CHAPTER

Quality in nutrition and dietetics is a measure of excel- lence. Practice must balance various aspects of quality—that is, quality of the organization and prac- tice setting that adopts a culture of safety; quality of management of ongoing evaluation of quality measure- ment and improvement in performance to meet national health objectives; and quality of the providers of care, treatment, and services. The registered dietitian nutritionist (RDN) cannot manage what he or she does not measure and cannot improve what he or she does not measure.

Quality management is a systematic process with identified leadership, accountability, and dedicated resources for the purpose of meeting or exceeding established professional standards (1). The RDN spe- cializing in extended care settings, long-term care, and the postacute marketplace must continuously provide unmatched quality distinction in services and elevate the quality and safety program of nutrition and dietet- ics. The RDN’s commitment to focus on person-cen- tered standards and to address the needs of the aging population may require diversification in services he or she provides, which include adult day care, home care, and assisted living as well as transition services to lower level of care settings and delivery of services. The topmost quality and safety challenges for the RDN include a strong emphasis on the following: per- son-centered care, postacute care, medically complex care, rehabilitative services, memory care, behavioral health, quality assurance and performance improve- ment processes and deliverables, and readmissions, falls, and infections. Depending on the importance of the RDN and the role the RDN plays in leading and managing these challenges within the organization and practice setting, the RDN may need to design strategies and tactics for the best measure of success accomplish- ments for quality nutrition and dietetics services. A measure of success is “a numeric or otherwise

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Scope of Practice for the RDN and NDTR

quantifiable measure usually related to an audit that determines whether an action was effective and sus- tained” (2).

QUALITY IMPROVEMENT AND

NATIONAL QUALITY STRATEGY Quality improvement uses techniques to assess and improve internal operations. It focuses on organiza- tional systems to improve quality, which involves setting goals, implementing systematic changes, mea- suring outcomes, and making subsequent improve- ments. According to the Joint Commission, the best way to achieve this is by first measuring the perfor- mance of processes that support care and then using the data to make improvements (3). In a 2007 BMJ Quality & Safety in Health Care editorial, a quality improvement definition, illustrative tool, and method in improvement was proposed as the combined and unceasing efforts of everyone—health care profession- als, patients and their families, researchers, payers, planners, and educators

—to make the changes that will lead to better patient and population outcomes (health), better system per- formance (care), and better professional development (learning) (4).

The quality talk has been evolving since the 1990s, beginning with the Institute of Medicine reports To Err Is Human (5) and Crossing the Quality Chasm (6) and cumulating in “Knowing What Works in Health Care” (7) and “National Strategy for Quality Improvement in Health Care” (8). “Since the passage of the Affordable Care Act, health care payers, pur- chasers, providers, and consumers have shown an increased commitment to health and health care quality. The National Strategy for Quality Improvement in Health Care (National Quality Strategy) establishes a framework for coordinating and focusing the significant efforts of these diverse