This article reports the use of various foodservice systems in hospitals of 300 beds or more and explores the relationship of system choice to hospital, city, and county size. The conventional system, which involves the production of food close to time of service, has been the traditional method of hospital foodservice for centuries. The technology of the 1960s initiated the use of alternative systems, such as cook-chill and cook-freeze. Data from a survey of 807 hospital foodservice directors indicate that the conventional system remains the primary choice for hospital foodservice, although an increasing number of hospitals are converting to the cook-chill system. Choice of foodservice system appears to be dependent on the size of the hospital, city, and county but did not differ by region across the United States. In general, the smaller the hospital, city, and county, the more likely the use of the conventional system. As size increases, so does the occurrence of alternative systems, with cook-chill systems being the primary alternative chosen. Additional information is needed on the comparative costs and cash flows of the various foodservice systems.