Quality Assurance Programme Tayside Nutrition Managed ... · The Scottish Government published ‘Preventing Overweight and Obesity in Scotland – A Route Map Towards Healthy Weight’

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Quality Assurance Programme

Tayside Nutrition Managed Clinical Network Date: 8 November 2012

Author: Jacqueline Walker, MSc RD Tayside Nutrition MCN Improvement & Development Manager Joyce Thompson, BSc MPH RD Dietetic Consultant in Public Health Nutrition/ Tayside Nutrition MCN Lead Clinician

Owner: Dr Drew Walker, Director of Public Health

Version No: 1.5

Quality Assurance Programme for NHS ‘Tayside Nutrition MCN

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Contents

1 Introduction 3 2 Meeting the underpinning core principles 14 3 Standards for the MCN 24 4 Performance assessment and monitoring of the MCN 25 5 Performance Assessment Arrangements for the TN MCN 26 6 References 27


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1 Introduction

Addressing the issue of nutrition-related premature morbidity and mortality requires attention to both prevention through public health nutrition, and treatment through clinical nutrition and diet therapy. To ensure that issues relating to food and nutrition are addressed appropriately and effectively requires the cooperation and co-ordination of a large number of people, organisations, agencies, services and programmes within and beyond NHS Tayside. The Tayside Nutrition Managed Clinical Network (TN MCN) was established in 2001 initially as a uni-disciplinary network for registered dietitians. The TN MCN has since evolved into a comprehensive, multi-disciplinary and multi-agency network for all personnel and patients/public that are involved with food and nutrition in Tayside. The TN MCN was formally accredited in November 2009 and has continually responded to the national guidance and evidence and supported local implementation. In 2003, NHS Quality Improvement Scotland (NHS QIS) published National Clinical Standards on Food, Fluid and Nutritional Care in Hospitals1. Implementation of these has been a priority for NHS Tayside as it tries to prevent and treat malnutrition (undernutrition). The organisation has demonstrated significant improvements in food, fluid and nutritional care over the years but a number of recent public reports have highlighted overt deficiencies which have led to a review and revision of the priorities within this work stream. In 2007 NHS Tayside and partner agencies worked through a complex process to produce and agree key nutrition priorities based on the needs of the Tayside population. The Best Value Review of Nutrition (BVRN)2 aimed to determine the extent to which nutrition activities in Tayside were achieving best value, and reach a consensus on the recommendations for NHS Tayside and its local authority partner organisations for the period 2007-2012. This work provided a critical starting point for NHS Tayside, its local authority partners and further education partners to plan, implement and evaluate the impact of nutrition services and programmes on the nutritional well-being of the population. NHS Tayside assigned responsibility to the TN MCN for taking forward all 28 recommendations outlined in the report. In 2008 the Scottish Government published - Healthy Eating, Active Living: An action plan to improve diet, increase physical activity and tackle obesity (2008-2011)3. The document outlined how the Scottish Government would use the resources identified in the Scottish Budget to improve the nation's diet, encourage greater physical activity and begin to establish a base for tackling obesity through both targeted interventions and by supporting the public in achieving and maintaining a healthy weight. The main actions within the report drove the TN MCN to adopt new nutrition priorities in NHS Tayside’s Healthy Eating, Active Living Action Plan (2012-2014). The priorities identified key life stages and settings in which we needed to focus, these were and still remain:

• Early Years

• Schools and School Age Children

• Adults and Workplaces

• Older People

• Communities In 2008 the Scottish Government also issued a Chief Executive Letter (CEL) to territorial NHS Boards regarding their roles and responsibilities relating to ‘Nutrition of women of childbearing age, pregnant women and children under five in disadvantaged areas’ 2008-2011(CEL36) 4.


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Five key areas were identified:

• Increase the uptake of Healthy Start

• Support delivery of the HEAT target on breastfeeding

• Invest in specialist nutritional services

• Support delivery of existing nutritional programmes

• Enable existing training for anyone involved in interventions with the target group to be taken up

Planning for the programme began in 2008 with interventions and activities delivered over the two year period 2009-2011. The Scottish Government published ‘Preventing Overweight and Obesity in Scotland – A Route Map Towards Healthy Weight’5 (The Route Map) in 2010 and is aimed at decision-makers in central and local government. Only by working together across all the public sector, the third sector and business and making the necessary changes required to impact on people’s lives will the health of Scotland’s population be improved. The current levels of overweight and obesity in Scotland are a serious cause for concern and the Scottish Government is committed to acting collectively to prevent overweight and obesity.

Providing high quality evidence based clinical nutrition is vital to many patients in Tayside who have conditions or disease states which require adaptation of their diet to ensure and maintain a healthy life e.g. coeliac disease patients following a gluten free diet. A large proportion of the dietetic workforce provides this service in collaboration and partnership with other professionals and organisations. The contribution of clinical nutrition to the whole nutrition agenda is small in population terms. However, this is where the majority of the NHS resource relating to nutrition and dietetics lie i.e. staffing and specialist nutrition products. Clinical nutrition is also indicated in secondary prevention for certain disease states and in maintaining the health and well-being of many patients within hospital and the community. For this reason the TN MCN endeavours to ensure that NHS Tayside provides quality and cost effective clinical nutrition services.

In January 2011 the Scottish Government launched the following documents:

� A Refreshed Framework for Maternity Care in Scotland6 – designed to address all NHS maternity care from conception, throughout pregnancy and during the postnatal phase, and sets the pace for continuous improvements.

� Reducing Antenatal Health Inequalities7 Outcome Focused Evidence into Action

Guidance – details the necessary actions required to improve access to antenatal healthcare services, improve the assessment of health and social need, and ensure equity in the quality of care.

� Maternal and Infant Nutrition: A Framework for Action8 - aimed at improving maternal

and infant nutrition, setting out the actions that should be taken by health boards, local authorities and others to improve the nutrition of women (pre-conception, pregnancy, and postnatal) and infants.

The Refreshed Framework for Maternity Care in Scotland responds to the compelling evidence of the critical nature of maternity care to child and maternal outcomes and to strengthen the contribution maternity care makes to wider early years work. The new framework’s principal aim is to improve maternal and infant health outcomes, whilst reducing the significant and unacceptable inequalities between and across groups. Nutritional wellbeing plays a vital role in providing women, their partners and their babies/young children with the care and support they need. Therefore the Scottish Government have recommended an integrated approach to the implementation of these frameworks.


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A chronology of the development of the Tayside Nutrition MCN

• Dietitians in Tayside, in conjunction with the University of Dundee, applied for funding from the ‘Learning Together’ initiative from the Human Resource Department at the Scottish Executive to develop a uni-professional clinical network for dietitians, which was named the Tayside Dietetic Clinical Network (TDCN) in 2000.

• The successful funding application enabled the establishment of a clinical network in

2001 which aimed to enable all dietitians to engage in the identification, development and implementation of best dietetic practice. The TDCN assisted dietitians in Tayside with their continual professional development and established the drive to achieve and improve clinical effectiveness as an inherent expectation in each dietetic post.

• A further two years of funding was provided by the Scottish Executive to embed the learning and standards developed in the TDCN. The TDCN was still at this stage a uni-professional clinical network and it was agreed that if the nutrition of the whole Tayside population was to be improved then the Network needed to include all professions and organisations in Tayside involved with food and nutrition.

• The Network was re-established as a multi-disciplinary and multi-agency network (TN MCN) in 2005. NHS Tayside subsequently agreed to provide permanent funding and it has evolved into a comprehensive, multi-disciplinary and multi-agency nutrition network.

• The TN MCN achieved full accreditation status on 23 December 2009 as a Managed Clinical Network (MCN) when NHS Tayside became the first Health Board in Scotland to apply the local accreditation process developed by NHS Quality Improvement Scotland.

� The long-term investment awarded to the TN MCN by NHS Tayside was timely as

awareness of the significance of nutrition to the wellbeing of the population has never been higher.

Tayside Nutrition MCN progression since accreditation The current TN MCN model has continued to evolve since accreditation in 2009. The TN MCN has evolved and developed a structure, Service Improvement Programmes (SIPs) in line with NHS Tayside’s nutrition priorities and MCN principles. The TN MCN assists and supports multi-disciplinary teams across the Tayside region to provide and deliver the highest possible standards of nutrition and dietetic care and services. Work therefore focuses on NHS Tayside priorities and is delivered in partnership with colleagues within and beyond NHS and in consultation with patients and the public. Four work streams have been strengthened and supported to evolve under the direction and support of TN MCN and are identified as:

1. Public Health Nutrition - As malnutrition (under-nutrition and obesity) is largely preventable and the development of diet related chronic disease can manifest during any part of the life course i.e. prenatally, antenatally, infancy, childhood, adulthood and ageing this quadrant focuses on public health nutrition within groups of the population that are especially vulnerable. The Public Health Nutrition work programme focuses on:

� Maternal and Infant Nutrition � Workforce Nutrition � Prevention of Obesity & Child Healthy Weight


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2. Food, Fluid and Nutritional Care - Tackling the problem of undernutrition and

providing appropriate nutrition in hospital, care homes and in the community.

3. Adult Weight Management - The level of obesity within the population has been rising steadily year on year with current Scottish Health Survey (SHS)9 data for 2010 recording 68% of adults as overweight or obese (BMI>25) which, equates to circa. 217,500 men and women in Tayside. Of this figure 25% of men and 27% of women are defined as obese (BMI>30) which equates to circa. 95,000 adults in Tayside. Current trends suggest that by 2030 >60% of adults will be obese (SHS 2010). Obesity is linked to the development of many long-term conditions e.g. cardiovascular disease, diabetes & cancer. A significant proportion of the population suffer form of obesity related long term conditions but there are others that are not e.g. food intolerance. All require access to diet therapy from NHS services as part of clinical treatment.

4. Therapeutic Nutrition – Quality evidence based therapeutic nutrition is vital for secondary prevention to patients who live with conditions and disease states where diet plays a significant factor in maintaining health and wellbeing. This demands the contributions of various staff but it is dietitians who play the greatest role in leading the changes around this aspect of nutrition in Tayside.

Scope NHS Tayside provides a population of approximately 387,950 with primary care, secondary care and full supporting services across Tayside. A number of NHS Tayside services are provided in partnership with other statutory and voluntary organisations and NHS Tayside has close links with, and provides teaching facilities for Dundee’s two universities. With the commitment of its workforce of approximately 14,000 NHS Tayside has a vision to provide the highest quality care that it can, by working together with its partners, those who use the services and the public. NHS Tayside also wants to help everyone in Tayside improve their own health by supporting them to lead healthier lives. Good nutrition plays a vital role in ensuring healthy lives at every stage of life from conception to old age, and in health and in disease. The TN MCN will assist NHS Tayside make this vision a reality by influencing the provision of good nutrition and nutritional care throughout the life course. TN MCN Role in Tackling Opportunities and Challenges Malnutrition refers to over nutrition (overweight/obesity) and under nutrition. There is a high prevalence of malnutrition and preventable diet related chronic disease within the Tayside population, especially in those from poor socio-economic groups, e.g.

• 68% of adults are overweight or obese (SHS 2010)9

• 20% of children are overweight or obese by 5 years of age (CHSS-PS 2011)15

• 30% of pregnant women are overweight/obese at booking (local audit 2011)16

• 58% of infants are exclusively breastfed at birth (CHSP-PS 2011)15

• 26% of infants are exclusively breastfed at the 6-8 week HV review (CHSP-PS 2011)15

• 10% of independently living older people are underweight (SHS 2010)9

• 16% of adult inpatients are either undernourished or at risk on admission to hospital (BAPEN 2011 – NHST results)12

• 36% of adults are either undernourished or at risk on admission to care homes (BAPEN 2011 – NHST results)17


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By the TN MCN supporting a co-ordinated approach to the prevention and treatment of nutrition-related chronic diseases a reduction in premature morbidity and mortality is expected. The TN MCN is set up to identify measures of improvement, resolve complex interagency difficulties and measure the impact of a variety of multi-faceted solutions. This is achieved by gathering together the appropriate NHS and non-NHS personnel and patient or public representatives, critically appraising services or care provision, assessing the overall risk associated with problems, developing possible best value improvement solutions, assisting with implementation, and then measuring and reporting on the impact. Patients and the public are integral to the success of the TN MCN and all activities have a patient or public focus. To ensure there is a robust mechanism and framework upon which to further enhance the vision for health improvement and care for patients around nutrition, the TN MCN is based on the ethos of collaboration and integration as featured in Delivering for Health10 and in the new guidance on MCNs (CEL (2012)29)11. The TN MCN has therefore developed a Quality Assurance Programme (QAP) incorporating the standards outlined in the Scottish Governments Core Principles outlined in NHS HDL (2002)6912 and NHS HDL (2007)2113 and NHS CEL (2012)29. The Healthcare Quality Strategy for NHS Scotland - putting people at the heart of our NHS (2010)14 refers to MCNs as one of the key elements in a long and strong tradition of providing high quality healthcare. The TN MCN has been keen to continue this tradition and ensure that NHS Tayside and its partners strive to continually improve the quality of nutrition to the population of Tayside. There are currently approximately circa. 50 whole-time equivalent (WTE) registered dietitians, support workers and public health nutritionists working across acute services, three Community Health Partnerships (CHPs) and the NHS Tayside Board. However, food and nutrition is an integral feature in the roles of a much wider range of personnel within and beyond the NHS. This means the TN MCN actively seeks partnerships with a range of staff from the NHS, local authorities, the voluntary sector and private organisations and incorporates staff from grass roots to executive level. The TN MCN has continually strived to be inclusive and improve care and services through a whole system approach to nutrition related activities. The TN MCN team comprises three Improvement & Development Managers (2.0 WTE), and two Administrators (1.6 WTE). The Dietetic Consultant in Public Health Nutrition (1.0 WTE) is the designated lead clinician and there are various part-time and full-time personnel from within the Directorate of Public Health and Operational Services who provide leadership for some TN MCN themes. Opportunity and Challenge 1 – Ensuring that nutrition and dietetic expertise is represented in the TN MCN and is able to support the entire nutrition agenda inclusive of public health nutrition, food fluid and nutritional care, weight management and therapeutic nutrition. Addressing the issue of diet related premature morbidity and mortality requires attention to prevention through public health nutrition, food fluid and nutritional care, weight management, and treatment through therapeutic nutrition. To ensure that food and nutrition is addressed appropriately and effectively requires the co-operation and co-ordination of different agencies, services and programmes. It also requires application of the generic model for the management of Long Term Conditions, which aims to provide the necessary level of nutrition and dietetic management based on level of need and clinical risk. An emphasis on achieving a ‘balance of care’ means that the majority of care for individuals with long-term illnesses is provided by general practice as opposed to within the acute hospital setting. There are very few public health nutrition personnel employed in the region and circa >95% of the NHS nutrition and dietetic workforce consist of registered dietitians working in clinical nutrition. Many more staff employed by NHS Tayside and in our partner organisations, work


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with food and provide nutritional care and dietary advice to the community and patients during periods of ill health. Only a small proportion of these personnel have received any training in nutrition nevertheless they are the front line staff providing the information and care. Midwives and community nursing staff provide expertise in supporting breastfeeding mothers, healthy eating advice and sign posting to other services. Due to the identified knowledge and skills deficit in the workforce TN MCN members provide a vital resource in providing the nutrition leadership, expertise and training to this much larger group of staff and organisations. It has therefore been necessary to invest time in developing this key nutrition workforce and have this group of staff undertake crucial roles within the TN MCN. Food and nutrition resources that could be utilised by partner agencies such as expert opinions, training packs, leaflets, guidelines, standards, protocols and key learning from experiences are driven by TN MCN members in multi-disciplinary groups of the TN MCN. Effective and informed food and nutrition activities depend on improving access to information, resources, services and expertise etc. Improving the nutritional health of the population requires an increase in community capacity through additional investment or redesign, productive partnership working and sharing best practice. Opportunity and Challenge 2 – Optimising the workforce by working with agencies and staff involved with food and nutrition in Tayside. Developing and delivering appropriate training and resources to staff so they can provide appropriate advice on public health nutrition, food, fluid and nutritional care, weight management and therapeutic nutrition. Long-term conditions such as coronary heart disease, stroke and cancer are the main causes of premature morbidity and mortality in the Tayside population. Such nutrition-related conditions already place a huge financial burden on the NHS and society as a whole, with a negative impact on the quality of life of the population. The importance of diet in relation to the prevalence of overweight/obesity was highlighted in HEAL2 and the Route Map, and deficiencies in our approach to undernutrition were emphasised in the NHS QIS National Overview of clinical standards for Food, Fluid and Nutritional Care in Hospitals (2006)18. NHS Tayside has made significant progress in staff training relating to breastfeeding, Healthy Start, healthy eating and weaning onto family foods. Further focus is required on the training, knowledge and skills of the wider workforce working across partner agencies and the voluntary sector. There remains significant challenges in transforming the attitudes and beliefs of staff to deliver consistent evidence based messages around nutrition. Opportunity and Challenge 3 – Ensuring food, fluid and nutritional care is given priority and that the ethos around nutrition improves throughout all organisations (public sector, voluntary and commercial) and the Tayside population. Over the past decade, there have been a number of reports, which have highlighted the need to place greater emphasis and priority on improving the food, fluid and nutritional care of the population or sub-groups of the population. Many have demonstrated that the culture around ensuring good nutrition was absent from many organisations. However, over the past 10 years there have been a number of policy drivers, standards, guidelines and recommendations produced by NHS Scotland, which ensure that nutrition is placed higher on the priority agenda. Opportunity and Challenge 4 – Monitoring improvements in nutrition. The ultimate aim of the TN MCN is for every person in Tayside (whether in a care setting or not, in good health or suffering from ill-health) is able to access a diet appropriate for his or her nutritional and dietary needs. However, monitoring this is unrealistic due to the complexity and expense of assessing nutritional intake, the size of the population and the sub-groups within it. Therefore proxy indicators specific to each sub-group of the Tayside population are required e.g. uptake of Healthy Start for pregnant women and the under 5’s population.


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Opportunity and Challenge 5 – Ensuring personnel deliver services that are best value and actively work towards reducing nutrition related health inequalities, by utilising asset based approaches Tayside faces significant demographic changes, large scale real reductions in public sector spending and an intractable gap between the life and health outcomes of the best and the worst off. Taking an asset based approach involves mobilising the skills and knowledge of individuals and the connections and resources within communities and organisations, rather than focusing on problems and deficits. The approach aims to empower individuals, enabling them to rely less on public services. Conventional approaches to the delivery of food, fluid and nutritional care services typically seek to identify cause and effect relationships, with interventions then designed to interrupt or modify these. However, for many people, the cause and effect pathways leading to ill-health are strongly influenced by the adverse social, economic or environmental circumstances in which they live. Unless these underlying determinants of health are addressed, tackling the direct causes may be difficult or impossible. An asset-based approach is therefore one which seeks positively to mobilise the assets, capacities or resources available to individuals and communities which could enable them to gain more control over their lives and circumstances. The TN MCN will be instrumental in facilitating this new approach to delivering on the nutrition priorities. Activities and Key Tasks Overall, addressing the significant nutritional problems and challenges that are prevalent in the Tayside population demands a co-ordinated and multi-faceted approach by a range of agencies and services that are able to influence both the promotion of good health and treatment of ill-health. The impact that can be achieved is dependent on the level of nutrition and dietetic interventions that are provided, as well as their range and quality. Some of the main activities within the TN MCN are around co-ordinating and facilitating the linking of agencies and services with patient and public involvement and addressing key nutrition priorities on behalf of NHS Tayside and its partners. Specific areas of TN MCN responsibilities include:

� Ensuring the delivery of NHS Tayside’s nutrition priorities through targeted work streams. Each stream has a TN MCN Improvement & Development Manager and various working groups focused on delivering key tasks. Each has a Service Improvement Programme (SIP) with a measurement plan that will enable assessment of the impact of activities on the nutritional well being of people in Tayside.

� Providing assurance that the delivery of nutritional care is in line with any nutritional standards e.g. NHS QIS Clinical Standards for Food, Fluid and Nutritional Care in Hospitals8 or locally developed nutrition standards.

� Providing strategic nutritional advice for NHS Tayside and its partners. � Undertaking service needs assessment. � Prioritising and developing new services, including implementation and evaluation. � Developing and implementing electronic records e.g. MiDIS. � Developing and implementing high quality audit tools providing instant feedback to

clinicians e.g. online surveys. � Developing educational initiatives for patients and staff. � Providing nutritional resources to support staff, agencies, patients and the population

to improve food, fluid and nutritional care. � Supporting training and development opportunities for multi-agency and multi-

professional teams around all aspects of nutrition. � Delivering or participating in a nutrition conference every two years.


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� Developing and implementing information, engagement and communication plans. � Maintaining Tayside Nutrition MCN internet site. � Developing new IM&T tools with the public to support self- care e.g. Gluten Free

Food App. � Implementing the Health Equity Strategy in all four themes. � Providing an annual report on TN MCN activities to NHS Tayside via the Director of

Public Health’s Annual report. � Implementing a quality assurance programme that is accredited by NHS Tayside.

This QAP outlines the programme that is already well underway for the development, implementation and review of multi-agency nutrition and dietetic services for Tayside. The QAP supports local health governance structures to address the clinical governance issues, which cross all health care professions and organisations participating in the TN MCN. Statement of Aims, Outcomes, Values and Principles Aim The TN MCN aims to achieve a joined-up approach and improve the quality of public health nutrition, food, fluid and nutritional care, weight management and therapeutic nutrition. Objectives The TN MCN achieves the above aims by implementing the following objectives:

• Co-ordinating, monitoring, evaluating and reporting on the implementation of NHS Tayside’s nutrition priorities and strategic drivers.

• Promoting the sharing and exchange of information and good practice across Tayside.

• Considering relevant national and local policies, plans, standards and guidelines and linking with other key strategic processes.

• Developing, implementing and evaluating information, engagement and communication plans to inform multi-agency personnel and the public, engage with them and ensure appropriate communication.

• Ensuring that nutrition work streams work to MCN principles.

• Helping people help themselves through working with the public to develop services and provide appropriate support and resources.

• Ensuring best value of nutrition by delivering optimal, evidence based care that adds value from the patient’s perspective, optimises productivity and reduces waste, variation and harm.

• Implementing the Healthcare Quality Strategy for NHS Scotland and using improvement methodologies.

• Focusing on the patient/public journey and working with all the stakeholders to improve that journey.

• Ensuring access to appropriate education and training with all stakeholders. The TN MCN will assist and support multi-disciplinary and multi-agency teams across the Tayside region to provide and deliver the highest possible standards of nutrition services. Work therefore focuses on NHS Tayside priorities and is delivered in partnership with colleagues within and beyond NHS and in consultation with patients and the public.


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Outcomes Tayside residents will experience minimal premature morbidity and mortality from diseases associated with poor diet and nutritional care. Outcome indicators � Improved quality of life and optimised nutritional wellbeing from food, fluid and nutritional

care. � Improved access to high quality nutritional care for all residents of Tayside. � Reduction in the health divide associated with poor nutrition and the provision of nutrition

services. � Improved performance and achievement of ‘best spend’ by nutrition services. � Shift in the balance of care from secondary care to primary/tertiary care around nutrition

services. � Shift in resources and services from a treatment focus to early interventions. � Services and resources are developed and improved continually using patient

experience and if possible co-produced with patients Values and Principles The TN MCN upholds the belief that people and patients should be treated as individuals (despite age, sex, faith or race), that they should be at the centre of their care, and have their views heard at all levels of the NHS in Tayside and its partner care organisations. The TN MCN Core Principles are detailed in Section 3 but in addition to these it will also ensure that it will:

• Tackle inequalities by ensuring nutrition resources are targeted at improving those in most need, often have the worst diets and nutritional care and therefore the poorest

health, and ensuring services are developed around their needs. • Provide access to relevant improved information and education to members of the multi-

agency or multi-disciplinary team working in public health nutrition, food fluid and nutritional care, weight management and therapeutic nutrition.

• Ensure access to appropriate nutrition services so that all people in Tayside have equal access to integrated nutritional care services which meet their individual needs. These services should be as close to home as possible and delivered in the best place for the patient or resident.

• Meet agreed standards and maintain quality assurance so that all people in Tayside have access to uniformly high standards of patient-centred care and services, assured through regular performance management and takes account of their views.

• Improve information, engagement, consultation and communication for all aspects of TN MCN work and put systems in place to ensure a high level of communication and co-ordination between the multi-disciplinary and agency teams caring for patients and the population’s nutritional needs.

• Develop and deliver resources that will assist individuals, carers and staff to deliver high quality food, fluid and nutritional care and allow people where possible to care for themselves.

The TN MCN must be appropriately resourced and supported to achieve these aims and enable all involved with providing nutrition services and nutritional care to cope at all levels with the increasing burden poor diet has on the health and quality of life of all patients and the residents of Tayside. In addition, the TN MCN adheres to the following five fundamental Health Care Development Principles laid down by the World Health Organisation:


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• Equity – by ensuring that appropriate care is delivered to patients with local accessibility. • Empowerment – by enabling a clinically led and developed service, which is sensitive to

patient needs. • Co-operation – by delivering a seamless service jointly provided by primary and

secondary care. • Participation – by including patient representation and all disciplines who are currently

involved in the delivery of care. • Primary Health Care – by, where appropriate, enabling a shift in the point of delivery of

care from secondary to primary care. Clinical Governance Clinical Governance is defined as a ‘framework through which NHS organisations are accountable for continually improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish’. The recent guidance in HDL (2007)21 indicates that Board Chief Executives will remain accountable for issues such as clinical governance, waiting time guarantees, delivery of clinical standards and quality improvement work and the use of resources, and this will be delivered through Clinical Directorates and CHPs. Part of the TN MCN role includes influencing the development of referral pathways, standards, treatment protocols, clinical audit and the provision of good quality, consistent information to service users, their carers and the public. This document provides information on how the TN MCN:

• Provides links between the TN MCN, NHS Tayside and its partners in care (see TN MCN Structure Diagram overleaf).

• Influences the planning of nutrition services.

• Integrates with NHS Tayside clinical governance, patient focus and public involvement, Steps to Better Health Care and strategic values and principles.


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TN MCN Structure Diagram


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2 Meeting the underpinning core principles

The following demonstrates that the TN MCN met the core MCN principles within the agreed timescales in 2009 which were agreed between the TN MCN and NHS Tayside at that time. The TN MCN has continued to build on the implementation of these core principles and have provided information on subsequent developments of the network since 2009. Core principles Core principle 1: Clear management arrangements and leadership of the MCN. (HDL core principle 10.1, ISO 9000 principle 2; CEL 36 core principle 8.1)

Expected benefit Assessment measure Timescale for delivery (from MCN inception)

Status and accompanying evidence

Achieved in 2009.

Defined objectives for the MCN

Within year one.

See evidence folder – QAP, SIPs for each of the four TN MCN themes. Achieved in 2000.

Lead clinician or officer appointed.

Within year one.

See evidence folder - TN MCN Lead Clinician and TN MCN Manager in post since 2000 - see evidence folder – job descriptions for TN MCN Lead Clinician and Improvement & Development Managers (2011). Achieved in 2010.

There is unity of purpose and direction of the MCN.

Publicly available annual report.

Within year one.

See evidence folder - DPH Annual Report

Continued progress since 2009:

• 2010 – Director of Public Health’s Annual Report used as the vehicle to explicitly report on TN MCN outcomes and progress towards tackling nutrition challenges within the population of Tayside.

• 2011 - TN MCN Reference Panel reviewed and a new TN MCN Programme Board established.

• 2011 - Dr Drew Walker, Director of Public Health, appointed TN MCN Programme Board Chair.

• 2011 - Reporting structure to NHS Tayside and beyond was approved by NHS Tayside.

• 2012 - Realignment of the Nutrition Standards Service Improvement Programme within the TN MCN. This led to a review of the TN MCN team and the establishment of three (1.93 WTE) Improvement & Development Managers each of which is aligned to a specific nutrition priority.


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• 2012 - TN MCN Improvement & Development Team meetings established to enable networking, shared learning and the application of cohesive approaches to all components of the TN MCN.


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Core principle 2: A defined MCN structure setting out the points at which the service is to be delivered and the connections between them. (HDL core principle 10.2, ISO 9000 principle 5; CEL 36 core principle 8.2)



Achieved in 2009.

Defined MCN organisational structure and management arrangements, linked to the relevant planning structures.

Within year one.

See QAP

Achieved in 2009.

Improved effectiveness of the MCN.

Defined patient pathway(s).

Within year one.

Defined patient pathways achieved, see evidence folder e.g. Coeliac Disease, nutritional support ‘MUST’, weight management (Appendix 1 in CQF report).


• 2009 - Public Health Nutrition Sub-group extended membership within and beyond NHS Tayside as it focused on maternal and infant nutrition as a result of CEL36 and ‘Improving Maternal and Infant Nutrition: A Framework for Action (2011).

• 2012 – Review of NHS Tayside Food, Fluid & Nutritional Care policy set out reporting arrangements for the TN MCN and the connections between it, operational services and NHS Tayside Board Committees.

• Improved sharing and coordination of information across TN MCN as a result of increased membership


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Core principle 3: The use of an MCN annual work plan. (HDL core principle 10.3, ISO 9000 principle 4; CEL 36 core principle 8.3)



Achieved in 2009. Improved efficiency of the MCN by focusing effort on the key activities that will best achieve the desired results.

An MCN annual work programme.

Within year one and annually thereafter. See evidence folder for

continued development - SIPs for each TN MCN theme


• Each TN MCN theme is required to have an explicit and standardised Service Improvement Programme with annual work plan which collectively constitutes the overall TN MCN work programme.


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Core principle 4: The use of a documented evidence base by the MCN. (HDL core principle 10.4, ISO 9000 principle 7; CEL 36 core principle 8.4)



Achieved.

Defined evidence-based standards within which the MCN will operate.

Within year 2.

See evidence folder – SIPs and SOPs which relate to evidence based published standards or where they do not exist, to evidence based best practice or clinical guidelines or policy. Achieved in 2009.

Informed decision-making based on the analysis of data and information, promoting the delivery of safe and effective care.

An MCN audit and research programme/improvement measures/reports.

Within year 2.

See evidence folder for continued development SIPs, Clinical Quality Forum (CQF) reports, Steps To Better Healthcare reports.

Continued Progress since 2009:

• TN MCN has moved to using Standard Operating Procedures (SOP) rather than the

older TN MCN Standard templates. This was in a move to align with current NHS Tayside templates. Therefore as older TN MCN standards are updated they are moved into the SOP template.

• TN MCN uses improvement methodology as its main vehicle to drive improvements. The use of audit has decreased as the rise in collection and interpretation of ‘real time’ improvement data has increased. Audit still has a place but the main role of the TN MCN has been to develop the audit tools, make the tools available to the service and then allow the service to audit as required.

• Research activity (and associated peer review publications) includes leading or contributing to research programmes such as WeighWell post partum weight management feasibility study and BeWell body weight & physical activity intervention in adults at risk of colorectal adenoma (Centre of Public Health Nutrition Research, University of Dundee); feasibility of delivering a Weight Watcher Programme within the NHS; evaluation of a maternal obesity service, and the FFIT (Football Fans in Training) weight management trial (multi-centred).


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Core principle 5: The multi-disciplinary and multi-professional constitution of the MCN. (HDL core principle 10.5, ISO 9000 principle 3; CEL 36 core principle 8.5)



Achieved in 2009.

Multidisciplinary and multiprofessional configuration of MCN.

Within year one.

See evidence folder for continued development – SIPS. Achieved.

Peoples’ skills, knowledge and abilities are used appropriately and for the benefit of the MCN.

Clarity of roles within the MCN.

Within year one.

See evidence folder for continued development – SIPs.


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Core principle 6: A patient-focused approach. (HDL core principle 10.6, ISO 9000 principle ; CEL 36 core principle 6)



Achieved in 2009.

Service User involvement in MCN including support to individuals to contribute to the planning and management arrangements

Within year one.

See evidence folder – Improvement, Engagement & Communication (IEC) plans, Programme Board Minutes. Achieved in 2010.

Voluntary Sector involvement in MCN contributing to the planning and management arrangements

Within year one.

See SIP for each TN MCN theme.

Achieved in 2009.

Mechanisms in place to capture the views of service users and their carers

Within year 2

See evidence folder – TN MCN Screenshot of ‘Tayside Nutrition’ webpages, Pilot report of TN MCN CD SIP, ‘Your NHS’ screenshot. Achieved

The MCN meets patient’s care requirements.

Dissemination of appropriate, up to date information to service users and their carers

Within year 2

See evidence folder - ‘Tayside Nutrition’ website screenshot, ‘Facebook’ site.


• TN MCN website development in partnership with NHS Education Scotland. http://www.knowledge.scot.nhs.uk/taysidenutrition.aspx

• NHS Tayside Mums and babies Facebook page. http://www.facebook.com/NHSTaysidebabies

• Development of smart phone application for prescribable Gluten Free Food Products (underway).

• 2011 NHS Tayside Quality Awards finalists for 2 submissions: Coeliac Disease and Breastfeeding Volunteers

• 2012 NHS Tayside Quality Awards shortlist for 2 submissions: Optimum (Weight Management in Pregnancy) and Breastfeeding Support Workers.


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Core principle 7: Optimising the MCN education and training potential and continuing professional development. (HDL core principle 10.8, ISO 9000 principle 3; CEL 36 core principle 7)



Achieved in 2009.

An MCN education programme, optimising education and training potential across community and primary care and hospitals and specialist centres.

Within year 2.

See evidence folder for continued development - SIPs, education programmes, AHP Practice Development Apprenticeship Programme, TN MCN Managers Development Sessions (held monthly). Achieved in 2009.

All clinicians are involved in a programme of continuing professional development (CPD).

Within year 2.

See evidence folder for continued development – TN MCN Managers have annual PDP and eKSF review. Achieved in 2009.

Motivated, committed and involved people within the MCN. Competent staff contributing to the continuous improvement in the quality of care and service provided by the MCN.

All professionals participating in appropriate appraisal systems.

Within year 1.

See evidence folder – eKSF.


• TN MCN themes required to include education and training within the SIPs e.g. o NHS Tayside Breastfeeding Management Programme. o Child Healthy Weight training programme (3 tiers). o Counterweight training. o Development of online ‘learnPro’ training modules e.g. infant feeding

(planned), weaning (complete), ‘MUST’ (underway).

• 2011 - UK UNICEF Baby Friendly accreditation.

• eKSF utilised by all TN MCN staff.


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Core principle 8: Generating better value for money. (HDL core principle 10.9, ISO 9000 principle 8; CEL 36 core principle 8)



Achieved in 2009 Achievement of the maximum benefits from the services the MCN both acquires and provides within available resources.

Evidence that the potential to generate better value for money has been explored.

Year four onwards.

See evidence folder for continued development - SIPs, SBHC reports.


• TN MCN SIPs for each of the themes are required to apply asset based approaches and consider the cost effectiveness and long term sustainability of the work.

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Contribution to NHS Tayside Strategic Aims

Strategic Aim 1: Contribute to closing the health inequalities gap within a generation

Description of contribution Status and accompanying evidence

Achieved

The TN MCN tackles health inequalities by ensuring nutrition resources are targeted at improving those in most need, often those with the worst diets and nutritional care and therefore the poorest health, and ensuring services are developed around their needs. This is achieved by the TN MCN implementing NHS Tayside’s Health Equity Strategy e.g. by targeting resources at SIMD 1 & 2 as in the Coeliac Disease pathway and active promotion of Healthy Start (welfare food scheme) and access to breastfeeding support.

See evidence folder – CQF and SIP for each theme.

Strategic Aim 2: Improve health life expectancy by supporting people to look after themselves Description of contribution Status and accompanying

evidence

Achieved

The TN MCN ensures that services are developed or re-designed by putting people at the centre and ensuring that services and resources are focused on allowing people to look after themselves where possible. One example of this is where gluten free food prescriptions have been taken away from GP control and put in the control of patients and community pharmacy.

See evidence folder – CQF and SIP for each theme.


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Strategic Aim 3: Ensure that services meet agreed quality standards, especially patient experience


Achieved

The TN MCN develops services, patient pathways, standard operating procedures and protocols etc using current evidence, and national guidelines & clinical standards. It constantly seeks people’s experiences and views to drive improvement. Using NHS Tayside’s improvement development and reporting templates and working with key personnel across Tayside e.g. Tayside Centre for Organisational Effectiveness, Patient Focus People Involvement Team, Feedback Team and Complaints Team the TN MCN ensures high quality services are developed.

See evidence folder – CQF and SIP for each theme Pilot report CD Awards - British Dietetic Association Dame Barbara Clayton Award for Coeliac Disease Runner up NHS Tayside Quality Award 2011 (2 entries) and short listed for 2012 (2 entries).

Strategic Aim 4: Be cost effective in all decisions, actions and services


Achieved

Using tools such as the Benefit Realisation Tool, the actual spend and grey cost spend is identified as is the revised or improved service spend. At each stage best value is considered whether this is on the drug spend or shifting the balance of care from secondary to primary care services. Theme leads focus on reducing waste, variation and harm within each area of work.

See evidence folder – CQF and SIP for each theme SBAR report on Coeliac Disease


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3 Standards for the MCN

Assessment measures Status and accompanying evidence

Achieved.

The standards within the Quality Assurance Programme are from recognised sources e.g.: 1. NHS Quality Improvement

Scotland.

2. Professional bodies (e.g. medical, nursing, allied health professions).

3. Scottish Government Healthcare Directorates.

4. Scottish Intercollegiate Guideline Network (SIGN).

5. National Institute for Clinical & Health Effectiveness ( NICE)

See evidence folder - SIPs.

Achieved. Relevant NHS QIS Clinical Governance and Risk Management Standards are adopted.

See evidence folder - QAP and SIPs.

Achieved.

The standards relate directly to the objectives of the MCN. See evidence folder - SIPs.

Achieved.

Additional standards focus on clinical issues.

See evidence folder – clinical standard example or see intranet link http://staffnet.tayside.scot.nhs.uk/

OurWebsites/TaysideNutritionNetwork/index.htm. Achieved. Standards developed by the MCN have

a sound evidence base. See evidence folder - SIPs.


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4 Performance assessment and monitoring of the MCN

Assessment measures Status and accompanying evidence

Achieved.

A suitable performance assessment methodology comprising: 1. Clearly specified evidence that is

required to meet each standard and demonstrate implementation of each core principle.

2. Agreed performance assessment criteria, e.g. met/not met.

3. How the performance assessment of the MCN will be carried out, e.g. a peer review system.

Accreditation process has allowed TN MCN to be evaluated and performance assessed against 8 core principles.

Achieved.

A detailed performance assessment work programme which is updated annually. See evidence folder - SIPs and associated

measurement plans. Achieved.

Defined reporting arrangements to inform stakeholders of the findings from the performance assessment process.

See evidence folder - IEC Plans.

Achieved. Defined arrangements for addressing relevant performance matters at the following levels: 1. MCN

2. NHS board

3. Regional (if applicable to MCN)

4. National (if applicable to MCN)

See evidence folder – QAP, CQF, SBHC reports at Board Level.


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5 Performance Assessment Arrangements for the TN MCN

The performance of the TN MCN in meeting its objectives towards implementing NHS Tayside’s nutrition priorities and MCN principles is reviewed by NHS Tayside’s Clinical Quality Forum. Each theme has a bespoke SIP with associated monitoring and performance plan which are reported as required e.g. Coeliac Disease SIP outcomes are reported monthly to the Steps To Better Healthcare Committee, and annually to the TN MCN Programme Board and CQF. Reporting Mechanism The TN MCN reports four times per year to the CQF and as required to the Improvement & Quality Committee. Annual reports are available to the public via the Director of Public Health’s Annual Report. TN MCN Programme Board The TN MCN Programme Board is charged with the responsibility of providing the strategic lead for the development of the TN MCN and ensures that it meets the priorities for nutrition, MCN core principles and NHS Tayside priorities and strategic drivers. It has governance responsibility for assuring that mechanisms are in place to address the four themes and that the performance of the TN MCN is reported. Links with NHS Tayside and partners Through the TN MCN group structures, the TN MCN links with NHS Tayside and its partners in care. Most TN MCN Groups have multi disciplinary and multi-agency membership. Influencing planning of Nutrition and Dietetic Services The TN MCN assists the managers of Nutrition & Dietetic Services to develop and implement a strategic approach to the delivery of nutrition and dietetic services in Tayside that address agreed priorities as set out in each TN MCN SIP. This is achieved by supporting the TN MCN Service Delivery Team which comprises those responsible for the operational management of nutrition and dietetic services throughout NHS Tayside.


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6 References

1. NHS Quality Improvement Scotland, Clinical Standards for Food, Fluid and Nutritional

Care for Hospitals (2003) 2. Thompson J, NHS Tayside Best Value Review of Nutrition (2007)

(full report available on TN MCN web link www.taysidepublichealth.com) 3. Scottish Government, Healthy Eating, Active Living: An action plan to improve diet,

increase physical activity and tackle obesity (2008-2011) 4. Scottish Government CEL36 (2008) 5. Scottish Government, Prevention of Overweight and Obesity: A Route Map Towards

Healthy Weight (2010) 6. Scottish Government, A Refreshed Framework for Maternity care in Scotland: The

Maternity Services Action Group (2001) 7. Scottish Government, Reducing Antenatal Health Inequalities (2011) 8. Scottish Government, Improving Maternal and Infant Nutrition: A Refreshed Framework

for Action (2001) 9. Scottish Health Survey (2010) 10. Scottish Executive, Delivering for Health (2005) 11. Scottish Government, Managed Clinical Networks: Supporting and Delivering the

Healthcare Quality Strategy CEL (2012)29 12. Scottish Executive, Core Principles for MCNs HDL (2002)69 13. Scottish Government, Guidance for Managed Clinical Networks HDL (2007)21 14. NHS Scotland Quality Strategy - putting people at the heart of our NHS (2010) 15. www.isdscotland.org 16. Barnett, C. CEL36 Report (2012) 17. NHS Tayside BAPEN Report (2011) 18. NHS Quality Improvement Scotland, National Overview August 2006, Clinical Standards

for Food, Fluid and Nutritional Care for Hospitals (2006)

Documents

Quality Assurance Programme Tayside Nutrition Managed ... · The Scottish Government published ‘Preventing Overweight and Obesity in Scotland – A Route Map Towards Healthy Weight’