Resource allocation manual

Transcription

1 Resource allocation manual 1st edition (April 2011) Composed for the Dietitians Association of Australia by Marjo Roshier-Taks, APD, AN Dietitians Association of Australia ABN

2 Acknowledgements The DAA Resource Allocation Manual 1st Edition has been compiled for the Dietitians Association of Australia (DAA) by Marjo Roshier-Taks, Accredited Practising Dietitian, in consultation with a reference group. Many thanks are extended to the DAA National Office staff, members of the reference group, and to those members of the DAA Dietetic Managers Discussion Group who have provided examples of business cases. Contributions have been received from Jean Symes (main work by Linda Giumelli), Helen Jackson, Cesarita Marzo, and Lee Cahill. Copyright 2011 Dietitians Association of Australia The DAA Resource Allocation Manual 2011 All rights reserved. No part of this manual may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording or by any information storage and retrieval system without prior permission in writing from DAA.

3 Contents Introduction 1 Section 1 Business planning What is business planning? Components of a business plan Advocacy 4 Section 2 Business case development What is a business case? Steps to develop a business case Risk management Where to go for support? 7 Section 3 Description of key components of nutrition and dietetic services Acute care services Community setting Food service setting Aged care setting 11 Section 4 Workforce planning 12 Section 5 Examples of business cases Proforma example of a business case Increasing nutrition services for adults with complex diabetes in the Regional Area Health Service (RAHS) Global Health Service business case for renal dietitians Additional casemix funding options for malnutrition DRG Clinical Service Unit: Radiation Oncology and Nutrition and Diet Therapy Departments Dietetics in Mental Health Metropolitan Health Service Food Service Foodservice Solutions Software Proposal Key features of proposed Home Enteral Nutrition model Brief regarding proposed purchase of feeding aide equipment Allied Health Services to Neurology 54 Section 6 References used for the preparation of the manual 61 Appendix 1 Business plan for Nutrition and Dietetic Department of Rural AHS Appendix 2 EQUiP 5 nutrition standard and background paper 66 Appendix 3 Estimate of percentage of staff time spent on clinical activities per grading 73 Appendix 4 Evaluation form for feedback to DAA 78

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5 Dietitians Association of Australia Resource allocation manual Introduction The Dietitians Association of Australia (DAA) has facilitated a project to develop a resource allocation manual to assist dietitians, particularly those working as managers, to complete business planning and plan resource allocation for dietetic services. The manual is a resource to assist with business and workforce planning in various settings, and provide advice for dietitians on the successful approaches and strategies for increasing dietetic resources and services. However, it is not a benchmarking tool for staff requirements. From time to time DAA is asked to provide recommended numbers of staff in a particular clinical setting. However, it is not appropriate to generalise numbers of staff across all settings or services due to the variability between sites, services and populations. Nor does a recommended staffing level guarantee an excellent service. The level of staffing required by one service can fall above or below that required by another even within the same clinical area. For example, client complexity, casemix, models of care, skills and expertise of staff, local level infrastructure and processes, local demographics impacting on the health needs of a community, and financial resources, all impact on staffing requirements. 1 health, including existing DAA resources. The manual has been developed by a consultant to DAA, in consultation with members of a reference group, consisting of dietitians with experience and/or expertise in workforce planning. The examples of business cases have been made available by members of the DAA Dietetic Managers Discussion Group, and have been de-identified for confidentiality. A business manual for dietitians working in private practice already exists, the edition, May The separate descriptions of the different dietetic settings will require the reader to look at various sections depending on their own work environment. For example, some community health positions have a clinical outpatient role as well as specific community/health promotion roles; hospital work/positions can include foodservice role, depending on size of facility, organisational structure and location. Introduction 1

6 Resource allocation manual Dietitians Association of Australia Section 1 Business planning 1.1 What is business planning? Business planning is a systematic process for examining an organisation and its environment in order to allocate resources to meet service demands. The plan articulates the objectives for achieving the goals of the service, which should be developed in line with the strategic directions for the larger organisation. A business plan gives direction to tasks and priorities, assists with identifying resources required to deliver the service and provides guidance for evaluation of service performance. 3 Whether a business is an engineering company or a health service, common principles apply to business planning. In the case of a business plan for a Nutrition and Dietetic (ND) service within a health service organisation, the planning process will be linked to the broader organisational vision and strategic direction. The business plan will describe which ND services will be provided, how they will be provided and by whom, and performance measures to evaluate the outcomes of the service. As part of the business planning process, consultation with key stakeholders is important to ensure appropriate direction for the service and appropriate implementation activities have been identified to meet the objectives and performance indicators of the plan. The stakeholders can be internal and external to the organisation. For example, for continuity of care following discharge from hospital, local primary health care services should be consulted; for health promotion activities local council, and non-government organisations (eg Cancer Council) should be involved. Engaging staff and stakeholders in the planning process results in commitment to the implementation Components of a business plan Components of a business plan include a mission statement of the organisation, strategic directions, key objectives, priorities, and performance indicators to evaluate the outcome of the implementation of the plan. 3 A Nutrition and Dietetic Department/Service plan should start with the health service or hospital mission, objectives and strategic direction and priorities: 1. Mission statement examples 1.1. The community of ABC Area Health Service will have optimum health and well being through access to quality health services and active involvement and empowerment in their own health, or 1.2. ABC area health service will be a leading regional health care provider delivering timely, accessible, integrated and appropriate services to our community and region. 2. Strategic Direction for Delivery of quality, accessible, coordinated health care 2.2. Enhancement of services available to the community 2.3. Improvement of financial viability and infrastructure 2.4. Attraction, retaining and development of quality staff 2.5. Engagement of the community in the work of the area health service. 3. ND service plan 3.1. Introduction: brief history of the service, and how placed in the organisation This would include the organisational structure of the department/service in the overall organisation and for a large department indicate department organizational structure, number of staff in full time equivalents (FTE) and total number, budget size, and key achievements 3.2. Key priority areas for the ND service (and how they are in line with the organisational strategies and directions) and actions on how to achieve these areas, indicating specific targets eg percentage reduction of people with malnutrition during admission 3.3. Performance indicators to evaluate the effectiveness and efficiency of the service, and which set of data will be used to measure this. For example, if the target is to improve the prevention, early detection and management of people with diet related disease, the implementation of evidence based practice guidelines would be an action. This could be evaluated by measurement of a reduction in HbA1C levels for those with existing diabetes. 2 Section 1 Business planning

7 Dietitians Association of Australia Resource allocation manual 3.4. The financial resources required with a detailed budget 3.5. Risk management strategies For example, a ND business plan could have the following priority areas, objectives and strategies for implementation: Priority Area 1 Objective 1.1 Monitor the nutritional quality of the AHS menu 1.2 Improve communication between Hotel Services Business Unit and Dietitians in the AHS 1.3 Improve the nutrition knowledge of staff working in Food Services Priority Area Improve the nutritional status of inpatients and outpatients in the AHS 2.2 Improve the prevention, early detection and management of people with diet related disease in the AHS 2.3 Improve the nutritional knowledge of staff in the AHS Target Area 3 Objective 3.1 Address nutrition needs for Aboriginal and Torres Strait Islander people in the AHS 3.2 Improve access to nutrition and dietetic services for Aboriginal and Torres Strait Islander people in the AHS 3.3 Improve nutritional knowledge of Aboriginal Health Workers Ensure ABC AHS provides a nutritionally adequate food service to meet the needs of clients. Strategies Advocate for a Dietitian (1 FTE) to be responsible for the coordination of the nutrition activities in the Hotel Services Business Unit Apply the Hospital Menu Assessment Tool to assess the nutritional quality of the AHS menu in Base Hospitals and smaller sites Implement changes to menu if not meeting guidelines outlined by DOH Dietitian(s) to attend AHS Menu Review Committee Documentation of meetings to occur with solutions to identified issues Provide training opportunities for staff on locally identified topics/issues. Improve the clinical management of diet related disease in the AHS Pilot the implementation of the Malnutrition at risk (MRC) screening tool Develop implementation plan for screening the tool in all hospitals in the AHS Provide accessible and adequately resourced inpatient and outpatient services to clients in the AHS Implement nutrition strategies according to Area Strategic Plan for NIDDM and Diabetes Expert Working Group Implement nutrition strategies for reducing diet related disease as identified at a local level Implement nutrition session of Wise Moves program across AHS Provide training opportunities for staff on locally identified topics/issues. Improve the nutritional status of Aboriginal and Torres Strait Islander people in the AHS Strategies Develop and implement nutrition activities in partnership with local Aboriginal and Torres Strait Islander communities Support the implementation of outcomes from the Aboriginal Heart Disease Prevention Project in Princes Town across the AHS flexible service delivery Conduct nutrition training with Aboriginal Health Workers in AHS and local Aboriginal Medical Services The example in Appendix 1 describes a business plan for ND services in a rural area health service with specific objectives to manage chronic disease through accessible, timely services in partnership with primary health care providers. A budget is not included information on costs can be found in the business case examples and reference 3 of the manual (see section 6). Section 1 Business planning 3

8 Resource allocation manual Dietitians Association of Australia 1.3 Advocacy A key competency for dietitians is the ability to advocate on behalf of individuals, groups and the profession to positively influence the wider political, social and commercial environment, about factors which affect eating behaviours and nutritional standards (DAA competency standard 9.5). 4 This includes the development of relationships with other stakeholders whether within the government, non-government or commercial sector, working in multidisciplinary teams, and providing culturally appropriate services for Aboriginal and Torres Strait Islander and culturally and linguistically diverse (CALD) communities. 4 At times, advocacy and business planning go hand in hand. For example, in daily practice, dietitians advocate for individual patients eg for access to home enteral feeding services (anecdotal), for groups of patients eg screening for malnutrition in the elderly, 5 for service development or change, for the wider community for improved food supply and the introduction of health promotion/prevention strategies. If these are major departmental objectives, they will need to be agreed to and included in the business plan. Recently strong opportunities for advocacy for food service improvement and improved patient care have arisen with the introduction of nutritional requirements in accreditation processes of the Australian Council of Healthcare Standards (ACHS). Even dietitians in organisations that do not have or seek accreditation may find this information useful. From 2011, ACHS EQuIP5 accreditation guidelines include a criterion on nutrition in the clinical standards area. Criterion states: the organisation ensures that the nutritional needs of consumers/patients are met. The prevention of malnutrition while in hospital is a key focus of this criterion. This criterion is not mandatory, but can be strongly linked to the mandatory criterion 2.1.2, which relates to both corporate and clinical risk management. * And as nutrition also plays a role in the management of the e plans and discharge-planning processes should consider nutritional needs where appropriate. The appropriate assessment and management criteria are mandatory, implying they should be met for accreditation. Another example for inclusion of nutritional management is criterion 1.5.3, which relates to the minimisation of breaks in skin integrity and pressure ulcers should be minimised through prevention and management plans. 6, With regard to business planning, there is a need for dietitians to actively advocate for the consideration of ND services when models of care are being developed or new services planned. A recent study to explore barriers to the introduction of a best practice nutrition and dietetics service model in rural areas, in NSW showed that dietetics and other allied health services are often not funded in increased service delivery funds at a state and areas health service level. 7 Current models of care involve early discharge of patients with complex needs from acute care hospitals to primary and community-based services in regional and rural areas. This leads to a shift in the caseload of rural dietitians towards an increasing specialist workload. The management of complex patients changes the skill mix required of allied health services. In some rural areas this has led to the development of specialist positions such as renal and oncology, in line with service plans for the area health service. 7 Anecdotal information from various dietitians indicates that in the planning process for new health services, the potential impact on the demand for dietetic services is often overlooked. The contribution that dietitians can make whether in the acute, community health, food service or aged care setting needs to be widely communicated. DAA plays a role in this through the development of evidence based practice guidelines and developing submissions to support ND, for example the recent aged care services submission highlights the role of the dietitians in residential aged care facilities. 8 In Queensland a implement this strategy, and a large number of community nutritionist and public health nutritionist, and indigenous nutrition worker positions have been established since. A key factor for this success was a combination of advocacy strategies, champions in the health department, supportive policies and the work of dietitians/nutritionists, 9 as well as perseverance as changes at state wide level often require 5 10 year planning, in some area health services it may take a long time before a major change will be considered. DAA advocates on behalf of the community and dietitians through submissions on nutrition related issues. For example, to the Department of Health and Ageing for improvement of nutrition in aged care facilities 8 and to Mental Health Workforce Advisory Committee to lobby for dietitian services in mental health as part of * Section 2.3 provides more information on risk management; examples of risk analysis can be found in the business cases in Section 5. If your AHS is undergoing accreditation with ACHS, full access to the documentation will be available through your local contacts. Appendix 2 provides detail on the standard and a background paper. For those not accredited or undergoing accreditation limited information is available on the ACHS website: 4 Section 1 Business planning

9 Dietitians Association of Australia Resource allocation manual the 2010 National Mental Health Workforce Strategy and Plan (see ). 10 An anecdotal example of the need for advocacy is the introduction of a private radiotherapy service in a regional town. This new service improved access for oncology patients to services closer to home, which reduced the need to travel to metropolitan areas, and reduced related costs. However, as the planning and consultation had occurred at senior levels in the private and public health service, there was no consideration of the impact of the new service to local public dietetic services, despite the support for referral of all patients requiring radiotherapy for head/neck or gastrointestinal cancers to see a dietitian before the start of treatment. 7,11 As soon as the service commenced, referrals to the local community dietitians started, which were unable to be met. Had the dietitians known this service was being planned there could have been proactive discussions with management to consider the implications and the need for additional dietetic services before commencement. At this stage there were no private dietitians in the area. Section 1 Business planning 5

10 Resource allocation manual Dietitians Association of Australia Section 2 Business case development 2.1 What is a business case? A business case can be developed for various purposes, for example, for the purchase of new equipment, the development of a new service (or component of a service), enhancement or maintenance of staff establishments or the computerisation of a department. The business case is a structured proposal that provides justification to decision makers for the identified purpose, in terms of evaluating the benefit, the cost and risk of chosen and alternative options and rationale for the preferred solution. Its purpose is to obtain management commitment and approval for investment in the project. 12 The difference between a business plan and a business case is that a business plan is an overall direction for a service or service component; a business case is the justification for a specific new development or maintenance of service. 12 The need for the new development can be identified through new demands on service, the introduction of new models of care, inefficiencies in current service delivery, risk to patient safety, and accreditation requirements. Many organisations have a standard form and process to identify the requirements of the organisation with regard to the type and level of information that is needed to support your case and to guide the presentation of the case. In the absence of an existing proforma a number of business case proformas are included in Section 5. The detail required in a business case depends on the intent. For a service request without a possible funding source, more detail is often required, in contrast with an opportunity to apply for already available funding in the area for a particular service (anecdotal). Some organisations even require a business case for the purchase of a new set of office weighing scales (anecdotal). In some instances a short briefing note may be sufficient (see example in business case 5.3.3). Regardless of the required proforma or detail of information required, a well structured case, with relevant references Steps to develop a business case The development of a business case is a step-by-step process, and in general the following key components are included: A description of the proposed new development, service or equipment purchase proposal. For example, 2. This is followed by a description of the current situation: for example, the staffing numbers in full time equivalents (FTE), vacancies, waiting times for appointments, rurality, the cost of chronic health care, work environment/community factors, impact on service needs due to high CALD/Indigenous population, lack of equipment, cost of preparation of textured modified foods and thickened fluids. 3. The description of the new development and current situation provide the basis for the rationale for the need for change. For example, an increase in referrals for in- or outpatient services for people with diabetes, link to strategic directions organisation (improved service delivery for people with chronic illness), inability to cope with demand for service, inefficiency of the food service ordering system. 4. The next step is the discussion of potential solutions to the proposed change with an analysis of the impact of the provided options. The options can include: Maintenance of the current status quo and the consequences of this option. For example, with the current staffing arrangement the department is not able to meet the demand for diabetes services according to evidence based management guidelines, which will have implications for hospital admission or re-admission, which needs to be substantiated*. Aim to meet demand for diabetes services at cost of other service components and consequences. An example is withdrawal from contribution to the pulmonary rehabilitation program with consequences for possible re-admission to hospital, again this needs to be substantiated*. Employment of eg an additional 0.5 FTE dietitian, which provides the ability to meet demand, without compromising other essential services. Employment of additional allied health assistant/administration staff for ND services. This enables the performance of relevant duties, relieving the current 0.3 FTE dietitian, who will then be able to meet some of the additional demand. 6 Section 2 Business case development

11 Dietitians Association of Australia Resource allocation manual * as part of solutions 1 and 2 it is recommended to reassess current practice, particularly if it is unlikely that an increase in funding is possible. Managers should look at how the department currently works and look for ways to streamline the work and save time on inefficiencies if they exist. Maybe clinical services do not have to suffer/be cut, if time can be saved elsewhere (personal correspondence). It is also recommended to match work with the necessary skills. If possible, skilled clinical time should be used for the provision of clinical services and not for administrative tasks that could be done with clerical assistance The next component is a discussion of the preferred option and why this option is selected. This should include risk management information: what will be the impact on service delivery if the proposal is not supported? See below. 6. Additional information that could be included is for example, a description of additional position duties/responsibilities, how the new position fits in the organisational structure and the expected outcomes. An example is: reduced re-admission for people with diabetes complications and how this will be evaluated. It is also important to include a financial analysis and cost benefit analysis. Examples can be found in the business cases in section The last component is a conclusion and a list of references 2.3 Risk management Risk is the possibility of incurring loss, damage or misfortune. Risk management involves developing systems to identify and analysing risks, with the aim of preventing an incident and/or reducing any harmful consequences from a potential incident. Risk is measured in terms of consequence or impact (How bad will an event be if it happens?) and likelihood (How likely is it that the event will happen?). This can relate to occupational health and safety, medication management, clinical procedures etc. To be effective, the approach to risk management needs to be consistent, standardised and integrated with activities in all areas that are relevant to risk; for example, strategic and operational, planning, performance, and clinical and general management. 14 With regard to ND services risk management can be applied to corporate areas eg the development of a home visiting policy for OH&S and to food safety practices. Examples in the clinical risk management are procedures to avoid side affects for naso-gastric feeding, the use of evidence based practice guidelines for the screening for and prevention of malnutrition during hospital admission, the management of people with diabetes etc. These clinical examples relate to corporate risks as well; if, for example, a patient during admission gets malnourished it is likely that the length of stay is longer than expected resulting in increased costs of the admission. In terms of describing risk management for a business case for a new service area or increased staffing, it is useful to refer to evidence based guidelines for the particular area, and seek support from specialists for the case. 14 For example, in the area of diabetes management, management of renal disease and in cancer treatment, an indication can be made that access to appropriate nutritional support can lead to improved patient outcomes with reduced risk of re-admission to hospital or adverse outcomes if eg radiotherapy treatment has to be ceased because of significant weight loss. 11 A letter from a specialist in the particular area can also assist to highlight the risk (anecdotal). 2.4 Where to go for support? The development of a business case can be a challenging process and successful outcome depends on the quality of information and discussion of benefits to an organisation. Some of the proformas required by your organisation could be difficult to complete and can be quite lengthy. It can be useful to seek assistance from colleagues, a mentor or a key person in the department, or other sections in your organisation. If the proposal involves changes in other departments or has impact on other service providers their support for the proposal as well as input in the case development can strengthen your arguments and having access to examples of previously submitted business cases in your organisation, even those non related to your department, can provide guidance for the level of detail required, how to structure the options for solutions to your argument. It is also useful to contact other hospitals or services similar in size or service focus, which can assist with benchmarking your service. Using professional networks, such as requesting information via the existing DAA discussion or interest groups can provide access to examples developed or used by colleagues in similar situations. This can guide the development of your case using information that is up to date and/or already researched.. Section 2 National Competency Standards for Entry-Level Dietitians in Australia 7

12 Resource allocation manual Dietitians Association of Australia Section 3 Description of key components of nutrition and dietetic services For the purpose of this manual the key components of nutrition and dietetic practice are categorised in acute, community, food service and aged care settings. It is recognised that dietitian positions can incorporate all categories and that others are very specialised. In addition, dietitians work in public health, academic and food industry environments; these are beyond the purpose of the manual. 3.1 Acute care services According to the Allied Health Activity Hierarchy, 15 the activities of a health professional working in a health service environment can be categorised in four key areas. These categories can be adapted to describe activities in community settings. Mapping the time spent on these activities can provide the necessary data for service management; skill mix and staff experience influence the data that are collected. The categories are summarised in Table 4. Table 4: Allied health activities in a hospital environment 15 Clinical care Clinical service management (CSM) Teaching and training (TT) Research Activities, which provide a dietetic service to an individual or group to influence health status. - example, taking a dietary history, diet advice to patients/clients and their families, and group education services are considered IPA, as is the travel to the ward to provide the service. Attending ward rounds is classified as NIPA Professional and management activities that support clinical care. For example, administration, staff management, financial management, meetings, travel related to management, meetings (non-patient related), quality improvement projects, resource development, professional development Activities related to imparting of knowledge, skills and clinical competency For example, delivery of inservices to the ND department staff, inservices to nursing staff, lectures at universities, and dietetic student supervision. Travel related to TT is also included in this category. Clinical supervision, if related to direct patient care is considered IPA, if staff supervision is not direct patient related it is considered a component of CSM Designated research activities An Allied Health staffing matrix has been developed as a guide to define staffing requirements in clinical areas in metropolitan hospitals in NSW. 1 This tool does not address competency levels of staff, but it assists to identify key activities for allied health in the acute care setting and as such is not a benchmarking tool. 1 Examples are provided to map nutrition and dietetic related activities and time spent on these for a general medicine ward, aged care and orthopaedics, intensive care, as well as outpatient clinic activities. The matrix allows for calculation of total intervention time, based on activities, number of cases per year, and average length of stay. The activities described for most patients are in Table 5. 8 Section 3 Description of key components of nutrition and dietetic services

13 Dietitians Association of Australia Resource allocation manual Table 5: Allied health activities according to the Allied Health Staffing matrix 1 Clinical patient related Non-clinical related Review of medical file, review of pathology Initial assessment: history of dietary intake, weight and medical, factors affecting intake etc Case planning/management, including discussion with other health professionals Liaison with food service department Documentation Monitoring and review Education for discharge: may include patient/carer/nursing home Handover/referral out Administration Department inservices Travel (not patient related) Clinical team meetings Occupational Health &Safety audits Quality improvement projects Another method to describe dietetic workload is provided by the British Dietetic Association (BDA). 13 This tool was developed to assist with workload assessment and planning for services, without providing staffing norms or ideal staffing levels, recognising that this varies with each setting. Workload elements are divided in patient related work with direct and indirect tasks*, and practice related work. Table 6 provides detail of the categories. The document indicates workload elements for managers, experienced and entry-level practitioners. For example, in the clinical management element an entry- level practitioner manages a designated caseload, the experienced practitioner acts as a professional lead and the manager has more responsibility to provide professional leadership and advice, and have a consultancy role at a regional or national level. 13 * Comment: the National Allied Health Casemix Committee recommends against using the terminology indirect tasks, as it is sometimes used by administrative staff to fund only staff time spent with a patient and not other relevant tasks related to patient care e.g. reading on unusual cases, liaising with hospital staff, obtaining history from family members etc. 16 Also described by BDA are the variable factors that affect workload and include population served, work setting, critical mass of staff, patient length of stay, complexity of caseload, skill mix. Calculation of actual available staff time for a department is recommended as this will impact on the ability to provide a service. If there is an expectation that a service will be available for 52 weeks of the year, 1 FTE position needs to be funded for 1.25 FTE. For example, a workweek of 37.5 hours per week equates to 1950 hours per year. Once annual leave, public holiday and sick leave is deducted this leaves about 80% of hours in this example 1533 hours per year per 1 FTE or effectively 29 hours per week. 13 Table 6: workload elements according to BDA 13 Patient related Direct Face to face contact with patients and/or carer/family, whether on individual level or in groups. Indirect Administration related to patient care including letters, phone calls, preparing patient information Catering service related work Ward rounds, case conferences etc Section 3 Description of key components of nutrition and dietetic services 9

14 Resource allocation manual Dietitians Association of Australia Practice related Teaching and education others Other health care professionals Outside agencies Support groups eg cardiac rehabilitation talks Student training Health promotion activities Health promotion/community development Professional/personal development Education activities Performance appraisal Clinical supervision Dietetic management Clinical management: requiring professional knowledge and experience eg clinical service planning Service management: administrative and management tasks eg recruitment and retention Work on behalf of the profession Clinical governance related work Membership of working groups of BDA Representation of the profession on committees Clinical audit Developing risk assessment Responsibilities of a dietitian relevant to patient care in an acute care setting can be the following: 13 Medical nutrition care of patients and patient groups requiring therapeutic diets or nutritional support, including general and specialist areas of dietetic practice Participation in the teaching program of the department including supervision of dietetic students from accredited university courses Provision of information and resources in the area of nutrition and dietetics Participate in research when appropriate. Contribute to the development of the department by participation in department portfolios and team projects. Whichever method of workload mapping is used depends on the type of ND service, requirements of your organisation and whether computerised databases are used to capture allied health activity. Recent activity in DAA foodservice discussion group indicates there are allied health data collection systems being used across Australia (anecdotal). An example of clinical activity mapping can be found in reference; 1 an example of an estimate of the percentage time is spent on clinical activities for various team members based on grading and role, can be found in Appendix Community setting Positions in the community health setting can be specifically focused on community and public health work, or comprise of a combination of responsibilities. This varies between and within States. For example, some positions provide an outpatient clinical service to the local communities, as well as health promotion and community development activities, including the development, implementation and evaluation of nutrition programs and interventions. In other situations, the position is specifically designed to provide community nutrition services in line with relevant national, state and department policy directions and needs of the local community. This can include working with school canteens to implement healthy eating policies, implement healthy eating programs for specific community groups, or education for It is possible a position works on a specific project or with a designated target group; this is usually the case if there is specific funding for a project or service. Where a position has clinical outpatient responsibilities, the same activities apply as for acute care services, though referral processes and communication chains will be more community focussed. In addition responsibilities can also include the development, implementation and evaluation of group education programs on eg diabetes. As mentioned on page 5, dietitians in the community may be referred clients with more complex needs, due to early discharge from the acute care setting and new models of care that aim to manage people at home. Responsibilities of a dietitian in a health promotion position could include: Implement chronic disease prevention programs through routine nutrition interventions which eating behaviour Implement community development strategies that influence the environment affecting food supply 10 Section 3 Description of key components of nutrition and dietetic services

15 Dietitians Association of Australia Resource allocation manual Provide public health nutrition advice to, and communicate and collaborate with a range of stakeholders within and outside the health sector Collaborate with partners in addressing nutrition issues for priority population groups, particularly those which are specific to the Aboriginal and Torres Strait Islander population, and culturally and linguistically diverse groups, to enhance population health outcomes 3.3 Food service setting Dietitian positions can include responsibilities in foodservices in hospitals, nursing homes, meals on wheels, hospitality and catering services. These can be in an advisory and/or management capacity depending on the purpose of the position. For example, in a large hospital there may be designated food service dietitians who have a management role, in a small rural hospital the dietitian can have an advisory role. Education on nutrition for food service personnel is usually included in the role (anecdotal). Responsibilities of a dietitian working in a food service setting could include: Provide an area wide dietetic consultancy service for both clinical and food service staff, to ensure the food service to patients / residents / clients within facilities is appropriate to their clinical / cultural and aesthetic needs. Identify opportunities to improve food service delivery and/or practice and develop and implement ongoing Quality Improvement activities in conjunction with other staff to support improved food service delivery and patient related outcomes. Advocate for efficient and effective Patient Food Service, which meets patient needs, supports improved patient outcomes and is cost effective, using expert knowledge of nutrition and dietetic practice and food service systems together with high level communication skills to. Ensure that patient menu planning is completed in accordance with appropriate stakeholders and incorporates Nutrition and Therapeutic Diet Specifications. Develop and maintain an effective communication system with site and/or region clinical and food service staff to ensure any changes to the food products are appropriate and communicated in a timely manner. Provide advice for other issues relating to provision of food in both healthcare facilities and in community settings. 3.4 Aged care setting The responsibilities for a dietitian working in the aged care environment can focus on the organisational level, as well as on an individual client level. The aged care environment is ideal for advocacy for the implementation of nutritional risk screening programs and falls prevention strategies. Residential aged care facilities need to meet accreditation standards in relation to nutrition and food services; dietitians can act as a consultant to assist to meet these standards, while also aiming to improve the nutritional value of the food provided. 8 Responsibilities can include: 8 At organisational level: Develop a food and nutrition policy for the organisation Develop a systems/models of care e.g. weight monitoring, nutrition Advocate for and implement risk screening processes, nutrition and dietetic referral pathways, and dietary intake reporting Educate nursing and food service staff, volunteers and carers on nutrition issues Work with residential aged care facilities to meet Commonwealth accreditation requirements related to nutrition and food service Asses menus and advice to ensure menu meets appropriate nutritional recommendations Implementation of quality improvement projects Implement health promotion programs Assist residential aged care facilities to order appropriate nutritional supplements At an individual client level Provide individualised dietetic interventions, Participate in multidisciplinary team care meetings Review of individuals with naso-gastric or gastrostomy feeding regimens regularly Assist individuals in the community Section 3 Description of key components of nutrition and dietetic services 11

16 Resource allocation manual Dietitians Association of Australia Section 4 Workforce planning How can you use this information for workforce planning? The challenges of providing best practice, meaning equitable, accessible, sustainable, timely and safe health care have become more apparent given existing and pending workforce shortages, a misdistribution of the workforce and resources in metropolitan and rural areas, higher complexity of clinical cases and higher expectations of service delivery. Workforce shortages across health care professions have been widely acknowledged and have become a high priority for State and Federal Health Ministers. 1,15 Workforce solutions are multi faceted. Recruitment and retention, education and training and maintenance of acquired skills all play an important role in addressing workforce shortages. Recruitment and retention of allied health professionals in rural areas is more likely to improve the needs of the younger workers, if they have access to continuing professional development and work exchange opportunities, a supportive and creative work environment and enhanced student placements. 17 In the literature various methods are identified for allied health workload assessment requirements and calculating workload capacity, ranging in complexity and data demands. 1,18 Benchmarking can be used for different purposes and the approach applied depends on the purpose. For example if the focus is on clinical improvement the outcome measures (eg return to mobility after a stroke) are relevant; for a focus on achieving excellence in management of a service, input measurements (staff numbers, patient attributable time) are relevant. One of the key issues for establishing benchmarks suitable for allied health services is the inconsistency in terminology used and the type of data collected. 15,16,18 as a measure of activity, unless used in the context of other performance measures. This is due to the variability in the definition of occasions of service and in the interpretation of the definition, even within a single jurisdiction. Another recommendation is that measures of outcomes should be used, rather than measures of output. 16 Issues that impact on staffing levels include casemix, client complexity, bed occupancy, models of care, seasonal fluctuations in incident rates, local service infrastructure, local demographics impacting on the health needs of the population, access to resources, evidence based practice guidelines, recruitment issues, service hours of operation (on-call, after hours, service 52 weeks of the year), financial resources. 1,14,15,16,18 For ND services there are few specific benchmarks for workforce requirements despite attempts made in the past, at national and international level. The many different work environments, different roles of dietitians, varying models of care and other factors limit the establishment of numbers of dietitians for eg number of hospital beds or population numbers. 3,8 An exception is the staffing guideline that has been developed for acute stroke services in a specialised unit and recommends FTE dietitians per 10 beds. 19 More recently the DAA Management Discussion group has attempted to develop a benchmark for acute medical assessment units (anecdotal). Section 4 describes the key elements for ND Services that should be considered as part of workload management. In addition, there are evidence based practice guidelines for dietitians for a range of diseases that can be used to plan, in a specific department or service, the level of dietetic service required and calculate the necessary FTE. For example, guidelines for the management of diabetes from the DAA 20 and the American Dietitians Association (ADA) indicate a minimum number of visits to a dietitian, and suggest length of appointments for people with Type 1, Type 2, and GDM. Depending on the prevalence of diabetes in a particular area this information can be used to estimate staffing requirements for optimum service delivery. Business case 1 describes the requirements for an appropriate and adequate diabetes service, based on these guidelines. Other relevant clinical practice guidelines, with reference to optimum service delivery, are available from the DAA website at They include: Radiotherapy: all patients requiring RT for head/neck or GIT cancer should be referred to see a dietitian before the start of treatment to screen for malnutrition and start prophylactic nutrition support if required. There are also recommendations for the number and frequency of review visits. 11 Cancer cachexia: recommendations for referral, time for consultations and type of intervention that has been shown to have clinical impact and improve quality of life. 21 Cystic fibrosis: due to the complexity of the management of cystic fibrosis dietetic services need to be provided by an experienced dietitian. Recommended staffing levels are 0.4 FTE per 50 patients in specialised clinics for routine care. However, when patients are unstable or malnourished, there is more demand on services Section 4 Workforce planning

17 Dietitians Association of Australia Resource allocation manual Evidence Based Practice Guidelines for the Nutritional Management of Chronic Kidney Disease: guidelines for referral to a dietitian in different stages of disease based on glomerular filtration rate levels, length of appointments and recommended reviews. 21 Malnutrition management: it is recommended to do routine screening for malnutrition in the acute care setting (level B evidence), as well in the rehabilitation, residential aged care and community settings (level D evidence), using a malnutrition screening tool appropriate for the specific population. The high prevalence figures for malnutrition in the acute care setting (20 50%), rehabilitation setting (30 50%) and residential aged care setting (40 70%) can be used to predict the number of individuals in a particular service that may suffer from malnutrition and require further assessment and intervention. 5 Recommendations for optimum workforce in the community health outpatient setting are also complex. A survey via to the DAA Public Health and Community Nutrition Interest Group, on the time spent by dietitians with clients in community health outpatient clinics indicated a variety in the allocation of time for new and review clients. The appointment times for new clients ranged from 45 minutes to 90 minutes in general community health and aged care environment. Waiting lists, client complexity and working in areas with migrant populations were reasons mentioned to decide on time. Review patients tended to get minutes appointments with less frequency to achieve sustainable behaviour change, instead of short review appointments. The respondents indicated that a longer first appointment was of benefit for outcomes for the clients, but this had an effect on the length of the waiting lists. 23 Changing government priorities and new models of care focussing on continuity of care in the primary health care setting influence workforce requirement. An example, applicable to all allied health services is the practice of early discharge from acute care hospitals of patients with chronic care management needs, whose support can be managed at home in regional and rural services. The consequence is an increased demand for community and primary health care services; 7 as well in an acute environment. 1 For example, due to the shorter length of stay, a patient may needs more education and more support services organised before discharge. Rural hospital and community health services often provide outreach services to other towns. Consideration is required for (at times lengthily) travel time due to long distances, and the time involved in counselling clients from indigenous communities. 7 Emerging technologies may assist in delivering services, where these are available. These technologies can also be used to access professional development and supervision or mentoring. Section 4 Workforce planning 13