How one foundation trust engaged the multidisciplinary team using Rapid Spread change methodology to improve patient nutrition throughout the organisation.
This article describes how we changed nutritional care throughout our trust. To carry out our “nutrition mission”, we used change methodology known as Rapid Spread. This programme of change gave our health professionals a step-by-step approach to bringing in and sustaining excellent evidence-based nutritional care across our trust very quickly. Since the initiative, there has been a massive improvement in the nutritional care of patients.
Citation: McKeane A (2012) Using Rapid Spread to improve hospital nutrition. Nursing Times; 108, 42, 24-25.
Author: Angela McKeane is assistant director of nursing, Blackpool Teaching Hospitals Foundation Trust.
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Our “nutrition mission” started when the chief nursing officer launched eight high impact interventions, known as the Essential Collection (NHS Institute for Innovation and Improvement, 2010).
One of the high impact actions for nursing and midwifery is Keeping nourished. Following its publication we brought together a multidisciplinary team to put it into practice. Action plans were drawn up and we hoped that finally some positive changes in our nutritional care would be realised. Much to our disappointment, it was evident early on that the project was already losing momentum. We feared that it would slip down the priority list.
The Rapid Spread approach
In 2010 two trusts (Southampton University Hospitals Trust and York Teaching Hospital Foundation Trust) piloted a new change methodology known as Rapid Spread (Stevens and Edwards, 2012).
The areas they chose to improve were also from high impact actions (NHS Institute for Innovation and Improvement, 2010). They were: Your skin matters and Staying safe - preventing falls. The methodology was refined and, following this, four new areas were chosen to test the modified methodology. Blackpool Teaching Hospitals Foundation Trust was selected as one of the testing organisations.
The National Institute for Health and Clinical Excellence (2006) guidance Nutritional Support in Adults says that a nutritional screening tool should be used routinely for all patients admitted to hospital.
We recognised that, to embed this, we would need to change our culture on a large scale and at a fast pace. Rapid Spread methodology helped us to disseminate evidence-based practice across our entire organisation quickly. This mass mobilisation technique engaged our workforce in a common aim.
Our mission was simple. We wanted to ensure every inpatient who was treated at one of our hospitals had access to the correct food and drink at the correct time, was helped with feeding where necessary and did not become malnourished or dehydrated while staying with us. The aim was to make a difference on all 39 wards in 90 days. The objective was to enhance patient care and dignity while ensuring all patients are supported to have adequate nutrition and hydration.
How we did it
We set up a multidisciplinary project team of key stakeholders that included nursing staff, dietitians, radiographers, speech and language therapists and representatives from the catering and communication departments.
This was followed by an immersion event. The aim of this event was to mobilise, energise, organise and enthuse staff to support the new way of working. Following this event, a further immersion event was organised.
Ward managers had four weeks to prepare for the actual change. They used this time to assess the practices on their wards and actively identify any barriers to change. Staff were encouraged to explore solutions and solve issues as a team and communicate to the rest of the trust the changes they had brought about. Progress and success measures were subject to ongoing evaluation. Through this, it was hoped that good practice would become embedded.
At the beginning of April 2011, 39 inpatient wards went live with the nutrition mission. To mark the event, there was a stand in the staff restaurant over the lunchtime period, head nurses visited all inpatient wards and departments to talk to staff about the campaign. Executive and non-executive directors visited wards over lunchtime to help serve food to patients.
We placed fliers about the mission on patient meal trays, circulated a newsletter throughout the trust, and the catering department worked closely with a catering company to arrange a taster session of a new and improved blended diet.
Box 1. Service improvements via Rapid Spread
- Introduction of “hungry to help” volunteers
- Review of timing of consultant ward rounds and radiology practices
- Review of staff rotas and break times
- Improved organisation of mealtimes to include bed-numbered trolleys to ensure quicker distribution of meals
- Pre-meal care and environment checks
- Introduction of adapted cutlery, all-day breakfasts and snack boxes
- Education of staff - mealtimes are as important as medicine rounds
- Improved patient satisfaction survey results
- Introduction of red alert system so patients at risk are readily identified
- Increased numbers of staff trained to undertake swallowing assessments
- Improvements in quality, range, presentation and the availability of food and special diets
- Review of medication times, for example for anti-emetic administration
- Incorporation of a food chart into the fluid balance chart
We knew from the outset that there would be barriers to overcome and that additional resources would be required. This was discussed with the executive team.
Barriers were mainly identified after the launch through investigating patient feedback on reasons for not eating. Some of the barriers that the executive team helped with were:
- Identifying funding to buy in a new, improved blended diet for three months and to train in-house chefs to provide the improved blended diets. This cost the trust over £6,000;
- Identifying funding to purchase adapted cutlery on the stroke unit;
- Encouraging multidisciplinary working across the teams who were housed in different divisions. For example, speech and language team and radiography were both incorporated into the facilities division. The executive lead for the facilities division was particularly supportive of the nutrition mission.
The Rapid Spread methodology has an accompanying week-by-week guide and workbook designed to take the team through a structured process before progressing to the next stage. The project team found this resource to be invaluable. A “must do” within the workbook is enlisting the help of the communications team. They informed the local press of our progress, developed an intranet site, published newsletters and team briefings and generally kept the whole mission very high profile.
Did it work?
The data collated so far has identified an improvement in patient care as a result of more robust nutritional assessment.
Food wastage has been reduced by over 50% and a more efficient use of dietary supplements is evident. Patient satisfaction has improved and staff have reported that they now feel empowered to make the changes required to deliver this important aspect of patient care. An official celebration of our success took place in September 2011. Improvements in the service are listed in Box 1.
Several measures are in place to sustain the momentum. These include:
- The executive team now carries out regular patient safety visits. Before team meetings, they visit clinical areas in pairs and continue to look for signs of the nutrition mission and talk to staff about it. Issues raised by staff are acted on quickly;
- The newsletter continues to highlight local stories and keep them in focus;
- The new intranet area dedicated to the nutrition mission allows staff to see the latest data and news;
- The director of nursing has written to all the wards reminding them of the commitment cards completed at the immersion events and regularly asks staff to take stock of where they are and what they have achieved;
- A celebration event took place in September 2011, which provided an opportunity to recognise the hard work of staff. Certificates and token gifts were awarded for achievement;
- The board will continue to have updates for the foreseeable future;
- Targets were set for a 12-month period to maintain momentum.
To achieve real culture change, sustainable outcomes and genuine benefits for our patients, it is important to maintain the momentum.
The whole hospital is aware of our nutrition mission, which did not happen with previous improvement initiatives. This has given nurses greater authority to protect patients’ mealtimes and nutrition is now seen as everyone’s responsibility. This is noticeable on all of our wards. People have felt involved and engaged and, as a result, the provision of good nutritional care is now the norm.
- Malnutrition is frequently unrecognised and untreated
- The “nutrition mission” was a success because it engaged all stakeholders
- This project provided an opportunity for multidisciplinary team members to come together to benefit patients
- Key performance indicators demonstrated improvements; there was also evidence of improved patient experience and staff satisfaction
- Ensuring the whole organisation is behind the change means it is easier to make it sustainable
British Association for Parenteral and Enteral Nutrition (2007) Nutrition Screening Survey in the UK in 2007: Nutrition Screening Survey and Audit of Adults on Admission to Hospitals, Care Homes and Mental Health Units. Redditch: BAPEN.
NHS Institute for Innovation and Improvement (2010) High Impact Actions for Nursing and Midwifery: The Essential Collection. Coventry: NHS III.
National Institute for Health and Clinical Excellence (2006) Nutritional Support in Adults: Oral Nutrition Support, Enteral Tube Feeding and Parenteral Nutrition. Clinical Guideline 32. London: NICE.
Stevens J, Edwards G (2012) Using Rapid Spread to achieve a change in practice. Nursing Times; 108: 37, 28-29.