oversight

VA Health Care: Food Service Operations and Costs at Inpatient Facilities

Published by the Government Accountability Office on 1999-11-19.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

                 United States General Accounting Office

GAO              Report to the Chairman, Subcommittee
                 on Oversight and Investigations,
                 Committee on Veterans’ Affairs, House
                 of Representatives

November 1999
                 VA HEALTH CARE
                 Food Service
                 Operations and Costs
                 at Inpatient Facilities




GAO/HEHS-00-17
      United States
GAO   General Accounting Office
      Washington, D.C. 20548

      Health, Education, and
      Human Services Division

      B-281940

      November 19, 1999

      The Honorable Terry Everett
      Chairman
      Subcommittee on Oversight and Investigations
      Committee on Veterans’ Affairs
      House of Representatives

      Dear Mr. Chairman:

      The Department of Veterans Affairs’ (VA) health care system requires a
      number of nonclinical services, such as food services, laundry, and
      housekeeping, to support the delivery of clinical care. About one-third of
      VA’s health budget is spent on support services. Because these services
      make up a sizeable share of health care operating expenses, one focus of
      health care systems in the 1990s has been on reinventing the way they
      provide support services as a part of their overall efforts to increase the
      efficiency of health care delivery. Health care systems have used a variety
      of methods in their efforts to increase efficiency. These methods include
      consolidation of services, changes in technology, reinvention of work
      processes, and outsourcing of services.

      VA provides many of these support services in inpatient settings. In fiscal
      year 1998, VA spent approximately $8.4 billion on inpatient
      services—which include clinical and support services—for about 650,000
      inpatients admitted to its facilities. VA provides inpatient health care in 175
      locations in its hospitals, nursing homes, and domiciliaries.

      You expressed concern that VA may not have focused adequately on
      increasing the efficiency of services that support its delivery of patient
      care. To address this concern, you asked us to develop a body of work
      providing baseline data on major VA support services and assessing
      options for increasing the efficiency of these services. You asked that we
      begin this work by examining VA’s inpatient food service operations. This
      report provides fiscal year 1998 baseline information on (1) the type and
      volume of food service VA provides, (2) how VA provides food services,
      (3) the cost VA incurs, and (4) the revenues VA generates from sales of
      excess food services. We will assess options for increasing the efficiency
      of VA food services in a subsequent report.

      To conduct our work, we surveyed the 22 Veterans Integrated Service
      Networks (VISN) to obtain data on food services at VA’s 175 inpatient




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                   locations. We also obtained data from VA headquarters officials and
                   conducted site visits and telephone interviews with local VA officials. (See
                   app. I for a complete description of our scope and methodology.) Our
                   work was performed between December 1998 and October 1999 in
                   accordance with generally accepted government auditing standards.


                   VA provides a variety of food services to meet the widely varying needs of
Results in Brief   patients. For example, patients frequently need specialized food services,
                   such as diet-restricted meals, snacks for special conditions like diabetes,
                   and liquid nourishment for those unable to eat solid food. Most hospital
                   patients need food delivery to their bedside. Many nursing home residents
                   also require food service in their rooms, although a larger proportion of
                   nursing home patients eat in congregate dining areas. The volume of food
                   service at individual locations also varies, with most locations serving
                   between 100 and 400 patients a day, although 25 percent serve fewer than
                   100 patients a day.

                   In fiscal year 1998, VA employees provided food services at 172 of 175 VA
                   inpatient locations; private contractors provided food services at the 3
                   remaining locations. VA-operated food service locations buy most of their
                   food supplies from prime vendors who provide discounts for high-volume
                   purchases. VA-furnished meals and snacks include food cooked from
                   scratch; pre-prepared foods that are purchased; and food cooked in
                   advance and chilled for later use. VA locations also use traditional and
                   advanced food delivery methods to maintain proper temperatures when
                   food is distributed. The mix of these methods varies by location.

                   VA spent about $429 million on inpatient food services in fiscal year 1998.
                   Of this amount, VA spent about $337 million to produce and distribute
                   inpatient food and nourishments, with the rest for patient-related activities
                   such as nutrition needs assessment and counseling. About 72 percent of
                   production and distribution costs were for the wages and benefits of about
                   7,348 full-time-equivalent wage-rate employees. VA’s daily food service
                   production and delivery costs averaged about $24.50 per patient, with
                   individual locations’ daily costs ranging between $8 and $51 per patient.
                   The range in costs partly reflects the range in nutritional needs, which are
                   generally less in domiciliaries than in hospital and nursing home settings.

                   In fiscal year 1998, 27 VA locations generated modest revenues of $739,000
                   by using excess food capacity to produce food service for 44 non-VA
                   organizations. Most sales were to private, nonprofit organizations; the



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                    other VA sales were primarily to federal, state, and local government
                    agencies.


                    VA operates 172 hospitals, 131 nursing homes, and 40 domiciliaries.1 These
Background          facilities—singly or in combination—are located in 175 inpatient locations.
                    Over the last decade, VA has dramatically decreased its use of inpatient
                    hospital care by about 58 percent, with most of the decline occurring in
                    the last 3 years. At the same time, VA has increased its emphasis on
                    outpatient care by establishing community-based clinics and increasing
                    outpatient care at hospitals. The downsizing of inpatient care has created
                    additional pressures on minimizing the costs of support services, as there
                    are fewer patients who need these services in most locations.2

                    VA provides food services at each inpatient delivery location to patients,
                    visitors, volunteers, and employees through its Nutrition and Food
                    Services (NFS) program and its Canteen Service. The NFS program is
                    responsible for ensuring that VA’s inpatients receive appropriate and
                    quality nutrition as an integrated part of VA health care. The Canteen
                    Service is generally responsible for providing food and other retail
                    services to outpatients, visitors, and employees at VA’s delivery locations.
                    NFS services are funded by appropriations; Canteen Service operations are
                    funded by revenue from sales.

                    VA has managed its inpatient delivery locations through 22 VISNs since
                    fiscal year 1996. These VISNs have the responsibility to make basic
                    budgetary, planning, and operating decisions to meet the health care needs
                    of veterans living within the geographic area, including the food service
                    needs of VA inpatients. VISNs vary in the extent to which they direct or
                    delegate initiatives regarding VA food service operations at their inpatient
                    delivery locations.


                    VA’s food service needs vary widely based primarily on individual patient
VA’s Food Service   needs as determined by VA’s dietitians and the numbers of patients at each
Needs Vary Widely   of the 175 inpatient delivery locations. NFS dietitians identify patient
                    nutrition needs, specify the food service appropriate to meet those needs,


                    1
                     A VA domiciliary is a residential rehabilitation and health maintenance center for veterans who do not
                    require hospital or nursing home care but are unable to live independently because of medical or
                    psychiatric disabilities.
                    2
                     See VA Health Care: Challenges Facing VA in Developing an Asset Realignment Process
                    (GAO/T-HEHS-99-173, July 22, 1999).



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                                        B-281940




                                        and ensure the quality of food and special nourishments that patients
                                        receive.

                                        VA inpatients need regular meals, diet-restricted meals, snacks for those
                                        with special conditions such as diabetes, and special liquid nourishments
                                        for those unable to eat solid food. Diet-restricted meals, snacks, and
                                        special nourishments are most commonly required for hospital patients
                                        and nursing home patients. Less specialized food services are more
                                        common for domiciliary patients.

                                        VA inpatients have food provided in different ways. Many hospital patients
                                        are bed-bound and need food delivered to their rooms. Bed-bound patients
                                        in nursing homes also need food delivered to their rooms, but a greater
                                        proportion of nursing home patients are able to eat in congregate dining
                                        areas than are hospital patients. Domiciliary patients are generally
                                        ambulatory and do not need special assistance with eating.

                                        VA served approximately 40,000 inpatients in its facilities on any given day
                                        in fiscal year 1998. Of these, approximately half received hospital care and
                                        half received extended care in nursing homes or domiciliaries (see fig. 1).
                                        VA provided inpatient food services in every state, the District of Columbia,
                                        and Puerto Rico.


Figure 1: Average Proportion of
Patients Receiving Food Service by
Type of VA Inpatient Facility, Fiscal
Year 1998




                                        Note: N=175 inpatient health care delivery locations.

                                        Source: GAO survey of VA’s VISNs.




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                                       The volume of food service needed also varies widely by delivery location
                                       because of differences in the size of inpatient population. The average
                                       daily population ranged between a low of 18 and a high of 778. Most
                                       locations had an average daily inpatient population of 100 to 400 in fiscal
                                       year 1998 (see fig. 2). However, about one-quarter of the locations had a
                                       average daily inpatient population of less than 100 and about one-seventh
                                       had a daily population above 400.


Figure 2: Percentage of VA Locations
by Size of Average Daily Inpatient
Population, Fiscal Year 1998




                                       Note: N=175 inpatient health care delivery locations.

                                       Source: GAO survey of VA’s VISNs.



                                       VAmeets its food service needs through its NFS-operated kitchens and
VA Prepares Food for                   Canteen-Service-operated kitchens and through private contractors. VA
Nearly All Locations                   uses a variety of methods to produce and distribute food.


NFS Provided Inpatient                 NFS fulfilled 99 percent of VA’s food inpatient service needs in fiscal year
Food Services at 168                   1998 through the operation of 158 kitchens. In providing these services, VA
Locations                              requires NFS kitchens to purchase most food items from prime vendors to
                                       save on procurement costs. Prime vendors agree to sell supplies to
                                       purchasers, such as VA, at discounted prices when the purchaser agrees to
                                       buy a large volume of specified products exclusively from the vendor. VA
                                       headquarters awards contracts to different prime vendors by region. VA’s
                                       NFS kitchens, however, purchase some items, such as milk and bread, from
                                       other suppliers.




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VA uses a variety of methods to produce and distribute food, and many
locations use a combination of these methods to provide inpatient food
services. Historically, NFS has produced most food in kitchens located at
health delivery locations where the food is consumed. Typically, this is
conventional food production or cooking from scratch, using raw
ingredients and recipes. Food production generally takes place just prior
to meals. Some locations use convenience foods primarily or exclusively
to reduce or eliminate cooking on site. Convenience foods are purchased
already cooked or processed. Food items that are served hot are reheated
or cooked just prior to meal time. Although convenience foods are
generally more costly than raw food products, some VA locations believe
that this method is less expensive overall than cooking from scratch
because VA reduces its labor costs for food preparation.

Some locations cook food in advance and chill until needed. There are two
cook/chill options, which may be used independently or together. The first
option, blast chill, can be used for most food items and can chill foods for
up to 5 days before being consumed. This option can, for example,
eliminate the need for weekend hours for many food preparation staff. The
second cook/chill option chills food for 21 to 40 days, but this option is
suitable for fewer types of food than blast chill. The second option
involves one of two processes, depending upon the type of food. The
tumble chill process chills items, such as pasta, that can be pumped into
various sized packets. The cook tank process chills items, such as roasts,
that are vacuumed sealed. Tumble and tank chill processes can produce a
high volume of food in one location—sometimes called food factories or
central production units—for distribution to multiple locations.

After food production, VA must distribute food to patients. This consists of
two steps—assembly and delivery. Most VA locations assemble food
centrally in or near the kitchen where the food was produced. Staff put the
food on plates and trays, usually in a “tray line” where different food
items are placed on a plate by staff at different food stations. Some health
care delivery locations use a decentralized approach, where food is
conveyed in bulk to serving galleys in patient areas where staff assemble
individual trays.

After food assembly, VA delivers food to patients—using traditional or
advanced food delivery methods—to serve food at the appropriate serving
temperature. A common traditional method is the “pellet” system which
consists of a heated pellet (constructed of sealed stainless steel shells) on
which a plate of food is placed and then covered to hold heat. Staff deliver



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                             food on these pellets to patients. Advanced food delivery systems heat and
                             refrigerate food that was prepared at an earlier time. This method is
                             designed to serve as an extension of the advanced food preparation
                             systems, although it can also be used with traditional food preparation.

                             VA uses these various food delivery systems to deliver meals in several
                             ways at its inpatient locations. VA, for example, provides food at bedside to
                             patients unable to leave their rooms, in congregate dining areas when
                             patients can leave their rooms but may need assistance with getting their
                             food, and in cafeteria lines for many domiciliary patients who do not need
                             assistance with eating.


VA’s Canteen Services        Kitchens operated by VA’s Canteen Service provided less than 1 percent of
Provided Inpatient Food      VA’s inpatient food services needs in fiscal year 1998. Canteen Service

Services at Four Locations   workers prepared food at these locations, although NFS dietitians
                             continued to have responsibility for assessing patients’ nutritional needs
                             and monitoring the adequacy of food the Canteen Service prepares to meet
                             these needs. Canteen Service food operations use a variety of methods of
                             food production and distribution similar to those used by NFS. The Canteen
                             Service provided inpatient food services at Marion, Illinois; Poplar Bluff,
                             Missouri; Wichita, Kansas; and at the Martinez, California, nursing home.


Private Contractors          Private contractors provided inpatient food services to meet less than
Provided Food Services at    1 percent of VA inpatient needs in fiscal year 1998. Private contractors
Three Locations              provided food service at three locations, although NFS dietitians continued
                             to have responsibility for assessing patients’ nutritional needs and
                             monitoring the adequacy of food prepared to meet those needs. Private
                             contractors used methods similar to those of NFS to produce and distribute
                             food. Sodexho Marriott provided food services for the Anchorage, Alaska,
                             domiciliary; Sky Chef provided food services for the Honolulu, Hawaii,
                             nursing home; and G & A Professional Services provided food services for
                             VA and Department of Defense (DOD) inpatients at the joint VA/Air Force
                             hospital (Mike O’Callaghan Federal Hospital) at Nellis Air Force Base in
                             Nevada.




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                                         VA reported that NFS spent about $429 million for inpatient food services in
VA Spends Hundreds                       fiscal year 1998. Part of these funds were spent for professional dietitian
of Millions of Dollars                   services. For fiscal year 1998, VA reported that NFS spent $92 million for
on Inpatient Food                        about 1,613 full-time-equivalent employee dietitians and related general
                                         service staff who determined patients’ nutrition needs, monitored the
Service                                  adequacy of food prepared to meet patients’ dietetic needs, and counseled
                                         patients on their continuing nutrition needs.

                                         The lion’s share of VA’s expenses for food service, however, were for
                                         producing and distributing food at VA’s 175 inpatient delivery locations. In
                                         fiscal year 1998, VA reported that it spent approximately $337 million, or
                                         about 80 percent of its inpatient food service expenditures, on the
                                         production and distribution of food to patients. This includes the costs of
                                         about 46 million meals as well as snacks and special nourishments. Most
                                         of VA’s inpatient food costs were for labor—the wages and benefits of
                                         about 7, 348 full-time-equivalent employee wage-grade staff who prepare
                                         and distribute food (see fig. 3).


Figure 3: Distribution of VA Inpatient
Food Service Costs by Source, Fiscal
Year 1998




                                         Source: GAO calculations based on data from VA.




                                         The daily costs of producing food services varied widely among the 134
                                         locations for which cost data were available, ranging from about $8 to
                                         about $51 per patient in fiscal year 1998.3 The range in costs partly reflects

                                         3
                                          Cost data for the other 41 inpatient locations were available only at the integrated facility level, which
                                         includes two or more locations. The average cost at these integrated facilities, however, is similar to
                                         the average cost of the 134 individual locations for which cost data were available.



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                                         the range in nutritional needs from location to location. Locations that
                                         have more ambulatory patients with lesser need for special diets in the
                                         domiciliary setting generally have lower costs than locations that have
                                         more bed-bound patients with more serious illnesses and more need for
                                         special diets in tertiary hospital and nursing home settings. These costs
                                         also include a measure to incorporate expenditures and workload for
                                         meals prepared for persons other than inpatients where NFS paid for such
                                         meals (see app. I for details).4 VA’s average daily food service cost was
                                         about $24.50 per patient. About one-fifth of the locations had average daily
                                         patient costs of at least $5 below VA’s average cost, and about one-fifth had
                                         an average daily cost of at least $5 above VA’s average cost (see fig. 4).


Figure 4: Distribution of VA Inpatient
Locations by Average Daily Food
Service Costs per Patient, Fiscal Year
1998




                                         Note: N=134 inpatient health care delivery locations.

                                         Source: GAO survey of VA’s VISNs.




                                         Among the 134 locations for which cost data were available, average daily
                                         costs per patient were higher in locations with smaller average daily
                                         inpatient populations than in larger locations (see fig. 5). These costs are
                                         higher, in part, because the fixed costs of food service operations are
                                         spread over a smaller volume of patients.




                                         4
                                          This includes meals provided by NFS locations for outpatients, volunteers, and employees.



                                         Page 9                                GAO/HEHS-00-17 Food Services at VA Inpatient Facilities
                                       B-281940




Figure 5: VA Average Daily Food
Service Costs per Patient by Size of
Location, Fiscal Year 1998




                                       Note: N=134 inpatient health care delivery locations.

                                       Source: GAO survey of VA’s VISNs.



                                       VA received $739,284 in fiscal year 1998 from the sale of food services by 27
VA Generates Modest                    VA locations to 44 non-VA organizations. Revenues were less than 1 percent
Revenues by Selling                    of VA’s expenditures on inpatient food services. VA sales to non-VA
Food Service to                        organization ranged from $9 to $75,640. The largest customers for VA food
                                       sales were private nonprofit organizations, such as Western South Dakota
Non-VA Organizations                   Senior Services in Hot Springs, South Dakota, and United Cerebral Palsy
                                       Day Care Center in Canandaigua, New York (see fig. 6). VA also made sales
                                       to government organizations, including federal agencies, such as
                                       Charleston Air Force Base; state agencies, such as the Idaho State
                                       veterans home; and local government organizations, such as the Los
                                       Angeles Homeless Authority Services. VA also sold food services to
                                       for-profit organizations, such as the Columbia Douglas Medical Center in
                                       Roseburg, Oregon.




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Figure 6: Non-VA Organizations
Buying VA Food Services, Fiscal Year
1998




                                       Note: N=134 inpatient health care delivery locations.

                                       Source: GAO survey of VA’s VISNs.



                                       In an October 25, 1999, letter in response to a draft of this report (see app.
Agency Comments                        II), VA said that our report provides an essentially accurate description of
                                       food service delivery in the Veterans Health Administration.


                                       As arranged with your staff, we are sending copies of this report to the
                                       Secretary of Veterans Affairs, interested congressional committees, and
                                       other interested parties. We will make copies of this report available to
                                       others upon request.




                                       Page 11                               GAO/HEHS-00-17 Food Services at VA Inpatient Facilities
B-281940




If you have any questions about this report, please call me at
(202) 512-7101 or Paul R. Reynolds, Assistant Director, at (202) 512-7109.
Other major contributors to this report were James C. Musselwhite, Senior
Social Science Analyst; John R. Kirstein, Evaluator; Elsie M. Picyk, Senior
Evaluator, Computer Science; and Susan Lawes, Senior Social Science
Analyst.

Sincerely yours,




Stephen P. Backhus
Director, Veterans’ Affairs and
  Military Health Care Issues




Page 12                     GAO/HEHS-00-17 Food Services at VA Inpatient Facilities
Page 13   GAO/HEHS-00-17 Food Services at VA Inpatient Facilities
Contents



Letter                                                                                               1


Appendix I                                                                                          16

Scope and
Methodology
Appendix II                                                                                         18

Comments From the
Department of
Veterans Affairs
Figures             Figure 1: Average Proportion of Patients Receiving Food Service                  4
                      by Type of VA Inpatient Facility, Fiscal Year 1998
                    Figure 2: Percentage of VA Locations by Size of Average Daily                    5
                      Inpatient Population, Fiscal Year 1998
                    Figure 3: Distribution of VA Inpatient Food Service Costs by                     8
                      Source, Fiscal Year 1998
                    Figure 4: Distribution of VA Inpatient Locations by Average Daily                9
                      Food Service Costs per Patient, Fiscal Year 1998
                    Figure 5: VA Average Daily Food Service Costs per Patient by                    10
                      Size of Location, Fiscal Year 1998
                    Figure 6: Non-VA Organizations Buying VA Food Services, Fiscal                  11
                      Year 1998




                    Abbreviations

                    DOD        Department of Defense
                    NFS        Nutrition and Food Services
                    VA         Department of Veterans Affairs
                    VISN       Veterans Integrated Service Network


                    Page 14                     GAO/HEHS-00-17 Food Services at VA Inpatient Facilities
Page 15   GAO/HEHS-00-17 Food Services at VA Inpatient Facilities
Appendix I

Scope and Methodology


             We focused our work on VA’s inpatient food services for fiscal year 1998 to
             provide baseline information on (1) the type and volume of food service VA
             provides, (2) how VA provides food services, (3) the cost VA incurs, and
             (4) the revenues VA generates from sales of food services.

             To obtain this information, we interviewed VA headquarters officials in NFS,
             Canteen Services, the Office of the General Council, and other offices. We
             obtained documents from headquarters on food service roles in VA, how
             food service is provided, and national data on total costs and employees.

             We obtained location-specific data through surveys and survey follow-ups
             to each VISN on food services at each inpatient location. Specifically, we
             obtained information on food service needs, how VA provides services, VA
             costs, and revenues from food sales at each VA inpatient location. VISNs and
             locations also provided us with reports and studies on various food service
             changes in food production and cost that were under way or planned. We
             tested need, financial, and other data provided in the survey by comparing
             data from the inpatient locations in various ways. We compared the data
             over time in the same location, compared data for locations of similar size,
             and compared location data with other published data, where available.
             Where differences were found that were material to our analysis, we
             conducted telephone follow-ups to VISNs, locations, and headquarters and
             reconciled conflicting data. We also did additional comparisons with
             locations whose costs were unusually high or low and followed up where
             necessary to confirm the accuracy of information. In addition, we
             compared our survey totals to nationwide VA data on average inpatient
             population and NFS costs and employees. We also obtained additional data
             through interviews, documents, and physical inspections of kitchen
             facilities and food delivery at VA locations. We visited VISN 8 (Bay Pines)
             and its Tampa and Bay Pines locations. We also visited VISN 15 (Kansas
             City) and its Marion, St. Louis Jefferson Barracks, and St. Louis John
             Cochran locations.

             We used the average daily cost per patient in our analysis as our measure
             of unit costs. We used this measure because it incorporates all nutrition
             and food service costs and provides for more comparability of costs
             across VA. This measure includes all costs of each patient for 1 day—all
             meals, the number of which can vary depending upon definition; snacks;
             and special nourishments. In addition, we incorporated the cost of NFS
             meals provided to persons other than inpatients to avoid overstating the
             food service costs at locations where the number of such meals is
             significant. To do so, we assumed that three meals to persons other than



             Page 16                     GAO/HEHS-00-17 Food Services at VA Inpatient Facilities
Appendix I
Scope and Methodology




inpatients equaled 1 day of inpatient food service. This somewhat
understates the daily cost per patient in locations that provided a
substantial number of meals to persons other than inpatients because this
assumption includes no costs for snacks and special nourishments. These
additional meals were primarily for outpatients but also included meals for
volunteers and employees.

We also conducted a literature review of the food services industry and
interviewed selected non-VA food service officials. These included officials
from the private sector, food service industry organizations, and DOD
health care.

We performed our review between December 1998 and October 1999 in
accordance with generally accepted government auditing standards.




Page 17                      GAO/HEHS-00-17 Food Services at VA Inpatient Facilities
Appendix II

Comments From the Department of
Veterans Affairs




(406163)      Page 18   GAO/HEHS-00-17 Food Services at VA Inpatient Facilities
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