The group agreed on the aim of the quality improvement exercise as being to improve the nutritional status of their residents. This involved focusing on assessment, meeting the residents' nutritional needs, and the planning and evaluation of care. For each of these key areas, an overall standard statement was agreed, drawing on previous work undertaken in the UK to develop national nutritional standards on the care of older people (RCN, 1993).
For each of the key standard statements, criteria are identified to illustrate the resources (structure) and actions (process) required to achieve the standard statement and the expected results (outcomes) for the patient. Structure criteria refer to the resources that need to be in place, in the form of staff, equipment and information and knowledge provision; processes describe the actions to be undertaken by staff, including assessment, planning, teaching and evaluation; outcomes define specific results to be achieved, for example, relating to the patient's nutritional status and satisfaction with the choice of meals provided.
These criteria are recorded on a standard form and provide a template for implementing the standard. Having agreed the criteria, the group then develop an audit form to assess the level of achievement of the standard. Depending on the results of the audit, appropriate remedial action is planned and implemented by way of an agreed action plan. This brings the group around to begin a second cycle of improvement. In this way, quality improvement becomes an ongoing, dynamic activity which is best visualised as a continuous spiral of improvement.
