Administrative Departmental Policy
This department-specific policy applies to the operations and staff of the Clinical Nutrition Department of
the University of Wisconsin Hospitals and Clinics Authority as integrated effective July 1, 2015.
Policy Title: Malnutrition Practice Council Policy and Procedures
Policy Number: 1.16
Effective Date: February 8, 2017
To establish guidelines for committee selection, eligibility, and service and expectations
for member and council outcomes.
II. POLICY ELEMENTS
The Malnutrition Practice Council is comprised of Registered Dietitian Nutritionists
(RDNs) and Nutrition Technicians representing each area of practice (i.e. inpatient,
ambulatory, and pediatrics). The council’s charge is to standardize and optimize
malnutrition identification, documentation, intervention and follow-up across UW
1. Job title of Registered Dietitian Nutritionist or Nutrition Technician
2. Have been employed at UW Health for at least 6 months
3. Endorsement from direct supervisor
4. RDN competent in Nutrition Focused Physical Exam (NFPE)
1. Potential committee members can self-nominate or be nominated by a peer or
supervisor. Nominations should be submitted as an email to the Clinical Nutrition
Managers (CNMs). Nominations are due January 15.
2. Nominated individuals will be reviewed by the Clinical Nutrition Managers,
Clinical Nutrition Specialist – Nutrition Practice (CNS), and Malnutrition Practice
Council Co-chairs. Nominees will need a majority approval (at least 3 votes) to be
considered for the council.
3. Council selection will take place every January.
4. Council members will be announced by January 31.
C. Council Structure
1. The council is lead by two co-chairs; one pediatric RDN, one adult RDN
2. Each member serves a two year term. Members will be staggered, so half of the
council turns over each year.
3. At the end of a two year term, an individual may be nominated to serve another
4. Must be a council member for one year prior to becoming a co-chair.
5. The co-chairs are selected by the council.
6. Council member size, including the co-chairs, will not exceed 8 people.
1. Co-chairs are responsible for:
i. Agendas, action items, meeting minutes
ii. Implementation of new practices with the support of CNMs and CNS to
optimize nutritional care of patients with malnutrition across UW Health.
iii. Providing monthly council updates to CNMs and CNS
iv. Department updates as requested
2. Council members are expected to be:
i. Engaged and actively participates by contributing ideas to support
standardization and optimization of malnutrition identification,
documentation, intervention, and follow up across UW Health
ii. A mentor to non-practice council members on appropriate malnutrition
identification, intervention, and follow-up
iii. A malnutrition champion
iv. Competent in NFPE and preform NFPE on >50% of patients
v. A repository for feedback from staff and to disseminate information to
Sr. Management Sponsor: Chief Nursing Officer, Inpatient
Culinary and Clinical Nutrition Services, Director
Author: Clinical Nutrition Specialist
Reviewers: Clinical Nutrition Manager(s)
Approval Committee: Nutrition Committee
Megan Waltz, MS, MBA, RDN
Director, Culinary Services and Clinical Nutrition
Sue Rees, DNP, RN, CPHQ, CENP
Vice President and Chief Nursing Officer, Inpatient
Previous revision: N/A
Next revision: February 2020