concessions carts and a full range of vending services allow it to extend foodservice to other locations on the campus and to offer service during extended hours when the cafè is closed.
"Some people would argue that we just gave up that business," says Miller. "On the other hand, we have facility constraints that limited how much service we could effectively provide. Instead, we decided to focus our efforts on making improvements on the production side. That showed the most promise in terms of helping to cut our costs."
The end of the microwave
Miller also looked at what was then a decentralized production operation and made plans to centralize it. She closed two satellite kitchens that were operating in the center's adjoining Psychiatric and Rehabilitation hospitals, consolidating all tray production in the main facility. The hospital's system re-therming patient meals also was costly and problematic, and she initiated plans to change that.
"Meals were heated in small microwave units on the floor, one plate at a time," she recalls. "You started with the soup, moved to the entree, then the sides. When you had three trays ready, you delivered them, then started over. We had a patient foodservice staff of over 50 people who were mainly involved just in providing this floor meal service three times a day."
Over a two-year period, arrangements were made to install a new re-therm system so that full trays could be moved via refrigerated carts to individual floor stations for bulk re-therm on demand.
After the system was introduced in 1996, "we had promised a 25 percent reduction in staff devoted to tray delivery and we achieved a 30 percent reduction," says Miller. "The project represented a three-to-five year payback, but we had an immediate improvement in patient satisfaction relative to the temperature of served meals."
In November, 2001, the old double-sided tray line was completely replaced by a more compact and efficient (and mobile) circular tray line. That mobility has already paid dividends: the tray line has been relocated twice since its installation.
Automating floor stock orders
Better management of floor stock—both bulk nourishment products and the variety of portion-controlled beverages and other food items supplied to patients between meals—was another issue OSU tackled with a technology solution.
"Almost $25,000 in floor stock is charged off here every month, and we needed a much better way to manage and account for those orders," Miller says. The old system was paper-driven, inefficient, and did not provide managers with enough control over ordering practices. It was also highly fragmented: floor stock is maintained in 13 galleys and provided to 37 patient areas in six buildings.
"It also made pricing updates a nightmare," says Julie Jones, director of nutrition services. "There was a real opportunity for improvement and we believed that online ordering would help us address all of these problems."
The project was initiated in mid 2001 and fully implemented in 2002. Today, authorized floor personnel place all orders via an intranet-based interface that has constantly updated inventory and pricing. A nurse manage at each unit can customize the order guide used by nurses on that floor so that only items he or she wants to have available appear.
When orders are placed, the product is automatically charged to the floor account, a picking order printed, and a delivery initiated (beginning next year, these will be delivered via the new ATS system). Among other benefits, it has saved the department about 28 hours a month in related chargecapturing labor, dramatically increased the accuracy of floor stock accounting and reduced floor stock complaints by 75 percent.
More recently, nutrition services moved to eliminate another paper-based procedure at the floor level—the old pre-select menu system. In 2002, the hospital moved to a spoken menu approach, with floor personnel taking orders using personal digital assistants (PDAs) that tie directly into the department's CBORD management software. They not only offer staff the ability to provide more personalized menu choices, but also automate dietary information so that choices can be automatically limited for specific patients as required.
On the retail side, the hospital intranet posts the daily cafè menu, with a link from the first level of the hospital's home page. While monthly paper flyers remain popular with employees, and are still produced, "our online menu is one of the most popular sites for employees," says Jones. "We consolidated our system so that menu data input into one place is used both for the daily posting and for the monthly paper version."
The robots are coming
The hospital first began to consider investing in the new robotic delivery system six years ago, although that was not its first venture into automated transport. When the Columbus facility was first built back in 1976, its original design included a ceiling-mounted, chain driven transport system. While it had never been practical for moving food, it had moved loads of linen and trash for many years until increasingly high maintenance costs began to outweigh its benefits in the mid 90s.
"When the Medical Center investigated the cost of replacing it, they looked to expand its applications to help justify the investment," adds Jim Warner, the department's associate director. "
Analysis showed that the large number of drops and pickups associated with patient foodservice would be an important contributor to the savings needed to put the project over its ROI hurdle."
Miller notes that another analysis showed that over a quarter of the work time of the department's nutrition aides was spent pushing meal carts to or from the hospital's various units. "This is not rewarding work and it does not add to the patient experience or the worker experience. It also tends to have a high rate of injuries occupationally."
Instead, "the new ATS system allows our nutrition aides to spend more time at bedside with the patients, rather than pushing carts around." In fact, even when the system had only been partially implemented, the labor it freed up allowed the department to institute a new beverage service program for patients.
The first robotic transportation began with trash hauling this past February; foodservice use followed quickly, for the movement of soiled tray carts back from the units to the dish room. Pilot deliveries of hot trays began in late November, with the goal of reaching 100 percent ATS delivery in the main complex over the next several months.
Although implementation of the ATS system and the associated central re-therm facilities has consumed much of the department's time over the last two years, it embarked on another major technology implementation as well: a new POS system that will make possible cashless retail transactions, faster credit card processing and a payroll deduction option for employees. Miller says the department is looking ahead to improved cash management as well as increased check averages as a result of these changes.
"The last major capital investment envisioned for the near term will fund a total redo of the Seasons Cafè prep and service area," says Miller. "When the old carousel goes, I'll know we've finally gone full circule in our initial master plan.
"It does seem that the pace of change has increased considerably," she admits. "But we have also earned more credibility with our administration over time. When we obtained capital dollars in the past, we ensured that we returned what we said we would as a result of those investments. That track record helped us when it came time to petition for new projects.
"We've also demonstrated our ability to use technology to address customer satisfaction, food safety and operational issues that go beyond issues of efficiency. In the end, the stability and quality of our own management team over the past 14 years has made as much of this possible as the technology has."
Successfully leveraging technology to lower operating costs takes planning, commitment, investments and time. Here's a timeline showing the major foodservice technology-related implementations The OSU Medical Center has made over the last 12 years:
1992 Foodservice production centralized
1996 Move to cook-chill re-therm cart system
1997 Move to electronic invoicing with prime vendor contract
1998 Computerized physician orderentry (including diet areas)
2001 Online ordering system implemented for bulk nourishment/ floor stock
2001 Intranet-based cafè menu system implemented
2003 "e-choice," PDA-based patient meal selection system implemented
2004 ATS robotic transport system for soiled tray return
2004 New POS system; UHEmeals (e-mail ordering of late and courtesy trays.)
Early 2005 Retail credit card processing system enabled
Mid 2005 Payroll deductions enabled; re-therm completely centralized
Robots Rule at OSU
The job of implementing foodservice applications for theMedical Center's Automatic Transport Service (ATS) has largely fallen to Jim Warner, the Nutrition and Dietetics department's associate director. But in fact, the ATS system as a whole serves several departments and was purchased after a facility-wide evaluation justified its investment costs, Warner says.
The system routes from the main building's first floor through the Rhodes facility next door and to the adjoining Doan facility. Dedicated materials transport lifts exist in all three buildings, integrated into the back side of the main public elevator shafts as part of the original building design. (The elevator banks and required building cross-over space were already in place because they had been required by the earlier chain-driven system.)
Key components include 46 self-guided vehicles that will travel to 264 locations throughout the medical center complex. Each laser-guided unit has a lift capacity of 1000 pounds and is powered by a bank of rechargeable Ni-cad batteries. The system also includes an automated cart washer that sterilizes carts and waste receptacles.
"One of the larger issues associated with our use of the system was the need to retrofit our fleet of 80 re-therm carts so they have enough floor clearance for the ATS transporters to slide under and lift them," says Warner.
Nutrition Services worked with both the cart manufacturer (Aladdin Systems) and the transporter manufacturer (FMC Corp.) to specify the necessary changes, then arranged for a third party fabrication shop to make the needed modifications, which increased their floor height by 13 inches. Before final approval, the modified prototype cart had to undergo a variety of tests, including a UL-type "tip test" to make sure it would meet safety standards.
The first group of modified carts was delivered at the end of the summer, with the remainder following last month. In a final step, each will be permanently attached to a loading "carriage" at the OSU facility, again undergoing inspections by Aladdin and FMC, before being placed into service.
Because the carts no longer fit the 10 unit galley stations where they had been re-thermed previously, the department has installed a new central cooler in the main kitchen where they will be stored and re-thermed, then transported to each unit on a just-in-time basis for meal periods.
Each automated cart has a unique bar code that identifies it and its specified use. Before a transporter picks a cart up, it reads the bar code to determine the appropriate delivery areas into which it can go. Thus, hazardous waste can not be transported to a kitchen area; soiled tray carts will never inadvertently go to the trash room, etc.
Cart pickups and deliveries are programmed through a drop-down menu interface on touch-screen workstations located at key points throughout the facility. Employee badge swipes are required for access to them, allowing a further level of security in terms of which carts can be sent to which areas. Environmental services workers, for example, have no control over foodservice carts.
What is now the large ATS staging room formerly housed both the foodservice department's old dishroom and the more limited older automated cart center. Because of the wear-and-tear factor, the ATS room and cart delivery area floors have all been treated with Altro flooring, a high-wearing coating designed for durability. Presently, the system handles about 1700 picks and drops a day; when fully implemented early next year, it will handle about 2400.
According to Warner, the ROI for the system was calculated by the Medical Center's materials management department. The total project cost was $18 million to service three hospitals; ROI, including equipment and renovation, is seven years.
"There have been both hard costs and soft costs associated with the overall installation," he adds. Centralizing re-therm necessitated the construction of a larger walk-in cooler, and the larger ATS staging room meant some renovation of the kitchen to make room for warewashing .
"In a lot of ways, the biggest things to consider had to do with cultural change. Today, instead of pushing a cart to another floor, a worker has to access a computer and initiate a pickup or drop of one of the carts. In that
Managing the Retail Mix
Even as the ATS implementation nears completion, foodservice is already embarked on another major technology advance with a new Point-of-Sale register and accounting system that will give it greatly enhanced abilities to manage its retail sales and service. "Even though our present system links the registers in our Seasons Cafè, those in our other operations are not connected," says Jones."That has really challenged us in terms of managing our overall cash flows, menu mix and pricing. With the new system, we will do all of our evaluation centrally."
Based on Micros registers and CBORD's Odyssey package, the new system will give the department improved cash control and allow it to integrate all of its cash reporting from seven locations on a real time basis. Other features include camera feeds on each register that record what cashiers are entering, so the process can be monitored for training and security purposes.
The cafè has accepted credit card payment for some time, but such transactions were slow because of the dial-up card approval process.The new system uses internet connections so that the initial swipe of a credit card initiates a one-step check that will cut processing time in half.
"Credit card usage has gone up each year and now represents about 12 percent of our retails sales," says Jones. She also notes that where the average transaction check is for $3.10, the average credit card check is for about $4.25.
The same software will also help manage the declining balance meal "credit" provided to medical residents for certain shifts, which is billed back to their departments under IRS rules.
"Our retail operations are not subsidized, and we cover all of our costs with incoming revenue," Jones adds."The revenue from the Wendy's and other contracted operations help offset the costs of department operations, but not the employee cafè."
Another long-sought retail meal payment feature, automatic payroll deduction, will also become available to medical center employees in the next few months. Jones admits it was a difficult idea to sell to the campus-wide accounting department, which has strict rules for such arrangements, but says her department found helpful allies in the Human Resources payroll department and the facility's gift shop manager, who wanted a similar arrangement for charges there.
"We set it up with several checks and balances," Jones notes. "The service remains completely voluntary, and we have policy standards that establish bi-weekly caps on how much can be charged. Also, employees can establish lower limits if they wish to when they sign up for the service—it is completely an opt-in program."