Optimising scope; Hunter New England Local Health District’s nutrition care for inpatients and residents policy compliance procedure and the adjoining Quality Audit Reporting System tool

Mrs Cassandra Knight1, Mrs  Amber Thoroughgood1

1Hunter New England Local Health District, Allied Health Directorate, Newcastle, Australia

Background: The NSW Health Nutrition Care Policy was revised in 2017 and with a new policy came a revision of Hunter New England Local Health District’s (HNELHD) Nutrition Care for Inpatients and Residents Policy Compliance Procedure (PCP). The policies outline the key elements to deliver excellent nutrition care to inpatients and residents; Governance, Weight and Height Assessment, Nutrition Screening, Nutrition Assessment, Nutrition Care Planning, Planning and Delivery of Food and Fluids, The Mealtime Environment, Provision of Assistance to Eat and Drink, Staff Education and Training and Evaluation. The District Patient Quality Nutrition Committee (PQNC) oversees compliance across HNELHD’s large geographical area spanning 25 local government areas (LGAs).

Method: The task was to rewrite the HNELHD Nutrition Care for Inpatients and Residents PCP to improve compliance. This involved collaboration and optimising scope to detail the policy requirements, staff responsibilities and evaluation in a way that will drive frontline nutrition care forward.

Results: The Allied Health Team revised the PCP with the direction of the District PQNC, which included;

  • Assessment of previous District wide nutrition audit results to identify gaps and areas for improvement.
  • Consultation with stakeholders; Nursing and Midwifery, Dietetics, Speech Pathology, Paediatrics, Mental Health, Aged Care and Foodservices.
  • Mapping of the elements to the National Safety and Quality Health Service Standards (NSQHS).
  • Streamlining nutrition evaluation into a short 12 question Quality Audit Reporting System (QARS) tool (results feed into local consolidated audit results/action plan).

Discussion: Amongst many competing health care demands, raising awareness and action to implement strategies to comply with the Nutrition Care Policy has been challenging. The reviewed PCP/audit drives compliance by;

  • Assigning evaluation responsibilities to the staff responsible for the tasks (supporting action).
  • Inclusion of NSQHS Standards to streamline workload and raise significance.
  • An efficient District wide Quality Audit Reporting System tool to focus on targeted improvement.


NSW Ministry of Health. Policy Directive: Nutrition Care PD2017_041. In: Office of the Chief Health Officer, editor. North Sydney: NSW Health, 2017. https://www1.health.nsw.gov.au/pds/ActivePDSDocuments/PD2017_041.pdf


Cassandra Knight
I have a Dietetic background with approximately 10 years of clinical experience across Hunter New England Local Health District (HNELHD) hospital, community, aged care, metro, rural and regional settings.
I have completed a Masters in Applied Management in Health and currently working in two positions:
• Food Service Project Officer, Allied Health Directorate, HNELHD
• Internal Auditor, Internal Audit and Corporate Governance, HNELHD

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