data to establish appropriate staffing ratios. As patient LOS declines and criteria for insurance reimbursement practices change, the focus on doing things in a timely and accurate way intensifies. An evaluation of current practices is an integral part of an effective clinical nutrition program. Evaluation of current practices may in- dicate specific areas in which role changes could improve the quality of nutrition care provided. Findings from a productivity study may lead to staff reassignment, altered processes, or the elimination of specific clinical activities. Clinical productivity can be defined qualitatively or quantitatively. Qualitative


measurement requires comparing services to accepted standards of care and impact on patient outcomes. Quantitative measurement requires selection of a method to collect data, usually in the form of a time management study. Time estimates can be obtained through time-sampling procedures to determine the average time required to perform a specific task or Nutrition Care Process (NCP) step. Clinical productivity studies should have an identifiable beginning and end, characterize activities (not skills or knowledge), be performed by individual staff members, differentiate be- tween activities that involve different kinds of knowledge and skills, be neither too broad nor too specific, and be expressed in clear and unambiguous statements that have the same meaning to all staff.


Direct vs Indirect Care


Time spent in direct vs indirect patient activities at each nutrition risk level can be tracked and analyzed to determine the average amount of services required for each level. For example, a high-risk patient may require a comprehensive nutrition assessment and several reassessments during an admission, whereas a low-risk patient may only require one visit by a clinical nutrition staff member. Specialty patient populations, such as patients in the intensive care unit or solid-organ trans- plant unit, may also influence the amount of time the nutrition staff member will spend on patient care. These patients typically require more visits by the clinician and additional activities such as medical rounds are often a part of the patient’s care. According to the Academy of Nutrition and Dietetics productivity study con- ducted in 2017, RDNs see an average of 59% of patients admitted to the hospital for at least an initial nutrition assessment and care plan development.1,8


According to


both the 2014 and 2017 Morrison Healthcare productivity benchmarking studies, 16% to 23% of the RDN’s time is spent completing indirect care activities.1,8


It is critical


that this segment of time during the RDNs’, workday be preserved, as it is often used to complete skill-enhancement training and quality improvement activities and to provide trainings to other members of the health care team. These activities are among many others necessary to ensure the RDN is providing high-quality care that leads to improved patient outcomes.1 of direct vs indirect activities.6,8


Box 4.4 provides further examples In addition, RDNs are becoming more involved in


quality improvement initiatives than ever before due to the increased focus on pa- tient safety and the provision of quality care by accrediting agencies such as TJC.8


CHAPTER 4: Clinical Nutrition Management


81


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