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IntegratedNutritionPathwayforAcuteCare(INPAC)ImplementationToolkit

Guidanceonthe‘what’and‘how’ofimprovinghospitalnutritioncare

2017

INPACToolkit©December4,2017 2

Acknowledgements

Thistoolkitistheresultofmanyhoursofclinicalpracticeandresearchthatoccurredduringthe More-2-Eat implementation study (2015-2017). Learning and best practices in thistoolkit are theory, practice and evidence-based. Several peer-reviewed manuscriptsresultingfromthestudyareavailableformorein-depthfindings.ThefollowingindividualsandorganizationsareacknowledgedfortheircontributionstothistoolkitandtheMore-2-Eatstudy.TheMore-2-EatTeam:PrincipalInvestigator:ProfessorHeatherKeller,UniversityofWaterlooHighlyQualifiedPersonnel(HQP):CeliaLaur,TaraMcNicholl,RenataValaitisCo-Investigators:CarlotaBasualdo-Hammond,JackBell,PauleBernier,LoriCurtis,PaulineDouglas,JoelDubin,DonaldDuerksen,LeahGramlich,ManonLaporte,BarbaraLiu,SumantraRayHospitalsites:RoyalAlexandraHospital,Edmonton,Alberta;PasquaHospital,Regina,Saskatchewan;ConcordiaHospital,Winnipeg,Manitoba;GreaterNiagaraFallsGeneralHospital,NiagaraFalls,Ontario;TheOttawaHospital,Ottawa,OntarioSiteChampions:MeiTom,MarlisAtkins,RoseannNasser,DonnaButterworth,BrendaHotson,MarileeStickles-White,SuzanneObiorahSiteResearchAssociates:MichelleBooth,SheilaDoering,ShannonCowan,StephanieBarnes,ChelsaMarcell,AndreaDigweed,LinaVescio,JosephMurphyCollaborators:BridgetDavidson(CanadianMalnutritionTaskForce),LindaDietrich(DietitiansofCanada),KhursheedJeejeebhoy,AliesMaybee(PatientsCanada),MarinaMourtzakis,HeatherTruber(CanadianSocietyofNutritionManagement)OtherContributors:HannahMarcus(GrandRiverHospital),ShivaniBhat(NNEdPro),Jo-AnneKershaw

ThisresearchisfundedbyCanadianFrailtyNetwork(knownpreviouslyasTechnologyEvaluationintheElderlyNetwork,TVN),supportedbyGovernmentofCanadathrough

NetworksofCentresofExcellence(NCE)Program


Contents

ToolkitOverview…………………………………………………………………………………………………5

What…………………………………………………………………………………………………………………………8Screening 9

Assessment(SubjectiveGlobalAssessment) 12StandardCarePractices 14

Monitoring 17

FoodIntakeMonitoring 17WeightMonitoring 19

AdvancedCarePractices 20ComprehensiveNutritionAssessmentandSpecializedCare 22

DischargePlanning 23

How…………………………………………………………………………………………………………………………25Necessaryingredientstomakingchangeinnutritioncare 25BehaviourChange 26

GetReady 27

BuildYourTeam 27TalktotheStaff 28

CollectLocalData 29CreatingMotivation 30

Areyouready? 31

BuyInandEngagement 32 KeepingEveryoneEngaged 32

LeadershipBuy-inandEngagement 33

BreakingDownSilos 34CommunicationisKey 34

Adopt 36EmbeddingintoRoutine 36

StandardizetheProcess 37


EvaluateProgressandReportResults 38

AcknowledgeAllSuccesses 38KeepitGoing 40

Re-energizetheMessage 40Don’tLoseFocus 40

EngageNewStaff 41

ExpandonYourSuccess 41

BecomePartoftheINPACCommunity……………………………………………………………42Appendices………………………………………………………………………………………………..…………..43Appendix1:IntegratedNutritionPathwayforAcuteCareandguidancedocument 44

Appendix2:SubjectiveGlobalAssessmentform 48

Appendix3:AppreciativeInquiry 50

Appendix4:INPACAudit 51

Appendix5:ADKARFramework 56

Appendix6:Involvingeveryoneinnutritioncare 58

Appendix7:AStep-by-StepGuidetoImplementingChange:theexampleofembeddingscreeningintopractice. 63

Appendix8:ModelforImprovement 65

Appendix9:Plan-Do-Study-Actcycles 69

Appendix10:DefiningandMatchingBehaviourChangeTechniquestoIntervention Functions:ExamplesfromMore-2-Eat. 70


INPACToolkit

Thefollowinginformation,fromtheMore-2-Eatstudy,providesyouwiththe

knowledgeandtoolsneededtotaketheveryrealandpracticalstepsthatleadtobignutritionalchangeforpatients.

ToolkitOverviewThis toolkit provides anoverviewof the ‘what’ and ‘how’ formaking change to improvenutrition care practices in your hospital. The ‘What’ section is about key nutrition careactivitiesbasedontheIntegratedNutritionPathwayforAcuteCare(INPAC)(Appendix1),an algorithm that promotes the prevention, detection and treatment of malnutrition inhospital.The ‘How’sectionrefers to the implementationandbehaviourchangestrategiesusedbythehospitalsthatimplementedINPACandimprovedtheirnutritioncareprocessesaspartoftheMore-2-Eatstudy.UndertheToolssectionoftheCanadianMalnutritionTaskForce(CMTF)websitearetips,strategiesandexamplesofdocumentsfortheINPACactivities(e.g.screening,assessmentetc.).TheResourcestabwilldirectyoutoothermaterialsthatwillsupportyourknowledgeonhowtoimplementINPACandchangepractice.More-2-EatStudyMore-2-Eatistheproductofseveralyearsofresearch, initiated by the CMTF in 2010.Beginningwithalargecohortstudy,deficitswith respect to nutrition care in Canadianhospitals were identified. Specifically,malnutritionandpoorfoodintakeduringthefirst week of admission were identified tolead to a longer length of stay for thesepatients, a costly $2000-3000/patient.Subsequently,INPACwasdeveloped,usingaconsensus and evidence-based process andcontentvalidated,toimprovenutritioncareprocesses. More-2-Eat demonstrated thatINPACwasfeasibleinCanadianhospitals.

“FoodIsMedicine”ismorethanjustaslogan.It’sabelief.Itisanapproachtocare.Itrepresentsatremendousamountofresearchthatidentifieswhatweneedtodotoimprovenutritionwithinourhealthcareinstitutions.

“IthinkthisMore-2-Eatisjustastart,andafterthestudyisoverweneedtocontinueandthatissomethingthatspeakstomeloudandclear,thatthisisn’tjustsomethingthatstopsafterthestudyisover.We’vegottokeepgoingandfiguringouthowwecancontinuemakingitimportant,andthatnutritionisimportantandthat

foodismedicine.”

-Dietitian&More-2-EatResearchAssistant


This innovative implementationstudyoccurredbetweenMay2015andMarch2017,andwasfundedbytheCanadianFrailtyNetwork(CFN),whichissupportedbytheGovernmentof Canada through theNetworks of Centresof Excellence (NCE) program. Five Canadianhospitals in four provinces evaluated their own nutrition care practices, identified gapswhencomparedtoINPACandworkedwiththehospitalunitandteamtoimprovepractices.Duringtheone-yearofimplementation(2016),manypracticechangesandsuccesseswererealized.The learning fromthe fivesites is included inthis toolkit.Formore informationabout the study, including summaries of findings and links to published papers, see theMore-2-Eatpage.HowdoestheCanadianMalnutritionTaskForcedefinemalnutrition?Malnutritionincludesboththedeficiencyandexcess(orimbalance)ofenergy,proteinandothernutrients.Inclinicalpractice,undernutrition,andinadequateintakeofenergy,proteinandnutrients,isthefocus.Undernutritionaffectsbodytissues,functionalabilityandoverallhealth.Inhospitalizedpatients,undernutritionisoftencomplicatedbyacuteconditions(e.g.atrauma), infections and diseases that cause inflammation. Such complications worsenundernutritionandmakeitmorechallengingtocorrectduetoextensivephysiologicalchangesandincreasednutritionalneedswhenappetiteisdecreased.AdaptedfromAWMcKinlay:Malnutrition:thespectreatthefeast.JRCollPhysiciansEdinb2008:38317–21.CanadianMalnutritionTaskForceRecommendationsfortheBestNutritionCareThese recommendations are the result of consultation with stakeholders at the annualCanadian Nutrition Society conference in 2011. CMTF undertakes education and advocacyefforts with respect to the prevention, detection and treatment ofmalnutrition in Canada,focusedon these recommendations.More-2-Eatprovides the researchandbestpractices tosupporttheimplementationoftheserecommendations.

1. MakestandardizedscreeningprotocolsmandatoryinhospitalsinCanada2. Includeaninterdisciplinaryteaminthenutritioncareprocessthatstartswith

nutritionscreening,subjectiveglobalassessment(forat-riskpatients),afullnutritionassessment(formalnourishedpatients),anddevelopmentofanutritioncareplanbyaRegisteredDietitian

3. Ensurestaff(nursingunitandfood/nutritionservices)providespatient-focusedandprotectednutritionthroughmealtimecarethatisconsistentwiththenutritioncareplan

4. Establishanationalstandardformenuplanningtoensurequalityfoodisprovidedinhospitalsandrequiresthatfoodservicesstaffprovideadequatenutrientstomeettheneedsofdiversepatients,asindicatedintheirnutritioncareplans

5. Educatehospitaladministrators,physicians,nursesandalliedhealthprofessionalsontheneedtointegratenutritioncareaspartofqualityinterdisciplinarypractice

6. Effectiveuseoforalnutritionsupplementation,enteralnutritionandparenteralnutritiontopreventand/ortreatmalnutrition


OverviewofINPACActivitiesThe Integrated Nutrition Pathway for Acute Care (INPAC) is an evidence and consensusbasedalgorithmthatsupports theprevention,detectionandtreatmentofmalnutrition inhospitals. INPAC is considered aminimum standard tomeeting the nutritional needs of(medical/surgical)patients. In the ‘What’sectionbelow,eachINPACactivity isdescribed.ToolsspecifictoeachactivityareprovidedundertheToolstabontheCMTFwebsite.INPACworksbestwhenyoubuildonexistingstrengthsandfocusontheactivitiesthatmeettheneedsofyourpatients.

INPAC: Designed to support nutrition health and care

What is INPAC?

An evidence-based algorithm developed by Canadian clinicians and researchers to detect, monitor, and treat malnutrition in acute care patients.

INPAC is based on the key principle that an integrated approach – or involvement from the whole health care team – is required to treat malnutrition. INPAC is a minimum standard; institutions that provide care beyond this minimum should continue to practice at their higher quality standard.

It is recommended that each hospital establishes an interdisciplinary team to promote and sustain the nutrition culture change required to implement INPAC.

Ad

mis

sio

n

NO RISK (“No” to one

or both questions)

Well-nourished (SGA A)

Mild/moderate malnutrition (SGA B)

Food intake ≤50%

See reverse for further detail…

Food intake ≤50%

Severe malnutrition

(SGA C)

AT RISK (“Yes” to both

questions)

Day

1D

ay 1

+

Standard Nutrition Care

Advanced Nutrition Care

Comprehensive Nutrition Assessment

and Specialized Nutrition Care

Subjective Global Assessment (SGA)

Completed by dietitian or designate

Post-Discharge Nutrition Care

Nutrition Screening at AdmissionComplete the Canadian Nutrition Screening Tool (CNST):

1. Have you lost weight in the past 6 months WITHOUT TRYING to lose this weight? 2. Have you been eating less than usual FOR MORE THAN A WEEK?

Food intake improvedFood intake improved

TM MC

INPAC: INTEGRATED NUTRITION PATHWAY FOR ACUTE CARE


What

INPACisapathwaythatsupportsthedetection,preventionandtreatmentofmalnutrition.

Activitiestoreachthesegoalsare:malnutritionscreening;assessmenttodiagnosemalnutrition;standardcaretoensureallpatientsaccesstheirfoodandhavesufficientfoodtheycaneat;monitoringtoensurepatientsareimproving;advancedcarestrategiestopromotefoodintakewithfocusedtreatments;andspecializedcare,providedbyanutritionprofessional.ExploreeachINPACactivityinmoredetail.

“IthinkMore-2-Eathasimprovedteamwork.Ithinkbecausewe’reallinittogether,it’snotjustthenursethatneedstodoit,it’snotthehealthcareaide,it’sanybodycomingandgoinginthatroom.Anybodycanhelp,it’snotjustoneperson’stask.”

-NurseManager


Screening

Nutrition risk screening is the first step in identifying patients at risk for malnutrition.ScreeningisalsothefirststepoftheIntegratedNutritionPathwayforAcuteCare(INPAC)andpromotesthedetectionofmalnourished(medicalandsurgical)patientswithin24hoursofadmission.WhatscreeningtoolshouldIuse?WerecommendCanadianNutritionScreeningTool(CNST)becauseitis:

• Short(only2questions)• Easytouse• Validandreliablefortheacutecaresetting• Questionscanbeaskedoffamilyorfriends• Doesnotneedtobecompletedbyanutritionprofessional• Nursesagreeitiseasytoincludeintheiradmissionassessment

“EverythingstartswithCNST[screening].It’sprobablythemostimportantthingwedid.Youcan’tmakeachange,youcan’tmakeanimprovementforpatientsifyoudon’tidentify

theatriskpeople.”

-Nurse


For CNST, a ‘Yes’ to both questions indicates that the patient is at nutritional risk andrequiresfurtherassessmenttodiagnosemalnutrition.(Oneyesanswerdoesnotdenoteapositivescreen.)Notethatareferraltoadietitianmaybenecessaryforothernutritionandhealthproblemsthatarenotmalnutrition.Whoshouldaskthescreeningquestionsandwhen?Whenplanningthescreeningprocess,talktostaffaboutwhoshouldaskthequestions,andwhen they should be asked.Having screening questions included in the existing nursingadmissionformscanbethesimplestoption.Nursingstaffhavesaiditwasnothardtoasktwomorequestionsandweremorelikelytoaskthequestionswhentheyknewitconnectedtoanactionthatbenefitedthepatient.TheCNSTquestionscanbeeasilyembedded inthecurrentadmission forms.Otherswhointeractwiththepatientwithina fewhoursofadmission(e.g.diet technician)couldalsocomplete nutrition screening. If your unit has long stay patients, consider weeklyrescreeningasapotentialmechanismtoidentifypatientswhohaveiatrogenicmalnutrition.This isespecially important if food intakemonitoring isnotbeingusedforallpatients toidentifypoorfoodintakeduringhospitalizationandmayrequireinterventiontoimprove.Adherence to and sustainability of screening can be increased by adding this tool to anelectronicmedicalrecord(EMR),whichcanprovideautomaticflagsforscreening,referral,andrescreeningforlongstaypatients.Ifaddingthequestionsintoanexistingform/EMRisnotimmediatelypossible,addingaseparatepagetotheadmissionpackagemaybeanoption.Thismethodtypicallyrequiresmoreremindersforstafftoaskthequestions.Howwillscreeningconnecttoassessment?Whenapatientisscreenedatrisk,referralforassessmenttodiagnosemalnutritionisalwaysneeded. All screening tools tend to over-identify risk for malnutrition, so assessment isessential.ReferralsthatcanbeautomatedthroughanEMRcanhelpensurethatthisimportantstepofreferralfordiagnosisafterscreeningoccurs.Otherwaysofensuringfollowthroughwithapositivescreenincludeeducationabout:

• Theimportanceofscreening• Theimportanceoffollowingthroughwithareferraltothedietitian• Usingexactwordingofquestions(notadapted/simplified)• Whatisapositivescreenforrisk• Howtomakeareferraltoadietitian• Whennottoscreenandtogodirectlytoareferral


Otherstrategiesforgettingscreeningintoregularpracticeare:

• Makeiteasytoreferatriskpatientsbyprovidinginstructionsorcontactinformationforunitdietitianonthescreeningform

• Providecheckboxesandotherremindersonassessmentformstopromoteaccountability(e.g.initialsforthosewhocompletedsteps)

• Workwithstaffwhoconductthescreeningtofindoutwhatwouldmaketheprocesseasier

• Auditscreeningcompletionandfeedbackthoseresultstothestaff• Celebratesuccesseswhenscreeningadherenceishigh

Whataresomepracticemodelsforscreening?The following chart provides an overview of the models tested by More-2-Eat studyhospitals.Considertheseasexamplesastohowtheprocessofscreeningandreferralcanbetailoredtoyourhospitalorunit.WhoScreens? Wherearethescreening

questions?HowistheDietitiannotified?

Nurses Admissionpaper-basedformwithdietitianreferralinstructionsincludedontheform

Referraltodietitian(phoneorpaperbased)

RD(ordesignate)checkstheadmissionformsforpositivescreen

Nurses Admissionform(electronic)

ElectronicreferraltodietitianorothercliniciantocompleteSGA

DietClerk/Technician

CNSTformcompletedwhendiets,preferencesandotherpertinentinformationcollectedfrompatients.

Dietclerk/technicianleavespaperCNSTforthosescoringat-riskindietitianmailbox.

TopTipThegoalistoscreenallnewlyadmitted/transferredpatients.Ifthepatientisat

nutritionrisk,areferralismadetothedietitian(orothertrainedhealthprofessional)todeterminethepatient’snutritionalstatususingsubjectiveglobalassessment(SGA).


Assessment(SubjectiveGlobalAssessment)

Patients identified to be at nutrition risk require a diagnosis to confirm malnutrition.Subjective global assessment (SGA) (Appendix 2) is an internationally recognized ‘bestpractice’fordiagnosingmalnutritionandidentifyingthosewhowouldbenefitfromnutritioncare.The updated (2015) SGA DVD can be orderedthroughtheCMTFwebsite.SGAtrainingisalsoavailablethroughtheCMTF.HowdoIdiagnosemalnutrition?TheSGAisrecommendedbyCMTFfortriagingnutrition care. SGA is a simple bedsideassessmentthatcanbecompletedin10minutes;itprovidesanaccuratediagnosis.SGAhasbeen validated in a variety of patient populations and is used worldwide to diagnosemalnutrition.TheSGAassessmentincludes:

• Changesinrecentfood/nutrient/fluidintake• Weightchange• Gastrointestinalsymptomsandotherreasonsforlowintake• Physicalexamforwastingofmuscleandlossoffat• Functionalcapacity

Remember that SGA only determines protein-energy malnutrition; there may be otherreasonsforadietitianassessmentandtreatmentofpatients.WhenshouldSGAbeused?DietitiansorothertrainedprofessionalsshouldconductSGAwithin24hoursofahospitalpatient determined to be at nutrition risk. SGA should also be usedwhen nutrition riskscreeningisnotpossibleornecessary(e.g.forthosepatientswithdeliriumordementia;highrisk conditions such as trauma, pressure injury or SIRS; language or communicationdifficulties; receivingenteralorparenteralnutrition;or recently transferred fromcriticalcare).Inthesecases,SGAshouldbecompletedtoruleoutmalnutrition,preferablyonthefirstdayof admission.Whendevelopinga screeningandassessmentprocess for triagingpatients, ensure that staffknows theprocessandwhat todo forpatientswhocannotbescreened(i.e.automaticdietitianreferralforSGAcompletion).

“Idon’tthinkI’mseeingmorepeople[becauseofscreening].I’mseeingprobablythesameamountofpeoplebutmoreappropriately.”

-Dietitian


HowDoITriagePatientsUsingSGA?TheSGAscoretriagespatientsintoStandardNutritionCare,AdvancedNutritionCare,andComprehensive Nutrition Assessment and Specialized Nutrition Care. Within INPAC, thepathofcareforeachis:

StandardNutritionCare(wellnourished/allpatients):Despiteapositivescreenfornutritionrisk,SGAApatientsdonotrequirefurtheradvancedorspecializedcaretoaddressprotein-energymalnutrition.Re-screenafteroneweekofadmission.AdvancedNutritionCare(Mild/moderatemalnutrition):Itislefttothediscretionand clinical expertise of the professional doing the SGA to determine if a morecomprehensive nutrition assessment is required to determine cause of protein-energymalnutrition,potentialmicronutrientdeficiency,orotherinvestigationsthatcouldchangethetreatmentplan.ComprehensiveNutritionAssessmentandSpecializedNutritionCare (severemalnutritionandsomemild/moderatemalnutrition):Patientsshouldreceiveamore comprehensive dietitian assessment and individualized treatment plan toaddressprotein-energymalnutrition.

KeyTipsThefollowingaretipstofacilitatedetectionandtreatmentofmalnutritionusingSGA:

• WhentheSGAiscompleted,itismoreefficienttoimmediatelycontinuewiththecomprehensivenutritionassessmentforallseverelymalnourishedpatients,andifdeemedappropriate,forpatientswithmild/moderatemalnutrition.

• Developaplanforstandardizedtreatmentandfollowupofpatients.Thisplanisespeciallyrelevanttomild/moderatelymalnourishedpatientswhomaybeputonadvancedcarestrategiesanddonotreceiveacomprehensiveassessment.

• Topromoteefficiency,mild/moderatelymalnourishedpatientscanbefollowedbyadiettechnician.Someregulatorybodieshavedeterminedthattreatingmalnourishedpatientsisaregulatedpracticefordietitiansonly.

• Atthepointofidentifyingmalnutrition,considerwhatstrategiescanbeputinplaceformild/moderatelyandseverelymalnourishedpatientsandimplementimmediately(e.g.liberalizingthedietorder,obtainingfoodpreferences,etc.).

• Someadvancedcare strategiesmaybeuseful forwellnourishedpatientsandareconsideredatthediscretionofthehealthprofessionalcompletingSGA.

• Considerimplementingmedpass(smallamountoforalnutritionalsupplementprovidedbynursing,typicallyatmedicationadministrationtimes)formild/moderatelymalnourishedandseverelymalnourishedpatients.


StandardCarePractices

Standardnutritioncarereferstotheminimumlevelofcarethatshouldbereceivedbyallpatients,regardlessoftheirnutritionalstatus.Poorfoodintakepredictslengthofstayandaffectsthepatient’soverallhospitalexperience,whichmakesfoodintakemonitoringofallpatients critical to their well-being. Standard nutrition care practices address patients’positioningforeating,visionordentitionneeds,concernsaboutpainornausea,andabilitytoopenfoodpackages.Inaddition,tasty,appealingfoodthatmeetsthenutritionalneedsofpatientsshouldbeconsideredastandardofcare.Foodqualityisimportanttorecoveryaswellaspatientqualityoflifeandneedstobeahighprioirty.Inthecontextofillness,foodismedicine,andmedicineheals.

Thefollowingareavarietyofnutritioncarestrategiestopromotefoodintakeforallpatients:

• Increaseawarenessabouttheimportanceofnutrition

o Increasingawarenessacrossdepartmentsabouttheimportanceofmealtimes,recognizingthateveryonehasaroletoplayinnutritioncare(Appendix6).

o Encouragestafftodecreasemealtimeinterruptions.

o Encouragestafftoassistthepatientgettingreadyforthemeal(e.g.aphysicaltherapistfinishingtheirtreatmentplancouldsupportthepatientbyencouragingthemtousethewashroombeforethemeal).

o Posterscanbeusedtoincreaseawarenessaboutthepatient’sneedsatmealtimes.

o BriefeducationsessionsabouttheimportanceofpatientfoodintakecanbeheldduringhuddlesoraLunchandLearn.

• Providepositiveencouragementtoeat

o Staffcanprovidepositiveencouragementthateatingisnecessaryforrecovery.o Duringmealdelivery,foodservicestaffcanencouragefoodintakebyproviding

positivefeedbackaboutthemeal.o Ifstaffopinionregardingfoodislow,providetheopportunityforstafftotaste

thefood,orprovidemoreinformationaboutwhereitissourced(i.e.locally)etc.

“There’ssomuchmoreawarenessandIguessinvolvementofthenurses[innutrition].Soit’snotjustthistrayisarrivingforthisperson.Yes,it’sthecorrectdiet.Excellent,they’reeating.Dotheyneedhelp?It’salittlebitmoreinvolvedthanthatnow.Sotheycanlookatapatientandidentifyapatientthat’satriskandmaybeevenstarttofeelmorecomfortabletakingactionsbeforethedietitiancomesintoseethatpatient.SoI

thinkveryimpactful.”

-Nurse


o Encouragefamilytobringinfavourite,nutritiousfoodsfromhometostimulateappetite.

o Encouragefamilytovisitatmealtimetoinspirethepatienttoeat.Theycanbringtheirownmealsothattheybothbenefitandenjoyeachotherscompany.

• Treatfoodasmedicine

o Laminatedpostersthatstimulatestafftoensureapatient’sglasses,hearingaid,dentures,etc.areinplaceatmealtime,canbepostedinpatients’rooms.Theposterscanidentifychallengesthataffectthepatient’sintake.

o Unitfridgescouldbestockedwithnutritiousfoodandbeverages.Thisextrasupplyallowsfoodtobeprovidedoutsideofmealtime,particularlyatnight.

o Ensurethataprocessisinplacefornursingstafftocommunicate,earlyinapatient’sadmission,tothefoodservicedepartmentthatapatientisunabletomarkaselectivemenu.

o Aimtohaveamealdeliveredataconsistenttimesothatwhenfamilycomestohelp,themealwillarriveattheexpectedtimeandfamilyisabletoassist.

o Whenapatientisnoteatingenough,allowandaccommodateforfamilyorfriendstobringinfoodthatwillbeeatenbythepatient.Haveasystemforlabellingandstoringfoodbroughtintothehospital

o Trytodecreasethenumberofstaffonbreakduringpatientmealtimetoincreasethenumberofpeopleavailabletoassistpatientstogetreadyfortheirmealandwhennecessary,provideeatingassistance.

o Traydeliveryforisolationpatientsisanissueinsomehospitals.Tryoutsomedifferentstrategiestoensureisolationpatientsreceiveahotmeal.Forexample,trayscanbeleftatthenurses’stationfordistributioninatimelyway.

• Involvevolunteers

o Developavolunteermealtimeprogram.

o Involvethehospitalvolunteercoordinatortorecruitandtrainvolunteers.o Recruitexistingvolunteers,dieteticinterns,students,etc.toassistduring

mealtimes.Thisisanexcellentwayforstudents/internstogainexperienceandinteractwithpatients.

o Asamplevolunteerroledescription,educationmaterial,andothertoolsareavailablehere.

o Volunteerscanhelptoclearthebedsidetable,openpackages,encouragepatientstoeat,andprovidesomesocialinteraction.

o Volunteerscanobtainfoodpreferencesfrompatientsandcommunicatethemtothediettechnicianordietitianthroughacommunicationbook.

o Volunteerscanprovideeatingassistance(feeding)ifadequatelytrained.


VolunteerProgramstoSupportStandardCareThechartbelowprovidesafewexamplesfromMore-2-Eatofmealtimevolunteerprogramsthatcouldbeusedforstandardnutritioncare.

Recruitment Training Role TimewitheachPatient

EatingAssistanceProvided

Neworexistingvolunteers

Bythedietitian Tocheckwithallpatientsontheunittoseeifanyonerequiresassistanceopeningpackagesetc.

Asneededbyeachpatientontheunit.

No

Neworexistingvolunteers

Bythedietitian Anyhospitalstaffmembercanenrolapatientasperestablishedcriteria.Eachvolunteervisitsatleastonepatientandprovidessocialsupport,assistancewithmealtrayset-up,openingpackagesetc.

Varieswithnumberofpatientsenrolledandvolunteeravailabilitybutgenerally,longertimewitheachpatient.

No

Existingvolunteers,interns,trainees,studentsetc.

Bythevolunteercoordinator(educationdevelopedwithnutrition&foodservicesteam)

Tofollowthefoodserviceworkerastheydeliverthetraysandchecktoseethateachpatienthaseverythingtheyneed,openpackagesetc.

Short.Typically20minutesintotalfollowingallthetraysthenreturnstotheirusualvolunteerrole.

No

StudentsinSpeechandLanguageTherapist(SLP)orNutrition

ByanSLPordietitian

Volunteerscheckwiththenursingstafftoseewhichpatientsrequireeatingassistance(lowriskforchoking/notdysphagiapatients).Volunteersopenpackagesencourageintakeandprovideeatingassistance(onlyiftrained).

Long.Typically1hourperpatient.

Yes


MonitoringWhydoweneedtomonitornutritioninhospital?Poorfoodintake,eveninawell-nourishedpatient,canextendthehospitalstay.Aswithbodyweight,thisisa‘vitalstatistic’tounderstandhowthepatientisrecovering.Obtainingbodyweightatadmissionandweeklyduringthehospitalstayisconsideredastandardofcareforallpatients.Weightcanchangequicklyduetofluidlossorgain.Arapidweightlosscanbean indication of dehydration (unless the patient is edematous),which can cause seriousconsequencessuchasdelirium,adversedrugreactionsandevendeath.Immobilitycanalsoresultinrapidlossofmuscletissue,especiallyifapatientisunwell.

FoodIntakeMonitoring

Malnutritioncandevelopquicklyinhospital,soitisimportantthatfoodintakemonitoringoccurs forallpatients.Poor food intake,even inawell-nourishedpatient,canextendthehospitalstay.TheMyMealIntakeTool(MMIT)hasbeendevelopedandtestedwitholderpatients, and can be completed by those with adequate cognition, by family or a staffmember.Other foodmonitoring tools arealsoavailable foruse.Thekey is ensuring thatwhenpoorfoodintakeisidentified,actionistakentoimproveintake.HowdoImeasurefoodintake?Lowintakeistypicallydefinedas≤50%ofthetray.Avarietyofmethodscanbeusedforfoodintakemonitoring.Manyhospitalswill alreadyhave some formof food intake monitoring (e.g. nurseflowsheets,vitalstatsreports,etc.),sothefocusshouldbeonmakingsuretheform is completed regularly, theportion of food consumed is recordedaccurately,andthatlowintakeisconnectedtoanaction.OneoptionofmonitoringistheMyMeal Intake Tool (MMIT). TheMMIT has been developed and tested for usewith olderpatients, and can be completed by patients with adequate cognition, family or a staffmember.Ifitisdecidedthatstaffwillcomplete(ratherthanthepatient)foodmonitoring,educationofstaffaboutportionsizeestimationisparticularlyimportant.Picturesofportionsoffoodandbeveragesconsumedarehelpfulfortrainingandascueswhenpostedinpatientrooms.Educationcantakemanyformsincludingapresentation,reviewingtools,andworkingwithindividual staff members on the necessary steps in the process. Remember to includetrainingonwhattodowiththeinformationonlowintake,whetheritisrecordedfromMMIT

“Ifthepatient’seatingpoorlythenyouneedtodosomethingaboutit.It’snotjustwritingitdownandnotdoinganythingaboutit....thiswaythereisanextsteptofollow,sothat

shouldbeaffectingthepatients.”

-FocusGroupParticipant


ornursingdocumentation.Thereisnopointinmonitoringfoodintakeifanactiontoimproveintakedoesnotoccur!HowdoIconnectfoodmonitoringtotreatment?Communicationoflowfoodintakeisnecessary.Workwithstaffmembersthatareassessingfoodintaketodevelopbuy-inandthenbuildaprocessthatfeasibleforimprovingpractice.Thekeytoimplementingafoodintakemonitoringprocessistotrainandmotivatestaffsotheyunderstandtheimportanceofthisfunction,andtheycanaccuratelymonitorintakeandconnectlowintaketoanappropriateactiontoaddressthereasonforlowintake.Lowintakedoesnotalwaysmeanareferraltoadietitianisnecessary.Forexample,ifitisidentifiedthatthepatientdoesnotlikethefood,theappropriateactionisaccommodatingfoodpreferences;orifpainisthereasonforlowintake,painmanagementstrategiesshouldbeconsidered.

ModelsforFoodIntakeMonitoringThefollowingareexamplesoffoodintakemonitoringusedintheMore-2-EatStudyandactionstakentorespondtolowintake.Whodoesthemonitoring?

Whattoolisused? Whatvalues

areused?

Whoandhowisactiontakenforlowintake?

Nurse NursesCharting/VitalSignsForm

0,25,50,75,100%

Nurse:referstodietitian/diettechnicianwhenintakeisconsistently≤50%.Thisischartedanddiscussedinclinicalrounds.Dietitianalsoreviewsvitalsignsformsforintake.

FoodServiceWorkers(nursesiftheymovethetray)

Foodmonitoringsectionofthewhiteboardineachpatient’sroom

0,25,50,75,100%

Lowintakeisdocumentedonthewhiteboardandthentransferredtothechartanddiscussedatbedsideroundseveryday.

Healthcareaides(orotherunitstaffwhopicksupthetray)

a)PatientMealIntakeRecord(for7dayperiod)oneachpatient’sdoorthatislaterincludedasapermanentpartofthepatientsmedicalchart.

0,25,50,75,100%orNPO

Intakerecorded3mealsdailyforentireadmission.If≤50%isconsumed,thepersonretrievingthetrayasksthepatient2questions(aboutappetiteandmealtimechallenges),recordspatientresponsesandcorrectiveactiontakenbytherelevantperson.Dietitianisconsultedifintakeis≤50%foratleast2


b)Laminatedreferencemealtrayposter(withphotosofmealtrayswithstandardized%consumed)onwallineachpatientroomtoguidetrayassessors.

meals/dayfor3consecutivedays.Dietitianalsoreviewsintakerecord.

WeightMonitoringWeight monitoring involves taking patient weights and tracking the weights regularlythroughoutthedurationofthehospitalstay.Thisvitalstatisticisnecessaryforphysicians,dietitians, pharmacists, social workers, occupational therapists, physiotherapists, andnurses,inordertomakeappropriatedecisionsaboutvarioustreatmentmodalities.Weeklyweightsshouldbeconsideredroutinecareforallhospitalpatients.HowdoIstartregularmeasurementofbodyweightduringhospitalization?

Obtaining an admission weight androutine monitoring of patients’weight throughout hospitalization isastandardcarepractice.Ifadmissionweight is not done, start witheducatingstaffonthe importanceofthisobjectivemeasuretothecareandrecovery of the patient. Getting

regularweightsduringhospitalizationcanbedifficultandtherewilllikelyberesistancefromstaff.However,oncestarted,moststaffrecognizeitdoesnottakelong,andisfairlyeasytodo. It is important to stress the benefits of actual patients’ weight for many of healthprofessionals caring for the patient. Having appropriate equipment available is alsoimportant(i.e.chairscale).Makingweightsaroutine,suchashavinga“weighday”forallpatientsontheunit,orencouragingfriendlycompetition,isimportantforsustainability.

“Honestly,atfirst,ofcourse,wewerekindofoverwhelmed[todoweeklyweights].But

nowIthinkit’sgettingbetter.”

-FocusGroupParticipant


AdvancedCarePractices

Some patients need more than standard care to recover. Malnourished patients needstrategiesthatprovideenhancednutrition,morefrequentlyandinamannerthatiseasyforthepatienttotolerate.Advancedcarepracticesareavarietyofstrategieswiththecommongoal of intensifying the ‘dose’ of energy, protein and micronutrients for malnourishedpatientswhooftenfeeltooilltoeat.Manyhospitalshaveprocesses forpromotingenergyandproteindense food intake (e.g.prescribeddiets,nourishments)totreatprotein-energymalnutrition.Considerliberalizingmalnourishedpatients’therapeuticdietsasameansofoptimizingintake.Medicationpass(medpass) of supplements (small amount of oral nutritional supplement provided bynursing,typicallyatmedicationadministrationtimes)isnotascommonlyused,butcanbeavitalmechanism for improving intakewhile also limitingwaste of larger portions of theproducts.Itisimportanttonotethatsystemsorprocessestoimplementmedpassmayneedtobeworkedoutwitheachunit.Formany SGAB patients, these advanced care strategies can be instituted as firstordertreatmenttostarttheprocessofimprovingnutritionalstatus.Tipstoimplementmedpassinyourhospital

• Learnfromotherunits/hospitalsinyourregioniftheyhavealreadyimplementedmedpass.

• Workwiththedietitianontheunitandthenursemanager/practitioners/pharmacist/educatorstoplanhowtorollitoutontheunit.

• Don’tforgetaboutthebudget.Considerprioritizingandstandardizingsupplementdeliveryoptions(i.e.,makemedpassthefirstchoiceifthepatientrequiresasupplement;then,ifthepatientdoesnotlikeortoleratemedpass,providesupplementswithsnacksormealsetc.).

• Createcriteriaforindications/contraindicationsandguidelinesforordering/discontinuing,processesfordeliveryofsupplementtounit,storage,considerationofshelf-lifeofopenedproduct,etc.

• Determinetheprocessfordiscontinuingmedpasspromptlywhenitisdeterminedtonolongerbesafeduetointoleranceoftheviscosity(i.e.patientrequiresthickenedfluids)orpatientrefusal.

• PutmedpassontheMedicineAdministrationRecord(MAR).Thiscantaketime.Workwithexistingprocessesandaspartofateamthatincludespharmacy,foodservices,andotherunit/hospitalmemberstoachievethisgoal.


• ApaperorpseudoMARmaybesuitableifunabletogetmedpassontheelectronicMAR.

• Workwiththesuppliersoftheproducttosetupaprocessforprocuringit,aswelltheequipmentthatwillsupportuse(cups,lids,fridgesetc.).Contactthesuppliertoseeiftheycanprovideanyoftherequiredsuppliesortraining.

• Providetrainingaboutwhatismedpass,whyisitimportant,whenitshouldbeprovided,andallowstafftosampletheproduct.

• Trainingmayneedtobetailoredtothespecificneedsofaunit.

• Continuetoprovidetraining,astheprocessbecomesaroutinejobfunction.Usecreativereminders.

• Trackandmonitoradherenceto,andintakeoftheproduct;reportthisbacktothestaff.

• Trackwastage(fromexpired/openedproduct);reportthisbacktothestaff.Identifyanychallengestheyexperiencewithadministeringtheproducttopatients,workasteamtosolvetheproblems.

• Databasesystems(e.g.CBORD)canbeusedtotrack/printreportsofpatientsreceivingmedpass.Thisishelpfultodietitianstoensuretimelyfollow-upandforFoodServicesforestablishingandmonitoringstocklevels.

“Patientsaremorecompliantwith[nutritionalsupplement]shotsthan

givingthemthewholebottle.”

-Nurse


ComprehensiveNutritionAssessmentandSpecializedNutritionCare

Hospitaldietitiansareaspecialistresourceandarebestpositionedtoprovidespecializedcare.This specialized care isprovided forawidevarietyof conditionsand in the caseofmalnutrition,isespeciallyappropriateforthosediagnosedasseverelymalnourished(SGAC). In somemalnourished SGAB patients, specialized nutrition caremay be needed andclinicianscompletingSGAareencouragedtousetheirclinicaljudgementinthesesituations.AcomprehensivedietitianassessmentisthebasisforINPACSpecializedNutritionCare.Thisassessmentshouldoccurwithin24hoursofcompletionoftheSGA.ThisassessmentinvolvesfurtherinvestigationbeyondSGAtounderstandthecauseofmalnutrition,suchasevidenceofmicronutrientdeficiencies,inflammation,pathologiessuchasdysphagia,etc.Treatmentistypicallyspecializedandrequiresanindividualizednutritionalcareplan.

“TheSGACsaretheoneswe’repayingmoreattentiontoandmightbetaking

moreofmytime,butIwouldn’thavebeenabletoweedallthoseout.Iwouldhavebeendoingtheexactsamething,afull

assessmentoneverysinglepatient,whichistime,timelostthatIcouldhavebeenseeingthepatientwhoreallyneededto

seemeinatimelymanner.”

-Dietitian


DischargePlanning

Patientswhoareidentifiedtobemalnourished(SGABorC)andwhodonotfullyrecovertheir nutritional status during their admission, require ongoing care in the community.Healthcareteamsshouldstrivetoprovideareferralforongoingnutritionaltreatmentwhenrehabilitation of nutritional status is necessary. Health care teams need to provide thepatientandfamilywithcommunityresourcesthatcansupporttheircontinuedrecoveryinthecommunity,forexample,aslistofmealprograms,on-linegroceryservices,etc.,thatareavailableinthecommunity.Tipsfordevelopinganutritioncaredischargeprocess

• Workwithateamwhoisactivelyinvolvedindischargeplanning,e.g.dischargeplanner,socialworker,hospitalcasemanagerforhomecare,nursemanager,occupationaltherapist,physicaltherapist,etc..

• Consultwithotherhospitalhealthprofessionalstodeterminewhattheydofordischargeplanning.Forexample,occupationaltherapistsmayalreadybemakingrecommendationsaboutgroceryshoppingassistanceorotherservicesthatcansupportfoodintakefortherecoveringpatient.

• Meetwithlocal/regionaloutpatientdietitiansandhealthprofessionalsinotherfacilities,primarycare,andhomecaretoidentifycommunityresourcesanddiscusshowreferralsarecurrentlymadetotheirserviceandhowthiscanbeimproved.

• Developalistofservicesinyourcommunitythatsupportfoodbeingaccessibletopatients;forexample,mealprograms(congregatediningwherethepatientgoestoalocationforthemeal;mealdelivery),groceryshoppinganddelivery,andfoodbanks.Reviewthislistonayearlybasistokeepituptodate.Providephonenumbers/locationsandcostinformation.

• Developahandoutforpatient/familymemberslistingthesecommunityservices,aswellasgeneralrecommendationstoencourageadequatefoodintakeinthe

“Weneedtoshowthatwe’reactuallymakingchange,andhelpingpatients,andkeepingthemoutofhospital,andputtingsafetynetsinplaceinthecommunity.

That’sourjob.Idon’tthinkthatuptothispointthatIreallyrealizedthatwecoulddoallthosethings.”

-Dietitian


community.Thiscouldalsoincludesignsandsymptomstowatchoutfor,suchasweightlossandpoorappetite/intake.

• Discusswithyourunit/hospitalteamhowreferralscanbemademoreconsistentlyforpatientsleavingthehospital.Identifyhowcommunicationscanbeimproved(i.e.,whiteboardnotesneededforreferralatdischarge;SGAstatusnotedonthepatientwhiteboards;stickeronpatientcharttonoteneedfordietitianreferralpostdischarge).

• Educatephysicianswhodictatedischargesummariestolistthediagnosisofmalnutrition.

• EducateHealthRecordcoderstoextractthediagnosisofmalnutritionfromthedischargesummaryandcodeusingtheappropriateICDcodeforproteincaloriemalnutrition.


How

NecessaryingredientstomakingchangeinnutritioncareNow that you have reviewedwhat needs to happen to improve nutrition care, the nextquestionishow.More-2-Eathelpedtoidentifywhatingredientsarenecessaryforsuccesswhen improving nutrition care. The following sections outline stages ofmaking change,however it is important torememberthatchange isadynamicprocess.Witheachnewlyimplementedpractice, stageswillneed tobe revisitedas required.Resources to supportmakingchangeinyourhospitalcanbefoundontheCMTFwebsiteunderResources.

Keylearningpoints:

• Everyonehasaroletoplayinimprovingnutritioncare.

• Achampioncandrivethechange,butneedsasupportiveteamtomakeithappen.

• ‘Context rules’ sowhatworks in one unit,may notwork exactly the same inanother.

• Educationaloneisnotenoughtoimprovecarepractices–youneedtodomore.

• Collectingunit leveldataand feedingback the results iskey tostimulateandsupportthechangeprocess.

“WhatI’mhopingisthatpeoplewillidentifysomesimplesmallchangesthatwillhaveamaximumimpactforthe

patient.”-Manager


BehaviourChangeAvarietyofbehaviourchangeandchangemanagementtheoriesandframeworkswereusedinMore-2-Eat.TheteamheavilyreliedontheMichieetal,COM-Bmodeltohelpmakechange:

Michie S, van Stralen MM, West R. The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implement Sci. 2011;6:42.

Withthisknowledgeinhandandrecognizingthatprocessesandeducationeffortsneedtobeflexibleandtailored,let’sbegin.

• Peopleneedtoknowwhatisexpectedofthemandhavetheskillstodotheactivity.Capability:

• Makeiteasytoimplementthenewpractice.Opportunity:

• Ifpeopledonotseetheneedforthechange,andtheyarenotinspiredtoimprovenutritioncareoftheirpatients,thenjusttellingthemwhattodowillnotbeenough.

Motivation:

• Thechangesinpracticeweareseekingfromallhealthprofessionalsandcareprovidersinourhospitalswhohaveastakeinimprovingthenutritioncareofpatients.

Behaviour:


GetReadyAreyouready?RatherthanrollingoutallofINPACatonce,itisrecommendedthattheteamstartwithoneactivityononeunit.Theunitstaff,hospitalmanagementandafewkeypeopleneedtobereadybeforeyoustartmakingchanges.Staffandmanagementneedtounderstandthatimprovementisneeded,andbewillingtostartslowlysothatprogresscanbemeasured.If the unit is not ready, change will be difficult. Readiness checklists may be useful todetermine if a unit is ready to take on the implementation effort. Before embarking onimproving nutrition care activities, have the mindset that this is a long-term process.Sustainedchangetakestimeanddedication.OnceeachINPACactivityhasbeentestedinoneunit,implementationofINPACcanstarttoslowlyberolledoutacrosstheotherunits/theorganization.

BuildYourTeamWhile senior management support isessential,a“champion”isrecommendedtoinitiate this change management effort.Champions shouldworkwithadedicatedteam who is interested in makingimprovements and can act on decisions.Havingachampionwithdedicatedtimetoimplementchangeiscriticaltoitssuccess.Timeandcommitmentofthefullteamwillleadtochangesbeingimplementedthoroughlyandquickly.In More-2-Eat, the composition of the core change team, led by a champion, varied byhospital,buttypicallyincluded:

• Unitmanager/leadership

• Dietitianatmanagementlevel

• Unitnurse

• Unitdietitian

“Somebodyhastoownit.Becauseifnobodyownsit,thenitgoesbythe

wayside.”-Dietitian&More-2-EatChampion

TopTipReadinessmeansthattheunithasthecapacitytotakeonanewinitiative.Toolscanhelpshowifthestaffarereadyforchange.Alistofreadinesschecklistsareavailableonthe

CMTFwebsiteunderResources.


Otherpeoplecanbebroughtinforspecificactivities,suchaspharmacyforstartingmedpassfororalnutritionalsupplements(ONS),foodservicemanagementandstaffformonitoringfood intake, or discharge coordinators for discharge planning. Education or qualityimprovement experts are also available in many hospitals and are a key resource forimprovingpractices.

TalktotheStaffUnitstaffaretheexpertsaboutwhatisgoingto work on the unit and how change canhappen. By talking to the staff, you arelearningfromthemandengagingtheminthechangeprocess.Whenstaffunderstandwhya change is happening, and are part of theprocessforsettingitup,theyaremorelikelytosustainthatchange.Somesuggestionsforengagingstaffinclude:

• Explainwhychangeisneeded;severalpresentationsontheaspectsofINPAChavebeencreatedtosupportthistypeofengagement

• Askwhatchangestheywanttosee;AppreciativeInquiry(Appendix3)isawayforsolicitingthisinputandawayofimagininghownutritioncarecanimprove

• Brainstormideasindiscussiongroups

• Seekrecommendationsformakingthatchange

• Discusstheimportanceofadequatefoodintakeinhuddles

• Increaseparticipationineducationactivitiesbyhostinglunchorsnacksessions

• Speakatprofessionalgroupmeetingsabouttheinitiative;usestatisticsandyourowndatatobuildengagementforchange

TopTipTalktopeoplewhohavemadechangeinotherareasofthehospital(outsideofthenutritiondepartment).Findoutwhatworkedforthem.Speakwiththoseinvolvedinhospitalimprovement,suchasimplementationspecialistsorqualityimprovement

committees.

“Workwiththestaffandtheybecomepartofthesolutiontothechange.It’seasiertogetitembeddedintheirdailyworkbecausetheyhelpeddefinewhatthatdailyworkreallylookslike.”

-RegisteredNurse+Manager


• Bepresentontheunitsostaffcanaskquestions

• Keepthenurseeducatorinformedsostaffcangotothemwithquestions

Talkingtostaffcanhelpimprovecommunicationandbuy-insotheyknowwhatisgoingonandfeelengagedintheprocess.

CollectUnitLevelDataData is invaluable! Data can convince seniormanagement that a change is needed. It will helpbusy professionals realize they need to makeimprovements for their patients. Find ways tocollectunitleveldatathatisrelevanttoyourchangeefforts. This could be surveys that determineknowledgeandattitudesofstaff,patientexperiencewithfoodservice,andbarrierstofoodintakeordataon what nutrition care practices are currentlyoccurring.Acriticalpieceofdatatocollectwhenimplementingscreeningasastandardpracticeistodemonstratehowmanypatientsareroutinelymissedbyusingroutinereferralprocesses.Simply conducting CNST on all patients admitted to one unit for a couple ofweekswilldemonstratethegaptostaffandmanagement.CollectbaselinedataonINPACactivitiesbeforestartingyourchangeeffort.Thedatawillnotonlydemonstrate thegap in carebutwill allowyou to trackyourprogresswithmakingchange. Everyone (unit staff,management etc.)wants to see evidence of success. Timelyreportingofresultsisimportantforkeepingstaffengagedandforknowingwhenmoreeffortisneeded.Somewaystocollectdatainclude:

• INPACaudittool(Appendix4)

• Nutritionknowledge,attitudesandpracticequestionnaireforstaff

“It[data]needstobelocal,itneedstobetimelyanditneedstobeinaformatwhereyoucanseeyourtrendandyourresults.Thereinforcementisextremely

important.”

-Manager

TopTipWanttocreatepositiveandproductivediscussions?“AppreciativeInquiry”usesastrengthbasedapproachtohelpdirectthesediscussionsMoreinformationisavailableinAppendix3.


• Physiciansurvey

• Nursesurvey

• Apatientfoodexperiencequestionnaire

• MealtimeAuditTool

• Considerotherrelevantdatathatmayalreadybecollectedontheunite.g.traywasteauditsaspartofyourchangeeffort

CreatingMotivationChangerequiresmotivatingtherightpeopletodotherightthingsattherighttime.Takeintoconsiderationthevaluesofyourorganization,hospital,unitandstaff.Simplyput,valuesarethethingsthatweviewasimportantandthatmotivateus.Discussmakingchangewithavariety of stakeholders (both supporters and resistors), to understand their values andmotivations.Determinewhatismotivatingtheircurrentbehaviour.Useyourdatatomakethecaseforchange,consideringwhattheyvalue.Forexample,ifyouaretryingtoconvincesenior management that nutrition risk screening is needed, show them the gap in yourpractice for identifying malnourished patients, then the research literature that hasdemonstrated that malnourished patients stay longer in hospital, and if the patient’snutritionalstatusdoesnotimprovetheyhaveaconsiderablylongerlengthofstaythanthosewhoimprove.Keyquestionstoconsiderinclude:

• Whatdoesthestakeholdervalue?

• Howdothesevaluesalignwithyourgoal?

• Whoaretheresistorstochange?

• Whyaretheyresistingthechange?

• Whatmighthelpthemtochange?

TopTipIt’sdifficulttoargueagainstthefacts.Unitleveldatawillhelptoestablishthatchangeis

neededandhelptotrackprogressonceimplementationhasstarted.

“Peoplestaymotivatedwhentheyknowthey'remakingadifference.”

-FoodServiceManager


• Whatdoesyourtargetgrouprelyonformakingdecisions?

o Publishedevidence?

o Unitleveldata?

o Nationaldata?

o Potentialsolutionstotheproblem?

o Theimpactofthechangeondailyroutines/workload?

o Costimplications?

o Patientbenefit?(Everyonewantschangestobenefitthepatients!)

Areyouready?Thisprocessofgettingreadywillhelpyouseeopportunitiesandchallenges.Understandingwhatmotivatespeopleandwherechallengesexistwillhelpthegroupnavigatethroughthenextsteps.Beflexibleandrealistic.Smallwinswillbuildmomentumforcontinuingnutritioncareimprovements.Celebratesuccesswitheachsmallwin.


BuyInandEngagement

Aswithanychange,youneedtogettherightpeopleinvolved.Everyonehasaroletoplayinnutritioncare,but not everyone needs to be involved all the time.You’llneed initialbuy-in frommanagementthroughtobuy-infromfrontlinestaffandanyonewhowillbeaffected by the changes. Start with the believers.Provideeducationabouttheproblem.Seekfeedbackon potential solutions. This will help the team feelengagedintheprocess,whichwillfacilitatetheirbuy-in. Remind staff why the change is important topatientoutcomes.TheADKARprocessisonewaytobuildthisengagement(Appendix5).KeepingEveryoneEngagedTheMore-2-Eat champions found thatdemonstratingmeaningful changes inpatient carewasimportantforengagement.Builda‘weareallinittogether’attitude,soeveryoneispartof the solution, and it’s not falling on one individual or profession. This engagement isimportantforboththechangemanagementteam,aswellasthestaffaffectedbythechange.Appendix6providesanoverviewofrolesthatvariousprofessionals,volunteersandpatientsandfamiliescantakeontosupportimprovednutritioncareforallpatients.Aquestionnaire,tohelpyouunderstandthenutritionknowledge,attitudesandpracticesofhospitalstaff,isavailable.CompletionofthisquestionnairebeforestartingthechangeinitiativecanidentifyareasofINPACtotarget,aswellastheeducationalneedsofstaff.

Volunteers, patients, their families andfriendsshouldhaveasayinwhatneedstobechanged to improve nutrition care. Solicittheirideasandfeedbackabouttheproposedchange. Two standardized questionnaires(Patient Experience and Mealtime AuditTool)canbeusedtoelicitthisinformation.

Remember:

• Engagementisacontinualprocess

• Continuallyinfusetheteamwiththenecessarysupportandacceptancethatcanleadtolastingpositivefeelings

• Listenandrespondtoconcernsandneeds

“Ithinkreallyaskingnursingandstafffeedbackwasagoodwayto

startandagoodwaytocontinueonthrough.Ithinkitkeptthem

engaged.”

-Dietitian+More-2-EatChampion

“It’salmostlikesayingeverypatientneedstowalkbutthatdoesn’tmeanthatphysioneedstowalkwitheverypatient.Right.Everypatientneeds

propernutritioncarebutthatdoesn’tmeanitshould

necessarilybeadietitian.”

-Physiotherapist


• Berespectfulandpositiveinyouractionsandcommunications

• Buildanenvironmentoftrustandcooperation

• CommunicateandcollaboratewithstakeholderstodeveloptheprocessforeachINPACactivity

• Showappreciationandacknowledgmentofideas,changeefforts,etc.

• Thankindividualseitherpubliclyorpersonallyfortheirpositiveactionstowardsmakingimprovements

• Makesureeveryoneknowsthatthisisamultidisciplinaryapproachthatdoesnotrelyononeprofession

LeadershipBuy-inandEngagementTypically,leadershipwantstoseetheevidencebehind any new initiative, how it will affectpatient care and the cost to implement.Demonstratingthebenefitforthepatientisastrong motivator for staff and management.Use the unit level baseline data collected in“GettingReady”andothernationalevidencetodemonstratetheproblem.Leadershipbuy-inmaytakesome ‘selling’bythe champion and change teammembers. Remember to go back and considerwhat thestakeholdervalues.Whatwillmotivatethemtosupportyourinitiatives?Whatevidencedoyouhavetoalignwiththatvalue?AvarietyofPowerPointpresentationshavebeencreatedtosupporttheseeffortsandarelocatedontheCMTFwebsiteunderResources.

TopTipProactiveactionsandinteractionswillbuildthenecessary‘warmth’tomakeandsustainpositivechangewithintheteamandthestaffoverall.Astrongteamwhois‘inittogether’is

kindtoeachotherandforgiveswhenmistakeshappen.

“Iftheythinkit’saffectingpatientcare,iftheythinkthey’llmakethepatientsbetterandiftheythinkit’llmakethecaremoreefficientandlessexpensive,Idon’tthinkit’satough

sellatall.”

-AttendingPhysician


BreakingDownSilosCross-departmental engagement andcommunication is needed for most INPACactivities.Considercarefullywhoneedstobeengaged and when. There are manydepartments and individuals that can beinvolved, such as food service, pharmacy,occupational therapy, physiotherapy, thevolunteer coordinator and many more.Appreciative Inquiry and ADKAR processescan develop the necessary buy-in from avarietyofstakeholders.

CommunicationisKeyKeepyourcommunicationswitheveryoneinvolvedsimpleandfocused.Somequestionstoconsiderinclude:

• Whatdoesthisstakeholder(management,unitstaff,etc.)needtoknow?

• Whendotheyneedtoknowit?

• Howmuchdetaildotheyneed?

• Whatquestionsdoyouhavethataremostapplicabletothem?

• Isthistherighttimetoaskthosequestions?

TopTipStartwiththebelievers-thosewhoagreethatchangeneedstobemade.Capitalizeontheirmotivationtohelpbuildcapacityandidentifyopportunitiestomakethenutritioncare

activitytheeasyandtherightthingtodo.

TopTipIntalkingtootherdepartmentsabouttheplans,askwhattheyarealreadydoingandmake

sureyoudon’tre-inventsomethingthatisalreadyworkingwell.

“Ithinkit[M2E]hasimprovedteamwork.Ithinkbecausewe’reallinittogether,it’snotjustthenursethatneedstodoit,it’snotthehealthcareaide,it’sanybodycomingandgoinginthatroom.…Anybodycanhelp,it’snotjustone

person’stask.”

-Manager


Somewaystocommunicateyourmessageinclude:

• One-on-onediscussions(preferablyface-to-face)

• Huddles

• Teamrounds

• Printedreminders/posters(ineasytoseeareasandchangedregularly)

• Brief(onepageorless)memos,newslettersore-mails(don’texpecteveryonetoreadtheire-mail)

• Informalchats

Everyone is busy. Respect the stakeholders’time;bemindfulthatover-communicatinghasadownsideiftoomanyupdatesortoomuchdetailisprovided.Thiscanbeoverwhelmingandthestakeholder may consider the change toodifficulttoaccomplishorthedetailirrelevantsotheybecomedisengaged.

There is also a fine balancewhen seeking feedback. Youwant several relevant opinions,howeverifpeoplefeelthattheirideasarenotputintoaction,thiscouldresultinlackoftrustfortheinitiative.

TopTipSeekingfeedbackandkeepingeveryoneengagedisimportant.However,justasimportantis

incorporatingthatfeedback,deciding,andmovingon.

“…youhavetofindawaytodothat[educatethem]withoutinundatingpeoplesotheysee

beyondit.”

-Nurse


Adopt

Changes need to be embedded into the routine.Startsmall.Maketheprocessaseasyaspossible.Create realistic goals that includea timelineandtargetsomomentumcanbebuiltthatwillkeeptheplanmovingforward(e.g.bySeptember1,80%ofall admitted patientswill be screenedwithin12hoursofadmissionbynursingstaff).More-2-Eatsites collected data (i.e. INPAC audits) andreportedresultstorelevantteammemberstostimulatecontinuedimprovementstomeetgoals.Rewardsuccessesandprovidecontinuedsupport to thosewhoneed it.Slowly, thechangeswillbecomepartoftheroutine.Now that a motivated, engaged group of stakeholders and teammembers interested inmaking improvements has been assembled, remember that change takes time. A slow,careful process is more likely to lead to lasting change. An example of the process foradoptingandembeddingnutritionscreeningintoroutineisprovidedinAppendix7.EmbeddingintoRoutineTobesustained,thechangeshouldbeincorporatedintotheroutine.TheModelforImprovement(seeAppendix8)andthePlan-Do-Study-Actcycle(seeAppendix9)areusefulforstartingyourchangeprocess.Keypointswhenembeddingchange:

• Determinewhomightbetherightperson/professiontoconductthetask/INPACactivity

• Findoutthecapacitylevelofthatperson/professionandhoweasy/challengingtheythinkitwouldbe

• Findoutwhatprocesstheythinkwouldworkforgettingthechangeintotheirroutine

• Trialtheactivity(e.g.screening)withafewofthestafforafewpatients(i.e.,aPlan-Do-Study-Actcycle)

• Oncetheyhavetrialedit,talktothoseinvolvedtofindoutwhatwouldmakeiteasiertodothisnew/differentactivity

“Soyouhavetostartsmall,ironoutthekinksifyouwillandthenreplicateit.”

-Manager

“Icertainlythinkthatpeoplefeelalotless,Ithink,angstknowingthatthey’retrialingsomethingforashortperiodoftimeandofitisnotgoingtoworkoutwecantweakitandmodify

itandthatit’snotsomethingthat’sfor,youknowlongerperiodsof

time.”

-Manager


• Ifneeded,adapttheprocesstomakeiteasier

• Decidewhatlevelofeducation/trainingisneededtorolloutthechange(i.e.trainingonscreeningcanbeshortandfocused,whileSGAtrainingwillrequiremoretime)

• Educatethestaffaboutthechangeandtheimpactitmayhaveontheirdailyroles

StandardizetheProcessOnceaprocesshasbeenestablished,standardizeit.Educatestaffontheprocess,reinforceby using data to ensure that the process happens the way it was planned (i.e. patientsscreened at risk are referred). A variety of techniques can be used to influence theopportunity, motivate and build capability with the aim of changing behavior to astandardized process. Examples of techniques used in More-2-Eat sites are provided inAppendix10.

When the activity is close to beingroutine, avoid micro-managing, andgive over control of the activity torelevant people. For example, oncescreening is consistently going well,the training for screening can be

incorporatedaspartofroutinenursingorientationfornewstaff.Itisimportanttorememberthatexcellencedoesnotequalperfection.Takeprideinthesuccessandconsiderhowfartheteamhascome.

TopTipTohelpembedchange,useresources,etc.thatareavailableinthehospital,suchasa

volunteerprogram,qualityimprovementspecialistorcouncils,formscommittees,decisionsupport,etc.

TopTipCommunicatesuccessesbeyondtheunittootherstakeholderssuchasrelevant

managementorregionalleaders.Thiswillkeepthenutritioncareimprovementsintheforefrontandwillbeapositivechangefortheunitandhospitaloverall.

“Ifeellikeit’sbecomingahabitnowthatwe’repayingattentiontonutrition.”



EvaluateProgressandReportResultsEvaluate progress todetermine effectivenessand if additional change is required. Reportresults to those involved (and management,when applicable). Collecting data meansattention isbeingpaidto thisnew/improvedcareactivity.IntheMore-2-Eatproject,dataonincorporationofINPACactivitiesintoroutinepracticewascollectedeachmonth.Championsthen presented the results in a variety offormatstoteammembersinvolvedinmakingthe change. Activities are perceived asimportantandrelevantwhentheyaretracked(particularlywhencomparedtobaselinedatathatwillhavebeencollected).TheINPACaudit(Appendix4)isakeydatacollectiontoolforusewithmakingchange.Considerotherideasfordatacollectionsuchasthetimeittakestocompletefoodintakemonitoring.Collecting data will also identify those ‘sticking points’ in the process that need to bereconsidered. If your strategy is not working (i.e. change is not becoming embedded),reassessandchangeyourstrategy.Astrongteamthatis‘inthistogether’willrecognizethatsometimestheyfail,evenwhentheyhaveconsultedandplanned.Thatdoesnotmeantheystop.Theygobacktothebeginning,re-thinkandrework.Passionatechampionsandcoreteammembersstickwithitwhenchangeishard.AcknowledgeAllSuccessesSupport thosemakingthechange.Acknowledgeallsuccesses–eventhesmallones.Thisrecognitionwillencouragetheteamoverall.Staffwillrecognizethatwhattheyaredoingandtheefforttheyaremakingisvalued.

Talkaboutthestrategiesusedtochangepracticeontheunitand their benefits, which may include the potential forincreasedjobandunitsatisfaction.Keepthenutritioncareimprovements visible and at the forefront for teammembers,especiallythosewhoareinfluential.Forexample,display“runcharts”ofINPACauditsfocusingonthespecificactivitybeingworkedon,sothatallstaffcanseetheresults.Considerincentives,friendlycompetitionandotherwaystomotivateunitteams.

“Well,wehavetokeepauditing.Auditsareahugething.Ifyoukeepauditingandyouseethatit’sfallentothewaysidethenyoucantalkaboutitmore.Andkeeptryingtosustaineverythingthatwe’ve

started.”


“Ithinkwemadegreatstridesintermsofmakingnutritiona

priorityonthemedicalunits,whichis

agreatthing.”

-Manager


Exampleofaunitleveldatausedtotrackratesofnutritionscreeningoveroneyear.

0% 2% 3% 0%

24%

72%77%

90% 94% 93% 89%95%

89% 90%

0%10%20%30%40%50%60%70%80%90%100%

Baseline(n=2/131)

January(n=3/60)

February(n=5/65)

March(n=8/64)

April(n=16/59)

May(n=44/57)

June(n=48/62)

July(n=55/60)

Aug(n=62/66)

Sept(n=63/68)

Oct(n=63/69)

Nov(n=59/62)

Dec(n=54/61)

Sustainability(232/257)

%ofpatients

%ofPatientsthatHadScreeningCompleted

Completed


KeepitGoing

Congratulations! You have reached your goal and made a new/improved nutrition careactivity part of the routine. But, it doesn’t stop here. Once changes are embedded intoroutine,occasionalINPACaudits,reminders,etc.areneededtomakesurethatthechangestayspartoftheroutine.Trynottolosemomentum.Theremaybeadropinperformanceofthenewpractice,butthisistobeexpected.Usedataasareasontore-engagestaffontheactivityandkeepitintheforefrontoftheirroutine.Championsneedtobetenaciouswithmakingandsustainingnutritioncareimprovements.Re-energizetheMessageChangingaprocesstakestimeandeffort.Re-energizethemessageandusevariousstrategiestokeepmomentumgoing.Takethelongview.Forthechampion,thismayresultinarolechange to support continued improvements and spread throughout the organization. Aswithotherstagesofthechangeprocess,conductoccasionalINPACauditsandprovidetimelyfeedbackoftheresults.Keepacknowledgingeffortsandcelebratesuccess.AllMore-2-EatchampionsrecognizedthatINPACauditdatawasthemostimportantwayofsustainingthenutritioncareimprovements.

Don’tLoseFocusPlan for refreshers on theimportanceofnutritiontore-ignitethe unit team. Report back theresultstoshowsuccessesandareasfor improvement. Results of smallresearch projects (e.g. dieteticinternorstudentvolunteertrackingmealtime barriers with theMealtimeAudit Tool) presented atmedicalroundsmaybeagoodwayto re-stimulate interest. Consider implementing another nutrition care activity in INPAConcethefirstoneisfirmlyembeddedasroutineintheunit.

EngageNewStaff

“Sowedecidedonadateandaprocessandacommunicationplanandyourolloutandyoukeeptalkingaboutit,keeptalkingaboutit,

keeptalkingaboutit.IttakesawhileforpeopletorememberorgraspthechangebutIthinkit’s

workingoutprettywell.”


TopTipMakethenutritioncarechangesasharedresponsibilityandanormaloccurrenceand

expectation.


Planhowtomotivateandbuildcapabilityofnewstaffforthenutritioncareactivity.Consider:

• Howwillyouensurethatnewstaffisaware,seestherelevanceof,andknowshowtocompletethenutritioncareactivity?

• Whatstandardcommunicationprocessesfornewstaffcanbeadapted?

• Doorientationpackages,trainingchecklistsfornewemployeesandotherorganizationalprocessesneedtobemodified?Ifso,how?

Usetemplatesforeducation,remindersetc.thatareprovidedontheCMTFwebsiteunderToolssotimecanbespentonimplementationactivitiesratherthandevelopmentofkeymessages.ExpandonYourSuccessSlowly start to roll out the successful changes. Remember, every unit/hospital/region isdifferentandwhatworkedinoneunitmaynotworkinanother.WhenstartingonanewunitorimplementationofanotherINPACactivity,itmaybetimetogobackto“GettingReady”.This time, you will already have learned from your previous experience, will have thesupportofunitstaffandmanagementwhohaveexperiencedthehardworkandsuccess,thuswillbealliesinimplementingchangebeyondtheinitialunit.

TopTipWhenpossible,workwiththeregion/hospitalsounitchangecanalignwith

regional/hospitalchanges.

“…Ithinkthis[M2E]isjustastart,andafterthestudyisoverweneedtocontinueandthatissomethingthat

speakstomeloudandclear,thatthisisn’tjustsomethingthatstopsafterthestudyisover.We’vegottokeepgoingandfiguringouthowwecancontinuemakingitimportant,andthatnutritionisimportant

andthatfoodismedicine.”-Dietitian+More-2-EatChampion


BecomePartoftheINPACCommunity

Doyouhavequestions,ideas,orthoughtsaboutchangesyouwanttomake?Doyouwanttolearnandsharewithothers?JointheINPACCommunityofPracticesowecanalllearntogether.

Contactinfo@nutritioncareincanada.caifyouwouldliketojointheCommunityofPractice.


Appendix

Appendix1:IntegratedNutritionPathwayforAcuteCareandguidancedocument

Appendix2:SubjectiveGlobalAssessmentform

Appendix3:AppreciativeInquiry

Appendix4:INPACAudit

Appendix5:ADKARFramework

Appendix6:Involvingeveryoneinnutritioncare

Appendix7:AStep-by-StepGuidetoImplementingChange:theexampleofembeddingscreeningintopractice.

Appendix8:ModelforImprovement

Appendix9:Plan-Do-Study-Actcycles

Appendix10:DefiningandMatchingBehaviourChangeTechniquestoInterventionFunctions:ExamplesfromMore-2-Eat.


Appendix1:IntegratedNutritionPathwayforAcuteCareandguidancedocument(Alsoavailablehere)

INPAC: Designed to support nutrition health and care

What is INPAC?

An evidence-based algorithm developed by Canadian clinicians and researchers to detect, monitor, and treat malnutrition in acute care patients.

INPAC is based on the key principle that an integrated approach – or involvement from the whole health care team – is required to treat malnutrition. INPAC is a minimum standard; institutions that provide care beyond this minimum should continue to practice at their higher quality standard.

It is recommended that each hospital establishes an interdisciplinary team to promote and sustain the nutrition culture change required to implement INPAC.

Ad

mis

sio

n

NO RISK (“No” to one

or both questions)

Well-nourished (SGA A)

Mild/moderate malnutrition (SGA B)

Food intake ≤50%

See reverse for further detail…

Food intake ≤50%

Severe malnutrition

(SGA C)

AT RISK (“Yes” to both

questions)

Day

1D

ay 1

+

Standard Nutrition Care

Advanced Nutrition Care

Comprehensive Nutrition Assessment

and Specialized Nutrition Care


Completed by dietitian or designate


Nutrition Screening at AdmissionComplete the Canadian Nutrition Screening Tool (CNST):

1. Have you lost weight in the past 6 months WITHOUT TRYING to lose this weight? 2. Have you been eating less than usual FOR MORE THAN A WEEK?

Food intake improvedFood intake improved

TM MC

INPAC: INTEGRATED NUTRITION PATHWAY FOR ACUTE CARE


Quality nutrition care and patient safety with INPAC

INPAC involves nutrition screening – followed by a subjective global assessment in individuals deemed AT RISK – to categorize patients according to the level of nutrition care that they require: Standard, Advanced, or Specialized.

This research was funded by the Canadian Frailty Network (CFN).

November 2017

Nutrition Screening at Admission

If patient answers “Yes” to both Canadian Nutrition Screening Tool (CNST) questions listed on reverse side OR if any of the following apply to the patient:• Requires enteral/parenteral nutrition• Unable to complete CNST (e.g., language barrier, altered mental status)• Transferred from critical care• Has high nutrient requirement conditions (e.g., trauma, burns, pressure injuries, SIRS, etc.)

…then follow “AT RISK” pathway (on reverse).If none of the above apply, then follow “NO RISK” pathway.

SIRS=systemic inflammatory response syndrome.


SGA is a gold standard for diagnosing malnutrition in hospitals. Dietitians or other trained professionals assess weight change, food intake, functional status, and body composition. SGA takes approximately 10 minutes.

Standard Nutrition Care• Sit patient in chair or position upright in bed• Ensure vision and dentition needs are addressed• Address nausea, pain, constipation, diarrhea• Confirm food is available between meals• Ensure bedside table is cleared for tray set-up, open packages, provide assistance and encouragement to eat• Encourage family to bring preferred foods from home• Monitor and report key clinical observations/measurements:

Food intake Duration of NPO/clear fluid intake Hydration status Body weight (preferably at admission and weekly) Signs of dysphagia

NPO=nil per os (nothing by mouth).

Advanced Nutrition Care Comprehensive Nutrition Assessment and Specialized Nutrition Care

Continue Standard Nutrition Care practices AND• Assess and address barriers to food intake • Promote intake with 1 or more of:

Nutrient dense diet (high in energy, protein, micronutrients)

Liberalized diet Preferred foods High energy/protein shakes/drinks (at/or between meals or as ‘medpass’, a small amount provided at each medication administration)

Continue Standard & Advanced Nutrition Care strategies where appropriate. Patient will undergo a comprehensive nutrition assessment completed by the dietitian, which involves:• More detailed assessment of nutrition status using

physical examination, body composition, food intake, clinical history, and biochemical markers

• Further identification of barriers to food intake (e.g., medication side effects, depression, etc.)

• Identification of eating behaviours that will support food intake

• Individualized treatment and monitoring• Enteral and/or parenteral nutrition


If patient is malnourished (SGA B or C) upon admission or during hospitalization, nutrition is an active issue in the discharge summary note (completed by dietitian, physician or nurse)• Education provided to patient and family• Referral to community resources (e.g., meal programs, grocery shopping)• Send discharge summary with patient and a copy to family physician/care provider in the community;

refer to appropriate resources in the community

For more information and details on how to implement INPAC, please visit http://nutritioncareincanada.ca/inpac/inpac-toolkit

TM MC

HOW DOES INPAC WORK?




Appendix2:SubjectiveGlobalAssessmentform(Alsoavailablehere)



Appendix3:AppreciativeInquiry

What is Appreciative Inquiry? Appreciative Inquiry (AI) can be used in INPAC implementation to create positive and productive discussions to determine what needs to be changed on the unit and how to plan for this change.

AI uses a strength-based approach, using affirmative and positive assumptions of the issue (e.g. providing quality nutrition care) and uses a 5-D cycle to help the team identify how to do things differently and make a change.

AI starts with identifying what supports nutrition care on the unit instead of what is not working.

To truly address change, the whole team needs to be engaged.

By directing attention on the positive components, such as best practices

or positive experiences, it helps the unit move towards this focus.

Application of Appreciative Inquiry There are a variety of applications for AI that

range from informal (e.g. framing a conversation with a colleague using AI principles) to organization wide interventions (e.g. AI Summit: a face-to-face large group planning meeting, such as a stakeholder meetings) AI framework applied to improving nutrition care: Element Sample Topics of Inquiry Definition What are you trying to achieve? E.g. Improving meal delivery so that food is hot

and patients have all that they need to eat. Discovery Describe a time when patients received exceptional quality mealtime care (e.g. hot

food was provided on time, a nurse was available to assist with eating, and the environment was suitable for mealtime).

Dream Imagine a system where the majority of patients receive this high quality of care and food is enjoyed and consumed, and patients leave hospital in a better nourished state. What is different in this system? What does this look like on a daily basis?

Design What could you do to create this ‘dream’ mealtime system? Delivery Design the plan to achieve the goal.

DefinitionWhatarewetryingtoachieve?

DiscoveryWhendid/doesthishappen?

DreamWhatcoulditlooklike?

DesignHowcanwecreate

thechange?

DeliveryImplementthechange

The Appreciative Inquiry Change Process (The 5-D cycle)


Appendix4:INPACAudit

TheIntegratedNutritionPathwayforAcuteCare(INPAC)AuditThe INPAC is an evidence-based algorithm for the prevention, detection, treatment andmonitoringofmalnutritioninacutecaremedical/surgicalpatients.ThealgorithmisbasedonconsensusfromleadingCanadianexperts,cliniciansandotherstakeholders(Kelleretal,2015).TheINPACAuditisatooltohelphealthcareteamstrackroutinenutritioncareactivitiesonone unit. Auditing practice will help to determine progress with the implementation ofINPACactivitiesinaunit/hospital(e.g.screeningatadmission).Theseauditsrepresentthestatusof activitiesasof theauditdate/timeandmaynot captureall activities (i.e. someactivitiesmaybecompletedlaterintheday).Howtocompletetheaudit:

• Anystaffmembercanbetrainedtocompletetheaudit

• Datacanbecollectedfromanyofthefollowingsourcesofinformation,typicallyavailableonthepatienthealthrecord:

o Ordersheets

o Assessmentforms(physician,nurse,dietitian,otheralliedhealth)

o Diagnosticrecords/reports

o Monitoringrecords

o Progressnotes

o Departmentspecificdocumentation

Note:Usethesamedatasourcesforeachaudit.Itisalsoadvisabletousethesamestaffmemberorasmallgroupoftrainedstaffmemberstocompleteaudits,toensurethatvariabilityovertimeisduetoimprovementandchangemanagementpractices.Datashouldonlybeinputtedfromwrittendocumentation,andshouldnotincludeverbalsources(i.e.ifastaffmemberverballymentionedataskwascompleted,butitisnotinthenotes,thisshouldnotbeincluded).

Whentocompletetheaudit:• Toassessbaselinelevelsbeforeimplementationofanewcareactivitybeginsitis

recommendedtocomplete2-4auditsoverarelativelyshorttimespan(e.g.2months).

• Itisrecommendedtocompletetheauditoncepermonthafterimplementationofanewactivityhasstarted.

• Tocompletetheaudit,dataiscollectedfromthedocumentationforeverypatientontheunitthatday,eveniftheyarejustadmittedorabouttobedischarged.


AuditItemClarifications:Auditorinitials:Initialsprovideanopportunityforauditorstoself-identifyifanyquestionsariseasaresultoftheaudit.Codes:Codescanbedevelopedfortheunithospital;theseshouldbeuniqueidentifierse.g.Unit3AatHudsonBayHospital.Apatientidentifier:Keepingthisidentifierasgenericwillhelptokeeppatientinformationconfidential;forexample,thefollowingidentifiestheunitandbedthatthepatientoccupiedduringtheaudit(3A1D)Dateofauditandauditnumber:Thesewillhelptokeeptrackofauditsandensurethatdataareincludedinthecorrectmonthofimplementation.

1. Patientinformation:a. Birthdate:Tokeepthedataanonymous,onlycollecttheyearofbirth(notdayor

month).Agecanbecalculatedfromyearofbirthtoprovidedescriptiveinformationonpatients.Recordsexforthispurposeaswell.

b. Dateadmittedtounit:Thisshouldbethedateadmittedtothecurrentunitonwhichtheauditisbeingcompleted.

c. Transfer:Transferinformationisusefulwhenpracticesvarybyunit,forexample,ifscreeningisnotcompletedonallunits.Indicateifthepatienthasbeentransferredfromanotherunitinthehospital(nototherhospitals).ReviewdocumentationfromthebeginningofthishospitalizationtodetermineifINPACactivitieswerecompleted.

2. Diagnoses:Listallmedicaldiagnosesthatarebeingtreated/managedaspartofthecurrenthospitalvisit,notfrompreviousadmissions.

3. Screening:Indicateifscreeningwascompletedandtheresultofrisk/norisk.Ifnotcompleted,attempttoidentifyandprovidethereason(e.g.newtounit,transferfromICU/CCUanddietitiantreatmentalreadyinitiatedetc.)

4. Subjectiveglobalassessment(SGA):Therearethreepotentialoptionsforthisquestionandonemustbecompleted.

Option1:SGAwascompleted;alsoprovidetheresultofSGAA,BorC.

Option2:ReferredforSGA,butyettobecompleted.Option3:SGAnotcompleted;identifythereason,eitherbecausethepatientwasnotatriskoranotherspecificreason.

5. Comprehensivedietitiannutritionassessment:Therearefouroptionstothisquestionandonemustbecompleted.

• Noassessmentrequiredischeckedwhenthepatientisnotatriskand/orisanSGAA/orB.Insomeunits/hospitalsSGABpatientswillberoutinelyprovidedadvancedcarestrategiesandnotautomaticallyundergoacomprehensivedietitianassessment.


• Ifoptionof‘notcompleted’isselected,thiswouldindicatetheassessmentshouldhavebeencompleted(i.e.,SGACorinsomeunits/hospitalsalsoSGAB).Provideareasonfornon-completion(e.g.palliative).

6. NutritiontreatmentofSGABorCpatients:CheckalltreatmentsprovidedtopatientsidentifiedtobeSGABorC.ONS=Oralnutritionalsupplement.Fillinadditionaldetailsif“other”isselected.

7. Foodintakemonitoring:Thisquestionhasseveralparts,dependentontheprioranswer.If7a=no,skiptoquestion8.If7b=no,skiptoquestion8.If7c=no,skiptoquestion8.For7d,provideanyactionstakenthatweretriggeredbylowfoodintake.Someactionsmayhavebeeninplacebeforefoodintakemonitoringwascompleted;onlyrecordnewactionstriggeredbythefoodintakemonitoring.

8. Bodyweight(admission):Indicateyesifabodyweightmeasurementwascompletedatadmission(notestimated).

9. Bodyweight(monitoring):Indicateyesifabodyweightmeasurementwascompletedafteradmission(notestimated).

10. Discharge:Nutritiondischargeplanningcantakemanyforms.Whatisimportanttonoteisifanysuchplanning/educationororganizationalactivitieswithrespecttodischargearenotedonthechartandotherdocumentatione.g.dischargeplanningdiscussedinroundsandspecifictomalnutrition,foodaccessetc.Tobenotedhere,thisactivityhastobespecifictonutrition.

Note:ThisauditisprovidedinWordformatsothatadditionalnutritioncareactivitiespertinenttotheunit/hospitalcanbeincludedasdesired.HowtoReportResults:

Astheaudittoolismeanttotrackprogressovertime,reportresultsbacktothehealthcareteamsotheyareawareoftheprogress.BelowisanexampleofanaudittrackingreportcreatedusingWord/Excel.

0% 2% 3% 0%24%

72% 77% 90% 94% 93% 89% 95% 89%

0%

50%

100%

Baseline…

January…

February…

March…

April…

May…

June…

July…

Aug…

Sept… Oc

t…Nov…

Dec…%

ofpatients


INPACAuditAuditorInitials:__________Unit/Hospital:__________________PatientIdentifierRoom/Bed:__________Date:______________Audit#:___________1. PatientInformation

YearofBirth(YYYY):_____________________Sex: Male Female OtherDateadmittedtounit:(YYYY-MM-DD):____________________

Wasthepatienttransferred? Yes NoIfyes,transferredfromwhere?_____________2.Specificmedicaldiagnosesthatarebeingaddressedinthishospitalization

3.NutritionScreening Completed; AtRisk: Yes No

Notcompleted:Reasonnotcompleted:___________________4.SubjectiveGlobalAssessmentCompleted:

A(wellnourished) B(mild/moderatemalnutrition)C(Severemalnutrition)

Referred,notyetcompleted

NotCompleted;Specifywhy:

Notatrisk Other:Specifyreason:________________


5.ComprehensiveDietitianNutritionAssessmentCompleted

No,notrequired(notatrisk/SGAAand/orB)Yes,requiredandcompletedReferred,notyetcompletedNotcompleted:Specifywhy?_____________

6. ActiontakentoimprovenutritionforSGABorCpatients(checkallthatapply)

NoactionONSasmedpass(smallamountofnutrientdenseproduct)ONSatothertimes/withmealsNutrientdensedietLiberalizeddietEnteralnutritionParenteralnutritionOther:Specify:_________________________

7.a.Foodintakemonitoringhasoccurred Yes Noskipto8 b.Foodintakeis≤50% Yes Noskipto8

c.Intake≤50%triggeredlocalactionplan Yes Noskipto8

d.Actiontakentoimprovenutritionwhenfoodintakeis≤50%(checkallthatapply)

Nonewaction RDconsult ONSbetweenmeals/atmedicationtimes Nutrientdensediet Liberalizeddiet Other:Specify:_________________________ 8.Bodyweight(measured)wasrecordedatadmission Yes No

9.Bodyweightmonitoringpostadmissionhasoccurred Yes No 10.HasaNUTRITIONdischargeplan/summary,education,and/orrecommendationforfollowuppostdischargebeeninitiated?

Yes No Ifyes,pleasespecifydetails:_________________________


Appendix5:ADKARFramework

What is ADKAR? • ADKAR is a model that can be used in Integrated

Nutrition Pathway for Acute Care (INPAC) implementation to support change management. This model specifically supports communication plans with unit staff, leading to acceptance of the changes being implemented as a result of following INPAC.

• Key belief: Organizational change is the outcome of cumulative individual change.

• ADKAR occurs in stages based on how staff experiences change. For example, awareness comes before desire, as staff needs to first recognize that malnutrition is a problem in their hospital. This recognition will lead to understanding that change is needed, thus create a desire to change.

ADKAR is a framework that will… • Help guide a change. It may help to clarify what steps should be taken to build desire and

succeed with the INPAC implementation. • Assist in tracking the progress of change. Each stage’s completion indicates that you are

on your way to successful implementation of INPAC with a specific group. • Helps you understand where gaps have occurred in your implementation, and provides

ideas for how they may be addressed. For example, if there is resistance to implementation of INPAC, identifying what stage the change and/or the individual staff member is at will help to identify the strategies needed to move them to the next stage of ADKAR.

"The secret to successful change lies beyond the visible and busy activities that surround change. Successful change, at its core, is rooted in something much simpler: How to facilitate change with one person." (Hiatt, 2006, p. 1)

Current

• Awareness of the need for change i.e. why is a change in hospital nutrition culture needed?

• Desire to support and participate in the change i.e. staff willingness to support the change; this is unique to the individual; what motivates staff to change?

Transition

• Knowledge of how to change i.e. having hospital staff know their specific role in making the change;

• Ability to implement required skills and behavior i.e. training is provided so staff know the problem, and are informed on how to make a change (for example, trained on how to screen for risk of malnutrition)

Future

• Reinforcement to sustain the change i.e. continued reminders of training principles and having change embedded in daily practice so change is sustained. This includes continuous monitoring to see if change is in place, and if not, what can be done to reinforce teaching.


Application of ADKAR to INPAC Implementation

ADKAR Elements

Facilitators Barriers

Awareness • Awareness of the prevalence of malnutrition (45% are malnourished on admission)

• Recognizing that those at malnutrition risk need to be diagnosed and those malnourished should receive appropriate care

• Recognizing that malnutrition and/or low food intake can increase length of stay

• Recognizing the credibility of INPAC

• Lack of understanding of the importance/prevalence of malnutrition

• Belief that changes will take a long time

• Lack of hospital support system (i.e. inability to incorporate a nutrition screening tool into the admission system)

• Lack of follow-through (i.e. screening results must link to referral)

• Miscommunication regarding reason for making a change.

Desire • Individual motivators for change i.e. belief that malnutrition is a problem in their hospital

• Acceptance or comfort with status quo and change fatigue

• Individual barriers for change i.e. perception of additional workload

Knowledge • Training materials are available for all hospitals regarding:

o Malnutrition: Definition, prevalence, outcomes and cost

o Identifying Malnourished Patients: Focus on the Canadian Nutrition Screening Tool and Subjective Global Assessment

o Becoming ‘Food Aware’ in Hospital: Strategies to improve food intake and the nutrition care culture

o The Integrated Nutrition Pathway for Acute Care (INPAC)

• Lack of time to attend training. • Difficult to access all staff (e.g. night

shifts).

Ability • The ability to apply what was learned in training to practice

• The INPAC implementation team will support application of training

• Limited time of all hospital staff (i.e. implementing certain changes may increase the amount of time doing certain tasks)

• Lack of support from hospital staff and/or management

• Lack of confidence performing SGA Reinforce-ment

• Reminders of the training • Reinforcement of changes • The INPAC implementation team

will work towards a supportive hospital structure

• All change will be monitored, and fed back to unit staff/hospital

• Change can be difficult to see, as it may not be immediate

• Lack of support from the hospital may make change more difficult

References:JeffreyHiatt.(2006).ADKAR:AModelforChangeInBusiness,GovernmentandourCommunity.www.change-management.com/tutorial-adkar-overview.htm


Appendix6:Involvingeveryoneinnutritioncare

InvolvingEveryoneinNutritionCare

Everyonehasaroletoplayinimprovingnutritioncare.HereareafewexamplesofhowALLstaffcanbeinvolved.

Leadership

• Select/helprecruitchampionsandasmallimplementationteam

• Redefinerolesforchampionorotherkeychangeagents(e.g.staffmembertocollectauditofpractice)

• Provide/secondanynecessaryresources(e.g.qualityimprovementexpert,IT)

• Clearlysupportchanges,trusttheimplementationteam

• Whererequired,supporttheimplementationteambyaddressingresistancetochangeandovercomeresistancebybeinginvolvedinmeetingswithopinionleaders

• Whenachangeissuccessfullyimplemented,standardizetheprocessthroughon-boardingofnewstaff,changingpolicyandprocedures

• HighlightsuccessesoftheINPACimplementationteamandunitsthathavemettargetsforimprovednutritioncare

• RecognizethatspreadofINPACthroughoutthehospitalandbeyond(i.e.regionally)willrequireeachunit/hospitaltotailoreachINPACactivityasneededandundergoachangemanagementprocess

Physician

• SupporttheimplementationofINPACandspecificallyscreeninganassessmentwithsubjectiveglobalassessment(SGA)todiagnosemalnutrition

• Ifaphysicianorderisneededfordietitianreferral,provideareferraltoadietitianforpatientsidentifiedtobeatnutritionriskfromthescreeningprocess

• Understandthemalnutritiondiagnosisprovidedbythedietitian(includingscoresbasedontheSGA)andplancareaccordingly

• Orderliberalizeddiets

• SayNotoNPO

• OrderMedpass(oralnutritionalsupplement)

• Avoidvisitingduringmealstodecreaseinterruptions

• Encouragethepatienttoeattopromotetheirrecovery

• Considersupplementalenteralorparentalnutritionwhenintakeisexpectedtobelowformorethanafewdays


• Considersocioeconomicissuesthatmayhaveleadtomalnutritionatdischargeandrefertoappropriatecommunityservices

• Diagnoseanddocumentmalnutrition,whenapplicable

• Includemalnutritionandtreatmentplaninthedischargenotetofacilitatethetransitionofcare

Nurse

• Screenpatientsfornutritionrisk

• Monitorfoodintakeandtakeappropriateactionforlowintake

• Encouragefoodintake

• Decreasebarrierstofoodintake,suchaspositionpatientstoeat,openingpackages,clearingbedsidetables,etc.

• Provideeatingassistancewhenappropriate

• Decreasemealtimeinterruptionsfornot-urgent/non-mealrelatedvisits

• Encouragepatientfamilyandfriendstovisitduringmealtimes

• Supportfamily/friendstobringfoodfromhomeifpatientisnoteatingwell

• Assistwithobtainingadmissionweightandmonitoringweeklyweights

Dietitian

• IncludeSGAresultaspartofthenutritionassessment

• Identifyanddocumentmalnutrition

• Determinethenutritionalcareplan

• OrderMedpass(oralnutritionalsupplement)

• Orderliberalizeddiets

• Bevisibleontheunit,includingatmealtimes

• Conduct/recommendrequiredassessmentstofurtherdefinespecializednutritioncareplan(e.g.swallowing,self-feedingability,biochemistryetc.)

• Advocateforimprovednutritioncare

• Whenimplementingchangeprocesses,providesupportbyauditingcareprocessesandfeedingresultsbacktotheteam

• ChampionimplementationoftheIntegratedNutritionPathwayforAcuteCare(INPAC);educateandraiseawarenessofnutrition

• Workwithotherdisciplinestoestablishadischargeplanandarrangerelevantcommunitysupport


HealthCareAide/Assistant

• Monitorfoodintakeandtakeappropriateactionforlowintake

• Encouragefoodintake

• Decreasebarrierstofoodintake,suchaspositionpatientstoeat,openingpackages,clearingbedsidetables,etc.

• Emptycommodesbeforemeals;provideassistancetothepatienttothewashroombeforemeals,andtowashtheirhands

• Provideeatingassistancewhenappropriate

• Encouragepatientfamilyandfriendstovisitduringmealtimes

• Supportfamily/friendstobringfoodfromhomeifpatientisnoteatingwell

• Assistwithobtainingadmissionweightandmonitoringweeklyweights

• Communicatepatientfoodpreferencestothefoodservicedepartment

Pharmacist

• Supportandfacilitatemedpass(oralnutritionalsupplement)program

• Screenpatientsfordrug-nutrientinteractions

• Optimizemedicationswhenintakeispoor(toreducenausea,vomiting,diarrhea,constipation,painetc.)

• Collaboratewithnutritionsupportteam

OccupationalTherapist

• Identifypatientswhomayhavephysicaland/orcognitiveimpairmentsthatwilllimittheirabilitytoopenfoodpackages,feedselfortopreparefood;informrelevantstaffifproblemsareidentifiedanddevelopacareplan

• Positionpatientappropriatelyformealtimesandassistwithopeningfoodpackagesifpresentbeforeamealstarts

• Educate/practicewithpatientandorstaff/caregiversregardingtheproperpositionforeating,useofadaptedutensils,howtoopenfoodpackages,walkersafetyinthekitchenetc.

• Workwithotherdisciplines,includingdietitians,toestablishadischargeplantoaddressacquiringgroceries,mealpreparation,adaptedequipment,positioning,environmentalsetupandsupportpersonsasneeded

Physiotherapist

• Identifypatientswithpoormusclemasslikelytoberelatedtomalnutrition

• Consultdietitianifmobilityisaconcernthatmayberelatedtomalnutrition

• Encouragepatientstogetoutofbedtoeatmeals


• Positionpatienttoeatandassistwithopeningfoodpackagesifpresentbeforeamealstarts

• Supporttheteambywalkingthepatienttogetanadmissionorweeklybodyweight

• Workwithotherdisciplines,includingdietitians,toestablishadischargeplanandarrangerelevantcommunitysupport

SocialWorker

• Identifypatientsatnutritionrisk(foodsecurity;groceryshoppingdonebyothers;supportsrequiredforcooking,etc.)

• Workwithotherdisciplines,includingdietitians,toestablishdischargeplanandarrangerelevantcommunitysupport

SpeechLanguagePathologist

• Assessswallowingfunctionandsuggestdietconsistencyappropriateforswallowingfunction

• Recommendleastrestrictivedietconsistencythatwillmaintainswallowingsafetyandadequateoralintake

• Workwithotherdisciplines,includingdietitians,toestablishadischargeplanandarrangerelevantcommunitysupport

FoodService

• Procure/developnutrientdensefoodoptions

• Procurenutritionallyadequateandappealingfood

• Considertheculturalpreferencesofpatientswhendevelopingmenus

• Ensurefoodisavailablethroughouttheday

• Enablefoodtobekeptontheunitoutsideoffoodservicehoursofoperation

• Ensurefoodisdeliveredontimetopreservefoodtemperatureandsofamilyandfriendscanarriveatthecorrecttimetosupportpatient’sintake

• Obtainfoodpreferenceswhenapplicable

• Monitorfoodintakewhenapplicable

• Ensurepresentationoffoodisappetizing

DiagnosticImaging/LaboratoryServices/Otherdiagnosticactivities

• Avoidconductingdiagnosticproceduresduringmealtimes

EnvironmentalServices

• Avoidcleaningroomsandfloorsontheunitwhenmealsarebeingserved• Encouragepatientandfamilytokeepthebedsidetableclearformealtrays

• Encouragepatientandfamilytokeepunconsumedfoodintheunitfridge


Patient

• Tellnursesanddoctorsifyouhavelostweightunintentionallyandareeatinglessthannormal

• Tellanurseifyouareonaspecialdiet

• Askforhelpwithsettingupyourmealtrayandopeningyourfoodpackages

• Aimtoeatasmuchaspossiblefromyourmealtray

• Ifyoudonotlikethefood,askyourhealthprovidersforotheroptions

• Askhealthcareproviderswhocomeatmealtimeforassessments/tests/treatmentstocomebacklatersoyoucanfinisheating

• Ifyouarenotfeelingwellandhaveapoorappetite,discussthiswithyourhealthcareproviders

FamilyandFriends

• Talktothenurseordoctorifyourfamilymember/friendhaslostweightandhasbeeneatinglessthannormal

• Assistyourfamilymember/friendwithsettinguptheirmealtrayandopeningfoodpackageswhenyouareavailable

• Encouragethepatienttoeatasmuchaspossiblefromtheirmealtray(especiallythehighcalorieandproteinfoods)

• Bringintheirfavouritefoodsatmealtimeifthepatientisnoteatingwell

Volunteer

• Decreasebarrierstopatientfoodintakebyopeningtheirpackages

• Encouragethepatienttoeatasmuchoftheirmealsaspossible(especiallythehighcalorieandproteinfoods)

• Provideafriendlychatduringmealtimes


Appendix7:AStep-by-StepGuidetoImplementingChange:theexampleofembeddingscreeningintopractice.

1. Thechampionneedstopulltogetherasmallimplementationteamthatcanmakedecisionsandhastherespectofhospitalmanagementandstaffe.g.nursemanagement,physicianchampion,nurseeducatorand/orimplementationexpertetc.

2. Createbuy-infromseniormanagementandotherstakeholders.Makepresentationsontheimportanceofmalnutrition,howitiscommonlymissedwithoutscreeningandthecostsofmalnutrition.PresentINPACasbestpracticeandhowscreeningisthekeyactivitythatwillensurenomalnourishedpatientsaremissed.Ifpossible,useyourowndataonmalnourishedpatientswhowerenotreferredbynursingorphysiciansthroughcurrentmechanisms.

3. Selectoneunittobeginscreeningandtestoutprocesses.

4. Selectascreeningtool(CNSTisrecommendedasitisshort,validandreliableforacutecare).

5. Considerwhofromtheunitneedstobeincludedinplanning.Itisimportanttoincludethosewhoarelikelytobekeyplayersintheactivityofnutritionscreeningandinvitetheseteammemberstoaplanninggroup.Keyplayerscouldinclude:unitdietitian,unitnurse(s),ITsupportperson(ifconsideringelectronicscreeningtools),diettechnicians(ifprocesswillincludethem),unitclerk,keyphysicians.

6. Collectsomeinitialdataoncurrentpracticetodemonstratetheneedforchangeandeventuallydemonstrateimprovedmetrics/outcomes.

7. Provideshortpresentationstounitstaffontheinitiative;useyourbaseline(initial)datatocreatebuy-inandmotivationtocompletescreening.Continuetoengagestaffthroughouttheimplementationprocess.

8. Discusswithunitstaffhowtheythinkscreeningandsubsequentreferralformsshouldbecompleted(hostadiscussiongroupwiththechampions).Usethisinformationtobuildtheinitialscreeningandreferralprocess.

9. Determinehowthetoolcanbeincorporatedintopractice:Willthisbedoneelectronicallyoronpaper?Whataretheprocessesandwhoarethekeystakeholderswhowillneedtobeinvolvedinordertofacilitatethisprocess?(Note:eachhospitalwillbedifferentanditisnecessarytoworkwithinthesystem.i.e.theFormsCommitteemaytakealongtime,sopreliminaryplanscanbeputinplacewhileworkisbeingdoneatotherlevels).

10. Trainasmallnumberofstaffonthescreeningandreferralprocessandpilottheprocessonafewpatients(keepitsmall!).

11. Discussthepilotwiththosetrained;howdiditgo,whatwouldtheychangeto


maketheprocessofscreeningandreferralworkforallpatients?Bringtheirresponsesbacktotheunitplanningteamfordiscussion.

12. Basedondiscussionoftheunitplanningteam,revisetheprocessasneeded,fixstepsthatdidn’twork

13. Pilottheimprovedprocessonafewmorepeopleforalittlelonger;collectsomedataontheprocessanddiscusswithstaff.

14. Discussresultsagainattheunitplanningteamandrevisetheprocessifneeded.

15. Continuetoexpandscreeningandreferralatarealisticrate;workatembeddingtheroutineonthisunitbeforemovingontootherunits.

16. Collectdataonincorporationofscreeningintotheroutine(e.g.%ofadmittedpatientswhoarescreenedandreferred),reportbacktotheteam/staff/managementonprogress,includingspecificsonhowtheteamhasmadeadifferenceontheunit.

17. Identifywherethereisresistanceandworkonit(i.e.iftheformsarenotbeingfilledinproperly,remindersmaybeneeded).

18. Providereminders,re-educating/re-trainingasneeded;occasionallycollectscreeningandreferralauditdatatodemonstratesustainingofpractice.

19. Celebratesuccessesalongtheway.

NOTE:embeddingSGAintopracticeshouldbedonealongsidethisprocesshoweveritisnotincludedinthisexample


Appendix8:ModelforImprovement

ModelforImprovementSaferHealthcareNow!

What is the Model for Improvement? • The Model for Improvement is composed of:

o 3 questions that define the direction, focus and context for the improvement

1. What are we trying to accomplish?

2. How will we know that a change is an improvement?

3. What changes can we make that will result in improvement?

o Plan Do Study Act (PDSA) cycles connect planning, action and learning that results from working through these three questions for an improvement (refer to Safer Healthcare Now! Improvement Frameworks Getting Started Kit (SHN) pg.7 for corresponding diagram)

• The Model is designed to be effective in large-scale implementation changes, such as the Integrated Nutrition Pathway for Acute Care (INPAC), which encourages gradual change and continuous testing (through PDSA cycles).

Forming Teams: Who should be involved?

• A champion with a core support team should lead the implementation of INPAC. The Model for Improvement suggests three types of expertise for this team:

o Day-to-day leadership: front-line staff members involved in the day-to-day processes that are affected by INPAC e.g. dietitians, nurses, foodservice

o Technical expertise: is a subject matter expert that understands key information e.g. site champion, dietitians, IT

o System leadership: hospital management sponsor that can support the team with time and resources and remove barriers within the unit or hospital

Setting Aims: What are we trying to accomplish?

• Improvement begins with a clearly defined aim, the implementation of INPAC, and the specific activities within INPAC, such as nutrition screening at admission.


• The implementation team jointly decides on activities, plans and timelines that will be focused on.

• For each activity in INPAC that you are working on implementing, specify goals/ objectives and timelines e.g. by this date, 15 nurses will have tested out the process of screening and referral and be ready to implement screening as part of their admission routine.

• Details on what activity you are attempting, your goals and a timeline should all be recorded.

Establishing Measures: How will we know that a change is an improvement?

• Record evaluation measures, which capture changes made on a patient care unit as it moves towards implementing INPAC.

• These include:

o Outcome measures: These measures describe the changes in care that have resulted from implementing INPAC, and how completely INPAC has been implemented. For instance, the INPAC audit captures these outcomes and demonstrates the fidelity of the site to INPAC e.g. proportion of patients screened at risk who are referred to SGA; proportion of SGA-B patients who received Advanced Nutrition Care strategies etc.

o Process measures: These measures describe how the change occurred. For example, a staff knowledge and attitudes at baseline and after the implementation phase can provide valuable information. It is anticipated that improved knowledge and attitudes will lead to improved practices captured in the INPAC audit. Implementation teams can create a variety of process measures as they are implementing a specific activity (e.g. time audit for monitoring food intake).

o Balancing measures: These measures assess other parts of the system to determine whether new problems are being created with the implementation of INPAC and what are barriers to implementation. Discussion groups with staff can be a way to collect this information. Resource utilization tracking (how much time a task is taking, new staff involved etc.) is another means.

• To help implementation teams understand the changes happening within the unit, INPAC audits can be conducted and results discussed with staff on the units.

Developing and Testing Changes: What changes can we make that will result in improvement?

The implementation team will meet routinely to identify what and how changes should be made in the unit routine to provide nutrition care in line with INPAC. During their meetings they will review collected data, brainstorm and be creative to consider how to make a specific change they want to implement e.g. how will we monitor food intake for patients? It is important that they


also consult with staff members on the unit about what desired changes and ways of implementing could work.

Observing how a process currently occurs (e.g. tray delivery) can be part of this planning. Hosting a discussion group at lunch with staff to get their input is a way to not only let staff know about the initiative, but also solicit ideas. The site implementation team may also informally interview staff, patients and others to more fully understand a process or get ideas on how routines can be changed towards the best practice of INPAC.

Testing a Change: The aim of testing a change is to increase confidence that the change will be an improvement from what is currently done. Testing involves trial and error until a process ‘works’ and is fully implemented. For example, the unit may trial different ways of supporting patient set-up for meals before deciding on the best way to do this activity consistently and in a way that is sustainable. Tests can fail, but implementation should not. PDSA cycles are used to conduct these tests. Refer to Safer Healthcare Now Fig 2, p.8 for flow chart depicting sequential flow of knowledge in this process.

Implementing a change occurs when the site implementation team believes that they have sufficiently figured out the process with unit staff to carry out a specific INPAC activity. The aim is for the change to become permanently integrated into the nutrition care processes of the unit.

PDSA cycles may still be used to manage a change until it is fully implemented. It is important to communicate with those on the unit that have been affected by the change to: understand why they may be resisting a change; to publicize the improved practices and results; and show appreciation for their dedication to improving nutrition care for patients. For example, provide positive feedback when staff is observed making the change and celebrate achievement of milestones.

In the implementation step for the change, it is also important to design the system around the activity so that it is to complete and difficult for staff to return to former routines.

Sustaining a change after implementation requires purposeful activities. The goal is to prevent unit staff from returning to old practices. These sustainability activities usually involve:

• Monitoring outcomes (e.g. the INPAC audit will monitor key activities)

• Integrating the change into daily processes (e.g. talking about screening or INPAC food intake monitoring at staff rounds)

• Changing job descriptions or unit/hospital policies

• Assign responsibility for monitoring sustained activities to a leader in that staff group e.g. senior diet technician or dietitian monitors unit and diet technicians process with respect to INPAC food monitoring


Spreading Success: Once INPAC is implemented and sustained in one unit, spreading this improved practice to other units in the hospital is the ultimate goal. Success within individual units will lead to spread throughout the organization. Key to promoting spread is to highlight that:

• The team has tested, implemented and sustained the INPAC on the test unit.

• Senior management desire spread beyond the single unit. The evidence from the More-2-Eat study can support decision making for these leaders.

• The improvement of nutrition care is important in the hospital because quality improvement of nutrition is a priority beyond the test unit.

• A senior leader is assigned accountability to spread INPAC to other units.

Refer to table on Safer Healthcare Now p.33 for common mistakes when spreading changes and strategies to overcome these barriers.

TheModelforImprovementhelpstodevelop,implementandsustainaqualitypractice,suchastheINPAC,topromotepatientsafetyandcare.

Basedon:ImprovementFrameworks.GettingstartedKit.CanadianPatientsafetyinstitute2011.www.saferhealthcarenow.ca/EN/Interventions/Pages/default.aspx


Appendix9:Plan-Do-Study-ActcyclesPlan Do Study Act (PDSA) Cycles

• Throughout INPAC implementation, the champion and implementation team can

conduct a series of PDSA cycles.

• Record the ‘Plan’ in the PDSA cycle. What are we trying to accomplish etc.

• The ‘Do and Study’ portions of the PDSA cycle are the testing, which allows the unit to attempt to change activities in a small sample, determining how best to implement components of the INPAC before the process occurs for all patients.

• Testing allows for trial and error, with some strategies failing, but providing information to support the next test.

• ‘Act’ in the PDSA cycle is when the unit uses the results of the test to change the activity or move on to implementation.

• A site will move into the implementation phase for an INPAC component when testing (e.g., a few patients are screened) has been sufficient to provide confidence that full implementation will be successful (e.g., all patients are screened at admission.

• Several PDSA cycles will likely occur before implementation of an INPAC component is undertaken.

Plan

• What are we trying to achieve? • For example, have all patients been screened for malnutrition at

admission.• Current Plan: Start small with a couple of nurses

Do• Test your plan• Have 1 or 2 nurses screen a few patients

Study• What worked? What didn't? • What do the nurses think of the screening tool? What is easy to use?

Time consuming? What could be improved?

Act• Can you increase the number of patients screened? Do you need to

replan your strategy?

PDSA Cycles are used to build knowledge of the implementation process and translate that learning into action. - Safer Healthcare Now

Basedon:ImprovementFrameworks.GettingstartedKit.CanadianPatientsafetyinstitute2011.www.saferhealthcarenow.ca/EN/Interventions/Pages/default.aspx


Appendix10:DefiningandMatchingBehaviourChangeTechniquestoInterventionFunctions:ExamplesfromMore-2-Eat.

InterventionFunction

MostCommonBehaviourChangeTechniques(BCT)

Definition BCTsusedinM2E

Education

Informationaboutoutcomesorconsequences

Providedetailonwhathappensasaresultofthenewactivityorbehavioure.g.malnourishedpatientsidentified,healthimprovement,qualityoflife

Education/informationsessionsforstaffonconsequencesofimprovedscreening/assessment/improvednutritioncarepractices,etc.

Feedbackonbehaviour/activity

Monitorandprovidefeedbackonperformanceoftheactivity

Education/informationsessionsonaccuracyoffoodintakemonitoring,SGA.

Feedbackonoutcome(s)ofthebehaviour

Monitorandprovidefeedbackontheoutcomewhenbehaviourisperformed

Unitauditsonnumberofpatientsscreened,assessed,referredfordietitianassessment,weighttracked,etc.

Prompts/cues

Introduceastimuluseitherenvironmentalorsocialthatpromptsorcuesthebehaviour;donewhereorattimebehaviourisdone

Postersonunittoremindstafftoscreen,removepatientbarrierstofoodintake,monitorfoodintake.Flagsincharttoincludemalnutritionasaconditionfortransitionnoteanddischargeplanning.Postersforfamilymemberstoencouragestayingformealtimes.

Self-monitoringofbehaviouroractivity

Establishamethodforthestafftomonitorandrecordtheirbehaviour

Trackingsheetsonpatientdoorforstafftofilloutaftermonitoringfoodintake,andsignforactiontakeniffoodintake≤50%

Persuasion

Crediblesource

Verbalorvisualcommunicationfromacrediblesourcethatfavoursthebehaviour

CanadianMalnutritionTaskforcewebinars;CanadianMalnutritionWeekvideos/materials


(oragainstbehaviourtryingtostop)

Informationaboutconsequences

Feedbackonbehaviour

Feedbackonoutcome(s)ofthebehaviour

AsaboveunderEducation

CNSTtrackingcompletiondatacompiledandputonpostersinvariousareasforstafftosee;weeklyupdateemailsenttostaffre:CNSTauditingPatientstoryofnegativeconsequencestoapatient,suchaslongerlengthofstay,duetonotscreening.

Incentivisation

Feedbackonbehaviour

Feedbackonoutcome(s)ofbehaviour

Self-monitoringofbehaviour

AsaboveunderEducation

Friendlycompetitionbetweenunitteamstocompleteactivityfor100%ofpatients

Monitoringofbehaviourbyotherswithoutevidenceoffeedback

Observeorrecordbehaviourwithoutstaffmember’sknowledge

AuditsoftrackingsheetsforvariousINPACactivitiese.g.nursingprovidinginitialswhenmakereferraltodietitian

Training

Demonstrationofthebehaviour

Observablesampleofhowthebehaviouristobeperformed.Canbein–personorvideo/pictures.

SGAtraining,foodintakemonitoringtraining,laminatedposterstoindicatelowfoodintakewhenmonitoring

Instructiononhowtoperformabehaviour

Adviceorwrittenagreementonhowtoperformthebehaviour

WritteninstructionsatnursingstationastohowtoidentifyapositivescreenwithCNSTandmakeareferraltothedietitian

Feedbackonthebehaviour

Feedbackonoutcome(s)ofbehaviour

Asabove Asabove



Behaviouralpractice/rehearsal

Thestaffmemberispromptedtopracticetheperformanceofthebehaviouroneormoretimestoincreasehabitandskill.Donetypicallyinahypotheticalcontext,nota‘liverun’.

SGAtrainingwithdietitians,foodmonitoringbyfoodservicestaff,volunteertrainingonopeningpackages

Environmentalrestructuring

Addingobjectstotheenvironment

Objectsaddedtoenvironmenttomakeiteasiertopreformbehavioure.g.redtraytosignalapersonneedsassistancewitheating

Whiteboardsabovepatientbedstoindicatewhatapatientneedstofacilitateeating(ie.Dentures,glasses,etc.)

Prompts/cues

Asabove Includecheck-offboxesonCNSTforscore,dateandsign-offbystaffthatcompleted.

Restructuringthephysicalenvironment

Changethephysicalenvironmentinordertomakeiteasiertoperformthebehaviouronaroutinebasis;createbarrierstoundesiredbehaviour

EmbedscreeningtoolintoMARornursingformstofacilitateroutinecompletion.

Modelling

Demonstrationofthebehaviour

AsaboveunderTraining

AsaboveunderTraining

Enablement

Socialsupport(unspecified)

Providesupportamongcolleagues/staffmembers;encourage,counsel,praise,rewardperformanceofbehaviour

Frequentstaffhuddlestoencouragestaffandpraisesuccesses.

Socialsupport(practical)

Colleagues/staffprovidepracticalhelptosupportbehaviour

Allstaff/disciplinesinvolvedinfoodintakemonitoring,teamworkingtogetheronweightdays


Adaptedfrom:MichieS,AtkinsL,WestR.(2014)TheBehaviourChangeWheel.Aguidetodesigninginterventions.GreatBritain:SilverbackPublishing.

ofotherstafftodothebehaviour

togetbodyweightcompletedonallpatients

Goalsetting(behaviour)

Agreeonagoalwiththestaff;defineintermsofbehaviourthatwillbeachieved

Teamsdevelopedtargetgoalsforkeyactivitiesthatwerebeingimplementede.g.timedeadlineforscreeningofadmittedpatients

Goalsetting(outcome)

Agreeonagoaldefinedintermsofapositiveoutcomeofdesiredbehaviour

Goalsettingtoreducemealtimebarriers,reducedaveragetimethatapatientisNPO

Problemsolving

Analysefactorsthatinfluencethebehaviour;considerhowtochangebehaviourwithvariousstrategiesthatovercomebarriersorincreasefacilitators

Gatherinfofromdietclerksregardingcurrentscreeningprocesses,barriers,facilitators,andhowtomakeroutine;MonitoringrateofNPOmeals/daytoseeifthisisasignificantbarriertofoodintake

Actionplanning

Detailedplanningofhowthebehaviourwillbeperformed(e.g.situation,frequency,duration,intensity)

MappingoutscreeningtoSGAtriagingprocess;gettingstaffinputonwhichformswouldbepreferredtouseforfoodintakemonitoring.


Restructuringthephysicalenvironment

Asabove Asabove

Reviewbehaviour/outcomegoal(s)

Reviewbehaviour/outcomegoalsjointlywiththestaffmember(s)andwhererequiredmodifythegoalorbehaviourchangestrategybasedonachievementtodate

Reviewofaprocessnotworkinge.g.foodintakemonitoringtodeterminehowitcanbestreamlinedandsimplified


ForaccesstotheToolsandResourcesthataccompanythistoolkit,pleasevisit:http://nutritioncareincanada.ca/inpac/inpac-toolkit

Documents

Integrated Nutrition Pathway for Acute Care (INPAC ...nutritioncareincanada.ca/sites/default/uploads/... · The Integrated Nutrition Pathway for Acute Care (INPAC) is an evidence