University Health Network
In Toronto

By Donna Boss, Contributing Editor

A new patient food procurement and meal assembly/distribution center for a group of three hospitals located in downtown Toronto has resulted in productivity enhancements and significant savings in labor and inventory. In order to surpass health code and HACCP requirements, the facility's equipment was positioned to eliminate cross-contamination and maximize sanitation and safety.

A large warehouse area, built with storage rooms for dry, chilled and frozen foods, is positioned so products can be brought in directly from dedicated receiving docks.

When University Health Network (UHN) installed a state-of-the-art, centralized foodservice operation in the Bell Wing of the Toronto General Hospital (TGH) site in 1994, the facility's life expectancy was estimated to be at least 15 years. The $3.84 million (Canadian $6 million) operation replaced conventional kitchen operations in TGH and its nearby affiliate, Toronto Western Hospital (TWH). Nearly all food products, including entrées, were purchased pre-prepared, then stored, thawed if needed, assembled in a chilled state on trays and delivered to patient floors. Food to be served hot was rethermalized on the floors, assembled with other menu items and presented to patients. Dirty dishes and trays were brought back to a centralized area for sanitizing.

But since change is the only constant, future predictions are often off course. So it was for UHN. In 1997, architects Hellmuth, Obata + Kassabaum Inc. were hired to develop a master plan for the redevelopment of the network's hospitals.

The firm's recommendations included demolishing the aging Bell Wing that contained the redeveloped kitchen to make way for a new addition to the TGH complex. The firm also recommended that a new, separate, support services building be constructed on the TGH site to house nutrition services, an emergency department, research and administrative offices, receiving docks and materials management. Because UHN is government-funded and government funding had been committed to other hospitals, bonds had to be issued to generate revenue to construct new facilities proposed in the master plan.

Soon after the master plan was accepted, foodservice consultants Marrack + Associates Inc. were retained to prepare a functional program, as well as design and oversee construction of the new R. Fraser Elliot Support Services building and its nutrition services operation, located in the basement. The new $33 million (Canadian $55 million) building opened in March 2002.

The patient food procurement and meal assembly/distribution center operates with the same basic system used in the old building, but with several improvements such as a single-floor layout, a designated tempering room and the addition of two new, highly automated dishwashers. The cost of new equipment and special ducting and refrigeration totaled $1.1 million (Canadian $1.74 million). An average of 2,400 trays are prepared and delivered daily to the adjacent 632-bed TGH, nearby 335-bed TWH and 101-bed Princess Margaret Hospital/Ontario Cancer Institute. (Currently, patient bed counts are 450, 250 and 130, respectively.) The process is accomplished by 260 employees, including 40 dietitians.

Automated warewashing enhances sanitation and productivity. Trays and cutlery are washed separately from dishes.

"No doubt this was a costly move and, for some, it was a heartbreaker because of the prior investment," 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. "However, we were able to save equipment, such as carts, the trayline and pulper. We were also able to reduce operational costs, including savings of nearly $150,000 annually for five FTEs [Full-Time Equivalent employees] because the new facility is on one floor versus two floors at the old building." In addition, he noted, communications has improved "considerably," the flow of the process was enhanced and inventory costs were reduced.

The mission of the new facility understandably includes long-term goals. When the project was in its initial planning stages, Mark Miles, UHN's director of Design and Construction for Project 2003, announced, "We want the new patient foodservice facility to be state of the art, to embrace technical innovation, to maximize operational efficiencies and to take us into the coming decades."

The process of patient food delivery begins with menu development. 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. On the other hand, patients who are in the hospital for two weeks or longer may select from a restaurant-style menu.

Once food has arrived, a computer program creates a tally and generates an "advance withdrawal" sheet that is used to inform staff of the type and quantity of food products needed for patient trays for each meal. Next, food is placed in either dry, refrigerated or frozen storage. Dry and refrigerated products, such as juices, fruit, vegetables, dairy items 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 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 the project's foodservice consultant, Matthew Marrack, principal partner, Marrack + Associates Inc. "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 food products, on the other hand, are taken on flatbed carts from the main freezer, which holds food at 14°F., to a decasing room held 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, which is to reduce the temperature of foods after cooking to a chilled or frozen state," 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 the tempering process more accurately, Marrack added, "a special probe is placed under the food, which senses temperature changes through the tempering 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 foods 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 food products ever goes into the danger zone through the tempering process.

The air continues to be recycled and circulated until foods reach 37°F." According to Seth, 2,400 trays (800 per meal) can be tempered in less than six hours. In the old system, tempering was done inside a regular refrigerator and, as a result, took two to four days.

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."

The plastic bins are next placed on carts and taken into a holding day-store refrigerator near the trayline, which is maintained at 37°F. "Food is always flowing forward toward plating," Seth noted. "It never returns to the chamber it was in previously, which prevents cross-contamination."

Immediately before the trayline begins, all chilled food is brought into this room, which is maintained at 50°F., and plated by dietary aides onto pre-chilled (to 37°F.) serviceware and trays. 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. Completed trays are placed in pre-chilled carts holding 16 trays each and held in another walk-in refrigerator at 37°F. until removed for delivery.

Food is removed from storage and taken into a decasing room with an ambient temperature of 50°F. where outside packaging material is removed. Products are placed on racks in carts and brought into a tempering chamber.

These insulated carts are delivered to each of the three hospitals 30 to 45 minutes before mealtimes and placed in Nutrition Center areas located on nursing units (one unit serves between 100 and 140 meals) at TGH and TWH; a single unit at Princess Margaret services all patients. 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 food are wheeled from the Nutrition Center units to patient rooms, where meals are delivered.

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 to be washed. Two dish-machines were installed, one for dishes and racks, and another for trays and cutlery. "We wanted to use the 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," explained Marrack, "we put in chutes and a water trough under the belt line so it is 'invisible' and doesn't allow the smell to become overwhelming. This has made a big difference for the employees." The newly selected dishwashers' manufacturer was asked to incorporate automated traits from the old dishwashers into the new models, which was successfully accomplished. Employees next place china on racks, while the cutlery remains on the tray. The racks are automatically loaded via a roller conveyor into a dishmachine. Simultaneously, a magnet picks up 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 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.

Meanwhile, Seth and the 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 installed in 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 in Toronto.

Food products are dished onto pre-chilled serviceware and trays in the tray assembly room, which is maintained at 50°F. Trays are placed in pre-chilled insulated transport carts holding 16 trays each, then held in another walk-in refrigerator at 37°F. until they are removed for delivery to the three hospitals.

Design Capsule

University Health Network built a patient food procurement and meal assembly/distribution center in the basement level of the new R. Fraser Elliot Support Services Building to serve three hospitals in the network: 632-bed Toronto General Hospital Division, 335-bed Toronto Western Hospital Division and 101-bed Princess Margaret Hospital/Ontario Cancer Institute. Cost of new food equipment purchased through the general contractor: $1.1 million (Canadian $1.74). In addition, a new dishmachine was purchased for $60,000 (Canadian $100,000). Reused from the 1994 project were the meal delivery/ retherm system, the waste pulper, tray assembly line, smallwares and utility carts. 2,400 meals are prepared in a temperature-controlled and -monitored room and served to patients daily. Staff includes 260 employees, including 40 dietitians who are involved in patient and outpatient services.

Total size of the R. Fraser Elliot Support Services Building: 175,000 BGSF (building gross square feet), built at a cost of $33 million (Canadian $55 million). Foodservice occupies 24,000 GSF.

• Foodservice Consultants: Matthew Marrack, principal partner, Marrack + Associates Inc., Toronto, Paul Cumpstey, director of design, and associates David Teixeira, Edward Morano and Ken Thompson
• Architects: Christopher Korsh, Hellmuth Obata + Kassabaum Inc., New York City, N.Y., with Hagen Mateme, Urbana Architects Corp., an HOK Worldwide Alliance Partner, Toronto
• Director of Design and Construction for the Project: Mark Miles, UHN, Toronto
• Director of Nutrition Services: Sanjiv Seth, UHN
• General Contractor/Project Construction Manager for Phase 1: PCL Construction
• Equipment Dealer/Fabricator: Julien Inc., Quebec City