Perceptions of local hospitals and food producers on opportunitie

CHAPTER ONE

Introduction

Introduction to the Study:

The 1970’s marks a significant period for the health and well-being of the United

States. It was during this time that the nation’s agricultural practices began to radically

shift to more closely align with the globalizing economy, and shifted from locally-driven

food systems to more industrialized and productivity based systems. The processes of food

production and distribution are now driven by global demand and supply and are creating

a highly monopolized industry (Hawkes, 2006). Such dramatic changes in agricultural

practices are resulting in significant consequences to both environmental and human

health. Monocrop production is greatly reducing the level of biodiversity and overall

resilience of the ecosystem. These changes increase the susceptibility of crops to

pathogens and reduce the amount of soil microbes necessary for productive crop growth

(Matson, 1997). Reduced crop resistance, loss of soil microbes, and leaching of nutrients

has resulted in excessive and inappropriate applications of fertilizers and pesticides,

inflicting significant damage to bystander species and polluting air, soil, and groundwater

(Horrigan, 2002). These fertilizers and pesticides are also being shown to impact human

health, including elevated risk for cancer, repressed immune and reproductive function,

and disruption in nervous system function (Horrigan, 2002). Consumption and dietary

trends have dramatically changed in response to the globalizing food system and are now

strongly correlated with rising rates of cardiovascular disease, type II diabetes and obesity

(Horrigan, 2002; O’Kane, 2011). Industrialized agriculture is now also associated with the

growing concern of antibiotic resistance as well as the increase in food-borne illnesses

(Horrigan, 2002).

The model and expansion of the globalized food system has shifted local economies,

culture, and social context. The farmer share of each food dollar has dramatically declined

since the 1950’s and prices of commodity foods have decreased by 30-50% since 1985

(Azuma and Fisher, 2001). As market prices decline and production prices continue to rise,

small-scale farmers are struggling to compete and the food industry is becoming

increasingly monopolized by large corporations. Such a shift towards mechanized, mass-

production of food by large scale corporations contributes to a disconnect between

communities and their food, a vital component of culture and well-being. This disconnect

is now driving a nation-wide movement to revitalize the community based food system.

This nation-wide movement is working to reestablish a connection between communities

and the food production and distribution process. Programs such as farmers’ markets, food

cooperatives and community supported agriculture (CSA) are serving to revive

partnerships between food producers and consumers and are being found to contribute to

stronger local relationships, culture, and economic viability (Gillespie and Smith, 2008;

O’Hara and Stagl, 2001).

Studies show that motivation to participate in local food programs arises from

concerns relating to the quality and freshness of foods, as well as the importance of

supporting local farmers and agriculture (Kloppenburg, Wubben and Grunes, 2008; O’Hara

and Stagl, 2001). These concerns and vision of stronger local food systems are beginning to

translate into reform at an institutional level. Connecting local farmers with institutions

such as hospitals, colleges, and correctional facilities is providing an outlet for small-scale

farms to reach into reliable markets and strengthen the role of local foods within local food

systems and economies (Bellows, Dufour, and Bachmann, 2003). For example, farm-to-

school programs are a growing initiative in the United States and are continuing to gain

momentum as potential for their role in the local food system and community health

become more widely understood. Such programs are now contributing to the nutrition

education and dietary habits of students, as well as the support of local farmers and

agriculture (Azuma and Fisher, 2001).

The 1960’s represents a paradigm shift in which environmental and human health

were beginning to be viewed as interconnected. This interdependence has resulted in a

realization that the health of the food system plays a significant role in the overall health

and well being of a community. This holistic model is now not only being supported by

environmentalists and advocates of sustainable agriculture, but also by the nation’s health

care system. As the relationship between sustainable food systems and a healthy

community are becoming more clearly understood, the health care system is proving to

play a significant role in supporting the return to local food systems. This leadership role

stems from the goals and mission of the health care system. In striving to support health

and healing, there is a fundamental responsibility to embrace the role of food in human

health and well being and support a community’s surrounding environment (Cohen, 2006).

The health care system is in a unique position of modeling the relationship between food

and health through potential influence on food policy reform, nutrition education, and local

food economies. The health care system and hospitals across the nation are now role

modeling creativity and dedication to the local food system movement. On site farmers’

markets and CSA programs, the availability of hormone-free milk and meat products, fair

trade coffee, and compost programs represent only a few of the systemic changes being

made within hospital facilities. Since the 2006 inception of Health Care Without Harm’s

Healthy Food in Health Care Pledge, 495 hospitals nation-wide have signed and committed

to the pursuit of engaging in healthy, sustainable food practices (Health Care Without

Harm, 2013). This initiative now serves as a framework with tools and resources for the

health care industry in connecting the health of patients, the community, and the

environment with the foods being served in hospital facilities.

The farm-to-hospital movement is still young and lacks formal assessment and

evaluation. However, initiatives within the overall farm-to-institution movement are being

examined and themes of strengths, as well as challenges, are beginning to arise. Challenges

relating to food cost, procurement, and supply are emerging and providing a platform and

working framework to begin modifying the processes of farm-to-institution programs to

increase the success of these efforts on strengthening local food systems and community

health (Kloppenburg, Wubben and Grunes, 2008). Little is known about the specific gaps

and opportunities for hospitals to participate in local, sustainable food efforts. One way

they might participate is to use locally-sourced food products in their food service meals.

Therefore, a formal exploration of current gaps and opportunities experienced by hospitals

might enhance discussions about how these institutions may use more locally sourced food

ingredients.

Purpose of the Study:

The purpose of this study was to explore current perceptions and attitudes of local

food producers and staff at Missoula hospitals towards working together in order to

incorporate locally-sourced foods and ingredients into hospital food services. Factors

currently impacting the use of locally-sourced foods in the institutional setting, in either

productive or unproductive ways, were identified and then incorporated into a framework

to work towards increasing the amount of locally-sourced foods used in hospital food

service meals.

Research Questions:

1. How do the two hospitals perceive local food purchasing? How do those perceptions,

and their associated individual, institutional, and policy based factors, create barriers

and opportunities for hospitals to purchase locally grown foods?

2. How do local and regional food producers and distributors perceive selling to

hospitals? How do those perceptions, and their associated individual, institutional, and

policy based factors, create barriers and opportunities for food producers to sell their

products to hospitals?

3. What knowledge, skills, and resources are needed by hospitals and food producers to

increase the amounts of locally-sourced food ingredients in hospital food service meals?

Significance of the Study:

The Healthy Food in Health Care Pledge is one of several initiatives advocating for

the incorporation of locally produced foods into hospital food services. Along with

environmental benefits and support to the local economy, such a transition to local foods

and healthy menus work to achieve congruency in the quality of care provided to patients

in the hospital setting. Four hundred ninety five hospitals across the nation have already

signed on this pledge (Health Care Without Harm, n.d.). While Missoula exemplifies a

locally-based city through initiatives such as farmers’ markets, community supported

agriculture, community gardens, and farm-to-school programs, only one hospital in the

Missoula region (and in Montana) has officially joined the movement. One hospital, out of

65 in the state, 2 in the county, and 8 others in surrounding counties, has signed the

Healthy Food in Health Care Pledge (the Agape Center, 2010). Such a statistic suggests

there are significant factors currently perceived as obstacles for regional hospitals in using

locally-sourced ingredients in their food service programs.

The model of a farm-to-hospital program is one of new conceptual framing and

development. Farm-to-hospital programs have only begun to gain ground in the past

decade. Exploring specific barriers and challenges that hospitals face in supporting local

food systems would be an important step to developing a framework that identifies ways to

increase the amount of locally-sourced foods that hospitals use in their food services. An

essential component is to integrate, through data-rich interviews, the perceptions of both

local producers and health care institutions into a single study in order to produce a more

comprehensive situational assessment.

Delimitations:

The delimitations of the study were as follows:

1. The study was delimited to local food producers located in Missoula and food

distributors located in the surrounding regional area within a 200 mile radius.

2. The study was delimited to hospital staff currently working at one of the two main

hospitals in Missoula, Montana in 2013-2014.

3. Data was collected by interviews

4. The study was further delimited to local food producers, distributors, and local

hospital staff who voluntarily took part in the interview process.

Limitations:

The limitations of the study were as follows:

1. The data was limited in that the individuals from the target population who

volunteer to participate in the interviews may have different issues and concerns

compared to those who chose not to participate. Therefore, the study was limited

by how well the participants in the study represent the population.

2. Due to the nature of the work of the target population, finding time for individuals

to participate in the interview process was challenging.

3. The study was limited by the assumption that hospital staff, producers, and

distributors perceive local food to be healthier. Using locally-sourced foods

theoretically suggests that these foods have required less processing. Local food

may also tend to be associated with products that are organic or pesticide-free.

These assumptions therefore suggest benefits to the health of patients, staff and

visitors at the hospital. Quality of local foods, however, is not guaranteed as greater

than the quality of non-local foods. Additionally, such health benefits may also be

achieved by generally using more whole foods in food service meals.

Definition of Terms:

Community Based Food System: A food system in which everyone has financial and

physical access to culturally appropriate, affordable, nutritious food that was grown

and transported without degrading the natural environment, and in which the

general population understands nutrition and the food system in general (American

Planning Association, 2008).

Community Supported Agriculture: Members, or "share-holders," of the farm or garden

pledge in advance to cover the anticipated costs of the farm operation and farmer's

salary. In return, they receive shares in the farm's bounty throughout the growing

season, as well as satisfaction gained from reconnecting to the land and

participating directly in food production (United States Department of Agriculture,

1993).

Economy of Scale: Reduction in cost per unit resulting from increased production, realized

through operational efficiencies. Economies of scale can be accomplished because as

production increases, the cost of producing each additional unit falls (Investor

words, 2014).

Farmers’ Market: A farmers market operates multiple times per year and is organized for

the purpose of facilitating personal connections that create mutual benefits for local

farmers, shoppers and communities (Farmers Market Coalition, 2010).

Food Service (Food Service Meals/Food Service Programs): The business of making,

transporting, and dispensing prepared foods, as in a restaurant or cafeteria (The

American Heritage Dictionary, 2013).

Food System: Comprise all aspects of food production (the way the food is grown or

raised; the way the food is harvested or slaughtered; and the way the food is

processed, packaged, or otherwise prepared for consumer purchase) and food

distribution (where and how the food is sold to consumers and how the food is

transported) (Grace Communications Foundation, 2013).

Group Purchasing Organization (GPO): An entity that helps healthcare providers — such

as hospitals, nursing homes and home health agencies — realize savings and

efficiencies by aggregating purchasing volume and using that leverage to negotiate

discounts with manufacturers, distributors and other vendors (Health Care Supply

Association, 2012).

Grower Cooperative (Coop/Co-op): Grower cooperatives depend on a group of producers

joining forces and, in return, obtaining bargaining power. Additional benefits

include cost savings associated with producing and/or processing larger quantities

(University of Kentucky College of Agriculture, Food and Environment, 2014).

Industrial Agriculture: Industrial agriculture emphasizes "inputs" (pesticides, fertilizers)

and "outputs" (crops). The end-objective is increasing yields while controlling costs,

often through the replacement of manual labor with machines and petro-chemicals

(PAN North America, n.d.).

Local Food System: A method of food production and distribution that is geographically

localized, rather than national and/or international. Food is grown (or raised) and

harvested close to consumers' homes, then distributed over much shorter distances

than is common in the conventional global industrial food system (Grace

Communications Foundation, 2013).

Western Montana Growers Cooperative (WMGC): A coalition of growers in the Flathead,

Jocko, Mission and Bitterroot Valleys whose goal is to provide the market in our

region with fresh, quality products from our farms. To reach that goal, the

cooperative provides a wholesale marketing and delivery service for its members

(Western Montana Growers Cooperative, 2013).

CHAPTER TWO

Review of Literature

Globalization on Our Food System

Our food system and agricultural techniques have been experiencing a dramatic

shift since the 1970’s. This shift is deeply rooted in the growing trend of globalization, an

effort to unite the world in an industrialized and economically efficient system. Integrating

the food system into this global, capitalistic economy has radically altered the way in which

our food is produced and distributed (Lyson & Green, 1999). This industrialized model

now dictates the types of food being produced, as well as the quantity and quality (Hawkes,

2006). Altering food production and distribution on such a massive scale further impacts

overall food access and availability. Similar to other industries moving into the globalizing

economy, the food industry has experienced modifications that reflect transnational trade

and large-scale investments. International food companies, increased foreign investment

and the growing abundance of trade agreements and investment treaties demonstrate the

effects of a unified economic system (Hawkes, 2006). Food production and distribution is

now directly dictated by global demand and supply, and is becoming an increasingly

monopolized industry. Such significant changes to our food system have produced a wide

variety of effects, both on environmental health and human health, and are summarized in

the following review.

Environmental Impacts:

Food production techniques evolved to increase productivity in order to meet the

demands for agricultural commodities in the growing mass market. Increasing

productivity and food production efficiency resulted in the streamlining of agricultural

practices. Such streamlining has translated into the exploitation of each region’s particular

agricultural strengths. Rather than fostering crop diversity, agricultural practices have

transformed into a monocrop system (Lyson & Green, 1999; Tilman, 1999; Matson, Parton,

Power, & Swift, 1997; Horrigan, Lawrence & Walker, 2002). Monocrop systems

significantly decrease the level of biodiversity within the area in both obvious and less

obvious ways and reduce the overall health and resilience of the ecosystem. Reducing the

variety of plant species in pursuit of high yield crop production impacts the composition of

insect populations as well as soil invertebrate and microorganism populations (Matson et

al., 1997). Pest densities tend to increase in monocrop systems where genetic resistance is

significantly lower compared to diversified crop systems, increasing the risk for endemic

pest or disease infestations. Along with increased susceptibility to infestation,

monoculture ecosystems are also associated with higher levels of leaching and loss of

nutrients due to the scale at which crops have homogenous nutrient demands.

Increased susceptibility to infestation and leaching loss of nutrients has resulted in

the widespread use of fertilizers and pesticides. Massive monoculture ecosystems

eliminate soil inhabitants supporting the natural life support cycles of soil turnover and

organic matter replenishment, leaving fields devoid of particularly vital nutrients such as

nitrogen and phosphorus. Since the 1960’s, fertilizers have been readily applied to counter

the leaching of these nutrients (Matson et al., 1997; Tilman, 1999). Excessive and

inappropriate application practices results in the incomplete absorption of fertilizers by

crops, leaving the remaining nitrogen and phosphorus to settle in the soil unused. This

remaining fertilizer promotes the growth of plant pathogens, contaminates groundwater

and can be transported to nearby water sources, greatly increasing the concentration of

nitrates in drinking water. The accumulation of nitrates in water sources can cause

eutrophication of the marine ecosystem, reducing levels of oxygen so severely that harmful

algae blooms can occur and diminish fish and shellfish populations (Horrigan et al, 2002;

Matson et al., 1997). Elevated nitrates in water also impacts human health and has been

associated with the blood disorder, methemoglobinemia. Excessive pesticide applications

also result in inadvertent contamination through water and air transport, impacting not

only the target pest, but a wide variety of species both in the cultivated fields and the

surrounding area.

The changes in agricultural practices in response to an industrializing food industry

have resulted in an interconnecting network of environmental effects. Monocrop farming

has reduced the level of biodiversity in these ecosystems, decreasing genetic variance and

crop resistance, as well as insect and soil microorganism populations. Nutrient leaching

and pest susceptibility has resulted in prolonged and excessive applications of fertilizers

and pesticides. Such chronic chemical applications are now resulting in the destruction of

bystander species, degradation of soil quality, and pollution of groundwater and drinking

water sources. Water sources are additionally abused through irrigation systems that

drain water sources and below-ground aquifers to redirect water to fields at unsustainable

rates (Horrigan et al, 2002). Ultimately, the industrialized agriculture systems has

developed at the cost of our surrounding environment and its naturally occurring cycles of

re-growth and rebalance.

Human Health Impacts:

The globalizing food system has indirectly, and directly, negatively impacted the

natural environment, surrounding landscapes, water, wildlife and human health. The

industrialized agricultural food system has had significant effects on human diet

worldwide. Through control over the foods and products selected for mass production and

distribution, consumption and dietary patterns have adapted to reflect these trends. The

adoption of modified foods, such as vegetable oils, high fructose corn syrup and processed

grains, has shifted caloric sources and intake and has altered levels of saturated fats in the

diet. The increasing intake of cholesterol, saturated fats and sugars in the American diet

are all contributing to high rates of cardiovascular disease, type II diabetes, and the rising

average body mass index (Horrigan et al, 2002; O’Kane, 2011).

Widespread use of pesticides has significant negative impacts on human health.

Long term exposure to pesticides (through ingestion and/or dermal contact) is associated

with effects including elevated risk for cancer, repressed immune and reproductive

function, as well as disruption in nervous system function (Horrigan et al., 2002). Factory

farming, a production method in which extremely high concentrations of livestock are

managed within an inadequate amount of space, impacts human health as well. Factory

farm workers, as well as people residing within close proximity of these farms, have

experienced elevated levels of respiratory disease (Horrigan et al., 2002). Foodborne

illness is also associated with the use of factory farming and increased consumption of

meat products. Nearly 76 million foodborne illnesses occur in the United States each year

as a result of consuming meat products contaminated with bacteria (Horrigan et al., 2002).

Crowded conditions of factory farming, along with the mechanized and efficient process of

slaughter, contribute to increased risk for undetected contamination (Horrigan et al.,

2002). Campylobacter and Salmonella currently contribute to nearly three million

foodborne illnesses in the U.S. each year, and the prevalence of E. coli and Listeria are

rapidly increasing as well (Horrigan et al., 2002).

Also associated with the consumption of factory raised animals is the increased risk

for antibiotic resistance. Nearly 70% of antibiotics produced in the U.S. are administered to

livestock in order to promote growth and prevent disease (Horrigan et al., 2002; Landers,

2012). Such excessive use of antibiotics increases the likelihood that drug resistant strains

of disease will evolve. Such strains can then potentially be transmitted to humans through

the food supply, thereby causing life threatening illness and even death. The incorporation

of genetically modified foods (GMO’s) serves as another potential health concern. Long

term exposure to GMO’s is still poorly understood. However, the blending of different

genes creates the potential for an introduction of new allergens into the food supply. As

genes are further spliced into a genome to create a crop that is resistant to pathogens or

dry or colder climates, materials used in this genetic engineering may include organisms

not previously consumed by humans (Horrigan et al., 2002). As the food industry has

become more efficient, specialized, and incorporated into the global economic system, the

quality and safety of our food supply becomes further and further compromised. Such a

globalized food system has thereby resulted in higher risk for cancer, suppressed immune

systems, foodborne illness and an increase in nutrition-related chronic disease.

Local Food Systems and Locally Driven Initiatives

Returning to Locally Based Food Systems:

“A community-based food system is conceptualized as one where all of the

components are localized to a particular place. Community food systems

ultimately aim to attain food security (for individuals as well as entire

communities), relational proximity, self-reliance, and sustainability” (Byker,

B.C., Shanks, J. & Serrano, E., 2012, p. 39).

The industrialized food system has resulted in a wide array of interconnecting side

effects that have significantly impacted the health and well being of both the environment

and humans. However, health alone is not the only aspect of human life that has been

affected by this drastic shift in agricultural practices. Globalizing the food system has

shifted local economies, culture and social context. The farmer share of each food dollar

has dramatically declined, beginning with an average earning of 41 cents in 1955,

decreasing to only 20 cents in 1999 (Azuma and Fisher, 2001). Commodity food prices

have decreased by 30-50% since 1985, further stressing the potential profit margin of

small-scale farmers. The globalized food system has resulted in a monopolized industry in

which economic conditions are extremely challenging for small, private farms to compete

in. As market prices decline and production costs rise, large corporations with substantial

financial resources and capabilities continue to expand while small-scale farms are forced

out of the market (Azuma and Fisher, 2001; O’Hara and Stagl, 2001). It’s this growing

disconnect between communities and these large scale food production corporations that

is driving a nation-wide movement to revitalize the community based food system.

Initiatives arising from a community based food system model are working to

reconnect communities with the food production and distribution process. Direct

marketing arrangements, such as farmers’ markets and CSA’s, revive working partnerships

between food producers and food consumers. Such direct interactions provide the

opportunity for the food cycle of production to consumption to take place in a manner that

is both cost-effective and environmentally sound (Gillespie and Smith, 2008).

Reconnecting food producers and consumers not only strengthens local relationships and

culture but also supports local economic viability by encouraging local spending (Gillespie

and Smith, 2008; O’Hara and Stagl, 2001). Community based initiatives have gained

momentum since the 1990’s and have continued to evolve in efforts to reverse the

globalized food system. A review of the literature by O’Hara and Stagl (2001) suggests such

development in this locally-based model strongly demonstrates the nation’s growing

discontent with the current system of industrialized agriculture.

Direct Marketing Initiatives:

Locally based initiatives and direct marketing arrangements are gaining momentum

and reflect growing discontent with the current industrialized model of agriculture. The

U.S. Department of Agriculture reported that the number of farmers’ markets operating

throughout the U.S. rose from 1,755 in 1994 to 5,274 markets in 2009 (Francis and Griffith,

2011). Interest in locally grown foods has resulted in this widespread growth of farmers’

markets and further reflects the nation’s rising concern over food source and quality

(Byker et.al, 2012; Francis and Griffith, 2011; O’Hara and Stagl, 2001). A national study

conducted by the Hartman Group in 2007 concluded that a primary motivation for people

to purchase locally grown foods was a belief that local foods are healthier (Hardesty, 2008).

Another study conducted by Wolf and colleagues (2005) more specifically explored

motivations to shop at a local farmers’ market. Interview data suggested that consumers

perceive produce at farmers’ markets to be fresher, healthier and higher quality compared

to non-local produce bought at a conventional supermarket. Such perceptions are

therefore motivating more people to shop at local farmers’ markets to purchase produce

(Alonso and O’Neil, 2010; Hardesty, 2008; Wolf et. al, 2005).

Farmers’ markets, food cooperatives and CSA’s are all examples of the direct

marketing initiatives that are gaining momentum in the rebuilding of local food systems.

Community supported agriculture programs is another alternative food market model

that’s beginning to contribute to local food systems. CSA’s connect local consumers and

producers by offering consumers the opportunity to purchase a share of the farmer’s

produce. Purchasing shares upfront supports farmers in production costs (O’Hara and

Stagl, 2001). Members then receive a portion of produce each week based on the particular

season and growing conditions. In this way, some of the risk of farming shifts from the

producer to the consumer, serving to help revitalize a community’s food culture and

connection with the cycle of food production to consumption. A survey of 74 CSA member

households in northern New York explored the various motivations for participating in a

CSA program. The top ranked priority for participation was a desire to purchase fresh

produce. The third highest motivating factor to participate in a CSA was to support local

farmers (O’Hara and Stagl, 2001). Other motivating factors related to physical,

environmental, and social reasons. Such social concerns related to the desire to regain a

connection with local farmers and to recreate the food system as a piece of local culture. A

large study conducted in Oregon compared survey results of 250 CSA member households

in two different communities. Although education and employment rates varied between

the two communities, attitudes and motivations towards CSA participation were very

similar. Survey results concluded that one of the most primary motivations was due to

concern for supporting local farmers. Members even admitted to a willingness to pay more

for locally produced foods (Stephenson, 2004).

Farm-to-Institution Programs:

Direct marketing initiatives are now expanding from the farmers’ markets and CSA

programs model. Connecting small, local farmers with local stores and institutions is

serving as another outlet for farmers to gain access to reliable and stable markets.

Expanding into larger institutions such as hospitals, colleges, and restaurants is providing

an opportunity for local foods to play a more influential role within local food systems and

contribute as greater investment of food dollars into the local economy (Bellows, Dufour,

and Bachmann, 2003). A study conducted by Alonso and O’Neill (2010) revealed that

nationally growing interest in local foods is now significantly influencing the restaurant

industry. Study results showed a key motivator for restaurant owners to purchase more

locally-based produce and ingredients comes from their perception that local foods are

much more superior in taste and in quality. This perception, along with a growing

customer demand for local cuisine has contributed to a slow shift in the restaurant industry

to using locally sourced foods (Alonso and O’Neill, 2010). The National Restaurant

Association has conducted a series of surveys with members of the American Culinary

Federation. A 2007 study revealed that 90% of the 1,282 chefs surveyed believed that the

demand for locally sourced food items would increase in the future. A follow-up survey

conducted in 2008 reported that the 1,609 participating chefs identified the use of locally

grown produce as the top trend in 2009 restaurant menus (Alonso and O’Neill, 2010).

Farm-to-school programs are one significant outcome of the local food system

movement and its associated farm-to-institution initiatives. Only two percent of school-

aged children are estimated to meet the USDA nutritional recommendations across all five

food groups. Additionally, 84% of students are consuming excessive levels of fats and

sugars, contributing to the rising prevalence of obesity and type II diabetes in children

(Kloppenburg, Wubben, and Grunes, 2008). Farm-to-school programs are therefore being

more widely considered to target two key aspects of nutrition faced by the U.S., that of

deteriorating diet and nutritional education in children, as well as the growing local food

movement (Azuma and Fisher, 2001; Kloppenburg et. al, 2008). The Community Food

Security Coalition estimated that in 2008 there were farm-to-school programs in over

1,000 school districts in 32 states. Farm-to-school initiatives are also being implemented

in higher education facilities across the nation, further contributing to the local food system

and economy. School administrators are recognizing these programs as realistic and

attainable aspects of a more holistic model to improve child and community health. Farm-

to-school programs are becoming commonly viewed as significant experiential learning

opportunities for students in fostering nutritional knowledge and understanding, educating

on local food production and consumption, and even in shifting dietary habits towards

more healthful choices (Kloppenburg et. al, 2008).

Farm-to-school programs are now being viewed as a piece of a holistic paradigm of

individual and community health. In a study interviewing 28 key stakeholders in two

Pennsylvania schools with farm-to school programs, several main themes arose. The 2009

study conducted by Bagdonis and colleagues revealed three broad frames of motivation for

supporting farm-to-school programs. Participants perceived these programs as addressing

the weakened local food environment, supporting improved nutritional choices and

revitalizing the surrounding community through support of local agriculture. As stated in a

2001 evaluation report by the Community Food Security Coalition,

“Farm-to-school projects fit squarely within the broader conceptual

framework of community food security. Community food security, a

relatively recent concept linked to anti-hunger, sustainable agriculture and

community development goals, refers to a system approach to addressing the

nation's food and farming problems" (Azuma and Fisher, 2001, p. 10).

This attitude closely reflects the attitudes of participants of farmers’ markets and CSA’s,

representing the national movement towards healthier, fresher foods, increased education

in nutritional needs and habits, improved health and well-being, and support for local

farmers and agriculture.

Local Food in Our Health Care System

Health Care in the Local Food System Movement:

Rachel Carson triggered the environmental movement in the 1960’s, a movement

that represented a paradigm shift towards a broader, holistic perspective of health. This

paradigm shift embraced a relationship between environmental health and human health

and a revelation that advocated for the health of the food system as an active component of

overall human health and well being (Sachs, 2011). This connection between a healthy

ecosystem and healthy community has become a predominant platform for people

advocating for local, sustainable agriculture systems. However, not only are

environmentalists embracing this connection, but the health care system has begun to

formally explore this relationship as well. The timeframe between 2005 and 2009 is being

recognized as the developmental period in which the health care system began to explore a

relationship between food systems and human health (Harvie, Leslie, and Shak, 2009).

Major health care organizations, including the American Public Health Association,

American Medical Association, and the American Nursing Association, are beginning to

officially make statements on the relationship between food production and health (Dauner

et. al, 2011). This convergence in beliefs among environmentalists and the medical health

field reflects the growing support for a more systems-based approach to improving the

encompassing health and well being of our planet and its inhabitants.

The health care system is emerging as an increasingly significant leader in the

exploration of the relationship between healthy, sustainable food systems and healthy

communities. Hospitals have been participants of the globalized food system that relies on

production and distribution methods that are harmful to both public health and

environmental health. Hospitals serve as a place of healing and re-growth. As such, there

is an intrinsic responsibility to provide foods that are healthful and supportive of people

and the larger community’s surrounding environment (Cohen, 2006; Dauner et. al, 2011).

This realization is working to diminish a disconnect that has been long established in the

health care system: While processed or preservative-filled foods may be served to patients

while healing in the hospital setting, consumption of quality, nutritious foods is directly

related to an individual’s health (Cohen, 2006). The health care system is in a unique

position to serve as a leader in food policy reform and the shift towards local, sustainable

food systems. The health care system can serve as a role model by creating healthy food

environments in hospitals and educating patients, staff, and visitors on the connection

between food production practices and health. Additionally, the purchasing power of

health care food procurement budgets has the potential to greatly influence and support

local food systems (Dauner et. al, 2011).

Health Care on Public Health:

“Individual health cannot truly be realized independent of public and environmental

health. Similarly, public and environmental health depend to a large degree on the health

of individuals” (Schettler, 2006, p. 128). The health care system organically fits within this

broader system’s approach to health through supporting the relationship between healthy

food systems and healthy communities. The health care system has played a role in health

reform on numerous accounts, demonstrating its influential capabilities in initiating policy

reform and improvements in public health. For example, it had a significant role in

advancing formal policy to remove lead from paint and fuel. The health care system also

exerted leadership in outreach campaigns warning the public of the dangers of tobacco

smoking. Hospitals and the health care system modeled the first smoke-free environments

and have worked to comprehensively eliminate mercury use by the public and health care

system as well (Harvie et. al, 2009). Such historical impact on public health policy further

supports the farm-to-hospital movement in which the health care system may strengthen

the local food system and overall health of community members.

This leadership is now being emulated by shifting towards local food systems to

support health and healing. The health care system is working to change hospital food

services by exerting its influence and impacting group purchasing organizations (GPO’s).

GPO’s act as prime vendors for hospitals, and contracts usually require that 90-100% of a

facilities total food purchasing be organized through the contractor. In 2004, the top health

care GPO contracts purchased approximately $2.75 billion worth of food and the total

health care market spent nearly $12 billion (Harvie, 2006). Health care system purchasing

power is therefore quite significant, and by demanding higher quality, local foods,

momentum is being created within GPO’s to shift towards more sustainable and local

producers and distributors.

Shifting from Treatment to Preventative Health Programs:

As the relationship between the health care system and local food systems has

progressed, hospitals across the nation have inspired creativity and ingenuity in realizing

this needed paradigm shift. On-site farmers’ markets and stands are being implemented in

hospitals across the country in order to serve patients, staff, and even the wider

community. Farmers’ market programs, while varying in size, time of operation and target

populations, all tend to target nutrition education and increased access to local, fresh foods

(Kulick, 2005). Fourteen Kaiser Permanente facilities throughout California, Hawaii, and

Oregon host farmers’ markets. The National Institute of Health in Maryland has served as a

leading role model in this initiative, as this facility has hosted farmers’ markets for over 20

years. Duke University Medical Center offers a stand for employees and Allen Memorial

Hospital in Iowa offers a farmers’ market open to both hospital staff and patients, as well as

to the general public and surrounding community (Kulick, 2005).

At the individual level, health care and hospital facilities have implemented

programs requiring varying degrees of change and commitment. For example, Good

Shepherd Medical Center in Oregon has eliminated fat fryers, serves organic produce and

rBGH-free milk, and has also substituted beef with the healthier and leaner alternative of

bison. Cancer Treatment Centers of America have placed a priority on reducing exposure

of patients to toxins and preservatives by emphasizing the use of organic foods and

produce (Kulick, 2005). St. Luke’s Hospital in Duluth, Minnesota has served as a leading

role model through its expansive system modifications, including comprehensive shifts to

Fair Trade coffee, organic fruit and rBGH-free milk. A local, organic-based salad bar is

available in the cafeteria and a compost and food-recovery program for unused food has

been implemented as well. Fletcher Allen Health Care of Vermont has also played a leading

role with efforts starting over 15 years ago. A patient menu emphasizes fresh, local items

and offers organic produce, hormone-free milk and Free Trade coffee. A comprehensive

compost and food-recovery program has been well established and employees have the

opportunity to enroll in an on-site CSA program (Harvie, 2006). Finally, healthy vending is

yet another example of efforts by the health care system to support health through

nutrition. While vending machines serve as convenient access to snacks, options are often

high in sugar and fat. Santa Rosa Memorial in California is just one example in which

efforts are being made to shift this commonality by offering organic, microwave-ready

meals, as well as more nutritious and portion-appropriate options (Harvie, 2008). Such

variance in programs and efforts demonstrates how moving towards local food systems

occurs on a continuum with a broad spectrum of opportunities and options.

Healthy Food in Health Care Campaign:

One key manifestation of the farm-to-hospital movement is the Healthy Food in

Health Care campaign. Health Care Without Harm’s Healthy Food in Health Care campaign

is an initiative for hospitals to pledge pursuit of, and engagement in, a healthy and

sustainable food system model. This initiative began in 2006 and serves as a framework

for the health care industry in connecting the health of patients, the community, and the

environment with the food that is served in hospitals (Health Care Without Harm, 2008).

The framework provides resources, education, and support in realizing changes in food

service programs and offers a tiered system in which these changes can be aspired to in

realistic and successful ways. The pledge contains nine core components that participants

commit to, including the implementation of a working framework to achieve more

sustainable, local food procurement; communication with local farmers and community-

based organizations; dialogue with vendors and GPO’s in offering more local, healthful

foods; and educating hospital staff and patients on the benefits and importance of local and

sustainable food practices (Health Care Without Harm, 2008).

A 2008 study conducted by Health Care Without Harm stated that “across the

country, health care organizations are implementing policies and programs that

demonstrate a commitment to “First, do no harm” by treating food and its production and

distribution as preventative medicine that protects the health of patients, staff, and local

and global communities” (Harvie, 2008, p. 3). This sentiment is now being reflected

throughout the health care system. Since the founding of the initiative in 2006, Health Care

Without Harm has gained the support and commitment of 495 hospitals nation-wide. The

2008 study surveyed Pledge signers to identify initiatives and models being used. Survey

results showed that 72% of pledge signers were purchasing local or organic foods, most of

which appropriated 10-40% of food procurement budgets to these types of foods. Eighty

one percent of respondents were purchasing rBGH-free milk and 44% were purchasing

antibiotic and hormone free meats. Additionally, 25% of Pledge signers had established a

farmers’ market or stand on-site, 60% had established composting programs, and 100% of

respondents reported an increase in the amounts of fruits and vegetables being

incorporated into meals (Harvie, 2008).

Healthy Food in Health Care Pledge Initiatives: The Healthy Food in Health Care

Pledge aims to provide flexibility and tools to allow for varying levels of change, thereby

providing room for creativity and success in pursuit of modeling sustainable, locally-based

health and healing. With such flexibility and room for customized programs, hospitals are

able to invest varying degrees of commitment based on their particular capacity for change.

Such flexibility creates endless possibilities in pursuing the tenets of the pledge. For

example, Catholic Healthcare West System (CHW) consists of 42 treatment facilities in

three states and has served as a leading role model in aspiring to, and fulfilling, the Healthy

Food in Health Care Pledge. CHW has taken a holistic, systems-wide approach to

implementing its sustainable food goals. CHW produce contracts are now selected and

awarded based on a criterion of being locally sourced. Fair Trade coffee is now emphasized

at many sites and bottled water has been greatly reduced (Harvie, 2008). CHW is also

working with contracting vendors to shift towards reusable packaging and away from

cardboard and plastics. Biodegradable serviceware is also being used at many of the CHW

health care sites, as well as redesigned patient menus and on-site gardens (Harvie, 2008).

Bartels Lutheran Retirement Community serves as another example of the

commitment of health institutions to local, sustainable food models. This Iowa retirement

facility has been building its sustainable health model since 2000 and now sources over

25% of its annual food procurement from local farms and producers (Harvie, 2008). Dairy

and beef are now locally sourced and contributed to the $70,000 that was put back into the

community’s economy through the purchasing of local foods. A composting program was

initiated in 2008 along with the increased use of biodegradable and reusable serviceware.

Since 2000, Bartels Lutheran Retirement Community has placed an emphasis on expanding

sustainability efforts and has advocated for continued support of the health of its residents

and of the local economy and environment (Harvie, 2008).

Fletcher Allen Health Care (FAHC) of Vermont was one of the first hospitals to sign

the Healthy Food in Health Care Pledge, although the facilities have been involved in

sustainability efforts for over 20 years and models lasting commitment to the farm-to-

institution movement (Fletcher Allen Health Care, 2013). FAHC implemented a Nutrition

Plan in 2007 emphasizing a renewed commitment to establishing relationships with local

producers. FAHC has fostered relationships with local fruit, vegetable, and beef producers

and has established an on-site farmers’ market program (Harvie, 2008). FAHC has a well

established composting program and redesigned patient menus in 2005 to further

emphasize local, fresh ingredients (Kulick, 2005). Along with general menu modifications,

a room service program in which patients are able to select a meal of their preference has

also been initiated, and has greatly contributed to a reduction in food waste and

improvement of the patient experience (Fletcher Allen Health Care, 2013). FAHC has

demonstrated commitment to local producers through contracts with businesses such as

Cabot Creamery for cheese and other dairy products and Green Mountain Coffee Roasters

for fair trade coffee. In addition to these efforts, FAHC has worked with vendors to

implement the use of more reusable packaging, complete shift to local beef and

continuation of the on-site CSA program for employees (Harvie, 2008).

Current Challenges of Farm-to-Institution Initiatives:

The farm-to-institution movement is still establishing roots and a place within the

United States’ health care system and therefore has had limited formal program

assessment and evaluation. However, various programs within the farm-to-institution

movement have been examined and common themes are beginning to emerge. Similar

challenges and barriers are being identified across various institutions as an increasing

number of organizations, facilities, and businesses become engaged in the local, sustainable

food movement. Such themes offer a platform to begin fine tuning the processes of

implementing farm-to-institution programs.

Kloppenburg et al. (2008) conducted a literature review on the implementation of

farm-to-school programs and also assessed the Wisconsin Homegrown Lunch program in

three schools of the Madison Metropolitan School District. These three schools

implemented an experiential program to connect students with local farmers. This

educational component was well received by students and increased awareness and

appreciation about local foods and the work of local farmers (Kloppenburg et al., 2008).

The second component of the program was to “link the land with the classroom,” and was

developed with much greater effort and challenges. Three core challenges that emerged

around implementation of a farm-to-school program pertained to cost, procurement, and

supply, and closely reflected challenges identified in the literature and other assessment

studies. Schools are often under very strict budgets and may therefore struggle with

paying additional costs for local and sustainable ingredients. Such restrictions on time and

money have resulted in the common preference of contracting with one primary

distributor that can ensure quality foods in the appropriate quantities and at the agreed

upon delivery dates (Izumi et. al, 2010).

Procurement of local or sustainable foods and ingredients serves as another

significant challenge to institutions working to shift their food models. For example,

Kloppenburg et al. (2008) reported that the three schools participating in the Wisconsin

Homegrown Lunch program were required to purchase at least 80% of their food from

their contracting GPO, limiting the degree to which local foods may constitute daily meals.

A 2002 survey of 66 institutions and 18 restaurants in Iowa identified several of the top

challenges to be related to procurement of local foods. Year round availability in regions

with shorter growing seasons has been identified as a challenge to menu preparation and

was identified through the surveys as the top concern for both restaurants and institutions

(Strohbehn and Gregoire, 2002). Local and state regulations, adequate supply, quality of

local foods, and the need to work with multiple vendors were also noted in the Iowa survey

(Strohbehn and Gregoire, 2002). Where contracting with a GPO allows for nearly all food

to be sourced from one distributor, the resources required to identify, collaborate, and

contract with multiple local vendors has been widely sourced as a significant challenge to

initiating a local food program (Hardesty, 2008; Kloppenburg et. al, 2008; Vogt and Kaiser,

2008). This current challenge can be summarized by the following description of food

services in the United States:

“Buying food directly from individual farmers departs substantially from

dominant school food procurement practices. School food service

professionals operate under extremely tight time and budget constraints.

These conditions favor ‘‘broadline’’ distributors—essentially one-stop-shops

which carry nearly all of the food, supplies, and equipment needed to operate

a food service kitchen—that are able to offer competitive prices, financial

incentives, streamlined service, and the convenience of buying food and non-

food items” (Izumi et. al, 2010, p. 336).

A case study in 2010 explored the attitudes and perceptions of restaurant owners

on buying local foods and supporting the local food system. While limited research has

been conducted on the degree to which these particular institutions are currently

participating in local food efforts, perceived challenges and benefits closely resemble those

being identified in farm-to-school and farm-to-hospital programs. In this 2010 case study,

21 interviews with small restaurant owners and managers revealed that predominant

challenges included the additional resources of time, knowledge, and money required to

shift away from large-scale distributors to use more locally-sourced ingredients (Alonso

and O’Neill, 2010). Seasonality of local produce was also cited as a significant challenge.

Previous negative experiences in attempting to procure local foods, as well as a lack of

knowledge around the creation of partnerships and contracts with local farmers, were also

identified as challenges to farm-to-institution programs (Alonso and O’Neill, 2010). A

study conducted by Strohbehn and Gregoire (2003) assessed perceived barriers of 10

foodservice institutions in central Iowa to using local foods, and reflected similar concerns,

including timely delivery, food safety and convenience of contracted distributors.

Themes of challenges and barriers facing the farm-to-institution movement are

being found to span across various types of institutions. These themes are also being

supported in studies assessing the farm-to-hospital efforts. Dauner and colleagues (2011)

conducted interviews at St. Luke’s Hospital in Duluth, Minnesota to gain insight into how

the hospital culture has worked in different ways to facilitate or hinder the process of

making changes towards sustainability. St. Luke’s Hospital signed the Healthy Food in

Health Care Pledge in 2006, committing to healthful and sustainable food procurement

practices, waste management, and reuse procedures (Think Globally, Eat Locally, 2008).

The study consisted of 25 semi-structured interviews with key individuals in food

acquisition, preparation and service. These key participants included: Hospital

administrators, the CEO, vice presidents, a resource consultant, representatives of the

hospital’s contracting GPO, the director of hospitality services, dieticians and marketing

specialists. Significant challenges pertained to going off contract with a GPO that provides

incentives for purchasing a majority of items from specific vendors and distributors

(Dauner et. al, 2011). Interviews provided a map of current challenges faced by the health

care industry in aspiring to local, sustainable food service programs. Other barriers

identified at St. Luke’s Hospital included a general lack of human, physical, and financial

resources to focus on such systemic changes, the inability of local farmers to cultivate and

provide sufficient quantities of produce, and the financial logistics of purchasing from

several different food producers and distributors (Dauner et. al, 2011).

Perceptions of Local Food Producers and Institutions on a Direct Relationship:

Perceptions of local food producers and institutions in establishing direct

relationships most often occur in separate studies. Several studies with similar design,

exploring either perceptions of producers or institutions through questionnaires, closely

reflect one another in identified benefits and barriers. Researchers Gregoire, Arendt and

Strohbehn (2005) conducted a study to explore the perceptions of Iowa producers around

marketing to local restaurants and other food service institutions. One hundred fifty one

producers participated and completed the survey to identify current barriers and

opportunities to marketing and working with local restaurants. The greatest benefits that

producers perceived from selling directly to restaurants and other institutions included

supporting local farmers, providing fresher food, and shorter travel distance (Gregoire et

al., 2005). Survey results also indicated that greatest challenges for producers to work with

institutions included year-round availability, lack of a dependable market, ability to change

or lower prices of products, communication with the food buyer and the ability to produce

demanded quantities (Gregoire et al., 2005).

A more recent study reflects similar perceptions, but explored hospitality

institutions using local foods in their food service meals. Two in-depth interviews were

conducted at limited service and full service hotels. To supplement this rich data, 40

questionnaires were completed by other hotels throughout Iowa. Interview data identified

the greatest benefits perceived by hospitality food service managers as being freshness;

supporting local economy; relations with local farmers; price; and taste. Greatest obstacles

were perceived as including inconsistent quality; multiple contacts; seasonality; and

inadequate quantity (Kang, 2012). Questionnaire data from this study closely mirrored

these perceptions and strengthened conclusions.

Researchers Gregoire and Strohbehn (2002) conducted a similarly structured study

examining perceptions of Iowa school systems around working with local producers to

source local foods. Two hundred thirty seven questionnaires were completed by school

food service management across the state. Good public relations, supporting the local

economy, ability to purchase smaller quantities and fresher food, and knowing the product

sources were identified as significant benefits for school systems in sourcing local foods

(Gregoire and Strohbehn, 2002). Primary challenges, however, were perceived as relating

to the lack of availability of foods year-round, ability to obtain adequate quantities, local

and state regulations and the need to work with multiple vendors (Gregoire and Strohbehn,

2002).

Conclusion

Farm-to-hospital initiatives are being implemented nation-wide and the health care

system is taking a leading role in shifting industrialized agriculture in the U.S. towards

more local and sustainable food models. A young movement translates into very limited

assessment and evaluation on these models and initiatives. Little is yet known about the

gaps and opportunities that exist specifically for the health care system in connecting local

growers with hospital food service programs. Additionally, studies with similar goals

primarily utilize surveys and other forms of questionnaires, and also focus either on

perceptions of producers or perceptions of institutions (vs. a combined, cross-analysis).

Therefore, it would be beneficial to conduct extensive, qualitative interviews integrating

the perceptions of local food producers with the perceived gaps and opportunities existing

specifically for hospitals in incorporating locally-sourced foods and ingredients in food

service meals.

CHAPTER THREE

Methodology

Purpose of the Study:

The purpose of this study was to assess the perceptions of hospital staff and local

food producers and distributors on opportunities and challenges to increasing the amounts

of locally-sourced foods used in hospital food service programs. From this assessment,

initial, regionally specific strategies were developed to suggest appropriate “next steps” in

strengthening the connection between Montana hospitals and the local food system. The

intent of this study was twofold. While results of this study were not intended to provide

generalizations, it did aim to contribute to the methodology and processes of conducting

similar studies. The second intent of this study was to provide a framework for change

that’s locally relevant and applicable to hospitals in Montana. This study thereby aimed to

provide a platform for discussion and action in increasing the use of locally-sourced foods

in hospitals food service programs.

Research Setting:

Missoula, Montana has two main hospitals in the city, Community Medical Center

and St. Patrick Hospital. St. Patrick Hospital, established in 1873, currently has 253

licensed beds and admitted nearly 8,000 patients in 2011 (St. Patrick Hospital, 2013). The

hospital represents the only health care facility in Montana that has signed the Healthy

Food in Health Care Pledge. St. Patrick’s sustainability efforts have manifested as the Green

4 Good campaign, a culmination of guiding principles supporting environmental

stewardship. Efforts of the Green 4 Good campaign include reducing landfill waste,

reducing greenhouse gas emissions, improving energy efficiency, and supporting

ecologically sound food systems (St. Patrick Hospital, 2013). Community Medical Center,

established in 1922, currently has 146 acute care beds. With a strong commitment to

pediatric care, Community Medical Center is the only hospital in Missoula County that

provides obstetrical and newborn care. Additionally, the hospital provides the most

comprehensive rehabilitation programs in the state (Community Medical Center, 2011).

The facility advocates a connection between the nutrition that is consumed and a person’s

overall health and well-being. A commitment and understanding of this relationship is put

into action through the hospital’s Big Sky Café. This dining service sources local dairy

products, breads, beef and seasonal produce for its food service program. Menu options

have also been modified to reflect seasonal availability of food products and a dedication to

healthy, appealing meals (Community Medical Center, 2011).

Montana contains a wide variety of food growers and producers, many of which are

located in the Missoula region. Foods include produce, dairy, meats, flowers, and other

artisanal products. Local food growers and producers have options in potential access to

market outlets in order to reach consumers. These options are demonstrated in the city of

Missoula in which a growing commitment to local foods and agriculture is reflected

through the numerous regular and organized farmers’ markets. Community gardens, food

co-ops, and CSA’s are also readily accessible in Missoula. Additional markets are beginning

to develop and become more strongly established as key components of Missoula’s local

food system. One example includes the farm-to-cafeteria initiatives, also representing a

core component of the town’s greater farm-to-institution movement. In 2003, the

University of Montana served as the gateway to these farm-to-cafeteria initiatives by

implementing a farm-to-college program that increased use of local food products and

ingredients in its food program (Farm to Cafeteria Network, 2013).

Research Procedures:

Study Design:

This study was conducted using a qualitative research design. Three main purposes of

qualitative data collection have been described to include exploration, explanation, and

description (Marshall and Rossman, 1999). Additionally, qualitative studies can “build rich

descriptions of complex circumstances that are unexplored in the literature” (Marshall and

Rossman, 1999). This particular study explored barriers and enhancers of incorporating

local food into hospital food service programs. Due to the nature of the research questions

and intentions, a qualitative approach was therefore an appropriate research method to

incorporate into this study. This approach was applied through semi-structured interviews

with the involved participants to create an understanding of the particular attitudes and

perceptions of Missoula’s health care providers and local producers on local foods in

hospital food services. The qualitative research design was also applied through the use of

a brief demographic survey preceding each interview session.

Protection of Human Subjects:

The research project in its entirety was reviewed and approved by the University of

Montana Institutional Review Board. All participants remained anonymous in the

integration of data and composition of the final report. All information collected

throughout this study was kept completely confidential.

Data Collection:

Interview Participants:

Interviews were conducted with various staff members at Community Medical Center and

St. Patrick Hospital and local food producers and distributors. Hospital staff participants

were connected to management of the facility’s food service program or sustainability

efforts and included positions such as manager of food services, chefs, dieticians, and

sustainability coordinators. Gatekeepers were identified at both hospitals. Once

relationships with gatekeepers were established, additional participant recruitment took

place through convenience and snowball sampling in which referrals were made by the

initial contact list. Local food producers and distributors included in the study were

identified by working with a local community food and agriculture policy organization that

has strong ties to these individuals. Potential interviewees were contacted, given an

overview of the study, and invited to participate in the study. Additional interviewees were

then recruited through convenience sampling and the process of snowball sampling.

Interview Setting:

Interviews took place in a location selected by the particular interviewee based on

particular preference and convenience. Interviews with hospital staff took place on site

while interviews with producers and distributors occurred at the site of business or at a

predetermined place of convenience.

Demographic Survey:

A brief demographic survey was administered to each participant preceding the interview

session. Questions revolved around level of education, current employment and initial

perceptions around local food (refer to Appendix A).

Interview Guide:

The interview guides were developed based on themes identified in the literature

pertaining to established barriers and enhancers to incorporating local foods into

institutional food services. Being that limited data exists on the barriers and enhancers

specifically experienced by hospitals, themes from more comprehensive analysis on

initiatives such as farm-to-school programs were integrated into question development.

Two interview guides were developed in order to more appropriately pertain to

participants in either the hospital or food production setting (refer to Appendices B and C).

These guides addressed (1) perceptions on current barriers and enhancers to using locally

sourced ingredients in hospital food services, (2) individual, institutional, and policy-

related factors contributing to these current barriers and enhancers, and (3) knowledge,

skills, and resources perceived to be needed by hospitals and producers to use more locally

sourced ingredients in food service meals. Each interview guide went through a test run

process with two volunteers (one volunteer from a hospital and one volunteer from a local

food production company). This step helped to fine-tune the interview guide for

conducting the actual interviews, thereby improving the quality of data collected from each

interview.

Interviewer:

The interviewer was a female graduate student in the Community Health Program of the

Health and Human Performance Department at the University of Montana. She was

responsible for acknowledging any potential biases, conducting the interviews, analyzing

data, and composing the findings.

Informed Consent:

The interviewer began the interview process at the scheduled meeting time and location.

The participant was given the opportunity to ask questions or raise any concerns. Once

procedures of the interview were discussed, the participant was asked to give consent in

reference to an IRB-approved verbal consent form. The participant received a copy of the

form for any personal reference. (The two involved hospitals deferred to the University of

Montana’s approved IRB application.) The demographic survey was administered after

consent was given. The interview then began with a brief description of the informal,

mildly-structured style of the interview.

Interviews:

Each interview was directed through the use of the semi-structured questions assembled in

the appropriate interview guide. Six to ten interviews were conducted at each of the

hospitals and six to ten interviews were held with local producers and distributors, or until

saturation occurred. Each of the interviews was conducted in person and was audio

recorded to support more active listening and engagement by the interviewer. Participants

completed one interview session, lasting approximately 30-60 minutes.

Data Analysis:

Results from the demographic surveys were summarized using SPSS analysis in

order to generate general descriptive statistics and analysis of the involved participants in

the study. For example, upon compilation of the survey data, SPSS allows for generation of

percentage distributions, means, medians and standard deviation (Glewwe and Levin,

2005). Distribution of the population was grouped by age, gender and ethnicity to more

clearly understand the composition of the interview participants.

Audio recordings were transcribed following the completion of each interview.

Based on a five step process, as described by Ulin, Robinson, and Tolley (2005), data was

interpreted, responses were related back to the study’s research questions and broader

conclusions were drawn around the data. Therefore, this qualitative data analysis

approach was inductive in approach, moving from specific data to more general data so

that larger, more general statements could be made. The first step of data analysis was full

immersion in the obtained data. The primary researcher (PR) read and re-read transcripts

to become as familiar as possible with the data. Becoming familiar with transcripts as they

were collected allowed the PR to assess the content and determine whether the

information being collected matched the intent of the study (Ulin, et al., 2005). By

reviewing the data on an ongoing basis, the PR was able to assess the effectiveness of the

interview questions and make any necessary adjustments to ensure questions were framed

correctly and probe questions were as appropriate and valuable as possible. Ongoing

review also allowed the PR to evaluate the quality of the data being collected and to begin

formulating initial thoughts on any emerging themes, relationships or other patterns.

The second step of the process was coding of the transcripts to formally identify

emerging themes. Coding significant themes and grouping them together allowed the

reader to discover new subthemes within the larger context and conduct a more in-depth

exploration of each key theme (Ulin et al., 2005). Coding scheme development is a dynamic

process that evolves as more interviews are conducted and more data is collected.

Therefore, the coding scheme transformed as themes that initially seemed relevant turned

out to rarely emerge in later transcriptions. Excel was used to conduct a coding sort in

which similarly coded blocks of text will be grouped together. This allowed the PR to

determine the frequency with which codes appeared in the data set as a whole. At this

point, another researcher with expertise in qualitative methods applied the coding scheme

to 30 randomly selected transcript quotes to determine the reliability of the initial coding

scheme. Overall agreement between raters (readers) was determined. If less than 80%

agreement was reached, the raters discussed discrepancies until agreement greater than

81%, or Cohen’s kappa equal to .820, was reached. Reaching a Cohen’s kappa equal to or

greater than .820 indicated that overall agreement was higher than expected to occur by

chance (Landis and Koch, 1977).

The third step was displaying the data. This step involved looking more closely at

the sub-themes of each coding sort and determining whether they originated from

particular subgroups (Ulin et al., 2005). Exploring the context of the subthemes allowed

the PR to begin developing hypotheses, formulate questions, and validate emerging

conclusions about the data. The fourth step was data reduction in which the most

significant concepts and relationships were identified. This process allowed the PR to step

back from the more defined scope of sub-theme analysis in step three to look at the

broader picture and identify central and secondary themes (Ulin et al., 2005). Finally, the

fifth step in the data analysis process was interpretation. This last step synthesized the

data to explain the core meanings, themes, and relationships that ultimately emerged from

the process. Significant themes were identified and summarized. From these themes,

connections, relationships and broader significance of the data was explored and discussed

in significant detail in order to maintain relevance of the project (Ulin et al., 2005).

Theoretical Foundations:

Theoretical models can be beneficial in providing a comprehensive framework for

the design and development of a project. Such models provide structure to the processes of

a particular project, from needs assessment, to data analysis, and finally to strategy

development. Such models appropriately apply to this particular qualitative study in which

the goal is to integrate the results into a working programmatic framework with suggested

“next steps.”

The Socio-Ecological Model

Theoretical models provide a framework in community and public health projects

and interventions. The socio-ecological model of health behavior explores health behavior

from a multidimensional perspective in which factors from a variety of levels interact to

influence a particular behavior (Elder et al., 2007).

Figure 1 Socio-Ecological Model

Source: Prevention Institute, 2003

This model suggests that factors derived from individual, community, institutional, and

political domains all interact to influence a particular health issue or behavior. As a result

of dynamic interrelationships among all of these different levels, programs that address

these various levels are more likely to be effective. The Institute of Medicine (2003)

defines the socio-ecological model as “a model of health that emphasizes the linkages and

relationships among multiple factors (or determinants) affecting health.” It’s through the

exploration of these interrelated factors that a program or intervention can be developed,

as potential areas in need of change or modification can be identified and informed by this

holistic assessment of a health behavior. Being a holistic, multidimensional approach to

program development, components of this model were integrated to guide the approach

and design of this study, including structure of research questions, methods design, and

development of the interview guide.

CHAPTER FOUR

Results

The purpose of this study was to assess the current farm-to-institution system in Montana

and more specifically, the farm-to-hospital system in Missoula, Montana. This study aimed

to provide a situational assessment on the use of local foods in hospital food service

programs in Missoula, Montana. Through semi-structured interviews, perceptions and

attitudes of staff and administrators at Missoula hospitals were explored for barriers and

opportunities to using local foods. Interviews were conducted (N=9) with hospital staff

who were involved in food service management. Interviews were then conducted with

local producers, distributors and processors (N=8) to explore their perceived barriers and

opportunities to working with institutions in Montana. All participants completed a ten

item demographic survey. Interviews were analyzed for common themes that provided a

basic framework for ways to increase the amounts of locally sourced foods in hospital food

service meals.

The results are discussed below, beginning with the survey data, followed by the

interviews. Separate interview guides were used for interviews conducted with hospital

staff and local producers, as differing perspectives and experiences are associated with

each sector. Therefore, while data from the two groups was integrated to research

Question three, the Results section will present each set of interview data separately to

answer the first and second research questions. Emergent themes from the interviews are

presented and accompanied by selected quotes to further demonstrate their significance

and context.

Demographic Survey:

Participants filled out a brief demographic study before beginning the interviews. Fifteen

participants completed the demographic survey (not all interview participants filled out

the survey). Eight surveys were filled out by hospital staff participants and seven were

filled out by local food producer and distributor participants. Hospital staff was located in

Missoula, Montana while producers were based at various locations throughout western

Montana.

Total Participant Group:

The following table displays the gender, age and education distribution of the study

participants. As this table shows, the majority of participants were female, 45-54 years old

and were split between having some college or an Associate’s degree and having a graduate

degree.

Table 1 Description of participants

Three questions on the demographic survey were presented using a Likert scale to explore

perceptions around local food and consumption tendencies. 73.3% (n=11) of participants

Percent

Gender

Female

66.7

Male

33.3

Age Range

25-34

35-44

26.7

45-54

33.3

55-64

Education

Some college/

Associates degree

26.7

College Degree 40

Graduate Degree 26.7

Doctorate Degree 6.7

felt that local foods are sometimes healthier than non-local foods while the remaining

26.7% (n=5) felt that local foods are always healthier than non-local foods. 86.7% (n=13)

of respondents strongly agreed that it’s important to incorporate local foods into one’s diet

while the remaining 13.3% (n=2) agreed that it’s important to consume local foods.

Reflecting responses to these questions, all (100%) of the study participants identified

consuming locally-sourced foods at least once a week. The farmers’ market was most

predominantly identified as an outlet to purchase locally-sourced foods, as 73.3% of

participants noted that they attend a local farmers’ market. Grocery stores were also

identified as a common outlet to procure local foods, as 60% (n=9) of participants

recognized grocery stores as a beneficial market.

Hospital Staff:

The hospital staff participants (n=8) were between the ages of 25 and 54 with 50% (n=4)

being 45-54 years old. 87.5% (n=7) of participants were female and 75% (n=6) of the

group had either four or more years of college or post graduate education. Additionally,

50% (n=4) of participants have a yearly income of $40,000-$60,000 and 37.5% have an

income of more than $60,000. Occupation titles ranged from sustainability coordinator,

nurse, dietitian, chef and food service manager.

Three questions on the survey were based on a likert scale to explore perceptions

around the use and purchasing of local foods. 75% (n=6) of participants felt that local food

is sometimes healthier than non-local foods, while 25% (n=2) felt that local foods are

always healthier. Along with this, 87.5% (n=7) of participants strongly agreed that it’s

important to incorporate local foods into one’s diet and 100% of participants noted that

they consume locally-sourced foods at least once a week. There were also several outlets

identified that participants use to purchase local foods. 87.5% of participants attend local

farmers’ markets, 50% are members of a food co-op or CSA and 75% (n=6) purchase local

foods from a grocery store. Friends and local vendors were also identified as sources to

obtain local food products.

Local Producers and Distributors:

The local producer and distributor participants (n=7) were between the ages of 25 and 64

with 42.9% (n=3) being 55-64 years old. 57.1% (n=4) of participants were male and

42.9% (n=3) of participants had a graduate degree. 42.9% (n=3) of participants had an

annual income of $20,000-$40,000 and another 42.9% of participants had an income of

$60,000 and above. Occupation titles ranged from farmer, manager and agriculture

coordinator.

All participants answered the Likert scale questions around purchasing and

consumption of local foods. 71.4% (n=5) of participants felt that local foods are sometimes

healthier than non-local foods while 28.6% (n=2) felt that local foods are always healthier.

85.7% (n=6) of participants strongly agreed that it’s important to incorporate local foods

into one’s diet, while 14.3% of participants agreed that it’s important. Similar to the

hospital staff participants, all (100%) of the local food producer and distributor

participants reported they consume locally-sourced foods at least once a week. Several

different outlets for purchasing local foods were identified by this group. Fifty seven

percent (n=4) of participants purchase local foods from farmers’ markets while

approximately 57% identified food co-ops as a source for local foods. Twenty eight percent

(n=2) of participants are members of a CSA program and 57.1% of participants procure

local foods from grocery stores. Along with these sources, local ranchers and participants’

own farms were identified as other sources for purchasing local foods.

Hospital Staff Interviews:

A variety of themes related to the use of local foods in hospital food service meals emerged

from the interviews and are summarized in Table 2. The themes naturally fell within four

primary themes and significant sub-themes emerged from each of these groups.

Additionally, sub-theme elements were also identified and included when appropriate. The

primary themes included: 1) Local food knowledge; 2) Hospital infrastructure; 3) Local

food in health care; and 4) Local food use and producers. Sub-themes and sub-theme

elements are presented and accompanied by relevant quotes below.

Table 2 Themes and sub-themes of interviews with hospital staff

Emergent

Theme

Sub-Theme(s)

Sub-Theme Elements

Element Sub-Theme(s)

1. Local food

knowledge

Personal

knowledge/

perceptions

Hospitals have hurdles to using local

Growing disconnect between people and

food/ less farming

Need increased education, awareness

and communication

Perceived benefits

of local food

Local economy

Environmental health

Human health

Political: Vote with your dollar

Community health/supports community

2. Hospital

infrastructure

Enablers

Staff

Passionate staff, supportive

administration

Dedicated, creative chefs: Effective

kitchen and cost management

Food Service management, financial

infrastructure

Thomas Cuisine Food Management

Flexibility of contract account

Long enduring sustainability emphasis on

site

Barriers

Restrictions of contract account

Lack of resources

Restricted patient diets, lack of

communication with patients about

"local"

Lack of marketing

Programs/ Efforts

Local initiatives in the kitchen/use of

local products

Removal of unhealthy foods and

beverages

Education

Food labeling and explanations

Outreach events/hospital wide

initiatives/ programs

Staff programs

CSA program

Preventative health care

Positive feedback

3. Local food in

health care

Enablers

Natural setting for health education

Barriers

Western health model is unsustainable,

doesn't emphasize nutrition

4. Local food use

and producers

Enablers of using

local foods in the

hospital setting

Benefits of working with local producers

More personal relationships, direct

communication

Coop situation: WMGC

Flexibility, adaptability, organized

Delivery to the hospital

Good work ethic/pride in work

Quality

Missoula is a uniquely supportive

community of local food

Growing popularity for local

In health care setting

In community setting

Networking: Meetings, conferences,

partnerships with other health care

facilities

Perceived barriers

to using local

foods in the

hospital setting

Time needed to work with multiple

producers

Quantity/ availability

Cost

Seasonality

Demand

Tastes different: Uncertain of change

and comfortable with established

eating habits

Lack of interest in eating local

Lack of knowledge/ awareness of local

foods and resources

THEME 1. Local Food Knowledge:

The local food movement is gaining momentum across the nation. Attitudes and beliefs

around local foods are dynamic and evolving rapidly as the movement gains support. The

interview data showed perceptions around using local foods were a dominant theme. This

theme related to use of local foods at a personal and at a larger institutional level. Such

perceptions offer insight into the ways in which the hospital staff personally relate to local

food and the farm-to-institution movement. Prominent sub-themes within this theme

include (a) personal knowledge and perceptions and (b) perceived benefits of local food.

Within these sub-themes, notable sub-theme elements emerged as well.

Sub-theme. Personal knowledge/perceptions: While support for local food is

growing, there is still a significant disconnect between communities and their food system.

Such disconnect creates a challenging environment for strengthening the local food system.

Sub-theme element. Hospitals have hurdles to using local: Based on the

particular job title of the interviewee, some participants were more closely involved in

working with local producers than others and therefore more aware of the associated

challenges and opportunities. However, there was a general and more overarching

perception that the hospital, as an institution, faces a variety of challenges to using locally-

sourced ingredients into the meal services program.

 “As far as bringing local foods into hospitals, I absolutely agree. I like to see that. I

realize that it’s difficult, because of the rules, probably. There are probably plenty of

health rules that keep us from using them. Demand, quantity, availability. There are a

lot of factors that go into it.”

 “Cost is probably an issue. It’s not cheap. Cost isn’t a significant issue for me personally

because I have a good job but for the individuals, sure. It would be an issue. I know the

food bank grows some of their own food and I hear people talk about how good it is.

They wouldn’t be able to afford to buy it. So I think affordability might be another

issue. Because I have a budget. For the hospital, I’m sure you can get it cheaper if

you’re having it shipped from somewhere else, or in a can. But for me individually, it is

worth it to pay extra, but it is extra.”

 “I’m not familiar with the safety rules and health regulations. I’m sure health

regulations stand in the way and for some obvious reasons”

Sub-theme element. Growing disconnect between people and food: Although

local farming and food systems are gaining in popularity, a concern was expressed that

sustainable food systems face great competition against the more global, dominant food

system of large-scale production and distribution. Participants discussed the effects such a

global system can have on communities and nutrition and particularly described the

growing disconnect that communities are having with their food supply and agricultural

landscape.

 “You know it’s amazing that it’s just been a few generations ago that everyone knew

where food came from and how it was grown. And some of that knowledge is already

gone. Sometimes people think food really is as it is at the grocery store and don’t

recognize where it came from before that, from the ground and from the animals.”

 “I think sustainability is a big issue. I think at one point they’re going to want to give us

a pill. We’re not going to be able to feel, taste, touch, smell the beautiful food that we

are given now”

 “Where it’s going? I would say in Missoula, that’s the real challenge right now. It’s a

current topic of discussion because we’re losing a lot of opportunities for local food.

Lots of housing going up and – I don’t know what that balance is. That huge thing of

apartments they put up on Russell? That could have been a local farm.”

Sub-theme element. Need increased education, awareness, and

communication: The local food system movement in Montana is young and therefore has

ample room for growth and development. Support for buying local continues to increase

and can be viewed as a reflection of a more general dissatisfaction with the country’s

approach to health. A sub-theme emerged from the data pertaining to needing more

education and communication pathways to further engage communities in supporting

farm-to-table efforts. Such efforts correlate with a potential shift in our health paradigm to

emphasize local, healthful nutrition and prevention-based health care.

 “We’re trying to keep our own population, which is our employees, well. But before

long it will be all people who use this facility, this system, and we will be paid based on

avoiding illness. So that’s a radical change and it’s such a needed change. And I think

with that comes more opportunity and potential for preventative health, which

nutrition is just such a fundamental key of.”

 “We have conversations, we demand local foods, we educate, we do cooking classes, we

do cooking demonstrations, we do handouts, we get little soldiers out there to just talk

about it all the time, you know? I think that’s the biggest way to get change because

then when people are personally invested, they’re willing to be like, “hey, I just saw

that video on your Facebook and it made me really think about whether I’m going to

buy that meat that’s less expensive.”

 “But I suppose it all has to improve with time. It sounds like the University has the

hydroponics going on with the micro greens and everything, I heard. It’s impressive.

That’s why it would be interesting to talk to that woman in Livingston, even for us to

find out what she’s doing and what changes we could make.”

Sub-theme. Perceived benefits of local food: Along with general perceptions and

knowledge of using local foods, a considerable degree of understanding around the benefits

of supporting local producers and foods was identified. Benefits were recognized across

the socio-ecological levels of a community, such as the individual, community,

environmental and economic levels. This distribution of benefits demonstrates a holistic

perception of local foods and the role that they are currently playing, or may play in the

future, for the country’s health and food culture.

Sub-theme element. Local economy: Many participants identified the potential

economic benefits of purchasing and consuming local foods. Through purchasing local

foods and products, local farmers are supported and agricultural businesses are

strengthened. Although still at the micro economic level, purchasing foods from local

producers helps keep money in the community and thereby supports local businesses,

employees, and community members. Such branching effects of purchasing local foods

were identified as a great benefit. Along with helping to keep money in the community, a

sense of pride in supporting local business people was also discussed by various

participants.

 “I’m for it because I’m for the local economy. Not only because of that, but one of the

things, you know I think that it helps the economy, it helps us. It’s grown here, it’s

produced here and helps pay for the people that live here.”

 “It turns out that in some cases, local food is probably better from a sustainability

standpoint – whether it’s organic or not. It supports, hopefully, your local economy, it

keeps some of that money in the state”

 “I think that it’s a trend that been taking place for a while and I think that it’s really

important, obviously, you know, in a broader perspective, our money is shipped to

other countries, that’s a bad thing, so I think we take it as we need to be more

sustainable in our own regions. Because obviously if not, jobs get shipped elsewhere.”

 “and it’s the key to solving a lot of the economic problems that go along with our

current practice of health care which is treat diseases.”

Sub-theme element. Environmental health: Environmental impacts of

purchasing local foods were identified as another component of the local food benefits.

Such benefits pertained to reducing the negative impacts of a larger, global food system.

For example, purchasing local foods decreases transportation distances which reduce

emissions and other resources spent as a result of global food production and distribution.

Along with decreased transportation time, local food systems are often more sustainable

compared to monocrop agriculture. Purchasing local food supports local agriculture.

Support and appreciation of local agricultural landscapes can thereby support the

preservation of these spaces and reduce development or industrialization.

 “I think it can really help enhance and strengthen our economy, to enhance our

relationship with the natural world – which I think is important not only for the planet

but for our own health and mental health.”

 “I think that local farmers, to a certain degree, practice biodiversity and I don’t know a

lot about it, but I know that – what I’ve learned about it seems a sustainable practice.

We’re talking, you know, after you and I are off the face of the Earth. How are we

going to sustain our land and our food supply? And biodiversity seems like a winner

but it’s a lot of work.”

 “So when I think about eating local foods the things that are important to me are,

number one that I’m getting food that’s produced within my region because it’s

traveling less time to get to me.”

Sub-theme element. Human health: Participants offered a wide variety of

comments regarding the positive health effects of consuming local foods. Local foods were

often perceived as being of higher quality compared to foods produced through the global

food system and therefore more conducive of good health. Local foods were often

considered higher quality as foods that travel farther distances were presumed to contain

greater amounts of preservatives. Local foods were thought to be more fresh and natural

and better support health and growth. Fresh, local food was also associated with

consuming a more seasonally-based diet and was further considered more ideal for the

human body. An increasing number of people are supporting the need for a more

prevention-based health care model in this country. Nutrition and quality food is often

associated with preventative health care and considered a core component of this model of

health. The role of nutritious, quality diet was identified by participants as a significant

health benefit of consuming local foods.

 “And high quality, to me, connotes local because there’s less loss, less nutrient loss.”

 “I think it’s good for our health. I think, I prefer when it’s organically grown, locally”

 “Well I can say personally that I have a firm belief in preventative health care and that

nutrition is the key to prevention”

 “To me it means that they are just foods that are available in your community that

have been grown and produced in your community that are readily available that may

be more nutritious because they’re not transported and all the delays that may come

in to play, especially in Montana.”

 “As well as, everyone gets more health benefits, especially with allergies and things.

Local honey, we all know that’s something that’s big. Apart from that, that’s really

what it’s about for me and if I can purchase local then awesome.”

Sub-theme element. Political: Benefits reaching into a broader, political level

were also identified as outcomes of purchasing local food and products. The global food

system based on mass-scale production and distribution has resulted in monopolizing

agricultural corporations and the subsidizing of commodity crops. Participants identified

the significant impacts that consciously choosing to purchase and support local food can

have on this corporatized food system. Purchasing any item is in effect voting with your

dollar. Conscientiously supporting local producers serves as an individual’s voice in

agreeing or disagreeing with a particular business and even with a larger, overarching

system. Policy, such as future agricultural regulations or Farm Bills may also be influenced

through this purchasing power.

 “I mean, I’m just like, it’s not just the food. You know, you vote with your dollars in

every way.”

 “But you know that bag of potato chips that gets subsidized. It’s so political and it so

easily becomes so overwhelming.”

 “Yeah, I would pay five dollars for a local potato chip if I didn’t have to give any money

to Monsanto.”

 “It’s about customer awareness and the more aware they are the more appreciative

they are and they’re going to continue to vote with that dollar. I mean that’s really it,

they vote with their dollar. That helps us and I think that starts with awareness.”

Sub-theme element. Community health and support: Relating to economic

support and health of a community, participants expressed community pride when they

purchased local foods.

 “I just think that it’s a great movement. I think that it’s necessary to keep communities

thriving because small businesses are going to close – it’s just the way of the world. The

bigger guys come in and they can do it cheaper and better and faster and so to avoid

that from happening, we have to support our local folks.”

 “So I think that as far as being chef, it’s something that’s really important no matter

what institution you’re in outside of probably fast food. So, I mean that’s kind of how

my thought is, wherever you go, you should support the people that are actually

supporting you. Whether that’s farmers or even people here, I mean they’re bringing

their money in, it’s nice just to keep that centralized and stuff instead of shipping it

elsewhere. It keeps – I know in the past that we paid more for local or for regional type

things but it ends up benefiting in the long run.”

 “Well personally I think of, you want to support your local environment, so that’s

important and whether or not Thomas Cuisine is on board with that or not, it’s

important to me as an individual just because I want to support locally, whatever I

do.”

THEME 2. Hospital Infrastructure:

As the farm-to-institution movement continues to grow, both barriers and enablers are

being identified within each institution and its particular infrastructure. While the two

Missoula hospitals differ in their financial profile and kitchen management styles,

commonalities and larger themes of opportunities and challenges clearly arose. Core sub-

themes that emerged within the larger theme of hospital infrastructure included (a)

enablers; (b) barriers; and (c) hospital programs and efforts.

Sub-theme. Enablers: Hospital staff identified various characteristics of their

institution’s infrastructure that facilitated efforts to join the farm-to-institution movement

and incorporate more locally-sourced ingredients in the food service programs. Staff

support, kitchen management and group purchasing organization (GPO) contracts were

recognized as significant enablers of local food initiatives on site at the hospitals.

Sub-theme element. Staff: The importance of the attitudes and energy of staff

involved in the local food initiatives and efforts at the hospital was strongly acknowledged

and discussed throughout the interview process. The process of locating and utilizing more

local foods was closely associated with, and a reflection of, the individuals involved.

Passionate staff: As a new movement, enthusiastic and knowledgeable proponents

of local food help drive awareness and support among other people. Such momentum is

necessary to successfully engage in change at the larger institutional level. Beacon leaders

among hospital staff were identified as significantly contributing to the successes so far

achieved in the food service programs and were considered responsible for initiating such

level of change.

 “Because several places have someone like myself who’s going to wave the flag and all.

And so does Olympia and so does Spokane and a number of places do.”

 “we have a Food Smarts Committee here with people from the kitchen, nutrition

services and dietary and from all different areas involved in changing what we serve

our patients and our staff and our community because we do value the idea that food

can be thy medicine. That’s a priority for a lot of people here that are interested and

motivated to making that change.”

 “If we prepare a lot thinking it’s going to be fantastic and it doesn’t turn out that way

that that’s unfortunate but I think just because of our commitment and our mission to

do what we’ve set out to do that part of the process, it’s going to happen.”

Dedicated, creative chefs, effective kitchen and cost management: Dedicated

and enthusiastic chefs and kitchen management were identified as key drivers to

strengthening local food initiatives. Chefs and kitchen staff are most directly involved in

food preparation. These individuals inherently coordinate and manage use of local foods.

As a result of commitment and enthusiasm among kitchen management, local foods are

used in more cost effective and creative ways. Such traits were identified as essential to

successfully achieving change within the food service programs and seen as an asset to

each hospital’s infrastructure. Additionally, administrative support for local food

initiatives was also recognized as a beneficial component to using more local ingredients in

hospital meals.

 “Cost is not as big a factor as what I thought it would be. And we’re, you know, you

have to be smart about it. I mean, if we’re going to do roasted celery root with

bruschetta or whatever, which is absolutely delicious, then we might pair it up with the

frozen corn or just, to balance”

 “So you really have to be, you have to want to do it, or the Chef. You have to know,

you’re going to put in some extra effort in terms of thinking outside the box, being

creative, figuring out, “ok, how can I incorporate this and how can I tell the story?”

Because if you don’t tell the story, who cares?”

 “So whenever we have hospital events, the hospital is incredible about supporting the

local businesses too. Maybe not so much with the intention of what food is actually

being brought in, they look at more, “we want to support the Big Dipper because

they’re local.” And so those are just examples, I know we’re talking about foods but we

use as many local services as we can in general.”

 “But we were fortunate enough, at least with our last chef, it takes an open mind. It

takes an open mind and a can-do attitude and then, obviously, you have to get people

excited about it.”

Sub-theme element. Food service management, financial infrastructure:

Hospital food service management structure varies has different effects on efforts for using

local foods in meal services. Financial infrastructure also plays a significant role in the

ability to use local. For example, whether a hospital is non-profit or for-profit impacts

customer prices and therefore produces different levels of space for creativity in meal

preparation. The particular financial structure also impacts the level of flexibility to engage

in the economic model of spending money to make money. The system of food service

management emerged as a prevalent theme in enabling the use of local foods. For instance,

cohesiveness in the process of creating menus and ordering the necessary ingredients was

found to be an important factor. Rather than disconnecting these processes and allocating

responsibilities to various staff members, chefs managing the entire spectrum allowed for

greater control, cost effective purchasing, and creative, appealing meals. Such flexibility

and cohesive planning was also associated with lower food costs for the hospital.

 “And I think for the prices here, I mean you’re paying six dollars, there’s no risk, there’s

not a lot of risk to try something new and that helps as well. And we’re not trying to

make a lot of profit and so that helps us as well purchase higher priced things.”

 “One thing I would also like to add is that, you know that fact that the chef is putting

together the menu as well as we are purchasing and ordering food. Sometimes in

different accounts, they might have a position set up so where maybe the café

supervisor, somebody else is looking at the menus, they’re looking at the numbers and

seeing some things and then they’re like, “this is the menu.” And then a store room

clerk is then ordering the food. We control both sides of those things so we can really

make sure that if we put together a nice menu, but then if you don’t order the correct

product that can create, obviously, you know, some issues there. So that we control

both I think that’s a huge thing. And obviously it results in a happier customer and a

better end product.”

 “Also, we’ve maintained a lower food cost actually so that way maybe we can make

those purchases on equipment or we can try some exotic things. We brought in, not

necessarily regional, but a blue tofu. You know, it wasn’t blue, but we have more

flexibility and leeway to buy some things that might cost more but once we do and we

can show purchases on those, then obviously the buyers, the distributors are more apt

to give us a lower price moving forward.”

Thomas Cuisine: Thomas Cuisine is a contracted working partner in the food

management of both hospitals. Participants viewed this company as having a strong

mission and values for supporting local communities and local food producers. Such

inherent values within the broader, managing company were described as an enabler to

finding creative ways to incorporate more local foods within meals. Such support at the

management level builds on the enthusiasm of individual staff members and more greatly

facilitates change.

 “I was here eight months before Thomas Cuisine took over and so it really started

happening then and it has just grown. Every year you take another step to add

something or try to do something better.”

 “I appreciate that and again also, it’s engrained in Thomas Cuisine’s values and

mission is you know, great food and genuine service and enduring relationships. And

that’s big. I’ll be able to pass this on to whoever’s, in five or 10 years and maybe we’re

not here but hopefully the relationship will last.”

 “It makes it so much easier when the company you work with [Thomas Cuisine], for,

has the same values as yourself. It makes it so much easier. I don’t think it’s like that

everywhere else.”

Flexibility of the contract account: GPO contracts make the hospital food and

supply ordering process streamlined and convenient. In exchange for this convenience and

discounted prices, contracts require varying levels of commitment relating to the amounts

of products ordered within the GPO compared to outside of the company. The flexibility of

these contracts was seen as supporting the use of externally purchased local products.

While the contract provides discounts and rebates for the hospital, contract flexibility

creates opportunities to use locally-sourced ingredients to meet the remaining hospital

food needs.

 “I think, it has to be monitored generally. We’ll be able to see obviously through our

purchases, through our accounting team as far as making sure that we’re in

compliance with those numbers. But you know, if it’s set at, like a lot of times programs

are at a 90/10, 90% from your primary vendor and then for your specialty and

secondary vendors it’s like 10%. There’s more flexibility in this account where, I don’t

know if it fluctuates at all but I think it’s like between 80 and 85. So if we got 20%

leeway, actually that’s really good because you know, the produce and things like that,

we buy a lot of the same stuff, like with the patient services.”

 “Yeah that eats up a lot of it actually. It allows us to have a lot of freedom. So as much

as there’s constraints, there’s plenty of opportunity to continue pushing the envelope a

little bit. It’s considered one of the best accounts within Thomas Cuisine. So I don’t

think that it limits us too much. Obviously we need to be cognoscente to make sure that

there are specific items that we need to make sure to order but as far as most of the

produce and protein, we do have a lot of free range.”

Sub-theme element. Long enduring emphasis of sustainability on site:

Participants discussed the challenging dynamics and hurdles associated with shifting the

institution towards locally-sourced foods. It can be a costly and challenging process to

move away from unsustainable systems of food preparation. Hospital staff participants

described this common scenario and the ways in which deeply rooted values in

sustainability and local support have changed the food service management in their facility.

 “Because you know some hospitals have gone so far as to have fast food chains in their

cafeterias, you know it’s just incredible. And so, luckily we’re never in that position but

some hospitals have had a really long way to go.”

 “It’s been a big hurdle and it’s surprising how difficult that is. We were fortunate

because we use reusable dishes, we always have, we never went through disposable

dishes. We have some for takeout and we have moved away from Styrofoam but I

always say that it saves you money to use reusables, if you can afford to buy them in

the first place.”

 “It’s just normal. It’s not something that’s different. We’re used to having multiple ones

[deliveries] here instead of the just one day a week, getting a big huge delivery and

then just storing it away.”

Sub-theme. Barriers: Several factors were identified as impeding efforts to use

more local foods in the hospital food service programs. Using more local foods has

required changes in food procurement and preparation methods. Making such changes for

an institution can be challenging. These factors were associated with management,

resources, and patient care at both institutions.

Sub-theme element. Restrictions of the contract account: The two hospitals that

participated in this study have different GPO contracts that vary in purchasing minimums,

general requirements and associated incentives. While contracted with the same company,

the contract differences were viewed as either a significant enabler or barrier to increasing

the amount of local foods purchased by the hospital. Contracts require a particular

minimum proportion of food products be purchased through the GPO. This requirement

was identified as greatly inhibiting flexibility and opportunity to turn outside of the

contract to purchase local ingredients. While staff members were enthusiastic and

supportive of using local, failure to comply with the contract forfeits potential rebates,

therefore resulting in a challenging dilemma when considering the use of local food in food

service meals.

 “So the novation contract, the group purchasing organization, we purchase the food

through U.S. Foods, but any rebates that come back, go to the hospital. So that’s part of

the deal. We save the hospital money by purchasing these things that fall under the

GPO’s. And I just met with a gentleman last week and, so that’s another, that’s a

completely different challenge in terms of, ok, well we didn’t meet our target. My

incentive is like, I got docked, as did we all, for not meeting our goal on the novation

side because we’re trying to do all this stuff over here.”

 “That’s really what I want to do, is continue to do what we’re doing and maybe even

push that forward more. But also meet the target. It’s not easy. It’s not easy and it’s a

really big monster for a chef to number one try to wrap your head around the whole

GPO, if you’ve never dealt with them. And then to really balance it. And to be honest,

I’ve told my boss this, if there is anything that I was going to sacrifice, that would be it.

I know that I’m not doing the right thing by not getting the rebates for the hospital,

but at the same time, I’m doing the right thing. And that’s a – Food Smarts committee

doesn’t even understand.”

Sub-theme element. Lack of resources: Time, staff, and skills: An institution’s

food management approach to food preparation and menu planning often needs to change

to incorporate local foods. A lack of adequate resources to accommodate these changes

was identified as a barrier to strengthening local food initiatives in the hospital.

Participants addressed the additional processing and preparation time often needed to use

local products. This additional preparation requires more time, staff, and money and can

therefore pose as a challenge and restrict local food purchases. Storage space was

perceived as a barrier as well. Purchasing local food connotes fresh, whole foods that need

to be adequately stored. Additional storage space for local foods is not readily available. For

example, hospitals were limited in their ability to hold multiple days worth of local salad

fixings, in which more than 1,500 meals a day are served. Financial support was also

identified as restrictive on local initiatives as facility budgets were described as very

limited.

 “They’re taking squash and processing it to the point where it’s diced, it’s frozen, we

can buy it from the Grower’s Coop and so there’s not all that prep. You know. I mean

that’s the hardest part about eating healthy is just the washing, the chopping of the

vegetables, right? So you’ve got this processing plant that’s processing food in season

and then, you know, yeah it’s frozen vegetables, but it’s local and sometimes it fits

within some of our applications”

 “So what we’ve tried to do, and I know it’s been such a challenge, because every time

you think you’re going to get on top of your mountain of paper work, something

happens. Someone calls in sick, you have to go out and work the station yourself.”

 “I guess if there were any other challenges, it’s the additional labor it takes to prep

that stuff which is why I really want to do a field trip. I understand that the processor

is looking to expand. I think they may have applied to a grant, they need another

facility. I mean, that’s way down the road but they will be able to produce more and do

more variety of what it is they’re doing. But yeah, I think that would be probably the

next step to ease some of the burden on our cook’s team and still provide our

customers with perhaps more local than we did last year.”

Sub-theme element. Restricted patient diets, lack of communication with

patients about “local”: The health care setting is naturally a site of health and re-growth.

Acute care facilities treat severe health issues. Patients are often prescribed very specific

and restrictive diets. Patient dietary needs emerged as a barrier to not only using local

food in patient meals, but also for educating patients about the importance of using local

food. Participants described the non-conducive nature of acute care due to the restrictive

nature of the diets and an inability to substitute parts of these diets with local ingredients.

 “We’re an acute hospital. People here are really sick. So if you’re coming into the

diabetes clinic you’re going to get a different experience then if you’re out because you

had a stroke because you have high cholesterol. Like, is this really the best time for me

to be like, we go over it. I might educate that to you but I certainly, personally can

speak to interactions I have with patients where I bring it like, “I’m watching you order

lunch, you had bacon, sausage, whatever, let’s talk a little bit about this.” But in this

setting it’s very tough. It really isn’t conducive because people are so stressed out

about being in the hospital, like, really this is not what I want to hear.”

 “One factor is always with the modified diets, some soft or mechanical soft diets, of

course no fresh fruits or vegetables. You kind of just have to go along with those

requirements of each diet.”

 “And patient meals are specific and sometimes they have no fiber and sometimes no

salt – there is quite a range of therapeutic diets.”

Sub-theme element. Lack of marketing: Another component that emerged in the

hospital staff interviews as a barrier was a perceived lack of marketing and awareness for

local, on-site food initiatives. Participants identified greater outreach as a component of

the local food efforts that could be strengthened in order to gain additional support.

Increased communication and awareness around the programs and foods being used were

perceived as factors that could use further development.

 You know, and as far as influencing others to finding the importance of it. We don’t

have the time or the marketing efforts to actually give them all the benefits and

educate our customers who are neutral on why this is so awesome. We could probably

do a better job with that.

 Yeah because I bet if you asked, you know, ten customers if they know that our beef

today was locally sourced, I bet they would not know that. And we might as well, that’s

a wonderful thing, we might as well put it out there.

 It’s hard for me to say but I think that, you know, we could always do a better job of

marketing. Our local purchases. And it’s tough because we already have signage out

there, you try not to bombard them too much.

Sub-theme. Hospital programs: Participants identified a variety of programs and

efforts taking place to increase awareness on the hospitals’ efforts in using more local

foods. Work both in the kitchen, and with patients and staff, demonstrates the holistic

approach the two facilities are taking in order to gain support and capacity in using more

locally-sourced ingredients.

Sub-theme element. Local initiatives in the kitchen and use of local products:

Participants identified significant efforts taking place within kitchen management to

become more creative in identifying and utilizing different outlets to locate local products.

These efforts were reflected in the wide variety of local foods that are now being served

and incorporated into hospital meals. The use of local, grass fed beef, grains and produce

were mentioned multiple times, and products such as Dixon melons, tomatoes and baked

goods were noted as excellent, locally-sourced items. Along with discussion around local

products being used in food service meals, participants also addressed the creative,

palatable ways in which these ingredients are being incorporated into the menus.

 “But he’s bringing in things like kamut and quinoa and you see different grains, you see

yellow and purple carrots. You see different colored beets. You see, he’s bringing in so

many colors and different, like really nutritious whole grains and wheat pastas”

 “We have an effort that we try to purchase as much produce as we can locally, just

depend what’s in season, most of our fresh herbs come from a local producer. As much

as we can of our fresh produce. So we particularly get tomatoes from up north, there’s

cantaloupes, certain times, there’s Dixon melons that we purchase. The majority of our

beef comes from a local ranch down in Dell. You know, any kind of initiative that we

have, we buy ice cream, we go Big Dipper, you know.”

 “So beef and produce, primarily we also purchase all of our breads from a local bakery

and I would say not all of them, but probably 75% of the breads we serve come from a

local bakery. And kamut grains come from Great Falls. We buy all of our kamut, it’s up

by Benton. So we use those for part of salads and main entrees and things like that.”

Removal of unhealthy foods and beverages: The Healthy Food in Health Care

Pledge contains several different components that hospitals can work towards to improve

their level of sustainability and use of local foods. One core component of the pledge

includes a commitment to decreasing the amounts of sugared beverages served in the

facility’s food service program. This is one change that was identified by participants as

occurring on site in order to shift towards more nutritious, local meals. Another significant

change that was identified was efforts to not only decrease the amount of meat being

served, but to also transition to providing local, grass fed beef. A third significant change

involved the removal of the cafeteria fryer. While the removal of fried items was described

to benefit nutritional health, the change was met with significant disapproval by hospital

visitors due to the popularity of these particular types of foods.

 “And so we have signed on for that and a few other of the areas and in the local and

sustainable foods section there are three goals. One is healthier beverages because one

of the big issues is that people consume so much unhealthy beverages”

 “So one of the three is healthier beverages. So we are working on that to decrease the

amount of sugary beverages we sell, but we do still sell it. We have shrunk our options

down. I think we had four coolers, now we have two coolers.”

 “So we’re working to reduce the overall meat that we purchase as a percentage of our

total food purchases. I don’t know if we’ve really made much progress in that direction,

although we do have something called “Meatless Mondays” and we’re having more

good protein options and more explanation about what they are, so that’s helpful.”

 “First thing was we wanted to get rid of the fryer, we wanted to incorporate, again,

healthier options. So our old Broadway grill went away”

Sub-theme. Education: In addition to changes within the kitchen and the tangible

shift to using more locally-sourced products, the hospitals are also emphasizing an

educational component for staff and visitors. Educational outreach is occurring in a variety

of ways is helping to increase awareness of both the hospital’s particular efforts as well as

the beneficial outcomes of purchasing and consuming local foods.

Food labeling and explanations: Participants described educational efforts to

support and guide staff and visitors in choosing nutritious food items. Such efforts

included signs and summaries of nutritional content and source of available foods. Color

coded signs accompany food items to clearly inform customers of the nutritional value.

Organic and local foods are accompanied by an additional flyer describing the particular

vendor and health benefits of the item. Participants identified such labeling as conducive

to dialogue around supporting local and the generation of greater awareness of the topic.

 “But if you have something written on the menu saying locally grown or locally

sourced or something, somebody will say, “oh, well that’s good, where’s it from?” So it

strikes up conversation so they’re interested.”

 “And we talk about if we bring out a new item, we’ll talk about the health benefits of

that item. We’ll have a little flyer on there that will tell you what you’re getting and

things like that. Nutritionals are on there. So they do get excited about that. So we

always label things too if it’s locally sourced. You’ll see it on the menu out there. You’ll

see that it’s locally sourced.”

 “We have labels on them in red, yellow, and green that say – the red say’s “high in

sugar, salt or calories.” The yellow says “moderate” and the green says “low in…” and

so they are grouped that way to help guide people to make healthier choices.”

Outreach events/hospital-wide initiatives and programs: Hospital-wide

initiatives, committees and events were identified as playing a key role in raising

awareness among staff and visitors around the use of local foods and importance of a

nutritional diet. The Food Smarts committee was identified as an important and strong

proponent for local food, portion control and healthy nutrition. Educational events and

outreach such as newsletters, and barbeques and local meals were recognized as another

successful outlet in raising awareness as well. Larger, national events such as Nutrition

Month, was also described as an ideal opportunity to initiate conversations with hospital

staff and visitors about consuming a local, nutritious diet.

 “It will be a therapeutic garden for the patients, it will be a respite space for staff, it

will be a beautification project, it will be an opportunity for the schools, particularly

the Catholic schools because they have not been engaged yet with the Garden City

Harvest and the public schools have. So it’s an opportunity for the Catholic schools to

get involved. And it’s a production garden and it’s an opportunity for education for the

staff and the public and we’ll have signage and that sort of thing.”

 “our focus this year during Earth week will be on local foods and particularly on

gardening. So we want to talk about that with staff. Every year we do something

different. Last year we worked on waste, another year we worked on toxic chemicals

and we’ve worked on energy. So we have a focus during Earth week each year to help

people particularly draw the connections to health, which sometimes seems like a long

dotted line because people say “well that’s the health of nature but why is it health for

me?” And so we have to paint the picture of how we’re all connected and how we

absorb what is around us in terms of chemicals and nutrients and so it’s a good

opportunity for that.”

 “Food Smarts committee are also pretty sustainable conscious anyway. So we talk

about local foods a lot. We talk about what can we do to highlight local foods. But it’s

also more, its primary focus is to educate staff, customers and patients on how to eat

right. How to take care of yourself through the food choices that you make.”

Sub-theme element. Staff programs: Participants described different efforts

taking place for improving staff awareness and increasing participation in supporting local.

Such programs not only emphasize the use of local foods but also address overall health

and well-being of hospital staff.

Community Supported Agriculture (CSA) program: Convenience and

education: A staff CSA program was recognized as a significant factor in raising awareness

and support of staff around the benefits of consuming local, whole foods. The program is

offered on a year-round basis and the shares are picked up on site at the hospital, a factor

identified as incredibly convenient for members. The program was described as

experiential with a strong educational component. Recipes and interactive education

supports staff in learning about the particular items arriving in their share and ways to

include them in family meals. Such an encompassing program was recognized as a

supportive and feasible way to encourage staff to support local producers and incorporate

more local foods into their diet.

 “So the whole learning experience is great. It’s really great on the pickup days because

I learn a lot about produce that I hadn’t used before. People say, “What did you do with

the fennel last week?” and I learn what other people do.”

 “There are people here that say “it’s Christmas every week.” Oh yeah, because you get

some awesome fruit and vegetables. And it’s fun getting things that you’re not as

familiar with too. There have been a few things that I wasn’t even sure of what it was

and they’ll come out with maybe a recipe to help you with – kale is a good example. A

lot of people don’t know how to cook kale. They’ll put a recipe out there and then when

people come and pick it up, sometimes we’ll share, “oh this is what so and so said that

the kale chips are supposed to be really popular.” So I’ve learned a lot about the local

produce from that program.”

 “But what our goal has always been, this kind of came out of the Food Smarts

committee, was if we’re going to run celery root or Jerusalem artichokes, can we

provide people with a recipe that day or if we know it’s going to be in the CSA, can we

coordinate running that vegetable and “oh, by the way, here’s the recipe.” And then on

Thursday, say we run it on Monday or Tuesday, then on Thursday they get this big

hairy, whatever it is, and they go, “oh, I think I can try that.”

Preventative health care: Some participants described another component of staff

oriented programs focused more broadly on preventative health care and support of staff

health and well-being.

 “We insure our own staff. We pay when a staff member gets sick, we pay when staff

members have higher risk for health problems, so obesity, hypertension, diabetes. And

so they have, thankfully, only again over the last few years decided to invest in keeping

people more well. So this is a good thing.”

 “So to be incentivized to keep our own population healthy is a great step. And so

therefore Home Base exists to help people reduce their risk and do education on

nutrition, which is a huge piece there.”

 “Because the whole Food Smarts thing is being driven by our Home Base program

which is, our self insured. The idea, if you want to get to the root of it, the idea is, we

need our staff to eat better so they stay out of the hospital because then we can keep

the cost of health care down. I mean that really, it’s super forward thinking compared

to the rest, that’s not the way the rest of the country thinks.”

Sub-theme element. Positive feedback: Participants perceived that feedback and

responses from staff and visitors regarding the use of local foods in hospital meals was

generally very positive. Positive reactions and surprise that quality foods were being

produced right in Montana was a prominent response to hospital efforts to promote and

use local. Such positive reactions have also worked to encourage conversations and further

education around the topic. Successfully presenting previously unknown ingredients was

also identified as encouraging to people in expanding their cooking repertoire and

nutritional knowledge.

 “They do because we have all of these initiatives that we’re working on. Like kamut.

We try to promote kamut a lot and that comes from a local producer and when you

first bring it in, they’re like, “oh, what is that?” And then after a while they’re like, “oh,

yay kamut is on the menu again.”

 “With new dishes I think, a lot of it, you do it one time and it’s, a few people get it. It

spreads by word of mouth so then it comes around a second time and that person goes

to whoever they’re working with, “hey, I got this last time. Or I heard from Linda this is

awesome.” You know? So then it picks up. And so then it becomes more popular and

they go, “oh, it’s not weird anymore.”

 “I’ve heard that resonate on the floor where I hear people that I’ve worked with, they’ll

be like, “oh I don’t go down there, everything’s fried and greasy.” To now, I’ll come up

with my plate of rainbow potatoes and they’re like, “oh my god, is that from

downstairs?” Yeah and it’s delicious, it’s great! So I’ve definitely seen a change at that

level.”

THEME 3. Local food in health care:

Health care institutions were identified as a unique setting in which to promote the use of

locally-sourced ingredients. Significant themes emerged as 1) opportunities associated

with the health care setting in promoting local food and 2) challenges associated with the

health care setting to participating in the farm-to-institution movement.

Sub-theme. Enablers: A primary theme that emerged pertained to the unique

environment created within the health care setting. Facilities promoting health and well-

being naturally serve as ideal opportunities to discuss the benefits of healthy, nutritious

diets consisting of whole and local foods. Participants explained that such a setting is one

in which people are expecting health education and are therefore more receptive to these

types of conversations. As a result, this serves as a conducive environment for outreach

and promotional efforts of supporting local producers and foods. In addition to this

opportunity for education, participants also discussed the logical connection between the

health care setting and healthy food service meals. As a setting for health promotion and

healing, such facilities should apply these messages and put them into practice. Physicians

and nurses promote healthy dietary patterns and foods offered on site should therefore

reflect these principles.

 “And it’s just a good way to raise attention and because it’s in a hospital there’s an

automatic expectation that it’s linked to health. That this is something that’s good for

you.”

 “The hospital, because of all the people and the general focus on health and a generally

well educated population, it’s a great place to educate and to talk about it.”

 “And so I think that well I’m a nurse and I’m in health care so let’s talk about the

health impacts because sometimes that’s lost I think in some of the conversations. And

so that’s one thing that I think the hospital can say is to continue to shine light on and

say, “ yes, this is good for the natural world, it’s good for our economy and it’s good for

our health and we support this because of X, Y, and Z.”

 “But we’re a hospital and we have a responsibility to promote wellness and I think that

idea is kind of catching on a little bit more. We can’t be feeding you foods that give you

diabetes and then treating you for it upstairs. That’s almost a conflict of interest.”

Sub-theme. Barriers: Several participants perceived a disconnect in the country’s

mainstream health model and associated this with challenges to further developing farm-

to-health care efforts. The Western health model was described as an unsustainable and

reactionary approach to health. Rather than emphasizing preventative health care,

medications and significant medical regimens are prescribed in response to the

manifestation of severe health issues. Nutrition was identified as a fundamental

component of a preventative approach to health care rather than a reactive health care

system. Therefore, the current model was not perceived as favorable to promoting diets

with whole, local foods and was not perceived as one that emphasizes nutrition in general.

Such a lack of focus on nutrition creates a challenging environment in which to gain

significant support among both staff and visitors of the hospital.

 “Health care is backwards because health care makes money when people are sick, not

when people are well. So that’s a perverse incentive, as they say it.”

 “And so, I’m very surprised at the physicians. And I think this is changing, but still.

Some physicians don’t even talk to you about diet. They write you a prescription and

send you on your way. They don’t talk about fixing long term, preventative.”

 “And that’s not the hospital’s stance, that’s my personal bias. But I feel like the models

of hospitals as they exist today are dinosaurs and they’re not ready for this change. I

mean, look around the country and hospitals aren’t making money because it’s not a

sustainable model.”

THEME 4. Local Food Use and Producers:

The last dominant theme that emerged from the interviews pertained to the current

dynamics and processes associated with locating and using locally-sourced ingredients into

food service meals at the hospitals. A variety of factors serving as enablers and barriers

were identified in using local foods in the health care setting. Unique circumstances are

associated with using local food in comparison to using foods supplied from a larger GPO

contract and result in varying opportunities and challenges.

Sub-theme. Enablers of using local foods in the hospital setting: A variety of

factors were identified as serving as enablers for hospitals in promoting and using local

foods.

Sub-theme element. Benefits of working with local producers: While the

dynamics vary for hospitals in working with a larger distributor compared to local

producers, participants identified several components unique to working with producers

that supported continuation of efforts in using local foods.

More personal relationships and direct communication: Participants identified

personal relationships as a significant contributor to the positive experiences associated

with interacting with local producers. In comparison to the larger, corporate-like

distributors, participants described enjoyment and appreciation for building these

personal relationships with local producers. Such relationships were highly supportive of

positive work experiences and have helped to facilitate greater use of local products.

Developing a relationship with a producer and establishing familiarity with a particular

person supported efficiency and greater outcomes in working with these local businesses.

The ability to engage in conversation based on familiarity and understanding, along with

the greater accessibility of staff and more direct communication, were all identified as

enablers for hospitals in sustaining partnerships with local producers.

 “And you actually get to talk to the person who’s in control of the production. Not

talking to a distributor who needs to talk to their distributor who needs to talk to their

producer. You’re so far removed. So you’re not as removed, you can actually contact

them which is nice.”

 “I’d say I appreciate the relationship piece. They’re calling me and it’s not just, “hey,

what do you want to order?” It’s, “hey, how was your weekend? What did you do? How

was the drive up to work?” It’s just a little more to it. You know, it’s guys that probably,

if I saw them out, I’d probably have a beer with them and that would be ok! It’s very

welcoming.”

 “Plus you also are able to have more of a personal relationship with those people and

you can get a little bit more of what you want. They can tailor to what your needs are

a little bit more.”

Aggregated food system: Western Montana Grower’s Cooperative: Themes

emerged around the benefits of using the framework of an aggregated food system, or a

cooperative (coop), in order to more productively work with local producers and achieve

positive, working relationships. The primary coop currently operating in Montana is the

Western Montana Grower’s Cooperative (WMGC) and was specifically referenced on

numerous occasions. Perceived benefits included the streamlined process associated with

working with a coop, whereas communicating with a representative on behalf of growers

results in a more efficient process of determining logistics of supply and demand of

ingredients. Another positive dynamic of working with a coop was the greater variety and

availability of products. Participants discussed ways in which this culmination of local

products from across the state creates such an appealing model in using more local foods at

the institutional level.

 “I think that’s a real benefit of having so many farms represented. Because, you know,

we get fruit from raspberries, cherries, apples, plums, melons. And there’s no single

farm that does all of that, plus the amazing range of vegetable produce. And then

they’ve [WMGC] been adding more and more options.”

 “But I can tell you the beauty of the coop is you are dealing with one person and not 17

different farms up the Flathead and down the Bitterroot. So it’s streamlined.”

 “That one contact. It’s shocking, yeah. They send you the list instead of, you’ve got six

emails from six different producers. They’re funneling all their information through

the coop and the coop sends that out. You place your order and bring it to your door.

So the communication is great. Knowing what’s coming to plan the menu. And

sometimes, they’ll throw us a little bit, if they have an abundance of something for

whatever reason, they’ll give us a special on it. I don’t know how many organizations

out there are actually using them for their food service operation. I think a lot of the

restaurants that believe in this like to deal with their farmer. You know, the coop has

to mark up a little bit to pay for what they do. But yeah, just having all the information

in one place, and then one contact saves you six phone calls twice a week probably.”

Flexibility, adaptability and organization: Commitment and adaptability of local

producers in fostering relationships with the hospitals was recognized as incredibly

supportive to the process of using more local foods. A sense of appreciation emerged

around the level of flexibility that producers offered in working to eliminate any challenges

encountered while developing a working relationship. While transitioning from large

distributors to working with smaller, local producers, hurdles were perceived as inevitable.

However, the level of flexibility and commitment offered by local producers has facilitated

a much smoother transition.

 “The Grower’s Coop has been just phenomenal. They’ve been so helpful. They’ve

adapted to what our needs are. So for instance, the first year, even figuring out where

they could park their truck. Things with hospitals are so complicated! So where can we

do that, knowing that there’s going to be dirt involved, and things like that.”

 “Everything always goes really smoothly. Every now and then they’re a little bit short

and then we just call them and they make up for it. They’re very easy to work with.

Very professional. Most of the time they’re on time.”

 “I’ve never noticed a trouble with getting anything. And you know, sometimes they

might forget to put something on the truck but the producer is going to call me up and

say, “hey, my bad. It’ll be here this day.”

 “We don’t usually have too many issues with the local producers that I’ve been involved

with. They’re always really willing to do whatever they can to help us out to keep the

business.”

Delivery to the hospital: A beneficial quality identified by multiple participants

was the ability of local producers to deliver the ordered items on a regular and reliable

basis to the hospital. Dependability and commitment were recognized as key, supporting

components of having the ability to sustain relationships with local producers.

Adaptability and personal relationships were associated with the flexibility in delivery

schedules that hospitals have experienced with local producers and have further supported

positive relationships among producers and hospitals.

 “The delivery dates and stuff like that have just been negotiated and set up. We might

be more apt to try to work with them instead of being so structured, we might have a

little bit more flexibility with local actually.”

 “He did it before Thomas the thing with Big Sky Beef. That was something I was

impressed with when I got here. It was like, “wow, you use local beef.” He just drives it

up here and delivers it to you and it’s all grass fed and that’s awesome.”

 “Whereas the locals, they come in and you’ve got somebody that checks the order in

and you immediately know we’ve got five cases vs. 225 cases, you can just put it away,

you’re done, you don’t even have to think about it.”

Good work ethic and pride in their work: Another component identified as a

benefit of working with local producers pertained to the genuine sense of pride associated

with their work. Participants identified a sense of commitment among producers in the

products being brought to the hospital and dedication to supplying only quality food items.

Such high standards and work ethic fostered stronger working relationships and has even

transferred a sense of pride among hospital staff through offering local products in the food

service meals.

 “And you can tell, you know that he loves what he’s doing, that he’s, that those animals

are not being abused. I mean that’s, to some that’s important. Some people don’t want

to think about it. That he, it’s his thing. He’s really passionate about it.”

 “I think, if I could say kind of in a casual term, a gentlemen’s agreement is kind of nice.

There’s a lot of trust, there’s a lot of pride in their product. So as far as if you’re not

satisfied with the product, they take so much pride that they want to make sure that

they fix it. And so I think that more of the old gentlemen’s agreement and kind of the

old morals and values on the quality of food, that’s their livelihood and you can tell

that they’re very proud. So that’ nice.”

 “But I think that because of the relationship they’re very forthcoming and they’ll let

you know that, because of the weather or transportation or something to do with the

distribution process that you know, might be limited but it all comes down to they

don’t want to put their name on something that’s not as the same quality.”

Sub-theme element. Quality: Quality of local foods was identified as an extremely

beneficial and supportive factor to using more locally-sourced ingredients in the food

service meals. A strong consensus among participants reflected great approval and

appreciation for the level of quality occurring in the local food products. Such high quality

was associated with facilitating further support and enthusiasm for using local foods at the

hospitals.

 “but there’s just more appreciation and more of a cognoscente thought process once

you realize something was local it just seems like, as much as it’s local it almost seems

like it’s kind of exotic. So you treat it like that type of an ingredient. You just really

treat it the best that you can without doing necessarily too much to it. So I don’t think,

if it’s a challenge at all, it’s just more work on the back hand but it’s something fun,

going through some of the offerings they have, some of the seasonal items”

 “Nature does the work for you. I’ve got a great rainbow, handful of rainbow, locally

grown tomatoes. And you don’t have to do anything to them. It’s like, “oh my gosh, that

looks delicious.”

 “Yeah it’s very true, you know the product price, as far as, we’re spending less money to

get a greater product and you can’t have, there’s kind of that saying like, you start

with something, a mediocre stock, a mediocre sauce, it’s the same way with anything

that you buy. Especially with the produce, we don’t have to necessarily try to do too

much with it if we have a great starting point, so.”

Sub-theme element. Missoula is a uniquely supportive community of local

food: Many participants thought the hospital’s location was an essential component of the

support and degree of change associated with the use of local food in food service meals.

Participants recognized that broader community support and enthusiasm was critical in

developing the framework of change and successful transition in using more locally-

sourced ingredients within the institutional system. As a result of the support and

enthusiasm for local food within the broader community, advocacy for local food within the

hospitals was more easily facilitated.

 “Well, only that Missoula probably is exceptional. Or at least very strong in its

commitment to local agriculture and availability of local foods and that is really

helpful. And I feel in some part it’s great that the hospital is involved and is doing this.

And yet because I’m aware of all that’s going on, I think “well we sure should be

involved!” Because some of our sister hospitals in other states, Providence is in five

states, they don’t have anything like this and have no access.”

 “So I think it partly depends on what is easy and available in a community and so

really the two places that are doing the most with food are Missoula and Portland, in

these five states where Providence is. And I think a lot of that is because of what’s

available in the community.”

 “I think that’s why Missoula thrives. Because people support local so well. You go to

other communities and that’s not the case. I just came from Butte, MT before I moved

here and it is not the case there. Missoula is impressive and unique and I think that

you’re going to find some communities that are progressive and then you’re going to

find some communities that just aren’t.”

 “Absolutely. It starts with the community itself and the culture of the community.

Definitely I just think Missoula is very unique in that way. Other towns are just not there

yet.”

Sub-theme element. Growing popularity of local: Participants perceived a

growing support for the local food movement across the various levels of a community and

identified this as benefiting the efforts of local food initiatives taking place within the

hospitals.

Growing support in the health care setting: An increasing level of awareness and

support within the health care setting and among health care physicians was identified as

one social level in which the local food movement is growing. Increasing support among

health care staff facilitates conversations with patients and visitors and works to further

educate on the positive outcomes of eating local, whole foods.

 “Absolutely. I mean, again, especially with different multimedia. I use my Facebook

page a lot to be like, “hey, did you see this article from this website about how the

Environmental Working Group did a study on some toxins that are in our shampoos

that we use every day?” And I posted it on my Facebook page and a lot of people I

work with will see that and so it becomes a conversation here. It might not be a

conversation they have with their patients but they certainly have with their

families and I would definitely say that I have noticed people switching to like,

homemade lotions that they’ll bring in. So there’s certainly an increasing awareness,

from my perspective anyways”

 “But I don’t know if it’s happening other places. Although Adventist, they’re a huge

health system and they’re really focused on nutrition and they keep an all

vegetarian kitchen in a lot of their hospitals. I know that – well the Adventist health

study is one of the largest next to the nurses’ health study and the Framingham

Heart Study. Like those, the Adventist health study is one of the larger more

comprehensive studies that’s run by their hospital. So they have pretty compelling

evidence for the way they run their kitchen.”

 “But certainly among my peers, it’s big conversations about what we’re doing for

our health. Is what we’re doing for our patients healthy for them? Whether or not

we’re having that direct conversation with them, it’s like, “hey, what’s in Miralax? Is

that really a good thing to make someone take? Or should we be offering warm

prune smoothies? Maybe that’s an option?” Yeah, there’s some good conversations.”

Growing support in the larger, community setting: Participants spoke to a

growing trend throughout the country in which people are becoming more aware of issues

around sustainability and healthy diet, and is a trend that’s resulting in increasing demand

for change. Awareness of the benefits of consuming whole, nutritious food is increasing

and the farm-to-table movement has continued to gain momentum. Such awareness and

demand for change was identified as supportive of the shifts in food service programs

being made at the hospitals.

 “I think probably everyone can go to the grocery store and pick out fruit or vegetables

in season and out of season but I think as a community we love to get our locally

grown and produced items. Like the Farmer’s markets and Dixon melons. And I don’t

mean just Missoula, I mean people in the local area”

 “People, with media being the way it is right now, people are more aware of it. My god,

you go into a market now and you can find two different kinds of kale in most super

markets. So views might be changing.”

 “So I know it’s happening there and I know at Intel, out in – Is it Intel? The computer

place out in Oregon? They turned one of their whole campus cafeterias vegetarian in

honor of local foods and kind of being part of the local food scene. So yeah, lots of other

places.”

 “I think in any kind of readings or in any kind of literature, there is a lot of farm to

table, there’s a lot of discussion about local foods. More, I wouldn’t want to call it

marketing but I would call it awareness than there ever used to be.”

Sub-theme element. Networking: Networking was discussed in several different

contexts and described as being very beneficial for hospitals in making changes within

kitchen management to incorporate more local food into meals. Meetings, conferences, and

other informational seminars have become much more prevalent in advocating for local

food and available resources. Conferences sometimes work to bridge local producers with

health care facilities and other institutions in order to facilitate dialogue between the two

entities and initiate working relationships. Informational meetings also provide resources

and productive guidance for health care facilities striving to work with more local

producers. Partnerships between health care facilities was also identified as beneficial in

supporting one another and troubleshooting any particular challenges arising in using

more local food.

 “And so to do this, we met in 2012 with a group from CFAC and the Western Montana

Grower’s Cooperative and we were actually talking about the food stream so how

could we get more regular produce. And they mentioned that they have this CSA option

themselves and that they could deliver.”

 “Well I didn’t go last year but we have gone for a couple of years over the last three

years to a sustainable, they have a big conference over there at the Double Tree. And

we’ve attended that so there were some ranchers, farmers, you know, local producers.

It was kind of a conglomeration of the full food chain where you have those that

produce the food, those that purchase the food, those that consume the food. Those

that support the process and so I didn’t go last year but it’s something they’ve had

every year. I can’t remember what they call it. I think Sustainable and Local

Constraints. So anyhow, I’ve attended that, so we’ve kind of had the networking that

we’re able to meet and mix with some of the folks.”

 “You know, mostly them coming to us or you hear from the guy over at St. Pat’s, “hey,

I’ve got this guy.” Or you hear from another account that they’re doing “this” and that’s

been kind of nice or you hear from the guy up in Kalispell, “hey, I’m doing this, this and

this.” I know that we used to get kamut straight from the kamut vendors”

Sub-theme. Perceived barriers to using local foods in the hospital setting:

Participants perceived several factors serving as barriers to the hospitals trying to use

more locally-sourced ingredients in food service meals.

Sub-theme element. Time needed to work with multiple producers: Limited

time was recognized as a restricting factor for hospital staff to use local food. A commonly

mentioned challenge was the extra time associated with working with multiple vendors.

Participants explained that multiple vendors are often needed in order to fulfill the

quantity and variety needs of the hospital food service programs when local farmers

produce smaller amounts of food and specialize in a particular food product. The extra

time needed to communicate with multiple vendors, along with the time needed to make

multiple orders and manage multiple deliveries, was identified as a significant challenge for

the hospitals in coordinating their menus.

 “So you know, as much as it’s easy to just, for a lot of people the reason why a lot of

people don’t like to have multiple vendors is because it’s more difficult. You spend more

time ordering, putting more deliveries away.”

 “I think that it’s about the vendor relationships and working with them that yeah, at

first it might be difficult just getting something established and then obviously putting

in more leg work to get on the phone and receive another delivery.”

 “But I’ve done a lot of things that are, the initiatives especially in the restaurant setting

are to buy local, especially when you have a local clientele. But I think that a lot of

people just fail in their execution because they try to treat it like they do with other

vendors, you know, it is more of a personal touch and so – you know if you order from

one of the larger companies, there’s that less personal touch there, it’s just going

through a computer. They find it more of a hassle, so that is a big challenge. And so

they’re just like, “ah, it’s not worth my time.”

 “The whole sustainability, going green, the buying local, I think that people want to do

that but most people aren’t willing to put in the work to at least get the ball rolling.”

Sub-theme element. Quantity and availability: Participants discussed the

challenge of providing more than 1,500 meals per day in the hospital. With such quantity

demands, adequate availability of local food supplies was identified as a barrier to

increasing the amounts of local foods used in hospital meals. Being that local producers are

often operating at a much smaller scale, participants perceived that if a sudden interest in

significantly increasing the amount of local foods being used was to occur, producers would

be unable to meet this demand.

 “And about four or five years ago we set out to do more with beef because we serve a

lot of beef. And it was just really difficult to get and partly because the University was

buying up a lot of the local beef.”

 “And you just can’t hardly get that around here. We would deplete the valley, more or

less. And that’s an interesting conundrum because why wouldn’t we grow enough food

for the people who live here? And when we can grow that food. And some things we

can’t grow, bananas, oranges, if we really want those, the hospital can’t be completely

local because they are going to meet peoples’ needs and wants. But in the areas that

we can, it’s just interesting that well, we just can’t produce that much.”

 “The only thing I can say is the fact that we have 1200 employees and obviously the

patients and the people we might be serving and catering and things that would love

to do more with maybe a smaller company but that would be a certain concern that

restaurants definitely can get away with it more because they don’t have high a

volume, their needs are much smaller. That might create an issue, not to say that we’d

necessarily be ordering a ton but we’re serving much larger audiences than you serve

in say a local restaurant would with, if they’re only serving a couple hundred people a

day vs. six times that amount.”

Sub-theme element. Cost: A prominent theme that emerged pertained to the

challenges associated with the cost of local foods compared to discounted prices acquired

through GPO contracts. Finances was recognized as being limited and somewhat

restrictive on local food initiatives, as effective management is necessary to balance higher

costs of local foods with limited resources of the hospital.

 “And then of course, the cost. The cost weighs in and I think they do a really good job

measuring what they can spend on and what not.”

 “We just have to figure out ways in which we can incorporate as much local and have

it be, you know, feasible from a cost standpoint and not have to raise prices.”

 “I think that the challenge is always going to be the finances. And that’s always where

they’re going to find barriers. But to break that barrier is communication and

awareness.”

 “They need to charge more. And then it’s a problem for them because it’s a domino

effect and it’s kind of like you need to have more volume in order to lower your price,

but how do you get to that volume? You can’t take the order because you can’t produce

that much. Even if you can’t produce that much, you have to turn down orders. And so

the growth, their own small business growth model is really tough. Because you have

to make money to grow but you have to grow to make money.”

Sub-theme element. Seasonality: A common barrier that emerged was the

uncontrollable factor of seasonality. The growing season in Missoula, Montana is not ideal

for growing crops year round. Participants were frustrated with these circumstances, as

the limited growing season results in limited local supplies.

 “I mean obviously, if you could take away these long winters. The short growing season

doesn’t really help us all that much.”

 “Because of our climate, we have kind of a short growing season. So that’s definitely a

barrier right there”

 “I feel strongly about it but at the same time it drives me crazy when it’s this time of

year, it’s like, ok. I go the Good Food Store and it’s like, California or Mexico, you know?

Or do you bite the bullet and go to the Costco and buy something that’s conventional

because it’s ripe.”

 “it’s really a challenge in a larger facility and in a state or a climate where you don’t

have it year round.”

Sub-theme element. Demand: Participants identified demand as a barrier to

increasing support and consumption of local products offered in the food service meals. As

mentioned earlier, participants strongly perceived that support for the farm-to-table

movement is growing at the community level and at the health care level. However, the

existing, opposing position to this support is that being a young movement, significant

education and further adoption still needs to take place. Participants recognized several

aspects associated with a lack of demand or support for consuming local foods being

offered in the hospital meals.

Local connotes a different, unappealing taste: Uncertain of change and more

comfortable with established eating habits: A key factor in hesitating to support and

consume local foods pertained to a sense of dissatisfaction with the presented items.

Participants described this sense of dissatisfaction in response to various changes made

within the kitchen management to expand the hospital’s local food initiative. For example,

offering locally-sourced, grass fed beef was reported to taste differently compared to the

more familiar, conventionally corn finished beef supplied in the country’s broader food

system. Other changes, such as the removal of the fryer and fried items, as well as other

less nutritious “comfort foods,” has been met with a degree of disagreement and frustration

as well. Participants perceived some of this dissatisfaction to be a result of hesitation in

exploring new or unfamiliar food items. People may have a deep connection to the foods

they are familiar with and therefore be tentative to expanding beyond this established

repertoire in order to experiment with different foods.

 “The issue with that, and I know it’s better for you, and that’s the thing, you know,

changing peoples’ minds that when you’re using a grass-fed, natural beef product, it’s

literally changing the structure of the meat. And so we, as Americans and maybe even

more so of the Montana palate, we grew up eating corn fed beef and where, you know,

they’re fattened before slaughter. And you get that nice marbling, which makes for a

really yummy steak and a really juicy, tender steak. To trying to do the right thing for

our diet, for our bodies, and going to a natural beef, which is completely grass-fed”

 “I mean, the fryer going away was a big deal. People are still pretty upset about that.

You know, and I was guilty of it too. You walk buy and they have like fried mushrooms,

fried mushrooms are delicious when you’re stressed out and hungry. So I think there’s

some resistance to that. But you know, there was resistance when we went to

electronic medical charting. There’s always resistance with change. And it’s

understandable. Especially when it comes to food, people don’t want to feel policed.

Like if I want to eat fried food, then I want to eat fried food. Which is fine.”

 “We’ve got into a lot of lentils lately though from Western Montana Grower’s Coop and

just changing the culture and peoples’ perception on what food, they have this idea of

what it was when they had it served by their mom or dad. But you got served pickled

beets growing up and I understand why you don’t like them now but, have you ever

tried a roasted, golden beet? It’s delicious!”

Lack of interest in eating local: In addition to some dissatisfaction with use of

local foods due to unfamiliarity and hesitation, another associated barrier was a more

general lack of interest and investment in the changes taking place. While changes in menu

items reflect a greater use of local, healthier foods, such efforts are meaningless if

customers won’t ultimately support the products and purchase them. Hospital food service

meals can consist of more local and nutritious items, but a disconnect in interest and

support from customers in participating in the farm-to-table movement can leave

initiatives disjointed.

 “it’s ironic that in a hospital where we want people to be healthier that we’re serving

way bigger sizes of foods that’s not healthy. And yet that is what the customer

demands. So that’s been interesting and we’re making some progress but it has been

quite difficult because the cafeteria doesn’t want people to be angry with them and

people don’t want to feel like they’re paying more for less”

 “And you can tell them, “this is good for you.” And they’re like, “well I’m not eating a

cheese burger because it’s good for me.”

 “So it’s a challenge, especially when people leave these walls and they go out and

they’re tired and they just want to get something that’s fatty and just almost a comfort

food to them, so I think it’s always a challenge.”

 “Definitely a little resistance with change. There’s been a few times people have been

like, “why can’t you just have a regular hot dog?”

Sub-theme. Lack of knowledge around local foods and resources: Participants

identified a lack of knowledge and accessibility to resources as another barrier to

strengthening support for local foods initiatives. The first aspect pertained to a lack of

awareness by hospital staff and visitors around the farm-to-table movement and the

supporting arguments for consuming local, whole foods. The second aspect pertained to a

lack of awareness around the resources and potential opportunities available to facilitate

increased use in the hospital meals.

 “we sell so much chicken. I guess, and we’ve never even looked at it. Because I don’t

think, and I don’t know, maybe we need to ask the question, “is there a chicken supplier

who has the processing facility?” I mean, are they maybe going to take on chicken? Is

there some way that we can incorporate local chicken into our menus, not just beef.

Fish? Forget it. Right? But we sell a lot of chicken. That would have some serious

impact.”

 “It will be slow though. It takes a lot of time to just plant a seed and then it takes like,

the germination time from someone putting the idea in your head that kale may be a

good thing to eat, to going vegan and eating locally all the time, that’s a huge shift in

someone’s life. It’s a whole shift in your lifestyle, in your priorities, so I think it’s going

to be really slow.”

 “Because even if you look at genetics – this maybe is getting off topic for you, but if you

look at just how hard it is to get your food, to know that your food is safely organic vs.

“natural.” There’s such a knowledge barrier between the average consumer who walks

into Safeway. You have to teach them there, like what they should be looking for first

and why this carrot is better than that carrot and why that’s even a priority and why

you should spend 45 cents more on this carrot.”

Local Producer Interviews:

A variety of themes related to local producers working with larger institutions emerged

from the interviews and are summarized in Table 3. The themes were organized into five

primary themes and significant sub themes fell within each of these groups. The primary

themes included: 1) Enablers for local producers to sell local; 2) Barriers for local

producers to sell local; 3) Enablers for institutions to use local; 4) Barriers for institutions

to use local; and 5) Components needed to support local producers. Sub-themes and sub-

theme elements are presented and accompanied by relevant quotes below.

Table 3 Themes and sub-themes of interviews with local producers

Emergent Theme

Sub-Theme(s)

Sub-Theme Elements

1. Enablers for producers to

sell local

Passionate leaders in the institutions

Supportive, lasting relationships between

producer and institution

Capacity is present to meet quantity demand

Western Montana Grower's Coop (WMGC)

Convenience of pick up: Provides access to small,

remote producers

Marketing for local products/ producers,

expanding market opportunities

Mission Mountain Food Enterprise Center

(MMFEC)

Use of "seconds": Reduces food waste and profit

loss by opening more markets

Allows for selling year-round

Montana Communities/ community members

support local food

Local institutions increasing in participation

Teamwork and networking among producers to

learn/support systems

2. Barriers for producers to

sell local

Reaching market saturation

Competition among producers: Many producers

in the market with limited demand

Market for core (highly demanded) crops is

saturated: Everyone plants same crops

Hard for new producers to become established:

High start up costs and many established

producers

High turnover in institutions: Need to reestablish

relationships and communication

Lack of consistency in demand and commitment

from institutions

Regulations

Food safety, certified organic, U.S. certifications

Corporate policy at conventional grocery stores

Unpredictable weather, short growing season

Economy of scale

Lack of economical infrastructure for small scale

producers

3. Enablers for institution to

use local

Western Montana Grower's Coop

Streamlines communication, ordering and

delivery processes

More variety and quantity to meet larger demand

Using "local" as a marketing tool

4. Barriers for institutions to

use local

Seasonality: Lack of consistency for meal

planning/selling of products

Need reliable, consistent service

Cost: Local is more expensive

More convenient to work with a large distributor:

Takes more time to work with many local

producers

Processing

Lack of time and resources to prepare/cook meals

5. Components needed to

support local producers

Networking and communication between

producers and institutions: Joint problem solving

Reorganization of infrastructure for small scale

producers to meet the demand

Menus, food preparation, and eating that's based

on seasonality

Education

Health and social benefits of local, whole foods

Cultural shift towards emphasis on nutrition and

local foods

Expand the market: Conscientious farming and

untapped markets

THEME 1. Enablers for producers to sell local:

Food producer participants identified a variety of factors that support their ability to sell

their products at a regional and local scale in Montana. Identified factors did not all

necessarily pertain specifically to working with hospitals in Missoula, Montana, but also to

experiences working with other institutions as well such as schools and restaurants.

Sub-theme . Passionate leaders established in institutions: The importance of

having passionate and motivated staff within institutions was seen as beneficial for

productive working relationships between local producers and institutions. Staff members

inherently dedicated to the farm-to-table movement serve as beacon leaders within the

institutions to advocate for local foods and encourage their use in meals. This dedication

results in greater creativity and receptiveness to developing solutions to challenges that

may arise in working to source food from local producers. Such individuals serving in

management positions and responsible for food procurement were recognized as playing

an essential role in expanding the use of local foods in institutions located throughout

Montana.

 “And I’m afraid that’s where we are. If you can deal with people that run institutions

that say, “I get it, this is better food. Show me the logistics.” We could solve those

problems. Not that it doesn’t take creativity, but I know that it can be done because

Mark is doing it and he’s been doing it for five or six years. But if you don’t have

someone in that position where, “oh, I get it,” it’s not going to happen with the green

Jell-o and Mac and Cheese guy. “

 “But Cheryl has taken it [Good Food Store] where it is now. Who knows where it would

have been without Cheryl. That’s not what I’m trying to say. But as far as produce goes,

it was on the road to where it is now. They’ve always had a serious, I mean, Paul, those

guys have always known what they’re doing.”

 “One of the biggest supporters has definitely been Jenny in Kalispell. She’s had a Food

Corp with her for the past, I don’t know, two or three years. And she just tries to

support as much as she can within her budget. And she’s getting local beef patties for

burgers at the lower valley processing up there and they’re actually cheaper than what

her previous supplier was, it was by a couple of cents, you know. It was great to show

her school board that they could support local and it not be more expensive.”

Sub-theme element. Supportive, lasting relationships between producer and

institution: Accounts between local producers and institutions with more history and

established collaboration contributed to more mutual understanding and smoother

business transactions. Such relationships were also identified as ones associated with

mutual trust and commitment in order to continue the working relationship. Therefore,

such relationships supported continued, and even increased, use of local foods within these

institutions, further strengthening the region’s farm-to-table movement.

 “For a couple of them, there’s three that I can think of. They’re re really great

customers. So we provide them with really great service. And we meet with them in the

wintertime and we say like, “this year I was thinking about doing this, can you do

that?” And they design their menu around what we’re going to provide. And these are

all, well two of the three are high end restaurants. Plonk and Scotty’s Table. It costs a

lot of money to eat at these places. So he’s fine.”

 “Our biggest restaurant customer is Biga Pizza. And he’s not nearly as high end but

he’s just as enthusiastic and he’s a great customer in that we have those two delivery

days but if he needs something on off days, he’ll come and pick it up. Because we just

don’t have the human resource to stop doing what we’re doing and send somebody

over to bring three bunches of oregano. So he’ll come and pick it up, which is great.

And I know that my wife and I also really enjoy those relationships and proud to be

part of these restaurants and part of the town and you just feel like you’re part of a

great community.”

 “More than anything else, I mean we have good relationships with everybody we work

with and they, when things go wrong on our end, they are understanding and when

things go wrong on their end, we’re understanding and so, so that type of thing”

Sub-theme. Capacity to meet the quantity demand is already present:

Participants strongly and adamantly spoke to an already present availability and capacity

to meet increased demand from institutions. A common sentiment reflected on the

dynamic that if a particular institution has passion and dedication to using local, the

necessary quantities and logistics can absolutely be worked out. “If there’s a will, there’s a

way,” reflects the perception of participants that opportunities do exist to overcome

challenges associated with developing direct institution-producer relationships.

Furthermore, participants perceived adequate amounts of food were either currently being

produced, or could be produced in the near future, to meet any rising demand in the

amounts of local food that may be requested from larger institutions with greater quantity

demands.

 “I think that we could definitely solve these problems in institutions if we were

thoughtful about how they were approached. If they’re on the same page in terms of

values, it’s pretty easy, we just do logistics.”

 “Yes. We just did an internal survey of the Coop and more than half the growers that

we have talked, it was over 50% that said, “I would like to increase production.” These

people are ready. Most of the folks have the land to do it. And we’re getting to the point

where we have the capability as a cooperative to service these people, to distribute to

them, to market to them. It takes a little bit of time I think. Yeah. The answer to that in

short is I think definitely, especially with the number of growers coming onto the

scene.”

 “Could be. It certainly could be. We have a lot of land. I mean at this point it’s not. But

we have 170 organic acres and across the street I think they have 300. And 150.

There’s like 400 organic acres within a half mile, quarter mile of our house. That’s

pretty, I mean, if we turned that into gardens, it could feed all of Bozeman. Well,

maybe. I mean, Missoula has tons of area. I just think yes, we could easily. If that

happens. And we certainly have distributors within the state who can get it to all those

little places.”

Sub-theme. Western Montana Grower’s Cooperative: The Western Montana

Grower’s Cooperative (WMGC) was identified as a significant benefit for local producers in

expanding access to Montana markets. The WMGC was referenced numerous times

throughout the interviews and was discussed based on the unique benefits that result from

working with them and participating in a cooperative (or coop) model. The amounts and

varieties of foods being requested by participating institutions is coordinated and balanced

among coop members. This coop model, in which food items from numerous producers are

compiled, was identified as creating opportunities for individual producers to work with

institutions that otherwise would not be feasible due to their small-scale production.

Several benefits of WMGC membership particularly emerged from the interviews.

Sub-theme element. Convenience of pick up: Provides access for small, remote

producers: Montana is the 4th largest state in the Unites States. Participants discussed

challenges associated with long travel distances and the resulting time and resources

needed to make deliveries throughout the state. Producers removed from populated areas

particularly encounter these challenges and face a dilemma in which time and resources

used in making deliveries is time and resources taken away from production. Participants

identified the WMGC as significantly reducing these barriers. As a member, the WMGC will

travel to pick up products from producers and make deliveries to participating institutions.

This pick up service was regarded as particularly supportive of isolated, small-scale

producers who otherwise would be unable to deliver their products to interested

institutions. The WMGC was therefore recognized as creating greater opportunities for

small-scale producers in reaching additional markets and facilitating greater amounts of

time to focus on production.

 “So it’s been great for a bunch of farmers who don’t live close to town. Or who are

trying to do direct marketing to customers or direct sales to restaurants or grocery

stores is really hard if you live an hour away. But the Coop will come pick up the food

nearby you, they have drop off points”

 “Huge benefits. The farms up north, they couldn’t exist without the Coop. And they’re

paying their bills, they’re doing really well.”

 “Yeah. And they go to Bozeman, Butte, Helena, Whitefish, you know, up to West Glacier.

They go all over to places that nobody is going to drive to deliver three boxes of salad

mix. But when they have a variety of accounts, it makes it worth delivering and opens

up a lot more availability for people to be growing.”

Sub-theme element. Marketing for local products and producers: Expanding

market opportunities: The WMGC was also identified as helping to expand market

opportunities for small, local producers. The Coop emphasizes outreach and marketing of

local products to institutions. It actively works to increase the number of institutional

accounts, picks up products from the producers, and then delivers orders to the

institutions. In return for these services, producers have more time and resources to focus

on production. Participants perceived such a cooperative model as facilitating greater

production rates and filled markets, as well as a more effective overall process from

growing to delivery.

 “They’re [WMGC] a tremendous boon and they’ve done a great job with some grocery

stores and some restaurants up and down the valley. There’s a lot more local food in

circulation now than there was because of the Coop. They’re doing great. And they’re

poised to do more.”

 “we sell a couple of items specifically through the Grower’s Coop. Which essentially

means that we don’t deal with restaurants or grocery stores at all. We let the Grower’s

Coop do all of the in-between work and we pack what we need and we put it in the

cooler for them and they pick it up. It’s really nice.”

 “Ours [WMGC model] is based off a model outside of Philadelphia. So they looked to

other successful models like that and so this grew out of that as a distribution and

marketing function of what they do. So basically they would sell their food as

wholesale and we add on their margin in order to pay for the service and then they can

spend more time doing what they’re doing. They can grow more food, they can grow

better food. Growing more food of course, the more you grow the cheaper it can get

too.”

Sub-theme. Mission Mountain Food Enterprise Center: Mission Mountain Food

Enterprise Center (MMFEC), a processing facility in Ronan, Montana, was identified as

facilitating working relationships between local producers and institutions. MMFEC

provides equipment and facilities for small, start-up producers to process or freeze their

products before delivering an order to an institution. There were several themes around

MMFEC that emerged as particularly beneficial for local producers.

Sub-theme element. Use of “seconds”: Reduces food waste and profit loss by

opening more markets: The Mission Mountain Food Enterprise Center provides access

for small producers to process or freeze their products. This ability allows producers to

process and sell “seconds.” “Seconds” are the products not considered to be in perfect

condition due to not having an ideal appearance. As a result of not having a perfect

appearance, these products, otherwise in adequate condition and completely edible, are

not sold at farmers’ markets or grocery stores. Participants identified “seconds” as a

significant source of food waste and therefore, also a profit loss. However, with the ability

to process and freeze products at MMFEC, local producers are able to use these “seconds”

and distribute them to institutions, particularly to school systems. Such processing

capabilities were identified as creating space in markets to sell additional and quality local

food ingredients.

 “And those [seconds] are being used in a really fabulous way instead of being shipped

off for compost, they’re going straight to the schools, which is super awesome. So we

had a couple hundred pounds of cucumbers that went to the schools this past year

that, you know, the cucumbers were just bent instead straight. So it makes us feel good

that they’re being used well even though they’re not number one in quality.”

 “Or let’s say there’s a massive hail storm, which there was this past year, a big hail

storm in the Bitterroot and we had one grower you had a couple thousand pounds of

zucchini that we couldn’t sell to grocers because, well, it looked like it had been

through a big hail storm. But it’s still great food, we can send it up to MMFEC and they

can shred it and freeze it and we have it all year round and it can go to the schools.

Actually the hospitals have been buying it more than anyone to bake in bread or

whatever they do.”

Sub-theme element. Allows for use of otherwise wasted food and for the

selling of products year-round: The processing facilities offered at Mission Mountain

Food Enterprise Center was identified as helping to not only reduce waste of “seconds” but

to also reduce waste of other products that may have otherwise been unused. The

processing facilities were identified as a way to freeze and store products in order to

expand business beyond the limited growing season and sell year-round. Such a change

has therefore resulted in increased profit as well.

 “So they [MMFEC] garner all the interest, we source the food. Sometimes we give it to

them directly. You know, for example, apples or something like that directly to the

schools without any processing. There are certain things for the snack program in

particular where they will do some processing or if we have just a lot of green beans,

for example, we’ll go to MMFEC, we’ll say we have all these green beans, they’re not

going to last, school is out of session, will you guys processes them, or freeze them for

us basically. And then we have this product and together, we’ll go to schools and try to

find ways to get rid of those green beans.”

 “And then it also enables us as a cooperative to have products which we can sell

throughout the course of the year. I’m thinking of the winter when I normally wouldn’t

be employed because if it weren’t for the eggs and the cheese and stuff like that, we

wouldn’t have enough money to pay any staff. When I first began here, Dave was ¾

times in the winter, I was driving and I was probably half time. And this year, Dave’s

full time, I’m fully time and we have our accountant who’s ¾ time, we have a driver

who’s essentially full time. And a lot of that’s due in part that we’re able to sell things

year round.”

Sub-theme. Montana communities and community members support local

food: Participants identified a generally growing support for local products and the use of

local foods throughout communities. Such support helps strengthen the farm-to-table

movement, thereby supporting Montana’s local producers and facilitating working

relationships between producers and institutions.

 “But all the food that CFO grows is sold in the Missoula Valley, for the most part. Some

that goes to the Grower’s Coop is sold to other places in Western Montana. But the

business wouldn’t exist if there wasn’t an appreciation and ethic for local food.”

 “I can say, this is not an entirely subjective opinion, but we’re pretty progressive in

Montana. I think part of that’s due to the larger towns in Montana all having

universities and ag. Universities. But even outside the university, people in Montana

are really independent, fiercely so. And despite all the connotations that may go along

with local and organic and stuff like that, you can talk to any rancher up in the Mission

Valley that’s pretty adamant about wanting to support local. Where we are is that

we’re really progressive. We’ve had pretty worldly growth rates as far as the Coop is

concerned and I like to attribute a lot of that to the work that we’ve been doing.”

 “Well I think Missoula is maybe a little bit ahead of the curve as far as local. You know,

that’s the nationwide trend, knowing the story behind your food. So local is big, out

there, getting bigger and Missoula’s been a little bit above average in that respect I

think for a long time.”

Local institutions are increasing participation in the local food movement:

Participants perceived that not only are community members supporting local food, but an

increasing number of institutions are also supporting local foods. An increasing number of

institutions throughout Montana were perceived to be sourcing local foods and working

with local producers. Such an increase is further opening market access and supporting

local producers.

 “We’re taking baby steps. It’s just beginning. We’ve done a great job in terms of the

local food movement and picking all of the low hanging fruit. Farmers’ markets,

boutique restaurants and the natural food grocery stores. We’ve crossed those boxes,

right. And not that I want to diminish any achievements there. Even those are sort of

low hanging fruits.”

 “And it [WMGC] started with several growers. I think the sales of the first year were

somewhere around five or six thousand dollars. Four years ago, I think we began the

CSA program, the last two years in a row we’ve grown, I think 36% and in this past

year 55%. We just reached over a million dollars in sales this year.”

 “Again. Like a lot of people’s attitudes have totally changes and they’re willing to make

exceptions now in order to get this local product. People, more people are coming to us

than us going to them and when we do have supply problems or something like that,

people, I’m not getting yelled at on the phone for a half an hour. There may be some

disappointment but then there’s also like, ok that’s fine, but I still want something from

you so what can we do? Let’s work this out”

Sub-theme. Teamwork and networking among producers, support systems:

Participants perceived a general support system among producers and identified this as

beneficial to successful business and the ability to expand into other markets. Guidance

and support are available for new and less experienced farmers and producers are working

together to more productively work with institutions.

 “And we have over 200 customers so I guess the point of that is getting some of these

projects off the ground initially is, it takes a lot of work and a lot of time. Time that we

haven’t always been able to give or make. And the Food Corp folks, that’s what they’re

there for”

 “But no, they’ve [Food Corp. students] really been invaluable kind of on that end.

Getting all the people excited, getting in this particular area in the Mission Valley,

they’ve started a collective buying program where they will round up several smaller

school systems who don’t necessarily have the money to get carrots processed for the

SNAP program or something like that. So they round up a bunch of people together,

get the order, and then they come back to us which is really nice. So we’re all talking to

fewer people. They’re talking to us instead of talking to 20 different growers, we’re just

talking to them instead of talking to five or six different schools.”

 “Which I’m all about and it’s a great thing, but it’s also a hard position to be in, where I

am because we as an organization doesn’t have time to train people to grow. So in the

community, there are certainly other growers that are willing to mentor newer

growers and stuff like that.”

THEME 2. Barriers for producers to sell local:

A variety of factors were identified as barriers to establishing or maintaining working

relationships between local producers and institutions. Such factors were related to the

dynamics of working with staff at institutions, the current level of supply and demand for

local products, economic structures and food regulations.

Sub-theme. Reaching market saturations: A theme that emerged from the food

producer interviews pertained to the current situation in which the market and demand for

local products is becoming saturated. These participants perceived a narrowing market

that limited outlets for selling local products. While some producers would like to expand

their outreach, demand for local foods appears to be stalled.

Sub-theme element. Competition among producers: Many producers are in the

market with limited demand: Increasing competition among producers was seen as a

challenge. While particular communities throughout Montana may be especially

supportive of local products and foods, the number of farmers and ranchers outweigh this

population and are facing a local food supply greater than the demand. Several

participants described this dilemma as one in which the needs of all invested, “low hanging

fruits” are now being met. Individuals, natural grocery stores and restaurants committed

to using local foods have already figured out ways to meet their needs and have already

established relationships with the WMGC or individual local producers. Therefore,

entering markets that are inherently less committed to supporting local is much more

difficult to accomplish. The existing population dedicated to local foods is small and has

ample options, resulting in a saturated market with significant levels of competition among

local farmers and ranchers for business with this population.

 “It’s this line. Like on one side, there are people who want to buy local food. Whether

these people are customers of the Good Food Store or customers of Scotty’s Table

Restaurant or the Missoula Community Coop. There are people already aligned with

these values and we are killing each other to meet their needs. There’s more farm

owners than those people need. So there are farmers being left out. The supply is

greater than the demand for people in this sphere of values.”

 “So it would be really hard. I mean, this is, Missoula is in a tough spot in that we have a

local food scene that’s like Portland but we have a population that’s like Missoula. We

have all these farmers and all this excitement and six restaurants. Where Portland’s

got 60. And the Coop is in a similar spot where if the Coop was serving Portland or

serving Seattle, they would be doing five million a year and they wouldn’t have the

cost because internally they’re dealing with farmers squabbling over who gets to sell

what. And if they were serving Portland or Seattle there would be enough to go

around. There would be enough market to go around. So it’s a really tight spot.”

Sub-theme element. Market for core (highly demanded) crops is saturated:

Everyone is planting the same crops: In addition to the perception that there is a general

saturation in the demand for local products, saturation is especially happening around food

items that are particularly easy and cost effective to grow. Such high levels of saturation in

these specific items create challenges for new producers trying to establish their business.

Food waste and profit loss can also become intensified by high levels of competition as a

result of the limited growth still available in core crops and other areas that are relatively

easy to make money in.

 “I mean, the growers in our community have done exceptionally well. It’s just that right

now, I guess to answer the question, there’s not a huge amount of growth left in the

areas that people can make money in.”

 “But now it’s kind of changing. If you’re interested in the Coop, Neva – have you seen

the report that she wrote? It’s definitely worth looking at. I feel like what’s happened

with the Coop is sort of reflective of the whole local farm situation meaning that we’re

saturated around these items that are relatively easy to sell.”

 “Everybody seems to want to grow the same things. So it gets pretty competitive.”

 “They do about the same at both markets. People who might tailor themselves to

markets might do well. Our type of farm would never make it. I mean, there’s nothing

really unique about us other than our longevity. We grow pretty traditional crops.”

Sub-theme. Difficult for new producers to become established: Participants

spoke to a variety of challenges currently faced by new producers. A common sentiment

reflected was the level of difficulty associated with agriculture and establishing an

agriculturally-based business. High start-up costs to acquire adequate land, equipment and

supplies can be extremely expensive, and in a business in which returns may not be

extremely high, balancing these costs can be challenging. Additionally, participants felt the

region is saturated with producers that are well established with loyal customers, creating

a competitive and challenging market for new producers to enter.

 “It would be really impossible for a new farm to break into that. Super hard. Because

there’s only like six or seven restaurants that would do it and they can get anything

they want from the Coop. Why would they go with “I’ve never heard of you, you’re

knocking on my door.” And what they don’t get from the Coop, they get form us. And

we’ve been serving their needs for 20 years. We have really good relationships with

these people. They’re our friends.”

 “The fact is, the bigger block is the availability of land because it’s so expensive.”

 “Yeah those things tend to go together. Where the people are, I mean, you know. I used

to say, why would anybody, I mean say this 40 acres of ours is worth a half a million

dollars. Well, why would anybody invest with equipment and everything and almost ¾

of a million dollars so they can make 60,000 dollars a year? I mean, it just doesn’t work

out. We did it because we started with nothing and bought it as we went along. But

never would you have slapped that money down. And that’s what it would take. There’s

only two ways to do it. The way we did it, which is probably the way a lot or some of

these young farmers will do it now. You know they’ll expand as they get older and

make more money and they’ll buy it gradually. But nobody’s going to, unless you’re

born into a farm, can afford to buy that much land for a good farm.”

Sub-theme. High turnover in institutions: Need to continually reestablish

relationships and communication: Participants were frustrated with high turnover in

food management and how it affects the ability to maintain relationships with institutions.

A lack of communication across changing staff can result in a lack of congruency in an

institution’s working contract with a producer. Food item requests can change

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unexpectedly based on differences in preference, interfering with a producer’s production

and potentially resulting in a supply of products no longer spoken for. A change in food

management and staff also requires a reestablishment of understanding and processes of

the working relationship in order to have common understanding of one another.

 “The Coop has run into situations where personnel has changed and suddenly, the

same institution just won’t buy anymore.”

 “I think another issue is, in terms of the institutions, is turnover. For example, two

years ago we grew a lot of lemon cucumbers because the University really liked them

and would buy a lot of them and then their, I’m not sure what rank it was, but someone

in the food buying sector changed and they didn’t want to use lemon cucumbers

anymore.”

 “The other thing with the restaurants is their chefs seem to come and go two or three

times, a couple times a year. There seems to be a really big turnover and so we’re

forever just trying to make introductions and talk to them and we have, we’re not

nearly at the level of trust and intimacy, if that’s the right word, that we have with the

Good Food Store.”

Sub-theme. Lack of consistency in demand and commitment from institutions:

Participants identified a lack of solid buying commitment from institutions as a significant

barrier to increasing the level of business interactions occurring between local producers

and larger institutions. As small businesses with limited resources, some producers felt

they were unable to take large risks by working with institutions without a solid buying

commitment. Taking such risks could result in wasted resources and therefore lost profit.

While this perceived lack of consistency and commitment can be a result of staff turnover,

participants also described separate, unexpected changes in an institution’s meal planning

after conversations and planning had taken place. Producers who were unwilling to make

significant commitments until institutions are willing to make significant commitments was

seen as problematic.

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 “It’s not always reliable, but no market is so that hasn’t really changed. With fresh

vegetables, you don’t, I mean one week they need X amount and then the next week

they over order something and then they don’t. So it’s always, you can’t really, it flows

pretty well but it doesn’t flow as well as you’d like it to from the grower’s point of

view.”

 “And so right now it’s a lot of like, well, we don’t have growers that necessarily want to

make a huge commitment because we don’t have institutions who are willing to make

the huge commitment. We, us as a cooperative and our individual growers are not in

the position just to take these large risks. We can’t.”

 “And they say, “ok I’ll buy from you this much cabbage at this time. You plant it, I’ll be

ready to buy it.” And it’s not an iron clad contract, it’s like, you can grow it and they

still might not buy it. Because if the people they sell it to say, “oh sorry we went out of

business,” or “we’re getting out of cabbage, we’re never going to serve cabbage again.”

So it’s more like a, we all agree to do the best we can and honor this agreement and

we’ll see where it goes.”

Sub-theme. Regulations: Some participants identified food regulations and

certification processes as a barrier to increasing market access and developing additional

contracts or working relationships with institutions.

Sub-theme element. Food safety, certified organic, and U.S. certifications:

Participants thought it was challenging to stay informed of food safety regulations and

changing certification processes. The wide variety of certifications creates a complex

decision making process on part of producers as well. A theme that emerged around

certifications was that choosing not to pursue them can restrict access to the institutional

market and reduce the number of businesses that will accept the products. While

producers recognized regulations and certifications as an effective way for institutions to

ensure customers and staff that their meals are safe, they were also recognized as a barrier

to some smaller producers.

 “And it’s possible that we will have to, that the Coop will be required to become GAP

certified anyway through the Food Modernization Safety Act.”

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 “Yeah. Very much so. I mean, we deal with one institutional buyer that they have a

sanitarian and boy, a lot of local producers are just frustrated to heck. In terms of rules

and regulations that change on them. And so much so, one they think it’s ridiculous.

And it can get extreme sometimes and it’s just not worth their time. You know, to jump

through the hoops and so that tends to be a barrier to entry for a lot of producers. And

some are, probably most are not nearly as strict, but that can be a barrier for some

local producers.”

 “Not necessarily. You know. This guy’s got an acre of vegetables and the sanitarium

wants him to put a porta potty out there. You know, it’s like, “oh my gosh.” I’ve got an

acre. You can walk into the house and use the restroom. You know, it’s almost comical,

some of these restrictions and requirements and things like that. So, some just kind of

throw up their hands and say, “I’m not worried about this particular institution. It’s

just too hard to deal with.”

Sub-theme element. Corporate policy at conventional grocery stores: A

common sub-theme that emerged around compliance with food safety regulations and

certifications was the especially challenging corporate policy of conventional grocery

stores. Larger, corporate grocery stores were identified as having particularly complex

processes in order to carry local products. The level of complexity was recognized as a

significant barrier to producers and greatly limited access to this particular institutional

market.

 “There’s a process you have to go through to get things approved [in conventional

grocery stores] or things like, for value added goods, you have to have UPC’s and stuff

like that. And things that we’re just getting into.”

 “I’ve had them in the local Albertson’s. Um it’s not worth it, going through their

corporate offices. It’s just, I mean, if you have, if you could supply them all, that’s one

thing. But Albertson’s will let you get into their local stores but it’s more hassle than

it’s worth.”

 “like Lucky’s is a chain. And you know, if your cheese is that good, they’ll buy it. It’s just,

I had to go through corporate with that, but and the natural grocers are owned by

Vitamin Cottage which is out of Denver also and they’re huge. And so you have to go

through their corporate. And I don’t know if farmers are willing to go through all those

hoops. “

Sub-theme. Unpredictable weather and short growing season: Another

challenge identified by participants in establishing and maintaining relationships between

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producers and institutions is the weather and growing season in Montana. Various

participants referred to broader challenges that accompany agriculturally-based

livelihoods and the dynamics of such a heavy reliance on the uncontrollable factor of

weather. Unpredictable weather conditions can threaten production and greatly influences

food quality. Participants paired this challenge with the challenge of Montana’s short

growing season. Producers rely on productive growing seasons to have the ability to

sustain themselves throughout the rest of the year. A natural link between a successful,

productive growing season was recognized with the capacity to meet the needs of

institutions and fulfill their commitments.

 “I see the work they’re doing as far as land stewardship is concerned and you know

there’s a lot of people who have a lot on the line. And it’s kind of a tenuous position to

be in. To live in Montana, the growing season is short”

 “weather could do anything at any time. And with that in mind, you know, they could

lose everything they have in a matter of a couple months, which means I could lose

everything I have in a matter of a couple of months. So that’s the way it is.”

 “Mostly you know, I just keep saying, the overall thing is challenging. I mean you can’t

really afford to have another job and so you have a 100-110 day growing season and

we have to make our annual income in that 110 days. So the whole thing, the whole

chess board that you put together to produce because, you know, maybe there’s easier

ways but the way we do it is not that easy. So it’s just like this sprint from right now

until October or mid September. So as you get more physically tired it becomes more

challenging. And things that don’t bother you in May bother you in July.”

Sub-theme. Economy of scale: Multiple participants identified economy of scale as

a significant barrier to expanding market access and increasing the amounts of food items

being produced and sold.

Sub-theme element. Lack of economical infrastructure for small scale

producers: A prevalent theme emerged around challenges associated with economy of

scale. Participants perceived a lack in need infrastructure for production and distribution

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of small-scale, local producers to occur in sustainable ways. Small-scale production often

connotes smaller profit margins. Resources and capacity to process and distribute

products may therefore be limited and in turn, restrict a producer’s flexibility in reducing

customer prices. As a result, effectively competing with lower, commodity food prices was

viewed as a barrier.

 “And I, this is probably jumping ahead, but I think that a lot of the infrastructure that’s

really needed for local food to be distributed and to become more sustainable for its

producers is not really there yet. Like distribution, processing, packaging, branding, all

that stuff is kind of, I think in the early stages. At least in this part of the world in

Montana.”

 “Part of that is because the cost is lower. So institutional markets, you get a lower cost,

generally wholesale you get a lower cost. So you need a higher retail. And I imagine

that institutional markets ask for even lower costs than even a lot of the wholesale

markets. So that trickling down to the farmer, for us, we wouldn’t be able to produce

our salad mix for a whole lot cheaper than we’re doing now just because we don’t have

that much space. But if we had 10 acres of salad mix, we could probably do it. So

there’s an economy of scale there that can be difficult for small farmers.”

Processing: Processing was identified as a particular challenge pertaining to

working on a smaller production scale. Institutions sometimes request that foods be

delivered pr-processed in order to shorten meal preparation time and reduce time and

staff costs. These requests can pose as barriers to producers, as limited resources of their

own may reduce access or capacity to processes their products in an economical way.

 And getting what we want, you know, baby carrots chopped into carrot coins. And they

sure will serve lettuce but we need romaine hearts washed, chopped and in a bag. And

the small farmer in Missoula can’t do that. So this is where like, if they had made the

choice, this is what we want, we could make it happen.

 Another hurdle is that many of these restaurants want to buy individual cuts and we

can’t handle that inventory. Or we haven’t figured out a way to do it economically.

 You know, as a for instance. This isn’t exactly right, but it’s close enough for

illustration purposes, it’s close enough to accurate to be good to illustrate. We take

trailer, horse trailer trips every other week to right now, Superior Meats where we

process and this depends a little, but let’s say we have four animals on that horse

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trailer. The mileage, the fuel, the labor to deliver those four animals to Superior on a

per head basis is about the same as it would take on a per head basis to ship a semi

load to Nebraska. And so there, you know, that cost, you know, when you start thinking

about how much difference scale makes, is really big.

Distribution: Distribution was identified as another challenge for small-scale

producers in working with institutions. Challenges were associated with small, remote

producers and the expansive regions of Montana in which extensive traveling is often

required to transport products to various customers and institutions. Such distances were

identified as a barrier due to limited resources in time and money. Such limitations can

therefore restrict producers’ access to markets and opportunities to develop working

relationships with institutions.

 And one of our early suppliers in northern Montana did these great little lentils that

are grown here in Montana and some other grains and things like that. I had the

owner tell me, “you know, I sell a lot of products like in Portland, a good distribution

there. You know, I sell product in Denver. But I don’t sell any product in Montana.”

Because they didn’t have any way to distribute their products. There just isn’t a very

good distribution network here. And customers want to buy direct but, a 25 pound of

lentils is heavy. It isn’t a real expensive item but it’s dense. And the cost of freight or

FedEx to get it there is almost as much as the cost of the product. So that becomes just

a real hurdle there.

 But that distribution company that would buy that whole animal and distribute it to

different places, that’s hard to do on a small scale and it gets real pricey when you

start doing that on the small scale. And that’s why the scale is the reason that the

commodity is cheaper than we can do it at a small scale locally. And then distribution

also becomes a challenge. If you can deliver stuff in semi loads, size lots, it becomes

much cheaper than smaller lot sizes. And so that’s a big challenge also when you try to

market locally.

Higher production costs than commodity food production: A significant theme

relating to economy of scale emerged around commodity prices of food compared to actual

prices reflected in local products and ingredients. Participants voiced frustration with food

price dynamics. While local producers are in a position of needing to charge prices

reflective of production costs in order to avoid accruing losses, commodity priced foods

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inaccurately reflect costs and are based on subsidies. Such an inaccurate reflection in costs

allows commodity priced foods to appear significantly cheaper than locally-produced

foods. Competing with foods marked so much lower can serve as a barrier to local

producers in supplying their products to institutions. A common sentiment was that

competing with commodity foods more accurately reflective of production costs would

make gaining support and business from institutions easier.

 “In my perfect world things would actually cost what they cost. So I think that’s the

biggest challenge is they’re getting these super cheap items that that’s not the real

price of them. It’s just a subsidy or that sort of thing. So I do think that we would be

able to be a lot more competitive if the things they purchased were the real price.”

 “Yeah, there are many hurdles. Obviously, well maybe it’s not obvious so I’ll, but a very

big one is price. And so our cost for, to produce this product and sell it locally is higher

than the commodity costs are, than commodity prices are. And so if one of these

businesses want to do business with us, it’s for reasons other than costs. We can’t do it

cheaper than they can get it from the commodity channels.”

 “You know, if you could somehow measure total cost, maybe it isn’t more. If you could

think about, and I can’t, I’m too slow minded, but if you could think about all the other

costs of our commodity model, I’m not a big fan of it. You know, if you could think

about obesity, if you could think about environmental degradation and those costs,

then if those costs were added on to the commodity cost, I would gladly compete with

that all day long! But they aren’t. They aren’t added on there. Those health issues, the

environmental issues and thinking about what the Farm Program subsidizes

production so their costs can be lower. If you think about all of those things, then I

think the local production is a better model, I really do. But it’s not our system and I

don’t have the knowledge or the energy or the understanding of how to fix what we’re

doing now.”

THEME 3. Enablers for institutions to use local foods:

Participants perceived several factors as contributing to supporting institutions in working

with local producers to include local foods in their meals or food service program.

Sub-theme. Western Montana Grower’s Cooperative (WMGC): WMGC was

identified as facilitating connections between institution food services and locally-sourced

ingredients. By working with the WMGC, institutions are able to conduct business with one

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representative of Montana’s food producers, resulting in a streamlined and more efficient

process. As communication, ordering and delivery is all coordinated through the WMGC,

institutions are able to conserve resources otherwise spent in working with multiple

producers. Participants also addressed the unique benefit of compiled variety and

quantity. Institutions choosing to work with WMGC receive products from producers

throughout the region, allowing them to more easily meet the quantity needs of the

particular food service program.

 “And if they worked in the wintertime and Safeway was to say, “ok we’ll buy lettuce

from you but we’ll need 57 cases every Tuesday.” Dave could say to all the farmers,

“alright, this is what I need, who can meet these needs?”

 “And in terms of local food, that’s kind of – as far as I can see in this area – that’s

[WMGC] the best local food distribution system in the area. So it compiles goods from

our area, from the Flathead, from the Bitterroot, from the Missoula area and then

redistributes them and the best part about it is that we can service accounts. Like the

grocery stores, even though any one farm doesn’t necessarily have enough to provide

them with what they need year-round, same for institutions, so it allows us to compile

food from a variety of farms and service these larger customers that any one farm

would unlikely be able to deal with.”

 “If we can make it easier for them to access those products, and they know our truck is

going to be there every Wednesday, they place their order every Tuesday, it sure makes

their task of replenishing the volume a whole lot easier.”

Sub-theme. Using “local” as a marketing tool: Support for the farm-to-table

movement has continued to expand. Communities are becoming more focused on

supporting locally-produced items. This growing support naturally results in a growing

demand for local foods across the social levels of a community. Participants identified this

growing demand for local foods as a potential outlet for institutions in strengthening their

clientele. “Local” was perceived as a very beneficial marketing tool, particularly for

restaurants. Using “local” as a marketing technique was suggested as a potential

perspective that could be presented to institutions still not fully on board with working

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with local producers. Presenting the use of local foods through this perspective can

support mutual gain in which the institution may experience a profit increase and

producers experience an expanded market.

 “But if they’re not, we need to really figure out how we can make local food, how we

could use local food as a tool for these food service providers to meet their goals. And if

they feel like buying our food will allow them to meet their goals better than they are

now getting food from Cysco, they might be willing to switch.”

 “And that’s a market strategy for them too. They promote that on their menu. You

know, locally sourced this or that, it’s beef or lentils or produce. And they use that as a

marketing tool.”

 “Right now a lot of the push or move towards a lot of local food has become an ego

thing in Missoula. You go down to the market on Saturday, every restaurant in town is

there. I see every single chef that we sell to because they want to be seen down there.

They want people to see them down there. It’s a marketing tool. I don’t blame them

because I wish they were buying directly from us but that’s not, I don’t really feel that

way. But it’s an ego thing. Even if they’re only buying a little bit. People see them down

there. They go back Saturday morning from the market, writing their lunch special for

that day or their dinner special for that day, which is from the Clark Fork Market. So

yeah, that’s a good thing. It’s getting local food services.”

THEME 4. Barriers for institutions to use local foods:

Several different factors were perceived by participants as challenges for institutions in

acquiring local foods and using them in their food service programs.

Sub-theme. Seasonality: Lack of consistency for meal planning/selling of

products: Seasonality was identified as a barrier for institutions in sourcing local products

in their meal service programs. Montana’s short growing season limits production and

availability of locally-grown products. Institutions were identified as often requiring

consistency and regularity in food deliveries to aid meal and menu planning. Supporting

local products year-round often connotes planning of menus based on seasonality and the

particular products available at the moment. Menus would therefore be changing

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somewhat frequently to align with this seasonality and such planning was perceived as

challenging based on the lack of infrastructure of some institutions.

 “They’re [UM] actually one of the biggest customers of the Montana Grower’s Coop. I

know that they’re up there. When school’s in session, which unfortunately doesn’t quite

line up with the farming season but they buy as much as possible from the Grower’s

Coop, which is great.”

 “So unless the institutions have very seasonal practices, it’s really hard for them to buy

just local food when all of their salads have tomatoes in them. I mean, part of that is

just kind of a reorganization of the kitchen and reorganization of the chef’s minds but

it’s also much easier for institutions to say that every Thursday, year-round, this what

we serve and this is how much we need to buy every week. Like they have really set

numbers and as soon as you start messing with, this week we have this many tomatoes,

this week we have half as many. I think that can be really frustrating and difficult. So

that’s another issue. And I think it’s workable, seasonality in institutions but I think it

can be difficult. Especially after many years of not having to think about it.”

Sub-theme. Need for reliable, consistent service: In addition to a consistent

supply of products, institutions were also perceived as needing trusting, dependable

relationships. Proving that relationships with small-scale producers can be just as reliable

and consistent as relationships with larger distributors was identified as on way to

increase the number of farm-to-institution accounts.

 “Because while as a collective we’re producing more, offering more that we could as a

single farm, I’m not sure that the supply is consistent enough for institutional buyers.”

 “Well just getting in the door is a problem. Sometimes. It takes a long time. Like

Thomas Cuisine, for example, Dave was working on that for a couple of years. Or Wally

will tell you that he did that work for a couple of years! But it’s a lot of people being

persistent I think, which is kind of – showing them that you can be dependable and

consistent is difficult”

 “So you know, it’s a finesse thing because chefs are funny. And they’re proud of what

they do and rightly so. And they’re proud like me. So you have to walk a fine line and

you have to be respectful and you know, it’s, you have to earn their respect and they

have to love your product. So that’s a huge thing.”

 “Well stores want to put your products on sale. And so you have to be able to work

with them on pricing and that kind of thing. You have to be dependable and show up

when you’re supposed to. That’s the same with restaurants.”

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Sub-theme. Cost: Local is more expensive: Cost was considered a significant

barrier for institutions using locally-sourced ingredients. Due to the smaller scale of local

producers, products reflect production costs in order to avoid accruing any profit loss. This

necessity of charging prices more reflective of costs can make competition with commodity

foods very challenging. Depending on the particular food item, costs between commodity

foods and local foods significantly vary. Such price differences were recognized as a barrier

to institutions based on their own limited resources. Costs of local products can be higher

and therefore, institutions will usually choose to use local foods for reasons other than

price. This dynamic was identified as a barrier in that institutions solely focused on profit

maximization may not be receptive to working with local producers or paying higher

prices, thereby narrowing market availability.

 “One thing, especially in the natural, organic and local products, just because they

don’t have economies of scale. Their prices tend to be higher. You know, then the

product that General Mills produces. So for many of our customers, they really need to

want that local product.”

 “So to a certain extent, that will limit us to a certain, and again, because our product

costs more, it tends to be the high end folks that can afford it. And frankly, that’s not

Montanans. So that’s a piece of it and as much as we would like to be the product that

the family , the young family with growing kids can afford, that’s what we would like,

but it’s just not what we’ve been able to do price wise. And so that limits, I think our

growth in Montana and obviously a lot of folks live in Montana for reasons other than

for high paying jobs.”

 “And price is a big deal for them. With goat cheese, organic goat cheese, a lot of

Montana is off the table because they’re mom and pop steak houses and you know,

they’re not high end, refined, fancy. You know what I mean? It has to be a certain

restaurant to use our product. So that’s an obstacle.”

Sub-theme. Lack of time to work with multiple producers: Working with

multiple small-scale producers can require extra time to coordinate, make orders and

manage deliveries. Limited time was recognized as a barrier for restaurants in working

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with local producers. Limited time can result in restricting the number of producers that

an institution can work with and therefore restrict the amount of locally-sourced foods that

can be used in the food service programs. Along with this, participants recognized that

working with large distributors can be much more convenient due to a streamlined process

and cheaper prices. The coordination required to manage multiple working relationships

with local producers was recognized as a task that requires skill, time, and dedication.

 “In many cases, it’s just hard to do. Especially in a setting like the hospitals. They don’t

want to have to work with dozens and dozens of suppliers.”

 “You know, around here, they’ve got guys walking in in cowboy hats every week saying,

“do you want to buy my stuff?” And a lot of them like that very personal connection.

But for some restaurants, that’s just impractical.”

 “And instead, he has to deal with all of us little farms, and he does. He’s very

professional and he’s very good at it. He calls at the right time, he does what he says

he’s going to do, we can rely on him. And he can rely on us. But still, you have to

understand that his job would be a lot easier if he didn’t have to deal with us all.”

Sub-theme. Processing: Participants identified processing as a challenge for

institutions in working with local foods and incorporating them into meals and menus.

Foods arriving from larger distributions are often pre-packaged or processed to facilitate

use, such as chopping or preparing certain vegetables or other produce. This processing

serves as a convenience for institutions and simplifies the preparation time for kitchen

staff. Products from local producers often arrive unprocessed or unmodified. The

additional time needed to prepare these foods can be a barrier to institutions in using such

local products.

Sub-theme element. Lack of time and resources to prepare or cook

unmodified foods: Receiving foods from larger distributors is often accompanied by

processing services that makes preparation much more convenient. A lack of this

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processing was identified as a barrier to some institutions due to very limited resources.

While an institution may be supportive of local products and interested in working with

producers, expectations may be in place that the process remain the same and only the

source of the food be different. A lack of resources and inflexibility around processing was

perceived as a challenge reducing the number of institutions using locally-sourced foods.

Another challenge identified by some participants pertained particularly to the

public school systems. Many schools operate on a satellite system in which a central

kitchen prepares all of the necessary meals and then delivers them to all the schools. Menu

creativity is often limited and restricted in using local, unprocessed foods because of the

transportation involved and the significant number of meals that need to be prepared.

 “So I guess this is about infrastructure and saying infrastructure could be, we need

everything to work just like it is now, except the suppliers will be different. In that case

we’ll need a processing infrastructure that’s right here, that kind of mimics the

processing infrastructure that’s in other places right now.”

 “I think a lot of food service directors and their helpers, they were just doing a lot of,

you know this isn’t true for every school, but a lot of them were doing heat and serve.

And I think it’s especially challenging for schools that have satellite, so they prepare

the food there and then they have to send it off to the different locations. I’ve just

heard, you know, it’s harder to prepare food for that. What are you going to make

that’s going to stay tasting good? So it’s been pretty simple stuff so I think people are

trying to get really creative.”

 “The processing, you know, we have all the equipment and that’s truly one of the

biggest barriers to getting local food to institutions. Most of those institutions don’t

have the processing capabilities. Not necessarily capabilities but time, money to pay

their staff, they don’t have, you know to cut a squash is a lot of work.”

THEME 5. Components needed to support local producers:

Several important components across the social levels of community were perceived as

integral to direct relationships between producers and institutions. Many of these

components, however, were perceived as either lacking or insufficient. Participants felt that

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producer-institution relationships would be more productive if these particular

components could be fostered and supported.

Sub-theme. Networking and communication between producers and

institutions: Joint problem solving: Participants addressed interpersonal

communication as an essential component to overcoming challenges faced by both

producers and institutions. Participants perceived substantial opportunity, possibility, and

feasibility in creating productive and successful producer-institution relationships if such a

dialogue took place. There is a strong interest among local producers to supply products at

a larger, institutional scale and they are therefore receptive to resolving any current

challenges. With such receptivity, equal support and interest from institutions was seen as

vital to engaging in productive problem solving conversations. Some participants also

recognized the importance of dialogue in order to overcome any misconceptions or

assumptions that may inadvertently be hindering fully productive relationships.

 “If Dave from the Coop were to sit with people from Safeway and it might take three

meetings before they get a contract and blah, blah, blah, but I think it totally can be

done. I think somebody would need to put the time and effort into it and really the only

entity that could do it would be the Coop. They’re not going to want to deal with one

farmer. And I think that they could do the same thing with an institution.”

 “And there are, we’re willing to do anything we can to work with these groups because

we see the value in it. And it’s kind of like a whole new world, really compared to

selling to grocery stores and stuff like that. To get people eating well and locally

sourced foods on that level is, would just be phenomenal. That’s kind of the Everest, the

one place where you don’t find people supporting local food.”

 “I think it was interesting because for a long time we were looking at how much the

price of a pound was for something and you know, we’re finding out that for schools, it

isn’t necessarily priced per pound but it’s priced per serving per student and how much

they typically spend for like a protein serving vs. a vegetable or fruit serving.”

Sub-theme. Reorganization of infrastructure for small-scale producers: As

discussed earlier, economy of scale was identified as a challenge for small-scale producers

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in competing against commodity food production and prices. Arising from the challenges

associated with economy of scale, participants addressed a need for reorganizing the

available infrastructure. Some participants suggested the general infrastructure for

processing and distributing was already established. However, reorganizing the processes

into a more cohesive and structured system could facilitate greater efficiency and capacity

for small-scale, local producers to compete against the conventional food system model. An

example of this restructuring was to facilitate greater coordination among producers as a

community, so that the needs of larger institutions could be more efficiently met. While

capacity may already be present, increased communication and coordination could allow

producers to more effectively manage their production and distribution.

 “It would take a group of farmers and organize so that, you know, “you do cauliflower

this week” and get everybody lined up in succession. But we’re not there.”

 “You can make, I mean if you had something around where you could process it, sell all

the side shoots and send it up to the Mission Mountain or something and they could

freeze it for schools so you can make more – you have to make more on that plant than

just that one single head. You can’t.”

 “I guess what I’m trying to say is if we’re able to be really well organized as a

community of growers, we can definitely fulfill the need for the food.”

 “I think what needs to happen – in this case, most of the infrastructure is there right

now to grow the food and process the food and deliver the food. It’s just a matter of

making that all flow in a way that is functional for everyone. That is difficult.”

Sub-theme. Menus, food preparation, and eating based on seasonality:

Another challenge previously described pertained to Montana’s short growing season and

the lack of consistency that comes along with this in the products that are available to

purchase and use. In response to this challenge, participants identified a cultural shift in

eating habits and food preparation as a significant solution to facilitating relationships

between producers and institutions. Popularity is growing at the institutional level to

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support the farm-to-table movement and incorporate local foods into food service meals.

However, such interest is difficult to align with the region’s growing season and availability

of products if menus don’t reflect this variability. Therefore, embracing this variability and

shifting eating habits and menu planning to fit within these changing seasons would

facilitate greater consistency in utilizing local foods. Such a shift would thereby further

support consistency in institution-producer relationships as well and further strengthen

Montana’s farm-to-table movement.

 “And others work with that. We understand them and we’ll feature that as such, as a

seasonal type product and we believe in the product and it’s a great product. And they

let their shoppers know or institutions just know that it’s not available all year round.”

 “But I do think that one thing that folks might keep in mind is that seasonal products.

So when you’re planning your menus, planning it around what’s available rather than

what you’re used to. So we can’t get you tomatoes in November or even in early May.

So I think changing the way people think about planning their menus as opposed to

just thinking about something that they want to make and then what they would want

to use. Like, “well ok, this is what we have available so let’s try to plan around that.”

And I think that’s kind of a shift for everybody, not just institutions but even families at

home cooking, trying to do local. It’s like, “ok well, I’m not going to have a tomato in

November.” So that’s been a challenge too.”

 “We need to know our farmer, we need to know our food, we need to eat local and in

season. And that would change everything. That would change the culture, that would

change the environment all for the better.”

Sub-theme. Education: Education advocating the benefits of healthy diets and

conscientious eating was identified as a component that could be strengthened in order to

raise awareness at both an individual and institutional level.

Sub-theme element. Health and social benefits of local, whole foods: Benefits

of local agriculture: Education around the benefits of not only local foods, but whole,

nutritious foods, was addressed as a component that could further strengthen support for

local products. This component reflects previous sentiment that nutrition is not always

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perceived as being emphasized in the current Western health model. Raising awareness

around the role of nutrition in health and well-being for individuals, communities, and the

environment was suggested as potentially supporting greater relationships between local

producers and institutions.

 “And say, “this is great, you’re getting people to eat this green Jell-o and the macaroni

and cheese. But really, that’s not food. It’s calories but it’s not going to make you

better. What you really need to have is fresh fruits and vegetables. And no, not the ones

that come in a can. But the ones that are really fresh."

 “Everything about, almost everything about local food I feel like, is a general positive

thing for a society. Food is fresher, it contributes to the economy, the ecology is better.

You think of whether a chunk of ground is going to be a farm next to a city? If it’s not

going to be a farm it’s going to be a development of some type. And comparing the

biodiversity in a development compared to a farm, I feel like the ecological health – we

gain ecological health by having small scale agriculture right near a city. We eat

better. Our money stays in the local economy. And my favorite, most important thing, is

having these farms on the landscape, reminds us of who we are. It reinforces a sense of

culture that’s specific to this place”

Sub-theme element. Cultural shift towards emphasis on nutrition: Some

participants addressed the need for a cultural shift beyond general education around

nutritious eating. Diet and nutrition was described as a challenging topic to discuss as a

result of potentially very value-laden connections to food. Eating habits can be perceived

as very personal. Therefore, engaging in conversations around the benefits of local food or

of changing an individual’s diet can be received with great hesitation. A larger, cultural

shift towards embracing healthful diets could be very supportive of the farm-to-table

movement and institution-producer relationships.

 “Well you know we have this cultural divide. Food and, because it’s so culturally laden

in values, it’s really hard to have conversations about it that are strictly about

efficiency and dollars and all the rest of it. Unless we’re already on the same values

page. Then we can adequately address things. But unless we’re on the same values

page, the differing values and the different cultures clash so much that you don’t

actually end up having the will. And there may be people who are, I’m imagining it’s

fairly polarized, but there may be people who don’t have a real strong opinion.”

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 “Well we need a cultural shift. We need to eat simply, we need to eat what’s in season,

we need to eat what’s local and we need to not eat grapes from Tierra del Fuego in

January in Missoula, Montana.”

Sub-theme. Expand the market: Conscientious farming and untapped markets:

High levels of competition and a currently saturated market for local products was

identified earlier as a significant barrier for producers to expand their production or

outreach throughout Montana. In reflection of this challenge, food producer participants

identified using strategic production to expand the local food market. Competition

particularly exists around core, cost-effective crops. While some problem solving may be

required to resolve challenges around production or cost, participants recognized that

there are a wide variety of specialty items that could potentially be profitable.

Conscientious production could therefore open additional markets for producers beyond

the food items with a fully saturated supply. Along with conscientious production,

participants also recognized the dynamic that while producers are facing competition and

market saturation, there are untapped markets with significant space for expansion. An

example particularly identified was the untapped market of conventional grocery stores.

Food producers expressed frustration pertaining to this market being extremely difficult to

enter due to corporate policies and food regulations. Participants suggested that targeting

such markets would be a productive “next step” in working to expand business

relationships with institutions.

 “Meanwhile, we’re completely empty at Safeway. You know what I mean? Like we’ve

got ten farmers ready to sell the Coop cabbage so the Coop can sell cabbage to the

Good Food Store. But there’s not a drop of local food at Safeway, at Albertson’s, at Wal-

Mart or at the school district or at the hospitals or at the city jail, county jail.”

 “But the potential for this market [conventional grocery stores] is huge. And we’ve

been successful with some of the larger grocers like the super ones up in the Flathead.

We’ve definitely increased the amount that we sell to them. But the potential there for

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these stores, considering the number of people that they serve, there’s years of growth I

think. And there’s a lot of work that we can do.”

 “But as far as farmers coming in. Yeah, I mean, cause there’s always farmers going out.

Like there’s a big farm leaving production for the Grower’s Coop and that’s a big hole

in corn and cabbage. So yeah, there’s room for growers, especially if they pay attention

to what crops.”

Results Conclusion:

Research questions One and Two of our study aimed to identify ways in which perceptions

and associated individual, institutional and policy based factors create barriers and

opportunities for using more local foods in hospital food services. To do this, knowledge

and perceptions of hospital staff and local producers were explored through in-depth

interviews. Four main themes emerged from the hospital interviews and five main themes

emerged from the food producer interviews. The third research question of our study was

to identify specific knowledge, skills or resources needed to support partnerships between

hospitals and local producers to increase the amount of local foods being used in food

service meals. To address this third question, main themes that emerged from the two

interview sets were integrated and more thoroughly discussed in the following section,

Chapter Five.

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CHAPTER FIVE

Discussion

The purpose of this study was to identify opportunities and challenges for hospitals and

local food producers to work together in bringing more locally-sourced foods into hospital

food service meals. The discussion will first compare the top ranked barriers and enablers,

as identified through hospital and local food producer interviews, with those most

predominantly identified in the established literature. Then, the discussion will integrate

the main themes that emerged from the two sets of interviews. The discussion will

conclude with suggestions to build knowledge, skills and resources to address the most

predominantly identified barriers to direct producer-hospital relationships.

Predominant Benefits and Barriers

Hospital Interviews:

Data collected from this study helped identify factors that enabled, or created barriers, for

hospitals to incorporate local, whole foods into their food service meals. The main enablers

included: Passionate staff; quality of local food; more personal relationships; Health care

institutions are a natural setting to support local; productive food service management;

networking; and supportive community (see Table 4). The main barriers that emerged

from the hospital interviews were: Food quantity/availability; cost; seasonality; restrictive

GPO accounts; lack of processing infrastructure; unsustainable health care model; and

demand. These findings are compared to similar studies below.

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Table 4 Enablers and barriers to hospitals using locally-sourced ingredients

Several studies have been specifically conducted in the hospital setting (Dauner et al.,

2011; Knight and Chopra, 2011; Myslajek, 2011; Sachs, 2011) while other studies have

been conducted in non-hospital institutions like schools and restaurants (Izumi et al., 2010;

Bagdonis et al., 2009; Kloppenburg et al., 2008; Strohbehn and Gregoire, 2003).

Collectively, these studies found challenges similar to those identified by hospital staff in

our study around farm-to-institution efforts. Such similarities are discussed below.

Research conducted in 2011 in St. Luke’s Hospital in Duluth, Minnesota explored the

process of procuring local food items and ways in which the hospital culture facilitated or

hindered the use of locally-sourced foods (Dauner et al.). The hospital’s GPO account and

associated contractual agreements were identified as significant barriers to working with

local producers (Dauner et al., 2011). Specifically, the contract required that 80% of food

products and supplies be purchased through the primary distributor. The investigators

concluded that agreements to purchase significant proportions of product through

approved vendors, along with additional purchasing incentives and rebates, can serve as a

Enablers Barriers

Passiona te s taff Quantity/availabi l i ty

Quality

Cos t

More personal relations hi ps

(with producers)

Sea s ona l i ty

Res tricti ve GPO account

Lack of processing

infrastructure

Hea lth ca re ins ti tutions a re a

natural s etting to a dvocate

nutritious and l ocal di ets

Wes tern health model is

uns ustainable a nd lacks

emphasis on nutrition

Food service mana gement Dema nd

Networki ng

Supportive community

Similar to other studies

Unique to this study

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limiting factor to purchasing directly from local growers or other unapproved vendors

(Dauner et al., 2011; Knight and Chopra, 2011; Myslajek, 2011). Limited flexibility to

purchase local foods and the restrictions of the GPO contract were also strongly identified

by participants in our study and clearly reflected the literature.

Similar to our findings, the St. Luke’s study identified significant challenges to

procuring adequate amounts of local foods for its high demand food service program.

Findings from both our study and that of Dauner and colleagues (2011) also identified

challenges in obtaining the additional resources needed to work with multiple local

vendors, such as time and labor hours necessary for the additional communication and

coordination. Additional resources were associated with coordinating multiple local

vendors compared to the streamlined process of the GPO contract.

Passionate staff, or champion leadership, was identified in our study as one of the

top enablers for local food initiatives to take hold within the hospitals. Although high level

hospital administrators do not necessarily place emphasis on, or mandate, the use of local,

whole foods in food service meals, other hospital staff personally invested in local foods has

contributed to on-site achievements. For example, personal investment by kitchen

management has resulted in procurement of local, grass fed beef by both hospitals.

Intrinsic dedication to the movement was recognized as contributing to the level of

willingness and creativity devoted to problem solving efforts. These findings closely

reflected those of a study comparing farm-to-school programs in one rural and one urban

Pennsylvania school (Bagdonis et al, 2009). Bagdonis and colleagues (2009) identified

civic engagement and champions as critical to the development of the farm-to-school

efforts in the Pennsylvania schools. As described by Bagdonis and colleagues (2009),

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“Such champions may bring to the table personal passions and commitments,

or prior organizational agendas. The histories and motivations of

‘champions’ inform their perceptions about the importance and possibilities

of FTS [farm-to-school]… Therefore, not only differences across community

contexts, but differences between local champions may shape the emergence

and character of FTS programs.”

Beyond kitchen management, our study and others (Dauner et al., 2011; Sachs, 2011; Izumi

et al., 2010) have recognized that champion leaders within the institutional workplace can

also help increase support for local, whole foods among coworkers and hospital visitors.

In agreement with other studies (Kang, 2012; Izumi et al., 2010; Kloppenburg et al.,

2008; Strohbehn and Gregoire, 2002), our study found main challenges to using local foods

in the hospitals to include seasonality, quality, local and state regulations, and a lack of

processing infrastructure. Identified barriers more unique to our study in comparison to

other studies included demand and an unsustainable health care model. Our study

reported that the main benefits of using local foods in hospitals included support of the

local economy and community, better quality of food, positive working relationships, and

flexible business contracts. All of these findings agree with other studies that have

identified freshness and taste, relationships with local farmers, flexibility of the

relationships, and support of the local economy as benefits to using local foods in

institutions (Knight and Chopra, 2011; Gregoire and Strohbehn, 2002).

Unique Themes and Sub-Themes of Hospital Interviews: Many of the study’s major

themes are similar to others exploring opportunities and challenges for hospitals to source

and use local foods. These include food quality, more personal relationships, cost,

seasonality, restrictive GPO accounts, and lack of processing infrastructure (see Table 4)

However, several of the predominant themes for opportunities and challenges for hospitals

to source and use local foods are unique to this study. These unique themes include: Health

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care institutions are a natural setting to support local; productive food service

management; networking; and supportive community (see Table 4). The findings unique

to this study will be discussed below.

Food Service Management: Variation in food service management stems from the

particular source of funding, infrastructure of management and the type of GPO account

that the hospital has been signed to. For example, flexibility in external spending results

from the particular stipulations of the GPO account in which some contracts require 80% of

spending to occur within the company, while others require only 60%. Although the two

hospitals participating in this study have different GPO contracts, they both hire on the

food service management company, Thomas Cuisine, to manage their food service

programs. Despite the differences in allotted external spending, core values of the

company revolve around a commitment to supporting local farmers and products and

results in significant efforts to source any potential ingredients from local producers.

Commitment from a management level was identified as further facilitating champion

leaders within the hospitals to procuring and using local foods in the food service meals,

and therefore was considered an enabler to the institutions.

Supportive Community: The capacity to engage in local food efforts at an

institutional level was closely connected to place. A natural relationship exists between a

thriving agricultural landscape and a deeper, cultural connection to local and whole foods.

A broader community-wide connection and support of local products greatly increases

capacity and opportunity to extend these values into the institutional setting. Missoula,

Montana was perceived as a community deeply tied to agriculture and thereby associated

with greater ability to incorporate local products in food service meals.

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Networking: Our study identified various challenges to expanding the farm-to-

table movement to a larger, institutional level. Group information sharing and problem

solving was a significant enabler that emerged from this study to help overcome some of

these challenges. Networking can take place in a variety of capacities. Partnerships among

hospitals, health care conferences and workshops bringing together food producers and

businesses were all identified as incredibly beneficial to the learning process. Such

partnerships and educational conferences were viewed as outlets to compare and contrast

experiences of producers and institutions trying to engage in direct relationships.

Furthermore, facilitating organized information sharing events also allows for joint

problem solving and collaborative learning.

Health Care Institutions are a Natural Setting to Support Local: Hospitals are

analogous with wellness and health education. Such an environment is ideal for advocating

nutritious dietary habits, food as preventative medicine, and purchasing local as a way to

support environmental and community health. For example, the hospital interviews

described the health care setting as a place in which patients may expect to discuss

appropriate dietary habits as part of a type II diabetes diagnosis. Such a discussion can

offer a natural opportunity to promote awareness around the source and quality of the

foods a patient may consume. Although some patient diets may not be conducive to local

foods while in the hospital (such as liquid or no fiber diets), patients and visitors entering

the hospital may at least be more receptive to dialogue and programs advocating the

consumption of local and whole foods outside of the hospital setting.

Demand: Customer demand for locally-sourced foods was identified as a significant

barrier to hospitals trying to purchase local foods. Purchasing and using more local foods

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results in changes across the scope of kitchen management, from food preparation to meal

presentation. For example, grass-finished beef tastes differently than corn-fed beef.

Participants identified that this difference in taste was sometimes received with

dissatisfaction by customers. Customers that were not as aware of the reasons and benefits

of supporting healthy, local food products were less willing to adjust to these differences in

taste. A lack of customer support for locally-sourced foods was even associated with

decreased beef purchases in the cafeteria. Without support of the local food movement,

removing fried food items and other unhealthier “comfort foods” from the menu has

resulted in frustrated and unhappy customers. The challenge lies in that food service

programs often aim to make a profit. While kitchen management may work to offer

healthier, local food options, success of the program ultimately relies on sales and customer

demands.

Western Health Model Doesn’t Emphasize Nutrition or Preventative Medicine:

The Western health model drives the primary health care model in the United States.

Health behavior counseling, illness diagnosis and treatment are most commonly driven by

this model and direct the health care system within hospitals. For example, participants

perceived appointments with physicians to be rushed, on a restricted timeframe and based

on prescriptions for medications rather than preventative health modalities. Hospitals

were identified as an opportune environment to advocate for whole food and local-based

diets. However, a common perception was that this predominant health model doesn’t

emphasize the role of nutrition in health or in preventative health care. Without nutrition

as a key element, conversations around consuming whole foods and locally-sourced

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products may not be included in a patient’s care plan. Prescriptions may be discussed and

offered more commonly than discussing nutrition as preventative medicine.

Producer Interviews:

The primary aim of this study was to identify current perceptions around

opportunities and challenges for health care institutions to use locally-sourced ingredients

in food service meals. To create a more holistic situational assessment of various factors

that either enable or hinder the use of local foods in hospitals, the researcher also

interviewed local producers and distributors. Their perspectives were explored at a more

general scale of establishing and maintaining direct business relationships with

institutions. This set of data identified predominant factors either creating opportunities

or creating challenges for food producers to sell products directly to institutions. The main

enablers that emerged from this set of interviews included: “Local” as a marketing tool;

aggregated food systems; champion leaders; capacity to meet demand; processing facilities;

and community support (see Table 5). The most significant barriers that emerged from

this set of interviews included: Economy of scale; lack of consistency in demand; cost;

processing; food safety regulations; convenience of large distributors; and reaching market

saturation (See Table 5). Similarities and differences in findings from this study compared

to the established literature are discussed below.

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Table 5 Enablers and barriers to local food producers selling products to institutions

The ability to meet quantity demand and offer competitive prices, seasonality, and lack of a

dependable market are often cited in the literature as some of the most significant barriers

for producers, and was closely reflected in the findings of our study (Worley and Strobbe,

2012; Izumi et al., 2010; Gregoire et al., 2005). Similar to a study conducted by Knight and

colleagues (2011), our study identified barriers for producers to sell directly to institutions

to include economy of scale, convenience of large distributors, local and state regulations,

lack of processing infrastructure, and overall demand for local food. Also similar to other

studies, (Worley and Strobbe, 2012; Knight and Chopra, 2011; Gregoire et al., 2005), our

findings identified some benefits of direct producer-institution relationships to include:

Fresh, high quality products; support of the local economy; positive partnerships with

buyers; and the perception that “local” is a current marketing buzzword that customers of

restaurants and other institutions appreciate and support.

Enablers Barriers

"Local" as a marketing tool Economy of scale

Aggregated food system

Lack of cons i s tency in

dema nd a nd commi tment

from i ns titutions

Cos t

Processing

Local, s ta te and federal food

safety regulations

Large di s tributor is more

convenient

Passiona te l eaders i n

ins tituti ons

Rea chi ng ma rket sa turation

Capa city to meet demand

Processing facil i ti es

Community support

Similar to other studies

Unique to this study

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Worley and colleagues conducted a study in 2012 assessing new and seasoned Iowa

farmers. The farmers participated in interviews and completed a survey ranking potential

barriers to selling wholesale and at the institutional level. In agreement with this study

(Worley and Strobbe, 2012), findings of our study showed that meeting quantity demands

and offering competitive prices were challenging for local farmers. Our findings reflected

those of Worley and Strobbe (2012) by identifying the lack of infrastructure as a challenge

to producers for processing and distributing their products to institutions. Our findings

further reflect those of the Iowa study in that a wide variety of perceived challenges for

food producers to sell products directly to institutions were identified, including cost,

convenience of large distributors and lack of processing infrastructure.

Enablers of the direct producer-hospital relationship also emerged from our study

that reflects findings of other studies. For example, in agreement with Worley and

colleagues (2012), our study identified high quality products, the ability to locate new

buyers, and positive relationships with buyers as enablers to strengthening relationships

between producers and institutions. Another enabler that our study identified in

agreement with others (Izumi et al., 2010; Gregoire et al., 2005) was the use of the

aggregated food system. This model creates markets for direct relationships between

producers and institutional food service management that may not otherwise take place.

The aggregated food system merges the efforts of individual producers to pool greater

quantities and varieties of products. This combined pool more easily meets the needs of

larger institutional meal services by providing a streamlined business relationship similar

to larger distributors.

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Unique Themes and Sub-Themes: Major themes of this study agree with other

similar studies exploring opportunities and challenges for local food producers to work

directly with institutional food service managers. Similar findings include: “Local” as a

marketing tool; aggregated food systems; economy of scale; lack of consistency in demand

and commitment from institutions; cost; processing; food safety regulations; and

convenience of large distributors (see Table 5). The findings unique to this study are

briefly described below and include: Capacity to meet demand; processing facilities;

community support; passionate leaders in institutions; and reaching market saturation.

Capacity to Meet Demand: A common concern voiced in this study showed there

is limited capacity for the local food market to meet the large quantity demands of

institutional food services. These programs often serve thousands of meals each day and

therefore have significant quantity demands. Rather than being identified as a barrier,

capacity was identified as a strong enabler of expanding the local food system. Capacity to

meet growing quantity demands was perceived as a manageable challenge. More

significantly, an enthusiasm and willingness to engage in collaborative problem solving

with institutions was expressed so that quantity and variety needs may be met. The

sentiment of “if there’s a will, there’s a way,” drove perceptions around capacity, suggesting

that if institutional buyers are invested in buying local, producers are invested in problem

solving to meet their needs.

Processing Facilities: Montana processing facilities were identified as a significant

enabler of working with institutions. These facilities were perceived as creating new

markets for direct producer-institution relationships. For example, large contracted

distributors offer institutions the convenience of food products that are pre-packaged and

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processed. This reduces the amount of resources required to prepare and present menu

items. As opposed to the streamlined, convenient service of large distributors, local, small-

scale producers often lack the necessary infrastructure to offer these same services. The

establishment of the processing facility, Mission Mountain Food Enterprise, was perceived

as creating an opportunity for local producers to offer more competitive services in

relation to large-scale distributors.

Community Support: Capacity for local producers to directly engage with

institutions was closely associated with location. Montana’s strong agricultural landscape

was perceived as fostering community-wide support for local products and foods. This

sense of support and pride for local products at the community and individual levels

thereby increases the capacity and opportunity to extend these values into working

producer-institution relationships. Community-based enthusiasm for local foods was

perceived as fostering support at the institutional level and encouraging producer-hospital

relationships to be established.

Passionate leaders in the institutions: Passionate, champion leaders within the

institutional setting were identified as a significant enabler of producer-institution

relationships. Working with multiple, local vendors often results in increased time and

effort to procure local foods. Intrinsic enthusiasm and passion for using local foods was

identified as supporting institutions in overcoming potential challenges associated with

moving away from the streamlined convenience of a large distributor. For example, food

procurement staff who are enthusiastic about supporting local producers were perceived

as being more receptive and willing to accommodate more frequent deliveries and

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coordinate with multiple vendors, as such tasks are often associated with using more

locally-sourced foods.

Market Saturation: Market saturation was identified as a significant barrier to

expanding or strengthening the local food system. With collaborative problem solving,

capacity to supply institutions and meet their large quantity demands was perceived as a

resolvable challenge. Despite this potential capacity, market saturation was identified as

limiting current potential for growth. “Low hanging fruits” of the local food market, such as

natural grocery stores and restaurants committed to using local foods, have already

established working relationships with producers to fill their needs for local products.

Supply of local products now outweighs demand of local products since invested

individuals and institutions are already engaged in the farm-to-table movement. In other

words, Montana is a strongly agriculturally-based state. Being that the “low hanging fruits”

have already been picked, there are currently more local food producers and supply,

compared to the demand for such products within the state. This market saturation is

therefore creating a challenging and competitive environment for new producers entering

the market, and is perceived as hindering the ability of producers to expand their

businesses.

Integration of Interview Sets

Main themes from the two interview sets were first explored separately, either in the

context of hospitals using locally-sourced foods or in the context of local producers

working directly with institutional food services. The two interview sets were then

integrated to address research question three:

What knowledge, skills, and resources are needed by hospitals and food producers

to increase the amounts of locally-sourced food ingredients in food service meals?

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From this data integration, identified barriers (by both interview groups) were found to fit

within three main groups. These core “grouped” barriers were: 1) Buying commitment, 2)

Cost, and 3) Lack of availability. These data are discussed below and explore the particular

elements contributing to the group barrier. Following discussion of each group, the

researcher suggests various knowledge, skills and/or resources that could be used, or

implemented, to overcome core barriers to using local foods in hospital food services.

Buying Commitment:

In the context of local producers working directly with institutions, a lack of

consistency in buying commitment was identified as a significant impediment to building

and expanding Montana’s farm-to-institution efforts. For example, without a solid buying

commitment, producers are hesitant to commit resources such as time and growing space

to supply food to hospitals or other large institutions. Small-scale food producers are not

often in a position to take a significant level of risk, as unsold products equates to wasted

time, labor, space, and money. Wasted resources can be detrimental to the stability of a

small business, as financial backing is much more limited compared to large-scale

distributors and food corporations. Therefore, without solid buying commitment from a

hospital or other institution, working directly with businesses with larger food demands is

much less feasible.

Year-round product availability and consistency contributes to greater efficiency in

menu planning. As a result, meals can be served on a regular and planned rotation.

Availability of local foods, however, is naturally connected to the seasonality associated

with agricultural growing cycles. A short growing season results in inconsistent food

availability and therefore, frequent adjustments to meal service menus. Inconsistent

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product availability and limited resources for meal planning and preparation may be

contributing to inconsistent demand and purchasing interest of institutional food services.

Additional processing and preparation time is often associated with using local

products and was identified in our study as a barrier and reflects finding of other similar

studies. The need for additional resources can be attributed to frequent changes in product

availability and the time necessary to plan new menus based on the particular season and

available foods. One benefit of working with a larger distribution company is that food

items are often pre-packaged or already processed (carrots are sliced, artichoke hearts are

trimmed and cleaned, etc.). Receiving food products that are already prepared for use

simplifies the food preparation process and helps conserve time and labor hours.

A lack of communication and commitment from an institutional buyer can result in a

compromising situation for the producer. For instance, a producer that grows lemon

cucumber in anticipation of supplying an institution may find themselves with an acre of

the product when the food service menu suddenly changes and the cucumbers are no

longer needed. Sudden changes in menu planning and desired products can often be

associated with a change in staff or management. Local producers identified this

discontinuous communication as challenging. Farm planning, organizing and seed planting

need to occur early in the spring. Therefore, farmers need to know what the product

demand will be from institutions early on in the year. High staff turnover was perceived as

contributing to such miscommunications and unused products. Turnover was also

perceived as requiring extensive time and energy to reestablish a working relationship and

mutual understanding. High turnover often connotes changes in menu planning and

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needed products, and may therefore contribute to a lack of consistency in buying

commitment.

Group purchasing contracts were identified as a barrier to using local foods in the

hospital food service meals. In exchange for the convenience of a streamlined ordering and

delivery process, as well as discounted prices, contracts require varying levels of

commitment and in-house purchasing. The restrictions set by the GPO contract can impact

the amount of flexibility that the food service management has in sourcing local food

products and can restrict potential growth of farm-to-hospital relationships. Such

purchasing limitations may thereby contribute to a lack of solid buying commitment with

local producers and may be impeding on efforts to increase the amount of locally-sourced

products being used in the hospital setting.

Suggested knowledge, skills, and resources to improve buying commitment:

1. Western Montana Growers Cooperative (WMGC): As discussed earlier, the WMGC was

identified as a resource that creates market opportunities for direct food producer-hospital

relationships. Capacity building aims to address gaps in a community’s capacity while building

on existing strengths already embedded in the community. The aggregated food system is

currently in place and is considered a strength of the state’s farm-to-institution movement.

Therefore, the WMGC can be considered a strength in community capacity in the context of

increasing the amount of locally-sourced products being used in the hospitals.

Strengths of the aggregated food model include streamlined communication for

institution food service management, as well as combined production to offer greater quantities

and varieties of local products. Formation of more personal relationships, along with flexible

delivery schedules have also been identified as benefits of this system. Such perceived benefits

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of partnering with the WMGC can serve as capacity building for direct producer-hospital

relationships, as such benefits more effectively compete with the services and convenience

offered by large distributors. Given this example, a capacity building strategy based on this

resource could be to more fully develop the aggregated food model to improve capacity,

particularly in the eastern region of the state. Strengthening capacity to compete with the

services of a large distributor on a state-wide scale may more effectively support institutional

food services and thereby improve institutional buying commitment.

2. Education, Training, and Networking for Hospital Food Management and Staff: Champion

leadership within kitchen management and related outcomes uniquely emerged from this study.

For example, in contrast to the other general hospital responses, seasonality was identified by

kitchen management as an opportunity. Other staff members and the established literature

strongly identified seasonality and inconsistent product availability as a significant barrier to

using local products in food service meals. While saturation was reached among the group as a

whole, participants most directly involved in food procurement and preparation processes viewed

seasonality as a creative challenge and opportunity, rather than a barrier. Champion leaders

within food management may therefore be considered a significant institutional strength and can

be developed as a capacity building strategy. Such creativity and enthusiasm for using and

preparing local products should be fostered among kitchen staff. Education and training

workshops for kitchen staff may serve as a feasible strategy in promoting group-wide enthusiasm

and support for menus adaptable to changing product availability, as well as the processing that

can be required to prepare local products.

Enthusiasm and knowledge of hospital kitchen management is an institutional strength

that can be fostered to support the participation of other, less experienced institutions in engaging

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in the local food system. Creating networking opportunities to connect institutional chefs is one

potential strategy to support problem solving and facilitation of greater use of local foods in

hospital food service meals. Chef-to-chef collaborations in which institutional chefs can engage

in dialogue to share information and problem solve may support institutional kitchens.

Information on how to more effectively balance the cost of local food ingredients with those of

large distributors, successful partnerships between institutions and local producers, and tips for

food preparation can all contribute to more successful integration of local foods into hospital

food service meals. Although GPO contracts can restrict flexibility in working with local or

other external food vendors, such collaborations may also support institutions in identifying

creative ways to most effectively utilize the contracted 10 or 15% purchasing power allotted for

external products, thereby sourcing as much local foods as possible.

3. Coordinated Producer-Hospital Communication: Enduring work relationships and

partnerships between producers and champion leaders throughout the region are significant

strengths to the farm-to-hospital movement. Solid relationships can serve to strengthen

institutional buying commitment, thereby supporting producer capacity to meet growing demand.

Established relationships can be used to promote greater communication and coordination

between institutional and producer partners before the growing season begins each year.

Producers can plan for crop management if they know what products food service management

desires. Early communication promotes greater institutional satisfaction for available products

and promotes guaranteed return for the producers. Therefore, a capacity building strategy is to

develop formal communication processes between producers and partner institutions before the

growing season. Early coordination can ensure that local producers can meet hospital food

service needs and in turn, support institutional buying commitment of local food products.

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Champion leaders and established working relationships are perceived as community

strengths and can be used to build capacity for producer-hospital relationships. Based on these

strong working relationships and shared interest of strengthening the local food system, a

capacity building strategy is to develop binding partnership contracts. Formal contracts can

ensure more solid buying commitments. Such contracts promote a degree of consistency in

purchasing and in turn encourage greater commitment and resource allocation from producers to

meet growing needs of institutional markets. Binding contracts integrates a more formal

business component to the producer-hospital relationship, but may promote greater consistency

and security for both partners and strengthen the overall working relationship.

Perception that Local is More Expensive:

High prices of local foods were identified as a significant barrier to building capacity

for Montana’s farm-to-institution efforts. Our study revealed that more than addressing

particular challenges associated with working with an institution, a broader, systemic

challenge impacts the ability to expand the farm-to-institution system. Commodity food

prices were perceived as inaccurately reflecting actual costs of food. Without accounting

for production and transportation costs, commodity foods prices appear incredibly

competitive and affordable. This inaccurate portrayal of food costs was identified as a

significant barrier to local producers trying to enter the institutional market. Small-scale

producers with limited resources necessarily charge customers prices that accurately

reflect input costs required for production. Consequently, prices of local foods are

generally perceived as being significantly more expensive than foods sourced from large,

corporatized distributors. As institutions often have limited resources, such a discrepancy

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in price can make competing with these commodity products extremely challenging for

local producers.

Economy of scale was identified as a considerable challenge to expanding farm-to-

institution efforts. Economy of scale describes the manner in which the marginal cost of

producing a particular product falls as larger quantities are made (Hamel, n.d.). Large-scale

operations enable the use of techniques to increase productivity and further reduce

manufacturing costs. Therefore, small, local businesses may struggle to compete with large

companies able to mass produce products at a significantly lower price (Hamel, n.d.). The

principles of economies of scale are reflected in interview data in which local products are more

expensive than food items offered by large-scale distributors. Local producers may struggle to

compete against large-scale distributors and hospitals may in turn struggle to afford such

differences in price margin necessary to support local food systems.

As previously discussed, processing of local foods has been identified as a barrier to both

producers and hospital food services in trying to establish and maintain a working relationship.

Hospital food services may lack the infrastructure necessary to process local foods into

components that can be used in menu options. Thus, the convenience and services of a large

distributor is often appealing and more feasible than use of local foods that are not yet processed.

Due to economy of scale, small producers often lack feasible options to process their own

products in order to compete with services of large distributors. Processing capabilities are

therefore often inaccessible or challenging to both producers and institutions, hindering any

ability to increase the amounts of local foods being used in the hospital setting.

Limited demand and affordability by customers were also identified as barriers to

hospitals in procuring and selling local food items. Differences in local and commodity food

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prices were identified as a barrier for hospitals in selling food items with locally-sourced

ingredients. A recognized concern of hospitals was to limit any potential cost burden that

customers may endure as a result of ingredients that are more expensive. Demand for local

products was also identified as a barrier to using more local foods in hospital meals. Local

produce and other food products can be unfamiliar to hospital visitors. Additionally,

shifting menu options to incorporate these different products can result in the elimination

of other previously offered items. The removal of “comfort foods,” such as fried items,

coupled with the introduction of unfamiliar foods can result in significant change in

available meal options. A lack of enthusiasm for local products and receptiveness to these

efforts and higher prices were perceived as creating dissatisfaction and frustration among

customers, and was identified as sometimes negatively impacting the level of food item

sales. Participants of our study perceived that a choice to procure and use local foods may

be for a variety of reasons, but it most likely won’t be due to local being more cost effective.

Demand and affordability of local foods are therefore important for successfully increasing

the use of local foods in hospital food services. Furthermore, a lack of commitment to local

products will likely hinder the ability to work through the challenge of higher prices and

may impede on using local foods at an institutional level.

Suggested knowledge, skill and resources to address high, local food prices:

1. Education and Wellness Programs for Staff and Administration: Demand and lack of

support for local products among hospital food service customers was identified as a

barrier to using more local foods. Without staff and customer support, transitioning away

from traditional foods such as fried items, and shifting to more local, whole food items will

likely be met with more opposition or hesitation. Since a lack of support can hinder

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receptiveness to foods that are different or perhaps slightly more expensive, advocacy

efforts have been taking place within the two health care facilities. Such advocacy includes

education through food item descriptions, recognition of local products, informational table

tents on the benefits of supporting and consuming local, and staff wellness programs.

Participants identified the health care setting as an enabler in advocating for local food

products, as such a setting is naturally associated with health education. Current

educational efforts and the inherent environment of the hospital setting can therefore be

recognized as institutional strengths in working to develop further community support for

purchasing and consuming locally-sourced food items.

Using inherent institutional strengths to expand staff-based wellness programs can

build capacity for using locally sourced foods in hospital food service programs.

Developing staff programs emphasizing preventative health and nutrition as preventative

medicine may foster greater institutional knowledge of local food consumption and

support capacity to address cost as a barrier. Such prevention based staff programs may

help promote a healthy workforce and thereby model healthful choices for patients. Study

participants identified concepts of such programs as being explored and developed within

their workplace. For example, staff CSA programs are perceived as one way to significantly

increase nutritional awareness and behaviors among staff and may be a beneficial

component of a wellness program. Local and regional programs such as the Western

Montana Grower’s Cooperative have established CSA programs and therefore potential

feasibility and accessibility to such a program already exists. Additionally, education and

workshops for hospital staff at the administration level may help foster support at a higher,

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managerial level. Support at a higher level in a hierarchical organization may help to more

broadly influence farm-to-institution efforts among hospital staff.

2. Processing Facilities: The Mission Mountain Food Enterprise Center (MMFEC), a

processing facility in north western Montana, has created accessibility for small-scale food

producers to more feasibly process particular products. In creating opportunity for

producers to process some of their products, access to the institutional market has

expanded and has supported the farm-to-institution system. This processing facility has

further expanded opportunities for producer-hospital relationships by providing the ability

to use seconds (products otherwise wasted) and to prepare and freeze products, allowing

for year-round sales of produce. Infrastructure supporting the processing of local foods

enables local producers to more comparatively compete with the convenience of large

distributors offering less expensive, pre-prepared commodity foods. Therefore, MMFEC is

strongly viewed as a strength by both producers and hospitals in supporting the use of

local foods in institutional food service programs.

A capacity building strategy might be expanding Mission Mountain Food Enterprise

Center. Strengthening partnerships between MMFEC and institutions, as well as with

producers, may help facilitate institutional procurement and use of local foods. For

example, MMFEC has recently partnered with the WMGC and together have focused on

bringing processed, local food items into some of Montana’s public schools. This

relationship has supported WMGC members by expanding the potential institutional

markets for their products. Hospital interview participants identified an interest in

becoming more familiar with the particular services of MMFEC in order to make better use

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of the processing facility and further facilitate the use of local products in the institutional

setting.

3. Assessment of Montana’s Processing Infrastructure: Processing local foods was

identified as a challenge by food producers and hospitals to working directly with one

another. Two possible solutions to this challenge might exist. One, more processing

facilities like MMFEC should be established throughout Montana for local producers to

utilize before selling products to institutions. Two, processing infrastructure should be

developed at the institutional level so that kitchen management at each institution has the

ability to more efficiently process procured local food products on site. Therefore, another

capacity building strategy addressing processing of local food products may be

implementing a state-wide strategic planning process that assesses Montana’s overall

processing infrastructure. A formal assessment could provide baseline data on the food

processing infrastructure and capacity of the state’s institutions, such as schools, hospitals,

and restaurants. This assessment could provide insight as to whether a focus should be

placed more on increasing infrastructure capacity (particularly processing) for producers

or for institutional food services. Capacity building strategies addressing resources may

also occur across the socio-ecological spectrum of community, from individual skill

development in local food preparation to infrastructural change at an institutional level. A

strategic planning process at an organizational level may allow for infrastructural change

within the hospital setting. It may further allow for a redistribution of time and

management to more effectively address the procurement and preparation of locally-

sourced foods. Identifying gaps within both hospital and producer capacity may provide a

more holistic assessment and approach to supporting greater competition between locally-

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sourced foods and the prices and convenience that are associated with commodity food

distributors.

Perceived Lack of Availability:

A perceived lack of availability in local products was identified by hospitals as a

barrier to increasing the amounts of local foods being used. However, our study found

dissonance between the two sets of interviews on perceptions of availability. For example,

hospital participants generally expressed concern around quantity and the ability of local

producers to fill food service needs. Producer participants, however, responded to this

concern in the context of market saturation rather than limited quantity. Market saturation

was referenced in the context that both individuals and institutions committed to using

local products have already accomplished this goal and have already established outlets for

procuring local foods. Farmers’ markets, natural food stores, and local-oriented

restaurants were identified as already engaging in the local food movement. Therefore,

untapped markets, such as conventional grocery stores and other institutions are more

challenging to enter and establish direct working relationships with.

Market saturation poses a challenging dilemma for producers trying to establish

direct working relationships with institutions. At this point, the needs of supportive

markets (individuals and local-oriented restaurants), or “low hanging fruits,” are being

sufficiently satisfied and met by local producers. The dilemma now arises that Montana’s

local food production is beyond the scope of interest for these products. For example,

participants identified farmers’ markets as an outlet for local products that demonstrates

market saturation. The number of small, local producers is so abundant that competition

for business is increasing and farmers’ markets are becoming a less profitable option.

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Product availability was therefore perceived as being limited by demand rather than

production capacity. A dilemma therefore arises in which producers aren’t able to expand

their level of production until demand increases. Yet conversely, institutional demand and

use of local foods can’t increase until levels of production expand.

Suggested knowledge, skills and resources to address lack of product availability:

1. Collaborative Problem Solving: Dissonance between interview groups suggests that

opportunities exist for capacity building and support of direct producer-hospital

relationships. Production of local products and food ingredients was identified as both a

local and regional strength by participants. Therefore, local production can be considered a

community strength and can be utilized in addressing some of the challenges associated

with using more local foods at an institutional level. Market saturation strongly emerged as

a barrier to the growth of local producers. However, a theme that was expressed just as

strongly was a willingness and readiness to engage with institutions in addressing

challenges so that greater quantities of products may be supplied. Challenges to direct

producer-institution relationships are inevitable and therefore mutual dedication is

necessary in finding solutions. Food producer study participants generally identified

themselves as being receptive to beginning this process and felt the saying, “if there’s a will,

there’s a way,” reflected community sentiment. Along with this, modes of networking, such

as medical conferences and hospital partnerships were identified as beneficial to

developing institutional capacity to procure and use local foods.

A capacity building strategy may therefore be networking aimed at identifying and

overcoming general misconceptions that local producers and institutions may have about

one another. Creating more structured opportunities for conversations to take place in

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which institutions and local producers are at the same table may be productive in working

to break down some of the main misconceptions and engage in joint problem solving. A

collaborative process may be supportive of a holistic, strategic assessment, creating

opportunity for more productive use of time and resources by both food producers and

institutions. Collaborative problem solving ensures that all invested stakeholders are at

the table. Therefore, through joint ownership of the process and outcomes, more durable

solutions can be generated and implemented in order to increase the amounts of local food

being used in the hospitals (McKinney, 2010). Such a process will facilitate identification

and resolution of misconceptions and challenges currently taking place between local food

producers and institutional food services, and support forward momentum of mutually

beneficial and successful producer-hospital relationships.

CONCLUSIONS

Limitations:

One limitation to this study was that collected information was limited and

specific to the experiences of the individuals who participated in the interview process.

Along with this, a limited participation rate equates to results that are 1) specific to

Montana and 2) therefore not generalizable. Another limiting factor was that as a result of

data being collected through interviews, participants may have felt compelled to give

socially desirable answers to the interview questions. Finally, rather than full triangulation

of emergent themes during the data analysis process, only two researchers established

coding reliability and agreement.

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Future Work:

This study identified community capacity dimensions relating to opportunities and

challenges for using local foods in hospital food service meals. From this data, the study

aimed to suggest capacity building strategies for addressing these opportunities and

challenges in the context of supporting direct local producer-hospital working

relationships. By exploring the perceptions of both hospital staff and local producers, an

initial situational assessment was developed to describe the strengths and needs of

Montana’s farm-to-hospital system. This assessment could be built upon by exploring the

particular local food initiatives taking place in other institutions. Other hospitals and

schools throughout Montana were identified as role models and successful examples of

farm-to-institution efforts in the state. Closer examination may contribute to greater

understanding of capacity building strategies locally relevant to increasing the amount of

local foods used in institutional food service programs throughout Montana.

Results from this study produced several related themes that would be worthy of

future exploration and discussion. Multiple participants addressed the observation that

while the use of local foods has increased in the health care cafeteria setting, these efforts

haven’t been applied to patient meals. Concern was expressed around this observation in

that patients are logically in need of healing and re-growth. Therefore, nutritious and local

foods should also be incorporated into these meals. This prevalent theme suggests that

future work could explore the particular barriers pertaining to the use of local foods in

patient meals compared to use in the cafeteria, as this seems to be a particular gap in local

food efforts.

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Participants identified untapped markets as a significant opportunity for

strengthening the farm-to-institution system. A particularly prevalent observation was in

regards to the extensive space for market development in conventional grocery stores.

Market saturation was identified as a challenge to expanding business for local producers.

However, participants recognized conventional grocery stores as having significant impact

on developing the farm-to-institution movement, as large quantities of food quickly and

naturally move through these outlets. In discussion around conventional grocery stores,

participants perceived significant barriers to currently be in place, impeding on potential

market entry. Thus, access to conventional grocery stores, and the particular barriers and

capacity associated with this access should be explored in future studies.

Conclusion:

The main purpose of this study was to identify opportunities and barriers for local

producers and hospitals to work together in order to use locally-sourced foods in food

service meals. Through conducting interviews with both hospital staff and local producers,

perceptions and attitudes around working with one another were more carefully explored

and understood. Developing the farm-to-institution system in Montana is an extremely

multi-dimensional and complex task. This study lays the groundwork of more

comprehensive efforts to build capacity and offer insight to particular opportunities and

challenges unique to Montana food and institutional systems. Efforts to connect producers

and hospitals in dialogue may be most significant. Collaborative dialogue to overcome

misconceptions and misinformation and to engage in joint problem solving may serve to

most successfully strengthen Montana’s farm-to-institution system and increase the

amounts of locally-sourced foods being used in hospital food service programs.

Perceptions of local hospitals and food producers on opportunitie

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