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Select Your QI Focus: Understand Your Existing Malnutrition Care WorkflowTable of ContentsSAMPLE PDSA Cycle: Malnutrition ScreeningProject: Malnutrition Quality Improvement InitiativeObjective of this PDSA cycle: Test completion of malnutrition screening using a validated tool for all admittedpatients age 65 yearsPLAN:Questions: Will all newly admitted patients age 65 years receive malnutrition screening?Predictions: All patients age 65 years will receive malnutrition screeningPlan for change: Who, what, when, whereComplete malnutrition screening using a validated tool for all newly admitted patients who are age65 years during a 24 hour period During the intake process, nurse will screen all eligible patients using a validated screening toolPlan for data collection: Who, what, when, where Nurse documents the results of the screening (i.e., “at risk” or “not at risk” for malnutrition) in the patient’smedical record or electronic health record (EHR) Nurse documents any issues that arise with the screening process and reasons for inability to complete thescreening for any patients If EHR does not already generate automatic dietitian requests or reminders for malnutrition-risk diet ordersbased on screenings that have identified patients “at risk” for malnutrition, this may be something to requestassistance with from an Informatics Representative to program in the EHRDO:Carry out the change: Collect data and begin analysis Conduct the malnutrition screening test during a 24 hour periodo For patients found to be at risk for malnutrition, attempt to have the EHR generate an automaticrequest to the dietitian to complete an assessmento For patients found to be at risk for malnutrition, attempt to have the EHR generates an automaticreminder to place a malnutrition-risk diet order Review medical records for 15 eligible patients admitted during the 24 hour period Record results of data collected (e.g., the nurse could not complete the screening for 5 out of 15 patientsbecause screening slowed the intake process and there was a backlog of patients)STUDY:Complete analysis of data Debrief: Discuss whether patients could be stratified to support the screening of patients during the intakeprocess. For example, could a screening be completed for planned admissions in the outpatient setting andprior to admission?Verify predictions How closely did the results of this cycle match the prediction that was made earlier? Summarize any new knowledge gained by completing this cycle. For example, malnutrition screening forplanned cases can be completed during the preadmission phase so that nurses will focus on emergent casesat admission. Nurse will still screen all planned cases who were not screened prior to admission.ACT:Identify actions List actions to take as a result of this cycle Repeat this test for another 24 hours after initiating preadmission malnutrition screening in the outpatient clinic.Plan for the next cycle (adapt change, another test, implementation cycle): Run a second PDSA cycle foranother 24 hour period.26
Select Your QI Focus: Understand Your Existing Malnutrition Care WorkflowTable of ContentsSAMPLE PDSA Cycle: Nutrition AssessmentProject: Malnutrition Quality Improvement InitiativeObjective of this PDSA cycle: Test completion of nutrition assessment using a standardized tool for all admittedpatients age 65 yearsPLAN:Questions: 1. Will all patients age 65 years identified as “at risk” for malnutrition following a malnutrition screeningreceive a nutrition assessment? 2. Will the diagnosis of malnutrition be properly documented in the electronic healthrecord using structured data?Predictions: All patients age 65 years identified as “at risk” for malnutrition will receive a nutrition assessment and adiagnosis will be correctly documented using structured dataPlan for change: Who, what, when, whereComplete nutrition assessment using a standardized tool within a 24 to 48 hour period for all patients age 65 yearswho are identified as “at risk” for malnutrition following a malnutrition screening Following malnutrition screening, dietitian or qualified clinician will assess all eligible patients for malnutritionusing a validated nutrition assessment tool Plan for data collection: Who, what, when, where Dietitian or qualified clinician documents the results of the assessment (e.g. cause of malnutrition diagnosis) inthe EHR Dietitian or qualified clinician documents any issues that arise with the assessment process and reasons forinability to complete the assessment for any patientsPlan for data collection: Who, what, when, where Part of the EHR documentation process includes a required field to document a diagnosis using structured data Plan for data collection: Who, what, when, where Nurse documents the results of the screening (i.e., “at risk” or “not at risk” for malnutrition) in the electronic healthrecord (EHR) Nurse documents any issues that arise with the screening process and reasons for inability to complete thescreening for any patients If EHR does not already generate automatic dietitian requests or reminders for malnutrition-risk diet orders basedon screenings that have identified patients “at risk” for malnutrition, this may be something to request assistancewith from an Informatics Representative to program in the EHRDO:Carry out the change: Collect data and begin analysis Conduct the assessment within a 24 to 48 hour period following the malnutrition screening through whichpatients identified as “at risk” Review EHR records for 5 eligible patients identified as “at risk” for malnutrition Record results of data collection (e.g., the dietitian or qualified clinician was able to complete assessment duringa 24 to 48 hour period for all eligible patients but was unable to document specific elements of the assessmentresults in structured data fields)STUDY:Complete analysis of data Debrief: Discuss whether there are modifications the hospital can make to the EHR to support thedocumentation of the results of nutrition assessment. For example, could the EHR template be modified toinclude the most frequently used data fields needed to document assessment results. Additionally, considerwhether all dietitians or clinicians have received appropriate training on the documentation of results. Verify predictions How closely did the results of this cycle match the prediction that was made earlier? Summarize any new knowledge gained by completing this cycle. For example, limitations in the EHRdocumentation template during nutrition assessment may prevent the documentation of screening results in atimely manner.ACT:Identify actions List actions to take as a result of this cycle Repeat this test for another 72 hours after providing modifications to the EHR template. Plan for the next cycle(adapt change, another test, implementation cycle): Run a second PDSA cycle for another 72 hour period.29
Select Your QI Focus: Understand Your Existing Malnutrition Care WorkflowTable of ContentsSAMPLE PDSA Cycle: Malnutrition DiagnosisProject: Malnutrition Quality Improvement InitiativeObjective of this PDSA cycle: Test completion of documentation of patient diagnosis in the medical record for allpatients age 65 years identified as malnourished.PLAN:Questions: Will all patients age 65 years identified as malnourished via a malnutrition assessment receive amalnutrition diagnosis?Predictions: All patients age 65 years identified as malnourished will receive a malnutrition diagnosisPlan for change: Who, what, when, whereRecord a diagnosis in the patient medical record and the “problem list” as soon as possible (within 24 hours)following a malnutrition assessment where the patient is identified as malnourished. Following the malnutrition assessment, the dietitian or qualified member of the Care Team should enter amedical diagnosis corresponding to the findings of the malnutrition assessmentPlan for data collection: Who, what, when, where Dietitian or other qualified member of the Care Team should document the malnutrition diagnosticstatement in the patient’s treatment record, this statement should include: Description of alternations in a patient’s statuso Malnutrition signs and symptomso Malnutrition etiologyo In addition to the diagnostic statement, the dietitian or other qualified member of the Care Teamalso documents the associated malnutrition diagnosis code(s) Dietitian or other qualified member of the Care Team documents any issues associated with establishinga diagnosis and documenting it in the medical record If EHR does not already provide a list of available diagnostic codes for easy selection by Care Teammember, this may be something to request assistance with from an Informatics Representative toprogram in the EHRDO:Carry out the change: Collect data and begin analysis Implement change of process including training, policy, incentives, and technology adjustments. Enter the malnutrition diagnosis in patients found to be malnourished immediately following a malnutritionassessment Review EHR records for 15 eligible patients identified as malnourished Record results of data collected (e.g., a complete diagnosis was not entered for 5 out of 15 patientsbecause providers were unaware of information)STUDY:Complete analysis of data Debrief: Discuss how to modify diagnosis entry processes to support the capture of complete diagnosticinformation. For example, could EHR templates be modified to include more diagnosis codes or moreclearly indicate information necessary to capture?Verify predictions How closely did the results of this cycle match the prediction that was made earlier? Summarize any new knowledge gained by completing this cycle. For example, diagnosis documentationis typically completed by a dietitian at the end of the work day when they complete administrative duties.However, an informal diagnosis is often listed in patient notes to support formal documentation.ACT:Identify actions List actions to take as a result of this cycle Repeat this test for another 48 hours after providing clearer instructions to the Care Team regardingdiagnosis details to be captured or after appropriate modifications have been made in the data collectionprocesses in the EHR. Plan for the next cycle (adapt change, another test, implementation cycle): Run asecond PDSA cycle for another 48 hour period.32
Select Your QI Focus: Understand Your Existing Malnutrition Care WorkflowTable of ContentsSAMPLE PDSA Cycle: Malnutrition Care Plan Development and ImplementationProject: Malnutrition Quality Improvement InitiativeObjective of this PDSA cycle: Test the documentation and implementation of a malnutrition care plan for allpatients age 65 years diagnosed as malnourishedPLAN:Questions: Will all patients age 65 years with a malnutrition diagnosis have record in the EHR of a developed andimplemented malnutrition care plan?Predictions: All patients age 65 years with a malnutrition diagnosis will have documentation in the EHR of adeveloped and implemented malnutrition care planPlan for change: Who, what, when, whereEnter in the EHR a malnutrition care plan and documentation that it has been initiated within 24 hours ofdocumentation of malnutrition diagnosis for all eligible patients age 65 years Following diagnosis, dietitian or qualified clinician will enter a malnutrition care plan for all eligible patientswith a malnutrition diagnosis, including identification of the interdisciplinary Care Team. The role of thepatient should also be clearly defined. Following documentation of the malnutrition care plan, members of the interdisciplinary Care Team willbegin implementing it within 24 hoursPlan for data collection: Who, what, when, where Dietitian or qualified clinician documents the malnutrition care plan (i.e. treatment goals, prescribedtreatment/ intervention) in the EHR Care Team members responsible for components of the malnutrition care plan document completion orstage of execution of various components in the EHRDO:Carry out the change: Collect data and begin analysis Conduct the assessment during a 24 hour period following the documentation of a diagnosis in the EHR Review EHR records for 15 eligible patients identified as malnourished Record results of date collected (e.g., components of the malnutrition care plan were not implemented for3 out of 15 patients because Care Team roles were not clearly delineated)STUDY:Complete analysis of data Debrief: Discuss how to facilitate greater Care Team coordination and communication to ensure allelements of the malnutrition care plan are implemented. For example, could a member of the Care Teambe designated to ensure that the roles and responsibilities of implementing the malnutrition care plan arecommunicated to all members?Verify predictions How closely did the results of this cycle match the prediction that was made earlier? Summarize any new knowledge gained by completing this cycle. For example, documentation of themalnutrition care plan and Care Team roles and responsibilities in the EHR is not sufficient to ensureeffective team coordination List actions to take as a result of this cycle Repeat this test for another 48 hours after providing clearer instructions to the Care Team regardingdiagnosis details to be captured or after appropriate modifications have been made in the data collectionprocesses in the EHR. Plan for the next cycle (adapt change, another test, implementation cycle): Run asecond PDSA cycle for another 48-hour period.ACT:Identify actions List actions to take as a result of this cycle Repeat this test for another 96 hours after designating a Care Team member responsible for teamcommunication. Plan for the next cycle (adapt change, another test, implementation cycle): Run a secondPDSA cycle for another 96-hour period.35
Select Your QI Focus: Understand Your Existing Malnutrition Care WorkflowTable of ContentsSAMPLE PDSA Cycle: Discharge PlanningProject: Malnutrition Quality Improvement InitiativeObjective of this PDSA cycle: Test the inclusion of malnutrition related components in the discharge planning for allpatients age 65 years diagnosed as malnourishedPLAN:Questions: Will all patients age 65 years with a malnutrition diagnosis have malnutrition related recommendations andorders included in their discharge plan?Predictions: All patients age 65 years with a malnutrition diagnosis will have malnutrition components included in theirdischarge planPlan for change: Who, what, when, whereInclude malnutrition-specific discharge materials tailored to the individual patient in the patient’s overall dischargematerials for all eligible patients age 65 years with a malnutrition diagnosis 24 hours prior to discharge, all members of the Care Team will provide input on the malnutrition componentsthat should be included in the patient’s discharge plan for all eligible patients with a malnutrition diagnosis,including care transition documents for the provider in the post-discharge settingPlan for data collection: Who, what, when, where All members of the interdisciplinary Care Team are eligible to provide documentation in the discharge templateof malnutrition components (i.e. education materials) that should be included in the discharge plan SAMPLEPDSA Cycle: Discharge PlanningDO:Carry out the change: Collect data and begin analysis Conduct the assessment during a 24 hour period prior to the discharge of patients with a malnutrition diagnosis Review EHR records for 10 eligible patients identified as malnourished Record results of data collected (e.g., malnutrition discharge planning materials were not provided for 2 out of10 patients because there is no reminder system in place to alert the Care Team to the need to provide thesematerials)STUDY:Complete analysis of data Debrief: Discuss what kinds of reminder systems could be employed to help ensure the Care Team providesmalnutrition discharge materials for eligible patients. For example, could a reminder system be incorporatedinto the EHR system to alert providers 24 hours prior to discharge that malnutrition discharge materials shouldbe prepared?Verify predictions How closely did the results of this cycle match the prediction that was made earlier? Summarize any new knowledge gained by completing this cycle. For example, the lack of a designatedreminder system to alert the Care Team 24 hours before patient discharge that malnutrition discharge planningmaterials should be prepared and provided decreases the likelihood that these components will be included inthe discharge materialsACT:Identify actions List actions to take as a result of this cycle Repeat this test for another 24 hours after providing modifications to the EHR system. Plan for the next cycle(adapt change, another test, implementation cycle): Run a second PDSA cycle for another 24 hour period39
During the intake process, nurse will screen all eligible patients using a validated screening tool . Plan for data collection: Who, what, when, where Nurse documents the results of the screening (i.e., "at risk" or "not at risk" for malnutrition) in the patient's medical record or electronic health record (EHR)
