Trays In Transition
Hennepin Healthcare in Minneapolis, like most hospitals across the country, faces some real challenges when it comes to tray makeup for patient meals, says William Marks, Director of Food, Nutrition and Environmental Services.
Patient services’ current system is spoken-menu “ambassador”-style ordering with traditional straight-line tray makeup. Runners deliver meals to floors at specific times; ambassadors use a tablet to record each patient’s order for the next meal. “Until five years ago, we had a traditional paper-menu system,” Marks says. “Since then, we’ve changed processes.” To keep cold foods as cold as possible on the trayline, the team put in for new air-curtain refrigerators, replacing and expanding on the old refrigeration lineup. Also new to the line was an on-demand plate heating system that, Marks says, “significantly helps maintain temperature through to delivery and increases patient satisfaction— which is always one of our top issues, so that was a great investment.”
About a decade ago, Hennepin Healthcare inaugurated a room service model for on-demand patient feeding as part of a major renovation. But management hadn’t quite realized that the move would increase staffing needs and complexity. The fact that some trays had to travel as far as a quarter-mile from the kitchen didn’t help. The room service experiment lasted only a few months before the hospital went back to a traditional tray-makeup and -delivery system—without the benefit of another kitchen remodel.
“We make it work, but it takes a lot of effort,” Marks says. “To do what we’re doing right now more efficiently, I would like to have a straight roller trayline with lots of ability to move around prep tables, refrigeration and equipment.”
But what would Marks do if he had an unlimited remodeling and staffing budget? “I would love to go to room service,” he says.
Chasing Patient Satisfaction
The Hennepin Healthcare experience is actually fairly typical. Food quality and efficiency in patient feeding are key to satisfaction scores, sometimes even more than the medical care itself. For nutrition services personnel, the pressure is on to “wow” patients—but the pressure to keep down costs for food and labor remains as intense as ever.
The demand to do more for patients without a substantial increase in revenue has led to “more short-order cooking, more menu-driven orders with more offerings,” says Ray Soucie, FCSI, Design Director at Webb Foodservice Design. “There used to be one or two options for lunch or dinner; now there are typically eight or 10 choices. That’s really changed what we do with trayline assembly.”
“Room service is primarily what people are aiming for,” says Georgie Shockey, Principal at Ruck-Shockey Associates, a management advisory services consultant who helps hospitals with patient meal makeup and delivery. “You don’t see a lot of straight, non-select trayline assembly anymore. Everybody is trying to incorporate some sort of choice and a little more enthusiasm.
“In the heyday of room service, people were all-in, 24/7; if a patient wanted a milkshake at 2 a.m., we’d get it there. The pendulum has swung back. There are a few models still out there doing room service the way a hotel would, but even they may have cut back hours.”
Nowadays, she explains, many hospitals offer a hybrid of traditional tray service and room service, with runners delivering patient trays from perhaps 6 a.m.- 8 p.m.; some have a limited menu until midnight. Many models are in place, with more ambitious foodservice offerings in major markets with many competing hospitals, and less elaborate systems in places where healthcare facilities are scarcer on the ground.
There are ways to adapt a kitchen with an old patient-feeding model to an updated system, Shockey points out. “You can retrofit in a small footprint if you have some adjacencies. If you have a cookline with some space around it, you can slip in some sort of tray assembly that can be adapted for cooking to order,” she explains. “But if the tray assembly is 50 ft. away from the cookline, you might put a printer by the line to tell the cook to make a burger and expend some time and money for a runner—adding day-to-day labor cost to overcome things you can’t change physically.”
Patient feeding systems have been evolving for some time, but there was a paradigm shift a decade ago with the arrival of pod workstation systems. Alberta Health Services, a hospital system in western Canada, approached a manufacturer to collaborate on creating a patient tray system in alignment with the latest trends in lean manufacturing (which focuses on analyzing and streamlining processes and process flow, reducing costs and boosting customer satisfaction through techniques such as just-in-time stocking and made-as-needed production).
“It’s got a lot to do with having a place for everything and everything in its place,” says the president of the company that worked with Alberta Health Services. “Everything is labeled. The work is standardized; you could take over from someone else in the line at the blink of an eye.”
One key principle, he says, is “making sure everyone has the same amount of work to do in the same amount of time.” That solves the problem of an out-of-sync employee throwing off the whole line.
Ergonomics is a central consideration, he explains. Everything that goes on the patient tray is within reach so workers don’t have to strain, they don’t have to reach more than 25.-in., they don’t pull the trays backward, and they never take more than three steps as they make up trays. As a result of this efficiency, installing a pod system tends to boost job satisfaction of foodservice staff.
“A pod can do up to 1,000 meals a day quite successfully,” he says. “You can have two or three pods running simultaneously; when the bed count goes down, you can go back to two pods or one, whereas with a large circular or straight-line system you would have to keep running the entire process.”
The pod system “is a ‘divide and conquer’ method to optimize the largest number of meals with limited staffing,” says a corporate chef with a manufacturer that supplies pod components, custom engineering and consulting services. He says that staff working in a pod, with all they need close at hand, can assemble a tray and get it into the delivery cart in 30 sec., far faster than on a traditional trayline.
Equipping Tray-Makeup Stations
Starter stations, work tables, prep tables, steam tables, chilled pan tables, air-curtain refrigeration, open storage racks for plates and dome lids, tray dispensers, plate warmers… . “You’ve got to have it all,” says Shockey. “Putting together a tray of seven or eight items takes a multitude of equipment, and I don’t think there’s a way to shrink that.”
Traylines vary, depending in part on the extent to which items are made to order, but following are a few general tips from experts:
• Setting up a new patient tray-makeup system is complex, so take full advantage of foodservice consultants and manufacturers’ expertise. Suppliers also may offer some staff training.
• Use the starter station for bins of condiments, chips, crackers or similar items. Gravity slide bins are the most ergonomic. Only stock what you need to keep inventory costs in check.
• Consider dispensers and cases that employees can restock from the rear; that way, the line needn’t stop when an item is about to run out.
• Plate warming technology is standard equipment on tray assembly lines. (Larger hospitals that use cook-chill will have a retherming system.) Less common but also handy is a plate chilling system. On a mixed tray of hot and chilled foods, keeping cold foods cold can be an even bigger challenge than keeping hot foods hot, particularly if cold foods are plated first.
• Makers can customize silverware dispensers depending on whether or not utensils come pre-rolled.
• Steam tables are still the standard for hot holding. However, waterless hot wells, whether induction or conduction, are slowly becoming more popular despite, in some cases, a higher cost since there are substantial ongoing savings in utility expenditures and equipment life, and reduction in labor, when you remove water from the equipment equation.
• Food wells that switch from hot to cold or vice versa boost menu flexibility. Choose cold holding for salads at lunch, and then switch to hot holding for a dinner menu item.
• Specialty cooking equipment, like a fast-cook oven or high-speed pizza oven, can be a useful addition to the trayline, making more options available to patients beyond the standard steam-table items. Most don’t require hoods.
• Air-curtain refrigeration is ergonomic and convenient for workers. However, undercounter refrigerators and freezers—with doors or drawers—work well for extra storage or for items that are less commonly added to trays. (Ideally, you would store items no lower than workers’ knee height.)
• Foodservice departments handle beverage stations at the end of the line many different ways. Portioned cold beverages, such as milk cartons or juice cans, require a refrigerated reach-in case. If it’s called for, employees can add ice to glasses at the beverage station or on patient floors. Employees may brew hot beverages, such as coffee and tea, at the beverage station (necessitating a water line) and portion into cups, then top them with a lid to keep the contents hot. In another method, employees place pre-portioned cups of coffee or tea into a retherm system, which holds them cold until about an hour before tray assembly when the system heats up all the beverages in mass. In other hospitals, employees may pour hot beverages only when trays reach patient floors.
• Although few hospitals rearrange a tray assembly line once it’s set up, be sure to put in for casters on every piece of equipment when possible, simply to make cleaning easier. (Casters also help when it’s time to roll old equipment away. Make sure two casters lock.)
• Think through electrical hookups. Equipment will have different requirements (120V, 208V, 240V, one-phase or three-phase) and you may need some rewiring. Heavy-duty electrical connectors that suspend from the ceiling make it easier to keep cords out of the way and switch out equipment as needed, but if the ceiling is too high, you’ll have to use an undercounter raceway. Avoid stub-ups from the floor as they’re trip hazards, vulnerable to flooding/drain backups/sprayers and too confining in their permanent locations.
• Proximity of the tray assembly line to the cookline can be important if the hospital uses a room service or hybrid model with cooked-to-order items. In some layouts, cooks on the cookline and workers on the tray assembly line work back-to-back; in other layouts, the cookline and tray assembly line are face-to-face with a pass-thru shelf.
Begin At The Beginning
It seems obvious that you should have a destination before starting a journey, but the consultants and other experts we talked to say they’re sometimes called in to help design a patient tray assembly system without the client having clearly defined goals.
“Clients spec things that they think are standard, and often don’t look at their menu before planning what they need,” says one manufacturer. “What is the percentage of hot vs. cold food? What beverages or other items are ambient products that don’t need refrigeration? Start with the menu and plan out the real estate and develop the equipment roster from there.”
Worker comfort also is key to proper planning, he says. “One client put together a pod system without thinking about staff until they complained they were tired because items were difficult to reach,” he relates. “They then asked us to get involved to develop something that took workers’ comfort into consideration.”
The corporate chef believes work flow is the key principle that equipment specifiers must grasp as they plan a new tray assembly system. “The primary mistake operators make is not taking time to look at flow and how to make it better,” he says. “Just throwing money at a problem won’t fix it. Look at your current system, design something properly, then incorporate the right equipment to get the trays out the door accurately and quickly.”
TRAY-MAKEUP EQUIPMENT SPECIALISTS
Aladdin Temp-Rite/Ali Group
Traycon Mfg. Co.
For more manufacturers, please visit the FER Buyers Guide at fermag.com.