JOE LEGGIO: The first thing is, are we asking the question on food? And coming from an inpatient setting, I will say Northwell-- 23 hospitals-- have 7 of our 23. So inpatient-- very high acuity hospitals. But are we asking the question on food? And we all know we have our HCAHPS surveys. Yay, HCAHP surveys. Thank you, CMS.
And I am not saying that I think CMS should be grading us on food. They should not be grading us on food. But us at Northwell-- there are a few things we really, really believe in that matter to us. And these are actually eight additional questions we ask every single patient at any Northwell facility, because this matters to us.
And obviously, there's a question there on, what was the quality of your food? We want to know. And whether it's Northwell or anywhere else, people walk into hospitals expecting the food to what? To suck. Right. You just expect the food to suck. I mean--
JOE LEGGIO: Right. Exactly. And so I look at that in two ways. One, the bar is so low, we are just tripping on it. So it's anything you do can be better. And it was like, let's have this brilliant idea of just-- let's just not have the food suck so much. Let's just figure out a way. We can do that, so it's not that bad.
And what does that look like? So here we go forward. So we made a few very fundamental changes, a lot of kind of what you heard here that's happening. A few simple things-- no frozen meat or vegetables. Just stop frozen everything. If you can't do it fresh, then don't do it.
Antibiotic-free chicken, fresh seafood. No canned soups. And every patient should use real silverware to eat. Just basic fundamental 101 changes. And what we did is we piloted this at Lenox Hill-- one hospital. Never want to roll everything out to everyone out of the gate.
But we said, let's make these changes. Let's just fundamentally change this. Change nothing else. Because unfortunately, we have so many diet restrictions that we have to comply with. And I wish we could serve pizza and beer to everyone. Maybe our HCAHP likelihood to recommend would be much higher.
Unfortunately, we cannot. But we said, let's just fundamentally change this. Then we said, all right, this whole concept of room service. And I spoke earlier this year-- a little bit about what we're doing in room service. And when you put room service out, there's a high expectation people have.
And obviously, we have 21 inpatient units inside Lenox Hill, so a lot of different variation even within our own building. Again, different patient population. So we picked three units to pilot room service. And so this is still-- the server would come to the patient's room.
They would take their diet order and their preferences. And everything is made to order. And it's all served as you can see here. Glassware, stemware, china, linen napkins all comes in just like room service. And now, from a presentation standpoint, looks like we're doing a pretty good job, even if this food isn't that great, right?
It looks like it's going to be pretty good, right? So you're setting expectation. The food is delicious, because it's fresh food and it's made to order, right? It's hard to mass produce anything and want it to be great. No matter how good your culinary expert is, when you start to multiply something, you're going to lose a little bit of quality, because you're cooking in that size.
So we did this pilot. And here are literally iPhone-taken photos of what that food looks like. And it's fresh. It's healthy. It is compliant. A lot of it is just simple, as you can see on our very simple china. And the next slide is my favorite slide of when we asked that food question.
What was the quality of your food? Right here. I always say this slide says it all, right? We were serving the worst food in the country. We literally were. I mean, pretty bad, now to serving the best food in the country and not just for a month or two of a spike of we did a really good job, but for continued months. You've got a question now.
AUDIENCE: Yeah, I've got [INAUDIBLE].
JOE LEGGIO: OK, all right. I'll get through this. And then we'll go through this. What I will mention, which I'm not sure if this is your question. What patient population did we pilot this with? And we did OB for many reasons. The least amount of diet restrictions.
Those patients are well, so very easy to test on a group that has little restriction. Now, to our cardiac telemetry-- Dash, low-salt sodium folks. We're getting there. We're not there yet, but easier to start with this population. And when we look at food for the entire building, did this have an impact on numbers out of the gate?
And what you can see right here is those food changes I was talking-- this is what-- our quality of food score right there, simply by making those changing-- jumping up to the 54th percentile in food for the whole building. And then obviously, having room service go. And this decline here-- I would expect to see.
Because what we did is we took a very normal operation and now put something different in it, so completely different way the kitchen had to function, right? Because now, we're really running one kitchen with two sets of food production, right? What everyone's getting and now what these three units are getting. So that's a disruptor to staff, to operations. And yeah, we definitely felt it.
I'm very happy to say that we're picking back up. And right now for 2018, we're in the 57th percentile for quality of food, which we're very happy of, based on where we were at 13, but by no means where we want to land. But this was one thing we did. And that was rolling out room service.
So our goal is, by the end of first quarter of next year, every patient room will have room service. It won't look exactly like that on the full tray, because not all of our rooms can accommodate a large dining room roll-in tray. But everyone will have linen napkins. Everyone will use silverware. You'd be surprised-- the impact that makes for people.
So what else are we doing? A few other innovations. And then I'll open it up for tons of questions, which I'm sure people have. So late night. So when we read our food scores-- and I was just talking about this. And we read our comments about food, right? The comments went into two buckets. One, your food sucks. It's awful. So you start drilling down into that.
And what we found is when we started to interview patients-- and why is the food so bad? They're like, well, I wanted cheeseburgers and fries. And I said, well, you're on a cardiac floor. You're not allowed to eat cheeseburgers and fries. You just had cardiac surgery. Maybe you shouldn't be eating those burgers and fries right now.
But it was finding that balance of what someone wants, to finding the yes, versus what they can technically, clinically have in our inpatient setting where we don't have that freedom and flexibility. The other set of comments was all about timing. Patients said, you serve dinner. And dinner is over by 6:00, 6:15. I don't really eat dinner by 6:15.
And what happens if I get out of the operating room, or I'm admitted, or I have a change in diet status after 6:00 PM? Which it's like, well, the kitchen closes. It's opened up at 6:00 in the morning when most patients probably want to sleep. And we do a great job of not allowing them to sleep at 6:00 in the morning, because that's convenient for us, right?
So we started to look at the data and found on any given day between 6:00 PM and midnight, there are anywhere between 15 and 18 patients that have a change in diet order status, meaning they were not able to eat. And now, they can eat. And now, they can't, right? And now, we did the first line of defense, right? We got the boxed lunches out.
We made those the nicest boxed lunches you have ever seen. And they're very nice boxed lunches, but they're cold boxed lunches. And if you've been NPO'd, if you have not been eating for 20 hours, the last thing you want is for me to try to sell you cut-up cheese with Brie with anything else.
You just don't want to hear it. You want hot food. So we're looking, starting in January to rolling out what we're calling our Late Night Eats Menu, a much smaller menu than what's served during the day, where we can staff every floor, every patient to have food between 6:00 PM and midnight to order the same way they would during the day.
And this was obviously-- there's financial cost to this. And a little bit of what I spoke about, even just mentioned earlier is, how are we paying for all of this? Those room service rooms are how we're paying for it. So our hospital's 654 beds were licensed out.
We run about 450. We have 20 suites. Those 20 suites pay for all of these extra things. We use that revenue for it. And it's one of those things. It's very hard to find extra operating dollars to buy the latest system, to hire the FTEs.
How are you going to do that, especially when this comes in the larger conversation of, you need new MRI equipment, you need additional nurses, phlebotomy needs this, radiology needs this. And oh, and then the kitchen. Food wants this. Who gets cut first? Unfortunately, right? I mean, I forgot who. Someone said it before.
But you're cutting something off the top to save a few cents, but huge value for people, right? Because it's the one thing patients get to control a little. You can't eat 100% what you want to eat. It'll be kind of what we tell you, you can kind of eat. So huge things. So we're working on this. And again, that's kind of what I just spoke about, of how the program is going to work.
And then one of the other things, which was really interesting, we looked at our data or even our Press Ganey data and found 22% of our patients do not select English as a first language. And so we look at that, obviously, for lots of reasons-- health literacy, translator services. What are we doing to be more culturally sensitive?
And then we started talking about, well, what about food in that space, right? If someone's choosing English not as a first language and doesn't speak English, well, then maybe there's different food preferences that we're not looking at. And what we found is 22% of our patients select Asian as their primary language.
And there's, again, a lot of subsets that exist in there. So we're starting in February of next year to launch a gourmet Asian menu option as a pilot to patients who do not speak English as a first language and select Mandarin or Cantonese as a first language, to offer a translated menu with very culturally appropriate options to different patients.
And this-- again, these are not stock photos. These were just taken actually last week, because our menu just got printed. These are all literally on a white napkin inside our kitchen that we've made-- everything here. I wish I could tell you exactly what each of these were. I can't. But we're very, very proud to be able to offer this.
And again, it's why this group, not that group. It's a little bit of numbers and little bit of piloting, right? I mean, we try to have as many options we can for every group. And we have kosher options. And we have vegan options and plant-based options.
And knowing that 22% is a large percentage of our patient population. And then once this works and we can get all the kinks worked out of here, how do we then roll that out to everybody else? And then a few. Sorry, just a few other photos we had there. And then, again, what we spoke about there.
And then I always say, does this have an impact on likelihood to recommend, right? Which is our HCAHP domain that everyone is looking at. And I'm glad, like I said, that HCAHPs and at CMS do not measure us on food. But in certain patient populations, we know that that really matters to them. Food does.
And what I'm proud to say is the blue line-- sorry, the light blue line is our patient experience scores over time. And then to the gentleman's comment before, over here-- Robert, I think, around the employee experience around food. And what you see is those one or two, of course, as we all know, very tied.
But when we started this patient experience scores in the 43rd percentile, 45th percentile, now up to the 56th percentile, there's a lot of things we're doing. Food can't take all the credit, but it definitely has a huge piece in what we're doing to have an impact on someone's experience.
So the numbers definitely support that. And that was it. So yeah, we really quick want to go through things. And I figured opening it up for questions on each one of these. All kind of different initiatives looking at very different things, but all centered around food. Yes?
AUDIENCE: Just a crazy leapfrogging question. Why is the hospital in the business of food, right? So this is based on-- and patients pack their bags, got an elective surgery, and spent two weeks in the hospital, and changed their mailing address. Before I retire, the hospitals are going to be ERs, ORs, and ICUs.
You're not staying. The only meal you're going to get is if we keep you overnight. And the only meal you're going to get is if you're in the hospital for some medical diagnostic, most of which is going to be done as an outpatient. Or if the patient-- if I get a complication or the patient needs to stay for a couple days.
So why aren't we just changing the paradigm and saying, we're going to have some basic healthy meal options for you? And then when you go through the airports now, you sit down at a table. You order up your menu on a computer, right? And then somebody comes from somewhere and delivers it.
Most of us are in urban hospital settings. There's Grubhub. There are all these delivery services. I mean, why aren't we simply allowing-- just take it off our plate literally and figuratively put it on somebody else's plate? New York City? My goodness. How many restaurants-- four and five star are around Lenox Hill?
We got a hundred restaurants within two blocks-- my hospital. And the families-- when we do the surgery, families aren't in the waiting room. They didn't eat, because they didn't want to eat in front of their loved one who's having surgery. They're at [INAUDIBLE]. Exactly. And sometimes they'll bring the family member food. But anyway, just a leapfrogging-type question.
JOE LEGGIO: No, no, it's 100%. That's right. That's exactly the way large hospitals are going to. And so what we do is we keep our patients very close to every decision we make. So we have an Executive Patient Family Advisory Council. Anytime we make any change, whether it's in food or it's attached to anything-- relating experience, we connect with our patients and say, what is it that you want?
Knowing this is where care is going, knowing you're going to be in the hospital for hours now, not days-- going. Patients still have an expectation that we are feeding them. Patients now more than ever-- I think because they're so educated and wanting healthy foods, that's a part of their recovery, is eating that healthy, sustained food.
And there's an expectation that they've told us that we expect the hospital to pay for that. And to the comment I made earlier, it was patients are coming in now more than ever assigning value, right? My co-pay is higher. My deductible is higher. So I came in. And now, clinically, I need the surgery to go well.
I need everyone to be "nice," and be empathetic and caring. And now, they're assigning value to the food I got, right? And-- been patient experience. Sometimes a lot of the calls we get are, oh, I'm not paying my bill. I'm not satisfied. Well, why aren't you paying your bill, Mrs. Smith? Well, what had happened?
Oh, well, this nurse was mean. This person was nasty. I had to wait a long time for my food. I didn't like it. And that's part of coming into the conversation. I'm ahead. I'm like, well, right. This isn't a restaurant, right? I'm so sorry you didn't like the food. But there's just this intrinsic value that people are placing in the overall experience we give them.
And I think we have to find ways to leverage technology, to leverage all those resources, so it's less-- maybe people strenuous, but that it works. Because people are still expecting it. Despite the short-- the length of stay is going down, I think our patients are telling us, we have an expectation that you're doing that for us.
AUDIENCE: I'm going to make a counterpoint to that. It's interesting because you say this. Because when my father was going through infusion at Hackensack Meridian down in Jersey, it was so fascinating to me. Like in New York City is an infusion room with many people with leaning-back chairs.
It was really [INAUDIBLE] to maybe go watch and be with him. But when he went to New Jersey, he had a room with a view of the water. They served him meals that actually he looked forward to getting and enjoyed being there. The staff could not have been nicer. And going back to what we were talking about-- the will to live.
It shifted his mindset from being someone who is on the brink of dying to someone who could actually survive. So I am a huge proponent of this. It was fascinating to me to see how he went from being really like, this is the beginning of the end, to like, I could actually get through this process in the most dignified, supportive way.
It's life altering. And as a family member like my mom, she was able to drop him off and go do something for her mental well-being that I set up for her for five hours a day, while my dad was laying there. And so as a caregiver-- and my dad-- I kept thinking like, I didn't want to ask my dad who was paying for it.
Because if it was him-- frankly, if it were him, he would not want to pay for it. But my brother and I were ready to subsidize if necessary. But it was this very funny thing. I'm like, if my dad ever gets hit with a bill, this party is over as fast as it started. And I don't think he was.
It's so interesting. Who's paying for this? Are you sending an-- is the cost of being fed-- is covered by Medicare and insurance? I didn't want to ask the question, because I didn't want to get the bill. But it did cross my mind. He was enjoying fabulous food. He was so happy. But who's paying for that?
JOE LEGGIO: No. I mean, for Medicare/Medicaid patient, we have to provide food as part of the bundled care that we get reimbursed on.
AUDIENCE: But you're saying the subsidy is from the private-- like the Beyonce suites where the birthings are happening.
JOE LEGGIO: Exactly. Right. Yep. We're not breaking HIPAA. Beyonce said it.
AUDIENCE: No, no, no, no, no, no. Yeah, right.
JOE LEGGIO: And the people have an expectation, especially walking into Lenox Hill off of Park Avenue, that because Beyonce and other celebrities live over there, that there's an expectation of all things. And we have 50--
AUDIENCE: If I were running your business, I would just do Lenox Hill, a whole suite hospital. It would be a total game changer in New York. Because to me, that's worth what people want. And it's very hard to get in Manhattan. But I'm not-- I mean, that would be like for me.
JOE LEGGIO: No, no. We're-- yeah.
AUDIENCE: I mean, that's-- if I were in your shoes, I would really-- thinking about. Clearly, this is what people are willing to pay for and they need and the market doesn't offer so easily.
JOE LEGGIO: Yep, absolutely. Yeah, sorry. Wait. We'll go here and start one right there.
AUDIENCE: Thanks. Can you-- so that improvement in patient experience relative to quality of food is just incredible. Can you talk a little bit more about some of the interventions that you put in place? Because, I mean, that is a meteoric rise, which I've seen before. But just be able to sustain that over time is unbelievable. So I heard about the no frozen meat or veggies, fresh foods. What else? What else happened during that time frame?
JOE LEGGIO: Yep. So actually, it's funny you're talking about plant-based food on some of our cardiac floors. Again, a lot of patients are upset with the food they're getting, because it's not what they want to be eating. But we need to have healthy options. Did an entire discovery of plant-based diets for all of our cardiac floors.
So you start taking 21 units. 3 run like this. You start-- you have 18. We've got 5 that run cardiac, right? So now, you're down to 13 floors and changed the entire menu to be plant-based options. And the feedback has been tremendous with people. And it was one of those things-- completely nervous for.
So we've definitely-- that was one. What we're starting to do now is happy hour on some of the floors. And we're doing these on our surgical floors and medicine floors. Not the happy hour you're thinking by any means that we would all probably love to go to, but as a way to test all the changes in food for patients.
And then we do that actually for staff. So one of the bold things we did for maternity before we switched-- and I think I'm back to clicking normally here. Before we switched to that food into these numbers, I did a bold move. I took my entire executive team. And I served them the food that we were serving patients and how it tasted like this.
And I said, what'd you think? This was disgusting. You've got 54 of your maternity patients eating this right now upstairs. That's the start of their food experience with us. So how is it? And it was a bold move. I'm still employed, so that worked out well for me. So now, we did that with staff as well when we switched the food, right?
Because where we can be our own best ally, our own worst enemy, right? Because we can very quickly not talk up the next team. Oh, the food's coming. Oh, if the food-- it is what it is. It's so easy for some to throw it under the bus. But how great would it be if a staff member, a nurse, a PCA, a tech said, oh, no, no. Our food's incredible.
Just try it. Before you order Seamless, try our food, especially this food right now. So we did tastings and samplings with staff. So it's a combination of pilots changing all of cardiac to plant-based. Happy hours for that. And I think it's going to be a combination of access to food.
It's going to be tremendous. So those-- honestly, it may be shocking. I'm proud to say that it's those little things that have actually yielded this. There's not a bigger secret that I promise I'm not sharing. I mean, specifically, that's what this is in the building. Yeah? Sorry, we'll go there in a minute.
AUDIENCE: So even though I'm in health care policy, I have very few personal experiences interacting with our health system. And two of them happened just in the same month with my mom landing in one hospital in Phoenix. They took one look at her. Does she have cardiac issues? No. But they said she's overweight.
We're putting her on a restricted diet. So every day when she ordered off the menu and I was right there, there were only certain things that she could order. And she grumbled. And she demanded to have her own way. And they said this is a hospital. We're about health, right? And so she couldn't get the cake. She couldn't get the cookies.
She couldn't get high sodium. But what happened in the process is that health system, an integrated health system, not just a hospital, invested in educating her about why they were restricting her diet, why they were restricting fat, sodium, carbohydrates. They sent in a registered dietitian to talk with her.
So when she went home, what I saw as someone that just kind of sits in an ivory tower and studies things all day, was behavior change. She said, Dani, before you give me that soup, let's look at the sodium. Let's look at the saturated fat. Bring out that paperwork from the hospital. Behavior change is hard, especially in a three-day change.
And I think you guys from the health systems can play a big role when someone has an acute issue, an emergent issue in their life. You are facilitators of behavior change. Four weeks later, she was in another hospital that looked at her, saw all the same data, saw all the EMR records and served her hamburgers and French fries.
So my question to you is, in the hospital system, in the integrated health system with the ACOs with the upside and downside risk, do you have like what Cornell had with the Menus of Change? Do you have someone to help you kind of with the system to provide these triggers, the baselines that you kind of have for health systems?
JOE LEGGIO: No. Absolutely. And that was a piece that I should have elaborated on more with the plant-based cardiac diet, is so anyone-- we've got bundles, right? Anyone who has got congestive heart failure that has now had-- lived a lifestyle, had an acute event and now needs to live really a different lifestyle to avoid this happening again.
Everyone that gets discharged with congestive heart failure is visited by a nurse practitioner, but now, also by a registered dietitian. And they're followed up with in the outpatient setting-- every single patient to that exact point, right? Because you're trying to change behavior, which is the hardest thing without the why.
And what I think we've been really successful in is that it's not saying one or the other, right? It's not, you can never have this again, right? You should-- to have this in moderation, right? Eat a hamburger-- cannot be what you eat five of the seven days of the week. It can be one, right? We have to balance that.
So every patient-- and we're working on bundles that way, congestive heart failure being the largest that we see, that they get seen by a registered dietitian and followed up with frequently. And now, that's part of-- what we're trying to do is connect that back with their primary care cardiologist outpatient.
So it's, hey, here's all the work we've done, right? To your point, they're seeing the EMR, right? [INAUDIBLE] the right intervention, medication. Management great. And what else is the diet piece that we're now getting in there? And it's hard. I'd like to say we're doing it for every service, for every discharge. We're not. But heart failure has been one we've really been able to show sustained growth.
And then if somebody is back readmitted in the hospital-- and of course, they'll be on a telemetry-based floor. Now, they're used to this food, right? And this is now what they eat at home. Because the minute you give someone something that they're not eating at home-- what is this, right? And we're trying to avoid that, what is this? moment. So a piece to that. Yeah?
AUDIENCE: So when you talk about the significant change to your menu and the processes in the kitchen, how did you introduce the change to your employees? Because that's a very different style of cooking, a different understanding of how the systems work in the kitchen. I mean, I know you did the tastings and the happy hours, which is great to try and get the initial buy-in. But that's a significant change to, I'm the cook who works in your kitchen-- in what they're doing.
JOE LEGGIO: Absolutely. Yeah. No, this was a complete disruptor, which is why I think this data is perfect. Because it doesn't show this perfect, great, getting better everyday line. It shows people had some real challenges with this. The first thing we did was, again, ask the question of all, everyone that worked in the kitchen, whether you're a chef, an executive chef, no matter what role you play.
What food would you love to serve to patients? If you could do any food, what would you want to serve? What does great food mean to you? Right? If you could serve the best food, what is the best food for you? And we've had a different definition of what that meant, right?
Some of it was flavor based. Some of it was more presentation. Everyone had a different story. And so that was the impetus for the buy-in of, well, we want to get there, right? And we know we can't get all 450 beds changed with the 1,500 meals we've got to serve, plus the cafeteria, plus the Starbucks cart.
But if we can change one, then we've done something. Then we can change two. And so it was-- when we told them-- fully transparent. We don't have all the answers here, right? And we said, we've been asking you to do a role that we have molded.
You guys are all experts in your field, or you're believers, or you want to work in the kitchen because you love food. Help us build this together. And it was a lot of-- it wasn't as official as like a Lean Six Sigma project, so I can't say that it was that. But it was a lot of roundtable discussion on, what do you think?
How do we do this? With a relatively new leadership team in our kitchen, in four years, we've had three directors of food and nutrition. So we've had some high turnover, because we wanted to make this change. And I said, no, no. We can't do that. Well, why?
Because this is the way we do it. Isn't that a great reason? Right? Love that. I mean, why can't we make it better? So it started with that. And then it was a little bit of changing everything. And the minute somebody believed what they were giving was incredible, everything changed, right?
I mean, my background is in luxury fashion, right? And I always say-- I worked at Louis Vuitton for seven years, right? And the difference in what-- an hourly salesperson is going to work on the Louis Vuitton sales floor versus someone who's working at the Gap, right?
You're talking it's $3 an hour, $4 an hour difference, right? How is someone getting a different experience, a different training? It's the investment, the development. And they believe what they are selling is the best. That changes everything, right? And I love Louis Vuitton. I have a lot of pieces, but it's plastic. And it's vinyl plastic, right?
I mean-- but it's the oldest, largest luxury brand in the world, because of how they invest in it, right? And someone at Gap trains three days. Louis Vuitton is eight weeks of training before you can be on that sales floor for retail. And again, I did it. So I mean-- because they believed in it differently. You got to find the passion.
SPEAKER: I think what we need to do is get to Odette--
JOE LEGGIO: Sorry. Yes.
SPEAKER: --and let her present. And then we can-- if there's more time at the end, we can do this. Or we can continue this over lunch. I don't want to be unfair to Odette. Let her get in. Thank you.
JOE LEGGIO: Perfect. Trying to be consciously clicking, so that it lands for you. There we go.
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Joe Leggio, Senior Director of Patient and Customer Experience, Northwell Health, speaks about the relationship between patient experience and food services, and opportunities that this relationship affords. The talk was part of the Healthy Futures Roundtable held on October 10th, 2018.