Continuous quality improvement in inpatient clinical nutrition services.

Defining quality patient care is a complex and often confusing issue. This article describes one hospital's experience in applying quality improvement theories to inpatient clinical nutrition practice. The key to measuring quality was the use of standardized practice guidelines. In this article, terms such as continuous quality improvement are clarified and fundamental assumptions such as "quality is defined as conformance to requirements" are discussed. We review a working model for the 10-step plan of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and its application in practice, including the indicators and measurement tools used. Actual results from ongoing quality improvement efforts are addressed and compared to the JCAHO nine components of quality patient care. Because of preexisting nutrition practice guidelines at the Yale-New Haven Hospital, improvements in the delivery of patient nutrition care could be demonstrated; these included enhanced efficiencies in screening and intervention. Continuous quality improvement initiatives do work, and practitioners can use the practice experience presented here as a conceptual framework to justify or validate the quality of patient nutrition care in their own institutions.

Managing inpatient clinical nutrition services: a comprehensive program assures accountability and success.

A major challenge facing clinical dietitians today is justifying inpatient clinical nutrition services. To meet this challenge, a comprehensive program for the delivery and management of clinical nutrition services was developed at Yale-New Haven Hospital. It is based on seven nutritional risk factors--age, diagnosis/treatment, diet, metabolic or mechanical problems, significant lab values, pertinent medications, and weight for height. These risk factors are used to categorize patients into one of seven classifications. In essence, this classification system is the screening tool used to provide the foundation for standards of practice and nutrition assessment and intervention. The inherent advantage of such a program is that it identifies patients at high nutritional risk, regardless of wide variations in patient population or diagnosis. It also provides standardized criteria for evaluating quality of care, patient acuity, and productivity and staffing. Clinical nutrition services can then be measured for both quality and quantity. Because protein-calorie malnutrition poses a serious threat to cost containment and quality patient care, this type of program can appeal to hospital administrators, physicians, and site visitors alike. It can serve as an adaptable model for the delivery and management of inpatient clinical nutrition services in a wide variety of health care facilities.

Development of a productivity index to increase accountability of ambulatory nutrition services.

The development of a system to assess the productivity of ambulatory nutrition services presented many challenges, including variations in provider settings and in the record-keeping techniques of ambulatory nutrition personnel. A model to measure the productivity of ambulatory nutrition specialists at a large urban teaching hospital was devised and was defined by the following equation: Patient/time productivity index = [(extended visits X 2) + (brief visits X 1) + (weigh-ins X 0.5) + (telephone consults X 0.25) + (group class census X 0.25)] divided by number of hours worked. Information obtained from this productivity measurement has been used to evaluate and improve patient scheduling and the organization of functions in various ambulatory nutrition settings. A productivity award based on the productivity index and distributed monthly has provided an incentive for all ambulatory nutrition specialists to streamline operations and maximize efficiency. The patient/time productivity index has been incorporated into performance reviews of ambulatory nutrition specialists as an objective measure of compliance with expectations. When used in conjunction with quality assurance techniques such as chart audits and patient satisfaction questionnaires, the patient/time productivity index can be a useful tool for management to maximize the quality and efficiency of ambulatory nutrition services.