TUESDAY, OCTOBER 26 POSTER SESSION: QUALITY ASSURANCE/QUALITY IMPROVEMENT Ill I
DIETETICS-NURSING QUALITY IMPROVEMENT TEAM PROJECT. S.H. Laramee, MS, RD, and H.T. Doherty, RD,
Department of Dietetics, Massachusetts General Hospital, Boston, MA The Departments of Dietetics and Nursing at the Massachusetts General Hospital utilized quality improvement methods in a review of problems related to the delivery of patient nutrition services. The sixteen member team met regularly over a one year period to identify and select problems, generate and select the best solutions, develop an action plan, then implement the changes. A period of monitoring has followed, with evaluation of the new process. Problems identified for action included increasing the awareness of organizational structure of each department; improving communications, including diet order change information, patient nourishment systems; and for both departments, employee education and orientation. Quality improvement tools and methods used included: brainstorming, multivoting, cause and effect diagrams,
top-down and detailed process flowcharts and deployment charts. In summary, outcomes of the project included: definition of roles and relationships for the patient care unit; development of a new communication system including a dedicated phone line for all patient nutrition needs; introduction of partnership philosophy into new employee orientation; redesign of diet order change form; implemented nourishment station par levels for all patient care units; and implementing "team meals"
DEVELOPMENT OFA DIET WRITING HANDBOOK FOR USE INTRAINING DIET OFFICE STAFF. JC Martin-Austin, MEd, RDand S.Compbell, RD, Deportment of Food and Nutrition Services, Illinois Masonic Medical Center, Chicago, IL. With significant turnover of clinical nutrition staff and reduced number of dietetic technicians, clerks have assumed diet writing responsibilities. A tool was needed which would minimize the decision making process for new staff as well as clerks with limited knowledge and education. Adiet writing handbook was developed as on adjunct to the diet manual. It serves as a self instructional module and reference manual. Using the handbook, the clerk is able to identify which of five selective menus (general, consistency controlled, calorie controlled, sodium controlled, healthy heart) to use in writing a diet modification. The handbook crossreferences major diets and specifies how to modify menus for special diet combinations. The handbook includes diabetic patterns for common calorie levels, foods available for special requests, ingredients in each recipe on the menus, approved menu abbreviations, and standard portions of foods served. The handbook also contains model menus based upon the general selective menu. The models, which ore age specific, ore designed to assure nutritional adequacy and patient satisfaction. They stipulate which menu items the clerk should mark when apatient is unable to or chooses not to mark his menu. With the diet writing handbook, technicians and clerks are able to make diet changes and write diets for patients without relying on dietitian support. The handbook ensures consistent diet writing according to defined standards. The department's quality assessment and training programs have been strengthened since development of the handbook.
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PROMOTING COST-EFFECTIVE TREATMENT OF PATIENTS WITH HYPERLIPIDEMIA. T.L. Larson, RD, E.F. Myers, PhD, RD, S. Cavanah, MD, and W.W. Waite, PharmD, USAF Medical Center Scott, Scott AFB, IL. Escalating cost of lipid-lowering medication provoked strong interest in the current management of patients with hyperlipidemia by multi-disciplinary team of dietitians, physician and pharmacist. Patients receiving Mevacor and Lopid were randomly selected from pharmacy computer database; 198 medical records were reviewed to determine compliance with the National Cholesterol Education Program (NCEP) guidelines; i.e., dietary education and criteria to be placed on drug therapy. Demographics, weight, cardiac risk factors, and lab values were documented. 78% of patients received Step I diet education but only 28% received a repeat Step I instruction. Average time between instructions was 3.25 years. 36% of patients receiving initial diet instructions did not receive 6 months of diet therapy prior to initiation of drug therapy; 3% of patients received Step II diet instruction prior to drug therapy and 12% received a diet instruction when drug therapy was initiated, and 43% of patients were tried on less expensive medication (Niacin, BAS) prior to use of Mevacor or opid. 37% were over 130% of their ideal body weight. Also, a questionnaire was developed using the NWLRC fat intake scale and distributed to the same 198 patients to evaluate current dietary compliance. 171 questionnaires were returned for an 87% return rate. Results indicated that 45% of patients' total fat intake was greater than that allowed on Step I diet, 47% do not exercise, 22% smoke, 13% reported never seeing a dietitian, 35%-1 visit to RD, 26%-2 visits, 20%-3 visits, 3%-4 visits, and 34% > 5 visits. Based on these findings a lipid protocol clinic was developed to allow comprehensive diet counseling during the entire 6 months of diet trial. Dietitians were given privileges to write lab slips for lipid panels for the follow-up clinic. The results have been used to educate physicians on the importance of optimizing diet therapy to help contain pharmacy costs.
THE EVALUATION ANDIMPROVEMENT OFPATIENT SCREENINGS BYDIETARY MANAGERS IN7 SHALL SOUTH GEORGIA HOSPITALS. D.C.NCCOY,RD,LD,emorial Health Services,Adel,GA. Small hospitals often employ registered dietitians on a monthly contract basis which means that thedocumentation ofpatient visitation isrequired ofthedietary manager or appointed employees whohave varied levels oftraining in nutrition.Screening efforts were evaluated in7 south Georgia hospitals;(70 beds. Theprocess included reviewing forms from allfacilities, chart audits andinterviews withthedietary wanagers.The following problems were identified: appearance ofscreening forms waspoor andunprofessional, forms required a lotofwriting, processing offorms wastime consuming since thedietary managers hadtomakecopies of completed forms before placing themoncharts, dietary managers lacked confidence andknowledge incompleting S-O-A-P format, labvalues werenotaddressed onanyof theforms, someforms asked inappropriate questions,(10t ofpatients were visited. Thedietary managers wereinvolved intheform review process andselected thefollowing goals forform design: 1)easytocomplete, 2)S-O-A-P format, 3)area on form tocomplete calculations, 4)labvalues addressed,5) duplicate. Using theJoint Commission Standards fordocumentation, a form wasdesigned which wasused bythemanagers ona trial basis prior toprinting. Adjustments were madetothefore using theinput from thedietary managers andthen printed in duplicate. Theimplementation ofthescreening form, which requires mostly checks orcircles tocomplete, hasresulted in thefollowing positive changes: 1)increased documentationofpatient visits, 2)pertinent information addressed, 3)complies withS-O-A-P format, 4) labvalues addressed, 5) dietary employees other than themanager caneasily be trained tousetheform, 6)immediate placement oftheform onthechart. A continuous uality improvement study hasbeen issued toeach ofthefacilities inorder tomonitor theadequacy of screening formcompletion. After using theforms forsixmonths, alldietary managers independently reported patient screenings asanarea of improvement intheir dietary department.
,IOURNAL OF THE AMERICAN DIETETIC ASSOCIATION / A-43