The challenges of improving hospital food
The saying “you are what you eat” has taken on more meaning in Canadian society, with growing interest in the quality, origins and farming practices of the food we eat.
For some hospitals, this phrase is “you are what you serve” with food service being increasingly scrutinized, and there are many Ontario hospitals with efforts underway to improve the quality of hospital food.
However, these efforts face formidable challenges because of the nutritional and regulatory constraints of serving food to sick patients as well as the costs of food services at cash strapped organizations.
Hospital food has traditionally had a bad reputation, and for good reason. Ontario’s hospitals feed patients three meals and two snacks a day on an estimated budget of less than $8 per day per patient, excluding labour costs. It is no wonder that many associate hospital food with bland sandwiches, canned fruit and Jell-O as hospitals aim to feed patients in a way that is nutritionally balanced, broadly appealing, cost effective and easy to assemble.
In an era of tight hospital budgets, food services are often cut or looked to for efficiencies. Ontario’s hospitals operate largely with global budgets, meaning that they receive a fixed amount of dollars per year from the Ministry of Health and Long-Term Care to run the entire operations of the organization – which includes staff salaries, equipment, medicines and supplies such as food.
Michael Young, Executive Vice President at Sunnybrook Health Sciences Centre, notes that “hospital executives find it difficult to make investments in food services with so many competing demands for investments in direct patient care.” With many demands on scarce dollars, Heather Fletcher, manager of food services at St. Michael’s Hospital agrees, saying “food isn’t always a priority.”
Despite the challenges of resource allocation, some Ontario hospitals are starting to pay more attention to food, and see the quality of the food provided as part of overall patient care.
Food and Ontario’s focus on Quality & Patient Satisfaction
In Ontario, the introduction of the Excellent Care for All Legislation in 2010 put an increased emphasis on the measurement and improvement of quality in hospitals. Quality of care is measured through a number of indicators, such as patients’ clinical outcomes and complication rates, as well as measures of the patient satisfaction. All hospitals in Ontario measure patient satisfaction using the same survey tool – which asks patients about various aspects of their hospital experience.
Research suggests that hospital food is an important part of the patient experience, and contributes to patient satisfaction, or dissatisfaction with their care.
Anne Marie Males, VP of Patient Experience at Scarborough General Hospital, says: “Food service is not considered a key department of most hospitals. It’s a service that it has to be there. A lot of people don’t give it much thought, but when you talk to patients, its amazing how important food is to them.” Males, who is leading the introduction of more fresh and home-cooked foods at the Scarborough General Hospital through a grant from the Ontario Greenbelt Foundation noted that a motivating factor in implementing this program was “being in the hospital at 6 pm and seeing families coming in with dinners from home… as the food being served to patients was so foreign and did not provide comfort.”
Providing comfort through food can be a challenge as many hospitalized patients are required to adhere to a strict diet. Heather Fletcher, director of food services at St. Michael’s Hospital notes that “nutrient targets are set for various diet types with goals for sodium, fats, carbohydrates, protein and total caloric intake” for various groups of patients. This can be quite complex.
For example, St. Michael’s Hospital serves 97 different diet types, and has 47 different diets to respond to allergy restrictions. The hospital serves more than 540,000 meals per year to patients.
Mary Keith, a registered dietician and nutrition education coordinator at St. Michael’s Hospital, notes that all food served to patients must go through ongoing nutrient testing and taste panels with hospital dieticians to ensure that meals are meeting nutritional targets and are appropriate to overall therapeutic needs of patients in the hospital.
The complexity of preparing and serving food to patients with specialized diets on a tight budget has lead many Ontario hospitals in the past few decades to move away from cooking food at on-site hospital kitchens, to outsourcing much of their food preparation and production. Companies such as Compass Group and Aramark specialize in food preparation for hospitals at large, off-site industrial kitchens.
Many hospitals have adopted an approach, known as “rethermalization” where hospital kitchens focus on the assembly and reheating of pre-prepared, frozen foods using special ovens. The “kitchenless” hospital has been described as an innovation that can save hospitals about 20% of food services costs.
This video details the complex processes involved in getting food from suppliers to patients’ bed sides at Sunnybrook Health Sciences Centre.
Innovations within Constraints: What Some Ontario Hospitals are doing to Improve Food
Heather Fletcher argues that “rethermalization technology doesn’t need to be a barrier to adding fresh items to hospital food menus” and that there are opportunities to add more fresh and locally-grown foods within existing food preparation, assembly and reheating processes by for example adding locally-grown blueberries to fruit crisps which can be prepared off-site, frozen and re-heated at the hospital.
One challenge of accessing fresh foods is the supply chain by which hospitals and hospital food providers purchase foods. Fletcher notes that efforts to add fresh, local foods to the hospital menu meant that the hospital had to engage in conversations and partnerships with suppliers, including farmers and help them learn how to participate in hospital food procurement processes, with which they were previously unfamiliar. All hospitals foods must comply with certain safety and quality standards. Fletcher noted that “Changes to the very structured supply chain meant that we had to develop relationships with farmers and communicate our criteria clearly ,so we were comfortable that we could provide the food to patients with no risks.”
Operating in a very different context, the Sioux Lookout Meno Ya Win Health Centre located in Northwestern Ontario and serving the needs of primarily First Nations communities was required to have specific legislative authority in order to serve traditional foods, such as game meats and fish, which are non-inspected foods. Dave Murray, CEO of the Health Centre notes that serving traditional foods “that are familiar to the palates of patients from remote, First Nations communities provides a great deal of comfort.” Murray describes the traditional foods program, which operates out of a separate kitchen as an organizational priority, linked to the “ethos and culture of the organization, which is to provide a culturally appropriate experience to our patients.”
The Scarborough Hospital is also aiming to improve the cultural appropriateness of food services, through their pilot project. Anne Marie Males noted that given the diverse patient population of Scarborough, there was a need to “discover universally appealing comfort food” for all cultures, with homemade soup stock being a major project.
One question is why hospitals would not raise their spending on food if it improves patients’ experience and satisfaction. For example, if a 300 bed hospital doubled the amount it spends on food (excluding labour) from $8 per day to $16 per day, this would add around $11,000 per week to food budgets or a little more than $500,000 a year. Given that Ontario’s hospitals make investments in new technologies, such as Magnetic Resonance Imaging (MRI) machines that can cost hundreds of thousands of dollars, perhaps investing in food, and the promise of improved patient satisfaction, is a worthwhile consideration for hospital executives.
There are major fiscal and operational challenges to improving patient satisfaction and comfort through better quality food. However, some hospitals in Ontario are developing approaches to improving the quality of food – it will be interesting to see whether they spread across the province.