1. Results in a SNAP A MUST for effective compliance monitoring? Emily Walters, Chief Dietitian

2. A brief history... Launch of policy for Malnutrition in Adults (2006) –Information on intranet –Hard copies of MUST paperwork for wards –Senior nurse briefings –Ward-based teaching –Nutrition Link Nurse training days –MUST score for inpatient referrals to Dietitian

3. Audit 2007 Southampton General Hospital Most nurses felt that “MUST” was important Three quarters believed that ‘all or most’ patients on their ward were routinely screened BUT… –14 % screened within 24 hours of admission –31 % screened within 7 days –81 % of patients at risk of malnutrition had been missed

4. Steps to support change included... Trust prioritisation of nutrition - nutrition is 1 of 7 key patient safety areas External interest e.g. CQC A Trust champion with power to change practice e.g. Associate Director of Nursing Individuals required to take ownership and responsibility e.g. Matrons, Ward Managers Links with other initiatives e.g. infection control team, catering red trays

5. Compliance remained variable – why? Competing pressures No central reporting or consequences of non- compliance unlike other areas e.g. hand hygiene A need for formal monitoring within the Trust if the policy is to compete with other agendas? MUST within 24 hours admission and evidence of care plans for ‘at risk’ patients became a KPI with central monitoring

6. Monitoring compliance How to monitor compliance? –Large organisation - time consuming to audit –Small ‘snapshot’ audits across the trust did not provide trustwide assurance –The ‘hawthorne effect’ was experienced with planned audits How were others monitoring compliance?

7. Introducing SNAP!

8. Developing the audit using SNAP SNAP software was used to create an online audit questionnaire and reporting system Who was involved? –Associate Director Nursing –Clinical Effectiveness Manager –Chief Dietitian What did we need to know? What would be useful to know?

9. SNAP audit questions Baseline data – month, area auditing, auditor MUST within 24 hours admission? MUST category? MUST score correct? Nutrition care plan for those ‘at risk’? Repeat score?

11. SNAP audit process Each ward submits a monthly audit of 10 patients Data entered by nursing staff directly into the on- line questionnaire –minimising data transfer work –reducing errors A monthly summary report provides compliance data at both ward and trust level. Validation of results is possible as patient hospital numbers are included in the audit data.

12. Did wards participate?

14. Example of data report

16. Did a KPI & monthly trustwide auditing make a difference to policy compliance?

18. Improved use of nutrition care plans for ‘at risk’ patients

19. Repeat screening improved from 83% to 89% (Feb–Dec 2011)

20. What other information?

21. Divisional data example

22. MUST score components

23. Data analysis to identify trends Acute medical unit (AMU) admitted approximately 30% of all cases in the audit. Other wards contributed a maximum of 3% each of the overall admissions.

26. Compliance on AMU increased from 73% to 82% (Feb – Dec 2011)

28. Impact of SNAP audit on MUST score within 24 hours admission 13% improvement Trust wide 81% Feb 2011 to 94% March 2012 12% increase Trust wide without AMU 85% Feb 2011 to 97% March 2012 16% increase on AMU 73% Feb 2011 to 89% March 2012

29. Summary of key findings A ‘trustwide’ approach needed Key leaders identified and available for support KPI set with central monitoring SNAP made monthly trustwide audits possible SNAP provides data for clinical quality dashboard SNAP e-results viewer (free to all areas) enables everyone to see results at their desk top SNAP data helps identify training needs Identification and treatment of malnutrition risk has improved as a result of using SNAP