CMS has released the adoption of revisions to the SOP Appendix PP. Among the changes is the ability for RD/RDNs to attain order writing privileges as delegated by the physicians. Our colleagues in the acute care setting have been establishing policy for credentialing and writing orders for almost 1 year. There is some useful information available for RDs in the LTC/Sub-acute setting.
The following article was written by Aimee Crant-Oksa, the Clinical Nutrition Manager at CentraState Medical Center. Aimee was one of the first Clinical Managers to initiate RD privileges in the state of New Jersey in her hospital.
Registered Dietitian Order Writing Privileges – One Institution’s Journey
by Aimee Crant-Oksa MS, RD
In May 2014 The Center for Medicare and Medicaid’s (CMS) proposal allowing Registered Dietitians the authority to manage a patient’s diet in the inpatient hospital setting. It was passed and went into effect in July of that year. As a Registered Dietitian (RD) for close to 20 years, and dreaming about this privilege since I was first a dietitian, I knew I wanted to pursue this in my facility. After the ruling came into effect, The Academy of Nutrition and Dietetics released a state by state guide stating who had a green light for ordering privileges, who had a red light and those that fell in between. In New Jersey, we fell in between in the yellow area.
In the fall of 2014, I contacted the dietitian from the New Jersey Department of Health (NJDOH) for guidance. She advised me that we needed a waiver to have the state regulation amended to allow ordering privileges for the RD. I met with the Chief Medical Officer (CMO) , the Director of Nursing and the AVP of Quality for support, guidance and permission to move forward with the process. I am very lucky to have had the support from these people. The CMO worked with me on every step of the project, and we had his and many other physicians wanting us to have ordering privileges. This was vital in having the privileges granted.
Initially I created a proposal and submitted it to the CMO. In it I stated the CMS ruling, why it was important for patient care, the outline of the privileges I was asking for and credentialing requirements. This document served as the basis for the Dietitian Order Writing Policy. I debated having a policy that allowed the dietitians to write orders without restrictions, but decided that there needed to be some guidelines. This is a new process for all of the medical staff, nursing staff and dietetic staff. I wanted the dietitians to be comfortable in their new role, but also have communication to the physician when necessary to make the decisions as a team.
I decided on the following as the outline of our policy:
After initial RD consult and evaluation:
- · RD’s can change existing po diets, order nutrition supplements and nourishments
- · RD’s can only advance from NPO or a liquid diet to a solid food diet with a conversation with the attending physician and documentation in the progress note
- · RD’s can write Enteral tube feeding orders if an order is written by the physician stating NGT/PEG/PEJ/GT/JT can be used
- · Total Parenteral Nutrition (TPN) orders can only be written by a Certified Nutrition Support Clinician (CNSC)
- · RD’s can order modified consistency diets based on Speech Language Pathologists recommendations
- · RD’s may order diet related laboratory tests
The policy successfully passed through The Medical Executive Committee (MEC) and The Governing Board. We submitted our application to NJDOH in December 2014. In June 2015, NJDOH after many applications were submitted from hospitals throughout the state, sent out a memo stating that “as a general waiver, licensed hospitals may allow a physician or an RD to write a specific dietary order for each patient; and patient nutrition needs for food and food supplements shall be met in accordance with physician or RD orders.” Upon receiving the memo, I contacted the CMO for our next steps. We created a privileging application for the dietitians to apply to the medical staff and a credentialing checklist to ensure we had all the necessary documentation. We are the only non-medical staff to have been privileged in our facility.
This is an example of our checklist:
Personnel file monitored and maintained in Human Resources Department
Meets all employment criteria for Registered Dietitian
Personnel file up-to-date
Employee in good standing
Professional Portfolio for 75 CE credits every 5 years (current and on file)
Medical Nutrition Therapy goal related to area of hospital practice with a
minimum of 5 CE credits annually (current and on file)
Registered Dietitian, verified by the Commission on Dietetic Registration - copy attached
Malpractice insurance for independent diet and TPN ordering - copy of current COI attached
Certified Nutrition Support Clinician (required for TPN order entry) – copy Attached
The dietitians are employed by the hospital so it was decided that Human Resources would sign off on the credentialing piece, and the privileging part would be signed off by the chairperson of the Credentialing Committee. I initially presented all of the applications at this meeting as the forms needed to be approved. After the chairperson and the committee approved the applications, they went to MEC and The Governing Board for final approval. All of the dietitians have been approved and are now placing orders for diets, supplements, etc.
This is a wonderful enhancement to our profession, and our role in the hospital setting. There is improvement in timeliness, accuracy and provision of nutrition care. I look forward to seeing the dietitians role continue to grow and change as we become a more valued member of the healthcare team.