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Tear Down the Walls

Tear Down the Walls

FROM COURTYARD TO CAFE. DCH Regional Medical Center FSD Dexter Hancock shows off a fresh-baked pizza created in the facility's newly renovated Patio Grille and cafe.

ANTICIPATION. Vertical displays of food help merchandise offerings as DCH employees wait their turn at various cafe stations.

RETAIL CONVENIENCE. Snacks and convenience foods, including healthful items like fresh fruit, are well merchandised throughout the Patio Grille servery.

FRESH FOOD, FRESH-PREPARED. Above, Executive Chef Gary Lane chats with staff by the carvery station and assistant director Annie Flanagan shows off the contents of the bakery case.

OVER THE TOP. A popular frozen yogurt station features a do-it-yourself topping selection that lets DCH employees customize their desserts.

At Top: FSD Dexter Hancock at the entrance to the Patio Grille's new eating area soon after the cafe opened for business last November. Next, the DCH foodservice management team.

Every once in a while, there occurs a "perfect storm" convergence of unpredictable, divergent forces that moves a healthcare foodservice renovation project front and center and even over the top. That's what happened at DCH Regional Medical Center in Tuscaloosa, Alabama. Last November, the 583-bed facility opened a new retail operation called Patio Grille and cafe that reflects a facility commitment to top-of-the-line quality and a dollar investment in foodservice operations that are rare in healthcare.

The fact is that administrators in healthcare, where industry performance standards are almost totally focused on costs, are a very tough sell when it comes to proposals that require a capital commitment. That's why healthcare foodservice directors have so much trouble expanding or renovating their operations. Return-on-investment arguments don't carry much weight with their bosses and projections of increased revenues don't get much attention, either. It's the competition with medical departments for scarce capital that stops projects cold.

The convergence of the "perfect storm" factors at DCH began in 1997, according to Dexter Hancock, R.D., DCH Health System's director of nutritional services. That was when a change in hospital administration resulted in the arrival of John Winfrey, the system's new chief financial officer (CFO), "who told me the first thing he noticed was that the cafeteria had to be redone."

Severely undersized retail seating capacity had been a problem for years, and Hancock had hired a foodservice consultant the year before to design a modest cafeteria expansion to increase it.

The project underwent several incarnations as options were considered and reconsidered, until a final presentation was made to the DCH capital planning committee in 2003 (see sidebar, below). It was at that meeting that Bryan Kindred, the president of the four-hospital DCH Health System, said, "I don't know what we are waiting for."

Setting the Stage
The stage had been set for a $4.2-million project that would create a dazzling environment to almost triple the employee/visitor cafeteria space and take the menu to new levels.

Meanwhile, there were other forces at work in moving the project forward. Under new leadership, the DCH System had recently rewritten its own mission statement. DCH is nearly 100 years old, with historic roots in the community.

Although it retains much of its country charm, Tuscaloosa is a booming Sunbelt City today and DCH has grown into one of the largest medical centers in the state. It now operates four facilities and is recognized as a cutting-edge regional institution. The University of Alabama, only a stone's throw from the DCH front door, is also booming and has helped the local community attract a continuing inflow of high-tech business and industry, along with a more diverse and more sophisticated residential base.

The DCH system is investing in other ways as well: a $23-million cancer center is under construction and a new medical office tower is on the drawing board. Patient foodservices are also scheduled for an upgrade when the department introduces a room service program next year.

People Factors
There were also several "people" factors that were instrumental in the cafe project's progress. There was Bill Cassells, DCH administrator, who is an amateur chef with a real interest in quality food and who lent his personal enthusiasm to the project. There was Gary Lane, a new executive chef , who has a well-tuned retail mindset and proven culinary skills. Lane was hired in 2001 to replace a retiring cook supervisor and has played a major role in the menu development that accompanied the cafe upgrade. And there was Hancock himself, who had the patience and tenacity to keep the project top of mind for everyone from hospital planners to financial administrators.

From the first preliminary—and tentative —plans drawn up for the cafeteria in 1996, DCH's planning committee got serious about the project in 2003. The final design was completed in 2004, construction began in 2005 and the renovated Patio Grille & cafe opened in November 2006.

From Cook-Freeze to Fresh-Baked
Despite the bandwagon of support that kept the project moving, the basic ingredients for its success were in place from the beginning.

"They had the customer base," says Paul Hysen, the consultant on the project. "There was a tremendous, underserved population in place. They also had available capital and were looking for projects that would have long-term impact. And Tuscaloosa itself was changing. DCH wanted to reflect that."

The one thing no one had ever questioned was the need for massive renovation. When Hancock first arrived at DCH Regional Medical Center in 1994 as director of nutritional services, he already had a 28-year career in army foodservice that spanned the globe. What he found was a foodservice operation that was little changed from its original construction in 1976.

Cook-freeze production systems served both cafeteria and patient foodservice, with the food production kitchen on the ground floor and the cafeteria on the level above. The original cafeteria boasted a circle-serve rotating counter, a piece of technology that was a widely heralded "advance" when it was first introduced back in the 1960s (see sidebar on page 40). Operationally troublesome since their introduction, few remain in operation today; those who still operate them cannot purchase spare parts and typically face constant maintenance challenges.

Hancock's first innovation was to install a traditional cafeteria line and add a pizza station to the 18-hour-a-day operation. "It was the same menu at lunch, dinner and night and there were no grills," Hancock says. "Everything was prepared, thawed, warmed and served."

Even those modest changes were so wellreceived by customers that the cafeteria ran out of space for them to sit down. That's when the department began to eye an outdoor patio between buildings that was adjacent to the cafeteria.

In successive design conversations, the discussion centered on taking over part of the patio, then moving farther out and, finally, to enclosing the entire area. There was still no food production on the cafeteria level —no grills because there was no ventilation —so the potential for menu changes was limited. Adding production capability on the cafeteria level was a pretty large investment on its own.

The time for small, incremental changes in the cafeteria area was running out. The next step would have to be a giant leap forward but there were competing projects at DCH. "There had not been many capital upgrades in the hospital since the late 1970s and early 1980s so the emergency room, operating rooms and intensive care were first in line," recalls Hancock. "There was a great deal of catch-up work to be done."

While waiting their turn for funding, Lane worked on the menu for a self-service bar he installed in the middle of the old cafeteria and he expanded catering. Hancock finished up two other projects. First, he tackled a run-down vending area near the medical center's entrance that tended to encourage loitering by hospital employees. It was replaced by an upscale Seattle's Best coffee bar that is immediately visible to incoming visitors. The popularity of the facility—and the fact that it recouped its $125,000 capital investment in 2.2 years—was also a selling point in rallying support for the project.

Second, he readied plans for an in-house bakery operation that would start production six months before the completion of the cafe. Usually, on-site bakeries are considered an unjustifiable luxury item in foodservice operations, but that was not the case at DCH.

"Local labor costs are reasonable and fresh-baked goods are extremely popular here," says Hancock. "You don't have to sell that many pieces of cake at $3 a slice to cover two bakers and a helper." In the best Southern tradition, the bakery turns out corn bread, biscuits, scones, pies, layer cakes—virtually all of the baked goods offered on site except for sandwich buns and Krispy Kreme doughnuts. And once the Patio Grille opened, the bakery became a highly visible anchor at its main entrance.

Down-Home Favorites
The menu reflects the down-home favorites of Southern country cooking—fried chicken and biscuits are on the menu every day, hush puppies and okra are offered frequently, and you can get fried bologna and field peas on a pretty regular basis. Most of the hot Southern comfort foods are served on the self-serve Meat & Veggie Bar, which is the most popular of the cafe's seven stations. But there also are specialties on the Chef's Table, another station, that are new to many Tuscaloosa natives. Rounding out the stations are the Corner Bakery, Stone Hearth Pizza and Pasta, Druid City Deli, Patio Grille, and a soup and salad station.

With the opening of the cafe, menu prices increased, according to Hancock, but not significantly. The operation is not subsidized and the goal is to break even on employees, who represent 81 percent of customer volume, and profit on visitors. Employees get a discount off posted menu prices and approximately 60 percent of DCH employees use a payroll deduction plan that was implemented in 2001.

By just about every measure, Hancock says the Patio Grille & cafe has exceeded expectations—not just in its bottom-line revenue impact but by its impact on overall employee satisfaction, within the medical center and within the foodservice department.

In the long run, the Patio Grille & cafe is about more than delivering a new and improved foodservice program. It is also about delivering a message from DCH administrators to the Tuscaloosa community and to DCH employees and visitors that the people at the top are truly committed to compete at the highest levels of quality and service.

DCH HEALTH SYSTEM: The system consists of four hospitals: the 583-bed DCH Regional Medical Center in Tuscaloosa; Fayette County Medical Center, 50 miles from Tuscaloosa, a 122-bed nursing home with 40 beds of acute care; Pickens County Medical Center, 40 miles away, an acute care facility with 40 beds; and Northport Medical Center, 4 miles away, 200 beds, specializing in womens' services, rehab and psychiatric services.

No. of beds: 583
Occupancy rate: 80 percent
No. of employees: 3,350

Operations: 1,200 patient meals per day, seattle's Best coffee shop, kiosk in outpatient center, doctors lounge, Patio Grille & cafe.
Foodservice FTEs: 122
Annual budget: $5.9 million.
Retail revenue: $3.8 million.

Making Outer Space into Inner Space

In preliminary designs, Paul Hysen, the DCH project's consultant, worked, as he says he often does, with three separate proposals—good, better, best—each tied to ascending dollar commitments. The "good" version was based on remaining within the existing footprint of the cafeteria, with the "better" expanding to a rooftop-patio area and the "best" taking over the entire adjacent outdoor patio space between two buildings.

"In the first design, we looked at what would be involved and the expense was hard to justify, given the little additional space we would be getting for seating," says Dexter Hancock, R.D., director of nutritional services.

"Then we looked at breaking out a wall and going about a third of the way out onto the patio and taking over that space. As we talked, the discussion evolved into a series of ‘what if?' scenarios. Finally, we asked, ‘What if we just kept going and moved all the way out and enclosed the whole outside area?' recalls Hancock.

"The construction people told us it wouldn't actually cost that much more to enclose the whole patio than it would to enclose part of it," he says. "At the same time, it was clear that by going the whole way, we would have a really beautiful space with which to work."

The final "best" design winner almost tripled the cafeteria area—from 7,000 square feet to 19,500—and has already boosted dollar sales from approximately $9,000 a day to $12,500 for a 28 percent revenue increase on a monthly basis.

What goes around, Comes around

ROUND AND ROUND SHE GOES. "Circle-serve" systems performed best at peak traffic times, but proved problematic in many other ways.

There was early and excited applause for the circle-serve cafeteria design when it was introduced by B & W Metal Products, of Cincinnati, Ohio, in the 1960s. It was not just a refinement or adaptation of existent cafeteria serveries; it was a revolutionary approach that promised to automate servery line re-stocking, solve traffic bottlenecks and bolster kitchen efficiencies.

"Prior to that, the world knew only straight-line cafeteria counters. Circle-serve was really hightech and it was considered breakthrough technology at the time," recalls Paul Hysen, principal of The Hysen Group.

Like many technologies, though, the circle-serve failed to live up to its theoretical promise. Rather than having the customer proceed down the service line, circle-serve had the customer stand in one place and make selections from a constantly revolving carousel. Food was displayed on it in individual dishes in alternating heated and cooled display areas. As the counter circled back into the kitchen, staff restocked the selections.

"Although these units are sometimes remembered fondly, they were an operational disaster in virtually every case," says Hysen unequivocally.

"In some cases, they almost made sense at peak serving times, when items were being removed from the serving counter and restocked at a pretty steady pace," he says. "But they immediately became problematic when traffic slowed down. The same food moved around and around. If serving compartments weren't kept fully stocked, they appeared ‘picked over,' so more food was displayed than necessary and food waste was horrendous. "

Circle-serve units were also beset by the luggage carousel effect: customers tended to crowd the installation where it first emerged from a servery wall, competing to get newly stocked food items instead of those that had been rotating.

The circle-serve quickly gained a reputation as a failed technology and many—including two at Walter Reed Hospital Army Medical Center and one at the smithsonian Institution's National Air and space Museum—were taken out of service. Today, the original manufacturer is out of business, spare parts are unavailable, and those that remain are reminders that early technology adopters sometimes pay the price for years to come.

Renovation Success Factors
When a major renovation project is a success, "a lot of the credit has to go to the director for having the courage to bet his or her job on the project because that, in essence, is what you are doing," says Paul Hysen, principal of The Hysen Group. "In the case of DCH, that was Dexter [Hancock], who got us before the right people in the beginning and continued to sell the project on a daily basis straight through to completion."

Beyond the issue of personal leadership, Hysen says that there are other characteristics common to almost all successful projects.

Make training an early priority. "You want to be sure the staff is well-trained so that when the facility opens, it works immediately," Hysen says. In the case of DCH, Dexter Hancock, FsD, says training was a major undertaking because "all of our staff cooks were experienced only in largequantity batch cooking. We began training six months out and, at three months, began training on the new equipment. At that point, we couldn't open the facility because it was still under construction but we could use the parts that were completed." Different departments of the medical center were invited in during the training period to serve as test customers for the new menu and the new production systems.

Ensure staff buy-in and ownership. "You have to get buy-in from your employees because the consultant won't be there every day," cautions Hysen. "The onsite staff has to carry the ball forward and overcome the inevitable obstacles and glitches in any new system." Hancock took members of his staff to visit operations where similar projects had been successful and he outfitted all employees in new uniforms. Previously they had worn standard-issue hospital scrubs, which they were responsiblefor purchasing and maintaining. The new uniforms were purchased by the medical center.

Don't watch the clock. The timeline for the Tuscaloosa project was five to six years, "not unusual for healthcare facilities, and colleges and universities often run that long, too," Hysen says. "Let's say we make a presentation this year. That gets us to the capital planning committee. We might get turned down but at least we've run the flag up and let everyone know what we're considering. We might hear back again in a year or two that they want to talk to us again. If the project moves forward and decision-makers sign off, there's a year in design and two to three in construction. Capital planning is always a matter of looking at projects several years out. Our advice to clients is to get solid proposals in the queue early and to keep a project's advantages top of mind while waiting in line."

At DCH, the initial design studies were completed in 1996. The project was revisited and re-proposed two years later. In 2003, it was resubmitted. This time it included a detailed economic analysis of customer traffic every hour of the day, with estimates of items that might be sold given new menus and production facilities, along with the potential profit each sale would generate. This information was presented as a pro forma with before and after financial results based on the experiences of other hospitals that had initiated similar projects. The project was sold on the basis of paying for itself in three to four years and, so far, it is exceeding initial projections.


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