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.

Inquiring minds want to know...How many countries are using NCP and IDNT?

Participants in the MEDNA pilot survey asked how many countries other than the US are using the NCP and IDNT (Nutrition Care Process Terminology)?  While we don't have a complete answer for exactly how many countries are currently using it or the extent of the use, here are some links to what has been posted on a number of websites relative to the Nutrition Care Process and standardized language in countries other than the US.

The International Confederation of Dietetic Associations (ICDA) has posted their support for the concept of having a global process that describes how dietitians approach nutrition care.  They have a tab on the ICDA home page for the NCPT and states “The Nutrition Care Process being promoted by the International Confederation of Dietetic Associations provides a framework for nutrition and dietetic practice”. 

The European Federation of Associations for Dietitians (EFAD) has also posted a document summarizing their thoughts called the Vision paper: The implementation of a Nutrition Care Process (NCP) and Standardized Language (SL) among dietitians in Europe.  The Professional Practice Committee recommends that all national dietetic associations "support the access and use of a chosen Nutrition Care Process/Dietetic Process (NCP) model and a SL developed for dietitians."  

The DietitiansAssociation of Australia website includes a document, Health Informatics and e-health, outlining their support for the standarized language saying that " A working party has now been formed to facilitate the the implementation of Nutrition Care Process Terminology (NCPT, formerly IDNT) in Australia" 

British Dietetic Association includes the statement that "The BDA has approved the adoption, with adaptations, of the international Nutrition Care Process Terminology (NCPT) as the preferred standardised language (terminology) for use in electronic records" in their document Nutrition and Dietetic Process Terminology.  Another document Model Process for Nutrition and Dietetic Practice states "The BDA believes that the implementation of the Process for Nutrition and Dietetic Practice is important as it enables you to show how you deliver effective and quality nutrition and dietetic services".

Dietitians of Canada discusses the need for NCP and Standardized language in a public policy statement called Canadian Perspectives on the Nutrition Care Process and International Dietetics and Nutrition Terminology .  They state  " The Nutrition Care Process (NCP) and International Dietetics and Nutrition Terminology (IDNT) are recommended by the International Confederation of Dietetic Associations for international adoption as a framework for dietetic practice" 

The Swedish Dietetic Association has fully supported the NCP and IDNT/NCPT and has issued a position statement, POSITION STATEMENT - NCP and IDNT,  that  "recommends the implementation of NCP and IDNT" and included a translation of key parts of the model description and terminology in Swedish on the ENCPT. 

Venezuela published an article, Nutrition Care Process and Model from the American Dietetic Association;  useful tool for nutrition transition countries by Marianella Herrera in 2010 

According to a website from Fukuoka Womens University, Professor Yoshinori Katagiri reported being at 2014 member of a Working Group of the Japan Dietetic Association for reviewing Nutrition Care Processes.  

Two documents summarize published research on use of NCP in other countries (Korea and Venezuela). A summary of research evaluating the use of the NCP use in Korea, A Survey on the status of Nutrition Care Process Implementation in Korean Hospitals by Kim and Baek was published in Jul 2013
A description of research conducted in Venezuela for childhood obesity prevention,  Going International:  Using Kids Eat Right to Address Childhood Obesity and Under nutrition Part II   by Marianella Herrera shows how to use INDT in describing their intervention. 

The Academy International Nutrition Care Process website includes a place for countries to share documents.  This tab includes a Venezuela implementation plan (under Documents, Implementation) 

While this list certainly is not inclusive, it gives a glimpse into what other countries are doing relative to the NCP and standardized language. 

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List of Links Embedded in Message:

ICDA - http://www.internationaldietetics.org/

EFAD - http://www.drf.nu/wp-content/uploads/2014/08/EFAD-Prof-Practice-Committee-2014.pdf

http://daa.asn.au/for-health-professionals/daa-committees/health-informatics-and-e-health/

https://www.bda.uk.com/professional/practice/terminology https://www.bda.uk.com/professional/practice/process

http://www.dietitians.ca/Dietitians-Views/Health-Care-System/NCP-and-IDNT.aspx

http://www.dietitians.ca/Downloadable-Content/Public/hospitalcare-position-paper

http://ncpt.webauthor.com/

http://anales.fundacionbengoa.org/ediciones/2010/2/?i=art6)

http://www.fwu.ac.jp/teachersdatabase/detail/english/?masterid=79&gakkaid=203&gakubuid=20

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3728464/

http://files.abstractsonline.com/CTRL/DE/9/B9B/F2E/1E8/41D/F82/583/074/54C/F84/87/a952_1.pdf

http://aincp.webauthor.com/

If I'm new to the Nutrition Care Process (NCP) and IDNT, where do I start?

A recent survey in Middle Eastern countries asked dietitians and nutritionists about their awareness, knowledge and use of the Nutrition Care Process and the standardized terminology.  They also identified questions they would like answered.  One of the questions was:  "If I am new to the Nutrition Care Process (NCP) and IDNT, where do I start?"  

There are a lot of resources available to you at no charge.  Some of these are located on the Academy of Nutrition and Dietetics and are available to you even if you are not a member of the Academy of Nutrition and Dietetics.

One of the first things you may want to do is to check out the Academy's website for Nutrition Care Process information for Health Professionals   It is located at:  health professionals information on the eatright.org website. (http://www.eatright.org/HealthProfessionals/content.aspx?id=7077)  

Another source of information is to the International NCP page, which is free to all and allows for discussion of international implementation issues at http://aincp.webauthor.com/ .  Although the website asks you to "register" there is no fee associated with registration and use of the site at this time.

When you access these sites, a way to get started might be the following:
1) read the article , Nutrition Care Process, Update Part 1, that describes the current model and the content of each of the steps.  This is a comprehensive description of the entire model as well as the steps in the nutrition care process.

2) Then read each of the snapshots as a review of the article's high points.  These are intended to be quick and easy references for each of the steps.  This document downloads 4 pages, a one page summary for each of the four steps in the nutrition care process:  Nutrition Assessment, Nutrition Diagnosis, Nutrition Intervention, and Nutrition Monitoring and Evaluation.

3) After getting an overview of the Nutrition Care Process, then you may want to read the article about the standardized language,  Part 2 of the Nutrition Care Process Update.  This article summarizes the way the terminology was created, organized and the basics on how to use it.

4) At this point you may want to find someone who is using it that you can discuss with them, or you may want to start looking at cases to see what it looks like in practice and will likely want to attend a workshop where you use cases to work with applying the NCP and terminology.  You could also read older blog issues on specific topics that you find challenging.

 If this was your question, please let me know if this was helpful.

If a picture is worth a thousand words...what is a "model" worth?

Lets examine the various components of the Nutrition Care Process and model...starting with the CORE of the model...the patient-dietitian relationship.  
Open access has been provided to an article that traces the history of one line of thinking that clearly influenced the formal development of the Academy of Nutrition and Dietetics' Nutrition Care Process and Model.  The article lays out the historical evolution of the dietetics teaching models that occurred at Pennsylvania State University starting in the 1970's and identifies the body of knowledge that was used to articulate some of the key concepts.

For example, this article traces the evolution of the core (center) of the model...the relationship between the dietitian and the client.

In the original hand drawn model the core/center of the model was just the words "dietitian" and "patient" with arrows indicating a two way interaction.   In the 1977 Hammond model the core depicted "The Helping Relationship, Rapport, empathy listening, objectivity, etc" and the concept reflected drew heavily on Dr Steven Danish's work at Pennsylvania State University from the Psychology department.

 In the 1984 Hammond model the core was depicted as a "Partnership" between the clinical dietitian and the patient/client with the two way interaction arrows.  In the 1986 model core was depicted as a "Partnership of Individuals" again listing the clinical dietitian and patient/client as those involved. As Marian Hammond described the thinking at the time, this notation reflected the belief that "each member’s individuality affected the partnership dynamics, process, and, most likely, quality of outcomes."

Later, both the original 2003 and the updated 2008 Academy of Nutrition and Dietetics (then called the American Dietetic Association)  models have the core of the model designated as the "Relationship between the patient/client/group and the dietetic professional".

Occasionally people ask whether the Nutrition Care Process is really patient-centered or client-centered. While it certainly it takes more that one component in a model to truly fulfill the concept of "patient centered-ness",  this evolution clearly shows the intent for the model to recognize the importance of putting the patient/client at the very "core" of the whole process.  

Hammond, M, Myers, E, Trostler, N. Nutrition Care Process and Model:  An Academic and Practice Odessey.  J Academy of Nutr and Diet, 2014.  FREE FULL TEXT LINK

Danish SJ. Developing helping relationships in dietetic counseling. J Am Diet Assoc. 1975;67(2):107-110.

Danish SJ, Ginsberg MR, Terrell A, Hammond MI, Adams SO. The anatomy of a dietetic counseling interview. J Am Diet Assoc. 1979;75(6):626-630.

LaQuatra I, Danish SJ. Effect of a helping skills transfer program on dietitians’ helping behavior. J Am Diet Assoc. 1981; 78(1):22-27.