Nutrition Care Process
and Change Management:
Making it Happen in
Dietetics!
Nutrition Care Process/Standardized Language Committee
September 2008
© 2006 American Dietetic Association ADA)
This presentation is for you
if…..
1)
2)
You are a nutrition manager
getting ready to implement NCP
at your facility
You are a member of an NCP
implementation team
© 2006 American Dietetic Association ADA)
Change is a challenge but the
rewards are great!
Effective application of Kotter’s 8 step change
management process can enable your team to
successfully implement the Nutrition Care
Process Model and Standardized Language while
minimizing the barriers usually associated with
change.
© 2006 American Dietetic Association ADA)
8 Stage Process of Major Change
(Listed in Chronological Order)
1.
2.
3.
4.
5.
6.
7.
8.
Create sense of urgency
Develop leadership team
Create shared vision and strategy
Communicate vision and strategy
Empower broad action and align organization
Celebrate short term gains
Consolidate short term gains and create opportunity
Institutionalize change
‘ Kotter, Harvard School Press 1996
Leading Change' by John P.
© 2006 American Dietetic Association ADA)
Your Role as Change Agent
1.
2.
3.
4.
5.
6.
7.
8.
Establishing a sense of urgency
Creating the leadership group
Developing a vision and strategy
Communicating the change vision
Empowering broad-based action or aligning the
organization
Generating short-term wins
Consolidating gains and producing more change
Institutionalizing new approaches in the culture
Leading Change' by John P. Kotter, Harvard School Press 1996
Handout with Steps to help you assess your progress
© 2006 American Dietetic Association ADA)
Stage 1: Creating Sense of Urgency

What is relevant to your institution?






Do Students/interns know more than their preceptors about
NCP?
Regulatory agencies are beginning to ask how NCP is
integrated into patient care
Evidenced based care-requirement for clinical practice
Lead the charge verses lagging behind
Recruitment edge for new RDs- how you differ from your
competitors
Need to justify staffing- NCP provides a systematic way to
collect outcome data on impact on nutrition care.
© 2006 American Dietetic Association ADA)
Stage 2: Creating Leadership Team

What has ADA Done?


BOD, HOD and Committees
Your Team (at each institutional this will vary)







Formal leaders (Dept head, CNO, CNM, IT, Medical
records)
Informal leaders
Individuals who are willing to go first and pilot the process
(evaluate individual staff members present learning level and
acceptance level in regard to NCP)
Consider variety of practice experience (veteran + new)
Individuals who are great at reward and recognition
Process people
Everyone needs a role!
© 2006 American Dietetic Association ADA)
Stages 3 & 4: Creating & Communicating
a Shared Vision and Strategy
ADA’s Actions:
 Implementation Strategy: provide resources to
key target audiences first: Educators, CNMs,
practitioners
 Specific Actions





President’s presentations include NCP
ADA Board of Directors updates
DEP & CNM presentations show application
FNCE sessions highlight implementation
Creation of Peer Network of early adaptors
What actions will you take at your facility?
© 2006 American Dietetic Association ADA)
Stages 3 & 4: Creating & Communicating
a Shared Vision and Strategy
Your Actions:
Create your own personal vision to help direct the
change effort
 Develop strategies for achieving that vision
 Be able to articulate the benefits of NCP

Consistency of documentation
 Communication with other disciplines etc.
 Outcomes reporting with potential reimbursement possibilities


Provide key resources at www.eatright.org: NCP
presentations, FAQs, Lacey and Pritchett article , NCP
IDNT reference manual and pocket guide
© 2006 American Dietetic Association ADA)

Stage 5:
Strategy 1: Determining Plan of
Implementation
Establishing a timeline: ADA
 10 years for full implementation in
profession
In Year 4 now
 Education must come first
 Support from Department and Clinical
Managers
© 2006 American Dietetic Association ADA)
Strategy 1: Determining Plan of
Implementation continued

Establishing your own personal timeline
 Varies by institution: ( 2-6 months)
 Assess present learning level and readiness level of
your staff: Education must come first. Teaching
resources available at www.eatright.org
 Make it realistic
 Build in enough time for practice
 Identifying things that can hold up the process: Lead
time necessary for changes in EMR or paper
documentation, significant staffing changes
 Many sample timelines available.
© 2006 American Dietetic Association ADA)
Implementation Plan continued

Assessing impact and barriers
Determining documentation system (paper vs EHR)
 SOAP, Narrative, ADI or ADIME, or other
 Assessing education needs and developing programs
 Frustration, RD’s need to be perfect, it takes longer at
first.
 Prepare and anticipate the hard questions
 If your institution uses a method to calculate RD
productivity- what will be the impact and who needs
to be aware?

© 2006 American Dietetic Association ADA)
Stage 5: Strategy 2-Identifying Performance
Improvement plan/measures

What Has ADA Done?







Charney’s Research (Entry level vs other
experience/expertise levels)
CARLE Research Project – Nutrition Diagnosis in
Ambulatory Medicare population
Pilot Projects – Virginia and VA in San Diego
DPBRN Standardized Language – Four settings
(Ambulatory, Long-Term Care, Outpatient, Renal)
Standardized Language Survey
NC BCBS- Nutrition Dx and Intervention – Ambulatory
overweight population
ADA Dietetics Measure
© 2006 American Dietetic Association ADA)
Identifying Performance
Improvement plan/measures cont…

What Can You Do?
 Staff competency validation
 Productivity measures
 Staff Satisfaction Measures
 Outcome studies: resolution of
specific nutrition diagnosis
© 2006 American Dietetic Association ADA)
Sample Staff Satisfaction Results
(one month post implementation)
Scale: 1=strongly disagree 2 =disagree 3 =somewhat agree 4 =agree 5 =strongly agree
(n = 31 dietitians)
Question
Avg. Score
Feel comfortable & confident in writing PES statements
3.7
PES case study assignment & review was helpful
4.1
Writing PES statements has decreased my productivity
2.4
Find reassessing PES in follow-ups to be problematic
3.2
Resources & guidelines provided are helpful in writing PES
statements
4.6
Resource: 2006 UPMC Presbyterian Shadyside, S. Jones, MS, RD, LDN
© 2006 American Dietetic Association ADA)
Stages 6 & 7: Measuring and
Celebrating Gains

Identifying short term gains





First RD to implement (reward and recognize staff all
throughout- remember, recognition doesn’t have to cost
money, certificates, balloons, buttons, silly prizes etc.)
First floor or unit to implement
First training completed
Support by institution (Department Head, Medical Staff,
Information Systems, Medical Records)
Consolidating gains and creating better opportunities
for future change


Use Performance Improvement principles
Revise guidelines/materials as needed
© 2006 American Dietetic Association ADA)
Stage 8: Institutionalizing Change





Change policies and procedures, standards of
care, and chart audit forms to reflect new
process
Destroy old forms to avoid relapse
Revise orientation program and competency
check off for new employees to include NCP
Revise student/intern curriculum if clinical site
Ensure ongoing monitoring measures continued
progress
© 2006 American Dietetic Association ADA)
Real-Life Pilot Test Results
Initiating Nutrition Diagnosis: Hospital Pilot

NOTE: This pilot project started as a dietetic intern
project – provide an in-service to RD staff on the
Nutrition Care Process

Adapted from Mandy Foust’s work at Virginia
Hospital, Arlington VA (2005)
© 2006 American Dietetic Association ADA)
Pilot Project Description

To improve consistency and quality of care


Implementing Nutrition Care Process
Implementing new documentation format that reflects the
Nutrition Care Process


Consistent communication with other healthcare providers
Use of quality improvement principles


PDSA approach (Plan, Do, Study, Act)
Organizational change, provider education, audit and
feedback
© 2006 American Dietetic Association ADA)
Charting Format:
From ADIME to ADI
Initial Charting Format
 Assessment
 Diagnosis, Nutrition
 Intervention
Subsequent Charting
 Monitoring
 Evaluating
© 2006 American Dietetic Association ADA)
Modified after use to
 Assessment or ReAssessment
 Diagnosis, Nutrition
 Intervention

Include specific plan for
follow-up monitoring and
evaluating
Initiating the Process


Meet with clinical RD team – agree to initiate pilot
Introduce through email and meetings to:
 VP over Nutrition Services
 Chief Nursing Officer or Director of Nursing
 VP of Nursing
 President of Medical Staff
 Nutrition Committee Director
 Director of Education and Research
© 2006 American Dietetic Association ADA)
Training Process – Changing our way of
thinking




Training sessions with individual staff dietitians
Weakest area – PES/diagnostic statement
Practice makes perfect
Weekly meetings with dietitians
 As one RD gears up to pilot, the others bring
practice notes for review to my office
 Focus - Nutrition Diagnostic Statement and
consistency from Assessment through
Intervention
© 2006 American Dietetic Association ADA)
Adapting Evaluation Tool for the Chart
Note
1. Was a nutrition problem/diagnosis identified?
Yes
No
If yes: Evidence for Assessment and Nutrition Diagnosis:
 2. Is there initial documented evidence in the Assessment portion of the note to
support
a nutrition diagnosis?
Yes
No
a related etiology?
Yes
No
 3. Does the PES diagnostic statement show clear relationship among nutrition
diagnosis, etiology, and signs and symptoms?
Yes
No
 4. Is extraneous information included in the note that is not related to the
identified Diagnosis of interest?
Yes
No
Goal
 For a documented patient goal is there a related documented nutrition
diagnosis?
Yes____ No____
 Documented nutrition etiology? Yes____ No____
 Goal not recorded____
© 2006 American Dietetic Association ADA)
Evaluation, Continued
Intervention
 6. For each patient goal is there a related documented plan
for an intervention or actual intervention?
Yes____No____Intervention not recorded____

7. Does Intervention section include summary of actual intervention already
implemented to date? Yes____ No____


Not applicable____(plan included but
not implemented)
8. Does Intervention section include a Plan for Monitoring and Evaluating
progress toward patient goals?
Yes____No____
© 2006 American Dietetic Association ADA)
Evaluation, Continued
Monitoring and Evaluating
Not a follow-up note______ or

9. For follow-up notes, does the Assessment section include a documented
patient outcome as indicated in previous note that is related to a documented
patient goal? Yes____No____Outcome not recorded____

10. Does the follow-up note in the Assessment section include a statement
that identifies the progress toward patient goals.
Yes____No____Progress not recorded____
© 2006 American Dietetic Association ADA)
Steps: Begin Pilot

Pilot begins on date selected

1 RD – Coverage area (for example, ICU,
Neurosurgery, or other specific unit)

All notes to be written in ADI format for initial;
ME for follow-up
© 2006 American Dietetic Association ADA)
Findings from Chart Audits

Outcomes monitoring is an issue with short hospital stays

Desire to use “Potential for” when problem does not exist now–
do not document that.

Temporary situations

Patient with temporary inadequate energy intake RT holding enteral feeds
AEB order to extubate patient
© 2006 American Dietetic Association ADA)
Findings from Chart Audits

Ensure the staff know that opportunities for improvement are expected!!
Some opportunities identified at other facilities included:
 Outcomes monitoring is an issue with short hospital stays
 Desire to use ‘Potential for’ when problem does not exist now, but might
in the future
 Desire to modify or reword nutrition diagnostic terminologyl
 Temporary situations
 Patient with temporary inadequate energy intake RT holding
enteral feeds AEB order to extubate patient
 Questions about how to capture all information provided by patient’s
family, but isn’t pertinent to current problem
© 2006 American Dietetic Association ADA)
Finally!!


Everyone on board – about two months
Many questions remain regarding formatting specifics
 When there is
 Not enough data or evidence for an etiology
 No new labs, data available for outcomes monitoring
 Specifics of documenting outcome monitoring and
evaluation of goals
 Some MD’s expect the RD to evaluate issues that are not
specifically nutrition problems, i.e. blood glucose elevated
due to corticosteroid use (not a nutrition related problem.)
© 2006 American Dietetic Association ADA)
Final Thoughts from Pilot Test





Use of reference book imperative
Start small – practice PES format first
Individual and Group Training
Audit by Manager or Team – helpful!
Through implementation, keep in mind that this
is a learning process…keep our minds open.
Embrace, do not fear, change.
© 2006 American Dietetic Association ADA)
Expect and Discuss Some Common
Questions Up Front

A FEW initial questions and comments from other
sites

“Can I use 2 diagnostic terms?”


What about the “not at risk patient”?


Indicate the reason for assessment and indicate that there is no problem at
the current time
“This is taking much longer than I thought it would!”


Yes if you intend to address both in the intervention, but simpler is better
Acknowledge that this is true…try to accommodate it in workload sharing if
possible. Remember how long it took you to do your very first assessment
and progress note….this will be similar because it is new to you at this point.
“What if there is no current nutrition problem, but I have to follow
due to facility protocols?”

Indicate “no nutrition diagnosis/problem at this time.” Address interventions
based on what potentially may be continued ie) diet order. M&E may consist
of what parameters you will reassess when you return for follow-up.
© 2006 American Dietetic Association ADA)
Anticipate Thoughts and Questions
after First Implementation





Time and Patient Load are issues
Still struggling with linking appropriate ‘E’ and ‘S’ to ‘P’
The urge to make blanket statements for ‘M’ and ‘E’ still
remains: i.e. monitor labs and po
Follow-up notes remain a challenge
Overall the process is becoming more clear and notes are
more focused and concise in format, but the VHC dietitians
still feel there are many unanswered questions.
© 2006 American Dietetic Association ADA)
Many questions remain regarding
formatting specifics




Not enough data or evidence for an etiology
No new labs, data available for outcomes monitoring
How specific do we need to be in outcome monitoring and
evaluation of goals
Some MD’s expect the RD to evaluate certain issues that may
not be specific nutrition problems, i.e. blood glucose elevated
due to steroid medication not a nutrition related problem.
Results in teaching moment with MD, other clinicians
© 2006 American Dietetic Association ADA)
Peer Network for Nutrition
Diagnosis-PNND
(Expanded Pilot)

17 RDs selected to represent ADA Members (2005)




Names posted on ADA Website




Geographic regions
Settings
Areas of practice
Webinars held for training
FNCE sessions each year since 2006
Presentations at State Dietetic Associations + DPGs
Over 100 volunteered

Asked to participate in Nutrition Diagnosis Survey

Survey mailed Jan 2006
© 2006 American Dietetic Association ADA)
Each facility is different





Contractual Management versus “Self-Op”
Teaching Hospital versus Non-Teaching
VA, CARLE, and Virginia Hospital all differed
Assess your facility and its environment/culture
Assess your staff and their readiness level



Learning Levels
Acceptance Levels
Compliance Levels
© 2006 American Dietetic Association ADA)
Select Documentation Format

Modified SOAP format





PES statement at conclusion of A section
ADI format
Narrative with PES statement
Discuss how to handle routine “screening” assessments
where there is no problem (lower risk pts/clients)
Determine your guidelines for how much is enough,
too much, just right


Examples provided in handout materials as starting point for
your facility
Establishing documentation guidelines are very helpful
© 2006 American Dietetic Association ADA)
The Evolution Process During
Implementation





Continuing practice with other RDs
Consider “mentor” groups/teams
Daily notes sent to CNM for audit (10%)
Reviewing errors one-on-one
Holding weekly group review sessions
© 2006 American Dietetic Association ADA)
In The End, Performance
Improvement Will Show






Overall – documentation and charting speed increased
Notes with greater consistency and focused
Monitoring and Evaluation techniques clearly stated
Outcomes in patients with greater LOS easier to
monitor and track due to specificity of chart note
Training new staff members – formalized
Improves Quality of Care
© 2006 American Dietetic Association ADA)
Nutrition Care Process Resources

Many resources available to members
ADA website materials and tutorials
 Presentations
 Books
 Published Articles
 Speakers Bureau
 Members of Committees and Peer Network for
Nutrition Diagnosis
 Evidence-Based Guides Toolkits

© 2006 American Dietetic Association ADA)
10.A.7
Just think…
“He who stops being
better stops being
good.”-- Oliver
Cromwell
The Moral: NEVER stop
being better.
© 2006 American Dietetic Association ADA)
In summary…
The Nutrition Care Process and
Standardized Language will take us
to a new level of performance and
recognition.
© 2006 American Dietetic Association ADA)
Acknowledgements
Kotter, J. Leading Change', Harvard School Press 1996
CARLE Research Project – Nutrition Diagnosis in
Ambulatory Medicare population
Pilot Projects – Virginia and VA in San Diego
Lacey K and Pritchett E. Nutrition Care Process and Model.
J Am Diet Assoc. 2003;103(8): 1061-1072.
International Dietetics and Nutrition Terminology (IDNT) Reference
Manual. Chicago, IL: American Dietetic Association. 2008
Sherri J. UPMC Presbyterian Shadyside. PNND
© 2006 American Dietetic Association ADA)
Questions???
Esther Myers
emyers@eatright.org
© 2006 American Dietetic Association ADA)