Friday, January 23, 2015

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

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