Shared learning database

Lancashire Care NHS Foundation Trust
Published date:
January 2014

An audit project undertaken by the Lancashire Care NHS Foundation Trust dietetics team, that aimed to understand and improve current practice for their clients.

Guidance the shared learning relates to:
Does the example relate to a general implementation of all NICE guidance?
Does the example relate to a specific implementation of a specific piece of NICE guidance?


Aims and objectives

To audit compliance with the NICE Quality Standard for Nutrition.

Reasons for implementing your project

A framework for the effective use of Quality Standards has been developed by Lancashire Care Foundation Trust, key steps in this framework include:
- Identifying which teams each quality standard is applicable to
- Undertaking a review with key staff working in that team / service
- Establishing a data source to evidence the quality standard
This process identified that the Nutrition Quality Standard published in November 2012 (NICE, 2012) was applicable to community and inpatient teams across the Trust and had particular relevance for the dietetic team in the adult community network.

The quality standard supports clients on transition from acute to community care to ensure they are confident and competent with the operation of feed delivery systems; the dietetics team were keen to support this as it should bring clinical care closer to home and promote health and well being through improved self management skills.

The initial review of the quality standard showed that statements 1-2 were applicable for other teams to meet and there would be data to support this in the Trust quality SEEL (see footnote). Statements 3-5 were applicable to the dietetics team, and although they felt the statements to be met they not have any data to support this belief.

The NICE Implementation Lead liaised with the clinical audit team to see if this topic could be included in the 2013/2014 audit calendar, ensuring the Nutrition Lead / dietetics team had some support with their audit.

Audit standards
All people who are screened for the risk of malnutrition have their screening results and nutrition support goals (if applicable), documented and communicated in writing within and between settings. People managing their own artificial nutrition support and/or their carers are trained to manage their nutrition delivery system and monitor their wellbeing. People receiving nutrition support are offered a review of the indications, route, risks, benefits and goals of nutrition support at planned intervals.

How did you implement the project

The information was collected by means of retrospective data collection from care records identified from the Home Enteral Feeding (HEF) database. Data collected related to the screening of patients for the risk of malnutrition, the documenting of nutritional support goals, people who manage their own artificial nutritional support and the review of those patients. All data collected was recorded on a Microsoft Access database. A pilot was completed on 4 records selected at random from the HEF database by the Audit Facilitator. Once all data was collected a 10% data validation was completed by a member of the project team.

Data was analysed by a clinical audit facilitator. The need for further investigation was raised by the audit facilitator at the time of analysis, and completed by staff with a clinical background. This was by means of further review of the clinical records.

As this was a baseline audit against newly developed statements. The cohort included all patients (n=195) on the HEF database from 1st November 2011 - 30th March 2013. The total sample was 16% (31/195), which included a mixture of individuals, a) those at home delivering their own enteral feeding (EF) (n=3), b) those at home receiving EF by a carer (7), c) residents of care homes who received EF from a carer (n=21).

This sample was agreed by the project team to be representative of the whole population in the database at the time of the audit.

To ensure the sample was accurate the Dietetic Assistant confirmed the database was up to date.

The compliance rating for each standard was calculated by reporting on the mean percentage for each statement. Where the standard has more than one component, all components are added together to generate the mean.

Key findings

Whilst the audit demonstrated some very good areas of record keeping and the provision of high quality dietetic care documented, the audit has demonstrated there are also some opportunities for change.

Also identified was a training need for Nursing home staff in the use of artificial feeding, a project will now be developed to support delivery of the training. The way patients were reviewed was not in accordance with the NICE Quality Standard and will be formalised with documentation developed to support this process.

These changes should enhance team performance and lead to better outcomes for the patients who access their service, it fosters self management skills and confidence and competence by the patients themselves. Results have led to an action plan that will be monitored through to completion via the networks governance group.

In relation to the quality standards process, at the time of initial review, the team had felt the standards to be met but this was not fully supported by the audit and led to a number of changes in the way clinical information was recorded and used. This shows completing the quality standards review was a worthwhile exercise, records are aligned to achieving the statements in the standard and routine recording can generate data more easily.

The dietetics team engaged in the process and were fully supported in the audit by the Clinical Lead and Associate Clinical Director for that business unit.

Key learning points

- Develop an excel review sheet for each quality standard, this enables staff to have a thorough way of reviewing each statement in the standard, it also makes them easier to report on.
- Map each statement to existing metrics before asking for it to be included in the audit programme, it means you have to audit less..
- Foster strong links between your NICE Lead and audit team; liaison leads to support for clinical teams who wish to audit against quality standards.
- Be clear about whose responsibility each statement is. For example, you don't want the service user in the middle having their nutrition assessed by 4 different people in 24 hours all trying to evidence against the Nutrition quality standard.
- Ensure you engage with the team impacted by the quality standard and have support from the person who manages that team

Contact details

Wendy Heckels
Clinical Lead
Lancashire Care NHS Foundation Trust

Is the example industry-sponsored in any way?