Can NCP be implemented without government or organizations enforcing implementation?

"You've convinced me. Now go out and make me do it."  This statement was made by Franklin D Roosevelt, 32nd President of the United States (1933-1945) when he met with supporters and asked for their grassroots support for his government programs.  
Perhaps this quote applies to one of the questions posed by participants in the MEDNA survey which was about the need for "enforcement" in order to successfully implementation of the Nutrition Care Process and standardized terminology.  

The NCP Model diagram clearly acknowledges the importance of the healthcare environment as it impacts the NCP ( it is specified in an outer ring).  Certainly support from government ministries, agencies that regulate healthcare, and professional organizations is highly desirable and will greatly facilitate the speed with which the NCP implementation and use of the standardized terminology can occur. Dietitians must be knowledgeable of their healthcare environment to determine how to best approach the implementation so that it is consistent with existing regulations in their healthcare systems.  

But since the NCP is the thinking process that the dietitian uses as they provide care, this aspect of our profession practice is rarely completely controlled or enforced by a governmental agency or professional association.  The same is true of the words (standardized terminology) that is used in our documentation in the medical record to describe the nutrition care that we provided.  Governmental agencies and professional societies/organizations often do not have the authority or desire to control a practicing dietitian at this level of detail.  So while support is highly desirable, it is not likely that "enforcement" is required prior to starting implementation of  the NCP and standardized terminology.

For example in the United States, the Academy of Nutrition and Dietetics fully supports the NCP implementation, but  does not have any authority to actually "enforce" the actual implementation in daily practice.  Position papers, practice papers, books, publications, and evidence based guidelines provided by the Academy to assist dietitians in practice now reflect the Nutrition Care Process.  The Commission of Dietetics Registration includes it in the national registration examination along with the other topics.  ASCEND, the accrediting body for dietetics education programs, also includes it in the standards of education, but seeking accreditation is technically a voluntary process.  The incorporation of the NCP into these processes and documents has taken a decade.

In the United States, the use of the NCP and standardized terminology are not in conflict with governmental regulations or other healthcare standards.  In fact, the use of the NCP is helpful in meeting accreditation standards by The Joint Commission that require that a standard approach to nutrition care be followed.  

The Clinical Dietetics manager typically would have a key leadership role in directing the dialogue about how the NCP and standardized terminology should be used in their facility. However we have found that dietitians at all levels in the organization have taken the lead in learning about the NCP,   bringing up the topic,  educating others on the topic,  and being the ones that "experiment" with implementation.  One of our first implementation sites in the United States was started by a dietetic intern who was assigned to provide an "inservice" to the dietetics staff on the new concept of nutrition diagnosis.  Her inservice project provided the impetus for implementation and eventually the publication of the article that described their implementation process. (See article listed below)

In the end, it is up to the healthcare organization that actually hires and directs the work of the dietitian to set the job performance standards and "ensure" that the NCP and standardized terminology are implemented.  The hospital or healthcare organization develops the position descriptions, determines if they will audit the records for completeness and accuracy of nutrition care, and establishes the scope of practice for the dietitian in their organization.  

Bottom line:   the healthcare organization that employs the dietitian usually has the most influence on the actual implementation process.  

Mathieu, J, Foust, M, Oullette, Implementing Nutrition Diagnosis, Step Two in the Nutrition Care Process and Model: Challenges and Lessons Learned in Two Health Care Facilities.  J of Am Diet Assoc 105(10):  2005.  P 1636-1640  http://dx.doi.org/10.1016/j.jada.2005.07.015

“We are stuck with technology when what we really want is just stuff that works.” NCP & EHRs

“We are stuck with technology when what we really want is just stuff that works.”  quote from -- Douglas Adams, author of The Salmon of Doubt.
We have a love-hate relationship with technology...especially Electronic Health Records (EHR).  It would be nice if someone just came up with the perfect answer for how to incorporate NCP into an EHR.  But, there are almost as many ways to incorporate the Nutrition Care Process and terminology into the E H R as there are dietitians.  You can start incredibly simple or it may require extensive  programming by informatics specialists.  Your organization needs to determine what will best meet your needs.

On the simplest end of the continuum, a template can be developed with standard headings with "free text boxes" to prompt the dietitian as they write their progress note.  As shown below, the dietitian then simply types in the data and information just as he/she might write a note long-hand but uses the terminology as appropriate.  Sample headings shown below:

• Assessment/Re-Assessment
• Monitoring and Evaluation Data (Follow-up Note only)
• Nutrition Diagnosis
• Status of Previous Nutrition Diagnosis (Follow-up Note only)
• Nutrition Prescription
• Nutrition Intervention
• Plan for Monitoring and Evaluation

The purpose of this type of template would be to assist the dietitians in remembering to follow the process and document their care using the standardized terminology.  However it provides only extremely limited ability to capture data to use for reporting outcomes management or summarizing the type of nutrition care being provided in the institution.  It relies completely on the dietitian to remember and use the correct terms.  If you are able to recall reports, the "data files" will be the free text and someone will have to go through and create "countable data" from each file manually in order to summarize.  The types of things that might be useful would be the percent of patients where the Nutrition Diagnosis is improved or resolved, the frequency of nutrition diagnoses, frequency of nutrition interventions.  This is clearly not optimal and does not harness any of the benefits of the electronic health record!!

On the other end of the continuum would be the capability to program decision support prompts to help the dietitian enter patient care, similar to what the Academy of Nutrition and Dietetics Health Informatics Infrastructure (ANDHII) system does.  It automatically incorporates the data fields, data terms for Nutrition Diagnosis, Nutrition Intervention, and Monitoring and Evaluation.  And it "prompts" the dietitian with the most common etiologies, signs and symptoms and intervention to match the nutrition diagnosis/etiology.  This type of "smart" system will yield the most benefit in terms of saving time and allowing the users to create meaningful reports and analyze data to answer key questions about outcomes.   

The website contains a number of short videos that describe how the ANDHII works so a person can visualize the potential capabilities.  The best video to start with might be the overview of the Smart Visit.  When you see the demonstration of the Nutrition Diagnosis you will see that ANDHII automatically pre-populates suggestions for etiologies and signs and symptoms. 

The solution for your organization is likely somewhere in between these two extremes.   If you need help learning about how to work with electronic health records a toolkit (one per institution) was created for dietitians is available in the Academy "shop".

Please share your experiences in incorporating both NCP and the terminology into electronic health records!!

References:

Murphy, W, Steiber, A.  A New Breed of Evidence and the Tools to Generate It: Introducing ANDHII

Journal of the Academy of Nutrition and Dietetics, 2014:115(1)p 19-22  

DOI: http://dx.doi.org/10.1016/j.jand.2014.10.025

Like Hand in Glove...The Evidence-Based Nutrition Practice Guidelines and NCP go together!!

The Evidence Based Practice Guidelines published on the Evidence Analysis Library are organized by the steps in the Nutrition Care Process.  The specific project on the EAL that discusses critical care is called the Critical Illness project.  

On the introductory page to the project the Executive Summary is available to the public.  The recommendations are organized into Nutrition Assessment, Nutrition Intervention, and Nutrition Monitoring and Evaluation.  

Recommendations that are included in the Nutrition Assessment section include the following topics:

• Assessment for Critically Ill Patient (identifies the types of data to be collected and evaluated)
• Reassessment of Critically Ill Adults (identifies the data commonly used in re-assessments)
• Resting Metabolic Rate Predictive Equations for Non-obese Critically Ill Adults
• Resting Metabolic Rate Predictive Equations for Obese Critically Ill Adults

Recommendations that are included in the Nutrition intervention section include the following topics:

• Nutrition Prescription for Critically Ill Adults (identifies what should be included)
• Enteral vs Parenteral Nutrition (includes when indicated and contra indicated)
• Use of Promotility Agent (identifies when they are recommended)
• Enteral Formulas Containing Immune-Modulating Nutrients in Patients without ARDS or Acute Lung Injury
• Enteral Formulas Containing Immune-Modulating Nutrients in Patients with ARDS or Acute Lung Injury
• Addition of Fiber to Enteral Nutrition to Reduce Diarrhea
• Supplemental Enteral Glutamine (summarizes research and identifies one potential target population)

Recommendations that are included in the Nutrition Monitoring and Evaluation Section are: 

• Monitoring and Evaluation of Critically Ill Adults (includes data  to be used)

If  you are a member of the Academy of Nutrition and Dietetics or if you subscribe to the Evidence Analysis Library, the systematic reviews and other supporting materials are also available.  

BOTTOM LINE:  The Nutrition Care Process steps are used to organize the recommendations for care in the Evidence Based Nutrition Practice Guidelines for Critically Ill Patients.  

Just do it!!! NCP and IDNT can be implemented without an electronic health record.

Dietitians who completed the MEDNA survey wanted to know if it was necessary to have an electronic health record before implementing the Nutrition Care Process.  Good news....there is no need to wait for implementation of an electronic health record to start using the Nutrition Care Process and standardized language.  They both can be implemented with or without electronic health records.

NUTRITION CARE PROCESS
Dietitians can use the nutrition care process to guide their thinking process and approach to nutrition care regardless of type of medical record being used. Often some (but not all) the activities outlined in the Nutrition Care Process are already being done by the dietitian.  The one step that may be missing in the past is the Nutrition Diagnosis step.  This is the step where dietitians formally define the nutrition problem(s) that they will be addressing.  The activity is summarized in a Problem-Etiology-Signs and Symptoms (PES) statement.

DOCUMENTATION
Healthcare institutions have policies and procedures that guide the type of documentation that dietitians can enter in the paper medical record as well as what section of the medical record the documentation is stored.   Documentation can be structured in a variety of formats.  Dietitians may find it easier to ensure that all the steps of the nutrition care process are documented if the documentation structure follows the nutrition care process.

Nutrition Care Process steps and standardized language can be incorporated into a variety of nutrition progress notes:  Narrative, Subjective-Objective-Assessment-Plan (SOAP), Subjective-Objective-Assessment-Intervention-Evaluation-Response (SOPIER) Problem-Intervention-Evaluation (PIE), Assessment-Diagnosis-Intervention (ADI) or,Assessment-Diagnosis-Intervention-Monitoring and Evaluation (ADIME). or FOCUS notes with separate data, action and response for each "focus".
Examples showing the information in Narrative, SOAP and ADIME formats are posted on the Academy website.  While some information is available to all, these examples are currently only available for Academy members.

Dietitians may also have separate templates for different types of documentation.  For example they may have a separate nutrition assessment form that collects all the data used in the nutrition assessment.  This form may be stored in a separate part of the medical record, just as the laboratory reports or radiological reports are stored separate from the medical progress notes.  See the previous blog about where the activities of each of the nutrition care process steps might be included in the various progress note formats: What Nutrition Progress Notes look like or Form follows function.  Toolkits are available for purchase that include examples of progress notes.

  But the biggest benefits occur when the standardized language is embedded in electronic health record software and the information entered in the progress note is collected as data that can be "counted" and reported.  When the terminology is embedded in an electronic health record, the E H R templates can prompt the dietitian for common data entries,  the data from the E H R can be summarized into reports and provide data for dietitians to use in evaluating the outcomes and characteristics of their nutrition care.  Multiple templates can be created with "smart" applications that assist dietitians as they provide care.

BOTTOM LINE:  You can start using NCP and standardized terminology any time, however the biggest benefits will occur when the electronic health records incorporate the terminology and process into documentation templates.