SummaryA hospital posts an adjustable “diet wheel” on each room doorway, and the nurse adjusts the wheel to indicate which of 15 physician-ordered diets the patient in that room should receive. When a dietary staff member arrives with the patient’s food, he/she checks to ensure that the diet label on the tray matches the diet specified on the wheel. Anecdotal evidence suggests the program has led to fewer instances in which patients eat the wrong meal type, along with associated problems, such as having to cancel surgery when a patient eats when he/she is supposed to be fasting. The program has also reduced diet-related interruptions for nurses and generated high levels of satisfaction among nurses and dietary staff.Suggestive: The evidence consists of anecdotal reports from nurses and dietary staff on instances of patients consuming the wrong type of diet, diet-related interruptions of nurses, and satisfaction with the program.
Developing OrganizationsMethodist LeBonheur Germantown Healthcare
Date First Implemented2008
Problem AddressedMany hospitalized patients require a special diet dictated by their condition or the need to prepare for surgery. Dietary staff typically begin to prepare patient food trays in the morning, before physician rounds. As a result, they may not learn of physician-initiated dietary changes in a timely fashion, resulting in the wrong type of food being delivered to (and often consumed by) the patient.1
- Frequent need for special meals: At Methodist LeBonheur Germantown Healthcare, approximately 30 to 40 percent of hospitalized patients require special diets to accommodate particular health or presurgical needs.
- Early preparation, leading to potential to miss changes: At 5 a.m. each day, Methodist LeBonheur Germantown dietary staff run a list of physician dietary orders and begin to prepare trays for delivery to patient floors. During subsequent physician rounding, physicians often make changes to the dietary orders, prompting a potential discrepancy between the ordered diet and the food delivered.
- Wrong food delivered to (and consumed by) patient: Before initiation of this program, discrepancies often led to the patient eating food that was not a part of their prescribed diet, such as a patient with diabetes eating from a tray that included a sugary dessert. In some cases, surgeries had to be postponed because a patient who was not supposed to eat had received and consumed a meal.
Description of the Innovative ActivityA hospital posts an adjustable “diet wheel” on each room doorway, and the nurse adjusts the wheel to indicate which of 15 physician-ordered diets the patient in that room should receive. When a dietary staff member arrives with the patient’s food, he/she checks to ensure that the diet label on the tray matches the diet specified on the wheel. Key elements of the program include the following:
- Placement of wheel listing potential diets on door: Every inpatient room on the medical/surgical and cardiology units (all of which hold only one patient) has an adjustable diet wheel posted on the door. (The oncology and labor/delivery/postpartum units do not use the wheel because they offer “dining on call,” which allows patients to contact dietary services personally to order individualized meals from menus.) The wheel can be turned so that one of 15 physician-directed diets shows through a small window. Diets listed include a regular diet, the American Diabetes Association (ADA) diet, the American Heart Association (AHA) diet, bland diet, clear liquids diet, ADA-clear liquids diet, renal diet, full liquids diet, low fat diet, low residue diet, low sodium diet, soft diet, Wise (cardiac) diet, bariatric diet, and “nothing by mouth.” A 16th option, “ask nurse,” can be used when the physician wants the nurse to advance the patient’s diet (for example, from liquids to solids) as tolerated.
- Updating of wheel by nurse: Whenever a physician modifies a diet, the revised order is entered into the computerized charting system. This system notifies the nurse electronically so that he/she can update the diet wheel on the patient’s door.
- List of diets run by dietary department: The dietary department prints an initial list of patients and their diets at 5 a.m. This list is periodically updated throughout the day so that current orders guide tray preparation for lunch and dinner.
- Confirmation of appropriate meal delivery: The dietary staff member who delivers the patient’s food tray checks the diet wheel against the label on the patient’s tray (which includes the patient’s name, room number, and diet). In cases of a discrepancy, the staff member will check with the nurse or unit secretary to confirm that a diet change has occurred (i.e., that the wheel is correct) and that a new food tray needs to be assembled and delivered to the patient.
Context of the InnovationMethodist LeBonheur Germantown Healthcare, part of Methodist Healthcare, is a 309-bed, not-for-profit, suburban community hospital serving Germantown, TN, and surrounding areas. A group of nurses spearheaded development of the diet wheel after becoming aware of the many miscommunications that occurred with dietary staff, resulting in wrong diets being delivered to and consumed by patients. These nurses wanted to develop a process to enhance communication with dietary staff and ensure that patients received the appropriate meal.
ResultsAnecdotal evidence suggests the program has led to fewer instances in which patients eat the wrong meal type, along with associated problems, such as having to cancel surgery when a patient eats when he/she is supposed to be fasting. The program has also reduced diet-related interruptions for nurses and generated high levels of satisfaction among nurses and dietary staff.
Suggestive: The evidence consists of anecdotal reports from nurses and dietary staff on instances of patients consuming the wrong type of diet, diet-related interruptions of nurses, and satisfaction with the program.
- Fewer cases where patients eat wrong meal type: Nurses report that they rarely, if ever, observe instances in which patients consume a different diet than ordered by the physician. As a result, instances in which miscommunication about diet have caused major problems or disruptions (e.g., surgeries being rescheduled because the patient ate something when he/she should have been fasting) have also been nearly eliminated.
- Fewer interruptions of nurses: The number of times nurses face interruptions due to diet-related issues and questions has decreased significantly, from approximately 10 per shift to 2 to 3 per shift.
- High levels of staff satisfaction: Both nurses and dietary staff report being highly satisfied with the program.
Planning and Development ProcessKey elements of the planning and development process included the following:
- Presenting idea to quality improvement staff: A day-shift nurse presented the problem of diet-related miscommunication to the hospital’s Transforming Care at the Bedside “champion group,” which includes a nurse representative from every unit and shift. (Transforming Care at the Bedside is a model for nurse-initiated quality improvement developed by the Robert Wood Johnson Foundation and the Institute for Healthcare Improvement; see the Tools and Other Resources section for more information.)
- Considering options: The champion group met with nursing and dietary staff representatives to come up with options to facilitate accurate communication about patient diets. An early idea—placing a “sticky note” on the patient’s door to indicate the diet ordered—evolved into the diet wheel.
- Creating and testing wheel: The champion group created a prototype diet wheel out of card stock and construction paper. A nurse on one medical/surgical unit tested the prototype for 2 weeks and confirmed its usefulness.
- Training staff to use wheel: The champion group introduced the diet wheel and its use to colleagues on their respective shifts/units. Newly hired nurses, nursing assistants, and dietary personnel receive training on how to use the diet wheel during orientation.
- Expanding program: Based on the positive pilot test, the hospital’s marketing department designed and produced laminated diet wheels for all 58 beds on the pilot test unit. Nurses from the other medical–surgical and cardiology units saw the diet wheels and requested that they be allowed to use it as well.
Resources Used and Skills Needed
- Staffing: The program requires no new staff, as existing staff incorporate it into their daily routines.
- Costs: The hospital spent less than $200 on this initiative, consisting of approximately $1.25 per wheel to produce the diet wheels in-house.
Funding SourcesMethodist LeBonheur Germantown Healthcare
Tools and Other ResourcesA downloadable graphic of the diet wheel can be accessed at: http://www.rwjf.org/content/dam/web-assets/2010/05
/diet-wheel-to-ensure-correct-patient-diets-and-reduce-errors, while a sample diet wheel can be obtained by contacting the program developers.
The Transforming Care at the Bedside Toolkit is available at: http://www.innovations.ahrq.gov/content.aspx?id=2327.
Getting Started with This Innovation
- Obtain buy-in from staff: Initially, dietary staff may express concern about the “extra step” of checking the diet wheel against the patient tray label. By emphasizing the benefits of this step—better patient care and communication with nurses—the hospital can help facilitate buy-in. In addition, both nurses and dietary staff should be included in meetings and testing related to the diet wheel so that their feedback can be incorporated.
- Test wheel before rollout: Run a small test of the wheel before expanding its use throughout the hospital. A pilot test can reveal optimal strategies for incorporating the use of the wheel into existing work processes.
- Consider which diets to include: Many diet options exist, and not all of them can be included on the wheel. Consequently, the wheel should incorporate those options frequently used on the unit, as determined by the needs of the patient population.
Sustaining This Innovation
- Remind nurses to update wheel: An early challenge involved ensuring that nurses updated the wheel every time a patient’s diet had been changed. To address this problem, unit managers and Transforming Care at the Bedside champions consistently reminded nurses to update the wheel. Eventually, all nurses incorporated this step as part of the routine care process.
- Incorporate information about wheel into new employee training: Incorporate information about the purpose and use of the wheel into training for newly hired nurses and dietary staff.
Contact the InnovatorPtosha Jackson, RN, MSN
Administrative Director of Nursing
Methodist LeBonheur Germantown Healthcare
7691 Poplar Ave.
Germantown, TN 38138
Bea Allen, MSN, RN-BC
Clinical Director of Nursing
Methodist LeBonheur Germantown Healthcare
7691 Poplar Ave.
Germantown, TN 38138
Innovator DisclosuresMs. Jackson and Ms. Allen have not indicated whether they have financial interests or business/professional affiliations relevant to the work described in this profile.
References/Related ArticlesRobert Wood Johnson Foundation. Diet Wheel to Ensure Correct Patient Diets and Reduce Errors. May 13, 2010. Available at: http://www.rwjf.org/content/rwjf/en/research-publications/find-rwjf-research/2010/05
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Original publication: December 22, 2010.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: December 18, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: December 03, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.