Future Dimensions

In Clinical Nutrition Management

VOLUME XXXIV, NUMBER 4

FALL 2011

Get in Shape: Exercising Lean Management in Health Care

Kelly Eiden, MS, RD, LDN Much like fad dieters, most organizations fail to recognize that long term success depends on a full commitment to a new and healthier lifestyle. In this economic and outcome based environment, managers need to provide value (building lean muscle mass) while getting rid of the waste (fat). Lean management provides the tools for a manager in any industry to increase productivity, simplify complex processes, engage employees and have the right equipment in the right place at the right time. The Lean process is a set of principles that optimize resources by improving work flow. This practice was started in the automotive industry by Toyota and has since successfully moved into all types of manufacturing and now into healthcare (1). Lean management is a strategy that has been employed in our academic medical center to improve outdated processes and allow for frontline staff to be a catalyst for change. Lean recognizes that the direct patient care providers are the true innovators of best practice. Creation of standard work builds in accountability by providing transparent key performance indicators that allow administration and staff to collaboraIN THIS ISSUE tively monitor quality outcomes. Table 1 Message From The Chair lists several key terms that are used in the Nutrition Informatics Chair Lean process. Update So how is Lean different from Total Featured Articles Quality Management (TQM) and Get in Shape: Exercising Continuous Quality Improvement (CQI)? Lean Management in Health Some concepts are the same, but TQM and Care CQI appear usually about every 3 years when The Joint Commission (TJC) is Patient Satisfaction from a about ready to come through a healthcare Clinical Perspective organizations door. The problem with CNM Member Receives these approaches is that they have not been National Recognition widely implemented throughout entire organizations (1). Commitment from all Mega Issues Outcome from the levels of an organization must occur to susFall HOD Meeting tain change. Lean is an organization-wide commitment to employees for change with

Managing Editor Courtney Spurlock, MS, RD Phone: 407/880-6708 Fax # 407/880-6962 E-mail:
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Lead Features Editor Lisa Trombley, MA, RD, CNSD Phone: 310/903-2900 E-mail: Mhilisa2@aim.com Features Editors Jennifer Doley, MBA, RD, CNSD Phone: 520/872-6109 E-mail: jdoley@carondelet.org Robin Aufdenkampe, MS, RD Phone: 734/936-5920 Email: robin.aufdenkampe@gmail.com

Future Dimensions
IN CLINICAL NUTRITION MANAGEMENT

Viewpoints and statements in these materials do not necessarily reflect policies and/or official positions of the Clinical Nutrition Management Dietetic Practice Group or the American Dietetic Association. 2011 Clinical Nutrition Management Dietetic Practice Group of the American Dietetic Association. All rights reserved.

Publication of an advertisement in FUTURE DIMENSIONS in Clinical Nutrition Management should not be construed as endorsement of the advertiser or the product by the CNM Dietetic Practice Group or the American Dietetic Association.

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employees taking the lead. Accountability is a requirement. This is often the hardest step in maintaining change. The Lean system is not about downsizing. It is about having the right equipment, people, supplies, etc in the right place at the right time. This creates a win, win for everyone. Lean starts with identifying the value-added and nonvalue-added steps in a process (2). A value stream map is created. Each step in a process is identified along with obstacles and bottlenecks. The time for each step of the process is recorded. The amount of waiting time between the steps is waste or non-value added time. The value map should be created with a team of employees who can talk about the process but, more importantly, visualize the

Table 1 - Lean Terminology 5S Flow Gemba Kaizen Kanban Muda Standardized Work Sort, Straighten, Shine, Standardize and Sustain Continuous delivery of value without interruption Go to the process and see for yourself Continuous Improvement A signal system used to trigger replenishment Waste; any activity that does not add value A set of work instruction and guidelines that define how a process should run. A set of easy-to-understand work instructions, standard operating procedures and visual work cues that facilitate standardized effort, problem exposure and waste elimination. The set of all activities (value and waste) required to provide product or service for the customer: Process Steps, Process Time, Waiting Times, Inventory, Communication and/or Information Flow.

Value Stream Map

steps. Data collection should be accomplished through actual observation of the process (2). The value map is then used to prioritize and drive change. When improve-

ments are identified, a future state map is created to outline the desired process by combining steps, removing steps, reordering steps and simplifying steps to create a

Figure 1. Example of a Value Stream Map in the G1 Lab

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more efficient process. Figure 1 shows an example of a value stream map. Lean in Action Have you ever felt the frustration of identifying a solution to a problem only to wait months to see the solution implemented? Our Lean transformation journey has greatly reduced, and in many instances eliminated, that frustration. The solution was the Kaizen event. In our institution, a Kaizen is a clearly scoped, intensive, process improvement event that starts on Monday and goes through Friday when a report-out to leadership on the weeks events is conducted. Kaizen events utilize focused teams to design and implement incremental improvements to promote a culture of continuous improvements. A team is developed, consisting of a leader, members of staff working in the area and outside eyes, or someone from another department who can look at the process from a different perspective. There are several Lean tools that are used during a Kaizen. One of the most powerful for improving process flow in our institution is the 5S. This stands for sort, straighten, shine, standardize and sustain. How much time do we waste at work or at home looking for things that we need? A 5S activity reduces the waste by organizing a space and using visual management (2). The 5S process is not just a spring cleaning although, it does start with identifying equipment or items that are out of date or not needed (sort). Equipment or items that are not needed in the area but may be used by others are put in a red tag area and can be

an IV are within arms reach at the patient bedside reducing the walking time to go to a The second step is cabinet across the to identify how often Creation of standard unit. Items used every items are used work builds in shift are within a short (straighten). Items walk and items used accountability by that are used most freproviding transparent only once a day are quently would be located farther away. key performance stored closest to the place they are used The last step, often indicators that allow (2). There may be the most difficult, is administration and more areas that need to prevent this process staff to collaborativeto have certain items from becoming a one ly monitor quality available for staff time experience (susoutcomes. within arms reach. tain) (2). The team Also, parking spots develops an audit plan are identified to store equipment for front line staff to sustain and by marking the floor with tape. for managers to have the ability to An example is a scale. How often see if the new standards are being do staff walk around asking others followed. It is up to the managewhere one is? By designating a ment team to sustain the changes. place the item should be returned There are many great examples of to after use, everyone knows where Lean in our organization. The first to go for the scale. area Lean was started was our GI The third step is to clean (shine). lab. There were long patient waitAfter the areas are freed of unnecing times and low customer satisessary items, the team cleans and faction. A value stream map was identifies areas that need painting created to outline the flow of a or repair. Supporting departments patient from registration to dissuch as housekeeping, charge. After the future state map facilities/physical plant and was created, 20 Kaizen events were grounds are available the week of held to evaluate and improve work the Kaizen event to complete the flow, update schedules and stanneeded repairs immediately. dardize procedure rooms. These Kaizen events decreased the numThe fourth step in a 5S is to make ber of forms from 26 to 9. The sure that the needed items identinumber of steps a nurse took fied in the straighten step are preparing a patient for a procedure stored in the same place in the decreased from 266 to 32. Prior to department or across departments the Lean initiative, there was a (standardize). An example is obserrequest for $2.5 million dollars for vation beds in our radiology unit. renovation to increase capacity. Each patient bay now looks exactly After Lean, this cost was avoided the same. Supplies are located and and the number of procedures that labeled the same in each bay so could be completed per day was regardless of which area the nurse increased from an average of 34 to works, supplies are located in the 61 cases per day. same place. The supplies to start

distributed elsewhere in the institution.

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To start Lean practice in our Table 2 - 5 Step Process of Managing for Daily Improvement department, our two lead dietitians 1. Structured daily rounding with a purpose (supervisor and above) attended training seminars and all staff completed a web based train2. Huddles led by employees ing program. Then, members of 3. Actionable metrics with targets our team participated in Kaizen events throughout the hospital. 4. Countermeasures to achieve the targets Nutrition staff was involved with 5. Daily accountability (who, what and when for countermeasures) the implementation of a Kanban, or pull, system of inventory control in the neona- Figure 2. Example of Standardized Work in the G1 Lab tal unit (NICU). Previously, the facility rented Omni Cells to store supplies. This required a nurse to enter a code to obtain items such as syringes, dressings, etc for individual patients. When a physician wanted an item, he/she would have to locate a nurse to obtain an item from the Omni Cell. This created a non-reimbursable charge to individual patient accounts. Because there was no reimbursement for these items, the step was deemed unnecessary and created a non-value-added process. The Kanban system utilizes bins in the supply rooms that have a system of ordering and replenishment organized by materials management. A par level is set for inventory controlled by one department, which has led to having the item available when needed, while avoiding costly overstock. When the last item on one side of the bin is taken, a card with a bar code is pulled and hung on a board where a supply chain employee can scan the card. When the product comes in, the items are restocked and the card is put back
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on the bin. Staff in each area is involved in eliminating non-essential items and deciding what supplies are required. The hospital has saved $105,000 per year by no longer having to rent the Omni Cells. Prior to the Kanban system, the nursing unit, the nutrition services department, and the food and nutrition department all ordered supplies for our formula room. Our technicians ordered and

stocked some of the materials needed in several areas while other items were delivered to the floor for the technicians to inventory and stock. Through a Kaizen event and implementation of the pull system, we took the opportunity to merge some of our NICU formula room supplies into the Kanban system. This has freed an average of six hours per week for our technicians that can now be used for direct patient care.

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In addition to the Kanban system, our department instituted standardized work into our formula room. The process started with a reevaluation of how we were making the infant formula in the formula room. Although a process was in place, we found there were differences between what employees were doing and how they were being trained. Before a serious event occurred, it was time to take another look at the process and ensure everyone was on the same page. The idea behind standardized work is to allow anyone to visualize the process and understand what is being done (see figure 2). Standardized work not only outlines the steps to a process but also shows the expected duration of an activity (2). This ensures adequate time is allocated to a process and that there are clear expectations for everyone. Standardized work also provides an opportunity for management to look at who is doing what task and ask the question: Is this the best person to be completing this task? Standardized work does not ensure that just because a process is outlined that it is being done correctly. Standardized work includes checklists, audits and inspections (2). If employees are expected to follow standardized work, it is up to the leadership to do a Gemba walk and verify that it is being completed properly. Acceptance of actions that do not meet expectations is a sign to the employee that it is okay not to follow the standards set before them. Front line employees need to understand the reason for standardized work optimal care of the patients. We did find some resistance to stan-

the same time each morning to dardized work. Change can be report out what they have for the hard for employees. Including day. This includes the number of them in decisions and building consults and follow-ups due for consensus are the best ways to gain that day, rounds, meetacceptance (2). We are It is important ings, outpatient clinics currently in the process of collecting data on that management and other miscellaneous activities. When the errors and process time is intimately huddles first started, and will discuss this aware of al the they were lead by the using our Key work that is director, manager or the Performance Indicator required to oper- clinical leads. Now, (KPI) board which is ate departments they also are lead by the discussed below. and be visible employees. During this Managing for Daily and accessible to time, team members Improvement share the workload by staff. Managing for Daily communicating the Improvement (MDI) is ability to assist other a fundamental tool of the Lean dietitians with their patient care. process that has lead to team work, Initially, the management team increased productivity and job sathad to ask some members of the isfaction for our dietitians. MDI is team if they could assist when it a concept that requires manageappeared their load was light for ment to be actively involved in the day, but this rarely occurs now. day-to-day operations. It is imporStaff willingly offers to assist cotant that management is intimately workers and therefore more aware of all the work that is patients are seen and staff feels that required to operate departments workloads are equal. This short and be visible and accessible to time spent each morning has constaff. MDI means becoming a role tributed to an increase in producmodel, ensuring discipline is maintivity from 6.7 patients seen per tained and decreasing the time day to 11.3 patients per day on spent putting out fires. During average and a more cohesive team. MDI activities, managers see the Part of MDI is the Key cause of the problems and support Performance Indicator (KPI) the problem solving efforts. The board. This is a visual board that manager prioritizes improvement defines what is being measured, the activities and serves as a champion target and the countermeasures. to communicate and remove any The countermeasure is the list of barriers that exist. MDI occurs in the problem descriptions, what will the workplace, not in the managers be done to solve the problem, the office. Table 2 shows the five step person responsible and the due process of MDI. date. Our organization uses a stanMDI in our department started dardized form for recording counwith daily huddles (Monday termeasures. For each departments through Friday) which we refer to KPI board, our organization has as touch base. All inpatient dietiidentified five areas for continuous tians, meet for 5 to 10 minutes at improvement that are aligned with
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our goals and objectives: Safety, People, Quality, Service and Finance. Under each area, our department has identified 1 to 2 metrics that are actionable and pertain to our staff and ultimately contribute to the goals of the organization. It is up to the huddle leader to address the status of the action items and if the responsible person is addressing the problem. The process of identifying metrics starts with the 5 Whys. This is a method of continually asking why in order to find the root cause of a problem. This is similar to the nutrition care process; you want to get to the root cause of the nutrition problem of your client. In order to solve the issue, it is important to know the exact reason it is occurring and the best solution. A great example is one that occurred at the Jefferson Memorial in Washington, DC. The National Park District noticed the Jefferson Memorial was crumbling at a very fast rate and found out it was being washed more than the other memorials. The simple solution was to stop washing it so much, end of story. However the solution was not that simple. When asking why the Jefferson Memorial was being washed so much, the answer was that there was a large amount of bird droppings everyday. When asked about why there were so much bird droppings, they discovered that the memorial had a large population of spiders that the birds were feeding on. The spiders had such a large population due to the abundance of midges (two winged flies) around the memorial. When the last why was asked, the root cause was found: the lighting
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around the memorial just before dusk created the perfect atmosphere for midges to come out and mate. The solution was to wait until dark to turn on the lights, which resulted in a cost savings for the National Park District. Conclusion Developing a Lean culture takes commitment from all levels of an organization. We have experienced many positive changes. Involvement from top organizational leaders who are ready to drive change is critical for Lean success. Physician support is also a key factor in success. There is no one way to start the Lean journey. Each organization has different goals and its own culture. Start small utilizing Lean tools and learning as you go. Share ideas and involve employees on the front line as catalysts for change. Kelly Eiden, MS, RD, LDN is the Director of Nutrition Services at Loyola University Medical Center in Maywood Illinois and she can be contacted by email, keiden@lumc.edu.

References 1. Chalice, RW. Stop Rising Healthcare costs using Toyota lean production methods: 38 steps for improvement. Milwaukee, WI: American Society for Quality, Quality Press; 2005 2. Graban, M. Lean Hospitals: Improving Quality, Patient Safety, and Employee Satisfaction. New York, NY: Productivity Press; 2009. 3. Moore S, Brooks G. Ineffective Habits of Financial Advisors (and the Disciplines to Break Them): A framework for avoiding the mistakes everyone else makes. Hoboken, NJ: John Wiley and Sons, Inc; 2011.

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Vol. XXXIV, No. 4, Fall 2011

Patient Satisfaction from a Clinical Perspective

Wendy Philips, MS, RD, CNSC, CLE and Janelle Webb, MBA
Patient Satisfaction has taken on a new meaning for healthcare organizations since 2006 when the Centers for Medicare and Medicaid Services (CMS) began using HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) as a survey instrument and data collection methodology for measuring patients perceptions of their hospital experience(1). Since July 2007, hospitals subject to the Inpatient Prospective Payment System (IPPS) annual payment update provisions must submit HCAHPS data in order to receive their full IPPS annual payment update. They must also publicly report the data or else receive an annual payment reduction of 2%. Beginning in October 2012 (for Fiscal Year 13), HCAHPS will be included as a measure for the Hospital Inpatient ValueBased Purchasing program through The Patient Protection and Affordable Care Act of 2010. The goal of these programs is to reward hospitals based on actual quality performance measures (2). HCAHPS survey results for healthcare organizations are posted on the internet at www.hospitalcompare.hhs.gov/hospitalsearch.aspx (1) and more information about this national benchmarking tool can be found at www.hcahpsonline.org (3). Patients and healthcare providers can use this information as part of their decision making process when choosing a hospital for elective admissions. Elective admissions are generally coveted by hospitals because they typically generate better revenue than emergency admissions. Additionally, the public nature of this information can affect the hospitals image, thereby affecting fund-raising efforts. As such, hospital administrators are fiscally motivated to enhance their patients perceptions of their hospital experience. For these reasons, contract foodservice management companies frequently have patient satisfaction goals and/or incentives written into their contracts with the hostrayline audits, test tray evaluations, and pital or facility. Likewise, all departments patient visitation are a basic part of the in a hospital, whether contracted services job. In other facilities, there is a clear or not, must demonstrate to hospital division between the clinical nutrition administration their action plans to maxidepartment and the foodservice departmize patient satisfaction. Several hospitals ment. In those cases, patient satisfaction have formed Patient Satisfaction may seem irrelevant to the RDs job. Committees with representaHowever, patients intimately tives from multidisciplinary associate RDs with food, teams to address common Due to relatively and although RDs play a issues. Many hospitals advolarger role in the managerecent increased cate scripting for the survey ment of the patients care focus placed on that is consistent throughout while hospitalized, the the hospital and guides the patient may not be made patient satisfacpatient towards the terminolaware of this. Due to the tion as a quality ogy used in the survey tool. relatively recent increased indicator, every Other systems, such as focus placed on patient satisNursing Hourly Rounding, employee within faction as a quality indicator, have been developed with the every employee within the the organization goal of improving patient organization needs to focus needs to focus on on patient satisfaction, satisfaction. including RDs. All employpatient satisfacTools other than HCAHPS ees and all encounters from tion, including are available to measure the pre-admission process patient satisfaction, including RDs. through discharge affect a Press, Ganey. These secondpatients perception of the ary surveys ask additional care they receive. questions and can be used in addition to, but not instead of, HCAHPS. Although Therefore, RDs need to act as ambassathese are associated with additional costs, dors for the food service department to some hospitals recognize the benefits of the patient to improve hospital satisfaction using them, such as the ability to compare scores and for the personal benefit of the to peer group hospitals. They are also patient. Additionally, patients may be especially useful for foodservice departasked on the survey if they understood ments since HCAHPS does not have any their diet order while hospitalized. Often, questions directly related to food service. the patient is never even told what their Secondary survey questions asked can vary diet order is! RDs play an obvious role for based on the healthcare organization, so being proactive in explaining the diet the individualized tool used at the facility order to the patients. An important note should be readily visible to all employees. is that if a hospital chooses to only use the For survey questions pertaining to the HCAHPS survey, which does not include foodservice department, patients may be any food service questions, this does not asked to rate the quality of their food, the exempt RDs from participating in Patient temperature of the food, and/or the courSatisfaction activities. tesy of the person serving the food. The department orientation for a Registered dietitians (RDs) in many newly hired RD needs to include a thorfacilities are integrally involved in the ough discussion of the organizations foodservice/operations side of the busiPatient Satisfaction plan with specific ness, and participation in activities like expectations for the RD outlined. The

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new RD needs to know all of the questions asked on the survey, including the foodservice questions. Likewise, every hospital employee ought to be oriented to all of the questions on the survey, including the foodservice questions. This way every employee can be cognizant of their actions with every patient, every day, as they influence the patients satisfaction with their care. A patients perception is their reality, which becomes the reality for the healthcare organization. Nurses have the most interaction with patients and can most directly influence the patients perception of their care. Food service personnel need to elicit their support in promoting the patients satisfaction with the food served. If patients overhear nursing complaining about the food, or if nurses agree with patients when they complain about the food, the perception is enhanced and more likely to be reported on the survey. RDs have frequent interactions with nursing staff during patient/medical rounds, committees, and when implementing multidisciplinary nutrition care plans for the patients. This makes RDs the natural liaison between the food service staff and the nursing staff to collaborate on patient satisfaction issues and provide feedback on providing quality patient food services. RDs need to have patient contact as part of this liaison relationship. Taking diet history and providing patient education is an integral part of this contact. As part of the diet history, RDs find out if the patient is eating well and try to help the patient maximize their intake based on their care goals. Every interaction with the patient is an opportunity to maximize their perception of the care they receive. The RD can utilize the food service staff to ensure alternate food preferences are provided to improve appetite and intake. It is important for RDs to be aware of how they interact with patients. Here is an example of a brief patient encounter: RD: Good morning, Mrs. S. Im the dietitian and I came by to see if youre eating well. Mrs. S: My appetite is very poor. I just cant seem to be hungry while Im lying in

bed every day. RD: I understand, but you need to eat to heal your wounds. Can you at least try a few bites each meal? The patient may agree to try, but they do not have an increased understanding of how their nutrition status affects their overall health, nor do they understand how the food services are part of the larger organizational goals for their care. Here is an example of how the RD can maximize the patients satisfaction with their food service: RD: Good morning, Mrs. S. Im the dietitian and I came by to see if youre eating well. Mrs. S: My appetite is very poor. I just cant seem to be hungry while Im lying in bed every day. RD: I understand how you feel. I know the chef here at Hospital A is very interested in helping you find food that you can eat within your diet order that may be more appealing to you. We do everything we can to ensure you are very satisfied with your care here, including taking care of your food. You have increased needs for healing because of your wounds, and foods rich in protein can help. I see the doctor has ordered a Heart Healthy diet for you due to your history of high blood pressure. This means we want to keep your total salt and saturated fat intake low, so we have several options of lean protein sources to choose from our menu. I will be sure to have the hostess assist you in your meal selections daily so we can best use nutrition to help you heal. Please let me know what questions you have about your Heart Healthy diet and how I can ensure you are highly satisfied with your stay here. This helps the patient to see that all members of their healthcare team work together to deliver quality care, and that they have multiple points of contact to get help for their needs. Above and beyond the questions directly related to a patients experience with the food, RDs need to be involved with the facility-wide patient satisfaction efforts. Although many of the HCAHPS questions refer to physician and nursing care, patients are likely to answer the questions based on their experiences

with any of the staff they interact with during their stay. RDs, like physicians and nurses, need to explain things in a way the patient can understand, while listening carefully to them and treating them with courtesy and respect. This respect is extended to encouraging a quiet environment by minimizing hallway conversations, maintaining patient confidentiality, and setting a good example for others. Patient satisfaction has been proven to be beneficial on many levels. It is costeffective for hospitals, essential for community relations, and an ethical responsibility to our patients. A patient who has received quality care during their stay will report their level of satisfaction with that care on the survey. RDs are an important link in the multidisciplinary committee working together to improve patient satisfaction scores, enhance nursing and foodservice departmental relationships, and improve patient care. Wendy Phillips MS, RD, CNSC, CLE is the CNM for Morrison Healthcare at the University of Virginia Medical Center in Charlottesville VA and she can be reached at wp4b@virginia.edu. Janelle Webb MBA is the California WIC Liaison, Clinica Sierra Vista in Bakersfield CA and she can be reached at webbj@clinicasierravista.org. REFERENCES 1. Centers for Medicare and Medicaid Services. CAHPS Hospital Survey. Baltimore, MD. Available at www.hcahpsonline.org. Accessed July 19, 2011. 2. Federal Register. Medicare Program; Hospital Inpatient Value-Based Purchasing Program. Available at www.gpo.gov/fdsys/pkg/FR-2011-0506/pdf/2011-10568.pdf. Updated May 6, 2011. Accessed July 19, 2011. 3. U.S. Department of Health and Human Services. Hospital Compare. Washington, D.C.; April 2011. Available at http://www.hospitalcompare.hhs.gov/hospital-search.aspx. Accessed July 19, 2011.

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Message from the Chair

Sherri Jones, MS, MBA, RD, LDN

Greetings CNM Members. Its hard to believe the fall season is upon us already. Boy, doesnt the summer manage to fly by so quickly?! If you are like me, I love the beauty of the fall foliage, but also know it signifies change for many of us colder temperatures, less daylight, end of vacations, etc. Change is a situation some struggle with while others embrace. But Im sure we could all agree we experience change constantly. As you are likely aware, the American Dietetic Association will undergo a major change on January 1, 2012 when the name changes to the Academy of Nutrition and Dietetics. What an announcement to hear first-hand (for some of us) during the opening ceremony at the Food and Nutrition Conference and Expo (FNCE) by ADA President, Sylvia Escott-Stump. To find more information on the name change, visit the ADA website press release at: http://www.eatright.org/Media/content.aspx?id=6442465361 Keeping in line with the theme of change, please consider attending the 2012 CNM annual symposium titled: Executing Change March 24-27, 2012 at the Savannah Marriott Riverfront in Savannah, Georgia. The CNM Professional Development Team has reviewed the various session proposals and selected the speakers/topics for the symposium. Ive seen a sneak peak at the agenda, and it looks awesome. Youll be pleased with the variety of topics and speakers. This year we are going green and plan to provide the symposium brochure electronically via the CNM website. However, you will likely receive a postcard in the mail informing you that registration has opened and directing you to the CNM website. Stay tuned for future eBlasts about the symposium and you can always continue to check our CNM website for updates as well. The CNM Executive Committee (EC) has many activities and projects underway. As you may recall, we provided feedback to ADA on the Future Connections Summit report. We have since learned CNM was one of 5 DPGs to provide feedback. Our feedback was reviewed by ADA, and CNM EC member volunteers were then assigned to provide guidance for the various initiatives. Other CNM EC efforts include consideration of hiring administrative support to help facilitate the transition to a new web design for CNM as well as provide additional administrative services to support board activities and our plan of work. This would enable us to better accomplish our strategic plan including initiatives to improve our resources and member benefits. Additionally, in the months leading up to FNCE, the EC was busy planning our various FNCE CNM activities and events. FNCE has since past. For those of you fortunate to have been able to attend, Im sure you would agree it was a great experience. And you all should be proud to know CNM definitely had a presence at FNCE. If you were in attendance, I hope you had the opportunity to participate in the various CNM events. I was very pleased with the exposure and participation of CNM members. I also have to point out the attention our CNM T-shirts (designed by Kathy Allen) received at FNCE. They really caught everyones eye in the Expo Hall, especially since the back of the shirts read Follow Me. In addition, one of the FNCE media photographers specifically came over to our CNM booth at the DPG Showcase and took a group picture. Who knows, perhaps our CNM group picture will appear in future ADA marketing material. Below, Ive highlighted the various CNM activities that took place at FNCE. We will try to get additional pictures posted on the CNM website for your viewing enjoyment. ?

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The Successful CNM Events Held at FNCE: DPG Member Showcase The DPG/MIG showcase was a popular attraction this year. Various CNM Executive Committee members manned the booth by marketing the benefits of CNM membership, encouraging non-members to join, and sharing our free give-a-ways. The theme of the booth was: We have the tools you need to lead.
CNM Member Services Committee proudly displays the CNM booth. Kathy Allen, Member Services Chair Linda Markiewicz and Janel Welch

Member Welcome Reception The CNM Member Reception was a great networking opportunity. Approximately 50-60 CNM members were in attenThe CNM Executive Committee showing our dance. A special creative CNM T-shirts at the welcome reception. thank you to Front row: Kim Brenkus, Sherri Jones, Krista Nestle for finanClark; Row 2: Frances Suen, Young Hee Kim, cially sponsoring Janel Welch, Kathy Allen, Mya Jones (ADA the event. DPG Manager), Monica Milonovich, Janet
Barcroft; Row 3: Terese Scollard, Lisa Trombley, Elizabeth Sommerfeld

CNM Sponsored Spotlight Session Although the session took place in the afternoon on the very last day of the conference, approximately 100 attendees were present. Our speakers did a wonderful job delivering the topic of: Tackling the Challenges of Clinical Staffing and Productivity: Doing More With Less.

CNM Spotlight Session speakers ready for their presentations. Kim Procaccino and Deb Yonkoski

As always, if you have any questions or suggestions for our DPG feel free to contact me. Id like CNM to meet your needs and expectations. Thank you for letting me serve as your Chair this membership year. All my best, Sherri Sherri Jones, MS, MBA, RD, LDN Chair, Clinical Nutrition Management DPG (2011-2012) Office: 412-623-1629 Mobile: 412-721-1713 jonessl@upmc.edu

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Congratulations to CNM Members!

CNM would like to acknowledge and congratulate 2 of our members on receiving national recognition within the American Dietetic Association: Janet J. Skates, MS, RD, LDN, FADA Janet was one of eight members presented with The American Dietetic Associations prestigious 2011 Medallion Award. The Medallion Awards have been given each year since 1976 in recognition of outstanding service and leadership to ADA and the dietetics profession. The winners received their awards at an Honors Breakfast on Sunday, September 25, during ADA's Food & Nutrition Conference & Expo in San Diego, Calif. Janets Medallion Award application was sponsored by CNM. A heartfelt congratulations to Janet. We are proud of you!!

CNM Member Janet Skates receives the prestigious ADA Medallion Award at the Honors Breakfast during FNCE. ADA Board Member, Pamela Charney introduced Janet while ADA Honors and Awards Chair, Judith Rodriquez joined her on the stage.

Susan R. Roberts, MS, RD, CNSC Susan R. Roberts, MS, RD, CNSC received third place recognition for her Dynamic Initiative in Dietetics Practice and Education display entitled Sustaining and Spreading Order Writing Privileges for Registered Dietitians. ADAs Council on Future Practice is the organizational unit that conducts the Dynamic Initiatives in Dietetics Practice and Education session during FNCE. This is the third year for conducting it, which recognizes practitioner contribution to the profession of dietetics. Susan was selected by her peers to receive this recognition. Congratulations and way to go Susan. We are proud of you!!

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Nutrition Informatics Chair Update

Terese Scollard, MBA, RD, LD
The informatics programs were fabulous at FNCE! Our energy is palpable! Check out the Nutrition Informatics Blog on eatright.org titled, Informatics at FNCE 2011 to get an update on all the action and learn if you are a NIRD! While you are at the Blog, locate the many topics of interest to CNMs such as: - The long awaited Diet Orders & Standards Meet - How to join the new Nutrition Informatics Community, http://adanic.webauthor.com - Learn about a new consumer and professionals health informatics resource, http://www.healthit.gov/ The American Dietetic Association, American Medical Informatics Association (AMIA) and Oregon Health Sciences University are likely to announce another nutrition focused 10 x 10 Biomedical Informatics course in 2012, culminating with the final class at FNCE 2012. This class will orient you to the basics of informatics and help prepare you for engagement in your worksite and to move nutrition and dietetics forward in healthcare, food and nutrition informatics. CNM is nearly ready to put out the request for proposal for a business to facilitate the CNM DPG website growth to support the strategic direction of the DPG. The board has determined to increase the tools and support for the website and this is the first much needed step in that process. Functions have been added to the current website. For example: A link to join the Nutrition Informatics Community of Interest, the ADA Nutrition Informatics Blog, and a link to an email box to send your name and contact information to be added to Subunit membership (free), and a membership directory by state and by name. Please take a moment to submit your name to be a member of the Food & Nutrition Informatics Subunit! Login to the CNM website, then go to Food & Nutrition Informatics Subunit; you will find an email link. Click on the link, and state your name, ADA number, and that want to join the subunit. We are hoping to update the membership list and create contacts within our existing database. The original data based changed as ADA updated their DMIS program. Plan to attend the CNM Symposium in Savannah in March 2012. The subunit has been invited to have another Open Session. Meet colleagues, exchange questions and ideas. Each time we have done this, the sessions have been energetic and enlightening and excellent networking.

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Mega Issues Outcomes from the Fall 2011 HOD Meeting

th The House of Delegates met in San Diego, September 23-24, for the 86 meeting of the House. For the second year the HOD hosted the HOUSEwarming event where nearly 200 members to network. New Delegates also participated in an orientation to a House Meeting while Table Facilitators learned about the intricacies of each dialogue session.

HOD Fact Sheet

Hous e of Delegates

November 2011

Two mega issues were discussed at the meeting: Licensure and Interdisciplinary Teams.

Friday mornings dialogue session was focused on the mega issue of licensure. This dialogue session began with testimonies from two delegates, Cindy Wolfram (Texas) and Lucille Beseler (Florida), regarding their states experience with licensure. The importance of licensure to the future of dietetics was explored. Meeting participants identified benefits, internal barriers and external threats to licensure. Existing or potential resources for addressing each piece was discussed. Key messages that could resonate with members, consumers, and legislators to communicate excitement, energy, value, and the desire to be engaged were crafted for use by ADAs Strategic Communications Team and Policy Initiatives & Advo cacy Team. The dialogue concluded with each meeting participant determining strategies they will undertake to support the efforts of their state in establishing, strengthening and/or maintaining licensure.

Licensure

Since the dialogue, the resulting motion was passed by the House. Based on the dialogue, a series of guiding principles were identified(the list provided is not all inclusive) :
Benefits of RD licensure include protection of the public, acknowledgment of the value by the consumer for the license including the services provided by the RD/DTR, opportunity for more referrals, job security and applicability to all areas of dietetics practice beyond Medical Nutrition Therapy.
Barriers of RD licensure include lack of funding for state licensure boards, lack of recognition of RD license by other health care providers, CDR credentialed practitioner apathy, lack of consumer and CDR credentialed practitioner knowledge about value of RD license, and inability to rapidly mobilize members.
Resources needed include multi-tiered national CDR credentialed practitioner education campaign, outcomes and cost-effectiveness data, web site focused on RD licensure, national database of harm to the public, and an educational toolkit (i.e., fact sheets, process for reporting harm to licensure boards, messaging focused on various audience). ADAs Policy Initiatives & Advocacy Team will be requested to develop a detailed plan of action for addressing Motion #1: Licensure. Several pieces for the plan are specified in the motion, including messaging to be crafted jointly by ADAs Strategic Communications Team and ADAs Policy Initiatives & Advocacy Team. All information collected during the Fall 2 011 HOD Meeting will be provided to the ADAs Policy Initiatives & Advocacy Team

Interdisciplinary Teams

The mega issue of interdisciplinary teams occurred Saturday morning. The video, Teamwork (http://www.youtube.com/watch?v=oz8RfU4GQZo&feature=related ) was shown to meeting

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Since the dialogue, the resulting motion was passed by the House. ADAs Professional Development Team will be requested to develop an action plan for addressing skill development related to interdisciplinary teams based on the HOD dialogue session outcomes. RDs/DTRs are encouraged to initiate participation on interdisciplinary teams to enhance services provided to customers and to promote and demonstrate the value of these teams. All information collected during the Fall 2011 HOD Meeting will be provided to the ADAs Professional Development Team.

Based on the dialogue, a series of guiding principles were identified (the list provided is not all inclusive):
Barriers identified include lack of skills (leadership, collaboration, negotiation, flexibility), institutional forces, lack of assertiveness and confidence, limited interdisciplinary teaming in dietetics education programs, and unwillingness or lack of opportunities to work in a team.
Opportunities that exist include utilizing technology, interdisciplinary team role modeling, utilizing preceptors to teach skills for participating in teams, mentoring of new RDs/DTRs to work in teams, and building on current relationships that exist.
Opportunities to create include involving local RD/DTR teams in community events, collecting data on effectiveness of interdisciplinary teams, developing interdisciplinary team resumes to promote value, offering educational activities for RDs/DTRs and other team members, and identifying key messages about the value of interdisciplinary teams.

participants. Forces critical to or having the biggest impact on moving RDs/DTRs towards interdisciplinary teams were talked about. Barriers and corresponding opportunities that exist for creating and being effective interdisciplinary team members/leaders were identified. These items will be categorized as to those: already being done; fitting with the 2011 Future Connections Summit on Dietetic Practice, Credentialing and Education pilot initiatives; or might need to be further developed.

HOD Meeting Material and Additional Resources

All materials related to Fall 2011 House of Delegates Meeting, includ ing slides from various Association related updates and outcome materials, are located online for members: www.eatright.org/hod > Fall 2011 Meeting > Meeting Materials.

CNM DPG Delegate Ann Childers, MS,MHA,RD,LD ann.childers@palmettohealth.org

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CLINICAL NUTRITION MANAGEMENT DIETETIC PRACTICE GROUP 2011 - 2012 EXECUTIVE COMMITTEE
Chair Sherri L. Jones, MS, MBA, RD, LDN jonessl@upmc.edu Chair-Elect Kim Brenkus MBA, RD, LD kbrenkus@roadrunner.com Immediate Past Chair Krista Clark, MBA, RD, LD, CNSD afrdrun@gmail.com Secretary Young Hee Kim, MS, RD, LDN, CNSD YoungHee.Kim@sphs.com Treasurer Monica Milonovich, MS, RD, LD mmilonov@yahoo.com Newsletter Managing Editor Courtney Spurlock, MS, RD cspurlock@IamTouchPoint.com Nominating Committee Chair Kerry R. Scott RD, CD Kerry.Scott@providence.org CNM DPG Delegate to the HOD Ann Childers, MS, RD, MHA, LD ann.childers@palmettohealth.org Nutrition Informatics Chair Terese Scollard MBA, RD, LD terese.scollard@providence.org Vice-Chair Cathy Welsh, MS, RD catherine.welsh@stjude.org Administrator, CNM Electronic Mailing List (EML) Deb Hutsler, MS, RD, LD dhutsler@chmca.org WebMaster Marcelle Karustis, MS, RD, RN, LDN mkarustis@gmail.com Newsletter Features Editors Lisa E. Trombley, MA, RD, CNSD Mhilisa2@aim.com Jennifer Doley, MBA, RD, CNSD jdoley@carondelet.org Robin Aufdenkampe, MS, RD robin.aufdenkampe@gmail.com Nominating Committee Chair Elect Caroline Steele, MS, RD, CSP, IBCLC csteele@choc.org Donna Quirk, MBA, RD, LD dqmba@sc.rr.com Legislative & Reimbursement Chair Frances Suen, MS, RD frances.suen@gmail.com Committee Member Jane Nuckolls, MA, RD, LDN NuckollJ@methodishealth.org Member Services Chair Kathryn Allen Kathy.allen@moffitt.org Committee Members Janel Welch jwelch02@unityhealth.org Linda Markiewicz, MBA, RD, CD linda.markiewicz@sodexo.com Professional Development Chair Sara Simard, MS, RD, LDN ssimard@lifebridgehealth.org Immediate Past Chair Sharron Lent, RD, LD lent-sharron@aramark.com Committee Member Jennifer Wilson, MS, RD, LDN wilsonjs@ph.upmc.edu Research/Quality Management Co-Chair Susan DeHoog, RD sdehoog@u.washington.edu Co-Chair Barbara Isaacs Jordan, MS, RD, CDN jordanb@mskcc.org Committee Members Debby Kasper, RD, LD debby_kasper@premierinc.com Jessie Pavlinac, MS, RD, CSR, LD pavlinac@ohsu.edu Young Hee Kim, MS, RD, LDN, CNSD vhkim58@sbcglobal.net Mary Jane Rogalski, MBA, RD, LDN mrogard@charter.net Ida Proco Ida.proco@centrahealth.com ADA Quality Liaison Sharon McCauley, MS, MB, RD, LDN, FADA smccauley@eatright.org Fundraising Chair Janet Barcroft, RD, LDN Janet.Barcroft@heahealthcare.com Immediate Past Chair Kim Brenkus, MBA, RD, LDN kbrenkus@roadrunner.com Committee Members Sky Joiner, RD sjoiner@andersonregion.org Megal ODonnell, RD, LD odonnem3@ccf.org

AMERICAN DIETETIC ASSOCIATION Manager, Relations Team Jeanette White, MS, RD, FADA Manager, DPG/MIG/Affiliae Relations jwhite@eatright.org

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