Nutrition and Mental Health Toolkit · ACI Nutrition and Mental Health Toolkit 1 The purpose of the...

Nutrition and Mental Health Toolkit

Resources to support the implementation of the ACI Nutrition Standards for Consumers

of Inpatient Mental Health Services in NSW

AGENCY FOR CLINICAL INNOVATION

Level 4, Sage Building 67 Albert Avenue Chatswood NSW 2067

Agency for Clinical Innovation PO Box 699 Chatswood NSW 2057 T +61 2 9464 4666 | F +61 2 9464 4728 E [email protected] | www.aci.health.nsw.gov.au

Produced by: ACI Nutrition Network Ph. +61 2 9464 4666

SHPN: (ACI) 150075ISBN: 978-1-76000-146-9

Further copies of this publication can be obtained from: Agency for Clinical Innovation website at: www.aci.health.nsw.gov.au

Disclaimer: Content within this publication was accurate at the time of publication.

This work is copyright. It may be reproduced in whole or part for study or training purposes subject to the inclusion of an acknowledgment of the source.

It may not be reproduced for commercial usage or sale. Reproduction for purposes other than those indicated above, requires written permission from the Agency for Clinical Innovation.

© Agency for Clinical Innovation 2015 Published March 2015

mailto:[email protected]

www.aci.health.nsw.gov.au

www.aci.health.nsw.gov.au

ACI Nutrition and Mental Health Toolkit iii

The Agency for Clinical Innovation’s (ACI) Nutrition Network commissioned Kate Fletcher, Consultant Dietitian, to prepare this toolkit. Members of the ACI Nutrition and Mental Health Working Group provided guidance and comments on drafts of the toolkit.

Members of the ACI Nutrition and Mental Health Working Group involved in this project:

Jan Plain Senior Dietitian, Macquarie Hospital, Northern Sydney Local Health District (Co-Chair)

Meg Vickery Senior Dietitian, Bloomfield Hospital, Western NSW Local Health District (Co-Chair)

Belinda Lee Senior Dietitian, Bloomfield Hospital, Western NSW Local Health District

Brad Roser Clinical Nurse Consultant, The Forensic Hospital, Justice and Forensic Mental Health Network

Corinne Cox Senior Food Service Dietitian, HealthShare NSW

Craig Locke Team Leader, Mission Australia

Elayne Mitchell Team Leader, Official Visitors Program (OVP)

Gladys Hitchen Senior Dietitian, Cumberland Hospital, Western Sydney Local Health District

Kate Fletcher Dietitian, Hunter New England Mater Mental Health, Hunter New England Local Health District

Katrina Davis Advisor, NSW Mental Health Commission

Lauren Reece Dietitian, St George Hospital, South Eastern Sydney Local Health District

Limor Weingarten Clinical Nurse Educator, Macquarie Hospital, Northern Sydney Local Health District

Peri O’Shea Chief Executive, NSW Consumer Advisory Group (CAG), Mental Health

Regina McDonald Area Clinical Nurse Consultant, Specialist Mental Health Services for Older People, South Western Sydney Local Health District, and Braeside Hospital Hammond Care

Sharon Mak Dietitian, Hornsby Hospital, Northern Sydney Local Health District

Suzanne Kennewell Director, Nutrition and Dietetics, Sydney Local Health District

Tanya Hazlewood Nutrition Network Manager, Agency for Clinical Innovation

The following people also contributed to the development of the toolkit by sharing existing tools and resources:

Claire Ward Food Service Dietitian, Western NSW Local Health District

Corinne Cox Senior Food Service Dietitian, HealthShare NSW

Gladys Hitchen Senior Dietitian, Cumberland Hospital, Western Sydney Local Health District

Helen Jackson Profession Director, Nutrition and Dietetics, Hunter New England Local Health District

Jan Plain Senior Dietitian, Macquarie Hospital, Northern Sydney Local Health District

Kate Fletcher Dietitian, Hunter New England Mater Mental Health, Hunter New England Local Health District

ACKNOWLEDGEMENTS

ACI Nutrition and Mental Health Toolkit iv

Kelly Dart Nurse Manager Policy, Practice and Initiatives, Nursing and Midwifery Directorate, Far West Local Health District

Lillian Forrest Nutrition Project Manager (FSIP), HealthShare NSW

Meg Vickery Senior Dietitian, Bloomfield Hospital, Western NSW Local Health District

Natalie Alborés Speech Pathologist, Macquarie Hospital, Northern Sydney Local Health District

Sharon Mak Dietitian, Hornsby Hospital, Northern Sydney Local Health District

Tracey Patricks Head Dietitian Coffs Harbour Health Campus, Mid North Coast Local Health District

Traci Cook Manager Dietetics, Nepean and Blue Mountains Hospitals, Nepean Blue Mountains Local Health District

The ACI Nutrition Network acknowledges and thanks the following for their valuable feedback on the consultation draft:

Carol Smith Nurse Unit Manager, Hilltop Lodge T-BASIS Unit, Hunter New England Local Health District

Craig Millington Appointment Liaison Nurse, Hunter New England Mater Mental Health, Hunter New England Local Health District

Helen Jackson Profession Director, Nutrition and Dietetics, Hunter New England Local Health District and Co-Chair of Nutrition in Hospitals Committee, ACI

Maria Roberts Dietitian, Intermediate Stay Mental Health Unit, Hunter New England Local Health District

Suzanne Johnston Clinical Nurse Consultant, Psychiatric Rehabilitation Service, Hunter New England Local Health District

Samantha Krupp Clinical and Food Service Dietitian, St Vincent’s Private Hospital, St Vincent’s Health Network

ACI Patient Experience and Consumer Engagement (PEACE) Team

ACI Nutrition and Mental Health Toolkit v

ABOUT THE ACI

The Agency for Clinical Innovation (ACI) works with clinicians, consumers and managers to design and promote better healthcare for NSW. It does this by:

• Service redesign and evaluation – applying redesign methodology to assist healthcare providers and consumers to review and improve the quality, effectiveness and efficiency of services.

• Specialist advice on healthcare innovation – advising on the development, evaluation and adoption of healthcare innovations from optimal use through to disinvestment.

• Initiatives including Guidelines and Models of Care – developing a range of evidence-based healthcare improvement initiatives to benefit the NSW health system.

• Implementation support – working with ACI Networks, consumers and healthcare providers to assist delivery of healthcare innovations into practice across metropolitan and rural NSW.

• Knowledge sharing – partnering with healthcare providers to support collaboration, learning capability and knowledge sharing on healthcare innovation and improvement.

• Continuous capability building – working with healthcare providers to build capability in redesign, project management and change management through the Centre for Healthcare Redesign

ACI Clinical Networks, Taskforces and Institutes provide a unique forum for people to collaborate across clinical specialties and regional and service boundaries to develop successful healthcare innovations.

A priority for the ACI is identifying unwarranted variation in clinical practice and working in partnership with healthcare providers to develop mechanisms to improve clinical practice and patient care.

ACI Nutrition and Mental Health Toolkit vi

PURPOSE ............................................................................................................................ 1

BACKGROUND .................................................................................................................... 2

TOOLKIT OVERVIEW............................................................................................................ 4Development Process ................................................................................................................................................4Structure ...................................................................................................................................................................4

PART 1: NUTRITION STANDARDS IMPLEMENTATION CHECKLIST .......................................... 5Overview ..................................................................................................................................................................5

PART 2: NUTRITION CARE GOVERNANCE AND LEADERSHIP ................................................ 6 LHD / Network Level Governance Committee Responsibilities ....................................................................................6 Facility Level Nutrition Care Governance Committee Responsibilities ..........................................................................6 Consumer / Carer Roles .............................................................................................................................................7 Meeting Nutrition Care Policy and Accreditation Requirements .................................................................................7 Other Key Nutrition Care Governance Reference Material ..........................................................................................7

PART 3: NUTRITION STANDARDS – EDUCATION AND INFORMATION .................................. 8 Staff Education .........................................................................................................................................................8 Information for Staff, Consumers and Carers .............................................................................................................8

PART 4: MENU DEVELOPMENT ............................................................................................ 9 Menu Review Key Stakeholders Role and Responsibilities ..........................................................................................9 Site or LHD / Network Information for Menu Development - Nutrition Care and Food Service Data Checklist.............9 Nutrient Checklist .....................................................................................................................................................9 Minimum Menu Choice Checklists ............................................................................................................................9 Banding Ready Reckoner ...........................................................................................................................................9 Menu Examples ......................................................................................................................................................10 Other Key Menu Reference Material ........................................................................................................................10

REFERENCES .......................................................................................................................11

APPENDICES ..................................................................................................................... 12 Appendix 1: Nutrition Standards Implementation Checklist ...................................................................................12 Appendix 2: NSW Health LHD / Network Nutrition Care Committee Agenda Template ..........................................20 Appendix 3: NSW Health LHD / Network Nutrition Care Committee Terms of Reference Template ........................21 Appendix 4: NSW Health Facility Nutrition Care Committee Agenda Template ......................................................25 Appendix 5: NSW Facility Nutrition Care Committee Terms of Reference Template ................................................26 Appendix 6: Nutrition Care Committees - Engaging Consumers / Carers ...............................................................29 Appendix 7: NSW Health Nutrition Care Policy: Mapping to Accreditation Requirements .......................................30 Appendix 8: The Menu Review Process - Roles of Key Stakeholders .......................................................................49 Appendix 9: Site or LHD/Network Information for Menu Development - Nutrition Care and Food Service Data Checklist .......................................................................................................................51 Appendix 10: Nutrient and Minimum Menu Choice Checklists and Banding Ready Reckoner ...................................55 Appendix 11: Example Menus .................................................................................................................................58

TABLE OF CONTENTS

ACI Nutrition and Mental Health Toolkit 1

The purpose of the toolkit is to provide guidance, tools and resources to support the:

1.) Implementation of the Nutrition Standards for Consumers of Inpatient Mental Health Services in NSW1 across Local Health Districts (LHDs) and Specialty Health Networks (Networks); and

2.) Development of governance structures and leadership for implementing the NSW Health Nutrition Care Policy directive (PD2011_78).2

The toolkit will assist LHDs / Networks and/or facilities in both developing and implementing an action plan to meet the requirements of the Nutrition Standards and Nutrition Care Policy. It may assist in developing food service partnership level agreements.

In addition, a resource has been included that may assist LHDs / Networks and/or facilities determine areas for improvement in terms of meeting the following national accreditation mandatory and desirable standards:

• National Safety and Quality Health Service Standards (NSQHS) - The Australian Commission on Safety, Quality in Health Care (ACSQHC)3

• National Standards for Mental Health Services (NSMHS) - Commonwealth of Australia4

• Evaluation and Quality Improvement Program (EQuIP) additional standards - The Australia Council on HealthCare Standards (ACHS).5

PURPOSE

Nutrition Standards

FOR CONSUMERS OF INPATIENT MENTAL HEALTH

SERVICES IN NSW

Policy Directive

Ministry of Health, NSW73 Miller Street North Sydney NSW 2060

Locked Mail Bag 961 North Sydney NSW 2059Telephone (02) 9391 9000 Fax (02) 9391 9101

http://www.health.nsw.gov.au/policies/

spacespace

Nutrition Care space

Document Number PD2011_078

Publication date 16-Dec-2011

Functional Sub group Corporate Administration - GovernanceClinical/ Patient Services - Governance and Service Delivery

Summary This document describes the NSW Health framework for nutrition careand support to be implemented by Local Health Districts and other NSWpublic health organisations.

Author Branch Office of the Chief Health Officer

Branch contact Office of the Chief Health Officer 9391 9463

Applies to Local Health Districts, Board Governed Statutory Health Corporations,Specialty Network Governed Statutory Health Corporations, AffiliatedHealth Organisations, Public Health System Support Division, PublicHospitals

Audience Administrative all staff, clinical, medical, allied health, nursing, dietitians

Distributed to Public Health System, Health Associations Unions, NSW AmbulanceService, Ministry of Health, Private Hospitals and Day Procedure Centres,Tertiary Education Institutes

Review date 16-Dec-2016

Policy Manual Patient Matters

File No. H11/100385

Status Active

Director-GeneralspaceThis Policy Directive may be varied, withdrawn or replaced at any time. Compliance with this directive is mandatoryfor NSW Health and is a condition of subsidy for public health organisations.


The NSW Health Nutrition Care Policy directive (PD2011_78)2 released in December 2011 sets out the “NSW Health framework for a strategic and coordinated approach to nutrition care and support from admission to transfer of care”, and includes patient menu selection.2

The implementation of the Nutrition Care Policy and its related standards in NSW Local Health Districts and other NSW public health organisations was to occur by December 2013.2

The Policy states that “menus should provide the nutritional requirements of patients in accordance with the following” related ACI documents:

• Nutrition Standards for Adult Inpatients in NSW Hospitals6

• Nutrition Standards for Paediatric Inpatients in NSW Hospitals7

• Therapeutic Diet Specifications for Adult Inpatients8

• Therapeutic Diet Specifications for Paediatric Inpatients9

The ACI Nutrition Standards for Consumers of Inpatient Mental Health Services in NSW1 (“the Nutrition Standards”) were launched in October 2013 by the Minister for Mental Health. The Nutrition Standards are “appropriate for most adults and older adolescents in mental health facilities, including those who are overweight/obese or nutritionally at-risk, due to over-or under-nutrition”.1 It has been recognised that “they may also be relevant for people in other long-stay settings e.g. spinal injuries or brain injury”.1

The Nutrition Standards aim to ensure that menus “provide the opportunity for consumers of mental health services across NSW to select food that satisfies their requirements and supports their recovery”.1 They support the development of menus that are based on sound evidence as well as ensuring that the food and nutrition provision is patient-centred.1

The process of implementing the Nutrition Standards is at the discretion of the LHDs / Networks and will be based on enhancing the current food service provision and overall nutrition care of consumers of mental health services within NSW.

LHDs and Networks are encouraged to implement these new Nutrition Standards within two years of their release (i.e. October 2015).

The Nutrition Standards form a component of the ‘food and fluids provided’ in the ACI Patient Nutrition Care Journey10 (Figure 1 page 3) in term of meals needing to be safe, adequate and appropriate for a mental health population.1 They also have links to the following components:

• “Policy and Governance” - by having a mental health representative at each LHD / Network and/or Facility Nutrition Care Committee, where appropriate.1, 2, 10

• “Mealtime environment, supervision and assistance, mealtime observations” - with the goal of normalising eating, supervising cutlery use; supervising meal time intake and therapeutic diets etc.1, 2, 10

• “Nutrition screening, assessment, care planning and monitoring” - in terms of malnutrition screening and/or metabolic monitoring; assessment by mental health dietitian as required and nutrition care planning.1, 2, 10

BACKGROUND

http://www0.health.nsw.gov.au/policies/pd/2011/PD2011_078.html


http://www.aci.health.nsw.gov.au/resources/nutrition












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Development Process The ACI Nutrition and Mental Health Working Group considered what would be required to support the implementation of the Nutrition Standards for Consumers of Inpatient Mental Health Services in NSW (the “Nutrition Standards”).1 A list of potential tools and resources was generated and then prioritised for inclusion in the toolkit.

Members of the ACI Nutrition in Hospitals Committee and ACI Nutrition and Mental Health Working Group were asked to share relevant existing documents and resources for consideration. The consultant prepared draft versions of documents and tools which were reviewed by the ACI Nutrition and Mental Health Working Group.

Draft versions of the toolkit were circulated to all members of the ACI Nutrition in Hospitals Committee for comment. The final version was endorsed by the ACI Nutrition in Hospitals Committee and the NSW Health Committee in November 2014. The ACI Executive team approved the Toolkit for release in December 2014.

StructureThe toolkit is divided into the following four parts:

Part 1: Nutrition Standards Implementation Checklist

Part 2: Nutrition Care Governance and Leadership

Part 3: Nutrition Standards – Education and Information

Part 4: Menu Development

Each part provides information and an explanation of the relevant tools and resources that are available as appendices.

TOOLKIT OVERVIEW




OverviewThe purpose of this supplementary checklist is to assist the implementation of the Nutrition Standards.1 It can be used in conjunction with the Nutrition Care Policy Implementation Checklist.2

The checklist provides the following:

1. An overview of the key elements required to meet the Nutrition Standards

2. An outline of the supporting tools and/or resources that have been included in the toolkit

3. Additional links to other useful information and suggested tools / resources that could be developed.

A copy of the Nutrition Standards Implementation checklist is included as Appendix 1.

PART 1: NUTRITION STANDARDS IMPLEMENTATION CHECKLIST

ACI Nutrition and M

ental Health Toolkit 12

Appendix 1: Nutrition Standards Implementation ChecklistThe purpose of this checklist is to guide implementation of the Nutrition Standards for Consumers of Inpatient Mental Health Services in NSW (“the Nutrition Standards”). It can be used in conjunction with the Nutrition Care Policy Implementation Checklist. It provides an overview of the key elements required to meet the Nutrition Standards. It includes an outline of the supporting tools and/or resources that are available in the toolkit. It also provides additional links to other useful information and make suggestions about tools / resources that could be developed locally.

TOOLKIT PART 2: GOVERNANCE AND LEADERSHIP

Nutrition Care Policy Element

Key Elements Required to Meet the Nutrition Standards

Tools and Resources Available in the Toolkit

Suggested Tools / Resources (that could be developed) or Useful Links

Current Compliance Status

Not Started

Partially Completed

Completed

1. Policy and Governance

An LHD/ Network committee responsible for nutrition care and food is in place and the terms of reference (TOR) includes: • Mental Health representation• Consumer and/or Carer representation• Responsibility for overseeing the

implementation of the NSW Health Nutrition Care Policy

• Responsible for conducting a LHD / Network review and developing an action plan for implementing the Nutrition Standards for Consumers of Inpatient Mental Health Services in NSW

• Endorsement of a Menu Review Sub-Steering Committee to assist with realignment of menus for the LHD / Network

Suggestion• Links to the NSW Health Nutrition and

Food Committee and ACI Nutrition Network

Appendix:• 2: LHD Agenda Template • 3: LHD TOR Template• 4: Local / Facility Agenda

Template • 5: Local / Facility TOR Template• 6: Engaging Consumer / Carer• 7: Nutrition Care Policy

Accreditation Mapping• 8: Menu Review Process –

Roles of Key Stakeholders

Useful Links:• Physical Health Care within

Mental Health Services Policy (PD2009_007)

• Physical Health Care of Mental Health Consumers Guidelines (GL2009_007)

• The Patient Nutrition Care Journey document

• The Patient Nutrition Care Journey presentation

• ChOICES: The Patient Menu Selection Process document

• ChOICES: The Patient Menu Selection Process presentation

Continued on page 13




NSW Health LHDs and Networks are responsible for the provision of nutrition care for all inpatients and residents within their facilities.2

The Nutrition Care Policy (PD2011_078) requires each NSW Health LHD and Network to establish governance structures for nutrition care (e.g. a Nutrition Care Committee).2

Each facility is encouraged to have an individualised governance structure for nutrition care2 either as a separate Nutrition Care Committee or by including nutrition care as an agenda item on an existing committee such as the Patient Safety and Clinical Quality Committee.

Another option is for facilities to establish a multi-focused Nutrition Care and Physical Health Committee to implement both the Nutrition Care Policy2 and the Physical Health Care within Mental Health Services Policy Directive (PD2009_027)12.

LHD / Network Level Governance Committee ResponsibilitiesResponsibilities of LHD and Network Nutrition Care Committees could include:

1. Coordinate and Oversee the implementation of the Nutrition Care Policy across their LHD / Network

2. Support / Implement 2.1. governance structures and communication

across the LHD / Network

2.2. local facilities to meet their accreditation requirements in terms of nutrition care

2.3. local facilities to meet their responsibilities of the Nutrition Care Policy.

3. Review, Develop and Recommend

3.1. areas for improvement and action plans for nutrition care across the LHD/Network according to the Nutrition Care policy elements.

3.2. the preferred food service model for the delivery of food to meet the nutrition care needs of their consumers within available funds and resources

3.2. food service priorities, products and services based on consumers’ needs and changes of clinical care practices and requirements within the context of a shared services framework.

4. Reporting 4.1. action plans

4.2. implementation progress

4.3. evaluation of compliance with the requirements of the Nutrition Care Policy.

To help guide the initiation and/or realignment to the recommended LHD / Networks Nutrition Care governance structure the following templates have been developed:

• LHD / Network Nutrition Care Committee Agenda Template (see Appendix 2)

• LHD / Network Nutrition Care Committee Terms of Reference (TOR) Template (see Appendix 3).

Facility Level Nutrition Care Governance Committee Responsibilities Responsibilities for facility Nutrition Care Governance Committees could include:

1. Oversee the implementation of the Nutrition Care Policy within the site / facility

2. Implement 2.1. regular Nutrition Care meetings and

communication pathways for the site / facility governance structure

2.2. all recommendations from the LHD / Network e.g. staff training, nutrition screening etc.

PART 2: NUTRITION CARE GOVERNANCE AND LEADERSHIP


http://www0.health.nsw.gov.au/policies/pd/2009/PD2009_027.htmlhttp://www0.health.nsw.gov.au/policies/pd/2009/PD2009_027.html

http://www0.health.nsw.gov.au/policies/pd/2009/PD2009_027.htmlhttp://www0.health.nsw.gov.au/policies/pd/2009/PD2009_027.html


3. Review, Develop and Recommend 3.1. site/ facility assignments of responsibility,

personnel and resources required to meet the nutrition care policy requirements

3.2. changes to current Nutrition Care procedures and develop site / facility based action plans for the implementation of the Nutrition Care policy

3.3. basic menu requirements for the site and menu changes in conjunction with LHD / Network and appropriate staff e.g. Dietitian.

4. Reporting 4.1. implementation progress to LHD / Network

4.2. site / facility accreditation progress

4.3. evaluation of compliance with the requirements of the Nutrition Care Policy for site / facility.

To support the initiation and/or realignment of a Facility Nutrition Care Committee governance structure the following templates have been developed:

• Local / Facility Nutrition Care Committee Agenda Template (see Appendix 4)

• Local / Facility Nutrition Care Committee TOR Template (see Appendix 5).

Consumer / Carer Roles It is mutually beneficial for the organisation to engage consumers and carers to ensure nutrition care is patient-centred.3-5, 13

A resource containing suggested roles of Consumers / Carers within Nutrition Care Committees has been developed (see Appendix 6). It provides guidance to managers and clinicians on engaging consumers / carers as well as supporting them to actively contribute to nutrition care discussions.

Meeting Nutrition Care Policy and Accreditation Requirements There is currently no mandatory national nutrition care accreditation standard within the 10 National Safety and Quality Health Service Standards (NSQHS).3

However, the Nutrition Care Policy does have links to:

• eight of the nine mandatory assessable National Standards for Mental Health Services (NSMHS) 4, 14

• nine of the mandatory 10 NSQHS3

• all five of the elective EQuIP standards in particular Standard 12: Provision of Care.5

To provide guidance on how the Nutrition Care Policy meets the accreditation requirements for NSQHS, NSMHS and EQuIP, the toolkit contains a resource that maps the standards to elements in the policy and provides examples of available and proposed evidence (see Appendix 7).

Other Key Nutrition Care Governance Reference MaterialOther key reference material related to nutrition care governance and leadership that has been developed and published by ACI include:

• The Patient Nutrition Care Journey document10

• The Patient Nutrition Care Journey presentation11

• ChOICES: The Patient Menu Selection Process document15

• ChOICES: The Patient Menu Selection Process presentation.16

http://www.safetyandquality.gov.au/our-work/accreditation-and-the-nsqhs-standards/resources-to-implement-the-nsqhs-standards/#NSQHS-Standards


http://www0.health.nsw.gov.au/resources/mhdao/standards/national_std_mhs_pdf.asp


http://www.achs.org.au/publications-resources/equipnational/








It is important there is education and information available for staff and consumers / carers on the Nutrition Standards.

Staff Education To assist in staff education, a presentation about the Nutrition Standards with speaker notes has been developed and is available on the ACI website.

The purpose of the presentation is to provide a brief overview of the Nutrition Standards for all staff and could be delivered by a clinician such as a Dietitian, Clinical/Nurse Educator and/or Clinical Nurse Consultant (CNC).

Some settings may utilise Volunteers and the presentation may need to be tailored to meet their information needs.

The presentation is generic and may require additional site-specific information to be prepared. This could include information about the staff available for implementing the Nutrition Standards and about the food service delivery system.

Information for Staff, Consumers and CarersThe following ACI information resources are available:

• Nutrition Standards for Consumers of Inpatient Mental Health Services in NSW: A Guide for Consumers and Families Factsheet

- Available in English and seven community languages - Arabic, Chinese Simplified, Chinese Traditional, Greek, Italian, Spanish and Vietnamese

• Introducing the Nutrition Standards for Consumers of Inpatient Mental Health Services in NSW: Factsheet (a resource for staff)

There are other resources available that were developed for the acute care setting. How they are applied in mental health settings will need to be considered at a local level. They include:

• ACI Food and Nutrition in NSW Hospitals: Brochure17

• ACI Food and Nutrition in NSW Hospitals: Factsheet18 - Available in English and seven community

languages - Arabic, Chinese Simplified, Chinese Traditional, Greek, Italian, Spanish and Vietnamese

• HealthShare NSW Guidelines for Bringing Occasional Food to Patients: Brochure19

• HealthShare NSW Guidelines for Bringing Occasional Food to Patients: Factsheet20 - Available in English and seven community

languages - Arabic, Chinese Simplified, Chinese Traditional, Greek, Italian, Spanish and Vietnamese.

PART 3: NUTRITION STANDARDS – EDUCATION AND INFORMATION

http://www.aci.health.nsw.gov.au/resources












http://intranet.hss.health.nsw.gov.au/publications/brochures





A key consideration for each LHD / Network is to ensure their current menus are compared to the new Nutrition Standards to help identify and prioritise areas for improvement, in collaboration with their Food Service Provider(s).

The menu development process is at the discretion of the LHD / Network and/or facility with input from the Food Service Provider(s).

It is suggested that each LHD / Network Nutrition Care Committee:

1. Liaise with their Food Service Provider(s) to:

• develop a project plan, governance structure and timeline for menu review and development at each facility; and

• discuss general budgetary considerations.

2. Coordinate a LHD / Network Steering Committee;

• to undertake a menu review for the LHD / Network; or

• to provide direction to each of their facilities Nutrition Care Committee on how to review their menus (i.e. the assessment of the current menus, identification of areas for improvement and the development of new menus should be a multidisciplinary approach).

To assist the menu development process the following tools have been developed and listed in order of their recommended use:

1. Menu Review Key Stakeholders Role and Responsibilities A list of the general roles and responsibilities of key stakeholders in relation to the menu development process (Appendix 8).

2. Site or LHD/ Network Information for Menu Development - Nutrition Care and Food Service Data ChecklistA site information collection tool on Nutrition Care and Food Services to provide a foundation for the menu review process. It includes consumer population demographics, menu cycle length required and potential practical issues (see Appendix 9).

3. Nutrient Checklist The checklist will help determine how the current menu meets the nutrient standards and the areas for improvement in terms of macronutrients (e.g. fat, protein, carbohydrate) and micro-nutrients (e.g. calcium, iron and folate). See Appendix 10: Table 1.

The nutrient checklist is designed to be used by a Dietitian and/or Food Service Provider for the analysis of average daily menu intakes. It can also be used to evaluate a newly proposed menu (i.e. to confirm all nutrient targets have been met).

4. Minimum Menu Choice ChecklistsThe checklist helps determine how the current menu meets the Nutrition standards and the areas for improvement in terms of the minimum number of choices for specific items (e.g. at least one protein food at breakfast), serve sizes (e.g. 125g yoghurt at breakfast) and nutrient requirements (e.g. the breakfast protein choice must contain at least 5g protein per portion). See Appendix 10: Table 2.

It is designed to be completed by the Facility Nutrition Care Committee or one of the key members (e.g. Dietitian, Food Service Provider) and discussed at a Nutrition Care Committee meeting.

Once a new menu is proposed, the checklist can be used to evaluate the proposed new menu in terms of meeting the minimum menu choices standards (i.e. a way of confirming all areas for improvement have been incorporated).

5. Banding Ready Reckoner “Bands” are a way of classifying the relative nutritional value of a range of dishes while incorporating variety within the menu structure.1

The Banding Ready Reckoner will help to determine if the menu items, such as soups, main dishes – meat, main dishes – vegetarian, salads, sandwiches, desserts, potato/rice/pasta and vegetables, meet the nutrition banding criteria (see Appendix 10: Table 3).

The Banding Ready Reckoner is designed to be used by a Dietitian and/or Food Service Provider to check menu product information and as a quick way of

PART 4: MENU DEVELOPMENT


identify areas for improvement. It can also be used to complete a check on current menu items and on any new menu items proposed.

It should be noted that both the Adult Inpatient and Mental Health Nutrition Standards have key information in terms of the application of the Bands. It is recommended that they are referred to when checking the Band of the above items against the standardised recipes and/or product nutritional information.

6. Menu Examples A generic example of a one week menu cycle has been developed to provide ideas for an outline for a mental health facility that meets the Nutrition Standards (see Appendix 11).

The example incorporates some strategies used in inpatient mental health settings to help normalise eating patterns (e.g. BBQ day, consumer preparation of sandwiches and/or salads).

All menu outlines should be localised and based on the individual population needs and practical considerations.

In addition, the Nutrition Standards include two test diets that meet the new nutrient targets (Part B 6: pp23 -25).1

Other Key Menu Reference Material

- ACI Nutrition Standards for Adult Inpatients in NSW Hospitals6

- ACI Nutrition Standards for Paediatric Inpatients in NSW Hospitals7







1. Agency for Clinical Innovation. Nutrition standards for consumers of inpatient mental health services in NSW. Sydney: Agency for Clinical Innovation, NSW, 2013.

2. NSW Ministry of Health. Policy Directive: Nutrition Care PD2011_078. North Sydney: NSW Health, 2011.

3. Australian Commission on Safety and Quality in Health Care (ACSQHC). National Safety and Quality Health Service Standards. Sydney 2012.

4. Commonwealth of Australia. National Standards for Mental Health Services 2010. ACT: Commonwealth of Australia., 2010.

5. The Australia Council on HealthCare Standards (ACHS). Introducing EQuIPNational: Australia’s Premier Accreditation Program. ACHS; 2014. (Also available from: http://www.achs.org.au/media/67054/achs_web_version_v4.pdf, accessed 28/05/2014).

6. Agency for Clinical Innovation. Nutrition standards for adult inpatients in NSW hospitals. Sydney: Agency for Clinical Innovation, NSW, 2011.

7. Agency for Clinical Innovation. Nutrition standards for paediatric inpatients in NSW hospitals. Sydney: Agency for Clinical Innovation, NSW, 2011.

8. Agency for Clinical Innovation. Therapeutic diet specifications for adult inpatients. Sydney: Agency for Clinical Innovation, NSW, 2011.

9. Agency for Clinical Innovation. Therapeutic diet standards for paediatric inpatients in NSW hospitals. Sydney: Agency for Clinical Innovation, NSW, 2012.

10. Agency for Clinical Innovation. The Patient Nutrition Care Journey: A guide to support implementation of the NSW Health Nutrition Care Policy - version 1. Sydney: Agency for Clinical Innovation, NSW, 2012.

11. Agency for Clinical Innovation. The Patient Nutrition Care Journey: A guide to support

implementation of the NSW Health Nutrition Care Policy Presentation. Sydney: Agency for Clinical Innovation, NSW, 2012.

12. NSW Ministry of Health. Policy Directive: Physical Health Care Within Mental Health Services (PD2009_027). North Sydney: NSW Health, 2009.

13. The Australian Commission on Safety and Quality in Health Care. Patient-centred care: Improving quality and safety by focusing care on patients and consumers. Sydney: ACSQHC, 2010.

14. Australian Commission on Safety and Quality in Health Care (ACSQHC). Accreditaton Workbook for Mental Health Services. Sydney: ACSQHC, 2014.

15. Agency for Clinical Innovation. ChOICES: The Patient Menu Selection Process. Sydney: Agency for Clinical Innovation, NSW, 2014.

16. Agency for Clinical Innovation. ChOICES: The Patient Menu Selection Process Presentation. Sydney: Agency for Clinical Innovation, NSW, 2014.

17. Agency for Clinical Innovation. ACI Food and Nutrition in NSW Hospitals: Brochure. Sydney: Agency of Clinical Innovation, NSW, 2013.

18. Agency for Clinical Innovation. ACI Food and Nutrition in NSW Hospitals: Factsheet. Sydney: Agency of Clinical Innovation, NSW, 2013.

19. HealthShare NSW. Guidelines for bringing occasional food to patients: brochure. Sydney: HealthShare NSW, 2013.

20. HealthShare NSW. Guidelines for bringing occasional food to patients: factsheet. Sydney: HealthShare NSW, 2013.

REFERENCES

http://www.achs.org.au/media/67054/achs_web_version_v4.pdf

http://www.achs.org.au/media/67054/achs_web_version_v4.pdf


App

endi

x 1:

Nut

riti

on S

tand

ards

Impl

emen

tati

on C

heck

list

The

purp

ose

of t

his

chec

klis

t is

to

guid

e im

plem

enta

tion

of t

he N

utrit

ion

Stan

dard

s fo

r C

onsu

mer

s of

Inpa

tient

Men

tal H

ealth

Ser

vice

s in

NSW

(“th

e N

utrit

ion

Stan

dard

s”).

It ca

n be

use

d in

con

junc

tion

with

the

Nut

ritio

n C

are

Polic

y Im

plem

enta

tion

Che

cklis

t. It

pro

vide

s an

ove

rvie

w o

f th

e ke

y el

emen

ts r

equi

red

to m

eet

the

Nut

ritio

n St

anda

rds.

It in

clud

es a

n ou

tline

of

the

supp

ortin

g to

ols

and

/or

reso

urce

s th

at a

re a

vaila

ble

in t

he t

oolk

it. It

als

o pr

ovid

es a

dditi

onal

link

s to

oth

er u

sefu

l inf

orm

atio

n an

d

mak

e su

gges

tions

abo

ut t

ools

/ re

sour

ces

that

cou

ld b

e de

velo

ped

loca

lly.

TOO

LKIT

PA

RT 2

: GO

VER

NA

NCE

AN

D L

EAD

ERSH

IP

Nu

trit

ion

Car

e Po

licy

Elem

ent

Key

Ele

men

ts R

equ

ired

to

Mee

t th

e N

utr

itio

n S

tan

dar

ds

Too

ls a

nd

Res

ou

rces

Ava

ilab

le

in t

he

Too

lkit

Sug

ges

ted

To

ols

/ R

eso

urc

es

(th

at c

ou

ld b

e d

evel

op

ed)

or

Use

ful L

inks

Cu

rren

t C

om

plia

nce

Sta

tus

No

t St

arte

dPa

rtia

lly

Co

mp

lete

dC

om

ple

ted

1. P

olic

y an

d G

over

nanc

eA

n LH

D/ N

etw

ork

com

mitt

ee r

espo

nsib

le

for

nutr

ition

car

e an

d fo

od is

in p

lace

and

th

e te

rms

of r

efer

ence

(TO

R) in

clud

es:

• M

enta

l Hea

lth r

epre

sent

atio

n•

Con

sum

er a

nd/o

r C

arer

rep

rese

ntat

ion

• R

espo

nsib

ility

for

over

seei

ng t

he

impl

emen

tatio

n of

the

NSW

Hea

lth

Nut

ritio

n C

are

Polic

y •

Res

pons

ible

for

cond

uctin

g a

LHD

/ N

etw

ork

rev

iew

and

dev

elop

ing

an a

ctio

n pl

an fo

r im

plem

entin

g th

e N

utrit

ion

Stan

dard

s fo

r C

onsu

mer

s of

In

patie

nt M

enta

l Hea

lth S

ervi

ces

in

NSW

•

Endo

rsem

ent

of a

Men

u Re

view

Sub

-St

eerin

g C

omm

ittee

to a

ssis

t w

ith

real

ignm

ent

of m

enus

for

the

LHD

/ N

etw

ork

Sug

ges

tio

n•

Link

s to

the

NSW

Hea

lth N

utrit

ion

and

Food

Com

mitt

ee a

nd A

CI N

utrit

ion

Net

wor

k

Ap

pen

dix

:•

2: L

HD

Age

nda

Tem

plat

e

• 3

: LH

D T

OR

Tem

plat

e•

4: L

ocal

/ Fa

cilit

y A

gend

a Te

mpl

ate

•

5: L

ocal

/ Fa

cilit

y TO

R Te

mpl

ate

• 6

: Eng

agin

g C

onsu

mer

/ C

arer

• 7:

Nut

ritio

n C

are

Polic

y A

ccre

dita

tion

Map

ping

• 8

: Men

u Re

view

Pro

cess

–

Role

s of

Key

Sta

keho

lder

s

Use

ful L

inks

:•

Phys

ical

Hea

lth C

are

with

in

Men

tal H

ealth

Ser

vice

s Po

licy

(PD

2009

_007

)•

Phys

ical

Hea

lth C

are

of

Men

tal H

ealth

Con

sum

ers

Gui

delin

es (G

L20

09_0

07)

• Th

e Pa

tient

Nut

ritio

n C

are

Jour

ney

docu

men

t•

The

Patie

nt N

utrit

ion

Car

e Jo

urne

y pr

esen

tatio

n •

ChO

ICES

: The

Pat

ient

Men

u Se

lect

ion

Proc

ess

docu

men

t•

ChO

ICES

: The

Pat

ient

Men

u Se

lect

ion

Proc

ess

pres

enta

tion

Con

tinu

ed o

n pa

ge 1

3

http://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0013/201091/ACI-Nutrition-Mental-Health-Inpatients-web-final.pdf#zoom=100

http://www0.health.nsw.gov.au/policies/pd/2011/pdf/PD2011_078.pdf




http://www0.health.nsw.gov.au/policies/gl/2009/GL2009_007.html












TOO

LKIT

PA

RT 2

: GO

VER

NA

NCE

AN

D L

EAD

ERSH

IP -

CON

TIN

UED

Nu

trit

ion

Car

e Po

licy

Elem

ent

Key

Ele

men

ts R

equ

ired

to

Mee

t th

e N

utr

itio

n S

tan

dar

ds

Too

ls a

nd

Res

ou

rces

Ava

ilab

le

in t

he

Too

lkit

Sug

ges

ted

To

ols

/ R

eso

urc

es

(th

at c

ou

ld b

e d

evel

op

ed)

or

Use

ful L

inks

Cu

rren

t C

om

plia

nce

Sta

tus

No

t St

arte

dPa

rtia

lly

Co

mp

lete

dC

om

ple

ted

1. P

olic

y an

d G

over

nanc

e (c

ontin

ued)

A s

ite/f

acili

ty g

over

nanc

e fr

amew

ork

- a

spec

ific

com

mitt

ee f

or n

utrit

ion

care

and

foo

d; o

r “N

utrit

ion

Car

e an

d Fo

od”

is in

clud

ed in

an

exis

ting

and

appr

opria

te lo

cal s

ite m

eetin

g:

• R

epor

ts to

the

LH

D le

vel c

omm

ittee

• R

espo

nsib

le fo

r co

nduc

ting

a fa

cilit

y re

view

and

dev

elop

ing

an a

ctio

n pl

an fo

r im

plem

entin

g th

e N

utrit

ion

Stan

dard

s fo

r C

onsu

mer

s of

Inpa

tient

M

enta

l Hea

lth S

ervi

ces

in N

SW in

co

njun

ctio

n w

ith d

irect

ion

from

LH

D /

Net

wor

k N

utrit

ion

Car

e C

omm

ittee

• C

onsu

mer

and

/or

Car

er re

pres

enta

tion

• M

enta

l Hea

lth r

epre

sent

atio

n if

exis

ting

mee

ting

• Fo

od S

ervi

ce r

epre

sent

atio

n (in

clud

ing

men

u de

sign

whe

n re

quire

d).

Sug

ges

tio

n•

Link

s to

the

AC

I Nut

ritio

n N

etw

ork

– N

utrit

ion

in H

ospi

tals

Com

mitt

ee

Ap

pen

dix

:•

2: L

HD

Age

nda

Tem

plat

e

• 3

: LH

D T

OR

Tem

plat

e•

4: L

ocal

/ Fa

cilit

y A

gend

a Te

mpl

ate

•

5: L

ocal

/ Fa

cilit

y TO

R Te

mpl

ate

• 6:

Eng

agin

g C

onsu

mer

/ C

arer

• 7:

Nut

ritio

n C

are

Polic

y A

ccre

dita

tion

Map

ping

• 8

: Men

u Re

view

Pro

cess

–

Role

s of

Key

Sta

keho

lder

s

Use

ful L

inks

:•

Phys

ical

Hea

lth C

are

with

in

Men

tal H

ealth

Ser

vice

s Po

licy

(PD

2009

_007

)•

Phys

ical

Hea

lth C

are

of

Men

tal H

ealth

Con

sum

ers

Gui

delin

es (G

L20

09_0

07)

• Th

e Pa

tient

Nut

ritio

n C

are

Jour

ney

docu

men

t•

The

Patie

nt N

utrit

ion

Car

e Jo

urne

y pr

esen

tatio

n •

ChO

ICES

: The

Pat

ient

Men

u Se

lect

ion

Proc

ess

docu

men

t•

ChO

ICES

: The

Pat

ient

Men

u Se

lect

ion

Proc

ess

pres

enta

tion

Con

tinu

ed o

n pa

ge 1

4




http://www0.health.nsw.gov.au/policies/gl/2009/pdf/GL2009_007.pdf












TOO

LKIT

PA

RT 2

: GO

VER

NA

NCE

AN

D L

EAD

ERSH

IP -

CON

TIN

UED

Nu

trit

ion

Car

e Po

licy

Elem

ent

Key

Ele

men

ts R

equ

ired

to

Mee

t th

e N

utr

itio

n S

tan

dar

ds

Too

ls a

nd

Res

ou

rces

Ava

ilab

le

in t

he

Too

lkit

Sug

ges

ted

To

ols

/ R

eso

urc

es

(th

at c

ou

ld b

e d

evel

op

ed)

or

Use

ful L

inks

Cu

rren

t C

om

plia

nce

Sta

tus

No

t St

arte

dPa

rtia

lly

Co

mp

lete

dC

om

ple

ted

Con

tinu

ed o

n pa

ge 1

5

2. N

utrit

ion

Scre

enin

gSc

reen

ing

and

mon

itorin

g to

iden

tify

peop

le a

t nu

triti

onal

ris

k fr

om p

rote

in

ener

gy m

alnu

triti

on a

s w

ell a

s m

etab

olic

sy

ndro

me

and

/or

Type

2 d

iabe

tes

mel

litus

Use

ful L

inks

:•

Die

titia

ns A

ssoc

iatio

n of

A

ustr

alia

Evi

denc

e Ba

sed

Prac

tice

Gui

delin

es f

or t

he

Nut

ritio

nal M

anag

emen

t of

M

alnu

triti

on in

Adu

lt Pa

tient

s A

cros

s th

e C

ontin

uum

of

Car

e•

Met

abol

ic M

onito

ring

Clin

ical

D

ocum

enta

tion

Mod

ule

(IB20

12_0

24)

• Ty

pe 2

Dia

bete

s Ri

sk

Ass

essm

ent

Tool

(AU

SDRI

SK)

3. N

utrit

ion

Ass

essm

ent

Acc

ess

to D

ietit

ians

and

Spe

ech

Path

olog

ists

for

peo

ple

with

hig

her

and

spec

ial n

utrit

iona

l nee

ds (f

or e

xam

ple

– st

aff

onsi

te, a

ref

erra

l sys

tem

/pro

cess

, ac

cess

to

a co

nsul

tant

)

Sug

ges

ted

to

ols

/res

ou

rces

:•

Stan

dard

ised

key

rea

sons

for

re

ferr

al t

o D

ietit

ians

and

/or

Spee

ch P

atho

logi

sts

in M

enta

l H

ealth

fac

ilitie

s•

Men

tal H

ealth

Die

titia

n an

d Sp

eech

Pat

holo

gist

fut

ure

st

affin

g p

lann

ing

profi

les

to

mee

t co

nsum

er n

eeds

http://onlinelibrary.wiley.com/doi/10.1111/j.1747-0080.2009.01383.x/full






http://www0.health.nsw.gov.au/policies/ib/2012/IB2012_024.html



http://www.health.gov.au/preventionoftype2diabetes

http://www.health.gov.au/preventionoftype2diabetes


TOO

LKIT

PA

RT 3

: N

UTR

ITIO

N S

TAN

DA

RDS

– E

DU

CA

TIO

N A

ND

INFO

RMA

TIO

N

Nu

trit

ion

Car

e Po

licy

Elem

ent

Key

Ele

men

ts R

equ

ired

to

Mee

t th

e N

utr

itio

n S

tan

dar

ds

Too

ls a

nd

Res

ou

rces

Ava

ilab

le

in t

he

Too

lkit

Sug

ges

ted

To

ols

/ R

eso

urc

es

(th

at c

ou

ld b

e d

evel

op

ed)

or

Use

ful L

inks

Cu

rren

t C

om

plia

nce

Sta

tus

No

t St

arte

dPa

rtia

lly

Co

mp

lete

dC

om

ple

ted

1. P

olic

y an

d G

over

nanc

e

8. S

taff

Ed

ucat

ion

and

Trai

ning

Info

rmat

ion

is a

vaila

ble

for

cons

umer

s/ca

rers

abo

ut :

• Th

e m

enu

and

food

ser

vice

s

• N

utrit

ion

care

in h

ospi

tal

• H

ealth

y ea

ting

AC

I Web

site

:

• N

utrit

ion

Stan

dard

s fo

r co

nsum

ers

of in

patie

nt m

enta

l he

alth

ser

vice

s in

NSW

-

Pres

enta

tion

and

Spea

ker

Not

es•

Nut

ritio

n St

anda

rds

for

cons

umer

s of

inpa

tient

men

tal

heal

th s

ervi

ces

in N

SW: A

gu

ide

for

cons

umer

s an

d Fa

mili

es F

acts

heet

• In

trod

ucin

g th

e A

CI N

utrit

ion

Stan

dard

s fo

r C

onsu

mer

s of

Inpa

tient

Men

tal H

ealth

Se

rvic

es in

NSW

Fac

tshe

et

Sug

ges

ted

to

ols

/res

ou

rces

:•

Shor

t ed

ucat

ion

sess

ions

/ e-

lear

ning

e.g

. nut

ritio

n ca

re

in h

ospi

tals

, hea

lthy

eatin

g et

c.

Use

ful L

inks

:•

Aus

tral

ian

Die

tary

Gui

delin

es

and

Aus

tral

ian

Gui

de t

o H

ealth

y Ea

ting

• G

et H

ealth

y: In

form

atio

n an

d C

oach

ing

Serv

ice

• A

CI F

ood

and

Nut

ritio

n in

N

SW H

ospi

tals

Fac

tshe

et a

nd

Broc

hure

• H

ealth

Shar

e N

SW G

uide

lines

fo

r Br

ingi

ng O

ccas

iona

l Foo

d to

Pat

ient

s Fa

ctsh

eet

and

Broc

hure

J

Info

rmat

ion

is a

vaila

ble

for

staf

f ab

out

the

Nut

ritio

n St

anda

rds

for

Con

sum

ers

of In

patie

nt M

enta

l Hea

lth S

ervi

ces

in

NSW

As

abov

eA

s ab

ove

Con

tinu

ed o

n pa

ge 1

6

http://www.aci.health.nsw.gov.au/resources#nutrition

http://www.aci.health.nsw.gov.au/resources#nutrition










http://www.eatforhealth.gov.au/guidelines



http://www.gethealthynsw.com.au/

http://www.gethealthynsw.com.au/









TTO

OLK

IT P

ART

3:

NU

TRIT

ION

STA

ND

ARD

S –

ED

UC

ATI

ON

AN

D IN

FORM

ATI

ON

– C

ON

TIN

UED

Nu

trit

ion

Car

e Po

licy

Elem

ent

Key

Ele

men

ts R

equ

ired

to

Mee

t th

e N

utr

itio

n S

tan

dar

ds

Too

ls a

nd

Res

ou

rces

Ava

ilab

le

in t

he

Too

lkit

Sug

ges

ted

To

ols

/ R

eso

urc

es

(th

at c

ou

ld b

e d

evel

op

ed)

or

Use

ful L

inks

Cu

rren

t C

om

plia

nce

Sta

tus

No

t St

arte

dPa

rtia

lly

Co

mp

lete

dC

om

ple

ted

1. P

olic

y an

d G

over

nanc

e

8. S

taff

Ed

ucat

ion

and

Trai

ning

Info

rmat

ion

is a

vaila

ble

for

staf

f an

d co

nsum

ers/

care

rs a

bout

pur

chas

ing

food

fro

m e

xter

nal s

ourc

es (v

endi

ng

mac

hine

s, t

ake-

away

s, c

afes

, re

stau

rant

s, s

uper

mar

kets

etc

.)

Sug

ges

ted

to

ols

/res

ou

rces

:•

Loca

l gui

delin

e on

pur

chas

ing

/ brin

ging

in e

xter

nal f

ood

sour

ces

and

thei

r st

orag

e /

man

agem

ent

•

Exam

ples

of

stra

tegi

es/

initi

ativ

es f

or s

taff

to

assi

st

cons

umer

s to

mak

e he

alth

ier

exte

rnal

foo

d ch

oice

s

Use

ful L

inks

:•

Que

ensl

and

Hea

lth M

enta

l H

ealth

Nut

ritio

n Ed

ucat

ion

Mat

eria

ls O

nlin

e (N

EMO

) A

ctio

n Ba

sed

Reso

urce

s

• D

ietit

ians

Ass

ocia

tion

of

Aus

tral

ia (

DA

A) D

INER

M

enta

l Hea

lth a

nd N

utrit

ion

and

Die

tetic

s In

form

atio

n (M

HA

ND

i) re

sour

ces

(not

e on

ly D

AA

mem

bers

hav

e ac

cess

)ND

ARD

S

• H

ealth

Shar

e N

SW G

uide

lines

fo

r Br

ingi

ng O

ccas

iona

l Foo

d to

Pat

ient

s Fa

ctsh

eet

and

Broc

hure

Con

tinu

ed o

n pa

ge 1

7

http://www.health.qld.gov.au/nutrition/nemo_mhindex.asp




http://daa.asn.au/

http://daa.asn.au/

http://daa.asn.au/

http://daa.asn.au/

http://daa.asn.au/






TOO

LKIT

PA

RT 4

: M

ENU

DEV

ELO

PMEN

T

Nu

trit

ion

Car

e Po

licy

Elem

ent

Key

Ele

men

ts R

equ

ired

to

Mee

t th

e N

utr

itio

n S

tan

dar

ds

Too

ls a

nd

Res

ou

rces

Ava

ilab

le

in t

he

Too

lkit

Sug

ges

ted

To

ols

/ R

eso

urc

es

(th

at c

ou

ld b

e d

evel

op

ed)

or

Use

ful L

inks

Cu

rren

t C

om

plia

nce

Sta

tus

No

t St

arte

dPa

rtia

lly

Co

mp

lete

dC

om

ple

ted

5. P

lann

ing

and

Del

iver

y of

Foo

d an

d Fl

uids

The

gene

ral m

enu

mee

ts t

he n

utrie

nt

goal

s an

d m

inim

um s

tand

ards

and

the

ne

eds

of t

he lo

cal p

opul

atio

n

• C

hoic

e of

foo

ds/fl

uids

• V

arie

ty –

with

in m

eals

, day

s an

d m

enus

• Th

e le

ngth

of

the

men

u cy

cle

cons

ider

s th

e av

erag

e LO

S

• Th

e m

eals

off

ered

on

the

men

u co

nsid

er t

he c

ultu

ral p

rofil

e of

co

nsum

ers

and

take

s in

to a

ccou

nt t

he

opin

ions

of

cons

umer

s

• D

iffer

ent

serv

e si

zes

are

avai

labl

e

Ap

pen

dix

•

8: M

enu

Revi

ew P

roce

ss –

Ro

les

of K

ey S

take

hold

ers

• 9

: Site

or

LHD

/ N

etw

ork

Info

rmat

ion

- N

utrit

ion

Car

e an

d Fo

od S

ervi

ce D

ata

Che

cklis

t •

10: N

utrie

nt a

nd M

inim

um

Men

u C

hoic

e C

heck

list

and

Band

ing

Read

y Re

ckon

er

• 11

: Exa

mpl

e M

enus

Use

ful L

inks

:•

Test

men

us in

clud

ed in

the

N

utrit

ion

Stan

dard

s (p

ages

23-

24)

Ther

e is

ear

ly a

nd o

ngoi

ng c

onsu

ltatio

n w

ith a

ll lo

cal s

take

hold

ers

and

the

loca

l go

vern

ance

com

mitt

ee t

hrou

ghou

t ea

ch

stag

e of

men

u de

sign

to

appr

oval

As

abov

e

Men

u re

visi

on p

roce

ss in

clud

es

cons

ider

atio

n of

pat

ient

sat

isfa

ctio

n su

rvey

res

ults

(i.e

. foo

d pr

esen

tatio

n,

appe

aran

ce, t

aste

)

As

abov

eU

sefu

l lin

ks:

• N

SW H

ealth

Adu

lt A

dmitt

ed

Patie

nt S

urve

y (B

urea

u of

H

ealth

Info

rmat

ion)

Food

pro

vide

d as

par

t of

BBQ

s, A

DL

kitc

hens

, reh

ab c

ooki

ng p

rogr

ams

and

lunc

h pa

cks

mee

ts t

he n

utrie

nt g

oals

an

d m

inim

um s

tand

ards

As

abov

eSu

gg

este

d t

oo

ls/r

eso

urc

es:

• Lo

cal g

uide

line

on o

ther

foo

d pr

ovid

ed a

s tr

eatm

ent

and

reha

bilit

atio

n pr

oces

s •

Exam

ple

reci

pes

for

cook

ing

sess

ions

or

AD

L ki

tche

n th

at h

ave

been

nut

ritio

nally

as

sess

ed

Con

tinu

ed o

n pa

ge 1

8


http://www.bhi.nsw.gov.au/nsw_patient_survey_program/adult_admitted_patient_survey



TOO

LKIT

PA

RT 4

: M

ENU

DEV

ELO

PMEN

T -

CO

NTI

NU

ED

Nu

trit

ion

Car

e Po

licy

Elem

ent

Key

Ele

men

ts R

equ

ired

to

Mee

t th

e N

utr

itio

n S

tan

dar

ds

Too

ls a

nd

Res

ou

rces

Ava

ilab

le

in t

he

Too

lkit

Sug

ges

ted

To

ols

/ R

eso

urc

es

(th

at c

ou

ld b

e d

evel

op

ed)

or

Use

ful L

inks

Cu

rren

t C

om

plia

nce

Sta

tus

No

t St

arte

dPa

rtia

lly

Co

mp

lete

dC

om

ple

ted

5. P

lann

ing

and

Del

iver

y of

Foo

ds

and

Flui

ds

(con

tinue

d)

Mea

l ser

vice

tim

es m

eet

the

need

s of

co

nsum

ers

and

the

faci

lity:

• Su

pper

is s

erve

d no

mor

e th

an 1

2 ho

urs

prio

r to

bre

akfa

st

• M

id m

eals

are

eve

nly

dist

ribut

ed

betw

een

mai

n m

eals

Ap

pen

dix

•

12: S

ite o

r LH

D /

Net

wor

k

Info

rmat

ion

- N

utrit

ion

Car

e an

d Fo

od S

ervi

ce D

ata

Che

cklis

t

Sug

ges

ted

to

ols

/res

ou

rces

:•

Loca

l gui

delin

e th

at in

clud

es

acce

ss t

o fo

od f

or c

onsu

mer

s af

ter

hour

s, a

dditi

onal

foo

d;

larg

e se

rves

and

mea

l tim

es.

Food

for

con

sum

ers

can

be a

acc

esse

d af

ter

hour

s; r

equi

re a

dditi

onal

foo

d as

hu

ngry

or

requ

ire la

rge

serv

es

As

abov

eA

s ab

ove

Ade

quat

e fo

od a

nd fl

uids

are

ava

ilabl

e to

min

imis

e th

e ne

ed f

or o

ral n

utrit

ion

supp

lem

ents

Sug

ges

ted

to

ols

/res

ou

rces

:•

Loca

l gui

delin

e fo

r w

hen

a co

nsum

er a

ppea

rs t

o ha

ve

an in

adeq

uate

ora

l int

ake

(i.e.

foo

d ch

arts

, che

ck in

take

hi

stor

y, m

edic

al r

easo

ns, f

ood

pref

eren

ces)

Mea

ls a

re s

erve

d in

a m

anne

r co

nsis

tent

w

ith f

ood

safe

ty r

egul

atio

ns.

Use

ful L

inks

:•

NSW

Foo

d A

utho

rity

The

mea

l sel

ectio

n pr

oces

s al

low

s co

nsum

ers

to c

hoos

e th

eir

mea

l with

in

the

faci

lity’

s fr

amew

ork

and

exam

ples

on

how

thi

s ca

n w

ork

in d

iffer

ent

sett

ings

e.g

. caf

eter

ia, p

rint

men

us a

nd

food

pre

fere

nces

Ap

pen

dix

:•

11: E

xam

ple

Men

usU

sefu

l Lin

ks:

• C

hOIC

ES: T

he P

atie

nt M

enu

Sele

ctio

n Pr

oces

s do

cum

ent

(pag

e 24

– 2

5 m

enta

l hea

lth

scen

ario

)

• C

hOIC

ES: T

he P

atie

nt M

enu

Sele

ctio

n Pr

oces

s pr

esen

tatio

nC

onti

nued

on

page

19

http://www.foodauthority.nsw.gov.au/






TOO

LKIT

PA

RT 4

: M

ENU

DEV

ELO

PMEN

T -

CO

NTI

NU

ED

Nu

trit

ion

Car

e Po

licy

Elem

ent

Key

Ele

men

ts R

equ

ired

to

Mee

t th

e N

utr

itio

n S

tan

dar

ds

Too

ls a

nd

Res

ou

rces

Ava

ilab

le

in t

he

Too

lkit

Sug

ges

ted

To

ols

/ R

eso

urc

es

(th

at c

ou

ld b

e d

evel

op

ed)

or

Use

ful L

inks

Cu

rren

t C

om

plia

nce

Sta

tus

No

t St

arte

dPa

rtia

lly

Co

mp

lete

dC

om

ple

ted

6. T

he M

eal

Tim

e En

viro

nmen

t

7. P

rovi

sion

of

Ass

ista

nce

to E

at a

nd

Drin

k

Cut

lery

and

ser

ving

war

e th

at is

ap

prop

riate

for

the

pop

ulat

ion

is u

sed

(e.g

. ada

ptiv

e ai

ds, m

odifi

ed c

utle

ry a

nd

drin

king

dev

ices

) and

ass

ista

nce

to o

pen

pack

ets

is p

rovi

ded

whe

re n

eede

d

Sug

ges

ted

to

ols

/res

ou

rces

:•

Loca

l gui

delin

e on

mea

l tim

e su

ppor

t an

d su

perv

isio

n

Con

sum

ers

need

s ar

e m

eet

in r

elat

ion

to a

dequ

ate

time

to c

onsu

me

mea

ls,

assi

stan

ce w

ith e

atin

g an

d dr

inki

ng,

cons

umer

saf

ety

and

type

of

unit

/fac

ility

e.

g. f

oren

sic

vs r

ehab

ilita

tion

Sug

ges

ted

to

ols

/res

ou

rces

: Lo

cal g

uide

line

on m

eal t

ime

supp

ort

and

supe

rvis

ion

9. E

valu

atio

nTh

ere

is a

pro

cess

in p

lace

to

dete

rmin

e co

nsum

er s

atis

fact

ion

with

foo

d an

d nu

triti

on c

are

Use

ful l

inks

: •

NSW

Hea

lth A

dult

Adm

itted

Pa

tient

Sur

vey

(Bur

eau

of

Hea

lth In

form

atio

n)

Sug

ges

ted

to

ols

/res

ou

rces

:•

Con

sum

er s

atis

fact

ion

surv

ey

• Lo

cal g

uide

line

on p

atie

nt

satis

fact

ion

surv

ey p

roce

ss

(i.e.

how

oft

en, w

ho’s

rol

e an

d co

nsid

erat

ions

in

Men

tal H

ealth

)

Eval

uatio

n re

sults

are

sha

red

with

co

nsum

ers

and

staf

f an

d us

ed to

impr

ove

serv

ices

(e.g

. new

slet

ters

, mee

tings

, in

tran

et s

ites,

info

mat

ion

for

cons

umer

s/ca

rers

, cha

nges

to t

he m

enu)

Sug

ges

ted

to

ols

/res

ou

rces

:•

Loca

l Nut

ritio

n C

are

in

tran

et p

age

• Lo

cal N

utrit

ion

Car

e

inte

rnet

pag

e




Appendix 2: NSW Health LHD / Network Nutrition Care Committee Agenda Template

AGENDA NUTRITION CARE COMMITTEE[Insert name of NSW LHD / Network Meeting ]

[Insert name NSW LHD / Network Area][Insert Date and Meeting Timeframe]

[Insert meeting venue location and room][Insert other attendance options e.g. teleconference, videoconference, webinar]

1. Acknowledgment of country

2. Attendance and apologies

3. Conflicts of interest

4. Confirmation of previous minutes from [Insert last meeting date]

5. Business arising from previous meetings

6. Nutrition care implementation 6.1 Policy and governance 6.1.1 Governance e.g. local / facilities 6.1.2 Action plan / Nutrition Care Policy checklist 6.1.3 Accreditation e.g. NSQHS, NSMHS, EQuIP 6.2 Nutrition screening 6.3 Nutrition assessment 6.4 Nutrition care planning 6.4.1 Transfer of care 6.5 Planning and delivery of food and fluids 6.5.1 Menus e.g. nutrition standard, therapeutic diets 6.5.2 Provision of food and fluids 6.6 The mealtime environment 6.7 Provision of assistance to eat and drink e.g. opening packets, feeding, supervision 6.8 Staff education and training e.g. clinical staff, food service staff

7. Nutrition Care Evaluation / KPI’s 7.1. Weight and height measurements 7.2. Nutrition screening e.g. MST, metabolic monitoring 7.3. Nutrition assessment 7.4. Consumer food satisfaction survey 7.5. Food service audits e.g. portion control, wastage 7.6. IIMs data 7.7. Complaints and compliments

8. LHD / Network nutrition care related updates

9. Documents for endorsement / notation / information

10. New business

11. Business without notice

12. Next meetings – [Insert meeting dates(s)]


Appendix 3: NSW Health LHD / Network Nutrition Care Committee Terms of Reference Template

TERMS OF REFERENCE NUTRITION CARE COMMITTEE[Insert name of NSW LHD / Network Meeting ]

[Insert name NSW LHD / Network Area]

REPORTS TO [Insert LHD/ Network Executive Committee name and/or NSW LHD / Network Patient Safety and Quality Committee name]

REPORTER [Insert Chairpersons name and/or other committee members name]

CHAIRPERSON(S) [Insert Chairpersons name]

SECRETARIAT [Insert Administration Staff name]

ENDORSED BY [Insert LHD/ Network Executive Committee members name ] DATE

NEXT REVIEW Annually

1. PURPOSEThe purpose of this committee is to:

• Oversee the provision of nutrition care for all inpatients and residents within [Insert LHD/Network name] as per the NSW Health Nutrition Care Policy directive (PD2011_078) and related accreditation standards

• Ensure nutrition care activities are in line with LHD / Network / Service strategic and operational plan(s).

2. RESPONSIBILITIES / FUNCTIONS

1. Coordinate, communicate and monitor the implementation of the Nutrition Care Policy (PD2011_078) and relevant aspects of the accreditation standards across the LHD / network.

2. Support the implementation of a governance structure across the LHD / network.

3. Support local facilities to meet their nutrition care accreditation documentation requirements.

4. Review and make recommendations regarding assignment of responsibility, personnel and resources to meet the requirements of the policy and accreditation standards.

5. Ensure systems are in place to support the evaluation of nutrition care.

6. Report on implementation progress and evaluation of the requirements of the policy to [insert LHD / Network Executive Committee or/ and [insert NSW LHD / Network Patient Safety and Quality Committee name].

7. Review and make recommendations to the [insert LHD / Network Executive Committee or / and insert NSW LHD / Network Patient Safety and Quality Committee name] on the delivery of food services to best meet the nutrition care needs of their consumers within available funds and resources.

8. Review and make recommendation on food service prioritises, products and services based on consumers’ needs and changes of clinical care practices and requirements within the context of shared services framework.


ROLE NAME RESPONSIBILITIES

Chairperson and/or Executive Sponsor

Chairing meeting Reporting to LHD / Network Executive Committee and/or LHD / Network Patient Safety and Quality Committee

Director of Nursing and Midwifery

Professional advice and contribution Two-way information flow with staff

Director of Allied Health Professional advice and contribution Two-way information flow with staff

Medical Services Director or Delegate


Director Nutrition and Dietetics and/or Senior Dietitian


Senior Food Service Provider Representative(s)


Director Speech Pathology and/or Senior Speech Pathologist


Director(s) and/or Senior Clinicians of other Allied Health professions


Director of Clinical Governance, Safety and Quality or Delegate


Director of Mental Health or Delegate


Workforce Development Representative

Professional advice and contribution on nutrition-related workforce

Consumer/Carer Representation Advice and contribution from consumer / carer perspective

LHD Food Service Dietitian(s), if appropriate

Professional advice and contribution

Administration Staff / Secretariat Booking rooms, organising equipment and organising timetable for meetings

Agenda item forwards to Chair for approval prior to the meeting

Agenda to be circulated one week in advance

Minutes to be circulated by email within two weeks of the meeting

3. REQUIRED MEMBERSHIPMembers of [Insert LHD/Network Committee Name / Title]

Correct as at: [Insert dd/mm/yyyy]


ROLE RESPONSIBILITIES

Director(s) Workforce Two-way information flow with workforce, as appropriate

Senior Dietitian(s), if appropriate Professional advice and contribution

Project Officer(s), if appropriate Undertaking delegated tasks by the Committee

4. OTHER MEMBERSHIP FOR CONSIDERATION / CIRCULATION OF MINUTES

The Committee may request the attendance of other personnel, as required. Other personnel in attendance are able to provide support and advice but have no formal role in decisions made by the Committee.

5. FREQUENCY OF MEETINGS

• [Insert frequency of meetings e.g. monthly/bimonthly/quarterly]

6. QUORUM

• 50% or at the discretion of Chairperson(s).

• If <50% present, issues or documents to be circulated to members prior to sign off.

7. REPORTING COMMITTEES

This committee reports directly to the following:

Examples could include • NSW LHD / Network Patient Safety and Clinical Quality Committee via [nominated member(s)]

• NSW LHD / Network Clinical Committee via [nominated member(s)]

• NSW LHD / Network Operational Committee via [nominated member(s)]

• All members provide reports to their professional line management, as appropriate.

Actions with respect to performance under the Food Service Partnership Agreement will be referred to:

Examples could include:• Director of Finance and Corporate Services

• Public Private Partnership Office Representatives.

An example of a reporting structure is below:

Figure 1: Reporting line for LHD / Network Nutrition Care Committee


8. LINKS TO OTHER COMMITTEES

The Committee has links to the following committees:

Examples could include:• NSW Health Nutrition and Food Committee via [nominated member(s)]

• ACI Nutrition in Hospital Committee via [nominated member(s)]

• HealthShare NSW Food Service Committees via [nominated member(s)].

9. METHOD OF EVALUATION

• Annual review of Terms of Reference against action plan

• Annual review of membership

Other examples could include: • Six monthly review of progress against action plan, Nutrition Care Policy checklist and/or Mental Health

Nutrition Standards implementation checklist

• Six monthly review of IIMS data.


Appendix 4: NSW Health Facility Nutrition Care Committee Agenda Template

AGENDA NUTRITION CARE COMMITTEE

[Insert name of NSW Facility Meeting][Insert name NSW LHD / Network Area][Insert Date and Meeting Timeframe]

[Insert meeting venue location and room][Insert other attendance options e.g. teleconference, videoconference, webinar]

1. Acknowledgment of country

2. Attendance and apologies

3. Conflicts of interest

4. Confirmation of previous minutes from [Insert last meeting date]

5. Business arising from previous meetings

6. Nutrition care implementation 6.1 Policy and governance 6.1.1 Governance e.g. local / facilities 6.1.2 Action plan / Nutrition Care Policy checklist 6.1.3 Accreditation e.g. NSQHS, NSMHS, EQuIP 6.2 Nutrition screening 6.3 Nutrition assessment 6.4 Nutrition care planning 6.4.1 Transfer of care 6.5 Planning and delivery of food and fluids 6.5.1 Menus e.g. nutrition standard, therapeutic diets 6.5.2 Provision of food and fluids 6.6 The mealtime environment 6.7 Provision of assistance to eat and drink e.g. opening packets, feeding, supervision 6.8 Staff education and training e.g. clinical staff, food service staff

7. Nutrition Care Evaluation / KPI’s 7.1. Weight and height measurements 7.2. Nutrition screening e.g. MST, metabolic monitoring 7.3. Nutrition assessment 7.4. Consumer food satisfaction survey 7.5. Food service audits e.g. portion control, wastage 7.6. IIMs data 7.7. Complaints and compliments

8. LHD / Network nutrition care related updates

9. Documents for endorsement / notation / information

10. New business

11. Business without notice

12. Next meetings – [Insert meeting dates(s)]


Appendix 5: NSW Health Facility Nutrition Care Committee Terms of Reference Template

TERMS OF REFERENCE NUTRITION CARE COMMITTEE

[Insert name of NSW Facility Nutrition Care Meeting][Insert name NSW LHD / Network Area]

REPORTS TO [Insert Facility Nutrition Care Committee name]

REPORTER [Insert Chairpersons name and/or other committee members name]

CHAIRPERSON(S) [Insert Chairpersons name]

SECRETARIAT [Insert Administration Staff name]

ENDORSED BY [Insert Site / Area Manager name] DATE

NEXT REVIEW Annually

1. PURPOSEThe purpose of this committee is to:

• Oversee the provision of nutrition care for all inpatients and residents within this facility/service as per the NSW Health Nutrition Care Policy (PD2011_078) directive and related accreditation standards.

• Ensure nutrition care services are in line with LHD / Network / Facility strategic and operational plan(s).

2. RESPONSIBILITIES / FUNCTIONS

1. Oversee the implementation of the Nutrition Care Policy (PD2011_078) and relevant aspects of the accreditation standards at the site / facility.

2. Commence and regularly hold nutrition care meetings that form the site / facility governance structure.

3. Facilitate communication of information on the implementation of the policy throughout the site / facility.

4. Demonstrate how their site / facility meets their nutrition care accreditation requirements.

5. Develop a site / facility based action plan for the implementation of the nutrition care journey process i.e. one that identifies areas for improvement, assign responsibilities to nutrition care steps, identifies procedures or guidelines that need developing and/or areas that need addressing by the [LHD / Network Nutrition Care Committee].

6. Review and make site / facility recommendations directly to the [LHD / Network Nutrition Care Committee] in terms of assignments of responsibility, personnel and resources to meet the policy.

7. Assist in outlining the menu requirements for the site and approval of menu changes in conjunction with [insert LHD / Network Nutrition Care Committee] and appropriate staff e.g. Dietitian.

8. Implement all LHD / network recommendations e.g. staff education and training, nutrition risk screening and nutrition assessment tools, nutrition evaluation tools.

9. Report on implementation progress and evaluation of the requirements of the policy to [insert LHD / Network Nutrition Care Committee] including staff and consumer feedback.


ROLE NAME RESPONSIBILITIES

Chairperson and/or Executive Sponsor

Chairing meeting

Reporting to LHD / Network Nutrition Care Committee

Nursing/Midwifery Manager(s) Professional advice and contribution Two-way information flow with site staff

Dietitian(s) and/or Consultant Dietitian


Nurse Unit Manager Representative(s)


Medical Staff Representative(s) Professional advice and contribution Two-way information flow with staff

Food Service Provider Representative(s)


Consumer/Carer Representation Advice and contribution from consumer / carer perspective

Administration Staff Booking rooms, organising equipment and organising timetable for meetings

Agenda item forwards to Chair for approval prior to the meeting

Agenda to be circulated one week in advance

Minutes to be circulated by email within two weeks of the meeting

3. REQUIRED MEMBERSHIPMembers of [Insert LHD/Network Committee Name / Title]

Correct as at: [Insert dd/mm/yyyy]

ROLE RESPONSIBILITIES

Finance and Corporate Services Representative Professional advice and contribution

Clinical Governance and/or Quality Representative Professional advice and contribution Two-way information flow with staff

Speech Pathologist Professional advice and contribution Two-way information flow with staff

Occupational Therapist Professional advice and contribution Two-way information flow with staff

Dietitian Assistant / Allied Health Assistant (Nutrition and Dietetics) Representative

Professional advice and contribution

4. OTHER MEMBERSHIP FOR CONSIDERATION / CIRCULATION OF MINUTES


The Committee may request the attendance of other personnel, as required. Other personnel in attendance are able to provide support and advice but have no formal role in decisions made by the committee.

5. FREQUENCY OF MEETINGS• [Insert frequency of meetings e.g. monthly/bimonthly]

6. QUORUM• 50% or at the discretion of Chairperson(s)

• If <50% present, issues or documents to be circulated to members prior to sign off.

7. REPORTING COMMITTEES • The committee reports directly to the [insert NSW LHD / Network Nutrition Care Committee and the Facility

Clinical Committee].

An example of a reporting structure is below:

Figure 1: Reporting line for Facility Nutrition Care Committee

8. LINKS TO OTHER COMMITTEESThis committee has links to the following committees:

• Examples could include:

- ACI Nutrition in Hospitals Committee- HealthShare NSW Food Service Committees (where appropriate)

9. METHOD OF EVALUATION• Annual review of Terms of Reference against action plan

• Annual review of membership

Other examples could include: • Six monthly review of progress against action plan, Nutrition Care Policy checklist and/or Mental Health Nutrition

Standards implementation checklist

• Six monthly review of IIMS data

• Six monthly review of complaints and compliments

• Official Visitors reports, if includes mental health units/facilities.


Appendix 6: Nutrition Care Committees - Engaging Consumers / Carers

It is mutually beneficial for the organisation to engage consumers and carers to ensure nutrition care is patient-centred. The aim of this document is to provide information about engaging consumer / carers and supporting them to actively contribute at Nutrition Care Committees. For additional guidelines about consumer representatives please refer to the following:

- Consumer Representatives – Working with Consumers in NSW Health, Guidelines for Secretariat (GL2005_043)

- Consumer Participation in NSW Drug and Alcohol Services (GL2005_075)

- Consumer and Community Representative Selection – Guidelines NSW Department of Health (GL2005_042)

The NSW Ministry of Health is in the process of finalising its Consumer and Community Participation Framework.

Invitations • The Nutrition Care Committee will determine

the number of Consumer / Carer committee representative(s) to be appointed and confirm the invitation and selection process.

• As part of the invitation, each LHD / Network and Facility Nutrition Care Committee should provide Consumer / Carer representatives with adequate information about the committee, scheduled meeting dates and time commitments involved.

Period of Appointment • The term of appointment will be at least 1 year,

unless other arrangements are made with the committee.

• Ongoing membership should be discussed with the Consumer / Carer member(s) at the end of the term by the Chair of the Nutrition Care Committee.

• Consumer / Carer representatives have the right to resign at any time.

• Outgoing Consumer / Carer representative(s) should be encouraged to provide feedback on their experience at the end of the appointed term to the Nutrition Care committee and assist the orientation of new Consumer / Carer representative(s) if possible.

Support • The Consumer / Carer representative(s) will be

provided with ongoing support during their term of appointment. This should include the provision of

terms of reference, minutes, meeting appointments, venue and times and any other relevant publications (e.g. Nutrition Care Policy, ACI Nutrition Standards etc.). Short briefing and debriefing sessions can help the consumer prepare for meetings and provide an opportunity for any clarification required.

• The Consumer / Carer representative(s) will be encouraged to contact the Chair of the Nutrition Care Committee if assistance or guidance is required (i.e. general information, background etc.).

• The Nutrition Care Committee members are to use plain English in their communications and dialogue so as to minimise medical language, abbreviations, acronyms, or organisational terminology. Commonly used terms, abbreviations and acronyms will be provided to the Consumer / Carer representative.

• Reimbursement for reasonable out of pocket expenses (e.g. travel, food, accommodation etc.) will be processed at the time of the meeting or as soon as possible afterwards.

Role of the Consumer• Consumers will be actively encouraged to

contribute from the perspective of the Consumer / Carer and/or their families. Contributions are highly valued and could include food and mealtime experiences, access to and support from staff, education and resource development recommendations etc.

• The Consumer / Carer representative(s) with appropriate support may be asked to share their experiences at relevant meetings, network events, and conferences and in media releases with their approval.

NSW Code of Conduct • The Consumer / Carer representative will receive

the NSW Health Code of Conduct and information about the NSW Health confidentiality requirements with support to complete the required form(s).

• Permission in writing is required prior to sharing/discussing any information outside the committee membership e.g. media.

Monitoring and Evaluation • The Consumer / Carer representative(s) will

be encouraged to actively participate in the monitoring and evaluation activities of the Nutrition Care Committee.

�Consumer Representatives – Working with Consumers in NSW Health, Guidelines for Secretariat (GL2005_043)





http://www0.health.nsw.gov.au/policies/GL/2005/GL2005_042.html




Appendix 7: NSW Health Nutrition Care Policy: Mapping to Accreditation Requirements

The purpose of this resource is to provide guidance on how elements of the NSW Health Nutrition Care Policy directive (PD2011_78) meet the accreditation requirements for the:

- National Standards for Mental Health Services (NSMHS),

- National Safety and Quality Health Service Standards (NSQHS); and

- Evaluation and Quality Improvement Program (EQuIP) additional standards.

It maps the standards to the Nutrition Care Policy elements and provides example evidence that LHD / Network and/or Facility Nutrition Care Committees could consider when mapping their own accreditation evidence.

1. Overview of Nutrition Care Policy Links to Accreditation Standards

The Nutrition Care Policy directive has nine elements:1. Policy and Governance

2. Nutrition Screening

3. Nutrition Assessment

4. Nutrition Care Planning

5. Planning and Delivery of Food and Fluids

6. The Meal Time Environment

7. Provision of Assistance to Eat and Drink

8. Staff Education and Training

9. Evaluation

There is currently no mandatory national nutrition care accreditation standard within the 10 NSQHS.

The Nutrition Care Policy does have links to the following:

• eight of the nine mandatory assessable National Standards for Mental Health Services (NSMHS)

• nine of the mandatory 10 NSQHS

• all five of the elective EQuIP standards in particular Standard 12 Criterion 2: Management of Nutrition Care.

2. Overview of the National Accreditation Standards

NSMHSAll NSW Mental Health Services are required to meet the following 10 NSMHS:

1. Rights and Responsibilities

2. Safety

3. Consumer and Carer Participation

4. Diversity Responsiveness

5. Promotion and Prevention

6. Consumers (not assessable)

7. Carers

8. Governance, Leadership and Management

9. Integration

10. Delivery of Care:

10.1. Supporting Recovery

10.2. Access

10.3. Entry

10.4. Assessment and Review

10.5 Treatment and Support

10.6. Exit and Re-entry.

NSQHSAll NSW hospitals are required to be accredited to the following 10 NSQHS:

1. Governance for Safety and Quality in Health Service Organisations

2. Partnering with Consumers

3. Preventing and Controlling Healthcare Associated Infections

4. Medication Safety

5. Patient Identification and Procedure Matching

6. Clinical Handover

7. Blood and Blood Products

8. Preventing and Managing Pressure Injuries

9. Recognising and Responding to Clinical Deterioration

10. Preventing Falls and Harm from Falls.

EQuIP There are an additional five EQuIP standards, that when combined with the 10 NSQHS are described as EQuIPNational:

11. Service Delivery

12. Provision of Care

13. Workforce Planning and Management

14. Information Management

15. Corporate Systems and Safety










3.

Map

ping

of N

utri

tion

Car

e P

olic

y to

Acc

redi

tati

on S

tand

ards

Tabl

e 1:

NSW

Hea

lth

Nut

riti

on C

are

Pol

icy

(NCP

) map

ped

to th

e N

atio

nal S

afet

y an

d Q

ualit

y H

ealt

h Se

rvic

e St

anda

rds

(NSQ

HS)

and

Nat

iona

l Sta

ndar

ds fo

r M

enta

l Hea

lth

Serv

ices

(NSM

HS)

(A

dapt

ed w

ith

perm

issi

on fr

om th

e H

NEL

HD

Nut

riti

on C

are

Pol

icy

Impl

emen

tati

on C

omm

itte

e, N

utri

tion

Car

e: C

heck

list

for

Acc

redi

tati

on, 2

014)

NSQ

HS

Des

crip

tio

n o

f th

e St

and

ard

Lin

ks t

o N

SMH

SR

elat

ed N

CP

Elem

ents

LHD

/ N

etw

ork

Nu

trit

ion

Car

e C

om

mit

tee

Evid

ence

Exa

mp

les

Faci

lity

Nu

trit

ion

Car

e C

om

mit

tee

Evid

ence

Ex

amp

les

1G

ove

rnan

ce f

or

Safe

ty a

nd

Qu

alit

y in

Hea

lth

Ser

vice

Org

anis

atio

ns

1.1

Impl

emen

ting

a go

vern

ance

sys

tem

th

at s

ets

out

the

polic

ies,

pro

cedu

res

and

/or

prot

ocol

s fo

r:

• es

tabl

ishi

ng a

nd m

aint

aini

ng a

cl

inic

al g

over

nanc

e fr

amew

ork

• id

entif

ying

saf

ety

and

qual

ity r

isks

• co

llect

ing

and

revi

ewin

g pe

rfor

man

ce d

ata

• im

plem

entin

g pr

even

tion

stra

tegi

es b

ased

on

data

ana

lysi

s

• an

alys

ing

repo

rted

inci

dent

s

• im

plem

entin

g pe

rfor

man

ce

man

agem

ent

proc

edur

es

• en

surin

g co

mpl

ianc

e w

ith

legi

slat

ive

requ

irem

ents

and

re

leva

nt in

dust

ry s

tand

ards

• co

mm

unic

atin

g w

ith a

nd

info

rmin

g th

e cl

inic

al a

nd n

on-

clin

ical

wor

kfor

ce

• un

dert

akin

g re

gula

r cl

inic

al a

udits

.

1) R

ight

s an

d Re

spon

sibi

litie

s

7) C

arer

s

8)

Gov

erna

nce,

Le

ader

ship

and

M

anag

emen

t

10) D

eliv

ery

of C

are

1) P

olic

y an

d G

over

nanc

e

8)

Staf

f Ed

ucat

ion

and

Trai

ning

9)

Eval

uatio

n

• Id

entif

y th

e C

hair

and

the

Cor

pora

te S

pons

or o

f LH

D

/ Net

wor

k N

utrit

ion

Car

e C

omm

ittee

• Ev

iden

ce o

f re

gula

r m

eetin

gs

with

:

- A

gend

a

- Te

rms

of R

efer

ence

(TO

R)

incl

udin

g m

embe

rshi

p

- M

inut

es a

nd A

ctio

n Li

sts.

• Ev

iden

ce in

form

atio

n is

co

mm

unic

ated

to

faci

litie

s vi

a:

- L

HD

/ N

etw

ork

Nut

ritio

n C

are

intr

anet

site

- F

acili

ty N

utrit

ion

Car

e C

omm

ittee

key

con

tact

re

pres

enta

tives

.

• N

utrit

ion

Car

e In

tran

et s

ite h

as a

te

mpl

ate

for

faci

litie

s to

rep

ort

on

the

Nut

ritio

n C

are

Polic

y au

dits

• Id

entif

y fa

cilit

y N

utrit

ion

Car

e C

omm

ittee

or

Patie

nt

Safe

ty a

nd Q

ualit

y C

omm

ittee

w

here

Nut

ritio

n C

are

is a

re

curr

ent

agen

da it

em

• Ev

iden

ce o

f re

gula

r m

eetin

gs

with

:

- A

gend

a

- T

OR

incl

udin

g m

embe

rshi

p,

mee

ting

sche

dule

- M

inut

es a

nd A

ctio

n Li

sts.

• Ev

iden

ce o

f re

gula

r nu

triti

on c

are

audi

ts u

sing

re

com

men

ded

NSW

and

/or

LHD

/ Net

wor

k st

anda

rdis

ed

audi

t to

ols

Con

tinu

ed o

n pa

ge 3

2


NSQ

HS

Des

crip

tio

n o

f th

e St

and

ard

Lin

ks t

o N

SMH

SR

elat

ed N

CP

Elem

ents

LHD

/ N

etw

ork

Nu

trit

ion

Car

e C

om

mit

tee

Evid

ence

Exa

mp

les

Faci

lity

Nu

trit

ion

Car

e C

om

mit

tee

Evid

ence

Ex

amp

les

1G

ove

rnan

ce f

or

Safe

ty a

nd

Qu

alit

y in

Hea

lth

Ser

vice

Org

anis

atio

ns

- C

ON

TIN

UED

1.2

The

Boar

d, C

hief

Exe

cutiv

e O

ffice

r an

d/o

r ot

her

high

er le

vel o

f go

vern

ance

with

in a

hea

lth s

ervi

ce

orga

nisa

tion

taki

ng r

espo

nsib

ility

for

pa

tient

saf

ety

and

qual

ity o

f ca

re

2) S

afet

y

8)

Gov

erna

nce,

Le

ader

ship

and

M

anag

emen

t

1) P

olic

y an

d G

over

nanc

e

8)

Staf

f Ed

ucat

ion

and

Trai

ning

9)

Eval

uatio

n

As

abov

eA

s ab

ove

1.3

Ass

igni

ng w

orkf

orce

rol

es,

resp

onsi

bilit

ies

and

acco

unta

bilit

ies

to

indi

vidu

als

for:

• pa

tient

saf

ety

and

qual

ity in

the

ir de

liver

y of

hea

lth c

are

• th

e m

anag

emen

t of

saf

ety

and

qual

ity s

peci

fied

in e

ach

of t

hese

St

anda

rds.

8)

Gov

erna

nce,

Le

ader

ship

and

M

anag

emen

t

As

abov

e•

Evid

ence

of

Nut

ritio

n C

are

trai

ning

pac

kage

s av

aila

ble

on

the

Nut

ritio

n C

are

Intr

anet

site

w

ith c

lear

rol

e an

d re

spon

sibi

litie

s fo

r ea

ch o

f th

e N

utrit

ion

Car

e Po

licy

elem

ents

• Ev

iden

ce o

f ar

ea o

f im

prov

emen

t in

nut

ritio

n ca

re w

orkf

orce

an

alys

ed

• Ev

iden

ce o

f pr

ovis

ion

of

assi

stan

ce t

o fa

cilit

ies

in r

egar

d to

new

pos

ition

fun

ding

and

/or

reco

mm

enda

tions

for

re-

alig

ned

pers

onne

l for

saf

e nu

triti

on

care

pro

visi

on (i

.e. A

CI P

atie

nt

Nut

ritio

n C

are

Jour

ney

and

AC

I C

hOIC

ES)

• Ev

iden

ce o

f th

e in

clus

ion

of

nutr

ition

car

e re

spon

sibi

litie

s in

pos

ition

des

crip

tions

for

all

pers

onne

l inv

olve

d in

nut

ritio

n ca

re p

roce

ss

• Ev

iden

ce o

f ap

prop

riate

su

perv

isio

n an

d re

port

ing

lines

, per

form

ance

de

velo

pmen

t re

view

for

all

pers

onne

l inv

olve

d in

the

nu

triti

on c

are

proc

ess

• Ev

iden

ce t

hat

staf

f un

dert

akin

g ta

sks

outli

ned

in

the

Patie

nt C

are

Jour

ney

have

ap

prop

riate

tra

inin

g

• Ev

iden

ce o

f st

aff

qual

ifica

tions

• Ev

iden

ce s

taff

rec

eive

d nu

triti

on c

are

educ

atio

n up

date

s on

a r

egul

ar b

asis

Con

tinu

ed o

n pa

ge 3

3






NSQ

HS

Des

crip

tio

n o

f th

e St

and

ard

Lin

ks t

o N

SMH

SR

elat

ed N

CP

Elem

ents

LHD

/ N

etw

ork

Nu

trit

ion

Car

e C

om

mit

tee

Evid

ence

Exa

mp

les

Faci

lity

Nu

trit

ion

Car

e C

om

mit

tee

Evid

ence

Ex

amp

les

1G

ove

rnan

ce f

or

Safe

ty a

nd

Qu

alit

y in

Hea

lth

Ser

vice

Org

anis

atio

ns

- C

ON

TIN

UED

1.4

Impl

emen

ting

trai

ning

in t

he

assi

gned

saf

ety

and

qual

ity r

oles

and

re

spon

sibi

litie

s

2) S

afet

y

8)

Gov

erna

nce,

Le

ader

ship

and

M

anag

emen

t

1) P

olic

y an

d G

over

nanc

e

8)

Staf

f Ed

ucat

ion

and

Trai

ning

9)

Eval

uatio

n

See

evi

denc

e fo

r 1.

3 ab

ove

See

evi

denc

e fo

r 1.

3 ab

ove

1.5

Esta

blis

hing

an

orga

nisa

tion-

wid

e ris

k m

anag

emen

t sy

stem

tha

t in

corp

orat

es

iden

tifica

tion,

ass

essm

ent,

ratin

g,

cont

rols

and

mon

itorin

g fo

r pa

tient

sa

fety

and

qua

lity

2) S

afet

y

8)

Gov

erna

nce,

Le

ader

ship

and

M

anag

emen

t

As

abov

e•

Evid

ence

of

the

use

of N

SW

Hea

lth s

tand

ardi

sed

inci

dent

in

form

atio

n m

anag

emen

t sy

stem

(IIM

S) in

the

rep

ortin

g of

nu

triti

on c

are

inci

dent

s

• Ev

iden

ce o

f re

view

s of

IIM

S da

ta a

nd p

rovi

sion

of

repo

rts

and

reco

mm

enda

tions

to

loca

l/ fa

cilit

ies,

as

requ

ired

• Ev

iden

ce o

f th

e us

e of

NSW

H

ealth

IIM

S to

rep

ort

nutr

ition

ca

re in

cide

nts

and

near

mis

ses

• Ev

iden

ce o

f re

view

of

IIMS

data

and

rec

omm

ende

d co

rrec

tive

actio

ns f

or

reso

lutio

n ar

e im

plem

ente

d,

as a

ppro

pria

te

1.6

Esta

blis

hing

an

orga

nisa

tion-

wid

e qu

ality

man

agem

ent

syst

em t

hat

mon

itors

and

rep

orts

on

the

safe

ty

and

qual

ity o

f pa

tient

car

e an

d in

form

s ch

ange

s in

pra

ctic

e

8)

Gov

erna

nce,

Le

ader

ship

and

M

anag

emen

t

As

abov

e•

Evid

ence

of

90 d

ay a

ctio

ns p

lans

• Ev

iden

ce t

hat

Nut

ritio

n C

are

is

inco

rpor

ated

into

fac

ility

/site

st

anda

rd p

ract

ice:

- 9

0 da

y ac

tion

plan

s

- Q

ualit

y pr

ojec

ts o

n nu

triti

on

care

and

/or

incl

uded

.

Con

tinu

ed o

n pa

ge 3

7






Con

tinu

ed o

n pa

ge 3

8

NSQ

HS

Des

crip

tio

n o

f th

e St

and

ard

Lin

ks t

o N

SMH

SR

elat

ed N

CP

Elem

ents

LHD

/ N

etw

ork

Nu

trit

ion

Car

e C

om

mit

tee

Evid

ence

Exa

mp

les

Faci

lity

Nu

trit

ion

Car

e C

om

mit

tee

Evid

ence

Ex

amp

les

1G

ove

rnan

ce f

or

Safe

ty a

nd

Qu

alit

y in

Hea

lth

Ser

vice

Org

anis

atio

ns

- C

ON

TIN

UED

1.7

Dev

elop

ing

and

/or

appl

ying

clin

ical

gu

idel

ines

or

path

way

s th

at a

re

supp

orte

d by

the

bes

t av

aila

ble

evid

ence

10)

Del

iver

y

of C

are

2) N

utrit

ion

Scre

enin

g

3)

Nut

ritio

n A

sses

smen

t

4)

Nut

ritio

n C

are

Plan

ning

• Ev

iden

ce o

f de

velo

pmen

t an

d us

e of

nut

ritio

n ca

re s

peci

fic p

olic

ies,

pr

oced

ures

, gui

delin

es a

nd

path

way

s fo

r LH

D/ N

etw

ork

e.g.

:

- N

utrit

ion

scre

enin

g -

Nut

ritio

n as

sess

men

t -

Par

ente

ral,

ente

ral a

nd o

ral

nutr

ition

sup

port

- N

utrit

ion-

rela

ted

acut

e an

d en

durin

g co

nditi

ons

path

way

s e.

g. d

iabe

tes,

ove

rwei

ght/

ob

esity

, eat

ing

diso

rder

s et

c.

• Ev

iden

ce o

f th

e us

e of

nu

triti

on c

are

spec

ific

guid

elin

es o

r pa

thw

ays

for

LHD

/ Net

wor

k in

con

junc

tion

with

loca

l gui

delin

es /

proc

edur

es d

evel

oped

, as

appr

opria

te


NSQ

HS

Des

crip

tio

n o

f th

e St

and

ard

Lin

ks t

o N

SMH

SR

elat

ed N

CP

Elem

ents

LHD

/ N

etw

ork

Nu

trit

ion

Car

e C

om

mit

tee

Evid

ence

Exa

mp

les

Faci

lity

Nu

trit

ion

Car

e C

om

mit

tee

Evid

ence

Ex

amp

les

1G

ove

rnan

ce f

or

Safe

ty a

nd

Qu

alit

y in

Hea

lth

Ser

vice

Org

anis

atio

ns

- C

ON

TIN

UED

1.8

Ado

ptin

g pr

oces

ses

to s

uppo

rt t

he

early

iden

tifica

tion,

ear

ly in

terv

entio

n an

d ap

prop

riate

man

agem

ent

of

patie

nts

at in

crea

sed

risk

of h

arm

2)

Safe

ty

10) D

eliv

ery

of

Car

e

2) N

utrit

ion

Scre

enin

g

3)

Nut

ritio

n A

sses

smen

t

5) P

lann

ing

and

Del

iver

y of

Fo

od a

nd F

luid

s

9)

Eval

uatio

n

• Ev

iden

ce N

utrit

ion

Scre

enin

g

is in

pla

ce

• Ev

iden

ce o

f us

e of

a

com

pute

rised

men

u pr

ogra

m

linke

d to

clin

ical

info

rmat

ion

i.e

. ale

rts

• Ev

iden

ce t

hat

resu

lts o

f ex

tern

al

patie

nt s

atis

fact

ion

surv

ey r

esul

ts

are

acce

ssed

, rev

iew

ed a

nd u

sed

to e

valu

ate

perf

orm

ance

(e.g

. H

ealth

Shar

e N

SW -

Foo

d Se

rvic

e Pa

tient

Sat

isfa

ctio

n, B

urea

u of

Hea

lth In

form

atio

n –

NSW

Pa

tient

Sur

vey)

• Ev

iden

ce t

here

is a

sys

tem

in

plac

e to

ass

ist

cons

umer

s in

m

enu

sele

ctio

n

- S

taff

pro

vidi

ng a

ssis

tanc

e ha

ve a

ppro

pria

te t

rain

ing

and

supe

rvis

ion

- C

onsu

mer

s re

ceiv

e in

form

atio

n ab

out

the

food

se

rvic

e-

Con

sum

ers

have

an

oppo

rtun

ity t

o pr

ovid

e fe

edba

ck v

ia a

pat

ient

sa

tisfa

ctio

n su

rvey

- Im

prov

emen

ts im

plem

ente

d ar

e co

mm

unic

ated

to

both

co

nsum

ers

and

staf

f

• Ev

iden

ce o

f si

te s

peci

fic

nutr

ition

pat

hway

s e.

g.

iden

tifica

tion

of t

hera

peut

ic

diet

nee

ds, n

utrit

ion

scre

enin

g,

nutr

ition

ass

essm

ent

• Ev

iden

ce o

f nu

triti

on

proc

edur

es/ g

uide

lines

rel

ated

to

hig

h ris

k co

nsum

ers

e.g.

m

alno

uris

hed,

dys

phag

ia,

alle

rgie

s, e

nter

al t

ube

feed

ing,

re

feed

ing

risk

• D

ocum

enta

tion

in m

edic

al

reco

rds

rega

rdin

g nu

triti

on

deci

sion

s an

d co

nsen

t e.

g.

ente

ral t

ube

feed

ing

etc.


NSQ

HS

Des

crip

tio

n o

f th

e St

and

ard

Lin

ks t

o N

SMH

SR

elat

ed N

CP

Elem

ents

LHD

/ N

etw

ork

Nu

trit

ion

Car

e C

om

mit

tee

Evid

ence

Exa

mp

les

Faci

lity

Nu

trit

ion

Car

e C

om

mit

tee

Evid

ence

Ex

amp

les

1G

ove

rnan

ce f

or

Safe

ty a

nd

Qu

alit

y in

Hea

lth

Ser

vice

Org

anis

atio

ns

- C

ON

TIN

UED

1.10

Impl

emen

ting

a sy

stem

tha

t de

term

ines

and

reg

ular

ly r

evie

ws

the

role

s, r

espo

nsib

ilitie

s, a

ccou

ntab

ilitie

s an

d sc

ope

of p

ract

ice

for

the

clin

ical

w

orkf

orce

8)

Gov

erna

nce,

Le

ader

ship

and

M

anag

emen

t

1) P

olic

y an

d G

over

nanc

e

8)

Staf

f Ed

ucat

ion

and

Trai

ning

9)

Eval

uatio

n

• Se

e ev

iden

ce f

or 1

.3 a

bove

• Se

e ev

iden

ce f

or 1

.3 a

bove

1.14

Impl

emen

ting

an in

cide

nt

man

agem

ent

and

inve

stig

atio

n sy

stem

tha

t in

clud

es r

epor

ting,

in

vest

igat

ing

and

anal

ysin

g in

cide

nts

(incl

udin

g ne

ar m

isse

s), w

hich

all

resu

lt in

cor

rect

ive

actio

ns

2) S

afet

yA

s ab

ove

• Se

e ev

iden

ce f

or 1

.5 a

bove

• Se

e ev

iden

ce f

or 1

.5 a

bove

1.15

Impl

emen

ting

a co

mpl

aint

s m

anag

emen

t sy

stem

tha

t in

clud

es

part

ners

hip

with

pat

ient

s an

d ca

rers

1) R

ight

s an

d Re

spon

sibi

litie

sA

s ab

ove

• Se

e ev

iden

ce f

or 1

.5 a

bove

• Se

e ev

iden

ce f

or 1

.5 a

bove

1.18

Impl

emen

ting

proc

esse

s to

ena

ble

part

ners

hip

with

pat

ient

s in

dec

isio

ns

abou

t th

eir

care

, inc

ludi

ng in

form

ed

cons

ent

to t

reat

men

t

1)

Righ

ts a

nd

Resp

onsi

bilit

ies

10) D

eliv

ery

of C

are

2) N

utrit

ion

Scre

enin

g

3)

Nut

ritio

n A

sses

smen

t

5) P

lann

ing

and

Del

iver

y of

Fo

od a

nd F

luid

s

9)

Eval

uatio

n

• Ev

iden

ce t

hat

resu

lts o

f ex

tern

al

patie

nt s

atis

fact

ion

surv

ey r

esul

ts

are

acce

ssed

, rev

iew

ed a

nd u

sed

to e

valu

ate

perf

orm

ance

(e.g

. H

ealth

Shar

e N

SW -

Foo

d Se

rvic

e Pa

tient

Sat

isfa

ctio

n, B

urea

u of

Hea

lth In

form

atio

n –

NSW

Pa

tient

Sur

vey)

• Ev

iden

ce t

here

is a

sys

tem

in

plac

e to

ass

ist

cons

umer

s in

m

enu

sele

ctio

n

- S

taff

pro

vidi

ng a

ssis

tanc

e ha

ve a

ppro

pria

te t

rain

ing

and

supe

rvis

ion

- C

onsu

mer

s re

ceiv

e in

form

atio

n ab

out

the

food

se

rvic

e-

Con

sum

ers

have

an

oppo

rtun

ity t

o pr

ovid

e fe

edba

ck v

ia a

pat

ient

sa

tisfa

ctio

n su

rvey

- Im

prov

emen

ts im

plem

ente

d ar

e co

mm

unic

ated

to

both

co

nsum

ers

and

staf

f

Con

tinu

ed o

n pa

ge 4

0


NSQ

HS

Des

crip

tio

n o

f th

e St

and

ard

Lin

ks t

o

NSM

HS

Rel

ated

NC

P El

emen

tsLH

D /

Net

wo

rk N

utr

itio

n C

are

Co

mm

itte

e Ev

iden

ce E

xam

ple

sFa

cilit

y N

utr

itio

n C

are

Co

mm

itte

e Ev

iden

ce E

xam

ple

s

1G

ove

rnan

ce f

or

Safe

ty a

nd

Qu

alit

y in

Hea

lth

Ser

vice

Org

anis

atio

ns

- C

ON

TIN

UED

1.20

Impl

emen

ting

wel

l des

igne

d, v

alid

and

re

liabl

e pa

tient

exp

erie

nce

feed

back

m

echa

nism

s an

d us

ing

thes

e to

eva

luat

e th

e he

alth

ser

vice

per

form

ance

3)

Con

sum

er

and

Car

er

Part

icip

atio

n

As

abov

e•

See

evid

ence

for

1.1

8 ab

ove

• Se

e ev

iden

ce f

or 1

.18

abov

e

2Pa

rtn

erin

g w

ith

Co

nsu

mer

s

2.2

Esta

blis

hing

gov

erna

nce

stru

ctur

es t

o fa

cilit

ate

part

ners

hip

with

con

sum

ers

and

/or

car

ers:

• st

rate

gic

and

oper

atio

nal/s

ervi

ces

plan

ning

• d

ecis

ion

mak

ing

abou

t sa

fety

and

qu

ality

initi

ativ

es

• qu

ality

impr

ovem

ent

activ

ities

3)

Con

sum

er

and

Car

er

Part

icip

atio

n

7) C

arer

s

10)

Del

iver

y of

C

are

1) P

olic

y an

d G

over

nanc

e

• Ev

iden

ce o

f co

nsum

er /

care

r re

pres

enta

tion

on L

HD

/ Net

wor

k N

utrit

ion

Car

e C

omm

ittee

• Ev

iden

ce o

f in

tran

et p

age

links

to

broc

hure

and

sta

ndar

ds t

hat

have

ha

d co

nsum

er a

nd/o

r ca

rers

inpu

t in

to d

evel

opm

ent

e.g.

A

CI r

esou

rces

• Ev

iden

ce o

f co

nsum

er /

care

r co

nsul

tatio

n in

nut

ritio

n ca

re L

HD

/ N

etw

ork

polic

ies,

pro

cedu

res

and

reso

urce

s et

c.

• Ev

iden

ce o

f co

nsum

er /

care

r re

pres

enta

tion

on f

acili

ty

Nut

ritio

n C

are

Com

mitt

ee

e.g.

inpu

t in

to s

ite b

ased

pr

oced

ures

or

guid

elin

es,

reso

urce

s an

d/o

r im

plem

entin

g m

enu

chan

ges

• Ev

iden

ce o

f us

e of

A

CI r

esou

rces

2.4

Con

sulti

ng c

onsu

mer

s on

pat

ient

in

form

atio

n di

strib

uted

by

the

orga

nisa

tion

As

abov

eA

s ab

ove

2.5

Part

nerin

g w

ith c

onsu

mer

s an

d/o

r ca

rers

to

des

ign

the

way

car

e is

del

iver

ed t

o be

tter

met

pat

ient

nee

ds a

nd p

refe

renc

es

As

abov

eA

s ab

ove

2.8

Con

sum

ers

and

/or

care

rs p

artic

ipat

ing

in t

he a

naly

sis

of s

afet

y an

d qu

ality

pe

rfor

man

ce in

form

atio

n an

d da

ta, a

nd

the

deve

lopm

ent

and

impl

emen

tatio

n of

ac

tion

plan

s

As

abov

eA

s ab

ove

2.9

Con

sum

ers

and

/or

care

rs p

artic

ipat

ing

in

the

eval

uatio

n of

pat

ient

fee

dbac

k da

ta

and

deve

lopm

ent

of a

ctio

n pl

ans

As

abov

eA

s ab

ove

Con

tinu

ed o

n pa

ge 3

8




NSQ

HS

Des

crip

tio

n o

f th

e St

and

ard

Lin

ks t

o

NSM

HS

Rel

ated

NC

P El

emen

tsLH

D /

Net

wo

rk N

utr

itio

n C

are

Co

mm

itte

e Ev

iden

ce E

xam

ple

sFa

cilit

y N

utr

itio

n C

are

Co

mm

itte

e Ev

iden

ce E

xam

ple

s

3Pr

even

tin

g a

nd

Co

ntr

olli

ng

Hea

lth

care

Ass

oci

ated

Infe

ctio

ns

3.1

Dev

elop

ing

and

impl

emen

ting

gove

rnan

ce s

yste

ms

for

effe

ctiv

e in

fect

ion

prev

entio

n an

d co

ntro

l to

min

imis

e th

e ris

k to

pat

ient

s of

hea

lthca

re a

ssoc

iate

d in

fect

ions

2) S

afet

y5)

Pl

anni

ng

and

Del

iver

y of

Fo

od a

nd

Flui

ds

7)

Prov

isio

n of

A

ssis

tanc

e to

eat

and

D

rink

• Ev

iden

ce o

f re

fere

nce

to t

he

NSW

Hea

lth H

and

Hyg

iene

Pol

icy

(PD

2010

_058

) with

in a

ppro

pria

te

nutr

ition

car

e re

late

d pr

oced

ures

/ gu

idel

ines

• Ev

iden

ce o

f ad

here

nce

to

man

dato

ry h

and

hygi

ene

/ in

fect

ion

cont

rol t

rain

ing

• Ev

iden

ce o

f ha

nd h

ygie

ne a

nd

pers

onal

pro

tect

ion

equi

pmen

t (P

PE) a

udits

for

all

pers

onne

l in

volv

ed in

nut

ritio

n ca

re

• Ev

iden

ce o

f co

mpl

ianc

e w

ith

NSW

Hea

lth f

ood

auth

ority

gu

idel

ines

• Ev

iden

ce t

hat

appr

opria

te

infe

ctio

n co

ntro

l pro

cedu

res

are

in

plac

e:

- H

and

hygi

ene

for

cons

umer

s be

fore

mea

ls

- M

anda

tory

han

d hy

gien

e /

infe

ctio

n co

ntro

l sta

ff t

rain

ing

- A

udits

of

hand

hyg

iene

and

PP

E us

e

- S

tora

ge a

nd /

or p

repa

ratio

n of

pa

tient

s fo

od

4M

edic

atio

n S

afet

y

4.1

Dev

elop

ing

and

impl

emen

ting

gove

rnan

ce a

rran

gem

ents

and

or

gani

satio

nal p

olic

ies,

pro

cedu

res

and

/or

prot

ocol

s fo

r m

edic

atio

n sa

fety

, whi

ch a

re

cons

iste

nt w

ith n

atio

nal a

nd ju

risdi

ctio

nal

legi

slat

ive

requ

irem

ents

, pol

icie

s an

d gu

idel

ines

10)

Del

iver

y of

Car

e1)

Po

licy

and

Gov

erna

nce

5)

Plan

ning

an

d D

eliv

ery

of

Food

and

Fl

uids

• Ev

iden

ce o

f LH

D/ N

etw

ork

proc

edur

es a

bout

the

re

quire

men

ts f

or c

orre

ct la

belli

ng,

stor

age

and

disp

ensi

ng o

f or

al,

ente

ral a

nd p

aren

tera

l nut

ritio

n su

pple

men

ts p

rovi

ded

as p

art

of t

hera

peut

ic d

iet

or v

ia t

he

med

icat

ion

char

t

• Ev

iden

ce o

f LH

D/ N

etw

ork

polic

ies

and

/or

proc

edur

es a

bout

the

re

quire

men

ts f

or c

orre

ct la

belli

ng

and

stor

age

of in

fant

for

mul

a an

d ex

pres

sed

brea

st m

ilk

• Ev

iden

ce o

f th

e us

e of

LH

D /

Net

wor

k pr

oced

ures

and

/or

deve

lopm

ent

of f

acili

ty g

uide

lines

fo

r co

rrec

t la

belli

ng, s

tora

ge a

nd

disp

ensi

ng o

f or

al, e

nter

al a

nd

pare

nter

al n

utrit

ion

supp

lem

ents

pr

ovid

ed a

s pa

rt o

f th

erap

eutic

di

et o

r vi

a th

e m

edic

atio

n ch

art

• Ev

iden

ce o

f th

e us

e of

LH

D /

Net

wor

k an

d/o

r de

velo

pmen

t of

fac

ility

gui

delin

es f

or c

orre

ct

labe

lling

and

sto

rage

of

infa

nt

form

ula

and

expr

esse

d br

east

milk

Con

tinu

ed o

n pa

ge 4

2




NSQ

HS

Des

crip

tio

n o

f th

e St

and

ard

Lin

ks t

o N

SMH

SR

elat

ed N

CP

Elem

ents

LHD

/ N

etw

ork

Nu

trit

ion

Car

e C

om

mit

tee

Evid

ence

Exa

mp

les

Faci

lity

Nu

trit

ion

Car

e C

om

mit

tee

Evid

ence

Exa

mp

les

5Pa

tien

t Id

enti

fica

tio

n a

nd

Pro

ced

ure

Mat

chin

g

5.1

Dev

elop

ing,

impl

emen

ting

and

regu

larly

re

view

ing

the

effe

ctiv

enes

s of

a p

atie

nt

iden

tifica

tion

syst

em in

clud

ing

the

asso

ciat

ed p

olic

ies,

pro

cedu

res

and

/or

prot

ocol

s th

at:

• de

fine

appr

oved

pat

ient

iden

tifier

s

• re

quire

at

leas

t th

ree

appr

oved

pat

ient

id

entifi

ers

on r

egis

trat

ion

or a

dmis

sion

• re

quire

at

leas

t th

ree

appr

oved

pat

ient

id

entifi

ers

whe

n ca

re, t

hera

py o

r ot

her

serv

ices

are

pro

vide

d

• re

quire

at

leas

t th

ree

appr

oved

pa

tient

iden

tifier

s w

hene

ver

clin

ical

ha

ndov

er, p

atie

nt t

rans

fer

or d

isch

arge

do

cum

enta

tion.

N/A

1) P

olic

y an

d G

over

nanc

e

3)

Nut

ritio

n A

sses

smen

t

4)

Nut

ritio

n C

are

Plan

ning

5) P

lann

ing

and

Del

iver

y of

Fo

od a

nd

Flui

ds

• Ev

iden

ce o

f LH

D /

netw

ork

pr

oced

ures

/ gu

idel

ines

tha

t cl

early

incl

ude

the

patie

nt

iden

tifica

tion

as a

ste

p es

peci

ally

in

:

- D

iete

tic A

sses

smen

t

- F

ood

and

Flui

d pr

ovis

ion.

• Ev

iden

ce t

hat

LHD

/ ne

twor

k

proc

edur

es /

guid

elin

es

inco

rpor

ate

Men

tal H

ealth

Act

re

quire

men

ts a

bout

pat

ient

id

entifi

catio

n, w

here

app

ropr

iate

• Ev

iden

ce th

at e

ach

faci

lity

has

in p

lace

a s

yste

m fo

r ide

ntify

ing

patie

nts

with

rega

rdin

g to

food

an

d flu

ids

prov

ided

esp

ecia

lly th

ose

cons

umer

s w

ith:

- A

llerg

ies/

into

lera

nces

- D

ysph

agia

.

• Ev

iden

ce th

at th

e fa

cilit

y/se

rvic

e ha

s in

pla

ce e

ffec

tive

com

mun

icat

ion

proc

edur

es th

at c

ontin

ue to

iden

tify

thes

e at

risk

pat

ient

s at

eve

ry s

tage

of

the

patie

nt jo

urne

y

• Ev

iden

ce a

ll nu

triti

on-c

are

staf

f co

nduc

t the

follo

win

g:

- C

onfir

m th

e id

entit

y of

con

sum

ers

prio

r to

initi

atin

g an

y as

sess

men

t / c

are

- C

lear

ly id

entif

y co

nsum

ers

with

all

hand

over

or t

rans

fer o

f car

e

- In

corp

orat

e re

quire

men

ts o

f the

M

enta

l Hea

lth A

ct in

han

dove

r, w

here

app

ropr

iate

.

5.5

Dev

elop

ing

and

impl

emen

ting

a do

cum

ente

d pr

oces

s to

mat

ch p

atie

nts

to t

heir

inte

nded

pro

cedu

re, t

reat

men

t or

inve

stig

atio

n an

d im

plem

entin

g th

e co

nsis

tent

nat

iona

l gui

delin

es f

or p

atie

nt

proc

edur

e m

atch

ing

prot

ocol

or

othe

r re

leva

nt p

roto

cols

.

N/A

1) P

olic

y an

d G

over

nanc

e3)

Nut

ritio

n A

sses

smen

t4)

Nut

ritio

n C

are

Plan

ning

5)

Pla

nnin

g an

d D

eliv

ery

of F

ood

and

Flui

ds

• Se

e ev

iden

ce f

or 5

.1 a

bove

• Se

e ev

iden

ce f

or 5

.1 a

bove

Con

tinu

ed o

n pa

ge 4

3


NSQ

HS

Des

crip

tio

n o

f th

e St

and

ard

Lin

ks t

o N

SMH

SR

elat

ed N

CP

Elem

ents

LHD

/ N

etw

ork

Nu

trit

ion

Car

e C

om

mit

tee

Evid

ence

Exa

mp

les

Faci

lity

Nu

trit

ion

Car

e C

om

mit

tee

Evid

ence

Exa

mp

les

6C

linic

al H

and

ove

r

6.2

Esta

blis

hing

and

mai

ntai

ning

str

uctu

red

and

docu

men

ted

proc

esse

s fo

r cl

inic

al

hand

over

N/A

1) P

olic

y an

d G

over

nanc

e

4)

Nut

ritio

n C

are

Plan

ning

• Ev

iden

ce o

f th

e im

plem

enta

tion

of N

SW H

ealth

Clin

ical

Han

dove

r –

Stan

dard

Key

Prin

cipl

es

(PD

2009

_060

)

• Ev

iden

ce o

f re

com

men

datio

ns t

o us

e LH

D /

Net

wor

k St

anda

rdis

ed

Tran

sfer

of

Car

e fo

rms

and

nutr

ition

car

e is

incl

uded

e.g

.

- D

isch

arge

Sum

mar

y

- IS

BAR

form

at.

• Ev

iden

ce t

hat

nutr

ition

car

e is

incl

uded

as

part

of

clin

ical

ha

ndov

er (w

ithin

and

bet

wee

n fa

cilit

ies)

in s

tand

ardi

sed

form

at

e.g

:

- T

rans

fer

of c

are

form

aud

its

- D

isch

arge

sum

mar

ies

audi

ts.

8Pr

even

tin

g a

nd

Man

agin

g P

ress

ure

Inju

ries

8.1

Dev

elop

ing

and

impl

emen

ting

polic

ies,

pr

oced

ures

and

/or

prot

ocol

s th

at a

re

base

d on

cur

rent

bes

t pr

actic

e gu

idel

ines

N/A

1) P

olic

y an

d G

over

nanc

e

2) N

utrit

ion

Scre

enin

g

3)

Nut

ritio

n A

sses

smen

t

4)

Nut

ritio

n C

are

Plan

ning

• Ev

iden

ce o

f th

e im

plem

enta

tion

of t

he N

SW H

ealth

Pre

ssur

e In

jury

Pr

even

tion

and

Man

agem

ent

Polic

y (P

D20

14_0

07)

• Ev

iden

ce t

hat

an L

HD

/ ne

twor

k gu

idel

ine

inco

rpor

ates

the

im

port

ance

of

nutr

ition

car

e an

d th

e ro

le o

f D

ietit

ian

in p

ress

ure

inju

ry

• Ev

iden

ce o

f th

e re

com

men

datio

n to

use

the

Evi

denc

ed B

ased

Pr

actic

e G

uide

lines

for

the

D

iete

tic M

anag

emen

t of

Adu

lts

with

Pre

ssur

e In

jurie

s (T

rans

-Ta

sman

Die

tetic

Wou

nd C

are

Gro

up, 2

011)

• Ev

iden

ce o

f co

mpl

ianc

e w

ith

pres

sure

ulc

er p

reve

ntio

n an

d m

anag

emen

t (e

.g. a

udits

) and

in

volv

emen

t of

a D

ietit

ian

• Ev

iden

ce o

f th

e in

clus

ion

of

pres

sure

ulc

ers

/ wou

nds

in c

linic

al

prio

ritie

s fo

r D

iete

tic A

sses

smen

t

• A

udit

of t

he u

se o

f In

tern

atio

nal

Nut

ritio

n C

are

Proc

ess

Term

inol

ogy

(NC

PT) i

.e. –

inad

equa

te p

rote

in-

ener

gy in

take

(N

I-5.3

) rel

ated

to

nutr

ition

al-f

ocus

ed p

hysi

cal fi

ndin

g –

skin

Con

tinu

ed o

n pa

ge 4

4







https://www.clinicalguidelines.gov.au/browse.php?treePath=&pageType=2&fldglrID=1987&







NSQ

HS

Des

crip

tio

n o

f th

e St

and

ard

Lin

ks t

o N

SMH

SR

elat

ed N

CP

Elem

ents

LHD

/ N

etw

ork

Nu

trit

ion

Car

e C

om

mit

tee

Evid

ence

Exa

mp

les

Faci

lity

Nu

trit

ion

Car

e C

om

mit

tee

Evid

ence

Exa

mp

les

8Pr

even

tin

g a

nd

Man

agin

g P

ress

ure

Inju

ries

- C

ON

TIN

UED

8.3

Und

erta

king

qua

lity

impr

ovem

ent

activ

ities

to

addr

ess

safe

ty r

isks

and

m

onito

r th

e sy

stem

s th

at p

reve

nt a

nd

man

age

pres

sure

inju

ries

N/A

As

abov

e•

See

evid

ence

for

8.1

abo

ve•

See

evid

ence

for

8.1

abo

ve

8.5

Iden

tifyi

ng r

isk

fact

ors

for

pres

sure

inju

ries

usin

g an

agr

eed

scre

enin

g to

ol fo

r al

l pr

esen

ting

patie

nts

with

in t

imef

ram

es s

et

by b

est

prac

tice

guid

elin

es

N/A

As

abov

e•

See

evid

ence

for

8.1

abo

ve•

See

evid

ence

for

8.1

abo

ve

8.8

Impl

emen

ting

best

pra

ctic

e m

anag

emen

t an

d on

goin

g m

onito

ring

as c

linic

ally

in

dica

ted

N/A

As

abov

e•

See

evid

ence

for

8.1

abo

ve•

See

evid

ence

for

8.1

abo

ve

9R

eco

gn

isin

g a

nd

Res

po

nd

ing

to

Clin

ical

Det

erio

rati

on

in A

cute

Hea

lth

Car

e

9.2

Patie

nts

who

se c

ondi

tion

is d

eter

iora

ting

are

reco

gnis

ed a

nd a

ppro

pria

te a

ctio

n is

ta

ken

to e

scal

ate

care

N/A

2) N

utrit

ion

Scre

enin

g•

Evid

ence

of

the

impl

emen

tatio

n of

the

NSW

Hea

lth R

ecog

nitio

n an

d M

anag

emen

t of

Pat

ient

s w

ho a

re C

linic

ally

Det

erio

ratin

g (P

D20

13_0

49)

• Ev

iden

ce t

hat

an L

HD

/ ne

twor

k gu

idel

ine

inco

rpor

ates

co

nsid

erat

ion

of n

utrit

ion-

rela

ted

cond

ition

s w

hich

pla

ce

cons

umer

s at

hig

h ris

k of

cl

inic

al d

eter

iora

tion

e.g.

eat

ing

diso

rder

s, T

PN, e

nter

al s

uppo

rt,

alle

rgie

s, p

ost-

surg

ery,

nil

by

mou

th, d

iabe

tes

requ

iring

insu

lin

trea

tmen

t et

c.

• Ev

iden

ce o

f nu

triti

on-r

elat

ed

cond

ition

s w

hich

pla

ce c

onsu

mer

s at

hig

h ris

k of

clin

ical

det

erio

ratio

n e.

g. e

atin

g di

sord

ers,

TPN

, ent

eral

su

ppor

t, m

alnu

triti

on, a

llerg

ies,

po

st-s

urge

ry, n

il by

mou

th,

diab

etes

req

uirin

g in

sulin

tre

atm

ent

etc.

are

rec

ogni

sed

and

actio

ns

are

take

n to

esc

alat

e ca

re e

.g.

freq

uenc

y of

obs

erva

tions

, wei

ght

freq

uenc

y, fo

od c

hart

s, a

sses

smen

t of

alte

rnat

ive

nutr

ition

sup

port

an

d D

iete

tic in

volv

ed in

clin

ical

m

anag

emen

t pl

an d

evel

opm

ent

Con

tinu

ed o

n pa

ge 4

5






NSQ

HS

Des

crip

tio

n o

f th

e St

and

ard

Lin

ks t

o N

SMH

SR

elat

ed N

CP

Elem

ents

LHD

/ N

etw

ork

Nu

trit

ion

Car

e C

om

mit

tee

Evid

ence

Exa

mp

les

Faci

lity

Nu

trit

ion

Car

e C

om

mit

tee

Evid

ence

Exa

mp

les

9R

eco

gn

isin

g a

nd

Res

po

nd

ing

to

Clin

ical

Det

erio

rati

on

in A

cute

Hea

lth

Car

e -

CO

NTI

NU

ED

9.3

App

ropr

iate

and

tim

ely

care

is p

rovi

ded

to p

atie

nts

who

se c

ondi

tion

is

dete

riora

ting

N/A

3)

Nut

ritio

n

Ass

essm

ent

4)

Nut

ritio

n C

are

Plan

ning

• Se

e ev

iden

ce f

or 9

.2 a

bove

• Ev

iden

ce o

f im

med

iate

Die

titia

n an

d/o

r Sp

eech

Pat

holo

gist

ref

erra

l fo

r nu

triti

on-r

elat

ed c

ondi

tions

w

hich

pla

ce c

onsu

mer

s at

hig

h ris

k of

clin

ical

det

erio

ratio

n

• Ev

iden

ce o

f D

ietit

ian

and

/or

Spee

ch

Path

olog

ist

asse

ssm

ent

with

in 2

w

orki

ng d

ays

of r

efer

ral

10Pr

even

tin

g F

alls

an

d H

arm

fro

m F

alls

10.2

Patie

nts

on p

rese

ntat

ion,

dur

ing

adm

issi

on, a

nd w

hen

clin

ical

ly in

dica

ted,

ar

e sc

reen

ed f

or r

isk

of a

fal

l and

po

tent

ial t

o be

har

med

fro

m f

alls

.

N/A

2) N

utrit

ion

Scre

enin

g•

Evid

ence

of

the

impl

emen

tatio

n of

the

NSW

Hea

lth F

alls

–

Prev

entio

n of

Fal

ls a

nd H

arm

fr

om F

alls

am

ong

Old

er p

eopl

e:

2011

– 2

015

(PD

2011

_029

)

• Ev

iden

ce o

f co

mpl

ianc

e w

ith fa

ll sc

reen

ing

and

invo

lvem

ent

of

Die

titia

n if

nutr

ition

issu

es id

entifi

ed

(e.g

. low

BM

I, w

eigh

t lo

ss e

tc.)






Tabl

e 2:

Rem

aini

ng N

atio

nal S

tand

ards

for

Men

tal H

ealt

h Se

rvic

es (N

SMH

S) m

appe

d to

the

NSW

Hea

lth

Nut

riti

on C

are

Pol

icy

(NCP

)

NSM

HS

Des

crip

tio

n o

f th

e St

and

ard

Rel

ated

NC

P El

emen

tsLH

D /

Net

wo

rk N

utr

itio

n C

are

Co

mm

itte

e Ev

iden

ce E

xam

ple

sFa

cilit

y N

utr

itio

n C

are

Co

mm

itte

e Ev

iden

ce E

xam

ple

s

4.0

Div

ersi

ty R

esp

on

sive

nes

s

4.5

Staf

f ar

e tr

aine

d to

acc

ess

info

rmat

ion

and

reso

urce

s to

pro

vide

ser

vice

s th

at a

re

appr

opria

te t

o th

e di

vers

e ne

eds

of it

s co

nsum

ers.

1) P

olic

y an

d G

over

nanc

e

8)

Staf

f Ed

ucat

ion

and

Trai

ning

• Ev

iden

ce th

e LH

D /

Net

wor

k pr

oced

ures

/ gu

idel

ines

/ re

sour

ces

abou

t nut

ritio

n ca

re a

re

appr

opria

te fo

r the

div

erse

nee

ds o

f con

sum

ers

• Ev

iden

ce o

f th

e re

com

men

datio

n to

use

A

CI n

utrit

ion-

rela

ted

hand

outs

spe

cific

for

m

enta

l hea

lth s

ettin

gs a

nd c

onsu

mer

s

• Ev

iden

ce o

f th

e us

e of

AC

I nut

ritio

n-re

late

d ha

ndou

ts s

peci

fic f

or m

enta

l hea

lth s

ettin

gs

and

cons

umer

s

5.5

Pro

mo

tio

n a

nd

Pre

ven

tio

n

5.6

The

MH

S en

sure

s th

at th

eir w

orkf

orce

is

adeq

uate

ly tr

aine

d in

the

prin

cipl

es o

f m

enta

l hea

lth p

rom

otio

n an

d pr

even

tion

and

thei

r app

licab

ility

to th

e sp

ecia

lised

m

enta

l hea

lth s

ervi

ce c

onte

xt w

ith

appr

opria

te s

uppo

rt p

rovi

ded

to im

plem

ent

men

tal h

ealth

pro

mot

ion

and

prev

entio

n ac

tiviti

es

As

abov

e•

Evid

ence

tha

t A

llied

Hea

lth a

nd F

ood

Serv

ice

staf

f w

orki

ng in

men

tal h

ealth

se

ttin

gs h

ave

time

allo

catio

n fo

r ba

sic

trai

ning

on

the

prin

cipl

es o

f m

enta

l hea

lth

prom

otio

n an

d pr

even

tion

and

/or

men

tal

heal

th s

peci

fic p

rofe

ssio

nal d

evel

opm

ent

• Ev

iden

ce t

he L

HD

/ N

etw

ork

incl

udes

nu

triti

on c

are

spec

ific

to m

enta

l hea

lth

sett

ings

on

the

Nut

ritio

n C

are

Intr

anet

pag

e e.

g. m

etab

olic

mon

itorin

g

• Ev

iden

ce o

f th

e us

e of

LH

D /

Net

wor

k pr

oced

ures

and

/or

guid

elin

es a

bout

Alli

ed

Hea

lth a

nd F

ood

Serv

ice

staf

f tr

aini

ng w

hen

wor

king

in m

enta

l hea

lth s

ettin

gs

10.0

Del

iver

y o

f C

are

10.2

.1A

cces

s to

ava

ilabl

e se

rvic

es m

eets

the

id

entifi

ed n

eeds

of

its c

omm

unity

in a

tim

ely

man

ner.

1) P

olic

y an

d G

over

nanc

e

2) N

utrit

ion

Ass

essm

ent

• Ev

iden

ce t

he L

HD

/ N

etw

ork

Nut

ritio

n C

are

Com

mitt

ee h

as id

entifi

ed a

nd m

ade

reco

mm

enda

tions

abo

ut m

enta

l hea

lth

nutr

ition

-rel

ated

wor

kfor

ce a

reas

of

impr

ovem

ent

(e.g

. Die

titia

ns, D

ietit

ian

Ass

ista

nts,

Spe

ech

Path

olog

ists

)

• Ev

iden

ce t

he F

acili

ty h

as id

entifi

ed a

nd

mad

e re

com

men

datio

ns o

n ar

eas

for

impr

ovem

ent

in m

enta

l hea

lth n

utrit

ion-

rela

ted

wor

kfor

ce (e

.g. D

ietit

ians

, Die

titia

n A

ssis

tant

s, S

peec

h Pa

thol

ogis

ts) t

o LH

D /

Net

wor

k N

utrit

ion

Car

e C

omm

ittee

• Ev

iden

ce t

here

are

doc

umen

ted

alte

rnat

ive

proc

edur

es in

pla

ce fo

r as

sess

men

t by

D

ietit

ian

and

/or

Spee

ch P

atho

logi

st if

the

re

are

gaps

in s

ervi

ce p

rovi

sion

.C

onti

nued

on

page

47


NSM

HS

Des

crip

tio

n o

f th

e St

and

ard

Rel

ated

NC

P El

emen

tsLH

D /

Net

wo

rk N

utr

itio

n C

are

Co

mm

itte

e Ev

iden

ce E

xam

ple

sFa

cilit

y N

utr

itio

n C

are

Co

mm

itte

e Ev

iden

ce E

xam

ple

s

10.0

Del

iver

y o

f C

are

- C

ON

TIN

UED

10.4

.6Th

e M

HS

cond

ucts

ass

essm

ent

and

revi

ew o

f th

e co

nsum

er’s

tre

atm

ent,

car

e an

d re

cove

ry p

lan,

whe

ther

invo

lunt

ary

or v

olun

tary

, at

leas

t ev

ery

thre

e m

onth

s

1) P

olic

y an

d G

over

nanc

e

1) N

utrit

ion

Scre

enin

g

4)

Nut

ritio

n C

are

Plan

ning

• Ev

iden

ce t

he L

HD

/ N

etw

ork

Nut

ritio

n C

are

Com

mitt

ee m

akes

rec

omm

enda

tions

to

the

men

tal h

ealth

ser

vice

to

incl

ude

nutr

ition

ca

re in

the

ir pr

oced

ures

for

reg

ular

as

sess

men

t an

d re

view

e.g

. wei

ght,

BM

I, fo

od a

nd fl

uid

inta

ke, i

nvol

vem

ent

with

D

ietit

ian

and

/or

Spee

ch P

atho

logi

st

• Ev

iden

ce t

he L

HD

/ N

etw

ork

Nut

ritio

n C

are

Com

mitt

ee m

akes

rec

omm

enda

tion

to t

he m

enta

l hea

lth s

ervi

ce to

incl

ude

nutr

ition

car

e re

view

as

part

of

the

requ

ired

asse

ssm

ent

and

revi

ew

• Ev

iden

ce t

hat

faci

litie

s in

corp

orat

e nu

triti

on

care

rev

iew

into

the

req

uire

d as

sess

men

t an

d re

view

pro

cess

for

men

tal h

ealth

co

nsum

ers

e.g.

wei

ght,

BM

I, fo

od a

nd fl

uid

inta

ke, i

nvol

vem

ent

with

Die

titia

n an

d/o

r Sp

eech

Pat

holo

gist


Tabl

e 3:

Eva

luat

ion

and

Qua

lity

Impr

ovem

ent P

rogr

am (E

QuI

P) M

appi

ng to

the

NSW

Hea

lth

Nut

riti

on C

are

Pol

icy

(NCP

)

EQu

IPD

escr

ipti

on

of

the

Stan

dar

dR

elat

ed N

CP

Elem

ents

LHD

/ N

etw

ork

Nu

trit

ion

Car

e C

om

mit

tee

Evid

ence

Exa

mp

les

Faci

lity

Nu

trit

ion

Car

e C

om

mit

tee

Evid

ence

Ex

amp

les

11Se

rvic

e D

eliv

ery

11.2

Acc

ess

and

adm

issi

on /

entr

y to

the

sys

tem

of

care

ar

e pr

iorit

ised

acc

ordi

ng t

o he

alth

care

nee

ds

2) N

utrit

ion

Ass

essm

ent

• Ev

iden

ce o

f LH

D /

Net

wor

k pr

oced

ures

on

clin

ical

prio

ritie

s fo

r as

sess

men

t (e

.g. D

ietit

ian

clin

ical

prio

ritie

s)

• Ev

iden

ce o

f th

e us

e of

rec

omm

enda

tions

fro

m

LHD

/N

etw

ork

on c

linic

al p

riorit

ies

for

asse

ssm

ent

(e.g

. Die

titia

n cl

inic

al p

riorit

ies)

.

11.3

Con

sum

ers

/ pat

ient

s ar

e in

form

ed o

f the

co

nsen

t pro

cess

, and

they

un

ders

tand

and

pro

vide

co

nsen

t for

thei

r hea

lth c

are

2) N

utrit

ion

Ass

essm

ent

• Ev

iden

ce o

f LH

D /

Net

wor

k pr

oced

ures

on

clin

ical

doc

umen

tatio

n in

clud

es o

btai

ning

co

nsen

t e.

g. D

ietit

ians

, Spe

ech

Path

olog

ists

, M

edic

al o

ffice

rs

• Ev

iden

ce o

f au

dits

of

nutr

ition

-rel

ated

pro

cedu

res

incl

ude

docu

men

ted

cons

ent

to a

sses

smen

t or

pr

oced

ure

e.g.

Die

titia

n as

sess

men

t, S

peec

h Pa

thol

ogis

t as

sess

men

t.

11.5

The

orga

nisa

tion

mee

ts

the

need

s of

con

sum

ers

/ pa

tient

s an

d ca

rers

with

di

vers

e ne

eds

and

from

di

vers

e ba

ckgr

ound

s

5) P

lann

ing

and

Del

iver

y of

Fo

od a

nd

Flui

ds

• Ev

iden

ce t

he L

HD

/ N

etw

ork

proc

edur

es /

guid

elin

es /

reso

urce

s ab

out

nutr

ition

car

e ar

e ap

prop

riate

for

the

div

erse

nee

ds o

f co

nsum

ers

• Ev

iden

ce o

f th

e re

com

men

datio

n to

use

A

CI n

utrit

ion-

rela

ted

hand

outs

– s

ome

avai

labl

e in

Eng

lish

and

othe

r la

ngua

ges

• Ev

iden

ce th

e LH

D /

Net

wor

k N

utrit

ion

Car

e C

omm

ittee

has

iden

tified

the

need

s of

con

sum

ers

in re

latio

n to

men

us a

nd fo

od p

rovi

sion.

• Ev

iden

ce o

f the

use

AC

I nut

ritio

n-re

late

d ha

ndou

ts

– so

me

avai

labl

e in

Eng

lish

and

othe

r lan

guag

es fo

r fo

od a

nd fl

uid

prov

ision

and

nut

ritio

n st

anda

rds

etc.

• Ev

iden

ce th

e Fa

cilit

y m

enu

and

food

pro

visio

n m

eets

th

e ne

eds

of c

onsu

mer

s w

ith d

iver

se n

eeds

and

from

di

vers

e ba

ckgr

ound

s

11.6

Bett

er h

ealth

and

wel

lbei

ng

are

prom

oted

by

the

orga

nisa

tion

for

cons

umer

s / p

atie

nts,

sta

ff, c

arer

s an

d th

e w

ider

com

mun

ity

1) P

olic

y an

d G

over

nanc

e•

Evid

ence

of

the

prom

otio

n of

nut

ritio

n ca

re

via

Nut

ritio

n C

are

Intr

anet

and

LH

D/N

etw

ork

Nut

ritio

n C

are

Com

mitt

ee

• Ev

iden

ce o

f th

e pr

omot

ion

of n

utrit

ion

care

in

the

deve

lopm

ent

of L

HD

/ ne

twor

k gu

idel

ines

/ pr

oced

ures

, whe

re r

elev

ant

• Ev

iden

ce o

f th

e de

velo

pmen

t of

nut

ritio

n-re

late

d pa

thw

ays

for

LHD

/ net

wor

ks

• Ev

iden

ce o

f the

pro

mot

ion

of n

utrit

ion

care

via

nu

triti

on c

are

gove

rnan

ce a

t eac

h fa

cilit

y

• Ev

iden

ce o

f pro

mot

ion

of th

e N

SW H

ealth

Get

Hea

lthy

coac

hing

and

info

rmat

ion

serv

ice

Con

tinu

ed o

n pa

ge 4

9




EQu

IPD

escr

ipti

on

of

the

Stan

dar

dR

elat

ed N

CP

Elem

ents

LHD

/ N

etw

ork

Nu

trit

ion

Car

e C

om

mit

tee

Evid

ence

Exa

mp

les

Faci

lity

Nu

trit

ion

Car

e C

om

mit

tee

Evid

ence

Ex

amp

les

12Pr

ovi

sio

n o

f C

are

12.1

Ass

essm

ent

and

care

pl

anni

ng e

nsur

e th

at

curr

ent

and

ongo

ing

need

s of

the

con

sum

er /

patie

nt

are

iden

tified

1) N

utrit

ion

Scre

enin

g

2) N

utrit

ion

Ass

essm

ent

3)

Nut

ritio

n C

are

Plan

ning

• Ev

iden

ce o

f an

LH

D /

Net

wor

k N

utrit

ion

Car

e C

omm

ittee

• Ev

iden

ce o

f an

LH

D /

Net

wor

k N

utrit

ion

Car

e C

omm

ittee

act

ion

plan

for

all

the

man

dato

ry

requ

irem

ents

of

the

Nut

ritio

n C

are

Polic

y

• Ev

iden

ce o

f th

e ev

alua

tion

of t

he N

utrit

ion

Car

e Po

licy

elem

ents

usi

ng s

tand

ardi

sed

audi

t to

ols

• Ev

iden

ce t

he L

HD

/ N

etw

ork

Nut

ritio

n C

are

Com

mitt

ee h

as id

entifi

ed t

he n

eeds

of

cons

umer

s in

rel

atio

n to

nut

ritio

n ca

re, m

enus

an

d fo

od p

rovi

sion

.

• Ev

iden

ce o

f a

Faci

lity

Nut

ritio

n C

are

gove

rnan

ce

stru

ctur

e (n

ame

of c

omm

ittee

and

/or

part

of

exis

ting

com

mitt

ee) a

nd a

n ac

tion

plan

bas

ed o

n al

l the

req

uire

men

ts o

f th

e N

utrit

ion

Car

e Po

licy

and

the

LHD

/ ne

twor

k re

com

men

datio

ns f

or t

he

impl

emen

tatio

n of

the

Nut

ritio

n C

are

Polic

y an

d re

late

d do

cum

ents

.

• Ev

iden

ce o

f th

e co

llect

ion

of e

valu

atio

n da

ta o

n re

quire

d el

emen

ts o

f th

e N

utrit

ion

Car

e Po

licy

usin

g re

quire

d au

dit

tool

s pr

ovid

ed b

y th

e LH

D /

Net

wor

k N

utrit

ion

Car

e C

omm

ittee

• Ev

iden

ce t

he F

acili

ty m

enu

and

food

pro

visi

on

mee

ts t

he n

eeds

of

cons

umer

s w

ith d

iver

se n

eeds

an

d fr

om d

iver

se b

ackg

roun

ds

12.2

The

orga

nisa

tion

ensu

res

that

the

nut

ritio

nal n

eeds

of

con

sum

ers

/ pat

ient

s ar

e m

et

1) P

olic

y an

d G

over

nanc

eA

s ab

ove

As

abov

e

12.3

Syst

ems

of o

ngoi

ng c

are

and

disc

harg

e / t

rans

fer

are

coor

dina

ted

and

effe

ctiv

e an

d m

eet

the

need

s of

the

co

nsum

er /

patie

nt

3)

Nut

ritio

n C

are

Plan

ning

As

abov

eA

s ab

ove

Con

tinu

ed o

n pa

ge 5

0


EQu

IPD

escr

ipti

on

of

the

Stan

dar

dR

elat

ed N

CP

Elem

ents

LHD

/ N

etw

ork

Nu

trit

ion

Car

e C

om

mit

tee

Evid

ence

Exa

mp

les

Faci

lity

Nu

trit

ion

Car

e C

om

mit

tee

Ev

iden

ce E

xam

ple

s

13W

ork

forc

e Pl

ann

ing

an

d M

anag

emen

t

13.1

Wor

kfor

ce p

lann

ing

supp

orts

the

org

anis

atio

n’s

curr

ent

and

futu

re a

bilit

y to

ad

dres

s ne

eds

1) P

olic

y an

d G

over

nanc

e•

Evid

ence

the

LH

D /

Net

wor

k N

utrit

ion

Car

e C

omm

ittee

has

con

side

red

and

mad

e re

com

men

datio

ns o

n nu

triti

on c

are-

rela

ted

wor

kfor

ce is

sues

(e.g

. Die

titia

ns, D

ietit

ian

Ass

ista

nts)

• Ev

iden

ce t

he F

acili

ty N

utrit

ion

Car

e C

omm

ittee

has

id

entifi

ed a

nd m

ade

reco

mm

enda

tions

on

area

s fo

r im

prov

emen

t in

men

tal h

ealth

nut

ritio

n-re

late

d w

orkf

orce

(e.g

. Die

titia

ns, D

ietit

ian

Ass

ista

nts,

Sp

eech

Pat

holo

gist

s) t

o th

e LH

D /

Net

wor

k N

utrit

ion

Car

e C

omm

ittee

14In

form

atio

n M

anag

emen

t

14.1

Hea

lth r

ecor

ds

man

agem

ent

syst

ems

supp

ort

the

colle

ctio

n of

in

form

atio

n an

d m

eets

the

co

nsum

ers

/ pat

ient

and

or

gani

satio

n’s

need

s

1) P

olic

y an

d G

over

nanc

e

2) N

utrit

ion

Ass

essm

ent

5) P

lann

ing

and

Del

iver

y of

Fo

od a

nd

Flui

ds

• Ev

iden

ce o

f th

e us

e of

a c

ompu

teris

ed m

enu

prog

ram

link

ed t

o cl

inic

al in

form

atio

n i.e

. ale

rts

• Ev

iden

ce o

f st

anda

rdis

ed e

lect

roni

c ac

tivity

da

ta c

olle

ctio

n fo

r nu

triti

on-r

elat

ed w

orkf

orce

(e

.g. D

ietit

ians

) to

be u

sed

for

serv

ice

impr

ovem

ent

purp

oses

• Ev

iden

ce o

f st

anda

rdis

ed e

lect

roni

c fo

od

serv

ice

data

(e.g

. num

ber

of m

eals

per

day

, fo

od w

asta

ge, f

ood

cost

s, la

bour

cos

ts e

tc.)

to

be u

sed

for

ser

vice

impr

ovem

ent

purp

oses

• Ev

iden

ce th

e Fa

cilit

y N

utrit

ion

Car

e C

omm

ittee

im

plem

ents

all

reco

mm

enda

tions

from

the

LHD

/ N

etw

ork

Nut

ritio

n C

are

Com

mitt

ee o

n co

mpu

teris

ed

men

u pr

ogra

m u

se, e

lect

roni

c al

lied

heal

th d

ata

colle

ctio

n pr

ogra

m a

nd e

lect

roni

c fo

od s

ervi

ce d

ata

colle

ctio

n w

here

pro

vide

d.

14.3

Dat

a an

d in

form

atio

n ar

e co

llect

ed, s

tore

s an

d us

ed

for

stra

tegi

c, o

pera

tiona

l an

d se

rvic

e im

prov

emen

t pu

rpos

es

As

abov

eA

s ab

ove

As

abov

e

14.4

The

orga

nisa

tion

has

an in

tegr

ated

app

roac

h to

the

pla

nnin

g, u

se

and

man

agem

ent

of in

form

atio

n an

d co

mm

unic

atio

n te

chno

logy

(IC

T)

As

abov

eA

s ab

ove

As

abov

e

Con

tinu

ed o

n pa

ge 5

48


EQu

IPD

escr

ipti

on

of

the

Stan

dar

dR

elat

ed N

CP

Elem

ents

LHD

/ N

etw

ork

Nu

trit

ion

Car

e C

om

mit

tee

Evid

ence

Exa

mp

les

Faci

lity

Nu

trit

ion

Car

e C

om

mit

tee

Ev

iden

ce E

xam

ple

s

15C

orp

ora

te S

yste

ms

and

Saf

ety

15.3

Exte

rnal

ser

vice

s pr

ovid

ers

are

man

aged

to

max

imis

e qu

ality

, saf

e he

alth

car

e an

d se

rvic

e de

liver

y

5) P

lann

ing

and

Del

iver

y of

Fo

od a

nd

Flui

ds

• Ev

iden

ce t

he L

HD

/ N

etw

ork

Nut

ritio

n C

are

Com

mitt

ee n

utrit

ion

care

eva

luat

ion

plan

in

clud

es F

ood

Serv

ice

Prov

ider

key

per

form

ance

in

dica

tors

(K

PI’s

) and

any

con

cern

s ar

e ra

ised

to

LH

D /

Net

wor

k Ex

ecut

ive

Com

mitt

ee a

nd/o

r ap

prop

riate

LH

D /

Net

wor

k C

omm

ittee

’s

• Ev

iden

ce t

he F

acili

ty N

utrit

ion

Car

e C

omm

ittee

ev

alua

te n

utrit

ion

care

, inc

ludi

ng F

ood

Serv

ice

Prov

ider

per

form

ance

, and

any

con

cern

s ar

e ra

ised

to

LH

D /

Net

wor

k N

utrit

ion

Car

e C

omm

ittee


Appendix 8: The Menu Review Process - Roles of Key Stakeholders

This document provides a guide to the potential roles of key stakeholders in the menu development process. The actual roles are at the discretion of each Local Health District (LHD) / Network. The process of reviewing the menu may differ between LHDs / Networks and between Food Service Providers.

LHD/Network Governance Roles LHD / Network Executive Committee

1. Establish the LHD/Network implementation framework for the Nutrition Standards and determine the process and timeline for menu revisions in conjunction with Food Service Providers.

2. Final endorsement of recommendations provided from LHD / Network Nutrition Care Committee.

LHD / Network Nutrition Care Committee or Patient Safety and Clinical Quality Committee

1. Make final District/Network recommendations related to menu review to the LHD / Network Executive Committee where required.

LHD / Network OR Facility Nutrition Care Committee or Patient Safety and Clinical Quality Committee

1. Follow direction of LHD / Network Nutrition Care Committee or Patient Safety and Clinical Quality Committee e.g. decide if an individual facility or shared menu development process will be utilised across LHD / Network.

2. Assign personnel to the menu review process.

3. Consider and use the menu development resources and tools included in the toolkit as appropriate e.g.:

- site information for menu development – nutrition care and food service checklist

- minimum menu choice checklist and nutrient goals checklist

- banding ready reckoner.

4. Provide site menu requirements to Food Service Provider.

5. Provide feedback on draft menu outlines developed by Food Service Provider.

6. Prioritise the implementation of changes to the menu, if required (i.e. cost or practicality constraints).

7. Provide final approval of proposed new menu.

8. Make recommendations to the LHD / Network Nutrition Care Committee (where relevant).

Clinical RolesDietitian and/or Consultant Dietitian

1. Member of the Facility and/or LHD / Network Nutrition Care committee.

2. Provide feedback to Facility and/or LHD/ Network Nutrition Care committee on menu compliance with the Nutrition Standards.

3. Consult with LHD/Network Director of Nutrition and Dietetics (or equivalent) if guidance and assistance is required to complete the menu review.

Speech Pathologist and/or Consultant Speech Pathologist

1. Member of the Facility and/or LHD / Network Nutrition Care committee.

2. Confirms compliance of texture-modified foods and thickened fluids to therapeutic diet requirements where the NSW Health Speech Pathology Advisory Network (SPAN) Texture Modified Food and Fluids Subgroup have not already done so.

Food Service Provider Roles Management team (or representative)

1. Negotiate the project plan, timelines and processes with the LHD / Network Executive Committee.

2. Provide advice to LHD / Network Executive Committee in terms of improvements to menu management systems and other menu related changes.

3. Assign personnel as required to complete menu development, as appropriate.

4. Assign personnel as required to provide relevant nutritional and other information to LHD/Network


or Facility Nutrition Care Committee e.g. menu nutritional analysis, standardised recipes, therapeutic diet compliance.

Food Service Manager / Food Service Dietitian and/or Consultant Food Service Dietitian

1. Propose the new menu based on any provided site requirements and/or initial consultation discussions.

2. Provide all nutritional information required to review the new menu to the LHD/Nutrition or Facility Nutrition Care committee, including:

a. Full product ingredient and nutrition information for all products.

b. Detailed potential cost projections for required menu changes (i.e. cost of additional Band 1 soup / hot meal at dinner, increased labour costs etc.)

- Including rationale for menu changes e.g. to meet a specific nutrition parameter(s)

c. Evidence for compliance to Nutrition Standards, including:

- Menu design principles (e.g. repetition, variety, colour, texture etc.)

- Nutrients (e.g. macro- and micro-nutrients)

- Minimum menu choices.

d. Evidence that the menu will cater for other common diets (e.g. allergy/intolerance, gluten free, halal, vegan, texture modified etc.).


App

endi

x 9:

Sit

e or

LH

D/N

etw

ork

Info

rmat

ion

for

Men

u D

evel

opm

ent -

Nut

riti

on

Care

and

Foo

d Se

rvic

e D

ata

Chec

klis

t•

This

doc

umen

t ha

s be

en d

evel

oped

to

prov

ide

a fo

unda

tion

for

the

men

u re

view

pr

oces

s an

d to

iden

tify

prac

tical

issu

es, g

aps

and

othe

r fa

ctor

s th

at t

he L

HD

/N

etw

ork

and

/or

faci

lity

need

to

cons

ider

.

• It

is s

ugge

sted

tha

t th

e Fa

cilit

y or

LH

D/ N

etw

ork

Nut

ritio

n C

are

Com

mitt

ee

and

/or

sele

cted

mem

bers

(e.g

. Die

titia

n, F

ood

Serv

ice

Prov

ider

) com

plet

e th

e fo

llow

ing

ques

tions

in p

repa

ratio

n fo

r in

itial

dis

cuss

ions

abo

ut t

he m

enu

revi

ew

proc

ess.

It c

ould

the

n be

tab

led

at t

he F

acili

ty N

utrit

ion

Car

e C

omm

ittee

and

LH

D

/ Net

wor

k N

utrit

ion

Car

e C

omm

ittee

.

Qu

esti

on

s /i

nfo

rmat

ion

req

uir

edR

easo

ns

/ Pr

om

pts

Yo

ur

Site

Info

rmat

ion

Are

as f

or

Imp

rove

men

t

Gen

eral

1.D

ate

Info

rmat

ion

mig

ht c

hang

e ov

er t

ime

2.N

ame

of t

he f

acili

ty

(or

faci

litie

s in

LH

D /

Net

wor

k)Fo

r yo

ur L

HD

/ net

wor

k re

fere

nce

3.N

ame

and

role

of

the

pers

on c

ompi

ling

this

in

form

atio

nFo

r yo

ur L

HD

/ net

wor

k re

fere

nce

4.N

ame

of t

he F

acili

ty N

utrit

ion

Car

e C

omm

ittee

Fa

cilit

y go

vern

ance

str

uctu

re in

pla

ce t

o im

plem

ent

the

Nut

ritio

n C

are

Polic

y

Site

Info

rmat

ion

5.Ty

pe o

f fa

cilit

y (o

r fa

cilit

ies)

e.g.

ter

tiary

, dis

tric

t, c

omm

unity

, MPS

, res

iden

tial

aged

car

e or

oth

er

This

can

influ

ence

pop

ulat

ion

dive

rsity

, # m

eals

/day

an

d pr

actic

al im

plic

atio

ns o

f m

enu

revi

ew d

ue t

o ki

tche

n si

ze e

tc.

6.N

umbe

r of

ove

rnig

ht b

eds

at t

his

faci

lity

(or

faci

litie

s)Th

is c

an im

pact

pop

ulat

ion

dive

rsity

, # m

eals

/day

an

d pr

actic

al im

plic

atio

ns o

f m

enu

revi

ew d

ue t

o ki

tche

n si

ze e

tc.

Pop

ula

tio

n In

form

atio

n

7.D

escr

ibe

the

inpa

tient

pop

ulat

ion

at t

he s

ite

(e.g

. acu

te, r

ehab

, men

tal h

ealth

, pae

diat

ric,

mat

erni

ty, a

dole

scen

ts, a

dult,

old

er p

erso

n,

shor

t-st

ay, l

ong-

stay

)

Influ

ence

s w

hich

nut

ritio

n st

anda

rds

need

to

be im

plem

ente

d an

d co

mm

on t

hera

peut

ic d

iets

re

quire

d

8.W

hat

is t

he a

vera

ge le

ngth

of

stay

(ALO

S) f

or e

ach

faci

lity

/ uni

t?

Hel

ps d

eter

min

e th

e le

ngth

of

the

men

u cy

cle

requ

ired

e.g.

1 w

eek

men

u cy

cle;

2-4

wee

ks e

tc.

Con

tinu

ed o

n pa

ge 5

2


Qu

esti

on

s /i

nfo

rmat

ion

req

uir

edR

easo

ns

/ Pr

om

pts

Yo

ur

Site

Info

rmat

ion

Are

as f

or

Imp

rove

men

t

Pop

ula

tio

n In

form

atio

n -

CO

NTI

NU

ED

9.If

mul

tiple

uni

ts, w

hat

is t

he a

vera

ge le

ngth

of

stay

(ALO

S) o

f ea

ch o

f th

e un

its?

Hel

ps d

eter

min

e th

e le

ngth

of

the

men

u cy

cle

requ

ired

e.g.

1 w

eek

men

u cy

cle;

2-4

wee

ks e

tc.

10.

Wha

t is

the

gen

der

ratio

or

are

ther

e an

y si

ngle

ge

nder

uni

ts?

Mal

e an

d fe

mal

e nu

triti

on r

equi

rem

ents

are

di

ffer

ent

11.

Are

the

re a

ny c

ultu

ral n

eeds

tha

t ne

ed t

o be

co

nsid

ered

? Th

e m

enu

need

s to

be

cultu

rally

app

ropr

iate

12.

Wha

t ar

e th

e m

ost

com

mon

the

rape

utic

die

ts t

he

site

(s) r

equi

res?

N

eed

to b

e co

nsid

ered

into

men

u de

sign

to

ensu

re f

ood

/flui

d ite

ms

are

avai

labl

e ei

ther

on

requ

est

or in

corp

orat

ed in

to t

he f

ull m

enu

13.

Whi

ch N

utrit

ion

Stan

dard

s w

ill n

eed

to b

e im

plem

ente

d at

the

site

(s) e

.g. m

enta

l hea

lth,

adul

t, p

aedi

atric

or

com

bina

tion?

May

nee

d to

impl

emen

t a

com

bina

tion

of t

he

stan

dard

s

Foo

d S

ervi

ce In

form

atio

n

14.

Who

is t

he F

ood

Serv

ice

Prov

ider

(e.g

. Hea

lthSh

are

NSW

, Pub

lic P

rivat

e Pa

rtne

rshi

p or

oth

er)?

N

eed

to w

ork

toge

ther

to

chan

ge t

he m

enu

and

dete

rmin

e w

ho is

res

pons

ible

for

pro

vidi

ng

all m

enu

revi

ew in

form

atio

n e.

g. m

enu

outli

ne,

com

paris

on t

o st

anda

rds,

cos

t ch

ange

bre

akdo

wns

et

c.

15.

Who

is t

he k

ey c

onta

ct f

or t

he F

ood

Serv

ice

Prov

ider

at

the

site

?W

ho y

ou n

eed

to t

alk

to a

bout

foo

d se

rvic

e is

sues

16.

Is t

his

key

Food

Ser

vice

Pro

vide

r co

ntac

t a

mem

ber

on t

he N

utrit

ion

Car

e C

omm

ittee

? It

is h

ighl

y re

com

men

ded

Con

tinu

ed o

n pa

ge 5

3


Qu

esti

on

s /i

nfo

rmat

ion

req

uir

edR

easo

ns

/ Pr

om

pts

Yo

ur

Site

Info

rmat

ion

Are

as f

or

Imp

rove

men

t

Nu

trit

ion

an

d D

iete

tics

Ser

vice

s

17.

Is t

here

acc

ess

to a

Clin

ical

Die

titia

n at

the

site

(s)?

Ke

y to

nut

ritio

n ca

re a

nd c

an h

elp

with

men

u as

sess

men

t. If

not

ava

ilabl

e, s

houl

d be

dis

cuss

ed

with

LH

D /

Net

wor

k N

utrit

ion

Car

e C

omm

ittee

18.

If a

Clin

ical

Die

titia

n is

ava

ilabl

e, h

ow m

any

hour

s pe

r w

eek

is t

he D

ietit

ian

fund

ed?

Con

side

r ho

w m

uch

time

can

be a

lloca

ted

to t

he

men

u re

view

pro

cess

19.

If a

Clin

ical

Die

titia

n is

ava

ilabl

e, a

re t

hey

a m

embe

r of

the

Nut

ritio

n C

are

Com

mitt

ee(s

)?

It is

hig

hly

reco

mm

ende

d

20.

Doe

s th

e LH

D/N

etw

ork/

Faci

lity

have

a F

ood

Serv

ice

Die

titia

n?

If so

, the

Die

titia

n w

ill n

eed

to b

e in

volv

ed in

m

enu

revi

ew

Men

u D

esig

n

21.

Do

cons

umer

s cu

rren

tly c

ompl

ete

a m

enu

in

adva

nce?

(t

his

coul

d be

a p

aper

men

u, e

lect

roni

c et

c.)

Influ

ence

s fo

reca

stin

g pr

oces

ses.

May

nee

d to

be

revi

sed

if ch

ange

s ar

e m

ade

to

men

u an

d/o

r fo

od s

ervi

ce d

eliv

ery

mod

el

22.

If a

men

u is

com

plet

ed, h

ow m

any

hour

s/da

ys in

ad

vanc

e?Th

is h

as d

irect

impa

ct o

n fo

od p

rodu

ctio

n/

orde

ring.

Cha

nges

may

be

requ

ired

or

reco

mm

ende

d by

the

Foo

d Se

rvic

e pr

ovid

er.

23.

Wha

t is

the

cur

rent

leng

th o

f th

e m

enu

cycl

e?Re

fere

nce

poin

t

24.

Is t

he c

urre

nt le

ngth

of

the

men

u cy

cle

appr

opria

te f

or t

he s

ite?

Doe

s it

suit

the

ALO

S? D

o so

me

units

nee

d di

ffer

ent

leng

ths?

25.

How

is f

ood

deliv

ered

to

cons

umer

s (e

.g. b

ulk

and

plat

ed a

t po

int

of s

ervi

ce, p

late

d in

the

ki

tche

n an

d tr

ay s

ervi

ce, c

onsu

mer

s m

ake

mea

ls in

as

sist

ed d

aily

kitc

hen

etc.

)?

Pote

ntia

l pra

ctic

al c

onsi

dera

tions

may

aris

e

26.

Wha

t is

the

typ

e of

foo

dser

vice

at

the

faci

lity?

(e.g

. coo

k-ch

ill, c

ook-

fres

h, c

ook-

free

ze a

nd/o

r co

mbi

natio

n)

Dire

ct im

pact

of

food

pro

duct

ion

/ord

erin

g/

prod

uct

stoc

k le

vels

etc

.

Con

tinu

ed o

n pa

ge 5

4


Qu

esti

on

s /i

nfo

rmat

ion

req

uir

edR

easo

ns

/ Pr

om

pts

Yo

ur

Site

Info

rmat

ion

Are

as f

or

Imp

rove

men

t

Men

u D

esig

n -

CO

NTI

NU

ED

27.

Are

the

re o

ther

pot

entia

l foo

dser

vice

rel

ated

co

nsid

erat

ions

for

the

site

e.g

. BBQ

day

s, a

ssis

ted

daily

livi

ng (A

DL)

kitc

hen,

spe

cial

eve

nts

cate

ring,

co

okin

g pr

ogra

ms?

Thes

e sh

ould

be

cons

ider

ed in

the

new

m

enu

outli

ne

Oth

er C

on

sid

erat

ion

s

28.

Is t

here

< 1

2 ho

urs

betw

een

serv

ing

supp

er a

nd

brea

kfas

t?Th

is is

the

rec

omm

ende

d m

axim

um t

imef

ram

e an

d m

ay im

pact

foo

d se

rvic

e / n

ursi

ng s

taff

29.

Doe

s th

e si

te h

ave

acce

ss t

o fo

od f

or c

onsu

mer

s af

ter

hour

s e.

g. s

andw

iche

s, f

ruit,

milk

etc

.?

Con

side

r co

nsum

ers

with

adm

issi

ons

afte

r ho

urs

or a

fter

a m

eal-s

ervi

ce a

nd l

ong-

actin

g ca

rboh

ydra

te h

ypog

lyca

emic

man

agem

ent

30.

Doe

s th

e si

te p

rovi

de a

cces

s to

add

ition

al f

oods

fo

r co

nsum

ers

who

are

hun

gry

or r

equi

re la

rge

serv

es?

May

be

requ

ired

for

som

e gr

oups

and

tho

se

need

ing

antip

sych

otic

med

icat

ions

31.

Doe

s th

e si

te h

ave

loca

l inf

orm

atio

n / g

uide

lines

th

at in

clud

e th

e fo

llow

ing

:

- S

yste

ms

for

mea

l sel

ectio

n -

Len

gth

of m

enu

cycl

e an

d nu

mbe

r of

cho

ices

to

be p

rovi

ded

- M

eal s

ervi

ce t

imes

-

Ser

vice

of

mea

ls t

o pe

ople

who

arr

ive

out

of

mea

l tim

es

- P

rovi

sion

of

extr

a he

lpin

gs

- W

ays

to s

uppo

rt p

eopl

e on

ene

rgy-

rest

ricte

d di

ets

who

are

hun

gry

- A

cces

s to

foo

d in

ven

ding

mac

hine

s, a

nd t

he

type

s of

foo

d av

aila

ble

in t

hem

-

Foo

d pr

ovid

ed a

t ba

rbec

ues

and

activ

ity o

f da

ily

livin

g ki

tche

ns

- R

ehab

ilita

tion

cook

ing

prog

ram

s-

Del

iver

y of

mea

ls b

ough

t fr

om e

xter

nal s

ourc

es,

e.g.

loca

l sho

ps a

nd r

esta

uran

ts

- P

rovi

sion

of

food

by

rela

tives

and

frie

nds.

Loca

l / f

acili

ty in

form

atio

n sh

ould

be

avai

labl

e fo

r st

aff

to a

cces

s


App

endi

x 10

: N

utri

ent a

nd M

inim

um M

enu

Choi

ce C

heck

lists

and

Ban

ding

Rea

dy

Rec

kone

r

The

thre

e ta

bles

tha

t fo

rm A

ppen

dix

10 a

re a

vaila

ble

on t

he A

CI w

ebsi

te in

Exc

el f

orm

at.

The

follo

win

g im

ages

pro

vide

an

exam

ple

only

.


Men

u Ite

mSt

anda

rd (M

H=

men

tal h

ealth

, AI =

ad

ult i

npat

ient

s)

Min

imum

Num

ber o

f Cho

ices

Min

imum

Ser

veN

utrit

iona

l Sta

ndar

ds &

Men

u D

esig

n Co

nsid

erat

ions

Mee

ts th

e St

anda

rd(s

) (Y

es /

No)

Min

imum

Men

u Ch

oice

Gap

s Id

entif

ied

MH

3/da

y1

med

ium

pie

ce (e

.g. a

pple

, pea

r, sm

all b

anan

a) o

r12

0g c

anne

d/st

ewed

or

30g

drie

d (e

.g. 4

pru

nes)

AI5

prun

es

MH

• 10

0% fr

uit j

uice

• N

o ad

ded

suga

r•

≥20m

g vi

tam

in C

per

100

mL

• En

ergy

rest

rictio

n di

ets –

lim

it to

1 s

erve

/ da

y AI

• N

o m

entio

n ab

out e

nerg

y re

stric

tion

diet

s

Cere

al-H

ote.

g. p

orrid

ge, s

emol

ina

Both

1/br

eakf

ast m

eal

180g

coo

ked

wei

ght

MH

• Ce

real

s to

cont

ain

less

than

30g

suga

r per

100

g•

≥2 v

arie

ties s

houl

d co

ntai

n at

leas

t 3g

fibre

/ ser

ve•

1 pr

ovid

ing

≥5g

fibre

/ ser

ve

AI•

No

requ

irem

ent t

o ha

ve 1

pro

vidi

ng ≥

5g fi

bre/

serv

e

Prot

ein

sour

ce a

t br

eakf

ast

Cont

inet

al o

r Tr

aditi

onal

coo

ked

Both

1/ b

reak

fast

mea

l12

5 yo

ghur

t,or

1 eg

g or

20

g ch

eese

or

110g

bak

ed b

eans

• ≥5

g pr

otei

n pe

r por

ition

(i.e

. = 1

egg

)•

In a

dditi

on c

an h

ave

low

-pro

tein

opt

ions

(e.g

. tom

ato,

m

ushr

oom

s etc

)

MH

• <

400m

g so

dium

/100

g•

Choi

ce fi

bre-

whi

te a

nd a

t lea

st o

ne o

f who

lem

eal,

who

legr

ain

or

mul

tigra

in

AI•

Not

requ

ired

to h

ave

fibre

-incr

ease

d w

hite

just

whi

te b

read

Purp

ose:

To

dete

rmin

e ho

w th

e cu

rren

t and

new

men

u m

eets

the

Nut

ritio

n st

anda

rds a

nd a

ny a

reas

for i

mpr

ovem

ent i

n te

rms o

f min

imum

men

u ch

oice

Idea

l use

rs: L

ocal

/ Fa

cilit

y N

utrit

ion

Care

Com

mitt

ee o

r one

of t

he k

ey m

embe

rs (e

.g. D

ietit

ian,

Foo

d Se

rvic

e Pr

ovid

er)

Refe

renc

e: It

is b

ased

on

the

Nut

ritio

n St

anda

rds f

or C

onsu

mer

s of I

npat

ient

Men

tal H

ealth

Ser

vice

s in

NSW

(MH)

Par

t B –

5: M

inim

um M

enu

Choi

ce S

tand

ards

(pp

17 –

22

and

inco

rpor

atin

g th

e N

utrit

ion

Stan

dard

s fo

r Adu

lt In

patie

nts i

n N

SW H

ospi

tals

(AI)

Part

B –

3: M

inim

um M

enu

Choi

ce S

tand

ards

(pp

12 -1

6)

Not

es: B

oth

Nut

ritio

n St

anda

rds h

ave

key

info

rmat

ion

in te

rms o

f the

app

licat

ion

min

imum

men

u ch

oice

s. P

leas

e no

te o

nly

the

diffe

renc

e ar

e lis

ted

unde

r the

Adu

lt In

patie

nt se

ctio

ns fo

r “N

utrit

iona

l Sta

ndar

ds &

M

enu

Desig

n Co

nsid

erat

ions

” co

mpa

red

to th

e M

enta

l Hea

lth S

tand

ards

. Con

sider

atio

n on

the

pres

enta

tion

/ app

eara

nce

of fo

od a

nd fl

uids

shou

ld a

lso b

e co

nsid

ered

in te

rms o

f are

as fo

r im

prov

emen

t. It

may

al

so b

e he

lpfu

l to

re-a

rran

ge th

is ta

ble

base

d on

exi

stin

g fo

od se

rvic

e co

ntra

ct a

gree

men

ts m

eal p

atte

rn (e

.g. b

reak

fast

, mor

ning

tea

etc.

) to

help

iden

tify

the

initi

al a

reas

for i

mpr

ovem

ent.

ACI N

utrit

ion

and

Men

tal H

ealth

Too

lkit

- App

endi

x 10

Tabl

e 2:

The

Min

imum

Men

u Ch

oice

Sta

ndar

ds C

heck

list f

or A

CI N

utrit

iona

l Sta

ndar

ds fo

r Con

sum

ers o

f Men

tal H

ealth

Ser

vice

s and

Adu

lt In

patie

nts

in N

SW.

1/da

y10

0mL

Frui

tFr

esh,

can

ned,

stew

ed

or drie

d fr

uit

Brea

dTo

ast /

bre

ad o

r bre

ad

roll

• Va

riety

• Se

ason

al w

here

pos

sible

• Cu

t up

if re

quire

d•

Cann

ed/s

tew

ed in

nat

ural

frui

t jui

ce o

r wat

er

Juic

e

Cere

al-C

old

4/br

eakf

ast m

eal

Port

ion

pack

s whe

re a

vaila

ble

or 3

0g

Offe

red

at e

ach

mai

n m

eal

Can

sele

ct u

p to

2 sl

ices

/mea

l1

slice

or

1 ro

ll (3

0g)


App

endi

x 11

: E

xam

ple

Men

us

The

four

tab

les

that

for

m A

ppen

dix

11 a

re a

vaila

ble

on t

he A

CI w

ebsi

te in

Exc

el f

orm

at.

The

follo

win

g im

ages

pro

vide

an

exam

ple

only

.


Mon

day

Tues

day

Wed

nesd

ayTh

ursd

ayFr

iday

Satu

rday

Sund

ayM

id A

M 1

Bisc

uits

Yogh

urt

Pike

lets

Frui

t Toa

stBi

scui

tsYo

ghur

tPi

kele

tsM

id A

M 2

Fres

h Fr

uit

Fres

h Fr

uit

Fres

h Fr

uit

Fres

h Fr

uit

Fres

h Fr

uit

Fres

h Fr

uit

Fres

h Fr

uit

Mid

PM

1PC

Fru

itFr

uit T

oast

Bisc

uits

Low

Fat

Che

ese

&

Crac

kers

PC F

ruit

Frui

t Toa

stBi

scui

ts

Mid

PM

2Fr

esh

Frui

tFr

esh

Frui

tFr

esh

Frui

tFr

esh

Frui

tFr

esh

Frui

tFr

esh

Frui

tFr

esh

Frui

t

Supp

er 1

Vege

tabl

e St

icks

with

Lo

w F

at D

ipLo

w F

at C

hees

e &

Cr

acke

rsPC

Fru

itYo

ghur

tPi

kele

tsLo

w F

at C

hees

e &

Cr

acke

rsPC

Fru

it

Supp

er 2

Fres

h Fr

uit

Fres

h Fr

uit

Fres

h Fr

uit

Fres

h Fr

uit

Fres

h Fr

uit

Fres

h Fr

uit

Fres

h Fr

uit

Cold

bev

erag

e 1

Skim

Milk

Skim

Milk

Skim

Milk

Skim

Milk

Skim

Milk

Skim

Milk

Skim

Milk

Cold

bev

erag

e 2

Full

Crea

m M

ilkFu

ll Cr

eam

Milk

Full

Crea

m M

ilkFu

ll Cr

eam

Milk

Full

Crea

m M

ilkFu

ll Cr

eam

Milk

Full

Crea

m M

ilkCo

ld b

ever

age

3 Di

et C

ordi

alDi

et C

ordi

alDi

et C

ordi

alDi

et C

ordi

alDi

et C

ordi

alDi

et C

ordi

alDi

et C

ordi

alHo

t bev

erag

e 1

Tea

Tea

Tea

Tea

Tea

Tea

Tea

Hot b

ever

age

2De

caff

Tea

Deca

ff Te

aDe

caff

Tea

Deca

ff Te

aDe

caff

Tea

Deca

ff Te

aDe

caff

Tea

Hot b

ever

age

2Co

ffee

Coffe

eCo

ffee

Coffe

eCo

ffee

Coffe

eCo

ffee

Hot b

ever

age

3De

caff

Coffe

eDe

caff

Coffe

eDe

caff

Coffe

eDe

caff

Coffe

eDe

caff

Coffe

eDe

caff

Coffe

eDe

caff

Coffe

eHo

t bev

erag

e 4

Herb

al T

eaHe

rbal

Tea

Herb

al T

eaHe

rbal

Tea

Herb

al T

eaHe

rbal

Tea

Herb

al T

eaHo

t bev

erag

e 4

Low

Fat

Milk

Drin

kLo

w F

at M

ilk D

rink

Low

Fat

Milk

Drin

kLo

w F

at M

ilk D

rink

Low

Fat

Milk

Drin

kLo

w F

at M

ilk D

rink

Low

Fat

Milk

Drin

kSu

gar

Suga

rSu

gar

Suga

rSu

gar

Suga

rSu

gar

Suga

rSu

gar S

ubst

itute

Suga

r Sub

stitu

teSu

gar S

ubst

itute

Suga

r Sub

stitu

teSu

gar S

ubst

itute

Suga

r Sub

stitu

teSu

gar S

ubst

itute

Suga

r Sub

stitu

teM

ilk T

/C 1

Skim

Milk

Skim

Milk

Skim

Milk

Skim

Milk

Skim

Milk

Skim

Milk

Skim

Milk

Milk

T/C

2Fu

ll Cr

eam

Milk

Full

Crea

m M

ilkFu

ll Cr

eam

Milk

Full

Crea

m M

ilkFu

ll Cr

eam

Milk

Full

Crea

m M

ilkFu

ll Cr

eam

Milk

Men

u Ite

mW

EEK

X

ACI N

utrit

ion

and

Men

tal H

ealth

Too

lkit

- App

endi

x 11

Tabl

e 4:

One

Wee

k M

id M

eal M

enu

Exam

ple

Purp

ose:

A 1

-wee

k m

id m

eals

men

u cy

cle

exam

ple

to p

rovi

de id

eas a

nd/ t

empl

ate

for a

men

tal h

ealth

faci

lity

that

mee

ts th

e N

utrit

ion

Stan

dard

sId

eal u

sers

: Die

titia

n an

d/or

Foo

d Se

rvic

e Pr

ovid

er

Refe

renc

e: It

is b

ased

on

the

Nut

ritio

n St

anda

rds f

or C

onsu

mer

s of I

npat

ient

Men

tal H

ealth

Ser

vice

s in

NSW

Par

t B 5

.2: M

inim

um m

enu

choi

ce st

anda

rds -

mid

mea

ls (p

age

22) a

nd 6

. Tes

t M

enu

(pag

es 2

3- 2

4)

Not

es:

- All

mid

mea

l out

lines

shou

ld b

e lo

calis

ed a

nd b

ased

on

the

indi

vidu

al p

opul

atio

n ne

eds a

nd p

ract

ical

con

sider

atio

ns.

- To

help

nor

mal

ise e

atin

g at

mid

mea

ls fa

cilit

ies c

ould

impl

emen

t any

of f

ollo

win

g su

gges

tions

:o

prov

ision

of p

latt

ers f

resh

frui

t and

/or v

eget

able

stic

ks a

nd d

ips;

o

heal

thy

snac

k sh

op i.

e. h

ave

a un

it ba

sed

snac

k sh

op w

here

con

sum

ers c

an p

urch

ase

heal

thy

snac

ks w

ith th

eir m

oney

inst

ead

of g

oing

to th

e ve

ndin

g m

achi

ne;

o ha

ve a

loca

l gui

delin

e ab

out v

endi

ng m

achi

ne u

se a

llow

ance

s etc

.- T

o he

lp c

onsu

mer

s reg

ulat

e th

eir s

leep

faci

litie

s cou

ld c

hoos

e to

serv

e on

ly d

ecaf

fein

ated

hot

drin

ks a

nd re

plac

e it

with

milo

and

/or l

ow fa

t hot

milk

drin

k at

supp

er.

Nutrition and Mental Health Toolkit · ACI Nutrition and Mental Health Toolkit 1 The purpose of the...

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Transcript of Nutrition and Mental Health Toolkit · ACI Nutrition and Mental Health Toolkit 1 The purpose of the...