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Will Innovate for Results

Will Innovate for Results

Fresh flowers greet customers at the entrance to UWMC's retail cafe.

Food & Nutrition Director Walter Thurnhofer oversees a hospital dining operation serving up to 6,000 meals daily.

AROUND UWMC. The new branded grill station in the Plaza Cafe

A recycling/customer service touch in the cafe

The soon-to-bediscontinued trayline

Walter Thurnhofer is a busy man and, clearly, he aims to stay that way.

As director of food and nutrition services for the University of Washington Medical Center (UWMC) in Seattle, he is responsible for dining operations at a 450 bed hospital, a $5 million retail operation and onsite catering services. The department serves up to 6,000 meals each day.

With that kind of volume, Thurnhofer has developed a firm faith in results-oriented management, and his department has shown how a large organization can still innovate effectively. Among the highlights:
• an automated, comprehensive, first-inthe-healthcare-segment HACCP monitoring system;
• the use of dishes brought in by chefs from local restaurants to bolster retail cafeteria menus;
• offering patient meal service in nontraditional locations like the emergency room and the outpatient surgery ward; and
• the use of a mobile cart that trolls the campus in the wee-wee hours of the night, giving night staff and visitors another food and beverage option besides the vending machines.

But there's more! In July, UWMC will debut a new room service patient dining program that will replace its current preorder system. The new service will come with a considerably upscaled menu designed to boost patient satisfaction. This menu will be available in five languages in addition to English, targeting the most numerous ethnic populations the hospital serves.

On the retail front, Thurnhofer is exploring the feasibility of putting in an upgraded, electronic POS system that would tie the medical center foodservices into the University of Washington's Husky Card campus debit program. It would be a move that could boost retail revenues even further, building on an already impressive track record in that area.

Meanwhile, there are the possibilities posed by the opening in 2009 of a new wing to the medical center that may allow Thurnhofer to realize his long-cherished dream of decoupling the retail and patient dining production areas in order to give both adequate space and capacity to meet present and future needs. In any case, the new wing will provide additional retail sales opportunities as well as 75 additional beds to feed.

It's quite a flurry of activity, but one over which Thurnhofer has steadfastly maintained solid financial control. Indeed, the food & nutrition department's contribution margin has exceeded budget in each of the four years of his tenure at UWMC.

A Life in the Business
Walter Thurnhofer is a healthcare foodservice lifer. He began work in St. Helena Hospital in Northern California's Napa Valley as a teenager, washing dishes. "I didn't enjoy washing dishes that much, but I did enjoy the business and they trained me to be a server in the cafï¿´´, then a cashier, then to work on the tray line, working in the cold food prep area, and finally as a relief cook," he recalls. "That was when I got excited. The person who trained me, Joe Sauly, was a European chef, a big round guy who took me under his wing."

Three-plus years of Sauly's tutelage extended into young Thurnhofer's tenure at nearby Pacific Union College. Eventually, he landed a job on campus in the dining commons as a cook and baker, learning skills like wedding cake decorating.

In college, Thurnhofer studied for a dietetics degree, aiming at the administrative side. He completed his degree at Loma Linda University where they had an internship program (and where his academic adviser was future ADA president Dr. Kathleen Zolber).

With his degree in hand, the former dishwasher returned to St. Helena Hospital, this time as assistant director. "For some of the old timers, this was something that took some adjustment!" he laughs.

The St. Helena post was just the first in a journey that took Thurnhofer through a career path with the Adventist Health West system. He eventually rose to a vice presidential post in charge of food and nutrition services in 25 hospitals. But by this point he was getting tired of the "corporate travel" so he took a position as a regional director at Portland Adventist Medical Center in 1987. He was there until 2002 when he received an offer from the University of CaliforniaSan Francisco Medical Center to serve as a consultant as they transitioned to self-operated food services. It was irresistible.

"I continued to live in Portland and commuted there each week for eight months," Thurnhofer says. "They had appointed me interim director and wanted me to take the position on a permanent basis, but I loved the Northwest and didn't want to relocate."

So when the UWMC job opened up, Thurnhofer had no hesitation in applying. He was hired and started on April 1, 2003.

"When I got here, this place was in pretty good shape operationally," he says. "Nothing needed to be ‘fixed,' but they did want it upgraded, front to back, with new production and service equipment."

Thurnhofer got down to work, putting some $400,000 into renovating the production kitchen. More recently, the retail Plaza Cafes dining areas received a cosmetic overhaul, with new flooring and furniture. The big changes weren't structural, but philosophical.

Tapping Local Talent
Over Thurnhofer's tenure at UWMC', retail revenues have steadily risen. They increased 13.9 and 6.2 percent, respectively, in the past two full fiscal years and are on track to grow another 5+ percent in the 06-07 period. In dollar terms, sales have gone from about $3.3 million to $5 million.

"A small component of that is price increases," Thurnhofer admits, "but mostly it is more volume from improved merchandising and promotion. We have added lots of new choices in the Plaza Cafe, both in the hot deck and the cold food area, as well as a grill where we make sandwiches to order."

More choices came from a new branded chicken concept and Thurnhofer has also not been afraid to turn to local culinary talent to boost the attraction of his menu. "We occasionally will have a local chef come in and we'll feature him or her either on the hot deck or at the grill. For instance, we have a Mediterranean chef people really like who comes in and does a largely vegetarian program for us."

This chef comes in every couple months, but several others are much more regular. One is a local Asian chef who brings in Vietnamese sandwiches as well as various other Asian specialties each day to augment the inhouse offerings.

This chef, who has a restaurant in downtown Seattle, was contacted after one of Thurnhofer's staffers ate there once and loved the food. "She suggested we see if he could bring some of his food out to us, so we did. It has been a great success."

No kidding. The cafe sells 15 to 20 dozen of the sandwiches each day. "And we didn't seem to cannibalize other volume," Thurnhofer adds. "It seemed to be additional."

Another vendor brings in Mexican graband-go wraps every day, while still another delivers Japanese food, especially sushi, which is very popular.

"The vast majority of what we sell is made internally," Thurnhofer emphasizes, "but this is a way to get more variety and push more volume through."

Thurnhofer credits longtime Retail Operations Manager Edith Cachero-Willard with the success of the program. "She has a great retail mentality and she runs this retail operation like it is her personal business. She's always looking for opportunities to bring in new things, to increase volume, to increase satisfaction."

In addition to the outside offerings, Plaza Cafï¿´´ features a big assemble-your-own salad bar, a make-your-own-cold-sandwich deli bar, as well as a separate deli counter with pre-made specialty salads. The main hot deck will usually have between four and five entree selections, plus sides and soups.

Thurnhofer says lots of choice is key. "We offer a good variety," he says. "If you want to eat really well, you can. There are lots of choices for a good, healthy diet. On the other hand, if you want more traditional American fare, we have that as well."

Plaza Cafe is only open from 6:30 a.m. to 7 p.m. To serve staff and visitors who must be around overnight, Food & Nutrition deploys a late-night service that minimizes costs while maximizing revenue opportunities by being mbile (see sidebar below).

The cart shows a commitment to serving customers wherever they are, and this philosophy extends to patient dining as well. In addition to the traditional meal service (which will morph to a room service model this summer--see sidebar below), the department has also expanded to various nontraditional areas: the post-anesthesia recovery room, the emergency department, the surgery pavilion for outpatient surgery and even the various outpatient units scattered around the medical center.

To serve these far-flung regions (the surgery pavilion, for example, is half a city block away from the production kitchen) Thurnhofer uses small tray delivery carts and a heat-on-demand system (which will also serve the room service patient dining system when it debuts).

The volume is not great—several dozen trays a day, perhaps. The motivation is service. "You may have patients in the emergency room for an extended period for observation, or people waiting for outpatient services who can't get to the cafe," Thurnhofer explains. "In those cases, if they are there for a while, the nurse will call down and ask for a tray to be sent up for the patient."

Managing Labor
As a manager, Thurnhofer seems to have the confidence, loyalty and even affection of his associates. Employee satisfaction surveys routinely give his department some of the highest scores in the institution and turnover is low—reportedly 6-10 percent a year over the past four years. (And some of that due to employees moving up after benefiting from Thurnhofer's encouragement of professional development training.)

All this was accomplished even as Thurnhofer took a rigorous handle on overtime hours, reducing that source of budgetary hemorrhage by 80 percent, to an average of about 0.1 percent of regular paid hours, a reduction he has been able to sustain.

"I spend about 20,000 hours of labor a month, and we have an average of about 20 twice a month of overtime now," he says proudly. "That is close to zero. Previously, we were running 200 plus hours of overtime."

The secret? "Tighter management controls," he says simply. "Getting people out of here on time."

Getting a handle on labor costs (the FTE count has not increased in his three years, despite increases in the number of meals served and the additional services he has implemented) has allowed UWMC food & nutrition services to reduce the net cost per meal equivalent by over 12 percent in the past three years.

A New Wing and a Prayer
For the near-term future, Thurnhofer is busy getting the planned room service program off the ground in a few months. Then, in 2009, a planned new wing with 75 more beds is slated to open.

"Because of this project, we will have to consider the possibility—the possibility, not certainty—of building a new kitchen in this area designed just to serve the patients," he says. "It would be much more efficient than where we are now, in the middle of a huge kitchen that serves everybody and everything. We want to move patient service out of the existing kitchen so we can expand retail operations.

"If we get the space that is currently in the plan, we'll have more dry and freezer storage as well as a catering room, a separate kitchen for patient dining room service and expanded retail serving room space, plus additional dining space on top of the main cafeteria area we already have. This will grow us from 450 to 700 seats and will allow us to add four new conference rooms, which means more catering opportunities.

"Frankly, we are now at capacity retailwise," he says. "We could increase volume 25 percent overnight if we had more physical space for serving and dining. We also need more retail production space. We currently have about 2700 sq.ft. and we need at least 3,500 to 4,000."

The additions would enhance the department's catering operations, which currently generates under a million dollars in revenue. A dedicated catering staff of four now manages up to 20 events a day, most of them small staff meetings. However, the department is also very capable of handling much larger events—the annual Winterfest celebration, which can draw up to 4,000, for example, or a summer picnic by the UWMC campus's picturesque lake for several thousand staffers.

In addition to the new wing and the introduction of room service, the other anticipated big change Thurnhofer would like to effect is the introduction of the University of Washington's Husky Card declining balance system to the medical center.

"We've never had that here because we've always had our own system," he says. "Right now it's either cash or credit cards, and we're dealing with way more cash than I'd like for safety and speed-of-service reasons. Widespread use of the Husky Cards would also allow us to do promotions because we'd have more information on who our customers are."

Fast Facts
Name: University of Washington Medical Center
Location: Seattle
Website: http://depts.washington. edu/plazacaf
No. of Beds: 450
Avg. Daily Meals: 6,000 (1,000 patient, 5,000 retail)
Annual Retail Sales: $5 milion
Annual Catering Sales: $950,000
Management: Patricia Riley (assistant administrator, Support Services); Walter Thurnhofer, RD, FHCFA (director of food & nutrition services); Edith Cachero-Willard (retail operations manager); Soi Wong (patient dining services manager); Susan DeHoog (associate director/clinical nutrition manager); Jana Huddleston (office manager)


With UWMC's automated temperature monitoring system, Thurnhofer can access the data from any internet-connected computer.

A Robo-HACCP Pioneer
Thurnhofer says that UWMC is the first healthcare facility in the nation to install an automated temperature monitoring system for all cold and hot holding units throughout the complex, connecting them all into a single integrated database using the data protocol technology laid out by the North American Foodservice Equipment Manufacturers Association (NAFEM).

UWMC's auto HACCP system covers all the angles. Hardware probes and a monitoring software package are attached to every refrigeration, hot box and stove unit—450 in all, located all over the hospital complex, from the refrigerators on the patient floors to the pharmacy (which is monitored by that department, but food/nutrition services provides live documentation), and even the dishwasher. The system logs temperatures every 15 minutes.

"You can look at tracked logs for a week, a month, whatever just by clicking on the unit," says Thurnhofer. "If the temps go out of spec, the system automatically sends a page."

Part of this project was the installation of a new roll-in blast chiller connected to the automated temperature monitoring system, another industry first. "Very soon, we'll have the probes installed to monitor the change of temp of food put in the blast chiller to document the actual cooling regression log. We will also have the opposite in the combi ovens, where we will be able to monitor food as it is thermed."

Thurnhofer is not finished. "The next piece we want to buy is a handheld device with a thermocouple that can check receiving temps as well as the temps of product in a retail operation. That way, when the food hits the deck during service, we can show its temperature at various stages of production."

To track the various items, which of course have different temperature specs, the handhelds have a keyboard where the code for each item can be punched in so that when the temperature is taken, it matches to the specs. The data is also time and date stamped.

"The advantage is that you do away with the blizzard of paperwork," Thurnhofer says. "We have files and files full of data-filled paper. This makes it more fun and certainly easier on the supervisor collecting the data."

The entire system, with materials and training, cost Thurnhofer around $140,000. The process included installation of wireless transponders throughout the hospital so that wireless signals could be relayed. The system is web-based, meaning it can be accessed from anywhere there is an online connection.

And the data says...well, that things weren't exactly right.

"We had records for years past that showed every refrigerator right on the money for temperatures," Thurnhofer says. "But when we activated this system, it immediately identified a dozen pieces of equipment that were always out of spec, and we had to take immediate action on those."

His conclusion? "The old system doesn't work."

That is really the big benefit. "It won't save you FTEs," Thurnhofer admits. "At most, it saves some staff time that can then be freed up for other things."


The Next Step in Patient Dining
This July, UWMC Food & Nutrition Services will embark down a path already trodden by many healthcare foodservice departments: patient room service. Thurnhofer has been working with consultant Romano Gatland on the conversion, which will require capital outlays in addition to the consulting fees. Thurnhofer estimates the expense at $350,000$400,000.

The project involves a remodeling of the production area and new equipment: a new combi as well as a new grill broiler setup, some new refrigeration, a new tray delivery system, pasta cooker and stainless steel workdecks. Also new will be the communications system and the servingware.

"We have been working on this for three years," Thurnhofer notes, adding that a good portion of that time was spent on getting the necessary funding. There will also be significant ongoing expenses, including the addition of seven FTEs.

"I am charged with finding offset costs elsewhere in the department to make this cost-neutral," he says. How this will be managed is something he has yet to work through completely.

"We waste about 40 trays a day now because patients are discharged without our knowing, or their diets were changed, so we'll see some savings from that as well as from not having to overproduce on the tray line and from the reduction in our floor stock. Still, for me to be able to pay for the extra labor, we'll have to be a little above 20 percent in food savings."

One "problem" is that the Food & Nutrition Department has already been running quite lean. Indeed, benchmarking data from the Solucient research service shows UWMC to be in the lower quartile of expense compared to the medical center's peers around the country, while also being in the top quartile for revenue and productivity.

Nevertheless, Thurnhofer feels a commitment to patients. "The biggest complaints I get are things like ‘I can't get what I ordered' or the order got lost, or was filled out wrong. With room service, a lot of these complaints go away."

The patient menu itself will undergo a radical revision and will be somewhat more upscale (and available in five languages—Vietnamese, Chinese, Spanish, Russian and Tagalog—as well as English) "so we won't be getting savings on the food," says Thurnhofer. The entree section will have three sections: Regional Northwest Specialties like salmon dishes, an International Market section with various ethnic offerings and a comfort foods section with traditional American favorites like meat loaf and mac-and-cheese. These will be augmented by a grill selections and entree salads.

Every meal will be cooked to order, so production will be like a restaurant or hotel operation. Turnaround is expected to be 30-45 minutes from the time of the order.


Late, LATE Night Service

UWMC's late-night food cart with staffer Thuan Huu Nguyen.

Late nights in healthcare facilities present an operational and financial conundrum. Obviously, there is staff—and often visitors—on the premises 24 hours a day, but their numbers are far fewer than during the daytime, making foodservice costly. Many institutions simply rely on vending to fill these hours, while some others bite the bullet and keep a portion of the cafe open to serve the late shift.

Just before Thurnhifer arrived at UWMC, the Food & Nutrition Dept. was in the process of coming up with an alternative: a mobile cart.

The cart is a large portable unit that goes around the complex every night from seven in the evening until 3:30 in the morning. It includes a refrigeration unit and cash register that are powered at each stop by simply plugging into a wall socket.

Typically staffed by one person, the cart has a set schedule of stops posted on the Food & Nutrition Dept. website as well as at various places around the premises. The predictable schedule offers staffers convenience in addition to the food and beverage choices.

"Nurses, for example, have a hard time leaving their stations because there are so few people working those late hours," Thurnhofer explains, "but if the cart comes up to their floor, they can go over and grab something quickly."

The cart offers coffee and tea as well as soups, sandwiches, salads, microwaveable meals and snacks, packaged drinks and fresh fruit. The typical evening's take is a little over $300, primarily from staff and visitors though occasionally a nurse will get something for a patient.

Thurnhofer is satisfied for now with the cart but would really like to get a cafe space in the planned new hospital wing that could stay open 24 hours a day.


A Premier Hospital

The University of Washington Medical Center is a nationally recognized academic medical school for the University of Washington School of Medicine. Listed as among the Top 10 medical centers in the country by U.S. News & World Report, the 450-bed facility employs nearly 400 attending physicians who are also full-time faculty members at the UW School of Medicine.

Opened in 1959, UWMC was the site of the world's first long-term kidney dialysis, housed the world's first multidisciplinary pain center and the nation's first Clinical Research Center, and it performed the first heart and total knee transplants in the Northwest.


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