Process, Structural, And Outcome Quality Indicators Of Nutritional Care .
Lorini et al. BMC Health Services Research (2018) 18:43DOI 10.1186/s12913-018-2828-0RESEARCH ARTICLEOpen AccessProcess, structural, and outcome qualityindicators of nutritional care in nursinghomes: a systematic reviewChiara Lorini1* , Barbara Rita Porchia2, Francesca Pieralli2 and Gugliemo Bonaccorsi1AbstractBackground: The quality of nursing homes (NHs) has attracted a lot of interest in recent years and is one of the mostchallenging issues for policy-makers. Nutritional care should be considered an important variable to be measured fromthe perspective of quality management. The aim of this systematic review is to describe the use of structural, process,and outcome indicators of nutritional care in NHs and the relationship among them.Methods: The literature search was carried out in Pubmed, Embase, Scopus, and Web of Science. A temporal filter wasapplied in order to select papers published in the last 10 years. All types of studies were included, with the exceptionof reviews, conference proceedings, editorials, and letters to the editor. Papers published in languages otherthan English, Italian, and Spanish were excluded.Results: From the database search, 1063 potentially relevant studies were obtained. Of these, 19 full-text articles wereconsidered eligible for the final synthesis. Most of the studies adopted an observational cross-sectional design. Theygenerally assessed the quality of nutritional care using several indicators, usually including a mixture of many differentstructural, process, and outcome indicators. Only one of the 19 studies described the quality of care by comparing theresults with the threshold values. Nine papers assessed the relationship between indicators and six of them describedsome significant associations—in the NHs that have a policy related to nutritional risk assessment or a suitable scale toweigh the residents, the prevalence or risk of malnutrition is lower. Finally, only four papers of these nine included riskadjustment. This could limit the comparability of the results.Conclusion: Our findings show that a consensus must be reached for defining a set of indicators and standardsto improve quality in NHs. Establishing the relationship between structural, process, and outcome indicators is achallenge. There are grounds for investigating this theme by means of prospective longitudinal studies that takethe risk adjustment into account.Keywords: Malnutrition, Nutritional care, Structural indicators, Process indicators, Nursing homesBackgroundWith the increase in life expectancy and the prevalenceof disabilities and comorbidity related to aging, nursinghomes (NHs) now play an increasingly important role.The quality of NHs has attracted a lot of interest in recent years and is one of the most challenging issues forpolicy-makers. In the NH sector, poor quality representsan issue of public concern and discussions are taking* Correspondence: chiara.lorini@unifi.it1Department of Health Science, University of Florence, viale GB Morgagni 48,50134 Florence, ItalyFull list of author information is available at the end of the articleplace to address it [1–4]. The quality of care in NHs is amultidimensional construct that is difficult to define andassess. According to Donabedian’s framework [5], qualityis a function of three domains: structure, process, andoutcome. Structure is defined by the attributes of thesettings in which care is provided, process by the activities of the care-giving practitioners, and outcomeby the change in the health status of the patient.Within these three domains, the quality of care canbe measured by using the structure, process, and outcome quality indicators. The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication o/1.0/) applies to the data made available in this article, unless otherwise stated.
Lorini et al. BMC Health Services Research (2018) 18:43The use of structural and process indicators for qualitymanagement offers several advantages — they are generally easy to measure and interpret and the collected dataare often routinely available. However, they might notreflect the level of the quality of care; structural andprocess indicators indicate the attributes of the NH andwhat is being done (or is supposed to be done), but theydo not automatically translate into a higher quality ofcare or better outcomes. Therefore, they are ‘necessarybut not sufficient’ characteristics and do not necessarilyindicate the appropriateness of what is being done [6, 7].Moreover, the NH context is complex and very littleknowledge translation has been carried out to date [8–10].Outcome indicators overcome these limitations and areconsidered to be more closely related to quality. However,they are influenced by the risk level of elderly patients—primarily due to their health status—as well as by thequality of the care process. For these reasons, outcomeindicators have to be risk-adjusted [7, 11].Moreover, in order for structural and process indicators to be valid for NHs in terms of other care settings,they must first demonstrate the ability to generate a better outcome [6]. Specifically, they should be associatedwith and influence the outcome indicator, for examplein terms of variation over time.These unresolved issues and limitations in the use andinterpretation of quality indicators have led to difficultiesin assessing the real influence of the structural andprocess indicators on the prediction of the outcome indicators. Difficulties have also arisen, in general, in theevaluation of the effectiveness of quality indicators andquality systems for improving the quality of care, healthstatus, and quality of life in NHs [12–15].Malnutrition and unintentional weight loss in the NHsare major issues because of their high prevalence, serioushealth consequences, and related healthcare costs [16–20]. Recent studies estimate that 20% of NH residentssuffer from some form of malnutrition, the prevalence ofwhich ranges between 1.5 and 66.5%, depending on thedefinition [17]. Moreover, malnutrition can influence thehealth status, leading to clinical complications such asimpaired immune response, depression, pressure ulcers,falls, and even death [18].The causes of malnutrition and weight loss in elderlypeople living in long-term care facilities can be classified aseither individual (age, comorbidity) or organizational [21,22]. For many elderly adults in NHs, aging is accompaniedby a progressive physiological and medical decline, whichleads to nutritional vulnerability. This in turn can create aprogressive feeding dependency. Many organizational factors can negatively affect the assumption of nutritionallyadequate diet for such people, thus increasing the likelihood of malnutrition and weight loss. Therefore, nutritionalcare (i.e. the substances, procedures, and setting involved inPage 2 of 14ensuring the proper intake and assimilation of nutrients) must be considered an important variable thatshould be measured from the perspective of qualitymanagement by using the related structural, process,and outcome indicators [12, 22–26].The aim of this review is to describe the state of theart with regard to:1. the use of quality indicators of nutritional care inNHs;2. the relationship between structural, process, andoutcome indicators of nutritional care in NHs.MethodsThe literature search was carried out in four databases—Pubmed, Embase, Scopus, and Web of Science—andwas completed with a manual search on the basis of thereferences given in the selected papers.While performing the research, a temporal filterwas applied in order to select papers published in thelast 10 years. Databases were last accessed on 18February 2016.The search strategies used in each database arereported in Table 1.Two reviewers independently selected papers based onthe inclusion criteria. Disagreements were resolvedthrough a consensus meeting in the presence of a thirdreviewer.In order to be included, papers had to examine bothcare quality and nutritional care in the specific setting ofNHs; moreover, they had to respond to the aims of thisstudy, namely to describe the use of quality indicators ofnutritional care in NHs and/or to assess the relationshipbetween structural, process, and outcome indicators ofnutritional care in NHs. All types of studies wereincluded, with the exception of reviews, conference proceedings, editorials, and letters to the editor.Papers published in languages other than English,Italian and Spanish were excluded.Figure 1 summarizes the selection process of thearticles.ResultsFrom the database search, 1063 potentially relevantstudies were obtained and screened for the presence ofall inclusion criteria. Of the 63 studies selected on thebasis of title and abstract, 44 were excluded: two becauseof language of publication, 11 for type of publication(four conference proceedings, three narrative reviews,three editorials, and one letter to the editor), 30 for outcomes (24 not concerning quality aspects, four notreporting quality indicators, and two not concerningnutritional aspects), and one for setting. Ultimately, 19
Lorini et al. BMC Health Services Research (2018) 18:43Page 3 of 14Table 1 Search strategies of systematic reviewDATABASESearch strategyPubmed((((((“Quality Assurance, Health Care”[Mesh]) OR “Quality Improvement”[Mesh]) OR “Quality Indicators, Health Care”[Mesh])OR “Health Care Quality, Access, and Evaluation”[Mesh])) AND “last 10 years”[PDat]) AND ((“Malnutrition”[Mesh] OR “nutritionalcare” OR “weight loss”) AND “last 10 years”[PDat]) AND ((“Nursing Homes”[Mesh] OR “Long-Term Care”[Mesh]) AND “last10 years”[PDat])Embasequality OR indicator* OR assurance OR ‘health care’/exp. AND (‘malnutrition’/exp. OR ‘nutritional care’ OR ‘weight loss’/exp)AND ‘nursing home*Scopus(((quality OR indicator* OR assurance OR “health care”) AND (malnutrition OR “nutritional care” OR “weight loss”) AND(nursing home*)))Web of Science(((quality OR indicator* OR assurance OR “health care”) AND (malnutrition OR “nutritional care” OR “weight loss”) AND(nursing home*)))full-text articles were considered eligible for the finalsynthesis (Fig. 1).Table 2 shows the main characteristics of each of theselected papers, including year of publication, country,setting, number of participants, type, and aim of thestudy. Most of the studies were conducted in the USAor Europe and adopted an observational cross-sectionaldesign. One study [27] combined the Delphi methodwith an observational design. In two papers, the authorsconducted a before/after analysis [28, 29].Seven studies only aimed to measure the prevalence ofmalnutrition/weight loss (as outcome indicator) and theuse of structural or process indicators [20, 27, 30–34].Fig. 1 Flow diagram of the study selection [58]Four others tried to assess both the prevalence ofmalnutrition and the relationship among the quality indicators [35–38]. Five only assessed the relationship between indicators (without describing their prevalence/use)[39–43], and three examined the effect of nutritional careinterventions on outcome indicators [28, 29, 44].With regard to the collection of information, the mostcommonly used instruments were the standardizedLandelijke Prevalentiemeting Zorgproblemen (LPZ) questionnaire, the Minimum Data Set (MDS), and the OnlineSurvey, Certification, and Reporting (OSCAR). LPZ ismore widely used in European countries and aims toassess malnutrition prevalence. MDS and OSCAR are
Lorini et al. BMC Health Services Research (2018) 18:43Page 4 of 14Table 2 Main characteristics of selected studies1st Author, Year ofpublicationCountrySetting/ n. participantsType of studyAim of the studyBonaccorsi, 2015 [35]Italy67 NHs; 2395 participantsCross-sectional surveyTo describe the quality indicators ofnutritional care in older residents in asample of NHs in Tuscany, Italy, and toevaluate the predictors of protein-energymalnutrition risk.Dyck, 2007 [39]USA2948 NHs for malnutrition;364,339 residentsCross-sectional analysisof two data setsTo examine the relationships betweennursing staffing and the nursing homeresident outcome on weight loss anddehydratation .Halfens, 2013 [30]The Netherlands,Austria,Switzerland211 hospitals (20,232 patients);165 NHs (6969 residents)Cross-sectionalmulticentre study.To measure care problems (includingmalnutrition) in terms of prevalence rates,prevention, treatment, and quality indicatorsin healthcare organizations in the Netherlands,Austria, and Switzerland.Hjaltadottir, 2012 [27]IcelandPanel for Delphi method: 12experts; 47 NHs (2247participants)Two rounds Delphi study To determine upper and lower thresholdsand observational study of Minimum Data Set quality indicators forIcelandic NHs.Hurtado, 2016 [40]USA30 NHsProspective ecologicalstudyTo examine whether quality of care inNHs was predicted by schedule control(workers’ ability to decide work hours),independent of other staffing characteristics.Lee, 2014 [41]USA195 NHsCross-sectional analysisof five data setsTo examine the association of registerednurse staffing hours and five qualityindicators, including process and outcomemeasures.Meijers, 2009 [59]The Netherlands50 hospitals, 90 NHs, 16 carehomes, and 20,255 participantsCross-sectionalmulticentre studyTo investigate screening, treatment, andother quality indicators of nutritional carein Dutch healthcare organizations.Meijers, 2014 [36]The Netherlands74 Care homes (41 participatedfour times,33 five times); 26,046participants (2007–2011)Cross-sectional studyTo analyse the trend of malnutritionprevalence rates between 2007 and 2011in Dutch care homes and the effect ofprocess and structural indicators onmalnutrition prevalence rates.Moore, 2014 [31]AustraliaFour Residential Aged Care (RAC) Cross-sectional studyTo explore relationships among the VictorianPublic Sector RAC Services quality indicatorsand other demographic and health-relatedissues.Rantz, 2009 [29]USA492 NHsBefore-afterobservational studyTo present and discuss the evaluation ofthe Quality Improvement Program ofMissouri in 2006, using some outcomeindicators.Schönherr, 2012 [32]Austria18 NHs (1487 participants); 18hospitals (2326 participants)Multicentrecross-sectional studyTo describe and compare structural andprocess indicators of nutritional care inAustrian hospitals and NHs.Shin, 2015 [42]Korea150 NHsCross-sectional studyTo investigate the relationship betweennurse staffing and quality of care in NHsin Korea.Simmons, 2006 [28]USA1 NHs (48 beds)Before-afterobservational studyTo train long-term care staff in conductingcontinuous quality improvement (CQI)related to nutritional care.Simmons, 2007 [44]USA7 NHsCross-sectional studyTo assess the impact of Paid FeedingAssistant (PFA) programmes on feedingassistance care process quality.Van Nie, 2014 [37]The Netherlands,Germany andAustria214 NHs 19,876 residentsMulticentrecross-sectional studyTo identify structural quality indicators ofnutritional care that influence the outcomeof quality of care in terms of prevalence ofmalnutrition and effect of possible differencesbetween malnutrition prevalence in Dutch,German, and Austrian NHs.
Lorini et al. BMC Health Services Research (2018) 18:43Page 5 of 14Table 2 Main characteristics of selected studies (Continued)1st Author, Year ofpublicationCountrySetting/ n. participantsType of studyAim of the study151 NHs, 10,771 participantsMulticentre crosssectional studyTo investigate possible differences inmalnutrition prevalence rates in Dutch andGerman NHs, as well as in structural andprocess indicators for nutritional carevan Nie-Visser, 2014 [34] The Netherlands, 214 NHs; 19,876 residentsGermany andAustriaMulticentre crosssectional studyTo investigate possible differences inmalnutrition prevalence rates in Austrian,Dutch, and German NHs, as well as instructural and process indicators fornutritional care; to investigate whetherresident characteristics influence possibledifferences in malnutrition prevalencebetween countries.van Nie-Visser, 2015 [38] The Netherlands, 214 NH; 22,886 participants,Germany andAustriaMulticentre crosssectional studyTo explore whether structural qualityindicators for nutritional care influencemalnutrition prevalence in Dutch, German,and Austrian NHsWerner, 2013 [43]Cross- sectional studyusing 2 data setsTo test how changes in NH processes improveoutcomes of care.van Nie-Visser, 2011 [33] The Netherlandsand GermanyUSA16,623 NHsmore common in the American context—the formerpredicts unplanned weight loss while the latter includesfacility-reported data on residents’ characteristics. Insome other studies [28, 35, 42, 44], ad hoc instrumentswere used. In one of them, the ad hoc instrument wasimproved on the basis of a literature analysis [35]. Hurtado et al. [41] used both standardized instruments andad hoc questionnaire.The selected papers show heterogeneity in the considered quality indicators, particularly the structural andprocess indicators. As regards the outcome indicators,the authors considered the risk of malnutrition (according to Malnutrition Universal Screening Tool), weightloss (according either to MDS or VPSRAC - VictorianPublic Sector Residential Aged Care Services - definition), and malnutrition prevalence (according to LPZquestionnaire) (Table 3).Of the19 selected papers, nine studies [29, 35–40, 42,44] examined the influence of structural and process indicators on the outcome indicators (Table 4).In four of the studies [35, 39, 40, 43], an individual riskadjustment procedure was applied by using different variables and determining heterogeneity among the different studies. While five studies [29, 35–38] showed asignificant association between some structural orprocess indicators and the outcome indicators, said association was found for different structural and processindicators.DiscussionIn this review, we selected 19 papers in the aim of investigating the use of quality indicators of nutritional carein NHs. The selected papers assessed the quality of nutritional care in NHs in general by using several indicators, normally including a mixture of several structural,process, and outcome indicators. Most of the studiesused standardized questionnaires or instruments to collect data on quality indicators, either routinely applied ata state level for mandatory reasons (MDS, VictorianPublic Sector Residential Aged Care Services[VPSRACS]), or implemented as an annual measurement of malnutrition prevalence and structural qualityindicators of nutritional care in the NHs that voluntarilydecided to participate to the study (LPZ). As for the outcomes, different indicators were taken into account.However, weight loss was always included, although different combinations of time periods and cut-offs wereconsidered for each instrument. It was evident that noconsensus exists on the sets of indicators to be used, especially outcome indicators, even though only a few instruments were used to collect data. Nevertheless,according to our findings, the presence of nutritionalscreening and its inclusion in the care file, the availability and use of protocols on malnutrition prevention andtreatment, mealtime assistance, and the use of nutritional treatment/supplements, all appear to be relevantindicators for nutritional care quality assessment. In anycase, studies aimed at testing the reliability and validityof these indicators, as well as the outcome indicators,need to be developed in order to identify the best set ofindicators for describing the quality of nutritional carein NHs. This is also in agreement with statements ofother authors [45, 46].Most of the papers aimed to describe the quality ofnutritional care in NHs, at times also to compare thedata in different geographical areas, settings, or time periods. However, they do not discuss the collected data interms of good or poor quality with respect to a standard,with the exception of the paper by Hjaltadòttir et al.[27], in which the quality of care in Icelandic NHs was
Lorini et al. BMC Health Services Research (2018) 18:43Page 6 of 14Table 3 Quality indicators of nutritional care reported in the selected papers1st Author, Year ofpublicationInstruments forcollecting data onquality indicatorsStructural/process indicatorsOutcome indicatorsBonaccorsi, 2015 [35]Ad hoc ural indicatorsPrevalence of subjects withmedium to high risk ofmalnutrition, according toMUST.Type of scales used to weigh residentsEmployment of dietitians and type ofconsultationNumber of operators assigned to manage theadministration of meals in a specific dayProcess indicatorsUse of a nutrition screening toolPresence of protocols/guidelines for weightassessmentPresence of protocols or guidelines foradministration of foodAssessment of dysphagiaDyck, 2007 [39]MDS; OSCARStaffing hours:Weight lossa- RN hours per resident per day- LPN hours per resident per dayHalfens, 2013 [30]LPZNot describedMalnutrition prevalencebHjaltadottir, 2012 [27]MDS–Weight lossaHurtado, 2016 [40]Nursing Home Compare/MDS; ad hocquestionnaireSchedule control (from ad hoc questionnaire):Weight lossa- to choose when to take day off or vacation- to choose when to start/end each work day- to choose when to take a few hours of break- to decide how many hours to work each dayLee, 2014 [41]MDS; the Colorado stateinspectionsRN staffing hours (from the Colorado stateinspections data)Weight lossaMeijers, 2009 [59]LPZInstitutional levelMalnutrition prevalencebAvailability of an up-to-date protocol/guidelineon malnutrition prevention and treatmentAuditing of protocol/guideline for malnutritionprevention and treatmentAvailability of malnutrition advisory teamsMultiple dietitians available in the institutionMalnutrition education (prevention and treatment)given by malnutrition specialist within the lasttwo yearsWard levelTrained malnutrition specialist working on thewardControl of use of prevention and treatmentguidelinesPolicy to measure weight at admissionDocumentation of malnutrition interventionsCorrect mealtime ambienceMeijers, 2014 [36]LPZStructural indicatorsInstitutional levelMalnutrition prevalenceb
Lorini et al. BMC Health Services Research (2018) 18:43Page 7 of 14Table 3 Quality indicators of nutritional care reported in the selected papers (Continued)1st Author, Year ofpublicationInstruments forcollecting data onquality indicatorsStructural/process indicatorsOutcome indicatorsThere is an agreed protocol/guideline for theprevention and/or treatment of malnutritionwithin the institution.There is an advisory committee for malnutritionat the institution or department level.There is someone within the institutionwho is responsible for updating andensuring that the necessary attention isdevoted to the malnutrition protocol.Over the last two years, a refresher courseand/or a meeting was organized forcaregivers, which was/were specificallydevoted to the prevention and treatmentof malnutrition within the institution.Ward levelThere is at least one person/specialist in thedepartment/basic care unit/team who isspecialized in the area of malnutrition.Work in the department/basic care unit/teamis done in a controlled fashion or in accordancewith the malnutrition protocol/guideline.Upon admission, every resident is weighed asa part of standard procedure.The nutritional status is screened upon admission.The care file/care plan specifies the activitiesthat must be implemented for residents whoare at risk of malnutrition.The department has a policy on when andhow to measure weight.Process indicatorsAssessment of the nutritional status by avalidated screening instrumentWeight monitoring in a controlled fashionDietitian consultationUse of nutritional treatmentMoore, 2014 [31]VPSRACS; data routinelycollected in the facilitiesincluded in the study–Weight losscRantz, 2009 [29]MDSNot described (QIPMO—nurse site visits tosuggest how to improve quality of care)Weight lossaSchönherr, 2012 [32]LPZStructural indicators:Malnutrition prevalencebGuideline for prevention and treatmentAuditing of guidelineAdvisory committee for malnutritionUpdating of guidelineCriteria for determining malnutritionEmployment of dietitiansRefresher course for caregiversInformation brochureStandard policy for handoverProcess indicators
Lorini et al. BMC Health Services Research (2018) 18:43Page 8 of 14Table 3 Quality indicators of nutritional care reported in the selected papers (Continued)1st Author, Year ofpublicationInstruments forcollecting data onquality indicatorsStructural/process indicatorsOutcome indicatorsAssessment of weightUse of nutritional screening toolAssessment of weight over timeUse of clinical viewUse of biochemical parametersDietitian consultedEnergy- and protein-enriched dietEnergy-enriched snackOral nutritional supportEnteral nutritionParenteral nutritionTexture-modified dietFluid 1–1.5 L/dNo interventions owing to palliative policyShin, 2015 [42]Ad hoc instruments(questionnaire-interviews)Nurse staffing, by type (RN, CNA, qualified careworkers):Weight lossa- hours per resident per day- skill-mix hours per resident per day- staff turnoverSimmons, 2006 [28]Ah hoc instruments(direct observation)Feeding Assistance Care Process Measure:–-% of residents who eat less than 50% of mealand receive less than one min of assistance.-% of residents who eat less than 50% of mealand are not offered a substitute.-% of residents who receive less than five minof assistance and a supplement.-% of residents who are independent but receivephysical assistance.- % of residents who receive physical assistancewithout verbal cue.Simmons, 2007 [44]Ah hoc instruments(direct observation)Feeding Assistance Care Process Measure, bytype of staff (CNAs, PFAs, no assistance fromeither type of staff):–-% of residents who eat less than 50% of mealand receive less than one min of assistance.-% of residents who eat less than 50% of mealand are not offered a substitute.-% of residents who receive less than five minof assistance and a supplement.-% of residents who are independent butreceive physical assistance.- % of residents who receive physical assistancewithout verbal cue.Van Nie, 2014 [37]LPZStructural indicatorsInstitutional levelThere is an agreed protocol/guideline for theprevention and/or treatment of malnutritionwithin the institution.Malnutrition prevalenceb
Lorini et al. BMC Health Services Research (2018) 18:43Page 9 of 14Table 3 Quality indicators of nutritional care reported in the selected papers (Continued)1st Author, Year ofpublicationInstruments forcollecting data onquality indicatorsStructural/process indicatorsOutcome indicatorsMalnutrition-related work within the institutionis carried out in a controlled fashion or inaccordance with a malnutritionprotocol/guideline.There is a multidisciplinary advisory committeefor malnutrition at the institutional or ward level.There is someone within the institution who isresponsible for updating and ensuring that thenecessary attention is devoted to themalnutrition protocol.Within the institution, criteria have been definedfor determining malnutrition.There are dietitians employed at the institution.Over the past two years, a refresher courseand/or a meeting has been organized forcaregivers, which was specifically devoted tothe prevention and treatment of malnutritionwithin the institution.An information brochure about malnutrition isavailable at the institution for clients and/orfamily members.Ward levelThere is at least one nurse in the ward who isspecialized in the area of malnutritionClients who are at risk of malnourishment orwho are malnourished are discussed on theward during multidisciplinary work consultations.Work in the ward is conducted in a controlledfashion or in accordance with a malnutritionprotocol/guideline.At admission, every client is weighed as a partof standard procedure.At admission, the height of each client isdetermined as a part of standard procedure.The nutritional status is assessed at admission.The care file includes an assessment as to eachpatient’s risk of malnutrition.The care file/care plan specifies the activities thatmust be implemented for clients who are at riskof malnutrition.In case of (expected) malnutrition, a protein- andenergy-enriched diet is provided in the ward as apart of standard procedure.Every client who is malnourished (or is at riskfor becoming so) and his or her family receivean informational brochure about malnutrition.The ambience at mealtimes is taken into accountwithin the ward.The care file includes the intake for each client.The ward has a weight policy.van Nie-Visser, 2011 [33]LPZStructural indicatorsInstitution levelPrevention and treatment protocol/guidelineMalnutrition prevalenceband prevalence of subjectswith risk of malnutrition.
Lorini et al. BMC Health Services Research (2018) 18:43Page 10 of 14Table 3 Quality indicators of nutritional care reported in the selected papers (Continued)1st Author, Year ofpublicationInstruments forcollecting data onquality indicatorsStructural/process indicatorsOutcome indicatorsMalnutrition advisory team‘At risk of malnutrition isdefined as meeting one ormore of the following criteria:(1) BMI 21–23.9 kg/m2, (2) noteaten or hardly eaten anythingfor three days or not eatennormally for more than a week.Auditing of protocol/guidelineDietitians employed in institutionEducation on malnutrition prevention andtreatment in last 2 yearsInformation brochure available for client or familyWard levelPerson specialized in malnutrition on unitControl of use of prevention/treatment guidelineMeasurement of
care quality and nutritional care in the specific setting of NHs; moreover, they had to respond to the aims of this study, namely to describe the use of quality indicators of nutritional care in NHs and/or to assess the relationship between structural, process, and outcome indicators of nutritional care in NHs. All types of studies were
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2.1 Structural Health Monitoring Structural health monitoring is at the forefront of structural and materials research. Structural health monitoring systems enable inspectors and engineers to gather material data of structures and structural elements used for analysis. Ultrasonics can be applied to structural monitoring programs to obtain such .
graphical comparison of an agency's actual outcome (1) with its expected outcome (using a "national" comparison group) and (2) with its risk-adjusted outcome for the prior year. An enumeration of the outcome measures with a brief rationale for why the current group of 41 outcomes was selected is provided in Section 5 of this document.
management (Cavus & Sharif, 2014; Degeng, 1989). Meanwhile, learning outcome is explained by two dimensions, precisely, actual outcome and desired outcome. Talking about actual outcome, it is defined as outcome that has been achieved through the use of certain strategy on certain condition (Hartini et al., 2017).
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Functional outcome assessment documented, care plan not documented, documentation the patient is not eligible for a care plan at the time of the encounter . OR . Functional Outcome Assessment not Documented, Reason Not Given . Performance Not Met: G8541: Functional outcome assessment using a standardized tool not documented, reason not given . OR
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Agile methods in SWEP Scrum (mainly) XP Head First Software Development Process The Scrum process follows the agile manifesto is intended for groups of 7 consists of simple rules and is thus easy to learn 15.04.2012 Andreas Schroeder 9
