After recognising the variable quality of nutritional care in its hospitals NHS Scotland implemented an improvement programme to engage staff at all levels
Healthcare Improvement Scotland (formerly NHS Quality Improvement Scotland) led an 18-month national programme that aimed to achieve reliable improvements in nutritional care by focusing on three priority areas: mealtimes; long-term conditions; and transition to care homes.
Citation: Bond P (2013) A hospital nutrition improvement programme. Nursing Times; 109: 39, 22-24.
Author: Penny Bond is implementation and improvement support team leader, Healthcare Improvement Scotland.
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Providing good nutritional care is crucial if patients are to have a positive experience of healthcare. This also addresses all three of the quality ambitions for care set out in the NHS Scotland Quality Strategy - care that is person centred, safe and effective (Scottish Government, 2010).
National standards in food, fluid and nutritional care in hospitals were developed for NHS Scotland in 2003 (NHS Quality Improvement Scotland, 2003) and reviews against the standards were carried out in 2005 and again in 2010 (NHS Quality Improvement Scotland, 2010). These showed progress had been made in many areas of nutritional care, such as a greater use of nutritional screening; however, they also highlighted the importance of maintaining the focus on improving nutritional care, specifically the need to share and spread good practice more widely.
A range of activities had been implemented between 2003, when the standards were launched, and 2010. The Scottish Government funded local nutrition champions within each health board for three years from 2007 to 2010. These champions helped to strengthen collaborative relationships between catering and clinical staff at local levels so that nutritional care aims and goals were shared and understood.
National networking events were held for champions and colleagues, including catering staff, nurses, dietitians and care home staff from across Scotland to come together to learn and to share experiences and good practice. A number of resources aimed at all levels of clinical and catering staff were developed, including an Improving Nutritional Care Toolkit and a web-based educational resource.
Healthcare Improvement Scotland’s Improving Nutritional Care Programme was set up in July 2010 to build on the progress made by nutrition champions in improving nutritional care for adults at risk of malnutrition. This 18-month programme was underpinned by the following key principles:
- Working with key stakeholders to build a culture of improvement to achieve measurable improvements in nutritional care;
- Maintaining and building on achievements to date;
- Extending the focus of activity to primary care/community settings;
- Building multidisciplinary working between different care settings;
- Building understanding of improvement among care home and hospital staff and managers;
- Ensuring integration with relevant national programmes such as Leading Better Care and Releasing Time to Care.
The programme reflected Healthcare Improvement Scotland’s approach to quality improvement, which aims to provide advice and guidance; support reliable and sustainable implementation and improvement; and link to feedback from assessment and measurement of performance (Fig 1).
Agreeing improvement priorities
Many factors affect the delivery of good nutritional care. We conducted a systematic review of the evidence on nutritional care to identify where we needed to focus our work, and shared its findings with nutrition champions and other key stakeholders across NHS Scotland. We identified three priority areas where improvement support was concentrated:
- Improving mealtime processes;
- Facilitating self-management of nutritional care needs for individuals with long-term conditions;
- Improving transitions between hospitals and care homes.
The programme drew on expertise from NHS Scotland’s Quality Improvement HUB and the Scottish Patient Safety Programme to support nutrition champions with the use of quality-improvement methodologies. Champions and colleagues were coached in the use of specific techniques such as the model for improvement (Langley et al, 2009), which encourages the use of small tests of change in practice to identify and make improvements in care for patients (see Innovation, page 20). The model for improvement has been widely tried and tested in Scotland as an essential part of the Scottish Patient Safety Programme.
We secured the support of executive nurse directors for the programme, and established strong working relationships with nutrition champions in every NHS board, with many executive nurse directors chairing their local nutritional care groups. These relationships helped to ensure close collaboration with staff and other key stakeholders from across NHS Scotland.
Each health board in Scotland was asked to identify a test site (either a hospital ward or a care home) to be involved with and contribute to this programme. Small teams representing each test site attended a series of three learning sessions held over an 18-month period; 70 delegates including staff nurses, ward managers, care assistants, catering staff and senior managers attended. The learning sessions aimed to bring teams together to learn and share in a supportive atmosphere. At each session, teams were given an opportunity to feed back on their progress and identify and discuss their particular highlights and challenges. Specialist improvement support and advice was available to help translate improvement theory into practice and to encourage shared learning.
Teams were encouraged to develop progress reports, case studies and story-boards to support this process and demonstrate their own progress. Teleconferences were held between learning sessions to maintain support and give teams further opportunities to share specific concerns and learn from each other.
The overall aim was to deliver improvements in the agreed nutritional care priority areas. As well as supporting specific activity at the test sites, the learning sessions were intended to increase the understanding of improvement tools and techniques among nutrition champions and their colleagues. As participants’ understanding of improvement increased, so did their confidence in applying their learning to other areas of care.
Local teams who took part in the programme agreed on the three priority areas they wanted to focus on. Subgroups were set up for each topic, led by nutrition champions, comprising a range of staff from test site areas (hospitals and care homes). Groups explored their specific area of focus in more detail, identifying gaps in practice and developing tools and resources to test using improvement techniques. The innovations on improving mealtime processes (Box 1) and improving transitions between hospital and care home (page 20) are examples of the improvement activity that was undertaken by teams.
Box 1. Improving hospital mealtimes
Interruptions at mealtimes occur for a range of reasons, including ward rounds, medication rounds, tests and investigations; these may involve taking patients away from the ward. Protected mealtimes have been introduced in many inpatient areas at NHS Scotland’s hospitals to reduce such interruptions, but implementation has been varied.
To address this issue, nutrition champions in NHS boards worked with colleagues to develop and test a Making Meals Matter resource pack, which includes:
- Principles of protected mealtimes;
- Observation tools to underpin the principles of protected mealtimes;
- Principles of safe and effective nutritional care from admission to discharge/transfer;
- A monitoring tool to underpin the principles of safe and effective nutritional care;
- Guidance for observing interactions at mealtimes.
The protected mealtimes observation tool is a two-part measuring instrument, which is designed to identify good practice and areas requiring attention; it also allows improvements in practice to be measured over time.
Part 1 of the observation tool supports the recording of information about what happens during mealtimes, while part 2 reflects how care is provided during mealtimes, with a particular focus on the quality of interactions between staff and patients.
Nutritional care improvement teams from NHS boards and care homes used the observation and monitoring tools to gather baseline data about mealtime processes. Feedback from patients, staff and carers was also collected. To identify specific improvement areas around mealtimes, data from other sources was examined, including clinical quality indicators, Releasing Time to Care meals module activity and complaints.
Areas for improvement identified through the observation process included:
- Some patients identified as requiring assistance were not receiving help with eating and drinking;
- Staff were not always available to assist at mealtimes;
- Non-essential clinical activity, such as bedmaking, was going on during the meal service;
- Invasive clinical procedures were being carried out during mealtimes;
- Patients did not always have the opportunity to wash their hands before meals;
- Bed tables were cluttered;
- Meal trolleys were on the ward for some time before the meals were delivered to patients, resulting in food being too cold.
Tests of change
A number of changes were tested in different areas using the model for improvement (Langley et al, 2009) including:
- Introducing nutrition as a key element of the safety brief;
- Altering timing of medication rounds to avoid mealtimes;
- Introducing a mealtime coordinator role to reduce unnecessary interruptions and ensure all ward staff are involved in supporting and encouraging patients with their meals;
- Using volunteers at mealtimes;
- Increasing opportunity for handwashing before meals;
- Identifying clinical champions to lead on nutritional care;
- Introducing baskets for patients’ belongings, so meals can be placed on tray tables where they are easy to access.
We noted the following improvements:
- Better compliance with completion of food charts;
- Reduction in the time between meals arriving on wards and delivery to patients (which maintained food temperature);
- Reduction in food wastage;
- Real-time feedback to multidisciplinary teams of good practice and areas for improvement to inform future practice;
- Improved multidisciplinary working.
- The process for identifying patients at risk of malnutrition was improved by:
- Better compliance with nutritional screening and assessment;
- Reviewing and developing ways to identify patients who require assistance at mealtimes, for example by using red trays;
- Introducing nutrition as a key element of the safety brief.
Increasing opportunities for patients to receive assistance at mealtimes was achieved by:
- Avoiding unnecessary interruptions at mealtimes including altering timing of medication rounds and introducing a mealtime coordinator;
- Changing staff breaks to ensure that ward staff were actively involved in the mealtime;
- Ensuring patients were positioned safely to allow them to easily reach their food and drink;
- Introducing volunteers at mealtimes;
- Increasing understanding of the roles and responsibilities of ward staff at patient mealtimes through mealtime coordinators.
A variety of approaches to disseminating the work have been adopted. A range of publications and presentations at national and international events and meetings, have helped raise awareness among practitioners about the potential of this work to improve nutritional care.
Feedback from patients, carers and staff was key to informing this work. The national development manager for patient experience developed a range of resources to assist healthcare teams to capture patient, carer and staff experience. These included:
- A training session on digital story telling;
- Guidance on capturing patients’ experiences, including observation tools and techniques;
- Observation tool for observing interactions at mealtimes;
- Guidance and training materials to support the observation tool;
- Comment cards for capturing and monitoring experiences of mealtimes.
The programme has contributed to NHS boards considering nutritional care from a more strategic perspective, and has helped to put nutritional care at the forefront of local and national policy. The nutrition champions’ network also helped to raise the profile of food, fluid and nutritional care and provided opportunities to share good practice and local experiences across Scotland. NHS boards have been supported in improving nutritional care through education and driving innovative practice.
The programme has helped build collaborative working between staff in some areas, with ward-based nurses, dietitians and catering staff acknowledging an increased understanding of each others’ roles.
A number of other national initiatives on nutrition will help to maintain the focus on this crucial aspect of patient care and support ongoing improvements. It is a key element of Healthcare Improvement Scotland inspections of older people’s acute care services, and clinical quality indicators for food, fluid and nutritional care are being reviewed as part of the Leading Better Care programme in Scotland. An Improving Nutrition… Improving Care community website has been established to help people to continue to share good practice resources and developments in nutritional care.
Providing good nutritional care is key to patients’ experience of healthcare and a core element of person-centred care. The feedback received from healthcare staff, patients and carers during the course of this programme clearly reflects this; nutritional care must remain a national, local and individual priority.
- Adequate nutrition is an essential part of person-centred, safe, effective care
- The success of a national nutrition programme requires support from senior managers
- Nutrition champions across NHS Scotland have been pivotal in improving hospital nutrition
- Change should be tested in small areas before being rolled out
- A Making Meals Matter resource pack has helped to improve patients’ experience of mealtimes
Langley GL et al (2009) The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. San Francisco, CA: Jossey-Bass Publishers.
NHS Quality Improvement Scotland (2003) Food, Fluid and Nutritional Care in Hospital: Standards. Edinburgh: NHS QIS.
NHS Quality Improvement Scotland (2010) National Overview – April 2010. Food Fluid and Nutritional Care in Hospitals.
Scottish Government (2010) NHSScotland Quality Strategy: Putting People at the Heart of our NHS.Edinburgh: Scottish Government.