University Health Network
in Toronto

By Donna Boss, Contributing Editor

Productivity enhancements and significant savings in labor and inventory have resulted from the construction of a new patient food procurement and meal assembly/distribution center for a group of three hospitals located in downtown Toronto. The facility's equipment was positioned to eliminate cross-contamination and maximize sanitation and safety requirements.

In March 2002, the new $33 million (Canadian $55 million) R. Fraser Elliot Support Services building was constructed for the University Health Network (UHN) in Toronto. It includes a patient food procurement and meal assembly/distribution center serving three UHN hospitals: Toronto General, Toronto Western and Princess Margaret Hospital/Ontario Cancer Institute. Each day, 2,400 meals are prepared daily in temperature-controlled and -monitored rooms, then sent out in insulated carts to the trio of institutions. Special nutrition centers at each hospital are equipped with retherm carts used for heating meal components that are served hot. Trays with hot and cold menu items are delivered to patients in the insulated carts. Once patients have finished their meals, trays are reloaded into the retherm carts and brought back to support services building for washing and sanitizing.

The current operation is actually the second food procurement and meal assembly/distribution center built for their health network. The first was located in a building that will soon be torn down due to structural weaknesses and other aging issues. "I'm well aware that it is rare for a director and staff to have an opportunity within a few years to build two perfect kitchens," explained Sanjiv Seth, UHN's director of Nutrition Services, a trained culinarian who worked as a chef and manager in hotel F&B programs before entering TWH's foodservice in 1990. "In the first one, however, there were challenges, such as operating on two floors. We worked to improve the system the second time around and gain efficiencies. Also, our hospitals' administrators asked us for our wish list and, though we didn't get everything, we were able to improve productivity and provide a safe, just-in-time system for producing patient food."

Patient satisfaction is always of concern for those who run patient foodservice programs. As many hospitals have discovered, a rise in patient satisfaction scores can be attained when more individual attention is paid. This year, a new position was created to orient new admissions so these patients don't feel "lost" in the system (or ignored at mealtime) during their first few hours in the UHN hospitals.

When assessing the recent project's success, Seth stated, "One of the main obstacles back in 1994 was convincing myself, a chef, to give up cooking and buy prepared food from manufacturers. But once I convinced myself, I could convince others. However, in the first facility, we didn't involve staff very much. Yet, the second time around, we asked everyone, including nurses, for input. They therefore feel a sense of ownership, which is much more productive for everyone." Involving manufacturer and supplier partners has also contributed to the overall success of the facility, he emphasized.

Chilled meal components are assembled on a trayline, which is positioned in a room that is maintained at 50°F. Dietary aides plate the food onto pre-chilled (to 37°F.) serviceware and trays. "Food is always flowing forward toward plating," Seth noted. "It never returns to the chamber it was in previously, which prevents cross-contamination." Breakfast is plated the evening before it is delivered, lunch is plated from 7 a.m. until 11 a.m. and dinner from 11 a.m. until 3 p.m. "Plate makeup takes a total of nine hours," Seth reported.

Seth and consultant Matthew Marrack, principal partner, Marrack + Associates, Toronto, are pleased with the new system as it is operating for UHN. Their work has proved so successful that they have been asked to consult by other hospitals that are looking for alternatives to their conventional foodservice systems. "Hospitals are combining resources into networks and groups," Marrack said. "They must find cost-efficient ways to consolidate and operate departments such as nutrition services. What held this up in the past was 'turf protecting.' But, under one director of foodservice, standardization and centralization are not only possible, they're necessary."

Meanwhile, Seth and his staff must continue to adjust to change. This year, the old Bell Wing at the TGH site will be demolished and replaced in August 2003 by a new building that will house patient care and research functions. Another building, which will undergo a major renovation, will become the outpatient services building. Nutrition Centers will be built at each building. If ever a staff and a system's equipment were put to the ultimate flexibility and endurance test, it is here at the University Health Network n Toronto.

For patients who aren't satisfied with their meals or those requiring late trays, each Nutrition Center is always stocked with extra trays for different diets. In addition, meal components are kept in the Nutrition Center units.

The process of patient food delivery begins with menu development. A one-week-cycle selective menu was developed to accommodate needs of patients who are in a UHN hospital for an average of seven days. Two main course selections are offered at breakfast, lunch and dinner, in addition to sides, such as juice or salad for dinner and choice of a starch, vegetables and a dessert. Menus are delivered to patients two days in advance.

For example, menus for Wednesday's dinner, which might include roast beef or grilled chicken breast with barbecue sauce, are delivered with dinner trays on Monday and are picked up by Nutrition Services staff members the following day at noon. "Our studies determined that we received fewer responses from patients when the menus were distributed a day before a meal than two days," noted Seth. On the other hand, patients who are in the hospital for two weeks or longer may select from a restaurant-style menu.

Completed trays are placed in pre-chilled carts that can hold 16 each and are kept in another walk-in refrigerator at 37°F. until removed for delivery. Pictured here, the insulated carts are ready to be delivered to each of the three hospitals 30 to 45 minutes before mealtime and placed in Nutrition Centers located in nursing units. These units are accessed only by Nutrition Services staff members. They are equipped with a small refrigerator, a freezer that holds ice cream and meals for late orders, a coffee machine and office equipment into which diets can be entered. A rethermalization cart is used to heat chilled portions of the meal. (A staff member transfers the chilled items from the delivered carts into the retherm carts for heating, then takes them out and combines them with the other meal components on the tray for delivery.) Carts with hot and cold foods are wheeled to patient rooms, where meals are delivered.

Once food products have been delivered to the new food production center, a computer program creates a tally and generates an "advance withdrawal" sheet that is used to inform staff of the type and quantity of items needed for patient trays for each meal. Next, products are placed in either dry, refrigerated or frozen storage. Dry and refrigerated items, such as juices, fruit, vegetables, dairy and desserts are taken to a 50°F. room equipped with prep tables, slicers, counter mixers and scales for preportioning and preplating. When completed, this food is moved into a portioned food refrigerator set at 37°F. until needed on the trayline.

"The entire refrigeration system technology provides centrally computerized monitoring from a strategic location, which enhances sanitation and safety," explained Marrack. "This information is combined with data gathered when products arrive and are used in the system. Therefore, food products can be traced to time and date of origin, if needed."

Frozen pre-prepared products, on the other hand, are taken on flatbed carts from the main freezer, which holds foods at 14°F., to a decasing room set at 50°F. where outside packaging material is removed. Next, frozen foods are moved into a specially designed room containing a tempering chamber. "This room works opposite to the way in which a blast chiller works," Marrack explained. "In a regular blast chiller, chilled air is rapidly passed over the top of hot foods and heat is removed. In this unit, chilled air at 37°F. is rapidly moved across the top of the frozen foods and the internal temperature of the products rises from -14°F. to 37°F. in approximately six to eight hours."

To control tempering more accurately, Marrack added, "a special probe is placed under the food, which senses temperature changes throughout the process. The sensor attached to the probe initiates some injection of heat into the air that is moving past the products during tempering, so the frozen items will increase in temperature to 37°F. The temperature of the air moving over the products, however, never goes above 37°F. Therefore, no part of the foods ever goes into the danger zone as a result of the tempering process. The air continues to be recycled and circulated until food reaches 37°F."

According to Seth, 2,400 trays (800 per meal) can be tempered in less than six hours. In the old system, added Marrack, tempering was done inside a regular refrigerator and, as a result, took two to four days. "In addition," he said, "this chamber occupies one-third of the space required for tempering compared to the old facility. This reduction in tempering times decreased the value of inventory by $25,000. Also, we realized better quality outcomes through the rethermalization process."

After food has been tempered, it is placed in a chilled state into plastic bins, labeled and checked for temperature and appearance. Because food is chilled, no tasting is done at this stage. "Qualified cooks empty food from bags into the bins," Seth remarked. "We wanted to be certain that people who were knowledgeable about food were assuring that it was acceptable."

According to Marrack, "The chilled environment maintained throughout the process helps not only to meet HACCP requirements and keep the food safe, but also contributes to a reduction in insurance costs for workers."

Dirty trays are picked up by Nutrition Services staff, placed in the same cart used to deliver plated trays, and returned to the main kitchen (pictured here) to be washed. Two dishmachines were installed, one for dishes and racks, and other for trays and cutlery. "We wanted to use an old machine but, when we disassembled it, we realized it had seen better days," noted Marrack. Thus, two new machines had to be purchased.

In the dishwashing area, staff members take china off the trays and remove waste into a trough, which leads to a pulper. "Instead of having open water troughs on the dishtable," ex-plained Marrack, "we put in chutes and a water trough under the belt line so it is 'invisible' and doesn't smell overwhelming. This has made a big difference to our employees."

The newly selected dishwashers' manufacturer was asked to incorporate automated traits of its old dishwashers into the new models, which was successfully accomplished. Employees now place china on racks, while cutlery remains on the trays. The racks are automatically loaded via a roller conveyor into a dishmachine. Simultaneously, a magnet picks up the cutlery from the trays and drops it onto a separate belt that goes into another dishmachine. The trays also are loaded onto a dishmachine automatically. Trays and cutlery are unloaded automatically, though the racks must be emptied by staff.

"We were careful to create a physical separation between incoming wares and waste and outgoing clean dishes and wares," explained Marrack. The dishwashing area is adjacent to a separate cart wash and drying chamber that, according to Seth, operates much like a car wash. Once they have been cleaned and dried, serviceware, trays and carts are all taken into a chilled room until needed for the next menu plating cycle. "Pre-chilling dishware and carts reduced the demand on refrigeration systems and increased food safety," asserted Marrack.