Barriers to Implementing Clinical Process Improvement Strategies

Lisa Jones, MA, RDN, LDN, FAND

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Any views and opinions expressed are those of the author(s) and/or participants and do not necessarily reflect the views, policy, or position of Consultant360 or HMP Global, their employees, and affiliates. 

This podcast series aims to highlight the science, psychology, and strategies behind the practice of dietetics. Moderator, Lisa Jones, MA, RDN, LDN, FAND, interviews prominent dietitians and health professionals to help our community think differently about food and nutrition.

In this episode, Lisa Jones interviews Sherri Jones, MS, MBA, RDN, LDN, SSGB, CPHQ, FAND, about barriers to implementing clinical process improvement strategies and how to address and overcome the barriers to improve patient care. For example, they discuss malnutrition in the hospital setting. This is episode 3 of a 4-part series. 

Additional Resources:

Academy of Nutrition and Dietetics. Accessed July 19, 2023.

Commission on Dietetic Registration. Accessed July 19, 2023.

Global Malnutrition Composite Score. Commission on Dietetic Registration. Accessed July 19, 2023.

Listen to episode 2 of this 4-part podcast series here.

Listen to episode 4 of this 4-part podcast series here.

Lisa Jones, MA, RDN, LDN, FAND

Lisa Jones, MA, RDN, LDN, FAND, is a registered dietitian nutritionist, speaker, and author (Philadelphia, PA).


Sherri Jones, MS, MBA, RDN, LDN, SSGB, CPHQ, FAND, is the Quality Manager at the University of Pittsburgh Medical Center (UPMC) Presbyterian Shadyside working in the Department of Quality Improvement (Pittsburgh, PA), a member of the Academy of Nutrition and Dietetics Board of Directors, Director of the Academy’s House of Delegates, and a member of the House Leadership Team. 



Speaker 1:

Hello and welcome to Nutrition411: The Podcast, a special podcast series led by registered dietician and nutritionist Lisa Jones. The views of the speakers are their own and do not reflect the views of their respective institutions or Consultant 360.

Lisa Jones:

Hello and welcome to Nutrition411: The Podcast, where we communicate the information that you need to know now about the science, psychology, and strategies behind the practice of dietetics. Today's podcast is part of a series of short episodes on clinical process improvement featuring a Q and A with Sherri Jones. I want the opportunity to introduce Sherri. First of all, Sherri, thank you for being here.

Sherri Jones:

You're welcome.

Lisa Jones:

Yeah. We're excited to have you today. Sherri Jones has been a registered dietician nutritionist for 35 years and is currently the quality manager at the University of Pittsburgh Medical Center Presbyterian, Shadyside, working in the Department of Quality Improvement. In this role, she manages seven full-time quality improvement specialists who are responsible for value-based care measures and quality scorecard outcomes. Sherri has worked in the field of quality improvement since 2012 and achieved her Six Sigma Green Belt in 2015.

She is also a certified professional in healthcare quality national certification in 2020. And you can read Sherri's full bio on our website. So again, welcome Sherri. We are excited for you to be here. Today, in episode three, we're going to be exploring key topics and debates in dietetics. So during our recent episode, Sherri, we talked about a deep dive into evidence-based practice, specifically focusing on clinical process improvement. Sherri, if you had to sum up that conversation in one or two sentences, what do you think are the key takeaways from that episode?

Sherri Jones:

I would say knowing what resources are out there and what is the best practice from the academy with regard to the consensus reports and knowing what resources, toolkits, and guidelines are that are out there, and then putting those into action. But more importantly, continue to monitor what your practice outcomes are and make sure that you are delivering quality outcomes by data measurement.

Lisa Jones:

Yes, it's very important, the data measurement and then monitoring those practice outcomes so then you can tweak and make any adjustments as necessary as you talked about in our last episode, which was fantastic. So today talking about the debates in dietetics, as dieticians, what do you think are the most critical elements of the clinical process improvement that dieticians should be mindful of? And then the second part of that question is, how can we then best implement these improvements in our daily practice?

Sherri Jones:

Well, I would say what's most critical with regard to clinical process improvement that we need to be aware of, I mentioned this in episode one when we were talking about trends, I would say malnutrition is so important right now. We talked about having a seat at the table and all of the strides that the academy took to get us into the MQI initiative, the Malnutrition Quality Improvement initiative, which then subsequently gave us the outcome of the Global Malnutrition Composite Score.

That is such an important piece. And there are many resources and examples of dieticians that were a part of that MQII collaborative, how they implemented the different strategies to have malnutrition recognition be a part of their institution and engaging their physicians and APP providers, how they collected data, how they use that data.

And then with regard to the Global Malnutrition Composite Score, for those of you that may not be aware of that, that is an electronic clinical quality measure or what's known as an ECQM. And this ECQM is actually stewarded by the Academy of Nutrition and Dietetics. And what it does is that it assesses the percentage of hospitalized adult patients, 65 or older prior to the start of the measurement period, with a length of stay equal to or greater than 24 hours, who received optimal malnutrition care during their current inpatient hospitalization.

So it's looking at their level of malnutrition risk and severity and looking at did they receive optimal malnutrition care. And there is a whole global malnutrition composite score specification manual that is available to clinical practitioners that you can look through. And what the academy is really hoping is that dieticians that work in acute care settings will get their facilities to get on board with these malnutrition composite scores and utilize that as one of the DRG measures that their facility reports back to CMS.

So there are mandated measures that CMS requires, and then you can choose a couple of additional volunteer measures for a lack of better term. I'm probably not using the right terminology. But wouldn't it be great if there were many facilities nationally that use that malnutrition composite score as their facilities measure so that we can really have a great data set of malnutrition to know what the prevalence is across our country or even globally?

That's why now they call it the Global Malnutrition Composite Score. There have been previous research studies on literature out there that if I recall, said that up to 30% of hospitalized adult patients actually have malnutrition. So getting more current data to that regard and then seeing where we are currently and then what dieticians can do to mitigate that. How can we decrease the prevalence of malnutrition in our hospitalized patients?

So I would say, Lisa, to answer your question about the most critical elements,, malnutrition is so hot right now as far as a current trend, and then having CMS agree to that global malnutrition score. We need to really capitalize on that because that in turn can help elevate the importance of having dieticians in the hospitals and involving dieticians as part of the collaborative healthcare team and really bring us to the forefront of patient care.

Lisa Jones:

Now that would be amazing when this happens, I'm going to stay positive when this happens, not if it happens. My question is, talking about this malnutrition, it sounds like it's a great tool and it can make things easier, but do you find that there are common barriers with it to implement?

Sherri Jones:

In quality and process improvement in general, there are always going to be barriers to anything that we do. Identifying those barriers when you are doing that whole planning part of the PDSA cycle. And I tend to always refer back to that improvement methodology because that's what we utilize at UPMC. But planning is such an important part, whether you utilize Team Steps or Lean Six Sigma.

Really trying to sit down and brainstorm, getting all of the primary stakeholders together that play any role whatsoever in the quality or process improvement initiative that you're embarking on, and seeing what's currently happening, what are the barriers right now, what are the perceived barriers in the future with what you may want to implement. And it's one of those things where knowing what the covert barriers are before you embark to then be hit with what an overt barrier was.

So really sitting down and thinking about what could impact what we are about to do, what could be the problems, doing a SWOT analysis, the strengths, weaknesses, opportunities, and trends, and really looking to everyone that's involved on what all the aspects are that could play a role in this improvement initiative. And to that same point, more importantly, how do we overcome them?

Lisa Jones:


Sherri Jones:

So not just identifying them, but how are we going to mitigate them? How are we going to make sure that we reach our ultimate goal, which is efficient, and effective, all of those six aims that I identified in episode one of the Academy of Medicine in delivering quality care to patients? And what I found, Lisa, in how can we overcome barriers, in my past 10 plus years as an improvement specialist, I think one of the biggest barriers to overcome is stakeholder buy-in and support.

That's why it's so key to really think about who the key stakeholders are. And I always tell people to step back and not just think of the direct stakeholders, the people that are directly involved and actively involved in the process, whether it be the bedside nurse, the dietician, the tray passer, the supply chain person, the cook, the chef, but step back and think of the indirect stakeholders, your administrators, your decision makers, the people that give you the resources or the money to do things.

And what I have found time and time again, one of the key stakeholders in any clinical patient improvement initiative is by far having a provider champion, finding a physician or an APP that can be a part of your clinical-based initiative, and having them championing it. And because I found a lot of providers, respect peer to peer kind of outcomes and peer to peer like, "Oh, if you get one physician willing to trial something or recognize malnutrition or implement tube feedings more timely, the other providers will follow suit." So key to a lot of clinical improvement initiatives is finding a provider champion.

Lisa Jones:

Yes, I love that idea. That's such a great idea. Because that goes back to what we're talking about in our first episode, and that's any aspect, no matter your practice, I think anybody can, it can be beneficial if they find a champion, someone that can help them. So thank you for that suggestion, and thank you for sharing both the common barriers and ways that we can then overcome them. And I appreciate you exploring this topic with us today and how we can enhance the quality of care that we provide. So thank you for being on this episode, Sherri.

Sherri Jones:

Sure. Thanks, Lisa.

Speaker 1:

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