Using Clinical Process Improvement Strategies to Optimize Patient Outcomes

This podcast series aims to highlight the science, psychology, and strategies behind the practice of dietetics. Moderator, Lisa Jones, MA, RDN, LDN, FAND, interviews prominent dietitians and health professionals to help our community think differently about food and nutrition.

In this episode, Lisa Jones interviews Sherri Jones, MS, MBA, RDN, LDN, SSGB, CPHQ, FAND, about the ways dietitians can utilize clinical process improvement strategies, supported by evidence-based practices, to optimize patient outcomes and improve the overall quality of care in a health care setting. This is episode 2 of a 4-part series. 

Additional Resources:

Academy of Nutrition and Dietetics. Accessed July 19, 2023. https://www.eatright.org/

Commission on Dietetic Registration. Accessed July 19, 2023. https://www.cdrnet.org/

Quality Management. Commission on Dietetic Registration. Accessed July 19, 2023. https://www.cdrnet.org/Quality

Listen to episode 1 of this 4-part podcast series here.

Listen to episode 3 of this 4-part podcast series here.

Lisa Jones, MA, RDN, LDN, FAND, is a registered dietitian nutritionist, speaker, and author (Philadelphia, PA).

Sherri Jones, MS, MBA, RDN, LDN, SSGB, CPHQ, FAND, is the Quality Manager at the University of Pittsburgh Medical Center (UPMC) Presbyterian Shadyside working in the Department of Quality Improvement (Pittsburgh, PA), a member of the Academy of Nutrition and Dietetics Board of Directors, Director of the Academy’s House of Delegates, and a member of the House Leadership Team. 

TRANSCRIPTION: 

Speaker 1:

Hello and welcome to Nutrition 411: The Podcast, a special podcast series led by registered dietician and nutritionist Lisa Jones. The views of the speakers are their own and do not reflect the views of their respective institutions or Consultant360.

Lisa Jones:

Hello and welcome to Nutrition 411: The Podcast, where we communicate the information that you need to know now about the science, psychology, and strategies behind the practice of dietetics.

Today's podcast is part of a series of short episodes on clinical process improvement, featuring a Q&A with Shari Jones. I want the opportunity to introduce Shari. First of all, Shari, thank you for being here.

Sherri Jones:

You're welcome.

Lisa Jones:

Yeah, we're excited to have you today. Shari Jones has been a registered dietician nutritionist for 35 years and is currently the quality manager at The University of Pittsburgh Medical Center, Presbyterian Shadyside, working in The Department of Quality Improvement. In this role, she manages seven full-time quality improvement specialists who are responsible for value-based care measures and quality scorecard outcomes. Shari has worked in the field of quality improvement since 2012 and achieved her Six Sigma Green Belt in 2015. She is also a certified professional on healthcare quality; with national certification in 2020. And you can read Sherry's full bio on our website.

So again, welcome Shari. We are excited for you to be here. In this episode today, we're going to be taking a deep dive into evidence-based dietetics practice. If you had to sum up a conversation in one to two sentences, from our last episode, where we were talking about the latest research and trends in dietetics, what would you say were the key takeaways from that episode?

Sherri Jones:

I would say just that quality and process improvement is important to every one of us, no matter what practice segment we work in. Really, quality and process improvement is important in any industry. I mean, you want to continually improve and look at the trends in your industry and make sure that you're meeting the best practice standards.

Lisa Jones:

Yes, and I was going to say: I'm glad that was your answer. My second one was something that's memorable from your first episode was making sure that you're taking a seat at the table.

Sherri Jones:

Exactly.

Lisa Jones:

Staying at the table. And then when we talk about evidence-based practice, what do you think? In what ways can dieticians then utilize the clinical process and improvement strategies? They can have support from evidence-based practices, and then of course, optimize patient outcomes and improve the overall quality of care provided in healthcare settings. Can you talk a little bit about that?

Sherri Jones:

Sure. I did make mention in the previous episode about the Evidence Analysis Library. In doing some research for this podcast, went on to the EAL and just tried to look at what were some of the important topics and things. There are also consensus reports that are available that are based on a systematic review and a critical analysis of current facts, data, and research that's in the literature. And what is really nice about those consensus reports is: They summarize all of those findings.

And I would say for dieticians to be aware of that and go onto the EAL. Look at those consensus reports, and then more importantly, from an application standpoint, there are evidence-based nutrition practice guidelines and toolkits that are published through the Evidence Analysis Library. Those toolkits help to bridge the gap between evidence and clinical practice to improve equitable patient care.

So I would really recommend that dieticians take a visit to that EAL and look and see what practice guidelines and toolkits are applicable to your practice setting and the type of care or services that you are delivering. Whether it be to inpatients, ambulatory care patients, or public health, it's such a broad scope related to the Evidence-based Analysis Library. It's not just specific to acute care clinical.

Lisa Jones:

Yeah, that's a great example, and who doesn't love a good toolkit, especially when it helps to provide equitable patient care? So that's an amazing resource to check out.

Could you walk us through an example of a successful clinical process improvement, specifically highlighting the specific steps that were taken and the results that were achieved? Because I think that would be helpful for listeners to hear from your perspective, with all your experience.

Sherri Jones:

So I can give an example that I use a lot when I'm teaching people about Quality Improvement 101, so to speak, at my facility. It's a nice little example, but before I get to that specific example, I do want to share that there are a lot of resources and quality improvement project examples on the CDR website. So something that I honestly, to be transparent, just learned: that a lot of the quality management committees tools and resources were moved over from the Academy website to the Commission on Dietetic Registration website. Everything now falls under CDR as it relates to quality management. When you log into the CDR website, there are a bunch of different little tabs at the top, and I believe it's on the very right-hand side, are the resources related to quality care. I think the little tag is Demonstrate Quality Care.

When you go into that section, there are four subsections it relates to quality care, and there's a section called Quality Improvement. When you go in, there are what are called Quickenars. The Quality Management Committee, for the past several years, and I believe they stopped doing this a little over a year ago, but they had actual dietician practitioners give little 30-minute Quickenars on quality improvement projects that they did in their facility. Oh, gosh, when I looked on there, there are at least 15, off the top of my head, Quickenars on actual quality improvement projects that other dieticians have done across the country. But let me give you a very quick example and kind of walking through a successful process improvement project that follows the PDSA Plan, Do, Study, Act Cycle.

So years ago, when I was a clinical nutrition manager at UPMC Presbyterian Shadyside, and how many times we get involved in quality improvement, there was a problem. The dieticians identified to me, and this was many years ago, back when calorie counts were something that we utilized to determine whether or not patients were eating enough to meet their nutritional needs and whether we needed to implement oral nutrition supplements or some form of enteral or parenteral nutrition if they needed that.

So we utilized calorie counts, and the dieticians were complaining to me that their calorie counts weren't being recorded appropriately. And when we did a current state assessment in the planning phase, we identified what was our current process, and then it was that nursing would record what patients ate. And we found that that was pretty difficult for the nurses at the bedside. They were doing a lot of different things. Sometimes they didn't even know when the patient was finished eating, and the tray would be taken away, so they didn't have a clue how much the patient ate.

So we put a group together of the primary stakeholders. That involved nursing, clinical dieticians, as well as food service staff. They were the ones that would deliver the trays and have the tray tickets and also take the trays away. And what we decided to do was, "Let's take that responsibility of calorie count recording away from the nurses, and let's give that responsibility to the food service staff that took the trays away." So the tray passer would come and pick up the tray. So we educated the tray-passers on how to evaluate the percent consumption of the different food items, and they would record directly on the meal ticket what the patient ate and then put it on the bulletin board in the patient's room.

So we did all of our education and training, followed the PDSA cycle. We planned. We implemented. We did the Do. We studied. We looked at our data of how often were calorie counts being recorded, and we had an increase in the percentage of calorie counts being recorded.

But one of the things that I've learned as a quality improvement specialist: In order to know whether something was a success, you never collect one post-implementation data point, because it could be a fluke. You need to collect at least three post-implementation data points, so we continued to collect our data on the percent of calorie counts that were being recorded appropriately. And lo and behold, it started declining. Many times with quality improvement, you have that honeymoon phase, where it's what's foremost on everyone's mind. They were just educated. "Here's our new process. Okay, good to go."

Well, we had to go back to the PDSA cycle and say, "All right, we're now trending back downward. What is the problem? Why is this new process not working?" And what we found, and many times it's because we didn't have any accountability built in. No one was watching whether or not the tray-passers were recording this on the tickets, because they were putting them in the room. So we implemented a second improvement stage and initiative, and we told the tray-passers they had to now bring the tray tickets down and turn them into the food service supervisor. So we added an accountability measure, and we found by doing that, in checking our post-implementation data points, we started going back up again.

So I always like to use that example because it's interdisciplinary. It involves nursing, as well as the clinical dieticians and food service from the Food and Nutrition Department, and also shows that you need to continually collect your data so that whether or not your improvement strategy was able to be sustained. And we found that our first pass-through did not work. We needed to add another improvement strategy of accountability, and then we found that we were able to sustain our improved outcomes.

Lisa Jones:

Well, thank you for sharing that wonderful example, Shari, because my next question was going to be asking you about evidence-based practice and how we can continue to improve and innovate in our field, and in the example that you just talked about, you did both of those things. So you were using the interdisciplinary factor, but then also, you had to go back and add an additional measure. So how could you then improve what you currently were doing? And then it's also a form of innovation if you think about it.

Sherri Jones:

Yes.

Lisa Jones:

So really great job on that.

Sherri Jones:

It's all about data collection and continuing to collect data and monitoring trends.

Lisa Jones:

Yes, so thank you so much for sharing all that with us. That's great for this episode for the listeners to hear. So I appreciate you sharing that with us today, Shari.

Sherri Jones:

Sure. Thanks, Lisa.

Speaker 1:

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