2016 nutrition program review presentation to: nutrition service directors and wic staff moderated...

2016 Nutrition Program ReviewPresentation to: Nutrition Service Directors and WIC Staff

Moderated by: Julianne Gaston RD, LD

Date: September 23, 2015

Objectives• To review the program review process and

areas routinely reviewed• To discuss 2016 review changes• Explain how to use review tools to conduct

self-reviews

Resources• Paper monitoring tool

– Will follow this order for discussion

• Spreadsheet– Will make calculations for user– Today’s training will focus on use of this tool– Not in the same order as the paper tool

District Reports• This sheet is protected with all sections in

“open”• Protected mode prevents someone from

clicking on a cell and deleting for changing a formula– Unprotect under “review”

• This is a summary of the data entered on the other sheets (tabs)

• If you discover any formula errors report them to Julianne

• Calculates scores by clinic and district

Total Points for clinicsTotal Points for district officeTotal Nutrition Points for District

Hemaglobin Obsveration - Summary

Nutrition Clinic High Risk Observation: Nutrition Education Session - Summary

Formula Log - Summary

Nutrition Clinic Group/Low Risk Observation: Individual - Summary

Anthropometric Observation - Summary

Nutrition District Record Review - Summary

Nutrition Clinic High Risk Record Review - Summary

Nutrition Clinic Certification: Individual Nutrition Education - Summary

Equipment - Summary

Total Score: Nutrition Education Observations (Cert + Low Risk + High Risk) - Summary

Breasrtfeeding Clinic Evaluation

Clinic #: Clinic ##DIV/0! #DIV/0!

Total Points

Tabs (Sheets)• District Reports• Clinic 1• Clinic 2• Clinic 3• Clinic 4• Clinic 5• Clinic 6• District

Points

Total Points for Nutrition = 445• District = 165• Clinic = 280

Note: Increase of 45 points over last year due to reassignment of some system points.

SUBMISSIONS AND ACTIVITIES

Pre-review

Information Submitted Prior to Onsite Visit

• 999 food package files• Nutrition education materials/class

outlines• Self-reviews • Orientation checklists• Continuing education• Breastfeeding education

Information Reviewed/Conducted Prior to Onsite Visit

• Nutrition Service Directors and Breastfeeding Coordinator interviews will be conducted by phone prior to the onsite visit– Decreases the amount time spent at the district

office

• Assessment of breastfeeding food package tailoring

• Breastfeeding Promotion and Support Evaluation

PROGRAM REVIEW ITEMS(DISTRICT TAB)

District Level

Secondary Nutrition Education• Currently pulled from chart review

– Low Risk = 25 points– High Risk = 25 points

• 2016 Score calculated: – (percent of charts with secondary education) x

(25) – i.e. (.91) x (25) = 22.75– Previously, 90 – 100% received full 25 points

System will populate the green cells, Data entry not required, data will be pulled from chart review. Only district item self-populated.

Secondary Education Percent

Possible Points

Points Awarded

1. Low Risk Education

96.7 25 24.2

2. High Risk Education

70.8 25 17.7

Overall Rating

50 41.9

2006 / 2007 State Average 2008 / 2009 State Average 2010 / 2011 State Average 2012 / 2013 State Average 2014 / 2015 State Average YTD

87.7 90.1

WIC Program Review: Secondary Nutrition Education

Percent of Participants Receiving Secondary Nutrition Education Percent of High Risk Participants Receiving High Risk Nutrition Education

AND SUPPORTBreastfeeding Promotion

Breastfeeding Promotion & SupportPossible Points = 25

Assigned District Breastfeeding Coordinator(s) is a full-time position (Possible Points = 4).

• 1+ FTE = 4 points• 80-99% FTE = 3 points• 60 -89% FTE = 2 points• 40 – 59% FTE = 1 point• < 40% FTE = 0 point• (Adjustment made based on caseload)

Evaluator must enter appropriate number

Breastfeeding Promotion and Support Point Assignment

Possible Points

Points Awarded

1. Assigned District Breastfeeding Coordinator is full time or district has FTE.(caseload adjusted)

1+ FTE = 4 points

80-99% FTE = 3 points60 -89% FTE = 2 points40 – 59% FTE = 1 point< 40% FTE = 0 point

Breastfeeding Promotion & Support

District Breastfeeding Coordinator is a Certified Lactation Counselor (CLC) or International Board Certified Lactation Consultant (IBCLC) (Possible Points = 2).

• IBCLC = 2 points• CLC = 1 point• Neither = 0

Breastfeeding Promotion and

SupportPoint

AssignmentPossible Points

Points Awarded

2. Breastfeeding Coordinator Credentials

IBCLC = 2 points

2 2CLC = 1 point

Neither = 0

All WIC staff received breastfeeding continuing education yearly (Possible Points = 5)

• 100% of staff received = 5 points• 95 – 99% received = 4 points• 90 -95% received = 3 points• 85 – 89% received = 2 points• < 80% received = 0 points

Support Point AssignmentPossible Points

Points Awarded

3. Breastfeeding Education - All staff

100% of staff received = 5 points

95 – 99% received = 4 points 90 -95% received = 3 points 85 – 89% received = 2 points80 – 84% received = 1 point< 80% received = 0 points

Peer counselors received 12 hours of continuing education (Possible Points = 2).

• 100% of staff received = 2 points• 90 – 99% received = 1 points• < 90% = 0 points

Points Awarded

4. Peer Counselor Continuing Education

100% of staff received = 3 points

95 – 99% received = 2 points 90 -95% received = 1 points< 90% received = 0 points

Evaluator must enter the appropriate number

Breast Pump• Maintains a perpetual inventory of all

pumps and kits (Possible Points = 1).• Follows state policies and procedures for

issuing pumps (Possible Points = 1).

Partial credit may be given (i.e. 0.5)

Breastfeeding Promotion and Support

Point Assignment

Possible Points

Points Awarded

5. Breast Pump Inventory Maintained

Yes=1, No=0

6. Follows State Procedure's for Pump Issuance

Yes=1, No=0 1 1

Local agency has developed a breastfeeding resource for prenatal and breastfeeding women (Possible Points = 1).

Support

Point Assignme

ntPossible Points

Points Awarde

d7. Prenatal BF Resource Yes=1,

No=0 1 0 Evaluator must enter the appropriate number

District is reviewing and correcting Breastfeeding Dyad report (Possible Points = 4).

Points Awarded

Breastfeeding Dyad Report (Average for all clinics)

Past year reports available, resolution of problem documented

Evaluator must enter a number

Breastfeeding Plan (Possible Points =3).• District nutrition services plan contained

breastfeedingBreastfeeding

Promotion and Support Point Assignment

Possible Points

Points Awarded

Breastfeeding Plan • Nutrition Service Plan submitted on time

• Plan contained breastfeeding activities

2014/2015Range (%) State

Average (%)

District Breastfeeding Promotion and Support

7.3 - 20 16

BREASTFEEDING PACKAGES

Tailoring

Tailoring Breastfeeding Food Packages(Possible Points = 15)

Percent of Mostly Breastfeeding Packages > 10% of contract formula packages.

• Meets Goal = 5 points• > 0.5% progress = 3 points• > baseline & < 0.5% increase = 2 points• Does not meet with no progress = 0 points

Note: baseline from March 2015Resource: Breastfeeding Food Package Create Report

Tailoring Breastfeeding Food

Packages Point Assignment

Possible

Points

Points Awarde

dPercent of Mostly Breastfeeding Packages: > 10% of contract formula packages are MBF or (Percent of Mostly Breastfeeding Packages plus Exclusively Breastfeeding Packages: > 19% of contract formula packages are MBF or EBF)

Meets Goal = 5 points

> 0.5% progress = 3 points

> baseline & < 0.5% increase = 2 pointsDoes not meet with no progress = 0 points

Tailoring Breastfeeding Food Packages

Percent of Fully Formula Packages < 85% of contract formula packages.

Point Assignment

Possible Points

Points Awarde

d 2. Percent of Fully formula packages: < 85% of contract formula packages are FFF

> 0.5% progress = 3 points> baseline & < 0.5% increase = 2 pointsDoes not meet with no progress = 0 points

Percent of Exclusively Breastfed Packages > 9% od contract/EBF packages

Tailoring Breastfeeding Food Packages Point Assignment

Possible

Points

Points Awarde

d3. Percent of Exclusively breastfeeding infant food packages: > 9% of infant food packages are EBF

> 0.5% progress = 3 points

> baseline & < 0.5% increase = 2 pointsDoes not meet with no progress = 0 points

FOOD PACKAGES999

999 Food Packages(Possible Points = 15)

District packages available for review. • Yes = 2 points• No or can not evaluate = 0 points

999 Food Packages

Food packages followed existing state and federal guidelines (descriptions).

• Yes = 2 points• No = 0 points

999 Food Packages

Food packages within federal minimum and maximum standards (full nutritional benefit).

• Minus 1 point for each over or under issuance (up to a max of 6 points)

999 Food Packages

Designated coordinator for district created food packages and approval process (Possible Points = 3).

999 Food Packages

District 999 food packages cover all of the packages needed by the clinics (Possible Points = 2).

• Based on evaluation of 999 food packages issued by clinics

999 Food Packages Point AssignmentPossible Points

Points Awarded

1. District packages available for review

Yes = 2 points; No or not able to evaluate = 0 points

2. Packages follow state and federal guidelines (descriptions)

Yes = 2 points; No or not able to evaluate = 0 points

3. Packages within allowed minimums and maximums

100% correct = 6 points

(Minus one point for each over or under issuance - up to 6 points)

4. Designated food package coordinator

Yes = 2 points; No = 0 points 3 3

5. District packages cover all of the identified packages needed

Yes = 2 points; No = 0 points 2 1

Overall Rating 15 13Evaluator must enter appropriate number; System will total

999 Food Package Points2012/2013 2014/2015

Range 2-15 2-15

State Average 8.6 8.7

RESOURCESNutrition Education

Nutrition Education Materials/ClassesPossible Points = 15

Class outlines available and include learning objectives (Possible Points = 2)

• Yes = 2 points• Outlines without objectives = 1 point• No = 0 points

Nutrition Education Materials/Classes

All district created Nutrition Education materials meeting guidelines, including current non-discrimination statement (Possible Points =3)

Appropriate and adequate variety of nutrition education materials available to meet participant category needs? (English, Spanish, low literacy, other). (Possible Points = 2)

All District created materials were approved by the Nutrition Unit and DPH (Possible Points = 3).

Available nutrition education resources for emergencies (Possible Points = 2).

• Food Safety• Food Preparation• Safe Water Supply• General Sanitation

Nutrition Education Materials/Class Outlines

Point Assignment

Possible Points

Points Awarded

1. Class outlines available/contain objectives

2. All participants groups represented 3 3 3. All district created nutrition education materials meet guidelines (non-discrimination)

4. Appropriate & adequate variety of NE materials available to meet participant need.

5. All District materials were approved by the Nutrition Unit and DPH

6. Nutrition Education resources available for emergencies: Food safety, Food Preparation, Safe Water Supply, General Sanitation

Overall Rating 15 14

Evaluator must enter appropriate number; System will total

2012/2013 2014/2015Range 6-15 6-15State Average 12.9 12.2

SELF-REVIEWSDistrict

District Self-Reviews for Nutrition(Possible Points = 15)

• Summary of findings completed for all required clinics (Points = 5)

• Chart Review - at least 10 per clinic (Points = 2)

• High Risk Chart Review (Points = 2)• Observations (Individual / Group) (Points =

2)• Breastfeeding Friendly Clinic (Points = 2)• Equipment /Formula Log/Nutrition

Materials (Points = 2)

Self Reviews

Point Assignme

Possible

Points

Points Awarde

d1. Summary of finding available for all clinics

2. Chart review (with at least 10 charts per clinic)

3. High Risk chart review 2 2

4. Observations 2 25. Breastfeeding clinic evaluation

6. Equipment 1 1

7. Formula log 1 1

Overall Rating 15 15Evaluator must enter the appropriate points; System will total

Self Reviews – New in 20152015

Range 7-15State Average* 13.0

*Average includes 9 districts

CHECKLISTSOrientation

Orientation Checklists • Increased from 5 to 10 total points• District CPA orientation checklists includes

all components of current the “state orientation checklist. (Possible points = 2).

• Checklists on file for all CPA’s hired since last program review (Possible Points = 4).

• All components completed, initialed and checklist signed (Possible Points = 4).

Orientation Checklists

Point Assignmen

tPossible Points

Points Awarde

d1. District CPA checklist inlcudes all components of the "state Orientation checklist"

2. Checklists on file for all CPAs hired since last program review

3. All components completed, initialed and signed.

Overall Rating 10 6

Evaluator must enter appropriate number, System will total

Orientation Checklists2012/2013 2014/2015

Range 2-5 1-5State Average 3.5 3.4

EDUCATIONContinuing

Continuing Education

Percent of CPA’s (or CPA’s + NA’s) received 12 hours (Possible Points = 18)

• 90 - 100% = 18 points• 80 - 89% = 14 points• 0 - 79% = 0 points

Continuing Education

All required NA observations (4/yr) completed. • 100% or no NA's = 2 points• 95-99% = 1 point• < 95% = 0 points

Continuing EducationPoint Assignment

Possible Points

Points Awarded

1. Percent of CPA's received 12 hours continuing education

90-100% = 18 ponts 18 14

or80-89.9% = 14 points

Percent of CPA's + NA's received 12 hours continuing education.

0-79.9% = 0 points

2. Percent of NA observations conducted

100% or no NA's = 2 points 2

0 (# of NA)* 4= Total observations required

95-99.9% = 1 points

< 95% = 0 points

Overall Rating 20 14

Evaluator must enter appropriate points; System will total

Continuing Education - CPA2011/2012 2013/2014

Range 65 - 100 70-100

State Average 97 96.7

TOTAL POINTSDistrict

Total District Points• Totaled on district page• Pulled to District Reports• See bottom right of report page

Points

Total Points for clinics 235

Total Points for district office 120Total Nutrition Points for District

BREASTFEEDING EVALUATION

Clinic

Equipment - Summary

Total Points

Breastfeeding Clinic Evaluation(Possible Points = 30)

Establish a clinic environment that clearly supports breastfeeding: posters, bulletin boards, displays, flyers throughout. No formula messaging. (Possible points = 5)

• Subtract 1 point from 5 for each space without breastfeeding messaging and for each formula messaging found.

Clinic 1 Breastfeeding Clinic Evaluation

Point Assignment

Possible Points

Points Awarde

d1. Clinic environment supports breastfeeding; breastfeeding friendly posters, bulletin boards, cups, displays through. No formula messaging

Subtract points from 5 for

each space without

Note: “na” is a place holder, prevents report page for adding zero points for a clinic page not in use

Evaluator must add appropriate points

Breastfeeding Clinic Evaluation

Women encouraged to breastfeed during pregnancy (chart review). Possible points = 3.

• 90-100% = 3 points• 80-89% = 2 points• 70-79% = 1 point• < 70% = 0 points

Note: these points are in addition to the three points received on the chart review

Point Assignment

Possible Points

Points Awarde

2. Women encouraged to breastfeed during pregnancy (chart review)

90-100% - 3 points

80-89% - 2 points

70-79% - 1 point

< 70% + 0 points

Evaluator must add appropriate points; Currently not pulled from chart review

Breastfeeding weeks documented correctly (chart review). Possible Points = 2

• 90-100% = 2 points• 80-89% = 1 points• < 80% = 0 points

Note: these points are in addition to the one point received on the chart review

Point Assignment

Possible

PointsPoints

Awarded3. Breastfeeding weeks documented correctly (chart review)

90-100% - 2 points

2 na80-89% - 1

points

<80% - 0 point

Evaluator must enter appropriate number, Currently does not pull from chart review

Designated private space for nursing mothers (Possible Points = 5)

• Special Designated room - 5 points• Shared space with a BF space in room - 4

points• Shared space with no breastfeeding

accommodations - 3 points• Shared made available on request - 2

points• No or inappropriate space - 0 points

Clinic 1 Breastfeeding Clinic Evaluation Point Assignment

Possible Points

Points Awarded

4. Designated private space for nursing mothers.

Special Designated room = 5 points

Shared space with a BF space in room = 4 points

Shared space with no breastfeeding accommodations = 3 points

Shared made available on request = 2 points

No or inappropriate space = 0 pointsNote: “na” is a place holder, prevents report page for adding zero points for a clinic

page not in use

Breastfeeding peer counselors available to provide additional support to prenatal and breastfeeding women.

• Clinic has regular PC hours = 4 points

• Clinic has PC as needed = 3 points

• PC available on referral basis = 2 points

• No PC coverage = 0 points

Possible Points

Points Awarded

5. Breastfeeding peer counselors available to provide additional support to prenatal and breastfeeding women.

Clinic has regular PC hours = 4 points

Clinic has PC as needed = 3 points

PC available on referral basis = 2 points

No PC coverage

Prenatal breastfeeding classes offered (Possible points – 4)

• Classes available on site or Videoconferencing

• BF class content provided on individual basis separate from certification

Possible Points

Points Awarded

6. Prenatal breastfeeding classes offered.

Classes available on site or VC

BF class content provided on individual basis separate from certification

Evaluator must enter appropriate numbe

Breastfeeding referral system: clinic level staff accurately describes district referral system (Possible points – 3).

Point Assignme

ntPossible Points

Points Awarded

7. Breastfeeding referral system: clinic level staff accurately describes district referral system.

Clinic follows policies and procedures for issuing breast pumps (Possible points -2).

Point Assignme

ntPossible Points

Points Awarded

8. Clinic follows policies and procedures for issuing breast pumps.

Clinic is maintaining an inventory of all breast pumps and kits (Possible points -2).

Point Assignment

Possible Points

Points Awarded

9. Clinic is maintaining an inventory of all breast pumps and kits.

OBSERVATIONSNutrition Education

Nutrition Education Observations

• Increased from 75 to 100 points• Do not enter the actual points• Enter the rating

– Enter 1 for satisfactory, 0 for unsatisfactory– Partial credit can be given (0.8, 0.6, 0.4)

• The District Report sheet will calculate points for the observation

Nutrition Education Observations

• Three types of observations instead of two– Certification– Low risk/class– High risk

Equipment - Summary

Total Points

Clinic # 000

Total Number of Certification Observations Reviewed per clinic 1

Total Number of Group/Low Risk Observations Reviewed per clinic 2

Total Number of High Risk Observations Reviewed per clinic 1

Total Number of Observations Reviewed per clinic 4

Total Observation Score 89.3

Total Observation score is an average of all observation scores

District Reports

Participant Category (group enter all that apply) P,I,B,C

Service Type L

Time estimated for total contact 30

Time estimated for NE contact 30

Criteria To ReviewA. Low Risk Nutrition Education Session

1. Had outline of topic and related questions/used topic suggested by participants. NA must have outline.

2. Made introduction of self and topic of discussion. 1

3. Invited questions and encouraged participation. 1

4. Remained courteous, respectful, and non-judgmental. 1

5. Used open ended questions and reflective listening to facilitate participation inlcuding the used of praise and encouragement.

6. Provided accurate nutrition educatiion information and appropriate materials.

7. Displayed respect for other cultures (used translator appropriately, eye contact, time mangement, greetings).

8. Used summary and closing. 1

9. .Evaluation of learning utilized. 1

10. Documented group education in the electronic medical record. 1

Clinic View

Criteria To Review Weight (%)# Correct Out of # % Score (%)

A. Group Nutrition Education Sessions 100 Points1. Had outline of topic and related questions/used topic suggested by participants. NA must have outline.

10 2 2 100.0 10.0

2. Made introduction of self and topic of discussion. 5 2 2 100.0 5.03. Invited questions and encouraged participation. 10 2 2 100.0 10.04. Remained courteous, respectful, and non-judgmental. 5 2 2 100.0 5.05. Used open ended questions and reflective listening to facilitate participation inlcuding the used of praise and encouragement.

20 1.8 2 90.0 18.0

6. Provided accurate nutrition educatiion information and appropriate materials.

10 2 2 100.0 10.0

7. Displayed respect for other cultures (used translator appropriately, eye contact, time mangement, greetings).

10 2 2 100.0 10.0

8. Used summary and closing. 10 2 2 100.0 10.09. .Evaluation of learning utilized. 10 2 2 100.0 10.010. Documented group education in the electronic medical record. 10 2 2 100.0 10.0

Total Score Awarded (%) 100 98.0

Weight : Points Report View

Establishing Rapport2014/2015 Range

(%)State

Average (%)

Made Eye Contact 90.9 - 100

Respect for other Cultures 100 100

Non-verbal Communication

88.9 98

Ensured Privacy 100 100

Appreciation of Participant’s Time

100 100

Completing Assessment Forms2014/2015 Range

(%)State

Average (%)

Reviewed Nutrition Questionnaire

50-100 93.3

Asked Probing Questions

50-100 94.5

Shared Finding 33.3 - 100

Counseling Skills2014/2015 Range

(%)State

Average (%)

Asked Open Ended Questions 35.7 - 100 73.4

Praised Participant 16.7 - 100 93.1

Client Lead 20 - 100 84.0

Reflective Listening 50 - 100 79.6

Nutrition risks, if not client lead 72.7 - 100 93.7

Exit Counseling 33.3 - 100 84.8

Goal Setting2014/2015 Range

(%)State

Average (%)

Summarized the Discussion 50 - 100 86.6

Participant Centered Goal Setting

50 - 100 69.7

Documented Goal 62.5 - 100 85.7

Accuracy of Certification Finding

2015 Range (%)

State Average

Correctly Identified Risks 37.5 - 100 69.6

Correctly Plotted 71.4 - 100 95.0

Accurate Nutrition Education

64.3 - 100 89.8

Appropriate Referrals Completed

40 - 100 87.8

EQUIPMENT

Anthropometric and Hematological

EquipmentIncreased from 5 to 10 points

Height board(s) = 2 points• Fixed measuring device (fixed to

vertical surface with no skirting)• Right angle headboard, slides easily• Accuracy of placement (for wall

mounted boards)

Equipment

Standing scale(s) = 2 points• Calibrated in last 12 months• Zeros out between measurements

Equipment

Length board(s) = 2 points• Movable foot piece that slides easily• Foot piece at 90 degree angle• Fixed headboard

Equipment

Infant scale(s) = 2 points• Calibrated in last 12 months• Zeros out between measurements

Clinic 1 Equipment1 2 3 4 5 6 7 8 9 10

ReviewerDate Height Board 1 0

Fixed measuring device (fixed to vertical flat surface/no skirting)Right angle head board Accuracy of placement (for boards mounted to wall)Standing Scales: 1 1

Calibrated in last 12 months (use scale test report or sticker)Beam (B) or Digital (D) D D

Length Board 1 1

Movable foot piece that slides easilyFoot piece at 90 degree angleFixed headboardInfant Scale: 1 1

Calibrated in last 12 months (use scale test report or sticker)Beam (B) or Digital (D) B D

Hematological Equipment: Document Brand Hemo Pronto

Bottle dated 1 1

Comments:1)2) hieght board has no kickboard and has slid, mesuring 1/4 in off3)4)5)6)7)8)9)

Enter “1” for satisfactory; Enter “0” for unsatisfactoryEnter “B” for beam and “D” for digitalEnter type of hematological equipment

Equipment Score

Range (%) State Average (%)

2014/2015 4 - 5 4.7

OBSERVATIONAnthropometric

Anthropometric Observation2.5 points/per measurement

Standing Height• Measured without shoes (0.5 points)• Proper stance for reading measurement

(0.5 points)• Headboard is level, touches top of head

(0.5 points)• Measurements taken and recorded

accurately to the nearest 1/8th inch (0.5 points)

• Measurements taken twice (0.5 points)

Anthropometric ObservationStanding Weight

• Participant dressed in minimal clothing (0.5 points)

• Scale zeroed prior to measurement (0.5 points)

• Correct angle for reading measurement (0.5 points)

• Measurements taken and recorded accurately to the nearest 1/4th pound (0.5 points)

Anthropometric ObservationRecumbent Length

• Body straight and lined up with measuring board (0.5 points)

• Proper stance for reading measurement (0.3 points)

• Head against headboard (0.5 points)• Footboard firmly against heels (0.5 points)• Measurements taken and recorded accurately

to the nearest 1/8th inch (0.3 points)• Measurements taken twice (0.4 points)

Anthropometric ObservationStanding Weight

• Participant dressed in minimal clothing (0.5 points)

• Scale zeroed prior to measurement (0.5 points)

• Correct angle for reading measurement (0.5 points)

• Measurements taken and recorded accurately to the nearest 1/4th pound (0.5 points)

Anthropometric Observation

Infant Scale Weight• Participant dressed in minimal clothing

(0.5 points)• Scale zeroed prior to measurement (0.5

points)• Correct angle for reading measurement

(0.5 points)• Measurements taken and recorded

accurately to the nearest one ounce (0.5 points)

Clinic 1 Anthropometric Observations1 2 3

ReviewerWIC TypeAgeStanding Height1. Measured without shoes2. Proper stance used for reading measurement3. Headboard is level, touches top of head4. Measrement taken and recorded accurately (to at least nearest 1/8 in)5. Two measurments takenStanding Weight6. Participant dressed in minimal clothing7. Scale zeroed prior to measurment8. Correct angle used for reading measuremnt9. Measrement taken and recorded accurately (to at least nearest 1/4 pound)10. Two measurments takenRecumbent Length11. Body straight and lined up with measuring board12. Proper stance used for reading measurement13. Head is against the headboard throughout measurement14. Footboard firmly against heels15. Measrement taken and recorded accurately (to at least nearest 1/8 in)16. Two measurments takenInfant Scale Weight17. Participant dressed in minimal clothing18. Scale zeroed prior to measurment19. Correct angle used for reading measuremnt20. Measrement taken and recorded accurately (to at least nearest 1 ounce)21. Two measurments taken

Comments:1)2)

“1” for satisfactory

“0” for unsatisfactory

Anthropometric ObservationRange (%) State Average

2014/2015 3.0 - 5 4.3

OBSERVATIONHematological

Hematological Observation5 points

Hemocue• Universal precautions used (1 point)• Followed correct procedures (3 points)• Collected when required (1 point)

Pronto• Followed correct procedures (3 points)• If unable to obtain reading, screened

with Hemocue (1 point)• Collected when required (1 point)

Clinic 1 Hemoglobin Obs 1 2

ReviewerDate HemocueStaff used universal PrecautionsFollowed correct proceduresHgb collected when requiredProntoFollowed correct proceduresIf unable to read, screened with HemocueHgb collected when required

Comments:1)2)

Enter “1” for satisfactory; Enter “0” for unsatisfactory

Hematological ObservationRange (%) State Average

2014/2015 4.3 - 5 4.8

TRACKING LOGFormula

Formula Tracking LogIncreased from 5 to 15 Points

Formula log• Formula inventory matches stock on

hand (3 points)• Inventory completed according to

guidelines (1.5 points)• Inventory verified at least quarterly (1.5

points)• Limited Stock on hand (1.5 points) • No expired formula (1.5 points)

Formula Tracking Log

State Ordered Formula log• Available for review (1.5 points)• Inventory completed according to

guidelines (1.5 points)• Historical logs (formula and state

ordered) available (1.5 points)

Clinic 1 Formula LogLog: 1Reviewer

1. Does the formula inventory match current stock on hand?

2. Was the inventory log book completed according to guidelines?

3. Was inventory verified at least quarterly?

4. Was there a procedure in place for issuing formula from stock intended to limit excess stock? 5. No expired formula in inventory? 6. Is formula issued/exchanged based on reconstituted fluid ounces? 7. State Ordered Formula Tracking Log available for review8. Was the State Ordered Formula Tracking Log book completed according to guidelines? 9. 5 years plus current history available for review?

Comments:1)

Formula Log ScoresRange (%) State Average

2014/2015 3.3 - 5 4.2

CHART REVIEW AND MEDICAL DOCUMENTATION

High Risk (Special Formula)

High Risk Chart ReviewPossible Points = 15

Charts pulled for participants on special formula or food packages

• CPA FPC beginning with R, S, X, Z, 199, 197, 999

High Risk Points• 13 - 15 points – Satisfactory• 10 – 12.9 points – Satisfactory Needs

Improvement• < 10 - Unsatisfactory

High Risk Chart ReviewNutrition Education

• Secondary nutrition education completed (1 point)• Complete Care Plan (1 point)

High Risk Chart ReviewMDF

• Medical Documentation Form complete (2 point)

• WIC Food authorization /restriction is clear without conflicting information (2 point)

• MDF has valid date for intended certification

(1 point) • Diagnosis matches intended use of

formula (1 point)

High Risk Chart ReviewIssuance/Referrals

• Formula issuance matches MDF (2 point)• Food issuance matches MDF (2 point)• Appropriate referrals made (1 point)• Food package changes adjusted correctly (2 points)

Chart: 1Participant Name Participant Category 1. Nutrition Education/High Risk Completed 2. Care Plan 3. Medical Documentation Form Complete 4. WIC Food Authorization/Restriction is Clear w/out Conflict 5. Medical Documenation in a Valid Date for Intended Certification 6. Diagnosis matches Indicated Use for Formula 7. Issuance Matches Medical Documentation - Formula 8. Issuance Matches Medical Documentation - Food 9. Appropriate Referrals 10. Food Package Changes Adjusted Correctly

Comments:1)

High Risk Chart Scores2014/2015 Range (%) State Average

Secondary Education

76.5 - 100 90.6

High Risk Care Plan

29.4 – 87.5 62.5

MDF Complete 37.5 – 93.8 73.5

MDF Valid Date 85.7 - 100 93.7

Diagnosis 64.7 – 100 81.8

MDF without Conflict*

81.3 - 100 91.4*New in 2015

High Risk Chart Scores2014/2015 Range

(%)State Average

Formula Issuance Matches MDF

62.5 - 100 79.5

Food Issuance Matches MDF

53.8 - 100 74.6

Food Package Change Correct

50.0 - 100 81.3

SUMMARYRecord Review

Chart Review

Total Possible Points = 100• 22 criteria• Enter 1 for satisfactory, 0 for

unsatisfactory• Each criteria weighted based on

– Importance– Amount of critical thinking required– Range of 1-15 points

Medical Data Date (1 point)• Date of certification if WIC staff obtained

measurements or• Date of referral measurements obtained• Referral measurements < 60 days prior to

certification• Data reflective of WIC status

Anthropometric• Length/Height Recorded (1 point)

– Consistent with past measurements– Entered to the nearest 1/8 in.

• Weight Recorded (1 point)– Current weight– Pregravid weight– Birth weight

Hct/Hgb Recorded (1 point)• Hematological date recorded• Measurement entered to a decimal place• Referral measurement < 90 days prior to

certification• For women, reflective of WIC status• Obtained at each certification

Age (1 point)• Date of birth recorded on certification form• Infant/child ages recorded on cert form

and/or growth charts

Anthropometric Scores2014/2015 Range

(%)State

Average (%)Medical Data Date

93.8 - 100 99.1

Weight Recorded

59.4 - 100 94.4

Height Recorded 93.8 - 100 96.9HCT/HGB Recorded

93.8 - 100 97.8

Age* *Age not scored because credit always given

Nutrition Risks• All Nutrition Risks Checked (10 points)

– All applicable nutrition risks selected– No risks assigned inappropriately

• All nutrition Risks Documented (10 points)– Required documentation is present for all risks

requiring documentation

• Except Inappropriate nutrition practices

–Evaluated separately

Inappropriate Nutrition Practices (5 points)

• If INP are present they must be correctly identified

• All INP must be correctly documented– Provide enough detail so it is clear what the

issue is

Nutrition Risk Scores2014/2015 Range

(%)State Average

Nutrition Risks Checked

62.5 – 92.5

Nutrition Risks Documented

77.4 – 98.6

Inappropriate Nutrition Practices

80.6 – 96.8

Priority/High Risk Identified

Priority (2 points)• Correct priority assigned• Missed risks can lead to wrong priority

being assignedHigh Risk Identified (3 points)• Assigned as HR, if risks criteria at high risk

level• CPA may overrule with documentation HR

status

Referral/Enrollment Documented (3 points)

• Screened for enrollment by clerical staff at every certification for SNAP, Medicaid, and TANF– System should capture enrollment

• Referrals– Participations not enrolled in SNAP, Medicaid,

and TANF must be referred at least • Once during pregnancy cycle• As an Infant• As a Child

• Other referrals as needed

Referrals2014/2015 Range

(%)State

Average (%)Enrollment/referral 79.6 - 100 92.3

Date/Signature and Title• Date (1 point)

– Date of certification/visit

• Signature (1 point)– First initial and last name or first name and last

name– Must be legible– Credentials must be included in the signature

Breastfeeding Weeks (1 point)• Breastfeeding women (Cert and Mid-

Assessment)• Non-breastfeeding postpartum women

(Cert)• Infants (Cert and mid-cert)• Children (Cert and half-cert until 2 yr)• Remain the same or increase• Correspond BF Now and BF Ever

questions

Breastfeeding Encouraged (3 points)

• All prenatal women unless contraindicated reason is documented

• Encouragement is not asking prenatal if she plans to breastfeed

• Document BF encouragement nutrition box and all topics discussed

Breastfeeding Scoring2014/2015 Range

(%)State

Average (%)Breastfeeding Weeks 88.7 -

10095.8

Breastfeeding Encouraged

77.8 - 100

Goal Documented (10 points)

Goal• Required in goal box at cert and at

midyear assessment• SMART format• Avoid compound (multipart) goals• Participant centered• Behavioral

Primary Education (5 points)• Nutrition education provided at Cert and

Midyear Assessments (for chart review purposes)

• From August 2016 must be documented in electronic record

• Must be appropriate for individual• Provided by CPA• Document specific topics covered from list

provided

Secondary Education (15 points)

• Nutrition education provided between Cert and Midyear Assessments and Midyear Assessment and cert

• Electronic documentation required • Document specific topics covered from list

provided• May look a previous 6 months if no NE for

current cert

Secondary Education • Must be appropriate for individual• Low risk

– provided by CPA or NA– Individual, class, Videoconference or online

High Risk Follow-up (15 points)

• Required for any participant with a high risk factor

• Requires care plan• Care Plan should indicate nutrition

counseling specific to their condition• Documentation in electronic record as HR• Provided by CPA

Exit Counseling (5 points)

During prenatal through postpartum visit a woman must receive education as least once on the following topics:• Importance of folic acid • Health risks of using alcohol, tobacco, and

drugs• Breastfeeding as preferred method of

infant feeding• Importance of immunization• Must be present at one NE contact to date

Exit Counseling (5 points)

Parents of infants and children must receive education as least once during the infant/child’s enrollment on the program on the following topics:• Health risks of using alcohol, tobacco, and

drugs• Importance of immunization• Must be present at one NE contact to date

Education/Goal Scores2014/2015 Range

(%)State

Average (%)Goal 68.8 – 97.4 82.0

Certification Education

95.8 - 100 98.4

Exit Counseling 35.5 - 100 89.9

Plotting (4 points)• Plotted accurately• Plotted as close as possible to exact age• Prenatal women plotted to nearest

completed weekLength/height for age

Weight for ageBMI/weight for length

Weight for gestational weekHead circumference for age (when

available)

WHAT IS THE FINAL RESULT

Wrap up

Scores• To calculate section scores must enter at

least one entry for each line item• To calculate clinic scores must have data

for each section – Use to compare clinics within district– Use to compare one clinics progress over time– Limit of six sites per spreadsheet

• District score is an average of clinic data

Tips• Do not attempt to enter any data on the

District Report (first tab)• All data entry is completed on the clinic 1-

6 and district tabs

Warning

2016 nutrition program review presentation to: nutrition service directors and wic staff moderated...

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secondary education

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