2016 Nutrition Program Review Presentation to: Nutrition Service Directors and WIC Staff Moderated...
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Transcript of 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
0
10
20
30
40
50
60
70
80
90
100
55.9
69.1
82.1
87.7 90.1
38.6
43.9
63.2
70.3
66.3
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
4 4
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
Evaluator must enter appropriate number
Breastfeeding Promotion & Support
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
Breastfeeding Promotion and
Support Point AssignmentPossible Points
Points Awarded
3. Breastfeeding Education - All staff
100% of staff received = 5 points
5 5
95 – 99% received = 4 points 90 -95% received = 3 points 85 – 89% received = 2 points80 – 84% received = 1 point< 80% received = 0 points
Evaluator must enter appropriate number
Breastfeeding Promotion & Support
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
Breastfeeding Promotion and
Support Point AssignmentPossible Points
Points Awarded
4. Peer Counselor Continuing Education
100% of staff received = 3 points
2 2
95 – 99% received = 2 points 90 -95% received = 1 points< 90% received = 0 points
Evaluator must enter the appropriate number
Breastfeeding Promotion & Support
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
11
6. Follows State Procedure's for Pump Issuance
Yes=1, No=0 1 1
Evaluator must enter appropriate number
Breastfeeding Promotion & Support
Local agency has developed a breastfeeding resource for prenatal and breastfeeding women (Possible Points = 1).
Breastfeeding Promotion and
Support
Point Assignme
ntPossible Points
Points Awarde
d7. Prenatal BF Resource Yes=1,
No=0 1 0 Evaluator must enter the appropriate number
Breastfeeding Promotion & Support
District is reviewing and correcting Breastfeeding Dyad report (Possible Points = 4).
Breastfeeding Promotion and
Support Point AssignmentPossible Points
Points Awarded
Breastfeeding Dyad Report (Average for all clinics)
Past year reports available, resolution of problem documented
4 2
Evaluator must enter a number
Breastfeeding Promotion & Support
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
5 5
Evaluator must enter appropriate number
Breastfeeding Promotion & Support
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
NEW
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
5 3
> 0.5% progress = 3 points
> baseline & < 0.5% increase = 2 pointsDoes not meet with no progress = 0 points
Evaluator must enter appropriate number
Tailoring Breastfeeding Food Packages
Percent of Fully Formula Packages < 85% 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
d 2. Percent of Fully formula packages: < 85% of contract formula packages are FFF
Meets Goal = 5 points
5 3
> 0.5% progress = 3 points> baseline & < 0.5% increase = 2 pointsDoes not meet with no progress = 0 points
Evaluator must enter appropriate number
Tailoring Breastfeeding Food Packages
Percent of Exclusively Breastfed Packages > 9% od contract/EBF 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
d3. Percent of Exclusively breastfeeding infant food packages: > 9% of infant food packages are EBF
Meets Goal = 5 points
5 3
> 0.5% progress = 3 points
> baseline & < 0.5% increase = 2 pointsDoes not meet with no progress = 0 points
Evaluator must enter appropriate number
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 2
2. Packages follow state and federal guidelines (descriptions)
Yes = 2 points; No or not able to evaluate = 0 points
2 2
3. Packages within allowed minimums and maximums
100% correct = 6 points
6 5
(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)
Nutrition Education Materials/Classes
Appropriate and adequate variety of nutrition education materials available to meet participant category needs? (English, Spanish, low literacy, other). (Possible Points = 2)
Nutrition Education Materials/Classes
All District created materials were approved by the Nutrition Unit and DPH (Possible Points = 3).
Nutrition Education Materials/Classes
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 1
2. All participants groups represented 3 3 3. All district created nutrition education materials meet guidelines (non-discrimination)
3 3
4. Appropriate & adequate variety of NE materials available to meet participant need.
2 2
5. All District materials were approved by the Nutrition Unit and DPH
3 3
6. Nutrition Education resources available for emergencies: Food safety, Food Preparation, Safe Water Supply, General Sanitation
2 2
Overall Rating 15 14
Evaluator must enter appropriate number; System will total
Nutrition Education Materials/Classes
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
nt
Possible
Points
Points Awarde
d1. Summary of finding available for all clinics
5 2
2. Chart review (with at least 10 charts per clinic)
2 2
3. High Risk chart review 2 2
4. Observations 2 25. Breastfeeding clinic evaluation
2 2
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 2
2. Checklists on file for all CPAs hired since last program review
4 2
3. All components completed, initialed and signed.
4 2
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
355
TIME
Break
BREASTFEEDING EVALUATION
Clinic
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
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
5 na
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
Clinic 1 Breastfeeding Clinic Evaluation
Point Assignment
Possible Points
Points Awarde
d
2. Women encouraged to breastfeed during pregnancy (chart review)
90-100% - 3 points
5 Na
80-89% - 2 points
70-79% - 1 point
< 70% + 0 points
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; Currently not pulled from chart review
Breastfeeding Clinic Evaluation
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
Clinic 1 Breastfeeding Clinic Evaluation
Point Assignment
Possible
PointsPoints
Awarded3. Breastfeeding weeks documented correctly (chart review)
90-100% - 2 points
2 na80-89% - 1
points
<80% - 0 point
Note: “na” is a place holder, prevents report page for adding zero points for a clinic page not in use
Evaluator must enter appropriate number, Currently does not pull from chart review
Breastfeeding Clinic Evaluation
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
5 na
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
Evaluator must enter appropriate number
Breastfeeding Clinic Evaluation
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
Clinic 1 Breastfeeding Clinic Evaluation Point Assignment
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
4 na
Clinic has PC as needed = 3 points
PC available on referral basis = 2 points
No PC coverage
Note: “na” is a place holder, prevents report page for adding zero points for a clinic page not in use
Evaluator must enter appropriate number
Breastfeeding Clinic Evaluation
Prenatal breastfeeding classes offered (Possible points – 4)
• Classes available on site or Videoconferencing
• BF class content provided on individual basis separate from certification
Clinic 1 Breastfeeding Clinic Evaluation Point Assignment
Possible Points
Points Awarded
6. Prenatal breastfeeding classes offered.
Classes available on site or VC
4 na
BF class content provided on individual basis separate from certification
Note: “na” is a place holder, prevents report page for adding zero points for a clinic page not in use
Evaluator must enter appropriate numbe
Breastfeeding Clinic Evaluation
Breastfeeding referral system: clinic level staff accurately describes district referral system (Possible points – 3).
Clinic 1 Breastfeeding Clinic Evaluation
Point Assignme
ntPossible Points
Points Awarded
7. Breastfeeding referral system: clinic level staff accurately describes district referral system.
3 na
Note: “na” is a place holder, prevents report page for adding zero points for a clinic page not in use
Evaluator must enter appropriate number
Breastfeeding Clinic Evaluation
Clinic follows policies and procedures for issuing breast pumps (Possible points -2).
Clinic 1 Breastfeeding Clinic Evaluation
Point Assignme
ntPossible Points
Points Awarded
8. Clinic follows policies and procedures for issuing breast pumps.
2 na
Note: “na” is a place holder, prevents report page for adding zero points for a clinic page not in use
Evaluator must enter appropriate number
Breastfeeding Clinic Evaluation
Clinic is maintaining an inventory of all breast pumps and kits (Possible points -2).
Clinic 1 Breastfeeding Clinic Evaluation
Point Assignment
Possible Points
Points Awarded
9. Clinic is maintaining an inventory of all breast pumps and kits.
2 na
Note: “na” is a place holder, prevents report page for adding zero points for a clinic page not in use
Evaluator must enter appropriate number
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
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
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.
1
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.
0.8
6. Provided accurate nutrition educatiion information and appropriate materials.
1
7. Displayed respect for other cultures (used translator appropriately, eye contact, time mangement, greetings).
1
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
99.5
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
85.2
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)
• Measurements taken twice (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)
• Measurements taken twice (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)
• Measurements taken twice (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)
Enter “1” for satisfactory; Enter “0” for unsatisfactory
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)
2)
Enter “1” for satisfactory; Enter “0” for unsatisfactory
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
80.8
Nutrition Risks Documented
77.4 – 98.6
91.0
Inappropriate Nutrition Practices
80.6 – 96.8
91.2
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
90.1
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