1. Healthy Food Procurement at Kaiser Permanente
Kathleen M. Reed, Sustainable Food Program Manager
National Nutrition Services – Procurement & Supply, Kaiser Permanente
Cindy M. Crawford, RD, MBA/HCM, Food and Nutrition Systems Manager
Food Policy Forum ~ Effective Strategies to Create Healthier Food Service Environments, April 15, 2011

2. “…to improve the health of our members and the communities we serve”
Our mission for 60 years…
KP’s Mission: to provide high-quality, affordable health care services and to improve the health of our members and the communities we serve.
Focus on preventive health and health promotion makes sustainable and healthy food a natural priority.
“…to improve the health of our members and the communities we serve”
| © Kaiser Permanente. All Rights Reserved.

3. Kaiser Permanente Stats
8.7 million members
35 hospitals
15,100 physicians
164,000 employees
14,000 patient meals/day
One of the nation’s largest not-for-profit health plans.
Comprised of three entities:
Kaiser Foundation Health Plan, Inc.
Kaiser Foundation Hospitals and their subsidiaries
The Permanente Medical Groups
KP serves members in 9 states and the District of Columbia: California, Colorado, Georgia, Hawaii, Maryland, Ohio, Oregon, Virginia, Washington.
Our size gives us a degree of leverage to move the market
14,000 patient meals served each day
Food spend = ~$52 million
| © Kaiser Permanente. All Rights Reserved.

4. Our Vision for a Healthy Food System
Environmentally Sound
Socially Responsible
Economically Viable
OVERVIEW
Health care organizations can make a difference by adopting food purchasing policies and practices in their own facilities that promote local, sustainable food systems.
As one of the largest health care organizations in the country, Kaiser Permanente has become a leader in the movement towards healthcare-driven demand for local, sustainable and healthy food.
We have also signed the Health Care Without Harm Healthy Food in Healthcare Pledge
| © Kaiser Permanente. All Rights Reserved.

5. Established a Comprehensive Food Policy
Access to and promotion of healthy food
Align with wellness, health education, nutrition, prevention
Promote fresh fruit and vegetable consumption
Incorporate contract language re: sustainable and healthy food
In 2006, established Kaiser Permanente’s Comprehensive Food Policy to Promote Individual and Environmental Health – aligns with Healthy Food in Health Care Pledge
Vision
Kaiser Permanente aspires to improve the health of our members, employees, our communities and the environment by increasing access to fresh, healthy food in and around KP facilities. We support food systems that are ecologically sound, economically viable and socially responsible by the way we purchase food.
Only 30% of the population consumes the minimum 5 fruits and vegetables per day. This is our challenge and why we want to promote more fruit and vegetable consumption.
| © Kaiser Permanente. All Rights Reserved.

6. Kaiser Permanente’s Healthy Food Journey…
National Salt Reduction Initiative
Healthy Picks
Sustainable Food Purchasing
Started with our farmers markets in 2003.
Healthy Picks Program in 2005.
Local produce sourcing and rBST-free milk in 2006; and now expanding our sustainable food purchasing to proteins, disposables and other areas.
| © Kaiser Permanente. All Rights Reserved.

7. Reducing Salt = Reducing Mortality
High Blood Pressure (HBP) is a major public health issue and leading risk factor for heart disease and stroke
Nearly one in three US adults has HPB
Excess sodium intake is a known risk factor for HPH and subsequently, cardiovascular events
| © Kaiser Permanente. All Rights Reserved.

8. NSRI Recommendations :
Current
Recommended Limit
2300 mg Sodium
Reduce cases of High Blood Pressure (HBP) by 11 million
Save $18 billion in US health care spending
Gain 312,000 quality-adjusted life years
Recommended Maximum for 70% of our Population
1500 mg Sodium
40 years of age or older
African American
Established diagnosis of high blood pressure regardless of age
Palar k, Sturm R. Potential societal savings from reduced sodium consumption in the US adult population. Am J Health Promotion Sep-Oct;24(1):49-57
| © Kaiser Permanente. All Rights Reserved.

9. Processed & restaurant foods
Salt Consumed in the American Diet
Processed & restaurant foods
77 %
12%
12 %
Added while eating
6 %
5 %
Source: Mattes, RD. Journal of American College Nutrition, 1991, 10:
| © Kaiser Permanente. All Rights Reserved.

10. Dietary Sodium in Foods
| © Kaiser Permanente. All Rights Reserved.

11. International Product Variability
Educate our vendors to reduce the sodium content of prepared foods.
| © Kaiser Permanente. All Rights Reserved.

12. Reduce US Goals in Sodium Reduction Decrease Decrease population
sodium in
foods
by 25% in
five years
Decrease
population
salt intake
by 20%
in five years
Education to vendors to reduce the sodium in prepared products.
| © Kaiser Permanente. All Rights Reserved.

13. Healthy Picks Program - Vending and Cafeterias
The Healthy Picks program aims to improve the health of KP’s members and employees by offering more nutritious options, educating people about healthy eating, and empowering individuals to make better food choices.
started with vending; 2006 – expanded to cafeterias
50% of products in vending machines are Healthy Picks; 100% in pediatric waiting areas
Healthy Picks guidelines implemented in all KP–owned cafeterias and in patient food services
Offer rBGH-free milk – cafeterias, vending, patients
Energy efficient vending machines installed in No. California
Increase in sales after Healthy Picks implementation
Next phase is to expand Healthy Picks vending and cafeteria options
| © Kaiser Permanente. All Rights Reserved.

14. Healthy Picks Program – Menu Labeling
Conducted a 12-week pilot in 2008/2009 with UC Berkeley Center for Weight and Health to determine the impact of calorie menu labeling in addition to Healthy Picks labeling on Kaiser Permanente cafeteria menus.
Posted of calories at the point of choice for Entrees, Grill, Salad Bar, Beverages and Snacks
Surveyed of patron and collected of sales data to determine impact
Conclusions
The majority of patrons want calorie and nutrition information and view it as a positive worksite wellness initiative
Menu boards more visible than posters so are noticed more by patrons
Contributed to a significant increase in purchases of lower calorie “target” side dishes and lower calorie “target” snack items
Observed changes 2 x/wk could result in a calorie savings enough to prevent 4-5 pounds of weight gain per year
The menu labeling program is now implemented throughout KP cafeterias.
| © Kaiser Permanente. All Rights Reserved.

15. Healthy Picks Program – Sweetened Beverages
Worked with our vendor to pilot an unsweetened beverages initiative in our facilities. Two scenarios in vending and cafeteria:
100% unsweetened beverages
75% unsweetened beverages; 25% sweetened beverages at higher price and reduced portion sizes, e.g., 12 oz sodas
Collected sales data and survey data from customers.
Developing a toolkit based on learnings to share with all of our facilities.
Challenges:
Impact on our vending sales.
Selection of unsweetened beverages limited due to current contracting
Customers want choice.
Education is key! Will take time to make a culture shift.
| © Kaiser Permanente. All Rights Reserved.

16. Farmers Markets, Patient Meals, Cafeterias, Vending
PHOTOS:
Farmers Markets – Moises Ontiveros from Resendiz Farms, Modesto, selling peaches at KP Walnut Creek Farmers Market.
Utilizing sustainable greens for Northern California patient menu
Cafeteria salad bar
Healthy Picks Program - vending machine
Farmers Markets
In May, 2003, Preston Maring, MD founded the first ever hospital-based farmers market at the Kaiser Permanente Oakland Medical Center.
KP currently hosts nearly 40 markets in four states.
KP also offers the delivery of produce "farm boxes" to employees and physicians who don’t have close access to farmers markets.
Local Produce Sourcing
KP is now serving local produce for patient meals at our hospitals in California, Oregon and Hawaii.
In 2006, KP began purchasing local produce from local family farms, through a partnership with the Community Alliance with Family Farmers, which supports family-scale agriculture that cares for the land, sustains local economies and promotes social justice.
In 2009, KP purchased over 100 tons of local, sustainable, family-farmed produce for patient meals and cafeterias..
In June 2010, KP began serving an additional 600 lbs per week of sustainably grown vegetables on patient entrée plates at 22 Northern California KP Hospitals, which represents over 4,000 plates per week.
Healthy Picks
KP has implemented a “Healthy Picks" program of defined nutritional criteria to support healthy food choices in all hospital based medical centers in California, Hawaii and Oregon. The program has been successful in helping our members and staff make healthier food and beverage choices through vending and cafeteria services.
In 2009, energy saving devices were installed on 719 snack and beverage machines at KP facilities in the Northern and Southern California regions. Annual energy savings and rebates are projected to be $73,000 and reduction in CO2 emissions to be over 413,350 pounds.
Cafeteria Contracting
KP Procurement & Supply has incorporated sustainable and healthy food criteria into its Northern California cafeteria contract language, and is partnering with its cafeteria vendors to offer more healthy and sustainable food choices.
KP incorporated questions related to sustainability into distributor RFPs, requiring vendors to explain how they will meet KP’s sustainable and healthy food requirements.
Asking these questions triggers suppliers to understand that sustainability is a priority for KP.
We now incorporate sustainable and healthy food language into our final contracts with food and food service vendors.
| © Kaiser Permanente. All Rights Reserved.

17. Environmentally Preferable Purchasing Policy
Natural Resources and Waste
Sustainable Food
Safe Chemicals
Energy
Environmental Purchasing is one of the five business principles of Procurement & Supply.
The mission of the EPP program is to build upon our overarching health promotion business model by utilizing our size and position in the healthcare supply chain to drive innovation with an environmental health benefit by requiring and inspiring transformation in the way our suppliers make products and do business.
We have developed internal sustainable food priorities which are integrated into our Environmentally Preferable Purchasing Policy, and are aligned with the organization’s overall environmental stewardship initiatives.
KP Procurement & Supply Environmentally Preferable Purchasing Policy:
“KP prefers products and services that…support healthy food systems by sourcing food products that are local, seasonal, nutritious and
produced in a way that minimizes degradation to human and environmental
health and vitality.”
| © Kaiser Permanente. All Rights Reserved.

18. Local Produce Sourcing – Distributor Partnership
Southern California – partnered with produce distributor/processor, Sunrise Produce
2010 expansion from 4 to 12 facilities
Customized produce processing
Replaced frozen vegetables with fresh
Tracking of sustainable, local purchases
Forecasting to create seasonal menus
Started in NCAL with a partnership with a local non-profit, Community Alliance with Family Farmers (CAFF).
Goal: local, seasonal produce from small to mid size family farms
2006 pilot – 25 tons of local produce
Initial focus – whole fruit
Fresh seasonal fruit became the first choice dessert on our menu for all lunches and dinners, instead of a cake or other sweets.
Currently sourcing 75 tons/year
Actions Taken
Getting buy in and commitment from SCAL Food and Nutrition Services Directors (FANS)
Negotiating a realistic goal for the region and commitment to achieve that goal
Evaluating capabilities of various suppliers against our criteria: reach of distribution, competitive pricing, high quality produce, ability to supply local and sustainable produce, and ability to report on purchasing trends.
RESULTS
Sunrise Produce has allowed us to leverage region-wide volume to meet the following goals:
Quality: Shortened supply chain by providing in-house produce processing, facilities able to replace frozen vegetables with fresh; consistent product and quality.
Pricing: Competitive pricing for sustainable, local and conventional produce (better than incumbents).
Service: Customized produce program - tailored produce processing, guidance on seasonal menu items, tracking and reporting of sustainable and local purchases
LESSONS LEARNED
Ensuring that all stakeholders understand goals and expectations.
Engaging FANS Directors directly in the early stages, and encouraging them to do site visits of the Sunrise Produce facility, helped to get their buy-in into the program across the region.
Bi-weekly meetings with supplier allow for quick issue resolution.
~~~~~~~~~~~~~~~
Local Produce Sourcing Implementation Steps:
Analyze current food sourcing
Adopt guidelines and set goals
Identify a partner and implement a pilot project
Communicate benefits and challenges – be flexible
Establish financial guidelines
Measure progress
Promote internally and externally
| © Kaiser Permanente. All Rights Reserved.

19. Local/Sustainable Produce Sourcing Challenges
Distribution
Pricing
Sizing and consistency of product
Planning menus around seasonal produce
Regular tracking of sustainable/local produce purchases
Distribution to our facilities –
We were used to having daily deliveries. Community Alliance with Family Farmers (CAFF) was a much smaller distributor and delivered only two times per week Required flexibility and extra time to manage separate account and deliveries.
Regional distribution system for small farmers not well developed, delivering to facilities that are out of regular distribution route
Pricing for local, seasonal, sustainably grown produce from small- to medium-scale family farms varies, some items 10% less due to sourcing locally when it’s seasonally abundant, some are 70% more, average is 25-30% more.
Sourcing seasonal produce may reduce the cost impact in some cases. (Total cost also depends on transportation/delivery costs). We established an upper level limit of cost for products we can purchase. Winter months tend to have less variety and higher prices, but smaller volumes.
Sizing & consistency of product – often more variability with produce from small, local family farms
Inconsistent sizing was a challenge because we needed a specific size to fit on our patient trays because of the way they are stacked – had to communicate this to CAFF and they had to educate the growers regarding our needs. In some cases, we could use larger or smaller fruit in our cafeterias.
Ripeness – sometimes too ripe or not ripe enough
Bugs, Pests - needs better monitoring before product is delivered to ensure no infestation occurs
Blemishes – while still good product, imperfect looking fruit can impact patient satisfaction; Consequently, inferior fruit with poor appearance cannot be accepted or used for patient meal service
Unusual varieties that are delicious, but unfamiliar to patients and staff, e.g., blood oranges.
Requires education of the farmer, the distributor, the food service personnel and the patients.
Planning menus around seasonal produce – requires flexibility to purchase local, seasonal products that are most cost competitive with conventional; requires regular communication with produce vendor and our facility food and nutrition services staff to stay abreast of the market and resolve issues quickly.
Tracking of sustainable/local purchases – we made this a requirement for the new vendor, they had to agree to do this before we were willing to work with them, put language in the new contract around this
| © Kaiser Permanente. All Rights Reserved.

20. Local Produce Sourcing Benefits
Fresh fruit is a patient satisfier!
Potential to reduce carbon footprint
Supports local farmers
Supply chain transformation
We found that fresh fruit was one of the most popular items on the menu – great feedback from patients.
Kaiser’s commitment to sourcing local produce through its partnership with CAFF has had an exponential impact on the availability of local produce provided to other institutions and communities, including schools, universities and public service organizations.
CAFF is now serving 97 farmers through its Farm to Institution program, up from just 12 in 2006
Kaiser’s ability to offer more local sustainably grown produce on its patient and cafeteria menus
| © Kaiser Permanente. All Rights Reserved.

21. Expanding Sustainable Food Purchasing Program
Baseline of current food purchasing
Sustainable food purchasing criteria
Key product categories
Potential cost impact and barriers
Strategies to achieve cost neutrality
Implementation steps:
Assess current food purchasing practices – not as easy as we thought it would be – difficult to determine what was already sustainable
Establish "sustainable" purchasing criteria
Identify key product categories and items for possible substitution with "green" alternatives
Guidelines for selecting categories:
Volume purchased
Availability of alternatives
Cost
Minimal operational impact
Environmental and human health impact
Initial list of items analyzed:
Chicken breast (antiobiotic and hormone free)
Ground beef, stew meat, top and bottom round (antibiotic and hormone free)
rBST-free & organic yogurt
Cage-free eggs
“Dirty dozen” produce items
Green alternatives to styrofoam
Identify sustainable alternatives available in the market
Analyze sustainable alternatives using triple bottom line methodology
Determine potential cost impact
Explore strategies to achieve cost neutrality – minimize cost and operational impact
Partner with Sourcing teams and vendors to ensure best pricing on sustainable and other products
Replace some beef menu items with vegetarian – “Balanced Menus” approach
Implement food waste tracking system in kitchens
Challenges:
Challenges to increasing sustainable food offerings at Kaiser Permanente include:
Availability of type of product we need in the volume we need, and that has minimal operational impact.
Distribution - getting local/sustainable products into our distribution system can be challenging
Cost of organic/sustainable/local is typically higher than conventional foods. Need to identify other cost savings opportunities to off set increased cost of sustainable foods
We are working to address these issues through our contracting process and by leveraging our purchasing volume. Remember, everything is negotiable!
| © Kaiser Permanente. All Rights Reserved.

22. KP Sustainable Food Purchasing Criteria
Dairy
rBGH/rBST free
Locally produced within a 200-mile radius
Third-party certified as sustainably produced
Ultimate goal: rBGH/rBST-free; from local/regional dairies; humanely produced; sustainably produced; free of synthetic pesticides
Criteria developed for nine food categories to evaluate products on a continuum toward an ultimate goal of sustainability
Dairy
Eggs
Vegetables and fruit
Poultry
Beef, pork, and other meats
Seafood
Grains/Pasta
Coffee/Tea
Disposable food service ware
Rationale for criteria development – developed in collaboration with external partners and content experts based on greatest impact to human health and environment
Aligned with HCWH GGHC Food Service Credits
Developed our criteria based on the Emory University criteria for sustainable food purchasing, with input from HCWH, Physicians for Social Responsibility (PSR) and other external partners, who are leading this effort, for guidance on sustainability standards and to help us identify sources for sustainable alternatives in the market. There are resources out there to help, local organizations, HCWH, PSR, others.
Rationale for criteria development - based on greatest impact to human health and environment. In alignment with our mission as a health care institution. The challenge is to weigh the social and environmental impacts, along with cost.
| © Kaiser Permanente. All Rights Reserved.

23. Procurement Process - Contracting
Sustainability questions in RFPs
Prioritize vendors who can support sustainable food program
Sustainable and healthy food language in contracts
Marketing and education
Incorporated questions related to sustainability into distributor RFPs
Vendors required to respond to sustainability questions, e.g., whether they will provide local food, rBST-free dairy products, reusable or biobased food service ware
Responses used to evaluate and rate potential vendors
Sustainability gets weighted and incorporated into the rest of the bid process, along with other factors such as cost, assurance of supply
The very act of asking these questions triggers suppliers to understand that sustainability is a priority for Kaiser Permanente
~~~~~~~~~~~~~~~~
Previously there were many different cafeteria contracts for our 21 Northern California facilities.
We leveraged the bid process to identify 2-3 vendors with whom we can work at the corporate level to ensure that our healthy food and sustainability goals are met.
They have agreed not only to provide more healthy, sustainable food and disposables in our cafeterias, but also to help us track our progress, e.g., percent of sustainable and local purchases.
Marketing and education of healthy and sustainable foods is key – need buy in and support from other departments – e.g., employee wellness, health education, leadership
| © Kaiser Permanente. All Rights Reserved.

24. A Gradual and Ongoing Process
Change hasn’t happened overnight. We’ve taken baby steps to get where we are, and still much more to do.
| © Kaiser Permanente. All Rights Reserved.

25. For further information…
Kathleen M Reed
Sustainable Food Program Manager
National Nutrition Services
Procurement & Supply
Cindy M Crawford, RD, MBA/HCM
Food and Nutrition Systems Manager
National Nutrition Services
Procurement & Supply
| © Kaiser Permanente. All Rights Reserved.