PRACTICE APPLICATIONS

Emerging Science and Translational Applications

Clinical Nutrition Stafng Benchmarks for Acute

Care Hospitals

UE TO BUDGET CONSTRAINTS
and increasing pressure in
hospitals to manage and
evaluate staff resources effectively, nutrition managers need
standards against which to compare
their stafng for registered dietitian
nutritionists (RDNs). The Academy of
Nutrition and Dietetics addressed the
issue of RDN stafng in the hospital
setting in a comprehensive book published in 2004 discussing factors that
should be included in a clinical stafng
analysis.1 At that time, a stafng ratio
of one RDN for every 65 to 75 patients
(average census) for a medical/surgical
acute care oor and a ratio of 1:30 to
1:60 for an intensive care unit was suggested, but not widely adopted, in the
hospital industry.1 There has not been
a universally accepted number of RDNs
that are employed based on average
daily census or any other metrics.2
Nutrition managers, therefore, have a
limited ability to assess whether
their clinical nutrition staff is meeting
productivity goals or to advocate for
adequate stafng. The Dietetics
Practice-Based Research Network is
currently evaluating RDN stafng and
productivity in acute care hospitals.3
The amount of time spent in patient
care activities such as obtaining diet
histories, performing nutrition-focused
physical exams, and providing patient
education can vary by clinician and by
patient. The amount of detail written in
notes, the speed and efciency of using
the patient care records, and the
amount of time spent in medical
rounds or committees can also affect

This article was written by Wendy

Phillips, MS, RD, FAND, regional clinical
nutrition manager, Morrison Healthcare,
Charlottesville, VA; director, nutrition
systems, University of Virginia Health
System, Charlottesville; and a certied
lactation educator and a certied nutrition support clinician, Crozet, VA.
http://dx.doi.org/10.1016/j.jand.2015.03.020

2015 by the Academy of Nutrition and Dietetics.

the overall number of patients seen

per day.
In addition, each facility serves
different patient populations, and the
expectations required of staff may vary
according to each hospital administrator. Separate stafng benchmarks
should be set for medical-surgical
oors vs critical care beds, but there is
variation within those care settings as
well. For example, critical care units
that treat transplant patients are likely
to have a higher acuity level than critical care units that do not treat such
patients.
Emerging health care trends also
affect RDN activities and would likely
change the suggested stafng ratios
from 2004 even if they had been
accepted as industry standard.4 As
more attention is focused on employee
health and wellness in hospitals, many
RDNs are being asked to participate in
these initiatives. This may include
designing hospital cafeteria menus,
providing wellness education displays,
and overseeing other wellness-related
items. Because health care accrediting
agencies such as the Joint Commission
have an increased focus on patient
safety and provision of quality care,
RDNs are even more involved in quality
improvement initiatives in todays
health care environment.5 These responsibilities are often added to the
existing patient care load, but RDN staff
is not increased. Although these activities add value and are worthy of RDN
time and involvement, an RDNs time
dedicated toward direct patient care
activities can be reduced.

ESTABLISHING PRODUCTIVITY
BENCHMARKS
Understanding the current workload
assigned to RDNs in the hospital
setting is the rst step toward establishing a standardized stafng ratio
that accounts for all activities the RDN
is responsible for, including direct and
indirect care activities. Using a standardized productivity monitoring tool,

baseline data collection to establish

these benchmarks was done over an
11-month period at hospitals contracted with Morrison Healthcare
(MHC) for clinical nutrition services.
Although policies and procedures for
nutrition care provided by MHC are
standardized, the large number of
participating hospitals in various
geographic locations with different
patient populations and levels of acuity
make the benchmarks established by
this study applicable to hospitals that
are not contracted to MHC. Hospitals
were classied as either: 1) academic/
tertiary care, or 2) community hospitals. Hospitals that are part of a university or other teaching setting were
considered in the rst category, as well
as hospitals with a level 1 trauma unit.
Although most MHC hospitals collected
data, hospitals were excluded from this
current analysis if the population
included an extended care facility or
other noneacute care hospital setting.
Only data recorded by RDNs was
included in this nal analysis because
the patient care duties performed by
nutrition and dietetics technicians,
registered (NDTRs), are usually substantially different than those performed by RDNs in the acute care
setting. Hospitals with a single RDN
who spent a lot of time completing
foodservice activities instead of clinical
responsibilities were excluded from
this current analysis. Clinical nutrition
managers (CNMs) were not required to
complete the form unless a substantial
portion of their day was dedicated to
direct patient care activities.
The Figure lists the categories of data
collected for direct and indirect care
activities. To ensure consistency in
documentation, education sessions
were provided in a variety of formats
for RDNs who would be using the tool.
Sessions were offered via webinar and
as individual in-person training or
small-group teleconferences; questions
were answered via e-mail and telephone; and step-by-step instruction

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PRACTICE APPLICATIONS

Figure. Categories used to document the productivity of registered dietitian nutritionists (RDNs) working in 420 hospitals. One
monthly summary report for each hospital, including information from each RDN, was sent to the researcher over an 11-month
period. A total of 1,311 monthly summary reports were analyzed. Comprehensive and limited assessments/reassessments and
patient education were tracked in total numbers of patients seen. All other categories were documented in 15-minute increments.
Total hours worked was also tracked. aQAPIQuality Assurance and Performance Improvement.
sheets were provided. Most CNMs took
part in more than one type of education session. The researcher was available to answer questions at any point
during the data collection time via
telephone or e-mail. The CNM at each
hospital sent one summary form per
hospital to the researcher at the end of
the month; the form included the
documentation from each RDN, and
the CNM was responsible for ensuring
accuracy of the data. If data appeared
awed in the nal version after being
submitted to the researcher, follow-up
contact was made to verify the accuracy of the results. If needed, corrections were made by the RDNs and
CNMs at the facility prior to the nal
version being accepted.
This study did not distinguish between initial or follow-up visits, but
rather RDNs tracked the number of patients seen per complexity of the care
provided (comprehensive or limited).
An assessment/reassessment was
dened as comprehensive or limited by
the activities performed, not in assumed
increments of time. RDNs were
instructed to document an encounter as
comprehensive if they completed multiple activities with the patient, such as
reviewing laboratory test results and
medications, obtaining and reviewing
diet and medical history, and documenting the patient encounter in the
medical record. Limited assessments
were dened as brief encounters for
follow-up on adequacy of intake, tolerance or acceptance of supplements
provided, or similar issues. If the RDN
was approached by another health care
team member to discuss the patient but
did not document this in the medical
record, the patient was still to be
2

counted as a limited assessment due to

the time required to discuss the patient.
Direct care activities are dened as
any activities that directly inuence
patients, whereas indirect care activities are those activities required to
provide services in that facility, but are
not directly linked to individuals or
groups of patients. For example, many
RDNs spend time in patient care committees, such as the Patient Satisfaction
Committee or the Provision of Care
Committee. Additional indirect care
activities commonly performed by
RDNs include completing productivity
monitoring forms; helping with foodservice audits; participating in performance improvement and quality
assurance projects, development of
care guidelines and policies, and
research; serving as a preceptor for
dietetic interns; and teaching nutrition
to other health care staff. RDNs were
not asked to track nonproductive time,
such as lunch breaks, because this is
nonpaid time. Institutional Review
Board approval was not needed as this
was a quality assurance project and no
patient identifying information was
documented or sent to the researcher.
Descriptive statistics were run using
Microsoft Excel (version 2010, Microsoft Corp). Benchmarks were determined for percent of time spent in
direct care and indirect care activities,
number of patients seen per hour spent
in direct care, number of patients seen
per hour worked, and number of patients seen per full-time equivalent
employee (see the Table).

Sample Analyzed
Total sample size was 1,311 summary
reports analyzed from 420 different

JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS

hospitals, which reected each hospital

reporting for multiple months over the
11-month data collection period. Of the
1,311 summary reports, 439 were from
hospitals classied as tertiary care
hospitals, and 872 were from hospitals
classied as community hospitals.
There were no statistically or clinically
signicant differences in data collected
from tertiary vs community hospitals,
so the data were aggregated and one
benchmark was established for all
hospitals.

RESULTS
On average, RDNs saw 2.42 patients
per hour spent in direct patient care
(see the Table). Since not all time was
spent in direct patient care activities,
the number of patients seen per total
hours worked was smaller, at an
average of 1.43 patients seen per hour
worked.
RDNs spent 77% of their time on
direct care activities and 23% of time on
indirect care activities. No trends were
consistently seen between hospitals for
the indirect care activities on which
RDNs focused their time, since division
of responsibilities among RDNs and
other management staff varied substantially depending on the hospital.
An average of 2.42 patients seen per
hour spent in direct care translates to
the RDN spending about 25 minutes on
each patient. Since RDNs spent 77% of
their time in direct care activities, and
2.42 patients were seen per hour spent
in direct care, about 15 patients were
seen per 8-hour work day (8
hours
0.776.16 hours spent in direct
care activities; 6.16 hours
2.4214.9).
Some RDNs will spend more time with
each patient than others, and some
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Table. Average productivity data for registered dietitian nutritionists (n1,311) working in 420 different hospitalsa

Meanstandard deviation

Average patients
seen per hour
spent in direct care

Average patients
seen per hour
worked

% Direct
care

% Indirect
care

2.420.022

1.430.014

770.004

230.004

Each hospital reported for multiple months over the 11-month data collection period. Every registered dietitian nutritionist working in the hospital reported data each month.

patients will require more time than

others. The numbers reported here are
averages over time.

IMPLICATIONS FOR PRACTICE

This work establishes metrics against
which RDN productivity can be
compared, but it does have limitations.
Data were self-reported by RDNs and
summarized by CNMs at hospitals
remotely located from the researcher.
This creates the same limitation as any
self-reported data would have, and is
similar to other productivity monitoring
research that has been completed or is
currently being completed. In addition,
exclusions of hospitals using NDTRs
limits the application of results to hospitals that do employ NDTRs. The simple
descriptive statistics utilized in the data
analysis make it impossible to control
for factors such as acuity level or patient
population. However, a strength of this
work is the large heterogeneous sample
size of hospitals in every geographic
region of the country, which helps to
ensure the results are applicable in
almost every acute care setting to use for
benchmarking comparisons.

In addition to using the numbers

reported here for external benchmarking, CNMs can monitor the effectiveness of the care provided by RDNs
in the hospital and the efciency with
which that care is provided. Using the
calculations obtained from this productivity monitoring tool, CNMs can
objectively compare productivity statistics between the RDNs in one hospital, keeping in mind the intricacies
inherent in the patient care oors
assigned to each of the RDNs and the
characteristics of the hospital population. For example, the CNM can evaluate whether RDNs are spending the
expected percentage of time in direct
care vs indirect care activities, or seeing
a comparable number of patients per
month as other RDNs at that hospital
or compared to an average from a
comparable population, as reported in
the Table.
It is essential to note that the metrics
reported in this article set benchmarks
for comparing select aspects of RDN
stafng in acute care hospitals. Since
patient outcomes related to RDN staffing were not tracked as part of this
study, this does not reect the stafng

ratio that is needed to ensure safe

and quality care, optimize patient
outcomes, or contribute to professional job satisfaction for the RDN.
Research is still needed to help
determine a standardized stafng ratio for optimal patient care in multiple care settings.

References
1.

Biesemeier C. Achieving Excellence: Clinical Stafng for Today and Tomorrow.

Chicago, IL: American Dietetic Association; 2004.

2.

Marcason W. What is ADAs stafng ratio

for clinical dietitians? J Am Diet Assoc.
2006;106(11):1916.

3.

Dietetics Practice-Based Research Network.

Academy of Nutrition and Dietetics website.
http://www.eatrightpro.org/resources/res
earch/evidence-based-resources/dpbrn.
Accessed March 12, 2015.

4.

Rhea M, Bettles C. Future changes driving

dietetics workforce supply and demand:
Future scan 2012-2022. J Acad Nutr Diet.
2012;112(3 suppl):S10-S24.

5.

Accreditation Council for Education in

Nutrition and Dietetics. Rationale for
future education preparation of nutrition
and dietetics practitioners. http://www.
eatrightacend.org/ACEND/content.aspx?id
6442485290. Updated February 18, 2015.
Accessed March 12, 2015.

DISCLOSURES
STATEMENT OF POTENTIAL CONFLICT OF INTEREST
No potential conict of interest was reported by the author.

FUNDING/SUPPORT
There is no funding source or any other disclosures to report.

ACKNOWLEDGEMENTS
The author would like to acknowledge the following people for their signicant guidance and support for this project: Jennifer Reiner, MS, RD,
LD, corporate director, Nutrition & Wellness, Morrison Healthcare; Gisele LeBlanc, MS, RD, LDN, FAND, corporate director, Nutrition & Wellness,
Morrison Healthcare; Peggy ONeill, MS, RDN, CSG, LDN, vice president, Nutrition and Wellness, Morrison Healthcare; and all of the Morrison
Healthcare RDNs and CNMs who contributed data to this project.

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