The community nutrition support team of dietitians provides dietetic care for adults with disease-related malnutrition and those requiring home enteral feeding for the whole of the city of Birmingham, UK, and is committed to individualised care close to home.
The dietetic care involves patient-centred initial consultations for new patients referred into the service and on-going regular reviews. All consultations require a detailed nutritional assessment and the development of an individualised care plan, based on the patient's concerns, clinical findings and social circumstances from the assessment, in order to ensure the best quality of care and outcomes.
This clinical audit and improvement plan has evolved over a 9-year period using NICE CG32 and QS24 as a basis to improve the quality of dietetic patient care for both adults with disease-related malnutrition and those requiring home enteral feeding under the care of the team. This guidance covers identifying and caring for adults who are malnourished or at risk of malnutrition and offers advice on how oral and enteral feeding should be started, administered and stopped.
The improvement plan has focused on annually auditing and improving the dietetic assessment and care plan, taking into account changes in processes over time, and the introduction of an electronic patient record which was challenging. The target set was for all parameters being measured to have 95% compliance. The impact of this initiative is that compared to the initial audit where no parameters had 95% compliance, the most recent audit has demonstrated that 83% parameters had 95% compliance which is a very significant improvement in compliance with the NICE recommendations and demonstrates consistency and quality of care across the team.
Aims and objectives
The overall aim of the initiative was to audit the compliance of dietetic care provided to adults with disease-related malnutrition and those requiring home enteral feeding against the NICE CG32 and QS24 recommendations with a view to making any improvements required to ensure excellent quality and consistency of care by the team.
The objectives were:
- Annual audit to benchmark the level of care against each relevant NICE CG32 recommendation.
- Annual action plan based on the audit findings to include any improvement required in the dietetic assessment and care planning tools, and any improvement required by the dietitians in completing these.
- Dissemination of the audit findings and action plan to the team and wider service.
- As time evolved the action plan had to include taking into account the change from paper patient records to electronic records, and changes of service provision to best meet the needs of the population and rising numbers of referrals.
Reasons for implementing your project
The initial clinical audit commenced in 2009 as part of a Trust and team initiative to benchmark the care being provided to patients receiving home enteral feeding and those with disease-related malnutrition against the then recently published NICE CG32 guidance which directly relates to the core purpose of the team. This guidance (and QS24), covers identifying and caring for adults who are malnourished or at risk of malnutrition and offers advice on how oral and enteral feeding should be started, administered and stopped with an emphasis on patient-centred care.
Given that the results of this initial audit did not demonstrate a very good level of compliance in all aspects, an improvement plan was implemented as the team's aspiration was, and still is, to provided excellent quality care. It was logical therefore to continue to audit the success of the improvement plan on an annual basis and the audit has evolved to measure, not only the parameters relating to the NICE guidance, but also additional local quality standards. After each audit a new action plan is produced in order to improve the quality of the patient consultation with a particular emphasis on effective and timely patient-centred care.
How did you implement the project
Data is collected annually and retrospectively from a randomly selected set of patient records completed over the previous 12 months for 10% of the caseload. Data was collected originally by dietetic students and now by team members collating from each others records. This data is submitted to a selected member of the team (rotated on an annual basis) who analyses it for compliance against the parameters. This approach allows all team members to be involved in the audit and promotes a commitment from all to improving the quality of care. The aim is to achieve 95% compliance for each parameter. In times of short staffing this audit and subsequent improvement plan have still taken place, such is the importance placed on it.
With time the audit content has evolved with data being collected on an increasing number of parameters, such as auditing the records to capture the clinical reasoning e.g. assessing that the individualised care plan in place relates to the dietetic problem; where there is a risk of re-feeding syndrome identified the plan demonstrates it is being acted upon.
After each audit the team discuss the findings and agree the improvement plan. An annual patient experience survey is done.
The baseline audit in 2009 demonstrated that no parameters had 95% compliance with CG32 guidance. Consultations took place in a timely manner, but the content was not always encompassing recommendations e.g. micronutrient status. As a result the assessment tools used by the team were expanded to include all parameters required and the dietitians asked to complete all sections fully.
The dietitians were encouraged when peer reviewing to feedback about the consultation with relation to the NICE guidance ensuring evidence based practice. As a result there was a marked improvement seen in the compliance in the subsequent five audits to 50% parameters achieving 95% compliance. The audit findings for 2014 demonstrated a down turn in compliance (36%). This reflected the introduction of an electronic patient system and laptops to use in patient homes. Alongside initial technical difficulties, the team also had staffing difficulties and required locum support.
Improvements to laptops and the electronic tools has ensured that the electronic record has become successfully embedded into practice and there has been year on year improvement in the audit findings with 2018 demonstrating 83% parameters achieving 95% compliance thus indicating consistent evidence-based care. The patient experience survey RAG rated as green.
Key learning points
- Ensure all the team is engaged with the purpose of any audit/improvement programme. Involving all in the data collection from their peers records over the last 2 years has promoted a significant improvement in their own records and a large improvement in overall team performance, so moving forwards would do this from the outset.
- To continue to improve the quality of care over time, the parameters being measuring need to evolve to push the level of quality achieved further.
- The audits have demonstrated that significant changes to processes or staffing can affect the quality of care detrimentally. The impact needs to be considered at the planning stage.
- The introduction of an electronic patient record system, while in the short term caused some issues in quality of care, has supported further improvement in the quality of assessments. it has enabled mandatory fields to be added to the tool which must be considered and completed before the tool can be saved thus improving compliance.
- Audit data, as well as being able to prove a service's worth to commissioners, can be used to demonstrate the effect of issues e.g. increased referrals on quality of care and assist in requesting extra provision of resource.