GVH QUALITY STEERING COMMITTEE

02/07/2018

Malnutrition Screening

Team

Food and Nutrition Services

Nursing Education
Food and Nutrition Services – Summary

Blue Print for Quality and Patient Safety

Mission: Leading Our Community to a Healthier Future
Vision: Recognized for Excellence – Chosen for Caring
Imperatives
Results and outcome-focus :
Perfect Care
Customer-focus, with the
patient and family as the
primary customers
Provider Engagement,
Leadership, and Accountability
Transitions in
Care/Coordination
Continual pursuit of eliminating
waste and adding value in care
delivery.
Priority Actions
 Strive to provide perfect care
 Implement clear lines of accountability
 Provide consistent and thorough communication with families and
patients regarding plan of care
 Increase patient and family involvement in care of the patient
 Strengthen the organization for continuous improvement and
promotion of patient safety
 Increase physicians involvement in service excellence, quality and
safety initiatives
 Hand-Off Communication between staff
 Discharge hand-off to patient and family
 Discharge hand-off to outpatient care
 Eliminate variations in care processes where evidence exists
 Provide personalized care
Food and Nutrition Services

PI Project
Malnutrition Screening
PI Project Step 1: Start Date
 PI Project Step 2: Problems Identified
• Review of Malnutrition Screening results
reflected that the answers to the questions
were often inaccurate.
• The inaccurate answers led to inconsistent
reporting of malnutrition (both over and
under reporting).
 PI Project Step 3: Goal of PI Project
• Identify most consistent inaccurate answers
to malnutrition screen
• Reduce number of inaccurate answers
 PI Project Step 4: Data Collected (PI.01.01.01)

• All new admission from April 17 – 20 and 24,

2017 were reviewed for malnutrition
screening.
• The Nutrition Staff assessed accuracy of the
answers to the screen by verifying the
answers with patient and or documentation
in chart.
PI Project Step 5: Compile and Analyze Data
(PI.02.01.01)
Screen Accurate? Malnutrition Discrepancy Accuracy
44 yes Reason Quantity 77%
13 no 1 4
57 total 2 2
3 1
4 1
5 1
6 2
7 2

Reason For Discrepency

1 Weight loss intentional

2 Unintended weight loss noted
but not documented
3 Patient inaccurate assessment of oral intake
4 Blank malnutrition score
5 Significant unexpected weight loss
6 Weight loss present, but not significant
7 No weight loss
 PI Project Step 6: Improve Performance
(PI.03.01.01)
Review malnutrition screen with all new hires
at Nursing Orientation with emphasis on
accuracy and impact of under reporting.
 PI Project Step 7: Follow-up Evaluation
• All new admission from November 6 thru 10,
2017 were reviewed for malnutrition
screening.
PI Project Step 7: Follow-up Evaluation
Screen Accurate? Malnutrition Discrepency Accuracy

83 yes Reason Quantity 85%

15 no 1 1
98 total 2 0
3 1
4 2
5 0
6 3
7 8

Reason For Discrepency

1 Weight loss intentional

2 Unintended weight loss noted
but not documented
3 Patient inaccurate assessment of oral intake
4 Blank malnutrition score
5 Significant unexpected weight loss
6 Weight loss present, but not significant
7 No weight loss
 PI Project Step 8: End Date
• Will continue to monitor malnutrition
screen accuracy for 12 months
• Will continue to work with Nursing Education
to educate with the goal of improving
accuracy and completion of malnutrition
screening.
 Questions
• What Questions do you have for us?

• Thank you!