Descriptive characteristics Descriptive information of the five health care organizations and ten interview participants is presented in Table 1. Basic information was obtained from the interview transcripts, supplemental document analysis, and a review of each organization’s public website. Median employment length was 5 years (7 months—15 years) among operational managers, and 22 years (6 years—35 years) among executive leaders.
Spectrum of HFEPs Adopted
For each organization, respondents described each of the HFEPs adopted by their organization. In total, 27 distinct HFEPs were identified across the five organizations (Supplement C). Common HFEPs among most organizations were: incorporating choice architecture within food venue layouts, implementing competitive pricing strategies to incentivize healthy purchases, improving the quality of food sourcing, and monitoring sales and procurement data to inform purchasing decisions. Notably, all of the food service departments were subsidized minimally or substantially by their institutions.
Iterative rounds of thematic analysis generated six categories of facilitators cited among respondents. In descending order of code frequency, categories were: institutional commitment (66 references), employee wellness prioritization (46), technical assistance (40), incrementalism (24), external pressures to change the food environment (21), and champion/change agent (19). For institutional commitment, every respondent affirmed the vital role that executive sponsorship and financial assistance played in adopting HFEPs:
“If leadership doesn’t get onboard, it frustrates the staff. We have to approve the budget, make sure all of that works. But the majority of the effort comes from the bottom-up … One of things we did was not charge rent to our cafeterias. So, we had to absorb that impact. And we’re big enough, so that’s not impossible” [2E].
Respondents also underscored the greater purchasing power that accompanied executive sponsorship: “This past year, we even went a step further … Suffice it to say that resources available for transitions will always have to have a return on investment” [4O]. Though Organizations 1, 2 and 4 had institutional commitments, the resistant stakeholders in Organization 1 led to fewer changes than in Organizations 2 and 4.
Employee wellness prioritization was cited twice as much among executive leaders (31 references) than operational managers across all organizations (15 references):
“Our diabetes numbers are outrageous, what we’re spending on this is expensive, we need meaningful solutions. When you look at the employee wellness triangle, with health and wellness, there’s only so much the health plans can do that the individual is responsible for themselves. So the focus really became us. And, if we can get our own house in order, what would that look like?” [1E]
Employee wellness committees and policies was an inductive finding during analysis, identified by participants as a first step in a process of garnering stakeholder support for HFEPs. References of vision, size, and organizational norms overlapped when discussing employee health:
“Going back to creating a healthier workforce. And supporting wellness, food is one of those areas, in addition to exercise and stress. [Redacted] is different because we have a health plan and a delivery system all together. When you have the health plan at the table and able look at the numbers, we’re an integrated system. You can do things when you have all parts at the table, and realize that investment” [2E].
The strong sense of employee wellness was present in both levels of leadership: “That is pretty much the biggest driver of this—not only do we want to help our caregivers be healthier, but we have an investment in our caregivers” [2O].
Most codes for the technical assistance category were predominantly cited at the operational level, with managers emphasizing the need for logistical support, nutritional expertise from dieticians, and organizational resources: “The [consulting group] did some market research for us. We already had the idea of where we were going and they helped reinforce that. And they actually helped us design and develop [redacted], our natural foods store that’s up there.” [3E] However, tensions rose if logistical support did not include the operational members:
“During this entire time, we’ve had 6 different consulting companies come through that I have not hired and they’ll tell [redacted] the same thing I’ve been telling them except they’ll accept what the consultant says and not so much from me. [Laughs] Which I thought about quitting and then telling them what to do! Just kidding. I still need a check.” [3O]
For the incrementalism category, Organizations 3, 4, and 5 had similar views on the value and benefits of building on existing policies and relationships to continually improve actions. Specifically, respondent 4O discussed at length how his food site was one of 10 that routinely piloted new HFEPs for the remaining 170 interorganizational food venues within his broader network: “We are going to continue offering the Beyond Burger indefinitely. [EW]: What about the sushi pilot, is that coming to a close? [4O]: No, it’s successful and definitely staying—it actually increased total sales.” Retaining a degree of control over potential outcomes was another desirable feature of incrementalism: “[It] allowed us to make the decisions and see how it was playing out.” [3E] Further, the ability to change the food environment gradually, as opposed to a step function, proved to be protective against scaling too quickly: “But we also learned from another site that took out both diet and regular [soda], they ended up bringing back the diet. So we said, OK, we’ll start with taking out regular and see where that goes” [2O].
The last two categories, external pressures to change and champion/change agent, had a positive feedback relationship, in that executive leaders cited external pressures and public criticism as impetus for their support in changing the food environments, while operational managers emphasized a need for an executive champion to support them in making changes:
“We knew internally that we were serving slop. Foods were very overcooked and lost taste, nutritional value. For the retail side of it, there aren’t any options on [redacted], basically, to eat. And so you have a closed system that was not performing very well.” [3E]
“When they did the surveying of when the new president came in, he did all the surveying of people of what mattered the most. Food was #1. I went to my boss and said, ‘Are you watching this?’ Do you see that this is a really great opportunity for us to like, basically, be like ‘Here’s what we need?’” [3O]
Of the organizations that most closely overlapped in facilitators cited between managers and leaders, Organization 4 had an overlap of 75%, diverging only on topics of nutritional expertise and the benefit of having a captive audience. Similarly, Organization 5 had an overlap of 68% between factors cited by both respondents. Of the organizations with the least amount of overlap, Organizations 1 and 2 diverged substantially (44% and 50%, respectively). Table 2 shows specific facilitators cited by each respondent.
Similar to the facilitator analysis, the five-stage coding process generated 30 barriers, which were collapsed into five categories: resource constraints (50 references), prescriptive centralization (42), complexity (30), pushback (28), and lack of leadership (19). Resource constraints were uniformly cited by all respondents as the largest barrier to implementing HFEPs, with some of these codes overlapping with an emergent barrier: mutual mistrust. For some respondents, this perceived mistrust was between food service operations and the host institution: “I’d say a barrier is that [redacted] is constantly saying how tough money is. [Chuckles] Especially during negotiations, right?” [3E]. “Isn’t it ironic? That the [redacted] was costing us $100K to operate and they closed it, only to put [redacted] here and it costs us more than $100K between utilities and loss of sales” [5O]. For others, it was between the operations staff and executive leaders: “I had that thought today, honestly, “Did [redacted] just hire me so that they could say we have a sustainability manager and we’re doing good things?” [3O].
One executive leader explained that the large resource constraints meant that food service staff were not paid competitive wages, leading to “high turnover and vacancy rate, [which] means we might not be able to have every single station open, we might have fewer cashiers, so there’s waits… and so that’s a more contextual barrier” [4E]. For some, the resource scarcity added pressure to make up the funds elsewhere: “Yes, there would be institutional pressure to make changes. We have done that. We have laid people off and reduced positions. We needed to downsize our catering group by a third, so a lot of people left the organization” [3E].
In addition to the resource constraints, prescriptive centralization stood as a top-down barrier for organizations who wanted to innovate within their onsite food environments:
“Interestingly, we have prohibitions in the federal government from advertising. We can educate but it’s set up to not compete with the private sector. So we can educate about the [redacted], but we can’t post them in the lobby because we can’t advertise. So, for the marketing question you have, it’s a little tricky to get the customers into the canteen but once they do, we have placards about healthy choices … but if they’re posted around the hospital, we take them down.” [4E]
Similarly, after respondent [1E] concluded that her current vendor was not meeting the needs of the building tenants, she was surprised to realize that she couldn’t competitively solicit bids for another vendor: “I don’t know if you’ve dug into the actual rules around the mini Randolph Sheppard Act in [State], because technically written into law is that the licensed vendors and the [redacted] have right of first refusal, which means they have priority over all of our state-contracted concessions.” While these institution-wide prohibitions or legislated stakeholders represented structural barriers, process-oriented barriers emerged in the form of pushback. When HFEPs were implemented, nearly every interview respondent said that there was some level of pushback, no matter how minor. For some HFEPs, consumers asked “why they didn’t go far enough” [5O]. However, the more frequent response to a HFEP was some version of liberty infringement: “Why are you telling me what to do, I’ll make that choice myself. When [redacted] took out their fryers, you would think that we extracted every first male born child” (sic) [2E]. Both operational and executive leaders cited this factor as a consistent barrier.
Complexity was also cited by both levels of leadership, typically in relation to untangling bureaucratic situations:
“So yes, we’d be one of very few—I’m trying to think—so, [redacted; “Agency”] is the agency that is—they’re basically our landlord for most of our facilities. So [redacted; “Division”], we rent this space from [Agency]. So technically, the cafeteria downstairs--that’s not in operation right now—[Agency] contracts with the [Vendor], and the [Vendor] then contracts with [Distributor]’s licensed vendors to operate the facilities” [1E].
For the last category, lack of leadership, this subset of codes was predominantly cited among operation-level leaders (three times more often than executives). Lack of leadership subsumed codes such as unclear goals and goal conflicts, and operation managers levied these failures against their executive counterparts:
“It used to be that all the supervisors and management would sit a room together every week and we would have conversations. That hasn’t happened in years. They just stopped. They just got tired of all the infighting and just stopped all of it. Because all the different locations are managed by different people. And they all can do whatever the hell they want. So there’s no consistency.” [3O]
Of the organizations that most closely overlapped in barriers cited between operational managers and executive leaders, Organization 1 had an overlap of 58%, diverging in perspectives on unclear messaging, lack of leadership/mandate authority, and consumer preferences. Similarly, Organization 5 had an overlap of 55% between factors cited by both respondents. Of the organizations with the least amount of overlap, Organization 4 diverged significantly among respondent perspectives, aligning only 33% of the time. Organizations 2 and 3 had a similar degree of overlap (40% and 44%, respectively) (Table 3).