Policies,Administrative,UWHC,Department Specific,Culinary Services,Administration

Quality Assurance (1.11)

Quality Assurance (1.11) - Policies, Administrative, UWHC, Department Specific, Culinary Services, Administration


Effective Date:
May 01, 2014
Revision Date:
September 1,

 Nursing Manual
 Culinary Services
 Clinical Nutrition

Policy #:

 Original
 Revision

Page 1
Of 1

Quality Assurance


To assure that food and nutrition services delivered to patients are appropriate, efficient, effective, safe, and
consistent with professionally recognized standards of care for an academic medical center and that the
efforts to improve performance are ongoing and integrated throughout the department and organization.


Quality is defined as the means for meeting and exceeding the needs, wants, and expectations of patients
and their families, students, employees and members of the community.

Performance improvement is achieved through the establishment and implementation of a relevant agenda
of ongoing performance measures, case reviews, and process improvement projects. These occur in each
department, service, program and by hospital-wide standing committees within UW Health as well as
through the conduct of process improvement team projects. The principles and dimensions of quality are
inherent. Performance improvement supports the Hospital's mission and achievement of its vision.

The goals of the UW Health Performance Improvement Plan are the guideposts which provide the focus of
Quality Improvement for the department.

The Nutrition Committee of the Medical Board directs the quality improvement function for nutrition care and
Culinary Services at UW Hospital and Clinics and UW Children's Hospital and Clinics with annual report to the
hospital's Quality Evaluation and Review Committee.

The quality assurance and performance improvement program is used to design, measure, assess, and
improve the Culinary Services and nutrition care functions of the Culinary Services and Nutrition Services


JCAHO, Accreditation Manual for Hospitals
UW Health Plan for Organizational Performance Improvement (10/09/00)
Department Scope of Services
Quality Improvement Tools-UWHC Management Development Program.
Quality Management Terminology
Department Plan for Organizational Performance Improvement
QA - IOP Data Collection and Analysis Forms
Quality Evaluation & Review Annual Report (QERC)

A. An ongoing quality assurance and performance improvement program designed to objectively and
systematically monitor and evaluate the quality, efficacy, and appropriateness of food and nutrition
services that then pursues opportunities to improve those services and resolves identified problems
will be established.
B. On an annual basis, the Director of Culinary Services and the Director of Clinical Nutrition Services,
in conjunction with the Medical Board Nutrition Committee, determine the major focus of quality

measures, and organizational performance improvement projects for the year. The Director of
Culinary Services and the Director of Clinical Nutrition Services are responsible for implementing the
monitoring and evaluation process.
C. The managers select and systematically apply appropriate department specific performance
measures; recommend and take action to foster improvements based on a systematic assessment of
data; establish or participate in relevant departmental and multi-departmental quality improvement
projects; apply relevant performance data to department competency review activities; and
periodically review the effectiveness of the departmental quality improvement effort, revising as
appropriate. Selected monitors track department quality improvement activities over time to
identify trends/progress and include evaluation of the previous year's recommendations for
improvement. The actions taken to improve care delivered by the department is documented. Data
sources include the patient's medical record and departmental records. Follow-up plans address
unacceptable findings from performance measures. Recommendations from other hospital
committees and external agencies are addressed.
D. The improvement processes include traditional quality assessment activities and peer review as well
as 5-step process improvement and 7-step problem solving method.
E. Plan, findings, conclusions and effectiveness of the monitoring and evaluation activities are reported
by Culinary Services and Clinical Nutrition Services Departments to the Nutrition Committee and
periodically reviewed by the Medical Board. Annually, the Nutrition Committee reports to QERC as
part of QERC's role in the reappraisal of UWHC's QI Program.
F. Dimensions of quality emphasize:
A. Doing the right thing….efficacy and appropriateness.
B. Doing the right thing well….availability, timeliness, effectiveness, continuity, safety,
efficiency, and respect and caring.
G. The goals and objectives of the department services are accomplished through the effective
utilization of resources. The activities and effects of interventions are monitored and evaluated with
performance measures. Outcomes are measured to understand results. Processes are measured to
understand the causes of results. The program includes:
A. Ongoing collection of relevant process data and outcomes about various aspects of food and
nutrition services. Outcomes may be clinical, humanistic, or economic. Ongoing
measurement determines the stability of processes and the predictability of outcomes.
B. The monitoring and evaluation process is designed to identify opportunities to make
improvements in patient care; identify and correct problems that have the greatest effect on
patient care; to identify patterns as well as important single events; and to determine how to
improve care or correct the problem with constancy of purpose.
C. The monitoring and evaluation process identifies those aspects of care that are most
important to the health and safety of patients served. This includes: those services that
occur frequently and those that place the patient at risk or would deprive the patient of
substantial benefit (high risk, high volume, problem-prove, sentinel events).
D. Indicators are identified to monitor the efficacy and appropriateness of important aspects of
care. These indicators are: objective, measurable and based on current knowledge and
clinical experience and reflect structures of care, processes of care or outcomes of care.
E. Data is collected for each indicator. The frequency of data collection for each indicator and
sampling of events or activities are related to the frequency, the significance and the extent
to which the important aspect of care has been demonstrated to be problem-free. Statistical
tools such as run charts, control charts, and histograms are especially helpful for comparing
performance with historical patterns and for assessing variation and stability, other tools to
use include Pareto charts, flow charts, work flow diagrams, deployment flow chart, process
map, check sheet, work sampling, etc.
F. Data collected for each indicator are organized so that situations in which an evaluation of
quality or appropriateness of care is indicated are readily identified.
G. The evaluation of an important aspect of care includes: analyses of trends and patterns;
review by peers when analysis of care provided by a practitioner is undertaken; identifies
opportunities to improve or identifies problems in quality and/or appropriateness of care.
H. When an opportunity to improve or resolve a problem in the quality and/or appropriateness
of care is identified, action is taken and the effectiveness of the action is assessed through
continued monitoring of care or service.
H. Improvement Processes
A. Traditional quality assessment monitoring and peer review.
B. PDCA Methodology (Plan, Do, Check, Act) for process improvement and seven step problem
solving method.
A. Plan description of reasons project selected as a departmental priority.
B. Baseline measured.

C. Root causes identified and verified with data.
D. Do description of intervention/solution.
E. Check solution piloted and results measured.
F. Act plan for implementation and ongoing monitoring.
G. Results of PI projects communicated with staff/multidisciplinary patient care team.
I. Performance measures are as follows:
A. All menus are reviewed for nutritional adequacy.
B. There is a means for identifying patients who are not eating or who are NPO greater than 4
days and not receiving nutrition support.
C. Diet orders are evaluated for appropriateness. Menu selections are monitored for
compliance with physician's order.
D. Not more than 15 hours elapse between the serving of the evening meal and the next
substantial meal for patients who are on oral intake and do not have special dietary
E. The nutritional intake of patients is assessed and recorded in the medical record as
F. As appropriate, patients with special dietary needs and their family receive nutrition
education relative to their diets. The patient's (or family's) understanding of this information
is documented in the medical record.
G. As appropriate, patients who are discharged from the hospital on therapeutic diets receive
written information and nutrition counseling before discharge. This information is
documented in the medical record.
H. As appropriate, patients are given information about potential food-drug interactions. This
information is documented in the medical record.
I. Qualified clinical nutrition staff participate in designated Medical Board appointed committees
and specifically the Nutrition Committee and its subcommittees. Nutrition staff also
participate in other multidisciplinary care committees/teams.
J. A maximum effort is made to assure an appetizing appearance, palatability, proper serving
temperature, and retention of nutrient value of food.
K. Patient food preferences are respected whenever possible.
L. Surveys to determine patient/customer acceptance of food and food quality are conducted
on a regular basis.


Director, Culinary and Clinical Nutrition Services