Nutrition Care Process and Change Management: Making it Happen in Dietetics!

1. Nutrition Care Process and Change Management: Making it Happen in Dietetics! Nutrition Care Process/Standardized Language Committee September 2008

2. This presentation is for you if….. You are a nutrition manager getting ready to implement NCP at your facility You are a member of an NCP implementation team

3. 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.

4. 8 Stage Process of Major Change (Listed in Chronological Order) • 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 ‘ Leading Change' by John P. Kotter, Harvard School Press 1996

5. Your Role as Change Agent • 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

6. 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.

7. 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!

8. 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?

9. 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

10. 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

11. 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.

12. 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?

13. 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

14. 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

15. 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) Resource: 2006 UPMC Presbyterian Shadyside, S. Jones, MS, RD, LDN

16. 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

17. 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

18. 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)

19. 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

20. Initial Charting Format Assessment Diagnosis, Nutrition Intervention Subsequent Charting Monitoring Evaluating Modified after use to Assessment or Re-Assessment Diagnosis, Nutrition Intervention Include specific plan for follow-up monitoring and evaluating Charting Format: From ADIME to ADI

21. 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

22. 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

23. 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____

24. 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____

25. 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____

26. 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

27. 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

28. 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

29. 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.)

30. 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.

31. Expect and Discuss Some Common Questions Up Front • A FEW initial questions and comments from other sites • “Can I use 2 diagnostic terms?” • Yes if you intend to address both in the intervention, but simpler is better • 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!” • 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.

32. 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.

33. 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

34. Peer Network for Nutrition Diagnosis-PNND (Expanded Pilot) • 17 RDs selected to represent ADA Members (2005) • Geographic regions • Settings • Areas of practice • Names posted on ADA Website • 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

35. 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

36. 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

37. 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

38. 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

39. 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 10.A.7

40. Just think… “He who stops being better stops being good.”-- Oliver Cromwell The Moral: NEVER stop being better.

41. In summary… The Nutrition Care Process and Standardized Language will take us to a new level of performance and recognition.

42. 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

43. Questions??? Esther Myers emyers@eatright.org