Future Dimensions. A Message From the Chair

Transcription

1 Future Dimensions In Clinical Nutrition Practice A Message From the Chair Kathy Allen, MA, RD, CSO Chair, CNM DPG Greetings Members!! As we embark on this new membership year, first I would like to acknowledge the superb leadership this past year by our immediate past chair, Young Hee Kim. I know I have some big shoes to fill and am honored to be able to continue the progress made by such amazing and talented predecessors. I must also acknowledge the work and many volunteer hours contributed by our EC and committee members. We could not have made any progress without your dedication and talent. Each year, I am amazed at the level of expertise and energy to be found in you, the members of this organization. Together, we can make significant changes in practice, policy, delivery of care and ultimately, the health and welfare of individuals. Our DPG has been selected by the Academy leadership to help implement coming changes such as competency based practice and meaningful use of nutrition informatics because of the influence you have as leaders. We, meaning YOU, have been recognized as the change agents and trusted leaders in the implementation of new initiatives that significantly impact nutrition practice. Our EC and committee members will be working diligently this year to carry out our new strategic plan that was based on your input and suggestions. This is our roadmap for directing our energy and financial resources. Your input matters so please make every effort to stay involved and provide input along the way. Also, be sure to take advantage of the many resources available to you as a DPG member. Our new website has been enhanced to improve navigation Summer, 2014 Volume 33, No 3 Inside this issue: Message From the Chair CPE (1) Article: Developing a Dual Career Ladder for RDs in a Large Health System Does Healthy Food Really Sell? CDR Specialist Credentials: Taking Practice to the Next Level CNM DPG Updates Featured Member CNM DPG Executive Committee Like us on Facebook! om/clinicalnutritionman agementdpg

2 and provide additional tools and resources. Our new QPI subcommittee has added its own EML for those with a special interest in Quality measures and process improvement. Planning for our 2015 Spring Symposium is underway please submit your proposals this is how we learn from one another! We will continue to offer webinars with CE credit per your request along with the CE in your newsletter. I look forward to hearing from you and thank you for your trust and support! Warm regards, Kathy One free CPEU available to CNM DPG members! 1. Read the article titled Developing a Dual Career Ladder for Registered Dietitians in a Large Health System by Marie Johnson and Megan McHenry 2. Log on to the CNM DPG website at cnmdpg.org 3. Go to the member s only section and click on the link for the CPE Exam 4. Take the exam; your CPE certificate will be ed to you within one week This article has been approved for 1 CPE, Level 2; Learning Needs Codes 1010, The test will remain available for three years after the publication date of this edition of Future Dimensions in Clinical Nutrition Practice (August 4 th, 2014). 2 Visit us at the CNM DPG website cnmdpg.org. Available resources include: Searchable member directory Resource library The DPG s guiding principles and strategic plan The Standards of Professional Performance for Dietitians in Clinical Nutrition Management Newsletter archives CNM annual report to members Eblast archives Information on the Informatics and Quality and Process Improvement (QPI) subunits Sign up for the CNM electronic mailing list (EML) Sign up for the QPI EML in the members only section, click on the Subunits tab, then QPI Update your CNM profile click on Edit Your Profile in the Member Info section For additional information, contact us at: ClinicalNutritionMgtDPG@gmail.com

3 Developing a Dual Career Ladder for Registered Dietitians in a Large Health System Marie Johnson, MS, RD, CSG, LD and Megan McHenry, MS, RD, LD, CNSC 3 Background and Definition Career ladders are used by many healthcare disciplines and businesses to provide a framework for individuals seeking professional advancement, career development, continual learning, or promotion. By definition, a career ladder can be categorized into two subsets: traditional and dual. A traditional career ladder is typically used in technical based occupations to promote employees into a supervisory role based on skill set. Conversely, a dual career ladder is namely used in scientific or medical-based professions. Its purpose is to promote employees who have specialized and/or advanced skill sets who do not want to pursue a management track. 1 Typically, when an employee obtains a promotion, they become a supervisor and manage others who perform that skill or duty. In contrast, in a dual career ladder setting, an employee who obtains a promotion does not supervise others but becomes more specialized in their skill or trade. Various professions in the healthcare sector utilize dual career ladders. For instance, respiratory therapy, pharmacy, substance abuse disorder counseling, physical therapy, and nursing professionals use dual career ladders to document and promote advancements in their careers. History of Career Ladders in Dietetics The dietetics profession has adopted the same ideology to foster the career growth of current and future practitioners. In the early 1990s, several publications highlighted the use of career ladders within the registered dietitian (RD) community. 2-4 For example, in 1994 the Baylor University Medical Center Nutrition Services Department created a Professional Growth Program that utilized the dual career ladder concept. The A dual career ladder s purpose is to promote employees who have specialized and/or advanced skill sets who do not want to pursue a management track program emphasized activities that extended beyond a performance appraisal and basic clinical duties to encourage growth of advanced practice skill sets without the intent of adopting a management role. The Professional Growth Program had a positive impact by reducing the rate of turnover among the clinical dietitians by 11%. 3 Also during the early 1990s, the Commission on Dietetic Registration created two advanced certifications, the Board Certified Specialist in Renal Nutrition (CSR) and Board Certified Specialist in Pediatric Nutrition (CSP). Almost a decade later, from 2006 to 2008, three more specialty certifications were created: the Certified Specialist in Sports Dietetics (CSSD), the Certified Specialist in Geriatrics (CSG), and the Certified Specialist in Oncology (CSO). Creating these advanced certifications for RDs allowed management and administration to see how a dietitian could further their career without entering a management position. In 2010, the Academy House of Delegates approved the Dietetics Career Development Guide developed by the Council on Future Practice, which became a structured guide for the RDs professional development track. In March 2011 the Summit Oversight Workgroup convened a group of educators, practitioners, and students to address mechanisms in which future credentialed dietetics professionals could carve innovative avenues to practice within emerging roles, define specialist and advance practice, and function across a career ladder. This group developed the vision and guiding principles for the future of dietetics. 5

4 Future Dimensions in Clinical Nutrition Practice Development of RD Career Ladder Due to the these new career development guidelines set forth by the Academy, the Memorial Hermann Health System (MHHS) Clinical Nutrition Council embarked upon the process of updating our existing dual career ladder for RDs. The initial MHHS RD Career Ladder was driven by stringent standards that relied solely on advanced degrees and/or certifications and years of experience. This led to the general dissatisfaction of clinical dietitians and poor retention rates of otherwise high performing RDs who had no means of recognition. We developed a subcommittee to update and revise the dual career ladder. The subcommittee utilized the following resources to create the dual career ladder: the Academy s Dietetics Career Development Guide 6, recommendations from the House of Delegates, Benner s From Novice to Expert to assess level of proficiency 7, and MHHS career ladders from the respiratory care, pharmacy, and nursing departments. In 2012, our career ladder was presented to all 83 RDs at 10 facilities within our health system. Staff provided feedback during meetings where the career ladder was presented and discussed, and adjustments and/or clarifications were implemented. Structure of MHHS RD Career Ladder In order to progress through the levels, a point system was developed to allow for the RDs to grow from Level I IV using 12 criteria that our system calls advanced attributes. The corresponding point ranges for each RD level was determined by utilizing the criteria for advanced practice RDs and the Dietetics Career Development Guide defined by the Academy in order to identify key characteristics of competent to expert level RDs. 8 With this, CNMs piloted mock point assignments for each level and developed the following ranges (Table 1). Each criterion, or advanced attribute, point value was weighted in relation to the Dietetics Career Development Guide and was assigned a cap value. A cap was placed on each criterion in an effort to promote a well-rounded practitioner. A specific project, presentation, and/or accomplishment can only be used in one advanced attribute category Table 1. RD Career Ladder Point Ranges (Table 2). Summer 2014 Registered Dietitian Level Point Range RD I (Competent) 3-8 points RD II (Proficient) 9-13 points RD III (Advanced Practice) points RD IV (Expert) 19 Documentation of RD Career Ladder Activities For RD Level I and II, competent and proficient RDs, respectively, a binder with documentation regarding involvement in any of the criteria is submitted to the local campus Clinical Nutrition Manager (CNM) for review. A scorecard is utilized to record points, and the CNM can review and make notes alongside each criterion in tandem. During the end of each fiscal year, advanced practice (RD III) and expert RDs (RD IV) and those wishing to be promoted to an advanced practice level submit the dual career ladder documentation to the Career Ladder Subcommittee. The subcommittee is an extension of the MHHS system Clinical Nutrition Council. The review process is designed to ensure that each submission is scored uniformly by an unbiased body. The valid review period covers MHHS fiscal year, July 1 through June 30. With the exception of criteria one and two, all activities must take place during the valid time period. All activities not occurring within the specified time frame will not be considered. Implementation of MHHS RD Career Ladder As with most large scale process change, anxiety, anticipation, and concerns were expressed by staff. Consequently, it was essential to clearly and concisely explain the impetus behind the career ladder while also soliciting staff feedback to ensure employee engagement and acceptance. The main concerns were as follows: the intent behind the career ladder, how to obtain a promotion, demotion guidelines, documentation requirements, and frequency of revision. Intent. Explaining intent behind the career ladder was extremely important during the 4

5 Criteria / Advanced Attributes Point Value Cap Specialty Certification 1 = Active certification 2 = Active certification plus renewal cycle 2 1 = Fellowship Program Fellowship / Advanced 2 = Master s Degree Education 3 = Doctoral Degree 6 Continuing Education 1 = Obtaining CPEs 2 = Obtaining 17 CPEs 6 Staff Development and Education Preceptor, Intern Coordinator or Mentor Role Committee, Interdisciplinary Council or Task Force Participation Continuous Quality Improvement (CQI) Contribution to Dietetics Profession and Public (external) Participation in a Nutrition / Dietetics Related Professional Organization Hospital Based Volunteerism Years of Experience Special Considerations for Achievements Table 2. RD Career Ladder Criteria 3 = Developing 2 CPEs for the system 1 = Conduct and develop food service based educational programs and/or in-services biannually 2 = Deliver 1 or more presentations to interdisciplinary partners 3 = Invited higher education institution/symposium/conference or presentation for MD/residents/nurse practitioner 1 = Preceptor 10 days (collectively regardless of the quantity of interns) 2 = Preceptor for 20 days (collectively regardless of the quantity of interns) 3 = Intern coordinator 3 = Mentor for at least 6 months 1 = Participant in hospital or unit based committee/council/ task force 2 = Acting as a participant in a system wide committee/council/task force 3 = Leading (i.e. chair) or co-leading (i.e. co-chair) a system and/or hospital committee/council/task force 1 = Participant for CQI project 2 = Lead or Co-Lead for CQI project 3 = CQI project leading to a major clinical or operational improvement in which the participant lead or co-lead the project 1 = Presentation OR in-service at the community level 2 = Conducting poster presentation or invited presentation at a local, regional or national level 3 = Published work in a professional journal; published book chapter; platform presentation 1 = Membership and active participation in local, state, or national professional organization/s 2 = Serve as a committee member in one or more state or local professional organization/ or national professional organization/s 3 = Acting in leadership role as appointed or elected officer in professional organization/s 1 = Volunteer at event/s for 8-15 hours collectively 2 = Volunteer at event/s for 16 hours collectively 3 = Chair or Co-chair of committee for event 1 = 5-15 years 2 = 16 years No point value assigned N/A 5 presentation and implementation of the new process. Requiring yearly qualifications and documentation for maintaining advanced practice and expert level status is a way to elevate and expand the role of the RD but could be misunderstood if not properly explained. Promotion. It is also important to clarify that obtaining a specified point level does not automatically qualify a staff member for promotion. The career ladder is used in conjunction with the performance appraisal and there are specific recommended prerequisites for each level. For example, if a corrective action has been given to an employee over the fiscal year, a promotion is not merited. Furthermore, in order to reach Level III or IV, a clinician must have a specialty certification and sufficient experience in his or her practice area.

6 Demotion. If an employee does not obtain the number of points required for their current level, the career ladder does allow for a onetime grace period in which the CNM will meet with the employee to develop an action plan. Typically, when an employee does not obtain the number of points required at their specific level, it is reflected in their performance appraisal. If the employee fails to meet the expected number of points for a second year, they will be demoted by one level regardless of the point level they achieved. No reduction in pay occurs; however, this fact will likely affect the performance appraisal and may result in no merit increase. Supporting Documentation. Documentation is essential to validate requirements in of each advanced attribute. For each criterion, a list of required documentation is described in detail. Revisions. Creation of an additional criterion, Special Considerations, was added due to potential unforeseen missed categories. After the annual review of submission, feedback is given to the Clinical Nutrition Council and updates may be added at that time. An example of this is under the category Professional Contribution. Specific avenues to achieve 1 to 3 points in this category were community presentations, regional media spots, and/or published work. With the rise in marketing using Facebook, Pinterest, Instagram, and other social media in our system, we recently added social media spot to this section of the dual career ladder. Human Resource Considerations Systematic changes took place in conjunction with the implementation of the career ladder. The Human Resources department was consulted regarding the dual career ladder for input and additional perspective. Furthermore, the MHHS Compensation Department was consulted in order to modify job descriptions and review compensation structure. Job descriptions from other disciplines along with the Standards of Professional Practice were utilized as resources to update the RDs job descriptions (8). Additionally, market analysis by the Compensation Department was utilized to ensure 6 salary grades were appropriately aligned with annual inflation rates and economic growth within the dietetics profession. First Year Outcomes After our first year of implementation of the MHHS RD Career Ladder, we reviewed highlights, employee feedback, and any improvements that could be made. The criteria fulfilled were examined and tallied at the conclusion of the review period for those eligible for promotion to an advanced practice or expert level focus or those who sought maintenance of their position (Table 3). The lowest participation was realized within the following three criteria: obtaining specialty certification, external contribution to the dietetics profession, and demonstrating active membership within a dietetics professional organization. Conversely, the highest participation was realized in the following five criteria: committee or task force participation, fellowship/advanced education, continuing education, continuous quality improvement, and years of experience. Compar- Table 3. Percent of Level III and IV RDs Meeting Criteria Criteria Percent meeting criteria Specialty Certification 55% Fellowship/Advanced Education 80% Continuing Education 80% Staff Development and Education 70% Preceptor, Intern Coordinator or Mentor Role Committee, Interdisciplinary Council or Task Force Participation Continuous Quality Improvement (CQI) Contribution to Dietetics Profession and Public (external) Participation in a Nutrition / Dietetics Related Professional Organization 70% 90% 80% 40% 55% Hospital Based Volunteerism 65% Years of Experience 80% Special Considerations for Achievements N/A

7 ing this data with the established standards of an advanced practice RD by the Academy, the MHHS Career Ladder Subcommittee identified an integral pitfall in our basic requirements for advanced level practitioners. Consequently, a basic requirement of obtaining and maintaining a specialty certification was included within job descriptions for level III and IV RDs for fiscal year Conclusions / Recommendations The Academy of Nutrition and Dietetics has developed many resources that will aid health systems in creating career ladders. We advise benchmarking with standards established by other ancillary disciplines and respective governing bodies when creating a dual career ladder. Clearly communicate to staff the premise supporting a career ladder and the expectations of the advanced practice or expert level RD as defined by the Academy. It is paramount that the developer and owner of the career ladder is regularly accessible to clarify concerns expressed by staff, and edits the requirements when deemed appropriate to allow and encourage employee engagement. Further assessment needs to be conducted by the Career Ladder subcommittee along with the system Compensation Department to fully assess employee retention and satisfaction in relation to the implementation of the career ladder. References 1. Career Development: What is a dual career ladder? (2012) Retrieved March 7, 2014, from hrqa/pages/termdualcareer.aspx 2. Edelstein SF. Dietitians, career ladders, and opportunity for advancement. Top Clin Nutr (3): Watkins L, Blue L, Cator K, et al. Dietitians and a clinical ladder program: a successful combination. J Am Diet Assoc. 94(9): Smith AE. Improving career outlook in clinical dietetics. CNM Newsletter (3): Spring 2012 HOD Meeting Update: Academy President. Academy of Nutrition and Dietetics Website. content.aspx?id¼ Accessed May 28, The Academy of Nutrition and Dietetics. The Career Development Guide. id=7665. Accessed on May 28, Benner P, Hall P. From Novice to Expert. Am J Nurs (3): Kieselhorst KJ, Skates J, Pritchett E. American Dietetic Association: Standards of Practice in Nutrition Care and Updated Standards of Professional Performance. J Am Diet Assoc. 105 (4): e10. Marie Johnson is currently a Clinical Nutrition Manager at Memorial Hermann Northeast. Prior to her current position, she worked at Memorial Hermann s The Institute for Rehabilitation and Research as well as the Rehabilitation Hospital- Katy. She has eight years of experience in clinical dietetics and earned her Master s Degree at Texas Woman s University-Houston. Megan McHenry is the Clinical Nutrition Manager at Memorial Hermann Hospital in the Texas Medical Center in Houston, Texas. She earned her Bachelor Degree at Baylor University and Master s in Clinical Nutrition at the University of Memphis. Prior to her current position, Megan worked as a Nutrition Support and Critical Care Dietitian in the adult, pediatric, and neonatal populations for five years. 7

8 Does Healthy Food Really Sell? Promoting healthier eating in hospitals can actually work. Here s how. By Lisa Roberson, RD and April Rascoe, MS, RD As Registered Dietitians, we value the importance of eating healthier, especially in the hospital setting. However, do our customers feel the same way? As the Corporate Director of Wellness for a national foodservice provider, this is a VERY important topic in my everyday work. In my line of business, I am charged with controlling the swinging pendulum between what our patients and customers should eat, while also providing what they want to eat - even if it doesn t always meet our definition of healthy. Another conundrum - we support our hospital administrators with growing the bottom line through increases in retail revenue (usually through sales of traditional foods such as burgers and pizza), while also promoting better health outcomes of both patients AND hospital staff. Are these goals mutually exclusive? Sometimes, but they do not have to be. In recent years we have experienced growing customer requests for better-for-you foods in the healthcare communities that we serve. Meeting the consumer demands in today s technically savvy world is a tall order for any foodservice provider. Today s well-informed customer has a growing awareness of food that has fewer calories, the right kinds of fat and less sugar. Not only do they clamor for higher nutrient quality but they also express interest in foods that support functional claims such as better gut or brain function or foods that support American Family Farms or are raised with fewer antibiotics. In 2012, Morrison Healthcare launched its broadbased Mindful Choices platform which includes everything from supply chain changes to wellness and sustainability commitments. This has been a labor of love many years in the making. We have been working with our client hospitals and health systems to implement standards for healthy food marketing, wellness meal offerings, nutrition labeling, food preparation, healthy beverages, and fruit and vegetable offerings. We nurtured strong relationships with prominent wellness organizations, Partnership for a Healthier America and Healthier Hospitals Initiative, which have helped strengthen our expertise in wellness. By leveraging these important partnerships and implementing changes nationally, we are making Mindful Choices easy and accessible to millions in our hospitals and health systems. Mindful Choices Wellness meal served in hospital cafes Through this wellness journey we have gained much experience, both good and bad, with customer responses and behaviors related to healthy eating initiatives. Here are some of the lessons we have learned about encouraging our communities to choose healthier foods. Healthy marketing sells! Or does it?? As dietitians, we think it s brilliant when restaurants do the work for us in finding and highlighting the healthy foods on a menu. However, we have learned that the typical consumer sees healthy food labels as a roadmap for foods to avoid. A recent survey by the National Restaurant Association shows that only half of the restaurants polled mark the healthy items on their menus. 1 So, what works? 8

9 Healthy, enticing food descriptions. Describe healthy food attributes by using words such as fresh or guiltless to invite guests to eat tasty, better-for-you options. Our chefs describe food in such a way that makes the smallest appetite hungrier with each word, such as fragrant aroma, mouthwatering freshness, crunchy and flavorful, abundant in seasonal produce you get the idea. Label menu items with catchy names. The Cornell Food and Brand Lab has seen great results using catchy names to win over school-aged children to eat more carrots. 2 Combining this strategy with a culinary makeover (see next section) brings great results in hospital cafes. As an example, an average hospital café may offer a black bean burger as the vegetarian option, selling around 6-8 black bean burgers daily. When Reinventing typical healthy menu items can attract customers to purchase healthier foods the black bean burger is loaded with srirachainfused coleslaw, crisp lettuce and tomato set atop a toasted whole grain bun and is re-named the Spicy Black Bean Dragon Burger, it then becomes a culinary masterpiece to the typical consumer, including nonvegetarians, selling upwards of burgers per day. Use purpose marketing. Pro-social marketing, or purpose-based marketing, wins over customers by highlighting the values and beliefs of the company selling the product. Panera Bread Company is a great example of this with their Baked Before Sunrise, Donated After Sunset campaign. 3 In the hospitals we serve, we have also seen increased purchases of vegetarian menu items when they are advertised through our Be A Flexitarian campaign, which encourages the customer to reduce meat consumption one meal per week by choosing a flexitarian or non-meat meal. This The Be A Flexitarian campaign enhances sales of healthy food by featuring purpose-based marketing campaign advertises our efforts to better the planet through fewer greenhouse gas emissions used to raise animal proteins, AND improve health by reducing saturated fat intake. Our Eat Local campaign, which advertises fruits and vegetables raised by local farmers, also increases the sales of our salad bar items by up to 55%, as compared to salad bar sales without this promotion. Everyone Loves a Makeover American pop culture demonstrates this cultural obsession through its many popular television shows targeted at transformation: The Biggest Loser, Extreme Makeover Home Edition, Dancing with the Stars, Project Runway the list goes on. This same makeover concept also works exceptionally well in promoting acceptance of healthier food. In a study that observed the decisions people make while under significant restrictions, consumers will react more favorably to restrictions that they perceive are not that different from their initial goals. 4 Quinoa-breaded chicken fingers with strawberry ketchup is popular on our children s menu, and is served in the cafe to adults For example, if a customer typically eats chicken fingers for lunch, in order to buyin to choosing healthier food at that meal, the customer will anticipate a suitable substitute that is very similar to fried chicken fingers. This is where our Culinary Research & Development Team creates healthier versions of comfort foods to meet that demand, such as crunchy baked quinoa-breaded chicken fingers with sweet strawberry ketchup. Along 9

10 Future Dimensions in Clinical Nutrition Practice with many others in the foodservice industry, we call this concept stealth health. Other examples of successful culinary makeovers include our black bean cupcakes, where we replace butter and oil with blended black beans, and our cream of broccoli soup which uses vegetable broth and quinoa flakes instead of cream and flour to thicken the soup. Healthy food reinvented - Southwestern Tortilla Tilapia 10 Culinary makeovers can also include a remake of a healthy item such as steamed tilapia (read as boring) into one that delivers flavor and texture, such as the Southwestern Tortilla Tilapia with whole wheat couscous, corn, black beans and finished with an avocado jicama relish. The tilapia is given extra crunch by breading it in 100% stone ground corn tortilla chips before baking. Stealth health. Making small, inconspicuous changes to food items or the food environment which may be transparent to customers can promote healthier eating. Examples of stealth health changes include: Replace butter with olive oil in potatoes and other side dishes Make meatloaf from a blend of 100% natural lean ground beef and turkey Create sauces with low sodium stocks and fresh herbs instead of high sodium bases Serve smaller portions of regular (non-diet) desserts as small bites Add legumes to baked goods to increase fiber and flavor Use flaxseed in pancakes and granola parfaits Add wheat germ to oatmeal Blend leafy greens such as spinach and basil into soups and pesto Incorporate functional foods such as probiotic-fortified items when possible Summer 2014 The concept of stealth health and healthy culinary makeovers can make a difference in moving our customers towards acceptance of healthier menu options. Location, Location, Location! Healthy choice architecture has become a wellness buzz word in the foodservice industry. Healthy choice architecture describes the way that consumer decisions may be influenced by how choices are presented. As an example, if you want the customer to buy bottled water instead of sugar-sweetened soft drinks, then the water should be placed at eye level and in easy reach of the beverage cooler, while the sugary soft drinks are placed out of direct line of sight - at the bottom of the cooler. Healthy choice architecture can also include reducing the price of healthier foods over traditional items so that the healthy item is more desirable. Does healthy choice architecture help promote the sales of healthy foods? Absolutely! Here s an example of using healthy choice architecture to drive retail sales. One of our wellness platform commitments is to remove low-nutrient dense impulse buys from the cash register and replace them with betterfor-you options. Statistics show that the majority of customers make impulse buys at the cash register, and offering items such as candy bars, fried chips and desserts can be considered a hidden risk factor for obesity and heart disease. 5 Our Register display BEFORE applying healthy choice architecture Register display AFTER applying healthy choice architecture

11 new cash register standards include placing fresh fruit, bottled water and snacks with less than 200 calories within 5 feet of the register. By replacing junk food impulse buys with bottled water, we increased the sales of bottled water by 144% over the previous year! Selecting the right location to promote healthier items can make a HUGE impact on sales. Last but not least deliver on FLAVOR. This last lesson is critical to the success of promoting healthy eating. As a Registered Dietitian, I have had many years of experience in educating, instructing, advising and preaching to our customers the benefits of healthy eating. No matter how much I encourage my customers to eat healthier foods, this magical experience never happens until we DELIVER on FLAVOR. When a customer is able to enjoy great-tasting foods that are also healthier, they have an epiphany that can be life-changing for the better. How does this happen? Here are some tips: Engage your chefs. Dietitians are great at planning healthy menus, but chefs can transform a healthy menu into a delectable experience. Chefs who are also credentialed as dietitians are transforming healthcare foodservice. Use dietitians and chefs to sell healthy food. No one tells a better story to customers than the experts. Capitalize on this unique relationship to create a Food Network-like experience. Active sampling. Give your customers a wow -experience by asking them to taste seasonal and fresh, great-tasting foods prepared at their peak. Promoting healthy eating in hospitals no longer has to be equivalent to the pursuit of the Holy Grail. Applying these basic principles to your foodservice strategy can help not only promote healthier eating, but also drive retail sales. Acceptance of Healthy Foods on Patient Menus Gaining acceptance of healthier foods can also be a challenge in the patient population. The Centers for Medicare and Medicaid Services (CMS) has also implemented a new survey tool which is causing a renewed focus on hospitals menus nutrition analysis. One of the first questions you will likely be asked by a CMS surveyor is, can I see your nutrient analysis for all menus? If you are not able to produce this information in a quick manner, and be able to explain it, this automatically raises red flags in the surveyor s mind. If you do not have your analysis in place, then it is highly advised that you develop a Quality Assessment and Performance Improvement plan to show how you intend to achieve this regulation. The next task is assuring that each diet is Dietary Reference Intake (DRI) compliant. What does that mean exactly? Surveyors are expecting to see that all nutrients are meeting 100% of the DRI for patients who receive a non-select menu. For condition specific diets that require certain nutrient restrictions, you must be able to explain each of these circumstances. It is a great best practice to have each diet explanation included with the nutrient analysis so anyone speaking to the surveyor about DRIs that are < 100% will easily be able to do so. When working with patient menus, you can overcome the challenges of meeting BOTH the regulatory requirements and patient satisfaction standards while still offering healthier choices for all diets. Here are some insights. Desserts For All? That s the million dollar question that dietitians are either for or against. It is our strategy to provide desserts in smaller portions as a teaching tool for showing how all foods can fit. It s unrealistic to believe Peach Yogurt Burst. Healthy desserts that are seemingly indulgent help patients accept a diet restriction. that patients are NEVER going to touch a dessert, so why not show them how to make better choices and keep their sweet tooth under control? By providing portion controlled desserts, 11

12 Future Dimensions in Clinical Nutrition Practice it s a slice of happiness for patients while they are not feeling well and under added stress. Flavor, Appeal and Presentation. It doesn t matter what a meal includes or how nutritious it is if it doesn t have good flavor, appeal and presentation, then the patient will not be satisfied. This is a key reason why, as dietitians, we need to be in the kitchen working with chefs. If the chef and dietitian are not communicating on a daily basis with each other, then it is likely your menu is lacking and you are not reaching your full patient satisfaction potential. Building the Chef / Dietitian Relationship. It is a great practice to walk a mile in someone else s shoes to improve your perspective. When we better understand each other s challenges, passions, and skills, it can only result in improvement. So take the initiative and ask your chef if you can spend a day with them. Challenges in Meeting DRIs For Inpatient Menus Step 1 Know your patient population. Access hospital statistics to learn what predominate population, by age and gender, is served at your facility. Your menu nutrient analysis should then be compared to the Dietary Reference Intakes (DRI) for this group. It is also necessary to determine what ethnicities you serve, as this should be one of the key factors to consider when choosing menu items. Step 2 Understand that there are gaps in USDA nutrient information. Most nutrient analysis software programs are based on USDA information. It is important to understand that some nutrients are not included, therefore it is impossible to conduct a complete and accurate nutrient analysis. Those nutrients include: Molybdenum, Chromium, Chloride, Iodine, Fluoride, and Biotin. Summer 2014 Step 3 Become a nutrient investigator. Manufacturers by law only have to provide information on 14 nutrients; however, a surveyor s expectation is that you meet the DRIs for all 43 nutrients. So what do you do when there are gaps in your information? You can use a reference such as Bowes and Church s Food Values to find comparison data to support your analysis without having to add unnecessary additional foods. Step 4 Balance your nutrient requirements with real food. Begin your focus on the challenging nutrients: Fiber You will not come close to meeting any DRI for fiber without having your default grain options set as whole grains. That doesn t mean you can t have a piece of white bread in the kitchen, but if a patient is unable to make a selection, then the default options need to be whole grains. Potassium Upon a first run of an analysis for a new menu, it is likely you will be deficient in a handful of micronutrients. Start with bringing your potassium up, and most other nutrients will in turn increase as well. Choline Finding a balance between choline and cholesterol can be challenging, but it is possible. One idea is to offer scrambled eggs that are made with a mix of egg substitute and real eggs. You are then able to increase your choline and keep your cholesterol < 200 mg for the day. Step 5 Continuously work with the culinary team. It s necessary to understand what works realistically for production purposes. Do your menu items match your culinary team s skill set? When you hear negative feedback about a specific food item, get in the kitchen and talk to your chef. Discuss ideas on how the menu item can be improved both from a flavor and nutritional aspect. Conclusion It is imperative that everyone in the food service department be aware and able to speak confidentially to the patient population your hospital serves, the nutritional content and compliance of your menus, and your actions for taking your pa- 12

13 tients needs into consideration. When we make the development of our menus a priority, both patient and retail menus, and work together to capitalize on all skill sets within the Food & Nutrition Department, our patient and customer satisfaction scores have only one place to go. up! Promoting healthier eating in our hospitals may actually be easier than we think. Our call to action is for each of you to take your inherent passion for promoting healthier eating in your hospital communities and apply some of these guidelines. At the end of the day, we hope to blur the lines of our customers and patients so that what they WANT to eat, and what they SHOULD eat, start to remarkably look like one and the same. References 1. Marketing Healthy Menu Items. Nestle Professional, en/sitearticles/pages/ InsightsMIXMagazineMarketingHealthy- Choices.aspx. Accessed on May 25 th, Wansink B, Just DR, Payne CR, et al. Attractive Names Sustain Increased Vegetable Intake in Schools. Preventive Medicine.2012:55 (4): Elliot S. Selling Products by Selling Shared Values. New York Times. February 13, business/media/panera-to-advertise-itssocial-consciousness-advertising.html. Accessed on May 25 th, Botti S, Broniarczyk S, et al. Choice Under Restrictions. Marketing Letters. 2009:19:3 4, DOI: /s Cohen DA, Babey SH. Candy at the Cash Register-A Risk Factor for Obesity and Chronic Disease. N Engl J Med. 2012:367: DOI: /NEJMp Raised in southern California, Lisa Roberson has a personal passion for wellness and sustainability and is the Corporate Director of Wellness for Morrison Healthcare. After completing her dietetic internship at Vanderbilt University Medical Center in Nashville, TN, she served as CNM and Regional CNM for Morrison Healthcare in several hospitals for over 10 years. Lisa has led her company to achieve awards in employee wellness such as the Kaiser Permanente Most Fit Company Award for three consecutive years and recognition as one of the top 10 Healthiest Employers by the Atlanta Business Chronicle. April Rascoe is the Director of Nutrition and Wellness Programs for Morrison Healthcare and has served in this role for 9 years. Prior to this position, April was a CNM for 4 years and has experience as the Director of Patient Programs, in which she was responsible for hospital adherence to patient services standards. April is the President-elect of the Georgia Academy of Nutrition and Dietetics and also serves as the secretary of the Georgia Dietetic Foundation. April completed both her Master s degree and dietetic internship at East Tennessee State University. Managing Editor: Jennifer Doley, MBA, RD, CNSC, FAND jdoley@carondelet.org Lead Features Editor: Lisa Trombley, MA, RD, CNSC ltrombley@dhs.lacounty.gov Features Editors: Leigh-Anne Wooten, MS, RD, LDN leighannewooten@yahoo.com Amanda Nederostek, MS, RD, CD (801) amanda.nederostek@imail.org Interested in contributing an article to the newsletter? Topics of interest include leadership, management, innovations in clinical practice, research and outcomes, nutrition legislation and public policy, reimbursement and coding, informatics, healthcare reform, and many others. If interested, please contact an editor. 13

14 Commission on Dietetic Registration Specialist Credentials: Taking Practice to the Next Level By Kathryn Hamilton, MA, RDN, CSO, LD Are you looking for opportunities to promote staff development and highlight expertise in one of several practice areas in nutrition and dietetics? The Commission on Dietetic Registration (CDR) currently has five established board certified specialist credentials to offer: Certified Specialist in Oncology Nutrition (CSO) Certified Specialist in Renal Nutrition (CSR) Certified Specialist in Pediatric Nutrition (CSP) Certified Specialist in Sports Dietetics (CSSD) Certified Specialist in Gerontological Nutrition (CSG) In addition to the above specialist credentials, an Obesity and Weight Management specialist credential application was approved by the Council on Future Practice in 2013, and is now in development as CDR s first interdisciplinary credential. This first article will explore the specialist credential in oncology nutrition. The oncology nutrition credential was approved for development in 2006, and the first examination was administered in All specialist exams are offered twice a year, and the oncology examination windows are in March and September. Because this is a practice-based exam, interested applicants must meet the eligibility criteria, which are: Current Registered Dietitian Nutritionist (RDN) status with CDR Maintenance of RDN status with CDR, for a minimum of two years from the original examination date Documentation of 2,000 hours of practice experience as an RDN in the specialty area within the past five years. Application fees and deadlines are posted on the CDR website at As with the RDN and DTR examinations, CDR conducts a practice analysis to identify tasks to be tested in the specialist exams. A new audit is performed every five years to ensure the exams reflect current practice. Specialists are required to successfully pass the exam every five years to maintain their credential. The content outline, reference list, candidate handbook, and other pertinent exam information can be found on the CDR website under the Specialist Certification tab, or at Specialists in oncology nutrition have worked hard to achieve recognition for the CSO in the clinical oncology practice area. Employment opportunities in healthcare facilities and cancer centers around the country are including the CSO credential in their position descriptions for dietitians in oncology nutrition. The CSO credential is often stated as preferred, or it is indicated that new hires are encouraged and/or required to obtain certification when eligible. References and recommendations to obtain this specialist credential can be found in the American College of Surgeons: Commission on Cancer s Patient Centered Standards 2012 for Accreditation, and in the Association of Community Cancer Centers published works. Doctors, nurses, social workers, and pharmacists working in oncology are also able to obtain specialty certification through their professional organizations. This shows the medical oncology community s support for CDR s Board Certification in Oncology Nutrition. Questions about examination requirements and application can be directed to CDR at , extension 5500, or specialists@eatright.org. The second article in the fall newsletter will highlight the Board Certified Specialist in Pediatric Nutrition (CSP) credential. 14

15 CNM DPG Announcements Quality and Process Improvement Sub-Unit Update By Sherri Jones, MS, MBA, RDN, LDN, FAND QPI Sub-Unit Chair Hope you are all enjoying your summer. The CNM QPI Sub-Unit is still going strong and continues to progress over time. It s hard to believe it has been over a year now that the not so new sub-unit has been in existence. We hope you have been taking advantage of the information and resources the QPI Sub-unit has to offer. We also hope you are aware of the special QPI electronic mailing list (EML). We have managed to recruit > 75 subscribers to this EML. Cindy and I have tried to share postings of quality and process improvement related CEUs, resources, etc. on a weekly basis. The QPI EML is not yet as robust as our general CNM EML. But, I am hopeful we will begin to see our subscribers posting questions and resources over time. As a way to generate more dialogue on the QPI EML, I may begin to post questions or a call for quality/process improvement resources for members to share. Let s take full advantage of the knowledge and tools our CNM members have to share. There is so much we have to learn from one another If you are not currently subscribed to the special QPI EML and wish to do so, you can subscribe to the EML through the QPI Sub-Unit webpage or enter the following URL directly: Do you have a Quality Improvement project you d like to share? Submit to our QPI Project Contest: The sub-unit is in the process of developing a Quality/Process Improvement Project Award Contest. We are asking interested CNM members and their teams to submit successful projects you d like to showcase. There are so many impressive projects and initiatives our CNM members have implemented. We will be posting the guidelines and directions on the CNM website shortly. All submissions will be judged by a panel of five judges from the CNM Executive Committee. One winner will be selected to receive a free registration to the 2015 CNM Symposium. In addition, the top ten projects will be showcased at the Symposium as posters. We will be sending an announcement for QI project submissions as an eblast to all members. Look for the announcement soon to come! Topic/Ideas for Annual Symposium April 2015: The QPI Sub-Unit will present a session each year at the CNM Symposium. This past year, Cindy and I gave a brief overview on Value-Based Purchasing and introduced the QPI sub-unit components to attendees. We are now looking for QPI topics to include in the 2015 session. Please let us know if there is a specific topic you d like to hear about. And as always, if you have any questions or suggestions for the new Quality and Process Improvement Sub-Unit feel free to contact the sub-unit Chair and/or Vice-Chair. The sub-unit is a member benefit, and thus, we want to be sure to meet your needs and expectations. Continue to visit the QPI Sub-Unit section of the website for updates. 15 QPI Sub-Unit Chair: Sherri Jones, MS, MBA, RDN, LDN, FAND jonessl@upmc.edu QPI Sub-Unit Vice-Chair: Cindy Hamilton, MS, RD, LD hamiltoc@ccf.org

16 Investment Reserve: $312,387 Total Expense Budget: $239,381 Percentage of Reserve: 130% Treasurer Report By Janet Barcroft, RD, LDN Informatics Sub-Unit Update By Janel Welch MS, MPA, RD, CDN The Informatics sub-unit has been working on the CNM website. There have been many enhancements and updates over the past few months. If you have not had a chance to check it out, be sure to take a moment and visit To log in, all you need is your Academy user ID and password. There have been several additions to the Resource Library, which is a collection of documents shared amongst the DPG members. In addition, you can find archived newsletters, information on upcoming events and ways you can participate with the CNM DPG! Research Committee Report By Susan DeHoog, RD The data collection phase has concluded for the Dietetic Practice Based Research Network RDN Productivity/Staffing study. The data is presently being analyzed, and results will be presented at FNCE in October, as well as in an article in the Journal of the Academy of Nutrition and Dietetics later this fall. Advertisements in Future Dimensions CNM accepts advertising for publication in Future Dimensions in Clinical Nutrition Management. All ads are subject to approval by the Review Committee and must meet established guidelines. All ads must be camera ready and received by the Editor by copy deadlines. Fees must accompany the ad at the time of submission. CNM members receive a 20% discount. Send all inquiries to the Managing Editor, Future Dimensions in Clinical Nutrition Management. 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 DPG or the Academy of Nutrition and Dietetics. 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 Academy of Nutrition and Dietetics Clinical Nutrition Management Dietetic Practice Group of the Academy of Nutrition and Dietetics. All rights reserved. 16

17 Future Dimensions in Clinical Nutrition Practice Summer 2014 Featured Member: Donna Belcher, MS, RD, LDN, CDE, CNSC 17 How long have you been a CNM? About 18 years in 7 different healthcare facilities and geographies east of the Mississippi. Briefly describe your current job Currently, I supervise 20 dietitians at the Massachusetts General Hospital (MGH). I manage the inpatient side and my counterpart manages outpatient, with the exception of dialysis and transplant. Mass General has 1001 licensed beds, including the MGH for Children. What do you love most about your job? The people encouraging my staff, seeing them grow. Working on ways to expand our services and roles, developing relationships throughout the hospital. I find interacting with a new generation of enthusiastic and dynamic young professionals, and fostering dietetic interns, the most rewarding part of my job. What is the most challenging part of your job? Undoubtedly, the budget is the most challenging part of my job. We are all trying to do more with less, to find ways to be more efficient, and to stand our ground to not take on additional areas without compensation. What advice do you have for new CNMs? The best advice I can give is to know your people. Make it a point to know the people who help your staff, network. I think most everyone knows this, however, be nice and be fair. Involve your staff by asking for their input and encourage them to help you problem-solve. Participate in research, both quality/process improvement and quantitative, and support your staff in this as well. Describe what you think the ideal role of the RD should be 30 years from now. What do you think we need to do as a profession to get to that point? In 30 years we need to be extremely tech savvy - technology will be ubiquitous. Global warming will have occurred, and preventative medicine will lead to an even larger aging population. Taking all of that into account, I think that there will be a relationship between technology and the basics, i.e. having your own garden. I believe that hospitals will be for emergent and acute events, and the dietitians there will be highly trained and specialized members of the fully integrated medical team. I think the medical home will actually become your own integrated medical home, where the home healthcare company will deliver your medical equipment/devices, while you are connected to the local network ehospital. It s possible that your TF/TPN will be genetically modified specifically for you, and your consultation with the dietitian will be via video-chat. As a profession, we need to be thinking ahead and planning for the future so that we will be an integral part of it; this means cutting edge technology, specialized practice, preventative medicine and not staying complacent as we see healthcare change. Take a poll of your own staff you may be surprised at what you hear regarding the future. If you couldn t be a dietitian anymore, what profession would you choose? This is a tough one...helicopter pilot, or maybe nail polish color namer?